IMAM Short Course
IMAM Short Course
IMAM Short Course
Short Course
Duration: 2month
• Protective foods:
• -vegetables, fruits, milk, etc
4
NUTRIENTS
• Organic and inorganic complexes contained in food
are called nutrients. They are broadly divided in
to:
• Macronutrients:
• -proteins
• -fats
• -carbohydrates
• Micronutrients:
• -vitamins
• -minerals 5
PROTEINS
• PROTEINS ARE COMPLEX ORGANIC
NITROGENOUS COMPOUNDS.
• Body building
• Repair and maintenance of body tissues
• Maintenance of osmotic pressure
• Synthesis of bioactive substances and other
vital molecules
7
Assessment of Protein
nutrition status
• Protein nutrition status is measured by Serum
Albumin Concentration.
10
The “non-calorie” roles of fat
• vegetable fats are rich sources of essential fatty
acids which are needed by the body for growth,
structural integrity of the cell membrane and
decreased platelet adhesiveness.
13
Sources of carbohydrates
• There are three main sources of carbohydrate,
viz. starches, sugar and cellulose.
• The carbohydrate reserve (glycogen) of a human
adult is about 500g. This reserve is rapidly
exhausted when a man is fasting.
• If the dietary carbohydrates do not meet the
energy needs of the body, protein and glycerol
from dietary and endogenous sources are used by
the body to maintain glucose homeostasis.
14
Dietary fibre
• Dietary fibre which is mainly non-starch
polysaccharide is a physiological important
component of the diet.
15
VITAMINS
• Vitamins are a class of organic compounds
categorized as essential nutrients.
17
Functions of Vitamin A
• It is indispensable for normal vision.
• It is necessary for maintaining the integrity and the normal
functioning of glandular and epithelial issue which lines
intestinal , respiratory and urinary tracts as well as the skin
and eyes.
• It supports growth, especially skeletal growth
• It may protect against some epithelial cancers such as
bronchial cancers.
18
Deficiency of vitamin A
• The signs of vitamin A deficiency are
predominantly ocular. They are:
• Night blindness
• Conjunctival and cornea xerosis
• Bigot's spots
• Keratomalacia
19
Functions of vitamin D and
its metabolites
• Intestine: Promotes intestinal absorption of
calcium and phosphorus
• Bone: Stimulates normal mineralization,
Enhances bone reabsorption, Affects collagen
maturation
• Kidney: Increases tubular reabsorption of
phosphate
20
Deficiency of vitamin D
Deficiency of vitamin D leads to:
• Rickets
• Osteomalacia
21
THIAMINE
• Thiamine (vitamin B1) is a water soluble
vitamin.
• It is essential for the utilization of
carbohydrates.
22
Deficiency of thiamine
• The two principal deficiency diseases are beriberi and
Wernick's encephalopathy.
• Beriberi may occur in three main forms:
• peripheral neuritis,
• cardiac beriberi
• infantile beriberi, seen in infants between 2 and 4 months
of life. The affected baby is usually breast-fed by a
thiamine-deficient mother who commonly shows signs of
peripheral neuropathy.
• Wernick’s encephalopathy is characterized by
ophthalmoplegia, polyneuritis, ataxia and mental
deterioration
23
VITAMIN B6
• Pyridoxine (vitamin B6) exists in three forms
pyridoxine, piridoxal and pyridoxamine.
• It plays an important role in the metabolism of
amino acids, fats and carbohydrate.
• The requirement of adults vary directly with
protein intake. Adults may need 2 mg/day, during
pregnancy and lactation, 2.5 mg/day.
• Balanced diets usually contain pyridoxine,
therefore deficiency is rare.
24
VITAMIN B12
.
• Vitamin B 12 cooperates with foliate in the
synthesis of DNA.
• Vitamin B 12 has a separate biochemical role,
unrelated to folate, in synthesis of fatty acids in
myelin
25
Vitamin B12 deficiency
• Vitamin B12 deficiency is associated with
megaloblastic anemia (pernicious anemia),
demyelinating neurological lesions in the spinal
cord and infertility (in animal species).
27
Deficiency of vitamin C
• Deficiency of vitamin C results in scurvy, the
signs of which are swollen and bleeding gums,
subcutaneous bruising or bleeding into the skin or
joints, delayed wound healing, anaemia and
weakness. Scurvy which was once an important
deficiency disease is no longer a disease of world
importance.
28
Thank ‘’U’’ All
Module 1
Malnutrition
Types of malnutrition
• Acute malnutrition:
– Marasmus: wasting
– Kwashiorkor: bilateral oedema
• Stunting: growth retardation
• Nutrients deficiency (iron deficiency,
vitamin A deficiency, iodine deficiency, …)
• Oedematous malnutrition (kwashiorkor)
Malnutrition
• Malnutrition refers to getting too little or too much
of certain nutrients.
• It can lead to serious health issues, including
stunted growth, eye problems, diabetes and heart
disease.
• Malnutrition affects billions of people worldwide.
Some populations have a high risk of developing
certain types of malnutrition depending on their
environment, lifestyle and resources.
Background
Starvation Malabsorption
Reduced Intake
Pathological loss Neglect
Loss of homeostasis
Death
Adaptation of the body =
Reductive Adaptation
What is it?
•It is the physiological response of the body to
under nutrition. i.e. Systems slow down and do
less in severe malnutrition in order to allow
survival on limited calories
•The most obvious response is a reduction in
body mass
Reductive Adaptation
• Whole body • Cell
– Activity – Protein synthesis
– Sodium pump
• Organ
– Cardiac function • General
– renal function – Temperature
– intestinal function regulation
– liver function – immune function
– muscle function
CELLULAR FUNCTION
• Sodium pump acitivity is reduced and cell
membranes are more permeable than
normal
• Which leads to an increase in intracellular
sodium and decrease in intracellular
potassium and magnesium
• Protein synthesis is reduced
RENAL FUNCTION
• Glomerular filtration is reduced
• Capacity of kidney to excrete excess
acid or water load is greatly reduced
• Sodium excretion is reduced
• Urinary tract infection is common
CARDIAC FUNCTION
• Blood pressure is low
• Renal perfusion and circulation time are
reduced
• Plasma volume is usually normal and red
cell is reduced
• Output and stroke volume are reduced
• Any increase in blood pressure can easily
produce acute heart failure
INTESTINAL FUNCTION
• Production of gastric acid is reduced
• Intestinal motility is reduced
• Pancreas is atrophied and production of
digestive enzymes is reduced
• Small intestinal mucosa is atrophied;
secretion of digestive enzyme is reduced
• Absorption of nutrients is reduced
MUSCLE FUNCTION
• The skin and subcutaneous fat and
glands are atrophied, which leads to
loose folds
• Many signs of dehydratation are
unreliable; eyes may be sunken because
of loss of subcutaneous fat in the orbit
• Many glands including the sweat, tear
and salivary glands are atrophied
LIVER FUNCTIO N
• Synthesis of proteins is reduced
• Abnormal metabolites of amino acids
are produced
• Capacity of liver to take up,
metabolize and excrete toxins is
severely reduced
• Bile seceretion is reduced
IMMUNE SYSTEM
• All aspects of immunity are diminished
• Lymph glands, tonsils and the thymus are
atrophied; T-cell (cell mediated immunity) is
severely depressed
• Tissue damage does not result in inflammation
or migration of white cells to the affected area
• Typical signs of infection such as fever are
frequently absent
• Hypoglycaemia and hypothermia are both signs
of severe infection
Temperature regulation in severe malnutrition
Effect of changing from 29oC to 38oC over 45 minuets on core temperature
38.0
37.5
Temperature (oC)
37.0
36.5
-30 0 30 60 90
Time Minuets
• Is this child severely
malnourished?
