guidelines for the integrated management of severe acute malnutrition

182 Pages·2011·3.52 MB·English

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ACF INTERNATIONAL

GUIDELINES

FOR THE INTEGRATED MANAGEMENT OF SEVERE ACUTE
MALNUTRITION: IN- AND OUT-PATIENT TREATMENT
GUIDELINES FOR THE INTEGRATED MANAGEMENT OF SEVERE
ACUTE MALNUTRITION:
IN- AND OUT-PATIENT TREATMENT

Nutrition and Health Department
ACF - International
ACF-In Guidelines for the integrated management of SAM Legal Information 3
LEGAL INFORMATION

Statement on copyright
The protocols on the Management of Severe Malnutrition contained within this document are the
copyright of Professor Michael H Golden and Dr Yvonne Grellety. These protocols can be reproduced
provided that the source is credited and copyright to the material remains vested in the original
owners. The material must not be abstracted, edited or changed without the written permission of the
copyright holders.
Those sections (indicated in ) that are not the property of Professor Michael H Golden
and Dr Yvonne Grellety but ACF can also be reproduced.
Where this is the case mention must be made that the results were obtained within the framework of
collaboration with the ‘Charity’ and ‘Consultants’ and ACF is prominently credited.
© Professor Michael Golden and Dr Yvonne Grellety

Non-responsibility clause
The present document aims to provide public access to information concerning the actions and
policies of Action contre la Faim International Network and the best practice advice of Professor
Michael Golden and Dr Yvonne Grellety. Our objective is to disseminate information that is accurate
and up-to-date on the day it was initiated. We will make every effort to correct any errors that are
brought to our attention. However, the authors and ACF bear no responsibility for information
contained in the present document.

This information
- is solely intended to provide general information and does not focus on the particular situation
of any physical person, or person holding any specific moral opinion;
- is not necessarily complete, exhaustive, exact or up-to-date;
- sometimes refers to external documents or sites over which the authors and ACF have no
control and for which the authors and ACF decline all responsibility;
- does not constitute legal advice.

The present non-responsibility clause is not aimed at limiting either the author’s or ACF’s responsibility
contrary to requirements of applicable national legislation, or at denying responsibility in cases where
this cannot be done in view of the same legislation.
ACF-In Guidelines for the integrated management of SAM Acknowledgements 4
ACKNOWLEDGEMENTS

The foundation for these guidelines grew out of the work done at the Tropical Metabolism Research
Unit, Jamaica from 1956 to 1991. The work was funded by the University of the West Indies and the
Wellcome Trust. The physiological and nutritional knowledge gained formed the basis for the WHO
(1999) guidelines for the management of Severe Acute Malnutrition.
The guidelines were first applied by Action Contre Le Faim (ACF) in 1994 in Rwanda and
subsequently applied in many Emergency situations. The experience gained showed the
shortcomings of the WHO guidelines which were then extensively revised. The revised version
formed the basis for many National Protocols which were then evaluated by the authors.
The subsequent evolution of the guidelines depended upon these field evaluations of actual
programmes, analysis of the data, identification of problems and situations not adequately addressed
by current versions of the guidelines, research undertaken by students of the University of Aberdeen
and deliberation by the ACF Scientific Committee. The ACF Scientific committee (M. Golden, A.
Briend, Y. Grellety, C. Prudhon and D. Bounie) was instrumental in the formulation, development and
initial testing of RUTF. This permitted effective treatment at home and large scale implementation of
the treatment of SAM in the community. The subsequent testing of the products was largely
undertaken by Andre Briend with collaborators and the implementation in emergency settings
spearheaded by Steve Collins of Valid International with Concern Worldwide and Save the Children
UK.
We gratefully acknowledge the contribution of the agencies, field staff and students to this latest
incarnation (version 6) of the guidelines. In particular, Action Contre la Faim-France and Action Contre
la Faim-International contributed to the earlier revisions or the WHO guideline and UNICEF (country
and regional offices) MSF-France and the European Community contributed to the later revisions by
supporting evaluations of the programmes in the field.

ACF addition: Andrew Tomkins, Carlos Navarro Colorado, André Briend; Sophie Laurence; Beatrice
Mounier and Alix Haentjens have also contributed to revise previous version and finalisation of this
version.
The Protocol for SAM management is in constant evolution. ACF is following closely the studies and
research performed by partners and is active in developing new evidence. Many questions are still
pending and ACF will regularly update the protocol following the evolutions.
Some example of ACF studies on-going:
- Studies on anthropometric measurement to better identify the most relevant criteria for detection,
admission and discharge in the nutrition programme.
- Systematic antibiotic in SAM children study in 2011-2012 (Central African Republic)
- “Alternative protocol” research (possibility of reducing the amount of RUTF given to the beneficiaries
in OTP in the latest phase of treatment).

