National Guidelines on the Management

of Severe Acute Malnutrition

for Children under Five Years

First Edition
June 2015

Manual of Operations
National Guidelines on the Management
of Severe Acute Malnutrition
for Children under Five Years

First Edition
June 2015

Manual of Operations ©UNICEF Philippines/2014/JReyna

 Acronyms
AIDS Acquired Immune Deficiency Syndrome

BHS Barangay Health Station

BHW Barangay Health Worker
BLHD Bureau of Local Health Development

CB-IMCI Community-Based Integrated Management of Childhood Illness

CHO City Health Office
CMAM Community-based Management of Acute Malnutrition
CNC City Nutrition Committee
CWCD Council for the Welfare of Children

DALY Disability Adjusted Life Years

DOH Department of Health
DOH RO DOH Regional Office
DepEd Department of Education
DSWD Department of Social Welfare and Development
DPCB Disease Prevention and Control Bureau

EPI Expanded Program on Immunization

F75 Therapeutic Milk containing 75kcal/100mL

F100 Therapeutic Milk containing 100kcal/100mL
FBF Fortified Blended Food
FDA Food and Drug Administration
FNRI Food and Nutrition Research Institute

GAM Global Acute Malnutrition

GMP Growth Monitoring and Promotion
GP Garantisadong Pambata
GNC Global Nutrition Cluster

HC Health Center
HEMB Health Emergency Management Bureau
HFDB Health Facility Development Bureau
HFSB Health Facilities and Services Regulatory Bureau
HIV Human Immunodeficiency Virus
HMIS Health Management Information System
HPCS Health Promotion and Communication Service

IMAM Integrated Management of Acute Malnutrition

IMCI Integrated Management of Childhood Illness
ITC Inpatient Therapeutic Care
IUGR Intra Uterine Growth Retardation
IYCF Infant and Young Child Feeding

LGU Local Government Unit

LMICs Low and Middle Income Countries

Manual of Operations 5
 MAM Moderate Acute Malnutrition
MNC Municipal Nutrition Committee
MNCHN Maternal, Newborn, Child Health and Nutrition
MNPs Micronutrient Powders
MMD Materials Management Department
MUAC Mid-Upper Arm Circumference

NGO Non-Governmental Organization

NIE Nutrition in Emergencies
NNC National Nutrition Council
NTC National Telecommunications Commission
NTP National Tuberculosis Program

OTC Outpatient Therapeutic Care

OPT Operation Timbang

PGN Promote Good Nutrition

PHO Provincial Health Office(r)
PIMAM Philippine Integrated Management of Acute Malnutrition
PMB Program Management Bureau
PMTCT Prevention of Mother to Child Transmission

RHU Rural Health Unit

RUTF Ready-to-Use Therapeutic Food

SAM Severe Acute Malnutrition

SC Stabilization Center
SD Standard Deviations from the mean (also known as Z-scores)
SFP Supplementary Feeding Program
SPEED Surveillance in Post Extreme Emergencies and Disasters
START SPEED Technical Assistance and Response Team
SUN Scaling up Nutrition

TCL Target Client List (for the sick child)

UNICEF United Nations Children’s Fund

WFP World Food Program

WHO World Health Organization
WFH Weight-for-Height
WFL Weight-for-Length

6 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
 Foreword
Undernutrition among children under five years of age remains a major problem in the Philippines.
The prevalence of stunting among 0-5 years old is 30.3%, the prevalence of underweight is 19.9% and the
prevalence of wasting is 7.9% (FNRI-DOST, NNS 2013 Survey). Thus, it is urgent that health and nutrition
services are provided for these children before they fall into the cracks.

Severe Acute Malnutrition can increase the risk of death in childhood from infectious diseases such
as diarrhea, pneumonia, and measles. Likewise, evidence shows that episodes of Severe Acute Malnutrition
can negatively affect linear growth and cognitive development, and therefore undermines child growth and
developmental milestones which have serious impacts on productivity and intellectual capacity in adult life.
The Department of Health, together with UNICEF, development partners, and other critical stakeholders
have converged efforts to develop this protocol and learn from the experiences of more than 21 local
government units, with more than 300 RHUs or BHSs as outpatient treatment sites and ten hospitals as
inpatient treatment sites. These facilities have been capacitated to provide appropriate management for
both uncomplicated and complicated cases of SAM using the treatment guidelines.

The DOH, as the steward in health and nutrition, has spearheaded the development of the National
Guidelines for the Management of Severe Acute Malnutrition: Manual of Operations, with technical support
from the Nutrition Section of UNICEF Philippine Country Office. This manual shall serve as a guide in
providing evidence-based standardized protocols for health care providers to manage cases of Severe
Acute Malnutrition in the communities, Local Government Unit (LGU) health care facilities, hospitals, as well
as in other health care settings such as during humanitarian response.

With this guide, I am confident that health care providers at different levels of service provision
shall be able to maximize the use of this comprehensive and practical tool in managing cases to reduce
preventable deaths from Severe Acute Malnutrition and improve the overall quality of care, nutritional status
and survival of children especially among the marginalized, poor, and vulnerable.

Janette Loreto Garin, MD, MBA-H

Secretary of Health

Manual of Operations 7
 Message
With an estimated 3.4 million children (30%) under-five who are stunted, the Philippines is among
the top ten countries that contribute to the burden of stunting across the globe. The country is also among
the top five countries in the East Asia and Pacific Region with high wasting rates. According to the 2013
National Nutrition survey, wasting for children under-five has gradually increased from 6.9% in 2008 to 7.9%
in 2013. Wasting continues to be a serious problem, with the Philippines being highly disaster-prone and the
risk of developing wasting being higher during emergencies. Children with severe wasting are nine times
more at risk of dying than well-nourished children. With appropriate nutritional and clinical management,
many of the deaths due to severe wasting can be prevented.

The Philippine Integrated Management of Acute Malnutrition, specifically the Management of Severe
Acute Malnutrition (SAM) for children under 5 years of age, is one of the core lifesaving interventions.
Together with the existing DOH thrusts and programs and the Philippines’ endorsement to the SUN, these
guidelines will put in place the protocols for the provision of quality treatment and management of children
with SAM within the broader range of interventions and approaches addressing all the forms of under-
nutrition. It also serves as one of the keystones of UNICEF’s essential interventions and strategies to
improve Child Survival and Early Childhood Development.

We can save millions of children who die each year from causes that we have the power to prevent
and diseases that we have the ability to treat. The Philippines has taken a big step in the right direction
with Kalusugan Pangkalahatan. We further applaud the Department of Health in taking this much awaited
decisive step toward reduced child mortality by improving access to services for children with SAM.

Lotta Sylwander
Representative
UNICEF Philippine Country Office 

8 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
 Message
Protein-energy malnutrition (PEM) and micronutrient deficiencies remain the leading nutritional
problems in the Philippines. The general declining trend in the prevalence of underweight, wasting and
stunting among Filipino children noted in the past 10 years was countered with the increase in the prevalence
rate in 1998. About 31.8% (4 million) of the preschool population were found to be underweight-for-age,
19.8% (3 million) were adolescents, and 13.2% (5 million) were adults, including older persons were found
to be underweight and chronically energy deficient, respectively. (FAO 2010 Report). The above condition
may have been caused by Severe Acute Malnutrition in the younger their younger years. Severe Acute
Malnutrition (SAM) is an emergency health condition that afflicts children, and is common to most parts
of the country. From 2013 data alone, some 2,014 kids aged one to four years have been found out to be
suffering from SAM (ACF Report 2014). Sam contributes to the risk of a child of having repeated episodes
of pneumonia and diarrhea, which if not adequately addressed, could cause irreversible negative effects on
their physical brain development. Thus, effective and evidence-based life-saving nutrition interventions for
the treatment of severe acute malnutrition (SAM) need to be in place and sustained at the country level.

Through its Nutrition Guidance Advisory Group - Subgroup on Nutrition in the Life Course and
Undernutrition 2010-2012, WHO developed the present evidence-informed recommendations for the
management of SAM in 2013. These recommendations, based on both direct and indirect evidence across
the globe, were also reviewed and adopted by the CMAM Working Group under the Philippine Department
of Health in developing and updating these SAM management guidelines.

I congratulate the Department of Health for its leadership and commitment in reducing the
preventable child mortality. I am truly heartened to know that the Philippines will help guide us in providing
quality Nutrition services for Filipino children with severe acute malnutrition.

Julie Lyn Hall, B.Sc, MBBS, MPH

WHO Representative in the Philippines
 

Manual of Operations 9
 Acknowledgement
The Community-Based Management of Acute Malnutrition (CMAM) approach was introduced in the
Philippines in 2008 as part of the Nutrition in Emergencies (NiE) interventions covering children aged 6 to
59 months in disaster-affected communities. It was first implemented in 2009 by Save the Children (SC),
Doctors without Borders/Medecins sans Frontieres (MSF) and Community and Family Services International
(CFSI), with support from UNICEF and World Food Program (WFP) in armed conflict-affected municipalities
in Mindanao, followed by attempts by ACF-International to implement CMAM in a developmental context in
selected municipalities of North Cotabato and Lanao del Sur in 2010.

The first version of the draft CMAM protocol was derived from the generic “Integrated Management of
Acute Malnutrition” guidelines by Professor Michael H. Golden and Dr. Yvonne Grellety in 2011. The draft
CMAM protocol, referred to as the Philippine Integrated Management of Acute Malnutrition (PIMAM) was
drafted through a consultative workshop (funded by UNICEF) with the Department of Health, the CMAM
Task Force and other stakeholders. Since then, these draft guidelines have been used in other emergencies
(such as Typhoons Sendong, Pablo, Yolanda, the Bohol earthquake and the Zamboanga Siege) and in the
development context in Davao City. In light of the evidences generated from these experiences, the release
of the WHO 2013 Global Guidelines on the management of SAM and the increasing demand coming from
the regions and LGUs especially during the Yolanda Response, the CMAM working group prioritized the
updating and revision of the existing PIMAM protocols. This current version of the National Guidelines for
the Management of SAM was developed through an extensive technical review and a series of consultative
meetings and workshops involving key PIMAM stakeholders, technical experts (national and global) and
implementers at the national, regional, provincial, city and municipal levels. These guidelines address both
emergency and development scenario programming with the objective of scaling up the access to life-
saving services for children under 5 years of age with severe acute malnutrition.

The Department of Health acknowledges the support of the CMAM working group, National and Regional
DOH and NNC staff, LGU staff, technical experts and development partners who actively and passionately
contributed to the development of this Manual of Operations for the Management of SAM. Support for the
development, technical review and finalization of this Manual were provided by UNICEF. In particular, the
DOH extends its gratitude to the following who, in one way or another, have propelled the development of
the National Guidelines for Management of SAM from the very beginning until this stage:

►► Revision through updating the technical and operational National Guidelines for Management
of SAM (2014 - 2015): Review and consensus building of the national guidelines was led by the
CMAM Working Group under the chairmanship of the Department of Health (Dr. Anthony Calibo). The
following agencies and their members have actively contributed to the development of the national
guidelines:

»» The Department of Health: Dr. Rosalie Paje (DOH-WMCHDD) and Dr. Cynthia Fabregas (DOH-
HFDB)
»» The National Nutrition Council: Asst. Secretary Maria-Bernardita Flores, Maria Lourdes Vega
(NNC-NPPD), Margarita Enriquez (NNC-NPPD), Hygeia Ceres Catalina Gawe (NNC-NSD)
»» The Philippine General Hospital: Dr Juliet Sio-Aguilar (UP Philippine General Hospital [PGH])
»» UNICEF: Dr. Aashima Garg, Dr. Rene Gerard Galera, Dr. Rene Andrew Bucu, Dr. Paul Andrew
Zambrano, Dr. Willibald Zeck, (UNICEF Manila); Christiane Rudert (UNICEF Regional Office); Dr.
Rosalia Bataclan (UNICEF Cotabato Field Office); Amina Lim (UNICEF Zamboanga Field Office)
»» WHO: Dr. Jacqueline Kitong
»» WFP: Dr. Martin Parreno, Dr. Corazon Barba
»» ACF: Dr. Oscar Fudalan, Jr.
»» Save the Children: Dr. Amado Parawan
»» World Vision: Dr. Yvonne Duque

►► Valid International consultants, Tanya Khara and Paul Binns, who carried out the technical drafting of
these revised national guidelines in close consultation with the CMAM working group

10 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
►► CMAM implementers and stakeholders who tirelessly gave their technical inputs, practical
experiences and time to review and give feedback that contributed to the enrichment of the guidelines:

»» 2014 - 2015 Workshops, Meetings and Field Consultation: Josephine Guiao (DOH-HFDB);
Hanna Grace Escamilla (DOH-HEMB); Dr. Rita Mae Ang (DOH Region 5); Ma. Azucena Arroyo
(DOH Region 6); Juliet Tutor (DOH Region 7); Jeline Marie Corpuz (NNC-NSD); Dr. Catalino
Dotollo (NNC Region 8) and NNC Regional Program Coordinators; Sheryl Macdipag (DILG); Gery
Villareal (DSWD); Sallie Jabinal (Eastern Samar Province); Giovanni Ed Napari (Leyte Province);
Rosenda Pajares (San Miguel, Leyte); Ma. Lumen Tabao (Tacloban City); Dr. Joy Villafuerte,
Vangie Genite, Vilma Cortez (Davao City); Virginia Sagrado (Zamboanga City) Drs Jossie
Rogacion, Jonathan Cu and Edilberto Garcia (UP Philippine General Hospital); Dr. Mohammad
Ali Amil (Cotabato Regional Medical Center); Jocelyn Tukas (DOH Dinaig Municipal Hospital); Drs
Hazel Arnaldo, Caroline Castro, Marilou Tan, Felizardo Gatcheco and Portia Monreal (Philippine
Society for Pediatric Gastroenterology, Hepatology and Nutrition, PSPGHAN); Dr. Rosario Cruz
(Pediatric Nephrology Society of the Philippines [PNSP]); Dr. Rodelia Cipriano (Philippine Society
of Pediatric Critical Care Medicine [PSPCCM]); Dr. Salvacion Gatchalian (Pediatric Infectious
Disease Society of the Philippines [PIDSP]); Evelyn Aduna (Integrated Midwives Association of the
Philippines, Inc [IMAP]); Balbina Borneo and Alice Estiller (Mother and Child Nurses Association of
the Philippines [MCNAP]); Allison Prather (International Medical Corps [IMC]), Selahuddin Hashim,
Jonathan Gorre and Dr. Celna Tejare (Health Organization of Mindanao [HOM]); Dr. Jojo Juguan
(ACF International); Dr. Juanita Basilio (independent consultant); Dr. Raoul Bermejo, Melvin
Marzan (UNICEF Manila); Nozizwe Chigonga, Junaid Ullah, Alvin Manalansan (UNICEF Tacloban
Field Office), Angelita Evidente (UNICEF Roxas Field Office)

»» 2011 Workshop and Field Consultation: Dr. Anthony Calibo (DOH - National Center for Disease
Prevention and Control); Ma. Lourdes Vega and Janice Feliciano (NNC); Florinda Panlilio and Dr.
Rene Gerard Galera (DOH - Health Emergency Management Staff), Marilou Galang (Department
of Science and Technology - Food and Nutrition Research Institute); Dr. Juliet Sio-Aguilar, Dr.
Rebecca Castro, Dr. Portia Monreal, and Dr. Karen Mercado (PSPGHAN); Dean Ma. Asuncion
Gonzaga (Philippine Nurses Association); Dr. Juan Antonio Solon (Philippine Association of
Nutrition); Ofelia Reyes (Philippine Society of Nutritionists-Dietitians); Cristina Sagum (Council of
Deans and Heads of Nutritionists and Dietitians); Dr. Miguel Noche, Jr. (Professional Regulatory
Commission - Board of Medicine); Dr. Carmencita Abaquin (Professional Regulatory Commission
- Board of Nursing); Dr. Perla Po (Professional Regulatory Commission - Board of Nursing); Dean
Ma. Imelda Javier (Association of Deans of Philippine Colleges of Nursing); Dr. Ma. Cynthia
Quintana (Association of Deans of Philippine Colleges of Nursing); Froiline Tancianco (St. Paul
University Manila - College of Nursing); Teresita Merin (Adamson University); Prof. Ma. Theresa
Talavera (University of the Philippines Los Baños Institute of Human Nutrition and Food); Dr.
Patria Angos (Vicente Sotto Memorial Medical Center); Dr. Teresita Mansilla (Cotabato Regional
Medical Center); Mia Gerigdig (German Doctors Hospital) Dr. Antonio Camacho, Jr. (National
Children’s Hospital); Dr. Judy Lyn Vitug and Elizabeth Limos (Philippine General Hospital); Melissa
Ortoño (University of Sto. Tomas Hospital); Dr. Arnold Cagulada (Association of Municipal Health
Officers of the Philippines); Dr. Catherine Layon-Miral (Northern Samar Provincial Health Office);
Cherie Fulk and Dr. Martin Parreño (Action Contra La Faim/ACF); Dr. Rosalia Bataclan (Save the
Children); Mark Alvin Albrigo (Philippine Red Cross); Alvin Saplan (Helen Keller International -
Philippines); Dr. Mariella Castillo (World Health Organization); Roselie Asis (World Food Program);
Henry Mdebwe, Dr. Pura Rayco-Solon, Dr. Paul Zambrano and Dr. Andrew Bucu (UNICEF); Dr.
Michael Golden and Dr. Yvonne Grellety

Manual of Operations 11
 contents
3.3 Nutritional Management 41
INTRODUCTION 16
3.4 Orientation to Caregiver 41

3.5 Management of Infants through

42
OBJECTIVES AND USE 17 Outpatient Breastfeeding Support
OF THE GUIDELINES 3.6 Individual Monitoring, Follow-up
43
SOURCES 18 and Referral

ACUTE MALNUTRITION 19 3.7 Discharge 45

Causes and Definitions 19 3.8 Managing links 46

Burden of Acute Malnutrition: Globally 19 4. INPATIENT THERAPEUTIC CARE 47

and in the Philippines (ITC)

Physiological Basis for Treatment of 20 4.1 Assessment and Admission 49

SAM 4.2 Medical Management 50
OVERVIEW OF PIMAM 21 4.3 Nutritional Management 51
Trends in the Management of Acute 21 of Children 6 - 59 Months
Malnutrition 4.4 Nutritional Management of 55
Brief History of PIMAM in the 21 Infants < 6 Months
Philippines 4.5 Orientation and Care to Caregiver 58

Principles of the Integrated 22 4.6 Individual Monitoring, Follow-up 58

Management of SAM and Referral

Components of the Integrated 22 4.7 Discharge 60

Management of SAM 4.8 Managing Links 63

PART 1. PART 2.
24 64
TECHNICAL GUIDELINES OPERATIONAL GUIDELINES

1. COMMUNITY MOBILIZATION 25 DEFINITION OF TERMS 65

AND OUTREACH
5. ADVOCACY & COMMUNITY
1.1 Achieving Coverage 25 MOBILIZATION FOR THE 66
1.2 Community Sensitization 26 MANAGEMENT OF SAM

1.3 Case Finding and Referral 26 5.1 Introduction 66

1.4 Follow-up of Children with SAM 28 5.2 Advocacy and Creating an
66
2. ASSESSMENT AT THE HEALTH 29 Enabling Environment
FACILITY 5.3 Stages in Community Mobilization 67

2.1 Arrival and Identification 29 6. MANAGEMENT & COORDINATION 75

of Acute Malnutrition OF THE INTEGRATED PROGRAM
FOR THE MANAGEMENT OF SAM
2.2 Further Assessment for 32
SAM children 6.1 Introduction 75
2.3 Decision Making and Referral 34 6.2 Organization of a PIMAM Program 75

3. OUTPATIENT THERAPEUTIC CARE 38 6.3 PIMAM National Program

75
(OTC) Management Team (NPMT)

3.1 Assessment and Admission 39 6.4 Roles and Responsibilities of the 76

3.2 Medical Management 39 Program Management Team

12 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
 6.5 Roles and Responsibilities of Chief 80 10.3 Responsibilities During 107
Executives Emergency

6.6 Roles and Responsibilities of 81 10.4 Scenarios in an Emergency/ 108

Program Implementers Disaster

6.7 Roles and Responsibilities of ITC 83 10.5 Logistics During Emergencies 111
Implementers 10.6 Reporting in Emergencies 111

7. IMPLEMENTATION 85 10.7 Transition (post-emergency) 111

ARRANGEMENTS 11. PROGRAM MONITORING 112
7.1 Introduction 85 AND REPORTING

7.2 Outpatient Therapeutic Care (OTC) 85 11.1 Program Performance Indicators 112
for SAM without Complications and Standards

7.3 Inpatient Therapeutic Care (ITC) 91 11.2 Program Process Indicators and 113
Standards
8. LOGISTICS AND SUPPLY 96
MANAGEMENT 114
11.3 Monitoring Formats and Systems
8.1 Introduction 96
11.4 Analysis and Feedback 118
8.2 Relevant Policies 97

8.3 Considerations in Supply Chain 98

Management

8.4 Procedures 98
8.5 Receiving of Medicines and RUTF 100

8.6 Storage of Drugs and Nutrition 100

Supplies

8.7 Maintaining Records for SAM 101

Treatment Medicines and Diagnostic
Supplies

8.8 Rational Use of Supplies 102

8.9 Stock and Drugs Delivery 102
8.10 Disposal of Expired Products 102

9. SUSTAINED FINANCING & 103

REGULATION FOR QUALITY
SERVICE

9.1 Introduction 103

9.2 Local Financing 103
9.3 DOH Assistance 104
9.4 PhilHealth Reimbursements 104

9.5 Resource Mobilization from 105

Development Partners, NGOs and the
Private Sector

9.6 Regulations for the Management 105

of SAM

10. MANAGEMENT OF SAM IN

106
EMERGENCIES

10.1 Introduction 106

10.2 Funding Sources for Emergencies 106

Manual of Operations 13
 LIST OF FIGURES,
TABLES AND BOXES
Figures
FIGURE 1. PIMAM COMPONENTS 23
FIGURE 2. DECISION FLOWCHART FOR INPATIENT AND OUTPATIENT THERAPEUTIC CARE. 34
FIGURE 3. OTC ACTIVITIES 38
FIGURE 4. FLOW OF ACTIVITIES IN ITC 48
FIGURE 5 SAMPLES OF F75 51
FIGURE 6. CORRECT FEEDING TECHNIQUE 52
FIGURE 7 SAMPLES OF F100 56
FIGURE 8. STAGES OF COMMUNITY MOBILIZATION 67
FIGURE 9. MUAC TAPE 69
FIGURE 10. EXAMPLES OF TYPES OF RUTF USED FOR TREATING SAM 70
FIGURE 11. PIMAM COORDINATION & REPORTING STRUCTURE 77
FIGURE 12. ALGORITHM FOR IDENTIFICATION, INITIATION OF TREATMENT IN OTC AND REFERRAL FOR SAM 88
FIGURE 13. ALGORITHM FOR FOLLOW-UP CARE IN OTC 90
FIGURE 14. MANAGEMENT CYCLE FOR MEDICINES AND NUTRITION SUPPLIES 96
FIGURE 15. SIMPLE TOOLS FOR MONITORING BARRIERS TO ACCESS 117
FIGURE 16. DEFAULTER ANALYSIS CONDUCTED FOR THE CMAM PILOT PROGRAM IN MAGUINDANAO 117
PROVINCE 2011. (BASED ON HOME VISITS AND OUTREACH BY BHWS AND FIELD VOLUNTEERS)

