IMAM Short Course

University of Health Science (UOHS)
Short Course
Duration: 2month
Course name: Integrated management of Acute

malnutrition (IMAM)
Training facilitator: Mr. Asad Garaad (Bsc Public

Health, MPH, MNFS)
INTRODUCTION
• Nutrition: may be defined as the science of food and
its relationship to health. It is concerned primarily
with the part played by nutrients in body growth,
development and maintenance.
• The word nutrient or “food factor: is used for

specific dietary constituents such as proteins, vitamins
and minerals.
• Dietetics: is the practical application of the principles

of nutrition; it includes the planning of meals for the
well and the sick.
• Good nutrition: means “maintaining a nutritional
status that enables us to grow well and enjoy good2
health.”
CLASSIFICATION OF
FOODS
• Classification by origin:
- Foods of animal origin
- Foods of vegetable origin
• Classification by chemical composition:

- Proteins
– Fats
– Carbohydrates
– Vitamins
– Minerals 3
CLASSIFICATION BY
PREDOMINANT FUNCTION
• Body building foods:
• -meat, milk, poultry, fish, eggs, pulses etc
• Energy giving foods:

• -cereals, sugars, fats, oils etc.
• 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.
• PROTEINS ARE MADE OF MONOMERS CALLED

AMINO ACIDS.
• THERE ARE ABOUT 20 DIFFERENT AMINOACIDS

WHICH R FOUND IN HUMAN BODY.
• OF THIS 8 AA ARE TERMED “ESSENTIAL” AS

THEY ARE NOT SYNTHESIZED IN HUMAN BODY
AND MUST BE OBTAINED FROM DIETARY
PROTIENS.
6
Functions of Proteins
• 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.
• It should be more than 3.5 g/dl.
• Less than 3.5 g/dl shows mild malnutrition.
• Less than 3.0 g/dl shows severe malnutrition.

8
FAT
• Most of the body fat (99 per cent) in the
adipose tissue is in the form of triglycerides.
• in normal human subjects, adipose tissue

constitutes between 10 and 15 per cent of
body weight.
• One kilogram of adipose tissue corresponds

to 7700 kcal of energy. 9
Functions of fats
• They are high energy foods, providing as much
as 9 kcal for every gram.
• Fats serve as vehicles for fat-soluble vitamins
• Fats in the body support viscera such as heart,
kidney and intestine; and fat beneath the skin
provides insulation against cold.
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.
• Diets rich in EFA have been reported to reduce

serum cholesterol and low-density lipoproteins.
• Polyunsaturated fatty acids are precursors of

prostaglandins.
11
Fat requirements
• In developed countries dietary fats provide 30 to
40 per cent of total energy intake.
• The WHO Expert committee on Prevention of

Coronary Heart Disease has recommended only
20 to 30 per cent of total dietary energy to be
provided by fats.
• At least 50 per cent of fat intake should consist of

vegetable oils rich in essential fatty acids. 12
CARBOHYDRATE
• Carbohydrate is the main source of energy,
providing 4 Kcals per one gram
• Carbohydrate is also essential for the

oxidation of fats and for the synthesis of
certain non-essential amino acids
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.
• It is found in vegetables, fruits and grains.
15
VITAMINS
• Vitamins are a class of organic compounds
categorized as essential nutrients.
• They are required by the body in a very small

amounts. They fall in the category of
micronutrients.
• Vitamins are divided in to two groups: fat
soluble vitamins- A, D, E and K and water
soluble vitamins: vitamins of the B-group and
vitamin C. 16
VITAMIN A
• «Vitamin A» covers both a pre-formed
vitamin, retinol, and a pro-vitamin, beta
carotene, some of which is converted to retinol
in the intestinal mucosa.
• The international unit (IU) of vitamin A is

equivalent to 0,2 microgram of retinol (or 0,55
microgram of retinal palmitate).
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).
• Dietary deficiency of B12 may arise the subjects

who are strict vegetarians and eat no animal
product.
.
26
VITAMIN C
• Vitamin C (ascorbic acid) is a water-soluble
vitamin.
• Vitamin C has an important role to play in tissue
oxidation it is needed for the formation of
collagen, which accounts for 25 per cent of total
body protein
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
• Over 40 nutrients are essential to health

• If any one is deficient then the person will
not be healthy and resist disease
• These nutrients are divided into two
groups:
– Type I nutrients
– Type II nutrients
• Type I – • Type II –
Functional nutrients Growth nutrients
(Fe, I, vit A, D, E, K, …) (K, Mg, Zn, Na,…)
 has a body store  has no body store
 reduces in concentration  stable tissue
with deficiency concentration
 Specific signs of  no specific signs of
deficiency deficiency
 Growth failure not a  Growth failure the
feature dominant feature
 variable in breast milk  stable in breast milk
Type II nutrient deficiency Psycological
Infection
Anorexia Neoplasm
Starvation Malabsorption
Reduced Intake
Pathological loss Neglect
Reduced mass Reduced requirement
Efficient use Reduced work of organs
Body composition Physiological and

changed: matabolic responses
organs, tissue and chemical changed
Infection Specific deficiency

Loss of reserve
Small bowel overgrowth Tissue and functional capacity Pathological losses
Skin, intestine, kidney
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?
• No. He was, but is

now recovering - he
has got back his
sweating response.
CONCLUSION
• A severely malnourished child do not only have
one organ deficient (like it is for diabete:
problem of insuline secretion by the pancreas).
• He has changes to all his physiological functions
- heart, liver, intestine, and kidney. As well as
their hormonal, immune, inflammatory and heat
regulating mechanisms.
• He cannot tolerate an excess of anything
without it disturbing his homeostasis.
• To treat such a child individually requires great
skill and understanding of the disturbances of all
the systems.
MODULE 2
COMMUNITY ASPECTS AND
PASSIVE & ACTIVE SCREENING
49
THE DIFFERENT STEPS
1- Importance of involvement of the community
2- Active screening at community level
3- Passive screening at health centre level
50
LEARNING OBJECTIVES
The participant should be able to
1 –Explain how to facilitate access to care
2- Take & interpret the anthropometric measurements
3- Check for bilateral oedema and its degree
4- Classify according to the criteria of admission into

MAM, SAM or normal (not MAM/SAM)
5- Calculate the monthly number of SAM, MAM, Normal
at community level and out-patient clinic/health centre
6- Collect the screening tally sheets of the CHW and
send them to the DNO to collate, map and indentify any
areas with a high prevalence
ACTIVE SCREENING
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
Screening is called passive when the patients present to

a health structure and active when it is house-to-house
in the community
57
PASSIVE SCREENING:
WHERE?
It should be routine in all hospitals &

health centres,
– Hospital level: OPD, Emergency Ward , SC
– Health centre during immunisation, IMCI –
Growth Monitoring, etc.
– Campaign: Vitamin A / deworming
campaigns, etc.
58
“WASTING”
Weight for Height/Length reflects
recent weight loss or gain
Height-for-Age (HFA) reflects

“STUNTING”
skeletal growth
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
MUAC < 11.5cm 11.5 ≤ MUAC <

and/or presence 12.5cm and absence of MUAC ≥
of bilateral bilateral oedema 12.5cm
oedema
Measure of weight
and height – W/H
index
W/H < -3 z- W/H ≥ -3&<-

score 2z-score
SAM MAM No wasting

using
MUAC
MEASURE THE LENGTH/HEIGHT
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.
female male total

