Federal Democratic

The Federal Democratic Republic of

Ethiopia Ministry of Health
Republic of Ethiopia

Guidelines
for the Management
of Acute
Malnutrition

Government of ethiopia
Federal ministry of health

April 2016
1
 Federal
The Democratic
Federal DemocraticRepublic
Republic of
ofMinistry
Ethiopia Ethiopiaof Health

Guidelines
for the Management
of Acute Malnutrition

Government of ethiopia
Federal ministry of health

April 2016

2
PREFACE
This guideline replaces the existing three guidelines/protocols, which are as follows:
(1) The 2007 Protocol for the Management of Severe Acute Malnutrition (SAM),
(2) The 2012 Guideline for the management of Moderate Acute Malnutrition (MAM), and
(3) The 2010 Guideline for HIV/AIDS and Nutrition.

The development of these guidelines was deemed to be necessary for the following key reasons;
1. The current management of acute malnutrition in line with newly updated National Nutrition
Program (NNP) (2016-2020) addressing the result areas clearly.
2. The need for harmonization of guidelines so as to replace the currently separate guidelines/
protocols for the management of SAM [FMoH March 2007], MAM [ENCU/EWRD/MoARD
September 2012] and Nutrition and HIV/AIDS [FMoH 2010].
3. The need for review of the acute malnutrition management based on current internationally
updated guidelines and evidence, particularly in the management of severe and moderate acute
malnutrition.

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 ACKNOWLEDGEMENT
The FMoH recognizes and gratefully acknowledge the contributions of all who participated in the
preparation and finalization of the Guidelines for the Management of Acute Malnutrition, especially the
following professionals for their technical input:
Dr Hailu Tesfaye- Save the children international
Dr. Tewoldebrhan Daniel UNICEF
Israel Hailu- FMoH
Tayech Yimer WFP
[Link] Ali WFP
Etsegenet Asseffa WHO
Jundi Ahmmed WFP
Molla Melese Gonder University
Kidist Negash UNICEF
Lubaba Hussein Concern Worldwide
Mestawet Gebru Tufts University Africa Regional Office

UNICEF contributed to the review of this document with technical and financial support.
FMoH would also like to recognize all the program managers and technical staff who contributed to
finalizing the document.

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Acronyms
AIDS Acquired Immuno Deficiency Syndrome
ALS Average Length of Stay
ANC Ante-Natal Care
ART Antiretroviral treatment
ARWG Average Rate of Weight Gain
BINLM Blended Integrated Nutrition Learning Module
BMI Body Mass Index
BSFP Blanket Supplementary Feeding Program
CBN Community Based Nutrition
CHD Community Health Day
CMAM Community based Management of Acute Malnutrition
CMV combined vitamins and minerals
CNP Critical Nutrition practice
CSB Corn Soya Blend
DHS Demographic and Health Survey
ENCU Emergency Nutrition Coordination Unit
EOS Enhanced Outreach Strategy
EWRD Early Warning and Rural Development
FBF Fortified Blended Food
FEFO first expiry, first out
FGD Focus group discussions
FMoH Federal Ministry of Health
GALIDRAA Greet, Ask, Listen, Identify, Discuss, Recommend Agree and Appointment
GFD General Food Distribution
HEW Health Extension Worker
had Health Development Army
HC Health Centre
HEP Health Extension Program
HCT HIV Counseling and Testing
HIV Human Immuno Virus
HP Health Post
IFRRF Inter Facility Reporting and Requesting Form
IMNCI Integrated Management Neonatal and Childhood Illness
IPLS Integrated Pharmaceutical Logistics System
ITNs Insecticide Treated Nets
IV Intravenous Therapy
KG Kilo Gram
LS Length of Stay
MAM Moderate Acute Malnutrition
MDG Millennium Development Goal
MoARD Ministry of Agriculture and Rural Development
MUAC Mid Upper Arm Circumference
NACS Nutrition Assessment and Counseling Services
NG Nasogastric
NGO Non-Governmental Organization
NGT Naso Gastric Tube

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 NNP National Nutrition Program
OI Opportunistic Infection
OPD Outpatient Department
ORS Oral Rehydration Solution
OTP Outpatient Therapeutic Program
PFSA Pharmaceutical Fund Supply Agency
PLW Pregnant and Lactating Women
PLWHA People Living with HIV
PMTCT Prevention of Mother to Child Transmission
RDA Recommended Dietary Allowance
ReSoMAL Rehydration solution for Malnutrition
RRF Reporting and Requesting formats
RHB Regional Health Bureau
RUSF Ready to Use Supplementary Food
RUTF Ready to Use Therapeutic Food
RWG rate of weight gain
SAM Severe Acute Malnutrition
SBCC Social and Behavior Change Communication
SC Stabilization Centre
SD standard deviation
SFP Supplementary Feeding Program
SS Supplementary Suckling
TB Tuberculosis
TFP Therapeutic Feeding Program
TSFP Targeted Supplementary Feeding Program
UNICEF United Nations International Children’s Emergency Fund
VCT Voluntary Counseling and Testing
WFH Weight For Height
WFP World Food Program
WHO World Health Organization

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Contents
List of Tables.......................................................................................................................... 10

List of Figures......................................................................................................................... 11

Definition of Terms.................................................................................................................. 12

INTRODUCTION..................................................................................................................... 15
Result 3.1: Improved nutrition service delivery for communicable and non-communicable disease 16

CHAPTER 2: SEVERE ACUTE MALNUTRITION (SAM) MANAGEMENT.................................. 27

2.1 SAM Management from 6 months old children to adulthood............................................. 27
2.1.1 Principle of care................................................................................................ 27
2.1.2 Admission criteria for acute malnutrition............................................................ 28
2.1.3 Admission procedures and triage...................................................................... 28
2.1.4 Phase I/Management of SAM in Stabilization Center (Care plan C).................... 33
2.1.5 Management of Complications......................................................................... 36
2.1.6 Daily care and Routine medicines in phase I..................................................... 51
2.1.7 Monitoring and problem solving in Phase 1....................................................... 61
2.1.8 Transition Phase................................................................................................ 64
2.1.9 PHASE II (In-patient).......................................................................................... 69
2.1.10 Outpatient Care for the management of SAM (care plan C)............................... 72
2.1.11 Criteria for discharging children from SAM treatment........................................ 77
2.2 Management of infants less than 6 months with SAM....................................... 77
2.2.1 Admission criteria to inpatient for infants under 6 month with SAM.................... 78
2.2.2 General recommendations................................................................................ 79
2.2.3 Management of SAM in young infants with a female caretaker.......................... 80
2.2.4 Uncomplicated SAM in young infants with prospect of breast feeding (care plan C) 81
2.2.5 Management of SAM in young infants who cannot be breast-fed...................... 82
2.2.6 Transfer to outpatient care................................................................................ 82
2.2.7 Discharge criteria for infants below 6 months with SAM.................................... 82
3.1 Blanket Supplementary Feeding Program (BSFP).............................................. 87
3.1.1 Case load estimation and beneficiary identification for BSFPs........................... 87
3.1.2 Admission and discharge criteria for BSFP........................................................ 88
3.2 Targeted Supplementary Feeding Program (TSFP)............................................ 88
3.2.1 Admission criteria for TSFP............................................................................... 88
3.2.2 TSFP distribution procedures at the site for new and registered beneficiaries... 89
3.2.3 Supplementary food ration................................................................................ 91
3.2.4 Discharge criteria.............................................................................................. 95
3.2.5 When to close the emergency TSFP................................................................. 98

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 CHAPTER 4: NUTRITION AND COMMUNICABLE DISEASES................................................ 99
Introduction............................................................................................................................ 99
4.1. Nutrition and HIV/AIDS..................................................................................................... 99
4.1.3 Contact points and targets for nutrition intervention For PLWHA................................... 103
4.1.4 Linking HIV infected clients to economic opportunities to prevent relapse of malnutrition. 104
4.2 Nutrition and TB............................................................................................................. 105
4.2.2 Nutritional support for malnourished patients with TB.................................................. 105
4.2.3 Management of SAM in TB patients............................................................................. 106
4.2.4. Management of MAM in TB patients........................................................................... 106
4.4 Nutrition and other infection (measles, malaria and intestinal parasites)........................... 107

CHAPTER 5: MONITORING, reporting and supervision........................................................ 109

5.1. Recording and reporting for SAM management.............................................. 109
5.1.1. Monitoring progress of individual patients........................................................ 109
5.1.2. SAM treatment performance........................................................................... 110
Total exit is the sum of total discharge and transfers (D+F1+F2)............................................. 112
5.2. Recording and Reporting for MAM management............................................. 114
5.2.1. Monitoring progress of individual beneficiaries................................................. 114
5.2.2. MAM treatment performance........................................................................... 114

CHAPTER 6: INVOLVEMENT OF MOTHERS IN CARE AND NUTRITION COUNSELING AND INFANT

AND YOUNG CHILD FEEDING IN EMERGENCIES................................................................ 117
6.1. Involvement of mothers in care......................................................................... 117
6.2. Nutrition counselling........................................................................................ 121
6.1.1 General guidance in counselling sessions....................................................... 121
6.1.2 Targeted counselling for caregivers of children with SAM................................ 122
6.1.3 Targeted counselling for caregivers of children with MAM................................ 124
6.1.4 Targeted counselling for care takers of PLWHA............................................... 125
6.3. Infant and Young Child Feeding in Emergencies............................................. 126
7.1 Partnership at community level....................................................................... 129
7.2 Estimating your target..................................................................................... 129
7.3 Why the need for early case identification at community level?........................ 130
7.4 What is the use of home visit and individual support to families
of acutely malnourished?.................................................................................. 130
7.5 Facilitation of women group discussions on key behaviours............................ 131
7.6 How do we know if there is good community involvement
in acute malnutrition management?................................................................. 131
Introduction.......................................................................................................................... 132
8.1.1. Supply forecasting....................................................................................................... 132
8.1.2 Stock management...................................................................................................... 133

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Storage of supplies............................................................................................................... 133
Proper Utilization of items provided....................................................................................... 133
Regulation of nutrition supplies............................................................................................. 134
Reporting and requesting for supplies.................................................................................. 134
8.2 Supply management in treatment of MAM...................................................................... 134
8.2.1. Storage and Warehousing............................................................................... 135
8.2.2. Determining the case load for TSFP................................................................ 135
8.3. Supply management for PLWHA..................................................................... 136

Annexes............................................................................................................................... 140

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 List of Tables
Table 1 Criteria for classification of acute malnutrition among young Infants 0 to 6 months

Table 2 Criteria for classification of acute malnutrition among children 6 to 59 months of age

Table 3 Criteria for classification of acute malnutrition among children 5 to 18 years of age

Table 4 Criteria for classification of acute malnutrition among adults 18 years or older

Table 5 Choice of antibiotics for children with SAM

Table 6 Dosage of Oral Antibiotics

Table 7 Dosage of Parenteral Antibiotics

Table 8 Deworming tablets dosage and schedule

Table 9 Summary table of systematic treatment of patients

Table 10 Transition phase amount of RUTF to give

Table 11 Transition phase: amount of F100 to give

Table 12 Amount of RUTF to give for meal substitution when mixed feeding with F100 and RUTF
is being used
Table 13 Ethiopia emergency phase classification and nutrition response

Table 14 Summary of routine medicines for children 6 -59 months

Table 15 Summary of routine medicines for pregnant and lactating women

Table 16 Criteria for MAM beneficiaries, discharge ‘recovered/cured’

Table 17 Criteria for other vulnerable groups with MAM , discharge ‘recovered/cured’

Table 18 Additional Energy Requirements for PLWHA (People Living with HIV)

Table 19 Daily Energy and Protein Requirements

Table 20 TSFP performance indicators

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List of Figures
Figure 1 Screening triage and admission procedure for patients with SAM

Figure 2 Monitoring algorithm for a child on ReSoMal

Figure 3 The important features of warehousing and storing food commodities

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 Definition of Terms
Acute malnutrition/ Wasting: measure of “thinness” due to rapid recent weight loss.

Anthropometry: The study and technique of human body measurement. It is used to measure and
monitor nutritional status in an individual or population group. Body measurements include: age, sex,
weight, height, oedema (fluid retention) and Mid Upper Arm Circumference (MUAC).

Blanket Supplementary Feeding (BSF): Feeding of all nutritionally vulnerable population irrespective
of nutritional status.

Body Mass Index (BMI): A number that indicates a person’s weight in proportion to height/length,
calculated as kg/m².

Body composition: The proportion of muscle, bone, fat, and other tissues that make up a person’s
total body weight.

Calories: Units by which energy is measured. Food energy is measured in kilocalories (1,000 calories
equals 1 kilocalorie).

Community-based Management of Acute Malnutrition (CMAM): International term for timely

detection of acute malnutrition in the community (social mobilization); provision of treatment for
severely malnourished without medical complications with ready-to-use therapeutic foods (RUTF) or
other nutrient-dense foods at home (OTP) combined with a facility-based approach for those severely
malnourished children with medical complications (TFU or SC) and treatment of moderate acute
malnutrition with TSFP in affected woredas.

Diet: Food and beverages a person habitually eats or drinks

Exclusive breastfeeding (EBF): Breastfeeding while giving no other food or liquid, not even water.
This is recommended for infants up to the age of 6 months.

F-100: Formula 100 (100kcal/100 ml) is the milk based diet recommended by WHO for the nutrition
rehabilitation of children with SAM after stabilization in inpatient care.

F-75: Formula 75 (75kcal/100 ml) is the milk based diet recommended by WHO for the stabilisation of
children with SAM with in inpatient care.

Global Acute Malnutrition (GAM): A population indicator that provides an aggregate of moderate and
severe malnutrition, i.e. ≤-2 Z-scores and oedema.

IYCF: Describes the feeding of infants and young children (usually 0-24 months).

Kwashiorkor: Bilateral pitting oedema (nutritional oedema) that is a clinical indicator for SAM.

Malnutrition: Any condition caused by excess or low intake of food energy or nutrient that causes
health problems. It is classified into under and over nutrition

Marasmic-Kwashiorkor: A combination of both maramus and kwashiorkor.

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Marasmus: Severe weight loss and muscle mass leaving ‘skin and bones’. Appearance can manifest
as ‘old man face’ and ‘baggy pants’.

Moderate Acute Malnutrition (MAM): Description of malnutrition level encompassing children 6-59
months with < -2 to ≥-3 z-scores and/or MUAC >11.5 and < 12.5; and Pregnant and Lactating Women
(PLW) with MUAC < 23.0 cm.

MUAC: Mid Upper Arm Circumference. It is a measurement of nutritional status by determining the mid
upper arm circumference in cm or mm.

Nutrients: Substances obtained from foods that are essential for the maintenance of life and growth.
These are used by the body to provide energy, structural materials and regulating agents to support
growth, maintenance and repair of the body’s tissue

Outpatient Therapeutic Program (OTP): Program run from a health center or health post offering
outpatient care to severely malnourished cases who have appetite and who do not have any medical
complications.

Over nutrition: A condition results from eating too much, eating too many unhealthy foods, not
exercising enough, or taking too much vitamins or other dietary replacements.

Ready-to Use Foods (RUFs); Ready-to use Supplementary Food (RUSF) and Ready-to Use Therapeutic
Food (RUTF): Energy dense, mineral and vitamin enriched food that do not require cooking or preparation
or dilution with water and can be eaten directly from the packet. RUTF has been specifically developed
for the recovery of severe acute malnutrition at home, while RUSF is for the recovery of moderate acute
malnutrition.

Recommended Dietary Allowance (RDA): The average daily amount of a nutrient considered adequate
to meet the known nutrient needs of practically all healthy people; a goal for dietary intake by individuals

Reductive adaptation: Is the physiological response of the body to under nutrition i.e. systems slowing
down to survive on limited macro and micro-nutrients intake. The system reduces activity to adapt to
the lack of nutrients and energy.

Severe Acute Malnutrition (SAM): Description of malnutrition level encompassing children 6-59
months with < -3 z-scores, and/or MUAC < 11.5 cm, and/or bilateral pitting nutritional oedema. Persons
with SAM have higher morbidity and mortality risks.

Sphere Project - was launched in 1997 by a group of humanitarian actors. The Sphere humanitarian
charter and minimum standards in disaster response provides a set of recommendations that
humanitarian projects should aim to meet.

Stabilization Center (SC): Unit in hospitals and health centres offering inpatient care to the severely
malnourished cases with complications and/or lack of appetite. If OTP is not available in the catchment
area, SCs offer full inpatient care with Phase 1, Transition Phase and Phase 2 with an average length of
stay (ALS) of 2-3 weeks.

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 Standard Deviation (SD) or Z-score: The deviation of the anthropometric value (weight, height etc.) for
an individual from the median value of the reference population.

Stunting - or chronic undernutrition, is a form of undernutrition that is defined by a height-for-age

(HFA) z-score below -2 SDs of the median WHO standards. Stunting is a result of prolonged or repeated
episodes of undernutrition often starting before birth. This type of undernutrition is best addressed
through preventative maternal health programs aimed at pregnant women, infants and children under
age two. Program responses to stunting require longer-term planning and policy development.

Supplementary Feeding Program (SFP): Provision of an additional food ration for moderately
malnourished individuals through a ‘Targeted Supplementary Feeding Program’; or to the most
nutritionally vulnerable groups (regardless of nutritional status) through ‘Blanket Supplementary Feeding’.

Therapeutic Feeding Program (TFP): Combination of inpatient (SC) and outpatient (OTP) therapeutic
feeding for the treatment of severe acute malnutrition.

Undernutrition: Is a consequence of a deficiency in nutrient intake and/or absorption in the body.

The different forms of undernutrition that can appear isolated or in combination are acute malnutrition
(bilateral pitting oedema and/or wasting), stunting, underweight (combined form of wasting and stunting)
and micronutrient deficiencies.

Underweight: Underweight is a composite form of undernutrition including elements of both stunting

and wasting and is defined by a weight-for-age (WFA) z-score below -2 SDs of the median (WHO
standards). This indicator is commonly used in growth monitoring and promotion (GMP) and child health
and nutrition programs aimed at the prevention and treatment of undernutrition.

WHO Growth Standards (WHO GS 2006) - Developed using data collected in the WHO Multicentre
Growth Reference Study in Brazil, Ghana, India, Norway, Oman, and the United States between 1997
and 2003 to generate new curves for assessing the growth and development of children from birth
to five years of age under optimal environmental conditions. They are intended to be used to assess
children everywhere, regardless of ethnicity, socioeconomic status and type of feeding.

Z-score - Indicates how far a measurement is from the median – also known as the standard deviation
(SD) score. The reference lines on the growth charts (labelled 1, 2, 3, -1, -2, -3) are called Z-score lines;
they indicate how far the measurement is above or below the median (= Z-score of 0).

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15
16
INTRODUCTION

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 INTRODUCTION

Ethiopia has faced recurrent drought affecting food security and water availability, which have
consequently resulted in high levels of malnutrition. Hence, over the past decade the country has been
following a two pronged approach to address this challenge. The first area of focus has been to increase
the availability of food through improved economic growth and better agricultural productivity coupled
with activities focusing on nutrition promotion and prevention of malnutrition. The second key aspect
has been to focus on strengthening early warning systems and timely emergency responses, together
with appropriate and wide scale access to treatment of severe and moderate acute malnutrition aiming
at avoiding any preventable death. This guideline focuses on this second aspect while other guidelines
address the promotion of good nutrition throughout the lifecycle focusing on women and children.

According to the 2011 Ethiopian Demographic and Health Survey (DHS), the prevalence of Global Acute
Malnutrition (GAM) at national level is estimated to be at around 9.7 per cent (specifically, 6.9 per cent
moderate and 2.7 per cent severe), with 44.4 per cent of children suffering from chronic malnutrition
Encouraging trends have been seen in the reduction of the under-5 mortality rate from 146/1,000 live
births in 2000 to 68/1,000 live births in 2011. Notable reduction was also seen in levels of chronic
malnutrition [stunting] from 57.8 per cent in 2000 to 44.4 per cent in 2011. Further reduction was also
reported in the 2014 mini DHS with prevalence of chronic malnutrition at 40per cent and GAM at 9per
cent. However, the reduction in Ethiopia’s acute malnutrition rate has been less marked, registering only
three percentage point over a decade from 12.9 per cent in 2000 to 9.7 per cent in 2011(2) and 9 per
cent in 2014. Further efforts are essential in order to accelerate the reduction in malnutrition prevalence,
achieve nutrition goals stated in the Health Sector Development Plan IV and the 2013-2015 NNP, and
to ensure to avert preventable morbidity and mortality among the most vulnerable population; women
and children.

As it is consistently reported, malnutrition is intricately related with infections. Malnutrition determines

immunity and increases vulnerability to infections, while infections can cause nutrient loss, malabsorption,
appetite loss and inadequate nutrition intake and make individuals susceptible to malnutrition. In
Ethiopia, HIV/AIDS, Tuberculosis (TB), Malaria, Measles and other infections are considered significant
public health problems and their impact on the nutritional status of the population has to be averted or
minimized.

This guideline replaces the existing three guidelines/protocols: (1) the 2007 Protocol for the Management
of Severe Acute Malnutrition (SAM), (2) the 2012 Guideline for the management of Moderate Acute
Malnutrition (MAM), and (3) the 2010 Guideline for HIV/AIDS and Nutrition. This guideline has been

18
developed with the aims of providing decision makers, program managers and health workers with
comprehensive instructions on acute malnutrition management and enhancing the quality of nutrition
care.

The development of these guidelines was needed for the following key reasons;
1. The need for an implementation guideline on management of acute malnutrition in line with
newly updated NNP (2016-2020) addressing the result areas clearly

2. The need for a harmonization of guidelines and to replace the currently separate guidelines/
protocols for the management of severe acute malnutrition [FMOH March 2007], moderate
acute malnutrition [ENCU/EWRD/MOARD September 2012] and Nutrition & HIV/AIDS [FMoH
2010]

3. The need for a review of the acute malnutrition management based on current internationally
updated guidelines and evidence, particularly with regard to the management of severe and
moderate acute malnutrition

Together with this guideline, Blended Integrated Nutrition Learning Materials (BINLM) is being
developed to allow capacity building at all levels in order to ensure for swift implementation of the
guidelines.

1.1 Scope of the guidelines

The scope of the acute malnutrition implementation guideline is to give all policy-makers, programrs,
health-care providers and other stakeholders a clearer direction on current standards, recommendations
and their day-to-day operation to facilitate the implementation of acute malnutrition management at
all levels. It also serves to ensure a harmonized, standardized and simplified implementation of most
of the National Nutrition Program [NNP, 2016-2020] components. It addresses the implementation of
the NNP Strategic objectives 1 (Improve nutritional status of women (15–49 years) and adolescent
girls (10–19 years)]; strategic objective 2 [Improve the nutritional status of children from birth up to 10
years ] and strategic objective 3 [Improve the delivery of nutrition services for communicable and non-
communicable / lifestyle related diseases .(5)
This guideline, with the blended training of health care providers in acute malnutrition management,
will serve to address the implementation of the NNP targets [Government of Ethiopia National Nutrition
Program II 2016-2020: specifically Reduce the Proportion of under 5 children with weight-for- height
Z-score below-2 SD (Prevalence of wasting) from 9 in 2014to 4.9per cent in 2020.

The implementation guidelines are linked to the following NNP (2016-2020) results:
• Result 2.1 and 2.3: Improved nutritional status of children 0 -59 month olds
• Result 3.1: Improved nutrition service delivery for communicable and non-communicable disease
• Result 4.6: Strengthened social protection services for improved nutrition

These guidelines are also intended to be used by all health and nutrition staff from government, agencies
and organizations involved in nutrition related activities in Ethiopia. The purpose of the guidelines are to
define basic concepts, recommendations and criteria related to the planning, implementation, monitoring
and evaluation of nutritional interventions aimed at treating and/or preventing acute malnutrition and to

19
 describe locally appropriate and internationally acceptable standards and recommendations for acute
malnutrition treatment programs.

These guidelines focus on the implementation of acute malnutrition management through treatment
modalities for SAM, MAM and nutrition and communicable disease inclusive of nutrition and HIV/AIDS,
TB and other infections/infestations like measles, diarrhoeal diseases, malaria, and pneumonia.

1.2 Implementation modalities

A. Implementation modalities for SAM management (Care plan C)

The principles of management of SAM, whatever the program setting, are based on three phases.

Phase 1 Inpatient (Care plan C inpatient): Patients with failed appetite, and/or with a major medical
complication are initially admitted to an in-patient facility for Phase 1 treatment. All children with +++
oedema or with Marasmic kwashiorkor are also first admitted to phase 1 inpatient care. The formula
used during this phase (F75) promotes recovery of normal metabolic function and nutrition-electrolytic
balance. Rapid weight gain at this stage is dangerous, that is why F75 is formulated so that patients do
not gain weight during this stage.

Transition Phase: exists only for those children that start treatment from phase 1 above. For most of
the children, transition phase is a 24 hour F100 or RUTF introduction phase where the health worker
ensures that there is adequate intake of RUTF and regain of appetite to enable continuation of the rest
of the treatment on an ambulatory basis at OTP. The quantity of F100 given in transition is equal to the
quantity of F75 given in Phase 1. As this is resulting in a 30 per cent increase in energy intake, the weight
gain should be around 6 g/kg/day; this is less than the quantity given, and rate of weight gain expected,
during Phase 2.

Phase 2 Inpatient: For children who cannot be discharged to OTP soon after stabilization: This
group of severely malnourished may remain to continue Phase 2 at in-patient either temporarily for
family or social reasons, or because there is no OTP service in reasonable distance from their home
environment. During this phase, the patients start to gain weight as F100 or RUTF is introduced.

Outpatient treatment program (OTP), care plan C– outpatient): Whenever patients have good
appetites and no major medical complications or have + and ++ oedema and do not have marasmic
kwashiorkor, then they enter the out-patient treatment program. Many patients who present with a
good appetite are admitted directly into outpatient treatment. In OTP, they are given RUTF according to
look-up tables. Those formulas are designed so that patients rapidly gain weight (more than 8 g/ kg/
day). The look-up tables are scaled so that the same tables can be used to treat patients of all weights
and ages.

Whereas the underlying principles of the protocol remain the same, the ways of implementing the
programs can vary considerably depending upon the numbers of patients that require treatment, the
severity of the illness and the facilities available.

When functional health posts are not available, OTP services are provided through mobile health clinics.
The management of severe acute malnutrition should be incorporated into mobile health clinics which

20
are especially important during emergency situations. Screening is done using the MUAC tape and
checking for oedema. Patients fulfilling the admission criteria are assessed and given a weekly RUTF
ration (if they pass N appetite test and medical check). Each week, their weight is measured until they
reach discharge criteria. A proper referral system and transport is important for the patients that need
in-patient care

B. Implementation modalities for Moderate Acute Malnutrition Management

(Care plan B)

There are two types of SFPs: Blanket or Targeted.

Blanket Supplementary Feeding Program (BSFP): is normally an emergency response for drought
or other nutritional emergencies. BSFP is a food supplement to all members of a specified at risk group,
regardless of whether they have MAM or not. BSFP is usually implemented in combination with the
General Food Distribution (GFD). It can also be implemented as a standalone program (while waiting for
the GFD to be established) or as short term measure during a seasonal hunger gap.
Irrespective of their nutrition status, young children, PLW, the elderly disabled and chronically sick
(approx. 35 per cent) are included in beneficiary lists of communities receiving relief food to benefit from
an extra ration of super cereal plus or fortified Corn Soya Blend (CSB+) . Individual nutritional status is
not monitored during the duration of the BSFP because the objective is to provide nutritional support at
population level (i.e. prevent development and/or deterioration of malnutrition).

Targeted Supplementary Feeding Programme (TSFP): Provides nutritional support to individuals

with MAM. It generally targets children 6-59 months, pregnant and breastfeeding mothers and other
nutritionally at-risk individuals. Targeted children with MAM will receive Plumpy Sup or super cereal plus
with regular monitoring of their nutritional status. For all the other groups, super cereal plus or fortified
Corn Soya Blend (CSB+) is given.

TSFP is implementation

Monthly/bi-monthly distribution: Admission depends on a diagnosis of MAM through anthropometry

at health post (HP) level by the health extension workers (HEWs) following the admission criteria. On
admission and on each distribution day, a standard protocol is followed which includes assessment of
nutritional status, provision of deworming tablet, Vitamin A supplement and health/nutrition promotion.

For management of MAM among children 6-59 months, Plumpy Sup of one sachet (92gm) per day or
super cereal plus 200gm per day is given. For the other groups, super cereal 250gm per day or CSB+
208gm per day is provided. When CSB+ is given 31gm of fortified vegetable oil is added to the ration.

Individuals are discharged based on their anthropometric status and according to pre-defined criteria.
The quarterly Community Health Days (CHD) or bi-annual Enhanced Outreach Strategy (EOS) screening
exercises are used for identification of malnourished children for targeted supplementary feeding in
food insecure priority one Woredas. This is not to replace the routine screening and treatment of the
moderately malnourished, rather to use the opportunity as “mopping up” all cases that are missed
during routine screening.

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 OTP Discharge Rations: children discharged from OTP will receive one sachet (92gm) of RUSF or
200gm of Super cereal plus per day on monthly basis for two consecutive months.

Management of acute malnutrition in other groups: For management of acute malnutrition with
communicable diseases (HIV/AIDS, TB, Malaria, Measles, Intestinal parasites) similar protocols of acute
malnutrition management are used for all patients irrespective of their HIV, TB or other infection status.
They respond well to the treatment regimen, usually regaining their appetites and gaining weight at
the same rate as other patients. A harmonized treatment algorithm has been developed mapping the
treatment of severely and moderately malnourished children with or without communicable disease.
The treatment modalities will remain the same. In the event when the cut-off criteria for admission are
different, it is reflected in the harmonized algorithm.

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24
CHAPTER I
OVERVIEW
AND CLASSIFICATION
OF MALNUTRITION

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 CHAPTER I
OVERVIEW AND CLASSIFICATION
OF MALNUTRITION
1.1 Types of malnutrition
Malnutrition refers to all deviations from adequate nutrition and can exist in two forms: over nutrition and
undernutrition of Macronutrients and/ or Micronutrients. Macronutrients provide the energy required for
growth and replacement of cells, which are required in large amounts and include protein, carbohydrate
and fat. Malnutrition also encompasses specific deficiencies (or excesses) of essential nutrients such as
vitamins and mineral (collectively referred to as micronutrients). Micronutrients are nutrients which are
required in much smaller amounts and ensure the healthy functioning of organs and body processes. In
the context of these guidelines, the term malnutrition always makes reference to undernutrition.
Malnutrition is common in Ethiopia and can be manifested as wasting (acute malnutrition), stunting
(chronic malnutrition), underweight and/or deficiencies of essential vitamins and minerals.
1. Stunting [individuals whose height is below the average expected height for their age, defined by
Height- For- Age] is generally a result of prolonged or repeated episodes of undernutrition that often
start before birth. Stunting is strongly associated with poverty, poor health and impaired physical
and mental development. Stunting can be reversed through ‘catch up growth’ until 2 years of age;
after which it is irreversible.
2. Wasting [a measure of thinness defined by Weight-For-Height (WFH) or MUAC measurements] is
characterized by rapid weight loss usually due to illness and/or reduced food intake. Wasting can
be reversed, however it is of particular concern during emergency situations because it can quickly
lead to excess morbidity and mortality.
Acute malnutrition leads to changes in the body related to cellular composition, tissue and organ
functions. Acute malnutrition can either present itself as a severe or moderate form.
3. Underweight is a general measure that captures the presence of wasting and/or stunting. It is
therefore a composite indicator, reflecting either acute or chronic undernutrition without distinguishing
between the two. The index does not indicate whether the child is ‘underweight’ due to reduced fat/
muscle mass (wasting) or due to unattained height for his or her age (stunting). As such, its utility as
an indicator for assessment or programming is limited because it does not indicate the nature of the
problem nor the timeframe for the required response. At the population level, it does not indicate
if an immediate emergency therapeutic response or longer term prevention program is needed.
At the individual level, it does not allow immediate detection or referral of acute malnutrition for
appropriate treatment. It is advantageous, however, because it is easier to measure than stunting
or wasting, for which an additional height measurement is required.

26
4. Micronutrient deficiencies: individuals can have a deficiency of either Type I or type II nutrients.
A. Type I nutrients are those required for adequate functioning of the body, such as iron, Vitamin
A, iodine, etc. These nutrients regulate hormonal, immunological, biochemical and other bodily
processes. While these deficiencies can cause major illness and increased risk of mortality,
anthropometric measurements (e.g. height and weight) can be normal, although it is common
for stunted or wasted individuals to also have some degree of micronutrient deficiency.
B. Type II nutrients are the growth nutrients required to build new tissue e.g. nitrogen, essential
amino-acids, potassium, magnesium, Sulphur, phosphorus, zinc, sodium, etc. Deficiencies will
result in the failure to grow, to repair tissue that is damaged, to replace cells that rapidly turn-
over (e.g. intestine and immune cells) or to gain weight after an illness, which can lead to an
increase in the risk of stunting and/or wasting.

1.2 Causes of Malnutrition

Undernutrition is the result of many causes, not solely related to food. The three layers of the determinants
of nutritional status; adapted from UNICEF(6) are detailed as follows:
1. Immediate Causes: are causes which act on individuals
These include inadequate dietary intake and infection or disease. Malnutrition is often exacerbated
by a vicious cycle between these two factors. Inadequate food intake can lead to a higher risk of
infection or disease, and conversely disease can lead to inadequate food intake.
2. Underlying Causes: they influence households and communities.
The main underlying causes of malnutrition include shocks, such as drought, flooding, household
food insecurity, inadequate social and care environment, inadequate access to health services
and environmental factors, such as poor water and sanitation facilities.
3. Basic Causes: they influence communities and societies
The basic causes of malnutrition include the country’s social, economic and political situation,
for example, the formulation and implementation of policies to address issues such as lack of
capital (financial, human, physical, social, agro-ecological, technical).
The new conceptual framework recommended by Lancet Series shows the means to optimum fetal
and child growth and development. In the Lancet 2013 Series, the new framework shows the dietary,
behavioural, and health determinants of optimum nutrition, growth, and development and how they
are affected by underlying food security, caregiving resources, and environmental conditions. These
are in turn shaped by economic and social conditions, national and global contexts, resources, and
governance. This Series examines how these determinants can be changed to enhance growth and
development. These changes include nutrition-specific interventions that address the immediate causes
of suboptimum growth and development. The framework shows the potential effects of nutrition-
sensitive interventions that address the underlying determinants of malnutrition and incorporate specific
nutrition goals and actions. It also shows the ways that an enabling environment can be built to support
interventions and programs to enhance growth and development and their health consequences.

27
 1.3 Assessment/Identification and classification of acute
malnutrition
Nutrition status should be assessed at any point of contact for example at a health facility or at
community level-where nutrition screening should take place alongside nutrition and health education.
Screening by MUAC should take place within the community, using methods that are: simple, low cost
and easy for HEWs. Components of an effective nutrition assessment include: medical and social
history, diet history and intake, clinical examination and anthropometrics. The table below describes
the classification of acute malnutrition, mainly using anthropometrics and clinical signs as per the 2013
WHO recommendations.

