Report Training Management Sam Accra 31aug 6sept2009 (1)

8/4/2019 Report Training Management Sam Accra 31aug 6sept2009 (1)

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REPORT ON TRAINING COURSE ON THE MANAGEMENT OF

SEVERE ACUTE MALNUTRITION AND ORIENTATION ON

COMMUNITY-BASED MANAGEMENT CARE OF SEVERE ACUTE

MALNUTRITION

HELD AT SUN LODGE HOTEL, ACCRA, GHANA

FROM 31ST

AUGUST TO 6TH

SEPTEMBER, 2009

BY DR BEATRICE C AMADI

UNIVERSITY TEACHING HOSPITAL

DEPARTMENT OF PAEDIATRICS

LUSAKA. ZAMBIA


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REPORT ON TRAINING COURSE ON MANAGEMENT OF

SEVERE ACUTE MALNUTRITION

INTRODUCTION/BACKGROUND INFORMATION

Severe acute malnutrition is a leading cause of morbidity and mortality in children in theunder-five age group in developing countries. Malnutrition contributes over 50% of the

10 - 11 million deaths from preventable causes, which occur annually in this age group.

In most developing countries, many severely malnourished children die at home withoutcare, and even when hospital care is provided, case fatality rates are very high, ranging

between 30-50%.

Factors which contribute to this high case fatality rate include:

Inappropriate diets high in protein, sodium and energy given in the acute phase ofmanagement

Lack of recognizing the fact that all severely malnourished children need to betreated with broad spectrum antibiotics, to treat infection which may not always

be apparent

Inappropriate use of intravenous fluids, particularly in patients who are not inshock. Equally use of fluids that have high sodium is dangerous

Use of iron in the early phase High dose of Vitamin A not given Failure to monitor food intake Lack of feeding at night Non provision of warmth Poor hygiene

Other factors which contribute to poor outcome of hospital management include:

Late presentation and delayed referral to inpatient facilities High prevalence of HIV/AIDS Shortage of staff Shortage of essential drugs and supplies e.g. antibiotics, Oral rehydration solution,

therapeutic feeds, and medico-surgical supplies.

The World Health Organization (WHO) has developed a manual that describes casemanagement guidelines for severely malnourished children. It has been shown that use

of appropriate case management protocols based on these WHO guidelines is capable of

saving lives of many severely malnourished children with reduction of case fatality rates

to less than 5%.

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Since 2002, the WHO Training Course materials on Management of Severe Malnutritionhave been used in trainings of senior health workers in several Asian and African

Countries. Doctors, Nurses and Nutritionists/Dieticians working in inpatient facilities and

Ministry of Health including, WHO, UNICEF National Programme Officers and otherpartners working in the area of childhood nutrition have been trained in case management

of severe malnutrition using these guidelines. As per these WHO guidelines all cases ofsevere malnutrition are admitted and managed as inpatients. Exclusive inpatientmanagement of severe malnutrition does not enable a large of children to be managed due

to limited hospital bed capacity.

In September 2006, WHO, UNICEF and VALID International held a combined two daymeeting on Integrated Management of Severe Acute Malnutrition (IMAM) in Dar es

Salaam, Tanzania for East and Southern African countries. This meeting targeted

recently trained facilitators on WHO Management of Severe Malnutrition Guidelines,trainees invited to undergo the 6 day Case Management Training Course of Severe

Malnutrition, decision makers from Ministries of Health including WHO and UNICEF

programme officers from represented countries (Tanzania, Kenya, Uganda, Ethiopia,Eritrea, Namibia, Botswana and Lesotho).

This meeting brought WHO, UNICEF and VALID International together to promote the

concept of IMAM which at the time was referred to as Community Therapeutic Care(CTC) as way to improve and increase coverage of affected children. At the time, it was

noted that CTC had become possible as a new way of managing severely malnourished

children due to the development and availability of Ready-to-Use Therapeutic Food(RUTF). Nomenclature has since changed from CTC to Community-based Management

of Severe Acute Malnutrition (CMAM).

Availability of RUTF has enabled children with severe acute malnutrition without

complications to be managed at home with weekly visits to Outpatient Care sites (OPC)for follow up. Only children with complicated severe acute malnutrition are admitted to

inpatient facilities for stabilization (Stabilization Care) with an option of early discharge

upon improvement of complications.

Children with moderate acute malnutrition are managed through a Supplementary

Feeding Programme (SFP) with supplies of either dry or wet rations of Maize-Soya

Blends and similar fortified food supplements.

According to the 2008 Ghana Demographic and Health Survey Report, nutrition

indicators for children in the under-5 age are as follows:

Underweight 14% Stunting 28%. Wasting 9% Severe wasting 2.2%. This is highest in the Upper West Region (3.9%) followed

by Eastern Region (3.7%), Northern (3.4%) and Upper East (2.9%)

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I was recruited as Temporary Advisor by WHO (African) Regional Office to undertakethe above mentioned assignment and travel arrangements were made in accordance with

the training schedule.

This report is presented in three sections as follows:

I Facilitator Training

II Case Management Training in the context of CMAM

III Course Directors Observations and Recommendations

IV Inpatient Case Management Protocol in the context of CMAM

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I FACILITATOR TRAINING

1.0 Introduction

The Training Course on Management of Severe Acute Malnutrition is designed for

senior nurses, doctors, nutritionists/dieticians in hospitals that have or plan to have severemalnutrition wards for children.

This training was held at the Sun Lodge Hotel, Accra from 25 th to 28th August, 2009.The facilitator training was conducted over a period of 4 days. The focus of the training

was mainly on facilitation skills and techniques used in the WHO Training Course on

Management of SAM. The second half of the last day was devoted to going through the

CMAM protocol and how it fits it with the traditional WHO training materials whichmainly focus on inpatient care of children with SAM.

During the facilitator training most of the time was spent in the classroom going through

the training materials. A planned clinical session was conducted in Reverend CampbellMalnutrition ward at the Princess Marie Louise (PML) Childrens Hospital on the third

day of the training. During this session, the trainees visited the kitchen and observedpreparation of therapeutic feeds and were shown the schedule of distributing the same to

admitted patients.

1.1 Course Materials

Each trainee facilitator was given a set of modules all at once in order to allow them towork ahead. However, when they actually facilitate in training, they give the participants

modules one at a time. The set of materials given to each trainee included:

SET OF 7 MODULES - IntroductionPrinciples of care

Initial management

FeedingDaily care

Monitoring and problem solving

Involving mothers in care

PHOTOGRAPHS BOOKLET FACILITATOR GUIDE ANSWER SHEETS SET OF FOUR LAMINATED REFERENCE CARDS SAMPLE OF DISCHARGE CARD

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The following additional training materials were also provided to each trainee:

New 2009 Updates to the WHO Training Course on the Management of SevereMalnutrition, issued by the Nutrition for Health and Development, WHO HQ.

Training Guide for CMAM (USAID, AED/FANTA-2, VALID International,Concern Worldwide, UNICEF 2008)

Draft Interim Ghana National Guidelines for CMAM 2009 Joint Statement by WHO and UNICEF WHO Child Growth Standards

and the identification of severe acute malnutrition in infants and children

2007 Joint Statement by WHO and UNICEF Community-based Management ofSevere Acute Malnutrition

1.2 Objectives for Facilitator Training Learn the course content Practice the teaching techniques used with the modules (for example, giving

individual feedback, leading group discussions, leading oral drills)

Become familiar with the severe malnutrition ward and how clinical practice willbe conducted

Learn ways to work effectively with a co-facilitator Practice communicating in supportive ways that reinforce learning Discuss problems that may be faced during the course (for example, slower

readers, logistical difficulties in the ward, or sections of a module which may be

difficult to teach) and prepare to handle these difficulties

1.3 Schedule for Facilitator Training

This 4 day training is condensed from the full 6-day case management course. Thetrainee facilitators were expected to move very quickly through the modules and other

relevant aspects of the additional materials with a focus mainly on teaching techniques.

1.4 Facilitator GuideTrainees learnt to use the Facilitator Guide during this training. A description of theroles and responsibilities of a facilitator are given in the Facilitator Guide. The major

duties of a facilitator include:

To introduce the modules To answer questions and assist trainees while they work To provide individual feedback on completed exercises To do demonstrations and give explanations of certain steps To conduct oral drills To lead and summarize video exercises and group discussions To coordinate role plays To summarize the modules To assist with clinical practice as requested by the clinical instructor

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Trainee facilitators were urged to learn to follow Procedures as described in the

Facilitator Guide to assist them effectively train participants on case management of

SAM.

1.5 Method of Work

The schedule of the facilitator training followed that in the Course Directors Manual

including additional topics on CMAM and new (2009) WHO updates on CMAM

The training commenced by mid morning of Tuesday 25th

August 2009 after addressingall the relevant administrative issues. There was a practical session during which the

trainees prepared ReSoMal. Therapeutic Feeds were not prepared during the facilitator

training, this was to be done during the case management training.