Tables
TABLE 1. DIAGNOSTIC CRITERIA FOR ACUTE MALNUTRITION IN CHILDREN AGED 6 - 59 MONTHS 19
TABLE 2. EXAMPLES OF BOOSTERS AND BARRIERS TO COVERAGE IN THE PHILIPPINES 25
TABLE 3. COMMUNITY-LEVEL CASE-FINDING CRITERIA 28
TABLE 4. IDENTIFICATION OF ACUTE MALNUTRITION IN CHILDREN 6 - 59 MONTHS 30
TABLE 5. IDENTIFICATION OF ACUTE MALNUTRITION IN INFANTS <6 MONTHS OF AGE 30
TABLE 6. CATEGORIZING RESULTS OF THE APPETITE TEST 32
TABLE 7. CRITERIA FOR NEW ADMISSION TO INPATIENT OR OUTPATIENT THERAPEUTIC CARE 35
(CHILDREN 6 - 59 MONTHS)
TABLE 8. SUMMARY OF CRITERIA FOR ADMISSION TO INPATIENT OR OUTPATIENT CARE 36
(INFANTS < 6MONTHS)
TABLE 9. SUMMARY TABLE OF ROUTINE TREATMENT ON ADMISSION IN OTC* 39
(SEE ANNEX 11 FOR DETAILS AND DOSAGES)
TABLE 10. CRITERIA FOR REFERRAL TO INPATIENT FROM OUTPATIENT TREATMENT DURING FOLLOW-UP 43
TABLE 11. DISCHARGE CRITERIA FROM OTC 45
TABLE 12. DEWORMING IN PHASE 2 50
TABLE 13. DISCHARGE CRITERIA FROM INPATIENT (TRANSITION PHASE) TO OUTPATIENT CARE 60
TABLE 14. DISCHARGE CURED CRITERIA FROM PHASE 2 61
TABLE 15. CRITERIA FOR CASE IDENTIFICATION AND REFERRAL IN THE COMMUNITY 73
TABLE 16. TASKS & RESPONSIBILITIES AT DIFFERENT LEVELS 78
TABLE 17. MANAGEMENT COMPONENT AND RESPONSIBLE UNIT FOR MANAGING 98
SAM TREATMENT COMMODITIES
TABLE 18. ESTIMATION OF SUPPLIES REQUIRED FOR SAM TREATMENT 99
TABLE 19. POSSIBLE SCENARIOS AND RECOMMENDED ACTIONS IN EMERGENCIES AND DISASTERS 110
TABLE 20. MINIMUM PERFORMANCE STANDARDS FOR THE MANAGEMENT OF SAM 113
TABLE 21. REPORTING SCHEDULE AND RESPONSIBILITIES 115

14 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
Boxes

BOX 1. ACTIVE ADAPTIVE CASE FINDING 27

BOX 2. DEALING WITH SAM COMMUNITY REFERRALS WHO DO NOT MEET ADMISSION CRITERIA 31
BOX 3. THE IMPORTANCE OF THE OBSERVED APPETITE TEST 32
BOX 4. CHECKLIST FOR TAKING MEDICAL AND DIETARY HISTORY AND EXAMINATION 33
AT PRIMARY HEALTH CARE LEVEL
BOX 5. APPROPRIATE REFERRAL OF COMPLICATED CASES 37
BOX 6. ADMINISTRATION OF ANTIBIOTICS 40
BOX 7. READY-TO-USE THERAPEUTIC FOOD (RUTF) 41
BOX 8. KEY MESSAGES FOR MOTHERS/CAREGIVERS 42
BOX 9. PRINCIPLES OF TREATMENT OF COMPLICATED SAM IN ITC 47
BOX 10. F75 51
BOX 11. VARIATION IN NUMBER OF FEEDS 52
BOX 12. INDICATIONS FOR USING NASOGASTRIC TUBE (NGT) 52
BOX 13. APPROPRIATE FEEDING TECHNIQUE 53
BOX 14. COMMERCIAL MILK FORMULAS 55
BOX 15. SUPPLEMENTAL SUCKLING TECHNIQUE (SST) 56
BOX 16. SPECIFIC CONDITIONS NEEDED IF REPLACEMENT FEEDS SUCH AS FORMULA MILKS 57
ARE TO BE GIVEN SAFELY TO INFANTS (AFASS CRITERIA)
BOX 17. CORE ELEMENTS OF A COMMUNITY ASSESSMENT 68
BOX 18. OTHER ELEMENTS OF THE COMMUNITY ASSESSMENT 68
BOX 19. KEY INFORMATION TO BE INCLUDED IN A SENSITIZATION PLAN 68
BOX 20. READY-TO-USE THERAPEUTIC FOOD (RUTF) - FREQUENTLY ASKED QUESTIONS 71
BOX 21. COMMUNITY LEVEL WORKERS FOR INVOLVEMENT IN CASE FINDING IN THE PHILIPPINES 72
BOX 22. PRIORITY CASES FOR FOLLOW-UP 74
BOX 23. TYPICAL PROVISIONS FOR AN ITC UNIT 92
BOX 24. ANTHROPOMETRIC REQUIREMENTS FOR ITC 93
BOX 25. REQUIREMENTS FOR RECORD KEEPING IN ITC 93
BOX 26. DIETARY REQUIREMENTS IN ITC 93
BOX 27. MEDICINE REQUIREMENTS FOR ITC 93
BOX 28. EQUIPMENT REQUIREMENT IN ITC 94
BOX 29. CONSIDERATIONS IN SUPPLY CHAIN MANAGEMENT 98
BOX 30. EXPIRY AND BEST BEFORE DATES 101

Manual of Operations 15
 INTRODUCTION

C
©UNICEF Philippines/2014/JMaitem
hildren with SAM are nine times
more likely to die than
well-nourished children.

It is estimated to be responsible for over a third from stunting globally. Stunting, severe wasting
of deaths among children under five years of and Intrauterine Growth Retardation (IUGR) are
age worldwide, or an estimated three million estimated to be responsible for 21% of disability-
children a year. The term undernutrition covers adjusted life years (DALY) lost. Undernutrition
several physiological conditions which frequently also causes sub-optimal physical and cognitive
co-exist: wasting and nutritional edema (acute development, lowers resistance to infections and
undernutrition), stunting (chronic undernutrition), hinders productivity. The Lancet 2008 and 2013
intrauterine growth restriction (IUGR) and Maternal and Child Nutrition series1,2 underscored
deficiencies in essential micronutrients. Around the burden of undernutrition in low to moderate
52 million (8%) of the world’s children under five income countries (LMICs) and the need for the
years old are wasted; 70% of them are living in expansion of appropriate interventions to tackle it.
Asia. Around 165 million (26%) of children suffer

1 RE Black et al. Maternal and Child Undernutrition. Paper 1. Global and regional exposures and health consequences. The Lancet 2008
2 RE Black et al. Maternal and Child Undernutrition. Paper 1. Maternal and child undernutrition and overweight in low-income and middle-income
countries. The Lancet. June 6, 2013 http://dx.doi.org/10.1016/S0140-6736(13)60937-X2013
16
 OBJECTIVES AND USE OF THE GUIDELINES

These guidelines aim to support the Together with the above, these guidelines
implementation and expansion of quality treatment incorporates lessons from the implementation of
for children suffering from the most severe and the Philippine Integrated Management of Acute
acute form of undernutrition in the Philippines: Malnutrition (PIMAM) to date. It is intended to be
severe acute malnutrition (SAM). These children used in emergency, recovery and development
with SAM are at most risk of dying as a result of contexts by health and nutrition care providers
their undernutrition. The guidelines aim to place (doctors, nurses and program staff) working at
management of these individuals within the all facility levels of health and nutrition service
broader range of interventions and approaches provision in the Philippines as well as by
addressing undernutrition in general as part of policy makers, academics and NGO staff. The
the National Nutrition Council’s Medium-Term guidelines primarily covers the age group from
Philippine Plan of Action for Nutrition 2011 - 2016 6 - 59 months (as the most commonly affected
(and future iterations) and the Department of by acute malnutrition) and infants. Some detail for
Health’s National Objectives for Health 2011 - 2016 other groups, however, is included as Annexes
and the Strategic Framework for Comprehensive in the event that cases are encountered. These
Nutrition Implementation Plan 2014 - 2025. It guidelines should be used in conjunction with
aims to be consistent with and complementary to the national guidelines on the management of
the protocols of other relevant guidelines. These MAM in areas where services for MAM are being
include: implemented.

►► Integrated Management of Childhood These guidelines are structured to give a basic

Illnesses (October 2014) introduction to PIMAM and the principles of its
►► Philippine Infant and Young Child Feeding approach in the Philippines. This is followed by
Strategic Plan of Action for 2011 - 2016, and two sections: the first deals with the technical
National Policies on Infant and Young Child protocols for the management of SAM, split into
Feeding (2005) the key service components; and the second
►► Draft National Guidelines on the Management gives guidance on the operational implementation
of Moderate Acute Malnutrition (2014) of services.

These two characters will appear

throughout the manual to draw
the attention of readers to critical
facts, important concepts, and key
messages in the guidelines.

Manual of Operations 17
 REFERENCES

The technical protocols contained in these The operational part of these guidelines draws on:
guidelines are based on standard protocols for
both inpatient and outpatient therapeutic care ►► National Guidelines on Micronutrient
listed below. Supplementation (2011)
►► National TB Control Program (2013)
►► FANTA, Training Guide for Community based ►► Field Health Service Information System
Management of Acute Malnutrition (2008) (2011)
http://www.fantaproject.org/focus-areas/ ►► Logistics Management in Emergencies (2012)
nutrition-emergencies-mam/cmam-training ►► Surveillance in Post Extreme Emergencies
►► FANTA, Semi-Quantitative Evaluation of and Disasters (2011)
Access and Coverage (SQUEAC)/Simplified ►► National Policy on Nutrition Management in
Lot Quality Assurance Sampling Evaluation Emergencies and Disasters (2009)
of Access and Coverage (SLEAC) Technical ►► Philippine Milk Banking Manual of Operations
Reference. Myatt, Mark et al. Washington DC, (2013)
2012. ►► Health Service Delivery Profile (2012)
►► The Sphere Project, The Sphere Handbook: ►► Republic Acts, Executive Orders,
Humanitarian Charter and Minimum Administrative Orders and Department
Standards in Humanitarian Response, Sphere Personnel orders in effect as of April 2015
2011.
►► Valid International, Community-Based These guidelines are also based on the
Therapeutic Care (CTC): A Field Manual, existing ‘draft protocol on Philippine integrated
Oxford 2006 Management of Acute Severe Malnutrition
►► WHO, Management of Severe Malnutrition: (PIMAM)’ 2011 which was in turn based on version
A Manual for Physicians and Other Senior 6, 2011, of the generic “Integrated Management
Health Workers, Geneva 1999. of Acute Malnutrition” guidelines by Professor
►► WHO, Management of the Child with Serious Michael H. Golden and Dr. Yvonne Grellety ©
Infection or Severe Acute Malnutrition, 1999 - 2011.
Geneva 2000.
►► WHO, Training Course on the Management of
Severe Acute Malnutrition, Geneva 2002.
►► WHO, Guideline: Updates on the
Management of Severe Acute Malnutrition in
Infants and Children, Geneva 2013.
►► WHO, Pocketbook of Hospital Care for
Children: Guidelines for the Management of
Common Illnesses with Limited Resources,
2nd Edition, Geneva 2013.

18 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
 ACUTE MALNUTRITION

Causes and Definitions

Acute malnutrition (or wasting and/or edema) relative to height compared to the WHO reference
occurs when an individual suffers from current, population and/or by identifying muscle wasting
severe nutritional restrictions, a recent bout of using Mid Upper Arm circumference (MUAC) and/
illness, inappropriate childcare practices or a or bilateral pitting edema. Acute malnutrition may
combination of these factors. The result is sudden be classified as moderate (MAM) or severe (SAM)
weight loss or the development of bilateral pitting according to the degree of wasting in comparison
edema, which can be reversed with appropriate to specific cut-off points or reference standards.
treatment. Acute malnutrition is diagnosed by Bilateral pitting edema is always classified as
assessing the child to be of inadequate weight severe (see Table 1.)

Table 1. Diagnostic criteria for acute malnutrition in children aged 6 - 59 months3

Measure Cut-off
Weight-for-height* (WFH) < -3 Z-scores
Severe Acute Malnutrition MUAC < 115mm (11.5cm)
Bilateral pitting edema Grades 1, 2 or 3
Weight-for-height* -3 Z-scores ≤ WFH < -2 Z-scores
Moderate Acute Malnutrition 115mm (11.5cm) ≤ MUAC <
MUAC
125mm (12.5cm)

*Based on WHO Standards (www.who.int/childgrowth/standards)

Burden of Acute Malnutrition: Globally and in the Philippines

Globally, there are an estimated 17 million and 20.6% in 2008), making it unlikely that the
children suffering from severe wasting, 34 million Philippines will achieve the MDG goal of a 50%
from moderate wasting4 and an unknown number reduction in underweight prevalence from the
suffering from bilateral pitting edema. Severely baseline of 27.3% in 1989.
wasted children5 have been estimated to have
a greater than nine-fold increased risk (relative Wasting/thinness increased to 7.9% in 2013 from
risk of 9.4) of dying compared to a well-nourished 7.3% in 2011 (p<0.05) and has been significantly
child and moderately wasted children a threefold increasing since 2005.7 This contributed to a
increased risk6. The 2008 Maternal and Child consistent upward trend from 5.8% in 2005 and
Nutrition Lancet series recognizes severe wasting 6.9% in 2008. The current nutritional status of
as one of the top three nutrition-related causes of children is considered poor (FNRI), based on the
death in children under five (Ibid). WHO cut-off points in determining the magnitude
and severity of wasting in children.
The Philippine prevalence of global acute
malnutrition or GAM was at 6.1% (FNRI, 2008). Stunting has gone down to 30.3% in 2013, from
This rose to 7.3% in 2011 (NNS, 2011).The 8th 33.6% in 2011, which is a substantial drop from
NNS of 2013 showed that underweight prevalence 2003 data of 33.9%. Among all age groups,
has gone down to 19.9%, a slight reduction from children aged 12 - 23 months had the highest
20.2% in 2011 (Updating Survey, 7th NNS). This percentage increase of underweight children
reflects a relatively unchanged status for the past (4.9% higher than the 6 - 11 months old age
10 years (from 20.7% in 2003, to 20.0% in 2005 group).

3 Adapted from WHO Child growth standards and the identification of severe acute malnutrition in infants and children: A joint statement by the World
Health Organisation and the United Nations Children’s Fund. 2009
4 Assessed according to Weight for Height z Scores using the WHO standards.
5 Assessed according to Weight for Height z scores using the WHO standards.
6 RE Black et al. Maternal and Child Undernutrition. Paper 1. Global and regional exposures and health consequences. The Lancet 2008
7 In the 2005 NNS Updating survey, wasting prevalence was 5.8%.

Manual of Operations 19
 The 2013 NNS noted regional variations in terms of Philippine adaptation of the new WHO Growth
percentage of underweight, stunting and wasting standards (A.O. No. 2010 - 0015). The standard
in children 0 - 5 years old. The lowest rates of measurement indicators to measure child growth
underweight, stunting and wasting/thinness are in are: weight for age for 0 - 71 months old; length
the following areas: for underweight – the regions for age for 0 - 23 months old or height for 24 -
of NCR (12.9%), CAR (16.5%) and Central Luzon 71 months old; and weight for length for 0 - 23
and Northern Mindanao (both 17.7%); for stunting months old or weight for height for 24 - 71 months
– NCR (22.4%), Central Luzon (23.1%) and old.
CALABARZON (25.3%); for wasting/ thinness –
CAR (5.9%), NCR (6.4%) and SOCCSKSARGEN In the most recent development, the current
(6.7%). Meanwhile, the highest prevalence of Integrated Management of Childhood Illness
underweight, stunting and wasting is among those (IMCI) also includes management of acute
in the poorest quintile. Among the regions, the top malnutrition. The IMCI is a strategy to reduce
three with the highest undernutrition prevalence under-five mortality caused by diarrhea and
are: for underweight – MIMAROPA (27.5%), dehydration, pneumonia, measles, malaria,
Western Visayas (26.0%) and Bicol (24.6%); dengue hemorrhagic fever and malnutrition and
for stunting – Bicol (39.8%), ARMM (39%) and anemia. Two batches of training courses on the
Zamboanga Peninsula (38.7%); for wasting/ IMCI Computer-based Adaptation and Training
thinness – MIMAROPA (9.8%), Ilocos Region Tool (IMCI-ICATT) were conducted in Palawan
(9.8%) and Western Visayas (8.9%). this year. A plan for IMCI-ICATT enhancement of
the curriculum for medical, nursing and midwifery
Assessment and management of acute education is underway.
malnutrition have been incorporated in the

Physiological Basis for Treatment of SAM

The pathophysiological responses to acute nutrient Because of the pathophysiological changes that
depletion place children with SAM at increased accompany SAM, these children often do not
risk of life-threatening complications that lead to present with typical clinical signs of infection that
increased risk of death. Therefore, successful sick children without SAM have when they are
management of SAM in children requires routine ill, such as fever. Consequently, children with
medical treatment of underlying infections and a SAM need to be provided with routine medical
dietary treatment or rehabilitation with specially treatment for underlying infections. Treatment
formulated therapeutic foods, such as F75 and protocols for children with SAM for some medical
F100 milk, or a ready-to-use therapeutic food complications, such as dehydration or shock,
(RUTF). Therapeutic foods have the correct differ from the classical treatment protocols for
balance of nutrients and a high nutrient density ill children without SAM. Misdiagnosis of medical
and bioavailability. The treatment aims to restore complications and inappropriate treatment and
the metabolism through correction of electrolyte feeding of children with SAM contributes to slow
imbalances, reversal of metabolic abnormalities, convalescence and increased risk of death; thus,
restoring the organ functions and provision of adherence to these treatment guidelines in their
nutrients for catch-up of growth. entirety is critical.

20 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
 OVERVIEW OF PIMAM

Trends in the Management of Acute Malnutrition

PIMAM is based on the WHO protocols for food (RUTF)10 and essential medicines with
inpatient therapeutic care and the Community- simple orientation to caregivers on a weekly basis.
based Management of Acute Malnutrition (CMAM) This allowed treatment to be distributed from
approach which was first piloted in Ethiopia in decentralized sites much closer to communities
2001. The CMAM approach demonstrated the than had previously been possible. The approach
possibility of treating children with SAM, if caught was linked to supplementary feeding for children
early on in the progression of the condition, on with MAM and proved to be both effective and
an outpatient basis. Until then formal treatment to offer the potential to treat far greater numbers
of SAM was restricted to inpatient approaches than ever before.11 Based on early successes,
focusing on intensive clinical and nutritional the approach was adopted in many countries in
protocols8 administered by highly trained Africa and Asia and was endorsed in 2007 with
health care professionals. The community- a joint statement of WHO, UNICEF, UNSCN
based approach introduced engagement with and WFP.12 This enabled governments to start
communities in order to identify severely acutely establishing and scaling up CMAM programming
malnourished children early9 and distribution of at the national level.
specially formulated ready-to-use therapeutic

Brief History of PIMAM in the Philippines

The approach was introduced in the Philippines was derived from version 6, 2011, of the generic
in 2008 as part of the Nutrition in Emergencies “Integrated Management of Acute Malnutrition”
(NiE) interventions covering children aged 6 to guidelines by Professor Michael H. Golden
59 months in disaster-affected communities. and Dr. Yvonne Grellety. The copyright holders
It was first implemented in 2009 by Save the have engaged with the staff of the Department
Children (SC), Doctors without Borders (MSF) of Health and with the CMAM Task Force of
and Community and Family Services International the Philippines in order to adapt their generic
(CFSI) with support from UNICEF and World protocol to version 1 of the Philippine Integrated
Food Program (WFP) in armed conflict- Management of Acute Malnutrition (PIMAM),
affected municipalities of Maguindanao, North a national protocol for the management of the
Cotabato, Lanao del Sur and Lanao del Norte in severely and acutely malnourished children,
Mindanao. In 2010, ACF-International attempted after a three-day consultative workshop. The
implementation in a developmental context in draft PIMAM guidelines, however, did not cover
selected municipalities of North Cotabato and MAM Treatment. Thus, WFP commissioned
Lanao del Sur. The key components of CMAM separate MAM treatment guidelines to be used
include: 1) Community Mobilization; 2) Outpatient in conjunction with this document which deals
Therapeutic Program (OTP) for the treatment of with the management of SAM. The draft PIMAM
severe acute malnutrition (SAM) cases without guidelines have since been used by NiE players in
medical complications; 3) Inpatient Therapeutic providing critical nutrition services in emergencies
Program (ITP) for the treatment of SAM cases such as Typhoons Sendong in Cagayan de Oro
with medical complications; and 4) Targeted and Iligan, Pablo in Compostela Valley and Davao
Supplementary Feeding program (TSFP) for the Oriental, and Yolanda in Regions VI, VII, and VIII;
management of children with Moderate Acute the Bohol Earthquake; and the Zamboanga Siege.
Malnutrition (MAM). As agreed globally, SAM These guidelines have also been successfully
treatment was supported by UNICEF while MAM applied in the development context as seen in the
treatment was supported by WFP. establishment of the first LGU-led SAM initiative
in Davao City in 2014. These experiences
CMAM has since been implemented by NGOs have generated both evidence and demand for
after the country experienced emergencies updating and finalization of the guidelines toward
affecting the nutritional status among children full adoption.
in disaster-hit areas. The draft CMAM protocol

8 Contained in the WHO protocols 1999 (WHO 1999) and later updated as part of the WHO training package in 2002 (WHO 2002).
9 Defined as - before their condition deteriorates to a stage where they require inpatient care for medical complications
10 A highly fortified oil-based paste made of peanuts, milk powder, oil, sugar and vitamin/mineral powder developed in the 1990’s by research scientist
Andre Briend and Nutriset (a private company making nutritional products for humanitarian relief). It is equivalent in formulation to Formula 100 (milk formula
recommended by WHO for the inpatient treatment of SAM).
11 Collins S, Sadler K. Outpatient care for severely malnourished children in emergency relief programmes: a retrospective cohort study. Lancet 2002;
360(9348):1824-1830
12 WHO/WFP/SCN/UNICEF, 2007. Community-Based Management of Severe Acute Malnutrition. A Joint Statement by WHO, WFP, UNSCN and UNICEF,
May 2007
21
 Principles of the Integrated Management of SAM

The integrated management of SAM is a continued rehabilitation of cases and sits as a

public health strategy to address severe acute component of the wider Philippine strategy for
malnutrition. It focuses on the integration of malnutrition prevention focusing on the critical
effective management of SAM into the on-going 1,000-day window outlined in the Medium-Term
routine health and nutrition services at all levels Philippine Plan of Action for Nutrition 2011 - 2016
while still striving for maximum coverage through and the Strategic Framework for Comprehensive
maintaining a strong community component. It also Nutrition Implementation Plan 2014 - 2025.
aims to make links across the wider sectors (e.g.
WASH, social welfare and protection, agriculture) The approach is based on four principles:
to ensure that treatment is linked to support for

PIMAM is designed to achieve the greatest possible coverage by making

Maximum coverage
services accessible and acceptable to the highest possible proportion of a
and access
population in need.

PIMAM prioritizes early case-finding and mobilization so that most of the

Timeliness cases of severe acute malnutrition can be treated before complications
develop.

PIMAM ensures the provision of simple, effective outpatient care for those
who can be treated at home and clinical care for those who need inpatient
Appropriate care treatment. Less intensive care is provided in some cases for those suffering
from moderate acute malnutrition (MAM) in which cases the services are
linked.

