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Guidelines for the Management of Severely
Acute Malnourished Children
Throughout the world especially in south Asia and sub-Saharan region, severe acute malnutrition (SAM) is one of the major causes of child mortality and morbidity. It was shown that proper early management of SAM can reduce the prevalence of child morbidity and mortality. This document provides procedure for treatment of SAM in facility and community basis. It focuses on the treatment of complications, feeding practices, psychological stimulation as well as knowledge. This manual is intended for health personnel, community health workers, physicians, nurses, program managers etc.
Rakhi Nandi and Md. Saroar Zubair
Institute of Nutrition and Food Science,
University of Dhaka
1
Content
r Abbreviations 3
r Key terms 4
r Rationale 5
r Methodology 6
r Assessment and admission criteria 7
r General Principals of Management 11
r Discharge and follow up 18
r Counseling 19
r Monitoring and supervision 19
r Recommendation 23
r Conclusion 23
r Appendix 24
r Reference 28
2
Table no. Table Headline Page
1 Enrollment criteria for SAM child 10
2 Time-frame and management for a child with
severe acute malnutrition in facility based program
13
3 A recommended schedule for initial feeding 16
4 Steps for management of SAM children < 6 months
of age
17
5 Criteria for discharging from program 18
6 Scaling the SAM treatment procedure of different organizations
21
Figure no. Figure Headline Page
1 Management of acute malnutrition for the children aged 6-59 months
11
3
Abbreviations
ARI Acute Respiratory Infection
CHW Child Health Worker
CMC Child Monitoring Card
CMV Combined mineral vitamin mix
EPI Expanded program of immunization
FD Field Distributor
IV Intra Venous
IM Intra Muscular
IMCI Integrated Management of Childhood Illness
MAM Moderate Acute Malnutrition
MUAC Mid Upper Arm Circumference
NG Naso-gastric
ORS Oral rehydration salts
ReSoMal Rehydration Solution for Malnutrition
SD Standard deviation
SAM Severely Acute Malnutrition
TF Therapeutic Food
TFR Therapeutic Feeding Rooster
TLI Team Leader Interviewer
WFH Weight for Height
WHZ Weight for Height Z score
WHM Weight for Height Median
WLZ Weight for Length
4
Key terms
UNDERNUTRITION There are four forms of under nutrition: v Acute malnutrition/Wasting v Stunting v Underweight v Micronutrient deficiency
Under nutrition is defined based on anthropometric indicators, clinical signs and clinical tests. The four forms often overlap in one child or in a population. The focus of these training modules is on acute malnutrition. ACUTE MALNUTRITION: Acute malnutrition is caused by a decrease in food consumption and/or illness resulting in bilateral pitting edema or sudden weight loss. It is defined by the presence of bilateral pitting edema or by wasting. Severe acute malnutrition (SAM) is defined by the presence of bilateral pitting edema or severe wasting. A child with SAM is highly vulnerable and has a high mortality risk. SAM can also be defined by the prevalence of bilateral pitting edema and severe wasting (based on the weight-for-height [WFH] indicator using the World Health Organization [WHO] standards references). The prevalence of wasting can be estimated based on WHZ or WHM mid-upper arm circumference (MUAC). INDICES: When body measurements are compared to a reference value, they are called nutrition indices. Three commonly used nutrition indices are WFH which is used to assess wasting, height-for-age (HFA) which issued to assess stunting, and weight-for-age (WFA) which is used to assess underweight. The WFH index is used to assess wasting, a clinical manifestation of acute malnutrition. It shows how a child’s weight compares to the weight of a child of the same height and sex in the WHO standard or NCHS reference populations. The index reflects a child’s current nutritional status. INDICATORS:
• Mid-upper arm circumference <110 mm
• Weight-for-height median (WHM) <70%
• Weight-for-height z-score (WHZ) <-3 SD
• Bipedal edema (kwashiorkor, marasmic kwashiorkor, edematous malnutrition, is
verified when thumb pressure applied on top of both feet for three seconds leaves a pit
in the foot after the thumb is lifted.)