28
 Table 1 Criteria for classification of acute malnutrition among young Infants 0 to 6 months

ASK LOOK AND FEEL Signs Classify Treat

1. Check for presence of oedema of • WFL <-3Z score,

both feet (orsacrum) OR Complicated Admit for in-patient management
Ask for signs · Does the child have oedema? • Visible wasting Severe Acute (CARE PLAN C-Inpatient)
of medical Malnutrition
OR
complications: 2. Check the weight and Length
•Is the weight-for-length less than- • Oedema of both feet
Is the child: 3z-score? And
• Too weak
to suckle 3. Check for signs of medical presence of any one of these
effectively? complications: complications
• Vomiting
everything? • Hypothermia: axillary temp <35 0C
or rectal < 35.5 0C
Does the child • Fever ≥ 37.5 0C
have • Ineffective feeding (attachment,
• Recent weight • WFL < -3Z score AND no Uncomplicated Course of broad-spectrum oral antibiotic, such as
positioning and suckling) directly
loss or failure to complications severe acute amoxicillin
observed for 15 to 20 minutes
gain weight OR malnutrition • Detailed assessment of underlying cause(s)
• Any medical or social issue needing
• WFL ≥ -3Z to < -2Z score, or of malnutrition and tailored action to address
detailed assessment or intensive
AND Moderate Acute these
support
• No edema of both feet Malnutrition · Plot and appraise growth chart for monitoring
• Severe anemia (severe palmar pallor)
progress
• Jaundice
• convulsions
• If WFL ≥ -2Z score No Acute Congratulate and
• Very Weak, Lethargic or
AND Malnutrition Counsel the mother on infant and child feeding/care
unconscious
• No edema of both feet (CARE PLAN A)
• Pneumonia or fast breathing

29
30
Table 2 Criteria for classification of acute malnutrition among children 6 to 59 months of age

ASK LOOK AND FEEL Signs Classify Treat

4. Check for presence of oedema of

both feet (or sacrum) • WFL/H < -3Z score OR MUAC <11.5 cm
• Does the child have oedema? OR oedema of both feet (+, ++), PLUS Complicated Severe Admit for in-patient
Ask for signs of medical • If yes, is it generalized involving • Any one of the medical Acute Malnutrition management
complications: upper arms and face? complications or (CARE PLAN C-Inpatient)
5. Check the weight and height • Failed appetite test
Is the child: •Is the weight-for-height less OR
• Unable to breastfeed, than-3z-score? • +++ oedema, OR
drink or feed? • Marasmic Kwashiorkor ( WFL/H < -3Z with
• Vomiting everything? 6. Check MUAC; is the MUAC edema, OR MUAC <11.5 cm with edema)
<11.5cm?
• WFL/H < -3Z score OR MUAC <11.5 cm Uncomplicated Manage in OTP using the

Does the child have: OR Severe Acute OTP protocol

7. Check for signs of medical
• Blood in stool? • oedema of both feet (+, ++) Malnutrition (CARE PLAN C-outpatient)
complications:
• Diarrhoea>14d? AND

• Bleeding tendencies? • No medical complication AND passes

• Hypothermia: axillary temp <35 0C
• History of recent appetite test
or rectal < 35.5 0C
Admit to TSFP if available,
sunken eyeball? • Fever ≥ 38.5 0C
• Pneumonia/severe pneumonia • WFL/H ≥ -3Z to < -2Z score OR Moderate Acute Counsel on infant and child
• Convulsion (more than
• Shock MUAC 11.5 cm to <12.5 cm Malnutrition feeding/care
one or prolonged for • Dehydration (watery diarrhoea with
recent sunken eye balls.) AND
>15 min)? • Hypoglycemia No oedema on both feet (CARE PLAN B)
• Sever anemia (sever palmar pallor)
• Jaundice
• Dermatosis +++ • If WFL/H ≥ -2Z score OR MUAC ≥ 12.5 cm No Acute Congratulate and
• Corneal clouding or ulceration
• Measles (now or with eye/mouth AND Malnutrition Counsel the mother on
complications) • No oedema on both feet infant and child feeding/care
• convulsions
• Very Weak, lethargic or (CARE PLAN A)
unconscious
 Table 3 Criteria for classification of acute malnutrition among children 5 to 18 years of age

ASK LOOK AND FEEL SIGNS CLASSIFY TREAT

1. Check for presence of oedema of both feet (orsacrum) Complicated

• WFL/H < -3Z score OR
Ask for signs of • Does the child have oedema? Severe Acute Admit for in-patient
MUAC in severe category
medical complications: • If yes, is it generalized involving upper arms and face? Malnutrition management
OR
• Is there no other cause for oedema? (CARE PLAN
BMI for age <-3SD
2. Check the weight and height C-Inpatient)
OR
1. Is the child vomiting • Is the weight-for-height less than-3z-score?
• oedema of both feet (+, ++),
everything? 3. Check BMI for age
PLUS
• Does he have low BMI for his age?
o Any one of the medical
2. Does the child have: 4. Check MUAC
complications , or
• Blood in stool?
o Failed appetite test
• Diarrhoea>14d?
OR+++ oedema, OR
• Bleeding
MUAC MUAC MUAC • Marasmic Kwashiorkor (
Tendencies? Age
severe moderate normal WFL/H < -3Z score with
• History of recent (years)
(cm) (cm) (cm) oedema, OR MUAC in severe
sunken eyeball?
catagory with oedema)
• Coughing for more
than 21 days Children
<13 13 - <14 ≥14 < -3Z score OR MUAC in Uncomplicated Manage in OTP using
• Active TB or on 5 to 9 •
severe category Severe Acute the OTP protocol
treatment for it? Children
<16 16 - <18 ≥18 OR Malnutrition (CARE PLAN
• Convulsion (more 10 to 14 • BMI for age <-3SD C-outpatient)
than one or
prolonged for >15 Children OR
<17 17 - <19 ≥19
min)? 15 to 17.9 • Oedema on both feet (+, ++)
AND
• No medical complication
5. Check for signs of medical complications: AND passes appetite test
• Hypothermia: axillary temp <35 0C or rectal < 35.5 0C
• Fever ≥ 38.5 0C • WFL/H ≥ -3Z to < -2Z score Moderate Acute Admit to TSFP if
• Pneumonia/severe pneumonia OR Malnutrition available
• Shock • MUAC in moderate category Counsel on feeding and
• Dehydration (watery diarrhoea with recent sunken eye OR care
balls.) • BMI for age -3 to <-2SD (CARE PLAN B)
• Hypoglycaemia • AND
• Severe anemia (severe palmar pallor) No oedema on both feet
• Jaundice • If WFL/H ≥ -2Z score OR
• Dermatosis +++ MUAC in normal category No Acute Congratulate and
• Corneal clouding or ulceration OR Malnutrition Counsel the mother on
• Measles (now or with eye/mouth complications) • BMI for age > - 2SD feeding and care
• Very Weak, Lethargic or unconscious AND (CARE PLAN A)
• No oedema on both feet

31
32
Table 4 Criteria for classification of acute malnutrition among adults 18 years or older

ASK LOOK AND FEEL Signs Classify Treat

1. Has the client lost weight 1. Check for presence of

unintentionally during the oedema of both feet (or • BMI <16 OR MUAC <18cm
past month? sacrum) • for PLWs <19 cm Complicated Admit for in-patient
• Does the client have • OR oedema on both feet without clear cut other Severe Acute management
2. Has the client had oedema? cause, Malnutrition (CARE PLAN C-Inpatient)
• Active TB or on treatment • If yes, is it generalized OR
for it? involving upper arms • FOR HIV Positive client: BMI >=16 and <17.5 OR
• Diarrhoea>14d? and face? MUAC >=18 and <21 cm
• Other chronic OIs or • Is there no clear cut PLUS
malignancies? (e.g. other cause? • Any one of the medical complications ,
oesophageal infection,
mouth soar or oral thrush) 2. Measure weight and height • BMI <16 OR MUAC <18cm Uncomplicated Manage in OTP using the
• Is the BMI <16? • for PLWs <19 cm OR Severe Acute OTP protocol (CARE PLAN
3. Has the client had 3. Check MUAC • Oedema on both feet without clear cut other cause, Malnutrition C-outpatient)
noticeable changes in his/ • Is MUAC <18 cm? AND
her body composition, • Is MUAC <19cm for • No medical complications
specifically his/her fat PLW?
distribution?
• Thinning of limbs and 4. Examine for conditions
face Admit to TSFP if available
that cause secondary
• Change in fat distribution • BMI >=16 and <17.5 OR MUAC >=18 and <21 cm Moderate Counsel on Critical Nutrition
malnutrition (see above and
on the limbs, breast, • For PLW: MUAC>=19t and <23 cm OR Acute Practice (CNP)
in “ASK” part)
stomach region, back or • For HIV positive client: Malnutrition (CARE PLAN B)
shoulders? 5. Check for signs of medical o Confirmed (>5per cent weight loss since last
visit) or reported weight loss (e.g. loose clothing)
complications:
4. Has the client experienced o Regardless of BMI or MUAC: Any of the
the following? following:
• Severe anemia
• Nausea and/ or vomiting • Severe dehydration
 Chronic lung disease, TB, persistent diarrhoea,
• Persistent fatigue other chronic Opportunistic Infection (OI) or
• Active TB
• Poor appetite malignancy
• Pneumonia
AND
• Shock
• Jaundice
• No edema of both feet
• Dermatosis +++ BMI >17.5 OR MUAC >21 cm (for pregnant and No Acute Congratulate and Cousel
• Very weak, lethargic or lactating mothers >23 cm) Malnutrition on CNP
unconscious AND (CARE PLAN A)
• No oedema on both feet
33
34
CHAPTER 2
SEVERE ACUTE
MALNUTRITION (SAM)
MANAGEMENT

35
 CHAPTER 2
SEVERE ACUTE MALNUTRITION
(SAM) MANAGEMENT

Introduction
Severe malnutrition is one of the most common causes of morbidity and mortality amongst children
under the age of 5 years worldwide. Many children with SAM die at home without care, but even when
health facility care is provided, mortality rates may still be high. It is not unusual that children with SAM
lose their lives due to the limited knowledge of health care providers. They unknowingly use practices
that are suitable for most non-malnourished children, but highly dangerous for severely malnourished
children. With appropriate case management in health facilities and follow-up care, the lives of many
children can be saved.

2.1 SAM Management from 6 months old children to

adulthood
2.1.1 Principle of care

A severely malnourished child is likely to have various health problems. Although the signs of those
health problems are subtle in many cases, it is crucial for HWs and caregivers to identify the signs
early and have the child receive appropriate care in order to prevent the aggravation of malnutrition,
associated health problems and premature mortality. Commonly reported signs are: visible ribs, dry
and loose skin of the buttock hanging (baggy pant), oedema, dermatosis, eye signs (Bitot’s spots, pus
and inflammation, corneal clouding and corneal ulceration). Other signs include appetite loss, emesis,
fever, hypothermia, coughing, diarrhoea and lethargy/unconsciousness.

In addition to looking for visible signs of severe malnutrition, it is crucial to regularly weigh and measure
the child. To evaluate the presence and the level of wasting, the child’s weight-for-height should be
compared to the 2006 WHO Child Growth Standards and Growth charts to monitor his/her recovery
and growth. The MUAC is also utilized to promptly identity wasting in children aged 6-59 months at
community settings. The techniques to properly measure weight-for-height and MUAC are describes in
the BNLM training module.

36
It cannot be underlined enough that children with severe malnutrition must be treated carefully according
to the clinical status of each child. The physiology of severely malnourished children is highly atypical due
to reductive adaptation, which is known as reduced body homeostasis to minimize energy expenditure
and allow survival. Whilst the majorly of children with severe malnutrition suffer from infections, the
symptoms of the infections are not critically apparent in most cases because of the reductive adaption
of their bodies. Examples of common infections in the severely malnourished children are ear infections,
urinary tract infections and pneumonia. It is essential to presume that infection is present and provide
antibiotics listed in the Routine Medicine section when children are administered to the TFP.

Furthermore, iron must not be given to severely malnourished children at the beginning of the treatment.
Due to reductive adaptation, a severely malnourished child makes less hemoglobin than usual. Iron that
is not used for making hemoglobin is put into storage. Thus, there is “extra” iron stored in the body, even
though the child may appear anemic. Hence, providing iron early in treatment does not cure anemia,
rather it fatally harms children.

Similar with iron, malnourished children already have excess sodium in their cells, so sodium intake
should be restricted. In reductive adaptation, the “pump” that usually controls the balance of potassium
and sodium runs slower. As a result, the level of sodium in the cells rises and the potassium leak out of
the cells, and is lost (for example, in urine or stools). Fluid may then accumulate outside of the cells (as
in oedema) instead of being properly distributed through the body. If a child has diarrhoea, a special
rehydration solution called ReSoMal should be used instead of regular WHO ORS. ReSoMal has less
sodium and more potassium than regular WHO ORS.

2.1.2 Admission criteria for acute malnutrition

All patients who are severely malnourished (see tables 1-4 of classification algorism) should be offered
therapeutic feeding in one of the available settings, either inpatient or outpatient management of acute
malnutrition. Those with complicated SAM should be treated in inpatient (SC) whereas those with
uncomplicated SAM should be treated as outpatient (OTP).

2.1.3 Admission procedures and triage

This below figure shows the schema for the decision making process. First, the patient is identified in
the community or health structure by MUAC and oedema. The severely ill are “fast tracked” to treatment
by the person doing triage. The appetite test is performed whilst waiting to see the health care provider
who looks for the presence of medical complications. He/she discusses with the caregiver and decides
upon the appropriate treatment options. Those that need in-patient treatment are referred for admission
to inpatient care/SC; those that can be treated as out-patients are referred to the OTP site nearest to
their home. The details are described within the next section.

37
 Figure 1 Screening triage and admission procedure for patients with SAM

38
 Screen the patients in the community/HP (MUAC and check for oedema) and the waiting area
of the OPD of HCs and hospitals (MUAC, weight, height/ length, oedema).Refer the patients to a
TFP if they fulfil the criteria for SAM. Every opportunity should be taken to identify patients that
require therapeutic feeding for SAM.

 At the TFP, retake the anthropometric measurements (MUAC at health post/mobile clinics and
both MUAC and W/H at HCs and hospitals) and check oedema. Errors during screening can
occur; the referred patients are given some benefits, but are not enrolled in the program1. There
has to be feedback to the community worker and retaining should be considered.

 On arrival at the TFP (OTP, SC, HC or hospital), obviously ill children and those that will clearly
need in-patient or other medical treatment should immediately be given sugar water2 and “fast
tracked” without having to wait for the rest of the patients to be seen. They get their anthropometry
checked and are then referred directly to the nurse-in-charge or to the in-patient facility to start
treatment3.

 For those that do not require “fast tracking” and fulfil the criteria for SAM - perform the appetite
test. This can usually be done whilst the patients are waiting to see the nurse/ medical officer. If
the appetite test is to be delayed until after the patient has seen the nurse, then, gives a drink of
sugar-water. All patients should have something to drink (water or sugar-water) and/or eat (RUTF
for during appetite test) shortly after they come to the centre.

1 Those patients that have been referred by the community worker but who do not fulfil the criteria for SAM should
either be admitted to the SFP (if it is operational); where there is no SFP they should be given a “protection ration” or
one week’s supply of RUTF. It is important that they receive some tangible benefit from attending the triage site.
2 Sugar water is approximately 10% sugar solution – 10g of sugar per 100ml of water
3 If the in-patient facility is a long way away the transport can lead to serious deterioration of the patient. Admit the
patient to OTP, keep the patient quiet and start treatment pending the availability of transport. Fill the transfer form
with the unique SAM number and treatment given. Consider not transporting the child if it is thought that the stress
of transport will be more detrimental than attempting to resuscitate the child on site or at home.

39
 The Appetite Test

Why do the appetite test?

 Malnutrition changes the way infections and other diseases express themselves – children
severely affected by the classical common childhood illnesses diseases, who are malnourished,
frequently show no signs of these diseases. However, the major complications lead to a loss
of appetite.
 Even though the definition and identification of the severely malnourished is by anthropometric
measurements, there is not a perfect correlation between anthropometric and metabolic
malnutrition. It is mainly metabolic malnutrition that causes death. Often, the only sign of
severe metabolic malnutrition is a reduction in appetite. By far, the most important criterion to
decide if a patient should be sent to in- or out- patient management is the appetite test. A poor
appetite means that the child has a significant infection or a major metabolic abnormality such
as liver dysfunction, electrolyte imbalance, cell membrane damage or damaged biochemical
pathways. These are the patients at immediate risk of death. Furthermore, a child with a poor
appetite will not take the food at home and will continue to deteriorate or die. As the patient
does not eat the special therapeutic food (RUTF) the family will take the surplus and become
accustomed to sharing it.
 If the caregiver/HW thinks the child is not taking the RUTF because s/he doesn’t like the taste
or is frightened the child still needs to be referred to in-patient care for at least a short time. If
it is later found that the child actually takes sufficient RUTF to pass the test, then they can be
immediately transferred to the out-patient treatment.
 The appetite test should always be performed carefully. Patients who fail their appetite tests
should always be offered treatment as in-patients. If there is any doubt then the patient should
be referred for in-patient treatment until the appetite returns (this is also the main criterion for an
in-patient to continue treatment as an out-patient).
 The patient has to take at least the amount that will maintain body weight. A patient should not
be sent home if they are likely to continue to deteriorate because they will not take sufficient
therapeutic food. Ideally, they should take at least the amount that children are given during
the Transition Phase of in-patient treatment before they progress to Phase 2 (good appetite
during the test).
 Sometimes a child will not eat the RUTF because he is frightened, distressed or fearful of the
environment or staff. This is particularly likely if there is a crowd, a lot of noise, other distressed
children or intimidating health professionals (white coats, awe-inspiring tone). The appetite test
should be conducted in a separate quiet area. If a quiet area is not possible then the appetite
test can be done outside.

How to do the appetite test?

1. The appetite test should be conducted in a separate quiet area.
2. Explain to the care giver/mother the purpose of the appetite test and how it will be carried out.
3. The caregiver/mother, where possible, should wash his/her hands.

40
4. The caregiver/mother should sit comfortably with the child on his/her lap and either offer the
RUTF from the packet or put a small amount on his/her finger and give it to the child.
5. The caregiver/mother should offer the child the RUTF gently, encouraging the child all the time.
If the child refuses then the caregiver/mother should continue to quietly encourage the child and
take time over the test. The test usually takes a short time but may take up to one hour. The
child must not be forced to take the RUTF.
6. The child needs to be offered plenty of water to drink from a cup as he/she is taking the RUTF.

The result of the appetite test

Pass.
1. A child that takes at least the amount shown in the table below passes the appetite test.
2. The patient is now seen by the health care provider to determine if he/she has a major
complication (e.g. pneumonia, acute watery diarrhoea, etc.). If s/he has no medical
complication, has not got open skin lesions, oedema +++ or wasting and oedema together
then s/he should normally be treated as an out-patient.
3. Explain to the caregiver/mother the treatment options available and decide with the caregiver/
mother whether the child should be treated as an out-patient or in-patient (nearly all care
givers/mothers will opt for out-patient treatment).
4. Give the patient a SAM-unique number and fill in the registration book and OTP treatment
chart (see annex 5).
5. Start the Phase 2 treatment appropriate for out-patients (see below)

Fail

1. A child that does not take at least the amount of RUTF shown in the table below should be
referred for in-patient care.
2. Explain to the care giver/mother the choices of treatment options and the reasons for
recommending in-patient care; decide with the care giver/mother whether the patient will be
treated as an in-patient or out-patient.
3. Refer the patient to the nearest SC for Phase 1 management.
4. At the SC, the patient is given a SAM-unique number and the registration book and multi chart
are filled (see annex 9).
5. Start treatment of Phase 1 and complications appropriate for in-patients.

The below table gives the MINIMUM amount of RUTF that should be taken.

41
 APPETITE TEST
This is the minimum amount that malnourished patients should
take to pass the appetite test
Plumpy’nut BP100
Body weight (Kg) Sachets body weight (Kg) Bars
Less than 4 kg 1/8 to ¼ Less than 5 kg ¼ to ½
4 – 6.9 ¼ to 1/3 5 -9.9 ½ to ¾
7 – 9.9 1/3 to ½
10 – 14.9 ½ to ¾ 10 – 14.9 ¾ to 1
15 - 29 ¾ to 1 15 -29 1 to 1 ½
Over 30 kg >1 Over 30 kg >1½
RUTF paste
body weight (Kg) Grams
3 - 3.9 15 - 20
4 - 5.9 20 - 25
6 - 6.9 20 - 30
7 - 7.9 25 - 35
8 - 8.9 30 - 40
9 - 9.9 30 - 45
10 - 11.9 35 - 50
12 - 14.9 40 - 60
15 - 14.9 55 - 75
25 - 39 65 - 90
40 - 60 70 - 100

 The appetite test must be carried out at each visit for out-patients.

 Failure of an appetite test at any time is an indication for full evaluation and probably transfers
for in-patient assessment and treatment.
 During the second and subsequent visits the intake should be very good if the patient is to
recover reasonably quickly.

If the appetite responds well during the appetite test and the rate of weight gain at home is poor then
a home visit should be arranged. It may then be necessary to bring a child into in-patient care to do
a simple “trial of feeding” to differentiate i) a metabolic problem with the patient ii) a difficulty with the
home environment; such a trail-of-feeding, in a structured environment (e.g. SC), is also frequently the
first step in investigating failure to respond to treatment.

42
2.1.4 Phase I/Management of SAM in Stabilization Center
(Care plan C)
Phase 1 treatment is always given in an in-patient setting. Children with complicated SAM are initially
admitted to an in-patient facility for stabilization. These children are admitted to a Phase 1 room. During
this phase:

 Life-threatening medical complications are treated

 Routine drugs are given to correct specific deficiencies

 Feeding with F-75 milk (low caloric and sodium) is begun

The children in Phase 1 should be together in a separate room or section of the ward and not mixed
with other patients. When they progress to Transition Phase, they physically move to the space where
transition patients are treated. These children should be admitted directly to the SC and not treated in an
emergency ward or casualty department for the first 24-48 hours, unless the staff of the emergency ward
have had specific training in the management of the complications seen in SAM patients. Experience
shows that the rapid staff turnover and workload in emergency wards are such that this is the main
place where misdiagnosis, mistreatment and iatrogenic death take place.

The mother is the primary caregiver. Nurses do most of the actual “nursing”. They weight, measure,
mix and dispense feed, give the oral drugs, assess the clinical signs and fill in the multi chart with all
the routine information. The nurses also need to give or supervise any intravenous treatment. The
physician’s main duty is to support the nurse and to concentrate upon any patients that fail to respond
to treatment or present with diagnostic difficulty. The physicians also function as a coach and supervisor
of the nurses to ensure that they are performing these functions correctly and accurately.

Staff turnover should be minimized and only one staff member should be rotated at any one point of
time. Any new staff must be specifically trained in the management of SAM and work for a period under
supervision before they are allowed to take charge, work alone or at night with these patients.

The multi chart is the primary tool used for in-patient treatment of the malnourished child. ALL the staff
should use the same multi chart to record all the information needed to manage the malnourished
patient – separate charts are not to be used by different categories of staff.

43
 FEEDING IN PHASE I
FEEDs/Diet for Phase I (F75 Formula)

F-75 is the “starter” formula to use during Phase 1, beginning as soon as possible and continuing for
2-7 days until the child is stabilized. Severely malnourished children cannot tolerate usual amounts of
protein and sodium at this stage, or high amounts of fat. They may die if given too much protein or
sodium. They also need glucose, so they must be given a diet that is low in protein and sodium and
high in carbohydrates. F-75 is especially made to meet the child’s needs without overwhelming the
body’s systems during the initial stage of treatment. The use of F-75 prevents deaths. F-75 contains
75 kcal and 0.9 g protein per 100 ml. 130ml F75 is 100 kcal.

Preparation of Feeds

Add either one large packet of F75 to 2 litres of water or one small packet to 500 ml of water. Where
very few children are being treated smaller volumes can be mixed using the red scoop (20 ml water
per red scoop or F75 powder).

Feed the child with F-75 and

Determine frequency of feeds
On the first day, feed the child a small amount of F-75 every 3 hours (8 feeds in 24 hours, including
through the night). If the child is hypoglycemic, give ¼ of the 3-hourly amount every half-hour for
the first 2 hours or until the child’s blood glucose is at least 54 mg/dl (3 mmol/l). Night feeds are
extremely important. Many children die from hypoglycemia due to missed feeds at night. Children
must be awakened for these feeds. Eight feeds should be given when the larger volume of F75 that is
required with a reduced number of feeds provokes osmotic diarrhoea. This is uncommon; as it only
applies to a few children, the work load for the night staff is greatly reduced when the eight feeds per
day are individually prescribed for those children that really require this regimen. These children need
residential care. Very occasionally, it is necessary to give the diet continuously by naso-gastric (NG)
drip.

Breastfed children should always be offered breast-milk before the diet and always on demand. After
the second day, increase the volume per feed gradually so that the child’s system is not overwhelmed.
The child will gradually be able to take larger, less frequent feeds (every four hours). Six feeds per
day are given where there are few staff working at night. Give eight feeds per day where there are
sufficient staff to prepare and distribute the feeds at night.

44
 Determine amount of F-75 needed per feed

Given the child’s starting weight and the frequency of feeding, use a table to look up the amount
needed per feed using his weight as reference. The admission weight should be used to calculate the
amount of F75 feed throughout the treatment. A copy of F75 look up table is in see annex 1 to find
look up table for F75 administration ( Annex 1 )Notice that the amounts per feed ensure that the child
will be offered a total of 130 ml/kg/day of F-75. This amount of F-75 will give the child 100 kcal/kg/day
and 1 - 1.5 g protein/kg/day. This amount is appropriate until the child is stabilized.

Record the child’s 24 hour feeding plan

Each child’s feeding plan should be recorded on the Multi-chart in the therapeutic diet box: record
the phase, diet name (type of feed) to be given (F-75), ml per feed, the number of feeds to be given
daily and ml per day. For example, if the child is on a 3-hourly feeding schedule, record that eight
feeds will be given.

Feeding Technique

The muscle weakness and slow swallowing of these children makes aspiration pneumonia very
common. The child should be on the caregiver/mother’s lap against her/his chest, with one arm
behind his back. The caregiver/mother’s arm encircles the child and holds a saucer under the
child’s chin. The child should be sitting straight (vertical). The F75 is given by cup, any dribbles
that fall into the saucer are returned to the cup. The child should never be force fed, have his/her
nose pinched or lie back and have the milk poured into the mouth.

Meal times should be sociable. The caregiver/mother should sit together in a semi-circle around
a nurse who encourages the caregivers, talks to them, corrects any faulty feeding technique and
observes how the child takes the milk.

The meals for the caregivers should never be taken beside the patient. It is almost impossible to
stop the child demanding some of the caregiver/mother’s meal; sharing of the care giver/mother’s
meal with the child can be dangerous. If the caregiver/mother’s meal has added salt or condiment
it can be sufficient to provoke heart failure in the malnourished child.

45
 Feeding children who have diarrhoea and vomiting

If the child has continuing watery diarrhoea after he has been rehydrated, offer ReSoMal between
feeds to replace losses from stools. As a guide, non-edematous children under 2 years should be
given 50 to 100 ml of ReSoMal after each loose stool, while older children should be given 100
to 200 ml. The amount given in this range should be based on the child’s willingness to drink and
the amount of ongoing losses in the stool. If the child vomits during or after a feed, estimate the
amount vomited and offer that amount of feed again. If the child keeps vomiting, offer half the
amount of feed twice as often. For example, if the child is supposed to take 40 ml of F-75 every 3
hours, offer half that amount (20 ml) every one and half hour until vomiting stops.

Nasogastric (NG) feeding

It may be necessary to use a NG tube if the child is very weak, has mouth ulcers that prevent drinking,
has pneumonia with rapid respiration or if the child cannot take enough F-75 by mouth. The minimum
acceptable amount for the child to take is 75 per cent of the amount offered. At each feed, offer the
F-75 orally first. Use an NG tube if the child does not take 75 per cent of the feed (i.e., leaves more
than 25 per cent) for two or three consecutive feeds.

A child with an NG tube is shown in photograph 6 of training module. The NG tube should be
checked every time food is put down. Check placement by injecting air with a syringe and listening
for gurgling sounds in the stomach. Change the tube if blocked. Do not plunge F-75 through the NG
tube; let it drip in or use gentle pressure. The use of the NG tube should not normally exceed three
days and should only be used during Phase 1.

Abdominal distension can occur with oral or NG tube feeding but it is more likely to occur with NG
feeding. If the child develops a hard distended abdomen with very little bowel sound, give 2 ml of a
50 per cent solution of magnesium sulphate IM.

Remove the NG tube when the child takes:

• 75 per cent of the day’s amount orally; or

• two consecutive feeds fully by mouth.

Exception: If a child takes two consecutive feeds fully by mouth during the night, wait until morning
to remove the NG tube, just in case it is needed again at night.

46
2.1.5 Management of Complications
When a patient develops a complication, always transfer him/her to Phase 1 for treatment (in-patients
are transferred back to Phase 1 and out-patients to in-patient treatment).

The management of medical complications has an objective of preventing death while stabilizing the
child. Any child presenting to the hospital or HC should be checked for serious medical complications
as part of standard procedures. If serious medical complications are present, many procedures must
be done very quickly, almost simultaneously.

Management of medical complication procedures may be performed in the emergency room or triage
area or OPD, before the child is admitted to SC/SC or wards for children with SAM. It is very important
that emergency room staff know to treat the severely malnourished child differently. They must be
taught to recognize severely malnourished children and to understand that these children may be
seriously ill even without showing signs of infection.

This guideline briefly describes the below common medical complications in SAM

• Hypoglycemia

• Hypothermia

• Shock

• Severe anemia

• Corneal clouding and ulceration

• Watery diarrhoea and/or vomiting and dehydration

• Heart failure

• Infections

• Abdominal distension

• High grade fever

• Extensive skin lesions

• Significant weight loss for HIV positive patients

• OIs

47
 Management of Hypoglycemia

What is Hypoglycemia? Hypoglycemia is a low level of glucose in the blood. In severely malnourished
children, the level considered low is less than <54 mg/dl (< 3 mmol/litre). The hypoglycemic child is
usually hypothermic (low temperature) as well. Other signs of hypoglycemia include lethargy, limpness
and loss of consciousness. Another sign of hypoglycemia is eye-lid retraction due to an overactive
sympathetic nervous system, thus a child sleep with eyes slightly open. Sweating and pallor may not
occur in malnourished children with hypoglycemia. Often, the only sign before death is drowsiness.

The short-term cause of hypoglycemia is lack of food. Severely malnourished children are more at risk
of hypoglycemia than other children and need to be fed more frequently, including during the night.
Malnourished children may arrive at the hospital hypoglycemic if they have been vomiting, if they have
been too sick to eat, or if they have had a long journey without food. Children may develop hypoglycemia
in the hospital if they are kept waiting for admission or if they are not fed regularly. Hypoglycemia and
hypothermia are also signs that the child has a serious infection.

Hypoglycemia is extremely dangerous. The child may die if not given glucose (and then food) quickly,
or if there is a long time between feeds.

Blood glucose level can be tested using treated paper strips such as Dextrostix, Glucostix or other
similar products.

Prevent Hypoglycemia / Begin F-75 If the child’s blood glucose is not low; begin feeding the child with
F-75 right away like in Phase one.

Treat Hypoglycemia If blood glucose is low or hypoglycemia is suspected, immediately give the child a
50 ml bolus of 10 per cent glucose or 10 per cent sucrose orally or by NG tube. Glucose is preferable
because the body can use it more easily; sucrose must be broken down by the body before it can
be used. However, give whichever is available most quickly. If only 50 per cent glucose solution is
available, dilute one part to four parts sterile or boiled water to make a 10 per cent solution.

If the child can drink, give the 50 ml bolus orally. If the child is alert but not drinking, give the 50 ml by
NG tube.

How to reconstitute 50 ml of 10 per cent glucose from available solutions:

Mixture of Gives

12.5 ml of 40 per cent dextrose + 37.5 ml of distilled water

7.5 ml of 40 per cent dextrose + 42.5 ml of 5 per cent dextrose 50 ml of

10 ml of 50 per cent dextrose + 40 ml Distilled water 10 per cent Dextrose

6 ml of 50 per cent dextrose + 44 ml of 5 per cent dextrose

If the child is lethargic, unconscious, or convulsing, give 5 ml/kg body weight of sterile 10per cent
glucose by IV, followed by 50 ml of 10per cent glucose or sucrose by an NG tube. If the IV dose cannot
be given immediately, give the first dose through an NG tube. If the child will be given IV fluids for shock,
there is no need to follow the 10per cent IV glucose with an NG bolus, as the child will continue to
receive glucose in the IV fluids.

48
Start feeding F-75 half an hour after giving glucose and give it every half-hour during the first 2 hours.
For a hypoglycemic child, the amount of F-75 to give every half-hour is ¼ of the 3-hourly amount shown
on your F-75 Reference Card. (Annex 7)

Take another blood sample after two hours and check the child’s blood glucose again. If blood glucose
is 54 mg/dl (3mmol/l) or higher, change F-75 feeding to 3-hourly feeds (eight feeds per day). If still
low, make sure antibiotics and F-75 have been given. Keep giving F-75 every half-hour and treat with
second-line antibiotics.

Management of Hypothermia

What is Hypothermia? Hypothermia is low body temperature. A severely malnourished child is

hypothermic if the rectal temperature is below 35.5 0C or if the axillary temperature is below 35 0C.

Severely malnourished children are at greater risk of hypothermia than other children and need to
be kept warm. The hypothermic child has not had enough calories to warm the body. If the child is
hypothermic, he is probably also hypoglycemic. Both hypothermia and hypoglycemia are signs that the
child has a serious systemic infection.

Take temperature: Rectal temperatures are preferred because they more accurately reflect core body
temperature. If axillary temperatures are taken, convert them to rectal by adding 0.5 0c. If possible, use
a low-reading thermometer (it is a type of thermometer that reads body temperature as low as 300C).
If no low-reading thermometer is available, use a normal thermometer. With a normal thermometer,
assume that the child has hypothermia if the mercury does not move.

Warm the child: Severely malnourished children have difficulty controlling their body temperature and so
must be kept warm and fed frequently. Keeping them warm also conserves their energy. Hypothermia
is very dangerous. If the child is hypothermic, re-warming is necessary to raise their temperature.

Maintain temperature (prevent hypothermia)

The following measures are important for all severely malnourished children:

• Cover the child, including his head. Promptly change wet clothes or bedding. Keep the child
covered at night. Avoid leaving the child uncovered while being examined, weighed, etc.

• Stop draughts in the room. Move the child away from windows and maintain room temperature
of 28 and 32 0C (82.4-89.6 0 F)

• Warm your hands before touching the child and dry the child thoroughly after bathing.

If it is not possible to warm the room, let the child sleep with skin to skin contact to the mother or
caregiver and cover them with a blanket.

Actively re-warm the hypothermic child

In addition to keeping the child covered and keeping the room warm, use one of the following re-

49
 warming techniques if the child is hypothermic:

• Have the mother hold the child with his skin next to her skin when possible (kangaroo technique),
and cover both of them. Keep the child’s head covered. Give warm fluid to the mother.

• Use a heater or incandescent lamp with caution. Use indirect heat (not too close). Monitor rectal
temperature every 30 minutes to make sure the child does not get too hot. Stop re-warming
when the child’s temperature becomes normal.

• Do NOT use hot water bottles due to danger of burning fragile skin.

• All hypothermic children should be treated for hypoglycemia and for infection as well.

Management of watery diarrhoea and/or vomiting and Dehydration

Children with SAM have profoundly disturbed normal physiology, including electrolyte imbalances and
altered fluid distribution. Children with bilateral pitting oedema typically have high intracellular sodium and
are therefore inclined to retain fluids. By comparison, intracellular potassium is lost to the extracellular
space and total body potassium is often very low. These changes at cellular level are part of the overall
adaptive responses to repeated infections and damage to cell membranes by free radicals. Children
with severe wasting but without oedema also have depleted intracellular and total body potassium
and similarly experience adaptive physiological changes such as reduced renal and cardiac outputs.
As a result, they are prone to fluid retention and susceptible to fluid changes and, in particular, have
reduced tolerance to rapid changes in circulating blood volume. For these reasons, fluid management
is complex in all children with SAM. WHO recommends a cautious approach to fluid management,
especially if children have diarrhoea. It is frequently very difficult to assess and determine the hydration
status and circulating volume of severely malnourished children.

Children with SAM who also have diarrhoea and are dehydrated need additional fluids to treat dehydration.
Because children with SAM are primed to retain sodium, there is concern that even low-osmolarity oral
rehydration solutions may still put these children at risk of sodium, and thereby fluid, overload.

WHO recommended the use of a modified oral rehydration solution for malnutrition (ReSoMal), which
contains 45 mmol/L sodium and 40 mmol/L potassium(11). ReSoMal is not, however, appropriate
for dehydrated children with SAM with cholera or profuse watery diarrhoea. Where ReSoMal is not
available for children with SAM with dehydration, dissolving a packet of low-osmolarity oral rehydration
solution to make up 2 L of solution instead of 1 L, and including additional potassium and glucose is
recommended.

Children with SAM and who have some or severe dehydration but no shock should receive 5 mL/
kg ReSoMal every 30 min for the first two hours. Then, if the child is still dehydrated, 5–10 mL/kg/h
ReSoMal should be given in alternate hours with F-75, up to a maximum of 10 hours.

Full-strength, standard WHO low-osmolarity oral rehydration solution (75 mmol/L sodium) should not
be used for oral or NG rehydration in children with SAM who present with some dehydration or severe
dehydration. Either ReSoMal or half-strength standard WHO low-osmolarity oral rehydration solution

50
should be given, with added potassium and glucose, unless the child has cholera or profuse watery
diarrhoea.

ReSoMal (or locally prepared ReSoMal using standard WHO low-osmolarity oral rehydration solution)
should not be given if children are suspected of having cholera or have profuse watery diarrhoea. Such
children should be given standard WHO low-osmolarity oral rehydration solution that is normally made,
i.e. not further diluted.

What is ReSoMal?

ReSoMal is a rehydration solution for children with SAM. ReSoMal contains less sodium, more
sugar, and more potassium than standard ORS and is intended for severely malnourished children
with diarrhoea. It should be given by mouth or by NG tube. Do not give standard ORS to severely
malnourished children unless they have cholera or profuse watery diarrhoea.

ReSoMal can either be prepared from a ready-to-dilute sachet (as per supplier’s instructions) or prepared
with one sachet of WHO low-osmolarity oral rehydration solution plus 2 liters of water with an added 50
g sugar and 40 ml mineral mix or one level scoop of combined minerals and vitamins.

Contents of ReSoMal as prepared from standard ORS:

Water 2 liters
WHO-ORS One 1 liter packet
Sugar 50 g
Mineral mix solution 40 ml or one leveled scoop combined vitamins and minerals (CMV)

Prepare ReSoMal from standard ORS:

• Wash hands.
• Empty one 1-litre standard ORS packet into container that holds more than 2 liters
• Measure and add 50 grams of sugar. (It is best to weigh the sugar on a dietary scale that weighs
to 5 g.)
• Measure 40 milliliters or one leveled scoop of CMV in a graduated medicine cup or syringe; add
to other ingredients
• Measure and add 2 liters of cooled boiled water
• Stir until dissolved
• Use within 24 hours

Recognize Dehydration and the need for ReSoMal

Misdiagnosis and mistreatment for dehydration is the commonest cause of death in children with SAM
who are being treated. It is difficult to determine hydration status in a severely malnourished child, as
the usual signs of dehydration (such as lethargy, sunken eyes and skin pinch) may be present in these
children all of the time, whether or not they are dehydrated. Diagnosis of dehydration is mainly based
on the history rather than on the patient’s examination alone. Ask the mother if the child has had watery
diarrhoea or vomiting, if there have been recent changes in the child’s appearance or recent sinking of
eyes.

51
 Consider the diagnosis of dehydration in non-edematous children and give
ReSoMal if there are:

• Definite history of significant recent fluid loss (diarrhoea looking like water, not just ‘loose’ stools,
appearing with sudden onset over the course of the last hours or days)

• Clear history of a recent change in the child’s appearance

• If the eyes are sunken then the mother must will say that the eyes are changed to become
sunken since the diarrhoea or vomiting started

Edematous children are over-hydrated but they are frequently hypovolemic due to dilation of blood
vessels with low cardiac output. If the child with oedema has definite watery diarrhoea and is deteriorating
clinically (excessive weight loss, more than 2 per cent of the body weight per day), then the child is
dehydrated.

Calculate amount of ReSoMal to give

For a child who is dehydrated but is showing no sign of shock, give ReSoMal as follows, in amounts
based on the child’s weight:

How often to give ReSoMal Amount to give

Every 30 minutes for first two hours 5 ml/kg body weight

Every hour for up to 10 hours 5 - 10 ml/kg*

* The amount offered in this range should be based on the child’s willingness to drink and the amount
of ongoing losses in the stool. Continue to give F-75 every three or four hours.

If the child has already received IV fluids for shock and is switching to ReSoMal, omit the first two hour
treatment and start with the amount for the next period of up to 10 hours.

The treatment of dehydration is shown in the below figure:

52
What should we monitor in a SAM child who is on treatment for dehydration?

The following signs of dehydration are important to detect improvements later and not for initial diagnosis.
(Also ask about blood in the stool as this will affect choice of antibiotics.) Even though the signs may be
misleading, if they go away after giving ReSoMal, you will know that the ReSoMal has had a good effect.

Signs of dehydration are as follows:

Lethargic A lethargic child is not awake and alert when he should be. He is drowsy and
does not show interest in what is happening around him.

Restless, irritable: The child is restless and irritable all the time or whenever he is touched or
handled.

Sunken eyes: The eyes of a severely malnourished child may always appear sunken,
regardless of the child’s hydration status. Ask the mother if the child’s eyes
appear unusual. Photographs 6, 30, and 31 (in the Photographs Booklet) show
sunken eyes.

Thirsty See if the child reaches out for the cup when you offer ReSoMal. When it is
taken away, see if the child wants more.

Monitor the child who is taking ReSoMal

Monitor the child’s progress every half hour for the first two hours; then monitor hourly, i.e., every time
the child takes F-75 or ReSoMal (see the monitoring algorithm below).

Figure 2: Monitoring algorithm for a child on ReSoMal

53
 Signs to check

• Respiratory rate - Count for a full minute

• Pulse rate - Count for 30 seconds and multiply by two
• Weight
• Urine frequency – Ask: Has the child urinated since last checked?
• Liver size: mark before any infusion
• Stool or vomit frequency – Ask: Has the child had a stool or vomited since last checked?
• Signs of hydration – Is the child less lethargic or irritable?

