HM Medical Clinic

 

Draft protocol

National
Medical Protocol
Community Based
Management of Acute Malnutrition
FOR PILOT
March 2009
Table of Contents

Routine medicines . Acronyms

Community Based Organisation Community-based Management of Acute Malnutrition Community-base Therapeutic Care Therapeutic milk used in Phase 1 of in-patient treatment for severe acute malnutrition Therapeutic milk used in Transition Phase and Phase 2 of in-patient treatment of severe acute malnutrition Female Community Health Volunteer Gastro-Intestinal Health Worker (at HP or SHP) Integrated Management of Childhood Illness International Units Moderate Acute Malnutrition Maternal and Child Health Worker Mid Upper Arm Circumference Naso-gastric Tube Nutrition Rehabilitation Home Out-patient Treatment Programme Out-patient Department Primary Health Centre Oral Rehydration Solution for severely Malnourished patients Ready to Use Therapeutic Food Severe Acute Malnutrition Stabilisation Centre Supplementary Feeding Programme Therapeutic Feeding Unit Village Health Worker Weight for Height Weight for Length CMAM Model
THE CMAM MODEL
The Community-based Management of Acute Malnutrition (CMAM), originally known as Community-based Therapeutic Care (CTC), approach maximises impact and coverage by bringing nutrition services closer to the household and reducing opportunity costs to carers. It works through decentralized service delivery at regular health facilities (e.g. Primary Health Care Centres, Health Posts and Sub Health Posts) managed by Ministry of Health and Population (MoHP) staff, where necessary supported by NGO staff. Early case-finding and mobilization are prioritized so that most of the cases of severe acute malnutrition (SAM) can be treated before complications develop. This allows the majority of children to be treated at home through the provision of basic drugs, a take home ration of Ready-to-Use Therapeutic Food (RUTF)1 and community based follow-up. CTC was developed in emergency settings, where it was mostly run directly through NGOs. The CMAM approach aims at the sustainable integration of management of acute malnutrition in the regular health services system. The approach combines three modes of care: Improved Feeding Program – counselling programme for children with moderate
acute malnutrition without complications promoting home-based production of
Sarbottam Pitto2 and behaviour change in child feeding and caring practices.
In the case of nutrition emergency this mode of care can be enhanced or substituted
by a Supplementary Feeding Program (SFP) – an extra food ration of fortified
blended flour for children with moderate acute malnutrition without complications
(either as dry ration for home preparation or through (wet-) feeding centres).
Outpatient Therapeutic Program (OTP) – home-based treatment and rehabilitation
with weekly (or in some cases fortnightly) ready-to-use therapeutic food (RUTF)
distributions, medical treatment using simplified medical protocols, and regular
follow-up for children with severe acute malnutrition without complications
Stabilisation Centres (SC) – Inpatient care for acutely malnourished children with
medical complications and/or no appetite using standard WHO/IMCI protocols as in
phase 1 of a standard Therapeutic Feeding Centre (TFC).
Emphasis is also placed on the linking of CMAM programs with other food security, health and sanitation interventions in order to more holistically address the needs of the affected population. 1 Ready to Use Therapeutic Food – this is a complete food for the treatment of severe malnutrition. It does not require any preparation. It contains no water and is therefore resistant to bacterial contamination. For specifications see Annex 6 2 Sarbottam Pitto is a nutritious mixed flour composed of roasted soya beans, maize and wheat or rice, developed specifically for the context of Nepal Core operating principles of CMAM3 Maximum coverage and access – CMAM is designed to achieve the greatest possible coverage by making services accessible to the highest possible proportion of a population in need. It aims to reach the entire severely malnourished population. Timeliness – CMAM aims to begin case-finding and treatment before the prevalence of malnutrition escalates and additional medical complications occur. Appropriate care – CMAM provides simple, effective outpatient care for those who can be treated at home and clinical care for those who need inpatient treatment Care for as long as it is needed. By improving access to treatment, CMAM ensures that children can stay in the programme until they have recovered. This national medical protocol for the community-based management of acute malnutrition (with focus on SAM, but including moderate acute malnutrition (MAM) in Nepal is intended for the instruction and reference of medical doctors, nurses, and programme staff involved in the management and supervision of CMAM programmes. The protocol is based on the WHO protocols for in-patient management of SAM. There are no essential differences as far as the systematic medical treatment is concerned between out-patient or in-patient management. The major difference is that children that do not need specific medical attention for stabilisation of their conditions are treated on an outpatient basis. This shift is facilitated by replacement of water-based F100 Therapeutic milk, which is highly susceptible to bacterial growth, by an oil-based ready-to-use Therapeutic food that can be fed at home under supervision of a caretaker. For the purpose of training in Nepal, a full package of training manuals and guidelines has been developed to train the different level of health staff and community workers. Further manuals and training suggestions on CMAM can be obtained from the website of FANTA (Food and Nutrition Technical Assistance). These materials have been developed internationally in a joint effort between nutrition organisations involved in the research and trials on which the approach is based. 3 Reference: Community-based Therapeutic Care: A Field Manual. First edition, 2006, Valid PROGRAMME DESIGN
Screening
Moderately Acutely Malnourished
Severely Acutely Malnourished
(aged 6-59 months) (aged 6-59 months) MUAC <125 mm and ≥115 mm MUAC < 115 mm AND: No bilateral pitting oedema OR: Bilateral Pitting Oedema Child with Complications referred for investigation Assessment of Complications Child with NO Complications NON Complicated
COMPLICATED
Counselling
For specifications OR: bilateral pitting See table (2) page (7) Child Feeding and Child Care At HF: Vit A / Albendazole APPETITE
Referral to FCHV for further counselling In emergency: admission to Admission
Stabilisation Centre
Supplementary Food WHO protocol Phase 1 Routine Medicines After discharge from OTP the child is referred to FCHV for counselling After stabilisation and transition phase the child can be referred to OTP If child deteriorates it should be referred to HF for investigation and If child deteriorates in OTP it should be transferred to SC if complicated transferred to SC for investigation Screening
ADMISSION PROCESS

Screening:
Malnourished children (aged 6 months to 5 years) are identified by: Measuring the mid –upper arm circumference (MUAC) and Checking for the presence of bilateral pitting oedema. This can be done: In the community (FCHV, VHW, MCHW, ECD staff, etc.) In SHP, HP, PHC and Out-Patient Department (OPD) of Hospitals The criteria to be admitted to the programme are shown in the table below.
Table 1 Admission and Discharge criteria
Nutrition status
Admission criteria
Discharge criteria
MUAC < 115 mm no bilateral pitting and/or presence of bilateral pitting minimum weight gain of 15% of admission (W/H < -3 Z-score) 5 and clinically well MUAC < 125 mm MUAC > 125 mm (W/H < - 2 Z-score (W/H > - 2 Z-score, for and > -3 Z-score) at least last two weeks)
MUAC and bilateral pitting oedema are the preferred admission criteria however, if
there is the desire to admit additional cases of malnutrition on the basis of weight-for-
height criteria, and there are the resources to do so and quality can be ensured, this
protocol has the flexibility to allow this.
4 Children less than 6 months should be treated as per WHO standard SAM protocols for inpatient care 5 All cases with confirmed 115 mm MUAC – also those with W/H > -3SD (new WHO standards) - will be admitted to OTP or referred to SC. At health facilities, where assessment capacity for height measurements exists, W/H criteria can be used to identify additional cases, if treatment capacity is available. 6 A joint WHO/UNICEF statement on the implications of the new WHO growth standards based on an informal consultation in June 2008 has been drafted and will be released soon. The statement endorses new admission and discharge criteria. A 15% weight gain for all children admitted to therapeutic feeding programmes, regardless of whether they were admitted on MUAC or on weight for height is the acceptable discharge criteria. For children with oedema discharge is based on 15% weight gain using the weight after oedema has disappeared as the baseline. For children who have a weight for height above -3SD or a MUAC above 115mm after oedema has disappeared, a discharge two weeks after oedema disappeared is usually sufficient to prevent relapse. MUAC is not a good indicator for recovery because the change of MUAC as a result of treatment is not well established. COUNSELLING OF MODERATE ACUTE MALNUTRTITION