5
Rationale
Under nutrition is a significant public health problem especially in case of child and maternal health around the world. Under-nutrition prevalence rates in South Asia range is 38% to 51%1. It is estimated that 41% of children under five are considered to be stunted and 15% are severely stunted (< -3SD) 2. It is shown that the prevalence of stunting increases with age from 18% of children six months to 52 percent of children 18-23 months and decreases to 42% among children 48-59 months2. 16% of children are considered wasted or too thin for their height and 4 % are severely wasted2. Wasting is highest at age 18-23 months (17%). 36% of children are underweight (low weight-for-age), and 10% are severely underweight2. The proportion of children underweight peaks at age 36-47 months (43%) 2. So from this trend it can be said that moderate malnutrition and severe malnutrition are actually the important issues that have impact on morbidity and mortality of children aged 6-59 months of age in Bangladesh. The death rate among children hospitalized for SAM was as high as 15 %3. Severe acute malnutrition is associated with child’s mortality and morbidity. Not only death but also many public health problems are aroused by it and cause health hazards in child’s growth and development. Some major problems associated with SAM children are found in childhood and adulthood: Ø Death Ø Stunting and wasting Ø Limiting mental development Ø Abnormal metabolic syndrome Ø Growth failure during adolescent age Ø Hampered reproduction and pregnancy outcomes etc.
So, malnourished children become burden to the social life. It is necessary to manage them as soon as possible to avoid the sequence of outcomes of malnutrition. In general, severe acute malnourished (SAM) children have been managed in a health facility. Facility-based care is essential when severe acute malnutrition has progressed to a stage where children have medical complications that are life-threatening. This requires the child and mother/caregiver must stay at the health facility for several weeks. As a result few children with SAM get complete treatment. Again treating large numbers of children with SAM at the facility is costly. Targeting of large numbers of acutely malnourished children at the community level through decentralized services is essential in order to reach the maximum number of children. SAM without complications and SAM that stabilize their complications in facility based treatment (after 4-7 days) can be continued in community4. Simple case detection tools can be used to identify cases and refer children for treatment before complications arise. Evidence has shown that when children are identified early, more than 85% of children with SAM do not have medical complications and can be effectively treated at the community level and do not need to go to a facility. Children with SAM without complications can be treated at an outpatient site (or outreach site) in the community or
6
directly at household level by a trained community health worker (CHW). These children receive specific nutritional treatment and routine medical care every week until meets the discharge criteria. The guidelines provide the step by step information for management SAM children (with or without complications) in the community. The guidelines are based on the Global guidelines of WHO for SAM management and National Guidelines for SAM management in Bangladesh. It focuses on the both facility and community health services of severely malnourished children aged 6-59 months. These can be used by any CHW responsible for any community service, medical stuffs, policy makers, program managers etc. according to their needs and logistic supports.
Methodology
This document was made during our internship at JiVitA*, Bangladesh and the objective is to
provide a guideline for the management of severe acute malnutrition (SAM) in children. Several
guidelines and protocols for severe acute malnutrition (SAM) in different countries
(Bangladesh, India) and by different organizations (WHO, Helen Keller International) were desk-
reviewed and relations as well as differences among them are outlined. These management
systems of SAM are compatible for developing countries like in south Asian region where
severe acute malnutrition is a major problem for children’s health, growth and development.
Guidelines, protocols and articles about SAM were found by searching in internet (such as
PubMed, Google scholar etc.). We have used some key words to search the articles and reports
such as malnutrition situation in Bangladesh and South Asia, SAM guidelines by WHO, National
guidelines, BDHS reports etc. “Guidelines for the management of Severely Acute Malnourished
Children” seeks to improve child’s health with SAM and to reduce mortality and morbidity.
To assess the SAM children based on height, following formula is used:
� � � = � � � � � � � � � � � � (� � � � � )— � � � � � � � � � � � � � � � � � � � (� � � � � )
� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �
*JiVitA is a maternal and child health research program of Johns Hopkins Bangladesh collaborating with the Ministry of Health and Family Welfare of the Government of the People’s Republic of Bangladesh
7
Assessment and admission criteria
COMMUNITY OUTREACH
Community outreach is an essential component of SAM management to provide care for
children with SAM with medical complications as well as for children with SAM without medical
complications and, in some contexts, services to address moderate acute malnutrition (MAM).
