Management of Severe Acute Malnutrition

Module 13

Apr 13, 2023 1

Learning objectives• Understand the importance of the internal and external links between the

different CMAM components and other health/ nutrition programmes in emergency and non-emergency situations.

• Understand the key elements of a community mobilisation strategy for the management of SAM and which actors should be involved in its implementation.

• Be aware of the different elements that support the diagnosis of acute malnutrition and how they are applied in the field

• Be aware of criteria for admission to treatment and discharge for each type of service (outpatient or inpatient care), including age

• Understand current protocols for the management of SAM cases as outpatients or inpatients, including who they target and where they are implemented

• Understand basic concepts related to the monitoring and reporting of CMAM activities and be familiar with practical tools for it

Apr 13, 2023 2

CMAM approach • Community-based management of severe

acute malnutrition endorsed by the United Nations system in 2007

• Its components are:– Community mobilization and active case-finding– Outpatient care for SAM without complications– Inpatient care for SAM with complications– Inclusion of management of moderate acute

malnutrition (MAM) where in place

Apr 13, 2023 3

Principles of CMAM• The shift from hospital-based to integrated

community-based approach for the treatment of severe acute malnutrition was possible thanks to several elements:– The advent of Ready to Use Therapeutic Foods

(RUTF) for dietary treatment at home – The new classification for acute malnutrition– Community participation on active case finding and

follow-up

Apr 13, 2023 4

Community mobilization (1)

• Community mobilisation in CMAM covers a range of activities designed to open a dialogue, promote mutual understanding, encourage active and sustained engagement from the target community as well as improve case finding and follow up.

Apr 13, 2023 5

Community mobilization (2)• The goal of the community mobilisation

component of CMAM is to improve treatment outcomes and coverage– active participation in the activities for the management

of acute malnutrition. – early detection and referral of cases to appropriate

nutrition or health services (clinics or hospitals) and their follow-up.

– It is an important factor for obtaining good coverage through good uptake of the services provided by the population in need within a specific health catchment area.

Apr 13, 2023 6

Community mobilization (3)• Initial community assessment:

– Community perceptions of acute malnutrition – Health seeking behaviour and decision makers for accessing treatment– Key community figures, and structures (administrative and leadership)– Existing community-based organisations and groups – Potential candidates for case-finder role – Existing links and communication systems between health facilities and

the community – Formal and informal channels of communication – Formal and informal health services – Potential barriers for children with SAM to accessing treatment

Apr 13, 2023 7

Community mobilization (4)• Developing messages and materials:

– Description of the target children using local descriptive terms for wasting and swelling,

– Explanation of the benefits of CMAM, noting that only a few children with SAM who are sick may need to be treated at the hospital,

– Explanation about the identification and referral process noting that thin or swollen children can also self-refer to the nearest health facility to be checked,

– Time and date of outpatient care sessions at the nearest health facility and locations of those facilities as well as locations of any hospitals or health centres offering inpatient care for SAM

– Visual aids enhance the impact of messages

• Raising community awareness works best through existing channels, organisations and structures within the community.

Apr 13, 2023 8

Community mobilization (5)• Roles and responsibilities :

– An overall (MOH national level) focal person should be identified to manage the whole mobilisation process and ensure a coherent nationwide strategy

– A responsible person for the implementation / monitoring should be identified at each district / department / health zone level. • The most appropriate person is who already has responsibility for Health Promotion,

Outreach or Extended Health / Nutrition activities

– In each health facility, the health worker in charge will be responsible for coordinating with Community Volunteers (CV) or Community Health Workers (CHWs)

– CV and CHW should be trained on case-finding, home follow up and community sensitisation. • They are the link between the population and the health / nutrition services and should

be identified within existing networks. • Where possible additional training on infant and young child feeding for example can help

to ensure the sort of linkages for prevention of SAM

Apr 13, 2023 9

Definition of severe acute malnutrition

• Low weight for height (WFH<-3 ZS) – and / or

• Low Mid-Upper Arm Circumference (MUAC<115 mm) – and / or the

• Presence of bilateral pitting oedema

Apr 13, 2023 10

Case-finding for SAM• Active case-finding – Identification of cases by community health

workers or volunteers in the communities• Mechanisms for referral should be in place

• Passive case-finding – Identification of cases by health workers during

routine child visits at the health facilities • Self-referral

Apr 13, 2023 11

Triage for SAM (1)• Once the “diagnostic” of SAM has been made:– Decide whether the child with SAM should be

treated in outpatient or inpatient care:– Absence or presence of medical complications:

medical complications should be assessed by a thorough medical examination and accurate medical history with the mother (or caregiver).

