Management of Severe Acute Malnutrition M odule 13

1. Management of Severe Acute MalnutritionModule 13

2. Learning objectives • Understand the importance of the internal and external links between the different CMAM components and other health/ nutrition programmes in emergency and non-emergency situations. • Understand the key elements of a community mobilisation strategy for the management of SAM and which actors should be involved in its implementation. • Be aware of the different elements that support the diagnosis of acute malnutrition and how they are applied in the field • Be aware of criteria for admission to treatment and discharge for each type of service (outpatient or inpatient care), including age • Understand current protocols for the management of SAM cases as outpatients or inpatients, including who they target and where they are implemented • Understand basic concepts related to the monitoring and reporting of CMAM activities and be familiar with practical tools for it

3. CMAM approach • Community-based management of severe acute malnutrition endorsed by the United Nations system in 2007 • Its components are: • Community mobilization and active case-finding • Outpatient care for SAM without complications • Inpatient care for SAM with complications • Inclusion of management of moderate acute malnutrition (MAM) where in place

4. Principles of CMAM • The shift from hospital-based to integrated community-based approach for the treatment of severe acute malnutrition was possible thanks to several elements: • The advent of Ready to Use Therapeutic Foods (RUTF) for dietary treatment at home • The new classification for acute malnutrition • Community participation on active case finding and follow-up

5. Community mobilization (1) • Community mobilisation in CMAM covers a range of activities designed to open a dialogue, promote mutual understanding, encourage active and sustained engagement from the target community as well as improve case finding and follow up.

6. Community mobilization (2) • The goal of the community mobilisation component of CMAM is to improve treatment outcomes and coverage • active participation in the activities for the management of acute malnutrition. • early detection and referral of cases to appropriate nutrition or health services (clinics or hospitals) and their follow-up. • It is an important factor for obtaining good coverage through good uptake of the services provided by the population in need within a specific health catchment area.

7. Community mobilization (3) • Initial community assessment: • Community perceptions of acute malnutrition • Health seeking behaviour and decision makers for accessing treatment • Key community figures, and structures (administrative and leadership) • Existing community-based organisations and groups • Potential candidates for case-finder role • Existing links and communication systems between health facilities and the community • Formal and informal channels of communication • Formal and informal health services • Potential barriers for children with SAM to accessing treatment

8. Community mobilization (4) • Developing messages and materials: • Description of the target children using local descriptive terms for wasting and swelling, • Explanation of the benefits of CMAM, noting that only a few children with SAM who are sick may need to be treated at the hospital, • Explanation about the identification and referral process noting that thin or swollen children can also self-refer to the nearest health facility to be checked, • Time and date of outpatient care sessions at the nearest health facility and locations of those facilities as well as locations of any hospitals or health centres offering inpatient care for SAM •  Visual aids enhance the impact of messages • Raising community awareness works best through existing channels, organisations and structures within the community.

9. Community mobilization (5) • Roles and responsibilities : • An overall (MOH national level) focal person should be identified to manage the whole mobilisation process and ensure a coherent nationwide strategy • A responsible person for the implementation / monitoring should be identified at each district / department / health zone level. • The most appropriate person is who already has responsibility for Health Promotion, Outreach or Extended Health / Nutrition activities • In each health facility, the health worker in charge will be responsible for coordinating with Community Volunteers (CV) or Community Health Workers (CHWs) • CV and CHW should be trained on case-finding, home follow up and community sensitisation. • They are the link between the population and the health / nutrition services and should be identified within existing networks. • Where possible additional training on infant and young child feeding for example can help to ensure the sort of linkages for prevention of SAM

10. Definition of severe acute malnutrition • Low weight for height (WFH<-3 ZS) • and / or • Low Mid-Upper Arm Circumference (MUAC<115 mm) • and / or the • Presence of bilateral pitting oedema

11. Case-finding for SAM • Active case-finding • Identification of cases by community health workers or volunteers in the communities • Mechanisms for referral should be in place • Passive case-finding • Identification of cases by health workers during routine child visits at the health facilities • Self-referral

12. Triage for SAM (1) • Once the “diagnostic” of SAM has been made: • Decide whether the child with SAM should be treated in outpatient or inpatient care: • Absence or presence of medical complications: medical complications should be assessed by a thorough medical examination and accurate medical history with the mother (or caregiver). • Good or poor appetite : this is evaluated through the “appetite test” whereby the child passes or fails the test to eat RUTF