PIMAM aims to link children to continuous and appropriate support for their
nutrition by embedding management of severe acute malnutrition as one
Care when and where of the basic health services to which a child has access and linking it to a
it is needed broader set of direct and indirect nutrition interventions (Infant and Young
Child Feeding [IYCF] support, micronutrient supplementation, deworming)
focusing on the 1,000-day critical window.

Components of the Integrated Management of SAM

The integrated management of SAM has Community Mobilization - involves engagement

three components: Community mobilization, with the community to promote a common
Inpatient Therapeutic Care (ITC) and Outpatient understanding of acute malnutrition and promote
Therapeutic Care (OTC) services which are the services offered. It also involves identification
implemented simultaneously. These may then of severely acutely malnourished children at the
be linked to the fourth component Management community level on an on-going basis to enable
of Moderate Acute Malnutrition (MAM) where widespread early detection and referral before the
this exists. Achieving the goals of the service patient’s condition deteriorates further. This aims
requires both attention to the clinical treatment of to increase coverage and maximize effectiveness
the patient and effective community mobilization. of treatment.
In some cases these components are linked to
management of MAM. Inpatient Therapeutic Care (ITC) - involves
management of complicated cases of SAM
according to WHO protocols on an inpatient basis
at facilities with appropriate capacity (hospitals).

22 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
Outpatient Therapeutic Care (OTC) - involves Management of Moderate Acute Malnutrition
the management of non-complicated cases (MAM) - This may form a component of the service
of SAM in outpatient care using ready-to-use in certain contexts. It targets cases of MAM with
therapeutic foods (RUTF) provided on a weekly/ supplementary food, some basic medicines,
biweekly basis. This includes provision of simple monitoring and nutritional education.
routine medicines and monitoring at orientation to
the mothers/caregivers. Outpatient care is offered These components sit within a multi-sectoral
through the decentralized health structures – range of health and nutrition interventions and
the Rural Health Units (RHU), Barangay Health services which focus on tackling the determinants
Centers (BHC), Barangay Health Stations (BHS) of undernutrition in the ‘critical 1,000-day window’
or within the OPD of hospitals. and are reflected in the Medium-Term Philippine
Plan of Action for Nutrition 2011 - 2016 and the
Strategic Framework for Comprehensive Nutrition
Implementation Plan 2014 - 2025.

Figure 1. PIMAM components

Inpatient Therapeautic
Care (ITC) for SAM
withcomplications

Health
System &
Services

Outpatient Therapeautic
Care (OTC) for SAM
without complications
Community Mobilisation
& Outreach

Programmes for
Management of
MAM

Manual of Operations 23
PART 1

©UNICEF Philippines/2011/KPalasi

TECHNICAL
GUIDELINES
 1. COMMUNITY MOBILIZATION AND OUTREACH

Community mobilization is a vital part of any ►► Sensitize the community to be aware of acute
program for managing SAM. It is essential to malnutrition and its effects
find cases of SAM and enable the child to attend ►► Make sure the community is aware that
treatment before life-threatening complications treatment is available locally
develop. Once in treatment, it is also important to ►► Find cases of acute malnutrition in the
ensure that treatment is continued until the child community and refer these for treatment
is cured. ►► Follow-up at-risk cases of severe acute
malnutrition at home when needed
Effective community mobilization should:
The steps to developing a strategy for community
►► Engage with the community prior to mobilization and outreach are outlined in Part 2.
commencing the service and during Operational Guidelines (Section 5).
implementation to understand their needs
and make sure the service is accessible and
appropriate to the local community by joint
problem solving on barriers to service uptake

1.1 Achieving Coverage

By maximizing the number of children with acute

malnutrition who can receive treatment we can number of children with
maximize child survival. This is referred to as SAM who are being
‘coverage’. treated
Coverage =
Total number of children
Many factors can influence coverage. Some of existing in the community
these factors can improve coverage (boosters) with SAM
while some can reduce it (barriers).

Table 2. Examples of boosters and barriers to coverage in the Philippines13

Boosters Barriers

►► Knowledge about acute malnutrition ►► Lack of knowledge about malnutrition

►► Awareness that treatment is available ►► Lack of awareness that treatment is available
►► Treatment is available locally ►► Distance to treatment is too far
►► Caregivers take children to the health center for ►► Caregivers’ workload
treatment quickly when SAM is identified ►► Caregivers take child to other places thus
►► Good standard of treatment delaying treatment when SAM is identified
►► Good community support for service ►► Physical barriers (mountains, rivers, landslides)
►► Good supplies of medicines and RUTF ►► Climate (heat, monsoon rains)
►► Poor standard of treatment
►► Service is not valued by the community
►► Shortages of medicines and RUTF

13 Semi Quantitative Evaluations of Access and Coverage SQUEAC reports: 1. Compostela Valley (2013), 2. Mindanao (2013)

Manual of Operations 25
 1.2 Community Sensitization

The aim of sensitization is to make the local OPT or GP should be advised of the signs and
community aware of SAM and the availability symptoms of SAM during consultations.
of treatment. It is conducted through a variety
of means so as to include all sectors of the Sensitization messages should include:
community.
►► Information about the signs and symptoms of
In order to do this, sensitization messages SAM
and IEC materials (e.g. MUAC tapes, RUTF, or ►► Why SAM and its treatment are important
photographs) are used to inform local leaders ►► How SAM is identified using MUAC, weight-
and prominent or other influential community for-height, or edema
members. This may be done through organized ►► Which age groups are eligible for treatment
meetings or less formal discussions with members ►► Information regarding where and when to
of the community. access treatment
►► What to expect when a child is in treatment
Caregivers and children attending the health (e.g. what is given, how long does it take)
center and community based activities such as

1.3 Case Finding and Referral

The aim of case finding is to ensure that children Case Finding Methods
are screened regularly so as to identify SAM in
its early stages, when it is most easily treated. Active Case Finding: is when the health worker
Different types of case finding are possible. The deliberately goes out looking for cases of SAM.
main difference is that case finding is ‘active’ For example, during house-to-house nutrition or
when the BHW/BNS/Midwife visits the community other health activities at community level (e.g.
to find cases of SAM and is ‘passive’ when the EPI), when the child is also screened for SAM.
child comes to the BHW/BNS/Midwife or health
center for some other purpose and is screened for Active Adaptive Case Finding: is a modified
SAM during that activity. Passive case finding may form of active case finding. Instead of going
also occur when Early Childhood Development house-to-house, the BHW/BNS may visit every
workers screen children that they come into third or fourth house screening for SAM and
contact with through their ECD activities. ask if the parents know of other children in the
neighborhood with signs and symptoms of SAM.
This method may include visiting other sources of
information such as schoolteachers, local religious
leaders and pharmacists to identify children with
SAM (see Box 1 below).

Passive Case Finding: is when a child attends

a health center or health or nutrition program for
some other purpose but is screened for SAM
during attendance. This may be through use of
the IMCI tool. Passive case finding should be
done systematically whenever possible so that
every child is screened at every visit.

26 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
Box 1. Active Adaptive Case Finding

Active Adaptive Case Finding is based on two principles:

1. It is active: SAM cases are specifically targeted. Case finders do not go house-to-house in the selected villages
measuring all children aged between 6 - 59 months. Instead, only houses with children matching the locally
understood and accepted descriptions of malnutrition and its signs are visited.

2. The method is adaptive: At the outset key informants help with case finding in the community but other sources
of information found during the exercise and through discussion with beneficiaries coming into the facility are
used to improve the search.

Step 1 Use findings of community assessment to identify:

• The appropriate case-finding question - according to the terminology used by the population
to describe the signs of SAM.
• The most useful key informants to assist with case-finding - those who are likely to be able to
identify cases, who know about the health of children in the community or who people consult
when their child is sick.
• Any context-specific factors affecting the case-finding process - such as cultural norms, daily
and seasonal activity patterns, general structure of villages.

Step 2 Using key informants identify the households with SAM children 6 - 59 months.

Step 3 Visit these households and check edema and MUAC for children 6 - 59 months.

Step 4 Make any adjustments to definitions required based on whether cases were
correctly identified.

Step 5 When children with SAM are identified, ask if the key informant or anyone
in that household knows where children who are similarly malnourished
live. Until the first SAM case is identified it is possible to go to every 3rd or
4th house.

Step 6 Use this method exhaustively in all locations within the community until only children
already measured are identified.

Manual of Operations 27
 Criteria for Identification Referral Process
of Cases
For cases of SAM identified by people other than
Children aged 6 - 59 months and infants are the the BNS/BHW or midwife at community level (e.g.
focus for the management of SAM. To determine by the ECD worker), these should be referred
age, birth dates can be identified and confirmed to the BNS/BHW or midwife for the next level of
with the help of a birth certificate, child health card assessment (see Section 2).
or ECCD Card. In some cases, age groups can
be identified by using a local calendar of events For these cases:
to help determine age if a birth date is not known.
This should be created for the particular local ►► Explain why referral is necessary and let the
context. An example is given in Annex 1. It is not mother/caregiver know what to expect when
recommended to use a height cut-off as proxy for they reach the BHS.
6 months of age; in a stunted population, many ►► Stress the urgency of bringing the child for
infants six months or older will have a height less consult as soon as possible. Offer to go with
than 65 centimeters (cm). the mother to the nearest BHS if needed.

In the Philippines, MUAC and assessment of Table 3. Community-level case-finding

edema are the priority tools for case finding at criteria
community level (see Table 3). For details on the
taking of measurements see Annex 2. Identified MEASURE REFERRAL CRITERIA
SAM children are then further assessed by the
MUAC < 115mm (11.5cm)
BHW/BNS or other facility staff for appetite and
complications (see Section 2s). Edema Bilateral Pitting

1.4 Follow-up of Children with SAM

Some children with SAM require follow-up at home Follow-up can therefore focus on:
by the BNS/BNW during their time in treatment in
addition to the follow-up they receive at the BHS/ ►► Children with medical complications who have
health facility on their periodic visits. Following up refused transfer to inpatient care and are
through home visits can be time consuming if done being treated on an outpatient basis
well as a variety of factors need to be discussed ►► Unresponsive cases in the program (loss or
during the visit. There is no need to conduct home static weight for two weeks), with aspects of
follow-up visits with all SAM children, especially the home environment are suspected to be
those gaining weight in the program. playing a role rather than medical issues
►► Repeated absentees from treatment
►► Infants < 6 months old not gaining weight at
each visit

A home visit should include:

Discussion with the caregiver to Whenever home visits are made, a
understand the constraints that record or relevant information should
they are operating under and offer be kept with the child’s treatment
suggestions/support record by the BNS/BHW and feedback
given to the midwife/other OTC
The provision of any appropriate worker where relevant. If the child has
counseling (based on IMCI/IYCF stopped attending treatment against a
materials and training – Annex 3), or health worker’s advice, the reasons for
medical referral if required based on default should be noted. This may help
CB-IMCI check (Annex 4) the program managers understand the
Linking clients to livelihood/safety net/ problems caregivers have in attending
social protection programs available SAM treatment and to be able to
where particular issues are identified identify solutions to make treatment
and/or clients are eligible (e.g. child more accessible.
cash grant, etc.)

28 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
 2. ASSESSMENT AT THE HEALTH FACILITY

Assessment should be made in the OPD of an MUAC is a measure of muscle wasting and has
Inpatient Therapeutic Care (ITC) facility or in been shown to have the highest correlation with
an Outpatient Therapeutic Care (OTC) facility risk of mortality of any anthropometric indicator.
(Barangay Health Station, Rural Health Unit Clinic, It is also a simple and transparent measure
or City Health Office). Initial MUAC assessment and therefore the most appropriate for use in
should also be carried out systematically at other decentralized services. It is an independent
points of contact within the health facility (e.g. TB- measure of SAM and does not require confirmation
DOTS clinics, HIV clinics, pediatric ward, PMTCT against weight for height measurements. Where
service, Maternity ward) and cases referred to WHZ is already in existence as a measure at
staff responsible for ITC and OTC in the same facility level (i.e. where the WHO Child Growth
facility for further assessment. Standards can be fully assessed), this can also
be used as another independent measure for
identification of cases presenting to the facility.

2.1 Arrival and Identification of Acute Malnutrition

On Arrival Take Anthropometric

Measurements
Procedure
CHILDREN 6 - 59 MONTHS OF AGE
Step 1 On arrival, give sugar-water immediately
to obviously ill patients and those that will clearly Procedure
need inpatient or other medical treatment:
approximately 10% sugar solution – 10g (1 Step 1 Take MUAC and weight14 measurements
tablespoon) of sugar per 100mL of water (fruit juice (see Annex 2) including for those children
can be given as an alternative, if available). This referred from the community or other facilities.
is done to prevent dehydration and hypoglycemia
which may be caused by infection or can occur Step 2 Examine for edema (see Annex 2) and
when a malnourished child has not been fed for take the temperature and respiratory rate15
four to six hours, as often happens during travel
to a health facility. Step 3 Where capacity exists, also take height,
and determine the Z-scores using the weight-for-
Step 2 Explain to the caregiver that you will be height table (see Annex 2 and Annex 5)
assessing their child to determine whether they
need treatment and let them know what to expect.
INFANTS < 6 MONTHS OF AGE
Determine Age
Procedure
Birth dates can be identified and confirmed with
the help of a birth certificate, child health card or Step 1 Take weight16 and length measurements
ECCD Card. Age groups are best identified by
using a local calendar of events (see Annex 1) to Step 2 Check the weight-for-length table and
help work out age if a birth date is not known. It is determine the Z-scores 17
not recommended to use a height cut-off as proxy
for 6 months of age; in a stunted population many Step 3 Examine for edema (see Annex 2) and
infants six months or older will have a height less take the temperature and respiratory rate
than 65 centimeters (cm).

14 Weight is necessary for monitoring and for calculation of some medicine doses.
15 Temperature and respiratory rate are taken at this stage so that the child can be fast-tracked if any issue is identified.
16 Note that pediatric balance scales are required for the accurate recording of weight in infants to precision of 10g.
17 It should also be noted that the use of the WHO growth standards for the assessment of infants < 6 months of age diagnoses a much larger group
than previously used standards.

Manual of Operations 29
 OTHER GROUPS - CHILDREN > 5 YEARS OLD, Identification of SAM
ADOLESCENTS AND ADULTS
Procedure
Procedure
Step 1 Determine if the child has SAM or MAM
Step 1 Take the anthropometric measurements based on the criteria below. (see Table 4 and 5)
(MUAC, weight, height or length; see Annex 2)
Step 2 For children identified with SAM, further
Step 2 Check the BMI/BMI for age tables and assessment is required (see Section 2.2 below).
determine the Z-scores where required (see
Annex 6) Step 3 For these children their details can be
entered in the Target Client List (TCL) for sick
Step 3 Examine for edema 8 and its severity (see children/registration book/hospital admission
Annex 2) and take the temperature chart depending on the level at which they enter
the service. If at Barangay level, the OTC chart
admission column can be started.

Step 4 The child’s Early Childhood Care

and Development (ECCD) number, existing
household number or TCL number (whichever is
in most common use) is noted on the OTC/ITC
charts. This will allow the child to be tracked if
they require home visits or referral in the future.

Table 4. Identification of acute malnutrition in children 6 - 59 months of age

CRITERIA

MUAC < 115mm (11.5cm)

OR
Presence of bilateral pitting edema
Severe Acute Malnutrition
OR
Weight-for-Height (WFH) or Weight-for-Length (WFL)
< -3 Z-scores
MUAC < 125mm (12.5cm) AND ≥ 115mm (11.5cm)
Moderate Acute Malnutrition
WFH or WFL < -2 Z-scores AND ≥ -3 Z-scores

Table 5. Identification of acute malnutrition in infants <6 months of age

CRITERIA

WFL < -3 Z-scores

Severe Acute Malnutrition OR
Presence of bilateral pitting edema
Moderate Acute Malnutrition WFL < -2 Z-scores and ≥ -3 Z-scores

Remi nder s
→→ At the OTC, all SAM cases identified must be registered including those who after the detailed assessment below will be
referred to Inpatient Care (ITC) as they will afterwards return to OTC.
→→ For identification of acute malnutrition in other age groups, see Annex 7.
→→ For SAM community referrals who on assessment at the facility do not meet the criteria of admission, see Box 2.

18 In adults, care must be taken to rule out edema as a result of cardiac failure.

30 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
 Box 2. Dealing with SAM community
referrals who do not meet
admission criteria

It is important not to reject these referrals as that will undermine the authority of community health and nutrition workers
and will negatively affect acceptance of the program. It is important that they receive some tangible benefit for taking the
time and effort to take their child to the health facility and not just be sent home. This is especially true for caregivers who
live far from the health facility. Options are:

►► Admit him/her to a supplementary feeding program (SFP) if and when available

►► If MUAC or WHZ are close to admission criteria (i.e. < 120mm/12.0cm MUAC) and there is no SFP in place, admit to
OTC (as a special case) rather than waiting for them to deteriorate
►► Explain to the mother or caregiver that the child is at risk or close to becoming acutely malnourished and give a
“family ration” or some other benefit

In all cases:

Give advice to the mother and facilitate enrolment in basic health services in the health facility (e.g. IYCF counseling,
micronutrient supplementation, pre-natal check-up if pregnant, EPI, under-five clinic and services for the other children,
family planning counseling, TB program for children if appropriate)

If a large number of inappropriate referrals attend, this should be discussed during the regular coordination meetings
between the facility and community-level staff and the relevant community health and nutrition workers followed up
and retrained.

Non-SAM Referrals

Procedure

Step 1 For children identified as MAM, use IMCI

protocols to provide counseling and medical
care and refer to Blanket or Targeted SFP if in
place (see guidelines for management of MAM)

Step 2 For infants < 6 months identified with

MAM, IYCF counseling should be provided for
caregivers and caregivers admitted to Blanket
or Targeted SFP if in place (see guidelines for
management of MAM).

Step 3 For children not meeting criteria, the

opportunity should be used to provide any
medical treatment required and any nutritional
counseling available at the facility (e.g. IMCI
feeding counseling Annexes 3 and 8 and IYCF
counseling cards)

Manual of Operations 31
 2.2 Further Assessment for SAM Children

Once a child has been diagnosed with SAM, Observed Appetite Test
it is important to make sure that he or she is
correctly assigned to outpatient or inpatient care Appetite is tested using RUTF, the product which
,based on his or her condition. This is based would be used to treat the child on an Outpatient
on whether the child has appetite and/or any basis (see Annex 15 for RUTF Ration). The
medical complication. “Fast track” those obviously appetite test is a critical part of the assessment
severely ill SAM cases for emergency medical of the child (see Box 3) and therefore needs to
treatment if required. Do not keep them waiting. be done precisely and according to the procedure
Following this, conduct the appetite and general below.
medical assessment below.

Procedure

Box 3. The importance of the Step 1 Set aside a separate quiet area to
observed appetite test conduct the test.

Step 2 Explain to the caregiver the purpose of

Malnutrition changes the way infections and the appetite test and how it will be carried out.
other diseases manifest – malnourished children
severely affected by the classical CB-IMCI diseases Step 3 The caregiver, where possible, should
frequently show no signs. However, these major wash her and the child’s hands.
complications lead to a loss of appetite. This is the
best sign of severe metabolic malnutrition. The Step 4 Ask the caregiver to sit comfortably with
appetite test is consequently the most important the child on their lap and either offer the RUTF
criterion to decide if a patient should be sent for from the packet or put a small amount on her
in- or outpatient management. finger and give it to the child.

SAM with a poor appetite means that the child has Step 5 Give the caregiver water for the child to
a significant and/or ongoing infection or a major drink from a cup as s/he is taking the RUTF.
metabolic abnormality such as liver dysfunction,
electrolyte imbalance and cell membrane damage Step 6 Ask the caregiver to gently offer the
or damaged biochemical pathways. These are the child the RUTF while encouraging the child
patients at immediate risk of death. In addition, throughout the process. If the child refuses,
a child with a poor appetite will not be able to then the caregiver should continue to quietly
consume the RUTF at home and will continue encourage the child and take time over the test.
to deteriorate or die. If appetite has not been The test usually takes a short time but if a child is
demonstrated and observed, a child should never distressed, it may take longer. The child must not
be sent home with RUTF and should be admitted be forced to take the RUTF.
to ITC.
Step 7 Observe if the child is able to consume
the required amount (the test MUST be observed
by a health worker).

Step 8 Record the result of the test (see Table 6

below) on the OTC or hospital chart.

Table 6. Categorizing results of the appetite test

Pass Fail

The child does not take at least 3 - 4 mouthfuls

of RUTF. They are considered to lack sufficient
The child takes at least 3 - 4 mouthfuls of RUTF
appetite for outpatient treatment and should be
referred to the ITC.

32 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
Remi nder s Remi nder s
→→ Sometimes a child will not eat the RUTF because When carried out by the BHW/BNS the medical
s/he is frightened, distressed, or fearful of the assessment is undertaken primarily to identify which
environment or staff. Common stress factors are children need direct immediate referral to ITC. For
overcrowding, noise, other distressed children, children remaining in OTC, the medical assessment
or intimidating health professionals with white will be checked by the midwife during weekly BHS
coats or harsh tone of voice. Therefore, the visits. There is no need to wait for the validation of
appetite test should be conducted in a separate medical assessments which unnecessarily delays the
quiet area. If a quiet area is not available in the admission of the child for therapeutic care.
health facility, then the appetite can be tested
outside.
→→ Even if the caregiver/health worker thinks
the child is not taking the RUTF because s/he
doesn’t like the taste or is frightened, the child Box 4. Checklist for taking medical
still needs to be referred to inpatient care. After and dietary history and
showing sufficient appetite in inpatient care, examination at primary
they can be transferred to outpatient treatment. health care level
→→ The appetite test should always be performed
carefully. If there is any doubt concerning the
appetite, then the patient should be referred
for inpatient treatment until appetite can be Medical History
demonstrated.
→→ The same observed appetite test is also
conducted during subsequent follow-up Any complaints
sessions. Appetite
→→ Cases of anaphylaxis after consumption of RUTF Recent sinking of eyes
have not been reported. However, if for any Duration and frequency of vomiting and
reason peanut allergy is suspected, or after the diarrhea, appearance of vomit and stool
appetite test there are signs of anaphylaxis, the Coughing
child should be referred directly to ITC to receive Changes in skin and hair
immediate treatment there. Time when urine was last passed
Contact with measles or tuberculosis
Any deaths of siblings
Immunization history

Medical Assessment Dietary History

Procedure
Food and fluids taken in past few days
Step 1 Take a medical and dietary history of the Usual diet before current episode of illness
child from the caregiver (see Box 4). Breastfeeding history

Step 2 Perform an examination of the patient

to determine if s/he has severe medical Examination
complications using IMCI/CIMCI criteria
depending on the level at which assessment is
taking place, i.e. BHS or higher health facility, Alertness
(see Annex 4 for IMCI/CIMCI procedure) noting Convulsions
that for malnourished children, clinical signs may Temperature
still be absent. For parameters which should Respiratory rate
always be checked see Box 4. Chest in-drawing
Visible anemia
Step 3 Make a record of the medical assessment Visible vomiting or diarrhea
on the OTC or hospital chart.

Manual of Operations 33
 Feeding Assessment for Infants ►► If there is no possibility of breastfeeding (i.e.
<6 Months death of mother, wet nursing not possible) this
should also be noted.
►► Full assessment should be made of ►► This assessment forms an important part of
the caregiver’s breastfeeding practice the decision-making process below.
in accordance with national IYCF/IMCI
guidelines and training package (Annexes 3
and 8).

