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IMAM IMPLEMENTATION – OUTPATIENT TREATMENT

IMAM IMPLEMENTATION – OUTPATIENT TREATMENT. Objectives of training. To know and understand the IMAM implementation To know the management of MAM children and SAM children in outpatient services. IMAM Implementation. IMAM = Integrated Management of Acute Malnutrition

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IMAM IMPLEMENTATION – OUTPATIENT TREATMENT

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  1. IMAM IMPLEMENTATION – OUTPATIENT TREATMENT

  2. Objectives of training • To know and understand the IMAM implementation • To know the management of MAM children and SAM children in outpatient services

  3. IMAM Implementation • IMAM = Integrated Management of Acute Malnutrition • Integrated to BPHS (and EPHS at provincial level) • Target children 0-59 months and PLW • 2 levels • Community • Health Facility => 3 components (OPD-MAM, OPD-SAM, IPD-SAM) Community - Active screening and referral - Sensitization - Follow-up (home visits) Health Facility - Passive screening / orientation - Treatment / Follow-up - Sensitization CHWs CHS Health staffs

  4. IMAM : HEALTH FACILITY • Reception of referral from community : check again anthropometric measurements to confirm diagnosis • Passive screening : each child from 6-59 months and PLW (from 2nd trimester of pregnancy to 6 months of breastfeeding) • Orientation : MAM/SAM identified => orientation to the right service(OPD-MAM / OPD-SAM / IPD-SAM) • Treatment and follow-up : nutritional product and systematic medical treatment, follow-up of nutritional status (referral if needed) Transversal => Sensitization nutrition / health topics

  5. IMAM for CHILDREN 0-6 months • Systematic screening must be done for each infant visiting the HF • Screening = Weight – Height – Oedema (NOT MUAC) • If the infant fit the eligibility criteria => Referral to IPD-SAM • A child from 0 to 6 months CANNOT be treated as outpatient

  6. IMAM – Children less than 6 months or less than 4 kg Children < 6 months or less than 4 kg should not be admitted to outpatient but referred to inpatient care • Children who are breastfed : treatment aims a re-establish breastfeeding by SST (with diluted F100) • Children who don’t have the possibility to be breastfed : therapeutic milk Example of SST

  7. IMAM for CHILDREN 6-59 months • Screening must be done at each services which receive children 6-59 months, according to the criteria described before • Should be done as a high priority BEFORE any decisions and treatment are made • When a child is identified as acutely malnourished (MAM or SAM): • Perform the appetite test (only where OPD-SAM is available) • Assess the clinical status • Direct the beneficiary to the right service (OPD-MAM or SAM, IPD-SAM, pediatric unit) for treatment

  8. Appetite test For each child identified as acutely malnourished (MAM/SAM) Aim: • To see if the child is able to eat sufficient quantity of nutritional product to recover • The loss of appetite in a child with acute malnutrition may indicate a serious pathophysiology • Appetite test: • Part of the initial diagnosis • At every follow-up visit

  9. Appetite test How conduct an appetite test ? • The carer and the child need to be in a quiet space • The child has clean water available • The carer and the child must wash their hands (soap and water) • The child may hold the packet by himself or be assisted by the carer : offer small amount of RUSF/RUTF, from the corner of the packet or on the carer’s finger • Offer the child clean water before and during the test • The test may take up to 30 min (or even a bit more) • The carer need to encourage the child, but must not force him/her

  10. Appetite test How assess the appetite? • Health staff look if the child is forced/has vomited/has diarrhoea • At the end of the test, health staff evaluate the amount eaten, without vomiting or diarrhoea

  11. Appetite test How assess the appetite? • If the child is declared to have good appetite : may be treated as an outpatient (after clinical exam and validation) • If the child is declared to have poor appetite : • MAM : should be examined for underlying causes and prescribed appropriate medication. May be transferred to another higher level HF • SAM : should be transferred to inpatient care and treated as a medical emergency

  12. Complications associated to acute malnutrition + any other diseases that need to be treated at the hospital (inpatient)

  13. Referral and treatment of acute malnutrition After clinical exam by a HF staff, the child will be oriented in the right service for treatment. Acute Malnutrition Child has MAM AND - No complications AND - Appetite for RUSF Child has SAM AND - Any complications AND/OR - No appetite for RUTF Child has SAM AND - No complications AND - Appetite for RUTF Outpatient Department for MAM (OPD-MAM) Outpatient Department for SAM (OPD-SAM) Inpatient Department for SAM (IPD-SAM) • Child has SAM and • Any complications • No appetite for RUTF • Child has SAM and • No complications • Appetite for RUTF • Child has MAM and • No complications • Appetite for RUSF • Child has SAM and • Any complications • No appetite for RUTF • Child has SAM and • No complications • Appetite for RUTF • Child has MAM and • No complications • Appetite for RUSF Inpatient Department for SAM Outpatient Department for SAM* Inpatient Department for SAM Outpatient Department for SAM*