Record the above information on the In-patient Multichart; then give ReSoMal and record the amount
taken. Note any changes when you check the signs above.

Signs of improving hydration status

• Fewer or less pronounced signs of dehydration, for example:

• less thirsty
• less lethargic

Note: Although these changes indicate that rehydration is proceeding, many severely malnourished
children will not show these changes even when fully rehydrated.

• Slowing of rapid respiratory and pulse rates

• Passing urine
• Gaining weight with clinical improvement

If a child has three or more of the above signs of improving hydration status, stop giving ReSoMal.
Instead, offer ReSoMal after each watery diarrhoea.

Signs of over hydration

Stop ReSoMal if any of the following signs appear:

• Increased respiratory rate by five breaths and pulse rate by 25 beats per minute (Both must
increase to be considered a problem.)
• Jugular veins engorged. (Pulse wave can be seen in the neck.)
• Sudden increase in liver size and tenderness
• Increasing oedema (e.g., puffy eyelids).
• Increasing weight with clinical deterioration

After rehydration, offer ReSoMal after each loose stool

When the child has three or more signs of improving hydration (see above), stop giving ReSoMal routinely
in alternate hours. However, watery diarrhoea may continue after the child is rehydrated. If diarrhoea
continues, give ReSoMal after each watery diarrhoea to replace stool losses and prevent dehydration:

54
 • Edematous Children: give 30 ml after each watery stool.
• Non-edematous children:
o < 2 years: give 50-100 ml after each watery stool
o 2 years and older: give 100 -200 ml after each watery stool.

Base the amount given in these ranges on the child’s willingness to drink and the amount of stool loss.

Management of Shock in SAM

The diagnosis of shock in SAM children is to be considered if a child has a weak or absent radial or
femoral pulse, and cool or cold hands and feet or low or un-recordable blood pressure. In addition, if
there is also loss of consciousness, it is severe shock. These children need IV fluids.

The treatment of shock in an edematous child is the same as the treatment of septic shock. Monitor
carefully fluid replacement in edematous children, as there is a high risk of heart failure. See the flow
chart to decide on the management of dehydration.

The severely malnourished child is considered to have shock if he/she is lethargic or

unconscious and has cold hands plus either:
• slow capillary refill (longer than three seconds), or
• weak, fast or absent radial or femoral pulses and
• absence of signs of heart failure in an edematous child

To check capillary refill: Press the nail of the thumb or big toe for two seconds to produce blanching of
the nail bed. Count the seconds from release until return of the pink color. If it takes longer than three
seconds, capillary refill is slow.

For a child 2 months up to 12 months of age, a fast pulse is 160 beats or more per minute. For a child
12 months to 5 years of age, a fast pulse is 140 beats or more per minute.

The four key steps to manage shock are:

1. Give oxygen (for infants 0.5 to 1 lit per minute, and for older children 1 to 2 lit per minute).
2. Give 10per cent Glucose 5 ml/kg by IV
3. Keep the child warm
4. Give IV fluids as follows

o Check the starting respiratory rate, pulse rates and time and record them on the Multi-chart
and also on the shock follow up chart.

o Infuse IV fluid at 15ml/kg over 1 hour. Use one of the following solutions, listed in order of
preference:

 Ringer’s lactate solution with 5per cent glucose*

 0.9 per cent normal saline with 5per cent glucose* (add 125 ml of 40 per cent or 100 ml
55
 of 50per cent glucose to 1 liter of 0.9per cent saline to make this fluid)
 *If either of these are used, add sterile potassium chloride (20 Mmol/l) if possible

o Observe the child and check respiratory and pulse rates every 10 minutes (use the shock follow
up chart). Follow the liver size too.

o If the respiratory rate (by five breaths per minute) and pulse rate (by 25 pulses per minute)
increase and child is gaining weight, stop the IV rehydration and assume septic or cardiogenic
shock.

o If respiratory rate and pulse rate are slower after one hour, the child is improving. Repeat the
same amount of IV fluids for another hour. Continue to check respiratory and pulse rates every
10 minutes.

o After two hours of IV fluids, switch to oral or NG rehydration with ReSoMal. Give 5-10 ml/kg
ReSoMal in alternate hours with F-75 for up to 10 hours or until fully rehydrated.

Management of septic shock

Septic shock presents with some of the signs of true dehydration and also of cardiogenic shock; the
differential diagnosis is often very difficult. The child is usually limp, apathetic and profoundly anorexic
but is neither thirsty nor restless. Children that appear “very ill” may have septic shock, cardiogenic
shock, liver failure, poisoning with traditional medicines, malaria, acute viral infection or other severe
conditions. All “very ill” children should not be automatically diagnosed as having septic shock; the true
reason for the condition should be sought.

If this develops after admission to the SC, then the treatment given to the child should be carefully
reviewed to determine if the treatment is the cause of the clinical deterioration. Any “unusual” drugs
should be stopped.

If the child fails to improve after the first hour of IV fluids for management of shock in dehydration, then
assume that the child has septic shock.

Diagnosis of septic shock: To make a diagnosis of septic shock requires the signs of hypovolemic shock
to be present. These are as follows:

 A fast weak pulse with;

 Cold peripheries.

 Disturbed consciousness

 Absence of signs of heart failure

 AND failure to improve after the first hour of IV fluids for management of shock in dehydration

56
Treatment of septic shock

All patients with signs of septic shock should immediately:

1. Be given broad-spectrum antibiotics

a) Second line and first line antibiotics together

b) Have third line antibiotics, antifungal treatment and anti-staphylococcal treatment

considered

2. Be ekpt warm to prevent hypothermia or

3. Be treated or ensure hypoglycaemia is prevented

4. Be physically disturbed as little as possible (no washing, excess examination, investigations in

other departments, etc)

5. Never be transported to another facility – the stress of transport leads to dramatic deterioration

6. Give maintenance IV fluids (4 ml/kg/hour) while waiting for blood transfusion. When blood is
available, stop all oral intake and IV fluids, give a diuretic to make room for the blood and then transfuse
whole fresh blood at 10 ml/kg slowly over three hours. If there are signs of heart failure, give packed
cells instead of whole blood as these re smaller in volume.

As soon as the patient improves (stronger radial pulse, regain of consciousness), stop all IV intake -
continue with F75 diet.

Management of Severe Anemia

What is severe anemia? Anemia is a low concentration of hemoglobin in the blood. Severe anemia
is a hemoglobin concentration of < 4 g/dl (or hematocrit <12per cent). If it is not possible to test the
hemoglobin, rely on clinical judgment. For example, you can judge the degree of anemia based on
paleness of gums, lips, palm, and inner eyelids.

Severe anemia can cause heart failure and must be treated with a blood transfusion. As malnutrition
is usually not the cause of severe anemia, it is important to investigate other possible causes such as
malaria and intestinal parasites (for example, hookworm).

Mild or moderate anemia is very common in severely malnourished children and should be later treated
with iron, after the child has stabilized. (Do NOT give iron during Phase 1 and Transition Phase as it can
damage cell membranes and make infections worse.)

57
 Symptoms of moderate and severe anemia may appear between day two and day 14 of the treatment
of malnutrition, due to the movement of fluids from tissues (oedema and intracellular water) to vascular
space. This temporary excess of fluids will produce dilutional anemia (i.e. pseudo-anemia) that should
never be treated with transfusions (this risks aggravating the problem and inducing cardiac overload and
death). Pseudo-anemia normally resolves spontaneously after two or three days when kidney function
recovers and excess fluids can be eliminated. For these reasons, transfusion is not recommended
between 48 hours and day 14 unless there is heart failure and the cause is other than dilutional anemia

Give blood transfusion in the first 48 hours if:

• Hgb is < 4 g/dl, ( Hct is < 12 per cent), or

• Hgb 4 to 6 gm/dl (Hct 12 to 18per cent) and respiratory distress

1. Stop all oral intake and IV fluids during the transfusion.

2. Look for signs of congestive heart failure such as fast breathing, respiratory distress, rapid
pulse, engorgement of the jugular vein, cold hands and feet, cyanosis of the fingertips and
under the tongue.

3. Give a diuretic4 to make room for the blood. Furosemide (1 mg/kg, given by IV) is the most
appropriate choice.

4. If there are no signs of congestive heart failure, transfuse whole fresh blood at 10 ml/kg slowly
over three hours. If there are signs of heart failure, give 10 ml/kg packed cells over three hours
instead of whole blood.

Management of corneal clouding and ulceration

Corneal clouding is haziness of the surface of the cornea (eye surface), whereas corneal ulceration is a
break in the surface of the cornea. In the later case, the eye may be extremely red or bleeding, or the
child may keep the eye closed. In corneal ulceration, if there is an opening in the cornea the lens of the
eye may extrude (push out) and cause blindness. Photo 12 in the Photograph Booklet shows corneal
ulceration. Corneal clouding and ulceration are dangerous conditions that may lead to loss of vision if
not treated urgently,

Examine the eyes: Wash your hands. Touch the eyes extremely gently and as little as possible. The
child’s eyes may be sensitive to light and may be closed. If the eyes are closed, wait until the child
opens his eyes to check them or gently pull down the lower eyelids to check. Wash your hands again
after examining the eyes.

4 Diuretics should never be used to reduce oedema in children with severe malnutrition. The purpose of giving a
diuretic before a blood transfusion is to prevent congestive heart failure from overloading the circulation with the
transfusion.

58
Give Vitamin A and atropine eye drops immediately for corneal ulceration

If the child has corneal clouding and ulceration, give Vitamin A immediately.

Child’s age Vitamin A Oral Dose

< 6 months 50 000 IU

6 - 12 months 100 000 IU

>12 months 200 000 IU

You should insert one drop atropine (1 per cent) into the affected eye(s) to relax the eye and prevent the
lens from pushing out. Tetracycline eye drops and bandaging are also needed but may wait until later
in the day. Daily Care session describes other treatments of corneal ulceration.

All severely malnourished children with eye signs need Vitamin A on Day 1, and many need additional
eye care which can wait until later in the day. Daily Care Session describes treatment of the various
eye signs.

Management of Heart Failure

Diagnosis: Physical deterioration with weight gain, sudden increase in liver size, tenderness of the liver,
increased respiratory rate, ‘grunting’ breathing, crepitation in lungs, prominent superficial and neck veins,
engorgement of the neck veins when the abdomen is pressed, increased oedema or reappearance of
oedema, amongst other clinical signs and symptoms. It progresses to marked respiratory distress with
rapid pulse, cold hands and feet, oedema and cyanosis and sudden death from cardiac shock.

Heart failure and pneumonia may be difficult to tell apart as they can be clinically similar. When weight
gain precedes or is associated with signs of respiratory distress, heart failure should be the first
diagnosis. If there is loss of weight, consider pneumonia instead.

Note: Children with oedema do not necessarily present weight gain during heart failure if the expanded
circulation is due to a mobilization of oedema fluid from the tissues to vascular space.

Treatment of heart failure

• Stop all intake of oral or IV fluids. No fluid or food should be given until heart failure has
improved (even if this takes 24 to 48 hours). Small amounts of sugar-water can be given
orally to prevent hypoglycemia

• Give Furosemide (1 mg/kg) single dose, repeat if necessary

• If it is due to severe anemia, manage accordingly

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 Treatment of Infections in SAM

Give all severely malnourished children antibiotics for presumed infection even if they do not have
clinical sign of systemic infections. Give the first dose of antibiotics while other initial treatments are
going on, as soon as possible.

Select antibiotics and prescribe regimen

Selection of antibiotics depends on the presence or absence of complications. Complications include

septic shock, hypoglycemia, hypothermia, skin infections or dermatosis (+++ with raw skin/fissures),
respiratory or urinary tract infections, or lethargic/sickly appearance.

• If no medical complications or only failed appetite test, give first line antibiotics: Oral
Amoxicillin (preferred) or Cotrimoxazole if Amoxicillin is not available.

• If complications present, give second line antibiotics:

o These complications include: unable to feed, vomiting everything, shock, convulsions, lethargic/
very weak, pneumonia/severe pneumonia, hypoglycemia, hypothermia, dermatosis with raw
skin/fissures, jaundice, bleeding tendencies, complicated measles,

Give, Gentamicin, plus IV Ampicillin for two days followed by oral Amoxicillin. But if child
is not seriously sick looking and can take oral medication, avoid IV Ampicillin and start
with oral Amoxicillin and IM Gentamycin.

o If the child has complications other than mentioned above like (dehydration, dysentery, persistent
diarrhoea, fever other than malaria, measles without complication),

 Give oral Amoxicillin and I.M. Gentamycin. If child is seriously sick looking, instead of oral
Amoxicillin & IM Gentamycin start with IV Ampicillin and IV Gentamycin,

• If the child fails to improve within 48 hours, add Chloramphenicol or Ceftriaxone)

• Almost all children improve on Gentamicin plus Amoxicillin and it is rare that Chloramphenicol
is needed. Note: You can use Amoxicillin-Calvulanic Acid (Augmentin), and Ceftriaxone as
additional second or third option drugs, according to you clinical judgment.

• If specific infections are identified which require a specific antibiotic not already being given,
give an additional antibiotic to address that infection. For example, dysentery may require
additional antibiotics. Certain skin infections such as candidiasis require specific antibiotics.
Antimalarial treatment should be given according to the national protocol.

Different formulations of drugs are available (tablets or syrups of varying strengths). The formulation
of the drug will affect the amount to measure for a dose. Some common formulations are given in
the dosage tables on the Antibiotics Reference Card, which is found in the annexed 7-10 in the chart
booklet For each formulation of a drug, the dosage tables have rounded practical doses to use for
children of different weights.

60
Note: Never base the dose on age.

Management of abdominal distension with absent bowel sounds, gastric dilatation and intestinal splash

Low potassium level in children with SAM may lead to decreased intestinal peristalsis leading to abdominal
distension. Overgrowth of gas producing bacteria in the bowel can also led to such conditions. The
following key measures should be taken to manage this complication:

• Give IV second line antibiotics

• Consider adding third line antibiotics like ceftriaxone

• Stop all other drugs that may be causing toxicity (such as metronidazole)

• Give a single IM injection of magnesium sulphate (2 ml of 50 per cent solution).

• Insert an NG-tube and aspirate the contents of the stomach, then “irrigate” the stomach and
check for the absorptive capacity of the stomach using 10 per cent sugar water.

• There is frequently gastric and oesophageal candidiasis: give oral nystatin suspension or
fluconazole.

• Keep the child warm.

• If the child’s level of consciousness is poor, give intravenous glucose

• Do not put up a drip at this stage. Monitor the child carefully for six hours, without giving any
other treatment

• Improvement is measured first by a change in intestinal function, decrease in the distension

of the abdomen, visible peristalsis seen through the abdominal wall, return of bowel sounds,
decreasing size of gastric aspirates– and second by improvement in the general condition of
the child.

• If there is intestinal improvement then start to give small amounts of F75 by NG tube

• If there is no improvement after six hours then:

 Consider putting up an IV drip. It is very important that the fluid given contains adequate
amounts of potassium. Sterile potassium chloride (20mmol/l) should be added to all solutions
that do not contain potassium. Use Ringer-Lactate in 5per cent dextrose or half-strength
saline in 5per cent dextrose. The drip should be run VERY SLOWLY – the amount of fluid
that is given should be NO MORE THAN 2 to 4 ml/kg/h.

 When the gastric aspirates decrease so that one half of the fluid given to the stomach is
absorbed, discontinue the IV treatment and continue with oral treatment only.

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 2.1.6 Daily care and Routine medicines in phase I
It is commonly observed that failure to provide consistent daily care compromises the quality of treatment
for the severely malnourished children. The routine of daily care in a severe malnutrition ward includes:

• daily tasks of weighing, feeding and bathing

• giving routine medicine

• monitoring and recording each child’s progress and

• moving the patient from one phase to the other phase by using proper criterion including
timely transfer to outpatient treatment as well as discharging those who fully recover from
treatment

Proper handling of the child

Children with SAM must be handled very gently, especially at the beginning of their care. The body of a
child with SAM is fragile and bruises easily. The child needs all his energy to recover, so he must stay
calm and not become upset. It is important to speak quietly and handle children as little as possible
at first. Hold and touch children with loving care when feeding, bathing, weighing and caring for them.

Through tone of voice, gentle manner, and caring attitude, the health care provider will set a good
example for the mothers/caregivers in providing tender, loving care. They will also win the trust of
the mothers/caregivers and make them more likely to stay with their children in the hospital for the
necessary length of time. It is critical for mothers/caregivers to stay with their children in the hospital.
The number of other adults interacting with each child should be limited and the most skilled staff
available should perform medical procedures, preferably out of earshot and sight of the other children.
As the child recovers, stimulation of the child should increase.

Play, physical activities, and mental and emotional stimulation become very important to the child’s
complete recovery.

Routine medicines and other medications

Give routine medicines according to routine medicine table BELOW.

With the exception of Amoxicillin, the other medicines/vaccine are given when the below mentioned
conditions are fulfilled.

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 Direct admission to in-patient Direct admission to out-patient
(Phase 1) (Phase 2)

- One dose at admission if signs - One dose at admission if signs of

Folic Acid
of anaemia anaemia

- Every day in Phase 1 + 4 more

- One dose at admission + give
Amoxicillin days in Transition, for a maximum
treatment for 7 days at home
of total 7 to 10 days
- One vaccine at admission if not
Measles (from vaccinated - One vaccine on the 4th week (4th
9 months old) visit) if not vaccinated
- One vaccine at discharge

Iron - Add to F100 in Phase 2 - No - iron is already in all RUTF

Deworming - One dose at the start of Phase 2 - One dose on the 2nd week (2nd visit)

Note: Pediatrics’ 24 hour dose shouldn’t exceed the daily adult dose of each drug.

Vitamin A

There is an adequate amount of Vitamin A in the F75, F100 and RUTF to manage mild vitamin A
deficiencies and to replete liver stores of Vitamin A during treatment.5 Children with SAM do not
require a high dose of Vitamin A as a supplement if they are receiving F-75, F-100 or RUTF that complies
with WHO specifications.

Children with SAM should be given a high dose of vitamin A (50 000 IU, 100 000 IU or 200 000 IU,
depending on age) on admission, if they are given therapeutic foods that are not fortified as recommended
in WHO specifications and Vitamin A is not part of other daily supplements.

*On the day of admission (day one), do not give Vitamin A for children except for those with eye signs
of Vitamin A deficiency or recent measles. For patients with eye signs of Vitamin A deficiency or recent
measles, give a second and a third dose on days 2 and 15 (or at discharge from the program), irrespective
of the type of therapeutic food they are receiving.

5 A 10 kg child taking maintenance amounts of F75 (1000 kcal) will receive about 7300 IU (2.2mg) of Vitamin A per
day. The RDA (USA) for such a child is 1700 IU (0.5mg) per day.

63
 Vitamin A systematic treatment6

Age Vitamin A IU orally in day 1,2 and day 15

6 to 11 months One blue capsule (100,000 IU = 30,000 µg)

12 months (or 8 kg) and more Two blue capsules (200,000 IU = 60,000 µg)

Folic acid

There is sufficient folic acid in F75, F100 and RUTF to treat mild folate deficiency7.

On the day of admission, one single dose of folic acid (5mg) can be given to children with clinical signs
of anaemia.

Other nutrients

The F75 (and F100, F100 diluted, RUTF) that is commercially manufactured, and the feeds that are
made locally from the ingredients with added CMV already contain all the other nutrients required
to treat the malnourished child. Additional potassium, magnesium or zinc should not be given to the
patients. Such a “double dose”, one coming from the diet and the other prescribed, is potentially
toxic. In particular, additional potassium should never be given with these diets. Even for children
with diarrhea, it is not advisable to give additional zinc. However, if they are not admitted to therapeutic
feeding and they are not accessing therapeutic feeds, children with SAM who have diarrhoea should
receive zinc, in the same way as children who are not severely malnourished. If they are now being
admitted to therapeutic feeding, they will get their zinc requirement from the therapeutic feeds.

Antibiotics

Antibiotics should be given to every severely malnourished patient, even if they do not have clinical signs
of systemic infection. Nevertheless, despite the absence of clinical signs, they are nearly all infected,
particularly if they require Phase 1 treatment (poor appetite) – these infections are treated blindly.

Small bowel bacterial overgrowth occurs in all these children (including those with moderate, and
some with good appetites). These enteric bacteria are frequently the source of systemic infection by
translocation across the bowel wall. They also cause malabsorption of nutrients, failure to eliminate
substances excreted in the bile, fatty liver, intestinal damage and can cause chronic diarrhoea. The
antibiotic chosen for routine treatment must be active against small bowel bacterial overgrowth.

Children with kwashiorkor have free iron in their blood and so bacteria that are not normally invasive,
6 For patients with eye signs of Vitamin A deficiency or recent measles
7 A 10 kg child taking maintenance amounts of diet will receive about 400 micrograms of folic acid per day. The RDA
(USA) for such a child is 80 micrograms per day.

64
such as Staphlococcus epidermidis and “exotic bacteria” can cause systemic infection or septicaemia.
If stapholcoccus is suspected then an antibiotic active against staphylococcus should also be used.

The position of antibiotic administration to children who pass their appetite tests and go straight to
outpatient treatment is less clear. They probably do not have a major systemic infection; however,
they usually have a small amount of bowel bacterial overgrowth and these bacteria should at least be
suppressed to ensure for optimal response to treatment. Thus, at the moment these children are usually
given antibiotics systematically in a similar fashion to those who require Phase 1 treatment initially.

Table 5 Choice of antibiotics for children with SAM

IF: GIVE:

No Medical Complications Oral Amoxicillin as indicated above under routine

medicine
If Amoxicillin is not available, give Cotrimoxazole for
five days
Failed Appetite Test

Gentamycin IV or IM once daily for seven days, plus:

Medical Complications
Ampicillin IV every six hours for two days followed by
(Unable to feed , vomiting everything, shock,
oral Amoxicillin for five days
convulsions, lethargic/very weak, pneumonia/
severe pneumonia, hypoglycaemia, hypothermia,
If the child is not seriously sick looking and can take
dermatosis with raw skin/fissures, jaundice,
oral medication, avoid IV Ampicillin and start with oral
bleeding tendencecies, complicated measles,)
Amoxicillin and IM Gentamycin.

If the child has medical complications other

Oral Amoxicillin and IM Gentamicin for 7 days.
than mentioned above,
If child is seriously sick looking, instead of oral
(dehydration, dysentery, persistent diarrhoea,
Amoxicillin and IM Gentamycin start with IV Ampicillin
fever other than malaria, measles without
and IV Gentamycin
complication)

Chloramphenicol IV or IM every eight hours for five

days. (Give IV every six hours if suspect meningitis) or
If child fails to improve within 48 hours, ADD:
ceftriaxone 100 mg/kg divided into two doses IV or IM
+ Gentamicin once daily for a total of 10 days.

If a specific infection requires an additional

Specific antibiotic as indicated.
antibiotic, ALSO GIVE:

65
 Doses for Selected Antibiotics

Table 6 Dosage of Oral Antibiotics

AMOXYCILLIN CHLORAMPHENICOL COTRIMOXAZOLE

(50-100mg/Kg/d) (50mg/Kg/d) (25mg SMX+5mg TMP/Kg/d)

WEIGHT
Give two times/day Give three times/day Give two times/day
Kg

ADULT PEDIATRIC SYRUP

CAPSULE CAPSULE TABLET TABLET SYRUP
TABLET TABLET 125
250mg 125 mg 240mg 120mg 120mg/5ml
500mg 125 mg mg/5ml

<5 ¼ 1 5.0 ml ¼ ½ ½ 1 5ml

5-10 ½ 2 10ml ½ 1 1 2 10ml

10-20 1 4 20ml 1 2 2 4 20ml

20-35 1½ 6 30ml 2 4 3 6 30ml

>35 2 8 40ml 4 8 4 8 40ml

Table 7 Dosage of Parenteral Antibiotics

AMPICILLINE GENTAMYCIN
CHLORAMPHENICOL CEFTRIAXONE
(50mg/Kg/dose) (5-7.5 mg/Kg/day)
(25/Kg/dose) (50mg/Kg/dose)
WEIGHT Four times/day Once per day
in Kg Three times/day 2 times per day
for two days for two days

1000mg/10ml
Vial of 500mg/2.5ml 10 mg/ml ampoule 1000mg/10ml
ampoule

<5 1ml 2.5 ml 1 ml 2 ml

5-10 2 ml 5 ml 2 ml 4 ml

10-20 4 ml 10 ml 4 ml 8 ml

20-35 6ml 15 ml 6 ml 12 ml

>35 8 ml 20 ml 10 ml 20 ml

Duration of antibiotic treatment:

• In-patient care: every day during Phase 1 + four more days or until transfer to OTP.

• Out-patient care: for seven days total. For out-patient care, antibiotic syrup is preferred. If this
is not available, the tablets should be used and cut in half by the staff before being given to the
caregivers (for children <5kg).

66
Administration of antibiotics

Wherever possible antibiotics should be given orally or by NG tube

Infusions containing antibiotics should not be used because of the danger of inducing heart failure.
Indwelling cannula should rarely be used. The disadvantages of indwelling cannula are:

• They give access to the circulation for antibiotic-resistant bacteria in these immuno-compromised
patients; the dressing quickly becomes dirty
• They often become colonised with Candida and can give rise to fungal septicaemia
• They require fluid or anticoagulants to keep the vein open – but these children have impaired
liver function (bleeding tendency) and are very sensitive to fluid overload
• They require skilled health persons to insert and maintain the cannula
• The administration of IV drugs takes more time, from higher grades of staff, than giving oral
drugs
• IV preparations are much more expensive than oral preparations and the cannula itself is
expensive
• Insertion of the cannula is painful and distressing for the child and they frequently need to be
re-inserted
• The cannula restricts the movements of the child and impairs feeding, washing, play and care
• Extravasation into the tissue or misplacement of the cannula in an artery can cause skin necrosis
and other complications

Malaria

Refer to national guideline for malaria treatment; Malaria, Diagnosis and Treatment Guidelines for Health
Workers in Ethiopia, 2nd edition, Federal Ministry of Health, July 2004.. Never give intravenous infusions
of quinine to a severely malnourished case within the first two weeks of treatment. Impregnated bed
nets should always be used in malaria endemic regions.

Measles

In in-patient settings, all children from nine months without a vaccination card should be given measles
vaccine both on admission and discharge after Phase 2.8The discharge dose is given if the child is not
transferred to OTP. If the child is transferred to OTP, the discharge dose will be given at OTP.

In out-patient settings, all children from nine months without a vaccination card should be given measles
vaccine during the fourth week of treatment (including those that have been initially treated as in-
patients).

8 The first measles dose often does not give a protective antibody response. It is given because it ameliorates the
severity of incubating measles and partially protects from nosocomial measles. This is usually unnecessary with
out-patient treatment. The second or week four dose is given to provoke protective antibodies.

67
 Deworming

Albendazole or Mebendazole is given at the start of Phase 2 for patients that will remain as in-patients.

For both those transferred from in-patients to Phase 2 as out-patients and those admitted directly to
OTP de-worming is given at the second out-patient visit (after seven days). Deworming tablets should
only be given to children aged two years old and above.

Table 8 Deworming tablets dosage and schedule

Give a single dose if child is ≥ 2 years

and didn’t get within the previous 6 months

Mebendazole Mebendazole Albendazole

Albendazole
Age 500 mg tablet, or Syrup, Syrup,
400mg tablet
5 tablets of 100 mg 100mg/5ml 100mg/5ml

2-5 1 tablet 5 tsp 4 tsp

1 tablet
years ( 500mg) (25ml) (20ml)

Table 9 Summary table of systematic treatment of patients

Direct admission to in-patient

Direct admission to out-patient
(Phase 1)

- Every day in Phase 1 + for four more - One dose at admission + give treatment
Amoxicillin
days during the Transition Phase for seven days at home

Measles (from 9 - One vaccine at admission if no card - One vaccine during the fourth week
months old) - One vaccine at discharge (fourth visit)

Iron - Add to F100 in Phase 2 - No - iron is already in all RUTF

- One dose during the second week

Deworming - One dose at the start of Phase 2
(second visit)

Care for skin and bathing the child

Bathe children daily unless they are very sick. If a child is very sick, wait until the child is recovering to
bathe him/her. If the child does not have skin problems, or has only mild or moderate dermatosis, use
regular soap for bathing. If the child has severe (+++) dermatosis, bathe for 10-15 min/day in 1per cent
potassium permanganate solution.

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Care for the eyes

Chloramphenicol or tetracycline eye drops are given for eye infections or possible eye infections.
Atropine eye drops are used to relax the eye when there is corneal involvement (i.e., corneal clouding or
ulceration). In some cases both types of eye drops may be needed.

Here is a summary of the eye drops needed for the eye signs discussed within these guidelines:

If the child has: Then:

Bitot’s spots only (no other eye signs) No eye drops needed
Give chloramphenicol or tetracycline
Pus or inflammation
(1per cent) eye drops

Give both:
- Chloramphenicol or tetracycline
Corneal clouding or Corneal ulceration
(1per cent) eye drops and
- atropine (1per cent) eye drops

Doses are as follows. Place drops into the affected eye(s):

• Chloramphenicol or tetracycline (1per cent): one drop, three to four times daily for 7 to 10 days
• Atropine (1per cent): one drop, three times daily for three to five days.

If both types of drops are needed, they may be given at the same time for convenience. For example,
give tetracycline four times daily, and at three of those times also give atropine. Continue drops for seven
to ten days. If eye signs persist after 10 days, consult an eye specialist.

Use special care and tenderness in examining the eyes and placing eye drops. To avoid spreading
infection, use a separate dropper and bottle for each child. Also be sure to wash hands before and after
treating each child. Cover the affected eyes with saline soaked eye pads, and bandage the eyes. Open
only for applying eye drop medications. The affected eye(s) should also be cleaned with 0.9per cent
saline solution until inflammation and irritation subside. Some severely malnourished children sleep with
their eyes open. Nurses should gently close the child’s eyes while sleeping to prevent abrasion.

Follow up vital signs and recognizing danger signs

Pulse will be measured, respirations will be counted and temperature will be measured every six hours,
before feeding. This monitoring is very important because an increase in pulse rate or respiratory rate can
signal a problem such as an infection, or heart failure from over hydration due to feeding or rehydrating
too fast. An increase or decrease in temperature to above or below normal can indicate infection.

It is critical to monitor the child closely (every six hours) during Phase 1 and during the Transition Phase.
After the child is stable and feeding freely on F-100 during Phase 2, you may decrease monitoring pulse,
respirations and temperature to once a day as long as the child is gaining weight. If there is no weight

69
 gain, or if the child loses weight, resume monitoring every six hours.

Record results of monitoring on the surveillance section of the multi-chart that allows you to record only
two records of temperature and one reading of pulse and RR per day. However, a child with medical
complications like, shock, dehydration, heart failure, hypoglycemia, hypothermia needs close follow up;
thus prepare your own monitoring chart for pulse, respiration and temperature with four readings per
day.

Recognize danger signs

Changes in pulse, respirations, temperature

The following increases in pulse and respiratory rate should be confirmed in order to determine if there
is problem:

• If pulse increases by 25 or more beats per minute from the last measurement, confirm in
30 minutes*
• If respiratory rate increases by five or more breaths per minute from the last measurement,
confirm in 30 minutes.*

* If on IV fluids, confirm in 10 minutes and watch closely.

If the above increases in pulse AND respiratory rates are BOTH confirmed, they are a danger sign.
Together, these increases suggest an infection, or heart failure from over hydration due to feeding or
rehydrating too fast. Call a doctor for help. Stop feeds and ReSoMal and slow fluids until a doctor has
checked the child.

If just the respiratory rate increases, determine if the child has fast breathing, which may indicate
pneumonia. If the child is from 2 up to 12 months old, a rate of 50 breaths per minute or more is
considered fast. If the child is 12 months up to 5 years old, a rate of 40 breaths per minute or more is
considered fast.

If just the pulse increases, there is no cause for concern, as the pulse may increase for many reasons,
such as fear or crying.

If a child’s axillary temperature drops below 35 0C, the child is hypothermic and needs re-warming.
Have the mother hold the child next to her skin, or use a heater or lamp with caution. Be sure the room
is warm (28 – 32 0C if possible) and the child is covered. Hypothermia may be a sign of infection.

Increases in temperature can also indicate infections. A sudden increase or decrease in temperature
should be closely followed for immediate identification of possible cause and swift action. Changes
in temperature can easily be seen on the temperature graph of on the monitoring record for pulse,
respiratory rate and temperature.

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 Summary of Danger Signs Related to Pulse, Respirations, and Temperature
Vital signs Description Suggestions:
Pulse and Confirmed increase in pulse rate of 25 or Infection or
Respirations more beats per minute, along with confirmed
increase in respiratory rate of five or more Heart failure (possibly from overhydration due to
breaths per minute feeding or rehydrating too fast)

Respirations Fast breathing:

only • 50 breaths/minute or more in child 2 Pneumonia
months up to 12 months old
• 40 breaths/ minute or more in child 12
months up to 5 years

Temperature • Temperature <35 0C Hypothermia (possibly due to infection, a missed

• Temperature ≥38.5 feed, or child being uncovered) Infection
• Any sudden increase or decrease of
axillary temp within the normal range.

Other danger signs

In addition to watching for increasing pulse or respirations and changes in temperature, watch for the
following danger signs and alert a physician if any of these danger signs appear.

 anorexia (loss of appetite)

 change in mental state (e.g., becomes lethargic)
 jaundice (yellowish skin or eyes)
 cyanosis (tongue/lips turning blue from lack of oxygen)
 difficult breathing
 difficulty feeding or waking (drowsy)
 abdominal distention
 new oedema
 large weight changes
 increased vomiting
 petechiae (bruising)

Provide continuing care at night

Many deaths in severely malnourished children occur at night because a feed is omitted or the child
becomes uncovered and cold. It is extremely important that enough staff are assigned to work at night,
and that they are properly trained.

Night staff must:

 Keep each child covered to prevent [Link] each child according to schedule during
the night (at first this will be
every three hours). This will involve gently waking the child to feed.
 Take six hourly measurements of pulse, respirations, and temperature.
 Watch carefully for danger signs and call a physician if necessary.

71
 Weigh the child daily and maintain weight chart

After weighing the child each day, record the child’s weight on the anthropometric section of the multi
chart. Then, plot the child’s weight on the Weight Chart included in the multi chart. The Weight Chart
will visually show the child’s progress towards discharge weight, any loss of weight due to oedema or
failure to improve.

2.1.7 Monitoring and problem solving in Phase 1

Many types of problems may occur in a severe malnutrition ward/inpatient care. There may be problems
with an individual patient’s progress or care, such as failure to gain weight or treat an infection. There
may also be problems that affect the entire ward, such as problems with staff performance, food
preparation or ward procedures or equipment. All of these problems require attention to prevent patient
deaths. A process of systematic identification of the problems and determination of the solution is
needed. The process includes:

I. Identifying problems through monitoring

II. Investigating causes of problems
III. Determining solutions
IV. Implementing solutions

This process can be used to solve problems with individual patients or problems that may affect the
entire ward.

This session also describes the multi chart relevant for monitoring and the monthly reporting formats.

Use a process to identify and solve problems

I. Identify problems
Identify problems by monitoring. By monitoring individual patient progress, weight gain and care, you
may identify problems such as failure to regain appetite or presence of unrecognized infection. By
monitoring overall weight gain on the ward, patient outcomes and the case-fatality rate, problems like
high mortality or defaulter rates could be identified. Additional problems could be identified by looking
closely at case management practices, food preparation, ward procedures and hygiene.

II. Investigate causes of problems

It is critical to find the cause(s) of a problem before trying to solve it. Different causes require different
solutions. Investigation of causes may involve doing laboratory tests for a patient, observing and asking
questions of staff, reviewing patient records, and/or monitoring food preparation and ward procedures.

72
III. Determine solutions
Solutions will depend on the causes of the problems. For example, if staff do not know how to do a
new procedure, a solution may be training. On the other hand, if the cause is a lack of equipment or
supplies, a different solution is needed. Solutions should remove the cause of the problem, be feasible
(affordable, practical, realistic); and not create another problem.

IV. Implement solutions

Implementing a solution may be relatively simple (such as speaking with an individual staff member, or
changing a child’s feeding plan) or quite complex (such as changing staff assignments throughout the
ward). Good communication with staff is important whenever any changes are made.

To promote good communication when solving problems:

• Hold regular staff meetings, during which positive feedback is given and any problems, causes
and solutions are discussed
• Provide staff with job descriptions, which list their assigned tasks
• Provide clear instructions whenever any change is made
• Provide “job-aids” such as checklists or posted instructions for any complex tasks (E.g. laminated
F-75 and F-100 reference cards.)

Follow up to determine if a solution is implemented as intended. Then, continue monitoring to determine

whether the problem is solved. Give feedback to staff that includes praise for work done well, along
with any instructions for improvement.

Monitor and solve problems of individual patients

Monitor individual patient progress and care

Nursing staff should monitor certain signs (such as pulse rate, respiratory rate, and temperature)
repeatedly during the day, especially during Phase 1 or initial treatment (as discussed in daily care
session). If there are danger signs (such as increasing pulse and respiratory rate, or a sudden drop in
temperature), the staff should immediately respond as described in Initial Management and Daily Care.
Otherwise, information is simply recorded on the multi chart, where it is reviewed by a clinician during
rounds.

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 Identify the child who is failing to respond

A child is failing to respond if he or she:

• does not improve initially (primary failure); or

• Deteriorates/regresses after having progressed satisfactorily to Phase 2 with a good appetite

and weight gain in the Transition Phase for in-patients and deteriorates after an initial response
in out-patients (secondary failure).

Failure to respond is a “diagnosis” in its own right. It should be recorded on the chart as such and the
child should then be seen by more senior and experienced staff. Some criteria for failure to respond are
listed below as a guide:

Criteria Approximate time after admission

Child in Phase I (Primary Failure)
• Failure to regain appetite Day 4
• Failure to start to lose edema Day 4
• Edema still present Day 10
• Failure to enter Phase 2 and gain more than 5g/Kg/d Day 10

Child in Phase 2 ( Secondary Failure)

• Failure to gain at least 5 g/kg/day for three successive During Phase 2

days after feeding freely on F-100

Note: the day of admission is counted as day 0

Monitor and solve problems for the ward

Compile data on weight gain in the inpatient care

Once a month, review records for the SC or inpatient care ward for a given week (for example, the first
week of the month) and compile data on Average Weight Gain Tally Sheet for the ward. Average Weight
Gain sheets are useful for showing the quality of feeding.

To complete the tally sheet:

• Identify the children who were on Phase 2 for the entire week. (Only children in Phase 2 are
expected to gain weight.)
• Calculate the average daily weight gain for each of these children

Determine if there is a problem with weight gain in the ward

If the weight gain of 20 per cent or more of the children in Phase 2 (on F-100) is poor, there is a problem
that must be investigated. If there is a negative change as compared to previous months, there may also
be a problem. For example, if the percentage of children in the “moderate” column increases and the
percentage in the “excellent” column decreases, investigate the reasons for this change.