2.3 Decision-Making and Referral

Deciding on Inpatient or Outpatient care

Figure 2. Decision flowchart for Inpatient and Outpatient Therapeutic Care

Age, anthropometric measurements,

edema check

Child with SAM Triage of emergency

cases

Appetite test, History, Clinical

examination

Outpatient Therapeutic Inpatient Therapeutic

Care (OTC) Care (ITC)

passes appetite test fails appetite test

and or
no medical complication medical complication
and or
no severe edema (+++) or severe edema (+++) or Marasmic
Marasmic Kwashiorkor Fail appetite test, Kwashiorkor
worsening edema or
development of a medical
complication
Stabilization
REFERRAL

Rehabilitation Return of appetite,

Transition
sufficient loss of
edema and resolving
complications Rehabilitation (if no OTC)

Recovery
(link to other services – including
SFP if available)

34 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
Procedure ►► If inpatient care is indicated, carefully explain
the benefits, the risks of outpatient care for
►► Assess whether outpatient or inpatient care the child and that the caregiver can request
is required based on results of the above discharge to outpatient care at any time after
assessments and the criteria below (see Table admission with the agreement of the staff.
4 for children 6 - 59 months and Table 5 for ►► If a caregiver refuses referral to inpatient
infants). See also Annex 9 for full admission care, accept the final decision of the caregiver
criteria. but make a note of the refused transfer on
►► Discuss the recommended treatment with the outpatient treatment card or referral
the caregiver and explain what will happen in document.
outpatient or inpatient care depending on the
decision.

Table 7. Criteria for new admission to inpatient or outpatient therapeutic care

(children 6 - 59 months):

Factor Inpatient Therapeutic Care Outpatient Therapeutic Care

Bilateral pitting edema Grade 3 (+++) Bilateral pitting edema Grade 1

Edema
OR Marasmic Kwashiorkor* or 2 (+ and ++)

MUAC < 115mm (11.5cm) OR MUAC < 115mm (11.5cm) OR

Anthropometry WFH or WFL < -3 Z-scores WFH or WFL< -3 Z-scores
AND one of the below AND both of the below
Appetite Fails appetite test with RUTF Passes appetite test with RUTF
Medical complications Any of the below NO medical complications
Intractable (empties contents of
Vomiting
stomach)
Fever > 38.5°C (101.3 °F) axillary
Fever > 39.0°C (102.2°F) rectal
Temperature
Hypothermia < 35°C (95 °F) axillary
Hypothermia < 35.5°C (96°F) rectal
≥ 50 resp/min from 6 to 12 months
≥ 40 resp/min from 1 to 5 years
Respiration rate ≥ 30 resp/min for over 5 year olds
And any chest in-drawing
(for children > 6 months)
Very pale (severe palmar pallor, roof
Anemia of the mouth (oropharynx), nailbeds,
eye palpebrae), difficulty breathing
Extensive skin infection requiring
Superficial infection
Intra-Muscular antibiotics
Very weak, apathetic, unconscious
Alertness
Fitting/convulsions
Recent history of diarrhea/vomiting
Hydration status
with appearance of sunken eyes

*MUAC less than 115mm (11.5cm) or WFH or WFL < -3 Z-scores AND with any grade of edema

Manual of Operations 35
 Table 8. Summary of criteria for admission to inpatient or outpatient care
(infants <6months)
Outpatient Breastfeeding
Support19 (IMCI medical
treatment, IYCF counseling
Factor Inpatient Care
at facility, supplementary
feeding for mother where
available) (see section 3.5)
Bilateral pitting edema WFL < -2 Z-scores
Anthropometry OR WFL < -3 Z-scores AND None of the complications
AND one of the below requiring inpatient care
Recent weight loss/inability to gain
History
weight
Any of the medical complications
outlined for children 6 - 59 months
(Table 2)
Medical
Any medical issue needing more
detailed assessment or intensive
support (e.g. disability)
Ineffective feeding (attachment,
positioning and suckling) directly
observed
Feeding practices Infant is lethargic and unable to
suckle
No possibility of breastfeeding (e.g.
death of mother)
Depression of the mother/ OR
Condition of mother caregiver, or other adverse social mother is malnourished or ill
circumstances

Referral

Ensure appropriate referral if required to an

inpatient facility or outpatient facility nearest to
their home for treatment. This includes:

►► Explaining the reason for referral to the

caregiver

►► Filling out an appropriate two-way

referral documentation with details of the
assessments conducted and any treatments
administered (see Annex 10)

►► Providing for transportation in coordination

with district or referral healthcare facilities

►► For children being referred to inpatient care

particular care should be taken as these
children can easily deteriorate (see Box 5)

19 No RUTF is provided to these infants <6months old.

36 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
Box 5. Appropriate referral of
complicated cases

For very ill malnourished children brought to an outpatient facility for SAM and who need to be “transferred” to
inpatient care, it is critical to ensure that referral should take place quickly. However, deterioration often occurs
during transport and can lead to death soon after arrival, due to the length and difficulty of the journey. This is
known as “transport trauma.” A number of measures are recommended to avoid this:

►► Explain to the caregiver that the patient is critically ill and needs urgent transport to an inpatient facility for
more specialized care.
►► Make the child as comfortable as possible and administer small amounts of 10% sugar water to keep them
hydrated before and during transportation.
►► Contact the inpatient facility by telephone for advice and support for the management of the patient. The
telephone call, advice given and the name of the doctor and inpatient facility contacted should be recorded on
the treatment card.
►► Where there is additional capacity (presence of the MHO) at the OTC and where training has been carried out
on ITC protocols and measures – in line with those protocols – further stabilize the child before transport is
taken.
►► Public transport is not recommended.

Manual of Operations 37
 3. OUTPATIENT THERAPEUTIC CARE (OTC)

Figure 3. OTC Activities

• Anthropometric measurements and edema check

• Triage of emergency cases
1 Admission • History, medical examination and appetite test
• Referal to ITC where required
• Recording

• Medical management - routine and additional medicines

• RUTF
2 Treatment • Routine medicines
• Additional medicines
• Orientation to caregiver

• Anthropometric measurements and edema check

• History, medical examination and appetite test
• Referral to ITC where required
Weekly
3 • Arrangement of home visit or futher clinical/social investigation
Monitoring where required
• Recording on OTC card
• Resupply RUTF and complete medical treatment

• Orientation for caregiver

• RUTF
• Refer for vaccination if required
4 Discharge • Link to SFP and/or other services available
• IYCF counseling
• Recording on OTC card

Outpatient therapeutic care provides treatment sufficient capacity in place) and should be a
for children with SAM who demonstrate adequate component of routine service delivery. This
appetite and have no medical complications. These ensures good access and coverage so that as
children can be treated at home with simple routine many acutely malnourished children as possible
medicines and RUTF. Outpatient therapeutic care can access treatment within a day’s walk from
achieves this objective through timely detection, their homes.
referral and early treatment before the onset of a
complication. Effective community mobilization, Children may be received directly into outpatient
active case finding, referral and follow-up therefore care when they come to the health facility, by
form the cornerstone of successful outpatient care referral from community level workers (BHW,
(see Section 1). BNS) or by referral from inpatient care once
their condition has been stabilized (i.e. medical
Outpatient therapeutic care should be delivered complications have been resolved).
from as many health facilities as possible (with

38 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
3.1 Assessment and Admission

The criteria of admission are given in Annex 9 Procedure

and admission procedures for new cases are
explained above in Section 2. Step 1 Review and record any relevant
information from the referral document (if
For cases already under treatment for SAM available) onto the OTC chart.
(transfer from other OTC or ITC facility):
Step 2 Continue with the same registration
number on referral document.

Step 3 Conduct assessments as above to check

information on referral document and identify any
additional issues which may have arisen during
the transfer.

Step 4 Complete existing registration

documentation and OTC chart.

3.2 Medical Management

Routine Medicines and symptoms in severely acutely malnourished

children (see below), ALL cases admitted to
In order to treat probable and potential underlying OTC should be treated according to the following
illnesses that may not always show classical signs routine treatment schedule.

Table 9. Summary table of routine treatment on admission in OTC*

(see Annex 11 for details and dosages)

MEDICATION DOSE ADMINISTRATION

< 10kg: 250mg

1 dose at admission then 2
Amoxicillin > 10 to < 14kg: 500mg
times a day for 5 days at home
14 to 19kg: 750mg
< 12 months Do not give to < 12 months
Albendazole/Mebendazole 12 to 23 months: 200mg Give 1 dose on the 2nd visit
≥ 24 months: 400mg (unless received in last month)

6 to 9 months Only during measles epidemic

Measles vaccine Refer to immunization clinic or
≥ 9 months: standard
1 vaccine on the 4th visit
Do not give outside regular
Vitamin A** RUTF has sufficient daily allowance
campaigns

*For children referred from inpatient therapeutic care/stabilization, a check should be made for the treatments already received and
the above adapted accordingly.
**Vitamin A is no longer recommended as additional supplement for children with SAM in OTC as a sufficient daily allowance is
available in RUTF20. It is given only during emergencies or measles outbreaks (symptomatic cases should be referred to ITC).

20 WHO 2013. Guideline. Updates on the Management of Severe Acute Malnutrition in Infants and Children, Geneva

Manual of Operations 39
 Procedure Additional Medicines

►► Routine antibiotics should be given to severely Other medical conditions/symptoms – eye

malnourished patients, even if they do not infections, ear discharge, mouth ulcers, fungal
have clinical signs of systemic infection. infections, minor skin infections and lesions –
Despite the absence of clinical signs, nearly should be treated according to the CB-IMCI
all will have small bowel bacterial overgrowth guidelines. Additional medication should be
(SBBO) and minor infections at the least (see prescribed conservatively.
Box 6).
►► The child’s immunization status should be
checked and the mother/caregiver referred to
the BHS for any vaccinations due (including
for measles vaccination). Remi nder s
►► Check for the date of the child’s last →→ Iron and folic acid should NOT be given routinely.
deworming and refer to BHS. Where severe anemia is identified according to
►► Refer to the national guidelines for malaria CB-IMCI guidelines, the severely malnourished
treatment. child should be referred to inpatient care. Where
►► Refer to the national guidelines for diagnosis moderate anemia is identified, treatment should
and treatment of tuberculosis. begin only after 14 days in the program and not
►► It is important to record any supplementation/ before, because a high dose may increase the risk
treatment given on the child’s ECCD chart if of severe infections. Treatment should be given
they have one. according to CB-IMCI protocol (one dose daily for
14 days).
→→ Zinc should not be given to patients taking RUTF.
→→ Anti-emetics should not be used in OTC.
Box 6. Administration of →→ Do not give cough suppressants.
antibiotics →→ Paracetamol should NOT be given routinely,
due to its toxicity in a malnourished child. For
management of fever, see Annex 13.
OTC treatment should be with oral amoxicillin in →→ Aminophylline should not be used in OTC.
areas where there is not widespread resistance →→ Normal/high dosage metronidazole should not be
to amoxicillin. Where resistance is common, use given. The dosage should be reduced as indicated
alternative antibiotics (see Annex 12). in Annex 12.
→→ Ivermectin must be avoided in any edematous
Procedure child.
Step 1 Do not give routine antibiotics to
children transferred to the OTC from ITC or who
have been transferred from another OTC after
having already received a course of antibiotics.
When in doubt, confirm with the referring facility.

Step 2 Do not give second line antibiotics

in OTC. Children who require second-line
antibiotic treatment or have significant infections
should be treated in ITC. Therefore, there are no
recommendations for second-line antibiotics for
use in outpatient treatment programs.

Step 3 Give the first dose under supervision

and tell the mother that the treatment should
continue for a total of five days. For OTC,
antibiotic syrup is preferred; if it is not available
the tablets should be used and cut in half by the
staff before being given to the caregivers (for
children < 5kg).

40 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
3.3 Nutritional Management

Nutritional rehabilitation in outpatient care is Determine the amount of RUTF required by the
through the use of Ready-to-Use Therapeutic child based on their current weight, as indicated in
Food (Box 7). the RUTF Ration Table in Annex 15. The amount
of RUTF a child should consume is determined
by the need for an intake of 200kcal/kg/day.
The amount given to each patient is therefore
calculated according to their current weight and
Box 7. Ready-to-Use must be adjusted as weight increases during
Therapeutic Food (RUTF) treatment.

RUTF is an energy dense mineral/vitamin

enriched food nutritionally equivalent
to F100, which is recommended by the
WHO for the treatment of severe acute
Remi nder s
malnutrition (see Annex 14 for the technical →→ RUTF is not recommended for treatment of infants
specification and more information on < 6 months. Infants referred for outpatient care
RUTF). RUTF provides a complete diet for are not given RUTF. Their caregivers should receive
the severely acutely malnourished child breastfeeding counseling and supplementary food
with the exact balance of micronutrients if it is available and their condition monitored
and electrolytes they require. It is an oil- (Section 3.5 Management of Infants through
based paste usually made of peanuts, oil, Outpatient Breastfeeding Support).
sugar and milk, with low water activity; thus, →→ If a child is suffering from known peanut allergy or
it is microbiologically safe and can be kept if during appetite, refer to ITC for treatment with
for months in simple packaging. Therefore, therapeutic milk (F75/F100).
with proper hygiene instruction, RUTF can
be safely used at home.

3.4 Orientation to Caregiver

Procedure Step 5 On subsequent visits, additional

counseling may be provided while mothers/
Step 1 Upon admission when giving the RUTF caregivers are waiting for their consultation. This
ration, the health worker should discuss a may focus on:
number of simple key messages on the use of
RUTF, continuation of breastfeeding, the need to »» Particular IYCF topics (Breastfeeding and
feed plenty of drinking water, the importance of Complementary Feeding in particular)
attending the service regularly for monitoring and based on the national IMCI guidelines
additional RUTF and orientation on hygiene and (Annex 3) and IYCF counseling cards
sanitation with the mother/caregiver (see Box 8). particularly for mothers of infants with
SAM referred for outpatient care
Step 2 It is important to give mothers /caregivers »» Hand washing with soap
sufficient time to ask any questions on the »» the importance of growth monitoring of
management process. the child especially once discharged from
OTC
Step 3 It is also important to make sure they are
aware of their local volunteer/health worker and
the support that they can offer for them.

Step 4 In addition, mothers/caregivers who

refused transfer to inpatient care facilities should
be informed that their local volunteer/health
worker (BHW and/or BNS) will be visiting them at
home during the week.

Manual of Operations 41
 Box 8. Key messages for mothers/caregivers

►► Explain how much RUTF to give the child each day (refer to RUTF ration card).
►► If the mother is still breastfeeding, advise her to continue breastfeeding as before and give the RUTF after each
feeding. If not breastfeeding, then always give plenty of safe water with RUTF as it doesn’t contain any itself.
►► The RUTF is all the food a child needs to recover. No other foods should be given until the full ration each day has
been finished.
►► Encourage child to take small amounts of RUTF frequently during the day directly from the packet. Do not mix RUTF
with water.
►► Whenever possible, wash the child’s hands and face before eating and after defecation.
►► RUTF is a medicinal food for thin and swollen children. It should never be shared with other members of the family.
►► If concerned about the child’s condition, tell the mother/caregiver to bring them straight back to the health facility.
For example – if the child has no appetite, is vomiting, has diarrhea, is sick, or has increasing edema – the child
should be taken immediately to the health facility for medical review and advice.
►► Give medicines as advised by the health worker.
►► Attend the health center weekly for monitoring and to receive the next weekly RUTF ration.
►► Return empty RUTF packets to the health center each week.
►► Malnourished children need to be kept warm (ensure child wears plenty of clothes).

Remi nder
Always ask the mother/caregiver if they have any questions and to repeat how s/he will feed the child and give any
medicines at home.

3.5 Management of Infants through Outpatient Breastfeeding Support

For infants younger than 6 months, SAM health center and receive individual counseling
management should focus on support for on breastfeeding promotion using IMCI materials
breastfeeding. These children should be managed (Annex 3) and appropriate IYCF counseling cards
on an outpatient basis unless the infant also in order to improve effective breastfeeding. If,
presents with an IMCI danger sign or complex after individual counseling, the mother does not
feeding complication (see Section 2), in which report improved breast milk intake or if the infant
case they should be referred to ITC. Also, if there fails to gain weight, the child should be referred to
is no possibility of breastfeeding (i.e. no mother inpatient care (see Section 4.4).
or wet nurse) or no human milk via a milk bank is
available, they should be referred to the ITC. Where possible, the support of a trained lactation
counselor needs to be engaged, as well as that
Management of the infant younger than 6 months of a human milk bank (wherever possible and
on an outpatient basis does NOT include use available) to ensure access to breast milk while
of RUTF. The mother should attend the local the feeding problems are addressed.

42 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
3.6 Individual Monitoring, Follow-up and Referral

Caregivers should be encouraged to attend OTC Referral to Inpatient Care

weekly with their child and the child’s progress
monitored and recorded on the patient card by the It is still possible for a child with SAM to develop
BNS/BHW. medical complaints which may not be present
when the child is first admitted to OTC. Any issues
identified during the weekly medical check and
appetite test should be appropriately addressed
through treatment at the health facility (according
Weekly Surveillance to IMCI protocols).

In addition, any child should also be referred to ITC

if they are not responding adequately to treatment
in the OTC. This includes the development and
diagnosis of any of the IMCI danger signs as
The BNS/BHW at each weekly visit should: listed in Table 7 or if any of the following additional
referral criteria are met (see Table 10). See Annex
17 for complete Action protocol for referral.
►► Measure MUAC, weight and check for
edema; check if height/length was
measured on admission day (take the
measurement if not done)
Table 10. Criteria for referral to
►► Check MUAC and WHZ (if appropriate) for inpatient from outpatient treatment
discharge criteria during follow-up

►► Take body temperature CRITERIA FOR

FACTOR REFERRAL TO
►► Do the appetite test either routinely for all INPATIENT CARE
children or whenever there has been a poor Increase of or
weight gain Edema
development of edema

►► Ask about the progress of the child, No appetite or unable

including IMCI danger signs to eat RUTF (3 - 4
Appetite
mouthfuls/failed appetite
►► Examine the child test)

►► For infants < 6 months old, ask Deterioration in medical

about breastfeeding practice and any Medical condition to develop any
improvement in milk production complications of the IMCI danger signs
as listed in Table 7
►► Give routine treatment at the appropriate Weight loss for 3
visits (if a visit is missed, give at the next Care when and consecutive weighings
visit) where it is needed Static weight for 5
consecutive weighings
►► Complete the OTC chart (Annex 16)
Reported breast-
►► Make any necessary referrals (see below) No improvement after
feeding issues (in-
1 week and continued
fants < 6 months
►► Recalculate the weekly RUTF ration weight loss of infant
only)
according to current weight and provide
the ration Other general signs as
identified by the health
General
worker that warrants
referral (as per IMCI)

Manual of Operations 43
 If referral is required: direct admission to the ITC ward. The patient’s
admission should not be processed through
Step 1 Write on the chart of the patient the the emergency department. This mechanism
reason for transfer. allowing for direct admission to the ward should
be institutionalized and practiced in the ITCs
Step 2 Complete the referral form which should whenever a patient arrives with a transfer form
contain all details of the child’s condition, the from an OTC.
summary of the treatments given and the patient
number (See Annex 10 for form). Step 5 Note: When the patient returns to the
OTC, similar contact should be made to avoid
Step 3 Give the referral form to the patient to losing the patient during the transfer.
take with them to the ITC.
Step 6 Take any steps to avoid transport trauma
Step 4 Call the relevant ITC supervisor to inform (see Box 5 above).
them about the transfer. They should facilitate

Referral for Further

Clinical or Social Referral for
Assessment Follow-up at Home

In some cases where children are not Follow-up through home visit should be
responding to treatment (loss or static weight triggered for:
for two weeks), chronic conditions may be
suspected and in this case, children should
be referred for further investigations in the ►► Children with medical complications who
hospital or appropriate site. This can include: have refused transfer to inpatient care
and are being treated on an outpatient
►► Referral for TB testing, counseling and basis
treatment (refer to the Municipal/City ►► Cases who are not responding in the
Health Officer) program (loss or static weight for
►► Referral for screening and assessment of two weeks) and aspects of the home
congenital abnormalities (e.g. congenital environment are suspected to be playing
heart defects, cerebral palsy, etc.) a role rather than medical issues
►► Referral for HIV counseling and testing ►► Repeated absences from treatment
►► Referral for assessment of family ►► Infants < 6 months of age not gaining
functioning and capacity for care (refer weight despite visits
to the Municipal Social Welfare Worker/ ►► See Section 1.4 for details on follow-up
Officer) visits

44 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
3.7 Discharge

Criteria for Discharge Cured

Discharge the patients when they reach the discharge criteria shown in Table 11.

Table 11. Discharge criteria from OTC

PATIENT GROUP DISCHARGE CURED CRITERIA

MUAC ≥ 125mm (12.5cm) for 2

consecutive visits
Admitted on MUAC, edema,
AND
or both MUAC and WFH/WFL
No edema for 14 days
Z-scores
AND
Clinically well
Children 6 - 59 months
WFH or WFL ≥ -2 Z-scores for two
consecutive visits
Admitted on WFH/WFL AND
Z-scores only No edema for 14 days
AND
Clinically well
Breastfeeding effectively
AND
has adequate weight gain (5g/kg/d)
AND
Infants < 6 months WFL ≥ -2 Z-scores for 2 consecutive
visits (where capacity exists to measure)

OR
Reaches 6 months of age 21

Discharge Procedure Step 5 The mother/caregiver should receive

counseling on IYCF practices, care practices,
Step 1 Explain to the mother/caregiver that the hygiene, feeding practices, food preparation
child has recovered sufficiently for discharging, for children, and so on, in line with standard
and congratulate them. IYCF counseling. If enrolled in the 4Ps program,
please ensure attendance in the Family
Step 2 If the child has reached 9 months of age Development Sessions.
during treatment in OTC and has not yet received
vaccination against measles, the mother/ Step 6 All the patients should be discharged to
caregiver should follow up at the BHS or RHU to the SFP for continued nutritional rehabilitation
ensure their child receives the vaccination. where this is available.

Step 3 Children admitted at age 6 to 8 months Step 7 Caregivers should be linked with any
should get a follow-up appointment for the other appropriate services for which they
second measles vaccination (booster) after one are eligible and which support the on-going
month. rehabilitation of the child (see Section 3.8).

Step 4 All children will get a last ration for seven Step 8 Fill in the patient record in the register
sachets of RUTF (one sachet each day for one with the discharge details (see Section 11.3
week) to aid the transition onto local and in below)
some cases, supplementary foods where SFP is
available.

21 At this point MUAC should be taken to assess whether the infant qualifies for enrolment in OTC as a child and to receive RUTF.

Manual of Operations 45
 Outpatient Therapeutic
Care

Recording the Outcome of Treatment

Register the patients discharged in the registration book and chart

according to the following possibilities:

CURED Discharge as non-

The patient has cured
D

S
reached the criteria for The patient does not
discharge cured. reach the discharge
criteria within four
DEAD months and all
xx The patient died during referral and follow-up
treatment in the OTC
|

options have been

or in transit to the ITC. tried (e.g. home
visit conducted and
DEFAULTER household situation
The patient has not assessed), they may
returned for three be discharged as
|

consecutive visits and non-cured. In these

a home visit, neighbor, cases, ensure that the
village volunteer, or child is referred for
other reliable source assessment of possible
confirms that the medical complications
patient is not dead. if not yet done (e.g.
TB) and linked with the
MAM program where
possible and to social
support systems (see
Section 3.8).