alive 3883 4211 8094
death 492 489 981
total 4375 4700 9075
Case Fatality rate 11.2 10.4 10.8
Chi-squared P 0.197 NS
When you have the weight in kg and g and the height/length rounded to
the nearest half-cm, look first to the height/length row and in/between
which columns the child’s weight lies.
Use for both boys and girls (highest for either gender)
Length Weight Kg – Z-score Length Weight Kg – Z-score
cm -4,0 -3 -2 -1,5 -1 0 cm -4,0 -3 -2 -1,5 -1 0
Use Length for less than 87 cm
45 1,75 1,90 2,07 2,16 2,25 2,46 66 5,5 5,92 6,4 6,65 6,92 7,5
45,5 1,81 1,97 2,14 2,23 2,33 2,55 66,5 5,6 6,02 6,5 6,75 7,03 7,62
46 1,88 2,03 2,21 2,30 2,41 2,63 67 5,7 6,11 6,6 6,86 7,14 7,74
46,5 1,94 2,10 2,28 2,38 2,48 2,72 67,5 5,8 6,2 6,69 6,96 7,24 7,85
47 2,00 2,16 2,35 2,45 2,56 2,80 68 5,8 6,29 6,79 7,06 7,35 7,97
47,5 2,06 2,23 2,42 2,53 2,64 2,89 68,5 5,9 6,38 6,89 7,16 7,45 8,1
48 2,12 2,30 2,50 2,61 2,72 2,97 69 6,0 6,47 6,99 7,26 7,56 8,2
48,5 2,18 2,37 2,57 2,68 2,80 3,06 69,5 6,1 6,56 7,08 7,36 7,66 8,3
49 2,25 2,44 2,65 2,76 2,89 3,16 70 6,2 6,65 7,18 7,46 7,77 8,4
49,5 2,32 2,51 2,73 2,85 2,97 3,25 70,5 6,3 6,74 7,27 7,56 7,87 8,5
50 2,39 2,59 2,81 2,94 3,07 3,35 71 6,3 6,82 7,37 7,66 7,97 8,6
50,5 2,46 2,67 2,90 3,03 3,16 3,46 71,5 6,4 6,91 7,46 7,76 8,1 8,8
51 2,54 2,75 2,99 3,12 3,26 3,56 72 6,5 7 7,55 7,86 8,2 8,9
51,5 2,62 2,84 3,08 3,22 3,36 3,68 72,5 6,6 7,08 7,65 7,95 8,3 9,0
52 2,70 2,93 3,18 3,32 3,47 3,79 73 6,7 7,16 7,74 8,0 8,4 9,1
52,5 2,79 3,02 3,28 3,42 3,58 3,91 73,5 6,7 7,25 7,83 8,1 8,5 9,2
53 2,88 3,12 3,38 3,53 3,69 4,03 74 6,8 7,33 7,91 8,2 8,6 9,3
53,5 2,98 3,22 3,49 3,64 3,80 4,16 74,5 6,9 7,41 8 8,3 8,7 9,4
54 3,08 3,33 3,61 3,76 3,92 4,29 75 6,9 7,49 8,1 8,4 8,8 9,5
54,5 3,18 3,44 3,73 3,88 4,05 4,42 75,5 7,0 7,56 8,2 8,5 8,8 9,6
55 3,29 3,55 3,85 4,01 4,18 4,55 76 7,1 7,64 8,3 8,6 8,9 9,7
55,5 3,39 3,67 3,97 4,14 4,31 4,69 76,5 7,2 7,72 8,3 8,7 9,0 9,8
56 3,50 3,78 4,10 4,26 4,44 4,83 77 7,2 7,79 8,4 8,8 9,1 9,9
56,5 3,61 3,90 4,22 4,40 4,58 4,98 77,5 7,3 7,87 8,5 8,8 9,2 10,0
57 3,7 4,02 4,35 4,53 4,71 5,13 78 7,4 7,94 8,6 8,9 9,3 10,1
57,5 3,8 4,13 4,47 4,66 4,85 5,27 78,5 7,4 8 8,7 9,0 9,4 10,2
58 3,9 4,25 4,6 4,79 4,99 5,42 79 7,5 8,1 8,7 9,1 9,5 10,3
58,5 4,1 4,37 4,72 4,92 5,12 5,56 79,5 7,6 8,2 8,8 9,2 9,5 10,4
59 4,2 4,49 4,85 5,05 5,25 5,71 80 7,6 8,2 8,9 9,2 9,6 10,4
59,5 4,3 4,6 4,97 5,17 5,39 5,85 80,5 7,7 8,3 9,0 9,3 9,7 10,5
60 4,4 4,71 5,09 5,3 5,52 5,99 81 7,8 8,4 9,1 9,4 9,8 10,6
60,5 4,5 4,82 5,21 5,42 5,65 6,13 81,5 7,8 8,5 9,1 9,5 9,9 10,7 69
61 4,6 4,93 5,33 5,54 5,77 6,26 82 7,9 8,5 9,2 9,6 10,0 10,8
61,5 4,7 5,04 5,44 5,66 5,89 6,4 82,5 8,0 8,6 9,3 9,7 10,1 10,9
Use for both boys and girls (highest for either gender)
Length Weight Kg – Z-score Length Weight Kg – Z-score
cm -4,0 -3 -2 -1,5 -1 0 cm -4,0 -3 -2 -1,5 -1 0
Use Length for less than 87 cm
45 1,75 1,90 2,07 2,16 2,25 2,46 66 5,5 5,92 6,4 6,65 6,92 7,5
45,5 1,81 1,97 2,14 2,23 2,33 2,55 66,5 5,6 6,02 6,5 6,75 7,03 7,62
46 1,88 2,03 2,21 2,30 2,41 2,63 67 5,7 6,11 6,6 6,86 7,14 7,74
46,5 1,94 2,10 2,28 2,38 2,48 2,72 67,5 5,8 6,2 6,69 6,96 7,24 7,85
47 2,00 2,16 2,35 2,45 2,56 2,80 68 5,8 6,29 6,79 7,06 7,35 7,97
47,5 2,06 2,23 2,42 2,53 2,64 2,89 68,5 5,9 6,38 6,89 7,16 7,45 8,1
48 2,12 2,30 2,50 2,61 2,72 2,97 69 6,0 6,47 6,99 7,26 7,56 8,2
48,5 2,18 2,37 2,57 2,68 2,80 3,06 69,5 6,1 6,56 7,08 7,36 7,66 8,3
49 2,25 2,44 2,65 2,76 2,89 3,16 70 6,2 6,65 7,18 7,46 7,77 8,4
49,5 2,32 2,51 2,73 2,85 2,97 3,25 70,5 6,3 6,74 7,27 7,56 7,87 8,5
50 2,39 2,59 2,81 2,94 3,07 3,35 71 6,3 6,82 7,37 7,66 7,97 8,6
50,5 2,46 2,67 2,90 3,03 3,16 3,46 71,5 6,4 6,91 7,46 7,76 8,1 8,8
51 2,54 2,75 2,99 3,12 3,26 3,56 72 6,5 7 7,55 7,86 8,2 8,9
51,5 2,62 2,84 3,08 3,22 3,36 3,68 72,5 6,6 7,08 7,65 7,95 8,3 9,0
52 2,70 2,93 3,18 3,32 3,47 3,79 73 6,7 7,16 7,74 8,0 8,4 9,1
52,5 2,79 3,02 3,28 3,42 3,58 3,91 73,5 6,7 7,25 7,83 8,1 8,5 9,2
53 2,88 3,12 3,38 3,53 3,69 4,03 74 6,8 7,33 7,91 8,2 8,6 9,3
53,5 2,98 3,22 3,49 3,64 3,80 4,16 74,5 6,9 7,41 8 8,3 8,7 9,4
54 3,08 3,33 3,61 3,76 3,92 4,29 75 6,9 7,49 8,1 8,4 8,8 9,5
54,5 3,18 3,44 3,73 3,88 4,05 4,42 75,5 7,0 7,56 8,2 8,5 8,8 9,6
55 3,29 3,55 3,85 4,01 4,18 4,55 76 7,1 7,64 8,3 8,6 8,9 9,7
55,5 3,39 3,67 3,97 4,14 4,31 4,69 76,5 7,2 7,72 8,3 8,7 9,0 9,8
56 3,50 3,78 4,10 4,26 4,44 4,83 77 7,2 7,79 8,4 8,8 9,1 9,9
56,5 3,61 3,90 4,22 4,40 4,58 4,98 77,5 7,3 7,87 8,5 8,8 9,2 10,0
57 3,7 4,02 4,35 4,53 4,71 5,13 78 7,4 7,94 8,6 8,9 9,3 10,1
57,5 3,8 4,13 4,47 4,66 4,85 5,27 78,5 7,4 8 8,7 9,0 9,4 10,2
58 3,9 4,25 4,6 4,79 4,99 5,42 79 7,5 8,1 8,7 9,1 9,5 10,3
58,5 4,1 4,37 4,72 4,92 5,12 5,56 79,5 7,6 8,2 8,8 9,2 9,5 10,4
59 4,2 4,49 4,85 5,05 5,25 5,71 80 7,6 8,2 8,9 9,2 9,6 10,4
59,5 4,3 4,6 4,97 5,17 5,39 5,85 80,5 7,7 8,3 9,0 9,3 9,7 10,5
60 4,4 4,71 5,09 5,3 5,52 5,99 81 7,8 8,4 9,1 9,4 9,8 10,6
60,5 4,5 4,82 5,21 5,42 5,65 6,13 81,5 7,8 8,5 9,1 9,5 9,9 10,7
61 4,6 4,93 5,33 5,54 5,77 6,26 82 7,9 8,5 9,2 9,6 10,0 10,8
61,5 4,7 5,04 5,44 5,66 5,89 6,4 82,5 8,0 8,6 9,3 9,7 10,1 10,9
62 4,8 5,14 5,56 5,78 6,01 6,53 83 8,1 8,7 9,4 9,8 10,2 11,0
62,5 4,9 5,25 5,67 5,89 6,13 6,65 83,5 8,2 8,8 9,5 9,9 10,3 11,2
63 5,0 5,35 5,77 6,00 6,25 6,78 84 8,3 8,9 9,6 10,0 10,4 11,3
63,5 5,1 5,45 5,88 6,12 6,36 6,9 84,5 8,3 9 9,7 10,1 10,5 11,4
64 5,1 5,54 5,99 6,23 6,48 7,03 85 8,4 9,1 9,8 10,2 10,6 11,5
64,5 5,2 5,64 6,09 6,33 6,59 7,15 85,5 8,5 9,2 9,9 10,3 10,7 11,6 70
65 5,3 5,74 6,19 6,44 6,7 7,27 86 8,6 9,3 10,0 10,4 10,8 11,7
65,5 5,4 5,83 6,29 6,55 6,81 7,39 86,5 8,7 9,4 10,1 10,5 11,0 11,9
Use for both boys and girls
Height Weight Kg – Z-score Height Weight Kg – Z-score
cm -4,0 -3 -2 -1,5 -1 0 cm -4,0 -3 -2 -1,5 -1 0
Use Height for more than or equal to 87 cm
87 9,0 9,6 10,4 10,8 11,2 12,2 104 12,0 13,0 14,0 14,6 15,2 16,5
87,5 9,0 9,7 10,5 10,9 11,3 12,3 104,5 12,1 13,1 14,2 14,7 15,4 16,7
88 9,1 9,8 10,6 11,0 11,5 12,4 105 12,2 13,2 14,3 14,9 15,5 16,8
88,5 9,2 9,9 10,7 11,1 11,6 12,5 105,5 12,3 13,3 14,4 15,0 15,6 17,0
89 9,3 10,0 10,8 11,2 11,7 12,6 106 12,4 13,4 14,5 15,1 15,8 17,2
89,5 9,4 10,1 10,9 11,3 11,8 12,8 106,5 12,5 13,5 14,7 15,3 15,9 17,3
90 9,5 10,2 11,0 11,5 11,9 12,9 107 12,6 13,7 14,8 15,4 16,1 17,5
90,5 9,6 10,3 11,1 11,6 12,0 13,0 107,5 12,7 13,8 14,9 15,6 16,2 17,7
91 9,7 10,4 11,2 11,7 12,1 13,1 108 12,8 13,9 15,1 15,7 16,4 17,8
91,5 9,8 10,5 11,3 11,8 12,2 13,2 108,5 13,0 14,0 15,2 15,8 16,5 18,0
92 9,9 10,6 11,4 11,9 12,3 13,4 109 13,1 14,1 15,3 16,0 16,7 18,2
92,5 9,9 10,7 11,5 12,0 12,4 13,5 109,5 13,2 14,3 15,5 16,1 16,8 18,4
93 10,0 10,8 11,6 12,1 12,6 13,6 110 13,3 14,4 15,6 16,3 17,0 18,6
93,5 10,1 10,9 11,7 12,2 12,7 13,7 110,5 13,4 14,5 15,8 16,4 17,1 18,8
94 10,2 11,0 11,8 12,3 12,8 13,8 111 13,5 14,6 15,9 16,6 17,3 19,0
94,5 10,3 11,1 11,9 12,4 12,9 13,9 111,5 13,6 14,8 16,0 16,7 17,5 19,2
95 10,4 11,1 12,0 12,5 13,0 14,1 112 13,7 14,9 16,2 16,9 17,7 19,4
95,5 10,4 11,2 12,1 12,6 13,1 14,2 112,5 13,9 15,0 16,3 17,1 17,9 19,6
96 10,5 11,3 12,2 12,7 13,2 14,3 113 14,0 15,2 16,5 17,2 18,0 19,8
96,5 10,6 11,4 12,3 12,8 13,3 14,4 113,5 14,1 15,3 16,7 17,4 18,2 20,0
97 10,7 11,5 12,4 12,9 13,4 14,6 114 14,2 15,4 16,8 17,6 18,4 20,2
97,5 10,8 11,6 12,5 13,0 13,6 14,7 114,5 14,3 15,6 17,0 17,8 18,6 20,5
98 10,9 11,7 12,6 13,1 13,7 14,8 115 14,5 15,7 17,2 18,0 18,8 20,7
98,5 11,0 11,8 12,8 13,3 13,8 14,9 115,5 14,6 15,9 17,3 18,1 19,0 20,9
99 11,1 11,9 12,9 13,4 13,9 15,1 116 14,7 16,0 17,5 18,3 19,2 21,1
99,5 11,2 12,0 13,0 13,5 14,0 15,2 116,5 14,8 16,2 17,7 18,5 19,4 21,3
100 11,2 12,1 13,1 13,6 14,2 15,4 117 15,0 16,3 17,8 18,7 19,6 21,5
100,5 11,3 12,2 13,2 13,7 14,3 15,5 117,5 15,1 16,5 18,0 18,9 19,8 21,7
101 11,4 12,3 13,3 13,9 14,4 15,6 118 15,3 16,6 18,2 19,0 19,9 22,0
101,5 11,5 12,4 13,4 14,0 14,5 15,8 118,5 15,4 16,8 18,4 19,2 20,1 22,2
102 11,6 12,5 13,6 14,1 14,7 15,9 119 15,5 16,9 18,5 19,4 20,3 22,4
102,5 11,7 12,6 13,7 14,2 14,8 16,1 119,5 15,7 17,1 18,7 19,6 20,5 22,6
103 11,8 12,8 13,8 14,4 14,9 16,2 120 15,8 17,3 18,9 19,8 20,7 22,871
103,5 11,9 12,9 13,9 14,5 15,1 16,4
These tables are derived from the WHO 2006 standards for Boys. Because using separate tables for boys and girls leads to many more boys being admitted to therapeutic
Exercise 1: Calculate the WfH in Z-scores
1- Shana, a girl of 63 cm length and 5.0 kg

