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Nutrition Manual
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OUR MISSION
Relief International is a humanitarian non-profit agency that provides emergency relief, rehabilitation,
development assistance, and program services to vulnerable communities worldwide. Relief
International is solely dedicated to reducing human suffering and is non-political and non-sectarian in its
mission. Relief International's mission is to:
Serve the needs of the most vulnerable - particularly women and children, victims of natural
disasters & civil conflicts, and the poor - with a specific focus on neglected groups and cases.
Provide holistic, multi-sectoral, sustainable, and pro-poor programs that bridge emergency relief
and long-term development at the grassroots level.
Empower communities by building capacity and by maximizing local resources in both program
design and implementation.
Promote self-reliance, peaceful coexistence, and reintegration of marginalized communities.
Protect lives from physical injury or death and/or psychological trauma where present.
Uphold the highest professional norms in program delivery, including accountability to
beneficiaries and donors alike.
_____________________________________________________
OUR PHILOSOPHY
RI dedicates itself to seeking and addressing
the long-term developmental needs of its
beneficiaries even while in the emergency
phase. The agency recognizes that disasters
have the most negative impact on the lives of
the poor; yet disasters, and especially the
movement of the populations, can also bring
about unexpected, positive social change. This
context can therefore serve as a window of
opportunity for eradicating poverty and social
injustice.
Relief International focuses on serving people
who typically have not received due attention,
and in several large-scale crises Relief
International has been the first US-based
agency to provide high-impact development
emergency programming to communities in
need. Relief International believes that as a
humanitarian agency one of its main functions
is to communicate the pronounced needs of the
vulnerable and affected populations to the
international community. Relief International
thus consults closely with the local communities
it serves in order to ensure that its programs do
not impose solutions from the outside but rather
address their needs and requirements for the
long term. This grassroots approach proves
effective in fostering an environment of self-help
and sustainability.
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Table of Contents
A. Abbreviations and Acronyms
B. Introduction
C. Part I: Setting Up a Nutrition Clinic
a. Site Selection
b. Layout
c. Logistics and Special Notes
d. Supplies and Drug List
D. Part II. Admission Criteria/Triage
a. Initial Assessment for both TFC and SFC
b. MUAC Procedures
c. Weight and Height Measurements
d. Signs and Symptoms of Malnutrition
E. Part II: Therapeutic Feeding Centers
a. Phase I
b. Treatment of Complications
c. Transition Phase
d. Phase II or Rapid Weight Gain Phase
e. Phase III or Consolidation Phase
f. Discharge
g. Special Notes for Children under 6 Months
h. Special Notes for Children over 6 Months and under 3kg
F. Part III: Supplementary Feeding Centers
a. TFC Follow Up
b. OTP?
c. Referral Guidelines (same as admission to TFC?)
G. Appendix
a. Quick Reference Tables
b. Forms
c. Checklists
d. References and Additional Resources
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Abbreviations and Acronyms
BMI Body Mass Index
CMAM Community Management of Acute Malnutrition
CMR Crude Mortality Rate
CMV Complex Minerals and Vitamins
CSB Corn Soy Blend
MUAC Mid-Upper Arm Circumference
NGF Naso-Gastric Feeding
ORS Oral Rehydration Salts
OTP Outpatient Treatment Program
ReSoMal Oral Rehydration Solution for severely malnourished patients
SC Stabilization Center
SFC Supplementary Feeding Center
TFC Therapeutic Feeding Center
W/H Weight to Height (%)
W/L Weight for Length (%)
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Introduction
Relief International (RI) is a humanitarian, non-profit, non-sectarian agency that provides emergency
relief, rehabilitation, and development interventions throughout the world. Since 1990, RI’s programs
have linked immediate emergency assistance with long-term economic and livelihood development
through innovative programming at the grassroots level. RI programs—in more than 25 countries
around the world—address a wide range of development issues, including livelihoods, local economic
development, emergency relief, conflict resolution, and education, training and youth initiatives.
From the earliest stage of intervention, RI’s
response activities are designed to help
communities transition from urgent relief to
long-term development for maximum
community impact. For over 20 years, RI has
been implementing these disaster relief and
development assistance projects in
demanding environments across the world,
resulting in the capacity to rapidly respond to
emergencies, as well as an ability to adapt
programs to changing and complex
environments.
Nutrition is a crucial component of health in vulnerable populations. Malnutrition and related disorders
can be caused by a variety of factors including poor agricultural yields, inability to purchase food,
political and economic instability, and other social factors. Severe acute malnutrition is caused by a
significant imbalance between nutritional intake and individual needs. It is most often caused by both
quantitative and qualitative deficiencies. Malnutrition and especially severe acute malnutrition can
rapidly lead to death if left untreated because malnutrition provokes severe physiological disorders and
suppression of the immune system.
This manual covers the basic setup of an emergency nutrition program and establishes standard
nutritional protocols to track a beneficiary from arrival at the health post to admission to discharge and
finally to follow-up. We focus on Therapeutic and Supplemental Feeding Centers and standard
protocols for admission and treatment. Often the beneficiaries of such a program will be refugees or
internally displaced persons. Some special considerations for these populations include the cause of
their migration—it may be caused by food shortage or another factor, access to food based on their
relationship with the local population, and expectations of potential repatriation.
It should be note that the goal of any emergency nutrition program is to provide immediate relief and
assistance, but also to facilitate the implementation of long-term, sustainable solutions within the
community.
_____________________________________________________
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Site Selection
[Info from other manuals]
Note: Ideally, camps and clinics are set up in areas with a slight incline so that rainwater will
not pool, however this will not be as relevant in areas of drought or low rainfall.
I. Layout When establishing a system for patient flow, the goal is to create an efficient, logical environment for both patients and staff. During examinations, patients should be provided with a covered area for privacy. The typical progression includes: 1. Patient registration 2. Triage/Nutritional Screening 3. Exam Table for Nurse Dressing and Vitals 4. Exam Table for Doctor 5. Dispensary/Drug Table [Get info from Jamila] Example of Efficient Patient Flow
Add a shaded table to hand out time cards/tokens; or add an exit from the Nutrition/Triage area so that
people can leave then return through the Entrance when it is their time
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OTP CHECKLIST FOR SET UP:
RUTF (average 20 sachets/child/week) 1 box of 150 sachets per 7 children
ROUTINE MEDICINES Amoxycillin, fansidar, folic acid, vitamin A, mebendazole
SUPPLEMENTAL MEDICINES (see OTP checklist) esp. ReSoMal, metrondiazole, chloramphenicol, paracetemol (paediatric)
EQUIPMENT (see list) Thermometers, centigrade x 6 Watches/small clock with second hand (per nurse for counting respirations)
OTP CARDS (see templates) x 500 of each OTP BENEFICIARY CARD: A4, coloured, double-sided, card OTP RATION CARD: coloured card
ID BRACELETS Different colour to SFP, usually red
OTP PROTOCOLS will follow when do set up at least 1 set per nurse or 8-10 sets in total
BASIC STATIONERY (see OTP checklist) 1 box folder per distribution site plus file dividers Clear plastic envelopes for OTP cards Basic stationery – see list
STABILISATION CENTRE / PHASE I TFC CHECKLIST: F75 RUTF ROUTINE MEDICINES – as for OTP SUPPLEMENTAL MEDICINES – as for OTP ADDITIONAL INJECTABLES AND EQUIPMENT – see list SC INPATIENT CARD – use current card or one available if needed MATS, COOKING EQUIPMENT, CUPS ETC
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AVERAGE STAFFING REQUIREMENTS:
MOBILE TEAMS Number depends on number of distribution sites – usually 2 teams, each team covering 4-5 sites The following is staffing for OTP only – assuming SFP teams already exist (with SCF-US or GOAL)
OTP 2 nurses 1 assistant / translator / educator 1 assistant (to help SFP team with weighing and measuring) 1 outreach worker per kebele (see below)
SFP (if not already in place) usually 7-8 people 1 team leader 1 nurse 1 registrar 2 measurers (weight and height) 1 educator (1 screener) 1 person to distribute Premix
OUTREACH 1 outreach Worker per kebele
STABILISATION CENTRE (minimum per working shift) 1-2 nurses (dependent on beneficiary numbers) 1-2 feeding attendant 1 cleaner and 1 cook (boiling water/making milk, caretaker meals etc)
DISTRIBUTION SCHEDULE: OTP takes place at every SFP site OTP takes place on a weekly basis (SFP can be a fortnightly basis) Good to avoid changing day of distribution once established Majority of children enter OTP directly; those who are sick or no appetite referred to Stabilisation
Centre
SENSITISATION / COORDINATION (pre set up): National, regional, zonal/district, woreda levels UNICEF, WFP Other NGOs in area Local chiefs, leaders, community structures
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II. Logistics and Special Notes
Waiting Areas It is important to establish a shaded seating area for beneficiaries and caregivers to wait under. Just because they live in a warm climate does not mean they are accustomed to sitting or standing in the sun for long periods of time. They may have been walking for long periods of time, so drinking water should also be available at all times.
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Assigning Appointment Times Upon arrival, each party should receive a colored and numbered card or token indicating when they should return for treatment. This will allow them to leave and come back at their assigned time slot so they will not need to wait all day. Not all beneficiaries will be literate, so this should be explained to each party at the time they are given the card or token. The information may also be posted
outside of the health facility. (Can also use Call to Prayer, Meal times, etc to mark times.)
RED – Return at 9am
GREEN – Return at 10am
BLUE – Return at 11am
YELLOW – Return at Noon
III. Supplies and Drug List [RI List of Supplies and Essential Drug List Nutrition Specific!]
- RI Storage and Inventory Protocols (In Appendix?)
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General Progression of Patient:
Arrival at Clinic
Fill out Registration Card
Anthropometric Measurements
Height
Weight
MUAC (under 10)
Age
BMI (Adults) Diagnosis/Treatment
Assignment
Admit to TFC Admit to SFC General OTP General Distribution
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Admission Criteria
Note: The management of severe malnutrition for infants under 6 months and low weight infant is explained at the end of section II. Arrival:
- Receive soap, water, etc… Upon arrival to the feeding center, pregnant or lactating mothers and children should be examined for signs of malnutrition in a triage area. They should have access to water and shade during this time. Staff will weigh and measure beneficiaries and then they will be admitted to a program based on the following criteria:
Children and adolescents, from 6 months to 18 years: Bilateral oedema
And/or weight for height percentage < 70
And/or MUAC < 110 mm for the above 1 year or for a height > 75 cm child.
Adults1 over 18 years: Bilateral oedema
And/or BMI2 < 16
And/or inability to move / to stand up alone. In order to speed up the admission process, identify patients showing signs whose state is critical:
Rapid triage using MUAC measurements for children.
Clinical diagnosis of people showing signs of critical nutritional status and / or obvious illness, including kwashiorkor, marasmus, dehydration, septic shock, loss of consciousness, or other medical emergency.
1 A proper medical examination has to be done in order to diagnose pathologies that are not manageable in TFC followed by a
referral to the appropriate structure if needed. 2 These criteria may have to be adapted to the general situation.