14. Triage for SAM (2) • All children 6-59 months will go to inpatient treatment if they present • Bilateral pitting oedema (+++) or • A combination of oedema and wasting or • SAM with poor appetite (failed appetite test) or • SAM with medical complications • Any other case will be treated as outpatient

15. Admission / discharge criteria for SAM

18. Admission at outpatient care for SAM 1. Fill individual card with all details 2. Registration 3. Assign admission number 4. Explain all process 6. Vaccination 5. Medical treatment 7. Give RUTF and associated explanations 9. Appointment for next visit 10. Nutrition / health education 8. Link family with assigned CHW

19. Medical management at outpatient care for SAM Most of the medical conditions that affect the child with SAM without medical complications can be treated following the IMCI protocols.

20. Nutritional management at outpatient care for SAM (1) RUTF is provided at between 150 and 220 kcal/kg/day • The most widely used RUTF (as lipid-based paste) is PlumpyNut®. If imported it comes in packets of 92 gr. totalling about 500kcals per packet. Locally manufactured RUTF can be in pots containing a greater amount of the product, thus ration tables must be adapted.

22. Nutritional management at outpatient care for SAM (2) • Most important messages for caregivers: • RUTF is a food and a medicine and should not be shared. • RUTF is the only food the child needs in order to recover. • Give small regular meals of RUTF and encourage the child to eat often (8/day) • Always offer the child plenty of clean water to drink while eating the RUTF. • For young children, offer breast milk first before every RUTF feed. • Wash children's hands and face with soap before feeding if possible. • Keep food clean and covered. • When a child has diarrhoea, never stop feeding. Give extra food and extra clean water. • Return to the health facility whenever the child’s condition or appetite deteriorates

23. Follow-up at outpatient care for SAM (1)

25. Follow-up at outpatient care for SAM (2)

26. Follow-up at outpatient care for SAM (2) • Home visits are an essential aspect and aim at assess: • Caregiver’s understanding of the messages received • Compliance with the treatment (RUTF and medications) • Reasons for non-compliance, absence or defaulting • Availability of water and sanitation facilities, hygiene practices • Health and hygiene and food safety practices and general household food security • Transfer to inpatient care: following the “action protocol”, at any time during treatment if signs of gravity (IMCI protocols)

27. Inpatient care for children 6-59 months with SAM • According to current WHO recommendations, hospital-based care for SAM is organized into phases: • Stabilization phase: treatment of medical complications and commencement of cautious feeding with F75 • Transition phase: RUTF is introduced gradually, together with feeds of F100 or F75 to foster child’s weight gain • Rehabilitation phase: or catch up growth phase. In most cases this phase is now replaced by outpatient therapeutic care

28. Admission at inpatient care 1. Start life saving treatment ASAP: Milk F75 + medical treatment 2. Fill the In-patient chart 5. Provide routine treatment as per protocols 4. Explanations to caregiver about all process 3. Assign admission number (if not already having one) 6. Counseling for caregiver: treatment, signs to watch out, good IYCF practices 7. Provide soap and food for caregiver

30. Stabilization at inpatient care (1) • Not meant for weight gain. Weight gain is a sign of serious complication in this phase. • F75 milk is designed for restoring metabolic functions and nutrition-electrolyte balance • F75 is given 8 times a day at quantity 130 ml/kg/day. • Force feeding is never to be used. • Naso-gastric tube can be used, on the other hand, if required. • Caregiver should be involved in all feeds, although given by a feeding assistant.

32. Stabilization at inpatient care (2) • Individual monitoring: • Weight changes • Edema changes • Body temperature • Clinicalsigns • Feeds (behavior, volume taken, etc.) • Promotion to transition is granted when the child has regained appetite, medical complications are under control and edema start reducing

33. Transition at inpatient care (1) • Meant for transition from F75 to F100 and to RUTF (same composition as F100). • F100 is often proposed on first day of transition. • Preference is given for RUTF as early as possible for the child to get used to it. • Frequency of meals remains the same • Monitoring is the same as in Stabilization phase.

34. Transition at inpatient care (2) • Promotion from transition to outpatient (in 2 to 4 days max) when: • Eat at least 75% of daily RUTF prescribed • Edema back to + or ++ maximum • Medical complications under control • Demotion happens when • Gain of weight > 10g/kg/day • Edema increase • Signs of fluid retention • Abdominal distension or diarrhea with weight loss • Complications that require intravenous infusion or NGT.