– Good or poor appetite : this is evaluated through the “appetite test” whereby the child passes or fails the test to eat RUTF

Apr 13, 2023 12

Appetite Observation Action

Good Child takes RUTF readily with little encouragement Continue in OTP

Poor Child takes RUTF only with encouragement

Child may continue in OTP with caution. Carer should

return to the clinic immediately if the child refuses to eat RUTF at

home

RefusedChild refuses RUTF despite repeated encouragement

from the carerTransfer child to inpatient

care

Apr 13, 2023 13

Triage for SAM (2)• All children 6-59 months will go to inpatient

treatment if they present– Bilateral pitting oedema (+++) or – A combination of oedema and wasting or– SAM with poor appetite (failed appetite test) or – SAM with medical complications

• Any other case will be treated as outpatient

Apr 13, 2023 14

Admission / discharge criteria for SAM

Criteria of admissionMUAC < 11.5cm and / or WFH < - 3 z-scores orbilateral oedema

Criteria of discharge

Cured

15% weight gain (from admission weight when free of oedema)For cases admitted on MUAC: 2 months min stay

No oedema for 2 consecutive weeksClinically well and alert

Defaulter Absent for three consecutive visits

Died Died during treatment in outpatient care

Non recovered Did not meet the discharge criteria after four months in treatment

Apr 13, 2023 15

Category Criteria (Children 6 – 59 months)

New admissions

Children 6 – 59 months or >60 months but <130 cm heightMUAC <11.5 cmorW/H < -3Z scores (WHO)Or <70% of median (NCHS)or Bilateral pitting oedema grade + or ++ and child is alert, has appetite, and is clinically well (has no IMCI danger signs)

Other new admissions Carer refuses inpatient care despite advice

Returned Defaulter Child has previously defaulted and has returned to OTP(the child must meet admission criteria to be re-admitted). A child is referred to as a defaulter after missing 3 consecutive OTP sessions

Readmissions/ Relapses A child is treated in OTP until discharge after meeting discharge criteria but relapses hence need for readmission

Transfer from inpatient care

From in-patient care after stabilisation treatment

Transfer from OTP Patients moved in from another OTP site

Apr 13, 2023 16

Category Criteria (Children 6 – 59 months) Cured

For all childrenMUAC > 12.5cm and* W/H > -2Z scores And No oedema for two consecutive visits And Child is clinically well

Defaulted

Absent for 3 consecutive visits

Died

Died during time registered in OTP

Non-Cured

Has not reached discharge criteria within 4 months. Link the child to other programmes e.g. SFP. IYCF, GMP, targeted food distributions

Transferred to TFC

Condition has deteriorated and requires inpatient care

Transfer to other OTP

Child has been transferred to another OTP site

Apr 13, 2023 17

Admission at outpatient care for SAM

1. Fill individual card with all

details2. Registration

3. Assign admission number

4. Explain all process

5. Medical treatment

6. Vaccination

7. Give RUTF and associated explanations

8. Link family with assigned

CHW

9. Appointment for next visit

10. Nutrition / health

education

Apr 13, 2023 18

Medical management at outpatient care for SAM

Medication When

Amoxicillin At admission

Anti malaria (according to national protocol)

Test at admission if clinical signs

Mebendazole or Albendazole Single dose at second week

Vitamin A Single dose at discharge

Measles vaccination During treatment

Most of the medical conditions that affect the child with SAM without medical complications can be treated following the

IMCI protocols.