The last half of 4th day was devoted to going through CMAM guidelines including how

this is being implemented in the learning sites (Agona East and West of Central Regionand Ashiedu Keteke sub Metro of Greater Accra Region) and in the Northern Region.

Trainee Facilitators were taken through some sections of CMAM Module 5 Training

Guide. This was done as a power point presentation and some handouts from the CMAM

Training Manual were given out to the trainees. A schedule of the Facilitator training isattached (Annex 1).

1.6 Trainee Facilitators

A total of 12 trainees facilitators were in attendance during the Facilitator Training. Twoof these were also trained as co-Course Director and Clinical Instructor respectively.

The trainee facilitators included:

o A Professor of Paediatrics from Korle Bu Teaching Hospitalo Two Paediatricians, from local hospitals, one was the co-course director, while

the other was trained a clinical instructor

o Three Nutrition Programme Officers working for WHO, UNICEF including theCMAM Specialist working with FANTA-2.

o One Programme Manager for Nutrition Rehabilitation (also CMAM focal person)working with GHS

o One nutritionist, Training Administrative Assistanto Four Medical officers working in inpatient facilities and 1 Assistant Medical

Officer.The full list of Trainee facilitators is attached (Annex 2)

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1.7 Expected Outcome

Skilled and knowledgeable facilitators who will spearhead CMAM training and

participate in the final development and implementation of the new CMAM guidelines

which were currently in draft form. These Facilitators will form a core team which willtake on the responsibility of conducting more facilitator and case management trainings

so that the country will have a critical mass of dedicated health workers well trained inCMAM guidelines to oversee the rolling out of this important programme throughout thecountry.

1.8 Opening Ceremony

The Training was officially opened by Dr Isabella Sagoe-Moses, Child Health

Coordinator for Child Health Service in GHS.

Dr Sagoe-Moses welcomed the participants to the training and gave a brief background

on the problems of malnutrition at National level. She reiterated GHSs commitment to

supporting such trainings in order to have trained facilitators who will take the lead intraining other health workers in order to ensure wider implementation of CMAM in the

country.

Trainee facilitators were counseled on the importance of maintaining standards taught inthis course and to ensure that they do not cut corners as they set about training the

countrys health cadres in CMAM guidelines. Attainment of the Millennium

Development Goals (MDGs) was a priority for the country, however, attainment of someof the MDGs would be possible, only if malnutrition was addressed at national level.

This was a great challenge to all the health workers in the country to put in their best inorder to make these desired achievements, including reduction of in children under-5

years.

She ended by thanking the partners, WHO, UNICEF and FANTA-2/FANTA for their

continued support to GHS for the technical, material and financial support being rendered

to the country through GHS and specifically for making this training possible.

Mrs Okwabi, GHS Infant and Young Child Feeding Coordinator Nutritionist informed

the trainees facilitators that the current training and many other associated activities were

all long overdue, hence the need to move very quickly so that the CMAM programme isimplemented throughout the country. She ended by thanking the partners, WHO,

UNICEF and FANTA-2/USAID for their continued support.

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1.9 Preparation for the workshopThe following observations were made on the preparations of the facilitator training:

The venue for the facilitator training had been secured at the Sun Lodge Hotelwhich was about 20-30 minutes drive from Princess Marie Louise (PML)

Childrens Hospital, where the inpatient training including practical sessions was

going to be held The course materials comprising training modules and the manual including the

additional training materials were delivered before the training.

However, the training Video provided by WHO HQ was defective. A copybrought by the Course Director was used. Several copies were made from thisDVD for use in future trainings.

Supplies for the facilitator trainees (stationery, pens, pencils, highlighters,calculators etc) and secretarial services were available within the classroom.

The Sun Lodge Hotel provided all the meals during training (lunch, midmorningand afternoon snacks and drinks). There were no complaints from the traineefacilitators as regards the quality of food.

The ingredients for preparation of the ReSoMal, Therapeutic Feeds (F-75 and F-100) and a box of RUTF had all been procured utensils and weighing scales

were available.

A familiarization tour of PML Childrens hospital was not undertaken by theCourse Director prior to the training. However, site visit had been conducted and

all the necessary permission obtained for the use of the hospital for training and

clinical sessions by the local team comprising Akosua Kwakwye ( NutritionProgramme Officer, WHO country office) Alice Nkoroi (CMAM and Emergency

Nutrition Specialist) and Michael Neequaye (Programme Manager, Nutrition

Rehabilitation)

The course director arrived 2 days before the training and met with the local teamthe following day for briefing and finalizing of the training preparations. It was

gratifying to note that all the necessary preparation had been put in place for thefollowing days training.

Training schedules, registrations forms were prepared by the course director Almost all the participants were accommodated at the Sun Lodge Hotel except for

3 who live in Accra. The morning sessions started at 0830 hours and ended at1730hours. It was commendable that all the participants worked very hard

throughout the training and kept to time.

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2.0 Activities during the training days

The training started soon after the mid-morning tea break. The trainees were given the

course outline including how the course was to be conducted:

Day 1:

Introductions Introduction to Facilitator Training:o Context of Facilitator Trainingo Materials neededo Objectives of Facilitator Trainingo Teaching Methodso Schedule for Facilitator trainingo Introduction to Facilitator Guideo Modules: Introduction

Principles of Care

Day 2:

o

Module: Initial Management

Day 3:

o Module: Feedingo Clinical Session visit to Princes Marie Louise Childrens Hospital

Day 4:

o Module: Daily CareMonitoring and Problem Solving

Involving Mothers in Care

oOverview of CMAM

o Practical arrangements for the courseo Teams of facilitators discuss plans for the first day of trainingo Closing Remarks to the newly trained facilitators by Course Director

After a power presentation to review the purpose of the course, the course director

introduced the use ofFacilitator Guide and gradually took the trainees through itpointing out the relevant sections which gave instructions on how to conduct the

facilitator techniques and skills including preparation required for specific tasks taught in

the course.

Initially the course director demonstrated to the trainees how the various facilitator

techniques and skills were performed at the first instance. Thereafter, trainees took turns

to practice the already demonstrated techniques and skills with emphasis on effective useof the Facilitator Guide as the course progressed. While one trainee practiced a

particular technique or skill, the others observed closely and gave feed back at the end of

the session. Positive feedback was given first followed by areas which could beimproved upon. The use ofFacilitator Guide was continuously emphasized throughout

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the facilitator training and the areas to be improved upon by each participant werehighlighted.

The course director maintained a Practice Assignment Grid to ensure that all the traineefacilitators were given a chance to practice the various facilitator techniques and skills

equally. The facilitator techniques and skills taught in the course are as follows:

o Introducing a moduleo Leading a discussiono Adapting for nurses groupso Individual Feedbacko Oral Drillso Video Activityo Summarizing a moduleo Conducting a Demonstrationo Coordinating role playso

While participants are workingo Group Discussion

The trainee facilitators continued with practicing of the various facilitator techniques and

skills throughout the course. By the end of the course trainees had mastered thefacilitator skills and techniques taught in the course.

No clinical session was conducted during facilitator training. The following observationswere made during the visit to PML childrens hospital on the 3 rd day of the training:

o The kitchen is located in the old building of the hospital adjacent to the newbuilding housing Reverend Campbell malnutrition ward situated on the same

floor.

o Participants had an opportunity to observe preparation of feeds by the diet cooksupervised by the Dietician. The feeds are prepared hygienically. There wererecipes for preparation of F-75 and F-100 using full cream milk on the wall.

The names of patients admitted on the ward and the amount of feed was also

put up on the kitchen wall.

o However, it was noted that the recipe for F-75 was incorrect. Instead adding100gm or sugar, 70 grams was being added. There was obviously a mix up

with the recipe for preparation of cereal based F-75 (70 grams of sugar isadded with 35 grams of cereal powder). This was brought to the attentions of

the Dietician and the recipe was corrected immediately.

o The patients are started on 4 hourly feeds during the stabilization phase andthis is continued through to the rehabilitation phase. The patients are only fed

during the day, receiving the last feed at 18.00 hrs. Thereafter the kitchen isclosed for the night to re-open at 07.30 hours the following day.

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o The amount of feed for each patient is measured by the kitchen staff who thengive to the patients. At times mothers go to the kitchen to collect the feeds. Eachcup is labeled with the childs name.

o The malnutrition ward had 3 children with SAM admitted on the day of thevisit.

o There was a much older version of MUAC tape by the Nurses desk (showingsevere wasting


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At the end of the training, planning for the following weeks case management trainingwas done. Twenty participants were expected for this training. A decision was made to

have two groups of 10 participants in each group. The facilitators were thus divided into

the two groups as follows:

Group A:Jennifer Welbeck, Prof.Clement Adams

Isaac Abban, Dr

Alice Nkoroi

Group B:

Memuna Tanko, Dr,

Kwabena Sarpong, DrRev. Sister Patricia Zaghe

Catherine Adu-Asare

Akosua Kwakye

Clinical Instructor: Matildah Agyemang, Dr

Co-course Director: Thelma Brown, Dr

Michael Neequaye was to be involved with administrative duties.