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Tag adverse outcomes on the multi-chart

Use a colored tag or some other means to indicate records with adverse outcomes (that is, death,
defaulter or referrals). The tag will make these records easy to find in the files when you are doing a
review.

Review patient records for common factors in adverse outcomes

Periodically and whenever there is a death, review patient records. Take note of common factors that
would suggest areas where case management practices or ward procedures may need to be carefully
examined and improved.

For example, note whether recent deaths have occurred within the first two days after admission or later.
Deaths that occur within the first two days are often due to hypoglycemia, over hydration, unrecognized
or mismanaged septic shock or other serious infections. Deaths that occur after two days are often due
to heart failure; check to see if deaths are occurring during transition to F-100.

An increase in deaths occurring during the night or early morning, or on weekends, suggests that care
of children at these times should be monitored and improved. For example, if there are many early
morning deaths, it is possible that children are not being adequately covered and fed during the night.

If many mothers are choosing to take their children home after only a few days, look for common
reasons. Are the mothers unable to leave other children at home? Is the ward uncomfortable for them?
Are the staff unfriendly? Early departures also suggest a need to monitor and improve ward conditions
and procedures.

Review of patient records for adverse outcomes can provide a basis for staff to discuss and solve
problems.

Criteria to move from Phase I

Details of criteria
to Transition Phase

From Phase 1 to Transition Phase • Return of appetite (easily finishes the F-75 feeds) and
• Reduced oedema or minimal oedema (++ or less) and
• No IV line, No NGT

Back from Transition Phase to Phase 1 • If the patient gains weight more rapidly than 10g/kg/d (this indicates
excess fluid retention)
• If there is increasing oedema
• If a child who does not have oedema develops oedema
• If there is a rapid increase in the size of the liver
• If any other signs of fluid overload develop
• If tense abdominal distension develops
• If the patient gets significant re-feeding diarrhoea so that there is weight
loss
• If patient develops medical complications
• If NG tube is needed
• If a patient takes less than 75per cent of the feeds in Transition Phase
even after interchange between RUTF and F100

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 2.1.8 Transition Phase
During the Transition Phase, a new diet is introduced: F100 or RUTF. This phase prepares the patient
for Phase 2 treatment either as an in-patient or, preferably, as an out-patient. The Transition Phase
should last between one and five days – usually two or three days.

Feeding in Transition Phase

The ONLY change that is made to the treatment on moving from Phase 1 to the Transition Phase is a
change in the diet that is given from F75 to RUTF or F100.

Once children are stabilized, have appetite and reduced oedema and are therefore ready to move into
the rehabilitation phase, they should transition from F-75 to RUTF or F100. The Transition Phase should
be used to prepare the children for outpatient treatment unless in exceptional circumstances.

Start feeding by giving RUTF as prescribed for the Transition Phase. Let the child drink water freely. If
the child does not take the prescribed amount of RUTF, then top up the feed with F-100. If the child
does not take the prescribed amount for Transition Phase over a 24 hour period, keep the child for one
more day. Ensure that the child is transferred to OTP after taking the RUTF well. If the child takes RUTF
and asks for more, give more.

The number of feeds, their timing and the volume of the diet given remains exactly the same in Transition
Phase as it was in Phase 1.

• Use RUTF in the Transition Phase. Those children who are going to continue treatment as
out-patients with take-home treatment should be changed to RUTF rather than F100 during
the transition phase. See annex 6 for look up table on amount of RUTF and F100 to be
given in transition phase. No other food should be given to the patient during this period.
They should be offered as much water to drink as they will take during and after they have
taken some of the RUTF.

OR

• Use F100 (130ml = 130kcal) in the Transition Phase. It is made up from one large package
of F100 diluted into 2 litres of water or one small package diluted into 500 ml of water

• In all cases, breastfed children should always get the breast-milk before F100 and on
demand.

Even if the child is going to remain in a facility for Phase 2, RUTF can be given for Transition Phase in
place of F100. Frequently, particularly at health centre level, F100 is given during the week days and
RUTF at night and during weekends to give a total intake equivalent to the amount in the table 10 and
11.

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Some patients initially refuse the RUTF. If this is the case, they should be given the F100 diet for one or
two days and then the RUTF re-introduced. Other children prefer the RUTF. It is good practice to give
the diet that the children prefer–the two options are nutritionally equivalent.

Warning: F100 should never be given to be used at home. F100 is always prepared and distributed in
an in-patient unit. F100 should not be kept in liquid form at room temperature for more than three hours
before it is consumed: if there is a refrigerator and a very clean kitchen/utensils, then it can be kept (cold)
for up to 12 hours. A whole day’s amount should never be made up at one time.

RUTF can be used both in in-patient and out-patient programs.

Table 10 Transition Phase: amount of RUTF to give

The amounts given in the above table are for the full 24 hour period. The amounts represent an
average increase in energy intake of about one third over the amount given during Phase 1. However,
this varies between an increment of 10per cent and 50per cent depending upon the actual weight
and the product used.

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 Table 11 Transition Phase: amount of F100 to give

Each of the RUTF products is nutritionally equivalent to F100, with the exception that they have an
appropriate amount of iron added during manufacture for children in Phase 2 (i.e. children who pass
the appetite test).

If both F100 and RUTF are being given, they can be substituted on the basis that about 100ml of F100
= 20g of RUTF9.

The table above gives the amount of F100 (full strength), that should be offered to the patients in
Transition Phase. They should normally be taking six feeds during the day and evening and none at
night. The table below gives the amount of RUTF to give per feed if some of the feeds are being given
as F100 and others as RUTF.

9 This is an acceptable approximation. If tables are to be constructed then 100 ml of F100 = 18.5g of RUTF: 10g of
RUTF = 54ml of F100 should be used and the resulting values rounded to the nearest 5 or 10 ml

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Table 12 Amount of RUTF to give for meal substitution when mixed feeding with F100 and RUTF is being used

A common variation is to give five or six feeds of F100 during the day and then two or three feeds of
RUTF during the night–this means that eight feeds in total are given during the day. The volume of F100
is then read off from the previous table and the grams of RUTF from the next table, both using the eight
meals per day column and the appropriate weight class.

Routine medicine during the Transition Phase

* Routine antibiotics should be continued for four more days after Phase 1 or until transferred to Phase 2
as an out-patient (patients entering OTP after having been in a facility do not need to be given antibiotics).

Monitoring and Problem Solving during the Transition phase

The surveillance of Phase 1 is maintained during the Transition Phase.

As the patient is now taking more than maintenance amounts of food, weight gain is expected. Because
it takes an average of about 5 kcal to make one gram of new tissue, the expected rate of weight gain
for marasmic patients during the Transition Phase is about 6 g/kg/day. This is the case if all the food is
taken by the patient and there is not excessive malabsorption.

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 Criteria to move from Transition to Phase 2 and from Phase 2 back to Phase I

from Transition phase Transition takes 2-3 days. After transition, the child is in the Phase 2 (“rehabilitation”
to Phase 2 feeding phase). A child is ready for Phase 2 if the following criteria are fulfilled:

• If he/she has a good appetite. This means taking at least 90per cent of the
RUTF or F100 prescribed for the Transition Phase.
• Edematous patients should remain in Transition Phase until there is a definite
and steady reduction in oedema (now at + level):
• For those who are going to remain as inpatients, they should normally remain in
Transition Phase until they have lost their oedema entirely.
• For those who are going to continue as OTP, they can go when their appetite is
good and they have reduced their oedema to ++ or +.

back from Phase 2 A child who has any one of the following should be returned to Phase 1:
to Phase 1
• Any signs of a complication
• Increase/development of oedema
• Development of refeeding
• Diarrhoea sufficient to lead to weight loss
• Weight loss for two consecutive weighings
• Static weight for three consecutive weighings
• Fulfilling any of the criteria of “failure to respond to treatment”

2.1.9 PHASE II (In-patient)

Phase 2 can be managed in the health facility, using F100 or RUTF, or in the community, using RUTF. It
is preferable to treat children in their communities. Never give F100 to be used at home, only use RUTF.
The principles of the treatment in the facility and in the community are exactly the same, however, the
diet, organization and documentation are different.

There has to be effective communication between the staff running the in-patient and the out-patient
services.

A child that is ready to go to Phase 2 should always be treated at home when the following are in place:

1. a capable caregiver
2. The caregiver agrees to out-patient treatment
3. There are reasonable home circumstances
4. There is a supply of RUTF
5. An OTP program is in operation in the area close to the patient’s home

Feeding in Phase II Inpatient

Feeds/Diet (F100 or RUTF)

In Phase 2, the patients have an unlimited intake. If significant “re-feeding diarrhoea” occurs so that they
lose weight, they are put back to the Transition Phase or to Phase 1; out-patients that lose weight are
transferred back to the in-patient facility.

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If mild “re-feeding diarrhoea” occurs, then it should not be treated unless there is also a loss in weight.
If there is a loss of weight, then return the child to Phase 1.

If a major illness occurs during Phase 2, particularly during the first week, the patient should be put
back to Phase 1 and given F75; out-patients should be transferred back to the in-patient facility for a
short time.

Breastfed children should always get breast-milk before they are given F100 or RUTF and also on
demand.

Diet to use

F100 or RUTF are used in Phase 2. Never give F100 to be used at home, use RUTF.

F100 (100ml = 100 kcal): five feeds of F100 are given. One porridge may be given for patients who are
more than 8kg (approximately 24 months of age); it is not necessary to give porridge unless the patient
asks for it. Five feeds of F100 should be given to those who are less than 8kg. RUTF: RUTF can be
used in both in-patient and out-patient settings.

 For breast-fed children, always give breast milk before RUTF

Amounts of feeds to give

For in-patients, offer the amount of feed given in the table 10. Either F100 or RUTF can be given. The
children must NEVER be force fed. After the feed, always propose an additional quantity to the patient
if the child takes all the feed quickly and easily. They should be able to take as much as F100 or RUTF
as they want.

As much water as is needed must be offered during and after the feed to satisfy the patient’s thirst when
RUTF is given. Thanks to the fact that RUTF can be kept safely, the amount for several feeds can be
given to the patient at one time. This is then eaten at the patient’s leisure, in his/her own time. This is
used in day-care when feeding is given overnight, at weekends or during staff shortages.

Routine medicine in phase II inpatient

* Iron: is added to the F100 in Phase 2. Add one crushed tablet of ferrous sulphate (200mg) to each 2
litres to 2.4litres of F100. For lesser volumes: 1000 to 1200ml of F100, dilute one tab of ferrous sulphate
(200mg) in 4ml water and add 2ml of the solution. For 500ml to 600ml of F100, add 1ml of the solution.
RUTF already contains the necessary iron.

* De-worming: Albendazole or Mebendazole is given at the start of the Phase 2 for patients that will
remain as in-patients

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 De-Worming tablets are only given to children two years of age and above (see table 10 above).

Monitoring and problem solving in phase II inpatient

Frequency In-patient Out-patient

Weight and oedema Daily Every visit
Height/Length is measured Every three weeks As required1
Every month

Body temperature is measured and pulse and respiratory rates are Every six hours in P1 Every visit
counted & Transition and once
per day in Phase II

History of the medical condition (vomiting, stool, fever, cough, Every day Every visit
appetite, etc.)

Standard clinical signs, physical examination to detect medical Every day Every visit
complication

MUAC is taken Every week Every visit

Appetite test is conducted Intake record is kept Every visit
on the chart

Criteria to move back from Phase 2 to Phase 1

Patients who develop any signs of a complication should be returned to Phase 1.

Out-patients who develop the signs of a serious medical complication (pneumonia, dehydration, etc. -
should be offered transfer to the in-patient facility for management of their condition until they are fit to
return to Phase 2 as out-patients.

In addition, if the patient being treated as an out-patient develops any of the following s/he should be
transferred to the in-patient facility:

 Failure of the appetite test

 Increase/development of oedema
 Development of refeeding diarrhoea sufficient to lead to weight loss
 Fulfilling any of the criteria of “failure to respond to treatment”
 Weight loss for two consecutive weighing
 Weight loss of more than 5per cent of body weight at any visit.
 Static weight for three consecutive weighing
 Major illness or death of the main caregiver so that the substitute caregiver requests in-
patient management

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Monitor treatment outcomes
Record each patient’s outcome on the multi-chart

On the front page and at the right upper corner of the MULTI-CHART, there is a discharge box for
recording patient outcomes. Record the outcomes for the patient whether they are successful or not.
Record any relevant comments, such as circumstances and causes of adverse outcomes. Record the
discharge outcomes in the outcome column and the reasons for any discharge outcomes, and within
how many hours the death occurs in the remark column of the Registration Book too.

Discharge Outcomes
1. Successful outcome:
Cured (Recovered): child that has reached the discharge criteria for in-patient care

Transfer Out to OTP: Child that is transferred from in-patient care to OTP.

2. Adverse outcomes:
Defaulter: Child that is absent for two consecutive days in in-patient care

Death: Patient that has died while s/he was in the in-patient care. Register after how many days the
death happened (<24 hrs, 1-3 days, 4-7 days, and >7 days)

Non-responder: Patient that has not reached the discharge criteria after 40 days in inpatient care

Medical Transfer: child is referred to higher health facilities for medical reasons and the referring health
facility will not continue the nutritional treatment or transfer the child back to the program( see annex 20
:example of filled multi chart)

2.1.10 Outpatient Care for the management of SAM (care plan C)

Introduction

Community-based management of SAM is implemented through the OTP. The 2007 joint statement
by the World Health Organization (WHO), World Food Program, United Nations Standing Committee
on Nutrition, United Nations Children’s Fund has endorsed the community based management of
uncomplicated SAM.

Children who are identified as having SAM should first be assessed with a full clinical examination to
confirm whether they have medical complications and whether they have an appetite. Children who
have appetite (pass the appetite test) and are clinically well and alert should be treated as outpatients.
Children who have medical complications, severe oedema (+++), marasmic kwashiorkor or poor appetite
(fail the appetite test), should be treated in an inpatient facility. Children with SAM who are admitted as

83
 in-patients can be transferred to outpatient care when their medical complications, including oedema,
are resolving and they have a good appetite, and are clinically well and alert. The decision to transfer
children from inpatient to outpatient care should be determined by their clinical condition and not on the
basis of specific anthropometric outcomes such as a specific MUAC or weight-for-height/length

Admission criteria

Children 6 to 59 months who have uncomplicated SAM are admitted to OTP; this includes children with
MUAC<11.5cm, weight for height z-score <-3 or oedema +/++ AND:

 who pass the appetite test

 without medical complications without +++ edema or marasmic Kwashiorkor

OTP Admission Procedure

Out-patient care in the community should also be organised from HPs or HCs or even non-clinical
facilities that are close to the patients’ homes. The patients are attended to on a weekly basis. Most
patients can be managed entirely on an out-patient basis; so that there are normally many more out-
patients than in-patients. For each in-patient facility there should be several/many satellite out-patient
distribution and assessment sites (“OTP sites”) close to the community.

If a child meets the admission criteria for OTP,

1. Explain to the care taker the condition of the child and the need for regular follow up

2. Register the patient on the OTP Registration Book

3. Fill out the outpatient care treatment card (OTP card): All information is recorded on the
child’s OTP card, which is kept on file at the health facility. The health care provider should
complete an OTP card for all children admitted to OTP.

Management of SAM in OTP

The HW provides the child with the following outpatient care services:

• Routine medication as specified in this guideline

• Provide RUTF adequate until the next visit
• Counsel the mother/caregiver with OTP key messages
• Link to other services, programs or initiatives as appropriate (e.g., TSFP, Voluntary counseling
and testing [VCT], Vaccination, GFD, PSNP and other food security initiatives).

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Routine Medicines

Routine medicines are given to all children admitted to outpatient care whether or not they show
symptoms because ill children with SAM might have suppressed immune systems and not show
symptoms until they begin to recover from SAM. As indicated in a prospective, randomized, double-blind
trial in southern Malawi, children with uncomplicated SAM, managed as outpatients were randomized
to receive either one week of amoxicillin 80–90 mg/kg/day, cefdinir 14 mg/kg/day or placebo The rate of
nutritional recovery [amoxacilline 89per cent vs placebo 85per cent] and mortality [amoxacilline 4.6per
cent vs placebo 7.5 per cent] of children who received antibiotics was significantly better than that of
those who received placebo(12)

A. How to give antibiotics: Amoxicillin oral is given routinely on admission irrespective of any clinical
sign of disease), If Amoxicillin is not available, give cotrimoxazole. Amoxicillin is given orally 50-
100mg/Kg/day divided in two doses for 7 days; OR cotrimoxazole (SMX+TMP), 25mg SMX+5mg
TMP/Kg/day divided two doses for seven days.
B. Give folic acid: this is a vitamin important for treating and preventing anemia and repairing the
damaged gut. There is sufficient folic acid in RUTF to treat mild folate deficiency. On the day of
admission, one single dose of folic acid (5 mg) should be given to children with clinical signs of
anemia.
C. Give vitamin A: vitamin A is available in RUTF and should not be given routinely as a supplement.
The vitamin A supplement is given only to children with signs of Vitamin A deficiency and measles.
These children will receive the recommended high dose Vitamin A on day 1, day 2 and day 15.
Any child with corneal clouding or ulceration should be treated as an in-patient as the condition
of their eyes can deteriorate very rapidly.
D. Give Measles Vaccine: All children from nine months who are not vaccinated should be given
the measles vaccine on the fourth week (including those that have been initially treated as in-
patients). It is given on the fourth week when there should be sufficient recovery for the vaccine
to produce protective antibodies and prevent subsequent measles attack.
Note: Patients directly admitted to OTP are unlikely to be incubating measles and will not be
exposed to nosocomial infection. Measles vaccine on admission to OTP is thus omitted except in
the presence of a measles epidemic.
E. Give deworming tabs: Worms are common in older children who play outside and they can be a
problem in severely malnourished children. They can cause dysentery and anemia. Albendazole
400mg or Mebendazole 500mg is given only once for children 2 years and above at the second
out-patient visit (after seven days) for both those admitted directly to OTP and those transferred
from in-patients to OTP without receiving deworming tablets on discharge.
F. Iron: Since RUTF contains the required amount of iron and folic acid, additional iron should not
be given to a child who is taking RUTF. If anemia is identified, it should be treated according to
Integrated Management of Neonatal and Childhood Illnesses (IMNCI) guidelines, and treatment
should be given after 14 days in the OTP service. Cases of severe anemia should be referred to
inpatient care.
G. Malaria Treatment: Investigate and treat malaria according to the national protocol of Malaria
and IMNCI Treatment and referral guideline.

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 Nutritional rehabilitation with RUTF (PlumpyNut)

RUTF, mainly Plumpynut, is high-energy, nutrient-dense therapeutic food that is used to treat SAM in
OTP. It is similar in composition to F100 (except plumpynut contains iron and is about five times more
energy nutrient dense). There are two types of RUTF: soft lipid-based paste (Plumpynut®) or crushable
nutrient bar (BP100), which is available mainly during emergencies. PlumpyNut has a caloric value of
545 kilocalories (kcal) per 100 g of product. RUTF has enabled the treatment of SAM to move outside
of feeding centers and into the community because of the following properties: it has minimal water
content and does not need to be cooked or mixed with water, which prevents growth of bacteria and
makes it safe and easy to use for out-patient or home management of SAM.

Amount of RUTF to give: The number of packets of RUTF given is based on the weight of children and
the frequency of follow up with enough amounts until the next visit. It continues to be taken regularly,
until the child is fully recovered. Plumpy’nut is the most common RUTF available at health facilities in
Ethiopia. Refer annex 14 for reference table.

Counsel on Key Messages of OTP

The details of the following key messages are given to mothers/caregivers and it is available in the
training BINLM module:

• How to feed RUTF to the child

• breast feeding
• Complementary feeding
• hygiene and how to care for the SAM child
• When and how to give the routine medicines to the child
• When to return to outpatient care for follow up and the child should be brought to the health
facility immediately if his/her condition deteriorates
• The RUTF is a food and medicine, only for malnourished children, It should not be shared
• How opened packets of RUTF can be kept safely and eaten at a later time

Emotional and physical stimulation

Emotional and physical stimulation through play programs from the start of treatment and after discharge
can substantially reduce the risk of permanent mental retardation and emotional impairment. Ensure
that the child is stimulated by the mother.

Follow-up in OTP

Follow-up of children being managed as outpatients, including monitoring of their response to treatment
and provision of the next supply of RUTF, should be done, ideally weekly, by a skilled HW in a nearby
clinic or in the community.

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Children treated in OTP are seen by a HW every week to assess progress through anthropometric
measurement and oedema checkups, appetite tests at each visit, use of RUTF, monitor weight gain,
do medical assessment and detect associated medical problems/illnesses or complications requiring
treatment or referral to inpatient care or risks that need home visits. The HW checks for weight, oedema
and MUAC every week and for height every month.

Follow up actions will include: A child might:

• Continue OTP without home visit if the progress is satisfactory

• Continue OTP with home visit support if there is progress but it is not satisfactory

• Be transferred to in-patient care if there are medical complications or failed the appetite tests

• Referred to a higher-level referral hospital for other underlying medical complications.

Follow up of absentees and defaulters

If children default and do not complete the treatment, they are still at risk of death. Each week a list
of absentees/defaulters can be compiled. In order to be able to trace absentees/defaulters, it is very
important that the address section of the OTP card is correctly filled out. The health facility can liaise
with community members/Health Development Army (HDAs)/WDAs and health extension workers to
follow up absentees and defaulters. If defaulters are traced and come back to the health facility, they
are admitted and continue the treatment as return after defaulting. This can happen only if they do not
fulfill the discharge criteria (that they are recovered).

Transfer to and from in-patient care

Children on OTP care and who develop any danger signs or signs of medical complications, or have
treatment failure/failure to respond, should be referred to the in-patient facility for management of their
condition, until they are fit to return and continue in OTP care. In addition, if the patient being treated as
an inpatient has improved [medical complication resolved, oedema reduced and appetite returned] he/
she will be transferred to a nearby OTP site.

If a child requires in-patient care, all anthropometric measurements, medical history and physical findings
are recorded in the OTP card and the child is classified as transfer. The card is filed in the discharge
folder until s/he comes back after the severe medical complications have been treated.

Explain to the caregiver that her child requires in-patient care and ask, if she is willing to go. Explain to
her also, that once the child is discharged from the inpatient care, she should bring her child back to
OTP. If you are referring the child to another health facility, clearly fill in the referral form and send it to
the nearest health facility providing inpatient care. Many caregivers refuse transfer to in-patient due to
distance, cost of travel, unwillingness to leave other kids at home, etc. The HW should try to persuade
the caregiver. If this fails, the child should be treated in OTP; it should be recorded as ‘refused transfer’.

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 Failure to respond

There are two types of failure to respond to SAM management in OTP:

• Primary failure: failure to start to lose oedema on second visit [day 15]; or oedema still present
or no weight gain on day 21 [third visit]

• Secondary failure: failed appetite test or 5 per cent weight loss or no weight gain for two
consecutive visits or failure to gain 2.5g/kg/day on day 21 for edematous child or on day 15 for
a non-edematous child in OTP care

Causes of failure to respond

The HW should investigate the cause of treatment failure in OTP so as to identify the cause early and
take action on time. This will help to improve the quality and performance of the OTP care. Usual causes
of treatment failure in OTP include problems with the treatment facility or the HW or the individual child.

Some of the actions required when failure to respond is commonly seen in a program are:

• Follow-up through home visits by HEWs/HDAs/outreach workers to check whether a child

should be referred back to the clinic between visits

• Discuss with caregivers on aspects of the home environment that may be affecting the child’s
progress in the program

• A follow-up home visit is essential when:

o Caregiver refused admission to in-patient care despite advice

o Failure to attend appointments at the out-patient program

• At the health facility carry out medical check and appetite test;

• Re-calibration of scales and length-boards

• Review of the supervision of staff with refresher training to improve their skills

Discharge criteria from OTP

A child stays in OTP until they meet the discharge criteria or until they have been in the program for a
maximum of two months. The discharge criteria are based the WHO updated guideline in 2013(9):

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2.1.11 Criteria for discharging children from SAM treatment
A. Children with SAM should only be discharged from treatment when their: weight-for-height/
length is ≥–2 Z-score and they have had no oedema for at least two weeks

OR

MUAC is ≥12.5 cm and they have had no oedema for at least two weeks.

B. The anthropometric indicator that is used to confirm SAM should also be used to assess whether
a child has reached nutritional recovery, i.e. if MUAC is used to identify that a child has SAM,
then MUAC should be used to assess and confirm nutritional recovery.

C. Similarly, if weight-for-height is used to identify that a child has SAM, then, weight-for-height
should be used to assess and confirm nutritional recovery.

D. Children admitted with only bilateral pitting oedema should be discharged from treatment
based on which ever anthropometric indicator: MUAC or weight for-height is routinely used in
programs.

E. Percentage weight gain/target weight should not be used as a discharge criterion.

Linkage of OTP discharges to supplementary feeding:

All the patients should be discharged to TSFP for follow up where this is available or a two month
discharge ration should be given when feasible/available.

2.2 Management of infants less than 6 months with SAM

Introduction:

Severely malnourished children less than 6 months are at increased need of special care. Infants <6
months are a unique group due to their particular feeding needs, physiological and developmental
differences from older children, vulnerability to a different range of pathologies and increased
mortality risk compared to older children. Before 6 months of age, physiological processes, including
thermoregulation and renal and gastrointestinal functions, are relatively immature compared with those
of older children and may require modified management approaches or clinical interventions. The period
0-6 months is part of a larger, critical ‘window of opportunity (9 to 24 months), within which the impact
of under-nutrition has both immediate and longer term adverse consequences. Sub-optimal infant and
young child feeding practices increase vulnerability to malnutrition, diseases. The feeding of infants is
different from older children and it is also different for infants on breast feeding or with a caregiver willing
to breastfeed and for infants who cannot be breastfed. RUTF is not suitable for them, as the reflex of
swallowing is not present yet.

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 Only a few studies have examined the risk factors for young infants developing SAM; similarly, there
are few reports describing approaches to managing SAM in this age group. Risk factors for increased
mortality are likely to include recent weight loss, failure to gain weight, failure to feed effectively and
the presence of bilateral oedema. To date, management of SAM in this age group has focused on
establishing, or re-establishing exclusive breastfeeding, and, where this is not possible, there are some
reports of using formula feeds and early introduction of complementary foods to treat these infants.

The general nutritional and infant feeding principles and their application to young infants with SAM
are very important. The general principles on the care of sick neonates and infants, such as identifying
and referring infants who are seriously ill for other reasons, can reasonably be extended to infants with
SAM. The relevance and value of other existing recommendations, like WHO Guiding principles for
feeding non-breastfed children 6–24 months of age, 2005, or the WHO Infant and young child feeding
counseling: an integrated course, 2006 are still applied .

As with older children, SAM in infants who are less than 6 months of age can be “uncomplicated”
or “complicated”. These infants should be managed in outpatient or in patient settings respectively.
The potential benefits of inpatient treatment should be carefully considered against the potential risks,
especially nosocomial infections.

Infants who are less than 6 months of age have small daily weight gains that cannot easily be assessed
with standard spring scales. Health-care workers taking care of infants with SAM should use scales
with at least a 20 g precision.

2.2.1 Admission criteria to inpatient for infants under 6 month

with SAM
Severe acute malnutrition in infants who are 0–5 months of age is defined as:

 weight-for-length less than –3 Z-score, or

 presence of bilateral pitting oedema;

Infants who are less than 6 months of age with SAM and with any of the following complicating factors
should be admitted for inpatient care (care plan C):

a. Any serious clinical condition, danger signs or medical complication as outlined for infants 6
months of age or older with SAM
b. recent weight loss or failure to gain weight
c. Ineffective feeding (attachment, positioning and suckling) directly observed for 15–20 min, ideally
in a supervised separated area
d. Any pitting oedema
e. Any medical or social issues needing more detailed assessment or intensive support (e.g.
disability, depression of the caregiver, or other adverse social circumstances)
f. Infants who have been identified as having poor weight gain and who have not responded to
nutrition counseling and support should be admitted for further investigation and treatment

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For infants, less than 6 months of age with SAM and who do not have the above complicating factors,
will not require inpatient care [uncomplicated SAM in under 6 month olds]. In addition, there could be
infants whose caregivers decline admission for assessment and treatment. These infants will be cared
as outpatients through IYCF/low birth weight counseling.

2.2.2 General recommendations

Infants who are less than 6 months of age with SAM should receive the same general medical care as
infants with SAM, who are 6 months of age or older:

A. Infants with SAM who are admitted for inpatient care should be given parenteral antibiotics to treat
possible sepsis and appropriate treatment for other medical complications.

B. Infants with SAM who are not admitted should receive a course of broad-spectrum oral antibiotic,
such as amoxicillin, in an appropriately weight-adjusted dose.

Feeding approaches for infants who are less than 6 months of age with SAM should prioritize establishing,
or re-establishing, effective exclusive breastfeeding by the mother or other caregiver.

Infants who are less than 6 months of age with SAM who are admitted:

A. Should be breastfed where possible and the mothers or female caregivers should be supported to
breastfeed the infants. If an infant is not breastfed, support should be given to the mother or female
caregiver to re-lactate. If this is not possible, wet nursing should be encouraged

Should also be provided a supplementary feed: supplementary suckling approaches should, where
feasible, be prioritized(16)

B. For infants with SAM but no oedema, expressed breast milk should be given, and, where this is not
possible, commercial (generic) infant formula or F-75 or diluted F-100 may be given, either alone
or as the supplementary feed together with breast milk; for infants with SAM and oedema, infant
formula or F-75 should be given as a supplement to breast milk

C. should not be given undiluted F-100 at any time (due to the high renal solute load and risk of
hypernatraemic dehydration)

D. If there is no realistic prospect of being breastfed, the infant should be given appropriate and
adequate replacement feeds such as commercial (generic) infant formula, with relevant support to
enable safe preparation and use, including at home when discharged

E. Assessment of the physical and mental health status of mothers or caregivers should be promoted
and relevant treatment or support provided.

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 2.2.3 Management of SAM in young infants with a female caretaker
Feeding infants below six months

A WHO meeting was held in 2004 to review programmatic data and theoretical considerations on the
management of SAM in young infants. During this meeting, it was concluded that young infants with
oedema should be fed with F-75 during the stabilization phase and F-75 would not be appropriate for
infants with SAM who are severely wasted and without oedema, rather, generic infant formula or dilute
F-100 would be appropriate and safer. There was also a consensus that children who are less than 6
months old with SAM should not be given undiluted F-100, owing to high renal solute load and risk of
insufficient water intake and hypernatraemic dehydration. The meeting report described the diversity of
opinions on the feeding strategy for the rehabilitation phase.

Infants who are malnourished are weak and do not suckle strongly enough to stimulate adequate
production of breast milk. The mother often thinks that she has insufficient milk and is apprehensive
about her ability to adequately feed her child. The objective of treating these children is to return them
to full exclusive breastfeeding.

Phase 1 – Transition – Phase 2

There are not separate phases in the treatment of infants with the Supplementary Suckling (SS) technique
as in older children age 6 months to 5 years. The supplementation is given using a tube the same size
as n°8 NGT (a size n°5 tube can be used, but the milk should be strained through cotton wool to remove
any small particles that could block the tube).

Preparation of F 100 diluted One packet of F100 is diluted in 2.7 liters of water, instead of 2 liters.

To make small quantities of F100 diluted,

• Use 100ml of F100 already prepared and add 35ml of water, then you will get 135ml of F100
diluted. Discard any excess waste. Don’t make smaller quantities.
• If you need more than 135ml, use 200ml of F100 and add 70ml of water, to make 270ml of F100
diluted and discard any excess waste.

SS technique: The mother holds a cup with the F100 diluted. The end of a NG tube (size nº8) is put in
the cup, and the tip of the tube on the breast, at the nipple. The infant is offered the breast in the normal
way. The cup is placed 5–10 cm below the level of the nipple for easy suckling. When the child suckles
more strongly it can lowered to up to 30 cm (see Fig. below)

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Treatment of complications: The treatment of complication is similar to children 6 months to 5 years
(See Section on management of complications).

Routine Medicines

• Folic acid: 2.5mg (1tab) in one single dose

• Ferrous sulphate: when the child suckles well and starts to grow, use the F100, which has
been enriched with ferrous sulphate (phase 2). Dilute this with 1/3 water to obtain the correct
dilution.

Give antibiotics according to the antibiotic reference table on Management of complications

(table 6-7).

Follow up: The child is weighed every day. When the child is gaining weight at 20g/day (absolute weigh
gain) the quantity of F100 diluted in the cup is reduced by half so that the child gets more breast milk. If
after this, weight gain is maintained by 10gm/day, then stop the supplement suckling completely. When
it is certain that the child is gaining weight on breast milk alone, he/she should be discharged, whatever
his weight or weight-for-length. If the child is not gaining weight, then continue with the SS technique,
but increase the quantity of F100 diluted in the cup to 5 ml for each feed.

2.2.4 Uncomplicated SAM in young infants with prospect of breast

feeding (care plan C)
For infants who are less than 6 months of age with SAM and who do not require inpatient care or whose
caregivers decline admission for assessment and treatment:

A. Counseling and support for optimal infant and young child feeding should be provided based on
general recommendations for feeding infants and young children, including for low-birth-weight
infants
B. Weight gain of the infant should be monitored weekly to observe changes
C. If the infant does not gain weight or loses weight while the mother or caregiver is receiving
support for breastfeeding, then he or she should be referred to inpatient care
D. Assessment of the physical and mental health and nutritional status of mothers or caregivers
should be promoted and relevant treatment or support provided

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 Care for the mothers

Check nutritional status of the mother (MUAC and oedema). Explain the treatment and discourage
self-criticism for the lack of milk. She should drink at least 2 liters of water per day, and eat about
2,500 kcal/day. She should also receive Vitamin A (200 000 IU unless there is a risk of pregnancy).
Micronutrient supplementation must also be given to the mother. The mother should be counseled
strongly on exclusive breastfeeding.

2.2.5 Management of SAM in young infants who cannot be

breast-fed
The management of infants for whom there is no prospect of being breastfed (e.g. no mother, no
wet-nurse) and are less than 6 months of age or less than 3 kg, with weight-for-length < -3 Z-score or
bilateral oedema is different from those breast fed.

This treatment applies to infants less than 6 months with SAM and for whom there is no prospect of
being breastfed (e.g. no mother, no wet-nurse):

Phase 1

Treatment of complications is similar to children 6 months to 5 years (See Complication Section in

training module and in this guide).

Feeding

• Infants without oedema: Feed with diluted F 100 according to annex 6

• Infants with oedema: Feed with F 75 according to annex 7

Routine medicines is the same as those who breastfeed

Transition Phase and Phase 2

A. Feeding

• In transition and Phase 2 use Diluted F100 (RUTF is not suitable for these children) at inpatient
facility
• During Transition Phase, the amount of diluted F100 in Phase 1 is increased by one third
• During phase 2, give diluted F 100 according to annex 4

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Routine Medicines: Continue routine medicines as in Phase 1

2.2.6 Transfer to outpatient care

Infants who are less than 6 months of age and have been admitted to inpatient care can be transferred
to outpatient care when:

a. all clinical conditions or medical complications, including oedema, are resolved, and
b. the infant has good appetite, is clinically well and alert, and
c. weight gain on either exclusive breastfeeding or replacement feeding is satisfactory, e.g. above
the median of the WHO growth velocity standards or more than 5 g/kg/day for at least three
successive days, and
d. the infant has been checked for immunizations and other routine interventions, and
e. the mothers or caregivers are linked with needed community-based follow-up and support

2.2.7 Discharge criteria for infants below 6 months with SAM

Children aged less than 6 months should be discharged if they fulfill the following criteria:

A. Are breastfeeding effectively or feeding well with replacement feeds, and

B. Have adequate weight gain, and
C. Have a weight-for-length ≥–2 Z-score.

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96
CHAPTER 3
MANAGEMENT OF
MODERATE ACUTE
MALNUTRITION

97
 CHAPTER 3
MANAGEMENT OF MODERATE
ACUTE MALNUTRITION
Introduction
The management of MAM has two main aims; first to treat the MAM, itself while the other aim is to
prevent individuals with MAM from developing SAM. It can also be used as an opportunity to provide
nutrition/health education and opportunities for counselling. Protocols have changed little over the years,
however, currently management of MAM is attracting considerable review and operational research with
on-going initiatives aimed at improving the dietary management of MAM through adjusting the nutrient
composition of food supplements used and emphasizing more preventative measures. Children with
MAM have a greater risk of dying because of their increased vulnerability to infections as well as the risk
of developing SAM, which is life threatening.

Supplementary Feeding Interventions

At present, the most common interventions for the management of MAM are SFP. Supplementary
feeding is the provision of nutritious rations to vulnerable children (usually classified at 6-59 months) or
those with special dietary needs (e.g. PLW, individuals with HIV/AIDS, etc.). SFPs also provide vital links to
ongoing SAM treatment programs. In most situations, SFPs are implemented in order to prevent excess
mortality amongst vulnerable groups. SFPs can either be blanket or targeted and aim to supplement
the energy and nutrients missing from the diet due to various reasons.

During emergency situations, SFPs should be a short-term measure and not necessarily be seen as a
means of compensating for inadequate household food securityA significant and continued reduction
in the prevalence of malnutrition is likely only if an SFP is implemented alongside adequate GFD and/or
is well aligned with the PSNP.

In areas where nutritionally-targeted interventions such as TSF or TFP are in operation, the households
of individuals who are registered for such nutritional support should automatically be included in the
registration for GFD. That is, current acute malnutrition should be an inclusion criterion for general rations.
All international experience shows that supplementary feeding is only effective when the household has
adequate access to basic foods. In PSNP woredas, similarly, no household should be excluded from
nutritional programs (e.g. TSF, TFP or BSFP) on the grounds that they are already receiving support
from the PSNP. Overlaps between these programs at the household level are desirable and represent
effective targeting of complementary assistance types.

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Planning the intervention

MAM is treated in food insecure areas of Ethiopia following the bi-annual nutritional screening (EOS)
or quarterly screening (CHD). However, in times of heightened food insecurity, emergency nutrition
interventions might be required. Prior to any emergency intervention, discussions must be held with
local authorities to discuss and determine the methodology, size, location and other important features
of the proposed program. Wherever possible, programs must be run within existing health structures/
facilities. SFPs are usually implemented through a large number of decentralized sites, the number of
which will depend on the area, terrain, density of population, expected number of beneficiaries, etc.
The exit strategy of any program must be clearly identified and communicated prior to implementation.

General criteria for establishing emergency SFPs

A SFP is established based on the hotspot classification level of a woreda or emergency phase
classification of malnutrition prevalence. Details of these two are indicated below;

Hotspot classification

Setting up a TSFP response is determined based on the hotspot classification conducted following
the multi-agency government led seasonal food security assessment results. During this assessment,
data on the different indicators including the cause’s food insecurity, geographic location, the severity
of food security and nutrition situation is analyzed. Based on the assessment results and the severity of
the food security situation, woredas are classified as priority woredas 1, 2 and 3.