Apr 13, 2023 19

Nutritional management at outpatient care for SAM (1)

RUTF is provided at between 150 and 220 kcal/kg/day

Apr 13, 2023 20

Weight(in kg)

PlumpyNut® (92 gm per sachet) BP100®

Packets / day Packets per week Bars / day Bars per week

3.5 - 3.9 1 ½ 11 Do not give Do not give

4 – 5.4 2 14 Do not give Do not give

5.5 – 6.9 2 ½ 18 Do not give Do not give

7.0 – 8.4 3 21 5 35

8.5 – 9.4 3 ½ 25 6 42

9.5 – 10.4 4 28 7 49

10.5 – 11.9 4 ½ 32 8 56

> = 12 5 35 9 63

• The most widely used RUTF (as lipid-based paste) is PlumpyNut®. If imported it comes in packets of 92 gr. totalling about 500kcals per packet. Locally manufactured RUTF can be in pots containing a greater amount of the product, thus ration tables must be adapted.

21

Nutritional management at outpatient care for SAM (2)

• Most important messages for caregivers:– RUTF is a food and a medicine and should not be shared.– RUTF is the only food the child needs in order to recover. – Give small regular meals of RUTF and encourage the child to eat often

(8/day)– Always offer the child plenty of clean water to drink while eating the RUTF. – For young children, offer breast milk first before every RUTF feed. – Wash children's hands and face with soap before feeding if possible. – Keep food clean and covered. – When a child has diarrhoea, never stop feeding. Give extra food and extra

clean water. – Return to the health facility whenever the child’s condition or appetite

deteriorates

Apr 13, 2023 22

Follow-up at outpatient care for SAM (1)Activity Frequency

Weight Each weekMUAC Each weekCheck for oedema Each weekHeight / length Once a month Medical history Each weekPhysical examination (including temperature and respiratory rate) Each week

Appetite test Each weekRoutine medical treatment According to treatment protocolHome visit As needed according to action protocol

Vaccinations As needed according to immunization schedule

Evaluation of health and nutrition status progress and counselling Each week

Health / Nutrition education Each weekEvaluation of RUTF consumption Each weekProvision of RUTF Each week

Apr 13, 2023 23

24

Follow-up at outpatient care for SAM (2)Sign Referral to Inpatient Care Home Visit GENERAL CONDITION Deteriorating

Child is absent or defaulting Child is not gaining weight or losing weight on 2 consecutive follow-up visits Child is not losing oedema Child has returned from inpatient care or refuses referral to inpatient care

BILATERAL PITTING OEDEMA

Grade +++ Any grade of bilateral pitting oedema with severe wasting (marasmic kwashiorkor)Increase in bilateral pitting oedemaBilateral pitting oedema not reducing by week 3

ANOREXIA * Poor appetite or unable to eat – Failed appetite testVOMITING * Intractable vomitingCONVULSIONS * Ask mother if the child had convulsions since the previous visit

LETHARGY, NOT ALERT * Child is difficult to wakeUNCONSCIOUSNESS * Child does not respond to painful stimuli

HYPOGLYCAEMIAA clinical sign in a child with SAM is eye-lid retraction: child sleeps with eyes slightly open.

DEHYDRATIONDehydration based primarily on recent history of diarrhoea, vomiting, fever or sweating and on recent appearance of clinical signs of dehydration as reported by the mother/caregiver

HIGH FEVER Axillary temperature ≥ 38.5° C, rectal temperature ≥ 39° C

HYPOTHERMIA Axillary temperature < 35° C, rectal temperature < 35.5° C

RESPIRATION RATE

≥ 60 respirations/minute for children under 2 months ≥ 50 respirations/minute from 2-12 months ≥ 40 respirations/minute from 1-5 years ≥ 30 respirations/minute for children over 5 years Any chest in- drawing

ANAEMIA Palmar pallor or unusual paleness of skinSKIN LESION Broken skin, fissures, flaking of skinSUPERFICIAL INFECTION Any infection requiring intramuscular antibiotic treatment

WEIGHT CHANGESBelow admission weight on week 3 Weight loss for three consecutive visitsStatic weight for three consecutive visits

REQUEST Mother/caregiver requests treatment of child in inpatient care for social reasons (decided by supervisor)

NOT RESPONDING Child that is not responding to treatment is referred to inpatient care or hospital for further medical investigation.