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Images: Testing for Bilateral Oedema
Acute malnutrition is treated differently depending on the severity and whether or not it is accompanied
by other medical complications. The condition will determine whether the patient is admitted to TFC,
OTP, or SFC.
As soon as somebody reaches one of the above criteria, he/she must be admitted. An identification
bracelet must be provided for each beneficiary with his/her name and admission number. A
Therapeutic chart must also be prepared and must be legible. Bracelets may be different colors to
distinguish between TFC, SFC, and OTP patients. Matching bracelet for caretaker?
Overall, each beneficiary is admitted with an adult caretaker preferably the mother. When we cannot do otherwise, an extra child can be allowed to stay within the centre as long as he is suckling or he cannot stay by himself. The caretaker must be briefed on the TFC’s organization and must adhere to the rules. The registrars are in charge of ensuring that all information is passed onto the caretaker.
(For more notes on Caretakers see ___)
Drinking water must be available at all times in the registration room for caretakers and extra children. Patients who do not appear to be in urgent medical emergencies should go through normal procedures for admission.
Acute Malnutrition
Severe acute malnutrition
with medical complications
Therapeutic Feeding (Part II)
Severe acute malnutrition
without medical complications
Outpatient Care (OTP?)
Moderate acute malnutrition
without medical complications
Supplementary Feeding (Part III)
[Example of ID Bracelets]
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Overview of Admission Criteria:
Admission
In SFC
Admission
In TFC
Children from 6 months to 10
years (or from 65 to 130
cm)
W/H , 80% of the median
And /or MUAC < 125 mm
W/H < 70% of the median
and/or Presence of bilateral pitting oedema
and/or MUAC < 110 mm
Adolescents from 10 to 18 years
(> 130 cm)
W/H < 80% of the median
And / or MUAC : not to do , mistakes
are common
W/H < 70% of the median
and/or Presence of bilateral pitting oedema
Adults (except pregnant and
lactating women)
MUAC : 160 185 mm
MUAC < 160 mm
or Presence of bilateral pitting oedema (Grade
3 or worse) 1
or
MUAC < 185 mm and poor clinical condition (Inability to stand, apparent dehydration etc.)
Pregnant and lactating women
MUAC : 170 185 mm
Rem/ at risk of malnutrition 185 210 mm
MUAC < 170 mm
and/or Presence of bilateral pitting oedema (Grade
3 and above) 1
Elderly
( 50-60 years) MUAC : 160 175 mm
MUAC < 160 mm
and poor clinical condition (Inability to stand, apparent dehydration etc.)
and/or Presence of bilateral pitting oedema (Grade
3 or worse) 1
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Weight to Height Measurement Procedures
- Best Weight and Height Method for Infants
- Best Weight and Height Method for Children
- Best Weight and Height Method for Adults
Weight / Height Severe
malnutrition
Moderate
malnutrition
Global
malnutrition
At risk of
malnutrition
Children
6 months 59 months
(5 years)
and/or
65 cm 130 cm of height
< 70 % of
median
< 80% 70 % of
median
< 80% of
median
Adolescent < 70 % of
median
< 80% 70 % of
median
< 80% of
median
Pregnant and Lactating
Women NO NO NO NO
Adults NO NO NO NO
Elderly NO NO NO NO
**See Appendix for detailed Weight-to-Height Charts for Boys and Girls and to determine the
percentage of the median.
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MUAC (Mid-Upper Arm Circumference) Procedures
MUAC is a quick and simple way to determine whether or not a child is malnourished using a simple colored plastic strip. MUAC is suitable to use on children from the age of 12 months up to the age of 59
months. However, it can also be used for children over six months with length above 65 cm.
Steps for taking the MUAC measurement of a child:
1. Determine the mid-point between the elbow and the shoulder (acromion and olecranon) as shown on the picture below.
2. Place the tape measure around the LEFT arm (the arm should be relaxed and hang down the side of the body).
3. Measure the MUAC while ensuring that the tape neither pinches the arm nor is left loose. 4. Read the measurement from the window of the tape or from the tape. 5. Record the MUAC to the nearest 0.1 cm or 1mm.
MUAC Severe
malnutrition
Moderate
malnutrition
Global
malnutrition
At risk of
malnutrition
Children
6 - 59 months and/or
65 - 130 cm of height
< 110 mm 110 125 mm < 125 mm <135 mm
Adolescents (up to 18 years) < 110 mm 110 125 mm < 125 mm <135 mm
Pregnant and Lactating Women < 170 mm 170185 mm < 185 mm 185 210 mm
Adults < 160 mm 160 185 mm < 185 mm
Elderly < 160 mm 160 175 mm < 175 mm
Results:
RED: Patient is Severely Malnourished
ORANGE: Patient is Moderately
Malnourished (Used in RI?)
YELLOW: Patient is At Risk of Malnutrition
GREEN: Patient is Properly Nourished
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Physical Manifestations of Malnutrition [Pictures?]
Wasting is a condition that reflects a recent weight loss or a failure to gain weight as a result of acute
malnutrition. It is a reversible condition that is most prevalent in children ages 12-24 months when
dietary deficiencies and diarrhea are more frequent. You cannot tell if a child is wasted just by looking
at his or her face, but instead must look at the body to diagnose.
Stunting, on the other hand, is a result of chronic malnutrition and is manifest in a height deficit when
compared to standard heights for a particular age group. Stunting is a slow process that develops over
time and it is nonreversible—it has already had an impact on the child’s height potential. It’s prevalence
increases with age, but is highest in children between 24-36 months. Stunting is a consequence of
poor social conditions or repeated exposure to diseases.
Marasmus and Kwashiorkor are both classified as forms of Protein Energy Malnutrition (PEM). The
type of PEM depends on diet and balance of proteins. Marasmus is characterized by gross muscle
wasting, extremely low weight, hunger, no fat under the skin, and sagging skin. Hair should appear
normal. Treatment?
Kwashiorkor is typically characterized by the presence of oedema, bleached hair, and skin lesions. It
is often preceded by measles. Kwashiorkor often accompanies mild anaemia, apathy, low weight, loss
of appetite, thin upper arms, and oedema. Oedemas can be tested for by pressing a finger onto the
swollen area, most often the feet. With oedemas, the affected skin may become very thin and atrophic
with many fine wrinkles. After the oedema has gone away, the skin may appear stretched and too
large. DO NOT give a child with Kwashiorkor too much protein. Their liver has lost much of its function
and will need to be slowly rehabilitated. The large stomach often seen in children with Kwashiorkor is
typically due to a buildup of fat in the liver.
Skin will become darker and then dry, then affected areas will start to crack and peel off to leave pale,
atrophic skin which can be very painful. The lesions typically have no redness, swelling, heat, or pain
even though they are often infected with bacteria because the inflammatory and immune systems are
too weak to respond. Lesions should be treated with the area exposed.
Hair is often a good indicator of nutritional deficiencies, especially for kwashiorkor. Affected hair may
become straight and discolored. Hair growing from the scalp may be white; however this is different
than blond hair. Blonde hair has no prognostic significance, although anemia is common. The ease at
which hair is pulled out is also a good measure of the reduction of protein synthesis and is a useful
sign. Eyelashes may grow to be very long. Fine, downy hair, also known as Lanugo may also be
present in malnourished patients.
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Diarrhea is also a feature of malnutrition. It usually occurs in multiple small green, mucoid stools.
Unlike in proficiently nourished patients, counting of stools... In malnutrition, orange stools can be
oxidized in exposure to the atmosphere and will turn green.
Eyes can reveal a lot in both malnutrition and dehydration. Lid retraction occurs only in true
dehydration, hypoglycaemia, anxiety, anger, etc and is due to activity of the sympathetic nervous
system.
In some areas families may prefer to try traditional medicine before seeking treatment at a medical
facility. If a patient arrives with several signs of traditional healing, it is often a bad sign because they
have come to you as a last resort.
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Overview of Methods for Anthropometric Measures
Method Uses Advantages Disadvantages Common
Thresholds
MUAC Detect wasting and acute malnutrition
Assess risk of death; does not depend on age; rapid, simple, no cumbersome
equipment
Risk of measurement error; lack of agreement on thresholds; does not
take oedemas and dehydration into account
<135 mm: at risk
3Z to < -2Z or 110 to < 125 mm: moderate
malnutrition
<-3Z or <110 mm: severe malnutrition high risk of mortality
Weight-
Height Detect Wasting and acute malnutrition
Does not depend on age
2 measurements needed; ratio is changed by
oedemas and dehydration; no
information on past nutritional status
-3Z to < -2Z or 70% to < 80%:
moderate malnutrition
<-3Z or <70%: severe malnutrition
Weight-Age
Detects a combination of stunting and
wasting, and acute and chronic malnutrition
Used extensively throughout the
world; Height not needed (difficult);
Interesting for monitoring individual
development
Requires age; Confusion in interpreting the
influence of acute and chronic malnutrition;
Oedemas and dehydration modify weight
-3Z to < -2Z or 60% to < 75%: moderate
malnutrition
<-3Z or <60%: severe
Height-Age Detects stunting and chronic malnutrition
Measurements unchanged by acute
malnutrition or by presence of oedemas;
dehydration does not change measures
Need to know age; Measuring height is technically difficult;
Provides no info on the presence of acute
malnutrition
-3Z to < -2Z or 80% to < 90%: moderate
malnutrition
<-3Z or <80%: severe malnutrition
Body Mass
Index (BMI)
Used for nutritional assessment in
adults; increasingly used for population
references
Not always accurate; Does not take muscle
mass into account
17-18: At-risk >= 16: malnutrition
Example: An adult female comes into your clinic weighing 49 kg and measuring 1.75m in height.
Is this patient malnourished?
Weight (kg) 49 kg BMI = ------------------ = ------------- = 15.8 or <16
(height)2 m (1.75)2
YES, this patient has a BMI below the
threshold and shows signs of malnutrition.
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DIAGNOSING MEDICAL EMERGENCY [Move to a different section?]
Patients in need of being admitted urgently must be diagnosed quickly and proper treatment must start
as soon as possible.
The conditions considered to be medical emergencies are:
Hypoglycemia
Hypothermia
Acute dehydration
Septic shock
Serious infection (hyperpyrexia)
Cardiac failure
Severe anaemia
Steps for Urgent Diagnosis of Medical Emergnecies:
1. Assess consciousness level in prostrate patients - Response to verbal stimulation - Response to touch: a look, smile, weeping…
6. Refer to Diagnosis and Treatment of Complications for
management of such cases.
5. Check for signs of serious dehydration or septic shock
4. Check for signs of hypothermia or hyperpyrexia - Take the body temperature
3. Check for signs of serious cardiovascular disorder: - Take the radial or jugular pulse (rapid, irregular) - Assess the peripheral circulation by checking how quickly
colors return to skin - Take the blood pressure
2. If there is no response:
- Response to painful stimulation
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Introduction:
Therapeutic Feeding Centers (TFC) involve inpatient care for patients with severe acute malnutrition
and other medical complications. These complications include …[Guidelines] TF is broken down into
phases:
1. Phase I or Initial Phase
2. Transition Phase
3. Phase II or Rapid Weight Gain Phase
4. Phase III or Consolidation Phase
5. Discharge and Follow-Up in SFC
Each Phase has particular guidelines for nutritional treatment, systematic medical treatment, specific
medical treatment, and evaluation. All TFC Patients will be followed up at Supplementary Feeding
Centers discussed in Part III.