weight
2- Rico, a boy of 101cm height and 11.8 kg

weight
3- Kareem, a boy of 82 cm length and 8.5 kg

weight
Answers Exercise 1
Calculate the WfH in Z-scores
1. Shana, WfH = - 4 Z score
2. Rico WfH between -4 Z and -3 Z score
3. Kareem, WfH = -3 Z score

Module 3
TRIAGE
AND
TRANSPORT
at health centre level
Version 2018 _ based upon protocol version 6.6.4

© Michael Golden & Yvonne Grellety
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 used without charge for
teaching UNICEF staff and Ministry of Health Staff in developing countries. 75
LEARNING OBJECTIVES
• *Take the anthropometric measurements
• *Check the presence of bilateral oedema & it’s degree
• *Use of the W/H unisex WHO2006 table
• *Undertake 1st Triage between the MAM & SAM
• Do an appetite test for the SAM patients
• Take the respiratory rate– temperature – presence of
oedema – take the standard history: diarrhoea, vomit etc.
• Examine the patient: clinical examination
• Undertake 2nd Triage to decide between treatment in the SC
or OTP
• Transfer the patients who need to be treated in SC
• Ensure (Organise) the transport of the patients 76
* Revise Module 2
TRIAGE PROCEDURE
1st Triage
1st triage - MAM or SAM triage
2nd Triage - (SAM only) OTP or SC triage
77
1st TRIAGE MAM : SAM TRIAGE
based on MUAC or W/L-W/H and Bilateral Oedema
ACTIVE OR PASSIVE SCREENING

MUAC
MUAC >11.5 to
≤11.5cm
≤ 12.5cm and
MUAC and/or
absence of
>12.5cm presence of
bilateral
bilateral
oedema
Measure of weight oedema
and height – W/H
index
W/H >-3 & W/H ≤ -3

≤-2 z-score z-score
Normal MAM SAM

2nd TRIAGE: SAM - SC / OTP
TRIAGE
SAM
Test appetite and Check for

Bilateral oedema
clinical complications (IMCI)
Caretaker choice, Caretaker choice,

Poor appetite Mod./Good appetite
or complication No complication
SC/IPF Out-patient treatment

THE DIFFERENT STEPS
1st step, select only the SAM patients using the
criteria of admission,
2nd step, give water / sugar-water
3rd step, do the appetite test
4th step, check for complications using IMCI

criteria
5th step, decide with the mother to treat as an
Out- or In- patient 80
CRITERIA FOR ADMISSION
• 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.........................
Child nº MUAC (mm) Weight (kg.g) Height/length(cm.mm)
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).
Thus - Even a 15% reduction in appetite can lead to

marasmus! 92
Please do the appetite test conscientiously!
APPETITE TEST
 Do the test in a separate quiet area (the children
together).
 Explain to the mothers how the test will be done.
 Ask the mothers:
 to wash their hands and to sit comfortably with their
children on their laps;
 to offer RUTF (from the packet, the medicine cup or,
more conveniently, on their fingers ).
 not to force their children and to take up to an hour, if
necessary.
 to offer to the child PLENTY of WATER to drink from a
cup as s/he is taking the RUTF
 When the child has finished, measure the amount
taken. 93
WASH HANDS
Refer to
community IMCI
section on hand
washing
94
Do the appetite test
•Directly from the sachet