Apr 13, 2023 25

Follow-up at outpatient care for SAM (2)• Home visits are an essential aspect and aim at assess:

– Caregiver’s understanding of the messages received – Compliance with the treatment (RUTF and medications) – Reasons for non-compliance, absence or defaulting– Availability of water and sanitation facilities, hygiene practices – Health and hygiene and food safety practices and general

household food security

• Transfer to inpatient care: following the “action protocol”, at any time during treatment if signs of gravity (IMCI protocols)

Apr 13, 2023 26

Inpatient care for children 6-59 months with SAM

• According to current WHO recommendations, hospital-based care for SAM is organized into phases:– Stabilization phase: treatment of medical complications

and commencement of cautious feeding with F75– Transition phase: RUTF is introduced gradually, together

with feeds of F100 or F75 to foster child’s weight gain – Rehabilitation phase: or catch up growth phase. In most

cases this phase is now replaced by outpatient therapeutic care

Apr 13, 2023 27

Admission at inpatient care

7. Provide soap and food for caregiver

6. Counseling for caregiver: treatment,

signs to watch out, good IYCF practices

5. Provide routine

treatment as per protocols

4. Explanations to caregiver

about all process

3. Assign admission number

(if not already having one)

2. Fill the In-patient chart

1. Start life saving treatment ASAP: Milk F75

+ medical treatment

Apr 13, 2023 28

29

Stabilization at inpatient care (1)• Not meant for weight gain. Weight gain is a sign of

serious complication in this phase. • F75 milk is designed for restoring metabolic functions

and nutrition-electrolyte balance• F75 is given 8 times a day at quantity 130 ml/kg/day. • Force feeding is never to be used. • Naso-gastric tube can be used, on the other hand, if

required. • Caregiver should be involved in all feeds, although

given by a feeding assistant.

Apr 13, 2023 30

31

Stabilization at inpatient care (2) • Individual monitoring:– Weight changes– Edema changes– Body temperature– Clinical signs– Feeds (behavior, volume taken, etc.)

• Promotion to transition is granted when the child has regained appetite, medical complications are under control and edema start reducing

Apr 13, 2023 32

Transition at inpatient care (1)

• Meant for transition from F75 to F100 and to RUTF (same composition as F100). – F100 is often proposed on first day of transition. – Preference is given for RUTF as early as possible

for the child to get used to it. • Frequency of meals remains the same• Monitoring is the same as in Stabilization

phase.

Apr 13, 2023 33

Transition at inpatient care (2)• Promotion from transition to outpatient (in 2 to 4 days

max) when: – Eat at least 75% of daily RUTF prescribed– Edema back to + or ++ maximum– Medical complications under control

• Demotion happens when– Gain of weight > 10g/kg/day– Edema increase– Signs of fluid retention– Abdominal distension or diarrhea with weight loss– Complications that require intravenous infusion or NGT.

Apr 13, 2023 34

Rehabilitation phase for SAM• Rehabilitation is completed as outpatient

treatment, except if:– Outpatient care is not available or too far from the

family’s home,– The child is continually unable or refuses to eat RUTF – Family refuses referral to outpatient therapeutic care

• If the patient stays at inpatient: treatment is the same as in outpatient, RUTF being given priority over F100

Apr 13, 2023 35

Medical management at inpatient careMedication When

Amoxicillin At admissionAnti malaria (according to national protocol) Test at admission if clinical signs

Mebendazole (or Albendazole)

When the child progresses from transition to rehabilitation phase OR on arrival at the outpatient service

IronDuring transition and rehabilitation phases WHEN THE CHILD IS NOT CONSUMING RUTF: one crushed tablet of Ferrous Sulphate 200 mg to each 2 litres of F100

Vitamin A Single dose at discharge Measles vaccination During treatment

Apr 13, 2023 36

Management of medical complications in the presence of SAM

• The metabolism of children with SAM and medical complications is seriously disturbed, and the immune system seriously impaired

• The standard treatment for conditions like dehydration and severe anaemia given to non-malnourished children can lead to death if applied to children with SAM

• Case management of children with SAM and medical complications should only be conducted by clinical staff who has received the appropriate training

Apr 13, 2023 37

Failure to respond• Failure to respond to the treatment at inpatient

care is when:– Failure to regain appetite after day 4– Failure to start to lose edema after day 4– Edema still present at day 10– Failure to fulfill the criteria for progressing to

rehabilitation – In transition or rehabilitation phase: weight gain less

than 5 g/kg/day by day 10 or for 3 successive days

Apr 13, 2023 38

Emotional stimulation at inpatient care• Children with SAM have delayed mental and

behavioural development. To address this, sensory stimulation should be provided to the children throughout the period they are in inpatient care.

