Management of Severe Acute Malnutrition

Module 13

1-May-20 1

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Learning objectives

Understand the importance of the internal and external links between the different CMAM components and other health/ nutrition programmes in emergency and non-emergency situations. Understand the key elements of a community mobilisation strategy for the management of SAM and which actors should be involved in its implementation.

Be aware of the different elements that support the diagnosis of acute malnutrition and how they are applied in the field Be aware of criteria for admission to treatment and discharge for each type of service (outpatient or inpatient care), including age Understand current protocols for the management of SAM cases as outpatients or inpatients, including who they target and where they are implemented Understand basic concepts related to the monitoring and reporting of CMAM activities and be familiar with practical tools for it 1-May-20 2

CMAM approach

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Community-based management of severe

acute malnutrition endorsed by the United

Nations system in 2007 Its components are: – Community mobilization and active case-finding – Outpatient care for SAM without complications – Inpatient care for SAM with complications – Inclusion of management of moderate acute malnutrition (MAM) where in place 1-May-20 3

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Principles of CMAM

The shift from hospital-based to integrated community-based approach for the treatment of severe acute malnutrition was possible thanks to several elements: – The advent of Ready to Use Therapeutic Foods (RUTF) for dietary treatment at home – The new classification for acute malnutrition – Community participation on active case finding and follow-up 1-May-20 4

Community mobilization (1)

• Community mobilisation in CMAM covers a range of activities designed to open a dialogue, promote mutual understanding, encourage active and sustained engagement from the target community as well as improve case finding and follow up. 1-May-20 5

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Community mobilization (2)

The goal of the community mobilisation component of CMAM is to improve treatment outcomes and coverage – active participation in the activities for the management of acute malnutrition. – early detection and referral of cases to appropriate nutrition or health services (clinics or hospitals) and their follow-up. – It is an important factor for obtaining good coverage through good uptake of the services provided by the population in need within a specific health catchment area.

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Community mobilization (3)

• Initial community assessment: – Community perceptions of acute malnutrition – Health seeking behaviour and decision makers for accessing treatment – Key community figures, and structures (administrative and leadership) – Existing community-based organisations and groups – Potential candidates for case-finder role – Existing links and communication systems between health facilities and the community – Formal and informal channels of communication – Formal and informal health services – Potential barriers for children with SAM to accessing treatment 1-May-20 7

Community mobilization (4)

• • Developing messages and materials: – Description of the target children using local descriptive terms for wasting and swelling, – Explanation of the benefits of CMAM, noting that only a few children with SAM who are sick may need to be treated at the hospital, – Explanation about the identification and referral process noting that thin or swollen children can also self-refer to the nearest health facility to be checked, – Time and date of outpatient care sessions at the nearest health facility and locations of those facilities as well as locations of any hospitals or health centres offering inpatient care for SAM – 

Visual aids enhance the impact of messages

Raising community awareness works best through existing channels, organisations and structures within the community . 1-May-20 8

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Community mobilization (5)

Roles and responsibilities : – An overall (MOH national level) focal person should be identified to manage the whole mobilisation process and ensure a coherent nationwide strategy – A responsible person for the implementation / monitoring should be identified at each district / department / health zone level. • The most appropriate person is who already has responsibility for Health Promotion, Outreach or Extended Health / Nutrition activities – In each health facility, the health worker in charge will be responsible for coordinating with Community Volunteers (CV) or Community Health Workers (CHWs) – CV and CHW should be trained on case-finding, home follow up and community sensitisation. • They are the link between the population and the health / nutrition services and should be identified within existing networks. • Where possible additional training on infant and young child feeding for example can help to ensure the sort of linkages for prevention of SAM 1-May-20 9

Definition of severe acute malnutrition

• • • Low weight for height (WFH<-3 ZS) – and / or Low Mid-Upper Arm Circumference (MUAC<115 mm) – and / or the Presence of bilateral pitting oedema 1-May-20 10

