This document provides national operational guidelines for community management of acute malnutrition (CMAM) in Nigeria. It outlines the roles and responsibilities at different levels for implementing CMAM programs. The guidelines cover community mobilization and case finding, screening and admission criteria for outpatient therapeutic programs and stabilization care, medical and nutritional management, counseling services, monitoring and evaluation, and record keeping and reporting. The annexes provide tools and job aids for measuring mid-upper arm circumference, assessing edema, registration and reporting forms, counseling guides, and other resources for effective CMAM implementation. The guidelines were developed with input from various stakeholders including UN agencies, NGO partners, and professional associations to standardize CMAM services across Nigeria.
This document provides national operational guidelines for community management of acute malnutrition (CMAM) in Nigeria. It outlines the roles and responsibilities at different levels for implementing CMAM programs. The guidelines cover community mobilization and case finding, screening and admission criteria for outpatient therapeutic programs and stabilization care, medical and nutritional management, counseling services, monitoring and evaluation, and record keeping and reporting. The annexes provide tools and job aids for measuring mid-upper arm circumference, assessing edema, registration and reporting forms, counseling guides, and other resources for effective CMAM implementation. The guidelines were developed with input from various stakeholders including UN agencies, NGO partners, and professional associations to standardize CMAM services across Nigeria.
This document provides national operational guidelines for community management of acute malnutrition (CMAM) in Nigeria. It outlines the roles and responsibilities at different levels for implementing CMAM programs. The guidelines cover community mobilization and case finding, screening and admission criteria for outpatient therapeutic programs and stabilization care, medical and nutritional management, counseling services, monitoring and evaluation, and record keeping and reporting. The annexes provide tools and job aids for measuring mid-upper arm circumference, assessing edema, registration and reporting forms, counseling guides, and other resources for effective CMAM implementation. The guidelines were developed with input from various stakeholders including UN agencies, NGO partners, and professional associations to standardize CMAM services across Nigeria.
FAMILY HEALTH DEPARTMENT NUTRITION DIVISION Table of Contents Acknowledgements .............................................................................................................................................. 13 Foreword ................................................................................................................................................................ 14 List of Contributors .............................................................................................................................................. 16 Acronyms and Abbreviations ............................................................................................................................. 17 Chapter 1: Introduction....................................................................................................................................... 19 Overview of CMAM in Nigeria ...................................................................................................................... 19 Chapter 2: Community Mobilisation ................................................................................................................. 25 Planning ............................................................................................................................................................. 25 Implementation................................................................................................................................................. 27 Case Finding ...................................................................................................................................................... 27 Follow up activities .......................................................................................................................................... 29 Chapter 3: Measurement and Triage for Acute Malnutrition ........................................................................ 30 Definition of Severe Acute Malnutrition ....................................................................................................... 30 Measuring MUAC ............................................................................................................................................ 30 Assessing oedema............................................................................................................................................. 31 3 steps in decision making for admission to OTP or SC ............................................................................. 32 Management of Children <6months .............................................................................................................. 35 Chapter 4: Outpatient Therapeutic Programme for Uncomplicated Severe Acute Malnutrition ............. 36 Admission Criteria for Outpatient Therapeutic Programme ..................................................................... 36 Medical Management....................................................................................................................................... 38 Nutritional Management ................................................................................................................................. 42 Monitoring progress in OTP ........................................................................................................................... 44 Discharge from OTP......................................................................................................................................... 48 Chapter 5: Stabilisation Care (SC) for Children (6-59 months) with SAM and Medical Complications .. 50 Admission to Stabilisation Care ..................................................................................................................... 50 Case management and follow up in Stabilisation care ............................................................................... 51 Management of SAM in stabilisation care for children 6-59 months: ....................................................... 51 Discharge from Stabilisation Care .................................................................................................................. 52 Chapter 6: Nutritional Counselling Services and programmes addressing Moderate Acute Malnutrition ................................................................................................................................................................................. 52 Breastfeeding ..................................................................................................................................................... 53 Complementary Feeding ................................................................................................................................. 54 Infant feeding in the context of HIV .............................................................................................................. 56 IYCF 3-step counselling /‘Reaching an agreement’ .................................................................................... 56 11 Chapter 7: Monitoring & Evaluation ................................................................................................................. 63 Rolesat different levels for the Implementation of CMAM ........................................................................ 63 Monitoring and evaluation at the health facilities ....................................................................................... 64 Individual monitoring in OTP ........................................................................................................................ 64 Discharge Categories from OTP ..................................................................................................................... 65 Record keeping and program monitoring .................................................................................................... 66 Supervision ........................................................................................................................................................ 70 Monitoring and Evaluation of Community Mobilisation activities .......................................................... 71 SQUEAC (Semi-quantitative evaluation of access and coverage) ............................................................. 71 Equipment and supply of therapeutic products .......................................................................................... 72 Guideline Annexes ............................................................................................................................................... 74 ANNEX 1: How to Measure Mid Upper Arm Circumference (MUAC) .................................................. 75 ANNEX 2: How to Assess for Bilateral Pitting Oedema ............................................................................. 76 ANNEX 4: How to Measure Length and Height ......................................................................................... 79 ANNEX 5: Example Register Page ................................................................................................................. 80 ANNEX 6: OTP card ........................................................................................................................................ 81 ANNEX 7: Summary of OTP routine medicines .......................................................................................... 83 ANNEX 8: OTP Tally Sheet ............................................................................................................................. 84 ANNEX 9: CMAM monthly report ................................................................................................................ 85 ANNEX 10: LGA/State/Federal Reporting Format .................................................................................. 86 ANNEX 11: Referral Form for OTP / SC ...................................................................................................... 89 ANNEX 12: Counselling Guide for Breastfeeding Difficulties ................................................................. 90 ANNEX 13: Supervision checklist .................................................................................................................. 93 ANNEX 14: Weight for Height tables (WHO 2006) ..................................................................................... 95
12 Acknowledgements
The Federal Ministry of Health acknowledges the erudite support and contributions of all the stakeholders in the production of this national operational guidelines for Community Management Acute Malnutrition (CMAM) in Nigeria.
The support of our partners from UNICEF, Clinton Foundation (CHAI), Medecins Sans Frontieres- France & Holland (MSF), Save the Children Uk, Action Contre la Faim (ACF), IYCN, WHO, morally, technically and financially is greatly appreciated.
Our thanks go to Valid International Consultants Nicky Dent & Paul Binns who facilitated the group that developed this document. I also wish to appreciate the contributions of the Professional bodies and associations- Nutrition Society of Nigeria, Nigerian Dietetics Association, Paediatrics Association of Nigeria and various public/private partners who reviewed this document and made useful contributions.
The immeasurable inputs of relevant programmes whose linkages to CMAM consolidate this protocol deserve our commendation.
Finally, the commitment and roles of staff members of Family Health Department especially the Head of Nutrition Division Mrs. B. N. Eluaka and her team for this guidelines is gratefully acknowledged.
Dr. P. N. Momah Head Family Health Department Federal Ministry of Health August, 2010.
13 Foreword The close relationship between malnutrition and underdevelopment has continued to be emphasized at various International & National Summits. Poor basic nutrition education and poverty has been recognized as major challenges to improving maternal, newborn and child health in Nigeria.. Acute malnutrition remains a life threatening and silent emergency in children under five years of age in Nigeria. It is a condition characterised by a very low weight for height (below -3 z scores of the median WHO growth standards) or and mid upper arm circumference (MUAC) of less than 115mm which is recognizable by visible severe wasting / with or without the presence of bilateral oedema. In developing countries including Nigeria, where malnutrition is common, the number of severe acute malnutrition cases has been reported to be beyond inpatient treatment capacity.
Nigeria is among the 20 countries in the World that account for 80% of undernourished children in the world, directly or indirectly contributing to more than 50% f deaths among U-5 children. Globally, only 56 percent of women deliver their babies in a health facility, and they are often discharged soon after delivery. Whether they deliver in a hospital or at home, mothers need ongoing infant and young child feeding support in their communities as well as Community-based approaches through CMAM, Breastfeeding support, Key household Practices (KHHPs) etc contribute to efforts at combating malnutrition.
Until recently, treatment of severely malnourished children has been restricted to facility-based management thus greatly limiting its coverage and impact. Management of severe acute malnutrition according to WHO guidelines reduced the case-fatality rate by 55% in hospital settings and recent studies suggest that communities that used ready-to-use therapeutic foods effectively managed severe acute malnutrition in developing countries.
The Community-based approach involves Community mobilization to ensure their participatory
ownership in timely detection of acute malnutrition in the community; support in the outpatient care of non-complicated cases and provision of ready-to-use therapeutic foods or other nutrient- dense foods at home. If properly combined with a facility-based approach for those malnourished children with medical complications and implemented on a large scale, community-based management of severe acute malnutrition could prevent the deaths of several children.
This Operational Guidelines on Community Management of Acute Malnutrition (CMAM) in
Nigeria were developed taking into consideration Nigeria’s local realities and circumstances and are aimed at the health practitioner and planners/managers involved in planning, support and supervision of CMAM activities. Users should also refer to the following documents: - National Policy on Food and Nutrition in Nigeria (2001) and National Plan of Action on Food and Nutrition (2004) - Related national guidelines on Infant and Young Child feeding, HIV/TB, IMCI, GMP/ENA, IMNCHS, management of moderate malnutrition etc. - Training packages and plans related to management of malnutrition - Tools for implementation, reporting and monitoring of nutrition related interventions It is my sincere hope therefore that all health workers in various health institutions and communities will find these guidelines useful in providing relevant information for management of acute malnutrition in Nigeria.
14 This guideline is a practical guide to help health and nutrition workers design, implement and evaluate CMAM programmes. It can be used by government institutions and donors interested in supporting or implementing CMAM programmes. Technical specialists and field practitioners including Community Based organization (CBOs)/ Faith based Organization (FBOs), multilateral agencies seeking to obtain an understanding of CMAM in practice can benefit tremendously from this national protocol.
Professor Christian Onyebuchi Chukwu
Honourable Minister of Health Federal Republic of Nigeria August, 2010
15 List of Contributors
FMOH Dr. P. N. Momah
Mrs. B. N. Eluaka Mrs. C. E. Njoku Mrs. V. N. Ogbolu Mrs. K. C. Thompson Mrs. B.N. Ali Mr. T. Farayibi Mrs. J. Adebari Mrs. J. E. Eruba Mrs. Nkoyo W. Onnoghen Mr. O. A. Ayanbeku NPC Mrs. Christiana Yunanah Mr. Suleiman Habu NPHCDA Dr. Nnenna Ihebuzor Dr. O. O. Olubajo Mrs. C. J. Ezeife Mr. O. Z. Olosunde SMOH Suleiman Mamman Hajia Rabia Mohammed FCT Mrs. C. E. Okoro UNICEF Dr. B. D. Omotola Stanley Chitekwe Dr. Alo Isiaka Dr. Abiola Davies Mr. Niyi Oyedokun Mrs. Florence Oni MSF William Hennequin Dr. Christopher Mambula SC Katsina Karina Lopez CF/CHAI Rebecca Egan Joann Tang ACF Maureen Gallagher IYCN Yeside Pikuda Academia ABU Dr. Muyiwa Owolabi Professional Bodies Paediatrics Association Dr. A. A. Orogade of Nigeria Consultant Valid International Nicky Dent Paul Binns
16 Acronyms and Abbreviations
ACT Artemisinin Combination Therapy
AIDS Acquired Immunodeficiency Syndrome ART Anti-Retroviral Therapy CBO Community-Based Organization CHEW Community Health Extension Workers CHW Community Health Worker C-IMCI Community-Integrated Management of Childhood Illness CMAM Community Management of Acute Malnutrition CMV Combined mineral and vitamin mix CORPS Community Resource Persons CV Community Volunteer DHS Demographic and Health Survey DOT Directly Observed Treatment EHA Environmental Health Assistant EHT Environment Health Technician ENA Essential Nutrition Actions EPI Expanded Programme 0n Immunisation F75 Formula 75 Milk F100 Formula 100 Milk FANTA Food and Nutrition Technical Agency F/SMOH Federal/ State Ministry of Health GAM Global Acute Malnutrition GMP Growth Monitoring and Promotion HBC Home-Based Care HIV Human Immunodeficiency Virus IMCI Integrated Management of Childhood Illnesses IU International Unit IYCF Infant and Young Child Feeding Kg Kilogram LGA Local Government Area LOS Length of Stay MAM Moderate Acute Malnutrition MDG Millennium Development Goal MNCH Maternal, Newborn and Child Health MUAC Mid- Upper Arm Circumference NDHS National Demographic Health Survey NGT Naso-Gastric Tube NPC National Planning Commission NPHCDA National Primary Health Care Development Agency ORS/ORT Oral Rehydration Salts/Therapy OTP Outpatient Therapeutic Programme PHC Primary Health Care PLHIV People Living with HIV PLW Pregnant and Lactating Women PMTCT Prevention of Mother to Child Transmission ReSoMal Rehydration Solution for Malnutrition RUTF Ready to Use Therapeutic Food SAM Severe Acute Malnutrition SC Stabilisation Care SD Standard Deviations (= Z scores) 17 SFP Supplementary Feeding Programme SNO State Nutrition Officer SST Supplementary Suckling Technique TB Tuberculosis UNICEF United Nations Children Fund VHW Village Health Worker VCT Voluntary Counselling and Testing WASH Water, Sanitation and Hygiene WFH Weight-for-Height (Z scores) WFP World Food Programme WHMT Ward Health Management Team WHO World Health Organisation Z score Z score = Standard Deviations
18 Chapter 1: Introduction
Malnutrition is recognised as a global problem, which weakens immune system & worsens illnesses. It is the underlying cause of more than half the deaths of under five children& it is widespread in Nigeria. Every year, about 20 million children under five years of age suffer from severe acute malnutrition and of these, about 1 million die annually. Severe acute malnutrition can be a direct cause of death, or it can act as an indirect cause by increasing times over, the case fatality rate in children with common childhood illnesses such as diarrhoea and pneumonia; thus making severe acute malnutrition a major killer condition of children less than five years of age.
The Nigerian Demographic Health Survey (NDHS), conducted in 2008, showed that the nutritional situation in Nigeria was 14% wasting, 23% underweight, and 41% stunting. Underweight levels increased when compared with the 2003 NDHS. Twenty four out of thirty six States (67%) had more than 2% Severe Acute Malnutrition (SAM) level and 19 out of 36 (53%) had level of Global Acute Malnutrition (GAM) above 10%. The States most affected are in the north east and North West zones of Nigeria particularly Sahel Regions bordering Niger and Chad with stunting levels above 50% and wasting levels above 20%.
Hitherto, treatment of children with severe acute malnutrition has been restricted to hospital based approach, thus, limiting the coverage and effect among the large numbers of children affected. In addition, health facility based treatment often comes with unbearable direct and indirect costs for the family of the sick children. Recent developments and evidence show clearly that most of these children can be treated in their communities without being admitted to a health facility or a therapeutic feeding centre.
The community based approach involves early detection of severe acute malnutrition in the community and provision of treatment for those without medical complications with ready-to-use therapeutic foods or other nutrient dense foods at home. If combined with a facility-based approach for those malnourished children with medical complications and implemented on a large scale, community based management of severe acute malnutrition could prevent the deaths of hundreds of thousands of children.
Evidence shows that about 90% of children with severe acute malnutrition who have been identified through active case finding, or through sensitising and mobilising communities to access decentralised services, can be treated at home. As a result, many countries are moving positively to embrace community approach to management of severe acute malnutrition as a key strategy in the drive to towards the attainment of MDG4.
Training for inpatient management of severe acute malnutrition (SAM) started in the first quarter of 2009, followed by a pilot for the Community Management of Acute Malnutrition (CMAM) approach which commenced in the second quarter of 2009. The pilot programme observed high caseloads with effective treatment outcomes.
This CMAM guideline lay the foundation for the scale up of the CMAM programme in a harmonised and coordinated way, linked with other key child health and nutrition interventions (HIV/AIDS, TB, Integrated Management of Childhood Illness (IMCI) and Infant and Young Child Feeding (IYCF)).