Assessment for Danger Signs / Medical Complications
The screening staff at the community level will assess all children with MUAC < 12.5
cm (moderate acute malnutrition) for medical complications based on "danger signs"
related to the criteria for transfer to in-patient care. All children showing any signs of
possible complications will be referred to the nearest health facility for further
assessment of the child‟s nutrition and health status.
At the health facility a qualified person should assess for medical complications using
the criteria for transfer to in-patient care (see page 8) and refer any complicated
cases to SC
Counselling
Non complicated moderately acutely malnourished children (MAM) identified by
MUAC < 12.5 cm should be given counselling on the importance of nutrition for child
development and proper child feeding and child care practices. Special attention
should be given to the home based preparation of Sarbottam Pitho, energy density of
child food and feeding frequency, hygiene and sanitation, and the importance of
sharing responsibilities for child care among family members as per their time
availability.
All non-complicated MAM children will be referred to the FCHV for further monitoring
and counselling of the child until it has reached MUAC > 12.5 cm. The FCHV will
encourage caretakers to take their children to the outreach clinic for growth
monitoring in order to track improvements or deterioration of their nutritional status,
and get relevant counselling.
If weight increase is not achieved within two months after identification of MAM or
when the nutritional status of the child further deteriorates, it will be referred to the
nearest health facility (with OTP) for investigation and systematic medical treatment,
and if necessary referred to the Stabilisation Centre.
Supplementary Feeding
In case of food insecurity or nutrition emergency supplementary feeding programme (SFP) can be started, distributing dry rations of fortified blended food to moderate acutely malnourished children without medical complications. Caretakers of MAM children should be counselled on the appropriate use and preparation of the food. HF-based Out-Patient Treatment
OUT-PATIENT THERAPEUTIC PROGRAMME
Uncomplicated Severe Acute Malnutrition
Identified by:
Children 6 months to 5 years MUAC < 11.5 cm Bilateral Pitting Oedema (+ and ++) (W/H < -3 Z-score) All children less than 6 months of age identified with severe acute malnutrition should be treated in in-patient care till complete recovery, as per the international WHO protocol. OTP Process
Give identified severely acutely malnourished children sugar-water7 10% solution to drink, or water if sugar-water is not available, as the majority of SAM cases will be hypoglycaemic. Give according to how much the child can tolerate but the amount should be approximately 50ml. If the children receive RUTF immediately after arriving then it may not be necessary to give sugar water8. However, all cases that are transferred to SC must receive it. Children referred from the Stabilisation Centre to an Outpatient Treatment Point after recovery from medical complications do not receive routine medicines because they did already get them during stabilisation. They are dealt with as in a follow-up visit for OTP. Anthropometrical Measurements If screening was done at the community level additional anthropometrical measurements need to be taken upon admission at the Health Facility: MUAC (in mm) Bilateral pitting oedema Weight (for weight gain assessment during follow up visits, and for W/H) Length or Height (in cm, with one decimal) (only for monitoring data collection and for W/H as admission criteria) 7 Sugar water is approximately 10% sugar solution – 10g of sugar per 100ml of water HF-based Out-Patient Treatment
Assess condition of child and presence of complications  Assess the appetite; test with RUTF (annex 8) – if child initially refuses move the child and carer to a quiet area. The health worker must observe the child eating the RUTF before the child can be admitted to out-patient care programme  Take history for Diarrhoea, Vomiting, Stools, Urine, Cough, Appetite, Breastfeeding, Swelling, Oedema (See annex 9)  Carry out medical assessment (as per IMCI with additional focus on malnutrition  Asses home situation on possible causes leading to malnutrition
Table 2. Criteria for admission to in- or out-patient care:
In-patient care
Out-patient care
Bilateral pitting oedema Grade 3 (+++) 8 Bilateral pitting oedema Marasmic kwashiorkor (WHZ<-3SD/ MUAC < 11.5 cm AND oedema) (+ and ++) Appetite
No appetite or unable to eat Yes, good appetite Vomiting Intractable (empties contents of stomach) Fever > 101.3 °F (38.5°C) under arm pit; (102.2°F/39°C rectal) Temperature Hypothermia < 95 °F (35°C) under arm pit; (96°F/35.5°C rectal) ≥ 50 resp/min from 6 to 12 months ≥ 40 resp/min from 1 to 5 years Respiration rate ≥ 30 resp/min for over 5 year olds And any chest in-drawing (for children > 6 months) Very pale (severe palmor pallor), difficulty Anaemia breathing Superficial Extensive skin infection requiring Intra- infection Muscular treatment Very weak, apathetic, unconscious Alertness Fitting/convulsions Severe dehydration based primarily on recent history of diarrhoea, vomiting, fever, anuria Hydration status (lack of discharge of urine), thirst, sweating & 8 See Annex 8 for specification of grades of Oedema HF-based Out-Patient Treatment
Decide if complications are present using the criteria defined in table 2 above.  If complications are present explain to the carer the need for in-patient care and refer to nearest Stabilisation Centre.  Assess whether the caretakers will go to the SC. Caretakers unable or unwilling to take their severely acutely malnourished child with medical complications to the hospital should be counselled about the increased risk of mortality due to SAM, and the limitations of the capacity of the health post to cure their child.  In case caretakers refuse to go to hospital, regular treatment of medical complications as per standard medical protocol should be undertaken. However, special care should be taken in consideration of compromised and weak metabolism. If the child recovers from medical complications and regains sufficient appetite, he/she can then be admitted to the Health Facility-based outpatient CMAM programme.  If there are no complications present the child can be treated in OTP TREAMENT UPON ADMISSION
Nutrition Treatment
Nutritional treatment is through the use of Ready-to-Use Therapeutic Food (RUTF) 9. (Plumpy‟Nut® is the imported RUTF produced by Nutriset in France). The amount of RUTF a child should consume is determined by the need for an intake of 200 kcal/ kg/ day. 10  Teach the carer how to open the packet (after making sure the packet is clean on  Explain to the carer how to give RUTF to the child in small amounts frequently (up to 8 times a day), and to finish the entire allocated daily ration each day before giving any other food.  If the mother is still breastfeeding, she is advised to always give the RUTF after  Emphasise that the RUTF is both a medicine and a diet that is vital for the recovery of the child.  Explain that plenty of clean water – what the households uses for drinking - should always be given to a child eating RUTF to maintain sufficient hydration. Children will need to drink more water than normal. Water should be given according to thirst as indicated by the child.  Give orientation on purification of water through boiling and cooling, with water guard, or with purification tablets.  Give orientation on hygiene and the importance of hand washing with clean water and soap for both caretaker and child before handling food (RUTF) and after each defecation 9 CMAM does not use a food-based approach for treatment of severe malnutrition, because it requires very intensive guidance and instruction on diet preparation, which can not be made available through regular health services at community level. 10 This is comparable to the WHO recommendation of 150 to 220 kcal/kg/day for phase 2 of the in-patient management of SAM (for justification see calculations in Annex 4). The CMAM recommendation allows for some sharing with siblings. HF-based Out-Patient Treatment
Amounts of RUTF to give The amount given to each patient is according to its current weight. Give the ration
amounts as per the table below to each patient to take home:
Table 3. Amount of RUTF to feed and take home in OTP*
92 g (1 sachet) of PN has 500Kcal
(average amount to feed: 200kcal/kg/day)
Weight of child
Consumption per
Ration per week
Ration per day
(No of Sachets)
(No of sachets)
(No of sachets)
Give small amount every 3 hours (day and night), with water to drink
* Since open packages could not be kept overnight in case of rats and other
infestations, the number of sachets has been rounded-up for the take-home rations.
Actual feeding requirements are reflected under „consumption‟; for further details see
Annex 5.
Systematic Treatment / Routine Medicines