Case-finding for SAM

• • • Active case-finding – Identification of cases by community health workers or volunteers in the communities • Mechanisms for referral should be in place Passive case-finding – Identification of cases by health workers during routine child visits at the health facilities Self-referral 1-May-20 11

Triage for SAM (1)

• Once the “diagnostic” of SAM has been made: – Decide whether the child with SAM should be treated in outpatient or inpatient care: – Absence or presence of medical complications: medical complications should be assessed by a thorough medical examination and accurate medical history with the mother (or caregiver). – Good or poor appetite : this is evaluated through the “appetite test” whereby the child passes or fails the test to eat RUTF 1-May-20 12

Appetite Observation Action Good

Child takes RUTF readily with little encouragement Continue in OTP

Poor Refused

Child takes RUTF only with encouragement Child may continue in OTP with caution. Carer should return to the clinic immediately if the child refuses to eat RUTF at home Child refuses RUTF despite repeated encouragement from the carer Transfer child to inpatient care 1-May-20 13

Triage for SAM (2)

• All children 6-59 months will go to inpatient treatment if they present – Bilateral pitting oedema (+++) or – A combination of oedema and wasting or – SAM with poor appetite (failed appetite test) or – SAM with medical complications •

Any other case will be treated as outpatient

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Admission / discharge criteria for SAM

Criteria of admission Cured MUAC < 11.5cm and / or WFH < - 3 z-scores or bilateral oedema Criteria of discharge 15% weight gain (from admission weight when free of oedema) For cases admitted on MUAC: 2 months min stay No oedema for 2 consecutive weeks Clinically well and alert Defaulter Absent for three consecutive visits Died Non recovered Died during treatment in outpatient care Did not meet the discharge criteria after four months in treatment 1-May-20 15

Category New admissions Criteria (Children 6 – 59 months) Children 6 – 59 months or >60 months but <130 cm height MUAC <11.5 cm or W/H < -3Z scores (WHO) Or <70% of median (NCHS) or Bilateral pitting oedema grade + or ++ and child is alert, has appetite, and is clinically well (has no IMCI danger signs) Other new admissions Carer refuses inpatient care despite advice Returned Defaulter Readmissions/ Relapses Child has previously defaulted and has returned to OTP (the child must meet admission criteria to be re-admitted). A child is referred to as a defaulter after missing 3 consecutive OTP sessions A child is treated in OTP until discharge after meeting discharge criteria but relapses hence need for readmission Transfer from inpatient care From in-patient care after stabilisation treatment Transfer from OTP Patients moved in from another OTP site

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Category Cured Criteria (Children 6 – 59 months) For all children MUAC > 12.5cm

and * W/H > -2Z scores And No oedema for two consecutive visits And Child is clinically well Absent for 3 consecutive visits Defaulted Died Non-Cured Transferred to TFC Died during time registered in OTP Has not reached discharge criteria within 4 months. Link the child to other programmes e.g. SFP. IYCF, GMP, targeted food distributions Condition has deteriorated and requires inpatient care Transfer to other OTP Child has been transferred to another OTP site

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Admission at outpatient care for SAM

1. Fill individual card with all details 2. Registration 3. Assign admission number 7. Give RUTF and associated explanations 6. Vaccination 5. Medical treatment 4. Explain all process 8. Link family with assigned CHW 9. Appointment for next visit 10. Nutrition / health education 1-May-20 18

Medical management at outpatient care for SAM

Medication When

Amoxicillin Anti malaria (according to national protocol) Mebendazole or Albendazole At admission Test at admission if clinical signs Single dose at second week Vitamin A Measles vaccination Single dose at discharge During treatment Most of the medical conditions that affect the child with SAM without medical complications can be treated following the IMCI protocols. 1-May-20 19

Nutritional management at outpatient care for SAM (1)

RUTF is provided at between 150 and 220 kcal/kg/day PlumpyNut® (92 gm per sachet) BP100® Weight (in kg) 3.5 - 3.9

4 – 5.4

5.5 – 6.9

7.0 – 8.4

8.5 – 9.4

9.5 – 10.4

10.5 – 11.9

> = 12 Packets / day 1 ½ 2 2 ½ 3 3 ½ 4 4 ½ 5 Packets per week 11 14 18 21 25 28 32 35 Bars / day Do not give Do not give Do not give 5 6 7 8 9 Bars per week Do not give Do not give Do not give 35 42 49 56 63 • The most widely used RUTF (as lipid-based paste) is PlumpyNut®. If imported it comes in packets of 92 gr. totalling about 500kcals per packet. Locally manufactured RUTF can be in pots containing a greater amount of the product, thus ration tables must be adapted.