Overview of CMAM in Nigeria
Until recently children suffering severe forms of acute malnutrition were treated exclusively at the hospital level. Several elements have informed the shift to a community-based integrated approach
19 that aims for improved coverage for the treatment of severe acute malnutrition cases. These include the following: • The advent of Ready to Use Therapeutic Foods (RUTF) that allows beneficiaries to be treated at home. RUTF does not need to be cooked or processed with water before utilisation and can be consumed as presented, thus limiting bacterial contamination due to low water activity. RUTF can be a paste (usually peanut paste) or a compact meal and has a similar formula to F100 therapeutic milk + iron used in phase 2 of inpatient care1. • The new classification for acute malnutrition (figure 1 ) that allows treatment adaptation according to the patient’s medical and nutritional conditions: o Children suffering from moderate acute malnutrition receive nutritional counselling or nutritional support in a supplementary feeding programme if available o Children suffering from severe acute malnutrition without medical complications are treated in Outpatient Therapeutic Programme (OTP) services in health centres, external clinics or mobile posts o Children suffering from severe acute malnutrition with medical complications are treated as inpatients within paediatric services in State Hospital and/or clinics with inpatient facilities
Figure 1.1: Classification of Acute Malnutrition2
Acute Malnutrition
Complicated Uncomplicated
Severe acute Moderate acute
malnutrition malnutrition Severe acute Moderate acute with medical with medical malnutrition with malnutrition with complications complications no complications no complications
Stabilisation Care Inpatient Outpatient Therapeutic Nutrition advice or
paediatric care Programme Supplementary Feeding programme
1 For details of F100 refer to WHO Management of Severe Malnutrition: a manual for physicians and other senior health workers, Geneva 1999 2 Adapted from Collins S The Lancet Vol. 362, July 19, 2003 20 Target Groups for CMAM This guideline is intended primarily for the management of acute malnutrition in children from *6 months up to 5 years of age. Although in specific situations older age groups can also be affected by acute malnutrition, this national guideline focuses on the youngest and most vulnerable age groups. * Infants below 6 months age should exclusively be treated in inpatient facilities as they are unable to eat RUTF
Principles of CMAM
• Access and coverage: Community involvement is key to promoting the understanding of
malnutrition and its proper treatment; CMAM offers opportunity for medical treatment and is not a food distribution programme. Community assessment also allows the appreciation of the factors which may act as a barrier in seeking treatment for malnutrition by the community. Services should be implemented so as to allow maximum access to the community accounting for physical, cultural, ethnic, religious and other barriers. Continuing efforts in sensitisation and promoting access will ensure the maximum proportion of children is able to receive treatment thus establishing good service coverage. Maximising coverage is the most important factor in determining the effectiveness of a CMAM programme • Timeliness: Community participation in the activities for the management of acute malnutrition allows early detection and referral of cases towards appropriate health services (clinics or hospitals) and their adequate follow-up. Use of Mid Upper Arm Circumference (MUAC) for detection of acute malnutrition and admission has facilitated this. Early treatment, before the development of complications results in better outcomes for the individual and programme effectiveness.. • Appropriateness: Communities in Nigeria possess a rich diversity in cultural practices and languages. Each OTP service established should ensure that this is done in a way which is acceptable and accessible to the community. This means that efforts in sensitisation and mobilisation will need to be adapted to properly meet the diverse needs of culture, language and literacy. A proper understanding of the clinical, social and environmental causes of malnutrition by staff promotes a professional approach to treatment and enables staff to identify the most prevalent causes of malnutrition in specific communities. This evidence may be used to improve the underlying conditions causing malnutrition through lobbying for additional local services. • Care as long as needed: The integration of CMAM in routine health care services packages ensures that the OTP service will be available to communities as long as malnutrition remains a problem. The treatment of SAM is sustainable but requires the wise use of resources, particularly RUTF, to ensure this sustainability. Every member of staff is responsible and accountable to ensure that only the appropriate children are admitted for treatment in OTP and are discharged in an efficient manner to improve cost effectiveness. Caregivers should understand that the child should stay in the programme until the child is recovered.
Components of CMAM The following four components have been defined for CMAM: • Community Mobilisation to raise awareness and ensure community involvement • Outpatient Therapeutic Programme (OTP) for the management of SAM in health centres, clinics, /dispensaries and health posts. • Stabilisation care (SC): hospital -based management of complicated severe acute malnutrition • Supplementary Feeding Programmes: Nutritional Care for the management of moderate acute malnutrition
21 The CMAM approach promotes the best treatment possible for the beneficiary's condition. In the absence of acute food shortages or a disease outbreak, the majority of cases of SAM are treated as outpatients at health centres, if the activities of early detection and community mobilisation are well run. When patients are not hospitalised, they have less risk of being exposed to cross infections and they have a lower risk of death. When necessary, the patient may be referred from OTP to a hospital and vice versa and these movements do not represent a loss of continuity of care, nor the double reporting of cases. The length of stay in SC should be as short as possible with the patient completing his/her treatment in the nearest OTP unit to their home.
Community Mobilisation Community mobilisation aims to sensitise, inform and educate the community on nutrition and malnutrition. This helps the community to be more aware of nutrition and actively participate in nutrition activities carried out by the health system (prevention and treatment, case finding and follow up) in collaboration with Community Health Extension Workers (CHEWs). Community mobilisation in CMAM covers a range of activities using community structures and resources designed to open a dialogue, promote mutual understanding and encourage active and sustained engagement from the target community. At the core of community mobilisation is the detection, referral and follow-up of SAM cases by community-based individuals trained in the identification of SAM through the measurement of MUAC and the assessment of oedema.
Outpatient Therapeutic Programme
The treatment of children suffering from SAM without medical complications and with appetite is offered in outpatient therapeutic programme sites (OTPs) based in exiting health centres, clinics, dispensaries, posts or outpatient department of a secondary health facility. Enrolment of beneficiaries goes through a screening process that starts in the community and finishes at health facility level. Those children corresponding to established admission criteria (anthropometrical and clinical) will receive appropriate nutritional and medical care for home-based treatment. Every week, children visit the closest OTP (local health facility) for monitoring of medical and nutritional status. During those visits, health and nutrition education sessions will be given to caregivers.
Stabilisation Care Children suffering from SAM with medical complications, not being able to eat RUTF or failing to recover as expected in OTP will be referred to a Stabilisation Care (SC) within hospital paediatric services in order to manage the medical complications and initiate improvement of their nutritional status. The difference between SC and paediatric care is that children in SC receive special therapeutic milks in order to “stabilise” the abnormal nutritional and physiological status.
Supplementary Feeding Programmes (SFP)
Supplementary feeding programmes provide supplementary food to children with moderate acute malnutrition (MAM). The supplementary food may be in the form of dry rations (fortified flour, oil and sugar) or ready to use supplementary food (an oil based food similar to RUTF). SFP programmes are not currently widespread in Nigeria. In the absence of an SFP, those with MAM should receive nutritional counselling, deworming, and verification of vaccination status along with treatment of any underlying infections. Nutrition counselling is covered in more detail in chapter 6 and may include the use of local food fortification / supplementation programmes where these are available.
Figure 1.2 shows the relationship between the different components and their integration with other health/nutrition services.
22 Figure 1.2: Relationship between CMAM Components
Ref. Adapted from FANTA CMAM Modules
Integration of CMAM into Health Services
Key for the implementation of CMAM is its integration into existing services and to establish links with other health/nutrition promotion and malnutrition prevention activities and approaches, such as IYCF, IMCI, HIV/AIDS/TB and related strategies.
Programmes / strategies to which CMAM should be linked are:
• Nutrition: Infant and Young Child Feeding (IYCF), Growth Monitoring and Promotion (GMP), Essential Nutrition Actions (ENA) • Health: Integrated Management of Childhood Illnesses (IMCI) and Community-IMCI, Expanded Programme of Immunisation (EPI), HIV/AIDS, Tuberculosis, Maternal, newborn and child health programme (MNCH) • Other: Social Welfare, Food Security, Emergency Preparedness / Response plans. CMAM is an additional entry point to other health and nutrition related activities. Ensuring proper linkage can provide opportunities for improved uptake of immunisation or HIV testing for example.
Integrated Management of Childhood Illnesses (IMCI)
The assessment of malnutrition is already part of IMCI. However some treatment protocols for children with SAM require adaptation to integrate CMAM with IMCI fully. IMCI danger signs are closely related to the CMAM criteria for defining complicated acute malnutrition requiring stabilisation care. Although CMAM has not been fully integrated into IMCI protocols, pilots have been initiated. Addition of MUAC and oedema to the routine growth monitoring and promotion checks facilitates prompt referral of acutely malnourished children to CMAM
Infant and Young Child Feeding (IYCF)
Promoting and supporting good IYCF practices is key to preventing malnutrition. Children up to 2 years old are particularly vulnerable; proper exclusive breast feeding up to six months and appropriate complementary feeding thereafter are essential. Proper nutrition education contributes to avoiding relapse in cases that have already experienced an episode of malnutrition or cases of SAM and MAM arising in other children in the family. Aspects of feeding for infants and young children should be included in training for CMAM.
Growth Monitoring and Promotion (GMP)
23 Ensure that all children attending under-5 consultations have their MUAC measured and are checked for oedema routinely. Special attention should be paid to those who are growth are faltering (not gaining appropriate weight for age). These cases should be identified and given appropriate counselling before they become acutely malnourished. Proper counselling is outlined in IYCF and IMCI guidelines and also in the feeding recommendations for infants and young children in the Child health card.
HIV/AIDS & Tuberculosis Services
Malnutrition is closely associated with the presence of HIV/AIDS and tuberculosis. Thus, key actions have to be taken into account when planning for CMAM in these contexts: • Ensure that children enrolled in CMAM, not responding to care with unknown/previously negative HIV status are offered counselling and testing opportunities and TB screening). • Ensure that positive cases benefit from existing HIV and TB services • Check adherence to treatment provided by HIV/AIDS and tuberculosis services (ARV, Cotrimoxazole, Directly Observed Therapy/DOT etc) while attending CMAM or combine both activities wherever possible • Ensure that all children attending HIV/AIDS and / or tuberculosis services have their MUAC measured and are checked for oedema. Special attention should be paid to those who are growth faltering with prompt referral to CMAM services for further examination.
Maternal, Newborn and Child Health Services (MNCH)The MNCH programme provides for improved primary health care for mothers, newborns and young children through the promotion of antenatal and reproductive health services, routine immunisation and improved nutrition among other interventions. The activities of CMAM and the MNCH programme should be integrated as far as possible. Screening for acute malnutrition through MUAC and oedema assessment may take place during MNCH weeks whereas all CMAM beneficiaries should be assessed within the standard primary health care system and assessed for immunisation status etc.
24 Chapter 2: Community Mobilisation Community Mobilisation aims to engage and inform the community about acute malnutrition and CMAM, to achieve and sustain good coverage. The various activities in the mobilisation process allow CMAM health care providers to understand and anticipate challenges and constraints to community participation and access to service and uptake. The key objectives for community mobilisation are: • Providing accurate information about CMAM services • Strengthening early case-finding and referral of new SAM cases, and follow-up of problem cases • Increasing service access and uptake to achieve maximum coverage • Follow up of absentees and defaulters from the programme • Mobilizing and utilizing of community resources for CMAM • Strengthening the links between health care providers and the community Planning A community mobilisation strategy should be planned and implemented before the start of treatment activities in the health facilities and OTP sites. Assigning responsibility for community mobilisation is essential to ensure adequate planning, implementation and monitoring of activities. An initial assessment and the subsequent development of adapted messages and materials and planning for a community mobilisation strategy is the responsibility of the LGA in collaboration with the state, federal and development partners. The implementation of the strategy for raising community awareness on acute malnutrition and CMAM services is shared by planners (all levels) and health facility staff. Community volunteers (CVs) will be trained and supervised by State or LGA Managers, in collaboration with health facility staff. These CVs should be trained on MUAC measurements and detection of oedema (for case finding), home follow up of cases and sensitisation. They should be the link between the population and the OTP site. Monitoring and evaluation of community outreach activities follows the same channels of responsibility as the care/treatment activities which integrates health promotion and community actors at all levels (national, zonal, state) and heath facility staff. The officer in charge of the health facility and the LGA Nutrition focal person will be responsible for coordination of trained Community Volunteers on case-finding and follow up.
Community Assessment A community assessment is the first task and the learning phase in preparation for community mobilisation. It will provide planners with an idea of how the community is organised, how undernutrition is understood there, how the new service is likely to be received, and how the community can best support the CMAM service. The assessment provides the opportunity to update and supplement existing knowledge. This assessment should not be bypassed due to assumed prior knowledge of the local community. Information should be collected from lay people in the target communities and from staff and caregivers of young children at selected health facilities using a qualitative methodology. It is important to explore the following features of the community which are likely to impact on service delivery, demand and access: • Community perceptions of malnutrition and health seeking behaviour • Key community figures • Existing community-based organisations and groups • Potential candidates for community health worker/community volunteer role • Existing links and communication systems between health facilities and the community • Formal and informal channels of communication 25 • Community Structure • Barriers to Access Formulating a Community Mobilisation Strategy Devising a strategy does not need to be complicated. Every operational setting will have some unique features; to maximise the effect of community mobilisation, the results and insights from the community assessment should be systematically reviewed and translated into a mobilisation strategy. The strategy will define the way that mobilisation activities – especially case-finding – are to be carried out and sustained. The community mobilisation strategy should: • Address the barriers to access identified in the assessment: ensure cooperation of key community figure to gain community participation, including marginalised populations, so as to maximise coverage. Identify how this can best be achieved. Identify cultural practices that exist which may prevent children attending treatment. • Build case-finding around the skills and resources identified during the assessment: Designate health staff (state, LGA, health facility) to take responsibility for supervising case finding efforts Assign health facility staff to make periodic home visits(e.g. for health or nutrition education) and active SAM case finding. . Community case-finding can be carried out during Community-GMP, relevant community meetings and during other opportunities at village level.
Developing messages and materials
The use of simple, standardised messages to explain CMAM (Why, how, to whom and when it is offered,) will help to replace rumour with accurate information. Messages need to be informative but concise – designed if necessary to be read aloud to an illiterate audience. They should be translated into the relevant local languages, and adapted as necessary for different audiences. Core information to be communicated in most settings includes the following: • Description of the target children also using local descriptive terms for wasting (very thin) () and oedema (swelling). Care should be taken to identify and avoid the use of local terms which may be associated with stigma. • Explanation of the benefits of CMAM, noting that children with SAM who are not sick can be treated at home meaning that caregivers no longer need to leave the family • Explanation about the identification and referral process by community health worker/community volunteers in the community noting that very thin children can also self- refer to the nearest health facility to be checked • The time and date of OTP sessions at the nearest health facility
Visual Aids Visual aids enhance the impact of messages. Pictures depicting SAM children with the most easily recognisable symptoms of oedema and wasting for the community will strengthen communications, and are an important means of avoiding some of the cultural and linguistic obstacles to describing the target population.
Selecting a local term/name for RUTF (Ready to Use Therapeutic Food)
Identify and use an appropriate term in the local language to communicate that the RUTF is a medicinal food. This will help to minimise misunderstandings about the services and the product when it is introduced. In a country with several major language groups, different terms may need to be used. All messages, visual aids and suggested local names for RUTF should first be tested with the community to ensure they are comprehensible and appropriate.
26 Implementation
Raising Community Awareness
The community needs to be informed about the CMAM services available. If community members are unaware of the service, or the type of children it treats, or are confused or misinformed about its purpose, they may not benefit from it or may even prevent others from benefiting. Raising community awareness works best through existing channels, organisations and structures within the community. The overall challenge is to provide access to CMAM in the most effective way. As new services are initiated, ineligible children should be discouraged from coming while as many eligible ones as possible must be encouraged to come. Rejection of referred children on presentation at health facilities is a common cause of ill-feeling in the community, and can rapidly impact on participation. Handling inadmissible children and their caregivers in a positive and informative way is paramount and can also contribute to raising awareness. The following is a suggested order of priority through which CMAM awareness raising activities may initially be carried out: • Start with Key community figures, and a meeting at the health facility to orient them to CMAM • Use selected formal channels of communication e.g. Village meetings, committee meetings, health days and education sessions, church services or mosques, pharmacies • Use informal channels e.g. weddings, funerals, markets, water-points, Encourage Caregivers of beneficiaries to bring other thin or swollen children that they know.