The TSFP intervention is therefore determined on the bases of this classification and mostly covers
priority one woredas. Some priority two woredas are also covered based on resource availability.

Emergency phase classification

The emergency phase classification is based of the nutritional assessment results of a woreda. The
below table describes the different levels of classification with the nutritional status:

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 Table 13 Ethiopia emergency phase classification and nutrition response

Indicators Stage of alert Emergency response

GAM prevalence ≥ 20per cent

And/or
SAM prevalence ≥ 5per cent
Critical Blanket SFP
GAM prevalence ≥ 15-19.9per cent
And
Aggravating factors

GAM prevalence ≥ 15 -19.9per cent and no aggravating

factors

Serious Targeted SFP

GAM prevalence ≥ 10 - 14.9per cent
And
Aggravating factors

No specific emergency programs

GAM prevalence ≥ 10 – 14.9per cent and no aggravating
(Focus on prevention of
factors
undernutrition)
Poor
GAM prevalence ≥ 5 - 9.9per cent
And
Aggravating factors

Typical for a No specific emergency programs

chronically (Focus on prevention of
GAM prevalence 2-9per cent malnourished undernutrition)
population

Source: Ethiopia Emergency Nutrition assessment guideline, 2008

Aggravating factors are defined in the Ethiopian context as:

• Increased number of admission to nutrition programs

• Poor household food availability and accessibility (due to poor harvests, poor pasture conditions,
high market prices etc.)
• Crude mortality rate ≥ 1.14 per 10,000 per day10
• U5 mortality rate ≥ 2.3 per 10,000 per day
• The GFD is below mean energy, protein and fat requirements. Outbreaks or epidemics of
communicable or vector-borne diseases are occurring. (e.g. high prevalence of respiratory or
diarrhoeal diseases epidemic of measles or whooping cough malaria, HIV/AIDS, etc.)
• Low levels of vaccination coverage
• Inadequate safe water supplies (quality and quantity) and sanitation

10 Ethiopia specific cut-off according to Ethiopia emergency assessment interim guidelines 2008. ENCU/EWRD/
MOARD

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Types of Supplementary Feeding Programs (SFPs)

Overview

SFPs need to address a variety of issues in emergencies. Individuals with MAM have additional nutritional
requirements for catch up growth. The medically ill have additional nutritional requirements for tissue
repair. The general food ration, in practice, rarely provides sufficient food to allow for catch-up weight
gain for those who are already malnourished.

SFPs aim to rehabilitate individuals with MAM or to prevent a deterioration of nutritional status of the
most at-risk groups by meeting their additional needs. In practice, SFPs focus on young children and
PLW, due to their nutritional vulnerability.

There are two types of SFPs: Blanket or Targeted. Blanket SFPs target a food supplement to all members
of a specified at risk group, regardless of whether they have MAM.

3.1 Blanket Supplementary Feeding Program (BSFP)

BSFPs are implemented at population level, therefore their objectives are primarily preventative. BSFPs
aim to prevent deterioration in the nutritional status of a population, to reduce the potential prevalence
of acute malnutrition and micronutrient deficiency in order to reduce excess morbidity and mortality
among those at-risk, through the provision of a food/micronutrient supplement.

Blanket SFPs target a food supplement to all members of a specified at risk group regardless of whether
they have MAM. Blanket SFPs are usually implemented in combination with the GFD. They can be also
be implemented as a standalone program (while waiting for the GFD to be established) or as short term
measure during a seasonal hunger gap.

In terms of process:

• All individuals in a specific group are registered for the blanket SFP

• These groups may be defined; by age (e.g. all children between 6-59 or 6-24 months); by status
(e.g. all individuals with a diagnosis of tuberculosis (TB), or all pregnant and lactating mothers)

• If possible, screening is done to ensure individuals with SAM and MAM are referred to
appropriate therapeutic and supplementary services, but anthropometric status is not a criteria
for registration in the blanket SFP

• All registered individuals receive the same nutritional support. Nutritional support is given over a
fixed period, often covering a particularly vulnerable period for the community (e.g. hunger gap,
immediately post disaster or displacement)

• Individual nutritional status is not monitored during the duration of the blanket SFP, because the
objective is to provide nutritional support at population level (i.e. prevent development and/or
deterioration of malnutrition).

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 3.1.1 Case load estimation and beneficiary identification for BSFPs
At community level, beneficiaries that fall within the defined group must then be identified, for example,
children 6 - 23 months or 6 - 59 months (less than 87 cm or 110 cm in height, respectively) and PLW.
This can be done through the woreda/kebele food security task force.

Depending on the seriousness of the situation and in discussion with local and regional authorities, it
may be decided to include other vulnerable groups in a BSFP,11 for example:

• All adults showing signs of malnutrition

• Older persons
• Those with a disability

Where possible, efforts should be made to provide Vitamin A supplements and deworming tablets
during contact points with the children on distribution days if these were not given in the past six
months. Where appropriate and resources allow, other interventions could also complement the BSFP
distribution mechanism, such as distribution of Insecticide Treated Nets (ITNs), water purification tablets,
etc. It is important to focus on nutrition, health and hygiene sensitization during any contact points with
beneficiaries. Appropriate IEC material should be disseminated/broadcasted.

3.1.2 Admission and discharge criteria for BSFP

Admission and discharge criteria for BSFPs do not rely on anthropometric indicators. Once the targeted
groups have been defined, those that meet the criteria are admitted (e.g. children aged 6 - 23 months).
After the emergency situation is stabilized and BSFP is closed, they are ‘discharged’12.

3.2 Targeted Supplementary Feeding Program (TSFP)

3.2.1 Admission criteria for TSFP

Admission to TSFPs for children 6-59 months rely on two types of anthropometric indicators of acute
malnutrition; MUAC and WFH z-score based on the 2006 WHO GS. Refer to table 2 of this guideline.

Children 6-59 months with MAM

MUAC is an internationally accepted independent criterion for admission for children 6-59 months of
age, although exact age may be difficult to obtain. Where this is so, the caregiver should be asked to
estimate the age of the child (or use the family health card, where available). The mother is likely to be
able to recall the time of birth of a young child and it is essential to obtain this information.13 Local
events calendars can help this process. Children should not only be selected on the basis of height as a

11 National Guidelines on Targeting Relief Food [Link] of Agriculture (Disaster Risk Management and
Food Security Sector), 2011Addis Ababa, Ethiopia.
12 Emergency Nutrition Intervention (ENI) Guidelines, Ethiopia, 2011.
13 A guide for selective feeding programs, UNHCR/WFP. Geneva, May 2009.

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proxy for age, as in populations with high stunting rates there will be many children older than 6 months
but shorter than 65 cm. Such children would therefore be excluded from the program if a proxy height
was used.

Infant’s under-6 months should never be included in the TSFP, but referred to the nearest TFP for
treatment when identified as malnourished.

Pregnant and Lactating Women (PLW) with Moderate Acute Malnutrition (MAM)

During pregnancy and lactation, women’s nutritional needs greatly increase. According to the
recommendations from 2003, pregnant women with a normal weight before pregnancy require an
additional 285 kcal/day and lactating women require an additional 500 kcal/day.14 Both pregnant and
lactating women also have increased needs for micronutrients. Iron, folate, Vitamin A and iodine are
especially important for the health of women and their infants.

3.2.2 TSFP distribution procedures at the site for new and registered
beneficiaries
Once the decision has been made to admit a beneficiary to the TSFP, the following steps should be
completed as follows:

1. Beneficiary registration
2. Administration of routine treatment
3. Follow-up procedures for those already registered in TSFP and referrals to OTP/SC
4. Nutritional counselling and education
5. Distribution of the supplementary food ration
6. Discharge criteria and procedures

Beneficiary registration

a) Provide the beneficiary or caregiver with a ration card and refer to food distribution
b) Ensure that the registration book is filled in with all essential information, e.g. name, age, sex,
home address, anthropometric details on admission, etc. (see annex 9 for example of registration
book)
c) Explain the process of the TSFP to the beneficiary or caregiver, including how the program works,
reasons for admission to the program, the ration given and expected length of stay. Posters
at the site (in local language and/or descriptions through pictures) can help the beneficiaries
understand what to expect at the site, and what they are entitled to
d) Inform the beneficiary about when is the next follow up date

14 * Well-nourished women with adequate gestational weight gain should increase their food intake by 505 kcal/
day for the first 6 months of lactation, while undernourished women and those with insufficient gestational weight
gain should add to their personal energy demands 675 kcal/day during the first semester of lactation. Energy
requirements for milk production in the second 6 months are dependent on rates of milk production, which are
highly variable among women and [Link] and Nutrition Needs in [Link]/UNICEF/WFP/
[Link], 2003. [Link]

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 e) Inform the beneficiaries/caregivers about the need for regular follow up (regular attendance,
food supplementation to be given only to the patients/beneficiaries)

Routine treatment

The TSFP should always provide routine medicines, such as, de-worming tablets, Vitamin A
supplementation and routine immunizations. Tables 14 and 15 detail each medicine, with specifications
of when to give and the dosage required. Pregnant women must be referred to the nearest health
facility for Ante-Natal Care (ANC) to receive additional services, such as iron/folate supplementation and
tetanus vaccinations.

Table 14: Summary of routine medicines for children 6 -59 months

Name of Medicine When Age Dose Prescription

Albendazole
On admission ≥ 24 months 400 mg Single dose on admission
OR

Mebendazole On admission ≥ 24 months 500 mg Single dose on admission

If vaccination card is not

Measles vaccination On admission 9-59 months Single dose
available

If not provided within the last six

Vitamin A On admission 6-59 months Single dose
months

Table 15 Summary of routine medicines for pregnant and lactating women

Name of Product When Physiological Status Dose Prescription

Albendazole 400mg
Second/Third
Albendazole or Pregnancy Mebendazole 500 Single dose
trimester
mg

Second/Third Mebendazole 500

Mebendazole Pregnancy Single dose
trimester mg

Follow up procedures for those already registered in TSFP

Beneficiaries may attend the program bi-monthly or monthly. The beneficiary’s progress should be
monitored at every visit; assess for oedema, weight and MUAC every visit and height every month
(where a height board is available). Record the measurements in the register and, importantly, analyze
whether there has been any improvement or deterioration. If any deterioration is noted, refer to the
nearest TFP. Each beneficiary should receive nutrition counselling and education sessions (including
the importance of using milk-based products for children) prior to receipt of the next ration. During each
follow up at the TSFP site, the following actions are encouraged:

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 • If the child is gaining weight, congratulate the caregiver and explain that the child is improving

• If the child has lost weight since the last visit, or has not gained weight in three consecutive
distributions, conduct a thorough medical examination to ensure there are no concurrent
medical problems. Explain the situation to the caregiver with a reminder of the importance
about not sharing the food rations; reinforce nutritious food preparation with the caregiver

• If the child or PLW fails to reach the target weight within four months, or loses weight on three
consecutive distributions, refer him/her to the outpatient department for a medical check-up.
Transfer to OTP or inpatient unit (SC) or from OTP to TSFP

Even while registered in the TSFP, MAM children can be at risk of becoming severely malnourished if
they suffer from an episode of illness or other problem. Their health and growth must be monitored at
each TSFP visit so as to ensure that they are improving as expected and also to identify those whose
condition has deteriorated. Children should be referred to the nearest OTP for further assessment if any
of the following occurs

 Bilateral pitting oedema develops

 MUAC drops below 11.5 cm
 WFH z-score decreases to less than -3
 Development of any medical complications

The HW at the OTP can then determine if the child should be admitted to OTP or referred to the nearest
SC (using the Algorithm for acute malnutrition).Children admitted to OTP will be referred to SFP where
ever the support is available when they recover and are discharged from OTP.

3.2.3 Supplementary food ration

There are a wide range of commodities currently in use to treat MAM. They generally fall into two
categories: dry rations/premixes (such as fortified blended foods like Super Cereal (CSB+), Super Cereal
plus or (Corn Soy Blend (CSB++)) or RUSF such as plumpy Sup.

1) Fortified blended food (FBF)FBF is a pre-mixed, fortified food which contains the necessary
nutrients to treat MAM. Types of FBF include:

A. Super cereal (CSB+)

Energy/nutrient per /100gm: 840kcal, 32gm protein, 18gm fat

Packaging: 25 kg bag

Ration Size: Corn Soy Blend (CSB+) 208gm/day = 6.25kg/month and Vegetable oil 30gm/day =
0.9kg of fortified vegetable oil/month.

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 Premixing the ration

When oil and sugar are given alongside the CSB+, it is essential to mix it into the CSB+ before distribution.
This is to ensure that the oil and sugar are not used for the family cooking or sold, as they can otherwise
be viewed as valuable cash opportunities for the caregivers. If rations are premixed at the distribution
site, the beneficiaries will be more likely to reap the full benefit of the ration, resulting in TSFPs being
more able to reach the objectives of successful treatment of MAM throughout the communities.

However, premix must be used within a two week period before any rancidity develops; if the distributions
are being conducted less frequently e.g. monthly, then FBF and oil should not be premixed at the site.

Note: Premix MUST be done under hygienic conditions and should be used within two weeks.

Cooking Demonstration

How to prepare premixed CSB+

• Ensure that the water being used for cooking is safe before starting to cook

• Wash your hands with soap before you start to prepare the porridge

• Mix the premixed CSB+ with part of the cold water to make a paste

• Add the rest of the water and bring to boil – ensure that it is not boiled for any longer than 10
minutes

• Where possible and resources allow, add additional oil, sugar, milk products, seasonal fruits
and/or local nuts to increase the energy density and improve the taste

• Serve on a clean plate or bowl

• Wash the child’s face and hands with water and soap before eating

• Use a separate plate for the child

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B. Super cereal Plus (CSB++)

Super cereal Plus (CSB++) is a take-home ration which is already premixed, pre-packaged and contains
animal sources of protein, which supports the linear growth and development of young children.

 Energy/Nutrient/100g
787kcal, 33g protein and 20g fat
 Packaging:
1.5 Kg bag- easy for handling and distribution
 Ration dose:
Children 200g/day = 6000g/month = 6 Kg/month = 4 bags/person/month Mothers 250g/day =
7,500gms/day =7.5kg /month =5 bags/month

 Super Cereal Plus contains corn flour, soya, milk powder, sugar, oil and vitamins and
minerals

Key messages on the use of Super Cereal Plus

• Super Cereal Plus is to be given only to malnourished children (6-59 months) or PLW) and
should not be shared with the rest of the family
• Super Cereal Plus should NOT be given to infants under 6 months, as they should be
exclusively breastfeed
• Super Cereal Plus porridge should be consumed within 30 minutes after cooking in order
to avoid contamination (and related risk of disease)
• Super Cereal Plus should be provided in addition to and not as a substitute for, the household
diet and breast feeding
• Breastfeeding should be continued and encouraged until the age of two years
• Store the closed bag in a cool, dry and hygienic place

Instructions for preparation

• Wash hands thoroughly with soap and water as well as utensils before preparing and
giving porridge to the child or pregnant/lactating mother

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 • If the water to be used for preparation is not potable, it should be boiled 15-20 minutes
before adding the flour

• For children, for 200g of Super Cereal Plus, prepare four cups of porridge per day

• 50 g of Super Cereal Plus make 1 cup of porridge

• To 1 cup of Super Cereal Plus add 4 cups of water

• For mothers, for 250 g of Super Cereal Plus, prepare five cups of porridge per day

Preparation Method

1. Open the Super Cereal Plus bag carefully

2. Mix one cup of flour with four cups of water

3. Cook the mixture over low heat for 5-10 minutes (stirring constantly)

4. Super Cereal Plus should be prepared as a thick porridge, ‘not too thin and not too thick’

5. Serve warm and consume within 30 minutes

6. Tightly close the bag with the remaining food

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 Good thickness poor thickness

C. Ready to Use Supplementary Food (RUSF)`

RUSF are energy dense are much less likely to support the growth of bacteria because of their low
moisture content. They do not require cooking. RUSFs are well suited to meet the nutritional needs of
young and moderate malnourished children.

Plumpy Sup:

 Packaging: Sachet =92 g

 Energy/nutrient/100g

• 500 kcal

• 12.5g Protein

• 32.9g fat

 Ration dose: 1 sachet/day/person

 Children 6 to 59 months are given one sachet per day

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 Treating MAM in children (6-59 Months)

Key Messages

 Gently mix by pressing the sachet for 30 seconds and make a small opening in the corner of the
sachet. The child can eat directly from the sachet
 Always offer plenty of breast milk and/or safe drinking water after eating Plumpy Sup as it can
make children thirsty
 Plumpy Sup is preferably given between normal meals
 Continue breastfeeding and consuming other meals during the treatment
 Plumpy Sup is ready to be used and should NOT be mixed with other foods
 When a child has diarrhoea, NEVER stop feeding. Continue to breastfeed and give extra food
and clean water
 Once opened, the Plumpy Sup sachet should be stored in a clean and cool place.

3.2.4 Discharge criteria

Discharge recovered cured

For admissions on WFH z-scores, discharge is recommended as ≥ -2 scores for two consecutive
distributions. Table 16 below elaborates the discharge criteria for recovery of children 6-59 months and
PLW suffering from MAM:

Table 16 Criteria for MAM beneficiaries, discharge ‘recovered/cured’

Corresponding
Target group Indicator Admission Criteria
discharge criteria:

Oedema None NA

MUAC: ≥11.5 cm to < 12.5cm MUAC ≥ 12.5 cm

Children: Anthropometric OR OR
6-59 months Measurements Weight-for-height (WFH) z-score: < -2 WFH ≥ -2 z-score at two
to ≥ -3 consecutive measurements

Discharged cured from OTP Discharged after receiving

Follow-up of SAM
(automatic admission to TSFP for 2 two months discharge
patients
months to prevent relapse) ration
Women: Pregnant
(second trimester/ visible
Anthropometric MUAC: >23.0 cm at 2
pregnancy) MUAC: < 23.0 cm
Measurement consecutive measurement
Lactating (infant < 6
months)

The discharge criteria must match the admission criteria. For example, children admitted on WFH
z-scores should be discharged using WFH Z-score ≥ -2. If a child was admitted based on MUAC, they
should be discharged based on MUAC ≥ 12.5 cm.

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Table 17 Criteria for other vulnerable groups with MAM , discharge ‘recovered/cured’

Vulnerable group Admission Discharge

Infants < 6 Weight-for-height z-score ≤ -2. Infants with MAM should immediately be referred to in-patient care
months where appropriate support for breastfeeding can be given, where possible.

Children 5 to MUAC ≥ 13 to < 14 cm MUAC ≥ 14.0 cm for two consecutive

9.9years distributions

Weight-for-height (z-score: < -2 to ≥ -3. Weight-for-height ≥ -2 z-score for two

consecutive distributions

Adolescents MUAC ≥ 16 to < 18 cm MUAC ≥ 18.0 cm for two consecutive

with MAM (10-14 distributions
years)
BMI2 –for-age, with results presented based on Weight-
for-height z-score: < -2 to ≥ -3 according to the WHO Weight-for-height≥ -2 z-score for two
growth Reference for children and adolescents consecutive distributions

Youth (15-18 MUAC >=17 to <19 MUAC ≥ 19.0 cm for two consecutive
years) distributions
BMI3 –for-age, with results presented based on Weight-
for-height z-score: < -2 to ≥ -3 according to the WHO
growth Reference for children and adolescents Weight-for-height ≥ -2 z-score for two
consecutive distribution
Adults with HIV/ MUAC ≥ 18.0 to < 23.0 cm MUAC ≥ 23.0 cm for two consecutive
AIDS and/or TB distributions
and MAM For non-pregnant or lactating
BMI < 18.5 UNHCR/WFP recommend discharge
for adults as
BMI ≥ 18.5

Discharges from TSFP other than recovered cured - children 6-59 months

Program discharges in categories other than those who ‘recover’ are described below:

• Died: Child died after admission to the program (this should be confirmed by a home visit or by
information provided by neighbours/relatives)

• Defaulter: Child is absent from the program for three consecutive distributions

• Transfer: Either the child’s condition deteriorated requiring transfer to the TFP (OTP or SC) or
the family moved and the child was transferred to another SFP site (transfers are not included in
calculations of program performance). Numbers of transfers to in-patient care should be closely
monitored, as high numbers could indicate a worsening food security situation in the area.

Non-response (failure to respond to treatment): Where a child fails to reach the discharge criteria over a
period of four months, they should be discharged as a non-responder. Investigations must be conducted
prior to discharge, as outlined below:

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 Criteria for investigating failure to respond to treatment:

1. No weight gain after six weeks in the program

2. Weight loss during four consecutive weeks in the program
3. Weight loss exceeding 5per cent of body weight at any time
4. Failure to reach discharge criteria after four months in the program

Possible reasons for failure to respond:

1. Problems with the application of the protocol

2. An underlying physical condition/illness, such as HIV/AIDS, TB
3. Nutritional deficiencies that are not being corrected by the diet supplied in the TSFP
4. Home/social circumstances of the individual
5. Excessive sharing of the ration
6. Other causes

Steps to take for failure to respond to treatment:

Step 1: Review the patient’s register card and confirm that the protocol for TSFP has been adhered
to correctly (ensure that the details on the child’s card are correct)

Step 2: Conduct a full medical examination and nutrition assessment. If the patient presents with
any signs of medical complications or nutrition deficiencies, refer immediately to the nearest
health facility for further investigation and/or treatment

Step 3: Request a home visit by community mobilisers to assess the home/social situation of
the child. Assess whether the caregiver is preparing the porridge correctly, whether it
is acceptable/tolerated by the child and whether the supplementary food is being given
exclusively to the child or excessive sharing is occurring (see annex 18 for home visit form)

Discharges from TSFP other than recovered cured - PLW

Program discharges in categories other than those who ‘recover’ are described below:

• Died: PLW died after admission to the program (this should be confirmed by a home visit or by
information provided by neighbours/relatives)
• Defaulter: PLW is absent from the program for three consecutive distributions
• Transfer: If the family has moved and the PLW was transferred to another SFP site (transfers are
not included in calculations of program performance)
• Other discharges/non-response

o For pregnant women-child is born. The woman should be encouraged to return to the
TSFP once the confinement period is over (usually 40 days), to check whether she is still
MAM and is entitled to receive TSF rations
o For lactating women - Infant reaches six months of age. Infant’s anthropometric status
should then be checked, if the infant is MAM, it should be admitted to the TSFP

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Discharges from TSFP other than recovered cured – Other vulnerable groups

Program discharges in categories other than those who ‘recover’ are described below:

• Died: Beneficiary died after admission to the program (this should be confirmed by a home visit
or by information provided by neighbors/relatives)
• Defaulter: Beneficiary’s absent from the program for three consecutive distributions
• Transfer: Either the beneficiary’s condition deteriorated requiring transfer to the TFP (OTP or
SC) or the family moved and the beneficiary was transferred to another SFP site (transfers
are not included in calculations of program performance). Numbers of transfers to in-patient
care should be closely monitored, as high numbers could indicate a worsening food security
situation in the area.
• Non-response (failure to respond to treatment): Where a beneficiary fails to reach the discharge
criteria over a period of four months, they should be discharged as a non-responder. Investigations
must be conducted prior to discharge, as outlined below:

Criteria for investigating failure to respond to treatment:

1. No weight gain after six weeks in the program

2. Weight loss during four consecutive weeks in the program
3. Weight loss exceeding 5per cent of body weight at any time
4. Failure to reach discharge criteria after four months in the program

3.2.5 When to close the emergency TSFP

TSFP will be continued until the hotspot classification is revised. If the area/woreda is not included in the
hotspot list, then TSFP will no longer be implemented.

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114
CHAPTER 4
NUTRITION AND
COMMUNICABLE
DISEASES

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 CHAPTER 4
NUTRITION AND
COMMUNICABLE DISEASES
Introduction
Undernutrition can make a person more susceptible to infection, and infection also contributes to
undernutrition, which causes a vicious cycle. An inadequate dietary intake leads to weight loss, lowered
immunity, mucosal damage, and invasion by pathogens for both adult and children and impaired growth
and development in children. A sick person’s nutrition is further aggravated by diarrhea, malabsorption,
loss of appetite, diversion of nutrients for the immune response and urinary nitrogen loss, all of which
lead to nutrient losses and further damage to defense mechanisms. These, in turn, cause reduced
dietary intake. In addition, fever increases both energy and micronutrient requirements. Similarly, poor
nutritional status has a synergistic relationship with infectious diseases as undernutrition can increase
the risk of infection while infection can predispose individuals to undernutrition.

4.1. Nutrition and HIV/AIDS

There were about 800,000 PLWHA in Ethiopia in 2014. The high rates of malnutrition in Ethiopia, (e.g.
40 per cent of children under age five are stunted) worsen the disease’s impact and pose significant
challenges to HIV care and treatment. HIV and malnutrition interact in a vicious cycle. For many PLWHA,
the infection causes or aggravates malnutrition through reduced food intake, increased energy
needs, or poor nutrient absorption. Malnutrition, in turn, hastens the progression of HIV and worsens
its impact by weakening the immune system, increasing susceptibility to opportunistic infections and
reducing the effectiveness of treatment.

People in low-income settings only present for treatment at an advanced stage of disease, when part of
their malnutrition may already be disease induced. HIV also disrupts livelihoods in that PLWHA often lose
the ability to earn an income, thereby leading to more food insecurity and its resultant undernutrition.
See the figure below.
Poor nutrition
Weight loss, muscle wasting and macro
or micronutrient deficiency

Increased nutrition needs Impaired immune system

Because of mal- absorption, decreased
food intake, infections, and viral HIV Poor ability to fight HIV and other
infections
replication

Increased vulnerability
to infection
116 Increased frequency and
duration of OIs
Thus, food and nutrition interventions help to break this vicious cycle by improving immune response,
management of symptoms, response to treatment, nutritional status, and quality of life and productivity.

Antiretroviral treatment drug interaction with food and nutrition

Antiretroviral treatment (ART) is a comprehensive care package for PLWHAs. PLWHAs still need
appropriate and adequate nutrition care to achieve the full benefits of ART. ART drugs can interact with
food and nutrition in a variety of ways, resulting in both positive and negative outcomes. Some ART
drugs interact with food in ways that can affect the nutritional status and effectiveness of the drugs. It
can change the way the body uses fats, proteins, and energy. These metabolic changes can generally
be managed without stopping treatment. Therefore, it is critical to understand the specific ART-nutrient
interactions and implications to enable effective management of the resulting condition that improves
drug efficacy, nutritional status and adherence to therapy.

Dietary management of HIV/AIDS related conditions or symptoms

Different conditions or symptoms associated with HIV /AIDS including anorexia, diarrhea, fever, nausea,
vomiting, anemia, constipation, thrush, heartburn, TB…etc. require specific dietary management.
Proper diet and nutrition management of HIV/ADIS-related symptoms can help to reduce the severity
of symptoms, improve nutritional status, improve treatment outcome, and boost immune response. (

Infant feeding in the context of HIV and prevention of mother to child transmission
of HIV

All pregnant women should be encouraged to be tested for the HIV infection due to the risk of mother
to child transmission of HIV. The nutritional status of an HIV-infected mother may influence her risk of
transmitting HIV to her infant. An HIV-positive mother can transmit HIV to her infant during pregnancy,
at the time of labor and delivery and via breast feeding during postnatal period.

Improving maternal nutrition during pregnancy and infant feeding, specifically exclusive breast feeding,
are found to reduce the transmission of HIV from positive mother to infant. Meanwhile, the implementation
of option B+, significantly reduces the risk of transmission of HIV from mother to infant.

Thus, a comprehensive Prevention of Mother to Child Transmission (PMTCT) service is needed to

prevent HIV transmission and strongly support HIV positive mothers to breastfeed exclusively for the
first 6 months and advise the mother never practice mixed feeding as this may increase risk of HIV
transmission and illness or death from diarrhea and other illnesses.

Therefore, taking international guidelines and their application, the following infant feeding options are
recommended:

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 4.1.1 Nutrition counselling and support for PLWHA

A. Nutrition Education and counseling for PLWHA

Nutrition education, which is the provision of key nutrition related information to target groups to achieve
desired behavior change, should be considered as part of health education sessions in health facilities
and/or community using various print and audiovisual media.

Nutrition counseling is an interactive ongoing process between a counselor and client. All PLWHA
should receive appropriate individual nutrition counseling based on their nutrition assessment results.
The nutrition counseling should interpret information generated during assessment, understand client
preferences, constraints and options, and plan a feasible course of actions that supports healthy dietary
practices and referral for additional services. Good counseling can result in positive changes in nutrition
related behavior and help to improve the quality of life of PLWHA.

In addition to treatment of malnutrition, comprehensive nutrition counseling should advocate for improved
diet through consumption of locally available foods and link individuals to appropriate support. Nutrition
counseling helps identify client preferences, barriers to behavior change, and possible solutions to
overcome those barriers. With such information, the client and care provider can jointly plan a feasible
course of action to support desired nutrition practices. The care provider may use job aids to select
appropriate messages and guide counseling sessions.

B. Counseling for PLWHAs

CNP SBCC is the strategic use of communication to promote positive health outcomes, based on
proven theories and models of behavior change. SBCC employs a systematic process, beginning
with formative research and behavior analysis, followed by communication planning, implementation,
and monitoring and evaluation. Audiences are carefully segmented, messages and materials are pre-
tested. All of the interpersonal, group, and mass media channels are used to achieve defined behavioral
objectives.

SBCC is an essential part of the clinical HIV and nutrition services being implemented through the NACS
approach. The counseling component of this approach cuts across all stages of the clinical nutrition
services and focus more on promotion of CNP mentioned below. These practices are promoted along
with the continuum of comprehensive HIV/ADIS care and support services, as a way of promoting
healthy lifestyle to maintain the health and strength for PLWHA. Health care providers should use
updated SBCC tools during nutrition education and counseling sessions.

4.1.2 Management of malnutrition in PLWHAs

Nutrition management of PLWHAs depends on a classification of the nutritional status of the patient, age
of the patient, other medical conditions and the available therapeutic or supplementary food products.
The management includes treatment of malnutrition by prescribing RUTF, supplementary foods and
locally available diversified energy and nutrient dense foods for rehabilitation from malnutrition based
on nutrition care plans.

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Nutrition care plans are interventions determined based on PLWHA clients’ nutritional status and health
conditions that affect their nutritional needs and absorption/utilization.

There are three nutrition care plans for treatment of malnutrition in PLWHA:

 Nutrition Care Plan C,

 Nutrition Care Plan B, and
 Nutrition Care Plan A

A. Energy Requirements of PLWHA

This is the amount of food energy needed to balance energy expenditure in order to maintain body size,
body composition, a level of necessary and desirable physical activity, and to allow optimal growth and
development of children, deposition of tissues during pregnancy, and secretion of milk during lactation,
consistent with long-term good health. For healthy, well-nourished adults, it is equivalent to total energy
expenditure. There are additional energy needs to support growth in children and in women during
pregnancy and for milk production during lactation. Energy requirements also increase during illnesses
like HIV. Refer table 19 for the daily energy requirement for different age group.

All PLWHA—regardless of age, sex, and physiological status—require more energy than uninfected
individuals of the same status in order to meet the elevated nutritional needs that result from the
infections and changes in metabolism caused by HIV/ADIS

Table 18 Additional Energy Requirements for PLWHA

Additional Energy Requirement for PLWHA

Category
(in percentage)

Symptomatic 20-30per cent

Adult
Asymptomatic 10per cent

symptomatic losing weight 50-100per cent

Children
symptomatic not losing weight 20-30per cent

WHO recommends that PLWHA increase energy incrementally depending on the stage of the disease
(see WHO, 2005). Nutrition, education and counseling messages should take locally available common
Ethiopian diets into consideration. Protein and Micronutrients

Although research unanimously shows a loss of body mass for PLWHA—the severity of which
increases with progression of the disease—it is not known whether PLWHA require additional protein or
micronutrients to address this loss. WHO does not recommend increasing protein, fat, or micronutrient
intake over the RDA, which state that protein intake should make up 12–15 per cent of total energy
consumption.

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 There is no evidence that PLWHA require more protein and micronutrients than uninfected people

Any micronutrient supplementation should not be more than one RDA unless the client is deficient

Table 19 Daily Energy and Protein Requirements

HIV negative HIV positive

Asymptomatic Symptomatic Protein

Group
Energy (not displaying (displaying (g/day)
(kcal/day) symptoms) symptoms)
(kcal/day) (kcal/day)

Men
Average active 2430 2670 2910–3160 57
Women
Average active 2170 2400 2600–2820 48
Pregnant 2460 2710 2950–3200 55
Lactating 2570 2830 3080–3340 68
Children
6–11 months old 730 800 880–950 10
1–3 years old 1250 1380 1500–1630 25
2–5 years old 1500 1650 1800–1950 26
5–10 years old 1800 1980 2160–2340 35
Boys
10–14 years old 2360 2600 2830–3070 64
15–18 years old 2800 3080 3360–3640 84
Girls
10–14 years old 2040 2240 2450–2650 62
15–18 years old 2100 2310 2520–2730 65

*Source: WHO, 1993

4.1.3 Contact points and targets for nutrition intervention For PLWHA

Contact Points

Nutrition care and support can be provided to PLWHA at various health care delivery points. The
following are important contact points for nutrition interventions for PLWH:

• HIV Counseling and Testing (HCT)

• Chronic HIV care and support clinics/ART clinics for adults and adolescents.
• Chronic HIV care and support clinics/ART clinics for children.

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 • ANC follow up clinics
• PNC follow up clinics
• PMTCT clinics
• Routine under five children OPD
• Reproductive and youth clinics
• Inpatient wards
• Orphanages

Activities to be performed at each contact points

The following are lists of activities that should be performed with PLWHA during every visit:

• Assess the nutritional status of PLWHA (anthropometric, clinical, biochemical, and dietary
assessments) and interpret findings
• Classify the nutritional status of PLWHA and assign an appropriate care plan based on the
classification
• Counsel on CNPs
• Assess for anemia by checking palmar pallor and treat accordingly
• Assess for any illness and treat accordingly.
• For PLWs, counsel on recommended infant feeding options
• For patients on ARTs, look for any ART drug-nutrition interaction and counsel accordingly

4.1.4 Linking HIV infected clients to economic opportunities to

prevent relapse of malnutrition
Clients often relapse into malnutrition after complete rehabilitation due to rampant poverty and food
insecurity that denies the affected people access to nutritious food. One of the primary cause of food
insecurity is the continued lack of economic opportunity to produce adequate amounts of food or to
obtain sufficient income to purchase adequate amounts of food. Different studies also revealed the
impact of HIV and AIDS on the household. These studies also emphasize how the economic burden
of HIV and AIDS-related crises can push households inexorably into poverty, wiping out the economic
resources of people.

Therefore, linking clients with social safety nets and economic strengthening opportunities, while fulfilling
their nutritional requirements should be part of an overall strategy in order to increase the capacity of
HIV-affected households to become independent and have sustainable livelihoods.

Economic strengthening interventions generally fall under one or more of three categories: ‘livelihood
provisioning,’ ‘livelihood protection,’ and ‘livelihood promotion.’ The appropriate intervention entry point
depends on where the household is located on this pathway, while the household’s rate of progression
along the pathway depends on its asset endowment. Five key outcomes exist on the livelihood pathway
indicating decreasing levels of vulnerability and increasing levels of livelihood and food security:

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 1. Recover assets and stabilize household consumption
2. Build self-insurance mechanisms and protect key assets
3. Smooth household consumption and manage household cash flow
4. Smooth household income and promote asset growth
5. Expand household income and consumption

4.2 Nutrition and TB

Malnutrition increases the risk of TB and in turn TB can lead to malnutrition. Malnutrition is therefore
highly prevalent among people with TB. It has been demonstrated that malnutrition is a risk factor for
progression from TB infection to active TB disease and that malnutrition at the time of diagnosis of
active TB is a predictor of increased risk of death and TB relapse.

This guideline includes initiatives that are targeting TB in the NNP, detailed as follows:

 To ensure that a nutritional assessment is done to determine nutritional status and that
referrals are provided for nutrition support when essential
 To ensure that nutrition education and counseling are provided on symptom management
and improved dietary intake during and after TB treatment
 To facilitate and link to food assistance and livelihood programs. These activities increase
treatment adherence in TB patients.
 To arrange a potential collaboration between TB and HIV programs, on the one hand,
nutrition on the other.

Health care workers should routinely provide nutritional care services for all TB patients and MDR-TB
along with the DOTS and other TB programs. This guideline will provide guidance on the principles and
recommendations for nutritional care and support of patients with TB as part of their regular TB care.

4.2.1 Energy and nutrient requirement for adults and children with TB
Active TB, like other infectious diseases, is likely to increase energy requirements. To assess the increase
needed, data on the actual level of increase in energy requirements caused by HIV infection may be
used as a guide. The proportion of dietary energy from macronutrients (e.g. protein, carbohydrate and
fat), is similar for people with active TB and for those without TB. It is generally recommended that all
people consume approximately 15–30 per cent of energy as protein, 25–35 per cent as fat and 45–65
per cent as carbohydrate. The anti TB drug isoniazid increases renal excretion of pyridoxine. Therefore,
pyridoxine supplementation is recommended along with isoniazid treatment.

4.2.2 Nutritional support for malnourished patients with TB

Nutrition assessment and counseling

All individuals with active TB including MDR-TB should receive an assessment of their nutritional status
and appropriate counseling based on their nutritional status at diagnosis and throughout treatment.

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Nutrition counseling for TB patient is a cross cutting action that could be applied across the continuum
of care of TB patients, and should focus on the seven CNP. Nutrition education and counseling is
advised to be individualized based on the findings from assessments.

4.2.3 Management of SAM in TB patients

All TB patients with SAM, including PLW, with active TB should be treated in accordance with the
guideline for management of SAM. There is no evidence for especial nutrition management for MDR-TB
patients.

4.2.4. Management of MAM in TB patients

All TB patients with MAM will be treated based on treatment care plan B. School-age children,
adolescents, adults, including lactating women, with active TB and MAM, who fail to regain normal BMI
after two months’ of TB treatment, as well as those who are losing weight during TB treatment, should be
evaluated for adherence and comorbid conditions. They should also receive nutrition assessment and
counseling, and, if indicated, be provided with locally available nutrient-rich or fortified supplementary
foods as necessary to restore normal nutritional status.

Children who are less than 5 years of age with active TB and MAM should be managed as any other
children with MAM. Pregnant women with active TB and MAM, or with inadequate weight gain, should
be provided with locally available nutrient-rich or fortified supplementary foods as necessary to achieve
an average weekly minimum weight gain of approximately 300 g in the second and third trimesters.

Patients with active MDR-TB and MAM should be provided with locally available nutrient-rich or fortified
supplementary foods, as necessary to restore normal nutritional status.

4.3 TB, HIV and malnutrition

HIV patients should be particularly screened for TB at the time of HIV testing, as co-infection is particularly
common. TB, HIV and malnutrition are linked and frequently appear in the same patients.