Vitamin A
One dose on the day of admission to OTP. Children with oedema should not be given Vitamin A dose, unless there are signs of deficiency (these children receive vitamin A on day of discharge) Do not give if the child has received vitamin A in the last one month, or if a national Vitamin A campaign is up-coming within the next month, to prevent toxicity. Vitamin A systematic treatment: Vitamin A IU orally on day of admission
6 months to 11 months 12 months to 5 years HF-based Out-Patient Treatment
Systematic Antibiotics
Antibiotics should be given to every severely malnourished patient, even if they do not have signs of systemic infection as the presence of infection may be masked due to immuno-suppression which limits response such as fever. Give on admission Give 3 times a day for 7 days (10 days if needed) The first dose should be given in front of the health worker and an explanation given to the mother on how to continue this treatment at home. The antibiotic regimen (this can be changed according to the resistance pattern of bacteria that arises from time to time):  First line treatment: Amoxicillin11 Dosage of Amoxicillin Weight (kg)
Tablets 250mg
125 mg (½ tablet) tid 250 mg (1 tablet) tid 375 mg (1½ tablet) tid 500 mg (2 tablets) tid Amoxycillin tablets and syrup are equally effective but risk of wrong doses is less in dispersible tablets. Weight (kg)
Syrup 125mg/5ml
Syrup 250 mg/5ml
125 mg (5ml) tid 125 mg (2.5ml) tid 250 mg (10ml) tid 250 mg (5 ml) tid 375 mg (15ml) tid  Second line treatment Oral Chloramphenicol can be used for children who have not responded to Amoxycillin e.g. continued fever that is not due to malaria. Give 3 times for 7 days. 11 Amoxycillin is also effective in reducing the overgrowth of bacteria in the GI tract, commonly associated with severe acute malnutrition, and therefore preferred over Cotrimoxazole which is standard first line antibiotic in Nepal. HF-based Out-Patient Treatment
Dosage of Chloramphenicol Weight (kg)
Syrup 125mg/5ml
62.5 mg (2.5 ml) tid 125 mg (5 ml) tid 250 mg (10 ml) tid 375 mg (15ml) tid Weight (kg)
Tablets 250mg
125 mg (½ tablet) tid 250 mg (1 tablet) tid 375 mg (1½ tablet) tid Measles All severe acute malnourished children from 9 months and older should be given measles vaccine on week 4 of their admission in the OTP programme12, 13. Children younger than 9 months at admission will be given the vaccination when they complete 9 months, after at least 4 week in OTP. Malaria In malaria endemic areas and for patients from endemic areas, where no tests are available, in case of fever below 39ºC and no further medical complications present, systematic treatment with Chloroquine for suspected malaria is given for all patients on admission, according to the national IMCI protocol. 14 15 Monitor the child closely for first 48 hours, and if fever condition develops and does not improve, immediately refer to nearest facility where Plasmodium falciparum can be diagnosed. 12 Severely malnourished children cannot build a sufficient antibody response to give satisfactory protection. The vaccination is given on week 4 so that the nutritional status has improved sufficiently to ensure an antibody response. 13 Measles vaccination for CMAM OTP patients should be arranged harmonised with EPI immunisation services for cold-chain requirements. 14 Sulfadoxine-pyrimethamine (Fansidar) is part of the regular protocol for treatment of Falciparum malaria, this drug should not be given within 7 days of folic acid supplementation. 15 An intravenous infusion of quinine is not safe in severe malnutrition HF-based Out-Patient Treatment
Dosage of Chloroquine Syrup 50mg/5ml** Age less than 12 Age less than 12 * Chloroquine syrup should not be administered on empty stomach ** One teaspoon is equal to 5 ml of chloroquine syrup Iron and folic acid Iron-folic acid is not to be given routinely. When moderate anaemia is identified according to IMCI Guidelines, treatment should begin after 14 days in the programme and not before16 and given according to National/WHO guidelines17. For severe anaemia (palmar pallor) refer to inpatient care. Folic acid is not part of the standard protocol, since the quantity of folic acid present in RUTF is sufficient for needs of the malnourished child.18 De-worming Albendazole is given at the second visit (week 2 [or week 3 for fourtnighly follow-up]) as it is better absorbed after re-conditioning of the Gastro-Intestinal tract with Amoxycillin. Dosage of Albendazole <1 year
1 to 2 years
>= 2years

Supplemental medicines
Other medical conditions/symptoms should be treated according to the clinician‟s judgement. See Annex 2 for a list of supplemental medicines. 16 Iron is contra-indicated in severely malnourished children as a high-dose may increase the risk of severe infections and therefore in case of moderate anaemia should be given after 14 days after initiation of the treatment. 18 Since Sulfadoxine-pyrimethamine (Fansidar) is part of the national protocol for Falciparum malaria treatment, if malaria is suspected upon admission, no folic acid should be given within 7 days. HF-based Out-Patient Treatment
Follow-up visits
Children‟s progress is monitored on a weekly basis19 at the health facility (SHP, HP, or PHC)  Weight is measured  Degree of oedema (0 to +++) is assessed  MUAC is taken.  Length or Height is measured every 4 weeks. (if W/H is admission criteria)  Medical check is completed  Discuss appetite and perform RUTF appetite test only if there seem to be problems (see page 7, and annex 8)  Give new ration according to current weight  Discuss home situation and needed changes in care, hygiene, and feeding  Arrange for home-visit by FCHV or VHW if weight gain is unsatisfactory (static weight or even weight loss since last visit)
At each subsequent visit, a full medical check is conducted. Based on this clinical
diagnosis, additional supplemental medicines may be given to children, as required
and according to protocols. The medical check and RUTF test will show if children
should be transferred to in-patient care.
Table 4. Criteria to move from out-patient to in-patient care
Additional Criteria during Follow-up
Increase of / development of oedema Marasmic kwashiorkor (W/H<-3 Z-score/ MUAC < 115 mm AND oedema) Appetite
No appetite or unable to eat As defined in table for admission to in-patient care (page 7; see also Annex 1) Weight changes
Weight loss for 3 consecutive weighings (2 consecutive weighings for 2 weekly follow-up) Static weight for 5 consecutive weighings (3 consecutive weighings for 2 weekly follow-up) Other general signs the health worker thinks warrants referral (as per IMCI) 19 Out-patient care can be carried out fortnightly depending on the situation. For example, if mothers are defaulting because they are too busy or the site is far then they may be more likely to attend a fortnightly session. HF-based Out-Patient Treatment
Discharge from OTP