Goals of TFC:
Recognize and properly diagnose the signs and symptoms of severe acute malnutrition and
related conditions.
Provide the appropriate life-saving treatment to each case
Upgrade the condition of each patient so they can eventually graduate to an outpatient
Supplemental Feeding Center.
The objective of a Therapeutic Feeding Programme (TFP) is to reduce mortality among severely
malnourished patients by providing intensive care until their recovery.
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1 packet
of F-75
premix
2 Liters of Water
2.4 Liters of F-75
Phase I or Initial Phase
In this phase, the vital problems are identified and treated, the deficiencies are corrected, the basic
metabolism is restored and the pathologies are treated.
It is important that the feedings:
Are liquid to be easily consumed by patient, who is usually very weak and with poor appetite.
Are limited in quantity to simply cover basic physiological requirements.
Are given in small and frequent quantity to avoid or limit vomiting, to reduce the incident of diarrhoea and to avoid hypoglycaemia.
Occur as soon as possible after admission. _________________________________________________________
A. Nutritional treatment
The milk to be use is F-75 (130ml = 100kcal). F-75 contains _______ and its purpose is to acclimate
patients with severe acute malnutrition to a normal level of nutrients. Amounts to be given are shown
below according to the age category:
F-75 Energy density: 75 kcal / 100 ml
AGE CATEGORY Amount (ml / kg of body weight / day)
Energy (Kcal / Kg of body weight / day)
6 months to 10 years 130 100
10 to 18 years 65 50
18 to 75 years 55 40
> 75 years 45 35
Preparation of F-75:
Always dilute with perfectly clean water. Once reconstituted the milk should be used within 2 hours. It should be kept in its original packaging. Once opened, the contents of a sachet must be entirely used up immediately. Destroy milk powder if the color or the smell or the aspect of the milk has changed, even if the expiry date is not yet reached, since there is a risk of organoleptic change of the product.
Added to Yields
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The quantity of milk to be given is calculated on the exact weight of each beneficiary. Meaning it
has to be adapted on daily basis and it is given in 8 meals per day, every 3 hours; spoon-
feeding is prohibited.
Breast-fed children should be offered breast-milk before the feedings and always on demand.
Source: Quantity of milk to be given per feed per 24h per Class of Weight. © M.Golden
Weight
Category (kg)
Daily amount
(ml)
Quantity in ml
8 meals per day
2.0 to 2.1 320 40
2.2 to 2.4 360 45
2.5 to 2.7 400 50
2.8 to 2.9 440 55
3.0 to 3.4 480 60
3.5 to 3.9 520 65
4.0 to 4.4 560 70
4.5 to 4.9 640 80
5.0 to 5.4 720 90
5.5 to 5.9 800 100
6.0 to 6.9 880 110
7.0 to 7.9 1000 125
8.0 to 8.9 1120 140
9.0 to 9.9 1240 155
10.0 to 10.9 1360 170
11.0 to 11.9 1520 190
12.0 to 12.9 1640 205
13 to 13.9 1840 230
14.0 to 14.9 2000 250
15.0 to 19.9 2080 260
20.0 to 24.9 2320 290
25 to 29.9 2400 300
30 to 39.9 2560 320
40 to 60 2800 350
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PHASE 1 FEEDINGS TIMETABLE
AM AM PM PM PM PM PM AM
7.00 10.00 01.00 04.00 06.00 08.00 10.00 01.00
Each feeding must be monitored properly by experienced staff. The quantity eaten by the beneficiary
has to be written down on the chart by shading the appropriate part, as well if the beneficiary vomits part of the milk or refusing to eat. The nurse on duty has to be informed [Include feeding chart]
B. Medical treatment
1. Systematic Treatment during Phase I
Age or weight category Dose
VITAMINS
Vitamin A
6 months to 1 year 100 000 IU
> 1 year 200 000 IU
Pregnant and bearing age women
None
At the admission and the following day Folic acid Every category 5 mg
Single dose at the admission
ANTIBIOTICS
Amoxicillin Every category 60 mg / kg / day
3 times a day throughout the entire phase
ANTIMALARIALS
Chloroquine Day 1 10 mg/ Kg
Day 2 10 mg / Kg
Day 3 5 mg / Kg
VACCINATIONS
Measles < 6 months Single vaccination at admission
6 months to 5 years One vaccination at admission
One vaccination at discharge
2. Specific Treatment
This treatment is prescribed according to the findings of the medical examination. Refer to the medical
protocol for specific treatment.
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DIAGNOSIS AND TREATMENT OF COMPLICATIONS*
*Adapted from Guidelines for the Management of Severe Acute Malnutrition, Ethiopia Ministry of Health, May 2004
A. HYPOGLYCEMIA All patients who are malnourished can develop hypoglycaemia but this is much less common than was formerly thought.
Diagnosis
One sign of hypoglycaemia is eye-lid retraction
– if a child sleeps with his eyes slightly open,
then he should be woken up and given sugar
solution to drink.
Prevention
Usually by the time when the beneficiaries
reach the TFC they have not eaten for several
hours. As soon as they are admitted they
should received sugared water supplemented
with CMV in the proportion of 5 ml / kg / hour.
Beneficiary with weigh less than 10 kg should
receive 50 ml per hour.
The aim is to minimize the risk of
hypoglycaemia.
Preparation of the sugar water Preparation of the CMV mother solution
1 litre of clean and safe water 50 g of sugar 2 ml of mother solution of CMV
Sugar water has an energy density of 200
kcal / litre.
20 ml of clean and safe water 6.5 g (1 red scoop) of CMV
Treatment
- All malnourished patients with suspected
hypoglycaemia should be treated with
second-line antibiotics.
- Patients who are conscious and able to
drink should be given a 50ml (5-10ml per
kg) of sugar water, or F75 (or F100 if
appropriate) by mouth.
- Patients losing consciousness should be
given 50ml (or 5-10ml per kg) of sugar
water by Naso-gastric tube immediately.
When consciousness is regained give milk
feed frequently.
- Unconscious patients should also be given
sugar water by naso-gastric tube. They
should also be given glucose as a single
intravenous injection (approx. 5ml/kg of
sterile 10% glucose solution).
_______________________________________________
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B. HYPOTHERMIA
Diagnosis
Severely malnourished patients are highly
susceptible to hypothermia. This is defined as a
rectal temperature below C or under arm
temperature below 35 C.
Treatment
- For children with a caretaker, use the
“kangaroo technique”
- Put a hat on the child and wrap caretaker
and child together.
- Give hot drinks to the mother so her skin
gets warmer (plain water, tea, or other hot
drink).
- Monitor body temperature during re-
warming
- The room should be kept warm, especially
at night (28 C-32 C): a minimum-maximum
thermometer should be on the wall during
Phase 1 to monitor the temperature.
- Treat for hypoglycaemia and give second-
line antibiotics.
Note: the thermo-neutral temperature range
28 C-32 C. Children should always sleep with
their mothers/caretakers and not in traditional
hospital child-cots. There should be adequate
blankets and a thick sleeping mat or adult bed.
Most heat is lost through the head; hats should
be worn by malnourished children. Windows
and doors should be kept closed at night.
_______________________________________________
A. DEHYDRATION
Dehydration and septic shock are both difficult
to diagnose and also to differentiate from the
other in severely malnourished patients.
Misdiagnosis and inappropriate treatment
for dehydration is the most common cause
of death in malnourished patients. IV
infusions are rarely used. In malnutrition there
is a particular renal problem that makes the
children sensitive to salt (sodium) overload.
The standard protocol for the well-nourished
dehydrated child should not be used.
A bucket of modified Oral Rehydration Solution
(ORS) or ReSoMal should never freely be
available to caretakers to take for their children
whenever they have a loose stool. Although it
is a common practice, it is very dangerous.
This can lead to failure to lose oedema, re-
feeding oedema, heart failure, and failure to
record significant problems while the diet and
phase remains unchanged.
Diagnosis
Treatment
Whenever possible, a person with severe
malnutrition and dehydration should be re-
hydrated orally. Intra-venous infusions are very
dangerous and are not recommended unless
there is 1) severe shock with 2) loss of
consciousness from 3) confirmed rehydration.
BEFORE starting any rehydration treatment: a) MARK the edge of the liver and the
costal margin on the skin with a permanent marker.
b) RECORD the heart sounds (presence or absence of gallop rhythm) in the notes
c) RECORD the pulse rate in the notes d) WEIGH the child.
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The malnourished child is managed entirely by
a) Weight changes and b) Clinical signs of improvement and c) Clinical signs of over-hydration
FLUID BALANCE is measured at intervals by WEIGHING the child.
Give re-hydration fluid until the weight deficit (measured or estimated) is corrected.
Stop as soon as the child is “re-hydrated” to the target weight.
Additional fluid is not given to the malnourished child with a normal circulatory volume to “prevent” recurrence of dehydration.
A total of between 50 and 100 ml of ReSoMal per kg of body weight is usually more than enough to restore normal hydration. Give this amount over 12 hours starting with 5ml/kg every 30 minutes for the first two hours orally or by naso-gastric tube, and then 5 to 10ml/kg per hour. Weigh the child each hour and assess his/her liver size, respiration rate and pulse. After rehydration, for malnourished children from 6 to 24 months give 30ml of ReSoMal for each watery stool that is lost. As the child gains weight, during re-hydration there should be definite clinical improvement and the signs of dehydration should disappear.
Make a major reassessment at two hours. If there is continued weight loss then:
Increase the rate of administration of ReSoMal by 10ml/kg/hour
Formally reassess in one hour
Important Notes:
If there is no weight gain then:
Increase the rate of administration of ReSoMal by 5ml/kg/hour
Formally reassess in one hour If there is weight gain and:
Deterioration of the child’s condition with the re-hydration therapy, then the diagnosis of dehydration was definitely wrong. Even senior clinicians make mistakes in the diagnosis of dehydration in malnutrition. Stop and start the child on F75 diet.
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.
Clinical improvement, but there are still signs of dehydration then continue with the treatment until the appropriate weight gain has been achieved. Either continue with ReSoMal alone or F75 and ReSoMal can be alternated.
Resolution of the signs of dehydration, then stop re-hydration treatment and start the child on F75 diet.
During re-hydration breastfeeding should
not be interrupted. Begin to give F75 as soon as possible, orally or by naso-gastric tube. ReSoMal and F75 can be given in alternate hours if there is still some dehydration and continuing diarrhoea. Introduction of F75 is usually achieved within 2-3 hours of starting re-hydration.
- A patient who needs to be treated for dehydration using ReSoMal MUST goes back to phase 1 and follow up his/her liquid intake and the liquid losses established (as for any re-hydration). See the follow up form attached
- ReSoMal must not be used in any phase other than Phase I. - ReSoMal should only be used at admission of children with watery diarrhoea (see below). All
other children should receive water with sugar (the objective being to prevent hypoglycaemia, not to treat dehydration).