Case Finding Early detection of acutely malnourished children is essential for the success of their treatment and should be done at community level and in health facilities. Health facilities play a critical role in confirming the eligibility of children referred by the community and ensuring they are enrolled in the appropriate service (nutrition/medical). In CMAM, case finding is categorised into active and passive. • Active case finding refers to the identification at an early stage of acutely malnourished children done by community volunteers (CVs) at household level, in villages and communities. Cases are actively looked for. • Passive case finding refers to the opportunistic identification of acutely malnourished children done by health workers during routine child visits and/ or consultation at the health facility. Case Finding in Health Facilities In health centres, clinics or health posts staff should also screen with MUAC and oedema checks, all children arriving to the facility including those who are growth faltering or registered in HIV or TB programmes. This should be regarded as a standard element of assessment and done during regular child clinic visits (EPI, Growth Monitoring & Promotion etc) or when children are sick and attend other consultations. When CMAM activities have been long established in an area and the community has been adequately mobilised most cases will arrive spontaneously to health facilities for screening and treatment and self-referral will usually become the greatest source of new cases.
27 Active Case Finding and Referral at Community Level Case identification of acutely malnourished children at community level will be done by MUAC measurement and identification of nutritional oedema. In addition to measuring the level of acute malnutrition, the MUAC identifies those children at increased risk of mortality. It is easy to use during outreach activities as it does not require sophisticated or heavy equipment. . Oedema checks can also be easily and rapidly carried out. At community level, active case identification of acute malnutrition can be done by trained CVs: Village Health Committees, Community IMCI, members from community groups and other community-based services providers (CORPs/TBAs/VHWs/Breastfeeding Support Groups including traditional health practitioners), religious leaders, teachers, social workers etc. It is essential that admission criteria at the health facility match – or at least include - referral criteria used by case finders (e.g., admission criteria used at the facility might include both WFH and MUAC, but never WFH alone.) Community health worker/community volunteers will suffer a loss of credibility if children are referred yet not admitted due to the use of different criteria Active case-finding in the community should be Training of case finders conducted on a regular and appropriate basis. Each Practical training is a prerequisite health area should adopt an adapted strategy balancing for all those who will be directly the need for regularly covering all target children and involved in CMAM case-finding in the “working” capacity (time) of community health the community. Training should be workers/community volunteers. organised at community level. The • Where unpaid volunteers are used, time selection of volunteers for training devoted to CMAM activities should not exceed should not be restricted to those who are literate only 1-2 days per month. Several volunteers may therefore be required to provide adequate support to CHWs. • A targeted approach of prioritising the measurement of children who exhibit relevant signs and symptoms for malnutrition and/or associated illnesses is usually more effective in promptly finding cases than a ‘blanket screening’ approach where all children in the 6-59 age group are measured. • Measurements can be performed during scheduled outreach activities (e.g. growth monitoring & promotion, maternal, newborn & child health weeks) and in an unscheduled way at community events and gatherings where children will be present. This can be done by both trained active community health worker/community volunteers and health facility staff whenever they go out into the communities. Note: Repeatedly (and unnecessarily) seeking to measure healthy children who are then not referred may lead to ‘screening fatigue’ and discourage caregivers, who assume their child can never benefit from the service (especially if this happens more than three times in succession). Screening for acute malnutrition should be coordinated and integrated at every opportunity into community based health activities such as Maternal Newborn & Child Health Week. The data collected during these weeks will be collated by the Nutrition Focal Person.
REFERRAL: CVs should refer all children presenting with bilateral pitting oedema or with MUAC <11.5cm (RED) to the closest OTP
Use of Weight-for-height (WFH)
WFH is an independent admission criterion to identify SAM in addition to MUAC and bilateral oedema. Assessment of WFH is more time consuming; If resources (staffing, training and height board equipment) are adequate WFH measures can be taken, but if not, and if numbers of 28 admissions are high, it is recommended, to just use MUAC and oedema for admission and discharge and in addition monitor weight changes at each visit to the health facility. WFH is not used for screening in the community by volunteers. Pictorial guides on how to carry out accurate weight and height measurements are in Annex 3 & 4 in addition to the weight for height charts (new WHO standards) used as references (See Annex 14)).
Follow up activities An essential element of support in the community is in the follow up of beneficiaries at home by volunteers. Follow up may be requested by the OTP staff for the following reasons; • Absenteeism • Defaulting • Death • Missing patients • Children recently transferred from stabilisation care to OTP or vice versa • Children not progressing as expected during treatment in OTP
The outcome of follow up visits should be documented by the volunteer and noted on the OTP Card by the health worker. If the volunteer is illiterate then verbal reports should be documented by the health worker.
29 Chapter 3: Measurement and Triage for Acute Malnutrition Definition of Severe Acute Malnutrition Severe acute malnutrition is defined by the presence of bilateral pitting oedema, Mid-Upper Arm Circumference (MUAC) of < 11.5cm and/or weight-for-height (WFH) of < -3 Z scores. The term severe acute malnutrition refers to two different entities with different clinical and pathological characteristics: Wasting (marasmus) and Oedema (kwashiorkor.) The most evident clinical feature in marasmus is the loss of muscle and fat mass, resulting in low MUAC and/or low WFH. Patients are emaciated with thin, flaccid skin and prominent scapulae, spine and ribs. Cases also present with associated infections and behavioural changes (apathy and irritability). Care must be taken to undress the child for examination since the face may be well preserved and be misleading as a visual cue to suspect malnutrition. Clinical features in kwashiorkor include bilateral pitting oedema of the lower legs and feet (generalized oedema in advanced cases, affecting face, hands, arms, trunk), loss of muscle and fat mass (that can be masked by oedema), skin lesions, changes of hair colour (lightening) and texture (dry, thin, and brittle) and behavioural change (apathy and more often irritability).
If not detected early during the course of malnutrition children with marasmus or kwashiorkor may develop anorexia and complications which require specialised interventions to prevent death.
Figure 3.1: Marasmus and Kwashiorkor
Child with Marasmus Child with Kwashiorkor
Measuring MUAC The mid-upper arm circumference is measured using a MUAC tape. The tape is usually numbered and colour coded.
30 Table 3.1 MUAC cut offs for acute malnutrition
Colour coding Measurement Indicator
Red < 11.5cm Severe Acute Malnutrition Yellow 11.5 – 12.5cm Moderate Acute Malnutrition Green > 12.5cm No acute malnutrition
The measurement procedure for MUAC is;
• Bend left arm at right angles • Locate tip of shoulder (acromion) and elbow (olecranon) • Measure the distance between the two points and locate the midpoint • With arm relaxed, wrap tape around the midpoint and measure (or note colour coding) • Note: Tape should be snug against the skin without pinching or leaving gaps. A pictorial guide to measuring MUAC is provided in annex 1
Assessing oedema Box 3.1: Assessing nutritional oedema Bilateral pitting oedema (also called kwashiorkor) is verified when thumb pressure applied on top of both feet for three seconds leaves a pit (indentation) in the foot after the thumb is lifted.
There are three grades of nutritional oedema:
Grade 1 or (+): when oedema is present in both feet Grade 2 or (++): oedema in both feet and legs Grade 3 or (+++): oedema in both feet, in legs and in hands or face (or generalised)
31 Apply pressure for 3 seconds Lift thumb and observe pitting
3 steps in decision making for admission to OTP or SC
In order to decide on appropriate treatment for a child with acute malnutrition, a 3 step process is followed; 1. Anthropometric / nutritional status assessment 2. Medical assessment 3. Appetite test
Nutritional Assessment After checking the anthropometric measurements of the child the health worker decides whether the child is acutely malnourished or not. All weight-for-height (WFH) z-scores are based on WHO 2006 growth standards. Figure3.2: Outcomes from Screening for Acute Malnutrition (6-59 months)
Severe Acute Malnutrition Moderate Acute Malnutrition Normal
• MUAC < 11.5 cm (red) • MUAC > 11.5cm and < • MUAC > 12.5CM (Green) • WFH < -3 Z scores 12.5cm (Yellow) • WFH > - 2 Z Scores • Bilateral pitting oedema • WFH > -3 and < -2 Z scores • No oedema • No oedema present
Assess for; Praise caregiver and give advice
1. Severe oedema +++* Give nutritional advice or refer to for future nutrition needs to be 2. Marasmic kwashiorkor** SFP if available. See chapter 7. sustained 3. medical complications 4. Appetite for RUTF
* Severe oedema (+++) is associated with a high risk of death. All children with severe oedema should be referred to stabilisation care even if there are no medical complications. ** Severe wasting (MUAC <11.5cm or WFH <-3Z) plus the presence of oedema of any grade (+++) is called marasmic kwashiorkor. All children with this condition should be referred to stabilisation care even if there are no medical complications due to the associated high risk of death.
Children with Severe Acute Malnutrition should undergo further assessment to decide if treatment in OTP or SC is most suitable Two new elements support this decision: • Absence or presence of medical complications: medical complications should be assessed by a thorough medical examination and accurate medical history with the caregiver. • Good appetite or child being unable to eat RUTF: evaluated through the “appetite test” 32 Medical Examination The medical consultation for an acutely malnourished child should start with the medical history followed by a physical examination. The steps to take are outlined on the individual OTP card (annex 6). The medical history is obtained from the caregiver and provides the background to the episode of malnutrition and highlights immediate problems and concerns. The clinical examination is performed by a trained health worker who assesses whether the child presents with any sign of severe illness or medical complications and needs to be referred to stabilisation care. The health worker checks the occurrence of vomiting, fever, fast respiratory rate, anaemia, superficial infections and dehydration. Taking the axillary temperature and conducting a respiration count for one full minute while the child is calm is an essential part of this assessment. The health worker should be aware that a child with SAM cannot auto-regulate his/her body temperature well and tends to adopt the temperature of the environment; thus the child will feel hot on a hot day and cool on a cool day. A child with any IMCI danger sign or a condition noted in table 3.2 below is considered to have complicated acute malnutrition and is referred for stabilisation care.
Table 3.2 below summarizes the main signs due to medical complications for SAM. Signs marked (*) are IMCI danger signs. Any complication requires immediate referral to stabilisation care. Table 3.2: Case Definitions of Medical Complications for Referral to Stabilisation Care
Medical complication Case definition
Intractable vomiting* Child vomits after every oral intake High fever High body temperature, or axillary temperature ≥ 38.5°C, (Hyperthermia) rectal temperature ≥ 39°C Low body temperature, or axillary temperature < 35.5°C, Hypothermia rectal temperature < 36 C > 50 respirations/minute (child between 2 and 12 months Lower respiratory old) tract infection > 40 respirations/minute (child between 1 and 5 years old) > 30 respirations/minute (child older than 5 years) Child has palmer pallor or unusual paleness of the skin Severe anaemia (compare the colour of the child’s palm with the palm of the caregiver or Hb < 7g/dl if lab services are available Skin lesion Broken skin, fissures, ulceration of skin Unconsciousness* Child does not respond to painful stimuli Child is difficult to awake. Ask the mother if the child is Lethargy, not alert* drowsy, shows no interest in what is happening around him/her, and cannot be roused easily Drowsiness is often the only sign of hypoglycaemia. Eye- Hypoglycaemia lid retraction( child sleeps with eyes slightly open) may be present or < 75mg/dl where lab services are available During a convulsion, child’s arms and legs stiffen because Convulsions* the muscles are contracting. Ask the mother if the child had convulsions during this current illness For children with SAM, diagnosis of severe hydration is based on clinical signs such as sunken eyes and recent changes in appearance reported by the caregiver associated Severe dehydration with a history of diarrhoea, vomiting, high fever or sweating Note: The skin pinch to test for skin turgor is not reliable in children with SAM 33 Appetite Test Lack of appetite for RUTF is a danger sign in an acutely malnourished child. It can be caused by infection, poor liver, gastro-intestinal or metabolic functions. The child unable to eat RUTF will not be consuming it at home leading to further deterioration in nutritional status and possibly death.
The appetite test is not necessary if the child has +++ oedema, Marasmic kwashiorkor or any of the danger signs in table 3.2 above requiring immediate referral to stabilisation care
The appetite is tested by giving the child a sachet of RUTF at the clinic and observing how he/she eats it. It can be done while the health worker starts the medical history with the caregiver. If the child appears to be afraid of the environment or health centre staff and thus refusing to eat it is generally better to leave the child with the mother alone in a calm and quiet place to continue with the appetite test for up to 30 minutes.
Result of the Appetite Test:
Pass appetite test: The child eats at least one third of a sachet of RUTF (92 g). Fail appetite test: The child does NOT eat one third of a sachet of RUTF (92 g)
Box 3.2: Points to Consider when Conducting an Appetite Test
1. Explain to the caregiver the reason for the test and how it is going to be carried out 2. Verify with the caregiver how long since the child ate or drank before the appetite test to ensure that a failed appetite test is not due to the child just having eaten 3. The caregiver should wash his/her hands and the child’s hands and face before the test starts 4. The caregiver should be comfortably seated with the child before offering the RUTF for the child to eat 5. If the child refuses to eat, the caregiver should continue to gently encourage the child to eat. However, the child should not be forced. Move the caregiver and child to a quieter place to continue the appetite test 6. Provide clean water for the child to drink while he is eating the RUTF
Outpatient or Stabilisation care
Children with good appetite that pass the appetite test, and are free from medical complications can be treated at the OTP. Those with complications should be referred to Stabilisation care. In the absence of acute food insecurity or disease outbreaks (e.g. measles, cholera, malaria) less than 10% of cases of severe acute malnutrition will need stabilisation care. This is minimised if community mobilisation and the active case finding and referral system from the community are adequately performed and cases present early before complications develop.
34 Figure 3.3: Criteria for Outpatient or Stabilisation care for Severe Acute Malnutrition
•MUAC < 11.5cm / WFH <-3 Z scores Outpatient
•Oedema +1 / +2 •Free of medical complications Therapeutic •Good appetite for RUTF Programme
•Marasmus Kwashiorkor •Oedema (+++) •< 6 months •> 6 months and < 3.5kg or Stabilisation •Severe Acute Malnutrition with •Medical complications and / or care •Lack of appetite for RUTF
Management of Children <6months
All children < 6 months with any of the signs below must be referred to stabilisation care as RUTF is not suitable for children of this age.
Criteria for referral of children < 6 months to stabilisation care
• WFH < -3 Z scores (if child is > 45 cm in length) • Visible severe wasting • Bilateral pitting oedema • Infant is not gaining weight on breast milk (despite counselling the caregiver on properpositioning & attachment) • Infant is too weak to suckle effectively Assessment in these cases may be more subjective relying on identification of visible wasting and recent history of weight loss. Signs of visible wasting in infants include “baggy pants” (reduced or absent buttocks), prominent ribs, scapulae and spine, thin appearance and “old man’s face”.
Visible severe wasting
35 Chapter 4: Outpatient Therapeutic Programme for Uncomplicated Severe Acute Malnutrition
The Outpatient Therapeutic Programme (OTP) is for SAM cases without medical complications and having good appetite. OTP should become a routine activity for all health centres and any other structures in the national primary health care network. Clinics or outpatient paediatric departments (OPD) located in hospitals should also integrate OTP for children with SAM without complications into their existing services.
Admission Criteria for Outpatient Therapeutic Programme
All beneficiaries enrolled in Outpatient Therapeutic Programme should meet criteria in Table 4.1:
Table 4.1: Criteria for New Admissions to OTP (children 6-59 months) MUAC < 11.5 cm Bilateral pitting oedema (+) or (++) WFH < - 3 SD (if used) Pass the appetite test for RUTF No medical complications While all centres will use MUAC and oedema criteria, if sufficient capacity and resources are available weight-for-height (WFH) can also be used to determine eligibility for OTP. Note: MUAC, WFH and oedema are independent criteria for admission in OTP. Meeting any one of these three criteria is sufficient to define SAM.
Types of Admission to OTP
There are two types of admission in OTP – new and old cases. The admission types are summarised in table 4.2 below.
Table 4.2: Types of Admission to OTP (children 6-59 months)
Children 6-59 months with SAM who meet the criteria in Table 4.1 that have not been under treatment elsewhere for this episode New cases of SAM (A child with relapse is considered as a new case of malnutrition and a new OTP card / register entry should be completed) Children Referred from Stabilisation care: children stabilised in Stabilisation care and transferred to continue treatment as outpatients Transfer from another OTP site: Children under treatment in one Old cases outpatient site and transferring to another one for further treatment Returned Defaulters: children who defaulted from treatment before recovery return to continue treatment within 2 months of defaulting Note: Relapsed cases: A relapse means that the child was previously successfully treated, discharged as recovered and now has an episode of acute malnutrition within 2 months discharge. A child with relapse is considered as a new case of malnutrition and a new OTP card / register entry should be completed. Returned defaulters: A return defaulter has defaulted from the programme (absent for 3 consecutive visits) and has returned to the programme to continue treatment. Returned defaulters must satisfy admission criteria in Table 4.1 to be readmitted to OTP. The continuing care may be documented on
36 the same OTP card as used before default. If admission criteria are not satisfied for OTP and the child is moderately acutely malnourished, refer to SFP if available or give nutrition advice according to chapter 6.