It helps to ensure that children with SAM are detected early, before the onset of medical
complications and referred for treatment, leading to better clinical outcomes and decreased
strain on inpatient services.
Community outreach is characterized by:
Active case-finding for early detection and referral: For any management to function
effectively and for acceptable coverage severely malnourished children should be identified
early through active case-finding. It will take place in the community level at the household
level. CHWs will actively identify children with SAM and MAM during ongoing community
activities such as growth monitoring and promotion (GMP), Children can be identified through:
• House to house visits.
• Growth monitoring sessions.
• During routine health visits for the sick and well child under five.
• At EPI sites during routine vaccination days and campaigns.
• Screening at community meetings.
• Upazila Health Complex or other health facility.
Case follow-up in the home:
A follow-up home visit is essential to:
- Check on a child who is not thriving or responding well to the treatment
- Learn why a child was absent from a care follow-on session
- Learn whether malnutrition relapses.
CHW maintains a child monitoring card (CMC) for each SAM child after identification and every
treatment and other information are updated in the card by CHW in every visit.
8
The following steps are required to establish the two components of community outreach
effectively:
• Community Assessment
• Formulation of Community Outreach Strategy
• Development of Messages and Materials
• Community Mobilization and Training
The purpose of community outreach activities
• Promoting understanding about acute malnutrition.
• Increasing program coverage.
• Finding children with SAM easily.
• Finding children with MAM if these children are to be included in community based
program.
• Follow up children who have may be absent or defaulted and those who have problems.
• Understanding reasons for absence and default so that they can be addressed.
• Promoting strong links between prevention and treatment so that the underlying causes
can also be addressed.
BASIC REQUIREMENTS FOR OUTREACH ACTIVITIES
1. Staffs:
Community outreach activities will be conducted by CHWs. This includes: Health
Assistant (HA), Family Welfare Assistant (FWA), Community Nutrition Worker,
Community Health Care Provider (CHCP) and NGO Community Health Workers and
community volunteers.
2. Instrument:
Ø Anthropometric measurement tool
Ø Home visit form
Ø Referral slips
Ø Key messages
Ø CMC
9
3. Training:
CHWs must be trained to identify, refer and follow up children with SAM and MAM. Training
can be done in two or three days. Frequent refresher training will be required. Training should
include:
Ø The purpose of community based management of SAM and MAM
Ø Basic information on the causes, identification and treatment of malnutrition
Ø Practice in identification of edema and wasting, use of anthropometry tool
Ø Case finding and Case referral
Ø Health and nutrition education (prevention).
4. Community participation:
It is important to directly engage the community. This can be done initially through meetings
with community and religious leaders. Other key community members should also be included.
It is necessary for CHWs’ to-
Ø Engage in discussion with the community to talk about the problem of malnutrition,
causes and possible solutions.
Ø Discuss the community based management of SAM and MAM and how it will work in
practice.
Ø Agree on relevant groups, organizations, structures to be involved in the program. This
may include the recruitment of volunteers/community nutrition workers to help with
case finding and follow up
Ø Develop clear roles and responsibilities.
PROCEDURE FOR ASSESSMENT
Following data are taken for the assessment of severe acute malnutrition through community
outreach activities:
History about
• Recent intake of food and fluids
• Usual diet (before the current illness) and breastfeeding
• Recent morbidity (fever, measles, diarrhea, dysentery, ARI, tuberculosis etc.)
• Knowledge, care, feeding and hygiene practices
• Socio-economic status
Anthropometry
• Height (length) and weight and Mid Upper Arm Circumference (MUAC) are taken by using calibrated anthropometric tool. Indicators are then matched with WHO reference value to identify SAM children.