• It is essential that the mother be with her child in hospital, and that she be encouraged to feed, hold, comfort and play with her child as much as possible

• Inexpensive and safe toys should be available, made from cardboard boxes, plastic bottles, tin cans, old clothes and blocks of wood and similar materials.

Apr 13, 2023 39

Inpatient care for infants under 6 months (or below 3.5 kg): admission criteria

If prospects of breastfeeding

Too weak to suckle effectively, orNot satisfactory weight gain at home, orVisible wasting (regardless of WFL), orWFL < -3 z-score, orPresence of bilateral oedema

If no prospects of breastfeeding

Presence of bilateral oedema, orWFL < -3 z-score, orVisible wasting (regardless of WFL)

Apr 13, 2023 40

Inpatient care for infants: medical management

• Antibiotics: only when signs of infection• Vitamin A: only if signs of deficiency• Folic acid: 2.5 mg single dose at admission• Ferrous sulphate: only when the child suckles

and starts to gain weight (to add in F100)

Apr 13, 2023 41

Inpatient care for infants: nutrition management (1)

• The objective of treatment of these infants is to return them to full exclusive breastfeeding. This is achieved through the Supplementary Suckling Technique (SST)

• F100 is prepared and then diluted according to specific protocols. Breastfeeding is given for 20 minutes every three hours (minimum), and in between F100 is given with SST.

Apr 13, 2023 42

Supplementary Suckling Technique

Apr 13, 2023 43

Inpatient care for infants: nutrition management (2)

• When no prospect of breastfeeding, standard SAM inpatient protocols are followed except that F100 is given diluted in the stabilization phase (instead of F75) for children with wasting (marasmus).

• Children with edema are fed with F75• When the child reaches WFL equal or >-1z-

score, switch to a breast-milk substitute before discharge, but avoid bottle feeding

Apr 13, 2023 44

Inpatient care for infants under 6 months (or below 3.5 kg): discharge criteria

Apr 13, 2023 45

If the child is breastfed (there are no anthropometric criteria for discharge)

Successful relactation Child is gaining weight on breastmilk alone + no medical problem, and the mother has been adequately supplemented with vitamins and minerals.

If the child is not breastfed

15% weight gain ANDBreastmilk substitute for the child is sustainable for familyANDChild is used to milk substitute, gaining weight and caregiver education on preparing and dispensing the milk substitute is completed Ensure proper follow up of these children, as formula feeding is associated with higher risk of diarrhoea and other infections, and higher mortality

Management of SAM for other age-groups: admission criteria

Age group Criteria for admission

Children >=5 – 9 yearsMUAC < 129mm, and / orBMI for age < -3 z-score, and /or Bilateral pitting oedema

Adolescents >=10 – 18 years

MUAC < 160mm and / orBMI for age < -3 z-score, and /orBilateral pitting oedema

Adults >18 yearsBMI < 16 (kg/m) and / orMUAC < 185mm‡ and / orBilateral pitting oedema

Apr 13, 2023 46

Management of SAM for other age-groups

• All protocols are the same as for younger children, with specific dosage of treatment and milk detailed in specific guidelines.

• In outpatient treatment (or rehabilitation phase) patients should be recommended to eat traditional food as much as they want.

• Discharge criteria are about having a good appetite, reaching 15% gain of weight, absence of edema and absence of medical complication.

Apr 13, 2023 47

Management of SAM in areas with high HIV prevalence

• Most aspects of treatment are the same, however:– Counseling on HIV should be proposed to patients

and families– Medical treatment should add Cotrimoxazole

prophylaxis and test for tuberculosis– ART should be initiated after recovery due to toxicity

• HIV positive individuals are at higher risk of acute malnutrition and take longer to recover.