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- ReSoMal should no longer be given systematically at admission. - ReSoMal should therefore be used only for treatment of dehydration in case of watery diarrhoea
and / or vomiting. High fever will also increase the risk of dehydration (DHA). - ReSoMal dosage in case of DHA remains the same.
Differentiation of diarrhoea
WHO recommends conducting the evaluation of diarrhoea according to the number of stools per day. It
is not necessary to evaluate the quantity or the characteristics of the stool. This cannot be applied to
malnourished children in the TFC, because we are feeding them several times a day (up to 6 or 8
times),
IT IS NORMAL THAT MOST PATIENTS HAVE MORE THAN THREE OR FOUR STOOLS PER DAY
AT THE BEGINNING OF TREATMENT (especially small children and elders).
Therefore, diarrhoea must be properly checked (quantity and characteristics of the stools), below is a
proposed classification:
Watery diarrhoea: Stool like water and loss of weight = high risk of dehydration. This is the only case, which should be treated with ReSoMal. (Loss of weight being defined as a decrease in weight during the day after the routine daily weighing.)
Non watery diarrhoea: liquid stools, persistent, often but without loss of weight = non-watery diarrhoea.
No ReSoMal is needed as the risk of dehydration is very low, providing correct hydration.
Re-feeding diarrhoea: Semi-liquid stool without loss of weight. No need for re-hydration, but try to split
up the meal (i.e. smaller meals but more often).
In practice:
- ReSoMal should not be available in the phases, but kept in the pharmacy and used only for treatment.
However WATER must be available everywhere in the phases.
_______________________________________________
B. SEPTIC SHOCK
Diagnosis
Most of the signs of true dehydration are also
seen in septic shock. However, a careful
history and clinical examination can usually
lead to the correct diagnosis and appropriate
treatment.
To diagnose developed septic shock the signs
of hypovolaemic shock should be present:
A fast weak pulse with
Cold peripheries
Disturbed consciousness
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Treatment
All patients of incipient or developed septic
shock should immediately:
- Be given broad-spectrum antibiotics
(second- and first-line antibiotics together)
- Be kept warm to prevent or treat
hypothermia
- Receive sugar water by mouth or naso-
gastric tube as soon as the diagnosis is
made (to prevent hypoglycaemia.
Incipient septic shock: Give the standard F75
diet by naso-gastric tube
Developed septic shock: Give a slow IV
infusion with 15 ml/kg over the first hour of one
of the following solutions (in order of
preference) if patient is unconscious:
- Half-strength Darrow’s solution with 5%
glucose
- Ringer’s lactate solution with 5% glucose
- Half-normal (0.45%) saline with 5% glucose
If available, give a blood transfusion of no more
than 10ml/kg over at least 3 hours. Nothing
should be given orally during a blood
transfusion.
Monitor every 10 minutes for signs of
deterioration, especially over-hydration and
heart failure.
- Increasing respiratory rate
- Development of grunting respiration
- Increasing liver size
- Vein engorgement
As soon as the patient improves (stronger radial
pulse, regain consciousness) stop all IV intake
and continue with F75 diet.
_______________________________________________
C. MARASMUS
D. KWASHIORKOR
E. HEART FAILURE
F. SEVERE ANAEMIA
Severe anaemia, associated with Kwashiorkor
generally indicates a poor prognosis and it is
often difficult to know what to do in this case.
Similarly, an inappropriate treatment of
anaemia with transfusions has an even worse
prognosis!
It seems that many deaths could be due to undiagnosed heart failure when there is fluid overload due to giving excess oral rehydration fluid and of course during transfusion, in association with severe anaemia. Often flaring nostrils are perceived as a sign of respiratory distress due to anaemia, when it is in fact a sign of heart failure (overloading). The difference can be seen by the precise surveillance of the
weight. Other potential symptoms of fluid overload are enlargement of the liver, increase in central venous blood pressure (only when highly qualified staff is on duty).
It is important to differentiate the anaemia
existing AT admission (before the increase
of plasma volume) from the one that
develops because of a treatment. Due the
nutritional treatment (F75, F-100) the plasma
volume is increased, and any Hb
measurement can be “diluted”. This is why
the Haemoglobin level is a meaningful
measure only when measured within 48
hours after admission. The test done after
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these first 48 hours will not be valid to
diagnose anaemia.
If anaemia develops in the absence of
haemorrhage or jaundice, and particularly, if
this happens at the time of introduction of
F100. Then it is likely to be due to
haemodilution (and it should not be treated
by transfusion, but with a reduction of the
quantities of liquids and solutes offered to
the patient).
Summary:
If anaemia is to be treated by transfusion
(according to Hb level) it has to be done
within 48 hours after the admission. The main reason is that because of the nutritional treatment, the plasma volume increases. Therefore the Hb level drops (i.e. is diluted) and laboratory results after 48H will show a very low reading, and an inaccurate picture of anaemia will be given.
For Kwashiorkor, IV infusions should be avoided as much as possible for the same reasons (risks of overload and diagnostic mistakes are extremely high).
At any rate, even if the anaemia has been present since the beginning of the admission (the first
48 hours) the risk of a heart failure (overload) during transfusion is still very high. A decision to
transfuse should be taken with care and surveyed to the minute. Unfortunately, transfusions,
when available, often happen out of our control (in a Hospital, etc.), where follow-up is weak or
non-existent.
_________________________________________
MEDICAL EXAMINATION
The beneficiaries identified as emergency cases as describe in Part B should be treated in
priority.
1. Check the patient’s medical history
2. Conduct a proper clinical examination by using the special from, especially look for signs of
hypoglycaemia, Hypothermia , severe acute dehydration and septic shock, infection and
tuberculosis
3. Prescribe systematic treatment according to the protocol
4. Prescribe specific treatment according to the findings of the clinical exam and the complaint and
as explain in the medical protocol.
All the information MUST be written on the chart.
Diagnosis and Treatment of Complications
- Hypoglycaemia - Hypothermia - Dehydration and Septic Shock - Marasmus - Kwashiorkor
-
Both specific and medical treatment has to be recorded properly on the chart as well medical
examination findings.
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C. MONITORING AND FOLLOW UP OF THE NUTRITIONAL AND MEDICAL CONDITION
The initial phase of treatment is very critical for the beneficiary. A close follow up of each beneficiary is
necessary in order to monitor improvement or deterioration of the medical and nutritional condition and
to be able to take appropriate decision.
ACTION FREQUENCY
Palpation of oedema Every day
Weight measurement Every day
Height measurement The day following the admission
Temperature Twice a day
Clinical examination At least once a day
PROMOTION TO THE TRANSITION PHASE
Beneficiaries are transferred to the Transition Phase as soon as:
They recover the appetite. For Kwashiorkor oedema has started to decrease They are no longer fed via naso-gastric tub They are not seriously ill.
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TRANSITION PHASE
The transition phase has a specific number of days according to the status of the beneficiary at the admission. Length of stay: Marasmus = 2 days
Kwashiorkor = 4 days
The aim of this phase is to accustom the child to F-100.
A. NUTRITIONAL TREATMENT
The milk to be used is F-100 according to the age category and as described below. Beneficiaries
receive the same amount of milk as in Phase I, but will intake more energy from the F-100 milk.
F – 100 Energy density : 100 kcal / 100 ml
AGE CATEGORY Amount (ml / kg of body weight / day)
Energy (Kcal / Kg of body weight per day)
6 months to 10 years 130 135
10 to 18 years 65 65
18 to 75 years 55 55
> 75 years 45 45
The quantity of milk to be given is calculated on the exact weight of each beneficiary and is
given in 8 meals per day, one every 3 hours. Spoon-feeding is prohibited
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Source: Quantity of milk to be given per feed per 24h per Class of Weight. © M.Golden
Weight
Category (kg)
Daily amount
(ml)
Quantity in ml
8 meals per day
2.0 to 2.1 320 40
2.2 to 2.4 360 45
2.5 to 2.7 400 50
2.8 to 2.9 440 55
3.0 to 3.4 480 60
3.5 to 3.9 520 65
4.0 to 4.4 560 70
4.5 to 4.9 640 80
5.0 to 5.4 720 90
5.5 to 5.9 800 100
6.0 to 6.9 880 110
7.0 to 7.9 1000 125
8.0 to 8.9 1120 140
9.0 to 9.9 1240 155
10.0 to 10.9 1360 170
11.0 to 11.9 1520 190
12.0 to 12.9 1640 205
13 to 13.9 1840 230
14.0 to 14.9 2000 250
15.0 to 19.9 2080 260
20.0 to 24.9 2320 290
25 to 29.9 2400 300
30 to 39.9 2560 320
40 to 60 2800 350
TRANSITION PHASE – F100 – MEALS TIME TABLE
AM AM PM PM PM PM AM AM
7.00 10.00 01.00 04.00 06.00 08.00 10.00 01.00
As for Phase I, each feeding has to be monitored properly by experienced staff. The quantity eaten by
the beneficiary has to be written down on the chart by shading the appropriate part, as well if the beneficiary vomits part of the milk or refusing to eat. The nurse on duty has to be informed for each significant event.
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B. MEDICAL TREATMENT
1. Systematic treatment
ANTIBIOTIC Age category Dose
Amoxicillin Every category 60 mg / kg / day
3 times a day throughout the entire phase.
The length of the course should not exceed 10 days.
2. Specific treatment
This treatment is prescribed according to the findings of the medical examination. Refer to the medical
protocol for specific treatment.
If the nutritional or medical condition has deteriorated do not hesitate to demote the child to
Phase I.
Both specific and medical treatment has to be recorded properly on the chart as well medical
examination findings.
C. NUTRITIONAL AND MEDICAL FOLLOW UP OF THE BENEFICIARY’S CONDITION
ACTION FREQUENCY
Palpation of oedema Every day until they disappear
Weight measurement Every day
Height measurement The day of promotion
MUAC Measurement Once weekly
W/H and BMI Twice weekly
Temperature Twice a day
Clinical examination At least once a day
PROMOTION TO PHASE II or RAPID WEIGHT GAIN PHASE
After 4 days in the transition phase for kwashiorkor and 2 days for marasmus and as long as the
nutritional and medical conditions are satisfactory, patients may be promoted to Phase II.
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PHASE II or RAPID WEIGHT GAIN PHASE
During this phase, the beneficiary should gain weight rapidly. The risk of developing infections is less
compared to Phase I and Transition phase, but nevertheless regular clinical care is necessary.
Particular attention is needed for the first 3 days of this phase where the mortality rate seems to be still important. Duration: 15 – 20 days
A. NUTRITIONAL CARE
1. Therapeutic Milk
The milk to be used is F-100 according to the age category and as described below. Beneficiaries in
Phase II receive an increased amount of milk as their bodies are more used to the amount of nutrients
provided.