•Use a graduated measuring cup 95
APPETITE TEST
“Moderate” is the minimum amount that malnourished patients
should take to pass the appetite test
Body weight Paste in sachets Paste in cups
(Proportion of whole sachet (ml or grams )
96g)
Kg poor moderate good poor moderate good
Less than 4 <⅛ ⅛ -- ¼ >¼ <15 15 – 25 >25
4 – 6.9 <¼ ¼ -- ⅓ >⅓ <25 25 – 30 >35
7 – 9.9 <⅓ ⅓ -- ½ >½ <35 35 -- 50 >50
10 – 14.9 <½ ½ --¾ >¾ <50 50 -- 75 >75

15 - 29 <¾ ¾ --1 >1 <100 100 - 150 >150
96
Appetite test exercises
1. Maria is going to the health centre and her WH
is <-3Z (weight: 8.3kg) and her MUAC is
<115mm. During her appetite test, she finished
one whole cup of 25g, she does not take any of
a second cup.
– What is the result of the appetite test?
2. Jestina was admitted to the OTP programme 3
weeks ago and she has lost 300g weight. Her
weight at admission was 10.1kg. During the
appetite test she finished 1+ ½ cups.
– What is the result of the appetite test? 97
Answer of the exercises
1- Maria has a weight of 8.3kg which is in the range of 7 to
9.9kg on the appetite test table; she should take 35 to 50g
according to the appetite test table to pass the appetite test
(moderate range).
She only took 25g which is <35g. She fails the appetite test.
2- Jestina has a weight of 10.1kg – 0.3kg=9.8kg which is in
the range of 7 to 9.9kg; she should take 35 to 50g according to
pass the appetite test table (moderate range).
She took 25+12.5g=37.5g. She just passes the appetite test.
(discussion – did she have oedema? Would this make a
difference to interpretation?)
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
CRITERION IN-PATIENT CARE OUT-PATIENT

CARE
Medical Any severe illness, Alert with no
complications using the IMCI medical
criteria: complications
Respiratory tract and no major
infection, signs of
Severe Anaemia,
Dehydration, Lethargy,
Immuno-
Hypothermia, Fever, incompetence:
Candidiasis e.g. candidiasis.
Carer No suitable or willing Reasonable
carer. home
circumstances
and a willing100
carer.
OTP
OUT PATIENT
THERAPEUTIC
PROGRAMME
PATIENTS WITH NO COMPLICATION –
A GOOD OR MODERATE APPETITE –
A WILLING CARETAKER
Module 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)
Monitoring and evaluation (see module 7)

1- Fill in the monthly report
2- Ensure the regular flow of drugs and
therapeutic products (RUTF) and their safe and
appropriate storage First In First Out (FIFO)
Coordination with:
Community (CHW, volunteers, etc.) – district (district
nutrition officer) – SC (keep track of transfers, etc)
109
ADMISSION CRITERIA
• Children from 6months to adolescents

- W/L or W/H <-3 z-score or
– MUAC <11.5 cm or
• Adolescents
– WH <70% NCHS
• Adults
– BMI <16 with recent weight loss or
– MUAC <18 cm with recent weight loss or
110
TYPES OF ADMISSION
• New admission spontaneous, referred

by CHW, from screening
• Relapse (New admission)
• Re-admission of defaulter less than 2
months
• Transfer from SC (Return)
• Transfer from another OTP
111
TYPE OF REFERRAL
Patient can be referred by:
•the community: CHW – volunteers
•the OPD or Health clinic
•Others: traditional healer, etc.
Or the patient can come to the health centre

•Spontaneously: their status is usually
worse with complications (need particular care with
assessment).
112
REGISTRATION PROCESS
• Measure and record MUAC (module 2)
• Take the patient's weight and height, and calculate
the weight-for-height (module 2)
• Calculate the target weight for discharge (if
admitted using W/H criteria)
• Write his/her SAM-number and register the new
and transferred patients in the registration book
• Do an appetite test (module 3)
• Check immunisation and Vitamin A capsule status
• Give routine medicines
• Complete the OTP chart
• Fill in the card for the caretaker if any 113
TARGET WEIGHT = DISCHARGE
WEIGHT
• The target weight is the weight the patient should
reach to be considered « cured ».
• The target weight is equal to the weight given in the
« -1.5 Z-score » column of the W/H table (WHO2006).
• The patient should be at or above the target weight
for 2 visits before the patient is discharged.
The weight should be re-measured and confirmed

before discharge.
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
SAM/Scope Caretaker's Transfer-IN W/Lor

DATE Reg # Patient's name Village & Phone No Type of Sex Age Wt Ht/L Oed MUAC
Number name H (Z-
admission Code/Name of M/F mo kg.g cm 0,1,2,3 cm
score
the SC/OTP mo.
1
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
3.0 – 3.4 105 750 1¼ 8 2 14

3.5 – 4.9 130 900 1½ 10 2½ 17 ½
5.0 – 6.9 200 1400 2 15 4 28
7.0 – 9.9 260 1800 3 20 5 35
10.0 – 14.9 400 2800 4 30 7 49
15.0 – 19.9 450 3200 5 35 9 63
20.0 – 29.9 500 3500 6 40 10 70
≥ 30.0 650 4500 7 50 12 84
117
ROUTINE MEDICINES -
OTP
 Admission
Amoxicillin for 7 days
Test/Treat malaria
4th Visit (28days)
•Vitamin A for all children
• Deworming (Mebendazol
or Albendazol) for children
of walking age
• Measles vaccine for all children
if no vaccination card.
Note: Iron, zinc, potassium, vitamin A,

folic acid, etc. are all incorporated in the
RUTF. – do not “double dose” except
where shown in the protocol (vit A) 118
DOSAGE OF
AMOXICILLINE
Amoxicillin (50-100 mg/kg/day)
Weight range
Dosage – Twice a day
Kg In mg Cap/tab (250mg)
<5kg 125 mg * 2 ½ cap * 2
5 – 10 250 mg * 2 1 cap * 2
10 – 20 500 mg * 2 2 cap * 2
20 – 35 750 mg * 2 3 cap * 2
>35 1000 mg * 2 4 cap * 2
• Do not give chloramphenicol in OTP

• Do not give systematic antibiotic to children transferred from the SC
• Do not give second line antibiotic (except for complicated patients who
refuse transfer to SC or acutely ill with transport difficulties)
• Give the first dose under supervision and tell the mother that the
treatment should continue for a total of 7 days 119
VITAMIN A
Age Vitamin A IU orally
6 to 11 months One blue capsule (100,000IU = 30,000ug)
Two blue or 1 red capsule (200,000IU =
Over 12 months
60,000ug)
• Give high-dose vitamin A once on 4th visit to all children (unless given
in SC for clinical deficiency).
• Do NOT give high-dose vitamin A routinely on admission to OTP.
There is sufficient vitamin A in the RUTF to treat sub-clinical vitamin
A deficiency. Controlled trials in Senegal and DRC show that there
is an increased mortality in those with oedema and increased
respiratory tract infections in both oedematous and wasted children
• Do NOT keep any child with clinical signs of vitamin A deficiency as
an outpatient -transfer to SC (or treat if patient refuses transfer)
• If an epidemic outbreak of measles is in progress, give to all children
vitamin A 120
DEWORMING
Age < 1 year 1 to 2 years ≥ 2 years
Albendazole 400mg Not given ½ tablet 1 tablet
Mebendazole 500mg Not given ½ tablet 1 tablet
Give de-worming for both those transferred from

SC to OTP and those admitted directly to OTP at
the 4th outpatient visit at the same time as the
measles vaccination. Worm medicine is only given
to children that can walk (play in the soil)
121
MEASLES
VACCINATION
• Give measles vaccine to children over the age of 9
months during their 4th visit*
• Give a second dose to those that have been given
measles vaccine as in-patients when SAM.
• Do not give measles vaccine on admission to patients
directly admitted to OTP (unless they are to be
revaccinated at the 4th visit - the antibody response will
be poor on admission)
Note* : 1) all SAM children who have a vaccination card
should be revaccinated as the antibody response will have
been poor if vaccine given whilst they were SAM – 2)
measles vaccine stimulates the immune system and
prevents many non-measles infections.
122
SURVEILLANCE
Observation FREQUENCY
MUAC is taken Every week
Weight and oedema Every week