Admission Procedures In the waiting area, triage critically ill children to receive priority treatment. ➢ Conduct medical examination and appetite test to indicate if child meets OTP admission critria (See Table 4.1). o If the child can be admitted to OTP give RUTF. o If the child needs transfer to stabilisation care or if the medical examination is delayed then treat the child to prevent hypoglycaemia as specified below. Treat the Child to Prevent Low Blood Sugar If the child is able to breastfeed: Ask the mother to breastfeed the child If the child is not able to breastfeed, but is able to swallow: - Give expressed breastmilk, If not available,
- If poor appetite, give sugar water.
- RUTF may be given to children > 6 months if sugar water is not available
Table 4.3 Preparation of sugar water (10% dilution)
Quantity of Water Quantity of Sugar Ratio Teaspoon to Sugar Cube 100 ml 10g 2 level teaspoons (2 sugar cubes) 200 ml (average cup) 20g 4 level teaspoons (4 sugar cubes) 500 ml (small bottle) 50g 10 level teaspoons (10 sugar cubes) 1 litre 100 g 20 level teaspoons (20 sugar cubes) Notes: • Take clean drinking water (slightly warm if possible to help it dissolve). Add required amount of sugar and shake or stir vigorously. • Provide sugar water solution to the child while they are waiting to be referred to SC. • Especially when the weather is very hot, make clean water available to all children attending Outpatient Therapeutic Programme while waiting. Provide a shaded waiting area for children and their caregiver.
When a child fulfils the criteria for admission, the health worker must: 1. Complete the OTP Card with the required information3 (see Annex 6) 2. Register the case in the CMAM Registration Book (see Annex 5) 3. Give explanations to the caregiver about the functioning of OTP and the expected progress of the child while in treatment until he/she reaches discharge criteria, including expected length of stay 4. Conduct a thorough medical examination to check for complications 5. Conduct the appetite test for RUTF 6. Prescribe and give routine medications and any other treatment the child may need (see below) 7. Verify immunisation status and update vaccinations if needed
3 Note: Check age with the birth registration card; if not available refer to service in the health facility for registration 37 8. Prescribe and give RUTF. Stress key messages on page 29 making sure they have been well understood. Caregivers shall repeat advice regarding medicines and RUTF. 9. Complete the Child Health Card and give to the caregiver. 10. Give health/nutrition education (i.e. IYCF messages) 11. Link the child’s family with the assigned CV for home visit and follow up. 12. Give appointment for the next visit to OTP (the same day each week). Note: Children should be admitted on any day of the week when SAM is identified and then followed up weekly. Follow up visits may be organised on the same day of the week for all beneficiaries to facilitate organisation, staffing and logistics for the health facility staff. The decision to use this arrangement or to split the caseload across different days should be reached by health staff following discussion with managers. The primary concern is to deliver an accessible CMAM service for the local community. Medical Management Children who are severely malnourished have lower immunity and are highly susceptible to illness and infection. Since they do not always show signs of underlying infections, there is a need to provide systematic treatment. Therefore, it is important that the management of SAM includes careful medical assessment and treatment, in addition to nutritional rehabilitation. Underlying infections and conditions should be treated so that the child’s recovery is quicker and more effective.
Routine Medications Give routine drugs to all children admitted. Most of the medicines are given as single dose treatment so that the health worker can observe their administration to avoid problems with adherence. The only exception is the antibiotic (amoxicillin) and some malaria treatments but the first dose should always be given to the child in front of the health worker and explanation provided to the caregiver on how to continue this treatment at home.
The following table gives the schedule for routine medication and Annex 7 gives a summary of all routine medicines including dosages.
Table 4.4: Schedule for Routine Medication in Outpatient Therapeutic Programme for SAM Medication When Antibiotic: Amoxicillin At admission At admission if no oedema and not Vitamin A already given within the last 1 month Anti malaria (refer to National Malaria Test at admission and give if positive Treatment Guide) Measles vaccination (if not already given at 9 At admission months)
Deworming (Albendazole or Mebendazole) Single dose 2nd visit
Note: Children who have been transferred from hospital based management of SAM should not receive routine medications that have already been administered during hospital stay
Amoxicillin • Give oral antibiotic treatment for a period of 5 days (2 times per day) to be taken at home (give 10 days if needed), According to table 4.5 • The first dose should be taken during the admission process under the supervision of the health care provider. An explanation should be given to the caregiver on how to complete the treatment at home. Table 4.5 Dosage of Amoxicillin
38 Give three times daily for 5 days Syrup Syrup Tablets Age (or weight) 125 mg/5ml 250 mg/5ml 250 mg of the child 5days 5 days 5 days 125 mg or 5 ml 125 mg or 2.5 ml 125 mg or ½ Tablet <10 kg 3x a day 3x a day 3x a day 250 mg or 10 ml 250 mg or 5 ml 250 mg or 1 Tablet 10-30 kg 3x a day 3x a day 3x a day 500 mg or 2 Tablets, >30 kg Give tablets Give tablets 3x a day
Note: Always check information on bottles for dosages and dilution of syrups as this can change between different manufacturers.
Vitamin A Vitamin A should be provided to children without oedema at admission in OTP and who have not received Vitamin A within the last 1 month. Studies have shown that giving high dose Vitamin A capsules in children with oedema can raise mortality There are sufficient amounts of Vitamin A available in RUTF and therapeutic milk to meet the requirements of oedematous children. However if the child has signs and symptoms of vitamin A deficiency or measles then vitamin A should be given even if oedema is present. Children with signs of vitamin A deficiency or eye changes/xerophthalmia should be referred to Stabilisation care, as the condition of the eyes can deteriorate very rapidly and the risk of blindness is high. Special attention to vitamin A and measles vaccination should be taken if there is an outbreak of measles in an area with high Vitamin A deficiency, as this is closely linked with a higher mortality.
Malaria
Malaria is classified as uncomplicated or severe
Uncomplicated Malaria with no life threatening manifestations and presents with such symptoms as fever, malaise, loss of appetite, headache, body aches, joint pains, nausea and vomiting, etc Severe When malaria becomes life threatening and manifests with complications such as confusion, convulsion, coma, inability to stand or sit, severe anaemia, jaundice, inability to pass urine, pulmonary oedema, generalized bleeding etc. Severe malaria needs transfer to Stabilisation Care (SC).
DIAGNOSIS OF MALARIA
• All individuals presenting with clinical symptoms as described above should be diagnosed for malaria using microscopy or Rapid Diagnostic test kits.
Treatment of Uncomplicated Malaria with ACT
Table 4.6: Dosage Regimen of Artemether-Lumefantrine
39 Weight Age Dosage Regimen 5 – 14kg 6mths – 3years 1 tab., 2 times a day for 3 days 15 – 24kg 4 years – 8 years 2 tabs., 2 times a day for 3 days 25 – 34kg 9 years – 14 years 3 tabs., 2 times a day for 3 days >35kg Over 14 years 4 tabs., 2 times a day for 3 days
Note: • First day’s dose must be taken 8 hours apart for optimum action. • Take ACT after RUTF to aid maximum absorption. • Must complete treatment course even if patient feels better by second day. • Not recommended for children less than 5kg. • Children less than 5kg should be treated with oral Quinine at10mg/kg 8 hourly for 7 days.
>4.5kg - < 2 mths – 11 mths 25mg/67.5mg 1 tablet. Once daily for 3 9kg days >9kg - < 18kg 1 year – 5 years 50mg/135mg 1 tablet. Once daily for 3 days >18kg - < 6 years – 13 years 100mg/270mg 1 tablet. Once daily for 3 36kg days >36kg Above 14 years 100mg/270mg 2 tablets. Once daily for 3 days
Tips on administration of anti-malarial medicines
• ACTs come in weight or age-specific and colour-coded packs and dispersible tablets; give the one that is appropriate to the child. • Make sure the child eats some food or breast milk for infants, before taking the medicine. • Crush the tablet if the child cannot swallow. • If the child vomits within 30 minutes of swallowing the medicine, repeat the dose. • Encourage the mother to complete the course of treatment even if the child feels better. • If there is any reaction the mother considers unusual, take the child to the nearest health facility. • Such reactions may be rashes and itching, difficult breathing or cough, restlessness etc. • Counsel the mother on use of LLINs and environmental sanitation.
Deworming
Table 4.8: Albendazole / Mebendazole dosages
Mebendazole Albendazole Age (Weight) of the child 100mg or 500mg 400 mg tablet tablet < 1 year NO NO 12-23 months (or <10 kg) 200mg or ½ Tablet *500mg or 1 Tablet ≥ 24 months (or ≥10 kg) 400mg or 1 Tablet
40 *Note, previously Mebendazole 250mg used for 1-2 years but MNCH guidelines now recommends the same dosage for all
Immunisation: Measles immunisation
Measles and malnutrition are closely associated with each condition raising the risk of the other condition. All children 9 months and older should be vaccinated on admission if they cannot provide the Child Health Card showing vaccination has been received. . Check if the other siblings have been vaccinated, if not, recommend caregiver to take them to EPI especially in the case of children between 6 to 9 months. Also take advantage of the child’s contact with the health structure for completing other EPI vaccinations.
Other Medical Treatments
Due to the frequent association between acute malnutrition and micronutrients deficiencies, other conditions have to be carefully assessed: e.g. anaemia and diarrhoeal diseases leading to dehydration. The treatment of these conditions for SAM differs in some respects to the treatment given in IMCI. Anaemia Folic acid or iron supplementation does not need to be supplemented as RUTF already contains the daily required doses of them. Moderate anaemia can be treated through consumption of RUTF. For severe anaemia refer to stabilisation care. If lab facilities exist refer children with a haemoglobin (Hb) < 7 g/dl.
Diarrhoea Children identified with SAM commonly have diarrhoea but should not be referred for or given Oral Rehydration Salts (ORS) as these are too high in sodium. ORS in a child with SAM will invoke sodium overload and enhance bilateral pitting oedema possibly leading to cardiac failure and death. It is safer to provide RUTF and water for children in OTP or, for those with poor appetite, 10% sugared water while awaiting transfer to Stabilisation care. RUTF also contains zinc. Additional zinc supplements (e.g. zincfant) should not be prescribed for diarrhoea for the child in OTP receiving RUTF. Children with SAM and severe dehydration with a diagnosis based on recent history of profuse watery diarrhoea and recent change in child’s appearance (sunken eyes) are referred to stabilisation care and receive Rehydration Solution for Malnutrition (ReSoMal) instead of ORS. ReSoMal contains less sodium and more potassium than ORS. ReSoMal should not be given in OTP. Inappropriate use of ReSoMal can also easily lead to cardiac failure and death.
Antibiotics A first-line antibiotic is provided in OTP at admission for all admissions. If the child shows signs and symptoms of a diagnosed infection without danger signs, re-assess the progress of the child and treat according to IMCI protocol for other antibiotics If a child shows infection with danger signs (see Table 3.2) or had a repeat course of antibiotics without improvement then refer to stabilisation care for further investigations.
HIV/TB Health workers should be aware of either the known presence of HIV or tuberculosis, including ART or TB medication, Children who do not respond to treatment will be transferred to SC where investigations for HIV and/or TB will be provided. HIV positive children on prophylactic Cotrimoxazole should continue on this throughout the treatment for SAM with routine OTP antibiotics given on admission in addition.
41 Nutritional Management
Types and Prescription of Ready-to-Use Therapeutic Food (RUTF)
Pastes: The most commonly used RUTF is a nutritionally complete, high energy peanut paste. It usually comes in packets of 92g with an average of 500kcals per packet and is given according to the child’s weight at a dose of 200kcal/kg/day. Locally manufactured RUTF may become available in the future and the unit size may vary; rations should be adjusted accordingly. (Rations are based on an average of 200g / kg / day). Table 4.9: RUTF Ration According to the Weight of the Child (based on 92g packets)
Note: Children weighing more than 12kg still should receive a maximum of 5 packets of RUTF per day.
BP 100 Biscuits: In emergencies there may also be the option of high energy, nutritionally complete biscuits e.g. BP 100®. These biscuits have a nutritional composition equivalent to that of F100 and RUTF paste. One bar (2 biscuits) of BP 100 contains 300 Kcal. For each bar of BP 100 the child should drink at least 250 ml water. Children 6 – 24 months should be given BP 100 as a *porridge due to the risk of choking on the biscuits. *Preparation and use of BP 100 porridge • Add 200-250 ml of boiled drinking water to each bar (2 biscuits). • Discard excess porridge not eaten by the child. • Due to the addition of water and consequent risk of bacterial contamination, the use of BP 100 porridge in the community is not recommended unless no other option is available.
Table 4.10: RUTF (BP100®) Ration According to the Weight of the Child (Source: Compact)
Weight BP 100 ration BP 100 ration
(in Kg) (bars per day) (bars per week) *3.5 – 4.9 2.5 17.5 5.0 – 6.9 4 28 7.0 – 9.9 5 35 10.0 – 15.0 7 49
* Children > 6 months and < 3.5kg should not receive RUTF and are to be referred to the SC 42 If needed, a mixed ration of RUTF paste and BP 100 biscuits can be used Table 4.11: RUTF Mixed Ration (and BP100®) According to the Weight of the Child
When a child has recovered and is being discharged they no longer require the RUTF, however 7 packets/units of RUTF are provided to help “wean” the child from RUTF and make the transition to home food less abrupt.
It is recommended to encourage caregivers to bring empty packets back each week.
Key Messages To ensure the proper use of RUTF, some important educational messages should also be given. The health worker shall go through the key messages with the caregiver after giving the prescribed weekly dose of RUTF.
1. RUTF is a food and medicine for very thin or swollen children only. Do not share it. 2. Sick children often do not like to eat. Give small regular meals of RUTF and encourage the child to eat often (if possible, eight meals per day). Your child should have recommended packets per day. 3. For breastfeeding children, continue to breastfeed. Offer breast milk first before every RUTF feed. 4. RUTF is the only food sick and thin/swollen children need to recover during their time in OTP. Always give RUTF before other family foods, such as pap, kunu, ogi, akamu.or other meals. 5. Always offer plenty of clean water or breast milk to drink while eating RUTF. Children will need to drink more water than normal. 6. Use soap for the child’s hands and face before feeding. Keep food packets clean and well stored. 7. Caregivers shall also use soap to wash their hands prior to feeding. 8. Sick children get cold quickly. Always keep the child covered and warm. 9. For children with diarrhoea, continue feeding. Give them extra food and water. 10. Return to the health facility whenever the child’s condition deteriorates or if the child is not eating sufficiently.
43 As well as receiving these messages, the caregiver can also benefit from any health/nutrition promotion sessions being given at the health centre or at home in the community (See Chapter 6: Services and Programmes for Moderate Acute Malnutrition).
Monitoring progress in OTP
Children admitted in to OTP should return to the health facility every week (on the same day) in order to be re-evaluated by the health workers to follow up their nutritional progress. Table 4.11 outlines the frequency of measurements and checks during follow up.
Table 4.12: Frequency of measurements and checks during Outpatient Therapeutic Programme Visits
Activity Frequency Appetite test Each week Weight Each week MUAC Each week Check for oedema Each week Height / length (if used) Once a month Clinical examination Each week Medical history Each week Routine medical treatment According to protocol on admission Home visit As needed according to protocol indicated in Table 11 (below) Vaccinations As needed according to vaccination schedule Health / Nutrition education Each week Evaluation of RUTF Each week consumption* Provision of RUTF Each week
* A child consuming all of the RUTF ration can be expected to gain 35 – 100 g per kg in one week (Example: Child weighs 5kg – Minimum expected weight gain is – 5 x 35 = 175g) If less than this, the reason should be investigated (e.g. sharing of RUTF or underlying illness). Encourage caregivers to bring empty packets back to assist the health worker to determine whether the whole ration has been used and to avoid environmental pollution.
Note: Empty packets do not necessarily mean that the SAM child has eaten them; therefore, consumption should be compared with the weight gain for that week.
According to the outcomes of each visit, the health worker will need to decide whether the child is making good progress or has deteriorated such that inpatient referral is required or, if deterioration is less severe, a home visit. The outcome of the weekly visit should be marked in the appropriate place on the OTP Card.
The following tables indicate the different criteria to assist the health worker to decide what actions to take for the beneficiary during weekly follow up.