F – 100
Energy density : 100 kcal / 100 ml
AGE CATEGORY Amount
(ml / kg of body weight / day) Energy
(Kcal / Kg of body weight per day)
6 months to 10 years 200 200
10 to 18 years 100
100
18 to 75 years 80 80
> 75 years 70 70
The quantity of milk to be given is calculated by weight category as described below. (Source: Quantity
of milk to be given per feed per 24h per Class of Weight. © M.Golden)
For children « special cases » less than 3 Kg, please refer to the appropriate chapter
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Feeding Guidelines
Phase 2 More than 8 Kg
Phase 2 > = 3 kg to < 8 kg
Weight Category
Daily Amount (ml)
Porridge
RUTF
Milk
(5 meals)
Milk
(7 meals)
3 to 3.4 kg 660
Patients of this weight should
only be given Milk.
95
3.5 to 3.9 kg 720 105
4 to 4.4 kg 900 130
4.5 to 4.9 kg 900 130
5 to 5.4 kg 1080 155
5.5 to 5.9 kg 1080 155
6 to 6.9 kg 1260 180
7 to 7.9 kg 1440 205
8 to 8.9 kg 1620 kcal/ 1120 ml of milk 1 1 225
9 to 9.9 kg 1800 / 1500 ml 1 1 300
10 to 10.9 kg 1800 / 1500 1 1 300
11 to 11.9 kg 2100 / 1600 1 1 320
12 to 12.9 kg 2700 / 2200 1 1 440
13 to 13.9 kg 2700 / 2200 1 1 440
14 to 14.9 kg 2700 / 2200 1 1 440
15 to 19.9 kg 3300 /2800 1 1 560
20 to 24.9 kg 3900 / 3400 1 1 680
25 to 29.9 kg 4500 / 3500 1 2 700
30.0 to 30.9 kg 5100 / 3600 1 3 720
40 to 60 kg 6000 / 4500 1 3 900
2. Ready to Use Product (RTUP)
RUTF could be introduced in this phase to
replace one milk feeding preferably when the
beneficiary is above 2 years and has no
oedema.
RUTF is distributed in the Phase II. The
sachet is opened and given to the
beneficiary together with one cup of water.
Make sure that RUTF and water are not
mixed together in the cup. Water is given to
facilitate the absorption of RUTF as it is a thick food. Empty sachets have to be
collected at the end of the feeding.
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One sachet provides 500 kcal.
3. Porridge
Semi-liquid food (like porridge) is introduced for
the above 1 year. The porridge should provide
300 to 350 Kcal of which 10 % to 15 % are
provided as proteins and 30 to 35 % as lipids.
This porridge is enriched with CMV (vitamins
and minerals complex). The porridge to be
given is the same whatever the age or weight
category.
As for milk and RUTF, the quantity eaten has to
be recorded properly on the therapeutic chart
by shading.
ITEM QUANTITY
CSB 60 g Kcal 338 Kcal
OIL 10 g Proteins 12.8 %
SUGAR 5 g Lipids 36.2 %
CMV3 3.4 ml
4. Feeding time table
AM AM PM PM PM PM AM
07.00 10.00 01.00 04.00 07.00 10.00 01.00
Milk Milk Porridge or milk
Milk RUTF or
milk Milk Milk
Porridge and RUTF should never be given in the same time as milk.
3 The preparation of the mother solution is explain in the admission chapter. 20 ml CMV mother solution fortified 2000 Kcal.
The number of ml of mother solution to add has to be calculated accordingly.
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B. MEDICAL TREATMENT
1. Systematic treatment
Age Category Dose
Iron > 6 months 3 mg / kg / day
Throughout the whole phase diluted in F100 milk
ANTIBIOTIC
Amoxicillin Every category 60 mg / kg / day
3 time a day if it has not gone beyond 10 days.
TREATMENT TO ELIMINATE PARASITIC INFESTATION
Mebendazole
< 1 year None
1 to 2 years 250 mg
Single dose
2 years 500 mg
D1, D2, D3
Dilution of iron sulphate in HEM
At this stage, Iron sulphate is added to the F-100 milk [WHY?]
Number of F-100 sachets
Amount of water to be
added
Amount of F-100 milk obtained
Amount of elemental iron to be added
(mg)
Amount of iron sulphate tablets
to be added (tab)
1 2 2.4 36 ½
2 4 4.8 72 1
3 6 7.2 108 2
4 8 9.6 144 2 ½
5 10 12 180 3
6 12 14.4 216 3 ½
7 14 16.8 252 4
8 16 19.2 288 5
9 18 21.6 324 5 ½
10 20 24.0 360 6
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[Picture]
Procedure for Dilution: (Put Procedures and tables at the end of each chapter?)
1. Measure the water needed for the preparation of the milk 2. Prepare the number of tablets to be added in the F-100 according to the number of milk
sachets. Crush the tablets and mix it with a small quantity of water already measured for the preparation of F-100 milk.
3. Mix the crushed in water tablet with the total of water measured 4. Mix the F100 powder with the amount of water prepared.
3. Specific treatment
This treatment is prescribed according to the findings of the medical examination. Refer to the medical
protocol for specific treatment.
C. NUTRITIONAL AND MEDICAL FOLLOW UP
ACTION FREQUENCY
Palpation of oedema Every day until they
disappear
Weight measurement Every two days
In case of static or decreasing weight not due to
oedema the weight has to be check the following day
Height measurement Once weekly
MUAC Measurement Once weekly
W/H and BMI Twice weekly
Temperature At least once a day
Clinical examination At least every two days
If the nutritional or medical condition has deteriorated the child has to be demoted to Phase 1 or
Transition Phase. The decision has to be made by the SECHN, the supervisor or the expatriate
in charge after proper checking.S
PROMOTION TO PHASE III or CONSOLIDATION PHASE
W/H > or = 85 % No oedema since 2 to 3 days Oedema have started to subside since 15 days
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PHASE III or CONSOLIDATION PHASE
The aim of this phase is to prepare for the discharge of the beneficiary. Discharged beneficiaries will
be referred to the Supplemental Feeding Centers (SFC).
Duration: 3 days to one week
A. NUTRITIONAL TREATMENT
1. Therapeutic Milk
As for phase II the milk to be used is F-100 according to the age category and as described below:
F – 100 Energy density : 100 kcal / 100 ml
AGE CATEGORY Amount
(ml / kg of body weight / day) Energy
(Kcal / Kg of body weight per day)
6 months to 10 years 200 200
10 to 18 years 100 100
18 to 75 years 80 80
> 75 years 70 70
The quantity of milk to be given is calculated by weight category.
2. Ready-to-Use Therapeutic Food (RUTF)
If RUTF has been introduced to the patient it should continue to replace one milk feeding if the
beneficiary is above 2 years and has no oedema.
RUTF is distributed in the Phase II. The sachet is opened and given to the beneficiary together with one
cup of water. Make sure that RUTF and water are not mixed together in the cup. Water is given to
facilitate the absorption of RUTF as it is a thick food. Empty sachets have to be collected at the end of
the feeding.
One sachet provides 500 kcal.
3. Porridge Corn-Soy Blend (CSB) porridge is continued for the above 1 year. The porridge should provide 300 to
350 Kcal of which 10 % to 15 % are provided as proteins and 30 to 35 % as lipids. The porridge to be
given is the same whatever the age or weight category.
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ITEM QUANTITY
CSB 60 g Kcal 338 Kcal
OIL 10 g Proteins 12.8 %
SUGAR 5 g Lipids 36.2 %
CMV4 3.4 ml
4. Feeding time table
Feeding Guidelines for Phase III
4 The preparation of the mother solution is explain in the admission chapter. 20 ml CMV mother solution fortified 2000 Kcal.
The number of ml of mother solution to add has to be calculated accordingly.
PHASE III FEEDING TIME TABLE
AM AM PM PM PM PM AM
07.00 10.00 01.00 04.00 06.00 08.00 10.00
Milk Milk Porridge Family meal
or milk Milk
RUTF or
milk Milk
Phase 3
More than 8 Kg
Phase 3
> = 3 kg to < 8 kg
Weight Category Daily Amount
(ml) Porridge
Family
meal RUTF
Milk
(4 meals)
Milk
(6 meals) Porridge
3 to 3.4 kg 660
Patients of this weight should only be
given milk.
110 If > 6 months
3.5 to 3.9 kg 720 120 If > 6 months
4 to 4.4 kg 900 150 If > 6 months
4.5 to 4.9 kg 900 150 If > 6 months
5 to 5.4 kg 1080 180 If > 6 months
5.5 to 5.9 kg 1080 180 If > 6 months
6 to 6.9 kg 1260 210 If > 6 months
7 to 7.9 kg 1440 240 If > 6 months
8 to 8.9 kg 1620 kcal/ 1120
ml of milk 1 1 1 280
1
9 to 9.9 kg 1800 / 1500 ml 1 1 1 375 1
10 to 10.9 kg 1800 / 1500 1 1 1 375 1
11 to 11.9 kg 2100 / 1600 1 1 1 400 1
12 to 12.9 kg 2700 / 2200 1 1 1 550 1
13 to 13.9 kg 2700 / 2200 1 1 1 550 1
14 to 14.9 kg 2700 / 2200 1 1 1 550 1
15 to 19.9 kg 3300 /2800 1 1 1 700 1
20 to 24.9 kg 3900 / 3400 1 1 1 850 1
25 to 29.9 kg 4500 / 3500 1 1 2 875 1
30.0 to 30.9 kg 5100 / 3600 1 1 3 900 1
40 to 60 kg 6000 / 4500 1 1 3 1125 1
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B. MEDICAL TREATMENT
1. Systematic treatment during Phase III:
Age Category Dose
Iron > 6 months 3 mg / kg / day
Throughout the whole phase diluted in F100 milk
Dilution of iron sulphate in Therapeutic milk (HEM)
Number of F-100 sachets
Amount of water to be
added
Amount of F-100 milk obtained
Amount of iron sulphate tablets
to be added
1 2 2.4 ½
2 4 4.8 1
3 6 7.2 2
4 8 9.6 2 ½
5 10 12 3
6 12 14.4 3 ½
7 14 16.8 4
8 16 19.2 5
9 18 21.6 5 ½
10 20 24.0 6
Procedure for Dilution:
1. Measure the water needed for the preparation of the milk 2. Prepare the number of tablets to be added in the F-100 according to the number of milk
sachets. Crush the tablets and mix it with a small quantity of water already measured for the preparation of F-100 milk.
3. Mix the crushed in water tablet with the total of water measured 4. Mix the F100 powder with the amount of water prepared.
3. Specific treatment According to the clinical exam and the prescription
C. MEDICAL AND NUTRITIONAL FOLLOW UP
ACTION FREQUENCY
Weight measurement Twice Weekly
MUAC Measurement Once weekly
W/H and BMI Twice weekly
Temperature At least once a day
Clinical examination At least twice a week
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DISCHARGE
A. CRITERIA
Children and adolescents (6 months to 18 years) W/H > 85 %
And MUAC >= 120 mm
And no bilateral oedema for at least 15 days.
And absence of medical problem.
Adults BMI > 17.5
And no bilateral oedema for at least 15 days
And ascending weight curve
And absence of medical problem
Beneficiary should not be discharged if under medication.