3.8 Managing Links

The child being treated for (severe) acute ►► Enrolment in a growth monitoring program
malnutrition has usually suffered some Operation Timbang Plus (if not yet enrolled).
combination of nutritional deficit and/or infection ►► Referral to a food security program.
and often may come from the poorest families in ►► Provide list of social welfare services
the community. In order to continue healthy growth available and referral to any relevant
and prevent relapse, follow-up care should be programs such as Sustainable Livelihood
sought. Depending on services available locally, and Pantawid Pamilyang Pilipino Programs
the following should be considered: (if eligible), Kapit-Bisig Laban sa Kahirapan-
Comprehensive and Integrated Delivery of
►► Referral to SFP (if available) or other Social Services (KALAHI -CIDSS) and Self-
supplementary feeding program. Employment Assistance-Kaunlaran (SEA-K)
►► On-going IYCF/nutrition counseling (e.g. Program).
IYCF Peer counseling, Family Development ►► Ensure enrolment and coverage of the
Sessions, Pabasa sa Nutrisyon). child and mother22 in PhilHealth. If family
►► Referral to Mother support groups, Promotion is indigent, coordinate enrolment in the
of Good Nutrition, MNP supplementation of PhilHealth indigent program with the Municipal
Complementary Feeding. or City Health Office. Ask the mother or
caregiver to show you the PhilHealth card or
to give you the PhilHealth number.

22 Mother and child are covered as dependents if the father is enrolled. Make sure enrollment status of both parents are established.

46 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
 4. INPATIENT THERAPEUTIC CARE (ITC)

Inpatient care for children with SAM is provided ►► Provide complete nutritional rehabilitation in
in order to: inpatient care for children with SAM where
there is no access to OTC.
►► Stabilize children with SAM aged 6 to 59 ►► Children in outpatient care may also be
months who also have medical complications referred to inpatient care for a period of more
or a lack of demonstrated appetite sufficiently intensive treatment/monitoring when they are
to allow them to continue their nutritional not responding appropriately to treatment as
rehabilitation with OTC. an outpatient.
►► Recover infants < 6 months with SAM who
require intensive treatment.

Box 9. Principles of treatment of

complicated SAM in ITC

Because of the changes in metabolic and be apparent, because the body does not use its
physiological responses in children with complicated limited energy to respond in the usual ways, such
SAM, they often do not present with typical clinical as inflammation or fever. Examples of common
signs of infection that well-nourished children show infections in the severely malnourished child are ear
when they are ill, such as fever. Moreover, they do infection, urinary tract infection, and pneumonia. In
not respond to medical treatment in the same a child with severe acute malnutrition we assume
way as if they were well nourished. Therapeutic that infection is present and treatment is given on
decisions that are life-saving in a well-nourished admission with broad spectrum antibiotics. Specific
child can be potentially fatal for the malnourished infections and medical condition are identified
child. Treatment protocols for children with SAM for (such as Shigella) and treated accordingly.
some medical complications, such as dehydration
or shock, differ from the classical treatment Great care should be exercised in prescribing drugs
protocols for ill children without SAM. Misdiagnosis to children with severe acute malnutrition because
of medical complications, inappropriate treatment, they will have abnormal physiological responses
and feeding of children with SAM contributes to such as abnormal kidney and liver function; changed
slow convalescence and increased risk of death. levels of enzymes that metabolise and excrete drugs;
excess entero-hepatic circulation (reabsorption) of
Successful management of SAM in children with drugs that are excreted in the bile; decreased body
complications aims to restore the metabolism fat hence increasing the concentration of fat-soluble
through correction of electrolyte balance, reversal drugs; and, in kwashiorkor, a possible defective
of metabolic abnormalities, restoring the organ blood-brain barrier. Few drugs have been examined
functions and provision of nutrients for catch-up of for pharmacokinetics, metabolism or side effects
growth, and treats underlying infections and other in persons with severe acute malnutrition. For
medical conditions as diagnosed. As the child is instance, a common drug, such as Paracetamol can
treated, the body’s systems must gradually learn to cause serious hepatic damage.
function fully again. Rapid changes (such as rapid
feeding or fluids) would overwhelm the systems, so
feeding must be slowly and cautiously increased.
Nearly all children with SAM have bacterial
infections. However, as a result of reductive
adaptation, the usual signs of infection may not

Manual of Operations 47
 Figure 4. Flow of activities in ITC

• anthropometric measurements and edema check

• triage of emergency cases
1 Admission • history, medical examination, and appetite test
• referal to OTC where required
• recording

• emergency medical management

• routine mediciness & additional medicines
• F75
Phase 1
2 • orientation to caregiver
Treatment • monitoring of feeds
• every 12 hrs and daily medical and anthropometric monitoring
• recording and assessment of readiness for transition
• transition to RUTF
• continue medical treatments
• monitoring of feeds
3 Transition • every 12 hrs and daily medical and anthropometric monitoring
• recording
• assessment of readiness for OTC/Phase 2
• orientation to caregiver
Discharge
4a • RUTF till next OTC distribution
to OTC • referral documentation and communication with OTC
• rehabilitation with RUTF (or F100)
• daily monitoring
4b Phase 2
• health and nutrition education
in ITC • recording
• assessment of readiness for discharge
• orientation to caregiver
Discharge
5 • recording
from ITC • links to other services

Inpatient care for children with SAM aged 6 Transition Phase: This phase marks the transition
to 59 months therefore focuses primarily on from stabilization to OTC where these facilities exist
the nutritional and medical stabilization of the (where OTC facilities are not available, the patient
child and appropriate management of medical proceeds to Phase 2 instead as below). Clinically,
complications. It occurs in three distinct phases, the return of appetite and/or the improvement of
as described below. Children younger than 6 clinical signs and symptoms related to the medical
months are treated using specific protocols for complication indicate entry into this phase (details
this age group, which are described in detail in below). In this phase, the diet is changed or
Section 4.4. transitioned from F75 to RUTF (or to therapeutic
milk F100 for Phase 2 inpatient care). The amount
Phase 1/Stabilization: Patients with an of protein, energy and micronutrients is increased.
inadequate appetite and/or an acute major This increase in energy is possible because of the
medical complication are initially admitted for restoration of physiological systems which are
to Phase 1 for stabilization treatment. During indicated by the return of appetite, the reduction of
this phase, the therapeutic milk F75 is used to edema and the improvement in the clinical status
stabilize and reverse physiological and metabolic of the child. Wasted children now start to gain
abnormalities and correct electrolyte imbalances. weight, while children with edema may continue
There is no expectation for wasted children to gain to lose weight until the edema is resolved. Once
weight during Phase 1. Edema cases should start the child is taking the prescribed amount of RUTF
to lose weight in this phase as the edema starts to and complications are adequately resolved, they
resolve (this should not be misinterpreted as poor are referred to OTC to continue their treatment at
treatment progress). home.

48 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
Phase 2: Where it is not possible to refer to OTC, infection and mortality. A prolonged hospital stay
children remain as inpatients until cured of acute may be disruptive to the whole family, especially
malnutrition. This phase continues treatment with for families with many children. While recovery
F100 therapeutic milk or RUTF, increasing the may be slower in the community setting, it is the
intake so as to promote rapid weight gain. The child preferred option where outpatient services exist.
remains under treatment until the anthropometric The child should be transferred from inpatient
criteria for discharge are reached. care to outpatient care as soon as possible during
recovery.
It is important to note that the hospital environment
places children under care at risk of nosocomial

4.1 Assessment and Admission

Admission criteria are summarized in Annex 9. For SAM cases assessed not to have
In the ITC setting, referrals from the BHSs and emergency care requirements:
RHUs of children assessed to have both SAM and
medical complications are received (e.g. SAM Conduct IMCI medical check.
children who fail the Appetite Test). However, Check medical history.
a considerable number of children will be Conduct the Appetite test (see Section 2.2).
brought straight to the hospital by their parent or Take weight for calculation of medical and
caregiver for a different complaint (e.g. diarrhea, nutritional treatment and to set the baseline
convulsions, decreasing level of consciousness) for weight monitoring during treatment.
without being previously diagnosed with SAM. Initiate feeding with F75 or refer to OTC if
This is especially true for larger hospitals with an there are no medical complications and good
emergency room and outpatient department. appetite is demonstrated (see Section 2).
Record all information on the patient record
For inpatient care, initial steps of assessment and ITC chart (Annex 27).
should focus primarily on rapid identification
of SAM with complications and on initiation of For cases already under treatment for SAM
treatment. In the inpatient facility, emergency (transfer from other OTC or ITC facility):
treatment for any life-threatening complications
(see Section 4.2 below) should be prioritized once Step 1 Review and record any relevant
SAM has been diagnosed. Once initial emergency information from referral document where there
care has been provided to those cases needing is one.
it, further anthropometry and the appetite test
can be conducted (as detailed in Section 2 and Step 2 Continue with same registration number.
summarized below).
Step 3 Conduct assessments as above to check
Prioritization of activities in ITC: information on referral document and identify any
additional issues which may have arisen during
1st Identify SAM (MUAC & Edema). the transfer.

2nd Triage emergency cases and provide Step 4 Record all information on the patient’s
emergency care if required (see Section 4.2). chart.

3rd Take weight for calculation of medical and

nutritional treatment and to set the baseline for
weight monitoring during treatment.23

4th Give first line antibiotics (Annex 18).

5th Initiate feeding with F75 (Annex 28).

6th Complete assessment and record on the

patient record and ITC chart (Annex 27).

23 The medical and nutritional treatment prescribed by the doctor is dependent on very accurate weighing. Children should be weighed naked.
Providing privacy for weighing facilitates this. Where privacy is not possible a very light undergarment may be worn. Inaccurate weighing may lead to
incorrect treatment and may have very serious consequences for the child. For children 6 – 59 months the accuracy of the scale must be to the nearest
100g.

Manual of Operations 49
 4.2 Medical Management

Emergency Treatment

►► Assess the child’s airway, breathing and

circulation and administer life-saving Remi nder s
interventions according to Pediatric Advanced →→ Vitamin A supplementation is not routinely
Life Support (PALS) protocols. indicated where commercially prepared F75/
►► Immediately treat life threatening F100 or RUTF are provided for treatment.
complications according to Annexes:24 In these preparations, vitamin A is already
»» Annex 19 - Treat/prevent hypoglycemia present in therapeutic amounts. Vitamin A
»» Annex 20 - Treat/prevent hypothermia supplementation should be given on admission
»» Annex 21 - Treatment for dehydration and when other preparations are used without
hypovolemic shock adequate vitamin A content (e.g. preparations
»» Annex 22 - Hypernatremic dehydration based on prescribed recipe but without CMV) or
»» Annex 23 - Treatment of septic shock where symptoms of Vitamin A deficiency25 are
»» Annex 24 - Treatment of severe anemia noted.
»» Annex 25 - Heart failure →→ Folic acid is present in adequate amounts in
»» Annex 26 - Absent bowel sounds, gastric therapeutic milks and RUTF to treat mild anemia.
dilation and intestinal splash If moderate anemia is diagnosed then give
a stat dose of 5mg on admission. There is no
Routine Medicines in Phase 1/ requirement for daily doses. For severe anemia
Stabilization see Annex 24.
→→ Antihelminthics are absorbed through the gut
►► Give first line antibiotics according to age/ and the active metabolite generated in the liver.
weight (if not already given). The type of Early in treatment, poor absorption in the gut
antibiotic given in Phase 1 primarily depends and poor liver function may render the drug
on whether the child presents to the inpatient ineffective.
unit with or without identified medical →→ Zinc is present in F75 and F100 therapeutic
complications. Oral antibiotics should be given milks and in RUTF. Episodes of diarrhea should
for uncomplicated cases and IM/IV antibiotics be treated with antibiotics and ReSoMal if
for children with complications. indicated by the presence of dehydration.
►► Give other routine medications according to If commercially prepared F75/F100/RUTF is
Annex 18. not available, then zinc should be used in the
management of diarrhea.
Routine Medicines in Phase 2 →→ Iron increases the risk of mortality in children
with SAM through the increased risk of infection
Deworming/antihelminthic treatment is given and sepsis. Iron is given only in Phase 2, where
in Phase 2 (day 7) for children who remain as it is added to the therapeutic milk (see Phase
inpatients (table 12). 2 care). Iron tablets do not need to be given to
children receiving RUTF as iron is already present
Additional Medicines in Phase 1 in RUTF in adequate amounts.
and 2

Other medicines are to be given in Phase 1 and

2 (e.g. for fungal infection such as candidiasis)
depending on presenting symptoms and according
to current recommendations for treatment of the
sick child.

Table 12. Deworming in Phase 2

Medication Age Dose Prescription

12 - 23 months 250mg Single dose on day 7
Mebendazole
≥ 24 months 500mg Single dose on day 7

24 The medical/fluid management of children with SAM is different from normally nourished children. Modified protocols should be applied according
to Annexes on the treatment of complications.
25 Micronutrient Supplementation Manual of Operations (2011)

50 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
4.3 Nutritional Management of Children 6 - 59 Months

►► For new admissions to ITC, use F75 for

Phase 1 nutritional management.
►► For admissions coming from OTC who are
already demonstrating appetite, RUTF can be
used and Phase 2 entered directly.
►► For infants < 6 months old see Section 4.4.

Phase 1/Stabilization

DIET
The diet used for children aged 6 - 59 months in
stabilization is F75 therapeutic milk26 (see Box
10). Box 10. F75
Step 1 Calculate the quantity of F75 to be
administered. The energy requirement of F75 is a low protein formulation (high protein at this
the child in Phase 1 is 100kcal/kg/day. This stage increases the risk of death) containing the right
translates to 130mL of F75 milk/kg/day. The F75 balance of macro and micronutrients to stabilize the
is therefore given according to the weight of the child’s condition. F75 provides 75kcal/100mL and
child (see Annex 28). Check manual calculations allows micronutrient deficiencies to be corrected and the
of milk requirement against the tables for abnormal pathophysiology of the child to be restored.
accuracy. The F75 already contains all of the micronutrients
required for stabilization. There is no need for additional
Step 2 Prepare F75 (see Annex 28 for F75 micronutrient supplementation. F75 is also a low-lactose
preparation), alternate F75 recipe (Annex 29) or feed.
F100 diluted (Annex 30) as a temporary measure
(administering the same volumes as given for It is possible to make F75 at the health facility if the pre-
F75 in Annex 28.27 packed F75 preparation is not available. In this case, the
recipe should follow one of the recommended recipes
Step 3 The milk should be given in divided provided in Annex 29. It is essential to add combined
feeds ideally every two to three hours in Phase mineral and vitamin mix (CMV) in order to provide the
1 depending on the condition of the child (8 - 12 micronutrients essential to recovery. F100 diluted (see
feeds per day, see Annex 28 for volumes of milk Annex 30) can also be used as a TEMPORARY substitute
to be administered according to number of feeds in an emergency if supplies are not available.
per day and Box 11 for varying feeds).
Commercial milk formula is not a suitable substitute. If
Step 4 Pre-prepared feeds may be used the caregiver brings commercial milk formula with them
overnight, but only where functional refrigeration to the hospital, they must be strongly advised NOT to use
units are available for storage following the commercial milk formula for the child.
preparation. The milk should be warmed before
use by placing the milk in a bowl of hand-hot
water for 5 - 10 minutes. Milk should not be
reheated by direct heat or microwave. Unused Figure 5. Samples of F75
refrigerated milk should be disposed of after 12
hours.

Step 5 If clinical assessment is delayed for

any reason, give 10% sugar water (10g or 1
tablespoon of sugar in 100mL of water) if the
child is able to take oral fluids in order to prevent
hypoglycemia. Fruit juice may be given if no
sugar water is available.

26 Other commercial milk formulas are NOT formulated for management of acute malnutrition and must not be used for this purpose.
27 When F75 is not available, F100 can be diluted to make a TEMPORARY alternative to F75. This is an emergency measure only and is not
acceptable as a standard replacement to F75.

Manual of Operations 51
 Box 11. Variation in number of feeds

Reducing the number of feeds per day is not ideal since sick children are often unable to drink large volumes of milk.
When the number of feeds is reduced, the volume of each feed is increased. However, if for any reason the frequency of
feeds (particularly during the evening or night shift) cannot be guaranteed (e.g. due to staff shortages), the volume of milk
given must be recalculated, as it is preferable to feed the child the required amount of milk for the day over fewer feeds (to
minimize the risk of hypoglycemia).

Remi nder s
→→ The reduced number of feeds should be a temporary measure only while issues of staffing and so on are addressed. It
should not be adopted as standard practice.
→→ Six to eight feeds per day is the minimum.
→→ The time between the last feed of the previous day and the first of the following day should be minimized as much as
possible (maximum of eight hours).
→→ It is essential that the prescription of milk is adjusted according to how many feeds can realistically be given per day.

Figure 6. Correct feeding technique

Feeding Method

►► Feeding should be done orally by cup and saucer

unless a particular need for Nasogastric Tube (NGT)
feeding is identified (Box 12).
►► Breastfed children aged 6 - 59 months should always
be offered breast milk before the diet and the milk
should always be given on demand.
►► Children with SAM have weak muscles and swallow
slowly. This makes them prone to develop aspiration
pneumonia. Appropriate feeding techniques are
therefore important (see Box 13 and Figure 6.)

©WHO/1997
http://survivalistbooks.com

Box 12. Indications for using Nasogastric tube (NGT)

An NGT of the appropriate size should be used if the child:

►► Is unable to consume at least 75% of the milk provided (the ITC chart is designed to monitor percentage of each
feeding consumed)
►► Has pneumonia (rapid respiration rate) and difficulties swallowing
►► Has painful lesions of the mouth
►► Has cleft palate or other physical deformity
►► Shows disturbed level of consciousness

The use of an NGT should not exceed three days and should only be used in Phase 1/Stabilization.

52 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
 Box 13. Appropriate feeding technique

►► The child should ideally be sat upright on the caregiver’s lap against his/her chest, with one arm behind his/her
back.
►► The caregiver’s arm should encircle the child and hold a saucer under the child’s chin (see Figure 6).
►► Any dribble that falls into the saucer is returned to the cup.
►► The child should never be force-fed, have his/her nose pinched, or laid back and have the milk poured into the
mouth (even with a spoon).
►► Never give more therapeutic milk than what is prescribed for the child in Phase 1, even if the child cries for more
food. The child may continue to breastfeed on demand.
►► Meal times should be sociable. The assistant should encourage the caregivers, talk to them, correct any faulty
feeding technique and observe how the child takes the milk.
►► The meals for the caregivers should not be taken beside the patient. It is almost impossible to stop the child
demanding some of the caregiver’s meal. Sharing of the caregiver’s meal with the child can be dangerous for the
child during Phase 1.

Transition Phase Procedure

Transition Phase normally takes one to three Step 1 Prepare indicated dose of RUTF, the
days but may take longer. It signals a change appropriate quantity of F75 for the child and a
in the nutritional management of the child. The glass of drinking water.
amount of energy provided in Transition Phase
is increased by 30% (to 130kcal/kg/day) and the Step 2 The caregiver should be instructed to
amount of protein is increased. wash their hands and the child’s hands and face.

Transition Phase is entered once: Step 3 Ask the caregiver to offer the child the
RUTF (refer to description of how to administer
►► Medical complications are resolving RUTF during the appetite test – Section 2.2).
►► Appetite returns
►► Edema is reducing Step 4 Observe the child eating the RUTF.

Transition may be divided into two distinct Step 5 After each mouthful, breast milk or a sip
management approaches: of water should be offered to the child.29

1. Transition to outpatient care for SAM where it Step 6 If the child fails to eat the required
is available amount of RUTF at each feed, the child should
2. Transition to Phase 2 inpatient care where finish the feed by being offered the ration of F75
outpatient care for SAM is not available to drink in addition to any RUTF that has been
eaten. The time taken to eat the RUTF and F75
TRANSITION TO RUTF IN PREPARATION FOR (if necessary) should be no more than 1 hour.
OUTPATIENT CARE
Step 7 Record the amount of both F75 and
The aim is to prepare the SAM child for nutritional RUTF taken on the patient’s treatment chart.
rehabilitation in outpatient care (i.e. to eat
sufficient RUTF to gain weight and recover) while Step 8 After each feed, the RUTF should be
ensuring they get all the nutritional requirements placed in a cool dry place, safe from insects and
they currently need. This is done by gradually re-used at the next scheduled feeding time.
introducing and increasing the proportion of the
daily feeding provided by RUTF (see Annex 31 for Step 9 The process of offering both RUTF and
detailed procedure). F75 continues until the child is able to take the
required amount for 24 hours (see below).

28 Availability in this sense primarily means that outpatient care must be available AND accessible to the caregiver following discharge from the
hospital.
29 RUTF is a thick paste and plenty of clean drinking water should be available for the child to drink. Older children can ask for water when they are
thirsty but young children must be offered the water regularly when taking RUTF. A thirsty child may refuse RUTF which may be mistaken for poor
appetite. Children over 6 months but with developmental delay in the motor skills associated with chewing food may have some difficulty manipulating
the thick paste in the mouth – sips of water will help.

Manual of Operations 53
 type of milk changes. The child should continue
to be breastfed on demand. The amount of F100
milk to be given in Transition Phase is indicated
Remi nder s in Annex 32. As above, this transition onto a
higher calorie diet can take one to three days.
The child should be monitored closely during this
→→ Prepare indicated dose of RUTF, the appropriate time (see Section 4.6). When at least 90% of the
quantity of F75 for the child and a glass of prescribed F100 ration is being taken orally and
drinking water. no other issues are identified during monitoring
→→ The caregiver should be instructed to wash (see Section 4.6), the child is considered ready to
their hands and the child’s hands and face. continue their rehabilitation in Phase 2.
→→ Ask the caregiver to offer the child the RUTF
(refer to description of how to administer RUTF Phase 2
during the appetite test – Section 2.2).
→→ Observe the child eating the RUTF. Average duration: 2 - 3 weeks
→→ After each mouthful, breast milk or a sip of
water should be offered to the child.30 DIET
→→ If the child fails to eat the required amount of
RUTF at each feed, the child should finish the In Phase 2, the energy and protein intake of the
feed by being offered the ration of F75 to drink child is increased to 200kcal/kg/day, giving F100
in addition to any RUTF that has been eaten. therapeutic milk. During Phase 2, iron is added
The time taken to eat the RUTF and F75 (if to the therapeutic milk. The amount of iron to be
necessary) should be no more than 1 hour. added is as follows:
→→ Record the amount of both F75 and RUTF taken
on the patient’s treatment chart ►► 200mg Ferrous Sulfate (1 tablet) in 2 liters
→→ After each feed, the RUTF should be placed in a therapeutic milk
cool dry place, safe from insects and re-used at ►► 100mg Ferrous Sulfate (1/2 tablet) in 1 liter
the next scheduled feeding time therapeutic milk
→→ The process of offering both RUTF and F75 ►► If smaller quantities of milk are being given,
continues until the child is able to take the crush 100mg (1/2 iron tablet) and mix
required amount for 24 hours (see below). thoroughly in 10mL of water (ensure the tablet
is well crushed and leaves no sediment).
►► Add 10mg Ferrous Sulfate (1mL of 10mL Iron
solution) in each 100mL of therapeutic milk
This change to RUTF normally takes one to
three days, but may take longer. The child must Annex 33 gives the volume of F100 therapeutic
be closely monitored at this time (see Section milk to be given in Phase 2. Feeds should be
4.6). When at least 75% of the full OTC daily given at least five times per day. The table gives
amount of RUTF (see Annex 39) is eaten within milk volumes depending on whether five or six
24 hours and there are no other issues identified feeds per day are given.
during monitoring (see Section 4.6), the child
is considered to be ready to continue their RESPONSIVE FEEDING AND EMOTIONAL
rehabilitation at home through the OTC. The child STIMULATION
may then be discharged from the ITC facility (e.g.
hospital) and referred to the OTC nearest to their In addition to nutritional management in Phase
home (or the referring OTC if previously enrolled). 2, as the child is continuing their treatment in an
institutional environment, it is important to also
TRANSITION TO PHASE 2 USING F100 support play and emotional stimulation as an aid
to psychological recovery. This should be done by:
When there is no outpatient treatment available,
the child must be treated and cured of SAM ►► Encouraging the caregiver to talk to the child
entirely within the inpatient care setting. For with good eye contact during feeding.
children remaining in inpatient care, the energy ►► Providing a brightly colored ward environment.
requirement of 130kcal/kg/day is given in the ►► Providing toys suitable for children of various
form of F100 therapeutic milk. F100 contains ages (see Annex 34).
100kcal/100mL of milk. This means that when the
milk is changed from F75 to F100 in Transition
Phase, the volume of milk the child has been
receiving in Phase 1 remains the same; only the

30 RUTF is a thick paste and plenty of clean drinking water should be available for the child to drink. Older children can ask for water when they are
thirsty but young children must be offered the water regularly when taking RUTF. A thirsty child may refuse RUTF which may be mistaken for poor
appetite. Children over 6 months but with developmental delay in the motor skills associated with chewing food may have some difficulty manipulating
the thick paste in the mouth – sips of water will help.