35. Rehabilitation phase for SAM • Rehabilitation is completed as outpatient treatment, except if: • Outpatient care is not available or too far from the family’s home, • The child is continually unable or refuses to eat RUTF • Family refuses referral to outpatient therapeutic care • If the patient stays at inpatient: treatment is the same as in outpatient, RUTF being given priority over F100

36. Medical management at inpatient care

37. Management of medical complications in the presence of SAM • The metabolism of children with SAM and medical complications is seriously disturbed, and the immune system seriously impaired • The standard treatment for conditions like dehydration and severe anaemia given to non-malnourished children can lead to death if applied to children with SAM • Case management of children with SAM and medical complications should only be conducted by clinical staff who has received the appropriate training

38. Failure to respond • Failure to respond to the treatment at inpatient care is when: • Failure to regain appetite after day 4 • Failure to start to lose edema after day 4 • Edema still present at day 10 • Failure to fulfill the criteria for progressing to rehabilitation • In transition or rehabilitation phase: weight gain less than 5 g/kg/day by day 10 or for 3 successive days

39. Emotional stimulation at inpatient care • Children with SAM have delayed mental and behavioural development. To address this, sensory stimulation should be provided to the children throughout the period they are in inpatient care. • It is essential that the mother be with her child in hospital, and that she be encouraged to feed, hold, comfort and play with her child as much as possible • Inexpensive and safe toys should be available, made from cardboard boxes, plastic bottles, tin cans, old clothes and blocks of wood and similar materials.

40. Inpatient care for infants under 6 months (or below 3.5 kg): admission criteria

41. Inpatient care for infants: medical management • Antibiotics: only when signs of infection • Vitamin A: only if signs of deficiency • Folic acid: 2.5 mg single dose at admission • Ferrous sulphate: only when the child suckles and starts to gain weight (to add in F100)

42. Inpatient care for infants: nutrition management (1) • The objective of treatment of these infants is to return them to full exclusive breastfeeding. This is achieved through the Supplementary Suckling Technique (SST) • F100 is prepared and then diluted according to specific protocols. Breastfeeding is given for 20 minutes every three hours (minimum), and in between F100 is given with SST.

43. Supplementary Suckling Technique

44. Inpatient care for infants: nutrition management (2) • When no prospect of breastfeeding, standard SAM inpatient protocols are followed except that F100 is given diluted in the stabilization phase (instead of F75) for children with wasting (marasmus). • Children with edema are fed with F75 • When the child reaches WFL equal or >-1z-score, switch to a breast-milk substitute before discharge, but avoid bottle feeding

45. Inpatient care for infants under 6 months (or below 3.5 kg): discharge criteria

46. Management of SAM for other age-groups: admission criteria

47. Management of SAM for other age-groups • All protocols are the same as for younger children, with specific dosage of treatment and milk detailed in specific guidelines. • In outpatient treatment (or rehabilitation phase) patients should be recommended to eat traditional food as much as they want. • Discharge criteria are about having a good appetite, reaching 15% gain of weight, absence of edema and absence of medical complication.

48. Management of SAM in areas with high HIV prevalence • Most aspects of treatment are the same, however: • Counseling on HIV should be proposed to patients and families • Medical treatment should add Cotrimoxazole prophylaxis and test for tuberculosis • ART should be initiated after recovery due to toxicity • HIV positive individuals are at higher risk of acute malnutrition and take longer to recover.

49. Monitoring and evaluation (1) • Routine monitoring of CMAM activities is essential for: • Monitoring the performance of the CMAM services • Taking decisions for quality improvement (staffing, training, resources, site locations) • Assessing the nutrition trends in the area • Monthly reports, routine supervision and coverage surveys are the main tools for monitoring

50. Monitoring and evaluation (2) • Routine data are collected on: • Nb. of new admissions , • Nb. of discharges: cured, died, defaulted, non-recovered • Nb. of children in treatment (beneficiaries registered) • These three basic elements allow calculation of key indicators: • Cure rate (should be > 75%) • Death rate (should be <10%) • Default rate (should be <15%) • Non recovery rate • Quantitative data should be accompanied by some narrative description or explanation of the main events that may have influenced attendance and performance