49
THE DIFFERENT STEPS
1- Importance of involvement of the community
50
LEARNING OBJECTIVES
The participant should be able to
1 –Explain how to facilitate access to care
2- Take & interpret the anthropometric measurements
AT COMMUNITY LEVEL
2nd Part
52
ACTIVE CASE FINDING:
MUAC
• Screening all children for acute malnutrition using
MUAC tapes
• Be careful to use the correct criteria and refer all
SAM children to the OTP
53
Take the MUAC for children of 6 month
of age or more
54
ACTIVE SCREENING:
BILATERAL OEDEMA
Check for bilateral oedema
Teach the CHW and the volunteers in a SC if
possible – so that they see positive cases
55
SCREENING , REFERRAL, FOLLOW-UP,
EDUCATION
• Refer cases of SAM/MAM to the
nearest TSFP/OTP sites.
• Record the SAM – MAM –
Normal – oedema and give the
screening sheet to the district
(DNO)
• Follow up at home of cases that
have been: 1) absent
2) discharged from SC & have
not enrolled at an OTP
3) failed-to-respond to treatment
• Promote good health practices –
Essential Nutrition Actions (ENA)
s56
PASSIVE SCREENING WITHIN
THE HEALTH STRUCTURES
3rd part
57
PASSIVE SCREENING:
WHERE?
Weight-for-Age (WFA) is a
WASTING
composite index and is used as a AND
measure of ‘underweight’ or STUNTING
‘overweight’
The 3 children have the same age
Same Same
height
weight
60
Normal Wasted Stunted Stunted &
Obese
61
WfA = 0 Z WfA < -3 Z WfA < -3 Z WfA
CLASSIFICATION OF ACUTE
MALNUTRITION
INDICATOR CLASS of AGE Moderate Acute Severe Acute
S MALNUTRITION MALNUTRITION
Bilateral All No Yes
Oedema
W/L(H) Children <-2 to – 3 Z-score < - 3Z-score
WHO2006
WH% Adolescents WH>=70&<80% <70%
NCHS
BMI Adults 16 to 17 <16
Children>6mo 115 to <125mm <115 mm
MUAC
Adults 180 to <210 mm* <180 mm*
With recent
62
weight loss
PASSIVE SCREENING
MUAC, W/H, BILATERAL
ŒDEMA
64
Feet here
Chi
ld s
ta
> 8 7 ndi ng
cm
Chi
ld l yin
g
<8
7 cm
65
80.0= 80
80.1 = 80
If you take the length or
80.2 = 80
height in cm
80.3=80.5
It is rounded to the
80.4=80.5
nearest decimal to look
80.5=80.5
up in the chart of
weight-for-height. 80.6=80.5
80.7=80.5
80.8=81
80.9=81
81.0=81
TAKE THE WEIGHT
For infants < 8kg: scale with 5 - 10g precision (e.g. SECA)
For children ≥ 8kg: scale with 100g precision (e.g. SALTER)
For patients > 15kg:UNISCALE/electronic scale
67
Boys and girls mortality rates
SAM children admitted to therapeutic feeding centres
using a UNISEX table (NCHS) shows that using exactly
the same anthropometric admission criteria for boys and
girls leads to a non-significant difference in mortality
rate: albeit girls have a slightly higher CFR. DO NOT
DISCRIMINATE against girls.
TRIAGE
AND
TRANSPORT
at health centre level
77
1st TRIAGE MAM : SAM TRIAGE
based on MUAC or W/L-W/H and Bilateral Oedema
• Children ≥ 6 months
– W/H<-3Z (WHO2006 Standards) or
– MUAC<11.5cm for a child (only children 6 to
60month)
• Adolescents
- WH<70% NCHS or
• Adults
– BMI <16 with recent weight loss or
– MUAC<18 cm with recent weight loss
81
- Have plain water freely available for mothers
and children waiting
- Give a drink of sugar water to the patients
when they arrive at the center
GIVE
WATER
82
TAKE THE MUAC FOR CHILDREN OF 6 MO.
&+
• Use the left arm (conventional)
• Find the middle of the upper arm
(measure or “double” a string)
• Put the end of the tape through
the hole around the arm
• Have the arm straight during
measurement
• Pull gently –so that there are no
gaps between the arm and the
tape and no compression of the
tissues of the arm.
• Read the measurement/colour
• Re-take the measurement for
SAM/MAM children and record 83
the results immediately
ALWAYS DO A STANDARDISATION TEST
AFTER TRAINING AND PRACTICING TAKING
MUAC
IT IS NOT AS EASY AS IT SEEMS TO BE
• First explain to thePRECISE/ACCURATE
mothers what you are doing
• After their consent, take 10 children from 6 months to 5 years
of age (use SC or out-patients, creche, infant school etc).
• Give each subject a number - one to ten –
• Tell each trainee to measure the MUAC of the 10 children and
to note the results on the form.
• Collect the results and wait for about half to one hour.
• Mix up the children so they are sitting in a different order, but
keep their numbers.
• Repeat the measures on the same 10 children without
knowing the first measurements
• Analyse the results using software from SMART (ENA)
Training module (http://www.nutrisurvey.net/ena_delta) 84
THE STANDARDISATION
TEST’S SHEET
Measurer nº:........... Name:………………….…………………….
1st round / 2nd round Time.........................
1
2
3
4
5
6
7
8
9
10
85
FORMALLY TEST FOR
OEDEMA WITH FINGER
PRESSURE
86
CLASSIFICATION OF THE
DEGREES OF OEDEMA
87
By looking at these children, try to 1
identify their degree of oedema
2
3
88
1 = 3rd degree but to be checked
2 = 2nd degree but to be checked
3= 1st degree but to be checked
3
2
1 89
APPETITE
• A poor appetite occurs with significant metabolic
disturbance, intoxication, infection, liver disease.
As metabolic malnutrition becomes more severe, clinical
signs (IMCI) become less reliable and appetite a more
important sign for children at very high risk of death - It
can be the only sign of severe metabolic malnutrition and
physiological decompensation
• A moderate appetite indicates that that there is
physiological decompensation but it is not very
severe.