Any errors or omissions are the responsibility of the Authors.
ACF-In Guidelines for the integrated management of SAM Contents 5

CONTENTS

ACRONYMS _________________________________________________________________ 10
GLOSSARY__________________________________________________________________ 12
INTRODUCTION ___________________________________________________________ 13
1. The nature of malnutrition ............................................................................................................. 13
2. Treatment of disease in the malnourished is different from the normally nourished ....... 14
3. Prevention of complicated malnutrition...................................................................................... 15
ORGANISATION of an IMAM programme _____________________________________ 16
HIV, TB and SAM __________________________________________________________ 17
COMMUNITY ASPECTS OF IMAM____________________________________________ 18
1. Community involvement ................................................................................................................ 18
2. Planning the community programme .......................................................................................... 18
3. Community awareness and involvement.................................................................................... 19
4. Staff at community level ................................................................................................................ 20
• Existing health staff ___________________________________________________________________ 20
• Outreach Health workers ______________________________________________________________ 20
• Volunteers __________________________________________________________________________ 20
• Selection of volunteers ________________________________________________________________ 21
5. Screening, referral for treatment, follow-up and education .................................................... 22
• Screening___________________________________________________________________________ 22
• Active case finding in the community ____________________________________________________ 22
• Constraints__________________________________________________________________________ 23
• Tools ______________________________________________________________________________ 24
• Data collation ________________________________________________________________________ 24
• Passive screening in health structures, in the OPD and the Emergency room at hospital/health centre
level ________________________________________________________________________________________25
• Other opportunities for screening _______________________________________________________ 25
• Follow-up ___________________________________________________________________________ 25
• Health Education, Mother-to-mother support with emphasis on breastfeeding ___________________ 26
TRIAGE PROCEDURE ______________________________________________________ 28
1. Definition of SAM – Criteria for admission to IMAM programme ........................................... 29
2. The appetite test and flow of patient ........................................................................................... 31
• Why to do the appetite test? ___________________________________________________________ 31
• How to do the appetite test? ___________________________________________________________ 31
• The result of the appetite test___________________________________________________________ 32
ACF-In Guidelines for the integrated management of SAM Contents 6
3. Medical complications (IMCI) ........................................................................................................ 34
• Specificity for HIV/TB patient ___________________________________________________________ 35
4. To summarise................................................................................................................................... 36
TRANSPORT OF SICK PATIENTS____________________________________________ 38
OUT-PATIENT TREATMENT PROGRAMME ___________________________________ 40
Admission ........................................................................................................................................... 40
Diet........................................................................................................................................................ 42
• Amounts to give______________________________________________________________________ 43
Routine medicines ............................................................................................................................. 45
1. NO other nutrients should be given ______________________________________________________ 45
2. Systematic Antibiotics _________________________________________________________________ 45
3. Duration of antibiotic treatment: _________________________________________________________ 46
4. Malaria _____________________________________________________________________________ 46
5. De-worming _________________________________________________________________________ 46
6. Measles ____________________________________________________________________________ 47
7. Vitamin A ___________________________________________________________________________ 47
8. Medicines for specific groups of SAM children in OTP. ______________________________________ 48
Surveillance in OTP ........................................................................................................................... 48
Transfer Out to In-patient care ........................................................................................................ 49
Failure to respond to treatment (out-patients) ............................................................................. 49
Discharge Procedure.............................................................................................................................. 54
1. Criteria of discharge __________________________________________________________________ 54
2. Recording the outcome of treatment _____________________________________________________ 54
Follow up after discharge................................................................................................................. 55
EMOTIONAL AND PHYSICAL STIMULATION __________________________________ 56
1. Emotional stimulation and play .................................................................................................... 56
2. Physical activity ............................................................................................................................... 57
IN-PATIENT CARE _________________________________________________________ 59
The principles of the management of In-Patient care ................................................................. 59
Diet (F75) ............................................................................................................................................. 62
1. Preparation _________________________________________________________________________ 62
2. Amounts to give______________________________________________________________________ 62
3. Naso-gastric feeding __________________________________________________________________ 63
4. Feeding technique____________________________________________________________________ 64
Routine Medicines ............................................................................................................................. 64
1. Systematic Antibiotics _________________________________________________________________ 64
The antibiotic regimen: ____________________________________________________________________ 64
2. Duration of antibiotic treatment _________________________________________________________ 66
3. Administration of antibiotics ____________________________________________________________ 66
Malaria .................................................................................................................................................. 67
Measles ................................................................................................................................................ 68
ACF-In Guidelines for the integrated management of SAM Contents 7
Medicines given under specific circumstances only.................................................................. 68
1. Vitamin A ___________________________________________________________________________ 68
2. Folic acid ___________________________________________________________________________ 69
3. Antihelminthics ______________________________________________________________________ 69
4. Other nutrients_______________________________________________________________________ 69
Surveillance ........................................................................................................................................ 69
Criteria to progress from Acute-Phase to Transition Phase ..................................................... 70
Treatment of Complications ............................................................................................................ 71
1. DEHYDRATION ................................................................................................................................ 71
• Diagnosis of dehydration ______________________________________________________________ 71
• Diagnosis of dehydration in the marasmic patient __________________________________________ 71