  14. OPD-SAM : new admission • The child has been oriented and admitted to OPD-SAM (admission can be done at any day, not only during the OPD-SAM day) • Fill the register, assign a registration number • Fill the OPD-SAM treatment card for admission • Give the routine medicines : to ALL SAM cases admitted

  15. OPD-MAM : new admission • The child has been oriented and admitted to OPD-MAM(admission can be done at any day, not only during the OPD-MAM day) • Fill the register, assign a registration number • Fill the OPD-MAM card for admission • Give the routine medicines : to ALL MAM cases admitted • Give the nutritional treatment (RUSF)

  16. OPD-MAM : medical treatment • Vitamin A: Do not give vitamin A except if measles or severe diarrhoea is diagnosed or if there are signs of vitamin A deficiency (xeropthalmia, Bitot spots) • Oral Rehydration Solutions (ORS / ReSoMal):not required for cases of mild or moderate dehydration when the child is eating RUSF or RUTF. • All of the electrolytes present in ORS are also contained in the RUSF/RUTF in the correct proportions; the child needs only to drink plenty of water to satisfy thirst. • If the child is severely dehydrated, this is a danger sign and the child should be transferred to the inpatient unit (MAM to paediatric ward)

  17. OPD-MAM : medical treatment • Iron / Folate: not required for the treatment of mild or moderate anaemia if the child is eating RUSF / RUTF. Iron and folate are both present in RUSF/RUTF in the correct proportions to treat anaemia. • Additional iron may be particularly dangerous for children with SAM as it may increase the risk of serious infection • Zinc: Do not give additional Zinc to treat diarrhoea when the child is eating RUSF/RUTF. There is enough zinc in the RUSF/RUTF to provide a therapeutic dose. • Additional zinc may displace the absorption of copper from the RUSF/RUTF and make the child more prone to infection due to immunosuppression.

  18. OPD-MAM : medical treatment • Multiple Micronutrient Tablets: Do not give multiple micronutrient tablets to children eating RUSF/RUTF. The proportions of micronutrients in RUSF/RUTF are carefully formulated to provide the correct amounts of macronutrients and micronutrients required for recovery. Additional micronutrient tablets will disturb this balance. • Where there is a need for other medicines to treat illnesses (in addition to the routine medications for MAM /SAM) other medications such as antibiotics, anti malarials may be given according to IMCI protocols.

  19. OPD-MAM : Nutritional treatment • RUSF: Ready to Use Supplementary Food • Nutritional treatment for the recovering from Moderate Acute Malnutrition. • Should be given to the MAM child IN ADDITION to the family ration The prescription of RUSF for cases with MAM is the same for all children irrespective of weight

  20. OPD-MAM : Follow-up • Every 1 or 2 weeks • Decision tool for follow-up visits during treatment * A child not gaining weight or losing weight should be followed up at home by a CHW or CHS and a home visit form completed and returned to the health centre.

  21. OPD-MAM : Follow-up During follow-up visits: • Measure the MUAC, weight and check oedema : each visit, and the height each 4 weeks (if eligibility criteria was W/H) • Appetite test • Make an IMCI clinical assessment : each visit • Assess the weight gain and the child improvement • Give additional counselling as required based upon the assessment • Complete the information on the treatment card including any home visits or counselling given • Record all data on the treatment card : each visit

  22. OPD-MAM : Documentation • Assign the patient registration number and write in all documentation / registers: admission • Complete the treatment card for MAM children : admission and follow-up • Complete the ‘ration card’ for the carer : admission and follow-up • Ask carer to repeat the instructions for medications and using RUSF • Check immunisations are up to date • Refer to other services as required (e.g. Ante natal clinic, TB clinic, IYCF counselling) • Tell the carer when to return for follow up

  23. OPD-MAM : Discharge categories Discharge criteria for children aged 6 to 59 months from treatment for MAM

  24. Categories of admissions OPD-MAM • A defaulter must satisfy the eligibility criteria • If a defaulter returns to the program after 6 months : must be considered as a new admission

  25. Questions ?

  26. OPD-SAM : new admission • The child has been oriented and admitted to OPD-SAM (admission can be done at any day, not only during the OPD-SAM day) • Fill the register, assign a registration number • Fill the OPD-SAM treatment card for admission • Give the routine medicines : to ALL SAM cases admitted