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Nutritional management at outpatient care for SAM (2)

• Most important messages for caregivers: – RUTF is a food and a medicine and should not be shared.

– RUTF is the only food the child needs in order to recover. – Give small regular meals of RUTF and encourage the child to eat often (8/day) – Always offer the child plenty of clean water to drink while eating the RUTF. – For young children, offer breast milk first before every RUTF feed. – Wash children's hands and face with soap before feeding if possible. – Keep food clean and covered. – When a child has diarrhoea, never stop feeding. Give extra food and extra clean water. – Return to the health facility whenever the child’s condition or appetite deteriorates 1-May-20 22

Follow-up at outpatient care for SAM (1)

Activity Weight MUAC Check for oedema Height / length Medical history Physical examination (including temperature and respiratory rate) Appetite test Routine medical treatment Home visit Vaccinations Each week Each week Each week Once a month Each week Each week Frequency Each week According to treatment protocol As needed according to action protocol As needed according to immunization schedule Evaluation of health and nutrition status progress and counselling Health / Nutrition education Evaluation of RUTF consumption Provision of RUTF Each week Each week Each week Each week 1-May-20 23

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Follow-up at outpatient care for SAM (2)

Home Visit Sign GENERAL CONDITION BILATERAL PITTING OEDEMA ANOREXIA * VOMITING * CONVULSIONS * LETHARGY, NOT ALERT * UNCONSCIOUSNESS * HYPOGLYCAEMIA Referral to Inpatient Care Deteriorating Grade +++ Any grade of bilateral pitting oedema with severe wasting (marasmic kwashiorkor) Increase in bilateral pitting oedema Bilateral pitting oedema not reducing by week 3 Poor appetite or unable to eat – Failed appetite test Intractable vomiting Ask mother if the child had convulsions since the previous visit Child is difficult to wake Child does not respond to painful stimuli A clinical sign in a child with SAM is eye-lid retraction: child sleeps with eyes slightly open.

Child is absent or defaulting DEHYDRATION Dehydration based primarily on recent history of diarrhoea, vomiting, fever or sweating and on recent appearance of clinical signs of dehydration as reported by the mother/caregiver Child is not gaining weight or losing weight on 2 consecutive follow up visits HIGH FEVER HYPOTHERMIA RESPIRATION RATE ANAEMIA SKIN LESION SUPERFICIAL INFECTION Axillary temperature ≥ 38.5° C, rectal temperature ≥ 39° C Axillary temperature < 35° C, rectal temperature < 35.5° C ≥ 60 respirations/minute for children under 2 months ≥ 50 respirations/minute from 2-12 months ≥ 40 respirations/minute from 1-5 years ≥ 30 respirations/minute for children over 5 years Any chest in-drawing Palmar pallor or unusual paleness of skin Broken skin, fissures, flaking of skin Any infection requiring intramuscular antibiotic treatment Child is not losing oedema Child has returned from inpatient c are or refuses referral to inpatient care WEIGHT CHANGES Below admission weight on week 3 Weight loss for three consecutive visits Static weight for three consecutive visits REQUEST Mother/caregiver requests treatment of child in inpatient care for social reasons (decided by supervisor) NOT RESPONDING Child that is not responding to treatment is referred to inpatient care or hospital for further medical investigation.