Routinely UNLESS there is good
Appetite test
weight gain
Body temperature is measured Every week
Clinical history and examination
Every week
(stool, vomiting, etc)
At admission & if unexpected large
Height/Length is measured
change in weight/appearance
W/H z score calculation/target ONLY on the day of admission123 – do
FAILURE-TO-RESPOND TO TIME
AFTER
TREATMENT
CRITERIA FOR FAILURE TO RESPOND
ADMISSI
ON
Failure to gain any weight (non-oedematous) 21 days
Weight loss since admission to program (non-oedematous) 14 days
Failure to start to loose oedema 14 days

Oedema still present 21 days
Failure of Appetite test At any visit
Weight loss of 5% of body weight (when oedema free) At any visit
Weight loss for two successive visits At any visit
Failure to start to gain weight satisfactorily after loss of oedema 124

At any visit
(kwashiorkor) or from day 14 (marasmus) onwards.
5% weight loss (for failure-to-respond in OTP)
ESTIMATION OF 5% Ist week

loss 2nd week Ist week loss 2nd week
WEIGHT LOSS 4,0

4,1
0,2
0,2
3,8
3,9
8,0
8,1
0,4
0,4
7,6
7,7
4,2 0,2 4,0 8,2 0,4 7,8
4,3 0,2 4,1 8,3 0,4 7,9
4,4 0,2 4,2 8,4 0,4 8,0
Example : 4,5 0,2 4,3 8,5 0,4 8,1
If a boy weighs 5kg; 4,6 0,2 4,4 8,6 0,4 8,2

4,7 0,2 4,5 8,7 0,4 8,3
the week after, he weighs only 4,8 0,2 4,6 8,8 0,4 8,4
4.75, 4,9 0,2 4,7 8,9 0,4 8,5
he loss more than 5% of his 5,0

5,1
0,3
0,3
4,8
4,8
9,0
9,1
0,5
0,5
8,6
8,6
weigh. 5,2 0,3 4,9 9,2 0,5 8,7
He is in failure to respond to 5,3 0,3 5,0 9,3 0,5 8,8

5,4 0,3 5,1 9,4 0,5 8,9
treatment. 5,5 0,3 5,2 9,5 0,5 9,0
5,6 0,3 5,3 9,6 0,5 9,1
5,7 0,3 5,4 9,7 0,5 9,2
5,8 0,3 5,5 9,8 125
0,5 9,3
USE OF THE GAIN OF WEIGHT
TABLE
Example,
A child with a
weight of 5.3 kg
is seen 14 days
later and s/he
now weights
5.4kg,
this child gained
weight at less
than 2.5g/kg/d
126
Exercise
Which of the following patients have poor weight gain and
need an appetite test, detailed history and examination, a
home visit and possibly transferred to the SC?
Initial weight: 7.7kg, weight after 14 days: 7.9kg?

127
STEPS TO UNDERTAKE FOR FAILURE-TO-
RESPOND
Check & Make the diagnosis of “Failure-to-respond” to treatment
Check organisation and application of the protocol
Evaluate the appetite test
Do home visit to check for home & social circumstances

(interview head of household as well as caretaker)
Residential care for up to 3 days for a trial of supervised feeding
Transfer to In-patient facility for full clinical assessment to search for

underlying undiagnosed pathology
Refer to centre with diagnostic facilities and senior paediatric personnel

for assessment and further management: They take over the future 128
management of the patient from the program.
POSSIBLE CAUSES OF
FAILURE-TO-RESPOND - OTP
• Inappropriate selection of patients to go directly to SC
• Poorly conducted appetite tests
• Inadequate instructions given to caretakers
• Wrong amounts of RUTF dispensed to children
• Excessive time between OTP distributions (e.g.
two weekly gives significantly worse results than weekly
visits)
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),
- Mal-absorption - Psychological trauma - Rumination

- Infections (e.g. diarrhoea, dysentery, malaria, pneumonia,
tuberculosis, urinary infection, otitis media, HIV/AIDS,
hepatitis/cirrhosis, schistosomiasis, leishmaniosis, etc.)
- Other underlying diseases, congenital abnormalities,
neurological damage, inborn errors of metabolism.
- Development of a medical complication (candidiasis,
fever, increase/development of oedema)
- Development of re-feeding diarrhoea sufficient to lead
131
to weight loss.
TRANSFER TO SC-TRANSPORT
If the diagnosis of failure-to-respond to treatment in
OTP is due to a suspected medical cause and the
patient should be transferred to the SC. Only if the
caretaker agrees:
=> Transport has to be organised – a transfer form given to
the patient and send to SC,
=>Telephone the SC and the DNO to discuss the case and
allow them to anticipate arrival
Similar communication should be made when s/he
returns back to the OTP.
132
SCREENING
TRIAGE
(CRITERIA OF ADMISSION – APPETITE TEST –
COMPLICATIONS)
Direct admission to OUT-PATIENT: Admission to SC:
PASS APPETITE TEST AND NO FAIL APPETITE TEST OR
COMPLICATION AND MILD/MODERATE COMPLICATION OR SEVERE OEDEMA (+
OEDEMA AND AGREEMENT OF THE
CARETAKER
Fails appetite test or
++) AND AGREEMENT OF THE
CARETAKER
develops medical IN-PATIENT
OTP complications TREATMENT
Acute Phase
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
• Adolescents from 120 cm height to 18 years of age

WH<70% NCHS
• Adults
– BMI ≥ 17.5 or
– MUAC ≥ 18.5cm and
134
CRITERIA OF DISCHARGE FROM OTP
Before discharge, make sure that:

•Education has been completed
•Immunisation is up-to-date
•Adequate arrangements have been made for follow-up
in the TSFP and/or by CHW
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)
The District Nutrition Officer/focal point has to

regularly:
• Supervise the OTP (supervision form)
• Do regular in-job training when necessary
• Collect monthly reports & compile them (with the
District health management staff) and forward to MoH
• Ensure that material, RUTF and systematic treatment
are in the OTP
• Facilitate transfers
• Ensure coordination within the district
137
SUMMARY OF MODULE 4:
OTP
• Give a Scope/SAM-No and register the patient,
• Fill in the OTP chart
• Give routine medicines,
• Give the RUTF,
• Monitor the patient,
• Diagnose failure-to-respond to treatment,
• Apply criteria for discharge and follow-up.
138
SC
IN PATIENT TREATMENT
PATIENTS WITH COMPLICATIONS OR/AND
POOR APPETITE – FAILURE-TO-RESPOND TO
OTP TREATMENT – CARETAKER REQUEST
Admission & Acute Phase
Module 5 – Part 1
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
Admission to OTP Admission to SC

Patient failing appetite test or medical complication or
Patient passing appetite test and no medical complication
severe oedema (+++) or Mar. Kwash (WH<-3Z) or no
and/or mild/moderate oedema and willing carer
adequate carer
Fail appetite test or

Development of medical Acute phase
OTP complication
Out-
Return of appetite and
Patient Sufficient loss of oedema
Transition Phase
Treatment and no medical
complication
Recovery ONLY if no
OTP
Discharge to
follow-up
STRUCTURE
 District Hospital: (2-10 patients);

 Day care, if necessary, in HC
if far from the main SC.
Both need a room to prepare the

diet & take measurements.
Patients should always be nursed

together, physically separate from
those with other diseases.
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
• Give sugar water and

do the appetite test
• Recheck the
measurements
• Fill the A3 multi-chart
and the register (the
same format as OTP)
145
ADMISSION CRITERIA
Factor In-patient care
Choice of caretaker (at any stage of Caretaker chooses to start, continue or
management – the caretaker is often the transfer to in-patient treatment. The
best judge of severity) caretaker’s wishes must be respected.
Appetite Failed or equivocal Appetite test
Bilateral pitting oedema +++

Oedema Both Marasmus and kwashiorkor (W/H<-
3z score and oedema)
Skin Open skin lesions

Any severe illness, using the IMCI
Medical complications criteria – respiratory tract infection,
(see section on triage) severe anaemia, dehydration, fever,
lethargy, etc.
Presence of candidiasis or other signs of
Candidiasis
severe immune-incompetence
Caretaker No suitable or willing caretaker 146
TYPE OF ADMISSIONS
• New admissions: can be spontaneous

admission or referred from community,
OPD, emergency department and outpatient
department
• Relapse: is in the category of New admission
- it is another episode of SAM.
• Transfer-in from OTP to SC
• Re-admissions of defaulter <2months
147
ACTIVITIES IN ACUTE PHASE
• Give the feeds (F75)

• Give routine medicine
• Monitor the patient
• Prevent, Diagnose and Treat the Complications
& Failure-to-Respond-to- Treatment
• Stimulate the children as they recover
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
An NG-tube should be inserted for feeding when the

patient is/has:
 Taking less than 75% of prescribed diet in phase 1
pneumonia with a rapid respiration rate
painful lesions of the mouth
cleft palate or other physical deformity
disturbances of consciousness.
Note: See appendix 15 how to put a naso-gastric tube
154
ROUTINE MEDICINE
• 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
- First line (no clinical signs of infection)