Discharge Criteria
(for all cases, both admitted on MUAC and on W/H)
If target weight gain (15%) has been reached. (See table in Annex 11) No oedema for two consecutive visits AND weight gain has been satisfactory for last two consecutive visits For children with oedema discharge is based on 15% weight gain using the weight after oedema has disappeared as the baseline. Children that have a weight for height above -3SD or a MUAC above 115mm after oedema has disappeared, will be discharged two weeks after oedema disappeared. (Children admitted based on MUAC, should not be discharged on targeted W/H, since this is not applicable to them, and may be reached earlier than actual rehabilitation) Upon discharge children admitted with Oedema will get one dose of Vit A Children that did not get a doses of Vitamin A upon admission, because they were admitted with oedema should get a single dose upon discharge. Other children do not get this discharge dose. Upon discharge children admitted at age 6 to 9 months should get follow-up appointment for second measles vaccination Children that were younger than 9 months when they were admitted and were not yet administered a measles vaccination should get a vaccination of measles once they complete 9 months of age, like any other child. If the child has completed 9 months of age during its treatment in OTP, and did not yet get a measles vaccination the caretaker should get a very firm appointment for follow-up visit during EPI hours, or to visit the nearest EPI outreach clinic as soon as possible to receive the vaccination. Upon discharge the child will get a last ration To facilitate a smooth transition from the complete and balanced RUTF diet to the regular family diet, a last ration of therapeutic food should be provided upon discharge. Child might get last ration of 7 sachets of RUTF (for one week) A ration of supplementary RUTF (logistically complex, but providing additional micro-nutrients to complement a nutrient poor family diet) A supplementary feeding programme (SFP) ration, and referral to nearest SFP site, if a programme is available in the area (generally only in situation of nutrition emergency) Upon discharge the caretaker should get Counselling Discuss home situation, care practices, feeding practices, food preparation for Support the mother to improve home feeding environment… (if young, suggest her to ask FCHV to explain to her husband and her in-laws) HF-based Out-Patient Treatment
Refer to the FCHV for follow-up counselling on improved child feeding and care practices after two weeks / one month/ and two months Follow-up of rehabilitated cases to prevent relapse
After discharge from OTP children are followed up for three times during 2 months in the community where the family is given counselling on Sarbottam Pitto and child feeding and caring practices.  FCHV should make follow-up visit after two weeks / one month / and two months to see how transition has gone, and if child is still growing well.  Any problems with child feeding, nutrition or health should be counselled. In-Patient Stabilisation Centre
STABILISATION CENTRE
Complicated Acute Malnutrition Identified by:
Acutely malnourished children 6 months to 5 years (severe or moderate):  Severe nutritional oedema (+++)  MUAC < 125 mm and/or Bilateral Pitting Oedema (+, ++) (or W/H < -2 Z-score) Medical complications (see Annex 1) and / or no appetite Children less than 6 months of age* with:  A body weight below 3 kg and incapacity to suckle, lack of breastmilk  Identified with severe acute malnutrition (weight loss, ‘baggy pants', and/or nutritional oedema * Infants less than 6 months of age should be treated in in-patient care till complete recovery, as per the international WHO protocol.
Cases identified as complicated will be treated in in-patient care as per the
International WHO protocol until their medical condition is stabilised and the
complications are resolved.
Then the child can continue rehabilitation in out-patient care until weight
recovery is achieved.
This part of the CMAM protocol for stabilisation treatment of severe acute malnutrition highlights treatment components of the inpatient treatment in relation to the outpatient programme. The general principles for routine care should be kept in mind at all times: Treat/prevent hypoglycaemia Treat/prevent hypothermia Treat/prevent dehydration Correct electrolyte balance Treat/prevent infection Correct micronutrient deficiencies Start cautious feeding Achieve catch up growth Provide sensory stimulation and emotional support Prepare for follow-up after recovery In-Patient Stabilisation
Upon admission, once immediate life-threatening conditions are taken care of as per WHO guidelines for treatment of severely malnourished children, reconfirm nutritional status of the child by anthropometric measurements. Anthropometric measurements:
Measurements to be taken during admission to In-patient Care MUAC Bilateral pitting oedema Weight Length or Height While MUAC is used as admission criteria Weight for Length/Height z-score should be calculated for monitoring purposes. Nutrition treatment
SAM cases with medical complications F75 (130ml =100kcal) should be given for patients of all ages except for the less than 6 months old infant without oedema. There should be 8 feeds per day (continue feeding at night) 20, see table 5. Breast-fed children should be offered breast-milk always before the diet and always on demand. Preparation Add 1 packet of F75 to 2 litres of water. This gives 2.4 litres of F75. The amount given to each patient is according to its current weight. Give the amounts as specified in table 5 on page 18 for each individual patient. MAM cases with medical complications21 Cases with good appetite are given RUTF to prevent nutritional deterioration. The amount is according to weight of the child as per table 3 (page 9). Cases with NO appetite are given F75 initially, till appetite returns, as per table 5. Children transferred to SC because of static weight Cases that are transferred to SC because of lack of weight gain in OTP are treated with RUTF immediately. 20 In case of unforeseen circumstances, like sudden absency of staff, the feeding schedule could be adapted to 6 feeds 21 The metabolic system and organ functions of MAM cases have not yet been decreased due to reductive adaptation and therefore they can start with RUTF immediately upon admission in the SC, if they have appetite. In-Patient Stabilisation
Table 5. Amounts of F75 to give during in-patient care
8 feeds per day
6 feeds per day *
Class of Weight (kg)
ml for each feed
ml for each feed
* Under regular circumstances always arrange for eight feeds per 24 hours, including night shifts. In exceptional circumstances, when eight feeds are suddenly not possible, this schedule should be re-adjusted to minimum 6 feeds per 24 hours. Routine medicines
Vitamin A Provide on the day of admission. Dosage of vitamin A systematic treatment Vitamin A IU orally on day 1
12 months (or 8 kg) and more On the day of admission – except for children with oedema, unless there are signs of deficiency (Children admitted with oedema receive vitamin A on day of discharge) In-Patient Stabilisation
Do not give vitamin A if child has received vitamin A in the last one month, or if there is a vitamin A campaign up-coming. Folic acid Provide on the day of admission.  5 mg as one single dose,  2.5 mg as one single dose, in malaria endemic area, if the child has no history Systematic Antibiotics Antibiotics should be given to every severely malnourished patient, even if they do not have signs of systemic infection. The antibiotic regimen (this can be changed according to the resistance pattern of bacteria that arises from time to time in the environment of the unit):  First line treatment: Amoxicillin 23 (if Amoxicillin is not available, use Ampicillin)  Second line treatment: two options: o plan a) add Chloramphenicol and continue Amoxycillin o plan b) add Gentamicin and continue Amoxycillin  Third line: individual medical decision. Duration of antibiotic treatment: Every day during Phase 1 + four more days. Dosage of Gentamycin, Amoxycillin and Chloramphenicol Gentamicin
Amoxycillin Chloram-phenicol
Amoxycillin
in mg (Syrup125mg/ml) 62.5 mg (2.5 ml) * 3 22 No folic acid should be given within 7 days after administrating Sulfadoxine-pyrimethamine (Fansidar) which is the national protocol for Falciparum malaria treatment, because it works antagonistic on drug effectiveness. Thus if malaria is suspected upon admission, no folic acid should be given till malaria status and treatment are determined. 23 This is recommended as second-line antibiotic by IMCI: it is given to these grossly immuno-compromised patients who are severe enough to be admitted into hospital Amoxycillin is also effective in reducing the overgrowth of bacteria in the GI tract, commonly associated with severe acute malnutrition, and therefore preferred over Cotrimoxazole which is standard first line antibiotic in Nepal. In-Patient Stabilisation
For inpatient treatment, national malaria treatment protocol should be followed. In case of fever, in endemic areas and for patients from endemic areas, if laboratory capacity for malaria microscopy or Rapid Diagnostic Test is available at the Stabilisation Centre / Hospital, all severe acute malnourished patient should be tested for malaria. Treat positive cases according to the national guidelines for Vivax malaria and Falciparum malaria respectively. Dosage of Chloroquine/ Primaquine for confirmed Plasmodium vivax Age less than 12 months**
Age 12-59 months
Chloroquine
Primaquine
Chloroquine
Primaquine
(tablet 150mg)
(tablet 7.5 mg)
(tablet 150mg)
(tablet 7.5 mg)
* Chloroquine syrup should not be administered on empty stomach; Repeat dose if there is vomiting within half an hour of Chloroquine administration ** Primaquine is not given to children below 1 year of age and pregnant women Dosage of Sulphadoxine-pyremethamine for confirmed Plasmodium falciparum Weight (Kg) Age
Single Dose
Single Dose
(tablet 500 mg
(tablet 7.5mg)
Sulphadoxine plus 25 mg
Primaquine*
* Primaquine is not given to children below 1 year of age and pregnant women; the dosis is given as a gametocytocidal after schizontocidal treatment If Sulfadoxine-pyrimethamine is administered no folic acid should be given within 7 days of administration, because of its antagonistic affect on drug effectiveness. All children should be watched carefully for the next 48 hours, as resistance is an increasing problem all over the country. In high Plasmodium prevalent districts Artemisinin-based combination therapy (ACT) with artemether-lumefantrine - Coartem® is given as first line treatment in patients whose body weight is higher than 10 kg. The dosage of Coartem® is 8/48 mg/kg body weight, in 6 doses divided over 3 days. Sulfadoxine-pyrimethamine will be phased out and completely replaced by Coartem®. In-Patient Stabilisation
Dosage of Artemether-Lumefantrine for confirmed Plasmodium falciparum Dose (for three days)
Weight (Kg)
(tablet 20 mg Arthemether plus 120 mg
Lumefantrine)
*Children aged 2-11 months and/or weighing less than 10 kg should not be treated with Coartem. However, they should also not be treated with intravenous quinine since this is not safe in severe malnutrition, so either oral or intra-muscular administration should be practiced. Where no tests are available systematic treatment of suspected malaria is given for all patients with fever and other symptoms of malaria, according to the national guideline for suspected malaria. Monitor the child closely for first 48 hours, and if fever condition does not improve, immediately refer to the nearest facility where Plasmodium falciparum can be diagnosed. If there is no response to malaria treatment or complications arise, refer to the national malaria treatment protocol for further treatment. 24 All children from 6 months and older should be given measles vaccine on admission. Children aged less than 9 months at admission should be given a second measles vaccination on discharge after completing 9 months of age.
Treatment of complications