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Follow-up at outpatient care for SAM (2)

Home visits are an essential aspect and aim at assess: – Caregiver’s understanding of the messages received – Compliance with the treatment (RUTF and medications) – Reasons for non-compliance, absence or defaulting – Availability of water and sanitation facilities, hygiene practices – Health and hygiene and food safety practices and general household food security • Transfer to inpatient care: following the “action protocol”, at any time during treatment if signs of gravity (IMCI protocols) 1-May-20 26

Inpatient care for children 6-59 months with SAM

• According to current WHO recommendations, hospital-based care for SAM is organized into phases: – Stabilization phase: treatment of medical complications and commencement of cautious feeding with F75 – Transition phase: RUTF is introduced gradually, together with feeds of F100 or F75 to foster child’s weight gain – Rehabilitation phase: or catch up growth phase. In most cases this phase is now replaced by outpatient therapeutic care 1-May-20 27

Admission at inpatient care

1. Start life saving treatment ASAP: Milk F75 + medical treatment 2. Fill the In-patient chart 5. Provide routine treatment as per protocols 6. Counseling for caregiver: treatment, signs to watch out, good IYCF practices 4. Explanations to caregiver about all process 3. Assign admission number (if not already having one) 7. Provide soap and food for caregiver 1-May-20 28

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Stabilization at inpatient care (1)

• • • • • • Not meant for weight gain. Weight gain is a sign of serious complication in this phase. F75 milk is designed for restoring metabolic functions and nutrition-electrolyte balance F75 is given 8 times a day at quantity 130 ml/kg/day. Force feeding is never to be used. Naso-gastric tube can be used, on the other hand, if required. Caregiver should be involved in all feeds, although given by a feeding assistant. 1-May-20 30

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Stabilization at inpatient care (2)

• • Individual monitoring: – Weight changes – Edema changes – Body temperature – Clinical signs – Feeds (behavior, volume taken, etc.) Promotion to transition is granted when the child has regained appetite, medical complications are under control and edema start reducing 1-May-20 32

Transition at inpatient care (1)

• • • Meant for transition from F75 to F100 and to RUTF (same composition as F100). – F100 is often proposed on first day of transition. – Preference is given for RUTF as early as possible for the child to get used to it. Frequency of meals remains the same Monitoring is the same as in Stabilization phase. 1-May-20 33

Transition at inpatient care (2)

• • Promotion from transition to outpatient (in 2 to 4 days max) when: – Eat at least 75% of daily RUTF prescribed – Edema back to + or ++ maximum – Medical complications under control Demotion happens when – Gain of weight > 10g/kg/day – Edema increase – Signs of fluid retention – Abdominal distension or diarrhea with weight loss – Complications that require intravenous infusion or NGT. 1-May-20 34

Rehabilitation phase for SAM

• • Rehabilitation is completed as outpatient treatment, except if: – Outpatient care is not available or too far from the family’s home, – The child is continually unable or refuses to eat RUTF – Family refuses referral to outpatient therapeutic care If the patient stays at inpatient: treatment is the same as in outpatient, RUTF being given priority over F100 1-May-20 35

Medical management at inpatient care

Medication

Amoxicillin Anti malaria (according to national protocol) Mebendazole (or Albendazole) Iron Vitamin A Measles vaccination

When

At admission Test at admission if clinical signs When the child progresses from transition to rehabilitation phase OR on arrival at the outpatient service During transition and rehabilitation phases WHEN THE CHILD IS NOT CONSUMING RUTF: one crushed tablet of Ferrous Sulphate 200 mg to each 2 litres of F100 Single dose at discharge During treatment 1-May-20 36

Management of medical complications in the presence of SAM

• • • The metabolism of children with SAM and medical complications is seriously disturbed, and the immune system seriously impaired The standard treatment for conditions like dehydration and severe anaemia given to non malnourished children can lead to death if applied to children with SAM Case management of children with SAM and medical complications should only be conducted by clinical staff who has received the appropriate training 1-May-20 37