Children responding to treatment
Children responding to treatment (If the beneficiary is not within the criteria in table 4.13 and 4.14 below) and is making good progress i.e. gaining weight, MUAC increasing, decreasing oedema, he/she has good appetite, no severe medical complications, is regularly attending weekly follow up visits, then the child continues in OTP until s/he reaches the criteria for discharge. Protocols for
44 monitoring weight gain and clinical condition should ensure that the child reaches discharge criteria in approximately 8 weeks (for Marasmic cases; sooner with oedema). Children not responding to treatment Possible causes for non response are outlined below. Common causes related to child or family • Sharing of RUTF with the family: insufficient RUTF given to the sick child or is taken / shared by siblings or caregivers. • Unwilling caregiver or caregiver overwhelmed with work and / or other responsibilities. • Pathophysiological reasons: malabsorption of nutrients, altered metabolism rumination, infections (e.g. diarrhoea, dysentery, malaria, pneumonia, tuberculosis, urinary infection, otitis media, schistosomiasis, leishmaniasis, hepatitis/cirrhosis) • Other serious underlying disease: congenital abnormalities, neurological damage • Psychological trauma Common causes related to the treatment facility • Inappropriate selection of patients to be treated in OTP • Poor assessment of presence of appetite • Inadequate / incorrect instructions given to caregivers • Wrong ration of RUTF dispensed • Excessive time between distributions If the child is not responding to treatment nutritionally or clinically according to weekly checks, the health worker should take the actions as summarized below: 1. Re-assess consumption and possibility of sharing of RUTF. 2. Assess for possible infection preventing response to treatment and use second line treatment – according to IMCI protocols for a diagnosed infection and testing/ treating for malaria, 3. Arrange a home visit (to see if there are social issues including ration sharing or poor environmental conditions) , 4. Arrange prompt referral to inpatient services where counselling and referral for HIV or tuberculosis testing is available. Before the child deteriorates and requires transfer to Stabilisation care, social causes of a non response to treatment should be investigated through a home visit by the volunteer. The home visit should be made at the request of the clinician according to the following criteria (table 4.13)
Table 4.13: Criteria for Home Visits
Parameter Outcome of the weekly visit
All transferred from Stabilisation care (during first week) Weekly appointments are not respected or followed regularly General (absences) Family refuses Stabilisation care despite health worker’s advice Weight and oedema Weight loss during two consecutive visits evolution Static weight during three consecutive visits Appetite Eats less than ¾ of the prescribed daily ration of RUTF
Home Visits Health facility staff will identify problem cases and they or the community health worker/community volunteer (as appropriate), can visit the home of the child to investigate and report back to the facility. It is important that a reliable system of communication is established for
45 follow up visits and those findings from the visit are documented, particularly with respect to reasons for defaulting or a child not progressing well. Where possible, communication systems which are already in use and have proved effective should be adopted. The facility should implement the following methods to notify case finders of the name of a child requiring follow-up: • Community health workers/community volunteers report to the health facility on a regular basis and collect the names of children who require follow up. • Health facility staff pass a message to the community health worker/community volunteer via a caregiver/reliable community member. Poor progress may indicate the need for stabilisation care. Criteria for referral during treatment in OTP are noted in table 4.13 below
Table 4.14: Criteria for Referral to Stabilisation care
Parameter Outcome of the weekly visit
Weight and oedema Weight loss during three consecutive visits (not related to loss of changes oedema) Static weight during four consecutive visits Onset of oedema when previously absent For cases admitted on WFH or MUAC: weight at week 3 lower than weight at admission Oedema is not disappearing at week 3 Appetite Failed appetite test Clinical condition Fever > 39°C or hypothermia < 35°C Severe dehydration Repeated vomiting Severe respiratory distress (IMCI criteria): > 50 respirations/minute (child between 2 and 12 months old) > 40 respirations/minute (child between 1 and 5 years old) > 30 respirations/minute (child older than 5 years) Chest in-drawing Severe pallor with respiratory distress (signs of anaemia) Malaria with signs of severity Abscess or extended skin lesions (needing IM or IV treatment) Very weak, apathy, unconscious Convulsions or fits
Emergency Procedures for Referral to Stabilisation care
Sometimes the distance between outpatient and inpatient services can be large, or families delay to inform key family members, obtain permission or basic materials. If the child is acutely unwell, immediate emergency interventions can improve the chance of the child surviving the journey and the Stabilisation care.
Note: If a caregiver’s child fulfils the criteria for admission to SC but declines the invitation for transfer from OTP , this should be noted in the OTP card as a REFUSAL-OF-TRANSFER with the referral date. This information can be an explanation for mortality in the OTP and, if frequent, should signal the need for investigation of the reasons (distance to SC, reputation of SC, etc.). The child will continue in treatment in OTP.
46 Table 4.15: Procedures for referral to Stabilisation care
ISSUE RECOMMENDED PROCEDURES
Hypoglycaemia If the child is able to breastfeed: Ask the mother to breastfeed the child If the child is not able to breastfeed, but is able to swallow: Give expressed breastmilk, or if not available, give sugar water Give 50 – 100ml of milk or sugar water before departure
Hypothermia Teach the mother how to keep the child warm on the way to the hospital Use ‘kangaroo technique’: Remove wet clothing, including nappies Dress the child in a warm shirt open at the front, a nappy, hat and socks Place the infant in skin to skin contact on the mother’s chest Cover the infant with mother’s clothes (and a warm blanket in cold weather)
When not in skin to skin contact, keep the child clothed or
covered as much as possible at all times. Dress the young infant with extra clothing including hat, gloves and socks, loosely wrap the child in a soft dry cloth and cover with a blanket -Check frequently if the hands and feet are warm-Breastfeed the infant frequently (or give expressed breastmilk by cup) or sugar water Hyperthermia Remove clothing and repeatedly damp sponge the child with tepid water (avoid cold water as this could cause shock) If >39°C give one tablet of paracetamol crushed in clean water (avoid aspirin as this may cause Reye’s Syndrome in a child < 12 years with fever) Infection If possible give first dose of antibiotic Referral Form Complete a form (annex 11) listing the key problems, medicines provided and action already given to facilitate appropriate stabilisation care
If a child has been receiving treatment in OTP for a period of 4 weeks and has still not reached discharge criteria for cure the child must be transferred to SC for further investigation. The lack of progress may be due to an undiagnosed underlying infection. The child in SC can receive the necessary medical tests and have direct observation of RUTF consumption. Only when all actions to investigate why the child is not responding to treatment have been exhausted (including home visits and transfer to SC) and a treatable cause has not been found, the beneficiary can then be discharged as “non recovered” Children who are Absentees and Defaulters The child should attend each OTP session for monitoring of progress towards recovery. If a child is absent from an OTP session, ideally the child should be followed up immediately by a volunteer to encourage the caregiver to attend the OTP. Absence means that the child will not receive the necessary RUTF for that week. 47 A child absent for 2 consecutive weeks should be followed up at home by a volunteer as a matter of urgency. The caregiver should be encouraged to return and the reason for non-attendance identified; the clinician may be able to suggest a plan of continued care which is acceptable to the caregiver. Identification of reasons for non-attendance will assist managers to improve the CMAM service to enhance access (and hence coverage) to the local community.
A child absent for a 3rd consecutive visit is considered a defaulter and is discharged from the programme as such. It is essential that defaulters are followed up since this may be hiding excess mortality in the OTP service. Defaulting is a particular problem which may be related to; • Clinic schedules making OTP service inaccessible • Poor attitude of health care staff • Lack of understanding by caregiver • Cultural barriers (e.g. male permission / male relative needed to attend OTP) • Migration to another location • Death of the child • Physical or climatic barriers • Harvesting / planting season • Distance • Cost of transport
Alternative plans of care should be considered to attempt to resolve these difficulties. Examples may be to adjust the clinic schedule or allow 2 weekly visits to OTP for stable children. Cultural barriers can be investigated and mitigated by effective sensitisation and mobilisation in the community.
Note: To be considered for 2 weekly visits the child must have good appetite for RUTF, be gaining weight above the minimum standard (35g / kg per week) and have no underlying illnesses.
Children Non-Recovered A child who has been treated in OTP for 12 weeks and has not reached discharge criteria is discharged from OTP as “non-recovered”. If proper care protocols are observed this situation should be almost impossible. All non-recovered cases must be investigated. Missing Patients Patients that are transferred to another facility and fail to attend the receiving facility to which they have been transferred within 7 days.
Discharge from OTP
Table 4.16: Criteria for Discharge as Recovered from OTP (children 6-59 months)
Criteria of admission Criteria of discharge
MUAC < 11.5cm • • MUAC >12.5cm (for 2 consecutive weeks) • Sustained weight gain • Clinically well Bilateral oedema • MUAC > 12.5cm • No oedema for 2 consecutive visits • Clinically well WFH <- 3 Z scores (if used) • MUAC >12.5cm and • WFH > -2 SD for 2 consecutive visits • Clinically well Discharge Procedures 48 At discharge ensure the following: • Complete OTP card. Complete all medications • Provide a 7-unit RUTF ration to help the child wean gradually from RUTF to family food • Health and nutrition education sessions should be completed • Immunisation schedule is updated, especially measles • Adequate arrangements for linking the caregiver and child with appropriate community initiatives (e.g., supplementary feeding, food security or welfare initiatives ) are made • The caregiver is aware he/she should return to the health facility if any deterioration is noted • For referrals to SFP, a reference slip should be completed with patient’s information: anthropometric data at the admission and discharge, treatments received
Note: Any patient treated and recovered in OTP can be referred to SFP, if available, for further nutritional support to help avoid relapse. If supplementary treatment is not available, then nutritional counselling should be given and links made to any social services/welfare or livelihood programmes in the area. Designation of CMAM model sites Each state should identify a health facility with adequate staff and best practices in CMAM service delivery and designate such as the model site. This will serve as training site for new staff and will also be used for advocacy purposes with policymakers.
49 Chapter 5: Stabilisation Care (SC) for Children (6-59 months) with SAM and Medical Complications
This chapter describes an overview of inpatient treatment of children 6-59 months with SAM and medical complications and / or poor appetite for RUTF. Detailed treatment protocol provided in stabilisation care for children 6-59 months, infants less than 6 months (or > 6 months and below 3.5kg) children older than 5 years, adolescents and adults is outlined in separate guidelines for the inpatient treatment of SAM4. Linkage between OTP and SC Children admitted into stabilisation care will be referred back to OTP once medical complications are resolved, appetite has returned and/or oedema is reduced. The average time a child may spend in SC is between 4to 7 days. However, in some exceptional circumstances, children will complete the full treatment in stabilisation care. These are if: • OTP is not available or too far from the family’s address • The child is unable to eat RUTF or continues to refuse it • RUTF is not available • Family refuses OTP
Admission to Stabilisation Care
Admission Criteria
Table 5.1: Criteria for Admission in Stabilisation care (children 6-59 months)
Bilateral pitting oedema (+++)
OR Marasmic kwashiorkor (Any grade of bilateral pitting oedema with severe wasting OR > 6 months and < 3.5kg
MUAC < 11.5cm and / or WFH <- 3SD or Bilateral pitting oedema (+) or (++) with: • Anorexia (lack of appetite) or unable to eat RUTF OR The following medical complications • Intractable/Continuous vomiting • Convulsions • Very weak, apathetic, lethargic, not alert or unconscious • Fitting, convulsions • Hypoglycaemia • High fever > 39ºC • Hypothermia < 35 ºC • Severe dehydration based on history and clinical signs • Severe respiratory distress (IMCI criteria) >50 resp/min from 2 to 12 months >40 resp/min from 1 to 5 years >30 resp/min for over 5 years-olds • Any chest indrawing • Very pale, severe anaemia
4 WHO (2003) Guidelines for the inpatient treatment of severely malnourished children Geneva WHO 50 • Extensive skin infection or open lesion that requires IM/IV treatment Any condition that requires IV infusion or nasogastric feeding OR Children referred from OTP with one or more of the following: • Progressive loss of weight for 3 consecutive visits in OTP • Static weight for 4 consecutive visits in OTP
Case management and follow up in Stabilisation care
Management of SAM in stabilisation care for children 6-59 months:
According to current WHO recommendations3, hospital-based care for SAM is organised into phases: • Stabilisation phase: treatment of infections, correction of hydro-electrolytic balance and start of cautious feeding (F75). The child stays in the stabilisation phase until the appetite has recovered, medical complications and / or oedema are resolving. • Transition phase: once the patient recovers appetite, main complications are under control and oedema is reducing, he/she is prepared for discharge to OTP. The appetite for RUTF is first assessed and must be prioritised. If refusing RUTF or unable to take the required daily ration, include F100 until child can consume adequate RUTF daily ration. o Before therapeutic milk is given offer RUTF o If > 75% of the RUTF ration is consumed continue with RUTF and water only o Observe child eating RUTF for 24 hrs minimum (>75%) and prepare for referral to OTP o If < 75% of the RUTF ration is consumed continue with therapeutic milk o Continue to offer the RUTF to the child before each meal of therapeutic milk o • Rehabilitation phase: or catch up growth phase. At this stage, the child is recovering and shall be referred to OTP. Only in exceptional circumstances will children remain as inpatient until complete recovery. Figure 5.1: Organisation of Stabilisation Care
Stabilisation phase
•Appetite is present •Complications resolving •Oedema resolving
Child has appetite for RUTF Refer to OTP
Transition phase & eats >75% of daily ration
•Child refuses RUTF
•OTP not available
Rehabilitation phase
51 Discharge from Stabilisation Care Most of the children admitted in SC will be referred to an OTP service for completing their rehabilitation. Only, in exceptional circumstances (child refuses RUTF, family lives too far away from an OTP or no outpatient services are available) will children complete the full treatment in Stabilisation care.
Discharge Criteria Discharge criteria to Outpatient Therapeutic Programme are as follows:
Table 5.2: Criteria for transfer from SC to OTP (children 6-59 months) (successfully treated)
Appetite for RUTF (eats at least 75% of daily ration)
reducing oedema (at least + or ++) Complications are resolved (or chronic conditions are controlled)
If these conditions are not met after 7 days, a thorough medical examination should explore the reasons (e.g. an undetected medical complication, the child not taken meals correctly, etc.) and correct it. If the child’s condition doesn’t improve during the transition phase s/he should be put back in stabilisation phase.
Prior to discharge, the health worker should ensure that:
• An OTP is available close to the child’s home • The caregiver is willing to continue the child’s recovery at home and understands importance of continuing the child’s recovery in OTP • Caregiver understands how to give RUTF at home • Key messages for RUTF have been understood by the caregiver • Any medications for use after transfer have been explained to the caregiver • Caregiver knows the location of the OTP and date of next OTP session • Sufficient RUTF has been given to last until the next OTP session • A transfer slip has been completed. Caregiver should give this to the health worker at the next OTP session • Individual monitoring card and register has been completed
When patients do not meet the requirements for referral to OTP, they will be discharged according to the criteria detailed in the table below.
Table 5.3 Discharge criteria for children remaining as an inpatient until recovered
Criteria of admission Discharge Criteria (recovered)
MUAC > 12.5cm for 2 consecutive days WFH > -2 Z scores (if used) All admissions with SAM No Oedema for 10 days Sustained weight gain and Clinically well and alert
Chapter 6: Nutritional Counselling Services and programmes addressing Moderate Acute
Malnutrition 52 INFANT AND YOUNG CHILD FEEDING (IYCF)
The WHO and UNICEF developed The Global Strategy for Infant and Young Child Feeding in 2002 to revitalize world attention to the impact that feeding practices have on the nutritional status, growth, development, health, and survival of infants and young children. This strategy involves global public health recommendation to protect, promote and support exclusive breastfeeding for six months and to provide safe and appropriate complementary foods with continued breastfeeding for up to two years of age or beyond.
Breastfeeding Breastfeeding is important to the infant/young child, its mother and the whole family
Importance of Breastfeeding for the Infant/Young Child
Breastmilk: • Saves infants’ lives. • Is a complete food for the infant, contains balanced proportions and sufficient quantity of all the needed nutrients for the first 6 months. • Promotes adequate growth and development, thus preventing stunting. • Is always clean. • Contains antibodies that protect against diseases, especially against diarrhoea and respiratory infections. • Is always ready and at the right temperature. • Is easy to digest. Nutrients are well absorbed. • Protects against allergies. Antibodies in breastmilk protect the baby’s gut preventing harmful substances from passing into the blood. • Contains enough water for the baby’s needs (87% of water and minerals). • Helps jaw and teeth development; suckling develops facial muscles. • Frequent skin-to-skin contact between mother and infant lead to better psychomotor, affective and social development of the infant. • The infant benefits from the colostrum, which protects him/her from diseases. The amount is perfect for newborn stomach size. • Promotes brain development; increased Intelligence Quotient (IQ) scores.