• A good appetite indicates that these conditions
are either not present or not very severe
90
EVEN A SLIGHT REDUCTION IN
APPETITE CAN LEAD TO
MALNUTRITION
We need 5 kcal to synthesize 1g of normal tissue
(and loose about 1g for each 5Kcal taken that is less than that
needed to maintain body weight).
Child needs 100 kcal/kg/d to maintain weight
Even a slight reduction in appetite is not negligible
Exercise:
– If a child takes only 85 kcal/kg/d how quickly will he
loose weight?
– Do the calculation for one day and for 100 days
(approximately 3 months)
91
Answer to the exercise
- If the child takes only 85 kcal/kg/d
- Then each day he has a (100kcal-85kcal=15kcal) 15kcal/kg/d
deficit
- As there are 5 kcal in a g, he will loose weight at 15/5 =
3g/kg/d; i.e. each day, he will loose 3g for each kg of body
weight;
- In 100 days he will lose: (3x100) 300g/kg
- This is 30% of his body weight and he will move from 100% to
70% W/H and be severely malnourished (if there is no
metabolic adaptation – there normally is adaptation, but this
adaptation leads to dangerous physiological vulnerabilities).
Refer to
community IMCI
section on hand
washing
94
Do the appetite test
98
CRITERION OF DECISION FOR THE TRIAGE FOR IN
OR OUT PATIENT CARE
CRITERION IN-PATIENT CARE OUT-PATIENT
CARE
Choice of carer Carer chooses to Carer chooses to
(at any stage of start, continue or start, continue or
management - transfer to in-patient transfer to out-
the carer is treatment. patient treatment
often the best Make it clear she has She knows her family
judge of the choice – after circumstances and
severity) counselling – and that constraints and will
her wishes will be default if they are
respected by all the ignored
staff
Appetite Failed, equivocal or Passes Appetite
uncertain Appetite test
99
test
CRITERION OF DECISION FOR THE TRIAGE FOR IN
OR OUT PATIENT CARE
Module 4
Version 2018 _ based upon protocol version 6.6.4
The moral rights of the authors have been asserted. The authors retain the copyright to this material. It cannot be abstracted, 102
divided or used to teach fee-paying students. It must not be changed or altered without reference to the authors. It can be used
without charge for teaching UNICEF staff and Ministry of Health Staff in developing countries.
LEARNING
OBJECTIVES
By the end of this session participants should be able to:
•Describe the type of structures
•Give a SAM No
•Define the types and criteria of admission
•Define the types of reference
•Fill in the OTP chart, SAM register and the transfer form
•Welcome the new patients and offer them some sugar-water
to drink
•Specify when to do an appetite test during the follow-up of
the patient
•Monitor the temperature, respiratory rate, and take the
clinical history and examination
10
3
LEARNING
OBJECTIVES
• Specify and administer the routine medicines
• Diagnose failure-to-respond to treatment
• Establish good communication between the community with
the help of the CHW (module 2)
• Define absentees, defaulters, refusal-to-be-transfer to SC
and the criteria of discharge
• *Calculate the need for consumables and ensure regular
supplies: RUTF, routine medicines, (module 6-7)
• *Run monthly meetings with the CHW (module 7)
• *Organise play with toys for children waiting (module 5)
• *For the DNO: Supervise the OTP (module 7) 104
STRUCTURE AND MATERIALS
1st Part
105
STRUCTURES
Health centre
Mobile team
A waiting area sheltered with
sugar-water distribution
An area for - Measurements,
Registration, Appetite test
with drinking water,
clinical examination,
routine treatment.
A consultation space for
further examination,
recognition of problems
and their treatment.
106
MATERIAL NEEDED
• MUAC
• Length board
• Hanging scale (e.g. Salter) AND Infant Scale (e.g.
Seca)
• Registration book
• OTP charts
• Ration/Ration Cards with SAM/Scope Number
• Monthly report form
• W/H + W/L charts (child and adolescent)
• Pens – pencils
107
• Laminated sheets
ACTIVITIES IN THE OTP
Admission:
1. Register the patient
2. Give the appropriate drugs
3. Give the RUTF
Follow-up each week
1. Assess the patient (growth, medical, appetite)
2. Give further RUTF supply
3. Diagnose Failure-to-respond to treatment
4. Arrange home visits for Failure-to-respond and
defaulters
Discharge or transfer 108
ACTIVITIES IN THE OTP (2)
114
SCOPE/SAM-NUMBER
SAM-Number is his/her insurance No.
The SAM-number allows tracking the patient;
• Write the SAM-No of the patient in all the record to be able
to track the patient (transfer etc.)
• register the patient,
• complete the transfer form
• and arrange transport.
THE SAM/SCOPE-NUMBER SHOULD BE KEPT
THROUGHOUT THE TREATMENT AND USED BY
ALL THE FACILITIES TO IDENTIFY THE PATIENT
115
Registration book
Entry to facility/Site
9
Register
10
11
A4 –landscape
12 Page 1
13
14
15
16
17
18
19
20
116
AMOUNT OF RUTF TO GIVE PER DAY &
WEEK
RUTF PASTE RUTF SACHETS (92G) BP100®
CLASS OF
WEIGHT (KG) GRAMS PER GRAMS PER SACHET PER SACHET PER BARS PER BARS PER
DAY WEEK DAY WEEK DAY WEEK
127
STEPS TO UNDERTAKE FOR FAILURE-TO-
RESPOND
Check & Make the diagnosis of “Failure-to-respond” to treatment
129
POSSIBLE CAUSES OF FAILURE-TO-
RESPOND SOCIAL
130
CAUSES OF FAILURE-TO-RESPOND
INDIVIDUAL - MEDICAL
-Uncorrected Vitamin or mineral deficiency (excess family
food being given to patient in place of RUTF),
Return of appetite
OUT and reduction of
Return of oedema
PATIENT
appetite and IN-PATIENT
CARE TREATMENT
reduction of Transition Phase
Good appetite: no
oedema oedema
IN-PATIENT
TREATMENT
DISCHARGE to Only if no OTP
Follow up
133
(TSFP/MCH/CHW)
CRITERIA OF DISCHARGE
• Children ≥ 6 months to adolescence
– W/H ≥ -1.5 Z (WHO2006) for one occasion if follow up
or
– MUAC ≥ 12.5cm
134
CRITERIA OF DISCHARGE FROM OTP
135
TYPE OF EXIT
• Cured: when the patient reaches the criteria for
discharge
• Confirmed defaulter: absent for 2 consecutive visits
and a home visit/message has been sent
• Unconfirmed defaulter: absent for 2 consecutive
visits and no information about the outcome
• Transfer-out to SC
• Transfer-out to another OTP
• Dead
136
SUPERVISION OF THE OTP
(MODULE 7)
Module 5 – Part 1
© Michael Golden & Yvonne Grellety
Version 2018 _ based upon protocol version 6.6.4
The moral rights of the authors have been asserted. The authors retain the copyright to this material. It cannot be abstracted,
divided or used for commercial or advertising purposes. It must not be changed or altered without reference to the authors. It can
be used without charge for teaching UNICEF staff and Ministry of Health Staff in developing countries. 140
LEARNING OBJECTIVES
By the end of this session participants should be able to:
• Describe the physical structures for the patients;
• Define the types and criteria of admission;
• Fill-in the SC chart, SAM-register (SAM No if needed/transfer
form);
• Welcome the newly admitted patient and offer her/him sugar
water to drink;
• Do the routine surveillance measurements (MUAC, weight,
temperature, respiratory rate, liver size, etc.);
• Administer the routine Acute Phase medicines;
• Prepare and administer F75 in the Acute Phase;
• Decide if NG-tube feeding is necessary;
141
• Treat psychosocial deprivation.