Failure to respond

• Failure to respond to the treatment at inpatient care is when: – Failure to regain appetite after day 4 – Failure to start to lose edema after day 4 – Edema still present at day 10 – Failure to fulfill the criteria for progressing to rehabilitation – In transition or rehabilitation phase: weight gain less than 5 g/kg/day by day 10 or for 3 successive days 1-May-20 38

Emotional stimulation at inpatient care

• • • Children with SAM have delayed mental and behavioural development. To address this, sensory stimulation should be provided to the children throughout the period they are in inpatient care. It is essential that the mother be with her child in hospital, and that she be encouraged to feed, hold, comfort and play with her child as much as possible Inexpensive and safe toys should be available, made from cardboard boxes, plastic bottles, tin cans, old clothes and blocks of wood and similar materials. 1-May-20 39

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

If prospects of breastfeeding If no prospects of breastfeeding Too weak to suckle effectively, or Not satisfactory weight gain at home, or Visible wasting (regardless of WFL), or WFL < -3 z-score, or Presence of bilateral oedema Presence of bilateral oedema, or WFL < -3 z-score, or Visible wasting (regardless of WFL) 1-May-20 40

Inpatient care for infants: medical management

• • • • Antibiotics: only when signs of infection Vitamin A: only if signs of deficiency Folic acid: 2.5 mg single dose at admission Ferrous sulphate: only when the child suckles and starts to gain weight (to add in F100) 1-May-20 41

Inpatient care for infants: nutrition management (1)

• • The objective of treatment of these infants is to return them to full exclusive breastfeeding. This is achieved through the Supplementary Suckling Technique (SST) F100 is prepared and then diluted according to specific protocols. Breastfeeding is given for 20 minutes every three hours (minimum), and in between F100 is given with SST.

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Supplementary Suckling Technique

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Inpatient care for infants: nutrition management (2)

• • • When no prospect of breastfeeding, standard SAM inpatient protocols are followed except that F100 is given diluted in the stabilization phase (instead of F75) for children with wasting (marasmus). Children with edema are fed with F75 When the child reaches WFL equal or >-1z score, switch to a breast-milk substitute before discharge, but avoid bottle feeding 1-May-20 44

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

If the child is breastfed (there are no anthropometric criteria for discharge) Successful relactation Child is gaining weight on breastmilk alone + no medical problem, and the mother has been adequately supplemented with vitamins and minerals.

If the child is not breastfed 15% weight gain AND Breastmilk substitute for the child is sustainable for family AND Child is used to milk substitute, gaining weight and caregiver education on preparing and dispensing the milk substitute is completed Ensure proper follow up of these children, as formula feeding is associated with higher risk of diarrhoea and other infections, and higher mortality 1-May-20 45

Management of SAM for other age-groups: admission criteria Age group

Children >=5 – 9 years Adolescents >=10 – 18 years Adults >18 years

Criteria for admission

MUAC < 129mm, and / or BMI for age < -3 z-score, and /or Bilateral pitting oedema MUAC < 160mm and / or BMI for age < -3 z-score, and /or Bilateral pitting oedema BMI < 16 (kg/m) and / or MUAC < 185mm‡ and / or Bilateral pitting oedema 1-May-20 46

Management of SAM for other age-groups

• • • All protocols are the same as for younger children, with specific dosage of treatment and milk detailed in specific guidelines. In outpatient treatment (or rehabilitation phase) patients should be recommended to eat traditional food as much as they want. Discharge criteria are about having a good appetite, reaching 15% gain of weight, absence of edema and absence of medical complication. 1-May-20 47

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Management of SAM in areas with high HIV prevalence

Most aspects of treatment are the same, however: – Counseling on HIV should be proposed to patients and families – Medical treatment should add Cotrimoxazole prophylaxis and test for tuberculosis – ART should be initiated after recovery due to toxicity HIV positive individuals are at higher risk of acute malnutrition and take longer to recover.