Importance of Breastfeeding for the Mother
• Putting the baby to the breast immediately after birth facilitates the expulsion of placenta because the baby’s suckling stimulates uterine contractions. • Reduces risks of bleeding after delivery. • When the baby is immediately breastfed after birth, breastmilk production is stimulated. • Breastfeeding is more than 98% effective as a contraceptive method during the first 6 months provided that breastfeeding is exclusive and amenorrhea persists. • Immediate and frequent suckling prevents breast engorgement. • Reduces the mother’s workload (no time is involved in boiling water, gathering fuel, on preparing milk). • Breastmilk is available at anytime and anywhere, is always clean, nutritious and at the right temperature. • It is economical. • Stimulates bond between mother and baby. • Reduces risks of breast and ovarian cancer.
Importance of Breastfeeding for the Family
• The child receives the best possible quality food, no matter what the family’s economic situation. 53 • No expenses in buying formula, firewood or other fuel to boil water, milk or utensils. The money saved can be used to meet the family’s other needs. • No medical expenses due to sickness that formula could cause. The mothers and their children are healthier. • As illness episodes are reduced in number; the family encounters few emotional problems associated with the baby’s illness. • Births are spaced due to its contraceptive effect. • Time is saved. • Feeding the baby reduces work because the milk is always available and ready.
Importance of Breastfeeding for the Community
• Not importing formula and utensils necessary for its preparation saves hard currencies that could be used for something else. • Healthy babies make a healthy nation. • Savings are made in the health area. A decrease in the number of child illnesses leads to decreased national medical expenses. • Improves child survival and reduces child morbidity and mortality. • Protects the environment (trees are not used for firewood to boil water, milk and utensils, thus protecting the environment). Breastmilk is a natural renewable resource
Recommended Practices for Breastfeeding
• Put infant skin to skin with mother immediately after birth • Initiate breastfeeding within half an hour of birth • Give first yellow milk (Colostrum) within half an hour of birth • Exclusively breastfeed from birth until six months (no water, other drinks or food) • Breastfeed on demand (day and night) • Allow baby to release self from breast at will, not forced. • No water should be given during the first six months • Breastfeed frequently during and after illness • Continue breastfeeding until 2 years of age or older • Mothers need to eat and drink to satisfy hunger or thirst. No one special food or diet is required to provide adequate quantity or quality of breastmilk • Avoid bottle feeding. Foods or liquids should be given by a spoon or cup to reduce nipple confusion and the possible introduction of contaminants
Complementary Feeding This is the process of giving age-appropriate, adequate and safe foods while breastfeeding continues for up to 2 years of age and beyond. Complementary foods should be introduced at 6 months, when breastmilk no longer meets the infant’s growing nutrient needs.
Recommended practices for complementary feeding
• At six months of age introduce complementary foods (such as thick pap (Kunu/Ogi/Akamu) 2-3 times a day) as well as family foods to breastfeeds • As baby grows older increase feeding frequency, amount, texture and variety • Give baby 2 to 3 different family foods: staple, legumes, vegetables/fruits, and animal foods at each serving • From 6 to 8 months breastfeed and give 2-3 servings of foods • From 9 to 11 months breastfeed and give 4 servings of food per day • From 12 to 23 months breastfeed and give 5 servings of food per day, • Be patient and actively encourage baby to eat all his/her food
54 • Wash hands with soap and water before preparing food, eating, and feeding young children • Feed baby using a clean cup and spoon • Continue breastfeeding until 2 years of age or older
Age Frequency Amount of Texture Variety (Per day) Food an (thickness/ average child consistency) will usually eat at each serving (in addition to breastmilk) 6-8 2 - 3 times 2 - 3 Thick Breastfeeding months food tablespoons porridge/pap + ‘Tastes’ up to ½ Mashed/ Staples cup (250 ml) pureed (porridge, family foods other local 9-11 4 times ½ cup/bowl Finely examples) months foods and (250 ml) chopped Legumes snacks family foods (local examples) Finger foods Vegetables/ Sliced foods Fruits (local 12-23 5 times ¾ -1 cup/bowl Family foods examples) months foods and (250 ml) Sliced foods Animal foods snacks (local examples) Vegetables/ Fruits (local examples) Animal foods (local examples Note: Add 1-2 Add 1-2 cups of If baby is extra times milk per day not food and breastfed snacks Responsive/Active Be patient and actively encourage your baby to eat Feeding Hygiene 1. Feed your baby using a clean cup and spoon, never a bottle as this is difficult to clean and may cause your baby to get diarrhoea. 2. Wash your hands with soap and water before preparing food, before eating, and before feeding young children. 3. Use iodized salt in preparing family foods
55 Infant feeding in the context of HIV5
A few babies born to HIV infected women, may become infected through breastfeeding. At the same time, many babies who are not breastfed because of fear of HIV transmission die from diarrhoea, pneumonia or other diseases (not related to HIV), because they are not protected by the immune substances found in breast milk. Thus, HIV infected mothers need to be well guided on how best to feed their infants to ensure that more babies survive without being infected with HIV.
Following extensive review of evidence-based research and global recommendations; and
discussions at a national consultative meeting consensus was reached on the following points: 1. The goal of all Prevention of Mother To Child Transmission (PMTCT) interventions in Nigeria is HIV free survival which focuses on both prevention of HIV transmission and child survival ; 2. All mothers, including HIV-infected mothers, should exclusively breastfeed their infants for the first 6 months of life and introduce complementary foods at 6 months. However, HIV-infected mothers should continue breastfeeding until 12 months while mothers who are HIV- negative should continue breastfeeding up to two years and beyond 3. Improved complementary feeding of all infants, especially those born to HIV- infected mothers, should be promoted and where possible, supported; 4. The Federal Ministry of Health will continue to provide antiretroviral drug interventions to reduce the risk of HIV transmission through breastfeeding and strongly recommends that all mothers, including those known to be HIV-infected should breastfeed their infants; 5. HIV-infected mothers should be assessed to determine if they need lifelong antiretroviral therapy (according to National Recommendations) and if so, to start as early as possible (after presentation to ANC /HIV diagnosis ); if HIV-infected mothers do not require ART for their own health, antiretroviral drugs to reduce the risk of HIV transmission should be started and provided until 1 week after the end of all breastfeeding;
IYCF 3-step counselling /‘Reaching an agreement’
The IYCF 3-step counselling/‘reaching-an-agreement’ process provides information and support to
the mother /caregiver and involves the following steps: 1. Assess age appropriate feeding: ask, listen and observe 2. Analyze feeding difficulty: identify difficulty and if there is more than one - prioritize, 3. Act – discuss, suggest small amount of relevant information; agree on feasible doable option that mother/ caregiver can try.
Step 1: Assess • Greet the mother/caregiver and ask questions that encourage her/him to talk, using listening and learning, building confidence and giving support skills. • Asking the following questions: a) What is your name and your child’s name? b) Observe the general condition of mother/caregiver. c) What is the age of your child (in completed months): 0 – 5; 6 – 8; 9 – 11; 12 – 23 d) Ask mother/caregiver if you can check child’s growth card. Is growth curve increasing? Is it decreasing, levelling off? (If decreasing or levelling off, mark ‘no’ to question: is growth curve increasing?) e) Ask about breastfeeding:
5 Infant Feeding in the context of HIV: Revised WHO Principles and Recommendations 2010; FMOH Consensus statement following a national consultation on infant feeding in the context of HIV in Nigeria 2010
56 - About how many times/day do you usually breastfeed your baby? = frequency - How is breastfeeding going for you? = possible difficulties - Observe mother and baby's general condition - Observe baby's attachment, baby's position. Ask about complementary foods: - Is your child getting anything else to eat? = what type/kinds - How many times/days are you feeding your child? = frequency - How much are you feeding your child? = amount - How thick are the foods you give your child? = texture (thickness/consistency). Ask about other milks: - Is your child drinking other milks? - How many times/day does your child drink milk? = frequency - How much milk? = amount. Ask about other liquids: - Is your child drinking other liquids? = what kinds? - How many times/day does your child drink “other liquids”? = frequency - How much? = amount. f) Does your child use a feeding bottle? g) Who assists child to eat? h) Has child been recently sick?
Step 2: Analyze • Identify feeding difficulty (if any) • If there is more than one difficulty, prioritize difficulties • Answer the mother’s questions (if any).
Step 3: Act • Depending on the age of the baby and your analysis (above), select a small amount of INFORMATION RELEVANT to the mother’s situation. (If there are no difficulties, praise the mother for carrying out the recommended breastfeeding and complementary feeding practices) • For any difficulty, discuss with mother/caregiver how to overcome the difficulty • Present options/small do-able actions (time-bound) and help mother select one that she can try to overcome the difficulty • Ask mother to repeat the agreed upon new behaviour to check her understanding • Let mother know that you will follow-up with her at the next weekly visit • Suggest where mother can find additional support (e.g. attend educational talk at CMAM site, IYCF Support Groups in community, and refer to Community Volunteer) • Refer as necessary • Thank mother for her time.
COMMON BREASTFEEDING DIFFICULTIES
The following are common breastfeeding difficulties: • Engorgement • Sore or cracked nipples • Blocked Ducts and Mastitis • Insufficient breastmilk Please refer to Annex 12 for a detailed counselling guide.
KEY HOUSEHOLD PRACTICES
57 1. Exclusive Breast Feeding (EBF) see above. 2. Hand washing Most illness and deaths in children results from germs through food and water. Frequent and proper hand washing with soap or ash and clean water kill and remove germs from hands. The Critical times for hand washing are: • Before preparing food, • before eating • After eating. • Before feeding baby • After using latrines. • After cleaning and disposing the child’s faeces.
3. Long Lasting Insecticide Treated Nets (LLINs)
All children under 5 should be provided with Long Lasting Insecticidal Nets (LLINs) to prevent malaria • LLINs are nets that are permanently treated with approved insecticides • LLINs must be aired for 24 hours before sleeping under it • Make sure you and your child sleep under the net every night. • Fold it up properly in the morning to avoid damage. • When the net is torn, repair by sewing. • Use of Treated Nets lead to drastic reduction in number of malarial illnesses and deaths in children • Using treated nets regularly is very important in preventing malaria illness • Do not use harsh soap like detergents to wash the net, but use a mild bathing soap • Do not hang rather spread it in the shade, not under the sun • ITNs must be retreated after every six months or after 3 washings for them to be effective • However, LLINs do not require re-treatment and can withstand about 18 – 20 washes and can last for 4-5 years.
4. ORAL REHYDRATION SALTS/ SALT SUGAR SOLUTION
• Diarrhoea is 3 or more loose stools per day • It causes dehydration or lack of water in body of children, If untreated can kill Home Management of Diarrhoea • Mix salt sugar solution and feed child frequently to replace lost water in the body. • 2 large Coke bottles (1000mls) of clean water and 1 level teaspoon salt and 10 level teaspoons sugar(5 cubes) • Take child to health worker if diarrhoea does not stop or child becomes weak
Note: Do NOT use ORS if a child has Severe Acute Malnutrition
5. Immunization • Know benefits of immunization. • Know the diseases immunization can prevent. • Know how community feels about immunization and demand for the service.
58 Vaccines and Schedule
Vaccines / No. of Age Minimum Route of Dose Vaccination
Suppleme Doses interval Site nts between Administration doses
BCG 1 At birth or as soon as Intra-dermal 0.05ml Upper arm
possible
OPV 4 At birth, 6,10 and 14 4weeks Oral 2 drops Mouth
week of age
DPT 3 At 6,10 and 14 weeks 4weeks Intramuscular 0.5ml Outer part
of age of thigh
Hepatitis B 3 At birth, 6 and 14 4weeks Intramuscular 0.5ml Outer part
weeks of age of thigh
Measles 1 At 9 months of age Subcutaneous 0.5ml Upper left
arm
Yellow 1 At 9 months of age Subcutaneous 0.5ml Right upper
Fever arm
6. HIV/AIDS HIV IS caused by a virus which infects human beings. AIDS is the disease condition resulting from low immunity HIV is spread through: • Sexual intercourse with an infected person • Infected blood and sharp instruments • Infected mother to babies through pregnancy, delivery and breast feeding. You can avoid HIV infection by: • Not having sex with many partners • Having one faithful sexual partner • Not sharing razor blades or sharp instruments with others • Using new injection needles for each person • Screening blood donors for HIV • Getting proper treatment for sexually transmitted infections. • Using condoms properly during sex . • Preventing spread from parents to children. • Seeking information advice on HIV/AIDS from trained health workers. • Voluntary counselling and testing. Other key messages: • Protect others if HIV positive. • Protect yourself when HIV negative. • Do not discriminate against those that are HIV positive. • Support HIV infected adult, children, orphans to live a positive life
59 7. Growth Monitoring & Promotion • Conduct in the health facility and community by weighing the child and plotting on the Child Health Card every month to check /see how the child is growing • Advice on caring for the child • Advice on proper feeding • Advice on prevention of diseases.
8. Adequate micro nutrient supplementation
• Micronutrients can be consumed from the following foods: Vitamin A- paw-paw, fortified sugar, flour and vegetable oil carrots, liver, mangoes, palm oil. • Zinc- egg, meat and fish. • Iron- egg, meat, fish, liver, pumpkin • Iodine- iodised salt, onions, fish, leafy vegetables (e.g. moringa, pumpkin leaves, spinach, etc.) Micronutrients can be supplemented the following ways: - ▪ Vitamin A capsule- after 6 months, 6-59 months. – For good eye sight, protection from infection, and reduction in mortality ▪ Iron- formation of blood and mental alertness ▪ Iodine- brain growth, mental and physical development, prevention from goitre.
9. Home management of Sick Children
• A Sick child losses water and energy requiring more food and drinks. - • Encourage child to eat and drink plenty of fluids • Give little at a time frequently • Remove clothes, lukewarm sponge when feverish. • Give paracetamol • De-worm children 1 year and above every 6 months. • Soothe with home remedies for cough like honey, rice water, Take the child to the nearest health facility, if there is no improvement, Supplementary Feeding Programme (SFP)
Objectives The objective of SFP is to manage and prevent moderate acute malnutrition in specific groups for a specified period of time as well as to prevent deterioration to SAM. SFP can also provide a continuum of care to children discharged from SC and OTP. SFP can be setup when there are high rates of acute malnutrition and/or the capacity of the health system to implement SFP services. Main groups targeted are children 6-59 months and pregnant & lactating women.
Types of SFP
There are two types of SFP: targeted and blanket SFP. Supplementary foods for an SFP programme may include fortified flours or Ready to Use Supplementary Food pastes (RUSF – similar to RUTF but used for moderate acute malnutrition). Their main details are outlined in table 6.2 below.
60 Table 6.2: Targeted and blanket SFPs Targeted SFP Blanket SFP The main aim of targeted SFP is to treat MAM Main aim of a blanket SFP is to prevent and prevent deterioration to SAM. widespread malnutrition and to reduce excess mortality among those at-risk by providing a This programme is set up when: food/micronutrient supplement for all o There are large numbers of moderately vulnerable groups (e.g. children under five, malnourished individuals people with HIV/TB, elderly and the o There are large numbers of children chronically ill). who are likely to become malnourished Blanket SFPs may be set up under one or a due to aggravating factors like serious combination of the following circumstances: food insecurity, or high levels of o There are large numbers of disease. malnourished individuals due to o There are children discharged from an aggravating factors. existing CMAM including OTP/SC. o Anticipated increase in rates of o High prevalence of people with HIV/ malnutrition due to seasonally induced TB. epidemics. o High prevalence of micronutrient deficiencies.
Voluntary food fortification
Another variety of supplementary food (in powdery form) is available at the health facility and/or women’s centre. In health facilities this is provided to malnourished children detected through growth monitoring. In women’s centre and communities it can be provided to all children 6-59 months to prevent malnutrition and growth faltering. These foods are different in nutritional content to the supplementary foods supplied through an SFP programme for Moderate Acute Malnutrition.
One example of voluntary food fortification is also known as Tom Brown, Garin Lafiya, etc. The overall recipe is described below.