PLEASE REFER TO WHO PROTOCOL FOR TREATMENT OF SEVERE ACUTE
MALNUTRTION
 Shock from dehydration  Shock from sepsis  Severe anaemia 24 An intravenous infusion of Quinine is not safe in severe malnutrition In-Patient Stabilisation
Monitoring at Stabilisation Centre (SC)
 Weight is measured each day.  The degree of oedema (0 to +++) is assessed each day.  Body temperature is measured twice per day.  The standard clinical signs (stool, vomiting, dehydration, cough, respiration, liver size, etc.) are noted each day.  MUAC is taken each week.  Length or Height is taken after 21 days  A record is taken if the patient is absent, vomits or refuses a feed, and whether the patient is fed by naso-gastric tube or is given I-V infusion or transfusion. This information is collected for each feed, each day.
Transition phase for discharge to OTP
As soon as the medical condition of the patient is stabilised and the complications are resolving, the transition phase is started. For transfer to OTP, transition is started by feeding the child RUTF at alternate feeds. If the child refuses the RUTF, the carer is encouraged to try to get the child to start eating at every other milk feeding. In the meantime, F75 is continued until appetite returns. To test and confirm the complete recovery of appetite of a child, the child should be able to eat at least three quarter of his/her RUTF ration at each meal in a day. The child can then be referred to the OTP for continuation of the treatment at home, with RUTF.
Discharge criteria from SC to OTP25
 Appetite returns – child eats >75% of RUTF daily ration  No medical complications  Oedema is resolving
Follow-up after discharge from SC
Children are followed up for rehabilitation in the OTP closest to their home. Caretakers should get clear instruction and counselling why it is important to get admission at OTP after discharge from SC. A referral slip specifying the treatment provided in SC should be given to facilitate admission and proper follow-up at HF-based OTP. A MAM child discharged from the SC is classified as cured and returns home where the FCHV provides nutrition counselling to the care taker. 25 Children <6 months old admitted into SC should be treated in in-patient care following WHO protocols till complete recovery, meaning until satisfactory suckling and sufficient breast milk production is observed leading to appropriate daily weight gain and the child is clinically well and alert. Appropriate weight gain for an infant under 6 months means a minimum of 20g per day gained due to breastfeeding alone over a period of 5 consecutive days. In-Patient Stabilisation
De-worming Upon discharge from SC all children are given a single dose of Albendazole. Dosage of Albendazole <1 year
1 to 2 years
>= 2years
Take-home ration of RUTF to bridge the referral gap till admission in OTP On discharge from SC give enough RUTF ration for one week (to last until the next OTP appointment). Provide the caretaker with key messages on use of RUTF and hygiene as specified in the OTP protocol (page 8). Discharge criteria
DISCHARGE CRITERIA

From SC to OTP:
Appetite returns – child eats >75% of RUTF daily ration No medical complications Oedema is resolving MUAC > 11.5 cm, No bilateral pitting oedema Clinically well 15% weight gain as compared to admission weight Other Discharges
Category of Discharge
Defaulter
Absent for 3 consecutive Absent from SC for 2 (or two consultations if follow-up visits are every 2 weeks) Died while in OTP Died while in SC Has not reached discharge criteria within 3 months Transfer
Medical transfer
Referred elsewhere for medical care and nutrition; treatment is not provided by the programme Where possible, VHW, MCHW and FCHV should trace those patients that default and need to be followed up. This is to encourage defaulters to return and complete treatment, but also to find out what are the reasons for defaulting and if there is anything that needs to be changed in the programme to prevent defaulting. The names and addresses of the defaulters can be obtained from the register. Monitoring and Evaluation
MONITORING AND EVALUATION
The following indicators are used to measure the performance of the programme. Data collection is performed through registration and reporting from community and
health facility level. Complicated calculations can be performed at the district level, or
health facilities with computer facilities.
Proportion of exits
Each month the numbers of cured patients, deaths, defaulters and transfers (referrals) are expressed as percentages of the total number of patients leaving the programme during the reporting month. Exit = Patients leaving the programme; whether discharged and recovered, or due to death, defaulting, or transfers to other (higher level) treatment facilities Recovery rate
Recovery rate = No of children successfully discharged (recovered) / No of exits Death rate
Death rate = No of deaths in the programme / No of exits Defaulter rate
Defaulter rate = No of defaulters / No of exits Transfer rate
Transfer rate = No of transferred / No of exits False admissions
Case admitted above MUAC and WFH criteria
Mean length of stay
This indicator should be calculated for ONLY the recovered patients for each category. Mean length of stay = Sum of (Number of days for each recovered patient) / Number of recovered patients
Mean rate of weight gain
Average weight gain is calculated for all RECOVERED patients for each patient category (OTP / SC, sex groups). Calculation is performed in three steps: 1. Individual Total weight gain = discharge weight(g) – admission weight(g) 2. Individual Weight gain in g/kg/d = Individual total weight gain (g) admission weight (kg) x no of days between date of minimum weight and discharge day 3. Average rate of weight gain is then: Average weight gain (g/kg/day) = Total sum of individual weight gains Total No of individuals To facilitate the calculation and speed up data processing a simple programme can be written in Excel. If the above mentioned monitoring data are entered into the computer then it is simple to calculate the length of stay and rate of weight gain. Monitoring and Evaluation

Minimum performance standards
Programme data is compared to monitoring indicators developed by the Sphere project. Reference values for the main indicators Sphere project Acceptable
Alarming
Recovery rate
Death rate
Defaulter rate
Coverage