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II CASE MANAGEMENT COURSE

1.0 IntroductionThe WHO case management course on Management of SAM is a 6 day training which is

designed for in-service, providing training to health workers who have already finishedtheir basic medical training and are working and treating sick children.

The course has a variety of methods of instructions, including reading, written exercises,

discussions, role plays, video exercises and demonstrations including practice in a realinpatient malnutrition ward.

Small groups of participants are led and assisted by facilitators as they work throughthe course modules which include:

Module 1 Introduction

Module 2 Principles of CareModule 3 Initial Management

Module 4 Feeding

Module 5 Daily CareModule 6 Monitoring and Problem Solving

Module 7 Involving Mothers in Care

The following additional training materials were given to each participant:

New 2009 Updates to the WHO Training Course on the Management of SevereMalnutrition, issued by the Nutrition for Health and Development, WHO HQ.

Training Guide for CMAM (USAID, AED/FANTA-2, VALID International,Concern Worldwide, UNICEF 2008)

Draft Interim Ghana National Guidelines for CMAM 2009 Joint Statement by WHO and UNICEF WHO Child Growth Standards

and the identification of severe acute malnutrition in infants and children

2007 Joint Statement by WHO and UNICEF Community-based Management ofSevere Acute Malnutrition

RUTF look-up charts MUAC tapes Weight-for-length/height tables based on WHO Growth Charts

Updates and additional information from these additional materials was included in the

appropriate WHO training modules by the participants assisted by Facilitators. This way,

the participants had updated modules to work through during the course.

As mentioned above, the WHO training course of management of SAM is based on

inpatient care of all severely malnourished children. However, recent developments andinnovations, specifically the new classification of SAM and the development of RUTF

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has made it possible to successfully manage severely malnourished children with nocomplications and a good appetite as outpatients with regular, usually weekly visits to the

health facility for evaluation and supplies of RUTF. CMAM has improved case

management of SAM in terms of increased coverage, good outcome as evidenced by highcure rates and reduced case fatality rates of


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1.3. Training Site

The training was held at PML Childrens Hospital in the Administrative block of the

hospital and Reverend Campbell malnutrition ward, were the clinical sessions were helddaily

All the logistics and supplies for the case management training were in place includingtraining modules and additional materials referred to above.

Most of the participants and facilitators were accommodated at the Sun Lodge, except for

a few who live within Accra. A bus was hired to ferry participants and facilitators to andfrom the PML hospital.

Sun Lodge hotel provided take away meals - lunch, mid morning and afternoon snackswith water and a variety of soft drinks. There were no complaints from the participants

regarding the quality of the food, except on 2 occasions when lunch was delivered late,

but this did not disrupt the training.

1.4 Participants

Twenty participants were expected for the case management training, however, on thefirst day, only 12 participants were available. Letters had been sent and followed up with

phone calls, so it was not clear why some of the invited participants did not turn up.

On the second day, 2 participants joined the course while 1 participant from the Eastern

Region joined midmorning on the 3rd day. The facilitators worked with the late comerswho were able to catch up with the rest of the group. Altogether 15 participants were

trained, 8 in Group A and 7 in Group B. Full list of participants is attached as Annex 3

1.5 Opening Ceremony

The training started at 0950 hours on Monday 31st

August, 2009 with a prayer, followedby introductions. The GHS Deputy Director of Public Health opened the training.

In his welcome remarks, the DDPH informed the participants that the programme to

improve management of SAM started 2 years ago, with support from several partners,namely, WHO, UNICEF, FANTA-2 and USAID. Consultants were brought in to

conduct training on CMAM. It was emphasized that in order to attain the MDGs,

something needed to be done about malnutrition, specifically, early identification andcorrect management of cases in hospital and in the community.

In order to achieve the above, there was need to improve management skills onmanagement of SAM and have standardized protocols all over the country. This was

going to be possible with the decision to implement training course on management of

SAM.

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The course director gave a brief overview of the training course and shared experiencefrom Zambia which had implemented the WHO guidelines since 2003 and community-

based management of SAM in Lusaka District Health Teams Health Centres since 2005,

starting with 5 and scaling up to 26 sites, where over 350 children were being treated inthe Outpatient centres with RUTF.

1.6 Conduct of the training

The course followed the following schedule:

Day 1: Monday 31st

August, 2009

The course started after the tea break at 11 hours. After group introductions, the

participants settled to work on the modules and the additional materials as follows:

Modules: Introduction/updates

Principles of Care/MUAC as a measure of wasting/updates

Video TransformationsClinical Practice: Tour of the ward

Day 2: Tuesday 1st

September, 2009

Modules: Initial Management/updates

Making ReSoMal

Video: Emergency CareClinical Practice: Clinical Signs/measuring MUAC

Weighing admitted children with SAM

Day 3: Wednesday 2nd

September, 2009

Modules: Initial Management/updates (finish)

Feeding/updates. Introduce RUTF reference card

Kitchen: Making F-75 and F-100/show RUTF and discuss compositionClinical Practice: Initial Management CCP chart/measuring MUAC//feeding F-75

Day 4: Thursday 3rd

September, 2009

Modules: Feeding/updates (finish)

Daily Care/updates

Clinical Practice: Initial Management/Feeding /Transition to RUTF.Situations requiring Transition to F100 were explained

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Day 5: Friday 4th

September, 2009

Visit to Nutrition Rehabilitation Centre

Modules: Daily Care/updates (finish)Monitoring and Problem Solving/updates

Clinical Practice: Monitoring Patients on RUTF/use of CCP charts to monitorProgress. Criteria for early discharge

Day 6: Saturday 5th

September, 2009

Modules: Involving Mothers in Care/updatesVideo: Teaching Mothers about home feeding

Malnutrition and mental development

Presentations: Overview of CMAM and its implementation in Ghana

CMAM in general and sharing Implementation of CMAM

in District Health Management Clinics in Lusaka, Zambia

Way Forward

The training was conducted over 6 days. The facilitators guided the participants throughthe training modules, including updates and new information on CMAM contained in the

additional materials given to each participant.

The modules were introduced one at a time by the facilitators who used the techniques

and skills they had learn during the facilitator training. The course director guided thefacilitators and provided counsel as and when required, including addressing questions

which arose during the training. Co-course director and the clinical instructor worked

closed with the course director who reinforced their knowledge and skills on how toconduct the training.

During the practical sessions, the participants had an opportunity to manage and followup a severely malnourished child who was transitioned from F-75 to RUTF with good

response within two days.

There was another child with a feeding problem which had not been noticed by the wardstaff. Participants were able to appreciate the importance of assessing and observing a

feed in all patients on admission in order to establish whether there was a feeding

problem or not. It is equally important to assist and teach mothers how to feed a severelymalnourished child with a feeding problem, this includes insertion of a naso-gastric tube

if the child is unable to take adequate amounts of a feed orally.

A third child admitted with poor appetite was successfully fed via a nasogastric tube until

the child was able to take F-75 by mouth on the second day.

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During the sessions in the Rehabilitation Centre, participants observed several childrenwith uncomplicated SAM being fed with RUTF. Two children with complications (one

with high fever and the other with marasmic-kwashiorkor) were identified and referred

for inpatient care in the malnutrition ward as per CMAM protocol of inpatient care.

During the clinical sessions, participants had an opportunity to learn and practice how toeffectively use the various daily monitoring charts to assess response to therapeutic andmedical care and use the same charts to identify and manage poor responders to

management. The participants had adequate practice on measurement of MUAC and

checking for oedema including monitoring of patients on OPC.

1.7 Facilitators meeting

The facilitators held daily meetings at the close of each day. During these meetings,facilitators presented progress reports including any questions from the participants

regarding course materials or any issues relating to the course.

During the training the following questions were raised:

Vitamin A in children with oedema and eye signs Provision of additional zinc in children with SAM presenting with diarrhea

The Course Director gave some guidance and provided literature on studies on Vitamin Ain children with oedematous SAM.

Children with oedematous SAM should not be given Vitamin A until after theresolution of oedema

An exception to this rule was a child with oedematious SAM with eye signs,suggestive of Vitamin A deficiency who should receive 3 therapeutic doses of

Vitamin A to prevent blindness

On the issue of additional zinc for severely malnourished children with diarrhea, the

course director provided guidance that all the therapeutic feeds (F-75, F-100 and RUTF)and ReSoMal had a lot of zinc, hence there was no need to give additional zinc

supplements

1.8 Outcome of trainingThe two groups worked almost at the same pace on the first day. However, from day 2,

Group A took the lead but by a small margin.

The participants worked well and went through all the modules as per course schedule

which is attached in annex 4 and Annex 5.