As much as possible each discharged beneficiary should be referred to TFC follow up.
B. SPECIFIC TREATMENT
Age or weight category Dose
VITAMINS
Vitamin A
6 months to 1 year 100 000 IU
> 1 year 200 000 IU
Pregnant and bearing age women
None
The day of discharge VACCINATION
Measles 9 months to 5 years One vaccination at the
discharge
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C. MEDICAL AND NUTRITIONAL FOLLOW UP
ACTION
DAY OF DISCHARGE
Weight measurement
Height measurement
W/H %
MUAC
The TFC team is in charge of preparing the TFC follow up chart [EXAMPLE]. It is advisable to write the
admission and discharge information and the under five chart as well.
The SFC team usually does the TFC follow up. Nevertheless the TFC team has to properly inform the
caretaker of the discharged about:
The closest distribution point. The day and frequency of the distribution. The TFC follow up timetable.
Sometimes the caretaker has no way to reach one of the distribution points. In that particular case, a
double ration (2 weeks ration) is given and the mother is encourage to make a regular checking at the
closest health facility.
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SPECIAL CARE FOR INFANTS UNDER 6 MONTHS [Picture]
A. ADMISSION
Infants under 6 months of age are admitted in
TFC if they meet the following criteria:
The infant is too weak to suck effectively
The mother is not producing enough milk.
Prior to admission the following has to be
checked properly:
A proper clinical examination has to be conducted
Check the presence of milk by carefully pressing the mother’s breast.
These beneficiaries are very fragile and must
as far as possible, be protected from risk of
infection. Hence it is advisable to isolate them
and to insure a close and regular monitoring.
As for other beneficiaries the infant is admitted
with a caretaker. As mothering for infant is one
of the key points of the treatment, mother is
admitted as caretaker / lactating woman. In
case of orphan infant the grandmother is
admitted. If it is not possible - even it is not in
the habit – we have to encourage a lactating
woman among the relatives to stay with the
infant.
B. STEPS
Conduct a medical examination Daily weight of the child Prescribe the systematic treatment Prescribe specific treatment Encourage the breast-feeding and cares to the mothers
C. MEDICAL CARE
a) Systematic treatment
Dose Days of administration
Vitamin A 50 000 IU D1, D2 and at discharge
Folic acid 5 mg D1
Amoxicillin 60 mg / kg / day divided in
3 doses From D1 to D10
Chloroquine
b) Specific treatment
The specific treatment is prescribed according to the medical examination findings and complaints.
Keep in mind that these beneficiaries are very fragile
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D. NUTRITIONAL CARE FOR INFANTS UNDER 6 MONTHS The nutritional protocol has to be adjusted to the physiological needs of these children. The objective of the treatment is to increase the mother’s milk supply whilst giving a supplement to the infant until it reaches the stage where the mother’s milk alone is sufficient to ensure the child’s growth.
The milk to be used is diluted F100 as it corresponds better to the nutritional needs of this age. 8 meals are given per day following the Phase I time table consisting of 130 ml / kg / day.
No iron has to be added in the diluted F100 for children under 6 months.
Diluted F-100
Energy density: 100 kcal / 100 ml
Quantity given: 130 ml / kg of body-weight / day
Quantity of diluted F-100 needed
F-100 needed (2/3)
Water to add (1/3)
50 33 17
100 67 33
150 100 50
200 133 67
250 167 83
300 200 100
350 233 117
400 266 134
450 300 150
500 334 166
The supplement is not increased during the
stay, so any increase in weight signifies an
increase in the infant consumption of breast
milk. However, the quantity of diluted F100 is
adapted according to the daily weight.
In case the breast milk production is sufficient
but the child is unable to suck, the breast milk
has to be manually extracted and given
immediately with a cup.
Particular attention has to be paid to the
mother. She should be listened to, reassured,
and encouraged to breast-feed.
The lactating women have to receive 2500 Kcal
/day. An additional porridge has to be
distributed.
The stay at the TFC should be as short as
possible as the environment can be dangerous
to the health of these infants. 15 days should be
a maximum.
1. Preparing for discharge
If the weight curve is ascending for 10 days: Cut the quantity of milk to be given by half and ensure the weight is still increasing After 3 days, if the curve is ascending, stop the supplementation with diluted F-100. Keep the child under observation for 3 days
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SPECIAL CARE FOR INFANTS OVER 6 MONTHS WEIGHING LESS THAN 3 KG
The objective is to get the mother to continue breastfeeding while giving the infant the supplements
required at this stage of development. In a child more than 6 months old who weighs less than 3 kg,
growth is seriously retarded. At the beginning of the treatment the child is treated in the same way as
infant less than 6 months old.
1. Nutritional
The nutritional protocol consists of three phases:
An initial treatment phase during which the energy intake is progressively increased. A rapid gain weight phase while the infant still weighs less than 3 kg A further rapid gain weight phase once the infant has reached 3 kg. At the start of the treatment and until the infant reach 3 kg the diet is based on diluted F-100.
Weight Category
Daily Amount (ml)
Diluted F-100 +
iron (8 meals a day)
2 to 2.1 kg 320 40
2.2 to 2.4 kg 360 45
2.5 to 2.7 kg 400 50
2.8 to 2.9 kg 440 55
[Picture]
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Preparation of the Diluted F100
Quantity of diluted
F-100 needed
F-100 needed
(2/3)
Water to add
(1/3)
50 33 17
100 67 33
150 100 50
200 133 67
250 167 83
300 200 100
350 233 117
400 266 134
450 300 150
500 334 166
1. Give diluted F-100 one hour after each breastfeeding:
2. Calculate the quantity of diluted F-100 according to the actual weight of the infant,
rounding up the quantity of milk to the nearest 5 ml.
3. Measure out the quantity with a syringe
4. Supplementary suckling technique
Supplementary suckling technique
Tell mother to put the infant to the breast every 3 hours for at
least 20 minutes. Since suckling stimulates the production of
milk, it is important to put the infant to the breast as often as
possible, and always before giving the diluted F-100 milk.
The diluted F-100 is given to the infant by using a gastric tube,
one end of which is placed on the mother’s nipple and the
other, which has been cut about 1 cm from the small holes, into
a cup of diluted F-100 milk. Do not forget to remove the
stopper.
When the infant suckles it takes in milk from the cup via the
tube together with the breast milk. The mother must hold the
cup about 10 cm lower than the breast, so that milk is not
sucked up too quickly.
It may require 2 or 3 days before the infant becomes used to
this technique. In the first few days, if the infant does not suck
all the milk from the cup through the tube, the balance should be given using the cup.
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2. Rapid weight gain phase:
When the child reaches 3 kg, the usual protocol needs to be followed. That means transition phase
with F100 – 8 meals a day during 4 days and then promoted to Phase 2. According to his weight,
the porridge will be given or not.
Close monitoring must be organized at the beginning of Phase II.
3. Discharge:
The child is cured when
W/H > 85 % The weight curve is ascending No medical problems
The child is referred to SFC for Follow Up.
E. MEDICAL AND NUTRITIONAL FOLLOW UP
ACTION FREQUENCY
Weight measurement Every days
A baby scale is used, 10 to 20 g precision
Height measurement Once weekly
W/H and BMI Twice weekly
Temperature At least once a day
Clinical examination Once daily
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SPECIAL NOTES ON THE CARETAKERS
Beneficiaries in TFC cannot stay by their own
hence a caretaker has to assist them. The
caretaker must be an adult, preferably the
mother, as mothering is crucial. When this is
not possible, somebody who is close to the
beneficiary should stay as the caretaker.
The treatment of severe malnutrition will not be
effective if we did not have the support of the
caretaker. Moreover the relationship between
the beneficiary and the caretaker is very
important. It should be strong (e.g.: a
beneficiary who is usually with the mother but
admitted in TFC with the grandmother may
refuse feeding because of lack of attention/
mothering).
The caretaker has to be briefed on the purpose
of TFC and its regulations. At the admission
non- food items are given:
mosquito net sleeping mat blanket cup spoon plate
These items are under their responsibility until
the discharge. Bathing and laundry soap are
distributed on a weekly basis.
The registrars have to explain how TFC is
organized and what we are expecting from
caretakers. They have to be involved in their
own food preparation and in the cleaning of the
entire centre. It is up to the team to organize the
caretakers by groups and to encourage them to
elect a caretaker leader.
The caretaker has to attend the health
education session according to the planning.
Because caretakers have to stay in TFC until
the discharge of the beneficiary they must be
fed as well. Most of the time they cannot
organize their own food provision and feeding
helps to limit defaulting of the beneficiary.
We have to provide them enough food to cover
their daily needs (2100 Kcal). Their daily food
ration is made of porridge and family meal.
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The porridge should provide 600 to 700 Kcal of which 35 % is lipids and 11 % is proteins.
The family meal should provide 1400 to 1500 Kcal of which 25 to 30 % of lipids and 10 to 12 % of
proteins.
Quantity (g)
CEREAL 300
OIL 35
PULSES 80
SALT 5
This family meal is accommodated with local food as cassava leaves, dry fish, hot pepper and other
condiments.
The beneficiary porridge and family meal can be fortified with CMV.
Quantity (g)
CSB 125
OIL 20
SUGAR 10
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Introduction:
Supplementary Feeding Centers involve screening and treatment of acute moderate
malnutrition, screening and referrals for acute severe malnutrition, Outpatient Treatment
Programs (OTP), and food distribution. OTP involves home-based treatment for patients with
severe acute malnutrition, but NO other complications.
Goals of SFC:
Recognize and properly diagnose the signs and symptoms of severe malnutrition and
related conditions.
Provide the appropriate life-saving treatment to each case
Upgrade the condition of each patient so they can eventually graduate to an outpatient
Supplemental Feeding Center.
The objective of a Supplementary Feeding Centre ( SFC) is to avoid that a child already
moderately malnourished becomes severely malnourished with the risk to death in the
days.
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FOLLOW UP
The aim of TFC Follow Up is to insure a surveillance of the discharged beneficiary for a 3-month period
and preventing the relapses. The TFC Follow up is usually conducted by SFC team nevertheless the
TFC team should be aware of the aim and protocol of TFC follow up.
A screening is conducted at each visit and a single premixed ration is distributed as for SFC
beneficiaries. The schedule is as explain below:
Along the TFC Follow up there are 7 contacts with the beneficiary. Defaulter is considered after 2
consecutive absences. Even after an absence, the schedule has to be strictly followed (e.g.: a
beneficiary which misses the 2nd visit and coming after absence will be registered as 3rd visit.
Beneficiary with stable or decreasing weight can be asked to come one week after for new screening.
Beneficiary reached SFC criteria has to be referred to SFC
All information regarding TFC Follow up is collected in a special register.