54 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
4.4 Nutritional Management of Infants < 6 Months

Assessment and admission procedures should be

the same as for older children with the addition
(as noted in Section 2) of an assessment of the Box 14. Commercial milk
breastfeeding practice. This age group is also formulas
given the same general medical care as older
children in general, though some of the medical
treatments are omitted (see Annex 20).

Infants younger than 6 months who are admitted

as inpatients require nutrition protocols different
from older children. This is because these infants
have an immature physiology and feeding them
the wrong diet may result in renal solute overload.
Commercial milk formulas can be dangerous. They can
When an infant becomes malnourished, it is expose the child to a higher risk of death when strict
usually preferable to attempt to improve the criteria are not adhered to. Staff should endeavour to:
breastfeeding practices or to re-establish them if
they have been discontinued. Inpatient staff should ►► Control and prevent the use of commercial infant
try to encourage and re-establish breastfeeding formulas while in inpatient care.
where this is a possibility. Where human milk ►► Indicate to the mother that therapeutic milk is
banks31 are accessible, it should be considered as different and is a ‘medical milk.’
an interim source of breast milk while re-lactation ►► Ask caregivers to drink and finish any commercial
interventions are ongoing as described below. milk formula they are carrying on admission
themselves so the infant can be appropriately
Infants younger than 6 months admitted to managed only with therapeutic milk.
inpatient care may be treated and discharged ►► Give support to caregivers who will need to use
according to two separate and distinct protocols. commercial milk formulas after discharge (no
It is important to ensure that the infant follows possibility of breastfeeding or re-establishing
the correct treatment plan and is discharged breastfeeding has proven unsuccessful). Refer
according to the correct criteria. them to support available nearer their home to
help ensure they can do so safely.
The two options for treatment are: ►► Abide by the national milk marketing code
(Executive Order 51) and avoid promoting the
1. Children who are currently breastfeeding or use of commercial infant formulas.
will be breastfed on discharge
2. Children who will not be breastfed on
discharge
Management of the Infant with
Re-establishing effective breastfeeding requires Breastfeeding Possibility
skilled and patient counseling by trained providers
(e.g. lactation nurses, lactation counselors, peer For these infants, there are no separate ‘phases’
support groups). It also requires adherence to of treatment. The amount of therapeutic milk the
and compliance with the principles and rules child receives decreases during treatment as the
in Philippine breastfeeding legislation.32 In the intake of breast milk improves while maintaining
hospital setting, compliance with the standards good progress in weight gain. Where mothers are
set by the Mother-Baby-Friendly Hospital Initiative not able to breastfeed successfully, the next best
(MBFHI) particularly with respect to the use of option is to encourage ‘wet nursing’ by a female
commercial milk formulas, should be ensured member of the family.34 The aim of treatment is
especially for MBFHI-accredited facilities33 (see to stimulate breastfeeding and to supplement
Box 14). the child’s diet with Diluted F100 therapeutic milk
until breast milk is sufficient for allowing the child
to grow properly. The Supplemental Suckling
Technique (SST) is usually used to achieve this
(see Box 15), but should be complemented by
other responsive infant feeding and care practices
(Annex 3).
31 The Philippine Human Milk Banking Manual of Operations (2010)
32 Executive Order 51 and its Revised Implementing Rules and Regulations and RA 10028
33 Administrative Order 2007-0026: Revitalisation of the MBFHI in Health Facilities with Maternity Services. Department of Health. Philippines. July
10, 2007
34 It is possible for the grandmother or other female relative to re-establish breastfeeding with support and nurse the child until they reach 6 months of
age. The mother or ‘wet nurse’ should always be encouraged to continue breastfeeding at least until the child reaches 2 years of age.

Manual of Operations 55
 Box 15. Supplemental Suckling
Technique (SST)
SST has proven to be an effective method in re-establishing
adequate breastfeeding (see Annex 35 for detail on the
technique). However, it takes some skill and patience
on behalf of the staff and the mother. When done well,
it can stimulate breast milk output, so it is important
to put the child to the breast as often as possible. As
breastfeeding improves and the child gains weight, the
amount of therapeutic milk is gradually reduced and
then discontinued. The infant is then discharged when
gaining weight on breast milk alone.
© Save the Children Philippines/2011

Procedure Step 4 Give counseling and support for any

issues identified during monitoring in relation to
Step 1 Encourage the mother/wet-nurse to attachment and feeding of the infant (see Annex
breastfeed on demand or offer breastfeeding 3).
every three hours until they feel that their breast
has been emptied by the child, without frequent Step 5 If the supplemental suckling technique
switching and more often if the child seems to is problematic, mothers can be supported to
want more. The infant should be breastfed as express their milk by hand either directly into
frequently as possible. The mother may assist the infant’s mouth or give it via cup feeding (see
the infant by expressing breast milk directly into Annex 37). Caution should be used in the feeding
the child’s mouth if the child is unable to empty technique and the positioning of the infant for cup
the breast fully.35 feeding in order to avoid possible aspiration.

Step 2 Between 30 minutes to one hour after a Step 6 Once the infant is gaining weight at 20g
normal breastfeeding session, give maintenance per day (absolute weight gain):
amounts of therapeutic milk using the »» Gradually decrease the quantity of F100-
Supplemental Suckling Technique (see Annex Diluted by one-third of the maintenance
35). intake so that the infant gets more breast
»» Provide F100-Diluted for infants with milk.
severe wasting at 130mL/kg bodyweight/ »» If the weight gain of 10g per day is
day, distributed across eight feeds per maintained for two to three days (after
day. F100-Diluted has a lower osmolality gradual decrease of F100-Diluted), stop
than F75 and thus is better adapted F100-Diluted completely.
to immature organ functions. Also, »» If the weight gain is not maintained,
the dilution allows for providing more increase the amount of F100-Diluted
water for the same energy with a better given to 75% of the maintenance amount
carbohydrate to lipid ratio.36 (see Annex for two to three days, then reduce it again
36 for preparation and quantities) if weight gain is maintained.
»» Provide F75 for infants with bilateral
pitting edema and change to F100-Diluted
when the edema is resolved (use the Figure 7. Samples of F100
same quantities as shown in Annex 36).

Step 3 If space is available, infants should

be nursed at a separate space from the
older malnourished children. This can be a
“breastfeeding corner.” This area may be useful
to bring breastfeeding mothers together for
mutual support and counseling by staff.

35 Infant & Young Child Feeding: Model Chapter for Textbooks for Medical Students and Allied Health Professionals. Geneva: World Health
Organization; 2009 ISBN-13: 978-92-4-159749-4
36 Note: F100-Diluted has a lower osmolality than some readily-available infant formulae and thus has a lower risk of causing diarrhoea.

56 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
Management of the Infant with No Procedure
Breastfeeding Possibility
Step 1 Prepare and administer diluted F100
For children with no prospects of being breastfed, according to the infant’s weight (see Annex 38).
in some cases it may be possible to utilize
regional milk banks.37 Where donor milk from a Step 2 The criteria for children to pass from
bank is not available, the infant must be treated Phase 1 to Transition Phase and from Transition
using therapeutic milk. For these infants there are Phase to Phase 2 are mostly the same as for
distinct phases of treatment, as for older children older children aged 6 to 59 months old (Section
using modified criteria for each phase. The amount 4.3 Nutritional Management of Children 6 - 59
of therapeutic milk the child receives increases in Months). However, if the infant is admitted with
each phase. The major difference for infants is the edema, all of the edema must have resolved
use of Diluted F100 during all three phases unless before progressing to Phase 2.
the infant is admitted with edema in which case
F75 is used until the edema has resolved. Step 3 If a child younger than 6 months is on
discharge, then the child must continue on
formula milk until the age of 6 months, when
complementary feeding is introduced. This is the
only situation when this is acceptable. However,
F100 formulations for infants < 6 months it is essential that if the infant is to be discharged
per phase home on formula milk, the international AFASS
criteria (see Box 16) must be considered and
Diluted F100 at 100kcal/kg/ the caregiver must be shown how to make the
Phase 1
day (8 feeds per day) formula safely and using the correct dilution. The
caregiver should be advised NOT to over-dilute
Transition Diluted F100 at 130kcal/kg/ the formula to make it last longer.
Phase day (8 feeds per day)
Step 4 During Phase 2, the Diluted F100 may
Phase 2 Diluted F100 at 200kcal/kg/ be substituted with commercial milk formula
day (6 feeds per day) appropriate to the child’s weight according to the
instructions on the tin/packet.

Step 5 The caregiver must also be advised

on the introduction of age-appropriate
complementary feeding when the child reaches
6 months of age and is referred to ongoing IYCF
counseling.

Box 16. Specific conditions needed if replacement feeds such

as formula milks are to be given safely to infants
(AFASS criteria)

Acceptable: The mother perceives no problem in replacement feeding. Potential problems may be cultural, social, or
due to fear of stigma and discrimination.

Feasible: The mother (or family) has adequate time, knowledge, skills, resources and support to correctly mix formula
or milk and feed the infant up to 12 times in 24 hours.

Affordable: The mother and family, with community or health system support if necessary, can pay the cost of
replacement feeding without harming the health or nutrition status of the family.

Sustainable: Availability of a continuous supply of all ingredients needed for safe replacement feeding for up to one
year of age or longer.*

Safe: Replacement food is correctly and hygienically prepared and stored and administered, preferably by cup.

*or linking the caregiver with a milk bank facility where possible

37 The Philippine Human Milk Banking Manual of Operations (2010)

Manual of Operations 57
 4.5 Orientation and Care for Caregiver

The admission of a child into inpatient care receive proper nutrition counseling and care that
is always a worrying time for the caregiver. facilitates their support for their child. Whenever
Care should be taken to ensure that all the possible, care will be given so as to promote (or
procedures and treatments their child will receive restore) age-appropriate breastfeeding practices,
are explained properly and the next stage of including breastfeeding overnight (particularly
the child’s treatment is also explained. The important in facilities not providing feeds during
opportunity should also be taken to ensure they night-time).

General advice to the caregiver to be given by the nurse in charge:

►► Prepare and administer diluted F100 according to the infant’s weight (see Annex 38).
►► The criteria for children to pass from Phase 1 to Transition Phase and from Transition Phase to Phase 2 are mostly
the same as for older children aged 6 to 59 months old (Section 4.3 Nutritional Management of Children 6 - 59
Months). However, if the infant is admitted with edema, all of the edema must have resolved before progressing
to Phase 2.
►► If a child younger than 6 months is on discharge, then the child must continue on formula milk until the age of 6
months, when complementary feeding is introduced. This is the only situation when this is acceptable. However,
it is essential that if the infant is to be discharged home on formula milk, the international AFASS criteria (see Box
16) must be considered and the caregiver must be shown how to make the formula safely and using the correct
dilution. The caregiver should be advised NOT to over-dilute the formula to make it last longer.
►► During Phase 2, the Diluted F100 may be substituted with commercial milk formula appropriate to the child’s
weight according to the instructions on the tin/packet.
►► The caregiver must also be advised on the introduction of age-appropriate complementary feeding when the child
reaches 6 months of age and is referred to ongoing IYCF counseling.

In addition, some specific actions should be taken Step 4 Counsel the mother on good IYCF
to care for the caregiver themselves in order to practices, including exclusive breastfeeding
facilitate their support for the child: for children younger than 6 months, continued
breastfeeding until the child is at least 2 years of
Procedure age and age-appropriate complementary feeding
(including meal frequency and food diversity).
Step 1 Assessment of the physical and mental
health status of the caregiver with the provision Step 5 If the caregiver brought commercial milk
of relevant treatment and ongoing support. formula with her, she may drink it herself or it
should be discarded. Commercial milk formula
Step 2 Other ward routines for meal times, should NEVER be fed to the child during the
washing clothes and attending to hygiene needs infant’s time in inpatient care.
must be discussed as soon as possible after
admission. Step 6 The mother should receive multiple
micronutrient tablets daily during admission if the
Step 3 Counsel the mother on maternal nutrition breastfeeding child is younger than 2 years of
and self-care. age.

4.6 Individual Monitoring, Follow-up and Referral

Monitoring the Child in Phase 1 Phase 1/Stabilization is extremely vulnerable

and at high risk of dying. The ITC chart in Annex
The minimum standards for monitoring in Phase 27 should be used in combination with existing
1 are outlined below. The recording of monitoring patient records to ensure appropriate monitoring
data should be clearly assigned to staff38 and is of feeds and nutritional status. The importance of
needed to manage the child with SAM who in the accuracy of the data should be emphasized.

38 Normally this would be the nutritionist or dietitian; however the clinical staff are responsible to ensure the charts are completed appropriately to
ensure proper clinical assessment of progress.

58 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
Surveillance

►► Record any breastfeeding taken before the therapeutic milk

After every feeding
►► Record the amount of therapeutic feed taken39 carefully on the therapeutic
session of therapeutic
surveillance sheet (see Annex 40 for detailed instruction on the use of the
milk, the medical staff
sheet)
should
►► For infants < 6 months: note the amount of therapeutic milk given

►► Measure and record the child’s temperature

Every 12 hours ►► Measure and record the child’s respirations
►► Measure and record the child’s pulse rate

►► Indicate the prescription for therapeutic milk

►► Measure and record the weight 40
►► Measure and record the level of edema
On a daily basis
►► Record symptoms such as cough
►► Indicate if the child has a nasogastric tube
►► For infants < 6 months: assess breastfeeding practice (see Annex 8)

On a weekly basis ►► Measure MUAC

Where a child has a complication or is undergoing It is not unusual for children to pass several very
fluid rehydration, the monitoring needs to be much soft stools during the recovery process of the
closer and should be indicated by the clinical staff intestinal tract. Unless there are signs of Re-
on an individual patient basis (see Annexes 19 to feeding Syndrome, acute watery diarrhea, or
26). osmotic diarrhea (see Annex 41 for information
and action if these are diagnosed), there is no
Monitoring and Referring the need for the child to pass back into Phase 1.
Child in Transition (to RUTF or There is also no need to treat the diarrhea unless
F100) the child loses weight. The child should continue
RUTF (or F100 if transitioning to Phase 2 inpatient
SURVEILLANCE care) and be observed closely. The diarrhea
should NOT be treated with Zinc.
The child should be observed closely for any signs
of deterioration during the Transition Phase: REFERRAL AND TRANSITION

Continue to monitor as above for Phase 1. Refer to Phase 1 care with F75 if:
►► There is deterioration in clinical status of the
In addition, after every feed: child or any of the above signs are noted (see
Annex 41 for main reasons for deterioration in
►► Record the amount of RUTF or F100 taken the Transition Phase).
►► Record the amount of F75 taken ►► This should be accompanied by a thorough
assessment/reassessment of the child’s
treatment (see Annex 42).
In addition be vigilant for any of the following signs that
the child is not coping with the transition: Switch from RUTF to F100 for Transition if the
child is:
►► Rapid increase in the size of the liver
►► Any sign of fluid overload Stable but appetite is not improving after three
►► Tense abdominal distension days in Transition (the required amount of each
►► Any significant re-feeding diarrhea involving weight feed is not being taken). In this case, switch to
loss F100 and transition the child to Phase 2. Transition
►► Any complication arising which necessitates onto RUTF can be attempted again after a couple
intravenous fluids of days.
►► Edema not reducing, any increasing edema or
edema developing when it was previously absent

39 In order to correlate the nutritional treatment with clinical recovery and any change in the weight of the child, the therapeutic milk intake must be
accurately monitored and recorded. This is a vital part of the child’s medical and nutritional care.
40 Record to nearest 100g for children and nearest 10g for infants < 6 months.

Manual of Operations 59
 Monitoring the Child in Phase 2 Transfer due to not reaching discharge criteria
after 40 days:
SURVEILLANCE
In this case, if all further investigations possible
During treatment in Phase 2, the child should at the inpatient facility have been tried, the
continue to be monitored until recovery. child should be transferred to a higher level
Observations should be recorded systematically facility/service for further investigation and
on the Therapeutic Surveillance Sheet. treatment.

REFERRAL AND TRANSFER

Refer back to Phase 1 care with F75 or transition

if:

►► There is deterioration in the nutritional status

of the child.
►► This should be accompanied by a thorough
assessment/reassessment of the child’s
treatment (see Annex 42.).

►► Record RUTF or F100 intake after each feed

►► Measure weight
►► Assess edema
►► Measure respiratory rate
Daily observations
►► Measure heart rate
►► Measure temperature
►► Assess clinical status (vomiting, diarrhea, dehydration, cough)
►► Assess nutritional status against discharge criteria

Weekly observations ►► Measure MUAC

Two-weekly observations ►► Measure height/length

4.7 Discharge

From Transition Phase to OTC

CRITERIA

Table 13. Discharge criteria from inpatient (Transition Phase) to outpatient care

CATEGORY DISCHARGE CRITERIA

Medical complications resolved (or chronic conditions controlled)

AND
edema subsiding (must have reduced to at least +2)
Child aged 6 to 59 months
AND
Appetite for RUTF (must be able to eat at least 75% of outpatient
ration in Annex 15)

Remi nder
→→ There is no anthropometric criterion for discharge when transitioning from ITC to OTC because nutritional rehabilitation is
continued and completed in OTC.

60 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
Discharge Procedure Step 6 Record the following on the referral slip:
»» Hospital registration/treatment number
Before the child is discharged from the inpatient »» MUAC (measurement)
care unit to a health facility offering outpatient care »» Weight (measurement)
for SAM which is accessible to them, the following »» Height (measurement)
should be accomplished: »» Weight for Height Z score (where capacity
exists)
Procedure: »» Grade of edema
»» Ration of RUTF given (number of packets
Step 1 Explain to the caregiver that the child has on discharge)
recovered sufficiently enough to be discharged »» Medications received and medicines to be
and congratulate them. continued after discharge
»» Clinical condition on discharge
Step 2 An adequate supply of RUTF must be
given to last until the next possible appointment Step 7 Record the child as a “discharge to
in outpatient care. outpatient care” in the tally sheet/monthly report.

Step 3 The caregiver must understand (and Step 8 Record the ration of RUTF given in the
repeat) the key messages for giving RUTF. stock register.
The caregiver must understand (and repeat) the
medications to be given after discharge (these Step 9 Complete other relevant clinical records
are any courses of medicines that the child and registers.
needs to complete after discharge).
From Phase 2 Inpatient Care
Step 4 Call the relevant RHU/BHS clinical staff
to notify them of the child’s transfer to outpatient CRITERIA
care. RHU/BHS clinical staff should advise the
BHW/BNS of the child’s return. Patients who are completing their full treatment
in ITC due to the absence of OTC should be
Step 5 Complete an appropriate referral form discharged when they reach the discharge cured
[Annex 10] and give it to the caregiver. This criteria shown in Table 14. Apart from taking
should be presented to the staff of the outpatient account of the difference in frequency of contact,
health facility at the next appointment. the criteria are the same as those for discharge
from OTC (see Section 3.7).

Table 14. Discharge cured criteria from Phase 2

CATEGORY DISCHARGE CURED CRITERIA

MUAC ≥ 125mm (12.5cm) for 2 consecutive visits

Admitted on MUAC,
AND
edema, or both
No edema for 10 days
MUAC and WFH
AND
Z-score
Children Clinically well
6 - 59 months WFH or WFL ≥ -2 Z-scores for two consecutive days
AND
Admitted on
No edema for 10 days
WFH Z-score only
AND
Clinically well
Child is gaining weight more than 5g/kg/day on breast milk or
milk formula for 3 consecutive days**
AND
Infants < 6 months
edema is absent
AND
Clinically well & childhood immunizations have been checked

** All therapeutic milk must have been stopped. The weight gain must be entirely due to breast milk or generic milk formula.

Manual of Operations 61
 Discharge Procedure length is greater than -2 Z scores (child’s
length is greater than 45cm).
Before the child is discharged from the inpatient »» Check that the caregiver understands the
care unit the following should be done: importance of continued breastfeeding
and timely introduction of appropriate
Procedure: complementary feeding. In cases where
infant formula will be used at home,
Step 1 Explain to the caregiver that their child ensure the caregiver is informed about
has recovered sufficiently to be discharged and proper preparation and use.
congratulate them.
Step 5 Complete a referral slip and advise the
Step 2 The caregiver must understand (and caregiver to attend the nearest local health
repeat) the medications which must be given facility:
after discharge. »» Record the child’s registration number on
all documentation
Step 3 Complete other relevant clinical records »» Record the MUAC and WFH/WFL
and registers. (measurement on discharge)
»» Record any continuing medications
Step 4 For infants: »» Advise attendance at a growth monitoring
»» Refer the infant to ongoing counseling program
and monitoring as an outpatient at the »» Advise attendance at the local health
RHU/BHS. The child may be discharged facility for further nutrition counseling
from care completely when the weight for

INpatient Therapeutic
Care

Record the Outcome of Treatment

Register the patients discharged in the registration book and chart

according to the following possibilities:

CURED Discharge as non-

The patient has cured
S
D

reached the criteria for If a child does not

discharge cured reach the discharge
criteria within three
DEAD months in ITC and all
xx If the patient died referral and follow-up
|

during treatment in the options have been

facility or during transit tried they may be
to another facility discharged as non-
DEFAULTER cured and linked
If the patient has not with the OTC or
returned for three MAM program where
|

consecutive days and possible and to social

a home visit, neighbor, support systems (see
village volunteer, or Section 4.8)
other reliable source
confirms that the
patient is not dead

62 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
4.8 Managing Links

The child being treated for SAM has usually

suffered some combination of nutritional deficit
and/or infection and often may come from the
poorest families in the community. In order to
continue healthy growth and prevent relapse,
follow-up care should be sought. Depending on
services available locally, the following should be
considered.

►► Referral to a SFP (if available) or other

supplementary feeding program.
►► On-going IYCF/nutrition counseling (e.g.
IYCF Peer counseling, Family Development
Sessions, Pabasa sa Nutrisyon, promotion of
good nutrition).
►► Referral to Mother support groups, as well as
baby clinics.
►► Referral to multiple micronutrient
supplementation or complementary feeding
support if available.
►► Enrolment in a growth monitoring program
Operation Timbang Plus (if not yet enrolled).
►► Referral to a food security program.
►► Provision of list of social welfare services
available and referral to any relevant
programs such as Sustainable Livelihood
and Pantawid Pamilyang Pilipino Programs
(if eligible), Kapit-Bisig Laban sa Kahirapan-
Comprehensive and Integrated Delivery of
Social Services (KALAHI -CIDSS) and Self-
Employment Assistance-Kaunlaran (SEA-K)
Program)
►► Ensure enrolment and coverage of the
child and mother41 in PhilHealth. If family
is indigent, coordinate enrolment in the
PhilHealth indigent program with the Municipal
or City Health Office. Ask the mother or
caregiver to show you the PhilHealth card or
to give you the PhilHealth number.

41 Mother and child are covered as dependents if the father is enrolled. Make sure enrollment status of both parents are established.