SCREENING
TRIAGE Step 2
SAM admission criteria,
Appetite test, Complications
143
THE DIFFERENT
STEPS
- AFTER TRIAGE in Emergency ward
If SAM children
or OPD: Direct Admission to SC
remain in an
emergency -ACUTE PHASE
department there is a Diet – Routine Medicine –
high risk of the Surveillance – Complications
wrong treatment - CRITERIA TO PASS from Acute
Phase to Transition
- TRANSITION PHASE: diet –
routine medicine - surveillance
- TRANSFER TO THE OTP
144
ADMISSION PROCEDURE
148
F-75
• F75 – is a therapeutic-milk based diet specifically design
for patients with severe complicated malnutrition who
have impaired liver and kidney function
• F75 is NOT a dilute form of F100. It has less sodium,
protein, fat, lower osmolarity and renal solute load than
F100. It is less energy dense
• Patients should NOT gain weight on F75
• It allows the biochemical, physiological and
immunological function to start to recover before the
additional stress of making new tissues
• It contains 75kcal/100ml
149
PREPARATION OF THE F75
- Prepare with safe drinking boiled water left to cool for not
less than 3-5 mins (no cooler than 70˚C). The vitamin
levels have been adjusted in the products supplied to
account for any nutrient losses during the preparation with
hot water.
- F-75 in canister (400g) use increment of 25ml of added
water per white levelled scoop to make 28 ml of F75. Do
not keep reconstituted F75 more than 2hrs.
1 canister of F75 (400g) use increment of 2200ml of water
to make 2480ml of reconstituted F75.
150
AMOUNTS OF F75 TO GIVE
• The amount to give is by class of weight using the
look-up table (do not try to calculate!)
• Quantity given is about 100kcal/130ml/kg/d for
children. More for small infants and less for older children
and adults – use the look-up table
• Always ask the mothers to breast-feed their children
before giving the F75
• Give 6 feeds/day (or 8 feeds for patients who do not tolerate
a large volume of F75)
• Feed the patient with a cup & saucer (or NG-tube) –
Never use a spoon or a baby bottle 151
Look-up table for volume of CLASS OF WEIGHT (KG) 8 FEEDS PER DAY 6 FEEDS PER DAY
ML FOR EACH FEED ML FOR EACH FEED
F75 to give per feed 2.0 to 2.1 kg 40 ml per feed 50 ml per feed
2.2 – 2.4 45 60
ACUTE PHASE (Phase 1) 2.5 – 2.7 50 65
2.8 – 2.9 55 70
Use a RED bucket for F75
3.0 – 3.4 60 75
8 or 6 feeds 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
6.0 – 6.9 110 140
7.0 – 7.9 125 160
8.0 – 8.9 140 180
9.0 – 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 – 29.9 300 152
350
≥30 320 370
Spoon should The child
not be used should be
sitting
vertically
Never pinch the
nose or feed
The saucer
with child lying
catches the
down – this
spillage which
causes
is returned to
aspiration
the cup
pneumonia
153
NASO-GASTRIC TUBE
• Systematic antibiotics
• Malaria treatment (if test positive)
• Measles vaccine
155
ANTIBIOTICS
WHERE NO AMOXICILLIN
RESISTANCE
Antibiotics are given during phase 1 + 4 days or
until transferred to OTP
Kg mg mg Cap/tab
<5kg 125 mg * 2 ½ cap.*2
5 – 10 250 mg * 2 1 cap * 2
5mg/kg give once
10 – 20 500 mg * 2 2 cap * 2
daily IM
20 - 35 750 mg * 2 3 cap * 2
> 35 1000 mg * 2 4 cap * 2
157
ALTERNATIVE IN AREAS WITH
AMOXICILLIN/AMPICILLIN
RESISTANCE
First line once daily IM injection of Cefotaxime or
Ceftriaxone for 2days (50mg/kg)
Second/third line:
– Cefotaxime (50mg/kg) IM injection + Ciprofloxacin
orally (10 to 30 mg/kg/d in 2 doses per day - this option
is particularly recommended where there is septicaemia
or septic shock)
– If suspicion of Staphylococcus infection add cloxacillin
(100 – 200 mg/kg/d: 3 times daily)
158
SMALL BOWEL OVERGROWTH
WHERE THERE IS AMOXICILLIN
RESISTANCE
- Give Oral (or rectal) metronidazole 10mg/kg/d
- Do NOT use the standard paediatric dose (30mg/kg/d)
in severely malnourished patients because the half life
of metronidazole is prolonged in SAM and standard
doses are toxic in these children
- It may cause anorexia – use for maximum of 4 days in
SAM children in acute phase – stop if there is
deterioration in general condition
159
ANTI-FUNGAL
1) Oral candidiasis and routinely for all patients in areas
with a high prevalence of candidiasis (>20%) or HIV.
Nystatin 100,000IU orally 4 times daily
2) Patients with signs of severe sepsis, septic shock or
systemic candidiasis
Fluconazole (3mg/kg once daily)
(it has been associated with mild hepatic damage – use with
caution. Do not use ketoconazole in SAM patients)
3) For skin lesions (ringworm/candida etc.) use
miconazole ointment/cream 2%
No amphetoracin B 160
ACUTE PHASE – MALARIA
•
•Malaria treatment –Artemether-Lumefantrine
as first line treatment using a 6 dose regimen
(at 0 and 8 hours then twice daily on each of the
following 2 days).
• Complicated malaria
- No diarrhoea: high dose artemisinin or
artesunate suppositories
-Diarrhoea: IM artesunate or artemether.
Note: Do not to use quinine: danger of fluid overload,
hypoglycaemia and cardiac toxicity. Only use arthemether- amodiaquine if
there is artemether-lumefantrine not available – amodiaquine has been associated with
hepatic damage. 161
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 cannulae should rarely be used.
The disadvantages of indwelling cannulae 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, reside 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
•Extravasations into the tissue can cause skin necrosis and other complications
162
Scalp necrosis
and then trying
again with new 163
MEASLES
Give Measles vaccine on admission if not vaccinated.