1st month
Weekly visit
1st visit
2nd visit
3rd visit
4th visit
2nd month Fortnightly visit 5th visit
6th visit
3rd month Single visit 7th visit
ITEM QUANTITY
Daily (g) Weekly (kg)
CSB 214 g 1.5 kg
OIL 30 g 0.210 Kg
SUGAR 14.2g 0.100 kg
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Options for ration composition for a targeted, dry supplementary feeding programme
A daily, take-home supplementary ration should provide:
1200-1600 kcal/day 10-12% energy from protein* 30-35% energy from fat*
*nb. protein provides 4 kcal/g, fat provides 9 kcal/g
Example rations:
Ration 1: Famix CSB WSB Oil** Sugar
Total from
blended ration
per day
Quantity for 2 weeks (kg)
3.5 kg
0.5 kg
Quantity per day (g) 250.0
35.7
Kcal per day 960.0
321.3
1281.3
Protein per day (g) 35.0
35.0
Fat per day (g) 17.3
35.7
53.0
% energy from protein
10.9
% energy from fat
37.2
Ration 3: Famix CSB WSB Oil** Sugar
Total from
blended ration
per day
Quantity for 2 weeks
4.0 kg
0.5 kg
Quantity per day (g)
286.0
29.4
Kcal per day
1087.0
264.6
1351.6
Protein per day (g)
51.5
51.5
Fat per day (g)
17.1
29.4
46.5
% energy from protein
15.2
% energy from fat
31.0
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Ration 5: Famix CSB WSB Oil** Sugar
Total from
blended ration
per day
Quantity for 2 weeks 4.0 kg
0.5 kg
Quantity per day (g) 286.0
29.4
Kcal per day 1098.0
264.6
1362.6
Protein per day (g) 40.0
40.0
Fat per day (g) 19.7
29.4
49.1
% energy from protein
11.7
% energy from fat
32.4
Ration 7: Famix CSB WSB Oil** Sugar
Total from
blended ration
per day
Quantity for 2 weeks 4.5 kg
0.5 kg
Quantity per day (g) 321.0
29.4
Kcal per day 1233.0
264.6
1497.6
Protein per day (g) 44.9
44.9
Fat per day (g) 22.1
29.4
51.5
% energy from protein
12.0
% energy from fat
30.9
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RUTF OTP Ration Guidelines
Weight of Child (kg) Ration per weekly
distribution Ration per day Ration per meal
3.5 - 3.9 11 1.5 ¼ sachet
4.0 - 5.4 14 2 ¼ sachet
5.5 - 6.9 18 2.5 ½ sachet
7.0 - 8.4 21 3 ½ sachet
8.5 - 9.4 25 3.5 ½ sachet
9.5 - 10.4 28 4 ½ sachet
10.5 - 11.9 32 4.5 ½ sachet
>12 35 5 ¾ sachet
Give small amount every few hours (day and night)
ALWAYS offer water to drink while eating RUTF.
ALWAYS offer breast milk first if the child is still breastfeeding
Follow the appetite of the child – NEVER force food On discharge, amount given should be “ration/day” x “number of days” until next SFP distribution date.
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OUTPATIENT CARE CHECKLIST
ANTHROPOMETRY
□ Assess for bilateral pitting oedema
□ Measure mid-upper arm circumference (MUAC), weight, height
□ Classify nutritional status
□ Record Nutrition indicators on outpatient care treatment cards and on ready-to-use therapeutic food (RUTF) ration card
NEW ADMISSIONS
□ Obtain registration details from mother/caregiver and record anthropometric measurement
□ Take medical history
□ Conduct physical examination
□ Test appetite
□ Decide if eligible for outpatient care (OTP) or needs to be referred to inpatient care (TFC)
□ Calculate doses and give routine medicines to child
□ Explain medical treatment to mother/caregiver
□ Calculate amount of RUTF for child and record and give the ration
□ Fill out RUTF ration card
□ Discuss key messages to mothers/caregivers
□ Ask mother/caregiver to repeat instructions on how to give medicine and RUTF
□ Link with outreach worker
OUTPATIENT CARE FOLLOW-UP SESSIONS
□ Take medical history
□ Conduct physical examination test appetite
□ Review information on outpatient care treatment card to date and interpret progress (Are they improving? Are they not improving? Why?)
□ Continue medical treatment as appropriate
□ Use action protocol to assess need for follow-up home visit and arrange if necessary
□ Use action protocol to assess need for referral and arrange if necessary
□ Discuss child’s progress with mother/caregiver
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□ Calculate amount of RUTF for child and record and give ration
□ Fill out RUTF ration card
□ Provide health and nutrition counseling
□ Inform mother/caregiver about linking with other services, programs, and initiatives (e,g, expanded program of immunization [EPI], voluntary counseling and testing [VCT], reproductive health)
DISCHARGES
□ Identify children ready for discharge.
□ Fill out outpatient care treatment card upon discharge
□ Provide appropriate information to mother/caregiver about child’s discharge (e.g. when to bring the child back, danger signs)
□ Give the discharge ration of RUTF
□ Inform mother/caregiver about linking with other services, programs and initiatives, if appropriate (e.g. supplementary feeding program [SFP])
ACCEPTING REFERRALS FROM INPATIENT CARE (TFC)
□ Review referral slip from inpatient care and record relevant information on outpatient CARE treatment card (including medicines).
□ Review Information and medications provided in inpatient care, confirm with mother/caregiver medicines received to date and adjust outpatient care medicines for admission.
□ Follow admission protocols (anthropometry, medical history, physical examination, test appetite, calculate RUTF ration, discuss key messages, fill out RUTF ration card, link with outreach worker).
DISCUSSIONS WITH MOTHERS/CAREGIVERS AT SITES
□ Where have you come from?
□ How long did it take to get here?
□ How did you hear about the service?
□ Why did you bring your child?
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Quick Reference Tables
Overview of Admission Criteria:
Admission
In SFC
Admission
In TFC
Children from 6 months to 10
years (or from 65 to 130
cm)
W/H , 80% of the median
And /or MUAC < 125 mm
W/H < 70% of the median
and/or Presence of bilateral pitting oedema
and/or MUAC < 110 mm
Adolescents from 10 to 18 years
(> 130 cm)
W/H < 80% of the median
And / or MUAC : not to do , mistakes are
common
W/H < 70% of the median
and/or Presence of bilateral pitting oedema
Adults (except pregnant and
lactating women)
MUAC : 160 185 mm
MUAC < 160 mm
or Presence of bilateral pitting oedema
(Grade 3 or worse) 1
or MUAC < 185 mm
and poor clinical condition (Inability to stand, apparent
dehydration etc.)
Pregnant and lactating women
MUAC : 170 185 mm
Rem/ at risk of malnutrition 185 210 mm
MUAC < 170 mm
and/or Presence of bilateral pitting oedema
(Grade 3 and above) 1
Elderly
( 50-60 years) MUAC : 160 175 mm
MUAC < 160 mm
and poor clinical condition (Inability to stand, apparent
dehydration etc.)
and/or Presence of bilateral pitting oedema
(Grade 3 or worse) 1
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Weight-for-length tables for boys and girls below 85 cm, in % of the NCHS median
*Children measuring BELOW 85 cm should be measured lying down.
WEIGHT-FOR-LENGTH WEIGHT-FOR-LENGTH
Malnutrition Malnutrition Moderate Severe Moderate Severe
Height 100% 85% 80% 75% 70% 60% Height 100% 85% 80% 75% 70% 60%
(cm) In Kg in Kg in Kg in Kg in Kg in Kg (cm) in Kg in Kg in Kg in Kg in Kg in Kg
49.0 3.2 2.7 2.6 2.4 2.3 1.9 67.0 7.6 6.5 6.1 5.7 5.3 4.6
49.5 3.3 2.8 2.6 2.5 2.3 67.5 7.8 6.6 6.2 5.8 5.4
50.0 3.4 2.9 2.7 2.5 2.4 2.0 68.0 7.9 6.7 6.3 5.9 5.5 4.7
50.5 3.4 2.9 2.7 2.6 2.4 68.5 8.0 6.8 6.4 6.0 5.6
51.0 3.5 3.0 2.8 2.6 2.5 2.1 69.0 8.2 7.0 6.6 6.1 5.7 4.9
51.5 3.6 3.1 2.9 2.7 2.5 69.5 8.3 7.1 6.7 6.2 5.8
52.0 3.7 3.1 3.0 2.8 2.6 2.2 70.0 8.5 7.2 6.8 6.3 5.9 5.1
52.5 3.8 3.2 3.0 2.8 2.6 70.5 8.6 7.3 6.9 6.4 6.0
53.0 3.9 3.3 3.1 2.9 2.7 2.3 71.0 8.7 7.4 7.0 6.5 6.1 5.2
53.5 4.0 3.4 3.2 3.0 2.8 71.5 8.9 7.5 7.1 6.6 6.2
54.0 4.1 3.5 3.3 3.1 2.9 2.5 72.0 9.0 7.6 7.2 6.7 6.3 5.4
54.5 4.2 3.6 3.4 3.2 2.9 72.5 9.1 7.7 7.3 6.8 6.4
55.0 4.3 3.7 3.5 3.2 3.0 2.6 73.0 9.2 7.9 7.4 6.9 6.5 5.5
55.5 4.4 3.8 3.5 3.3 3.1 73.5 9.4 8.0 7.5 7.0 6.5
56.0 4.6 3.9 3.6 3.4 3.2 2.8 74.0 9.5 8.1 7.6 7.1 6.6 5.7
56.5 4.7 4.0 3.7 3.5 3.3 74.5 9.6 8.2 7.7 7.2 6.7
57.0 4.8 4.1 3.8 3.6 3.4 2.9 75.0 9.7 8.2 7.8 7.3 6.8 5.8
57.5 4.9 4.2 3.9 3.7 3.4 75.5 9.8 8.3 7.9 7.4 6.9
58.0 5.1 4.3 4.0 3.8 3.5 3.1 76.0 9.9 8.4 7.9 7.4 6.9 5.9
58.5 5.2 4.4 4.2 3.9 3.6 76.5 10.0 8.5 8.0 7.5 7.0
59.0 5.3 4.5 4.3 4.0 3.7 3.2 77.0 10.1 8.6 8.1 7.6 7.1 6.1
59.5 5.5 4.6 4.4 4.1 3.8 77.5 10.2 8.7 8.2 7.7 7.2
60.0 5.6 4.8 4.5 4.2 3.9 3.4 78.0 10.4 8.8 8.3 7.8 7.2 6.2
60.5 5.7 4.9 4.6 4.3 4.0 78.5 10.5 8.9 8.4 7.8 7.3
61.0 5.9 5.0 4.7 4.4 4.1 3.5 79.0 10.6 9.0 8.4 7.9 7.4 6.4
61.5 6.0 5.1 4.8 4.5 4.2 79.5 10.7 9.1 8.5 8.0 7.5
62.0 6.2 5.2 4.9 4.6 4.3 3.7 80.0 10.8 9.1 8.6 8.1 7.5 6.5
62.5 6.3 5.4 5.0 4.7 4.4 80.5 10.9 9.2 8.7 8.1 7.6
63.0 6.5 5.5 5.2 4.8 4.5 3.9 81.0 11.0 9.3 8.8 8.2 7.7 6.6
63.5 6.6 5.6 5.3 5.0 4.6 81.5 11.1 9.4 8.8 8.3 7.7
64.0 6.7 5.7 5.4 5.1 4.7 4.0 82.0 11.2 9.5 8.9 8.4 7.8 6.7
64.5 6.9 5.9 5.5 5.2 4.8 82.5 11.3 9.6 9.0 8.4 7.9
65.0 7.0 6.0 5.6 5.3 4.9 4.2 83.0 11.4 9.6 9.1 8.5 7.9 6.8
65.5 7.2 6.1 5.7 5.4 5.0 83.5 11.5 9.7 9.2 8.6 8.0
66.0 7.3 6.2 5.9 5.5 5.1 4.4 84.0 11.5 9.8 9.2 8.7 8.1 6.9
66.5 7.5 6.4 6.0 5.6 5.2 84.5 11.6 9.9 9.3 8.7 8.2
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Weight-for-height tables for boys and girls above 85 cm
*Children measuring 85 cm and ABOVE should be measured standing.