Tom Brown 6-3-1
Ingredients: 6 cups of millet or maize seeds 3 cups of soya beans 1 cup of ground nuts
Preparation: 1. Soak the millet or maize in hot water for 2 hours 2. Remove from water and sundry. 3. Soak soya beans in clean water for 24 hours. 4. Sundry soybean and roast until golden brown 5. Roast groundnuts until golden brown and remove husk. 6. Mix all ingredients together and grind to powder. 7. Package the mixed powder into small portions for a single meal. 61 Note: Packages can be stored for up to 6 months when well sealed and kept dry. Some centres add ground crayfish or palm oil and/or sugar during preparation. Other fortified recipes are available through the Ministry of Agriculture.
62 Chapter 7: Monitoring & Evaluation
Monitoring and Evaluation are essential for:
• Providing Information about implementation of activities • Noting outcomes, analysis and identifying appropriate corrective actions • Assessing the situation and identifying needs for improvement • Generating data about nutrition/health situation to be used for planning and decision making
Rolesat different levels for the Implementation of CMAM
The individual performance of the different components of CMAM will greatly depend on the practical links between them, from Federal level via the different levels Zone/State/LGA down to community/ health facilities. Every structure and every staff member has an important role in effective CMAM implementation.
At Federal level (Responsible person: Head of Nutrition Division)
• Planning for rollout, training, supplies • Coordination of programme and stakeholders involved in CMAM • Development of national protocols and guidelines, create conducive policy environment • Harmonisation of CMAM with other related strategies and vice versa (e g IYCF, HIV, MNCH) • Provision of supportive supervision/monitoring to ensure quality of service delivery • Provision of periodic national programme data and information (manage a database of admission numbers, average performance indicators, etc.)
At Health Zonal, State and LGA Level (Responsible persons: Zonal Technical Officer, State Nutrition officer, LGA Nutrition Focal Person) • Planning and commitment for rollout, training, supplies • Monitoring of supply provision and distribution of materials for CMAM (RUTF, medicines,) • Monitoring and evaluation of CMAM at all levels • Policy dialogue and sensitization • Training at implementation levels • Supportive supervision to health facilities • Establishment and management of a database for the programme
At Health Care Catchment/Facility Level (Responsible person: Officer in Charge)
Health facilities have to: • Check and confirm whether cases identified and referred by the community should be admitted to OTP/SC or not • Provide medical and nutritional treatment through OTP to SAM cases without medical complications • Provide hospital based management for complicated SAM cases or referral services to closest inpatient centre • Provide nutritional counselling to MAM cases • Offer counselling on IYCF and other health/nutrition education issues Coordinate and support community volunteers and community structures. • Rule out any underlying health conditions such as HIV/AIDS or tuberculosis which may be contributing to malnutrition • Systematically report the outcomes of CMAM activities to the LGA nutrition focal person. In order to be able to respond to their roles in the management of acute malnutrition, health facilities need to: • Have qualified and trained health staff • Have the necessary equipment (anthropometric, medical, guidelines and protocols) 63 • Receive regular supply of drugs, RUTF and renewable materials or forms. Monitoring teams Monitoring teams are expected to be formed at the Federal, Zonal, State and LGA level to ensure frequent visits to the sites. Suggested members of those teams should include: • Federal and Zonal: Nutrition Division, Child Health Division and Health Promotion Division FMOH; Community Services Department of NPHCDA, Nutrition Division of National Planning Commission • State: State Nutrition Officer (SNO), Deputy SNO, Ministry of Agriculture (nutritionist), IMCI Coordinator, MNCH Coordinator, , Social Mobilisation Officer / Health Educator, Monitoring and Evaluation Officer • LGA: Medical Officer of Health (where available) or Nutrition Focal Person are to ensure regular supervision of the quality of service provided by all the facilities; other members who will monitor include the following: IMCI Coordinator, MNCH Coordinator, M&E Officer, Social Mobilisation Officer / Health Educator Partners involved in nutrition (UN Agencies, NGOs, CBOs, etc) will support monitoring at all levels. Table 7.1: Frequency of monitoring visits
From To Frequency What to do
- review data with the State team Federal / - visit at least 1 LGA State Quarterly Zonal - visit at least 1 site / community - provide feedback - review data with the LGA team - visit all implementing LGAs State LGA Monthly - visit all implementing sites/ communities - provide feedback
Health Weekly or bi-weekly - check records with last monthly
LGA Facilities/ (depending on number of report Communities sites) - mentoring and supervision - provide feedback
Standard indicators (quantitative data) should be analysed and combined with qualitative information collected through consultation with the community and stakeholders. Through supervisory visits, strengths and weaknesses can be identified, feedback provided and timely adjustments carried out. The main performance indicators should be plotted against time (months) to provide a picture of how the performance of the activities and the situation has evolved. Monitoring and evaluation at the health facilities Monitoring at service delivery points includes two levels: - Individual monitoring to ensure appropriate treatment and continuum of care - Record keeping and program monitoring to assess outcomes and performance
Individual monitoring in OTP
Tools for Individual Follow up and Tracking System
64 To facilitate a continuum of care between services a numbering system and various tools have been developed.
Individual/Unique Number Every child (both those staying in OTP and those referred to SC) should be given a unique number to avoid loss and allow follow up between the services, double registration or double counting of cases. Numbers should be used on all documents (OTP cards, register, Child Health Card, referral forms)
The HMIS system in Nigeria has not been modified yet to include indicators for acute malnutrition. However the standard codes to identify the LGA and health facility should be used and include an identifying code for OTP
LGA Code: The code used to identify the LGA in HMIS
Health facility code: The code used to identify the health facility in HMIS Year: The year in which the admission took place OTP Code: 3 letter abbreviation unique to each health facility to identify the OTP clinic e.g. MTS for Matsai OTP Beneficiary Serial Number: 0-9999 (starts from 0 for each individual site)
If the child is a relapse case, they should be given a postfix to her/his SAM number thus _ _ _ / _ _ _/____ -2
Specific Tools Ensure to record the individual/unique SAM number of the children in the different forms the child uses to assess services in the health facility to link with other medical treatment provided in health facility.
In order to ensure quality and continuity of care during the management of SAM cases, the following documents should be used: • OTP card (see annex 6): contains all information regarding the child’s condition at admission and discharge and his/her evolution during treatment • Referral slip (see annex 11): allows tracking information about the child’s condition and evolution during movements between services (outpatient to inpatient and vice versa). The standard MOH system and referral slip will be used for CMAM. Registration book (see annex 5): separate register for CMAM can facilitate data collection and quick evaluation of workload and outcomes • Child Health Card: The child health card is used to; o Register admission o Indicate date of weekly attendances and RUTF ration given o Discharge date and outcome. Double registration: If it is suspected that a child is registered at more than one OTP site, a fingernail can be marked using indelible ink (permanent marker) to indicate registration in OTP. A specific finger can be identified for use by each health facility in an LGA or given area. Discharge Categories from OTP 65 Table 7.2: Discharge Categories from Outpatient Therapeutic Programme
Category Definition Recovered Meet the discharge criteria Defaulter Absent during three consecutive visits (declared DEFAULTER at third absence) Death Died during treatment in OTP or during transit to SC Non recovered Did not meet the discharge recovered criteria after four months in treatment
Transfers between services have not been discharged from therapeutic care and should be recorded as follows:
Referred to The child fulfils criteria for referral to SC
inpatient Transfer to another Child with SAM under treatment that moves to another outpatient outpatient unit site while being in treatment
The distinction between discharges and referrals to another therapeutic unit are indicated in figure 7.1 below. True discharges are no longer receiving therapeutic care. Referrals have ‘exited’ from the site (OTP or SC) but are still receiving treatment in the therapeutic programme.
Figure 7.1: Difference between referrals and discharges
Discharges •Cured Stabilisation care •Died Referral to / from OTP & SC •Default Discharges •Non recovered OTP •Cured •Died •Default •Non recovered
OTP OTP
Record keeping and program monitoring
Monthly Reporting Quantitative data are collected on the outcome of all activities and allow the calculation of standard indicators. Standard indicators should be compared to CMAM national guideline standards. Basic routine data are collected in: 66 • Admissions: new cases and old cases (by age group), • Exits: numbers and by category (by age group) • Number of children (beneficiaries) in charge These three basic elements allow monitoring of trends along time and help the appropriate allocation of resources. Other additional information that may be relevant are: • Percentage of relapses (among total new admissions) • Admission per typology (marasmus, kwashiorkor) • Average length of stay (and weight gain), mainly for inpatient services • Causes of death • Reasons for defaulting • Data on admissions disaggregated by gender This should be accompanied by some narrative description or explanation of the main events that may have influenced attendance and performance (e.g. opening or closing of facilities, outbreaks of infectious diseases, insecurity, seasonal trends in agriculture and weather, etc.). There are two levels of reporting: • Reporting of individual services (outpatient or inpatient: health centres with OTP, hospital with SC) • Compilations prepared with the outcomes from the different individual facilities providing CMAM services (outpatient and inpatient) and representing an accountable unit or area (LGA, State, Zonal, Federal)
Individual site reporting
The monthly site report (tally sheet) is completed by the responsible health care provider (i.e. Officer in Charge) for each facility offering CMAM services with inputs from the Registration book or the individual charts and sent to the LGA. A copy of the compiled report should be kept in the health facility. . Consolidated Reporting (compilation by area or programme) The reports from the individual facilities operating within an LGA are examined and collated (either in a database or hard copy according to means available) to produce a compilation report for the LGA by the Nutrition Focal Person. This report will be forwarded to the State Nutrition Officer at State level and also shared with health facilities. The report provides a summary of quantitative information to assess performance, monitor trends and identify areas that require investigation at the health facility level: • Total number in treatment at the beginning of the month • Admissions as new cases (by age-group and gender if required) • Admissions as old cases (incoming referrals and returned defaulters) • Total admissions of the month • Total exits (denominator for discharge rates) • The number and proportion of children that are discharged recovered, died, defaulted or non-recovered • Total exits • Total number in treatment at the end of the month
At the State level, data from all LGAs will be compiled and analysed by the State Nutrition Officer, then forwarded to the Nutrition Division at Federal level. Similarly, at the Federal level the Nutrition Division CMAM focal person will compile and analyse country-wide data. The national compilation of data will be shared to all nutrition stakeholders.
67 Figure 7.2: Reporting at different levels in the Ministry of Health
Federal •Monthly summary for the Country on a quarterly bases (i.e. Jan-Mar at the end of April, etc.) •Contact: Nutrition Division FMOH, NPHCDA
State •Monthly summary for the State to the FMOH by 15th of the following month •Contact: State Nutrition Officer
LGA •Monthly summary for the LGA to the State by the 10th of the following month •Contact: Nutrition Focal Person
Facility •Weekly tally sheet report to be compiled monthly and sent to the LGA by 5th of the follwinng month •Contact: Officer-In-Charge
Responsible officers at each level will be expected to take appropriate action based on the analysed data.
Examples for tally sheets and weekly/ monthly reports can be found in annexes 8, 9 and 10.
Annual reporting Annual reports will present the totals for a whole year and explain the evolution of trends and performance for the year. These are to be done at LGA, State and Federal Levels.
External evaluation reports
Mid Term Review: It is recommended that a mid- term review be conducted at every 1.5 years of CMAM activities with a team formed and led by FMOH at federal level (including, NPHCDA, partners, etc.). This team will visit randomly selected CMAM sites. The report is to be shared with visited sites, states, and followed by a review meeting.
Three- year external evaluation: The evaluation should include:
a) a review of each component of the CMAM program (community aspects, screening, OTP, SC, organisation etc.) with an overview of monthly and annual reports; b) review of tools, modules, and methods of training; c) the quality of supervision; d) the staffing and organisation; d) the logistics; e) financing of the program; f) recommendations for adjustment.
Maternal, Newborn, & Child Health Weeks screening reports: Screening done during MNCHW will be compiled by the Nutrition Focal Person at LGA level and the State Nutrition officer at State level
Performance Indicators Performance indicators are based on discharge outcomes from OTP and SC. For the purposes of analysis the outcomes of OTP and SC are combined. The time needed to achieve the discharge 68 outcome indicators for a CMAM programme is 1-3 months. Discharges from a CMAM programme are those no longer registered. The discharged individuals are made up of those who are recovered, non-recovered, defaulted and died.
Recovered rate: a discharged individual must be free from medical complications and have achieved and maintained appropriate weight gain without nutritional oedema (e.g. for two consecutive weighing). Protocols outlining discharge criteria which should be adhered to, in order to avoid the risks associated with premature exit. International standards aim for >75% of discharges to be recovered.
Cure rate = Number of children recovered
Total number of discharges
Death rates: causes of death should be noted and acted upon to improve services for other children. All defaults could be potential deaths so need to be followed up. International standards aim for <10% of discharges to be deaths.
Death rate = Number of children died
Total number of discharges
Defaulter rates: a defaulter from a therapeutic feeding programme is an individual who has not attended for a defined period of time (e.g. for more than 48 hours for in-patients, or 3 consecutive return visits for outpatients). Defaulter rates can be high when the programme is not accessible to the population (e.g. the distance of the treatment point from the community, conflict/lack of security, the level of support offered to the caregiver of the individual treated, the number of caregivers who are left at home to look after other dependants (this may be especially relevant in situations of high HIV/AIDS prevalence), and the quality of the care provided).
International standards aim for <15% of discharges to be defaulters.
Defaulter rate = Number of children defaulted
Total number of discharges
Non-recovered rates: There are no set international standards but should be almost zero if protocols are properly followed. Instances of non-recovery need careful investigation into both the services provided and the environment (disease outbreaks, food insecurity etc)
Non-recovery rate = Number of children non-recovered
Total number of discharges Coverage refers to those needing treatment actually getting treatment. Coverage estimates vary according to method used. The methodology must be stated when reporting. Coverage assessment should be seen as a management audit tool and should be conducted on a regular basis.
Table 7.3: Summary of international standards (SPHERE 2004)
Indicator Standard Recovered > 75% Default < 15% Died < 10% Non-recovered No standard
69 Rural > 50% Coverage Urban > 70% Camp > 90% The overall effectiveness of a programme is the product of the cure rate multiplied by coverage (see figure 7.3 below). This illustrates the importance of the community mobilisation component of CMAM. Without good coverage, even the best clinical care outcomes will only partially meet the needs of the community as a whole. Figure 7.3: Effectiveness of CMAM programmes
Supervision Supervisory visits to CMAM sites are designed to improve the quality of care offered in: • Identifying strengths and weaknesses in the performance of CMAM activities, take immediate action and apply shared corrective solutions • Strengthening the technical capacity of health providers through encouragement of good practices • Providing feedback to health workers at the health facilities
Supervisors must ensure that the performed activities and that the functioning of the services meet standards of quality. Supervision for CMAM activities should be combined with those for other services and by the same personnel. Supervision visits are done by the direct observation of the performance at the health centres while filling a “supervision checklist” which should cover the key practical aspects of the guidelines in use (example of supervision checklist in annex 13). During supervision other documents that should be reviewed: • OTP cards • Registration book • Data collection sheets (tally sheets and monthly reports) • Stock cards and stock levels Supervision checklists should facilitate the evaluation of logistics-management and technical aspects related to the provision of services (outpatient or inpatient) in structured manner: • Organisation of the activities • Structural condition and hygiene of the facilities • Storage of products and equipment 70 • Reference documents and job aids available • Filling of forms and filing: follow up cards, monthly reports etc • Adherence to criteria, protocols and procedures • Performance of tasks: anthropometric measurements, clinical examination and appetite test, prescription/ administration of medicines and RUTF, and • Education and prevention activities Prior to each visit, supervisors should examine all the available documentation for each facility, the records of previous supervision and routine monitoring outcomes. That will allow for identifying the priority areas to observe and make the supervision more efficient. During the visit, gaps and discrepancies should be identified in consultation with the health staff and, as much as possible, with representatives of the community. Immediate feedback should be given to the health care provider and to the community, jointly searching for solutions to the problems identified. Supervisions are also essential for improving staff capacities through the organisation of formal or informal refresher training (on-the-job training) during the visits, mainly in less accessible areas where staff displacement is difficult.
Monitoring and Evaluation of Community Mobilisation activities
The effectiveness of community mobilisation must be monitored on a regular basis and contact maintained with key community figures and those involved in case-finding. This will enable problems to be promptly identified and corrective action to be taken. The collection and analysis of routine data will provide an indication of the success of the service and community mobilisation or highlight issues which need investigation.