This is to protect against nosocomial measles and
stimulate the immune system generally, but will not
give a good antibody response – a second measles
vaccination is given in OTP to provide a long lasting
protection
Do not give DPT to these children during the acute phase.
164
VITAMIN A
• Do NOT give high-dose vitamin A on admission unless:
Measles epidemic
Signs of vitamin A deficiency
• Under these circumstances only:
– 6 to 11 months: 100,000IU (one blue or half a red capsule)
– 12 months (or 8 kg) and more: 200,000IU (two blue or one red capsule)
• Day 1
– Give a unique dose of 5mg Folic acid to all children with
clinical anaemia
BUT:
– DO not give folate if Fansidar is being used as
antimalarial as there is antagonism.
169
CRITERIA TO MOVE FROM
ACUTE PHASE TO TRANSITION
• There is no “fixed” timePHASE
that a child should remain in the
acute phase – the sicker the child the longer s/he will remain
in acute phase
• Criteria to transfer from acute phase to transition:
– return of appetite AND
– beginning of loss of oedema AND
– the patient appears to be clinically recovering
• Patients with gross oedema (+++) should stay in Acute
Phase until oedema (++)
170
Thank “U’All
SC
IN PATIENT FACILITY
Complications
Module 5 - Part 2
The moral rights of the authors have been asserted. The authors retain the copyright to this material. It cannot be abstracted,
divided or used for commercial purposes or advertising. It must not be changed or altered without reference to the authors. It172
can
be used without charge for teaching UNICEF staff and Ministry of Health Staff in developing countries.
USE OF AN ACCURATE
SCALE
174
DEHYDRATION
• Malnourished children are SENSITIVE to excess sodium
intake!
• All the signs of dehydration in a normal child occur in a
severely malnourished child who is NOT dehydrated –
only a HISTORY of fluid loss and very recent change in
appearance can be used
• Giving a malnourished child who is not really
dehydrated treatment for dehydration is very dangerous
• Misdiagnosis of dehydration and giving inappropriate
treatment is the commonest cause of death in severe
malnutrition. 175
DEHYDRATION
• The treatment of dehydration is different in the
severely malnourished child from the normally
nourished child
• Infusions are rarely used and are particularly
dangerous in the malnourished – they are reserved for
certain very severe and specific cases
• ReSoMal must not be freely available in the SC – but
only taken when prescribed
• The management is based mainly on accurately
monitoring changes in weight
176
DEHYDRATION
12
(% of sodium filtered) 10
Sodium excretion
0
Norm al ECF Expanded ECF 178
DEHYDRATION - DIAGNOSIS
• History of recent change in appearance of eyes
• History of recent fluid loss
• NO OEDEMA - Oedematous patients are over-
hydrated and not dehydrated (although they are often
hypovolaemic from septic, cardiac or other shock)
• Veins NOT visibly full
• Check the eyes lids to see if there is lid-retraction – a
sign of sympathetic over-activity
• Check if the patient is unconscious or not
179
MONITORING REHYDRATION
FLUID BALANCE is measured at intervals by WEIGHING the
child – the change in weight gives a very accurate estimate of
fluid balance.
Do not attempt to measure the volume of fluid lost this is much
less accurate and very time-consuming – it is quick and
accurate to weigh the child.
THERE MUST BE AN ACCURATE SCALE IN PHASE ONE,
that is easy to use and safe for acutely ill children
Monitor every hour
• the liver edge marked on the skin before any rehydration
treatment starts
• the weight, the respiration and pulse rate
• the heart sounds 180
TREATMENT OF
DEHYDRATION
ONLY rehydrate until the weight
deficit is corrected & then STOP
– DO not give extra fluid to
“prevent recurrence”
Conscious Unconscious
ReSoMal IV fluid
10ml/kg/hr - first 2hours and Darrow solution or
then reassess using the weight Ringer lactate & 5% dextrose,
and the clinical change
if not available: Ringer lactate
at 15ml/kg
If improving, 15ml/kg the
2nd first
hr; hour ->
reassess
If conscious, NGT: ReSoMal
If not improving, look for shocks/cerebral
malaria, drug intoxication, acidosis.
• If there is continued weight loss, then:
– Increase the rate of administration of ReSoMal by 10ml/kg/hour –
to 20ml/kg/h
– Formally reassess in one hour
182
• If there is weight gain and deterioration of the child’s
condition with the rehydration therapy:
– Then the diagnosis of dehydration was definitely wrong
– Stop and start the child on F75 diet.
183
Weight
185
TARGET REHYDRATION
WEIGHT
• A SAM child arrives at the SC from the OTP and
has a weight of 5.5kg. He had diarrhoea since 2
days.
• You estimated that he lost 3% of his body
weight.
• His target rehydration weight will be
5500g + 0.03*5500g = 5500 + 165 = 5665 g
186
HYPERNATRAEMIC
DEHYDRATION
(HYPEROSMOLAR SYNDROME)
• Due to water deficiency (without loss of salt)
• Is common in very dry areas (deserts)
• It also occurs when the feeds are over-
concentrated (do not use full strength F100 for
small infants).
• Prevent by giving plenty of plain water or
sugar-water
187
DIAGNOSIS OF
HYPERNATRAEMIA
• The skin feels like dough (flour + water for bread making).
• The eyes can sink somewhat
• The abdomen may becomes flat or sink and wrinkle –
patient appears very ill
• Fever may develop
• Progressive increase in drowsiness and then unconscious
• Convulsions: the convulsions are not responsive to the normal anti-
convulsants and may be misdiagnosed as meningitis/encephalitis
• Death
• Serum sodium more than 150mmol/l
188
TREATMENT OF
HYPERNATRAEMIC DEHYDRATION
(1)
Incipient:
• Skin changes with patient alert & conscious:
• Breast feeding is the best
• 10ml/kg/h of 10% sugar-water in sips (little by little)
over several hours until the thirst of the child is
satisfied. At this early stage treatment is relatively
safe
• Give water but the child should not drink large
amounts rapidly – take several hours to correct the
mild hypernatræmic dehydration 189
HYPERNATRAEMIC
DEHYDRATION
TREATMENT 2
Developed: unconscious/drowsy/convulsing
• The treatment must be slow. If it is possible, monitor
serum sodium.
• The aim is to reduce it by 12 mmol/24h: to correct the
hyper-natraemia more quickly than this risks death
from cerebral œdema.
• If no measurements possible - then aim to take at least 48h
to correct the water deficit. (The text book treatment (giving
IV saline) is NOT used in SAM)
• First, put the child in a relatively humid, thermo-neutral
(28˚ to 32˚ C) environment (mist or spray water into the air
in desert areas) – this is the most important step and must
not be omitted 190
HYPERNATRAEMIC
DEHYDRATION
TREATMENT 3
• Weigh the child on an accurate balance and record the
weight.