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III COURSE DIRECTORS OBSERVATIONS

AND RECOMMENDATIONS

OBSERVATIONS:

The training was generally well organized. The Hotel where most of theparticipants and facilitators were accommodated was good, comfortable withprofessional and courteous staff. All the rooms had internet connection free of

charge. The meals as mentioned were satisfactory and there were no significant

complaints from the participants on quality of the meals.

Transport was arranged for the pick from the hotel in the morning and eveningsfrom PML Childrens hospital. However, since there was only one bus,

participants who finished classes earlier had to wait for the facilitators to join after

their meeting. This probably inconvenienced the participants, even though no onecomplained. The journey back to the hotel took much longer due to heavy traffic

The classroom work generally went on well with no major problems. The twogroups of participants had the video sessions together after which they held group

discussions in their respective classrooms.

PML Childrens hospital had made efforts to implement inpatient managementguidelines of SAM after the 2007 training. The hospital has separate ward forchildren with SAM and mothers are allowed to say by their childrens bedside 24

hours a day.

All the admitted patients are given broad spectrum antibiotics on admission withprovision to go to second line in case of non response

Baseline investigations (Full Blood Count, Malaria test) and HIV testing in somepatients are carried out during inpatient admission. Other investigations arecarried out as indicated.

All the patients receive broad spectrum antibiotics including Vitamin A and ZincSupplements.

Generally the hospital has good record keeping, with all patients given casemanagement files which are stapled together to avoid loss of the notes There is a day room on the same floor where mothers have their meals, receive

visitors and spread out on the floor to lie down for a quick nap. However, thehand wash basins are non functional and need to be replaced.

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There is no sharing of beds, this is good in that it prevents direct correct infectionfrom one patient to another

Hospital stay is free of charge for the first 5 days, after which a charge is imposedfor patients staying longer

There is an ablution block on the same floor of the ward for patients andcaregivers

F75 is incorrectly reconstituted since the amount of sugar added is less thanrecommended in the recipe given in the training modules. This puts patients atrisk of hypoglycaemia.

Some of the monitoring charts are maintained well and completed every day,these are: drug, feed (only amount given, not amount taken), temperature andweight charts (though all the weights recorded were incorrect).

There were some problems identified on the implementation and overallmanagement of admitted children with SAM. Among these are:

1. Admission to the malnutrition ward is based on clinical signs. Eventhough there was an old MUAC tape found at the Nurses post, none of

the admitted children had MUAC measured on admission to determine

presence of severe wasting. Children are weighed with clothes on. Thisresulted in recording a higher than the actual weight of the patient. This

was evident during the training when patients were weighed correctly by

the participants all the patients had higher than the actual weight

recorded on the charts.

2. Generally the management of admitted children was poor, feeding of thechildren is not assessed. During the training one of the admitted patientswith SAM had feeding problems and needed a naso-gastric feed. But this

was not done and the patients continued to feed poorly with poor response

3. Ghana has adopted MUAC as a measure of wasting and this is reflected indraft National Guidelines which have been developed to address SAM in

children aged under-5 years. However, it is unusual for children aged 5

years and above to present with SAM, particularly in relation withHIV/AIDS and other chronic illnesses e.g. tuberculosis.

MUAC as a measure of wasting is only applicable for use in children aged6 59 months. In infants aged


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During the case management training, a child aged six and half years wasadmitted with SAM on the malnutrition ward. This child needed to have

weight-for height measured to determine the presence of severe wasting

In view of the above, there is need for GHS to consider including

measurement of length/height in children outside the age range covered byMUAC in order to correctly measure wasting in these children by way ofweight-for-length/height SD scores.

.

4. Vitamin A was given routinely to children with oedema on admission5. All children were given zinc supplements despite being on therapeutic

feeds which already contained a lot of zinc. Such practice may lead to

zinc toxicity. ReSoMal also contained zinc, hence there is not need togive additional zinc SAM children presenting with diarrhoea

6.

Feeding was not regular, children were started on 4 hourly feeds onadmission from morning till 18.00 hours when the kitchen was closed for

the night. Even during the daytime, some of the feeds are missed

7. Admitted children are given other foods, mainly a light porridge (pap) andsome family foods from home when they should be exclusively on

therapeutic milk feeds

8. Generally the care of admitted SAM patients is poor, there is noobservation and supervision of feeds. This results in non identification ofchildren with poor feeding

9. SAM children with diarrhea are given WHO formulation of OralRehydration Solution which is unsuitable and dangerous for children with

SAM as it contains a lot of sodium, less potassium and inadequate

amounts of glucose. ReSoMal is never prepared despite the hospitalhaving Combined Mineral and Vitamin Mix (CMV) in the pharmacy. The

pharmacy is supposed to make ReSoMal but this is not done.

10.As mentioned above, the F-75 prepared in the kitchen contains lessglucose putting newly admitted SAM patients at risk of hypoglycaemia

11.The pharmacy dispenses CMV in small quantities to make 1 litre of feed,however, on cross checking, the amounts dispensed are more than half a

scoop which is the amount required to make one litre of milk feed

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12.The scale on the ward is not digital and difficult to caliberate13.The length board on the ward is made according to the correct

specification but this is rarely since length/height is not routinelymeasured on admission and during hospital stay. The plastic length

measuring mat is wavy and does not stretch out smoothly

14.The ward is not free of draughts and is cold at night15.The hospital does not provide individual Insecticide Treated Mosquito

nets

16.Mothers are not given food while in hospital17.There is no facility for hand washing for mothers in the ward and in the

day room. There are two sinks which are non functional

18.The Fische chart is not fully and correctly filled out for each individualadmitted patient with SAM. MUAC is not measured on admission and

and oedema is not monitored as required on the monitoring chart

19.There is a Rehabilitation Centre behind PML where RUTF is being givento children with uncomplicated SAM. However, children admitted forinpatient care of SAM are not started on RUTF as per CMAM guidelines.

This probably results in prolonged hospital stay since patients aretransitioned to F-100 on the malnutrition ward

During the training participants picked out the correct and incorrect practices of inpatient

management of SAM during the clinical practice sessions. The incorrect practices were

discussed in class with the facilitators. Corrections were made and communicated to theward staff, dietician and the medical officer in charge of the hospitalto effect change.

Some action points were discussed with the hospital in charge.

Discussions and suggestions were made to the hospital in-charge and dietician(both were participants in the case management training) to give 3 hourly feeds

of F-75. A discussion was held with the dietician, specifically on the incorrect

recipe of F-75. A change was made immediately to correct this situation Suggestions were made to ensure day and night provision of therapeutic feeds.

Some suggestions were made as follows:

(i) consider changes to enable kitchen staff work shifts(long term).

(ii) Hospital to purchase thermos flasks where feeds couldbe stored so that patients are fee 3 hrly at night after the

kitchen closed (immediate)

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(iii) Consider involving nurses on the malnutrition ward towarm refrigerated feeds and give the same to the

patients overnight when the kitchen closed. This wouldbe achieved if more nurses on the ward were trained in

case management of SAM

One of the admitted patients was successfully transitioned from F-75 to RUTFwith a possibility of early discharge as soon as the medical complications wereunder control

Identified a severely malnourished child whose poor feeding had not beenidentified by the ward staff. A nasogastric tube was inserted for feeds withappropriate counseling to the mother.

Course director prepared a protocol for inpatient management of SAMmalnutrition with input from the co-course director and clinical instructor. Thisattached at the end of this report as Annex 6

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COURSE DIRECTOR SUMMARYTraining Course on Community-based Management of Severe Acute Malnutrition

Location of course: Sun Lodge Hotel/Princess Marie Louise Childrens Reverend

Campbell Malnutrition Ward, Accra. Ghana

Facilitator Training:

Dates of Facilitator training: 25/08/2009 - 28/08/2009

Number of full days: 4Number of Facilitators trained 10 + 1 trained as Clinical Instructor +

1 trained as Co-Course Director

CMAM Course:

Dates of course: 31/08/1009 - 5/09/2009

Number of full days: 6

Total number of hours worked in course: 40Total number of participants trained: 15

Clinical Sessions:

Number of sessions conducted 5

Number of hours( per group) devoted to

Clinical sessions 5 hours

Modules Completed:

All the participants completed all the 7 Modules, including the updates toThe training modules and additional materials provided on CMAM

Each of the participants received a copy of the course materials and manual to

Take home including all the additional materials provided during the course

Number of facilitators serving at the course: 9

One of the trained facilitators, Mr Neequaye involved in administrative assignmentcourse.

Ratio of facilitator to participant: 1 : 2

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RECOMMENDATIONS

1. There is need to effectively use the Course Directors Guide to ensure adequatepreparation of the facilitator and case management trainings. This includesguidance on selection of inpatient facility including all the necessary equipment

and supplies

2. The inpatient and Outpatient training facility should have all the necessaryfunctional anthropometric equipment. Preferably mother-infant SECA scales,

digital infant weighing scales, MUAC tapes, length/height measuring boards

should be made available

3. The National guidelines should include guidelines on management of SAM inchildren 5 years and above

4. There is need to train more facilitators who should be selected from the pools ofhealth workers who have been trained in case management.