Quantitative Indicators • Admissions of referred cases over time • The percentage of referrals who do not attend and their reasons. • The source of referrals (community health worker/community volunteer, other caregiver, spontaneous etc.) • Community volunteer activity and accuracy (number of children correctly referred) • The number of self referrals rejected as ineligible who have misunderstood the service • The number of absentees tracked and brought back by CVs • The percentage of defaulters of the total exits and the reasons for defaulting Qualitative Data In addition to monitoring statistics it is important to also measure quality. The perceptions of service users, those involved in mobilisation activities and the wider community should be gathered. • Community awareness, understanding and opinions of the CMAM service • Community volunteer motivation and challenges to performing activities • Caregivers’ experience of the service and areas identified for improvement Ongoing mobilisation activities for CVs Ongoing mobilisation activities are also important to maintain community engagement, motivation, ownership, and foster a genuine sense of partnership. • CV attending refresher training for case finders on SAM and case identification (MUAC & bilateral oedema) • Number of meetings between health facility staff and CV to share experiences and air any problems which need to be resolved • Number of feedback sessions on results done with the community SQUEAC (Semi-quantitative evaluation of access and coverage) One of the most important elements behind the success of the CMAM approach is its proven capacity for achieving and sustaining high levels of coverage over wide areas. 71 A new method called SQUEAC (Semi-Quantitative Evaluation of Access and Coverage) uses a two- stage process to assess access and coverage. The SQUEAC method combines quantitative data collected through routine monitoring of the CMAM activities (admissions, exits, defaulting rates etc), quantitative surveys and qualitative (anecdotal) data collected using informal group discussions and interviews with a variety of informants. Stage 1- the examination of the pattern of admissions and defaulters over time can identify patterns and potential problems with the programme. Mapping of the locations of beneficiaries and defaulters (obtained from Individual follow up cards) and outreach activities (CVs) can help identify potential barriers to accessing CMAM services. Information about other barriers or boosters to access can be acquired through informal group discussions and interviews with a variety of informants or made available from sources such as nutritional anthropometry surveys and food-security assessments. At the end of stage 1, areas of low and high coverage are identified (hypotheses) as well as reasons for coverage failure.
Stage 2 - A wide area survey is conducted to provide further quantitative data in support of stage 1 findings
Statistical analysis of the results provides an estimate of coverage for the CMAM services. However, the true value of the methodology lies in the information obtained regarding the barriers and boosters to service access which can then be addressed to improve coverage and service quality.
Equipment and supply of therapeutic products
Calculating Estimated RUTF Needs in OTP
Estimated RUTF Needs for OTP per Month are based on a RUTF Diet of 200 kilocalories (Kcal) per kg per day on average. Each child in Outpatient Therapeutic Programme consumes about 20 sachets of RUTF a week. Total consumption in OTP per time period is calculated as follows:
Table 7.4: Calculation of RUTF requirements
A Number of OTP beneficiaries (according to the
OTP) B Monthly consumption per child (@20 sachets/child/week) 80 C Monthly sachets consumption for OTP AxB D Monthly carton consumption for OTP C/150 E Monthly net weight (MT) (@13.8 kg/carton) D x 13.8/1000 F Monthly gross weight (MT) (@14.7 kg/carton) D x 14.7/1000
EXAMPLE RUTF Number of OTP beneficiaries 1,000 children Monthly consumption per child (@20 sachets/child/week) 80 sachets Monthly sachets consumption for OTP 1,000 x 80 = 80,000 sachets Monthly carton consumption for OTP 80,000/150 = 533.33 Monthly net weight (MT) (@13.8 kg/carton) 533.33 x 13.8/1000 = 7.35 MT Monthly gross weight (MT) (@14.7 kg/carton) 533.33 x 14.7/1000 = 7.84 MT
72 73 Guideline Annexes
1. Measuring MUAC
2. Measuring oedema
3. How to measure weight
4. How to measure length / height
5. Example of OTP register page
6. OTP card
7. Summary of OTP medicines
8. OTP tally sheet
9. CMAM Monthy report sheet
10. CMAM report for LGA, State, and Federal level
11. Referral Slip for OTP / SC
12. Counselling Guide for Breastfeeding Difficulties
13. Supervision Checklist
14. Weight for Height tables (WHO 2006)
74 ANNEX 1: How to Measure Mid Upper Arm Circumference (MUAC)
1. Find the midpoint. Ask the patient to stand, or for a small child, have the caregiver hold the child, with the patient’s left arm bent at a 90-degree angle. Find the bone that forms the tip of the shoulder (acromium process), and place the zero point of the MUAC measure there (it is usually the middle of the window). Extend the MUAC tape down to the tip of the elbow (olecranon process). Read the length in mm of this distance between shoulder and elbow; then divide this number in half to find the mid-point (or fold the tape in half between the zero and the elbow point). Mark the mid-point in pen on the patient’s arm.
2. Position the patient to read the MUAC. Have the patient stand or sit with the left arm hanging loosely by the side of the body. Muscles should not be flexed at all.
3. Measure the MUAC. Place the MUAC tape around the left arm at the midpoint mark. It should fit snugly around without constricting the arm. Read the measurement from the window of the tape. Take the measurement to the nearest 0.1cm.
75 ANNEX 2: How to Assess for Bilateral Pitting Oedema
1. While child is sitting, grasp both feet in your hands. Apply firm thumb pressure to the tops of both feet for three full seconds (count 101, 102, 103). Remove the thumbs. 2. If the depression from your thumbs remains on both feet, then the patient has bilateral pitting oedema. It may be easier to feel this depression than to see it. 3. If tops of feet are oedematous, repeat the process on the shins and hands. 4. If the shins / hands are oedematous, observe for oedema around the eyes. Oedema is nutritionally significant if it is present on both feet. However, bilateral pitting also be caused by medical conditions such as nephritic syndrome. Medical causes should be first ruled out before the diagnosis of nutritional Oedema is made 5.
+1 oedema Bilateral Pitting Oedema
Grade of Oedema Observation
+2 Absent Absent
Grade + Mild: Both feet/ankles
Grade ++ Moderate: Both feet, plus lower legs
Severe: Generalized oedema including both feet, legs,
Grade ++ hands, arms, and face/head
Oedema +3 Oedema
National Operational Guidelines for CMAM Nigeria Page 76 of 87
National Operational Guidelines for CMAM Nigeria Page 77 of 87 ANNEX 3: How to Measure Weight
How to Measure Weight
1. Before weighing the child, take all his/ her clothes off 2. Zero the weighing scale (i.e. make sure the arrow is on 0) 3. Ensure that the weighing scale is at eye level 4. Place the child in the weighing pans 5. Make sure the child is not holding onto anything 6. Read the child’s weight. The arrow must be steady. 7. Record the weight in kg to the nearest 100g e.g. 6.6 kg 8. Do not hold the scale when reading the weight
National Operational Guidelines for CMAM Nigeria Page 78 of 87
ANNEX 4: How to Measure Length and Height
How to measure LENGTH (when lying
down) If the child is less than 87cm, he/she should be measured lying down. 1. One person holds the child’s head, making sure the child’s head is touching the back of the board. The child’s eyes should be looking straight up. 2. The other person holds down the child’s knees, pressing the sliding wood piece against the child’s heels and soles of the feet. 3. Align the child with the board 4. Child’s arms should be lying alongside his/her body, and if necessary, the mother can hold the arms down The person holding the feet reads the measurement.
How to measure HEIGHT (when standing)
If the child is more than 87cm, he/she should be measured standing. 1. Place the child’s feet flat and together in the centre of and against the back and base of the board/wall. 2. One person places their right hand just above the child’s ankles on the shins, left hand on the child’s knees and push against the board/wall. Make sure the child’s legs are straight and the heels and calves are against the board/wall 3. Tell the child to look straight ahead making sure the child’s line of sight is level with the ground. 4. The second person should place their open left hand under the child’s chin. Do not cover the child’s mouth or ears. Make sure the shoulders are level, the hands are at the child’s side, and the head, shoulder blades, and buttocks are against the board/wall. With the right hand, the headpiece is lowered on top of the child’s head When the child’s position is correct, person holding the legs reads (at eye level) and call out the measurement to the nearest 0.1 cm.
National Operational Guidelines for CMAM Nigeria Page 79 of 87
ANNEX 5: Example Register Page
Admission & Discharge details
Sex Admission Discharge Entry # REG. No. Admission Date Name Age Discharge Outcome^ (M/F) Criteria* Date (months) 1
National Operational Guidelines for CMAM Nigeria Page 80 of 87
ANNEX 6: OTP card ADMISSION DETAILS: OUTPATIENT THERAPEUTIC PROGRAMME Child's REG. No Name / / Physical address / Caregiver's Mobile No. Name Date of Age (months) Sex M F Admission Referral Walking Self- From other From Admission from distance to Referral centre inpatient Community home (hrs)
Admission: Drug Date Dosage (& type) 2nd visit: Date Dosage Albendazole/ Antibiotic mebendazole
Antimalarial (ACT) Immunization Measles Yes No
On discharge Fully Immunised Vitamin A Yes No
Other Treatment Date .+ve / -ve Other Drugs Date Dosage
HIV Test
ART Yes No
TB therapy Yes No
Cotrimoxazole Yes No prophylaxis
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FOLLOW UP: OUTPATIENT THERAPEUTIC PROGRAMME
Name REG. N o. ADM Visits (1) 2 3 4 5 6 7 8 9 10 11 12
Date
Anthropometry Weight (kg) Weight loss* * * (Y/N) No change in weight ** (Y/N) Height (cm) WFH ZS MUAC (cm) Oedema (+ ++ +++) * if below admission weight arrange home visit or refer to inpatient care ** if the weight does not change by the 4 th visit, arrange home visit or refer to inpatient care
Medical History Diarrhoea (# days) Vomiting (# days) Fever (# days) Cough (# days)
Initials of Examiner ** A= absent D= defaulter (3 consecutive absences ) T= transfer to inpatient R = Refused inpatient care X= died R= Recovered NR= non-recovered Community Health Worker:
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ANNEX 7: Summary of OTP routine medicines
Name of Product When Age / Weight Prescription Dose
6 months to 11 100 000 IU Single dose on At Admission months (blue capsule) admission DO NOT GIVE IF THE VITAMIN A* Do NOT give CHILD HAS ≥12 months to 200 000 IU to children ALREADY RECEIVED 59 months (red capsule) with oedema DURING THE LAST 1 MONTH 3 times per day for 7 See separate days AMOXICILLIN At admission All children protocol or 2 times per day for 5 days ANTI MALARIAL Test at TREAT with ACT ACT according to national (follow national admission if ONLY IF POSITIVE Malaria protocol protocol) malarial area TEST < 12 months DO NOT GIVE None DEWORMING: Single dose at 12-24 months 200 mg Single dose on second ALBENDAZOLE** second visit ≥24 months 400 mg visit According to MEASLES at UPDATE CHILD’S ≥ 9 months national admission VACCINATION IMMUNISATIONS calendar CALENDAR DURING According to According to national EPI TREATMENT clinic schedule protocol *Vitamin A has been shown to increase mortality if given to children with oedema ** If using MEBENDAZOLE: ≥12 months 500mg MCH Guidelines)
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ANNEX 8: OTP Tally Sheet SITE MONTH
Week TOTAL Date (A) Total start of week New 6-59m SAM (including relapses) Other (adults, adolescents, infants) From OTP/Inpatient care (or returned defaulters) (D) TOTAL ADMISSIONS Recovered Death Defaulter Non-Recovered To Outpatient/Inpatient care (G) TOTAL DISCHARGES Total end of week (A+D-G) Gender: New Admissions only Total Male Total Female HIV Testing: Total Number tested/week Total positive Total negative
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ANNEX 9: CMAM monthly report
MONTHLY CMAM SUMMARY
Health Facility with OTP site MONTH / YEAR
LGA STATE Name and signature of officer completing form SUPPLIES sachets boxes
RUTF Stock start of the month
RUTF Received during the month
RUTF Consumption (month)
RUTF Stock Levels (end of month)
NEW CASES OLD CASES TOTAL DISCHARGES TRANSFER (B) (C) ADMISSIONS (E) (F) TOTAL Total 6-59m From TOTAL END OF beginning (According to Other Outpatient EXITS NON- To Inpatient or MONTH of the admission criteria (adults,infants, or Inpatient (D) RECOVERED DEATH DEFAULTER (G) RECOVERED Outpatient (H) month (A) and includes adolescents) Care (B+C=D) (E1) (E2) (E3) (E+F=G) (E4) Care (A+D-G=H) relapse ) (B2) or returned (B1) defaulters 0 0 0 #DIV/0! #DIV/0! #DIV/0! #DIV/0! GENDER NEW CASES ONLY TARGET (Sphere Standards) >75% <10% <15% TOTAL HIV TESTED/MONTH Total male Total positive Total female Total negative
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ANNEX 10: LGA/State/Federal Reporting Format CMAM Data Report
STATE MONTH
A. CMAM Statistic Summary
A1. Admissions and Exits Admissions Exits
Total OLD NEW CASES Discharges Transfers Total Nb of children in CASES Nb of OTP children in OTP sites programme LGA sites Total Total programme reports at the start functional Other From SC Admissions Exits at the end of received of the 6-59 (adults, or OTP or Non- Transfer to the month month Recovered Death Defaulter months infants, returned recovered SC or OTP adolescents) defaulters
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A2. Performance indicators, Gender new cases, and HIV testing Gender Performance Indicators Total HIV (New Cases Tested only) LGA Non- Recovered Death Default M F +ve -ve recovered
Figure 3. Admissions per LGA, New and Old cases, NAME State, MONTH YEAR (Copy and paste the graph on admissions here) Admission Trends • Give details and explanations why the trends are as they are in the excel report sheet • List all events/ actions that influence the number of the admissions for the month
Figure 4. Program performance per LGA, NAME State, MONTH YEAR
(Copy and paste the graphs on exits here) Exit Trends • Explain why the exits are as they are, for example reasons for high default rate,....
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C. Table showing partners LGA Partner (agencies)
D. Stock Report Stock Management
End of month Starting Balance In Out STATE Balance
• Give Details on the RUTF,- new orders made, expiry, problem of stock out, • etc...
E. Additional Information • Share any challenges faced by CMAM activities, constraint, proposed solutions, etc. • Highlight the important event related to nutrition for this month • Give details of upcoming funds • Survey Results
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ANNEX 11: Referral Form for OTP / SC
Ideally an already existing MoH transfer form should be used with nutritional information added. If this does NOT exist, then the following can be put into place. OTP SC Name: Age: Sex: Date of Admission:
Weight Admission Data (kg): MUAC (cm): Facility: Height (cm): WHZ/WHM: Oedema: + ++ +++ REG. No: (circle) Date of Transfer: Criteria for Transfer: Anorexia Acutely Oedema No Weight Other: (circle) Ill Gain Treatment given: Comments:
SC OTP Name: Age: Sex:
Date of From Admission: Type of Admission: Direct OTP (circle)
Date of Discharge: Discharge Data Weight: MUAC: Height: WFZ score: Oedema: + ++ (circle)
Treatment given: Comments:
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ANNEX 12: Counselling Guide for Breastfeeding Difficulties
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National Operational Guidelines for CMAM Nigeria Page 91 of 87 National Operational Guidelines for CMAM Nigeria Page 92 of 87 ANNEX 13: Supervision checklist Quality(poor, Discussed Comments/actions average, with staff taken good (Y/N) Anthropometry Oedema assessed accurately MUAC measured accurately Height measured accurately Weight for height calculated accurately Community outreach Active case finding conducted by community providers Children referred accurately from the community Community leaders understand purpose of the program Children absent, defaulted are followed up Monitoring and reporting Number system used correctly Cards filed correctly Transfer slips filled out correctly Outpatient therapeutic program(OTP) Admission procedures and criteria correct Admission history recorded accurately on OTP card Medical examination performed correctly and recorded Appetite test conducted correctly Routine medicines given correctly Action protocol used correctly Children correctly referred to inpatient care OTP card filled correctly RUTF available and given correctly Key messages given correctly Follow up history and examination performed correctly Reasons for follow up identified correctly Links between health facility and community established Children absent or defaulted followed up in community Non responders referred for medical investigation Exit procedures and criteria correct Inpatient care Therapeutic milk (F 75 and F 100) given correctly Medical history and examination performed correctly Complications treated correctly
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Infants < 6months managed correctly children transferred to OTP appropriately Inpatient cards filled correctly Monitoring and reporting Number system used correctly Cards filed correctly Transfer slips filled out correctly Monthly reports filled out correctly and on time Supplies, equipment and organisation Break in supplies (yes/no) Stocks stored correctly Necessary equipment and supplies available (yes/no) OTP/SFP well organised Staff capacity sufficient to manage case load (yes/no) Nutrition Counselling Nutrition advice given appropriately for SAM / MAM Health worker uses tools provided in CMAM guidelines
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