WEIGHT-FOR-HEIGHT WEIGHT-FOR-HEIGHT
Malnutrition Malnutrition
Moderate Severe Moderate Severe
Height 100% 85% 80% 75% 70% 60% Height 100% 85% 80% 75% 70% 60%
(cm) in Kg in Kg in Kg in Kg in Kg in Kg (cm) in Kg in Kg in Kg in Kg in Kg in Kg
85.0 12.0 10.2 9.6 9.0 8.4 7.2 107.5 17.7 15.0 14.1 13.3 12.4
85.5 12.1 10.3 9.7 9.1 8.5 108.0 17.8 15.2 14.3 13.4 12.5 10.7
86.0 12.2 10.4 9.8 9.1 8.5 7.3 108.5 18.0 15.3 14.4 13.6 12.7
86.5 12.3 10.5 9.8 9.2 8.6 109.0 18.1 15.4 14.5 13.6 12.7 10.9
87.0 12.4 10.6 9.9 9.3 8.7 7.4 109.5 18.3 15.6 14.6 13.7 12.8
87.5 12.5 10.6 10.0 9.4 8.8 110.0 18.4 15.7 14.8 13.8 12.9 11.0
88.0 12.6 10.7 10.1 9.5 8.8 7.6 110.5 18.6 15.8 14.9 14.0 13.0
88.5 12.8 10.8 10.2 9.6 8.9 111.0 18.8 16.0 15.0 14.1 13.1 11.3
89.0 12.9 10.9 10.3 9.7 9.0 7.7 111.5 18.9 16.1 15.1 14.2 13.3
89.5 13.0 11.1 10.4 9.7 9.1 112.0 19.1 16.2 15.3 14.3 13.4 11.5
90.0 13.1 11.1 10.5 9.8 9.2 7.9 112.5 19.3 16.4 15.4 14.4 13.5
90.5 13.2 11.2 10.6 9.9 9.2 113.0 19.4 16.5 15.5 14.6 13.6 11.6
91.0 13.3 11.3 10.7 10.0 9.3 8.0 113.5 19.6 16.7 15.7 14.7 13.7
91.5 13.4 11.4 10.8 10.1 9.4 114.0 19.8 16.8 15.8 14.8 13.8 11.9
92.0 13.6 11.6 10.8 10.2 9.5 8.2 114.5 19.9 16.9 16.0 15.0 14.0
92.5 13.7 11.6 10.9 10.3 9.6 115.0 20.1 17.1 16.1 15.1 14.2 12.1
93.0 13.8 11.7 11.0 10.3 9.7 8.3 115.5 20.3 17.3 16.2 15.2 14.2
93.5 13.9 11.8 11.1 10.4 9.7 116.0 20.5 17.4 16.4 15.4 14.3 12.3
94.0 14.0 11.9 11.2 10.5 9.8 8.4 116.5 20.7 17.6 16.5 15.5 14.5
94.5 14.2 12.0 11.3 10.6 9.9 117.0 20.8 17.7 16.7 15.6 14.6 12.5
95.0 14.3 12.1 11.4 10.7 10.0 8.6 117.5 21.0 17.9 16.8 15.8 14.7
95.5 14.4 12.2 11.5 10.8 10.1 118.0 21.2 18.0 17.0 15.9 14.9 12.7
96.0 14.5 12.4 11.6 10.9 10.2 8.7 118.5 21.4 18.2 17.1 16.1 15.0
96.5 14.7 12.5 11.7 11.0 10.3 119.0 21.6 18.4 17.3 16.2 15.1 13.0
97.0 14.8 12.6 11.8 11.1 10.3 8.9 119.5 21.8 18.5 17.4 16.4 15.3
97.5 14.9 12.7 11.9 11.2 10.4 120.0 22.0 18.7 17.6 16.5 15.4 13.2
98.0 15.0 12.8 12.0 11.3 10.5 9.0 120.5 22.2 18.9 17.8 16.7 15.5
98.5 15.2 12.9 12.1 11.4 10.6 121.0 22.4 19.1 17.9 16.8 15.7 13.4
99.0 15.3 13.0 12.2 11.5 10.7 9.2 121.5 22.6 19.2 18.1 17.0 15.8
99.5 15.4 13.1 12.3 11.6 10.8 122.0 22.8 19.4 18.3 17.1 16.0 13.7
100.0 15.6 13.2 12.4 11.7 10.9 9.4 122.5 23.1 19.6 18.4 17.3 16.1
100.5 15.7 13.3 12.6 11.8 11.0 123.0 23.3 19.8 18.6 17.5 16.3 14.0
101.0 15.8 13.5 12.7 11.9 11.1 9.5 123.5 23.5 20.0 18.8 17.6 16.5
101.5 16.0 13.6 12.8 12.0 11.2 124.0 23.7 20.2 19.0 17.8 16.6 14.2
102.0 16.1 13.7 12.9 12.1 11.3 9.7 124.5 24.0 20.4 19.2 18.0 16.8
102.5 16.2 13.8 13.0 12.2 11.4 125.0 24.2 20.6 19.4 18.2 16.9 14.5
103.0 16.4 13.9 13.1 12.3 11.5 9.8 125.5 24.4 20.8 19.6 18.3 17.1
103.5 16.5 14.0 13.2 12.4 11.6 126.0 24.7 21.0 19.7 18.5 17.3 14.8
104.0 16.7 14.2 13.3 12.5 11.7 10.0 126.5 24.9 21.2 19.9 18.7 17.5
104.5 16.8 14.3 13.4 12.6 11.8 127.0 25.2 21.4 20.1 18.9 17.6 15.1
105.0 16.9 14.4 13.6 12.7 11.9 10.1 127.5 25.4 21.6 20.4 19.1 17.8
105.5 17.1 14.5 13.7 12.8 12.0 128.0 25.7 21.8 20.6 19.3 18.0 15.4
106.0 17.2 14.6 13.8 12.9 12.1 10.3 128.5 26.0 22.1 20.8 19.5 18.2
106.5 17.4 14.8 13.9 13.1 12.2 129.0 26.2 22.3 21.0 19.7 18.4 15.7
107.0 17.5 14.9 14.0 13.1 12.3 10.5 129.5 26.5 22.5 21.2 19.9 18.6
130.0 26.8 22.8 21.4 20.1 18.7 16.1
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Overview of Methods for Anthropometric Measures
Method Uses Advantages Disadvantages Common
Thresholds
MUAC Detect wasting and acute malnutrition
Assess risk of death; does not depend on age; rapid, simple, no cumbersome
equipment
Risk of measurement error; lack of agreement on thresholds; does not
take oedemas and dehydration into account
<135 mm: at risk
3Z to < -2Z or 110 to < 125 mm: moderate
malnutrition
<-3Z or <110 mm: severe malnutrition high risk of mortality
Weight-
Height Detect Wasting and acute malnutrition
Does not depend on age
2 measurements needed; ratio is changed by
oedemas and dehydration; no
information on past nutritional status
-3Z to < -2Z or 70% to < 80%:
moderate malnutrition
<-3Z or <70%: severe malnutrition
Weight-Age
Detects a combination of stunting and
wasting, and acute and chronic malnutrition
Used extensively throughout the
world; Height not needed (difficult);
Interesting for monitoring individual
development
Requires age; Confusion in interpreting the
influence of acute and chronic malnutrition;
Oedemas and dehydration modify weight
-3Z to < -2Z or 60% to < 75%: moderate
malnutrition
<-3Z or <60%: severe
Height-Age Detects stunting and chronic malnutrition
Measurements unchanged by acute
malnutrition or by presence of oedemas;
dehydration does not change measures
Need to know age; Measuring height is technically difficult;
Provides no info on the presence of acute
malnutrition
-3Z to < -2Z or 80% to < 90%: moderate
malnutrition
<-3Z or <80%: severe malnutrition
Body Mass
Index (BMI)
Used for nutritional assessment in
adults; increasingly used for population
references
Not always accurate; Does not take muscle
mass into account
17-18: At-risk >= 16: malnutrition
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Forms
- Registration cards - Initial Assessment cards - Meal Trackers - Weight tracker -
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Sample Inventory Checklist
Sheet
No.
Date
Performed
By
Department
Inventory No. Item Description Purchase Price Quantity Location
$
Signature
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Check Lists
- Set up
- TFC
- SFC/OTP
- Personnel
- Supplies
- Drugs
- Actions Diagnosis, treatment, etc
- Systematic treatment at each stage
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References and Additional Resources Action Against Hunger, Strategic Programming for Community Nutrition Interventions. 2007. http://www.actionagainsthunger.org/sites/default/files/publications/ACF-Community-Nutrition-Guide.pdf Medecins San Frontieres, Clinical Guidelines: Diagnosis and Treatment Manual. 2010. http://www.refbooks.msf.org/MSF_Docs/En/Clinical_Guide/CG_en.pdf Medecins San Frontieres, Essential Drugs. 2010. http://www.refbooks.msf.org/MSF_Docs/En/Essential_drugs/ED_en.pdf Medecins San Frontieres, Rapid Health Assessment of Refugee or Displaced Populations. 2006. http://www.refbooks.msf.org/MSF_Docs/En/Rapid_health/RAPID_HEALTH_en.pdf Medecins San Frontieres, Refugee Health. 1997. http://www.refbooks.msf.org/MSF_Docs/En/Refugee_Health/RH.pdf World Health Organization, Guidelines for the Inpatient Treatment of Severely Malnourished Children. 2003. http://www.who.int/nutrition/publications/severemalnutrition/guide_inpatient_text.pdf World Health Organization, Management of Severe Malnutrition: A Manual for Physicians and Other Senior Health Workers. 1999. http://www.who.int/nutrition/publications/severemalnutrition/en/manage_severe_malnutrition_eng.pdf World Health Organization, Management of the Child with a Serious Infection or Severe Malnutrition: Guidelines for Care at the First-Referral Level in Developing Countries. 2000. http://whqlibdoc.who.int/hq/2000/WHO_FCH_CAH_00.1.pdf World Health Organization, Manual for the Health Care of Children in Humanitarian Emergencies. 2008. http://whqlibdoc.who.int/publications/2008/9789241596879_eng.pdf