Integrated Management of acute malnutrition Session 6 : Management of moderate acute malnutrition

1. Integrated Management of acute malnutritionSession 6:Management of moderate acute malnutrition

2. Objective Enable health workers manage moderate acute malnutrition at OTC.

3. Session 6: Learning Objectives • By the end of this session the participants should be able to:- • Understand the requirements for MAM. • Know the enrollment and exit criteria. • Use data for collection and monitoring tools.

4. Session 6: Content • Overview • Requirement for MAM • Enrollment criteria and procedure. • Treatment • Nutrition, health and hygiene education and counseling • Follow up visits • Failure to respond to treatment. • Exit. • Data collection and monitoring.

5. Overview • The risk of a child dying is lower for moderate acute malnutrition (MAM) than for SAM. • Children with MAM may suffer life-long consequences including -stunting, • poor cognitive development, • poor school achievement and • reduced work productivity in adulthood. • They also have a significant risk of developing SAM. It is therefore essential that MAM be managed.

6. Overview cont… • The diagnosis of MAM is confirmed at an outpatient facility. • Children with MAM and no medical complications are given routine medical treatment • Children with MAM and medical complications are referred to an inpatient department for treatment according to IMCI guidelines until the medical complications are stabilized .

7. Overview cont… • After the medical complications are stabilized, the nutritional status of the child should be assessed. • The child is then referred to OTC (for SAM without complications) or outpatient management of MAM according to their nutritional status on completion of treatment.

8. Requirements for management of MAM Staff i) Sites with RCH • Nutritional assessment, counseling and routine medical treatment can be done by existing health service providers in the RCH clinics ii).Sites with SFP • 1-2 health care providers to assess nutritional status, give nutrition counseling, give routine treatment, and give supplementary food • 1-2 general assistants • 1 food distributor • 1 community health worker to assist the health service provider and conduct follow-up.

9. Equipment and supplies • Anthropometric equipment: MUAC tapes with colour-coding, weighting scales, height/length boards (optional) and WHZ tables (optional) • Routine medicines and micronutrient supplements • Fortified supplementary food • Mixing and measuring equipment • Monitoring and reporting forms for SFP (SFP Ration Cards, SFP Site Tally Sheets, SFP Site Monthly Report Sheets)

10. Physical structures: • Many communities have adequate accommodation in existing health facilities, community structures or shaded areas under trees that can be used as SFP sites. • Temporary shelter must be provided. • Poles and plastic sheeting might be needed. • It is important to have strong referral linkages between OTC and the management of MAM to ensure the continuation of care for children recovering from SAM.

11. Enrollment criteria: A child aged 6-59 months is enrolled if he/she is alert, clinically well (no medical complications requiring inpatient treatment or oedema requiring therapeutic care) and has oneof the following criteria: • MUAC 11.5 cm to 12.4 cm • WHZ -2.1 SD to -3 SD Other criteria include: • Children who have been discharged from OTC (or ITC in areas that lack OTC)

12. Enrollment procedure: • Take anthropometric measurements (Annex 1) • Take medical history and perform medical examination (Annex 4). • Refer any child with oedema to ITC. • Refer any child with medical complications to and inpatient health facility for treatment.. • Check immunization status, and give or refer child for immunizations, if required.

13. Enrollment procedure cont.. • Give routine medications • If SFP is available, register the patient. • Explain the treatment and procedures to the caretaker. • Provide bi-weekly amount of supplementary food and fill in the SFP Ration Card. • The Ration Card stays with the caretaker as a record of the child’s progress. • Caretakers should bring the card with them to the site each week.

14. Enrollment procedure cont.. • On exit, the card should be marked as exited from the programme, but it should stay with the caretaker. • Counsel caretaker on: -How to prepare and feed the supplementary food to the child -When to return for biweekly check-ups and supplies -Return to health facility immediately if child refuses to eat the food or becomes ill -All caretakers should be offered HIV testing and counseling services for their child and for themselves. • Link caretaker with other services, as appropriate (e.g. PMTCT, HIV Care and Treatment services, etc).

15. Treatment Dietary treatment • Where available, children with MAM should be enrolled in a SFP. • The SFP may operate at an outpatient health facility or at a community-based site. • For the first two months, the child should attend every two weeks, and thereafter the frequency can be reduced to every four weeks.

16. Dietary treatment cont.. • Children should receive a pre-mixed dry rations of a supplementary feeding product which is cooked and consumed at home, for example:‘ fortified blended foods’ • Corn-soya blend (CSB) and vegetable oil • Wheat-soya blend (WBS) and vegetable oil • UNIMIX and vegetable oil

17. Medical treatment • All children identified with MAM should receive a full medical history and examination, and be given treatment according to the Zanzibar IMCI guideline. • The medical history includes a check of immunization status, vitamin A supplementation status and de-worming status.

18. Routine treatment: Refer to Table 4 in OTC guideline

19. Nutrition, health and hygiene education and counselling • All caretakers of a child identified with MAM should receive nutrition, health and hygiene education and counseling to prevent malnutrition from recurring. • The grandparents or other guardians of the child should be included in these discussions. • The messages should include: - Infant and young child feeding -Preventing infectious diseases -Hygiene and sanitation

20. Nutrition, health cont… • Maternal health and nutrition • Nutritional care of sick children • Annex 8 provides a list of key messages. • Caretakers of children with MAM should as much as possible be linked with food security/livelihood initiatives.

21. Follow-up visits Children should be followed up every two weeks during the first two months, and thereafter the frequency can be reduced to every four weeks if the child continues to improve. • At each follow-up visit, the following should be conducted: • MUAC and weight (where possible) of the child should be measured at every visit. Height (where possible) should be measured every four weeks and WHZ determined. • Provision of supplementary food, if applicable • Nutrition, health and hygiene education and counseling (compulsory).

22. Failure to respond to treatment REFER the child to a health facility if: • No improvement in weight/MUAC or decrease in weight/MUAC over 3 consecutive sessions • Oedema develops • Medical complications develop

23. Exit criteria 1.Cured:Children maintains MUAC ≥12.5 cm and/or WHZ ≥-2 SD for two consecutive visits. 2. Defaulted: Absent for 3 consecutive visits. 3.Died:Died while registered in the SFP 4.Non-recovered: Has not achieved exit criteria within 4months. 5.Transferred:Transferred to OTC or ITC

24. Exit procedure • Inform the caretaker that treatment is completed. • Record the exit date and reason for exit in the appropriate registration book, RCH Card 1 and SFP Ration Card, if applicable. .

25. Data collection and monitoring The monitoring tools include: 1. SFP Ration Card: The Ration Card is kept by the caretaker. It is updated at every visit to the OTC and provides information on nutritional status, medical treatment and supplementary food rations received. On discharge, the card should be marked as exited from the programme, but it should stay with the caretaker. 2. SFP Site Tally sheet: At the end of each programme day, the health worker or supervisor fills in a tally sheet that records SFP activity and outcomes. The tally sheet is used in monitoring the overall effectiveness of the programme. 3. SFP Site Monthly Report: The site tally sheet information is compiled by the health service provider at the end of each month in the SFP Site Monthly Report.

26. Summary • Children with MAM may suffer life-long consequences including • stunting, • poor cognitive development, • poor school achievement and • reduced work productivity in adulthood. • They also have a significant risk of developing SAM. It is therefore essential that MAM be managed. • Children with MAM and medical complications are referred to an inpatient department for treatment according to IMCI guidelines until the medical complications are stabilized .