• Objective: to have positive water balance of ~ 60ml/kg/d
• That is a weight gain of 60g/kg/d (5g/kg/2h)
• Start with 2.5ml/kg/h of plain water/sugar-water or breast-
milk and increase depending upon rate of weight change
• Insert an NGT and give fluids by tube.
• Do not give F75 at this stage,
• Never F100 or infant formula
191
HYPERNATRAEMIC
DEHYDRATION
TREATMENT 4
• Reweigh the child every 2 hours.
– If the weight is static or continuing weight loss:
o cool and “mist” the environment
o increase the amount of sugar-water intake to
compensate for the on-going weight loss
(calculated as g/h and increase the intake by this
amount)
– If the weight is increasing, continue treatment
until the child is awake and alert
192
PERSISTENT OR CHRONIC
DIARRHOEA
• Children without an acute watery exacerbation do not need
acute rehydration therapy
• They have adapted over the weeks to their altered
hydration state and should not be rehydrated over a few
hours or days
• The appropriate treatment is nutritional with F75 and the
suppression of small bowel bacterial overgrowth
(Amoxicillin/metronidazole)
193
RE-FEEDING DIARRHOEA
AFTER ADMISSION
Diagnosis:
•Increase in the stool output and loose stools when the diet
is changed/increased
•No weight loss: the child is not dehydrated
197
DIAGNOSIS OF SHOCK
Shock occurs when there is a poor cardiac output so that the
organs are not receiving enough blood. This occurs when
there is:
Any problem with the heart
Insufficient blood volume
Dilatation of the blood vessels (increased vascular space)
Conscious Unconscious
Loosing conscious
- DO NOT GIVE A FLUID BOLUS
F75 by mouth or - Give 1/2 saline & 5% glucose or Ringer
Lactate & 5% glucose at 10ml/kg the first
NGT
hour
- Reassess every 10min
- if not improving after 30 minuts
REDUCE TO 4ml/kg/h
-If improving -> F-75
- If conscious -> NGT: F75 201
HEART FAILURE - CARDIAC OUTPUT
7
Cardiac output (L/min/m3)
2
50 60 70 80 90 100
202
We ight-for-he ight (%)
DIAGNOSIS OF HEART FAILURE
Diagnosis
• Physical deterioration with a gain in weight
• An increase in liver size.
• Tenderness over the liver
• An increase Respiration Rate (>50/min for 5 to 11mo &
>40/min for 1-5 years, or an acute increase in
respiration rate of more than 5 breaths/min).
• ”Grunting respiration” during each expiration –
sign of “stiff lungs”.
• Crepitations in the lungs
• Prominent superficial and neck veins
• Heart sounds - Development of triple rhythm
• Increasing or reappearance of oedema during treatment
• A fall in Hb concentration (needs laboratory) – falling Hb is
usually a sign of fluid overload and NOT of loss of red cells 203
RESPIRATORY DISTRESS
205
MONITORING DURING
TREATMENT OF HEART
FAILURE
• Weight (patient should loose weight to pre-heart failure
weight)
• Respiration rate
• Liver size (mark on abdomen with indelible marker)
• Pulse rate
• Jugular vein or visible vein engorgement
• Heart sounds
206
DIAGNOSIS AND TREATMENT OF
ANAEMIA
Check Hb at admission if any
clinical suspicion of anaemia
208
DIAGNOSIS AND TREATMENT OF
HYPOGLYCAEMIA
Diagnosis:
•Check for eye-lid retraction (sign of active sympathetic nervous
system activity)
•Check if the patient is loosing consciousness
Treatment:
Give the patient:
•If conscious: about 50 ml of 10% sugar water (~5g or one spoon of
sugar in 50ml) or F-75 by mouth
•If loosing consciousness: 50 ml of 10% sugar water by NGT
•If unconscious: sugar water by NGT AND glucose as a single IV
injection (~ 5ml/kg of 10% solution – stronger solutions of glucose clot
and obliterate the vein)
Start second-line and first line antibiotics together
Reassess after 15 minutes; If rapid improvement does not occur then
209
revise your diagnose
HYPOTHERMIA – EFFECT OF THE
ENVIRONMENT
• Thermoneutral temperature
range is 28oC to 32oC 37.5
C)
due to a low environmental 37.0
o
temperature, lack of cover
Core Temperature (
36.5
or washing
36.0
• The figure shows the effect
of lowering room 35.5
Time (min)
210
DIAGNOSIS & TREATMENT OF
HYPOTHERMIA
Diagnosis:
•Check the Tº of the patient: T° rectal < 35°C or Tº axi. < 35.5° C
•Check the temperature of the room (28 - 32°C)
•Check that the child sleeps with his/her mother (do not use little cots
for SAM children)
Treatment:
Do not wash severely ill children!
Warm the patient using the “kangaroo technique” for children
with a caretaker
Put a hat on the child and wrap mother and child together
Give hot drinks to the mother (hot water is sufficient) to warm her
skin
Monitor body temperature during re-warming
Treat for hypoglycaemia and give second-line antibiotic 211
FEVER
• Has malaria treatment been given?
• Is the child on routine antibiotics? (in some areas amoxicillin
resistance levels are very high)
• Most fever is due to a high environmental temperature.
Treatment
• Treat with sponging with room-temperature water. (never
use alcohol)
• Give EXTRA WATER to drink
Note : Do NOT give aspirin or paracetamol – it does not work
in the severely malnourished and they have defective liver
function. Children on admission may have aspirin
poisoning if the mother has noted the fever
212
FEVER
Effect of changing from 29oC to 38oC
38.0
37.5
Temperature (oC)
37.0
36.5
-30 0 30 60 90
Time Minuets 213
SKIN LESIONS
• Kwashiorkor dermatosis
=> 1st & 2nd line antibiotics & fluconazole
=> Silver sulfadiazine with tulle gras/zinc ointment on the affected
skin – exposed to air if possible
=> Gentle oil massage to the area of unaffected skin
• Perineal excoriation
Prevention
leave the child naked as much as possible –
never use plastic pants (mothers should have aprons)
regularly massage the child
Treatment
If severe treat as the kwash dermatosis
If not so severe, 2nd line antibiotic and nystatin and miconazole
2145%
nitrate cream/ointment until lesions are dry.
SKIN LESIONS (1)
• Scabies/Lice
Treatment for scabies
=> Perimethrin cream (5%)/lotion (1%) on the whole body for
12h and wash with soap. Do not apply on face or mucus
membranes.
Treatment for lice
Perimethrin lotion (1%) to the infested hair
Change and boil all clothes and bed clothes
• Fungal infection: intertrigo – ringworm – athlete’s
foot
Treatment: Miconazole nitrate cream/ointment (2%) 215
Module 5 – Part 3
Version 2018 _ based upon protocol version 6.6.4
The moral rights of the authors have been asserted. The authors retain the copyright to this material. It cannot be abstracted,
divided or used to teach fee-paying students. It must not be changed or altered without reference to the authors. It can be used221
without charge for teaching UNICEF staff and Ministry of Health Staff in developing countries.