10
After taking these information children are enrolled in facility and community basis treatment by following criteria:
Table 1: Enrollment criteria for SAM child
SAM children with complications SAM children without complications
Weight for Height Z score (WHZ)<-3SD Weight for Height Z score (WHZ)<-3SD
Weight for Height Median (WHM) < 70% Weight for Height Median (WHM) < 70%
MUAC < 110 mm MUAC < 110 mm
Bilateral pedal edema
Other
complications
No appetite
Persistent vomiting (>3
per hour)
Fever >39.°c or 102.2° F
(axillary temperature)
Hypothermia < 35.°c or
95°F(axillary temperature)
Rapid breathing
> 60/min for children <2
months > 50/min for
children 2-12 months >
40/min for children 12-59
months
Dehydration (skin pinch,
sunken eyes, dry mouth,
diminished urine flow)
Anemia (severely pale)
Infection
11
General Principals of Management
Figure 1: Management of acute malnutrition for the children aged 6-59
months6
Severe acute
malnutrition
(SAM)
SAM With Complications
Facility-based (inpatient) care
Treatment comprises first 7 steps
of the National Guideline for
Management of SAM
(stabilization). When completed,
the child is transferred to
community based care.
SAM Without Complications
Community-based (outpatient)
care
Children with SAM without
complications are given Nutritional
Treatment (NT) and routine
medicines at an outpatient site or
directly in the community.
12
FACILITY BASED MANAGEMENT FOR SAM CHILDREN
Target group
Community based survey will be conducted regularly to find malnourished children. When a
child (6-59 months) having any criteria to be identified as severely malnourished (WHZ < -3 SD,
WHM < 70%, MUAC < 110 cm and presence bilateral pitting edema), then s/he will be visited by
CHW. If the child is found complications then s/he will be recommended for facility-based
treatment. Otherwise s/he will be included in community-based program.
Major principles for routine care for malnourished child
There are ten essential principles for management of malnourished children with complication5.
• Treat/prevent hypoglycemia
• Treat/prevent hypothermia
• Treat/prevent dehydration
• Correct electrolyte imbalance
• Treat/prevent infection
• Correct micronutrient deficiencies
• Start feeding cautiously including breast feeding
• Achieve catch-up growth
• Provide sensory stimulation and emotional support
• Prepare for discharge and follow-up after recovery
In facility-based treatment program these steps are accomplished in two phases:
o Stabilization phase: to manage acute medical conditions and life threatening problems.
o Rehabilitation phase: to start intensive feeding to recover weight loss and to send back
to community based treatment.
13
Table 2: Time-frame and management for a child with severe acute malnutrition in facility
based program5
Steps Time-frame Treatment/ requirement
1.Hypoglycaemia 1-2 Days • 50 ml of 10% glucose or sucrose solution, orally or by NG tube.
• Then starter diet F-75 every 30 minutes for two hours.
2. Hypothermia 1-2 Days • Re-warming the child: (including head), with a warmed blanket or by putting the child on the mother's bare chest (skin to skin) and cover them.
3. Dehydration 1-2 Days • The standard oral rehydration salts (ORS) solution (90 mmol sodium/L) and the newly modified WHO-ORS (75 mmol sodium/L) that contains too much sodium and too little potassium for severely malnourished children or special Rehydration Solution for Malnutrition (ReSoMal).
4. Electrolytes 1-6 Weeks • Extra potassium 3-4 mmol/kg/d
• Extra magnesium 0.4-0.6 mmol/kg/d
• When rehydrating, giving low sodium rehydration fluid (e.g. ReSoMal)
• Food without salt
5. Infection 1-7 Days • Broad-spectrum antibiotic(s)
6. Micronutrients with iron
no iron: 1-7 Days with iron: 2-6 Weeks
• Vitamin A orally on Day-1 (for age >12 months, 200,000 IU; for age 6-12 months, 100,000 IU) (on admission) Daily:
• Multivitamin supplement (without iron)
• Folic acid 1 mg/d (5 mg on Day 1)
• Zinc 2 mg/kg/d
• Copper 0.3 mg/kg/d (if available)
• Elemental iron 3 mg/kg/d but only when gaining weight
14
Steps Time-frame Treatment/ requirement
7. Cautious feeding 1-7 Days • Small, frequent feeds of low osmolarity and low lactose
• Energy intake of ~100 kcal/kg/d
• Protein intake of 1-1.5 g protein/kg/d
• Total fluid intake through feeds should not be more than 130 ml/kg/d (100 ml/kg/d if the child has severe edema)
• Continuing breastfeeding with prescribed amounts of starter formula (F-75) to make sure the child's needs are met.