Manual of Operations 63
PART 2

©UNICEF Philippines/2011/PTy

OPERATIONAL
GUIDELINES
 DEFINITION OF TERMS

Community Mobilization: Community mobilization Procurement: The process of acquiring

includes the activities conducted in sensitizing commodities either through purchase or donation
the community about the program, screening via international, regional, or local sources of
children in the community to find cases eligible supply.
for treatment and community-based activities that
support keeping the child in treatment until cure. Inventory Management (Distribution and
Storage): The process by which the SAM
MUAC tape: MUAC is an abbreviation for Mid- treatment supplies procured are received,
Upper Arm Circumference. A MUAC tape is a assessed and stored until they are distributed
color-coded tape, marked in millimeters, used to to the next level from the central warehouse to
measure the midpoint of children’s upper arms the regional and provincial warehouses, down to
children to see if they are eligible for treatment in the health facilities where they are dispensed to
OTC or ITC. A measurement of less than 115mm patients.
(< 11.5cm) indicates a child has SAM and is at an
increased risk of death (four to 20 times higher Rational Use of Medicines and Diagnostic
than well-nourished children). Supplies: Refers to the appropriate, safe and
effective use of routine medicines, RUTF and
RUTF: RUTF is an abbreviation for Ready-to- diagnostic supplies based on program guidelines.
Use Therapeutic Food. This is a pre-packaged
medicinal food similar in taste to peanut butter Quality Monitoring: Refers to the continuous
and containing all of the nutrition required for the monitoring of the quality of the commodities and
child to recover from SAM. Typically the child eats the logistics process for suitability, effectiveness
two to three packets per day during recovery over and efficiency.
a period of approximately six weeks.
Emergency: Any actual threat to public safety; an
Supply Chain Management Cycle: A systems- exceptional event of any magnitude that produces
based process consisting of product selection, damage and injury demanding immediate action.
quantification and procurement; inventory
management (distribution and storage); Disaster: Any emergency, any actual threat to
and rational use. The cycle is guided by the public safety and or public health, whereby local
national policy and legal framework that defines emergency management, services and measures
the goals for the management of drugs and are unable to meet the immediate needs of the
diagnostic supplies and supports the continuous community whether due to lack of time, capacity
availability of these commodities and their or resources, resulting in unacceptable levels of
appropriate use. Management systems that damage or numbers of casualties.
include planning; financial management; logistics
information management system; organization Health Information System: A system that
and infrastructure; human resources; training; integrates data collection, processing, reporting
monitoring and evaluation and quality monitoring and use of the information necessary for improving
of the commodities and the logistics process health service effectiveness and efficiency through
support it. better management at all levels of health services.

Product Selection: The process of establishing

a limited list of essential supplies to be procured
based on the treatment guidelines and national
formulary.

Quantification: The process of estimating the

quantity and cost of the products required to
ensure an uninterrupted supply. It is an on-going
process of monitoring, reviewing and updating
forecast data and assumptions and recalculating
the total supply requirements and costs.

Manual of Operations 65
 5. ADVOCACY AND COMMUNITY MOBILIZATION FOR
THE MANAGEMENT OF SAM

5.1 Introduction

This section complements Section 1 in the mobilization is started before the program is
technical part of the guidelines on Community implemented and is a continuous process while
Mobilization and describes how these activities the program remains available to the community.
may be supported at local level. Community

5.2 Advocacy and Creating an Enabling Environment

The implementation of effective services for ►► Training of clinical and community-based staff
the treatment of SAM requires an enabling and volunteers in the management of SAM
environment which ensures the provision of ►► Integration of treatment of SAM into routine
policies, provision of access to services, provision health and nutrition services
of adequate supplies and ensuring quality and ►► Establish linkages between health facilities
competency of services. and other community and social services

Advocacy for the creation of an enabling 3. Access to supplies

environment should be conducted at each level
so as to ensure the implementation of high quality, ►► RUTF to be included in the National
high coverage and effective services at LGU level. Formulary
►► Integrate procurement and supply chain
1. Policy and Technical Environment management into existing systems
►► Integrate procurement of supplies into existing
►► Provision of National Guidelines for the systems
Management of SAM ►► Provide adequate storage for SAM treatment
►► Formation of linkages to the National Program supplies at every level
Management Team ►► Ensure efficient recall and redistribution
►► Strategic plans for scale up of services systems for supplies
►► National Health and Nutrition Policies are ►► Request Halal certification from RUTF
put in place including Executive Orders, manufacturers
Administrative Orders and Department
Personnel Orders 4. Provision of quality services
►► Establish/enhance coordination systems
(Nutrition Committees and Nutrition Clusters) ►► Technical support from National PMT,
►► Establishment of technical leadership for Nutrition Committees, Nutrition Clusters
management of SAM ►► Adherence to National Guidelines
►► Funding for SAM treatment supplies ►► Provision of certified RUTF which adheres to
incorporated into budget at all levels international CODEX standards
►► Contingency planning including liquidation of ►► Adequate support and supervision systems
emergency funds at LGU ►► Systematic screening of MUAC and edema
for all children aged less than five years at
2. Access to Services every visit to a health facility to promote high
service coverage
►► Learning sites before province- or region-wide ►► Addition of screening for MUAC and edema to
scale up OPT, GP and other community based services
►► Prioritization of Regions/Provinces/Cities and to promote high service coverage
Municipalities in scale-up of services ►► Allocation of assigned tasks to staff at LGU
►► Promote community sensitization and level (Section 7. Implementation of Services)
mobilization for acute malnutrition to promote timely interventions and high
►► Standardized referral system between service coverage
community and OTC, OTC and ITC and vice-
versa

66 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
►► Standardized system of monitoring and ►► Integration of pre-service training into courses
reporting of SAM treatment service for other health and nutrition care providers at
performance with linkages to FHSIS the community level
►► Evaluation of SAM treatment service ►► Community mobilization, screening and
performance (patient outcomes and treatment treatment of SAM to be included in job
coverage) descriptions of staff of health, nutrition and
allied health services
5. Competencies for the management of SAM ►► Establish effective accountability and
feedback systems which include mechanisms
►► Integration of pre-service training into medical, for feedback from the community
nursing, nutrition and other allied health and
nutrition training courses

5.3 Stages in Community Mobilization

Figure 8 below summarizes the stages of Community Mobilization.

Figure 8. Stages of Community Mobilization

Links with other community initiatives

Training
Community Developing Recording
Community community Case finding
sensitization message and Follow up and
assesment outreach referral
and dialogue materials reporting
workers

Ongoing community sensitisation and mobilisation

Planning Phase Implementation Phase

1. Community Assessment

A community assessment aims to understand

the existing capacities in health, nutrition and
community awareness of malnutrition at local
level and how this information can best be used
to ensure the maximum number of children with
SAM are able to access treatment.

This community level assessment takes place

through a series of interviews and focus group
discussions conducted with key community
informants. These may include the barangay
captain, other community leaders, other influential
people (e.g. teachers), committees, caregivers,
fathers and traditional healers.

Manual of Operations 67
 Box 17. Core elements of a
Community Assessment ►► Ethnic, social and cultural characteristics related
to the feeding and nutrition of young children,
including identification of the most vulnerable
►► Identifying local terms for acute malnutrition groups and food taboos
(e.g. “payat at sakitin” or “niwang ug masakiton”), ►► Formal and informal channels of communication
perceived causes and common treatments. Refer that are known to be effective
to NNC Nutrition Information and Education ►► Attitudes toward illness (particularly malnutrition)
Division for further material. and usual health-seeking behaviors
►► Identification of key community persons, leaders ►► Child care practices and locally available services
and other influential people and organizations ►► Other existing nutrition and health interventions
to help sensitize the community regarding the in the community including for child care
program for the management of SAM (National programs implemented at City/
►► Existing structures and community-based Municipal/LGU level such as the OPT and GP
organizations/groups should be included here)

2. Community Sensitization
Box 18. Other elements of the Based on the Community Assessment, a
Community Assessment sensitization plan should be developed by the
City/Municipal Nutrition Committee (C/MNC) in
►► Map the community structures, focal persons and collaboration with local chief executives (and
means of communication which can be used to local nutrition cluster in times of emergency). This
raise awareness on acute malnutrition and the sensitization plan aims to inform all sectors of
program the community regarding the services for treating
►► Map all opportunities to access children at SAM. In particular:
community level for identification and follow-up
of SAM cases
►► Establish a dialogue with the community about
the SAM treatment services Box 19. Key information to be
►► Generate a clear picture of local perceptions of included in a sensitization
acute malnutrition and the terms used to describe
plan
it
►► Understand what treatment (if any) is normally
►► Information about the signs and symptoms of
given for children with malnutrition
SAM
►► Why SAM and its treatment is important to the
community
Other support mechanisms such as the ones ►► How SAM can be identified using MUAC tape,
below are additional resources that can be weight for height, or checking for edema
accessed or engaged by communities to help ►► Which age group is eligible for treatment
them in community mobilization: ►► Information on where and when to access
treatment for SAM
►► Local ordinances and memoranda ►► Whether the treatment of SAM is part of regular
►► National and regional policies/guidelines and health services or an emergency response
manuals related to health and nutrition ►► Most children can be treated at home but some
►► Referral and reporting systems may still need hospital treatment
►► Service delivery networks ►► What treatment is given at home, including RUTF
►► Training and medicines
►► Databases ►► How long treatment can be expected to last
►► Implementers of OTC/ITC ►► RUTF will be certified as Halal
►► Nutrition Clusters and local nutrition
committees

68 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
In preparation for sensitization activities at After the program has started, the community
the community level, local meetings with chief dialogue is continued in order to continue
executives should be organized. This meeting maximizing the number of children with SAM
should bring together City/Municipal/LGU who are able to access treatment. Continued
officials with key community representatives to sensitization also allows feedback on program
discuss the objectives and principles of the SAM performance, to be given to the community and
treatment services. The City/Municipal Nutrition help to continue any changes in health-seeking
Committee, City/Municipal Health Board and behavior through the sharing of success stories.
the City/Municipal Council for the Protection
of Children may be venues for this discussion. 3. Developing Messages and
There should be an agreement on what needs to Materials
be done; the relevant groups, organizations and
structures to be involved in different aspects of Based on the information gathered during the
SAM treatment should also discuss clear roles as assessment and preparation for sensitization,
well as responsibilities. simple sensitization messages for acute
malnutrition and the SAM treatment service
A sensitization plan should be developed, detailing were developed. These may include handbills or
whom to target and how to sensitize based on the pamphlets, local radio (Nutriskwela), as well as
information gathered during community capacity television.
assessment. Review the plan with influential
persons in the community to check if it is culturally The local terms for RUTF and supplementary
appropriate before disseminating it. feeding commodities should be used in all
communications. These can be based on generic
This is a first advocacy step in highlighting the messages and materials developed centrally, but
need for the program from the service providers’ adapted to each locality.
perspective and to hear the community’s
response. This initial meeting could be done Flyers containing SAM treatment
in parallel with the community assessment. service information
However, the community assessment is more
in-depth in building an understanding around A short flyer, translated into the local language/
malnutrition, and acute malnutrition in particular, dialect, may be provided to reinforce messages
and therefore can provide a basis for more given at the community sensitization meeting or
meaningful discussions about the need for the to distribute to communities unable to access the
service. orientation meeting. An example of a sensitization
message that can be adapted for local use is
Before implementation of the SAM treatment provided in Annex 46.
service, the City/Municipal Nutrition Committee
(C/MNC) with the Barangay Nutrition Committee MUAC tape
(BNC)/Barangay Captain, in coordination with the
local nutrition cluster, should conduct community A MUAC tape (ensuring the correct type is supplied)
sensitization. should be shown to community members during
the orientation meetings, indicating the cut off
During implementation, SAM treatment activities point for treatment.
and community mobilization support should be
coordinated at the local level by the C/MNC (and SAM - Less than 115mm/11.5 cm (colored RED)
local nutrition cluster in times of emergencies). MAM - 115mm/11.5cm to 125mm/12.5cm (colored
When needed, the Local Council for the Protection YELLOW)
of Children should be involved (e.g. when child Normal - Greater than or equal to 125mm/12.5 cm
protection issues arise). (colored GREEN)*

Figure 9. MUAC tape

Photograph sourced from UNICEF

*A normal MUAC only means that no acute malnutrition is present according to MUAC. Measurements of weight-for-height or edema
may also indicate an acutely malnourished status.

Manual of Operations 69
 RUTF

Figure 10. Examples of types of RUTF used for treating SAM

A packet of RUTF should be provided during RUTF, whether imported or locally produced,
meetings to show to community members. Flyers should carry certification that it is Halal.
with the key messages for using RUTF (see Manufacturers of RUTF should liaise with religious
Section 3.2) may be printed and distributed. Some leaders in order to obtain the certification.
frequently asked questions are indicated in Box
20 below.

Photographs

Photographs of children (ensuring anonymity) who and after treatment. These can provide a powerful
have successfully completed treatment should be visual message.
supplied, showing the condition of the child before

Before treatment After treatment

with RUTF with RUTF

© Save the Children Philippines/2011 © Save the Children Philippines/2011

Other IEC materials for SAM Media

treatment services
Information regarding SAM treatment may be
Other IEC materials may be available from disseminated through media sources. Nutriskwela
DOH either through the Health Promotion and Community Radio (supported by NNC and
Communication Service (HPCS) or the Family National Telecommunications Commission/NTC)
Health Office (FHO). aims to empower the community through the
dissemination of correct and up-to-date nutrition
and health information, as well as educational
and developmental information from all relevant
sectors of the community, government agencies
and non-government organizations.

70 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
Box 20. Ready-to-Use Therapeutic Food (RUTF) - Frequently Asked Questions

Q. What is RUTF?
A. RUTF is a medicinal food specially designed for treating SAM.

Q. What is in RUTF?
A. RUTF is made of peanuts, milk powder, oil, sugar and a special blend of minerals and vitamins. It is made into a paste
that tastes like a sweet peanut butter and does not contain any water. Because it contains no water, germs cannot grow in
RUTF, so it is very safe to use at home.

Q. Can anyone eat RUTF?

A. RUTF can only be used by children who are being treated for SAM. While it is not harmful for others to eat it, it should not
be shared with others because the amount given to the SAM child is just the right amount needed for the child to recover.

Q. How do I use RUTF?

A. RUTF is ready-to-eat straight from the packet. It should never be cooked or mixed with other foods. It should never be
mixed with water before eating. If the child is too young to eat it from the packet, you can use your finger (provided it is
clean!) or a spoon to feed RUTF to the child.

Q. Can you mix RUTF with water?

A. No. Never mix RUTF with water before eating. However, after each mouthful of RUTF, the child should be offered small
sips of clean water to drink. If the child is breastfeeding, you can also give breast milk instead of water. If you mix RUTF with
water, it may cause bacteria to grow and may cause diarrhea.

Q. How much RUTF should my child eat?

A. The amount of RUTF your child needs is based on their weight. Your local health/nutrition staff will advise you how many
packets the child should eat per day. The amount should be spread out over the day (e.g. if the child needs to eat three
packets you can give one at breakfast, lunch and dinner). Treatment with RUTF usually continues over for four to six weeks.

Q. Can my child eat other foods as well as RUTF?

A. Yes. However, RUTF is vital to recovery and it is the most important food for your child until s/he is cured. During each
meal, the child should eat the full amount of RUTF needed. Ideally, the whole daily ration should be eaten before other
family foods are given. In very difficult cases, the child may be given family food in between meals of RUTF. After eating the
RUTF at each meal and the child is still hungry after 30 minutes, then (and only then) can he/she have some family food.

IMPORTANT: You should not feed the child so much family food that they cannot eat the next dose of RUTF!

Q. What if my child gets bored with RUTF?

A. As the child recovers, they may want to eat a greater variety of food. That is OK as long as the RUTF is given first. Sometimes,
a lot of patience is needed to feed young children RUTF, especially if they are sick and sometimes it can be the caregiver
who gets bored. Try getting help in feeding the child from other family members after teaching them how to use RUTF.

Q. Is RUTF Halal?
A. Yes. The manufacturer should provide a certificate if requested.

Manual of Operations 71
 4. Training Outreach Workers Technical guidance may be provided by the local
Health Officers to ensure that their proposed
SAM treatment training activities related to training activities are in line with the principles and
community mobilization should be coordinated objectives of the management of SAM.
through the Barangay/City/Municipal Nutrition
Committees. Responsibilities of government The City/Municipal Health Officer (MHO) and the
departments for training and support for City/Municipal Nutrition Action Officer (MNAO), as
community mobilization are given in Annex 48. well as supervising midwives have a responsibility
to ensure that the BNSs/BHWs (and other
Community-based organizations can coordinate volunteers in times of emergency) are trained
with the City or Municipal Health Office should in engaging with the community, disseminating
they have planned or proposed activities that sensitization messages effectively and identifying
are related to nutrition or feeding programs. and referring SAM cases.

Box 21. Community level workers for involvement in case finding in the Philippines

►► Local Nutrition Committee/Cluster

►► BNSs and BHWs
►► Midwives and other staff from Rural Health Units (RHU’s) who deliver primary health care services
►► Barangay Council for the Protection of Children (BCPC) members
►► Municipal and Barangay Social Workers
►► Early Childhood Development Center staff and Facilitators
►► WASH volunteers
►► Traditional healers and traditional birth attendants (“hilot”)
►► Caregivers’ Group Members and individual caregivers
►► Social Mobilizers
►► Community Health Workers of CBOs/local NGOs/clubs
►► Ward citizen forums
►► Citizen Awareness Centers
►► Women Cooperatives/Federations
►► Faith-based groups
►► Teachers

Remi nder s
→→ Where BNS/BHWs are active and serve as the primary community level workers acting in an area, they
can act as a focal point for all these other community workers who are conducting case finding (i.e. these
workers can refer children to the BNS/BHW for checking of MUAC and edema measurements before they are
referred to the health facility).
→→ Any individuals from these groups able to reliably measure MUAC and check for edema may refer children
identified as having SAM to the nearest treatment location.

5. Case Finding and Referral When a case of SAM is found, the child is then
referred to the nearest treatment point. In many
Case finding for SAM treatment involves cases, this may be the RHU but may also be the
identifying children who are eligible for treatment. local Barangay Health Station.
Case finding may be ‘passive’ or ‘active’ (see
Section 1.3). For the purposes of community
mobilization, case finding is accomplished
primarily in the community by the BNS/BHW or
other local volunteer worker.

72 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
 Table 15. Criteria for case identification and referral in the community

Identification of Child with SAM

Criterion Finding Result

Less than 115mm (11.5cm) (RED) Severe Acute Malnutrition (SAM)

Between 115mm (11.5cm) and
Moderate Acute Malnutrition (MAM)
MUAC 125mm (12.5cm) (YELLOW)
Greater than or equal to
Normal
125mm (12.5cm) (GREEN)
Bilateral pitting edema (any grade) SAM
Edema
Bilateral pitting edema is absent Normal

The BNS/BHW and other identified community who have been absent from treatment or are
level personnel should: recovering slowly or who may be at increased risk
(e.g. following admission for inpatient treatment).
►► Act as a focal point in their community whom
caregivers can turn to if they are worried An effective follow-up requires a good linkage
about their child losing weight or being sick so between the community and health facilities and
that they can be assessed for SAM. therefore, is best carried out by the BNS/BHW
►► Screen for acute malnutrition in children linking with the midwife, public health nurse and
during routine contact opportunities (e.g. other facility staff. It should entail the following:
home visits, community meetings, BHS
outreach programs, OPT, GP) and at other ►► Identification of priority cases by the C/MHO,
opportunities identified during assessment PHN and midwife for follow-up by BHW/BNS.
(passive case finding). It is important that ►► Conducting home visits which focus on
this is done systematically for every child assessing the home environment related to
and not just for children who appear to be recovery from SAM.
underweight. ►► Counseling regarding the use of RUTF and
►► Screen for acute malnutrition through active or other foods. For children less than two years
active adaptive case finding during coverage of age this also includes assessment and
assessments or other house-to-house health/ counseling for IYCF practices.
nutrition-related activities (e.g. EPI). ►► Any children with the following should be
►► Identify and refer SAM children to the nearest referred immediately to the nearest health
treatment location. facility for review by a clinician:
►► Provide counseling on IYCF, WASH, »» Eating less than 50% of the RUTF daily
vaccination and other health care practices ration
for caregivers of children with SAM in »» General deterioration in health since the
collaboration with the midwife responsible for last health check
supervising treatment. »» Untreated persistent vomiting or diarrhea
►► Refer directly to ITC for inpatient care if the
Coverage assessments may involve specific active child has:
case finding activities in order to assess whether »» Any IMCI danger sign
the program is enabling access to treatment for »» A lack of appetite for RUTF
all children with SAM in the community. Specific ►► A record of the home visit (and a home visit
training will be given in this circumstance to checklist) should be completed and given
the BHW/BNS and clinical staff involved in the to the responsible clinician (health officer or
assessment. midwife). If it is only possible to give a verbal
report (e.g. by phone) the responsible clinician
6. Follow-up should document the report in the child’s
treatment record.
Some children with SAM require a follow-up at
home during their time in treatment, in addition
to the follow-up they receive at the health facility
during their periodic visits. These may be cases

Manual of Operations 73
 ►► Children with medical complications who have
Box 22. Priority cases for follow-up
refused transfer to inpatient care and are being
treated on an outpatient basis
►► Cases who are not responding in the program (loss
Following up through home visits can be time or static weight two weeks) whose aspects of the
consuming if done well, as a variety of factors need home environment are suspected to be playing a
to be discussed during the visit. There is no need to role rather than medical issues
conduct home follow-up visits with all SAM children, ►► Repeated absentees from treatment
especially those gaining weight in the program. ►► Infants < 6 months old not gaining weight during
a period of IYCF counseling
Follow-up should focus on the following:

Children who are repeatedly absent or who have Home visit assessments also provide an
defaulted from treatment against the advice of the opportunity to assess whether the child/caregiver
health worker should be checked for edema and has been linked with other social protection or
the MUAC measured. A ‘defaulter form’ should nutrition support programs or counseling. The
be completed (Annex 53), which identifies the BNS/BHW should promote and facilitate linkages
reason for defaulting. If the child has defaulted but to other support programs where these exist in the
remains SAM, the caregiver should be urged to local area.
bring the child to the health center immediately.
All defaulted cases should be counseled to return
to treatment and counseled in health, hygiene and
nutrition practices as appropriate.

74 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
 6. MANAGEMENT AND COORDINATION OF THE
INTEGRATED PROGRAM FOR THE MANAGEMENT OF SAM

6.1 Introduction

This section identifies the roles and responsibilities reporting structure is described. The roles and
of the PIMAM program management team (PMT) responsibilities of the individual members of the
from local to national level and those of the PIMAM PMT are detailed in Annex 48.
Chief Executives. A PIMAM coordination and

6.2 Organization of a PIMAM Program

The organization of the Philippine Integrated The units of the PIMAM organizational structure
Management of Acute Malnutrition (PIMAM) are dynamic; their composition and members
program is critical to its success. The can change depending on the identified needs
implementation of the PIMAM program requires and priorities. This flexibility allows each unique
organizational structure, systems development implementing unit to adapt the basic structure to
and partnership building at all levels of the health fit local conditions and situations to better serve
and nutrition sectors. the malnourished population.

The PIMAM Organizational Structure makes use

of existing structures and systems. It is composed
of the two major units.

1. The National Task Force for CMAM created

under Department Personnel Order (DPO)
2011 - 2453 (Annex 47) shall now serve
as the management of SAM Program
Management Team.
2. The Local Implementers or the health and
nutrition service providers at different levels.