Apr 13, 2023 48

Monitoring and evaluation (1)

• Routine monitoring of CMAM activities is essential for:– Monitoring the performance of the CMAM

services– Taking decisions for quality improvement (staffing,

training, resources, site locations) – Assessing the nutrition trends in the area

• Monthly reports, routine supervision and coverage surveys are the main tools for monitoring

Apr 13, 2023 49

Monitoring and evaluation (2)• Routine data are collected on:

– Nb. of new admissions , – Nb. of discharges: cured, died, defaulted, non-recovered – Nb. of children in treatment (beneficiaries registered)

• These three basic elements allow calculation of key indicators:– Cure rate (should be > 75%)– Death rate (should be <10%)– Default rate (should be <15%)– Non recovery rate

• Quantitative data should be accompanied by some narrative description or explanation of the main events that may have influenced attendance and performance

Apr 13, 2023 50

Monitoring and reporting (3)• Other additional information that may be relevant that can be

derived from routine monitoring is:– Relapse rate – Admissions per typology (% of marasmus, kwashiorkor and

marasmic kwashiorkor)– Average length of stay – Average weight gain– Causes of death– Data on admissions disaggregated by gender

• Other essential information derived from different sources and methods: – Reasons for death and/or defaulting– Investigation of non-recovery– Coverage of treatment and barriers to access.

Apr 13, 2023 51

Monitoring and evaluation (4)• Supervisions: – Supportive supervision visits to sites are designed

to improve the quality of care offered in: • Identifying weaknesses in the performance of activities,

taking immediate action and apply shared corrective solutions • Strengthening the technical capacity of health workers

and motivating staff through encouragement of good practices

• Supervisors and managers ensure that the performance of activities and organization meet quality standards.

Apr 13, 2023 52

Monitoring and evaluation (5)• Coverage is one of the most important

elements behind the success of the CMAM approach. – It is measured through studies using two main

approaches:• The centric systematic area sampling (CSAS)• The Semi-quantitative evaluation of access and

coverage (SQUEAC)• Coverage should reach at least 90% of severe cases in

camps situation, 70% in urban setting, 50% in rural setting (SPHERE standards)

Apr 13, 2023 53

Apr 13, 2023

Which criteria are used for implementing

or closing management of SAM

activities?

*54

When to start?• According to WHO framework:– GAM rates >10% or between 5% and 9% + aggravating

factors. Sometimes SAM > 1% is considered as sufficient.

– Contextual factors (causes of malnutrition, the socio-economic situation, the food security situation, general ration quantity and allocation, etc.)

– Public health priorities or whether other priority needs are already being met (e.g., access to food, shelter, safe water, sanitation)

– Availability of qualified human, material and financial resources.

Apr 13, 2023 55

When to close / handover?• Some criteria used by NGOs to end CMAM activities

and handover to national or local structures include:– Global acute malnutrition rate is below 5%– Low number of cases in treatment in individual treatment

sites – Local structures can cope with current case load, and/or

would be able to cope with the influx of new cases

– General ration should be reliable and adequate– Crude mortality rate should be low– Effective health and disease control measures are in place

(e.g. no disease outbreaks)– The population is stable and no population influx is expected

Apr 13, 2023 56

Practical issues• Outpatient care for SAM: integrated in health

centers or located close to other facilities. • Inpatient care for SAM: integrated in pediatric

wards of hospitals or nearby.

• Staffing: numbers, qualification, training…

Apr 13, 2023 57

Key messages• Severe acute malnutrition is a complex medical condition needing specialised care to save the

patient's life. Current protocols for the management of severe acute malnutrition can obtain high recovery rates and good coverage by offering adapted care for the specific conditions of the patient.

• Management of acute malnutrition cases involves a combination of routine medication, specific therapeutic foods and individualised care, and includes four components: – Community mobilisation and community case finding– Outpatient care for children 6-59 months with SAM without medical complications– Inpatient care for children 6-59 months with SAM with medical complications, and for infants,

adolescents and adults– Management of Moderate Acute Malnutrition (MAM) for children, pregnant and lactating women with

infant under 6 months, and other vulnerable groups (see module 12)• Activities for the management of SAM cases should be integrated, when possible, into routine

health care services (outpatient and inpatient) with sites decentralised to provide optimal access to services

• Community mobilisation combined with community case finding for early detection of cases are key elements for the success of the treatment and the reduction of SAM related mortality and morbidity

• HIV-infected patients with SAM can recover their nutrition status with the current treatment protocols for SAM. Immediate cotrimoxazole prophylaxis and antiretroviral treatment (when available after the stabilisation of medical complications) should be given.

Apr 13, 2023 58