8. Catch-up growth 2-6 Weeks • Rapid weight gain of >10 g/kg body wt./day
• The recommended milk-based F-100 contains 100 kcal and 2.9 g protein/100 ml. Khichuri, halwa, modified porridges or modified family foods can be used if they have comparable energy, protein and micronutrient concentrations.
9. Sensory stimulation
1-6 Weeks • Tender loving care
• A cheerful, stimulating environment
• Structured play therapy 15-30 min/d.
• Parental/caregiver involvement when possible
10. Prepare for follow-up
2-6 Weeks • Who has achieved 80% weight-for-length or weight -for-height Z-score -2 SD
Generally SAM children with complications are preferably suggested to facility-based treatment
and SAM children without complication are preferable for community based treatment. If
facility-based treatment is difficult to conduct, then all SAM children will be included in
community–based treatment.
15
COMMUNITY BASED MANAGEMENT FOR SAM CHILDREN
Target group:
1. SAM Children aged 6-59 months having WHZ<-3SD or WHM<70% or MUAC<110mm and without any complications are included in community based treatment5.
2. If any SAM children with complications are not possible to be provided by facility based treatment, then he or she will be included in community based treatment.
3. SAM children returning from the Facility based treatment after stabilization.
Methodology for Treatment: 1. Enrollment of SAM children is done directly according to the enrollment criteria and
target group definition. 2. Assessment of anthropometric data for criteria is done by appropriate tool by CHW. 3. Target groups are mainly provided with Nutritional Treatment. The amount of NT given
is based on weight (175 - 200 kcal/kg/day) until child does not meet the discharge criteria.
4. The necessity of treatment is explained to mother or caregiver and they are emphasized not to share NT with anyone as it is important to child.
5. Mothers are promoted to continue the breast-feeding and when child’s appetite has return home foods are recommended to provide.
6. Weekly follow up visit is done to check the child’s recovery rate, medical complications, and immunization until discharge.
Nutritional Treatment:
Nutritional Treatment (NT) is a specially prepared or pre-packaged treatment for SAM without
complications. Nutritional Treatment is mainly oil based energy-dense mineral/vitamin
enriched nutritious food. Its composition is 450-550kcal/100g of which fat is 45-60% of total
energy and protein (including milk products) is 10-12% of total energy. Multi-micronutrient
content of NT is equivalent to F100.
Packaged Nutritional Treatment does not require any mixing or cooking, therefore there is
minimal chance to microbiological contamination. It can be consumed directly from the packet.
It has very little water content and therefore can be safely stored at home in a dry place
without risk of contamination. As it does not require cooking loss of micronutrients by heat is
minimal. It can be imported or produced locally wherever possible. Locally produced NT, made
of local food ingredients, meeting international and national standards for quality, safety and
cost, is preferred for community based management of SAM.
Where NT is not available, mothers can be taught to prepare some local food which is very
energy dense like Khichuri (144Kcal/100g,2.9g protein/100g) and Halwa (240kcal/100g,5g
protein/100g) [The recipes developed by ICCDR,B].
16
Feeding procedure:
In the initial phase, a cautious approach is required because of the child’s fragile physiological
state and reduced homeostatic capacity. The child with SAM has to be fed with gradual increase
in the feed volume and gradual decrease in feeding frequency.
Table 3: A recommended schedule for initial feeding7
Days Frequency Volume/kg/feed Volume/kg/d
1–2
2-hourly 11 mL 130 mL
3–5 3-hourly 16 mL
130 mL
6-onwards 4-hourly 22 mL
130 mL
For children with a good appetite and no edema, this schedule can be completed in 2–3 days.
The volumes/feed calculated according to body weight. : If staff resources are limited, give
priority to 2-hourly feeds for only the most seriously ill children, and aim for at least 3-hourly
feeds initially. Get mothers and other careers to help with feeding. Show them what to do and
supervise them. Night feeds are essential and staff rosters may need to be adjusted. If, despite
all efforts, not all the night feeds can be given, the feeds should be spaced equally through the
night to avoid long periods without a feed (with the risk of increased mortality).