Oral Amoxicillin 50 -100mg/kg/d (or oral Ampicillin)
or
Amoxicillin-clavulanic acid combination
- First/Second line (any signs infection)

add Gentamicin 5mg/kg IM once daily during Phase 1
Metronidazole (10mg/kg/d) can be added 156
DOSAGE OF GENTAMICIN
AND AMOXICILLIN
Gentamicin Amoxicillin
Weight range Dosage once per (50-100 mg/kg/day)
day Dosage – twice a day
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)
• Repeat on day 2 if clinical signs of vitamin A deficiency
F75, F100, RUTF supplies a 10kg child with 7300IU (2,2mg) of

Vit. A/day (RDA is 1700IU – 0.5mg/d). This is enough to
replete stores & treat subclinical vitamin A deficiency. (High-dose
is associated with increased infection and mortality in SAM
165
FOLIC ACID
• 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.
Note: F75, F100, RUTF supplies a 10kg child with

400micrograms/d (RDA = 80ug). This is enough to treat
mild folate deficiency and replete stores.
166
MONITORING
- Weight - each day.
- The degree of oedema (0 to +++) each day.
- Body temperature twice per day.
- Stool, vomiting, dehydration, cough, respiration rate,
liver size, each day.
- MUAC each week.
- Length/Height on admission only (do not repeat)
- A record is taken (on the intake chart) if the patient 1) is
absent, 2) vomits 3) refuses a feed 4) is fed by naso-
gastric tube 5) is given I-V infusion or 6) transfusion.
167
THE PSYCHO-SOCIAL
ENVIRONMENT
• Many children have psycho-social deprivation. Many
have seen parents or relatives suffer or die.
• There must be a caring environment, toys, attention and
love. There is no place for strict staff, oppressive rules, or
blame of the parents. The mother is the primary carer and
her wishes must always be considered.
• Put children who are not acutely ill together on a mat to
play during the daytime.
• Teach the mothers to make toys and the importance of
playing with their children during recovery and at home .
168
I am an orphan and see no point in living.
I saw my mother and father die and have no friends.
I got better when I was given a football.
The two photographs were taken 24h apart
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
Version 2018_ based upon protocol version 6.6.4
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
• The next slide shows that severely wasted

patients cannot excrete excess sodium and
retain it in their body
• This leads to volume overload and
compromise of the cardiovascular system
• The resulting heart failure can be very acute
(sudden death) or be misdiagnosed as
pneumonia
177
Renal function in severe malnutrition
Sodium excretion with a normal and an expanded extracellular fluid compartment:
Normal patient in blue – severely wasted patient in red
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
• If there is no weight gain, then:

– Increase the rate of administration of Resomal by 5ml/kg/hour – to
15ml/kg/h
– Formally reassess every hour
• If there is clinical improvement but there are still signs of

dehydration
continue with the treatment until the rehydrated weight has been
achieved.
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.
• If there is no improvement in the mood and look of the

child or reversal of the clinical signs:
– Then the diagnosis of dehydration was probably wrong
– Either change to F75 or alternate F75 and ReSoMal
Do not give Resomal 10ml/kg/h plus IV infusion 15ml/kg/h

Do not reconstitute Resomal Use Low osmolarity ORS
instead
183
Weight
Gain Stable Loss

Clinically Clinical Not
Improved improved
continue - STOP ALL - Increase - Increase

rehydration fluid ReSoMal to ReSoMal to
Target - Give F75 15ml/kg/hr 20ml/kg/hr
weight - Re-diagnose & - Reassess - Reassess
assess every hr every hr184
F75
ALL REHYDRATION (ORAL OR
INTRAVENOUS) THERAPIES SHOULD BE
STOPPED IMMEDIATELY IF
• The target rehydration weight has been achieved
• The visible veins become full (go to F75)
• The development of oedema (overhydration–go to F75)
• The development of prominent neck or superficial veins
• An increase in the liver size by more than one cm
• The development of tenderness over the liver
• An increase in the respiration rate by 5 breaths per mn or
more
• The development of a “grunting” respiration
• The development of crepitations in the lungs
• The development of a triple rhythm
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
Treatment without weight loss:

•Do NOT give ReSoMal
•Amoxicillin (metronidazole – max 10mg/kg/d) should
suppress the small bowel overgrowth
•F75 will repair the intestine – diarrhoea should subside
with the improved nutrition after a few days
RE-FEEDING DIARRHOEA AFTER
ADMISSION (1)
• Do not use inappropriate recipes for F75
(hyperosmolar recipes due to the excess of sugar can
cause osmotic diarrhoea);
Treatment with weight loss
1- Divide the diet into many feeds (8 to 10) – the
diarrhoea is due to the osmotic effect of unabsorbed
carbohydrate
2- Add pancreatic enzymes directly to the feed
just before it is given;
195
RE-FEEDING DIARRHOEA AFTER
ADMISSION (2)
Third: Change the diet to F75-yoghurt instead of
unfermented F75
Or
change to a goat’s milk or milk-free diet
If there is mucus and blood in the stool, check for and
treat amoebiasis or shigella dysentery
DO NOT treat with ReSoMal

Note: Re-feeding diarrhoea appears to be more common
in children with oedematous malnutrition – weight
loss can be due to resolution of oedema 196
What are the diagnoses?
How would you treat this child?
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)
Shock should be diagnosed when there is:

• Poor capillary refill (≥2secs = moderate, ≥ 3secs sever)
• Cold arms and legs (in a warm climate)
• A fast weak pulse (or absent pulse at the wrist and ankle)
• Pallor (and other signs of adrenergic stimulation – not anaemia)
• Disturbed consciousness (there are other causes)
198
CAUSES OF SHOCK
There are several common causes of shock in the SAM child.
They need to be differentiated as giving treatment for one
pathology can make another worse.
– Dehydration (acute body fluid loss – diarrhoea)
– Hypernatraemic dehydration (water loss/over-concentrated
feeds)
– Toxic shock (traditional medicine, drug toxicity, aflatoxins, etc)
– Septic shock (bacterial, viral, fungal infection, severe malaria)
– Cardiogenic shock (fluid overload, high sodium intake, blood
transfusion, refeeding syndrome)
– Liver failure
More than one of these may be present in the very sick child.
Other causes of shock very rare in SAM (haemorrhage, anaphalaxis)
199
TREATMENT OF SEPTIC SHOCK
If cardiogenic shock is excluded (no antecedent weight gain or
increased respiratory rate) then treat as septic shock.
• Physically disturb as little as possible (no transport)
• Give third line antibiotics (see section on antibiotics) +
antifungals – consider metronidazole/cloxacillin
• Kept warm to prevent or treat hypothermia
• Give sugar-water by mouth or NGT as soon as the diagnosis
is made (to prevent hypoglycaemia)
• Can give Oxygen if available
• Do NOT give a bolus infusion
• If loosing consciousness/unconscious give IV circulatory
support slowly and cautiously. 200
FLUID FOR SEPTIC SHOCK
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
the heart is weak and very easily precipitated into failure

9
Cardiac output
8
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
Examine daily weights
Weight Increase Weight decrease

Weight stable
Fluid overload Pneumonia

Heart failure Aspiration
204
TREATMENT OF HEART
FAILURE
• Stop all intake of fluids or feeds (oral or IV)
• No fluid or food should be given until the heart failure
has improved or resolved (even 24-48 hours)
• Small amounts of sugar-water can be given orally if
worried about hypoglycaemia
• Give frusemide (1mg/kg) – usually not very effective
• Even if very anaemic do not transfuse – unless there are
facilities and expertise to perform an exchange
transfusion
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
- Hb ≥ 4g/100ml or - Hb < 4g/100ml or

-Packed cell vol ≥12% - Packed cell vol<12%
- Or between 2 and 14
ONLY during the first 48hrs
days after admission after admission:
Give 10ml/kg whole or
No acute treatment
packed cells 4hrs - No food
for 3 to 5 hrs after 207
HYPOGLYCAEMIA
• The good results of day-care show that
significant hypoglycaemia is very uncommon
• Best prevented by regular feeding
• Often there are no clinical signs at all
• Treatment has no adverse effects
• Always treat patients with septic shock and
hypothermia as if they also have hypoglycaemia
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
• Nearly all hypothermia is
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
temperature to 25oC – the 35.0

SAM children in red -30 0 30 60 90 120 150
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
twice/day for at least 10 days.