The drugs that are used for TB and HIV are quite toxic to the liver and pancreas. These organs are
particularly affected by malnutrition. If treatments with anti-TB drugs or ART are started in the severely
malnourished patients, they are likely to develop very severe side effects from the drugs. This leads to
withdrawal of many of the patients from the treatment programs.

Neither TB nor HIV are rapidly fatal illnesses. The natural history of untreated TB in adults is:

• About one third are dead after two years, one third have self-cured and one third progress
to chronic extra-pulmonary TB. 33 per cent die in 24 months; this reflects an approximately
1.5 per cent chance of death each month. A delay of one week or so in starting treatment
will have little effect upon the overall mortality rate (unless the patient has TB meningitis or
milliary TB). Mortality from the severe malnutrition with modern treatment is less than 5per

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 cent, but with conventional treatment, it rises to 20per cent or higher within the first week
to treatment.

• Therefore, the treatment priority for patients with TB, HIV/AID, and malnutrition is correcting
the nutritional status except for those with TB, meningitis and milliary TB.

Children with SAM and TB should not be transferred to a TB center, somewhere where they have little
experience in treating SAM, as soon as the diagnosis is made. The treatment of SAM takes precedence;
the treatment of TB can be carried out in the SC more easily and efficiently than the treatment of SAM
at the TB center.

It is better to first start the treatment of severe malnutrition in all patients and to delay introduction of
TB treatment and ART for one or two weeks until the liver, pancreas and intestine have recovered
sufficiently to metabolize the drugs safely.

Once started, the treatment of the HIV and TB should follow the national guidelines.

Indeed, HIV, TB and nutrition services in most regions should be integrated both administratively and
operationally.

4.4 Nutrition and other infection (measles, malaria

and intestinal parasites)
Measles malaria and intestinal parasites are the most common infectious diseases in Ethiopia, which
have a deleterious effect on the nutritional status of patients.

A. Measles

Measles is an important acute childhood viral infection which has severely affects the nutritional
status. The adverse nutritional effects of measles are experienced by both the well-nourished and the
malnourished children. Measles is far more severe in children who are malnourished, especially if they
are also vitamin A deficient. Any child who acquires measles should thoroughly be screened for acute
malnutrition from the time of infection up to three months after acute infection and managed according
to the degree of malnutrition.

B. Malaria

Malaria and malnutrition are closely related and there is a synergetic effect of acute malaria and
malnutrition. Repeated attacks of malaria combined with associated immunodeficiency state leading to
other additional morbidities (pneumonia and diarrhea) in children which further worsen the nutritional
status. Malaria is the common cause of death in under five children in developing countries. It is also
found that malaria infections can result in acute weight loss, specifically in children. Evidence suggests
that improving the nutritional status amongst young children may reduce malaria morbidity and mortality.
Children who are underweight are susceptible to malarial infection for a variety of reasons, most notably
reduction in the functions of the immune system.

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Although, an understanding of the influence of nutrition on malaria is far from complete, it is clear
that adequate nutrition strongly influences the disease prevention and treatment. The risk of malaria
mortality increases the severity of malnutrition. Most child deaths occur in only mildly to moderately
undernourished children, because of the high prevalence of children of this nutritional status in many
countries. Therefore, all children must be tested for the presence of malaria parasites and treated based
on IMNCI guideline.

In addition to the macro-nutrient deficiencies, micro-nutrient deficiencies also occur in patients with
malaria. Studies have shown that micronutrient supplementation particularly iron, Vitamin A and Zinc
have beneficial effects of reducing the risks and intensity of malaria infection.

Protect all patients in therapeutic feeding centers from dusk till dawn with ITNs, and make an ITN
available to take home on discharge. In addition, equip the center itself with mosquito-proof screening
for windows and doors and use insecticide-impregnated curtains. SFPs provide an opportunity for
distribution of ITNs (preferably long lasting variety) to the households.

C. Intestinal parasites

Parasitic infestations are among the most common and widespread infections in Ethiopian children.
Parasitic infestations negatively affect the nutritional status of children. These infestations may be
considered as the main risk factors associated with the poor nutritional status of children.

Intestinal parasites could affect the nutritional status of their host:

 By feeding on host tissues, including blood and serum, which leads to a loss of iron and
protein
 By causing mal-digestion or mal-absorption of nutrients
 By causing inflammatory responses that lead to the production of substances that may
affect appetite and food intake, or modify the metabolism and storage of key nutrients such
as iron
 By increasing the metabolic rate as a response to infections such as fever.
 By causing hypertrophy of muscles and by immune responses to infection.

4.4.1 Nutritional support for malnourished patients with malaria,

measles and intestinal parasitosis
All individuals with malaria, measles and intestinal parasitosis should have an assessment of their
nutritional status and appropriate nutrition counseling based on their nutritional status at diagnosis
and throughout treatment. Management of both severe and moderate malnutrition for patients with
measles, malaria and intestinal parasitosis uses similar treatment care plans for HIV and TB patients.

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126
CHAPTER 5
MONITORING, reporting
and supervision

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 CHAPTER 5
MONITORING, reporting and
supervision
Introduction
Monitoring and reporting is an essential component without which the health facilities cannot provide
quality health services. Monitoring and reporting of services allows monitoring the individual child
progress and immediate correction of the treatment, if necessary and appropriate, and includes the
following measures;

 properly track individual children when they are referred from in-patient to out-patient, from out-
patient to supplementary feeding and vice versa
 monitor the performance of services provided and take the necessary action to maintain high
quality services
 Supervise and support the health care providers to maintain their skills and ensure quality care

The monitoring and reporting addresses the TFP recording and reporting skills, including registration of
children, in the TFP registration book; preparation of the TFP monthly statistical reports; and calculating
and interpreting TFP performance indicators. It also addresses similar recording and reporting formats
for management of MAM.

5.1. Recording and reporting for SAM management

5.1.1. Monitoring progress of individual patients

Assign Unique Registration Number

Each child receives a registration number when she/he is first admitted to outpatient care or inpatient
care to overcome the problems of confusing registration. The patient then keeps this same number
during all transfers.

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The importance of registration and being able to follow a patient, as they are transferred from OTP to
inpatient care, and to ensure that the person is not lost from the system, is critical. Each registration
number has three parts: the health facility’s name or code, the child’s individual number and the service
code indicating where the child started treatment (inpatient care or outpatient care). Child individual
number is assigned sequential five digit number. The first child to start the treatment in the facility will
be given the number 00001. Most children will be admitted to outpatient care, the majority of cases
fulfill the outpatient criteria, as it is the most decentralized service and, therefore, the most common and
accessible entry point for treatment.

Example: Standard 3-part numbering system: NYL/00001/OTP or IN

Note: The Facility Registration – number, which is a number used by the facility for internal filing only
(5-digit number followed by year) and is not used for transfer of children in TFP or for constructing a
database of children in TFP. This number should also be recorded on the child Multi Chart or OTP card.

Recording in the individual follow-up cards

Inpatient multi-chart

This individual multi chart should be filled for any child admitted to in-patient care. A sample individual
multi-chart is displayed on annex 10.

OTP card

This OTP card should be filled for each patient. It is the primary tool for monitoring the progress of each
individual child and managing malnutrition in OTP. A sample OTP card is also displayed on annex 11.

Recording in TFP Registration book

The information regarding the children under the program needs to be compiled in the TFP registration
book. This will help to prepare the monthly OTP statistics report. Note that the registration book now
includes length of stay and rate of weight gain. These two are filled out from the information on the
registration book for non-oedematous 6 to 59 months old children who are cured.

5.1.2. SAM treatment performance

Prepare monthly TFP statistic report

The admissions and exit outcomes from the registration book are summarized monthly using the monthly
TFP reporting format (annexed 15This will help to calculate performance indicators for in-patient care
or OTP. The monthly reporting format looks somewhat like an accounting balance sheet. The four main
parts of the monthly reporting template include:

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 a) Number of children in the program at the beginning of the month
b) Number of children admitted during the month
c) Number of children exiting from the program in the month; and finally
d) Number of children still in follow up at the end of the month.

It should be filled for infants less than 6 months, and children 6 months to 5 years of age, as well as
older age groups separately all disaggregated by sex as indicated in the reporting format (Annex 15.
The monthly reports should be reviewed during the morning meetings or quarterly review meetings to
assess and improve the performance of a facility. The data should be utilized at facility level and then
should be reported to the next level (district, Zone or Regional Health bureau).

Description of the Admission and Discharge boxes of in the Monthly Statistics Report

ADMISSIONS

New admission: Patients that are directly admitted to the program to start the nutritional treatment
(new admissions to phase 1 or direct new admission to phase 2/OTP) are new admissions. They are
recorded into three different columns:

1- “Wasted patients” (B1)

2- “Oedematous patients” (B2)
3- “Relapses” (B3)

Note: “Relapses”: A case is considered a relapse if that patient has ever been severely malnourished
before and cured. For these cases, identify how many are edematous and non-edematous. Children
that have relapsed are particularly vulnerable and the fact that they are relapses should be noted in the
major problem section of their charts – relapses should normally start treatment as in-patients.

Readmission after defaulting (B4): Patient that have defaulted from a nutritional treatment program and
he/she is re-admitted with in a period of less than two months. If the defaulter patient is coming back
after two weeks (In-patient) or after two months (out-patient) then he/she is recorded as new admission.

Transfer in (B5): These are patients that have started the nutritional therapeutic treatment in a different
OTP site or SC or other facility and are referred to the program to continue with the treatment.

DISCHARGE

Cured (Recovered) (D1): Patient that has reached the discharge criteria

Death (D2): A patient that has died while he/she was in the program in a facility. For the out-patient
program, the death has to be confirmed by a home visit.

Unknown (D3): A patient that is absent for three consecutive weighing in out-patient care (21 days) but
the outcome (actual defaulting or death) is not confirmed/ verified by a home visit.

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Defaulter (D4): A patient that is absent for two consecutive weighing (two days in in-patient and 14
days in out-patient), confirmed by a home visit for out-patient component of the program

Non-responder (D5): A patient that has not reached the discharge criteria after six weeks in the in-
patient program or two months in the out-patient program. Non-responders from the OTP program
should be transferred to the SC for detailed investigation–the SC will determine the outcome of the
patient15*.

Medical transfer (D6): A patient that is referred to a health facility/hospital for medical reasons but this
health facility will not continue the nutritional treatment or transfers the patient back to the program.

Transfer Out (F): This is not a discharge. The “transfers out” from an OTP program who do not return
can be considered to be a discharge with UNKNOWN outcome, unless the outcome is otherwise
determined.

A patient that has started the nutritional therapeutic treatment in your SC/OTP and is referred to another
site to continue the treatment

“Transfer Out to OTP” (F1): patient referred to OTP.

“Transfer Out to in-patient care” (F2): patient referred to in-patient care.

TOTAL END OF THE MONTH (G): = Total beginning of the month (A) + Total admissions (C) - Total
exits (G)

Total exit is the sum of total discharge and transfers (D+F1+F2)

Monitoring Performance of acute malnutrition management

Quantitative data are collected on the outcome of all activities of TFP including in-patient care, and
standard indicators mentioned below are calculated. This enables the quality and effectiveness of TFP
in this case in-patient care to be monitored. They should be calculated for infants less than 6 months,
and children 6 to 59 months and older years of age separately as per the reporting format.

Calculate Performance Indicators

Each TFP should calculate the following performance indicators separately for in-patient and out-patient.
If a HC has both in-patient treatment (SC) and out-patient treatment (OTP), the monthly performance
of each should be calculated separately and sent to the next level separately. This is because the
interpretation of some of the performance indicators significantly differs for OTP and in-patient. For
example, deaths in OTP are much less acceptable, even if very few of the out-patient team could pick
up deterioration through weekly follow up and home visit and admit any severely malnourished child
who presents with complications or develops complications while on OTP follow up. In addition, while
OTP is under the out-patient department, SCs are in the in-patient department of health facilities. The
15 *Patient with slow weight gain and with medical condition justifying the slow weight gain may be discharged later
on. If there is no regular weight gain, the patient should be discharge as a non-responder.

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 performance of these two teams should be assessed separately to allow appropriate feedback for
continuously increasing performance.

Death rate

Calculate the death rate monthly. This will allow improvements to be seen rapidly. To calculate the death
rate:

• Determine the number of those children who died during the past month (D2)

• Determine the total number of children who were discharged from the program within the
past month (E) which includes cured/recovered, died, defaulted, non-responder, unknown, and
medical transfer

• Divide the number of deaths by the number of children who were discharged from your care in
the past month and express the result as a percentage. ((D2/E)*100)

Any death in OTP is alarming and should be thoroughly audited

For in-patient treatment, a death rate of:

• >15per cent is Alarming

• 10-15 per cent is poor
• <10per cent is acceptable

Recovery (Cure) rate

= No of children that have reached the discharge criteria for TFP and discharged /
Total No of discharges (D1/E*100)

Defaulter rate

= No of true defaulters / Total No of exits (D4/E*100)

Non responder rate

= No of non-responder / Total No of exits (D5/E*100)

Medical transfer

= No of patients that are referred to a health facility/hospital for medical reasons/Total No of

discharge

(D6/E*100)

Optional Performance Indicators

The optional indicators of Average rate of weight gain and Mean length of stay of cured children are

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calculated for children who are discharged cured ONLY. The indicators are calculated for non-edematous
cases only. Previously, this calculation was recommended to be undertaken for 30 to 40 randomly
selected beneficiaries cured over the month. However, decentralized therapeutic feeding programs in
Ethiopia rarely treat over 40 children in one facility. Therefore Average Rate of Weight Gain (ARWG) and
ALS should be done for all non-oedematous 6 to 59 months old children cured in the month. Use the
appropriate columns on the registration book to enter the length of stay (LS) and rate of weight gain
(RWG) for each cured child in the specified age range. At the end of the month, when it is time to do
the mean RWG, you will only need to add up the values for individual cured children and divide to the
number of non-oedematous children cured in the same period.

LS: is the number of days elapsed between admission and discharge. It is calculated for recovered
beneficiaries one by one.

Formula of ALS

Average RWG

This indicator is particularly useful to show the quality of feeding.

This is calculated as:

= the discharge weight minus the admission weight multiplied by 1000 to convert the weight gain to
grams

= This is then divided by the admission weight to give grams of weight gained per kilo body weight

= Lastly, this total weight gain is divided by the number of days from the date of minimum weight to the
date of discharge, to give g/kg/d. The ARWG is then:

Formula of Individual and AWG

AWG =

W1 = Weight in kg on the day of entry to the program

W2 = Weight in kg the day of discharge from the program

T = Number of days elapsed between W1 and W2

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 5.2. Recording and Reporting for MAM management

Monitoring

It is important to know whether the intervention is making progress towards its objectives. Monitoring
helps implementers to understand what is working well and what is sub-optimal, and where gaps may
be.

If management and information systems are simple, the burden on program staff will be reduced,
but sufficient and useful information to ensure program effectiveness can be provided. Robust and
regular monitoring information can also facilitate program managers in decision making and whether
any adjustments are required.

5.2.1. Monitoring progress of individual beneficiaries

Four tools are available:

i) Individual ration/record cards

ii) Registration books

iii) Referral slips

iv) Records of home visit/post distribution monitoring forms

Beneficiaries are anthropometrically monitored at each visit, with details recorded in the registration
book and on their ration cards to assess their progress. Similar to the SAM management, monitoring
numbering systems are also applied here to enable tracking of individual beneficiaries, especially for
those transferring between SFP and OTP. When beneficiaries are referred with in these programs, the
same patient number will be kept.

Home visits using post-distribution monitoring questionnaires (see annex 25.) should be conducted
when indicated and wherever possible.

5.2.2. MAM treatment performance

Several tools are available for use:

 Monthly reports with data on admissions and discharges (statistical data) are compiled for TSFP
 Supervision checklists and/or reports-supportive supervision of TSFP sites should be conducted

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 regularly by program managers and federal/regional MoH counterparts (see annex 24 for
supervision checklist). Joint supervision between partners is more likely to result in successful
outcomes
 Collection of additional information – re-admissions, cause of death, reasons for default and
non-recovery. Collected by community outreach workers, mobilisers or other program staff
 Mapping–simple mapping can also be done. This will help identify where most of the admissions
are coming from and can help determine if more sites should be opened. This can also help
program implementers better understand possible issues in the program such as high default
or low coverage
 Focus group discussions (FGD) with community members-discussions with affected communities
by the MoH and program staff can also provide useful insights into program perceptions, and
identify any barriers to uptake
 Coverage monitoring surveys

Reporting

Completing the monthly report

• Program data can be compiled at each distribution site (usually bi-monthly/monthly) on tally
sheets. The compilation sheets can be used for combining information from various sites and
also for collecting information into monthly data
• Program data must be extrapolated according to admission group e.g. 6-59 months, PLWs and
other vulnerable groups
• Data should be disaggregated by sex e.g. no of boys/girls recovered cured, died, etc.
• Program data should then be compiled every month from the tally and compilation sheets and
collated into one monthly report per woreda
• To facilitate calculations and speed up data processing, the monthly reports may be collated
into a simple excel spread sheet or access database reports must be filled in accurately. Cases
should not be double counted. Particular attention should be given to accurately recording
returning defaulters and/or readmissions. In areas where there is considerable movement of
the population (e.g. pastoralist livelihood zones), care should be given to track ‘moved’ cases,
where possible.

Using the monthly reports to determine program performance

• Program outcomes (numbers of beneficiaries who have recovered, died, defaulted and non-
recovered) can be compared to international minimum standards in order to provide information
on how well the program is performing

• Following analysis at facility level with health staff, the reports should be sent to the woreda
health information system and then to zonal, regional and federal levels

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 Table 20 TSFP performance indicators

Recommended Recommended
Indicator4* Description Formula Unit
cut-off by

Recovery rate Proportion of No. recovered/total per >75per cent SPHERE AND MoH
discharged as no. of discharged cent
cured/recovered (recovered, died, default
and non-response) X
100
Death rate Proportion of No. of death/total no. of per <3per cent SPHERE AND MoH
discharges due to discharged (recovered, cent
death died, default and non-
response) X 100

Default rate Proportion of No. of defaulters / per <15per cent SPHERE AND MoH
defaulters from total no. of discharged cent
the program (recovered, died, default
and non-response) X
100

Non-response Proportion of No. of non-responder/ per NA

rate discharges due to total no. of discharges cent
non-response (recovered, died, default
and non-response) X
100

Mean length of ALS for recovered Total number of days for Days <90 days WFP/UNHCR
stay children recovered children /No.
recovered

Average weight Average number Sum [(weight on g/kg/ >=3g/kg/day WFP/UNHCR

gain of grams gained discharge (g) – weight day
per kg per day on admission (g))/(weight
since admission on admission (kg)) X
to TSFP duration of treatment
(days)]

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137
138
CHAPTER 6
INVOLVEMENT OF MOTHERS
IN CARE AND NUTRITION
COUNSELING AND INFANT
AND YOUNG CHILD
FEEDING IN EMERGENCIES

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 CHAPTER 6
INVOLVEMENT OF MOTHERS
IN CARE AND NUTRITION
COUNSELING AND INFANT
AND YOUNG CHILD FEEDING IN
EMERGENCIES
6.1 Involvement of mothers in care

Introduction

One way of managing acute malnutrition is through addressing the improper behaviors and practices
of community members that contribute to malnutrition. It is imperative to educate members of the
community on causes of malnutrition and best practices to manage and prevent malnutrition at
household level. Involvement of the community in designing and developing education materials is
essential and contributes greatly towards behavior changes.

It is essential for the mother (or other caregiver) to be with her severely malnourished child in the health
facility. For the following reasons, she must be encouraged to feed, hold, comfort, and play with her
child as much as possible:

• Emotional and physical stimulation are crucial for the child’s recovery and can reduce the risk of
developmental and emotional problems

• The child’s mother can provide more continuous stimulation and loving attention than busy staff

• When mothers are involved in care at health facility, they learn how to continue care for their
children at home

• Mothers can make a valuable contribution and reduce the workload of staff by helping with
activities such as bathing and feeding children.

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Organize facility routine to encourage mothers’ involvement

There are many ways to encourage mothers’ involvement in facility care. Mothers can be taught to:

• prepare food
• feed children
• bathe and change clothes; and
• Play with children, supervise play sessions, and make toys

The staff must be friendly and treat mothers as partners in the care of the children. A mother should
never be scolded or blamed for her child’s problems or made to feel unwelcome. Teaching, counseling
and befriending the mother are essential to effective long-term treatment of the child.

Mothers should have a place to sit and sleep (preferably sleep with their children) in the SC. They also
need washing facilities and a toilet, and a way to obtain food for themselves. Some mothers may need
medical attention themselves if they are sick or anemic.

The staff should also make other family members feel welcome. All family members are important
to the health and well-being of the child. When possible, fathers should be involved in discussions of
the child’s treatment and how it should be continued at home. Fathers must be kept informed and
encouraged to support mothers’ efforts in caring for the children.

Involve mothers in comforting, feeding and bathing children

Staff should informally teach each individual mother certain skills. First, they may need to show the
mother how to hold her child gently and quietly, with loving care. Immediately after any unpleasant
procedure, staff should encourage the mother to hold and comfort her child.

At all times, staff must communicate clearly with mothers in a way that builds their confidence in their
ability to take care of their children. For example, when a HW examines the child, he should explain what
is happening and show the mother how to hold the child during the examination. Staff must treat the
mothers as partners in helping the child to recover.

Teach mothers about feeding and care

1. Teach groups of mothers about preparing and feeding

There are many topics that can efficiently be presented to groups of mothers and other interested family
members. Group teaching sessions may be held on topics such as nutrition and feeding, hygiene,
making ORS to treat diarrhea, family planning, etc.

2. Prepare for feeding the child at home

After the child recovers and reaches weight for length or weight for height >-2Zs or MUAC>12.5cm or

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 transferred to TSFP, the child should be fed at home according to national IMNCI and IYCF guideline
recommendations. The recommendation states; for a child 6 to 24 months of age, giving two-three
meals plus one-two other solid foods (snack) each day. In addition, for a child age 2 years or older, it is
recommended to give the child three meals each day, plus giving nutritious food between meals twice
daily.

Appropriate mixed diets are the same as those recommended for a healthy child. They should provide
enough calories, vitamins and minerals to support continued growth. Home foods should be consistent
with the guidelines below:

A. The mother should continue breastfeeding as often as the child wants

B. If the child is no longer breastfeeding, the mother should be counseled and supported on re-
lactation

C. If breast feeding is not possible at all, animal milk is an important source of energy, protein,
minerals and vitamins

D. Solid foods should include a well-cooked staple cereal. To enrich the energy content, add
vegetable oil (5-10 ml for each 100 g serving) or butter. The cereal should be soft and mashed
to be fed by spoon or clean hand.

E. Give a variety of well-cooked vegetables, including orange and dark-green leafy ones. If possible,
include fruit in the diet as well

F. If possible, include meat, fish, or eggs in the diet. Pulses and beans are also good sources of
protein

G. Give extra food between meals (healthy snacks)

H. Give an adequate serving size (large enough that the child leaves some) and encourage the
child to eat more using various techniques

I. Continue breast feeding and adequate feeding during child’s illness

J. Mothers should wash their hands with soap and water before food preparation, before feeding
the child, before meal, after using toilet and after attending the child’s toilet.

K. Cooked food should be stored covered at all times.

L. Child’s urine and feces should be disposed of safely in a toilet or separate prepared place

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3. Teach mothers the importance of stimulation

Severely malnourished children have delayed mental and behavioral development. As the child recovers,
he or she needs increasing emotional and physical stimulation through play. Play programs that begin
during rehabilitation and continue after discharge can greatly reduce the risk of permanent mental
retardation and emotional problems.

Create a stimulating environment in the treatment centers, provide opportunities for play activities with
toys and interaction between children and with their mothers or caretakers. Promote physical activity
of children that can move and passive mobilization of limbs for those that cannot. Avoid wrapping the
child: the child should be able to move freely.

A comprehensive emotional and physical stimulation program should be set up in each centre, led
by a person from the health staff. The hospital can provide stimulation through the environment, by
decorating in bright colors, hanging colorful mobiles over cots and having toys available.

Mothers should be taught to play with their children using simple, homemade toys. It is important to
play with each child individually at least 15-30 minutes per day, in addition to informal group play.

4. Give general discharge instructions

Signs to bring the child back for immediate care if the child:

• Is unable to drink or breastfeed

• Stops feeding
• Develops a fever
• Has fast or difficult breathing
• Has a convulsion
• Has diarrhea for more than a day, or blood in stool
• Has edema (swelling in feet, legs, hands, or arms).
• Has lost weight according to the child
• Is not well and has health problems according to the child

In addition to feeding instructions, mothers will need to be taught:

• When and where to go for planned follow-up at OTP or outpatient follow up

• Any currently needed immunizations should be given in the health facility and counsel given
on when to return for next immunization.
• When to go to the health facility for vitamin A (every six months);
• How to continue stimulating the child at home with play activities.

5. If early discharge is unavoidable, make special arrangements for follow-up

If a child must be discharged before reaching the discharge criteria, it is critical to make arrangements
for the follow-up of the child (for example, special visits by a HW to the child’s home, or outpatient care
at a health facility). Mothers will need special training to prepare feeds.

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 In no case should a child be discharged until the following conditions are met:

• The child is in Phase 2 (is feeding freely on F-100)

• Antibiotic treatment is finished
• The child is eating well
• The child is gaining weight
• Arrangements have been made for support and follow-up (e.g., home visits, or visits to an
outpatient facility).

6.2 Nutrition counselling

Nutrition counseling in acute malnutrition management

Caregivers/mothers and family members need to understand the need for proper care and nutritional
support of malnourished children or individuals while they are in care and when they are discharged from
a nutrition program. The counselor, in this case the nurse or nutrition educator, has the responsibility of
giving appropriate information to the caregiver.

Nutrition counselling is a process of finding the solution to the child’s nutritional problem together
with their mother or caregiver. Unlike nutrition education, nutrition counselling is a two-way process,
during which the mother is actively involved in describing the child’s problems as well as participating
in analyzing the causes and identifying the available resources and solutions. Working together in this
way with the mother or caregiver will help them reach a decision about the doable actions. Analyzing
causes and identifying actions are an important part of the overall process.

6.2.1 General guidance in counselling sessions

The individuals to be counseled include; acutely malnourished patients (especially if pregnant and
lactating mothers), caregivers (parents or guardian) of children under 5 years, and for the chronically ill
and community groups. Nutrition counseling can be conducted during actual management, discharge,
and follow-up of malnourished individuals in the inpatient, outpatient or at the supplementary feeding
program distribution sites.

Admission

 Encourage mothers to continue breastfeeding

 Discuss any breastfeeding difficulty
 Share responsive feeding and care practices

Weekly or bi-weekly follow-up

 Encourage mothers to continue breastfeeding

 Discuss any breastfeeding difficulty
 Assess age-appropriate feeding: child’s age and weight, child’s (usual) fluid and food intake and

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 breastfeeding difficulties perceived by the mother
 Share responsive feeding and care practices
 Initiate IYCF 3-Step counselling on recommended complementary feeding practices when
appetite returns and/or at four weeks before discharge.

Discharge

 Encourage mothers to continue breastfeeding

 Support, encourage and reinforce recommended breastfeeding and complementary feeding
practices
 Work with the mother/caregiver to address any ongoing child feeding problems
 Support, encourage and reinforce recommended complementary feeding practices using
locally available foods
 Share responsive feeding and care practices
 Encourage monthly growth monitoring visits
 Improve health seeking behaviors
 Encourage mothers to take part in IYCF Support Groups
 Link mother to HDA
 Set appointment for follow-up visit

The GALIDRAA steps can be used by counselors for conducting effective counseling sessions with the
following steps;

• G-greet the client and or caregiver and establish confidence

• A-ask the client and or caregiver about current feeding practice
• L-listen to what the client and/or caregiver say
• I-identify key difficulties, if any, and select with the client and or caregiver the most important
one to work on
• D-discuss feeding options
• R-recommend and negotiate do-able actions to help the client and or caregivers select best
options to try, depending on their context and resources
• A-agree to try one of the options and ask them to repeat the agreed upon, do-able actions
• A-appointment, make an appointment for the follow-up visit

6.2.2 Targeted counselling for caregivers of children with SAM

Inpatient care

The monitoring practices and procedures in the monitoring and problem solving session of the training
module has included detailed information on correct feeding preparation, feeding procedures and
hygienic procedures in the inpatient management of SAM. The following are some important points to
mention to the caregivers:

 All children being breastfed need to continue breastfeeding during all phases

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  All caregivers need to be informed on what type and frequency of feeding will be happening in
the different phases of feeding. For example, if the child is on a three hourly feeding schedule,
inform and record that eight feeds will be given per day

 It is best to feed the child with a cup (and spoon, if needed)

 Encourage the child to finish the feed. It may be necessary to feed a very weak child with a
dropper or syringe

 Do not use a feeding bottle

 The formula feeds and RUTF are for the children with SAM

 The children should be fed day and night. Night feeds are extremely important. Many children
die from hypoglycemia due to missed feeds at night. Children must be awakened for these
feeds

 Each child’s feeding plan should be communicated to the caregiver and recorded on the Multi-
chart and feeding planner

 Inform the caregiver on the first day that small frequent feeds [8x] will be given and the child will
gradually be able to take larger, less frequent feeds (every four hours) within two to seven days.

 It takes skill to feed a very weak child, so nursing staff should do this task at first if possible.
Mothers may help with feeding after the child becomes stronger and more willing to eat.

 Never leave the child alone to feed. Spend time with the child, hold the child and encourage it.
Children on F75/F100 should not be fed any other food or fluid especially during Phase 1 and
Transition Phase unless recommended by the HW.

 All feeds at each meal are measured and need to be given within 30 minute to one hour time
and should be finished at each meal; any leftover milk has to be fed to the child. Catch dribbles
by holding a saucer under the cup and re-feed.

 Any feeding problems [ feeds less than 75per cent of the meal, Refusal, vomiting, diarrhea]
should be reported to the health care provider

 Caregivers should be taught how to feed through NGT and should also be informed on how to
continue and follow feeding through the mouth while a NGT is inserted

 Procedures on how to feed with F75/F100 during vomiting and diarrhea is described in the
feeding session of the training module

 Failure to respond is usually related to improper feeding preparation, amount, or duration;

children with both primary or secondary failure need to be investigated for proper feeding

 Food for care taker in the inpatient should be available in the health facilities and care takers can
prepare their own food

 Care takers can be thought on how to keep their children themselves, the inpatient ward, the
feeding utensils, and the milk preparation area in hygienic manner

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Outpatient Care

 OTP key messages on RUTF use and storage is described in the OTP session

 Feeding counseling after discharge/transfer from inpatient or discharge from OTP should be
provided to the caregiver and to the child to prevent any relapse of malnutrition

 Failure to respond in OTP is also related mostly with RUTF sharing at household level, misuse of
RUTF. To9 avoid this problem, caregivers need proper education on how to use RUTF

Nutrition counseling for uunder six month children with SAM

 The development of SAM in this age group commonly reflects suboptimal feeding practices,
especially breastfeeding practices

 Infants who are less than 6 months of age should be exclusively breastfed to gain optimal
nutrition and the greatest protection against infections

 Management of SAM in this age group has focused on establishing or re-establishing exclusive
breastfeeding

 If an infant is not breastfed, support should be given to the mother or female caregiver to re-
lactate. If this is not possible, wet nursing should be encouraged

 Mothers should be encouraged and counseled on the supplementary breast feeding technique
for infants under six months with SAM

 if there is no realistic prospect of being breastfed, the infant should be given appropriate and
adequate replacement feeds such as commercial (generic) infant formula, with relevant support
to enable safe preparation and use, including at home when discharged

 counseling and support for optimal infant and young child feeding should be provided based on
general recommendations for feeding infants and young children [IYCF], including for low-birth-
weight infants

6.2.3 Targeted counselling for caregivers of children with MAM

Distribution sites and demonstration sessions are good opportunities to deliver appropriate messages
focusing on proper child care practices, household and personal hygiene, use of safe drinking water,
hygienic preparation and protection of foods and use of nutritious local ingredients for complementary
feeding.

Key messages

 Children identified as malnourished may be referred directly to the feeding program with a referral
slip (SFP, OTP or SC), or be told to present themselves at the next distribution. The outreach
workers and the communities should have a good understanding of the target groups for the
different programs, in order to reduce inappropriate referrals and rejections at the distribution
site.

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  The regular distribution of FBF or other nutritional products (e.g. RUSF) can be provided to
assist in home treatment of MAM.

 FBF is a pre-mixed, fortified food which contains the necessary nutrients to treat MAM. It is also
provided in dry rations; oil and sugar are given alongside the FBF rather than premixed.

 When oil and sugar are given alongside the FBF, it is essential to mix it into the FBF before
distribution. This is to ensure that the oil and sugar are not used for the family cooking or sold,
as they can otherwise be viewed as valuable cash opportunities for the caregivers.

 If rations are premixed at the distribution site, the aim to ensure that the TSFPs attains the
objectives of successful treatment of MAM in the community.

 Premix must be used within a two week period before any rancidity develops.

 FBF can be ‘spoiled’ if it the porridge is cooked for too little time and it also can lose its nutrients
if it is cooked too much. The ideal cooking time to maximize the nutrients available in FBF is
10 minutes. In order that the beneficiaries understand how best to cook the ration, cooking
demonstrations conducted on-site can be very helpful. FBF is a pre-mixed, fortified food which
contains the necessary nutrients to treat MAM. It should NOT be shared with other members of
the family other than the person who is suffering from MAM.

 Prepare cooking with clean water and in a hygienic way.

 Wash children’s hands and face before feeding, Use soap and water for washing children’s
hands and face.

 Keep the cooked food clean and covered all the time and give to the child whenever he/she
demands for it.

 Always offer the child plenty of clean water to drink or breast milk while he or she is eating.

Notes:

The caregiver should be asked to repeat back to check that the messages have been correctly
understood.

These key messages can be supplemented with more detail and more messages if time allows.

6.2.4 Targeted counselling for care takers of PLWHA

Critical Nutrition Practices

There are seven CNPs that should be given due attention during counseling but the counseling may be
contextualized depending on patient conditions and existing resources. The seven CNPs are:

1. See a health care provider for periodic nutrition assessments (especially weight).

• Periodic weight helps you track the trend of weight changes and take action early
• Unintentional weight loss or gain may imply poor health and lead to hospitalization

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 • Unintentional weight loss of more than 6 kg in 2–3 months indicates that your health or eating
habits are not adequate to maintain your weight or that the disease is fast progressing to AIDS

2. Increase energy intake by eating a variety of foods, especially energy- rich foods, and eating
more often, especially if sick.

• People with HIV need to consume more energy every day than uninfected people of the same
age, gender, and level of physical activity
• Eating a balanced diet ensures that your body gets all the nutrients required
• HIV infection affects digestion and absorption
• Increasing energy intake helps you get enough energy and other nutrients (proteins and
micronutrients) that your body needs
• Fruits and vegetables help strengthen immunity

3. Drink plenty of clean and safe (boiled or treated) water.

• The body needs water to remove the toxins caused by HIV or antiretroviral medications
• Drink only clean, treated water to prevent infections such as diarrhea

4. Maintain a healthy lifestyle by avoiding alcohol, tobacco, sodas, and other colored and
sweetened drinks and do physical activity (get exercise).

• Practicing safer sex avoids infection and transmission of other sexually transmitted infections
• Alcohol interferes with digestion, absorption, storage, and utilization of food
• Smoking interferes with appetite and increases your risk of cancer and respiratory infections,
particularly TB.
• Most sweetened, colored drinks sold in shops contain water, sugar, food color and artificial
flavors—they are not fruit juice. Junk food has little nutritional value and can even harm our
health, so try to avoid eating it.

5. Maintain high levels of hygiene and sanitation

• People with HIV can easily get infections. These can weaken, cause vomiting and diarrhea and
cause appetite loss
• Diarrhea affects digestion or absorption of food and sheds essential nutrients from your body

6. Seek early treatment for infections and advice on managing some symptoms through diet

• Illnesses affect the body’s intake, digestion, absorption and use of food. Late treatment of
illnesses affects nutritional status
• Always seek advice from a health professional concerning use of nutrition supplements
• Be aware of aggressive advertising of some nutrition supplements which may have false claims
• Nutrition supplements should not replace food and do not treat HIV

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 7. Manage food and drug interactions and side effects

Not following your drug and food schedule may affect the effectiveness of the drugs or produce side
effects that can affect your health or nutrition.

Not adhering to prescribed drug regimens may make your body resistant to the drugs, making them
less effective and possibly requiring you to change to stronger drugs.

6.3. Infant and Young Child Feeding in Emergencies

Infant and Young Child Feeding in Emergencies (IYCF-E) is concerned with interventions to protect,
promote and support safe and appropriate feeding practices for both breastfed and non-breastfed
infants and young children in all emergencies wherever they happen.

Practical Steps to Ensure Appropriate Infant and Young Child Feeding in Emergencies (for details see
AMIYCN Guideline page 46)

1. Ensure that action is based on an adequate understanding of the factors affecting infant
feeding practices in the specific situation

2. Create a mechanism for coordinating and monitoring infant feeding activities

3. Eliminate practices that undermine breastfeeding

4. Recognize the special needs of women feeding infants

5. Minimize the dangers in feeding infants and their families

6. Increase awareness and knowledge about the benefits of maternal nutrition and infant
feeding among all stakeholders in emergency situations

Recommended infant and young child feeding practices in emergencies

Breastfeeding

• The most effective way of protecting babies from illness, malnutrition and death is to ensure
breastfeeding

• All newborns should be put to the breast within one hour of birth. This will safeguard the
health of both the mother and the infant

• Exclusive breastfeeding guarantees food and fluid security for infants less than six months
provides active immune protection

• Children over 6 months should continue to breastfed until the child is least 2 years of age

• Continued breastfeeding until the child is 2 years old and beyond, contributes to the food and
fluid security of the young child; it is especially important in contexts where water, sanitation
and hygiene conditions are poor, and where breast milk is likely to be the most nutritious and
accessible food available for the young child in emergency situations

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Complementary feeding practices

• Appropriate complementary foods should be introduced at 6 months and breastfeeding

continued to 2 years and beyond

• The general food ration should contain commodities that are suitable as complementary foods
for young children – for example, include ready-to-use or easily-prepared complementary
foods and supplementary foods appropriate for children from 6 up to 24 months of age.

• When possible, add inexpensive, locally available foods from the various food groups (grain,
roots and tubers; legumes and nuts; fruits and vegetables; and animal source foods)

• A micronutrient FBF (e.g., corn soya blend, wheat soya blend) should be included in the
general ration for older infants/young children when a population is dependent on food aid

• Additional nutrient-rich, RUTF may be provided in SFPs or in ‘blanket’ feeding programs to

targeted age-groups, especially those aged from 6 up to 24 months

• Multi-micronutrient powder can be added to the local foods or general food rations given to
children aged 6 months to 5 years and to PLWs

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CHAPTER 7
COMMUNITY INVOLVEMENT

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 CHAPTER 7
COMMUNITY INVOLVEMENT

Introduction
There is a clear mechanism that has been established to ensure active community involvement in
health and development. The pillar of the strategy is establishing a HDA and building their capacity
(MOH, 2010). A HDA is a community level group of 30 households (women) organized in “1 to 5”
network, where one women functions as leader of the network and five women as network members.
Model women (leaders) are elected as “a model” based on the status of her implementation of the
16 components of the HEP (of which nutrition is one). This approach facilitates horizontal and vertical
support and monitoring activities that help identify bottlenecks and gaps to provide solutions as early
as possible.