5. There is need to quickly conduct case management training to enable the newlytrained facilitators consolidate their newly acquired skills and improve capacity in

all the implementing inpatient facilities

6. All staff from PML childrens hospital need to be trained, particularly the nursesand doctors working in the malnutrition ward, the matron, sisters in charge from

all the wards including staff working in the emergency and outpatient wards. .

7. Supplies of therapeutic feeds, combined Mineral and Vitamin Mix (CMV) andutensils for preparation of therapeutic feeds and ReSoMal including kitchen

weighing scales should be procured, if not made available at the site of trainingand in all health facilities where the recently trained participants are working. .

8. PML hospital and other health facilities where inpatient care of SAM are admittedshould implement the Ten Steps of case management of SAM. Priority shouldbe given to transition from F-75 to RUTF and not F-100 as is currently being

done. This will enable the hospital to fully implement CMAM since there is

already a programme of OPC just behind he hospital (in case of PML) wherepatients are being successfully managed with RUTF with some form of

supplementary feeding programme going on in this same centre

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9. As the country sets about implementing CMAM within its health system, there isneed to open up a lot of OPC sites as close to the community initially. Successful

implementation of OPC alongside Community Outreach activities which will

enable both acute moderate and severe uncomplicated cases of SAM to beidentified and managed at community level. This will lead to reduction of

complicated cases of SAM which require hospital care. Establishment of OPCshould then follow implementation of community based care services.

10.Once several OPC sites have been set up with the catchment areas of the inpatientfacilities, CMAM will be successfully implemented leading to significant

reduction in case fatality rates due to SAM

11.There is need to adopt a multi-sectoral approach in management of SAM andfoster linkages with other programmes like HIV/AIDS and Malaria programmewhich are well funded in order to improve care of SAM

12.The country should seriously consider treating children with SAM free of charge,particularly that, currently management of these children is supported by partners.

Equally attainment of MDG4 is closed linked with early and improved care of

SAM cases

13.There is need to partner with other stakeholders (WHO, UNICEF, FANTA,USAID etc) to ensure uninterrupted supply of therapeutic feeds (F-75, RUTF and

to lesser extent F-100, which is not longer required in large stocks with use ofRUTF), CMV, ReSoMal and essential drugs used in the case management of

SAM in inpatient and outpatient facilities.

14.The effort being made to promote local production of RUTF in partnership withNutriset France should be commended as this will result in a local source ofsupplies and reduce the costs since some of the major ingredients are available

locally.

15.There is need to advocate for large scale implementation and support of thesupplementary feeding programme in order to curb the large number of acute

moderately malnourished programme waiting to become severely malnourishedin order to access care

16.There is need to change the working conditions of kitchen staff in all inpatientfacilities to ensure continuous provision of feeds day and night

17.There is urgent need to finalize the National Guidelines on CMAM since anumber of health workers have been trained and will be in position to contribute

to this process. Equally the additional information from the WHO casemanagement modules should be included into the guidelines

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18.There is need to revise the current WHO case management training materials in

order to include proceedings of the 2004 and 2007 consultations including new

evidence which has been made available including new adaptations in view ofrecent developments (new WHO growth standards and use of RUTF). The

training materials should include CMAM guidelines and all the Reporting Formsrequired for appropriate programme monitoring and evaluation. In the currentform the training modules are outdated and training with a lot of annexes causes

confusion among participants

The updates received from WHO still have some omissions and certain areas require to

be revised still. There is need to constitute a small group of experts to look at all the

available materials with a view to produce one set of training materials which willinclude all the new information

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ANNEX 1 SCHEDULE FOR FACILITATOR TRAINING

DAY 1 Tuesday 25th August, 2009

Activity Time

1. Opening session

A. Introductions

B. Administrative tasks

C. Review of purpose of the course

2. Introduction to facilitator training

A. Context of facilitator training

B. Materials needed

C. Objectives of facilitator training

D. Teaching methods

E. Schedule for facilitator training

F. Introduction to Facilitator Guide

3. Module: Introduction

A. Review and Demonstration

B. Facilitator Techniques: Working with a Co-Facilitator

4. Module: Principles of Care

A. Facilitator Techniques: Introducing a module

B. Reading and work on module

C. Facilitator Techniques: Leading a discussion

D. Reading and work on module

E. Facilitator Techniques: Adapting for nurses groups

F. Facilitator Techniques: Individual feedback

G. Reading and work on module, practice group discussion

H. Facilitator Techniques: Oral drills

I. Reading and short answer exercisesJ. Facilitator Techniques: Video activity

K. Facilitator Techniques: Summarizing a module

5. Module: Initial Management

A. Reading and practice introducing moduleB. Facilitator techniques: Conducting a demonstration

6. Assignments for the next day:

Read and doe exercises inInitial Management module Read corresponding facilitator guidelines Prepare for assigned activities

30 minutes

45 minutes

15 minutes

4 hours

1.5 hours

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DAY 2 Wednesday, 26th

August, 2009

Activity Time

1. Continuation of Module: Initial Management

A. Practice of facilitator techniques

B. Facilitator Techniques: Coordinating role plays

2. Module: FeedingA. Introduction and Exercise A, preparing F-75 and F-100. Introduce

RUTF and discuss its composition

B. Facilitator Techniques: While participants are working

C. Reading/work through Exercise B; practice of facilitator techniques

D. Reading/work through end of module; practice of facilitatorTechniques

3. Assignments for the next day

Read and do exercises inDaily Care Module Read and corresponding facilitator guidelines Prepare for assigned activities

3 hours

4 hours

DAY 3 Thursday, 27th August, 2009

Activity Time

Clinical practice session

1. Module: Daily Care

A. Introduction of module, discussion of questions

B. Practice of facilitator techniques

2. Module: Monitoring and Problem Solving

A. Introduction and work on the module


3. Module: Involving Mothers in Care

A. Introduction of module


C. Facilitator Techniques: Review

2 hours

1.5 hours

3.5 hours

DAY 4 Friday, 28th August, 2009

Activity Time

1. Module: Overview of CMAM

2. Practical arrangements for the course

3. Closing Remarks to facilitators

4. Co-facilitators discuss plans for first day; set up classroom if possible

2 hours

1 hour

1 hour

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ANNEX 2 FACILITATOR LISTNAME DESIGNATION REGION TELEPHONECo-Course Director:Dr Thelma Brown Paediatrician Regional Hospital,Eastern Region +233 243 827519Inpatient Instructor:Dr Matilda Agyemang Medical Superintendent Ga South DistrictHospital - Greater Accra

Region+233 277 159809 matildaagyemang

Alice Nkoroi CMAM & Emergency NutritionSpecialist FANTA-2

Nutrition Department

GHS, Head Quarters +233 266 106542 [email protected] Adams Health & Nutrition Officer UNICEF ,Northern

Region +233 244 721294 cadams@unicefAkosua Kwakye Programme Officer, Nutrition WHO, Accra +233 243 316706 [email protected] Isaac Kobina Abban Senior Medical Officer,

Paediatrics PML ( Greater Accra) +233 244 776574 eboabban@gmaD Kwabena Sarpong Municipal Director of Health Saltpond Municipal

Hospital Central Region +233 244 292684 kobbymed@yahMichael Ammon

Neequaye Co-ordinator NutritionRehabilitation Nutrition Department,GHS Head Quarters +233 244 684216 mikeneeq@yahooRev. Sister Patricia Zhage Medical Assistant St. Joseph Hospital,

Kirapa, Upper West

Region+233 20 7021044

Dr. Memuna Tanko Senior Medical Officer Ridge Hospital, GreaterAccra Region +233 244 539960 mmabtanko@hotm

Catherine Adu-Asare Training Administrativeassistant

Nutiriton Department,

GHS, +233 244 871133 [email protected] Jennifer Welbeck Paediatrician Korle-Bu Teaching

Hospital, Accra +233 244 963625Course Director:Dr. Beatrice Amadi Paediatrician University TeachingHospital, Lusaka Zambia +260 966 752739 Beatriceamadi@y

32
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]


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ANNEX 3 : LIST OF PARTICIPANTS

NAME DESIGNATION REGION TDR ERNEST K ASIEDU MEDICAL OFFICER ASSIN FOSU,CENTRAL +23DR AUDREY FRIMPONG

BAAFI PAEDIATRICIAN KORLE-BU TEACHINGHOSP.ACCRA +23MONICA YELALIERE NURSE PRATITIONER REGIONAL HOSP,UPPER WEST +23DORIS AMARTEY NURSE PML,ACCRA +23SAMUEL GBOGBO ASSISTANT PROGRAM