Learning Objectives
By the end of this session participants should be
able to:
•Diagnose and treat failure to respond to treatment
•Identify the causes of failure to respond
•Define the criteria to move from Acute Phase to Transition
Phase (TP)
•Administer the routine medicine
•Prepare and administrate RUTF/F100
•Prepare & arrange the discharge of the patient
•Define the type of discharge
•Coordinate with the DNO & OTPs of the district (Module 7)
•222
FAILURE TO RESPOND TO
TREATMENT
223
CRITERIA FOR FAILURE
225
PROBLEMS WITH THE
TREATMENT FACILITY (1)
• Inaccurate weighing scales, weight taken irregularly or
not graphed so weight cannot be easily used for clinical
decisions
• F75 not prepared or given correctly – incorrect recipes
being used – excess sugar in the diet – child taking the
mother’s food
• Incorrect or failure of surveillance (esp. at night)
• Disinterested medical leadership, demoralised staff, poor
motivation, expectation of poor outcomes
226
CAUSES OF FAILURE-TO-
RESPOND
- UncorrectedINDIVIDUAL
Vitamin or mineral- deficiency
MEDICAL (excess family food
being given to patient in place of RUTF),
228
TRANSITION PHASE
PREPARATION FOR
TRANSFER TO OTP
•Feeds
•Routine medicine
•Monitoring
229
TRANSITION PHASE
THE ONLY difference is a change in the type of diet –
everything else is the same as phase 1
Note: In desert areas, F100 dilute should be used and the volume
230
increased by 30%.
LOOK UP TABLE FOR RUTF
IN TRANSITION PHASE (24H INTAKE)
CLASS OF WEIGHT PASTE PASTE BARS TOTAL
IN GRAMS SACHETS BARS KCAL
3.0 – 3.4 90 1.00 1.5 500
3.5 – 3.9 100 1.00 1.5 550
4.0 – 4.9 110 1.25 2.0 600
5.0 – 5.9 130 1.50 2.5 700
6.0 – 6.9 150 1.75 3.0 800
7.0 – 7.9 180 2.00 3.5 1000
8.0 – 8.9 200 2.00 3.5 1100
9.0 – 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
≥20 450 5.00 8.0 2500231
PREPARATION OF F100
IN TRANSITION PHASE (24H INTAKE)
• Prepared with safe boiled drinking water left to cool
for not less than 3-5 mins (no cooler than 70˚C).
The vitamin levels have been adjusted in the
products supplied to account for any nutrient losses
during the preparation with hot water.
• F100 is in canister (400g). Use increments of 25ml
of added water per blue levelled scoop to make
29ml of F100. For 1 canister add 1850ml to make
2158ml of F100 reconstituted.
• No more than 2 hours in the room temperature.
232
Example of a Look-up table for CLASS OF WEIGHT (KG) 6 FEEDS PER DAY
volume of F100 per feed
F100 full strength should not
Transition phase Less than 3.0
be used
6 feeds 3.0 – 3.4 75 ml per feed
Use a different look up table for 3.5 – 3.9 80
different frequencies of feed 4.0 – 4.4 85
4.5 – 4.9 95
5.0 – 5.4 110
5.5 – 5.9 120
6.0 – 6.9 140
7.0 – 7.9 160
8.0 – 8.9 180
9.0 – 9.9 190
10.0 – 10.9 200
11.0 – 11.9 230
12.0 – 12.9 250
13.0 – 13.9 275
14.0 – 14.9 290
15.0 – 19.9 300233
≥20.0 320
CRITERIA TO MOVE BACK FROM
THE TRANSITION PHASE TO
ACUTE PHASE
• Rate of weight gain more than 10g/kg/d (means there is excess fluid
accumulation – there is not enough energy to gain weight so quickly)
• Increasing oedema of development of refeeding oedema
• Rapid increase in the size of the liver or liver tenderness
• Any sign of fluid overload, heart failure or respiratory distress
develops
• If tense abdominal distension develops
• If there is sufficient refeeding diarrhoea to give weight loss (some
loose stools normally occur but do not cause loss of weight)
235
SCREENING
TRIAGE Step 2
SAM admission criteria,
Appetite test, Complications
237
PROCEDURE FOR TRANSFER TO
OTP
• Complete the multi-chart, register, transfer form
• Record the patient as “successfully treated” and not
as cured/discharged
• Give provision of RUTF until next opening day of the
OTP, the transfer form (with the SCOPE/SAM-
Number) and address of the OTP to the patient
• Inform the OTP (text message/phone) & DNO about
transfer
• Ensure transport in coordination with the OTP &
DNO
238
TYPE OF DISCHARGE/EXIT
FROM THE
SC
• Successfully treated/Internal transfer to the OTP:
when the patient reaches the criteria of transfer to the
OTP
• Defaulter: absent during 2 consecutive days
• Transfer-out to SC
• Dead
• Cured, when the patient reaches the criteria of
discharge from the programme
• Medical referral/non response to treatment
239
SUMMARY OF MODULE 5.3
SC
• Failure to respond to treatment
• Clinical assessment
• Criteria to move to transition phase
• Criteria and procedure for transfer-to OTP
• Type of discharge from the SC
• Supervision of the SC by the DNO
241
Thank ‘’U’’ All
Infant from 0 to 6 months of age
and the treatment of severe
malnutrition
Criteria
It is clear that s/he is gaining weight on
breast milk alone after the SS technique has
been used,
There is no medical problem
The mother has been adequately
supplemented with vitamins and minerals
Type
“Successfully treated”
Thank ‘’U’’ All
TREATMENT OF
CHILDREN WITH
MODERATE ACUTE
MALNUTRITION
TARGET SUPPLEMENTARY
FEEDING PROGRAMS
1st part
269
Queuing at
an SFP site
STRUCTURE AND HUMAN
RESOURCES
• Structure
– A store-room (stock for 2 to 3 months – 2 M3 for each
metric ton – or more if seasonal delivery/travel difficulties)
– A waiting room (or comfortable shady place with water)
– A room/space for
• Measurements
• Registration
• Routine medicine
• Distribution of prepared food ration (oil and blended food
or RUSF)
• Human resources: 2 to 3 persons for 50 to 100
beneficiaries
MATERIALS - OTHERS
• MUAC
• Length board
• Hanging scale (Salter) – infant scale (precision
to the nearest 20g for<8kg)
• Registration book – ration cards - referral forms
• Monthly report form
• W/H or W/L chart – laminated sheet on key
message – criteria – preparation of ration etc.