SKIN LESION (2)
• Impetigo
Prevention =>Cut the nails – wash frequently with soap and
dry frequently – do not share towels etc.
Treatment => Wash with warm soapy water
=> Start the patient on oral cloxacillin
If the lesions do not respond within 48 hr, change to
erythromycin, clindamycin or cefotaxime treatment.
• Cancrum Oris
Clean the lesions - full course of second line antibiotics. If available
give clindamycin + metronidazole 10mg/kg/d;
• Surgery should not be attempted until after full nutritional recovery.
216
REFEEDING SYNDROME
• “Refeeding syndrome” occurs when a malnourished
patient suddenly has a large increase in food intake
• They suddenly develop: acute weakness, “floppiness”,
lethargy, delirium, neurological symptoms, acidosis,
muscle necrosis, liver and pancreatic failure, cardiac
failure or sudden unexpected death
• It is due to nutritional disequilibrium with reduced
plasma phosphorus, potassium and magnesium
• Prevention: Start treatment with 100kcal/kg/d and
increase to 130kcal/kg/d for a few days before going to
the full intake. Never force-fed more than the amounts
in the look-up table (100kcal/kg/d)
217
TREATMENT OF REFEEDING
SYNDROME
•Fast for 1 day

•Returned to the Acute Phase
•Start with 50% of the recommended intake of F75 until
all signs and symptoms disappear; then gradually
increase
•Check to make sure that there is sufficient K and Mg in
the diet
NOTE: If the diet is not based on cow’s milk (or the mother is
also giving cereals/pulses etc.) additional phosphorus should be
given to prevent re-feeding syndrome. 218
SUMMARY OF COMPLICATIONS
MODULE 5.2
• Critical care chart – monitoring the complications

• Dehydration – difficulty in diagnosis and different
management from normal children
• Persistent diarrhoea
• Hypernatraemic dehydration
• Septic/toxic shock
• Re-feeding diarrhoea
• Anaemia, Heart failure, Hypoglycaemia, Hypothermia,
Fever, Re-feeding syndrome.
• Skin lesions 219
Thank “U” All
SC
IN PATIENT TREATMENT
Failure to respond, transition phase, transfer
to OTP
Module 5 – Part 3
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
• Most children respond rapidly and well to

treatment
• Those that do not respond need to have their
history and examination repeated and the reason
for non-response determined
• Making these diagnoses is the main role of the
clinician in the treatment of the malnourished
223
CRITERIA FOR FAILURE
Criteria for failure to Time after admission

respond
Failure to improve/regain Day 4
appetite
Failure to start to lose Day 4
oedema
Oedema still present Day 10
Failure to fulfil the criteria for Day 10
recovery-phase (OTP)
Clinical Deterioration AFTER At any time
admission
224
PROBLEMS WITH THE
TREATMENT FACILITY
• Poor environment for malnourished children
• Staff are too strict, intimidating, poorly trained or
there are insufficient staff (particularly at night)
• Failure to treat the children in a separate area away
from other patients
• Failure to complete the multi-chart correctly
(overloaded staff) or use of traditional hospital
records
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),
- Mal-absorption - Psychological trauma - Rumination

- Infections (e.g. diarrhoea, dysentery, malaria, pneumonia,
tuberculosis, urinary infection, otitis media, HIV/AIDS,
hepatitis/cirrhosis, schistosomiasis, leishmaniasis, etc.)
- Other underlying diseases, congenital abnormalities,
neurological damage, inborn errors of metabolism.
- Development of a medical complication (candidiasis,
fever, increase/development of oedema)
- Development of re-feeding diarrhoea sufficient to lead
227
to weight loss.
CRITERIA TO MOVE FROM
ACUTE PHASE
TO TRANSITION PHASE
•At least the beginning of the loss of oedema

AND
• The return of a good appetite
AND
• No NGT, infusions, no severe medical problems
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
 Monitor the patient

 Feed the patient in exactly the same way as in Phase 1
except that RUTF is given instead of F75 with water.
or
F100 (130kcal/130ml/kg/d) if the child refuses RUTF
The same volume is given so that the energy intake increases by

30% and the child starts to gain tissue.
(expected weight gain is about 6g/kg/d if no oedema – or
exchange of oedema fluid for tissue)
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)
• If any complication develops that requires an intravenous infusion

of drugs, or rehydration therapy or loss of appetite 234
RECOVERY PHASE
This should nearly always be as an Out-

Patient
If good circumstances at home
235
SCREENING
TRIAGE Step 2
SAM admission criteria,
Appetite test, Complications
Admission to OTP Admission to SC

Patient passing appetite test and no medical complication Patient failing appetite test or medical complication or
and/or mild/moderate oedema and willing carer severe oedema (+++) or no adequate carer
Fail appetite test or

Development of medical Acute phase
complication
OTP
Return of appetite and
Out- Sufficient loss of oedema
Transition Phase
Patient and no medical
complication
treatment Recovery ONLY if no
OTP
Discharge to
follow-up
CRITERIA FOR TRANSFER TO
OTP
• Pass the appetite with RUTF and finish
the feeds
• At least 1 day for wasted patients
• Major reduction or loss of oedema
• No other medical problem
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
Infant from 0 to 6 months of age
and the treatment of severe
malnutrition
© Michael Golden & Yvonne

Grellety
2018
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 can
be used without charge for teaching UNICEF staff.
Learning Objectives
• Define the types and criteria of admission and discharge
• List the types of reference in the SC
• Fill the SS chart, the SC register
• Weight the baby on a accurate scale (10g precision)
• Welcome the patient
• Monitor the patient
• Administrate the routine medicines
• Prepare & give the appropriate diet (F75
/F100-dilute/Infant formula/express breast-milk)
• Follow the flow of material, products, drugs, and the
stockpiling
• Follow the nutritional status of the mother
Malnourished infants
• Do not cry - they are thus neglected
• Have no strength - do not stimulate
milk
• Have a very high mortality
• Are often infected
The different Steps
• Admission:
Criteria of admission – Measurements
Registration
• Diet & the SS-technique
• Routine medicine
• Surveillance
• Care for the mother
• Exit: Criteria & Type - registration
Criteria of admission
Infant less than 3kg or less than 6 month
 Too weak or feeble to suckle effectively

(irrespective of his/her WL, WA or other
anthropometry).
or
 Not gaining weight at home (by serial
measurement of weight during growth monitoring,
i.e. change in WA)
or
 W/L less than <-3 Z
or
 Presence of bilateral oedema.
Measurements
1) Precision of the scale:

10 to 20g for the babies
below 8kg
2) The table W/L stops at
49cm length,
therefore it is difficult to
calculate the WHZ for
these infants.
Salter scales should not be used : it only has a precision of 100g

Product used
 F100 dilute if wasted infant
Why? Because babies of that age need more
water and they are wasted, they need
100kcal/kg/day
or
 Expressed breast milk
or
 Generic Infant formula if wasted infant
or
 F75 if oedematous infant only until the
beginning of loss of oedema.
Preparation of the F100 diluted
• Take 100 ml of F100 reconstituted and add 35 ml

of boiled water at 70°C or more if you need 135ml
or less for the feeds.
• Take 200 ml of F100 reconstituted and add 70ml of
boiled water at 70°C or more if you need 270ml or
less for the feeds.
• Do not try to do small quantities!
CLASS OF ML PER FEED 50% OF THE 75% OF THE
WEIGHT (KG) (FOR 8 FEEDS REQUIRED REQUIRED
/DAY) QUANTITY QUANTITY
(100%)
F100-dilute
>=1,2 kg 25 ml per feed 12,5 18 ml

1,3 – 1,5 30 15 24 ml
1,6 – 1,7 35 18 27 ml
1,8 – 2,1 40 20 30
2,2 – 2,4 45 23 35
2,5 – 2,7 50 25 40
2,8 – 2,9 55 28 45
3,0 – 3,4 60 30 45
3,5 – 3,9 65 33 50
4,0 – 4,4 70 35 55
Diet
 Breastfeed every 3 hours, during at least 20
minutes, more often if the child ask for more.
 One hour after breast-feeding, complete with

F100 diluted using the supplementary suckling
technique:
F-100 dilute: 130ml/kg/day (100kcal/kg/day),

divided in 8 meals
The Suckling Technique
- The mother holds the tube at the breast with
one hand and uses the other for holding the
beaker.
- It may take one or two days for the infant to

get used of the tube but it is important to
persevere.
-The supplementation is given via an NGT n°8 or
6: n°5 is too small
-The tip is cut back beyond the side ports
approximately 1cm and the cap at the end of the
tube is removed
-F-100 dilute is put in a beaker. The mother holds
it.
-The end of the tube is put in a cup.
-The tip of the tube is put on the breast at the
nipple and the infant is offered the breast.
- When the infant sucks on the breast with the tube in
his mouth, the milk from the cup is sucked up
through the tube and taken by the infant.
- The beaker is placed at least 10cm below the level
of the breast so the milk does not flow too quickly
and distress the infant.
- Clean the tube: After feeding, flush the tube
through with clean water using a syringe & spin
rapidly to remove the water & inspect that no water
remains in the tube.
Routine medicine
Antibiotics
 Amoxicillin (from 2kg):
30mg/kg 2 times a day (60mg/day)
 Gentamicin:
4 mg/kg give once daily IM
Never use chloramphenicol in the young infants