  27. OPD-SAM : medical treatment • Except the routine medicines, care should be used prescribing some medicines (Vit A, Iron/Folate, Zinc and multiple micronutrient). • Special attention should be done for dehydrated child: • Oedematous child is never dehydrated • Marasmic child can have usual signs of dehydration without being dehydrated • ORS should not be used (inappropriate for SAM cases) • ReSoMal is used, but only in inpatient care and under strong supervision • Other medicines that have to be added to routine medicines must follow IMCI protocols (antibiotics, anti malarials…)

  28. OPD-SAM : Nutritional treatment RUTF: Ready to Use Therapeutic Food • Breastfeeding should be continued, as often as usually • Breastfed the child and then give RUTF • RUTF must always be given before other family foods. • RUTF is a medicine = treatment for SAM children only SHOULD NOT be shared.

  29. OPD-SAM : Nutritional treatment Amount of RUTF prescribed according to the weight

  30. OPD-SAM : Follow-up • The child needs to return to the HF for follow-up ideally every week (every 2 weeks if not possible) • Decision tool for follow-up visits during treatment * A child not gaining weight or losing weight should be followed up at home by a CHW or CHS and a home visit form completed and returned to the health centre.

  31. OPD-SAM : Follow-up During follow-up visits: • Measure the MUAC : each visit • Check for oedema : each visit • Measure the weight : each visit • If W/H was used for the eligibility criteria measure height : each 4 weeks • Conduct the appetite test : each visit • Make an IMCI clinical assessment : each visit • Record all data on the treatment card : each visit

  32. OPD-SAM : Follow-up At each follow-up visits: • Assess the weight gain of the child (or weight loss for oedema cases) • Assess if child is improving or not (investigate possible causes) • Prescribe any medicines as required for diagnosed illnesses • Request a CHW/CHS home visit if required • Assess if child has reached discharge cured criteria • Give additional counselling as required based upon the assessment • Complete the information on the treatment card including any home visits or counselling given

  33. Actions to be taken

  34. OPD-SAM : Discharge categories Discharge criteria for children aged 6 to 59 months from treatment for SAM

  35. Follow up after discharge SAM To prevent relapse, follow-up care is ALWAYS required • On-going IYCF / nutrition counselling • Referral to diversified local food production and demonstration • Enrolment in a growth monitoring programme • Referral to Well Baby Clinic • Referral to any other relevant social service programme

  36. Categories of admissions OPD-SAM

  37. Welcoming and Counseling • Welcome the mothers/caretakers and children in a good way + counseling is VERY important => integral part of malnutrition management

  38. OPD-SAM : Documentation • Assign the patient registration number and write in all documentation / registers • Complete the SAM register • Complete the treatment card for SAM children : at admission and at each follow-up visit • Ask carer to repeat the instructions for medications and using RUTF • Check immunisations are up to date (check at admission, if not => refer to immunisation service when the child is recovering: may be too weak at the beginning to manage a vaccine) • Refer to other services as required (e.g. Ante natal clinic, TB clinic, IYCF counselling) • Tell the carer when to return for follow up

  39. Standards of service for OPD-MAM/SAM services MAM Standard SAM Standard

  40. Questions ?

  41. IMAM – Pregnant and lactating women Pregnant women from 2nd trimester Lactating women with a infant less than 6 months Systematic screening done in ante natal clinic, MCH clinic or OPD. • Check the MUAC=> If MUAC is less than 23 cm enrol PLW for OPD-MAM • Check the weight (for pregnant women)

  42. IMAM – Pregnant and lactating womenNew admission If a P/LW is identified as acutely malnourished, then: • Record the assessment on the clinic record • Record the ration given on the mother’s ration card • Refer to midwifery or post-delivery clinical services (if not already done) • Refer to IYCF counselling • Ensure the mother’s registration number is recorded on ALL documentation

  43. IMAM – PLWMedical treatment • Routine medicines • Other medications should be given according to national protocols. Since MNT are being given there is no need for additional supplementation of Vitamin A, Iron/Folate or other micronutrient tablets

  44. IMAM – PLWNutritional treatment and follow up • Follow-up: • On a Monthly basis • Reception of rations • MNT • MUAC / Weight • Recording • Ensure continued counselling for ANC ONC and IYCF Nutritional treatment: A supplementary ration: Dry take home ration Typical ration size:

  45. IMAM – PLWDischarge * Cured : only a reporting criteria. PLW will receive continued rations/MNT until the child reaches the age of 6 months

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