17
Management of SAM children < 6 months of age Management of the SAM children below 6 months of age is quite difficult and different from
the procedure for older children. Although the procedure for treating the complications is more
or less same in these two cases, some special differences in case of feeding procedure have to
keep in mind. Some special procedures like ensuring the presence of mother in facility also have
to keep in mind as mothers are the main caregiver for infant. Here the whole procedure is
figured out in a table.
Table 4: Steps for management of SAM children < 6 months of age5
Initial assessment and treatment
Procedure of identification, measurement, diagnoses and treatment of complications are same as older child.
Stabilization Children are fed with special type of milk feeds for initial recovery and stabilization.
Care of mother If mother is available, then she is provided with special care and feed to make eligible for taking care of infant, produce milk and restore the health.
Promoting breast feeding Exclusive breast feeding is promoted to continue as soon as possible from the beginning of treatment besides the milk therapy, if necessary supplementary suckling technique is provided.
Catch-up growth Supplementary milk formula or diluted F-100 is provided along with breast feeding for catch up growth.
Discharge When infant is gaining weight or one on breast-feeding for 5 consecutive days or has a weight-for-length 80-85% of the median WHO standards reference values.
18
Discharge and Follow-up:
Table 5: Criteria for discharging from program5
Category Criteria
Recovery WHM >80% or WHZ >-2SD
Edema has resolved.
Child has normal appetite.
All infections and other complications are treated.
Defaulted Absent for 3 consecutive visit
Died Child has died within intervention time.
The discharge process for all children should include: Ø Correct timing of discharge. Ø Counseling the mother on treatment and feeding of the child at home. Ø Ensuring that the child’s immunization status and record card are up-to-date. Ø Instruction on proper follow up care and on symptoms and signs indicating the need of
using health facilities.
Children discharged from the program need regular follow-up
v to check that the child’s illness was resolving satisfactorily v to check for delayed (or hidden) complications that may arise after the child has
recovered (e.g. hearing loss or disability after meningitis) v to check the child’s nutritional status after discharge v To check whether child show continuous growth on home food.
Routine follow up should be done monthly basis in community level. In every visit, mother
should be reminded about next visit as well as child’s immunization. Advises should be given to
mother to use health facility if child develops any of dangerous sign (loss of appetite, fever, fast
breathing, cough, watery stool etc.)
19
Counseling
v Mother / caregiver should be provided with knowledge about proper feeding practices
(frequency of meal, breast feeding, use of cup instead of bottle etc.) of child to prevent
the relapse of malnutrition.
v Mother/caregiver should also be taught about the proper and locally available home-made complimentary food like thick cereal with added oil, milk or milk products, fruits, vegetables, pulses, meat, eggs and fish.
v Knowledge about hygiene and sanitation should be given and also history of attitude
and practices should be taken.
v Mother or other family members should be encouraged to provide psychological
stimulation (playing, speaking etc.) for proper development.
v Posters, placards, leaflets with pictures and other pictorials can be used in counseling
and community education. A mother’s card (a simple pictorial card developed by IMCI)
can be used for reminding mother about home care instruction, dangerous signs, food
preparation etc.
Monitoring and Supervision
The purpose of monitoring
Monitoring is very essential for any program as it helps to know about the effectiveness of
program. So before planning a program Management and information systems (MIS) must
provide sufficient minimal information to determine effectiveness.
Children or women who are included in the program are needed to be tracked as they are
transferred between different components of treatment.
Again monitoring is needed for appropriate data about the indicators of the SAM child as faulty
treatment can be happened any time which can bring burden for both program initiator as well
as the children under program.
For effective monitoring to be effective, the health worker needs to know: v The correct administration of the treatment. v The expected progress of the child. v The possible adverse effects of the treatment. v The complications that may arise and how these can be identified. v The possible alternative diagnoses in a child not responding to treatment.
20
Monitoring procedure
As monitoring is very important and key for a successful program, following steps should be
taken to monitor the SAM management:
Ø A CMC (child monitoring card) has to be maintained by CHW from the assessment
procedure.