MANAGER,IDD NUTRITIONHEADQUARTERS,GHS +23PRISCILLA TETE-DONKOR DIETITIAN PML, ACCRA +23PEACE SODOKPO NURSING OFFICER PML,ACCRA +23DR ERIC SIFAH MEDICAL

SUPERINTENDENT PML HOSPITAL,ACCRA +23SOFIE G. LASSEN ASSOCIATE

PROFESSIONALOFFICER(CHILD

&ADOL.HEALTH

WHO +23

CHRISTIANA AKUFO NURSING OFFICER INTITUTIONAL CAREDIVISION/GHS +23

DR GIFTY SUNKWA- MILLS MEDICAL OFFICER KASOA HEALTHCENTRE,CENTRAL +23

DR JULIANA MITCHELL MEDICAL OFFICER KORLE-BU TEACHINGHOSP.ACCRA +23

JULIANA PWAMANG MATERNAL AND CHILDHEALTH SPECIALIST USAID

DR PATRICK ATOBRAH SENIOR MEDICALOFFICER ZEBILLA HOSP. UPPER EAST +23DR ABDULAI A. FORGOR MEDICAL OFFICER NAV. MEMORIAL HOSP,UPPER

EAST +23

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ANNEX 4

CASE MANAGEMENT TRAINING ON COMMUNITY MANAGEMENT OF SEVERE ACUTE

MALNUTRITION (CMAM) - PML HOSPITAL, ACCRA

31st August 5th September, 2009

DATE ACTIVITY TIME

Monday:

31st August, 2009

09.30 - 17.30hrs

Registration

Module: Introduction+ updates

Module: Principles of Care + updates

MUACas measure of wasting

Composition ofRUTF(page 20)

Video: Transformations

Ward: Tour of the ward

5 hours

Tuesday:

1st

September, 2009

08.30 17.30

Module: Initial Management + updates

Video: Emergency Care

Kitchen: Making ReSoMalWard: Clinical signs, measuring MUAC

Weighing children

7 hours

Wednesday:

2nd

September, 2009

08.30 17.30

Module: Initial Management + updates(finish)

Module: Feeding + updates. Introduce RUTF

Reference Card

Kitchen: Making F75/F100. Discuss RUTF

Ward: Initial Management CCP Chart, including

MUAC assessment. Feeding on F-75

7 hours

Thursday:

3rd

September, 2009

08.30 17.30

Module: Feeding + updates (finish)

Module: Daily Care+ updates

Ward: Initial Management and Feeding transition

From RUTF/when to give F-100

7 hours

Friday:

4th

September, 2009

08.30 17.30

Visit to Rehabilitation Centre (PML)

Module: Daily Care + updates(finish)

Module: Monitoring and Problem Solving

+ updates

Ward: Monitoring patients on RUTF

Use of CCP charts to monitor progress

Criteria for Early Discharge

7 hours

Saturday:

5th

September, 2009

08.30 16.30

17.00

Module: Involving Mothers in Care + updates

Video : Teaching mothers about home feeding

Malnutrition and mental developmentPresentations: Overview of CMAM, Implementing

CMAM in Ghana. Monitoring Tools

WAY FORWARD (GHS)

CLOSING CEREMONY

6 hours

NOTE: TEA BREAKS : 10.30 11.00 and 16.00 16.30

LUNCH BREAK: 13.00 - 14.00

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Annex 5

Schedule for Clinical, Kitchen and Video Sessions:MONDAY TUESDAY WEDNESDAY THURSDAY

31st August 1st September 2nd September 3rd September

Ward 11.00 - 12.00 14.00 - 15.30 11.00 - 12.30 14.00 - 15.30

Tour of the ward Clinical signs and

MeasuringMUAC

&Weight

InitialManagement

CCP Chart

Feeding - F75

InitialManagement andFeeding: F-75 to

RUTF

Use of F-100

Kitchen **16.30 - 17.15 15.00 - 16.00

**Preparation ofReSoMal

Preparation of F75,F100Show RUTF

Video **14.00 - 14.30 **11.00 - 11.30

Group

A

**Transformations **Emergency

Care

Ward 12.00 - 13.00 11.00 - 12.30 14.00 - 15.30 15.30 17.00

Tour of the ward Clinical Signs andMeasuringMUAC

&Weight

InitialManagement

CCP Chart

Feeding F-75

InitialManagement andFeeding: F-75 to

RUTF

Use of F-100

Kitchen 14.30 - 15.15 10.00 - 11.00

Preparation of

ReSoMal

Preparation of F75,

F100show RUTF

Video **14.00 - 14.30 **11.00 11.30

Group B

**Transformations **Emergency

Care

**** FRIDAY 4TH SEPTEMBER: ECAH GROUP VISIT THE REHABILITATION CENTRE at the times

indicated in the schedule

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PROTOCOL

INPATIENT MANAGEMENT OFSEVERE ACUTE MALNUTRITION

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DEFINITION OF SEVERE ACUTE MALNUTRITION: SEVERE WASTING - Weight-for-length/height


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PRINCIPLES OF CARE

The child with Severe Acute Malnutrition (SAM) MUST be treated differentlybecause his physiology is seriously abnormal due to reductive adaptation.The systems of the body begin to shut down with SAM. The systems slow downand do less in order to allow survival on limited calories. This slowing down isknown as reductive adaptation.

As the child is treated, the bodys systems must gradually learn to function fullyagain. Rapid changes (such as rapid feeding or fluids) would overwhelm thesystems, so feeding must be slowly and cautiously increased (see Appendix 3 :Physiological basis for treatment of severe malnutrition)

How does Reductive Adaptation affect care of the child? Presume and treat infection Do not give iron early in treatment Provide potassium and restrict sodium

Things NOT to do: Do not give diuretics to treat oedema Do not give iron during initial feeding phase. Add iron only after the child

has been on F100 for 2days (usually week 2).

Do not give high protein formula Do not give IV fluids routinely

Ensure that personnel in the Emergency Treatment Area of the ho pital know theseimportant things NOT to do, as well as what to do! sPROCESS FOR SUCCESSFUL MANAGEMENT OF THESEVERELY MALNOURISHED CHILD

Treat/Prevent hypothermia and hypoglycaemia by feeding, keeping warmand treating infection

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Treat/prevent Dehydration using Rehydration Solution for Malnutrition(ReSoMal) Correct electrolyte imbalance (by giving feeds and ReSoMal prepared with

CMV) Presume and treat infection with antibiotics Correct micronutrient deficiencies (by giving feeds prepared with CMV andfolic acid as needed) Start Cautious feeding with F-75 TO STABILIZE the child (usually 2 7days) Rebuild wasted tissues through higher protein/calorie feeds READY-TO USE-THERAPEUTIC FOOD (RUTF) and plan for early discharge oncetaking RUTF well (finishes >75% of days ration) Provide stimulation, play and loving care Prepare parents to continue proper feeding and stimulation after earlydischarge to Outpatient Therapeutic Programme (OTP)

Note: If patient refuses to eat RUTF, but is finishing F75 CONSIDER giving F100for 1-2 days, then try giving RUTF again. Once able to consume >75% ofRUTF and has no complications, DISCHARGE to OT P

ON ADMISSION: Assess/Treat SHOCK, if present Assess/Treat hypoglycaemia

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Examine eyes (bitots spots, inflammation/pus, cornealclouding, corneal ulceration)

Check for diarrhea and managed accordingly**(Use CCP initial management chart)

MANAGEMENTOF HYPOGLYCAEMIA If blood glucose


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If diarrhea, circle signs present: skin pinch goe back slowlyRestless/irritable Lethargic ThirstySunken eyes Dry mouth/tongue No tearsIf diarrhea and/or vomiting, give ReSoMal, every 30 minutes for first 2hours, monitor and give:5ml/kg body weight ReSoMal every 30 mins for 2 hrs

Note and write down time of starting ReSoMal Monitor respiratory rate, pulse rate, if passed urine or not, number of stools,

number of vomits, hydrations signs and amount of ReSoMal given every 30minutes for 2 hours STOP ReSoM al if: increase in pulse and respiratory r tes, jugular veins

ngorged, increasing oedema e.g. puffy eyelidsa

eAFTER 2 HOURS:(re-weigh patient and use this new weight to calculate amount ofReSoMal and F-75 to give patient)For the next 10 hours, give ReSoMal and F-75 in alternate hours.Monitor every hour. Amount of ReSoMal to offer:)5 10 ml/kg body weight ReSoMal and alternate with F-75

Note and write down the time ReSoMal and F-75 is given Monitor respiratory rate, pulse rate, if passed urine or not, number of stools,

number of vomits, hydration signs and amount of ReSoMal and F-75 givenevery hour

STOP R SoMal if: increase in pulse and respiratory rates, jugular veinsengorged, increasing oed ma e.g. puffy eyelidse e

MANAGE SEVERE ANAEMIA: If haemoglobin


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Record amount of blood to be transfused, time transfusion started andended

Monitor temperature, pulse and respiratory rates during transfusionCHECK EYES FOR SIGNS OF VITAMIN A DEFICIENCYAND INFECTION

Check eyes for: bitots spots pus/inflammation corneal cloudingCorneal ulceration If ulceration, give Vitamin A and Atropine immediately. Record on daily

care page

Oral doses of Vitamin A:12 months 200,000IU Do not give Vitamin A to children with oedem . Give Vitamin A afteroedema resolves

FEEDING: Begin feeding with F-75 as soon as possible. If child is rehydrated, reweigh child before determining amount to feed. New

weight______ Amount for 3 hourly feedings: _____ml F-75 Record time of first feed If hypoglycaemic, feed of this amount (recorded above) every 30 minutesfor first hours. Continue until blood glucose reaches 3 mmol.lRecord all feeds on 24-hour Food Int ke Chart!