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Monitoring and evaluation (1)

• • Routine monitoring of CMAM activities is essential for: – Monitoring the performance of the CMAM services – Taking decisions for quality improvement (staffing, training, resources, site locations) – Assessing the nutrition trends in the area Monthly reports, routine supervision and coverage surveys are the main tools for monitoring 1-May-20 49

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Monitoring and evaluation (2)

Routine data are collected on: – Nb. of new admissions , – Nb. of discharges: cured, died, defaulted, non-recovered – Nb. of children in treatment (beneficiaries registered) These three basic elements allow calculation of key indicators: – Cure rate (should be > 75%) – Death rate (should be <10%) – Default rate (should be <15%) – Non recovery rate Quantitative data should be accompanied by some narrative description or explanation of the main events that may have influenced attendance and performance 1-May-20 50

Monitoring and reporting (3)

• • Other additional information that may be relevant that can be derived from routine monitoring is: – Relapse rate – Admissions per typology (% of marasmus, kwashiorkor and marasmic kwashiorkor) – Average length of stay – Average weight gain – Causes of death – Data on admissions disaggregated by gender Other essential information derived from different sources and methods: – Reasons for death and/or defaulting – Investigation of non-recovery – Coverage of treatment and barriers to access.

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Monitoring and evaluation (4)

• • Supervisions: – Supportive supervision visits to sites are designed to improve the quality of care offered in: • Identifying weaknesses in the performance of activities, taking immediate action and apply shared corrective solutions • Strengthening the technical capacity of health workers and motivating staff through encouragement of good practices Supervisors and managers ensure that the performance of activities and organization meet quality standards.

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Monitoring and evaluation (5)

• • Coverage is one of the most important elements behind the success of the CMAM approach. – It is measured through studies using two main approaches: • The centric systematic area sampling (CSAS) • The Semi-quantitative evaluation of access and coverage (SQUEAC)

Coverage should reach at least 90% of severe cases in camps situation, 70% in urban setting, 50% in rural setting (SPHERE standards)

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When to start?

• According to WHO framework: – GAM rates >10% or between 5% and 9% + aggravating factors. Sometimes SAM > 1% is considered as sufficient. – Contextual factors (causes of malnutrition, the socio economic situation, the food security situation, general ration quantity and allocation, etc.) – Public health priorities or whether other priority needs are already being met (e.g., access to food, shelter, safe water, sanitation) – Availability of qualified human, material and financial resources.

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When to close / handover?

Some criteria used by NGOs to end CMAM activities and handover to national or local structures include: – Global acute malnutrition rate is below 5% – Low number of cases in treatment in individual treatment sites – Local structures can cope with current case load, and/or would be able to cope with the influx of new cases – – – – General ration should be reliable and adequate Crude mortality rate should be low Effective health and disease control measures are in place (e.g. no disease outbreaks) The population is stable and no population influx is expected 1-May-20 56

Practical issues

• • Outpatient care for SAM: integrated in health centers or located close to other facilities. Inpatient care for SAM: integrated in pediatric wards of hospitals or nearby. • Staffing: numbers, qualification, training… 1-May-20 57

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Key messages

Severe acute malnutrition is a complex medical condition needing specialised care to save the patient's life. Current protocols for the management of severe acute malnutrition can obtain high recovery rates and good coverage by offering adapted care for the specific conditions of the patient.

Management of acute malnutrition cases involves a combination of routine medication, specific therapeutic foods and individualised care, and includes four components: – – – Community mobilisation and community case finding Outpatient care for children 6-59 months with SAM without medical complications Inpatient care for children 6-59 months with SAM with medical complications, and for infants, adolescents and adults – Management of Moderate Acute Malnutrition (MAM) for children, pregnant and lactating women with infant under 6 months, and other vulnerable groups (see module 12) Activities for the management of SAM cases should be integrated, when possible, into routine health care services (outpatient and inpatient) with sites decentralised to provide optimal access to services Community mobilisation combined with community case finding for early detection of cases are key elements for the success of the treatment and the reduction of SAM related mortality and morbidity HIV-infected patients with SAM can recover their nutrition status with the current treatment protocols for SAM. Immediate cotrimoxazole prophylaxis and antiretroviral treatment (when available after the stabilisation of medical complications) should be given.

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