• Pens – pencils – rubber
STOCKS - MEDICINES &
RATION
• Supplementary ration
– Ready to Use Supplementary Food (RUSF):
100g/d/person or
– Fortified Blend Food (FBF) like Supercereal Plus:
200g/d/person with Oil : 20 to 25g/d/person
• Basin – bucket
• Mebendazol
• Vitamin A
• Iron Sulfate (200 mg) – folic acid
273
PREPARATION OF THE PRODUCTS
AT DISTRICT LEVEL
1. Calculate the number of kits and material (tables &
chairs, etc..).
2. Calculate the total volume for ration and drugs for the
total length of the programme or at least 4 month of
stock
– Supercereal plus: 200g 400persons 4 MAM-
OTP 180days
= 57.600MT (+4%) =~60MT
3. Calculate & organise the transport of the goods from
the central to the district warehouse
274
TREATMENT OF MAM
2 Part
nd
275
MAM MANAGEMENT IS NOT THE
SAME AS SAM
• Need to open TSFP during situations with community food
insecurity and where there is a rapid increase in number of
MAM children – normally an emergency program, in non-
emergencies, an alternative approach is preferable ( SAM
treatment is on-going in all development situations).
• MAM program designed to manage relatively large
numbers of children (SAM programs usually have far fewer,
sicker children)
• Unless there are very few children, do NOT use Health
centres. - Use a site close to the Health centre.
– The health staff and facilities will be overloaded and critical
health programs disrupted (including the SAM program).
– Always use separate non-clinical staff and not the health staff.
276
MAM MANAGEMENT IS NOT THE
SAME AS SAM
• Do not give a SAM number but the child can have a
Scope-N°
• Never use RUTF for MAM children – use products
specifically for MAM (FBF/RUSF)
• Use only a register and not individual charts
• Do not do an Appetite test
• Treat Medical complications according to the IMCI
protocol rather than the SAM protocol.
In summary: Do not combine/confuse SAM and MAM
programs with each other.
Separate organisation, staff, structures, diet, treatment of
complications, etc! 277
STEPS FOR ADMISSION
1. Measure MUAC, weight and height
2. Register the patient
3. Look up the target weight – enter target weight
(and MUAC) in the register.
4. Give the routine medicines
5. Ask about health problems (for referral to HC)
6. Explain the procedure and expectations
7. Prepare and give the ration to the caretaker
Comment on these pictures…
MUAC,
Height/length is
taken as well as the
weight of the child
ADMISSION
CRITERIA
• Children over 6 months
– W/L or W/H ≥-3 and <-2 z-score
– MUAC≥11.5cm and <12.5cm
– Absence of bilateral oedema
280
If the child fulfils the
criteria of admission
s/he is registered and
the mother is given a
ration/ID card.
REGISTRATION
PROCEDURE
1. Register the patient in the register
2. Ask about any medical complications, vaccination
status and whether the child has recently received
vitamin A.
3. Explain how treatment will be organized, the reasons
for admission to the MAM program and expectations:
– Patients will receive medical treatment and a nutrition
supplement because s/he is thin for his height and to prevent
him/her deteriorating or getting a complication
– Nutrition supplement is only for patient (not to be shared within
the family) and is to be taken in addition to the family meal
– Follow-up is every 2 weeks: weight and MUAC
– Discharge is based on target weight and/or target MUAC
4. Give a ration card to the caretaker 2
8
TYPES OF
ADMISSION
• New admission: the criteria for admission can be
either MUAC, Z-scores or both.
• Ex-SAM follow up (ration card with a different colour)
• Relapse: a cured MAM child readmitted for a second
episode of MAM without considering the duration
between two episode of MAM.
• Readmission of defaulters after less than 2 months
of absence.
• Transfer from another TSFP
• Refer for Medical problem to the hospital
283
Routine drugs -
Mebendazole
Vitamin A
Vaccination checked
Iron and folic acid
If the child is sick, s/he
should be referred to
the health centre
NUTRITIONAL SUPPLEMENTS
TO USE
• Type of nutrition supplement:
1st Fortified Blended Flour (FBF):
– give 200g/child/day ~1000kcal/child/day
– For children
• 10 to 12% of protein energy density
• 25 to 30% of fat energy density
• Fortified with ALL essential minerals, electrolytes and vitamins (type
1 and type II)
2nd Ready-to-Use-Supplementary-Food (RUSF):
around 500 kcal/child/day
• Explain how to prepare and give the ration and
how to keep it at home 285
PREPARATION OF FBF – WHAT THE
TEAM HAS TO DO
• Before the distribution:
Clean the room for the preparation
Estimate the quantities needed according to the number of
expected beneficiaries – take this amount from the store
(“first in – first out : last-in – last-out”)
Wash your hands
287
KEY MESSAGES - 1
1. The ration is designed for the MAM child enrolled in
the program – the ration should not be shared with
the rest of the family (this may not be realistic – never
chastise any family where sharing is taking place – do not
“punish victims” – if sharing is extensive add/increase
protection ration)
2. The ration should be given 2 to 3 times a day
between the family meal (if work and other commitments
allow this to happen). It is only a supplement for the child who
should continue to get family meals – on his own plate – not a
communal dish from which all the family/children eat!
3. Continue breastfeeding until 24 months (this should be
emphasised – it is very important. If the mother is breast
feeding then you should tell her that she should share the288
supplement with the child – half-half)
KEY MESSAGES - 2
4 Wash your hands before preparing the food and before
you feed your child. Wash the child’s hands.
5 The water used should be drinkable water.
6 The prepared porridge should not be kept more than 2
hours at room temperature.
7 Store the food in a sealed/covered container.
8 Do not stop feeding the child - Do not stop
breastfeeding specially if the child has diarrhoea.
289
ROUTINE MEDICINE
Before giving any ROUTINE DRUG, make sure that
the patient has not already received it during a
mass campaign OR at the health centre.
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ALBENDAZOLE/
MEBENDAZOLE
Albendazole (mg) Mebendazole (mg)
Age
Orally on admission Orally on admission
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SURVEILLANCE
EVERY 14DAYS
• Take MUAC and compare it to the target MUAC
• Take weight and compare it to the target weight and
to the minimum weight for referral for SAM treatment
• Check if the patient has any criteria of the failure-to-
respond to treatment. If yes, take action!
• Ask the mother about any medical problem (send to
health centre)
• Record the data in the register
• Give iron-folate tablets
• Encourage and counsel the mothers and discuss the
change in the nutritional status to the caregiver
• Give the nutrition ration and fill the ration card
• Give nutrition/health education to waiting caretakers
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FOLLOW UP OF THE EX
SAM CURED
The follow up is to ensure that he/she is not
Relapsing
• 1st & 2nd month: once every 2 weeks
• 3rd month: once a month
Do the follow up with a ration card of a different
colour
Do not give routine medicine
CRITERIA TO REFER TO OTP
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CRITERIA OF FAILURE-TO-
RESPOND TO TREATMENT
Weight loss by the 2nd visit in the programme (4th
week )
Absence of weight gain by the 3rd visit in the
programme (6th week)
5% weight loss at any time
Failure to reach the criteria for discharge after 3
months in the programme