INVESTIGATIONS TO BE DONE ON ADMISSION: Malaria slide Full Blood Count

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Blood culture Urea and electrolytes including creatinine Urinalysis/urine culture

Lumbar puncture if indicated Stool examination (for persistent diarrhea only) Gastric lavage if indicated CXR Counsel and Test for HIV Other investigation as indicated

MEDICAL MANAGEMENT OF SEVERE ACUTE

MALNUTRITION with complications

1st line antibiotics: Benzyl penicillin 50,000 units/kg IV/IM every 6 hours for 5 days Gentamicin 7.5mg/kg IV/IM once daily for 7 days Cotrimoxazole prophylaxis for patients who are HIV positive (use dose

schedule as provided in ART Clinic)

2nd line antibiotics:

Cefotaxime (or any other cephalosporin) - follow sensitivity patternTreat Malaria as per National Guidelines

Amodiaquine/artesunate (dosage age-dependant)

Vitamin A 1 dose 12mo 200 000 IUDo not give Vitamin A to children with oedema. Give dose after

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Oedema clears.Do not give Vitamin A to children who recently received dose(during the past 4 weeks)

Give 3 doses of Vit min A (therapeutic doses) to all childr n withe Eyes signs of Vitamin A deficiency. Give therapeutic doses to suchChildren even when they have oedema to prevent blindnessVitamin A therapeutic dosing: Days 1, 2 and Day 14

Mebendazole 500mg stat (give to children > 2 years) Folic Acid 5mg OD Ferrous Sulphate in REHABILITATION PHASE (2 days after starting

F100)

NUTRITIONAL INPATIENT MANAGEMENT OFSEVERE MALNUTRITION:

1. Start 3 hrly feeds with F-75 orally or via NG tube if patient unable to takeorally. CHECK F-75 Reference Card for correct amount of 3 hrly feed

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using admission weight (or new weight if patient received ReSoMal for 1st 2hrs) . FEED DAY AND NIGHT!

i. Remember to use the right side of F75 reference card accordingto presence of oedema (+++) or (0, +, ++)ii. Record feeds offered and amount taken on 24-hr Feed IntakeChart

2. Every day CHECK and RECOGNISE readiness for Transition:i. Return of appetite (easily finishes 3 hrly feeds of F75)ii. Reduced oedema or minimal oedemaiii. Child may also smile at this stage

3. If patient is ready for TRANSITION start RUTF (Use Chart to lookup number of packets child should have per day. CONTINUE giving F75,but change to 4hrly feed (Look amount on the F-75 Reference Card, useadmission weight for amount to be given 4 hrly)

4.Offer RUTF (plumpy nut) - Explain key messages about RUTFHow to give RUTF to the child5. Ensure patient is being given RUTF as per instructions:

i. Eating RUTF from the packetii.

Being given clean and safe water to drink as patient eats RUTFiii. RUTF being given in small regular feeds (if possible x8/day)and patient finishes prescribed pkts/day (>75% of days rationeaten)6. Ensure mother does not:

i. Mix RUTF with waterii. Mix RUTF into porridgeiii. Put RUTF on breadiv. Give share RUTF with other children/adults for whom it has

not been prescribedDAILY CARE, MONITORING AND INVOLVINGMOTHERS

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1. Monitor patients progress every day by recording and reviewing informationrecorded on the CCP Charts ( Drug Chart; Temperature with RR and PRrecording; Weight Chart; Feed Intake Chart):

Ask mother/caretaker about patients any new symptoms every day as youdo the ward round (diarrhea, vomiting, cough, fever, sores in the mouthetc)

Ask if patient is finishing feeds (check patients cup to confirm that allmilk feed is finished and if on RUTFcheck how much RUTF is stillremaining)

It is important to observe how patient is taking milk orally and if onRUTF, observe feeding on same

Check Temperature Chart and note if hypothermia, hyperthermia present.Check Respiratory and Pulse Rate as recorded

Check Drug Chart to ensure that all prescribed medications are beinggiven correctly. Check how long patient has been on particularmedication and made decision if needs to continue

Check 24-Food Intake (Feed) Chart to see if prescribed feed is enteredcorrectly and patient is receiving feed. Check intake and ensure patient isbeing given feeds correctly

Check Weight Chart and assess response of patient as follows:i. If patient is on F-75, no weight gain is expected. If gainingweight (>0.2kg), reassess patient, diagnosis of severe acute

malnutrition may be wrongii. If weight gain while on RUTF praise and encouragemother/caretaker to continue feedingiii. If weight is static or weight loss on RUTF, try to investigatecause and intervene (evaluate patients condition symptoms,temperature and check intake of feeds). Counselmother/caretaker about your findings and actions required toremedy the problemiv. Children on F100 are expected to gain weight every day. If

no weight gain or weight loss, check if patient is taking feedswell; evaluate patient for continuing infection and/or newinfection and act accordingly2. If patients medical condition is under control and patient is finishing days

ration of RUTF, counsel mother about childs condition and prepare for earlydischarge to OPC to continue care

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CRITERIA FOR DISCHARGE TO OPC (Outpatient Care) Appetite returned (passed appetite test)and Medical complication resolvingand Bilateral pitting oedema decreasing ( + or ++)and Clinically well and alert

(marasmic kwashiorkor admission: bilateral pitting O dema resolved)

PRACTICAL IMPLICATIONS IN DISCHARGES FROMINPATIENT CARE:

Children with SAM who are discharged from inpatient care are referred tothe nearest outpatient centre (OPC). Please check the list of OPCs nearest toyour hospital including the clinic day

If there is no OPC site, continue outpatient treatment in the OPD by stafftrained in Outpatient care of children with SAM

Complete the Inpatient to Outpatient Treatment Card (Yellow card) withdetails of patients status on discharge. Fill out the patients status ondischarge in the first column on the reverse side of this card (Follow-up:Outpatient Care). The mother should be given this card to take to the OPCsite on first attendance.

Communicate with OPC site where the child is being referred (phone call orradio communication) Give details of the discharged patients for possiblefollow-up at home if the patient does not turn up

Children discharged from inpatient care are considered a priority for follow-up home visits during the first week in outpatient care, according to actionprotocol

On discharge, the mother is given sufficient RUTF to last until the nextOPC follow-up session. Key messages about the use of RUTF and basichygiene are discussed again with the mother

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Key messages should include:i How to feed RUTF to the childii When and how to give medicines to the child (if any given on

discharge )iii When to go to OPC for continued careiv The child should be taken to the health facility immediately if

his/her condition deteriorates (develops fever, fast breathing,unable to feed, has diarrhea and vomiting)

INPATIENT CARE FOR THE MANAGEMENT OF SAMIN INFANTS UNDER SIX MONTHS OF AGE

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Treatment for infants with SAM under 6 months of age, or with a weight belowfour kg, should be done within the context of infant and young child feedingrecommendations1. Breastfeeding support is an integral component of therapeuticcare for severely malnourished infants. This support includes protection and supportfor early, exclusive and continued breastfeeding, as well as reducing the risks ofartificial feedingfor non-breastfed infants. Infants who are not breastfed, and whoare particularly at risk, also need to be ensured of protection and support.

Problems related to feeding that lead to severe malnutrition in infants include amongother factors:

Lack of breastfeeding Partial breastfeeding Inadequate unsafe artificial feeds Mother dead or absent Mother malnourished and/or traumatised, ill, and/or unable to respond

normally to their infants needs

Disability that affects the infants ability to suckle, or swallow, and/or adevelopmental problem affecting infant feeding.

Severely malnourished infants need special care. The main objective of treatment ofthese infants is to improve or re-establish breastfeeding, provide temporary or longerterm appropriate therapeutic feeding as well as provision of nutritional,psychological and medical care for their caregivers. Ideally these infants should be

admitted into a separate section, away from where the other older severelymalnourished sick children are admitted. Infants less than 6 months withmalnutrition should always be treated in inpatient care. RUTF is not suitable forinfants less than 6 months as the reflex of swallowing is not yet present.