• Diagnosis of shock with dehydration in the marasmic patient _________________________________ 72
• Treatment of dehydration in the marasmic patient __________________________________________ 73
• Treatment of shock from dehydration in the marasmic patient ________________________________ 75
• Monitoring of rehydration ______________________________________________________________ 76
• Diarrhoea in the oedematous (kwashiorkor) patient_________________________________________ 78
• Persistent or chronic diarrhoea _________________________________________________________ 78
• Re-feeding diarrhoea after admission ____________________________________________________ 78
2. HYPERNATRAEMIC DEHYDRATION ........................................................................................... 79
• Diagnosis ___________________________________________________________________________ 80
• Treatment __________________________________________________________________________ 80
3. SEPTIC (OR TOXIC) SHOCK .......................................................................................................... 82
• Diagnosis of septic shock ______________________________________________________________ 82
• Treatment of septic shock _____________________________________________________________ 82
4. ABSENT BOWEL SOUNDS, GASTRIC DILATATION AND INTESTINAL SPLASH WITH
ABDOMINAL DISTENSION. ................................................................................................................... 84
5. HEART FAILURE.............................................................................................................................. 85
• Signs and symptoms__________________________________________________________________ 85
• Treatment __________________________________________________________________________ 87
6. HYPOTHERMIA ................................................................................................................................ 88
7. FEVER ................................................................................................................................................ 89
8. SEVERE ANAEMIA .......................................................................................................................... 90
9. HYPOGLYCAEMIA........................................................................................................................... 91
• Clinical signs ________________________________________________________________________ 91
• Treatment __________________________________________________________________________ 91
10. Other conditions .............................................................................................................................. 92
11. DRUGS............................................................................................................................................... 92
12. Re-feeding syndrome ..................................................................................................................... 93
Severe Acute Malnutrition and HIV/AIDS ...................................................................................... 95
FAILURE TO RESPOND to treatment (in-patients) ...................................................................... 98
• Action required when failure to respond is commonly seen in a programme ____________________ 100
• Chronic diseases____________________________________________________________________ 100
TRANSITION PHASE ........................................................................................................................101
1. DIET ...................................................................................................................................................101
2. ROUTINE MEDICINE ......................................................................................................................104
3. SURVEILLANCE ..............................................................................................................................104
4. CRITERIA TO MOVE BACK FROM TRANSITION PHASE TO THE ACUTE PHASE ............104
5. CRITERIA TO PROGRESS FROM TRANSITION PHASE TO OTP ..........................................104
ACF-In Guidelines for the integrated management of SAM Contents 8
PHASE 2 FOR CHILDREN WHO CAN NOT BE TRANSFERRED TO OTP ...............................105
1. DIET ...................................................................................................................................................105
2. DISCHARGE CRITERIA .................................................................................................................107
INFANTS LESS THAN 6 MONTHS OLD ______________________________________ 108
Infant with a Female Caretaker.......................................................................................................108
1. Organisation ....................................................................................................................................109
2. Admission criteria ..........................................................................................................................109
3. Management ....................................................................................................................................110
• Preparation of the SS-milk ____________________________________________________________ 111
• Amounts to give by SS technique ______________________________________________________ 112
• Progress___________________________________________________________________________ 112
4. Supplementary Suckling Technique...........................................................................................113
5. Routine Medicine ............................................................................................................................114
6. Care for the mothers ......................................................................................................................114
• Drugs that stimulate milk production ____________________________________________________ 115
• Cleaning the tube ___________________________________________________________________ 115
7. Discharge criteria ...........................................................................................................................115
Infant without any Prospect of Being Breast-Fed ......................................................................116
1. Admission Criteria ........................................................................................................................116
2. Management ....................................................................................................................................116
• ACUTE-PHASE _____________________________________________________________________ 116
• TRANSITION PHASE ________________________________________________________________ 117
• RECOVERY-PHASE ________________________________________________________________ 117
3. Discharge criteria ...........................................................................................................................117
MONITORING AND EVALUATION ___________________________________________ 119
1. The SAM number ............................................................................................................................119
2. Definitions used in compiling the reports .................................................................................120
• Categories of patient _________________________________________________________________ 120
• Type of admission to an OTP__________________________________________________________ 121
• Types of discharge and transfer from OTP _______________________________________________ 121
• Type of admission to an in-patient facility ________________________________________________ 123
• Type of discharge and transfer from an in-patient facility ___________________________________ 123
3. Tools .................................................................................................................................................124
• OTP tools __________________________________________________________________________ 124
• In-Patient Tools _____________________________________________________________________ 125
• In patient multi-chart is the primary tool for managing in-patients (see annexes 9 and 10) ________ 125
4. Quantitative indicators ..................................................................................................................126
• Monthly statistics report for In and Out Patients (see annex 14)______________________________ 126
• Indicators for each in-patient facility. ____________________________________________________ 127
• Indicators for each OTP ______________________________________________________________ 129
• RUTF consumption __________________________________________________________________ 131
• Consolidated report for whole programme _______________________________________________ 131
5. Minimum standards .......................................................................................................................133
REFERENCE LIST ________________________________________________________ 134
ACF-In Guidelines for the integrated management of SAM Contents 9
ANNEXES ________________________________________________________________ 140

