Date post: | 23-Jun-2015 |
Category: |
Health & Medicine |
Upload: | oliyad-tashaaethiopia |
View: | 172 times |
Download: | 1 times |
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