In this section guidance is provided on treatment of two categories of children lessthan 6 months as outlined below:1. Breastfed infants: infants less than 6 months with lactating female caregiver2. Non-breastfed infants: infants less than 6 months without prospect of being

breastfed

Infants over 6 months of age with a bodyweight below 4 kg will fall in thesecategories as well.

1 As outlined in WHO and UNICEF 2003 and IFE Core Group 2007.

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1. Breastfed Infants less than 6 months who have lactating mother or caregiver forwet nursingAdmission CriteriaBreastfed infants less than six months or less than 4 kg, if the infant has:

Presence of bilateral pitting oedema Visible wastingAlso:

Too weak to suckle effectively (independently of weight-for-length), or1.1. Routine Medicines and Supplements1. Antibiotics: No antibiotic treatment is provided unless there are signs ofinfection. Amoxicillin (for infants weighing minimum 2 kg): 30 mg/kg 2 times a

day (60 mg/kg/day) in association with Gentamycin.

Do not use Chloramphenicol in young infants.2. Vitamin A: 50,000 IU single dose at admission only.3. Folic acid: 2.5 mg (1 tab) in a single dose.4. Ferrous sulphate: As soon as the child suckles well and starts to grow, use F100,

which has been enriched with ferrous sulphate, diluted with 1/3 water (F100-Diluted). (See Feed Preparation in Section 5.1.2) It is easier and safer to use

F100-Diluted than to calculate and add ferrous sulphate to very small amountsof feed.

1.2. Dietary TreatmentThe objective is to supplement the childs breastfeeding with therapeutic milk whilestimulating production of breastmilk.

The infant should be breast fed as frequently as possible. Breastfeed every threehours for at least 20 minutes (more if the child cries or demands more)

Between one and a half hours after a normal breastfeeding session givemaintenance amounts of therapeutic milk

Provide F100-Diluted for children without oedema. (See Feed Preparation,below)

Provide F75 for infants with oedema and change to F100-diluted when theoedema is resolved.

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Quantities of F100-Diluted

F100-Diluted is given at 130 ml/kg/day, distributed across eight feedings perday

Use the look-up tables 1 below for maintenance amounts of F100-Diluted togive to infants during feeding using the Supplementary Suckling technique (seeFeeding Technique, figure 1 below). The quantity of F100-Diluted is notincreased as the child starts to gain weight.

Table 1: Look-up Table for amounts of F100-Diluted to give to an individualinfant per feedBodyweight (kg) F100-Diluted per feedif 8 feeds per day 1.2 Kg 25 ml per feed1.3 1.5 301.6 1.7 351.8 2.1 402.2 2.4 452.5 2.7 502.8 2.9 553.0 3.4 603.5 3.9 654.0 4.4 70

Regulation of Amount of F100-Diluted GivenThe progress of the infant is monitored by daily weight.

If the infant loses weight over 3 consecutive days but continues to be hungry andis taking all his F100-Diluted, add 5 ml extra to each feed2.

Generally supplementation is not increased during the stay in the facility. If theinfant grows regularly with the same quantity of milk, it means the quantity ofbreast milk is increasing.

If, after some days, the child does not finish all the supplemental feed, butcontinues to gain weight, it means that the intake from breast milk is increasing

and that the infant is taking adequate quantities to meet his/her requirements. The infant should be weighed daily with a scale graduated to within 10 g (or 20

g).

2 Maintenance amounts of F100 diluted are given using the Supplemental Suckling technique. If the volume of F100diluted being taken results in weight loss, either the maintenance requirement is higher than calculated or there issignificant mal-absorption.

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When an infant is gaining weight at 20 g per day (absolute weight gain):

Decrease the quantity of F100-Diluted by one quarter and gradually to one halfof the maintenance intake so that the baby gets more breast milk.

If the weight gain is maintained (10 g per day regardless of current weight) thenstop supplementary suckling completely.

If the weight gain is not maintained then increase the amount given to 75% ofthe maintenance amount for 2 to 3 days, and then reduce it again if weight gainis maintained.

If the caregiver is agreeable, it is advisable to keep the infant in the centre for afurther few days on breastmilk alone to make sure that s/he continues to gainweight. If the caregiver wishes to go home as soon as the infant is taking thebreast milk with increased demand, then they should be discharged.

When it is certain that the child is gaining weight on breast milk alone he or sheshould be discharged, no matter what his current weight or weight-for-length.

Feed PreparationFor a large number of children

Add a packet of F100 to 2.7 litres of water, instead of 2 litres to make F100-DilutedFor a small number of children

Add 35 ml of water to 100 ml of F100 already prepared, and that will give 135ml of F100-Diluted. Discard any excess milk after use. Do not make smaller

quantities. If you need more than 135 ml, use 200 ml of F100 and add 70 ml of water, to

make 270 ml of F100-Diluted and discard any excess milk after use. If F100 is not readily available these infants can be fed with the same quantities

of commercial infant formula diluted according to the instructions on the tin. Ifthere is a range of milk formulas to choose from, use a formula designed forpremature infants. However, infant formula is not designed to promote rapidcatch up growth. Unmodified powdered whole milk should not be used.

Feeding Procedure Ensure good breastfeeding through good attachment and effective suckling.

Avoid distractions and let the infant suckle the breast at his/her own speed.

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Build the mothers confidence to help milk flow. Encourage more frequent and longer breastfeeding sessions to increase milk

production and remove any interference that might disrupt breastfeeding. Use the supplementary suckling technique to provide maintenance amounts of

F100-Diluted.

ONLY feed with a naso-gastric tube (NGT) when the infant is not taking sufficientmilk by mouth. The use of NGT should not exceed 3 days and should be used inthe stabilization phase ONLY

Feeding TechniqueUse thesupplementary suckling technique to re-establish or commence breastfeedingand also for providing maintenance amounts of F100-Diluted to severelymalnourished infants. This technique entails the infant sucking at the breast while

also taking supplementary F100 diluted from a cup through a fine tube that runsalongside the nipple. The infant is nourished by the supplementary F100 dilutedwhile at the same time suckling stimulates the breast to produce more milk.

The steps required in using the supplementary suckling technique are simple. Thecaregiver holds a cup with the F100 -Diluted. The end of a NGT (size n8) is putin the cup, and the tip of the tube on the breast, at the nipple. The infant is offeredthe breast with the right attachment. The cup is placed 5 10 cm below the level ofthe nipple for easy suckling. When the child suckles more strongly it can lowered to

up to 30 cm.

Figure 1: Supplementary Suckling Technique

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After feeding is completed the tube is flushed through with clean water using asyringe. It is then spun (twirled) rapidly to remove the water in the lumen of the

tube by centrifugal force. If convenient the tube is then left exposed to directsunlight.

1.3. Individual monitoringThe following parameters should be monitored daily and entered on the individualtreatment card (multi-chart):

Weight Degree of oedema (0 to +++) Body temperature (twice per day) Standard clinical signs: stool, vomiting, dehydration, cough, respiration and

liver size

Any other record: e.g., absent, vomits or refuses a feed, and whether thepatient is fed by naso-gastric tube or is given IV infusion or transfusion.

1.4. Supportive care for mothersSupportive care for breastfeeding should be provided to mothers, especially in verystressful situations. Focus needs to be directed at creating conditions that willfacilitate and increase breastfeeding, such as establishing safe breastfeeding cornersfor mothers and infants, one-to-one counselling, and mother-to-mother support.Traumatized and depressed women may have difficulty responding to their infantsand require mental and emotional support which should also support an increase inbreastfeeding. It is important to assess nutritional status of the mother (MUAC andoedema). Explanation should be provided to the mother on the different steps of

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treatment that their child will go through and efforts should be made to strengthenthe mothers confidence and discourage self criticism for perceived inability toprovide adequate breast milk. Alert the mother on the risk of having a newpregnancy during this period.

Adequate nutrition and supplementation for breastfeeding mothersBreastfeeding women need about 450 kcal per day of extra energy. Essentialmicronutrients in breast milk are derived from the mothers food or micronutrientsupplement. Therefore it is important that the mothers nutrient and energy needsare met. The mother should consume at least 2,500 kcal/day. It is suggested that thehealth facility should provide nutritious food for the mother. The mother shouldalso receive Vitamin A (200,000 IU, unless there is a risk of pregnancy) if the infantis less than two months. Dehydration may interfere with breast milk production. It istherefore important to ensure that the mother drinks at least two litres of water per

day.

1.5. Discharge CriteriaDischarge Criteria

Breastfed infant less than six months or less than four kg on admission:

Successful re-lactation with effective suckling = Minimum 20g weight gain per day on breastmilk alone for five days

No bilateral pitting oedema for two weeks Clinically well and alert and has no other medical problemAdditional recommendations: Mother has been adequately counselled and has received the required amounts of micronutrient

supplements during the stay at the health facility and for use at home.

1.6. Follow-up after dischargeFollow-up for these children is very important. In areas where services are available,

the mother should be included in t

Report Training Management Sam Accra 31aug 6sept2009 (1)

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