Annexe 1: ACFIN missions – HIV prevalence per country – October 2009 .......................................... 140
Annexe 2: Out Patient Therapeutic Care Programme Draft plan ........................................................... 142
Annexe 3: anthropometric measurements ................................................................................................ 148
Annexe 4: Weight-for-height table (WHO ) - © Michael Golden ......................................................... 154
2006
Annexe 5: Weight for Length (measured lay down Height<85cm) in percentage of the median (NCHS
references) .......................................................................................................................................... 156
Annexe 6: Weight-for-height charts for adolescents (NCHS) ................................................................. 158
Annexe 7: Registration book OTP /TFC (French & English) ................................................................... 160
Annexe 8: OTP Chart (front page & back page) ...................................................................................... 162
Annexe 9: In-patient Chart ......................................................................................................................... 164
Annexe 10: History and examination sheet for SAM ............................................................................... 166
Annexe 11: Referral forms and community reports (1. Transfer – 2. OTP to in-patient – 3. Home vistit
report – 4. Community screening) ..................................................................................................... 168
Annexe 12: Ready to Use Therapeutic Food (RUTF) NUTRITIONAL INFORMATION ....................... 171
Annexe 13: - 5% weight loss ...................................................................................................................... 176
Annexe 14: Monthly report ......................................................................................................................... 177
Annexe 15: Recipes for F75, F100 and ReSoMal using CMV. ............................................................... 178
Annexe 16: UN Statement on micronutrients ........................................................................................... 179
ACF-In Guidelines for the integrated management of SAM Acronyms 10
ACRONYMS

ACT Artemisinin-based Combination Therapy (WHO recommended treatment for malaria)
ARV Anti RetroViral (drug combinations used to treat HIV/AIDS)
ART Anti Retroviral Treatment programmes
BMI Body Mass Index
BMS Breast Milk Substitute (Infant formula milk)
CHW Community Health Worker
CMAM Community Management of Acute Malnutrition (see IMAM for complete programme)
CMV Complex of Minerals and Vitamins (mix added to reconstitute F75/F100/ ReSoMal)
CMW Community Mid-Wife
CTC Community Therapeutic Care (no longer used – see IMAM)
DOTS Directly Observed Treatment/Therapy Short Course
ENA Essential Nutrition Action (a programme by USAID through BASICS and LINKAGES)
EPI Extended Programme of Immunisation
ER Emergency Room (normally a hospital facility to receive cases for emergency medical
treatment)
F75 Therapeutic milk used in Acute-phase of SAM in-patient treatment
F100 Therapeutic milk used in Transition/Recovery Phases of SAM treatment
F100dil Diluted F100 used in the treatment severely malnourished infants less than 6 months.
HC Health Centre
IEC Information, Education, Communication (programmes and strategies)
IFE Infant Feeding in Emergency (documents on feeding infants less than 6 months, See
ENN – Emergency Nutrition Network)
IMAM Integrated Management of Acute Malnutrition
IMCI Integrated Management of Childhood Illness (WHO/UNICEF programme)
IPF In-Patient Facility (used for treating the severely malnourished: replaces the terms
TFC, SC and other acronyms for residential clinical care).
IU International units
LoS Length of Stay
MUAC Mid Upper Arm Circumference
MAM Moderate Acute Malnutrition
MCH Maternal and Child Health (clinic based programme)
NCHS National Centre for Health Statistics of USA (old anthropometric standards)
NGT Naso-Gastric Tube
NRU Nutrition Rehabilitation Unit (largely redundant, has been replaced by OTP)
OPD Out-Patient Department (of health facility – normally a hospital)
OTP Outpatient Therapeutic Programme; the acronym also refers to Distribution Sites for
out-patient management of SAM.