For the management of acute malnutrition, the HDA will play an indispensable role. For effective
management of malnutrition, robust nutrition promotion and malnutrition prevention activities must
be carried out. Once someone is malnourished, you want the person to be identified early before
malnutrition progresses and complicated with other morbidities; you want those that have been identified
to continuously follow the management and those who are absent to be traced and encouraged to
continue. Very strong linkages between HCs and HPs, coupled with strong team work between the
HEWs and the HDA is key for such active community involvement.

7.1 Partnership at community level

Coverage of the acute malnutrition management is essential for the success of such a program. Facilities
may be attaining 90 per cent cure rates for the cases treated for acute malnutrition and that is to be
commended. However, if the malnourished cases are coming only from the immediate surroundings of
the health facility, you may be missing the vast majority of cases. The true success depends on both a)
the proportion of malnourished that you are successfully treating, as well as b) the proportion of those
reached from the total number of acutely malnourished in the community (coverage). In a community
where there are a total of 500 acutely malnourished persons, if you treat 50 children and cure 45
of them you can claim 90per cent cure rate. If you also treat all 500 of them and cure 450 acutely
malnourished children you can still claim 90 per cent cure rate. Evidently in the latter case, you treated
ten times as many children. In terms of contributing to reduction in malnutrition and mortality, your
performance is much stronger in the latter case. Therefore, community mobilization is indispensable in
the management of acute malnutrition.

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7.2 Estimating your target
You need to know the catchment population of your health facility, the number of kebles and the total
population. If possible, knowing the estimated number of acutely malnourished person will help you
estimate what proportion of the total are being reached by your facility and the other facilities nearby.
You can use different opportunities for estimating the number of malnourished cases in your catchment
including:

• Community Health Days (CHD)/Enhanced Outreach Strategy (EOS) or other regular opportunities
where the HEW undertakes screening for acute malnutrition

• If there is any nutrition survey that is covering your Woreda

• Regular screening and referral by HDAs

7.3 Why the need for early case identification at

community level?
Malnutrition is very easy to treat when identified early and very complicated to treat if identified late. By
identifying early, you will avoid unnecessary risks of death and disability to the malnourished person.
You will also avoid the cost of related infections, need for in-patient treatment at distant health facility
and time lost by family members in caring for the sick.

Families may not be too far away from health facilities and people may assume that they know about
all the services available. However, increasing awareness to all the type of service available, explaining
that management for acute malnutrition is free and engaging with families to identify any barrier that is
preventing them from coming and receiving services is key for the successful management of acute
malnutrition.

The HDAs should be trained on identifying key selected health conditions to increase the demand for
health services. They should be trained on physical observation and identification of possible risks of
malnutrition. Once they identify, the HDAs should tell the malnourished person or his/her family to go
and see the HEW.

7.4 What is the use of home visit and individual support

to families of acutely malnourished?
Acute malnutrition does not only result from lack of food at home, it also results from inappropriate
hygiene and sanitation at home, poor utilization of available food, as well as other infections. Hence, the
HDAs and HEWs may identify what is the likely contributor for malnutrition in a particular household.
It is not a must that we have to come up with one possible cause because usually a combination of
factors may have resulted in the malnourishment of the individual. Through home visits, the HDAs or
HEWs could:

• Try to identify what contributed to the malnourishment of the individual

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 • What exists at household level to improve the feeding and caring for the malnourished individual

• What behavioral change could be promoted in the setting/context of that household

• If the child has developed fever or other complications, see if he needs to be referred

• If he has missed his treatment, encourage him to continue until he is cured

The HEW should be equipped to facilitate individual counselling (discussion) in a manner that encourages
behavioral change towards the appropriate practices and behaviors as indicated in the Health Extension
Program (HEP) service package. HEWs should also be adequately trained to demonstrate some key
skills such as: how to use water treatment chemicals, breastfeeding and attachment of a young infant.

7.5 Facilitation of women group discussions on key

behaviours
• The HDAs/HEW should organize monthly community discussion sessions on selected
topics. The topics should be selected from two sources; one, based on the felt needs of the
mothers, and second based on the HEW package in discussion with the HEW supervisor

• The HEW should organize monthly growth monitoring and promotion sessions The timing
of these sessions may or may not be at the same time as the community discussions.
Using the findings of the month to month change in weight among the children, the HEW
and the HDA should facilitate women’s’ group discussion on where their team is in terms of
healthy growth of children

7.6 How do we know if there is good community

involvement in acute malnutrition management?
It is vital to continuously and objectively monitor the performance and for the HDA to recognize/realize
that someone knows and appreciates when they do well. For this, there is a need for a reporting
system. As it is not a must for HDAs to be able to read and write, the reporting/ feedback mechanism
does not put written reports as precondition. In areas where it is possible, writing down plans jointly and
revisiting them at the end of the month will facilitate continuous improvement in community involvement.
In areas with good community involvement you will have:

• Cases coming early to treatment, and hence complicated cases will decrease

• As there will be strong and ongoing early identification of cases, campaigns, EOS and CHD will
not identify large numbers of new cases

• In times when there is drought or other emergency, the community will be able to demand for
timely response early, and the Woreda will identify those kebeles before there is a nutritional
crisis

• As there will be very good home visits and follow up, the defaulter rate and mortality rate will be
very low and the cure rate will be high

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158
CHAPTER 8
SUPPLY MANAGEMENT

159
 CHAPTER 8
SUPPLY MANAGEMENT

Introduction
Some nutrition interventions like management of acute malnutrition and micronutrient supplementation
are heavily dependent on a good supply chain. The weight of RUTF needed to cure a severely
malnourished child is usually over 12 kg. You can compare and notice that the weight and volume of
supplies needed for acute malnutrition is much bigger than other commodities typically handled by the
health facilities. Hence, the quantity needed for nationwide coverage represents a substantial volume.
Successful treatment of acute malnutrition requires an uninterrupted supply of therapeutic milks (F75
and F100), RUTF, essential medicines (iron tablets, folic acid, vitamin A, antibiotics, deworming tablets
Resomal and other medical supplies to manage complications), Fortified Blended Foods (CSB++,
CSB+, RUSF), anthropometry equipment, and print materials including protocols, quick references,
look up tables, patient and follow up cards. Through good supply planning, you can avoid malnourished
children missing treatment because of stock outs; and also avoid overloading the pharmacy with excess
stock.

8.1. Supply management in treatment of SAM

8.1.1. Supply forecasting
It is necessary to assess how much supplies were consumed during each month from the monthly
reports on how many children received supplies corresponding to the time period. Such information
enables the consumption of supplies at each facility to be forecasted. For specific supplies, there
may be a standardized format for easy use by facilities as well as Woredas. Below is an example of
therapeutic feed requesting format:

Example: supply forecasting for management of SAM

• First, review the average number of new severely malnourished children treated in your area
of interest (facility or Woreda). Put this number under column C. Depending on the seasonality
of malnutrition in your area, you may decide to increase or decrease the estimated monthly
admission beyond your admission in the past month. Data from previous years showing monthly
admission could be of great help in facilitating your decision

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 • Next, decide the number of months you need to keep stock for. Depending on your distance
from the next supply level, you may decide to request for one month or more months’ worth of
supplies. Indicate the number of months you need under column D

• Finally, you need to check with your pharmacy to indicate the stock levels of each of the items
and put in column E

• Once you get the above information, you can do the calculation of the amount of supplies
needed using the formula on column H

Therapeutic feed requirement estimation sheet16*

Number of
Current
Ration/ child/ new cases Number Weight of
stock
treatment anticipated of months 1 cartons Quantity requested (CTN)
levels
(MT) (admission per requested (kg)
(CTN)
month)
Product
H

B C D E G
[(B X C X D X 1000) ÷ G] - E

F75 0.001230.01 12.30 -

F100 0.000456 10.26 -

ReSoMal 0.0000168 10.92 -

BP100 0.0125 12.24 -

Plumpynut
0.0125 13.80 -
(RUTF)

In addition to the above supplies, you need to estimate and plan for monitoring materials like OTP cards,
registration book and multi-charts. While these items can be planned for and requested on quarterly
basis, it is advisable to plan for them on an annual basis as they do not occupy a large amount of
space. There are also other items that are requested at the start of the program and to replace in case
of damage. These items include anthropometric equipment and SC/SC opening kits.

8.1.2 Stock management

All health facilities must use stock cards and/or bin cards. As this is standard practice, the pharmacy
normally keeps such bin and stock cards.

Storage of supplies

Make sure adequate storage space is available. Stores should be secure, dry and with good ventilation.
To the extent possible, pallets or shelves should be used to keep supplies off the ground. You also need
to keep the store clean and free of insects and rodents. Make sure TFP products are stored separately
from equipment and harmful chemicals.
16 *Note that ration per child per treatment changes from time to time and hence should not be taken as fixed
estimates. You can study consumption within your facility over time.

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 Supplies should be rotated on a “first expiry, first out” (FEFO) basis. Stock nearing its expiry date
when goods are initially received should not be accepted unless they can be used before the expiry
date. Stocks that have passed their expiry date or are damaged must be separated and disposed of
as per the standard practice. Store supplies in a manner accessible for FEFO, counting and general
management. Large stocks should be avoided unless in exceptional situations. If your facility is in a
remote area and road access is likely to be difficult in rainy seasons, you may decide to keep large stock
for a while until the anticipated dry season.

Proper Utilization of items provided

Stock should be physically counted and checked once a month and prior to each supply distribution.
Depending on the commodity, this may be daily or weekly. You have to ensure that nutrition supplies
are treated as pharmaceutical logistics. Previously, some facilities stored nutrition supplies like RUTF
outside pharmacies with no strong control system. This usually leads to misuse of these items and
stock outs. In such situations, a severely malnourished child that presents later in to your facility for
life-saving treatment will be at risk because of mismanagement. With good use of stock cards and
bin cards, you will be able to easily tell your average weekly or monthly consumption of commodities.
This, in turn, will allow you to estimate how long your stock at hand will last. Make a request well before
stock rupture. A minimum of one month’s stock is usually recommended to have at hand or more when
transportation is critical.

Every month you should compare the monthly consumption of the facilities with the number of reported
cases. Looking at the number of children admitted to your facility and their weights, you can calculate
the number of sachets that should be used to treat for the number of days the children stayed in
program. Now, if this calculation is not matching with actual consumption on your stock card you should
investigate for possible causes. Some of the causes may be:

• The national protocols are not being respected, and hence children are receiving less or
more than what is recommended by the guidelines

• Some of the RUTF has been given without being recorded either in patient follow up card
or the warehouse stock monitoring systems

• There may be misuse of supplies by the staff

• There may be damage of some supplies. Remember that damaged supplies must be
discarded using appropriate rules and regulations of the facility

Regulation of nutrition supplies

Your facility and Woreda should regularly check the nearby market to assess the availability of nutrition
commodities in local markets and shops. You should coordinate with the health office to ensure a
minimization of selling the nutrition commodities that are provided freely for saving lives. Whenever
found, take all necessary steps; including investigation of sources and legal action against all parties
involved.

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Reporting and requesting for supplies

Use standard Reporting and Requesting formats (RRF) for commodity supplies through health sector.
Specific reporting and requesting formats may be present for some supplies like supplementary feeds.
You may need to coordinate with the appropriate person to ensure timely reporting so that the children
that require service are not missed due to stock outs

8.2 Supply management in treatment of MAM

Supplies, equipment and transport

The size of the area and number of beneficiaries expected for the SFP will determine the amount of
materials, equipment, food and other items that are required. The minimum supply requirements for an
emergency SFP may include:

1. Food commodities; FBF, oil, sugar and/or other products to treat MAM

2. Routine and other common drugs and vitamin supplements

3. Monitoring materials; ration cards, referral slips, registration books, reporting formats, supervision
formats

4. Anthropometric equipment; salter scale or electronic scales, height/length boards, MUAC tapes,
WFH reference tables in z-scores

5. NFIs; shelter, soap for washing hands and utensils, clean water, cups, spoons, cooking
demonstration equipment, tables, chairs/benches

6. Documentation; IEC materials, training materials, national guidelines, job aids, field guides (e.g.
CSB+, RUSF usage), pictorial information for beneficiaries outlining what they can expect at the
site, such as ration entitlements, etc.

7. Sufficient transport must be available to effectively implement the program; to ensure

uninterrupted product supply chains and to move staff around, as necessary

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 8.2.1 Storage and Warehousing

Figure 3 The important features of warehousing and storing food commodities

• Products should be stored 40 cm off the wall and 10 cm off the floor. Supplementary
food should be stored on pallets to prevent weevil infestation/contamination. At times when
pallets are not available, plastic sheets should be used. Supplementary food should be
protected from rodent infestation.

• Supplementary food should be stored separately from other commodities, e.g. medicines
or stationary

• Bags must not lie directly on the floor. Stacks of bags should be no more than 2m high

• Separate damaged bags/boxes. Record and report any damage that occurs

• Keep an inventory of all of the items in the store; a record list should indicate the name of
item, quantity, date received, date dispatched, from whom, by whom, balance and expiring
dates. It is helpful to have a stock control system, using the ‘first in, first out’ storage strategy
(but also considering the expiry date; goods with earlier expiry dates should be used first).
annex 26 for tips on good warehouse management (supplied by WFP)

8.2.2 Determining the case load for TSFP

For new programs, the number of beneficiaries can be estimated based on the findings of the most
recent nutritional assessment. Examples are given below for how to calculate the expected case-loads:

Total number of malnourished group =

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Total population of vulnerable group X Prevalence rate of MAM17

For planning purposes, it is common to estimate that between 70-80per cent coverage of the population
will be reached by the TSFP.

Example 1:

A standard nutrition survey conducted in Borena Zone indicated a GAM level of 14.6per cent and a SAM
of 1.6per cent. The estimated total population of the survey area was 50,000. Based on the nutrition
survey results, the estimated number of children to be enrolled in the program can be calculated as
follows:

• Total population of the area = 50,000

• Under 5 population (for example, 18per cent of total population) = 50,000 x 18/100 = 9,000
• Prevalence of MAM = GAM- SAM = MAM level (14.6per cent - 1.6per cent)= 13per cent
o Number of MAM children in the area = 9,000 x 13/100 = 1,170
• 75per cent of MAM children expected to be reached by TSFP = 1,170 x 75/100 = 878*

It can be more difficult to estimate the expected case load of PLW for the TSFP because the exact
percentage of the women of childbearing age in the population that is pregnant or lactating is generally
unknown (if the figure is known, then it can be used for the calculation). However, a rough measure can
be used, estimating that approximately 5per cent of the total population will be women of childbearing
age, who are likely to be pregnant or lactating at any one time.

Example 2:

The same standard nutrition survey in Borena Zone also measured the MUAC of all PLW included in the
survey. This indicated that 10per cent of PLW were moderately malnourished.

• Total population in the area = 50,000

• Estimated population of PLW in the area (5per cent of total population) = 50,000 x 5/100 =
2,500
• Estimated number of PLW who are MAM (10per cent) = 2,500 x 10/100 = 250
• 75per cent of PLW with MAM expected to be reached by TSFP = 250 x 75/100 = 188*

For ongoing programs (and where it is not possible to conduct a nutrition assessment), trends of
admissions can be used, to forecast expected case-loads for the next phase of the program.

17 *The incidence rate should also be accounted for as new cases will arise during program implementation. However,
as yet there is no international consensus about what number to use as the incidence multiplier, although at global
level, WFP is currently using prevalence multiplied by 2.

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 8.3 Supply management for PLWHA

Central to Facility level Logistic Management

Nutrition and HIV commodities, especially the therapeutic food procurement and distribution, mainly
use Integrated Pharmaceutical Logistics System (IPLS) for ARV and other HIV commodities of
Pharmaceutical Fund and Supply Agency (PFSA). RUTF and FBF are the two main commodities in the
pipeline and are presumed to be procured optionally from both international and local markets.

In the IPLS, the whole process of commodity movement begins with procurement of commodities
based on the national quantification, which is done under the leadership of PFSA in consultation with
partners. PFSA stores the commodity in its central warehouse and upon receipt of regional allocation
regional hubs or facilities delivers stock to each regional PFSA hubs, which further deliver stocks to
respective health facilities up on request by health facilities with nutrition and HIV services.

In the IPLS system, the document that serves to link the health facility and regional PFSA hubs is called
RRF. Plumpy’Nut and FBF are listed amongst the pharmaceuticals that have to be reported upon
consumption and requested for stock every two months. Each health facility is expected to quantify
its average monthly consumption and place stock requests accordingly in such a way that it would
not run out of stock until the following reporting and requesting period. Each facility is expected to
have a maximum stock for four months and minimum stock for two months, depending on its storage
capacity. If facilities face untimely stock out situation, they can also place an emergency stock refill to
their regional PFSA hubs.

There are other systems to deliver RUTF to facilities for management of SAM among children, which is
through the Regional Health Bureau (RHB). In this system, UNICEF delivers to the RHBs stores based
on their stock report and demand. The RHBs in turn distribute to the health facilities including the health
posts.

Facility level logistic management

IPLS has the intra-facility management as well where by products are dispensed through the pharmacy
(preferably ART pharmacy) of the facility. Inter Facility Reporting and Requesting Form (IFRRF) is the link
between the facility store and dispensary unit to record the transaction and dispense of commodities
between the store and pharmacy.

The HW writes a prescription to the clients based on their nutritional status and the clients receive the
commodities from the pharmacy.

Roles and Responsibilities

The role of PFSA is to procure and distribute the commodities to regional hubs and health facilities.
They also provide capacity building for the storekeepers and pharmacy staff. The health facilities are
responsible for managing the commodities properly, documenting consumption record, reporting

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on time to PFSA hubs by the RRF, documenting and managing the issuing of commodities to the
dispensary units by the IFRR and documenting prescription papers and record keeping of periodic
dispensary of the commodity.

Partners will provide technical support in the procurement, distribution, reporting and utilization of
commodities and capacity building activities.

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CHAPTER 9
ROLES AND
RESPONSIBILITIES OF
STAKEHOLDERS IN
MANAGEMENT OF
ACUTE MALNUTRITION

169
 CHAPTER 9
ROLES AND RESPONSIBILITIES
OF STAKEHOLDERS IN
MANAGEMENT OF ACUTE
MALNUTRITION
The role and responsibilities of different stakeholders at all levels in the implementation of this plan are
outlined and described below:

1. Roles and Responsibilities of FMoH

 Gives guidance in the implementation of this plan in line with NNP objectives

 Gives guidance and implementation directions to regions and partners

 Ensures program quality through supervision and monitoring

 Coordinates national orientation/consultative workshops

 Mobilizes resources for implementation;

 Ensures supply of therapeutic products, drugs, job aids and equipment at HPs, HCs and
hospital level

 Coordinates trainings at regional level

 When necessary, reviews policy and implementation guidelines

2. Roles and Responsibilities of RHB/ZHD

 Gives guidance and implementation directions to Zonal health department and Woreda
health offices;

 Supports health facilities in implementing quality programming through supervision and

monitoring

 Coordinates trainings and follow up training implementation at HC and hospital level

170
  Mobilizes resources for regional/zonal and woreda level trainings

 Ensures supply of therapeutic products, drugs, job aids and equipment at HPs, HCs and
hospital level

 Ensures timely and quality reporting

3. Roles and Responsibilities of Woreda Health Office

 Coordinates trainings and follow up after training of HWs and HEWs

 Ensures continuous supply of supplementary/therapeutic products, drugs, job aids and

equipment for HCs, HPs and district hospitals

 Monitors supply status and requests on time

 Strengthens the referral linkages and communication systems between the HPs and HCs
by building the capacities of both referral points

 Ensures that the HCs staff conduct regular supportive supervision to enhance the capacities
of the HEWs in assessing, classifying and managing acute malnutrition

 Conducts supportive supervision and regular review meetings in order to enhance the
program management

 Ensures complete and timely reporting of activities on acute malnutrition interventions from
HPs, HCs and hospitals

 Ensures timely reporting of activities to the zonal health bureaus

4. Roles and Responsibilities of PHCU/ Referral HC

 Gives appropriate and constructive feedback to referring HP/HEW after giving appropriate
care to referred cases

 Supports HEWs in building their skills in assessing and managing acute malnutrition;

 Ensures a continuous supply of supplementary/therapeutic products like F75, F100, RUTF,

RUSF and CSB++ for their HCs and for HPs

 Ensures a continuous supply of routine drugs for SAM for their HCs and HPs

 Coordinates and participates in training sessions for HWs and HEWs

 Ensures CBNC implementation is well coordinated, implemented and followed at the kebeles
of their respective catchment areas

 Ensures that essential supplies are in place at HCs and HPs by strengthening their capacities
in keeping track of supplies

 Conducts timely and regular recording and reporting

171
 5. Roles and Responsibilities of HEWs

 Ensures quality implementation of SAM and MAM management

 Ensures 24/7 functions of the HPs for OTP

 Ensures the availability and proper utilization of necessary supplies (drugs, job aids and
equipment) in the HPs and requests for timely supply to the HCs

 Properly registers SAM and MAM managed children and PLWs with the kebele and reports
to the HC on time

 Builds the capacity of 1-5 HDA networks leaders and model families to recognize acute
malnutrition, thereby, strengthening the tracing of cases and in community involvement

 Ensures that referred patients are reach the health centers; by giving proper counseling
on the reasons for referral to mothers/care givers, visiting the houses following referral,
addressing reasons for potential hindrance for not going to HCs, informing the 1-5 network
leaders to closely follow up in collaboration with community leaders kebele management
and community social organizations

 Ensures that nutrition issues are discussed in community conversations in 1-5 network

6. Roles and Responsibilities of HDA (1-5 network leaders)

 Have the appropriate skills and tools to increase the knowledge, attitude and health seeking
behavior of mothers, caregivers and the community at large

 Continuously undertake health promotion, counseling and social mobilization activities in the
community to improve the knowledge, attitudes and health seeking behavior of caregivers

 Support the caregiver to ensure treatment compliance and home management of

supplementary and therapeutic food

 Ensure that referred cases are actually going to HP/HCs by giving proper counseling and
creating enabling conditions for referrals

172
References
1. Ethiopia Demographic and Health Survey. The Central Statistics Agency of Ethiopia. 2011

2. Report on the Levels and Trends in Child Mortality. The UN Inter-Agency Group for Child Mortality
estimation. 2013.

3. FMOH. National protocol for management of severe acute malnutrition. 2007.

4. FMOH. Management of moderate Acute Malnutrition guideline 2012.

5. National Nutrition Program 2016-2020

6. Chastre C LS. Nutrition and food security response analysis in emergency contexts. 2010.

7. serious Tln. Framework for actions to achieve optimum fetal and child nutrition and development
2013 1.

8. WHO. Guidelines for an integrated approach to the nutritional care of HIV-infected children (6
months-14 years). 2009.

9. WHO. Guideline: Updates on the management of severe acute malnutrition in infants and children.
Geneva: World Health Organization. 2013.

10. WHO child growth standards and the identification of severe acute malnutrition in infants and
children A Joint Statement by the World Health Organization and the United Nations Children’s
Fund. 2009.

11. The WHO Management of severe malnutrition: a manual for physicians and other senior health
workers. 1999.

12. Trehan I ea. Antibiotics as part of the management of uncomplicated severe malnutrition. N Engl
J Med. 2013(368):425-35.

13. Briend A MB, Fontaine O, Garenne M. Mid-upper arm circumference and weight-for-heightto
identify high-risk malnourished under-five children. Matern Child Nutr. 2012(8):130-3.

14. Organization WH. Guiding principles for feeding non-breastfed children 6–24 months of age.
Geneva: . 2005.

15. Organization WH. Infant and young child feeding counselling: an integrated course. Geneva: .
2006.

16. Amthor R CS, Manary M. . The use of home-based therapy with ready-to-use therapeutic
food to treat malnutrition in a rural area during a food crisis Journal American Diet Association.
2009(109):464-7.

173
 WHO. Guideline: Updates on the management of severe acute malnutrition in infants and children.
Geneva: World Health Organization; 2013.

WHO. Guideline: Nutritional care and support for patients with tuberculosis. Geneva: World Health
Organization; 2013.

FMOH. Guidelines for clinical and programmatic management of TB, TB/HIV and leprosy in Ethiopia,
2013

Annexes
1 F75 look up table in phase one

2 Transition Phase: amounts of F100 to give

Amount of RUTF to give (in grams) for meal substitution when mixed feeding with F100 and RUTF is being
3
used
4 Phase 2 Amount of F100 or RUTF to give at each feed for 5 or 6 feeds per day

5 Amount of F-100 diluted to give for infants during Supplementary Suckling

6 Amounts of diluted F100 to give for infants not breastfed and without edema in Phase 1

7 F75 during phase 1 or children under six months with edema

8 RUTF reference table for OTP

9 Sample registration book for therapeutic feeding

10 Therapeutic treatment multi-chart for severe acute malnutrition (in-patient)

11 Outpatient Therapeutic Program (OTP) card

12 Monthly statistics report for SAM management

13 Monitoring Checklists

14 Calculating Estimated RUTF Needs

15 TSF registration book children 6- 59 months

16 Registration book for Pregnant and Lactating Women

17 TSF Ration card for children 6-59 months

18 TSF Ration Card for Pregnant or Lactating Women

19 TSF ration card for Pregnant and Lactating Women

20 TSFP referral Slip

21 TSFP monthly Statistics Report Children 6- 59 months

22 TSF monthly Statistics Report for Pregnant and Lactating Women

23 Suggested equipment and supplies required for TSFP

24 TSFP supervision checklist

25 Home Visit Form

26 Warehouse Management: General Store Keeping

27 Post Distribution Monitoring (PDM) questionnaire for TSFP beneficiaries

28 CMAM program performance monitoring scorecard

174
Annex 1. F75 look up table in phase one

I. Transition Phase: amounts of RUTF to give

Class of Weight Paste Plump Nut BP100 total

gram/day sachets/day bars/day kcal

3 - 3.4 90 1.00 1.5 500

3.5 - 3.9 100 1.00 1.5 550

4 - 4.9 110 1.25 2.0 600

5 - 5.9 130 1.50 2.5 700

6 - 6.9 150 1.75 3.0 800

7 - 7.9 180 2.00 3.5 1000

8 - 8.9 200 2.00 3.5 1100

9 - 9.9 220 2.50 4.0 1200

10 - 11.9 250 3.00 4.5 1350

12 - 14.9 300 3.50 6.0 1600

15 - 19.9 370 4.00 7.0 2000

25 – 39 450 5.00 8.0 2500

40 – 60 500 6.00 10.0 2700

175
 Annex 2 Transition Phase: amounts of F100 to give

Class of Weight (kg) 8 feeds per day 6 feeds per day 5 feeds per day

Less than 3kg F100 full strength should not be given–only F100 diluted should be given

3.0 to 3.4 kg 60 ml per feed 75 ml per feed 85 ml per feed

3.5 – 3.9 65 80 95

4.0 – 4.4 70 85 110

4.5 – 4.9 80 95 120

5.0 – 5.4 90 110 130

5.5 – 5.9 100 120 150

6 – 6.9 110 140 175

7 – 7.9 125 160 200

8 – 8.9 140 180 225

9 – 9.9 155 190 250

10 – 10.9 170 200 275

11 – 11.9 190 230 275

12 – 12.9 205 250 300

13 – 13.9 230 275 350

14 – 14.9 250 290 375

15 – 19.9 260 300 400

20 – 24.9 290 320 450

25 – 29.9 300 350 450

30 – 39.9 320 370 500

40 – 60 350 400 500

176
Annex 3. Amount of RUTF to give (in grams) for meal substitution when mixed feeding with F100 and
RUTF is being used

Amount of RUTF to give for meal substitution when mixed feeding with F100
and RUTF is being used

8 meals / day 6 meals/day 5 meals / day

3.0 to 3.4 kg 11 g per feed 14 g per feed 16 g per feed

3.5 – 3.9 12 15 17

4.0 – 4.4 13 16 20

4.5 – 4.9 15 18 22

5.0 – 5.4 17 20 24

5.5 – 5.9 18 22 28

6 – 6.9 20 25 30

7 – 7.9 25 30 35

8 – 8.9 25 35 40

9 – 9.9 30 35 45

10 – 10.9 30 35 50

11 – 11.9 35 40 50

12 – 12.9 40 45 55

13 – 13.9 40 50 65

14 – 14.9 45 55 70

15 – 19.9 45 55 75

20 – 24.9 55 60 80

25 – 29.9 55 65 80

30 – 39.9 60 70 90

40 – 60 65 75 90

177
 Annex 4. Phase 2 Amount of F100 or RUTF to give at each feed for 5 or 6 feeds per day

6 feeds/ day 5 feeds/d

Class of weight
F100 RUTF F100 RUTF
(kg)
ml/feed g/feed ml/feed g/feed

<3 kg Full strength F100 and RUTF are not given below to children weighing less than 3kg

3.0 to 3.4 110 20 130 25

3.5 - 3.9 120 22 150 30

4.0 - 4.9 150 28 180 35

5.0 - 5.9 180 35 200 35

6.0 - 6.9 210 40 250 45

7.0 - 7.9 240 45 300 55

8.0 - 8.9 270 50 330 60

9.0 - 9.9 300 55 360 65

10.0 – 11.9 350 65 420 75

12.0 – 14.9 450 80 520 95

15.0 – 19.9 550 100 650 120

20.0 - 24.9 650 120 780 140

25.0 – 29.9 750 140 900 160

30.0 - 39.9 850 160 1000 180

40 - 60 1000 180 1200 220

178
Annex 5 Amount of F-100 diluted to give for infants during supplementary suckling

Weight (Kg) Diluted F100 in ml per feed in Phase 2, (8 feeds/day)

< 1.3 25 ml per feed

1.3 - 1.5 30

1.6 - 1.7 35

1.8 - 2.1 40

2.2 - 2.4 45

2.5 - 2.7 50

2.8 - 2.9 55

3.0 - 3.4 60

3.5 - 3.9 65

4.0 - 4.4 70

Note: The quantity is NOT increased as the infant starts to gain weight

Annex 6. Amounts of diluted F100 to give for infants not breastfed and without edema in Phase 1

Weight (Kg) Diluted F100 in ml per feed in Phase 1,(8 feeds/day)

< 1.6 30 ml per feed

1.6 - 1.8 35 ml

1.9 - 2.1 40 ml

2.2 - 2.4 45 ml

2.5 - 2.7 50 ml

2.8 - 2.9 55 ml

3.0 - 3.4 60 ml

3.5 - 3.9 65 ml

4.0 - 4.4 70 ml

179
 Annex 7. F75 during phase 1 or children under six months with edema month

8 feeds per day 6 feeds per day

Class of Weight (kg)
ml for each feed ml for each feed

2.0 to 2.1 kg 40 ml per feed 50 ml per feed

2.2 - 2.4 45 60
2.5 - 2.7 50 65
2.8 – 2.9 55 70
3.0 - 3.4 60 75
3.5 – 3.9 65 80
4.0 – 4.4 70 85
4.5 – 4.9 80 95
5.0 – 5.4 90 110
5.5 – 5.9 100 120
6 – 6.9 110 140
7 – 7.9 125 160
8 – 8.9 140 180
9 – 9.9 155 190
10 – 10.9 170 200
11 – 11.9 190 230
12 – 12.9 205 250
13 – 13.9 230 275
14 – 14.9 250 290
15 – 19.9 260 300
20 – 24.9 290 320
25 – 29.9 300 350
30 – 39.9 320 370
40 – 60 350 400

180
Annex 8. RUTF reference table for OTP

RUTF Paste PLUMPY’NUT® BP100®

Weight (kg) grams grams sachet sachet bars bars

per day per week per day per week per day per week

3.0 - 3.4 105 750 1¼ 9 2 14

3.5 - 4.9 130 900 1½ 9 2½ 16

5.0 – 6.9 200 1400 2 14 4 28

7.0 – 9.9 260 1800 3 21 5 35

10.0 - 14.9 400 2800 4 28 7 49

15.0 – 19.9 450 3200 5 35 9 63

20.0 – 29.9 500 3500 6 42 10 70

30.0 - 39.9 650 4500 7 49 12 84

40 - 60 700 5000 8 56 14 98

181
182
Annex 9. Sample registration book for therapeutic feeding
183
184
Annex 10. Therapeutic treatment multi-chart for severe acute malnutrition (in-patient)
185
186
Annex 11. Outpatient Therapeutic Program (OTP) card

187
188
 Annex 12. Monthly statistics report for SAM management
Monthly Statistical Report - Management of Severe Acute Malnutrition

Facility Implementing agencey/Health Facility:

Region Report prepared by:
Zone Month/Year of reporting in Ethiopian Calender:
Woreda Type of program
Opening Date:

New Admisions Discharge Transfer (F) Total Total end of

Group Age Sex Total Begining W/H<-3 Zs OEDEMA( Relapse( Re- Transfer Total Cured Death ( Unknown Deafault Non- Medical Total Transfer Transfer Exit (G)- the month
of the month (A) or MUAC < B2) B3) Admissio in from (D1) D2) (D3) er (D4) responde Transfer( Out to to
admissions( C )- discharge E+F1+ (H)- (A+C)-G
115mm n after another r (D5) D6) inpatient outpatie
(children or defaultin therapeu B1+B2+B3+B4 (E) - (F1) nt (F2) F2
MUAC g (B4) tic unit +B5 D1+D2+D3+
<180mm (B5) D4+D5+D6
(adults) -
(B1)

Male

< 6 months Female

Male
6-59 months Female
Male
5-10 years Female
Male
11-17 years Female
Male
> 18 years Female
Total

New admission = Patient directly admitted to your programme to start the nutritional treatment (new admission to Phase 1 or direct new admission to Phase 2). Marasmic (B1), Kwashiorkor (B2) or Relapse (B3) admissions are recorded in 3 different columns
Re-admission after defaulting (B4) = Patient that has defaulted from a nutritional therapeutic treatment and he is re-admitted in your unit within a period of less than 2 months for OTP and less than 2 weeks for SC.
Transfer In (B5) = Patient that has started the nutritional therapeutic treatment in a different site and is referred to your programme to continue the treatment. This can be transfers from in-patient to out-patient OR from out-patient to in-patient.
Cured (D1) = Patient that has reached the discharge criteria
Death (D2) = Patient that has died while he was in the programme. For out-patient programme, the death has to be confirmed by a home visit
Unknown (D3) = Patient that has left the programme but his outcome (actual defaulting or death) is not confirmed/ verified by a home visit
Defaulter (D4) = Patient that is absent for 2 consecutive weighing (2 days in in-patient and 2 weeks in out-patient), confirmed by a home visit
Non-responder (D5) = Patient that has not reached the discharge criteria after 40 days in the in-patient programme or 2 months in the out-patient programme
Medical transfer (D6) = Patient that is referred to a health facility/ hospital for medical reasons and this health facility will not continue the nutritional treatment
Transfer Out (F) = Patient that has started the nutritional therapeutic treatment in your programme and is referred to another site to continue the treatment
Transfer out to in-patient (F1): patient referred to in-patient care.
Transfer out to out patient (F2): Patient reffered to out patient care
Total end of the month (H) = Total beginning of the month (A) + Total admissions (C) - Total exit (G)

Average weight gain and average length of stay (only

for children 6-59 months cured)

Number of
Value sample children Weight gain=(dicharge weight (g)-admission weight (g))/(admission weight(kg)*#days between admisison and discharge day)
Average weight gain
(g/kg/day) Average weight gain=sum of weight gains/#of sampled 6-59months cured
Average length of stay
(days) Average length of stay=sum of length of stay/number of sampled 6-59 months cured

189
 Annex 13. Monitoring Checklists

1. Checklist for monitoring food preparation

No OBSERVE: YES NO COMMENTS

1 Are ingredients for the recipes available?

Is the correct recipe being used for the ingredients that are
2
available?

Are ingredients stored appropriately and discarded at

3
appropriate times?

4 Are containers and utensils kept clean?

Do kitchen staff (or those preparing feeds) wash their hands

5
with soap before preparing food?

Are the recipes for F-75 and F-100 followed exactly? (If
6 changes are made due to lack of ingredients, are these
changes appropriate?)

Are measurements made exactly with proper measuring

7
utensils (e.g., correct scoops)?

8 Are ingredients thoroughly mixed (and cooked, if necessary)?

Is the appropriate amount of oil mixed in (i.e., not left stuck

9
in the measuring container)?

10 Is mineral mix added correctly?

Is the correct amount of water added to make up a liter

11 of formula? (Staff should not add a liter of water, but just
enough to make a liter of formula.)

12 Is food served at an appropriate temperature?

Is the food consistently mixed when served (i.e. oil is mixed

13
in, not separated)?

14 Are correct amounts of food put in the dish for each child?

15 Is leftover prepared food discarded promptly?

16 Other:

190
2. Check List for Monitoring Ward Procedures

No OBSERVE: YES NO COMMENTS

Feeding
1 Are correct feeds served in correct amounts?
Are feeds given at the prescribed times, even on nights and
2
weekends?
3 Are children held and encouraged to eat (never left alone to feed)?
4 Are children fed with a cup (never a bottle)?
Is food intake (and any vomiting/diarrhea) recorded correctly after
5
each feed?
6 Are leftovers recorded accurately?
Are amounts of F-75 kept the same throughout the initial phase,
7
even if weight is lost?
After transition, are amounts of F-100 given freely and increased
8
as the child gains weight?
Warming
9 Is the room kept between 250C to 300C (to the extent possible)?
10 Are blankets provided and children kept covered at night?
11 Are safe measures used for re-warming children?
12 Are temperatures taken and recorded correctly?
Weighing
13 Are scales functioning correctly?
14 Are scales standardized weekly?
15 Are children weighed at about the same time each day?
Are they weighed about one hour before a feed (to the extent
16
possible)?
17 Do staff adjust the scale to zero before weighing?
18 Are children consistently weighed without clothes?
19 Do staff correctly read weight to the nearest division of the scale?
20 Do staff immediately record weights on the child’s MULTICHART?
21 Are weights correctly plotted on the Weight Chart?
Giving antibiotics, medications, supplements

22 Are antibiotics given as prescribed (correct dose at correct time)?

When antibiotics are given, do staff immediately make a notation
23
on the MULTICHART?
24 Is folic acid given daily and recorded on the MULTICHART?