Standardised recording and reporting formats
Standardised recording and reporting formats will be developed in line with this protocol by the Nutrition Section (MOHP), in consultation with pilot implementing partners during preparation of the implementation, and should be used for programme monitoring and reporting. Standardised patient cards and tally sheets will be developed accordingly. (To be attached as Annexes, once developed and tested within pilot programme) 1. Medical complications
2. Supplemental medicines
3. Medical equipment and supplies
4. Community Mobilisation
5. Energy and Protein Intake for Out-Patient Treatment
6. Ready to Use Therapeutic Food
7. Comparison of Nutrient Content
8. Appetite Test
9. Checking for Bilateral Oedema
10. WHO – W/H table
11. 15% Weight gain table
MEDICAL COMPLICATIONS

Medical Complications requiring In-patient Care
Child younger than 6 months Bilateral pitting oedema Grade 3 (+++) Marasmic kwashiorkor (W/H< -3SD / MUAC <11.5 cm AND oedema + or ++) Increasing or development of oedema Appetite
No appetite or unable to eat Vomiting Intractable (empties contents of stomach) Fever > 101 °F (38.5°C) under arm pit; (39°C rectal) Temperature Hypothermia < 95 °F (35°C) under arm pit; (35.5°C rectal) ≥ 50 resp/min from 6 to 12 months ≥ 40 resp/min from 1 to 5 years Respiration rate ≥ 30 resp/min for over 5 year olds Any chest in-drawing (for children > 6 months) Anaemia Very pale (sever palmar pallor), difficulty breathing Extensive skin infection requiring Intra Muscular injection Superficial infection treatment and follow-up monitoring Very weak, apathetic, unconscious Alertness Fitting/convulsions Severe dehydration based primarily on recent history of Hydration status diarrhoea, vomiting, fever, anuria, thirst, sweating & Weight changes
Weight loss for 3 consecutive weighings (2 consecutive weighings for 2 weekly follow-up) Static weight for 5 consecutive weighings (3 consecutive weighings for 2 weekly follow-up) Other general signs the health worker thinks warrants Non response
Not recovered after 3 months in OTP and repeated home visits; should be examined in SC to investigate causes SUPPLEMENTAL MEDICINES FOR OTP
Medicine
Special Instructions
Chloramphenicol syrup or tablets (second line antibiotic for non- Continue for 7 days Bloody diarrhoea, longer Syrup 100mg/5ml and 200 Dose 20-30 mg/kg/day* Continue for 5 days Wash eyes before application Tetracycline eye ointment Apply 3 times per day Continue for 2 days after infection has gone Continue for 7 days Lower doses according to Fever over 101ºF (38.5ºC) Syrup 125 mg/5ml Single doses only – do weight than for IMCI** NOT give to take home26 Apply over whole body Avoid eye contact. Lotion 25%; 200ml below neck; repeat without Do not use on broken or bathing following 3 days. secondary infected skin. Wash off 24 hours later. Ringworm and other fungal Continue treatment until Whitfields or zinc ointment Apply twice a day condition has completely resolved Minor abrasions or fungal Can be repeated at next 1% watery solution visit and continued until condition is resolved Betadine solution All children referred to SC 10 g sugar in 100 ml 50 ml to all children (to make sugared water 10% (before leaving); if possible all children waiting for OTP 26 Patients with fever over 101.3ºF /38.5 ºC (axillary) should be referred to hospital or stabilisation centre; the single doses should be given at health facility before transfer. Medicine
Special Instructions
Moderate anaemia According to WHO Ferrous Sulphate/Folate according to IMCI ONLY to be given after 14 protocols (INACG 1998) days in the programme Do NOT give Intravenous For non-response to first According to national infusion of Quinine to Second line anti-malarial malaria treatment protocol severely malnourished children
*Metronidazole dosages
Syrup: 125 mg / 5 ml
62.5 mg (2.5 ml) tid 125 mg (5 ml) tid 250 mg (10 ml) tid **Paracetamol dosages
Syrup: 125 mg / 5 ml
25 mg (1 ml) stat 62.5 mg (2.5 ml) stat 125 mg (5 ml) stat 250 mg (10 ml) stat Medical Equipment required at OTP facility
Medical Equipment
Nutritional status assessment Cut-off at 115 and 125 mm 10 Weight measurement (25 kg, 100 g) plus pants Length/height measurement Weight for Height Z- Nutrition assessment % weight gain table Nutrition assessment To dispense medicines to be Symbols to indicate proper Water for washing Hand towels / paper Examination gloves Serving sugar solution Serving sugar solution Water jug with lid Water purification tablets, For drinking water Dressing scissors Normal saline for Mortar and pestle COMMUNITY MOBILISATION
Community mobilisation is a range of non-clinical activities that are carried out in the catchment area of the health facility (SHP, HP, or PHC). The two main objectives are: to ensure that the maximum possible number of severely malnourished children access treatment (achieve good programme coverage), to increase community awareness on malnutrition. Initiating community mobilisation encompasses discussions held with key people in the community to give orientation on the nutrition, malnutrition, and the CMAM programme. This may be through having group discussions with key people or through more informal channels (e.g. informal one-to-one conversations). Through these discussions community organisations and community groups that can be agents for community sensitisation and awareness raising can be identified. Working with these community agents the awareness on the importance of nutrition, causes of malnutrition, and other determinants of nutrition status can be created. The CMAM programme and the treatment they can expect can be explained and promoted to the community members. Once the people understand the programme, they can spread the message and mothers will know about the opportunities how and where to seek treatment for their malnourished child. Key messages to disseminate are:  Describe the physical characteristics of target children  Announce the location and schedule of programme activities (screening and Subsequently, community volunteers (from CBOs), if feasible in collaboration with Female Community Health Volunteers (FCHVs), are mobilised to perform screening of children under five during group meetings to actively identify SAM cases among their members‟ children. FCHVs can screen children during their regular community work. This can be either when children come to the Female Community Health Volunteer for other issues, or by going house-to-house. Once mothers come to know about the service and are worried their child is malnourished, they may come to the FCHV specifically for screening. Screening is simple and involves two things: Taking the MUAC Checking for bilateral pitting oedema If the child meets the admission criteria for either MUAC or oedema they can be referred to the nearest OTP centre ((Sub) Health Post / Primary Health Care centre) for further assessment and admission to the programme. Referral can also take place on the basis of danger signs for medical complications and a MUAC of 115-125 mm (yellow) These activities are additional to regular health services like outreach clinics providing growth monitoring, as performed by VHW and MCHW, that should be enhanced with MUAC screening. These health workers play an important role in community sensitisation, screening and referral. The joint community mobilisation and screening activities should disseminate the messages necessary to eventually ensure maximum coverage by: ensuring that mothers/carers know if their child is severely malnourished and what to do if he/she is malnourished Female Community Health Volunteers working in the community make sure they screen for severely malnourished cases Where possible, VHW, MCHW and FCHV can trace those patients that default and need to be followed up. This is to encourage defaulters to return and complete treatment, but also to find out what are the reasons for defaulting and if there is anything that needs to be changed in the programme to prevent defaulting. The names of the defaulters can be obtained from the register. For example, if mothers face large distance or time pressures, the day of the OTP consultation at the health facility could be planned according to other activities in the area like a market day when mothers are in the vicinity anyway. ENERGY AND PROTEIN INTAKE FOR OUT-PATIENT TREATMENT
Literature References
1. Energy and protein requirements. Report of a Joint FAO/WHO/UNU Expert Consultation. Technical Report Series. 724. WHO, Geneva. 1985. (http://www.fao.org/DOCREP/003/AA040E/AA040E07.htm#ch6.3) 2. Management of severe malnutrition: a manual for physicians and other senior health workers. WHO, Geneva, 1999 (ISBN 92 4 154511 9) 3. MSF Nutrition guidelines Energy Requirements for Rehabilitation
Energy requirements for healthy children: Ref 1, page 91 - Average energy requirements for children aged 1 to 5 years is 100 kcal/kg/day Ref 1, page 143 - Children need 5 kcal per gram of tissue laid down Energy requirements for children recovering from severe malnutrition: Ref 2, page 21 - WHO recommends between 150 and 220 kcal/kg/day Ref 3, page 85 - MSF recommends a minimum of 200 kcal/day Ref 2, page 22 – WHO states children usually gain 10-15 g/kg/day Ref 3, page 150 – MSF recommends 10-20 g/kg day weight gain At a rate of 5 kcal per gram tissue lay-down:  10g/kg/day means a child would need an extra 50 kcal/kg  15g/kg/day means a child would need an extra 75 kcal/kg  20g/kg/day means a child would need an extra 100kcal/kg This amount added onto the 100kcal/kg/day energy requirement for healthy children means 150 - 200 kcal/kg/day for children in rehabilitation. There is a margin for sharing, wastage etc. included in the overall recommendation of 150-220 kcal/kg/day. The WHO protocol states that if children‟s intake is less than 130 kcal/kg/day the child is failing to respond. Protein Requirements for Rehabilitation
Ref 1, page 104 – Protein requirements for health growing children 1.13 gram protein /kg/day Ref 1, page 143 – Children need 0.23 gram of protein per gram tissue laid down In relation to targeted weight gain this means:  10g/kg/day requires 2.3 g/kg (total requirement of 3.43g)  15g/kg/day requires 3.45 g/kg (total requirement 4.58g)  20g/kg/day requires 4.6 g/kg (total requirement 5.73g) Ref 3, page 85 - MSF mentions protein requirement is 5g protein /kg/day 10% of energy should be protein calories: 10% of 200 kcal is 20 kcal; 1g protein gives 4 kcal, therefore 20 kcal is 5g of protein. The recommendation of 10% protein-energy ratio is given in the 1985 Joint report (Ref 1). Ref 2, WHO protocol of 150 kcal/kg using F100 therapeutic milk gives 3.75 g protein; 220 kcal/kg gives 5.5 g.
Amount of RUTF to feed based on energy and protein recommendations
92 gm (1 sachet) of PN has 500Kcal
(average amount to feed: 200kcal/kg/day)
Weight of child
Consumption
Ration per week
Ration per day
(No of Sachets)
(No of sachets)
(No of sachets)
Give small amount every 3 hours (day and night), with water to drink
READY TO USE THERAPEUTIC FOOD