Surveillance
• Weigh infant daily and see if his/her weight is
increasing using a proper scale (10 to 20g
precision)
• If the infant is taking the same quantity of F100D

and is increasing, it means that the breast-milk
quantity is increasing.
Surveillance
When the infant is gaining weight at 20g per day,
 Decrease F100D to 1/2 of the maintenance intake
(50kcal/kg),
If the weight gain is maintained at 10g per day,
 Stop “SS” feeding technique completely,
If weight gain is NOT maintained

 Increase the amount by ¾ of the maintenance
intake (75kcal/kg).
Finally,
Keep the child on breast milk alone to make sure that
he continues to gain weight.
CLASS OF ML PER FEED 50% OF THE 75% OF THE
WEIGHT (KG) (FOR 8 FEEDS REQUIRED REQUIRED
/DAY) QUANTITY QUANTITY
(100%)
F100-dilute
>=1,2 kg 25 ml per feed 12,5 18 ml

1,3 – 1,5 30 15 24 ml
1,6 – 1,7 35 18 27 ml
1,8 – 2,1 40 20 30
2,2 – 2,4 45 23 35
2,5 – 2,7 50 25 40
2,8 – 2,9 55 28 45
3,0 – 3,4 60 30 45
3,5 – 3,9 65 33 50
4,0 – 4,4 70 35 55
Care for the mother (1)
- Explain the mother what you do and
why; do not make the mother feel guilty,
reassure her.
- Be attentive to her.
- She should drink at least 2 litters per
day: sugared water, normal water or
herbal tea, etc....
She must eat enough: 2500kcal/day
– 1 porridge in the morning
– 1 family meal
– 1 porridge in the afternoon
which means that at the 2100kcal for the

care takers an additional porridge has to
be given to the mother (~ 400kcal)
The mother who is admitted in the centre
with her child has to receive:
• Vitamin A:
– If the child is below 2 months: 200.000UI
(there should be no risk of pregnancy)
– If the child is above 2 months: 25.000UI
once a week
• Micronutrients’ supplementation
Criteria and type of discharge
Infant less than 3kg or less than 6 month
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”
TREATMENT OF
CHILDREN WITH
MODERATE ACUTE
MALNUTRITION
TARGET SUPPLEMENTARY
FEEDING PROGRAMS
Module 8.1 266

MAM TREATMENT –
ALTERNATIVE APPROACHES
There are alternatives programs to manage and
assist vulnerable families and those with MAM
children –the programs are not mutually exclusive.
1)direct distribution of food products (Target

Supplementary Food Programme (TSFC))
2)cash transfer
3)income generation support
4)family micro-credit
5)home-production (gardening/livestock) support
267
6)Hearth program (positive deviance).

USE OF SUPPLEMENTARY
FEEDING
• Needed particularly in emergency situations;
• Should be implemented when there are large numbers
of children with MAM children (high prevalence and/or
large population) present or anticipated;
• Gives destitute families access to food for their children –
should be integrated with a general ration distribution
and/or a protection ration for the family.
• Where there are functioning markets with reasonably
priced food, cash transfer may be added or substituted;
• The program pregnant and lactating mothers should be
run by obstetric services independently of the MAM
program. See separate presentation
268
STRUCTURE –
HUMAN RESOURCES -
MATERIALS
OTHERS
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
• Follow up of the Ex-SAM patients

keep separate register
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
•At the end of the distribution:

Wash the utensils, tables and floor (room)
Record the quantities used
Return any unused foodstuffs to the store
Secure any part-used products to prevent insect/rodent
attack.
Up-date the stock cards 286
PREPARATION AND USE OF THE
RATION
The child should receive a porridge two or three

times each day
1 volume 3 volumes of clean

water
Cook for 10 minutes
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.
For MAM patients (children from 6 months)

in the TSFC but not for the ex SAM follow
up
• Mebendazole/Albendazole (once)
• Vitamin A (once)
290
VITAMIN A
Age Dose at admission

6 to 11 months 100,000 IU (30,000µg)
More than 12 months* 200,000 IU (60,000µg)
Note: DO NOT give to the ex SAM children

MAM children even if older than 59 months, should receive
Vit A. They are at risk of deficiencies.
291
ALBENDAZOLE/
MEBENDAZOLE
Albendazole (mg) Mebendazole (mg)
Age
Orally on admission Orally on admission
< 11 months None None
12 to 23 months* 200mg 250mg
> 23 months* 400mg 500mg
* Do not give for ex SAM cured children
292
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
293
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
Criteria to refer to OTP

Weight loss WH/L < -3 Zscore
MUAC < 11.cm
MUAC loss
Presence of If any bilateral oedema

oedema appears
295
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
 Examine the causes of failure-to-respond and

take action!
296
ACTION TO TAKE IF FAILURE-TO-
RESPOND TO TREATMENT
Failure to
respond to
treatment
Check the
application of the
protocol
Change the diet to check for
uncorrected nutritional
deficiencies
Do appetite test - Check for
problems with home
environment / social
Refer to health problems
centre to admit for full
clinical assessment to search for underlying
undiagnosed pathology
Refer to centre with diagnostic facilities and
senior paediatric personnel for assessment and
further management
Idiopathic of the case
– non response – to be followed up
297
by clinical facilities
CRITERIA OF
DISCHARGE
• Children of ≥6 months
– W/H ≥ -1.5Z after two consecutive weights*
– MUAC ≥ 12.5cm after two consecutive
measures
• Ex-SAM children after 3 months follow-up
*Note: do not “warn” the mothers that their child will be

discharged if the weight is maintained for the second weighing
– otherwise they may loose weight in order to remain in the
program. If children do loose weight when approaching
discharge criteria it indicates a family food shortage and
assistance for the whole family is required
TYPE OF
DISCHARGE
• Cure: MAM patient reaching the criteria of
discharge
• Defaulter: Absence during two consecutive visits
• Dead: while the child is registered in the
program or within 24 hours of referral to a health
facility (follow up required after referral)
• Medical referral: refer to hospital
• Transfer: transfer to another TSFP
• Referral to OTP: refer to an OTP 299
Thank “U’’All

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University of Health Science (UOHS)

Course name: Integrated management of Acute

Training facilitator: Mr. Asad Garaad (Bsc Public

• The word nutrient or “food factor: is used for

• Dietetics: is the practical application of the principles

• Classification by chemical composition:

• Energy giving foods:

• PROTEINS ARE MADE OF MONOMERS CALLED

• THERE ARE ABOUT 20 DIFFERENT AMINOACIDS

• OF THIS 8 AA ARE TERMED “ESSENTIAL” AS

• It should be more than 3.5 g/dl.

• Less than 3.5 g/dl shows mild malnutrition.

• Less than 3.0 g/dl shows severe malnutrition.

• in normal human subjects, adipose tissue

• One kilogram of adipose tissue corresponds

• Diets rich in EFA have been reported to reduce

• Polyunsaturated fatty acids are precursors of

• The WHO Expert committee on Prevention of

• At least 50 per cent of fat intake should consist of

• Carbohydrate is also essential for the

• It is found in vegetables, fruits and grains.

• They are required by the body in a very small

• The international unit (IU) of vitamin A is

• Dietary deficiency of B12 may arise the subjects

• Over 40 nutrients are essential to health

Reduced mass Reduced requirement

Efficient use Reduced work of organs

Body composition Physiological and

Infection Specific deficiency

• No. He was, but is

2- Active screening at community level

3- Passive screening at health centre level

3- Check for bilateral oedema and its degree

4- Classify according to the criteria of admission into

Screening is called passive when the patients present to

It should be routine in all hospitals &

Height-for-Age (HFA) reflects

MUAC < 11.5cm 11.5 ≤ MUAC <

W/H < -3 z- W/H ≥ -3&<-

SAM MAM No wasting

female male total

1- Shana, a girl of 63 cm length and 5.0 kg

2- Rico, a boy of 101cm height and 11.8 kg

3- Kareem, a boy of 82 cm length and 8.5 kg

2. Rico WfH between -4 Z and -3 Z score

3. Kareem, WfH = -3 Z score

Version 2018 _ based upon protocol version 6.6.4

ACTIVE OR PASSIVE SCREENING

W/H >-3 & W/H ≤ -3

Normal MAM SAM

Test appetite and Check for

Caretaker choice, Caretaker choice,

SC/IPF Out-patient treatment

2nd step, give water / sugar-water

3rd step, do the appetite test

4th step, check for complications using IMCI

Child nº MUAC (mm) Weight (kg.g) Height/length(cm.mm)

Thus - Even a 15% reduction in appetite can lead to

•Directly from the sachet