Ø All the information about anthropometry, medical complications (fever, diarrhea,
vomiting frequency etc.) and immunization status of every SAM children has to be
recorded in every visit carefully in CMC.
Ø Every detail about the treatments or supplements (amount of feeding given, leftover
etc.) on facility or community basis has to be recorded in CMC.
Ø In every follow up, the anthropometry of every SAM children has to be recorded in
follow up section of CMC card.
Ø Every child should be designated or identified with individual number given by
monitoring board.
Ø CHW has to maintain another record file containing number of meet children, number
of defaulter (absent in 3 visit) and number of death are recorded. It will be checked by
monitoring board and the necessities of treatment are determined by the service
provider based on the information.
Ø A monthly record file is made containing information of weekly treatment, new
enrollment, number of discharge and this is then supervised by program supervisor and
service provider.
Ø Recovery rate, mortality rate, default rate can be measured after summarizing the
monthly report and compared with other existing programs for determining the
effectiveness of the program.
Ø Coverage of the program can be known by conducting a coverage survey.
Supervision:
Ø Supervisor must closely work with service provider.
Ø Supervisor must conduct a monthly meeting with CHW and check the record files.
Ø If any support is needed then decision must be taken by service provider based on
the report of supervisor.
21
Table 6: Scaling the SAM treatment procedure of different organizations
Criteria National SAM guidelines of Bangladesh
HKI CMAM program Our proposal
Assessment Based on single or combination 4 indicators: § MUAC<110
mm § WHM<70% § WHZ<-3SD § Bipedal
edema
Assessment is done via a channel of 3 indicators: § Bilateral
edema § MUAC<115
mm § WHZ<-3SD
(SAM) § WHZ:-2to -
3SD(MAM)
Assessment should be based on 4 indicators as one indicator does not cover the overall malnutrition criteria.
Target population § General protocol for SAM children aged 6-59 months
§ Special protocol for SAM children aged >6 months
Protocol for management of MAM and SAM children aged 6-59 months.
Target population should be SAM children aged 6-59 months and also>6 months.
Treatment procedure
§ Total facility based care have to be provided.
§ Treatment has to be provided based on IMCI on inpatient care (for SAM child with complication) and outpatient care (for SAM child without complications and for MAM child) basis
§ Treatment should be provided in facility and community basis.
22
Criteria National SAM guidelines of Bangladesh
HKI CMAM program Our proposal
Complication § Each complication has to be corrected according to WHO recommendation.
§ In case of absent of medical complications therapeutic feeding (SAM) and supplementary feeding (MAM) are provided.
§ Correction of complications should be done in facility basis according to WHO.
Feeding § Feeding has to be started with F-75 and F-100.
§ In case of medical complication sugar has to be provided and has to refer to therapeutic feeding center.
§ Therapeutic feeding should be done with F-75 and F-100. If not possible locally made NT can be provided.
Special procedure § Some play therapies have to be given to develop language and motor skills of malnourished children.
§ No guidelines for psychological stimulation and knowledge.
§ Knowledge also needed to be provided about feeding practices and hygiene to prevent the relapse of malnutrition and for psychological development.
Follow-up • Monitoring records are maintained for clinical conditions of child.
• In HKI module follow-up is not focused.
• Regular follow up till the child maintain constant growth is required.
23
Recommendation
Our recommendation in respect to Bangladesh:
Though our national guidelines for the management of SAM and CMAM focus all dimensions
required for management, the procedures cannot be implemented for the lack of proper
facilities. So government or any policy maker should take some steps for proper
implementation like:
Ø They should develop locally available NT and make them available in community.
Ø Health care facilities should be made more available to community.
Ø People should be encouraged to use more health care facilities.
Ø Nutrition education is necessary to be provided in community to make people aware
about the SAM.
Ø Immunization should be made available to every level.
Conclusion
This report is theoretically developed based on existing guidelines the management of severe
acute malnutrition and it has not been implemented practically. We hope that it can provide
necessary information for successful management of severe acute malnourished children in
community basis even when there are limited resources.