25 Is vitamin A given according to schedule?

26 Is a multivitamin given daily and recorded on the MULTICHART?

After children are on F-100 for 2 days, is the correct dose of iron
27
given twice daily and recorded on the MULTICHART?
Ward environment

28 Are surroundings welcoming and cheerful?

29 Are mothers offered a place to sit and sleep?

30 Are mothers taught/ encouraged to be involved in care?

31 Are staff consistently courteous?
As children recover, are they stimulated and encouraged to move
32
and play?

191
 3. Check List for Monitoring Hygiene

No OBSERVE: YES NO COMMENTS

Hand washing
1 Are there working hand-washing facilities in the ward?

2 Do staff consistently wash their hands thoroughly with soap?

3 Are their nails clean?

4 Do they wash hands before handling food?

5 Do they wash hands between caring for each patient?

Mothers’ cleanliness
6 Do mothers have a place to bathe, and do they use it?

Do mothers wash hands with soap after using the toilet or

7
changing diapers?

8 Do mothers wash their hands before feeding children?

Bedding and laundry
9 Is bedding changed every day or when soiled/wet?

Are diapers, soiled towels and rags, etc. stored in bags, then
10
washed or disposed of properly?

11 Is there a place for mothers to do laundry?

12 Is laundry done in hot water?

General maintenance
13 Are floors swept?

14 Is trash disposed of properly?

15 Is the ward kept as free as possible of insects and rodents?

Food storage

Are ingredients and food kept covered and stored at the

16
proper temperature?

17 Are leftovers discarded?

Dishwashing
18 Are dishes washed after each meal?

19 Are they washed in hot water with soap?

Toys
20 Are toys washable?

21 Are toys washed regularly, and after each child uses them?

192
Annex 14: Calculating Estimated RUTF Needs

Estimated RUTF needs for outpatient care per facility per month are based on a RUTF diet (Plumpy’nut®)
of 200 kcal per kg per day per child on average

Each child in outpatient care consumes about 20 packets of Plumpy’nut a week. Total consumption in
outpatient care per facility per time period is calculated as follows:

A Number of outpatient care beneficiaries per facility A

B Monthly consumption per child (20 packets/child/week) 80 Sachets

C Monthly packet consumption for outpatients per facility boxes

D Monthly carton consumption for outpatient care C/150

E Monthly net weight (MT) (13.8 kg/carton) D x 13.8/1000

F Monthly gross weight (MT) (14.9 kg/carton) D x 14.9/1000

Example

A Number of outpatient care beneficiaries per facility 100

B Monthly consumption per child (20 Sachets/child/week) 80 Sachets

C Monthly sachet consumption for outpatients per facility 80X100= 8000 Sachets

D Monthly carton consumption for outpatient care 8000/150= 53.3 Cartoon

E Monthly net weight (MT) (13.8 kg/carton) 53.3 x 13.8/1000= 0.73 MT

F Monthly gross weight (MT) (14.9 kg/carton) D x 14.9/1000= 0.01 MT

193
 TSF Registration Book for children 6-59 months

194
Admission Medication Given
Ser. No Sex Age in Admission
Date MUAC Wt. in KG Ht in WFH Z- Mebendazole/
Full Name Village/Got (F/M) Months Code
(cm) CM score Vit. A Alebendazol

Code Medication Given

Code Admission Code
New New admissions (children 6-59) ≥11.5-< 12.5cm or WHZ 1 Vit A
Score ≥ -3Z to < -2
Read Readmission (up to 3 months) 2 Mebendazole/Albendazol
Return Returned after default (within 2 months)
Trans In Transferred in 3 Measles
Annex 15: TSF
Tras OTP registration
Transferred book
from OTP children 6- 59 months
to SFP
Date Weig Height MUAC WFH Date Weight Height MUAC WFH Date Weight Height MUAC WFH Date Weight Height MUAC WFH Disc
ht (cm) Z-score (cm) Z-score (cm) Z- (cm) Z-score ge
score Cod

Discharge Code
Rec Cured/Recovered
Died Died
Default Defaulter/(absent for 2 consecutive distributions)
Trans out Transfer out
NR Non-respondent (failure to respond to treatment with a period of 4 months
OTP Dis OTP discharges

195
196
Annex 16: Registration book for pregnant and lactating women

Registration Book for TSFP Pregnant and Lactating

(Pregnant) (Lactating) Admission Admission Code

No. Full Name Village/Gott Admissio MUAC(cm Expected Child Age at Code pregnant Date MUAC (cm)
n ) Delivery Admission Lactating
Date Date

Code Lactating Admission Code Pregnant Admission

101 New case with infant < 6m and MUAC < 23.0cm rd
102 Mother enrolled as pregnant and gave birth with MUAC < 23.0cm 104 New cases 3 trimester/visible pregnancy and MUAC < 23.0cm
103 Re-admitted 105 Transferred in from Other HP/HC

Code Lactating Discharge Code Pregnant Discharge

205 Discharged recovered (MUAC>23.0cm for 2 consecutive distributions 201 Discharged recovered (MUAC>23.0cm for 2 consecutive distributions
206 Child reached 6 months 202 Gave birth
203 Died while registered in SFP 203 Died while registered in SFP
207 Defaulted (absent for 2 distributions) 204 Defaulted (absent for 2 distributions)
 Date MUAC (cm) Date MUAC (cm) Date MUAC (cm) Date MUAC (cm) DISCH Code (remark

Code Pregnant Discharge

201 Discharged recovered (MUAC >23.0cm for 2 consecutive distributions)
202 Gave birth
203 Died while registered in SFP
204 Defaulted (absent for 3 distributions)

Code Lactating Discharge

205 Discharged recovered (MUAC >23.0cm for 2 consecutive distributions)
206 Child reached 6 months
203 Died while registered in SFP
207 Defaulted (absent for 3 distributions)

197
 Annex 17: TSF Ration card for children 6-59 months
TSFP RATION CARD; CHILDREN 6-59 MONTHS
Childs Name
(include Grandfather's Registration Number
name)

Facility/ Distribution
Gott/Kebele
Site

Admission date Age (months)

sex M F

W/H z-score MUAC (cm)

Admission weight Admission Height

Distribution/Week

Date

Weight (kg)

Height (cm)

W/H z-score

MUAC (cm)

Type and amount of food

(kg)
Routine Admission Medication
Medication Date Dosage Medication Date Dosage

Vitamin A (IU)
Measles
De-worming (mg)
Other
Additional Information

Visit date
Visit signature
Comment

198
Annex 18: TSF Ration Card for pregnant or lactating women

TSFP RATION CARD; PREGNANT or LACTATING WOMEN

Mother's Name Gott Kebele

Facility/
Admission MUAC (cm) Preg. expected Lac. Baby reach 6 Distribution
delivery date month date Site

Admission Date Registration Number

Distribution/Week

Date

MUAC (cm)

Type and amount of

food (Kg)
Medication Date Dosage Medication Date Dosage

Vitamin A (IU) De-worming

Annex 19: TSF ration card for pregnant and lactating women

TSFP RATION CARD; PREGNANT or LACTATING WOMEN

Mother's Name Gott Kebele

Facility/
Admission MUAC (cm) Preg. expected Lac. Baby reach 6 Distribution
delivery date month date Site

Admission Date Registration Number

Distribution/Week

Date

MUAC (cm)

Type and amount of

food (Kg)
Medication Date Dosage Medication Date Dosage

Vitamin A (IU) De-worming

Notes:

199
 Annex 20: TSFP referral Slip

TSF refral Slip to Health Facility/another distribution site

DATE:

CHILD'S NAME: MUAC: cm

CARER'S NAME: OEDEMA: YES NO

AGE (months): Weight:

Height:
KEBELE:
Comment:
GOTT:

REFERRED BY: Signature: ____________________

200
Annex 21: TSFP monthly Statistics Report Children 6- 59 months

Monthly TSFP statistics report children (6-59 months)

Region:_________________________ Zone:__________________________

Woreda:___________________________ Health Post: ________________________

Reporting Month:__________________________

6-59 month Total

Boys Girls

1 TOTAL LAST MONTH

Total Admission

New admissions (children 6-59) ≥11.5-<

2a 12.5cm or WHZ Score ≥ -3Z to < -2

2b Readmission (up to 3 months)

2c Returned after deafult (within 2 months)

2d Transferred in

2e Transferred from OTP to SFP

2 Total AdMISSIONS (2a+2b+2C+2d+2e)

3a Recovered (cured)
Total Discharges

3b Deaths

3c Defaulters (after two months)

3d Non-recovered (after 4 months)

3e Transferred out

3 TOTAL EXITS (3a+3b+3c+3d+3e)

4 TOTAL MONTH END (1+2- 3)

HEW Reporting :_________________

Signature:_______________________

Date:_______________________________
_

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 Annex 22: TSF monthly Statistics Report for Pregnant and Lactating Women

Monthly TSFP statistics report (Pregnant and Lactating Women)

Region:_________________________

Zone:__________________ Woreda:_____________

Reporting Month:__________________________

PLW

Pregnant Lactating Total

1 TOTAL LAST MONTH

Total Admission

New Admissions Pregnant and Lactating

2a <23cm

2b Transferred in
2c Readmitted (up to 3 months)

2 Total Admissions (2a+2d+2c)

Total Discharge

3a Recovered (cured)

3b Deaths

3c Defaulters (Absent for two months)

3d Transferred out
Other discharges (child born or over 6
3e months) PLW

3 TOTAL EXITS (3a+3b+3c+3d+3e)

4 TOTAL MONTH END (1+2- 3)

HEW Reporting:________________

Signature:_____________________

Date:___________________________

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Annex 23: Suggested equipment and supplies required for TSFP

(per Health Facility/distribution site)

Amount per Health Facility/

Item
distribution site

1 TSFP file for admission cards 1

2 Pens 3

3 Calculator 1

4 Water jug (with lid) 2

5 Plastic cups 20

6 Teaspoons or medicine cups 6

7 Thermometer 2

Salter scale (25kg) and pants; ‘Mother and Child’ Weighing

8 1-2 depending on caseload at each site
scale

9 Height board 1-2 depending on caseload at each site

10 MUAC tapes 4

National Protocol for the management of MAM; admission

11 and discharge criteria, Weight for Height z-score reference 1
tables

Scale/balance to measure food rations or

12 calibrated container that holds known weight 1
of food ration

Amount per Health facility/distribution

Minimum stock to keep topped up
site

1 TSFP ration cards for new admissions 100

2 ID bracelets (optional) 100

3 Clear plastic envelopes for filing cards (optional) 100

4 Drinking water 1-4 jerry cans or at hand-washing station

5 Food: e.g. FBF Depends on expected case-load

6 Routine medicines - Vitamin A and de-worming Depends on expected case-load

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 Annex 24: TSFP supervision checklist

TSFP Facility/Distribution Site: _____________ Kebele: ______________

Woreda: ______________________________ Date: _______________
Zone: _______________________________ Region: ______________

Quality Discussed with

Activity Comment
(Poor, Average, Good) supervisor
(Y/N)
Registration numbers allocated
correctly

Weight measured accurately

Height measured accurately

Weight-for-Height calculated correctly
MUAC measured accurately

Edema measured accurately

Information recorded on card and in
registration book
Beneficiary correctly referred to either
TSFP, OTP, SC, hospital or home
Admission medication given
according to protocol and recorded
Children with no measles vaccination
referred to nearest health facility
Correct amount of food distributed
Follow up weight, MUAC and height
recorded correctly
Appropriate education given to
caregivers and TSFP beneficiaries
Cooking demonstrations conducted
Beneficiaries discharged according to
protocol

Absentee and defaulter beneficiaries

being followed up on within the
communities

Home visits and post-distribution

monitoring being conducted by
community workers

TSFP tally and compilation sheets

correctly completed (spot check with
cards)

TSFP monthly reports accurately

completed

Sufficient stocks of supplementary

food and other supplies available to
effectively implement the program

Food commodities and other stock

stored correctly

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Annex 25: Home Visit Form

HEW/ Community Worker’s Name: ______________________

Date of Visit: _____________________________________
Beneficiary name: _______________ Kebele:___________
Gott:___________________________________________

Feeding Practices
Is the supplementary food ration present in the home Yes No

If not, where is the ration?

Is the available ration enough to last until the next SFP distribution? Yes No

Is the food ration being shared or eaten only by the beneficiary? Shared Beneficiary only

Is the child/beneficiary given other foods in addition to the ration? Yes No

If yes, what type of food?

How many times per day is the child given food to eat?

Does someone help/encourage the child to eat? Yes No

What does the caregiver do if the child does not want to eat?

Is the child currently breastfeeding? (for children < 2yrs) Yes No

Is clean water available? Yes No

Caring Practices
Are both parents alive and healthy?

Who cares for the child during the day?

Is the child clean? Yes No

Health
What is the household’s main source of water?

Is there soap for washing in the house? Yes No

Does the caregiver wash the child’s hands and face before feeding? Yes No

Is food covered and protected from flies? Yes No

What action does the caregiver take when the child has diarrhoea?

Food Security
Does the household currently have food available? Yes No

What is the most important source of income for the household?

Is the household registered for PSNP?

Does the household receive any other form of external support?

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 Annex 26: Warehouse Management: General Store Keeping

Objective:

• accounting of what has been received, stored and issued

• maintaining the quality of the food and minimizing looses

Standard Practices:

1. Receiving, storing and dispatching of food and Non Food Items

Counting when receiving and issuing

• Checking, conditions of what is received, stored and issued

• Keeping records(remarks)

2. Store and store premises: Check any damages of sections of store, repair, ensure adequate
lighting, arrange security guarding and ensure padlocking

3. Standard food handling and stacking (depending store size, keep 40-100 cm space,
distance from wall and in-between stacks)

• Counting
• Careful unloading
• Inspect for damages, record remarks
• Proper stacking

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 1. Cleaning and ventilating the store(s): cleaning and ventilating the store, daily, weekly and
periodical thorough store cleaning is mandatory

2. Inspection of stocks and store: periodically make inspection, look for physical damages(insect
damage), staining caused by leakages ,water and evidence of theft and report findings,

3. Stock rotations: oldest stock should be issued first - First in, first out (FIFO).

4. Waste disposal: spillage and sweeping,

• Grain and pulses spilled onto a clean floor are usually not waste – they may be re-bagged,
after cleaning, by sieving if necessary - but small quantities of dirty spilt grain should be
destroyed.

• Spilled flour and blended food are normally considered as waste.

Note: that spoiled commodities are still the responsibility of the storekeeper until properly disposed of,
and must be accounted for in the records.

5. Pest Control:

• Insecticides and fumigants to control insects, and rodenticides to control rats and mice are
dangerous to human health and should only be used by trained staff.

• Regular inspections of the stock will give early warning of attacks by these pests and of the
need for control.

6. Temporary Outdoor Storage (outdoor stacks): Only wholegrain cereals and pulses and
vegetable oil can be temporarily stored in outside stores.

N.B. Outside stores should never be used to store flour, blended food, milk powder or canned food.

207
 Effective outside storage needs: a prepared stacking platform; should have dunnage and a waterproof
groundsheet; waterproof covers (tarpaulins) and ropes for tying down tarpaulins.

7. Documentation and Record keeping: the overall objective is to provide a commodity

tracking system from

First receipt to final discharge. Main documents include,

• Waybills, sometimes known as delivery notes: Signing a waybill is a formal acceptance of

the consignment; therefore, it is important to check that the consignment exactly matches the
description on the waybill.

• Stack cards - record any movement into or out of the stack and display the current stock level.

• Warehouse ledgers (or stock cards): provide an overview of the total stock position in the
warehouse.

• Stock-taking or physical audit forms: record the results of independent physical checks on
stock levels.

• Loss or damaged cargo reports: provide full details of the problem and any action taken to
repackage or reconstitute.

• Inspection reports provide full details of the condition of the warehouse or the commodity.

• Certificate of destruction describes authorized action taken to destroy or dispose of unfit

commodities.

• When a final distribution report is made to the donor, it will be supported by copies of many of
the above documents.

Basic Warehouse Equipment that helps to keep it clean and to the Required Standards

• Brooms

• Ladders

• Repackaging equipment e.g. sack needles and twine (or stitching machine), empty sacks,
cartons, oil containers,

• adhesive tape

208
 • Sampling spears

• Shovels

• Sieves

• Torch

• Weighing scales

N.B. Fire extinguishers and First aid box if available

209
 Annex 27: Post Distribution Monitoring (PDM) questionnaire for TSFP beneficiaries

Kebele: ________________ Gott: ___________________ Date: ______________

PSNP: yes: no:

1. What do you understand as the reason for receiving your/your child’s supplementary food?

2. What are the advantages of receiving this supplementary food?

3. How was the supplementary food that you received last distribution used?

Use proportional piling techniques to assess

Shared
Eaten within Other
Use of food outside Sold
household (explain)
household

per cent

4. If any supplementary food was sold or exchanged what was bought/received in return?

5. How was the supplementary food that you received last distribution prepared?

Porridge Gruel Bread Other:_____________

(thick) (thin)

6. Who consumed the supplementary food you received last distribution?

Only the beneficiary registered in the SFP

The beneficiary registered in the SFP and other children in the family

The beneficiary registered in the SFP and other adults in the family

All the children and the adults in the family

Other: _________________________________

7. For how long does the supplementary food ration last? ______________­­­­­_________________

8. Do you have any comments on the quality of the supplementary food?___________________

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Annex 28: CMAM program performance monitoring scorecard (for OTP, SC, IYCF and TSFP)

Therapeutic Feeding Programme (TFP) Performance Monitoring Scorecard

PART ONE- A: OUT-PATIENT THERAPEUTIC PROGRAMME

Region: Zone: Woreda:
Kebele: Date of Supervision:
Level of health facility: HC / HP
Monitoring Team leader:
(circle)
Health system representative(s):
Name of health facility: Y/N Score
Section 1: Quality of performance
(calculate the cure, mortality and defaulter rates and ALS from recent discharges in the current month)
Q 1.1 Is the cure rate above 75per cent: Score out of 2:____
Q 1.2 Is the mortality rate less than 5 per cent: Score out of 2:____
Q 1.3 Is the defaulter rate less than 15per cent: Score out of 2:____
Q 1.4 Is the average length of Stsay less than 60 days: Score out of 2:____
Overall Quality performance score (score out of 8 ) ___________________

Section 2: Staff Capacity at OTP

Score out of 4:__________
How many HEW/HW are trained in SAM
Q 2.1 (At least 2 trained ____4; one
management at OTP?
trained ______2; none ___0)
Is there at least one HW/HEW trained on IYCFE at
Q 2.3 Score out of 2:____
this OTP?
Overall Staff capacity & supervision score (score out of 6 ) ___________________
Section 3: Community Mobilisation
Did HEW screen >80per cent target children from
Q 3.1 Score out of 4:_________
this kebele last month?
Do the HEW meet with HAD weekly to promote
Q 3.2 Score out of 4:____
service uptake and home follow up?
Overall Community Mobilization score (score out of 8 ) ___________________
Section 4: Management of admission and discharge as per national protocol
Q 4.1 Is the registration number allocated correctly? Score out of 2:____
Q 4.2 Is MUAC measured accurately? Score out of 4: ____
Q 4.3 Is Edema correctly identified? Score out of 3:____
Are weight and height measured accurately?
Q 4.4 Score out of 3: ____
(at HC)*
Q 4.5 Is the temperature taken correctly? Score out of 2: ____
Q 4.6 Is the respiration rate taken correctly? Score out of 2: ____

Q 4.7 Is the admission history recorded accurately? Score out of 3: ____

Is the RUTF appetite test accurately and
Q 3.8 Score out of 2:____
systematically conducted for all admissions?
Q 3.9 Is correct discharge criteria followed? Score out of 3:____
Overall admission/discharge score (score out of 24 ) ___________________
Section 5: Referral and management of complications
Scores based on recall by HEW/HW of past actions taken if not observed on the day.
Are Children with complications correctly referred
Q 5.1 Score out of 2:____
to Hospital/SC as per protocol?
Are non-responders correctly referred for check-
Q 5.2 Score out of 2:____
up?
Overall referral/complications score (score out of 4 ) _______________________

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 Section 6: Follow-up treatment
Q 6.1 Is follow-up anthropometry recorded completely? Score out of 2:____
Q 6.2 Is follow-up history recorded completely? Score out of 2:____
Q 6.3 Is follow-up physical exam recorded completely? Score out of 2:____
Is follow-up routine medicine recorded
Q 6.4 Score out of 2:____
completely?
Is weight loss identified and appropriate action
Q 6.5 Score out of 2:____
taken?

Is an appetite test conducted correctly at each

Q 6.6 Score out of 2:____
follow-up visit?

Overall follow up procedures score (score out of 12): ____________________

Section 7: Treatment management
Is the correct amount of RUTF is given and
Q 7.1 Score out of 3:____
subsequently recorded?
Are routine medications given according to
Q 7.2 protocol and recorded accurately at admission Score out of 3:____
and during follow up visits?
Is health education for caregivers provided at
Q 7.3 Score out of 2:____
each visit?
Treatment score (score out of 8): _______________________

Section 8: Recording and Reporting

Are monthly reports accurate and complete, and

Q 8.1 Score out of 2:____
submitted last month to Woreda on time?
Q 8.2 Are OTP cards accurate and complete? Score out of 2:____
Are registration books filled in accurately and
Q 8.3 completely? (check completion of previous Score out of 2:____
weeks)
Recording and reporting score (score out of 6): _____________
Section 9: Supplies
Assess stock situation based on current case load
Is the stock control/balance form correctly
Q 9.1 Score out of 2:____
completed?
RUTF
Q 9.2 Are there at least two weeks of RUTF? Score out of 2:____
Essential medication
Are there at least two weeks of Amoxicillin
Q 9.3 Score out of 2: ____
(dispersable tab/syrup)?
Are there at least two weeks of Albendazole/
Q 9.4 Score out of 2: ____
Mebendazole ?
Q 9.5 Are there at least two weeks of Vitamin A? Score out of 1.0: ____
Q 9.6 Are there at least two weeks of Measles vaccine? Score out of 0.5: ____
Q 9.7 Are there at least two weeks of Antimalarial? Score out of 0.5: ____
Equipment
Is there a functioning Salter scale and height
Q 9.8 Score out of 0.5: ____
board?
Q 9.9 Are there sufficient MUAC tapes? Score out of 0.5: ____
Q 9.10 Is there a functioning thermometer? Score out of 0.5: ____
Stationery
Q 9.11 Are there sufficient OTP cards? Score out of 0.5: ____
Q 9.12 Are there sufficient monthly reporting forms? Score out of 0.5: ____
Q 9.13 Is there a registration book? Score out of 0.5: ____

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Q 9.14 Are there sufficient referral slips? Score out of 0.5: ____
Are there FMOH ‘HEW Quick Reference Guide:
Q 9.15 Management of SAM’ at HP level; Look up charts, Score out of 0.5: ____
RUTF dose guide?
Stock and supplies score (score out of 14):___________________________

Section 10: Water, sanitation and hygiene practice (WASH).

a) Is there a sufficient supply of clean water for

Q 10.1 Score out of 2:____
hand washing and tatse test?

Q 10.2 b) Is there soap for hand washing? Score out of 2:____

c) Is there a hygienic, functional latrine available

Q 10.3 Score out of 2:____
for use by clients?

Recording and reporting score out of 6: _____________

Section 11: Supportive Supervision

Score out of 4:____ (once in

a) Did your nutrition supervisor visit this site in the
Q 11.1 the last 4 weeks=4; once in
last month?
last 2 months =2; less than=0

Total Score for OTP performance out of 100 _________________per cent

Monitoring Team leader: Signature
Health system
Signature
representative(NAME/POSITION):
Signature
Signature

213
 Therapeutic Feeding Program (TFP) Performance Monitoring Scorecard

PART TWO- B: STABILIZATION CENTER

Region: Zone: Woreda:
Kebele (or town if hospital based): Date of Supervision:
Monitoring Team leader: Level of health facility: Hospital / HC (circle)
Health system representative(s):
Name of health facility: Y/N Score
Section 1: Quality of TFP performance in this woreda
(calculate the cure, mortality and defaulter rates and ALSfrom recent discharges in the current month)
Q 1.1 Is the cure rate above 75per cent: Score out of 3: _____
Q 1.2 Is the mortality rate less than 10per cent: Score out of 2:____
Q 1.3 Is the defaulter rate less than 15per cent: Score out of 2:____
Q 1.4 Is the average length of stay 3-7 days: Score out of 2____
Overall Quality performance score (score out of 9) ___________________
Section 2: Staff capacity in stabilization center.
Is there at least one staff per shift has knowledge
Q 2.1 of/ observed best practices in managing Score out of 3________
complications due to SAM?
Are there daily staff update meetings to discuss
Q 2.2 Score out of 2________
patient progress?
Is there a system of refresher training and skills
Q 2.3 Score out of 2________
development in place?
Is there at least one health facility staff who has
Q 2.4 Score out of 2________
been trained on IYCF-E?
Capacity in SC score (score out of 9):___________________________

Section 3: Management of admission and discharge as per national protocol

Check past records, present records and recall by staff.
Admission
Q 3.1 Is the registration number allocated correctly? Score out of 2:____
Q 3.2 Is the admission history recorded accurately? Score out of 2:____
Q 3.3 Is edema correctly identified? Score out of 2:____
Are weight and height/length measured
Q 3.4 Score out of 2:____
accurately?
Is a systematic medical examination correctly
Q 3.5 Score out of 2:____
administered?
Q 3.6 Are systematic drug treatments received? Score out of 2:____
Are dietary treatments received (sugar water,
Q 3.7 Score out of 2:____
F-75)?
Discharge and transfer
Q 3.8 Is discharge /transfer criteria followed? Score out of 2: _____
Q 3.9 Is an appetite test conducted? Score out of 2:____
Q 3.10 Is a medical examination conducted? Score out of 2:____
Q 3.11 Is discharge information recorded accurately? Score out of 2:____
Overall admission/discharge score (score out of 22) ___________________
Section 4: Referral and management of complications
Scores based on recall by HEW of past actions taken if not observed on the day.
Is there a systematic and effective system of
Q 4.1 Score out of 3:____
referral in place to/from OTP?
Is there a system for referrals for medical
Q 4.2 Score out of 3:____
complications beyond capacity of SC?
Overall referral/complications score (score out of 6): _______________________

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Section 5: Recording and Documentation
Is the monthly report accurate and complete, and
Q 5.1 Score out of 2:____
submitted last month to Woreda on time?
Are registration books filled in accurately and
Q 5.2 Score out of 2:____
completely? (check completion of previous weeks)
Q 5.3 Is the multi chart filled completely and correctly? Score out of 2:____
Overall recording and documentation score (score out of 6): ____________________

Section 6: Food Preparation

Are nutrition workers well oriented on how to

Q 6.1 Score out of 3:____
prepare the therapeutic milks?
Is the milk preparation room and materials kept
Q 6.2 Score out of 2:____
clean every time?

Overall food preparation score (score out of 5): _______________________

Section 7: Other
Is there food or money for food for caretakers?
Q 7.1 Score out of 2:____
Ask caretakers
Q 7.2 Is the treatment free? Ask patients Score out of 1:____
Q 7.3 Are ITNs available and being used? Score out of 1:____
Are sufficient NFIs (blanket, mattress, cups,
Q 7.4 Score out of 2:____
buckets, spoons,etc) available?
Overall other (score out of 6): _____________
Section 8: Supplies
Assess stock situation based on current case load
Is the stock control/balance form correctly
Q 8.1 Score out of 2:____
completed?
Q 8.2 Are the drugs in date and stored properly? Score out of 2:____
Therapeutic Food
Q 8.3 Is there at least one month of F75? Score out of 2:____
Q 8.4 Is there at least one month of F100? Score out of 2:____
Q 8.5 Is there at least one month of ReSoMal? Score out of 2:____
Essential medication
Is there at least one month of Amoxicillin
Q 8.6 Score out of 1:____
(dispersable tab/syrup)?
Is there at least one month of Albendazole/
Q 8.7 Score out of 1:____
Mebendazole ?
Q 8.7 Is there at least one month of Vitamin A? Score out of 1:____
Q 8.8 Is there at least one month of Measles vaccine? Score out of 1:____
Q 8.9 Is there at least one month of Antimalarial? Score out of 1:____
Q 8.10 Is there at least one month of Folic acid? Score out of 1:____
Q 8.11 Is there at least one month of Gentamicin? Score out of 1:____
Q 8.12 Is there at least one month of CAF injections? Score out of 1:____
Equipment
Is there a functioning Salter scale and height
Q 8.13 Score out of 2:____
board?
Q 8.14 Are there sufficient MUAC tapes? Score out of 1:____
Q 8.15 Is there a functioning thermometer? Score out of 2:____
Are there sufficient Pediatrics Nasogastric tubes
Q 8.16 Score out of 2:____
and syringes?

215
 Stationery
Are there sufficient multi charts and monthly
Q 8.17 Score out of 2:____
reporting forms?
Q 8.18 Is there a registration book? Score out of 1:____
Q 8.19 Are there look up charts and RUTF dose guide? Score out of 1:____
Overall stock and supplies score (score out of 29):___________________________
Section 9: Water, sanitation and hygiene practice (WASH).
Is there a sufficient supply of clean water for hand
Q 9.1 Score out of 2:____
washing and taste tests?
Q 9.2 Is there soap for hand washing? Score out of 1:____
Is there a hygienic, functional latrine available for
Q 9.3 Score out of 1:____
use by clients?
Q 9.4 Are the rooms clean and well ventilated? Score out of 2:____
Is there an efficient and safe system for waste
Q 9.5 Score out of 2:____
disposal (sharps, medical and materials?)
Overall WASH (score out of 8): _____________
Total Score for SC performance out of 100 _________________per cent
Monitoring Team leader: Signature
Health system
Signature
representative(s): Name / Position
Signature
Signature

216
Therapeutic Feeding Program (TFP) Performance Monitoring Scorecard

PART THREE: INFANT AND YOUNG CHILD FEEDING

Region: Zone: Woreda:
Kebele: Date of Supervision:
Monitoring Team leader: Level of health facility: HC / HP (circle)
Health system representative(s):
Name of health facility: Y/N Score
Section 1: IEC materials
Q 1.1 Is IEC material with context-specific IYCF messages visible? Score out of 6:____
Is IEC material with context-specific IYCF messages culturally
Q 1.2 Score out of 6:____
appropriate?
Is IEC material with context-specific IYCF messages appropriately
Q 1.3 Score out of 8:____
used during one on one counselling sessions
Overall IEC materials score (score out of 20 ) ___________________
Section 2: During admission
During admission, all children under 2 undergo IYCF assessment. Use recall for Q 2.3*
Does the HEW/HW use the breastfeeding observation tool for
Q 2.1 Score out of 6:____
lactating women?
Does the HEW/HW encourage lactating women to continue
Q 2.2 Score out of 6:____
breastfeeding?
Does the HEW/HW explain to a pregnant woman how to initiate and
Q 2.3* Score out of 4:____
establish breastfeeding after delivery and on optimal breastfeeding?

Q 2.4 Does the HEW/HW correctly identify any infant feeding difficulties? Score out of 6:____

Does the HEW/HW note the outcome of the assessment on the

Q 2.5 Score out of 6:____
child’s card?
Following assessment, the HEW takes action to address any identified IYCF difficulties.
If you do not observe a case with infant feeding difficulties directly, ask the HEW what they would do in such a case
If there are IYCF issues, does the HEW/HW provides appropriate
Q 2.6 Score out of 4:____
Basic Aid (counselling)?
If there are IYCF issues, does the HEW/HW note the issue to ensure
Q 2.7 Score out of 4:____
regular follow up?
If an infant < 6 months and cannot be breastfed, is the infant
Q 2.8 Score out of 4:____
referred to a health center for skilled IYCF support?
Overall during admission (score out of 40) ___________________

Section 3: During follow up

Does the HEW/HW HEW check with the mother for breastfeeding
Q 3.1 Score out of 4:____
or other infant feeding difficulties (by asking her)?
If the child’s card indicates a feeding difficulty, does the HEW/HW
Q 3.2 Score out of 4:____
check the actual feeding situation during the follow up visits?
Does the HEW/HW encourage lactating mothers to continue
Q 3.3 Score out of 4:____
breastfeeding along with messages on how to use RUTF?
Overall during follow-up (score out of 12) _______________________
Section 4: During discharge
Does the HEW/HW ensure that the caregivers have the knowledge
Q 4.1 Score out of 6:____
and support they need to address IYCF difficulties?
Does the HEW/HW verify that the caregivers understand key IYCF
Q 4.2 Score out of 6:____
messages?
Does the HEW/HW link the caregivers to the HDA leader or peer to
Q 4.3 Score out of 6:____
peer support group?
Overall during discharge (score out of 18): ____________________

217
 Section 5: Breast Milk substitute Code violation

Does the facility display any product, poster, pamphlet, calendar,

Q 5.1 clock, chart or other items produced by a baby food producing Score out of 3:____
company?

Please list the names and logos of companies:

Do companies provide HWs with gifts, such as desk calendars,

Q 5.2 writing pads, pencil holders, prescription pads, diaries, rulers, pens, Score out of 3:____
etc.?

Please list name and logo of companies:

Q 5.3 Are breastmilk substitutes available or promoted by the HEW/HW? Score out of 4:____

What product/brand is being used and what are the reasons for
using/promoting BMS as explained by the HW?
Overall BMS (score out of 10): _______________________
Total Score for IYCF performance per site out of 100 _________________per cent
Monitoring Team
Signature
leader:

Health system
representative(s): Signature
Name / Position

Signature

Signature

218
Targeted Supplementary feeding program Performance Monitoring Scorecard
PART THREE- TARGETED SUPPLEMENTARY FEEDING PROGRAMME
Region: Zone: Woreda:
Kebele: Date of Supervision:
Monitoring Team leader: Level of health facility: HC / HP/ MHNT (circle)
Health system representative(s):
Name of health facility: Y/N Score
Section 1: Quality of performance
(calculate the cure, mortality and defaulter rates and ALSfrom recent discharges in the current month)
Q 1.1 Is the cure Rate above 75per cent: Score out of 4:____
Q 1.2 Is the mortality Rate less than 3 per cent: Score out of 4:____
Q 1.3 Is the defaulter rate less than 15per cent: Score out of 4:____

Q 1.4 Is the non-response rate less than 15per cent: Score out of 3:____

Overall Quality performance score (score out of 15 ) ___________________

Section 2: Management of admission and discharge as per national protocol
Are registration numbers allocated correctly for both
Q 2.1 Score out of 4:____
children and PLWs?
Q 2.2 Is MUAC measured accurately? Score out of 4: ____
Q 2.3 Is edema correctly identified? Score out of 4:____
Q 2.4 Is weight measured accurately? Score out of 4: ____
Q 2.5 Are admission details recorded accurately? Score out of 3: ____
Q 2.6 Is the correct discharge criteria followed? Score out of 3:____
Overall admission/discharge (score out of 22 ) ___________________
Section 3: Referral and management of complications
Scores based on recall by HEW of past actions taken if not observed on the day.

Are children with SAM/complications correctly referred

Q 3.1 Score out of 2:____
to OTP/SC/hospital if required as per protocol?

Are non-responders correctly referred for check-up or

Q 3.2 Score out of 2:____
linked to relief or PSNP?
Overall referral/complications (score out of 4 ) _______________________
Section 4: Follow-up treatment
Has follow-up anthropometry been recorded
Q 4.1 Score out of 4:____
completely?
Has follow-up routine medicine been recorded
Q 4.2 Score out of 3:____
completely?
Has weight loss been identified and appropriate action
Q 4.3 Score out of 4:____
taken?
Overall follow up procedures score out of 11: ____________________

Section 5: Treatment management (question for FDA’s and beneficiaries )

Is the correct amount of Plumpy Sup or Super Cereal

Q 5.1 Score out of 3:____
Plus given and recorded?
Are routine medications given according to protocol
Q 5.2 and recorded accurately at admission and during Score out of 3:____
follow up visits?
Health and nutrition education for caregivers provided
Score out of 3:____
at each visit
Have food preparation and daily rations been
Q 5.3 Score out of 3:____
explained to caretakers
Treatment score out of 12: _______________________

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 Section 6: Recording and Reporting

Monthly reports are accurate and complete, and were

Q 6.1 Score out of 4:____
submitted last month to Woreda on time?

Q 6.2 Are TSF cards accurate and complete? Score out of 4:____
Are registration books filled in accurately and
Q6.3 Score out of 4:____
completely? (check completion of previous weeks)
Recording and reporting score out of 12: _____________
Section 7: Supplies at Food distribution centre (FDC)
Assess stock situation based on current case load
Supplementary Food
Is there at least a one month supply of Plumpy Sup or
Q 7.1 Score out of 2:____
Super Cereal Plus to hand?
Q 7.2 Has food been delivered before stock run out Score out of 2:____

Q 7.3 Have beneficiaries received the right amount of rations Score out of 2:____
FDAS accurately record food received and distributed
Q 7.4 Score out of 2:____
at FDC

FDAs receive a copy of food distribution register from

Q 7.5 Score out of 2:____
HEW immediately after screening measurement

Essential medication
Are there at least two weeks of Albendazole/
Q 7.7 Score out of 2: ____
Mebendazole ?
Q 7.8 Are there at least two weeks of Vitamin A? Score out of 0.5: ____
Equipment

Q 7.9 Are there a functioning Salter scale and height board? Score out of 0.5: ____

Q 7.10 Are there sufficient MUAC tapes? Score out of 0.5: ____
Stationery
Q 7.11 Are there sufficient TSFP cards? Score out of 0.5: ____
Q 7.12 Are there sufficient monthly reporting forms? Score out of 0.5: ____
Are there registration books for both children and
Q 7.13 Score out of 0.5: ____
PLW’s?
Q 7.14 Are there sufficient referral slips? Score out of 0.5: ____
Are there HEW Quick Reference Guide: Management
Q 7.15 Score out of 0.5: ____
of MAM’ at HP level; Look up charts?
Stock and supplies score out of 18:___________________________
Section 8: Water, sanitation and hygiene practice (WASH).
a) Is there a sufficient supply of clean water for hand
Q 8.1 Score out of 3:____
washing and taste test?
Q 8.2 b) Is there soap for hand washing? Score out of 3:____
c) Is there a hygienic, functional latrine available for use
Q 8.3 Score out of 2:____
by clients?
Recording and reporting score out of 8: _____________
Total Score for TSFP performance out of 100 _________________per cent
Monitoring Team leader: Signature
Health system
Signature
representative(s): Name / Position
Signature
Signature

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(Footnotes)

1 There is sometimes “child substitution” in order for the family to continue to access services
when the index child has recovered, moved away or died. Height should be measured if there
is an unexpected change in weight (large increase or decrease) to check if the same child has
attended the OTP site. If there has been child substitution then the “new” individual should be
fully assessed.

2 BMI defined as the (weight in Kg)/(height in m)² for assessing the nutritional status of adults

3 BMI defined as the (weight in Kg)/(height in m)² for assessing the nutritional status of adults

*Transfers in/out of the program are not included in the calculation of program performance

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Guidelines
for the Management of Acute
Malnutrition

Government of ethiopia
Federal ministry of health
April 2016
Addis Ababa, Ethiopia

Federal Democratic
The Federal Republic
Democratic Republic of
ofMinistry
Ethiopia Ethiopiaof Health