Ready-to-Use Therapeutic Food (RUTF) is an energy dense mineral/vitamin enriched
food nutritionally equivalent to F100, which is recommended by the WHO for the
treatment of malnutrition27. It is oil-based with low water activity; thus it is
microbiologically safe and can be kept for months in simple packaging. Therefore,
with proper hygiene instruction, RUTF can be safely used for outpatient treatment of
Severe Acute Malnutrition. As it is eaten uncooked, it is an ideal vehicle to deliver
many micronutrients that might otherwise be broken down by cooking. Studies have
shown that severely malnourished children given RUTF had a faster rate of recovery
than those given F-10028.
While RUTF is a generic name, Plumpy‟nut® is the trademark name for the
manufactured product from the French company, Nutriset29.
General Description:
Ready-to-Use Therapeutic Food, in individual sachets of 92 grams. (Plumpy'Nut®)
Composition:
Vegetable fat, peanut butter, skimmed milk powder, lactoserum, maltodextrin, sugar,
mineral and vitamin complex.
1 sachet = 92 grams of product = 500 kcal.
Nutritional value per 100g of product:
Energy: 545 kcal Proteins: 13.6 g = 10% protidic calories Lipides: 35.7 g = 59% lipidic calories (Thus by deduction: 31% carbohydratic calories = 42.2 g carbohydrates ) Vitamins:
Minerals:
Vitamin A: 910 micrograms Vitamin D: 16 micrograms Phosphorus: 394 mg Vitamin E: 20 mg Potassium: 1111 mg Vitamin C: 53 mg Magnesium: 92 mg Vitamin B1: 0.6 mg Vitamin B2: 1.8 mg Vitamin B6: 0.6 mg Vitamin B12: 1.8 microgram Iodin: 110 microgram Vitamin K: 21 microgram Sodium: <290 mg Biotin: 65 microgram Selenium: 30 microgram Folic acid: 210 microgram Pantothenic acid: 3.1 mg Niacin: 5.3 mg 27 WHO 1999 „Management of severe malnutrition; a manual for physicians and other senior health workers‟. 28 Diop EHI, Dossou, NI, Ndour MM, Briend A, and Wade S (2003): Comparison of the efficacy of a solid ready-to-use food and a liquid, milk-based diet for the rehabilitation of severely malnourished children: a randomised trial. Am J Clin Nutr 2003; 78:302-7 29 The company producing other therapeutic supplies such as F-100 and F-75 Shelf life:
24 months from manufacturing date (under well ventilated storage conditions with
maximum 40°C temperature; humidity has no impact)
Packaging and labelling:
Airtight sachet which includes an aluminium layer to protect against UV, light and
humidity.
Local Production of RUTF
Since RUTF has to be imported, the costs are high. With this problem in mind, the development of locally produced RUTF has been commenced in some countries30, in order to try to ensure a cheaper and more sustainable supply of the product. As peanut-based recipes require unfortified milk powder, which often has to be imported, and the peanuts can be prone to aflatoxin contamination, which complicates quality assurance, investigations into alternative recipes eliminating the use of both peanuts and milk are underway. Such investigations are ongoing in Bangladesh but as the recipes have not been fully developed, there is currently no locally available RUTF for Asia. 30 Mainly on the African continent COMPARISON OF NUTRIENT CONTENT

Below table shows the comparability of F-100 Therapeutic Milk with Plumpy'Nut®
Nutritional value
Plumpy'Nut® (100 grams) F-100 (100 g dry product) F-75 (100 g dry product) Energy: 545 kcal
Energy: 520 kcal
Energy: 446 kcal
Proteins: 10% calories Proteins: 10% calories Proteins: 5% calories Lipids: 59% calories Lipids: 45% calories Lipids: 31% calories Thus by deduction: Thus by deduction: Thus by deduction: Carbohydrates 31% Carbohydrates 45% Carbohydrates 64% Vitamin A: 910 μg Vitamin A: 800 μg Vitamin A: 900 μg Vitamin D: 16 μg Vitamin D: 15 μg Vitamin D: 18 μg Vitamin E: 20 mg Vitamin E: 20 mg Vitamin E: 20 mg Vitamin C: 53 mg Vitamin C: 50 mg Vitamin C: 59 mg Vitamin B1: 0.6 mg Vitamin B1: 0.5 mg Vitamin B1: 0.5 mg Vitamin B2: 1.8 mg Vitamin B2: 1.6 mg Vitamin B2: 1.2 mg Vitamin B6: 0.6 mg Vitamin B6: 0.6 mg Vitamin B6: 0.6 mg Vitamin B12: 1.8 μg Vitamin B12: 1.6 μg Vitamin B12: 1.6 μg Vitamin K: 21 μg Vitamin K: 15 μg Vitamin K: 24 μg Folic acid: 210 μg Folic acid: 200 μg Folic acid: 200 μg Pantothenic acid: 3.1 mg Pantothenic acid: 5.8 mg Pantothenic acid: 3 mg Phosphorus: 394 mg Phosphorus: 300 mg Phosphorus: 330 mg Potassium: 1111 mg Potassium: 1100 mg Potassium: 775 mg Magnesium: 92 mg Magnesium: 80 mg Magnesium: 50 mg Iron: <0.2 mg Iron: <0.3 mg Sodium: <290 mg Sodium: <290 mg Sodium: <87 mg Selenium: 30 μg Selenium: 20 μg Selenium: 30 μg THE APPETITE TEST