24
Appendix
F-75 recipes5
Type of milk Ingredients Amount for
Types of milk Ingredients Amount
Dried skimmed milk Dried skimmed milk 25 g
Sugar 70 g
Cereal flour* 35 g
Vegetable oil 30 g (35ml)
Mineral Mix 20 ml
Water Make up to 1000 ml
Dried whole milk
Dried whole milk 35 g
Sugar 70 g
Cereal flour* 35 g
Vegetable oil 20 g (20ml)
Mineral Mix 20 ml
Water Make up to 1000 ml
Full-cream cow’s milk Full-cream cow’s milk 300 ml
Sugar 70 g
Cereal flour* 35 g
Vegetable oil 20 g (20ml)
Mineral Mix 20 ml
Water Make up to 1000 ml
*Cereal flour may be rice, wheat, maize, or whatever cereal *If cereal flour is not available then the amount of sugar will be 100g.
25
F-100 recipes5
Types of milk Ingredients Amount
Dried skimmed milk Dried skimmed milk 80 g
Sugar 50 g
Vegetable oil 60 g (70ml)
Mineral Mix 20 ml
Water Make upto 1000 ml
Dried whole milk
Dried whole milk 110 g
Sugar 50 g
Vegetable oil 30 g (35ml)
Mineral Mix 20 ml
Water Make upto 1000 ml
Full-cream cow’s milk Full-cream cow’s milk 880 ml
Sugar 75 g
Vegetable oil 20 g (20ml)
Mineral Mix 20 ml
Water Make upto 1000 ml
Local alternative NT
Halwa recipes5
Ingredients Amounts
Wheat flour (atta) 200 g
Lentils (mashur dal) 100 g
Oil (soya) 100 ml
Molasses (brown sugar or gur) 125 g
Water (to make a thick paste) 600 ml
Total energy/kg 2,404 kcal
Total protein/kg 50.5 g
26
Khichuri recipes5
Ingredients Amount
Rice 120 g
Lentils (mashur dal) 60 g
Oil (soya) 70 ml
Potato 100 g
Pumpkin 100 g
Leafy vegetable (shak) 80 g
Onion (2 medium size) 50 g
Spices (ginger, garlic, turmeric and coriander
powder)
50 g
Water 1000 ml
Total energy/kg 1,442 kcal
Total protein/kg 29.6 g
27
Recipes for ReSoMal and electrolyte-mineral Solution5
ReSoMal
Ingredients Amount
Water (boiled and cooled) 850 ml
WHO-ORS (new formulation) One 500 ml-packet Sugar 20g
Electrolyte-mineral solution (see below) 16.5 ml
Electrolyte-mineral Solution5
Ingredients Amount(g)
Potassium Chloride: KCl 224
Tripotassium Citrate: C6H5K3O7.H2O 81
Magnesium Chloride: MgCl2.6H2O 76
Zinc Acetate: Zn(CH3COO)2.2H20 8.2
Copper Sulphate: CuSO4.5H2O 1.4
Water make up to 2500 ml
28
References
1. World Bank report,2012 (http://go.worldbank.org/64682WRWYO)
2. Bangladesh demographic and Health Survey, 2011.
3. Islam KE, Rahman S, Molla AH, Akbar N, and Ahmed M. Protocol management of
children with severe malnutrition: lessons learn from a tertiary-level government
hospital. Abstract book, 8th Common wealth Congress on Diarrhea and Malnutrition, 6-
8 February 2006, ICDDR,B, Dhaka, Bangladesh, P36.
4. WHO/WFP/UNSCN/UNICEF community based management of SAM, joint statement,
2007.
5. National guidelines for the management of severely acute malnourished children in the
Bangladesh (By IPHN/DGHS/MHFW/Government of People’s Republic of Bangladesh,
May 2008).
6. National guidelines for community based management of acute malnutrition in
Bangladesh (By IPHN/DGHS/MHFW/Government of People’s Republic of Bangladesh,
September 2011).
7. MANAGEMENT OF THE CHILD WITH A SERIOUS INFECTION OR SEVERE MALNUTRITION, Guidelines for care at the first-referral level in developing countries (by Department of Child And Adolescent Health and Development of WHO, UNICEF).
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