Why do the appetite test?
 Malnutrition changes the way infections and other diseases express themselves – children severely affected by the classical IMCI diseases, who are malnourished, frequently show no signs of these diseases. However, the major complications lead to a loss of appetite. Therefore, an important criterion to decide if a patient should be sent to in- or out- patient management is the Appetite Test. A poor appetite means that the child has a significant infection or a major metabolic abnormality such as liver dysfunction, electrolyte imbalance, cell membrane damage or damaged biochemical pathways. These are the patients at immediate risk of death.  Furthermore, a child with a poor appetite will not take the diet at home and will continue to deteriorate or die.
How to do the appetite test
1. The appetite test should be conducted in a separate quiet area. 2. Explain to the carer the purpose of the appetite test and how it will be carried 3. The carer, where possible, should wash her hands. 4. The carer should sit comfortably with the child on her lap and either offer the RUTF from the packet or put a small amount on her finger and give it to the child. 5. The carer should offer the child the RUTF gently, encouraging the child all the time. If the child refuses then the carer should continue to quietly encourage the
child and take time over the test. The test usually takes a short time but may
take up to one hour. The child must not be forced to take the RUTF.
6. The child needs to be offered plenty of water to drink from a cup as he/she is taking the RUTF.
The result of the appetite test

Pass
A child that takes at least 3-4 mouth full of RUTF, or the equivalent of ¼ of a sachet

Fail
A child that does not take at least 3-4 mouth full of RUTF is considered to lack sufficient appetite for outpatient treatment and should be referred to hospital for in-patient care.  Even if the caretaker/health worker thinks the child is not taking the RUTF because s/he doesn‟t like the taste or is frightened, the child stil needs to be referred to in-patient care. After showing sufficient appetite in inpatient care, they can be transferred to the out-patient treatment.  The appetite test should always be performed carefully. If there is any doubt concerning the appetite then the patient should be referred for in-patient treatment until the appetite returns.  The appetite test is to ensure that - in the course of a day - the patient will take at least the amount that will maintain body weight. A patient should not be sent home if there is a risk they will continue to deteriorate because they will not take sufficient Therapeutic food.  Sometimes a child will not eat the RUTF because he is frightened, distressed or fearful of the environment or staff. Common stress factors are crowds, a lot of noise, other distressed children or intimidating health professionals with white coats or harsh tone of voice. Therefore, the appetite test should be conducted a separate quiet area. If a quiet area is not available in the health facility then the appetite can be tested outside. Follow-up

 Discuss appetite and perform RUTF appetite test if there seem to be problems: the caretaker did not bring all empty sachets back; or he/she tells that the child is not eating well, or does not like the RUTF; or the child is not gaining weight.  Failure of an appetite test at any time is an indication for full evaluation of the health and nutrition condition of the child and probably for transfer to in-patient assessment and treatment.  During the second and subsequent visits the intake during appetite test should be good, thus without much persuasion more than ¼ of a sachet, if the patient is to recover reasonably quickly.  If the appetite is "good" during the appetite test and the rate of weight gain at home is poor then a home visit should be arranged, if feasible, to gain understanding of the reasons for failure to respond. It may then be necessary to bring a child into in-patient care to do a simple "trial of feeding" to differentiate i) a metabolic problem with the patient from ii) a difficulty with the home environment; such a trial-of-feeding, in a structured environment (e.g. Stabilisation Centre), is also the first step in investigating failure to respond to treatment.
CHECKING FOR BILATERAL OEDEMA

Bilateral oedema is the sign of Kwashiorkor. Kwashiorkor is always a severe form of malnutrition. While lesser degrees of oedema can be effectively treated in OTP care, children with generalised, third degree oedema are at high risk of mortality and need to be treated in a stabilisation centre urgently. In order to determine the presence of oedema, normal thumb pressure is applied to the both feet for three seconds. If a shallow print persists on both feet, then the child presents oedema. Only children with bilateral oedema are recorded as having nutritional oedema. Degrees of oedema Severity
Usually confined to both feet and pre- Pit stays for 3 seconds On both feet and legs Whole body, legs, hands, and eyes Pit is deep and stays for 3 minutes or more If the pit is shallow and fills in within about 3 seconds then oedema is mild (+) If the pressing finger sinks into the pit and then the pit remains for several minutes it is severe (+++) Moderate is in between WHO – WEIGHT FOR LENGTH / HEIGHT TABLE

WHO Child Growth Standards 2006 Weigth for Length (6-24 months) (up to 87 cm)
(recumbant)
"-3 SD"
"-2 SD"
"-1 SD"
"-1 SD"
"-2 SD"
"-3 SD"
(recumbant)
"-3 SD"
"-2 SD"
"-1 SD"
"-1 SD"
"-2 SD"
"-3 SD"
recumbant
"-3 SD"
"-2 SD"
"-1 SD"
"-1 SD"
"-2 SD"
"-3 SD"
WHO Child Growth Standards 2006 LENGTH WHO Child Growth Standards 2006 Weight for Height
"-3 SD"
"-2 SD"
"-1 SD"
"-1 SD"
"-2 SD"
"-3 SD"
"-3 SD"
"-2 SD"
"-1 SD"
"-1 SD"
"-2 SD"
"-3 SD"
WHO Child Growth Standards 2006 HEIGHT 15% Weight Gain Table
ADMISSION
DISCHARGE
ADMISSION
DISCHARGE
15% Weight Gain Table (continued) ADMISSION
DISCHARGE
ADMISSION
DISCHARGE
OTP instructions for Treatment of Children aged under 6 months and over 5 years
The CMAM programme is targeting children aged 6 months to 59 months.
The under-limit of the target group is determined by the fact that children less than 6 months
of age have specific needs and can not yet digest the RUTF efficiently. Severely acutely
malnourished children under the age of 6 months (weighing less than 3 kg) should therefore
always be referred to the hospital or therapeutic feeding centre to receive specialised
medical attention and nutrition treatment.
The upper-limit is determined by vulnerability criteria related to the age less than 5 years.
There can be exceptional cases of extreme severe acute malnutrition in children over the
age of 5 years that would warrant treatment. Therefore, children with increased vulnerability
due to HIV/AIDS (either identified in the child or in the mother), which have elevated nutrition
requirements, will be admitted for treatment if identified as severely acutely malnourished.
Admission of such cases should always be reported to the overall CMAM programme
managers.
OTP instruction for use of Multi-Micronutrient supplementation
The Nepal Ministry of Health has a new policy for the Multi-Micronutrient supplementation for
children aged 6 to 24 months, to prevent anaemia and improve overall nutritional status. In
2009 the supplementation programme will be piloted in selected districted to try out the
distribution process and relevant messages. Furthermore, under food insecurity crisis, the
international protocol for emergencies recommends multi micronutrient supplementation for
all children aged 6 to 59 months. A common name for the multi micronutrient powder that is
used for this supplementation is "Sprinkles".
Children under treatment for SAM following the CMAM outpatient protocol receive RUTF that
has been formulated to provide the exact balance of micronutrients and electrolytes required
for children suffering from acute malnutrition. These children should therefore not receive
any supplementation with multi micronutrients.
Children suffering from acute malnutrition in combination with (moderate) anaemia are
treated specifically for anaemia as per the national CMAM protocol. Even these children
should not receive any supplementation with multi micronutrients.
In areas where multi-micronutrients supplementation is already in place, caretakers of
children under treatment by the CMAM programme should be explicitly informed that their
child should not take the multi-micronutrients until it has been discharged. After discharge it
can be recommended to give multi-micronutrients as per the standard protocol for
supplementation.

Source: http://nnfsp.gov.np/PublicationFiles/12ebd581-7ed9-4839-bf42-3c5893a0b058.pdf