6.3 PIMAM National Program Management Team (NPMT)

The National Program Management Team

provides the overall direction and policy support
in the implementation of the SAM treatment
program. It is the program management team,
which can operationalize the implementation of
SAM treatment, give advice and address concerns
regarding program implementation, roll out
and scale-up. The roles of the various bureaus,
offices, units and attached agencies of the DOH
are described in Annex 48.

Manual of Operations 75
 Lead: Members:
►► DOH-Disease Prevention and Control Bureau ►► DOH - Epidemiology Bureau
►► DOH - Health Facility Development Bureau
►► DOH - Health Promotion and Communication Service
►► DOH - Health Facilities and Services Regulatory Bureau
Co-lead: ►► DOH - Health Human Resource Development Bureau
►► DOH-National Nutrition Council ►► DOH - Bureau of Local Health Systems and Development
►► DOH-Health Emergency Management Bureau ►► DOH - Procurement Service
►► DOH - Materials and Management Bureau
►► PhilHealth
Non-governmental ►► Department of Science and Technology - Food and
organizations: Nutrition Research Institute (DOST-FNRI)
►► Academic and professional organizations ►► Department of Social Welfare and Development -
►► National and International NGOs Protective Services Bureau (DSWD-PSB)
►► UN agencies and other developmental partners ►► Council for the Welfare of Children
►► Civil society and other relevant stakeholders as ►► Department of Education
deemed necessary ►► Department of Interior and Local Government

6.4 Roles and Responsibilities of the Program Management team

General Roles and Functions b. Strengthen referral system in the

management of SAM through a
1. Policy Standards and Guidelines functional service delivery network from
Development outpatient therapeutic program (OTC)
Formulate and disseminate and update (as needed) to inpatient facility (ITC) and vice-versa
the plans, policies, guidelines and protocols on and the referral and action on reports of
PIMAM and ensure the implementation of their adverse reactions. Develop and ensure
provisions at all levels of the health and nutrition effective implementation of appropriate
sectors. health financing strategies to provide
financial risk protection.
2. Capacity-Building c. Provide technical assistance to its
Develop capacities of health and nutrition human counterparts at the regional and local
resources, infrastructure or technology for the government units.
management of SAM. d. Strengthen networking with the academe
and professional organizations to ensure
3. Logistics Management PIMAM integration in the curriculum,
Develop the mechanism, standards and particularly in medical and allied health
procedures for the supply and logistics courses.
management (planning, procurement, storage, e. When an emergency is declared or
allocation, distribution and monitoring) of PIMAM anticipated, link with existing emergency
program. coordination mechanisms.
f. Ensure that information and appropriate
4. Information and Knowledge Management interventions are immediately
Develop and conduct research and documentation coordinated with the regular
strategies to provide evidence-based information program managers for sustainable
and identified best practices for the continuous implementation.
improvement of the PIMAM program.
7. Advocacy and Social Mobilization
5. Monitoring and Evaluation Lead in advocacy, promotion and social
Lead in the assessment, monitoring and evaluation mobilization as sustainable support for the PIMAM
of the implementation of PIMAM program. program (targeting decision makers at local level;
social mobilization aimed at community level).
6. Coordination, Networking and
Partnerships

a. Define strategies and mechanisms

necessary for the effective coordination
and partnership building.

76 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
 Figure 11. PIMAM coordination and reporting structure

National PIMAM Department of

National Nutrition
Management Health
Council
Team DPCB

Regional Regional DOH Regional

DOH and Regional
Nutrition Program Nutrition Director or Regional
Hospitals
Coordinator Committee Nutritionist Dietician

Provincial or
Provincial Provincial
Provincial Health District Hospitals
Nutrition Action Nutrition
Officer Private Hospitals/
Officer Committee
Clinics

City/Municipal City/Municipal Municipal Hospitals

City/Municipal Health
Nutrition Action Nutrition Private Hospitals/
Officer
Officer Committee Clinics

Supervising ITC Doctor/

Nurse Chief Nurse

Midwife

Barangay Barangay
Nutritionist/
Nutrition Health Nurse Social Worker
Dieticiam
Scholar Worker

The routes of data that the SAM treatment service utilizes are based primarily on the country’s nutrition
and health care system frameworks. Data (solid arrows) from the grass roots (Barangay Health Centers/
Stations, clinics, or even evacuation centers) are sent up to the different levels via two routes: a) those
belonging to municipalities and cities are sent to the MHO/ CHO, then to the PHO and finally to the DOH
Regional Offices; b) for cities in the NCR and other chartered cities, data are sent directly to the DOH
Regional Offices. Data coming from all Regional and DOH Hospitals are reported to their respective DOH
Regional Offices. All data from the various DOH Regional Offices are finally sent to DOH-FHO. Similarly,
Nutrition Action Officers can also collect the reports and send them to the next reporting level until they
finally reach the NNC. Coordination of activities should be done through the Nutrition Committees at each
level. If Barangay Nutrition Committees are active, then the BNS/BHW should report activities to the BNC
under the Barangay Captain.

Manual of Operations 77
 Table 16. Tasks and responsibilities at different levels

Institution/ Organization Roles and Responsibilities

►► Provincial/City/Municipal Nutrition Council oversees all nutrition

programs.
►► Plans, implements, organizes, coordinates and controls the
management of SAM program within the municipality.
City/Municipal Health Offices ►► Overall organization of the program in the city/municipality:
(CHO/MHO) through the Local recruits and recommends staff appointments, in-job training,
Nutrition Councils supervision, monitoring and evaluation, management of the
therapeutic products and routine drugs at OTC level and
coordination and referrals with the inpatient facilities at city/
municipality level (normally the pediatric or medical ward within
the municipal hospital).
►► Plans, implements, organizes, coordinates and controls the
management of SAM program within the hospital and with nearby
OTCs.
►► Overall organization of the program in the hospital: recruits and
Hospitals
recommends staff appointments, in-job training, supervision,
monitoring and evaluation, management of the therapeutic
products and routine drugs at ITC level and coordination with the
outpatient therapeutic facilities at city/municipality level.
Provide technical support and supportive supervision to the City/
Municipal Health Offices in the following:

►► Based on national guidelines, formulates/improves and

disseminates and updates (as needed) the plans, policies,
guidelines and protocols on the management of SAM and ensure
the implementation of their provisions at the provincial level.
►► Ensures the effective implementation of the mechanism,
standards and procedures for the supply and logistics
management (planning, procurement, storage, allocation,
distribution and monitoring) of the program for the management of
SAM at the provincial level.
►► Develops and conducts research and documentation strategies
to provide evidence-based information and identified best
practices for the continuous improvement of the program for the
management of SAM.
Provincial Health Offices ►► Develops capacities of health and nutrition human resources,
(PHO) infrastructure or technology for the management of SAM.
Identifies, orients and capacitates provincial-level trainers and
technical assistance providers for the management of SAM.
►► Supports the assessment, monitoring and evaluation of the
implementation of the management of SAM.
►► Defines strategies and mechanisms necessary for the effective
networking, coordination and partnership building.
►► When an emergency is declared or anticipated, links with existing
emergency coordination mechanisms.
►► Ensures that information and appropriate interventions are
immediately coordinated with the regular program managers for
sustainable implementation.
►► Leads in advocacy, promotion and social mobilization as
sustainable support to the program for the management of SAM
(targeting decision makers at local level; social mobilization aimed
at community level).

78 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
 Institution/ Organization Roles and Responsibilities

►► Formulates and disseminates and updates (as needed) the plans,

policies, guidelines and protocols on the integrated management
of SAM and ensure the implementation of their provisions at all
levels of the health and nutrition sectors.
►► Develops capacities of health and nutrition human resources,
infrastructure or technology for the management of SAM. Identify
orient and capacitate National level trainers and technical
assistance providers for the integrated management of SAM.
►► Develops the mechanism, standards and procedures for the
supply and logistics management (planning, procurement,
storage, allocation, distribution and monitoring) of the program for
the management of SAM.
►► Develops and conducts research and documentation strategies
to provide evidence-based information and identified best
practices for the continuous improvement of the program for the
management of SAM.
►► Leads in the assessment, monitoring and evaluation of the
implementation of the program for the management of SAM.
►► Defines strategies and mechanisms necessary for the effective
coordination and partnership building.
Regional Offices for Health
►► Strengthens referral system in the management of SAM through
a functional service delivery network from outpatient therapeutic
program (OTC) to inpatient facility (ITC) and vice-versa and the
referral and action on reports of adverse reactions.
►► Develops and ensure effective implementation of appropriate
health financing strategies to provide financial risk protection.
►► Provides technical assistance to its counterparts at the regional
and local government units.
►► Strengthens networking with the academe and professional
organizations to ensure SAM management integration in the
curriculum particularly in medical and allied health courses.
►► When an emergency is declared or anticipated, links with existing
emergency coordination mechanisms.
►► Ensures that information and appropriate interventions are
immediately coordinated with the regular program managers for
sustainable implementation.
►► Leads in advocacy, promotion and social mobilization as
sustainable support to the program for the management of SAM
(targeting decision makers at local level; social mobilization aimed
at community level).

►► When needed, provides support for the management of SAM

NGOs/Private Organizations through training, coordination, IT support, advocacy, etc. and
intensified implementation during emergencies and disasters.

Manual of Operations 79
 6.5 Roles and Responsibilities of Chief Executives

Chief Executive Roles and Responsibilities

►► The Provincial Governor shall convene PNC members to discuss the need
to establish SAM treatment in the local health systems:

»» Ensure effective implementation of the national and/or issue regional/provincial

directives to support the LGUs in integrating the management of SAM in the
health system.
»» Disseminate the management of SAM protocol, IEC materials and collaterals to
the LGUs and local health system.
Provincial Nutrition
»» Lead in the capacity needs assessment of all local health systems.
Committee (Chaired »» Ensure planning and conduct of training of trainers for health and nutrition
by Provincial implementers both for OTC and ITC.
Governor), through »» Facilitate access, storage and distribution of SAM supplies from the regional
the Provincial level to the OTC and ITC.
Nutrition Action »» Facilitate the timely and quality submission of plans, statistical and stock
Officer under the reports from the OTC and ITC to be submitted to the regional level through the
supervision of the Regional Nutrition Coordinator.
Provincial Health »» Ensure the timely collection, collation, validation and analysis of submitted
Officer reports both during regular and emergency situations for planning purposes.
»» Provide a feedback mechanism and make recommendations to the City/
Municipality on the submitted reports.
»» Monitor and evaluate the implementation of the management of SAM in the
province.
»» Conduct periodic consultative meeting and refresher course to the local health
systems.
»» Provide the RPMT with results of rapid nutrition assessment of LGUs affected
by emergency/disaster.

►► The Mayor shall appoint an individual to be responsible for the SAM

treatment program within his/her municipality
»» Conduct training on active screening and nutrition education of the Rural Health
Midwives (RHMs) and BHWs/BNSs at the municipal level.
»» Conduct active screening (organized by the C/MNAO) involving the BHWs and
BNSs.
»» Integrate the systematic measurement of MUAC and checking for edema into
the routine schedule for Operation Timbang (OPT), Garantisadong Pambata
(GP), routine immunization (EPI) and maternal and child care consultations.
»» Lead and monitor PIMAM implementation.
»» Conduct of active screening and registration of eligible children.
»» Use of the approved and updated protocols for the treatment and referral of
City/Municipal patients with SAM.
»» Secure availability of adequate supplies for the management of SAM from the
Nutrition Councils
province and properly distributed to the OTCs and ITCs.
(Chaired by City/
»» Set schedule for the submission and collation of monthly stock reports and
Municipal Mayor) statistical data to be further submitted to the provincial level.
»» Analyze and evaluate monthly statistical data in terms of the degree and
change in nutritional state of the barangay and of the municipality and the
reliability of the data collected.
»» Provide a feedback mechanism and make recommendations on the submitted
reports.
»» Provide necessary refresher course to the management team and the OPT
(and ITC only in the existence of a municipal hospital in special situations such
as in the geographically isolated and disadvantaged areas).
»» Utilize the existing referral system to its full extent to support the functional
service delivery network.
»» Advocate to Barangay Captains for the formation or strengthening of Barangay
Nutrition Committees in their City/Municipality.

80 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
6.6 Roles and Responsibilities of Program Implementers

Program Implementer Roles and Responsibilities

Where funds are available, the C/MNAO should be a full-time post and have
responsibility for all nutrition programs within the City/Municipality under the
direction of the City/Municipal Health Officer. In LGUs where or situations when
they are not the same person, the P/C/MHO and P/C/MNAO should coordinate
with each other regarding the following tasks:

►► In areas where a logistic officer or pharmacist is available, they should

manage supplies in coordination with the Municipal Nutrition Action Officer.
►► Be part of the City/Municipal Health Management Team (HMT) and
coordinate the program for the management of SAM with those responsible
for other health programs and activities within the municipality (e.g.
EPI, IMCI, TB, HIV, MCH, Family Planning and Reproductive Health,
Epidemiology and Surveillance and Health Information Systems).
►► Identify particularly vulnerable villages for additional support in collaboration
with DOH Environmental and Occupational Health Office and FIVIMS under
NNC and DA.
►► Register each facility as part of the program for the management of SAM,
whether it is an OTC site or an ITC, before the site is opened and informs
the DOH of the facility’s registration details.
►► Assess the needs of the program and initiate their procurement for
replenishment.
►► Ensure the flow of therapeutic products from the center to the municipality,
storage at municipal level and then transport from the municipality to the
The City/Municipal OTC (HC) and supply to the ITC.
Health Officer ►► When a new OTC is opened, ensure that all material (tools, RUTF and
(C/MHO) or City/ drugs, etc.) are available.
Municipal Nutrition ►► Conduct in-job training as necessary and train all newly appointed staff.
Action Officer ►► Implement the strategy for Community Mobilization (see Sections 1 and 5).
(C/MNAO) as PIMAM ►► Compile, map and analyze the screening tally sheets (in collaboration with
Manager the Planning and Development Officer) in order to determine the degree
and change in nutritional state at village level and give feedback to the
supervisors of the OTC.
►► Ensure mechanisms:
»» To transfer patients safely between OTCs and ITC
»» To establish mechanisms for information on the individuals transferred to be
passed to the receiving facility through referral forms and/or telephone
»» Feedback to referring facility regarding patient outcome
►► Support coordination and between ITC and OTC through regular (monthly)
meetings.
►► Conduct monitoring visits to provide supervision on the quality of service
provided by all the facilities (ITC and OTC) within the municipality.
►► Identify and recommend corrective actions for problems found during
supervision (using check-lists) for ITC, OTCs, storage facilities, RUTF
stocks and supplies (charts, registers etc.).
►► Organize monthly coordination meetings at municipal level with OTC and
ITC supervisors (reports, supplies of therapeutic products, drugs).
►► Ensure the availability of transport and fuel for monitoring visits/supervision
and coordination meetings.
►► Establish a list of the days of consultation for each OTC in the municipality
with the name and contact phone numbers of the persons in charge and
disseminate this list to all OTC and ITC sites.
►► Ensure the completion of SAM treatment monthly reports by each health
facility.
►► Take the lead in the follow-up and investigation of death cases.

Manual of Operations 81
 Program Implementer Roles and Responsibilities

►► Compile the OTC and ITC Monthly reports (with the Municipal Information &
Statistics Officer) and submit them on time to the Municipal Medical Officer
and the DHMT.
►► Submit the monthly individual and compiled reports to the Provincial/
Regional and National Nutrition Department by the second Tuesday of each
The City/Municipal month.
Health Officer ►► Collate monthly and annual reports with an overview of the program
(C/MHO) or City/ achievements and constraints including survey and screening data and
Municipal Nutrition budgets.
Action Officer ►► Organize an annual meeting at municipal level with all involved with the
(C/MNAO) as PIMAM management of SAM in the municipality including community leaders and a
Manager representative from the National Nutrition Council for a presentation of the
annual report and discussion of planned changes. Minutes of the meeting
are submitted to provincial, regional and national levels.
►► Facilitate activities of BNS and BHW for the management of SAM.
►► Liaises with any other agencies or NGOs that collaborate in the
government’s program for the management of SAM.

The midwife in-charge or Nurse-in-charge of the Health Center/OTC works in

coordination with the MNAO and under supervision of the MHO.

►► Train the BHWs and BNSs on how to conduct systematic screening using
MUAC tapes and examination for bilateral edema done during Operation
Timbang, Garantisadong Pambata, Maternal and Child Care Consultation
and other health/nutrition-related activities.
►► Assign BHWs and BNSs their specific areas for screening.
►► Coordinate with the BHWs and BNSs on management of SAM activities at
each visit to the BHS.
►► Where trained staff and equipment is available and staffing and caseload
allow, also measure weight for height.
►► Train the BNS/BHW how to conduct the appetite test for RUTF.
►► Supervise and validate data entry in the registers and OTC charts.
Midwife and Public
►► Take the lead in the overall supervision of the OTC including medical
Health Nurse
consultation of referred cases, their admission, discharge and appropriate
referral of cases to the MHO and/or ITC.
►► In collaboration with the BNS/BHW, follow up defaulters and non-
responders from treatment. Where possible, integrate these activities with
the other community-based activities (OPT, GP, maternal and child care
consultation).
►► Submit monthly statistics and logistical reports to the MHO.
►► Meet the BHWs and BNSs regularly (every two weeks) to collect community
information, provide feedback and address any difficulties that arise (e.g.
logistical and technical issues related to the management of SAM).
►► Participate and facilitate community mobilization for the management of
SAM in the community.
►► Start routine medication as described in the guidelines including antibiotics.
►► Supervise the chain management of supply.

82 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
Program Implementer Roles and Responsibilities

Through the supervision of the midwife, the BNS and BHW shall:

►► Health Volunteers to work together in conducting screenings for acute

malnutrition in applying Community-IMCI assessments of children. Refer to
the midwife, PHN, MHO as needed.
►► Perform the appetite test with RUTF, start the OTC treatment and fill-up
OTC treatment card and do any follow-up and home visits as agreed with
the midwife.
►► Lead in the mobilization of peer support groups, caregivers and
sensitization of community leaders about the program for the management
of SAM.
►► Encourage barangay leaders to maintain their involvement in the program
and provide feedback about the program.
►► Perform IYCF counseling especially on feeding practices.
Barangay Health
►► Follow up absentees and defaulters from OTC treatment to encourage the
Workers/Barangay
caregiver to attend. If possible, determine reasons for absence or default
Nutrition Scholars/
and report findings to midwife.
Community
►► Report observations of any problems such as absenteeism, defaulting, lack
Volunteers
of progress in recovery to the midwife.
►► Refer complicated cases to midwife or directly to ITC.
►► Assist midwife in the chain management of supply and logistic.
►► Maintain a strong link between the health center and its services, the
Barangay Nutrition Committee, barangay leaders and other community
groups such as people’s organization, women’s groups, local NGOs and
hospitals/ITC.

Specifically, Barangay Nutrition Scholars shall:

►► Record cases and update OTC registry and inform midwife of admission,
discharges and referrals.
►► Consolidate and submit monthly report to the midwife or health worker
supervising the OTC.

6.7 Roles and Responsibilities of ITC Implementers

ITC Implementer Roles and Responsibilities

►► Obtain the vital information, vital signs, history and anthropometric

ER NURSE measurements
►► Refer to ER Physician for clinical assessment and management

►► Obtain the vital information, vital signs, history and anthropometric

measurements
OPD NURSE ►► Conduct Appetite Test and if ITC criteria is not met, refer or admit to OTC
►► If the child fails the appetite test and ITC criteria is met, refer to ITC
management

►► Conduct clinical assessment, admits the child to ITC and gives appropriate
ER OFFICER / management
ITC DOCTOR ►► Follow up/monitor the patient when in the ward
►► Facilitate discharge from ITC to OTC

Manual of Operations 83
 ITC Implementer Roles and Responsibilities

►► Execute Doctor’s orders and administers medications

►► Coordinate with the doctor regarding the patient’s progress
ITC/WARD NURSE
►► Prepare the Referral Slip and take-home medications/RUTF and liaise with
the OTC facility

►► Prepare and monitors the feeding for the admitted SAM child
NUTRITIONIST/ ►► Give nutrition and IYCF counseling to the caregivers, during ITC stay and
DIETITIAN discharge
►► Supply management

MEDICAL SOCIAL ►► Provide social assistance to the patient

WORKER ►► Follow up the referral to OTC, ensuring the patient is admitted to the OTC

CHIEF NURSE ►► Oversee information management for Reporting, monthly ITC census

84 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
 7. IMPLEMENTATION ARRANGEMENTS

7.1 Introduction

This section complements Sections 3 and 4

of the technical guidelines and describes the
practical implementation arrangements for the
management of SAM.

7.2 Outpatient Therapeutic Care (OTC) for SAM without complications

Location The distance that children and their caregivers

are able to travel will vary depending on factors
The management of SAM through OTC is a such as topography and climate and may show
public health intervention that aims to maximize seasonal differences. Establishing the locations
coverage and access to treatment. The distance of outpatient services for the treatment of SAM
and the cost/time to travel to obtain care can have should provide access of the majority of cases
a major effect on access to services. As such, to treatment through use of the BHS or BHC at
outpatient services should be decentralized as barangay level, but access to care and treatment
far as possible to Rural Health Units (RHUS) and coverage for communities located far from a
Barangay Health Centers/Stations (BHC/BHS). health facility may also be improved through
adapting the mechanism of service delivery.

Manual of Operations 85
 Structure Doctor/Medical Officer: Shall see cases of SAM
only once on admission and subsequently, if there
Outpatient treatment services are centered on the are medical problems arising or the patient does
RHU and BHC/BHS. Normally, the health officer, not respond to care. Cases with SAM should
midwife, or nurse will supervise the care from be seen in clinics along with children with other
these treatment centers every one to two weeks, needs/ illnesses.
although the monitoring of recovery and delivery
of RUTF to patients need not be limited to these Midwife/Nurse: Shall be primarily responsible
physical structures and may be mediated through for monitoring recovery and should see SAM
the BHW and/or BNS. cases during routine visits to the RHU/BHS
for the delivery of other services. Children are
The RHU should allot sufficient space to store required to be followed up on once per week at
boxes of RUTF that may then be dispensed to the beginning of treatment and when recovering
the BHS or directly to the caregiver as required. well, may be followed up on every two weeks.
Where space allows, the storage of RUTF
may be done through the pharmacy, provided BHW/BNS: Shall assist the midwife/nurse in the
that the pharmacy’s opening hours provide delivery of care and may be requested to follow
sufficient access to RUTF as needed. Under up on children at home in between visits to the
normal circumstances, the number of cases BHS. These home visits are normally limited to
of malnutrition will be relatively low, such that cases not responding to treatment, being absent
medicines should be handled through the normal from follow-up visits or those recently discharged
pharmacy storage facility. There should normally from inpatient care. See Annex 49 for detailed
be a very limited requirement to store RUTF and role requirements.
medicines at BHS level. Refer to Section 8 for
details regarding logistics and storage. Requests for increased staffing should be made
with respect to the delivery of priority services
Where caregivers and children attend the RHU and will rarely be required for the management of
or BHS for follow-up visits during recovery, there acute malnutrition alone.
should be adequate shelter to protect them from
adverse weather conditions (heat or rain). Tools and Materials

The monitoring of treatment requires the Materials required specifically for the identification
measuring of weight (ideally done with the and treatment of SAM are listed below;
patient undressed). Where possible, a private
area (separate room or curtained area) should be Minimum requirements
provided to allow the weighing of patients.
►► MUAC tape with appropriate coloring and
Unless indicated by high patient loads or for cut-offs
more efficient service delivery, there is no need to ►► Spring-type Weighing scale accurate to within
allocate specific days or rooms for the treatment 100g
of children with acute malnutrition. They may be ►► 20 to 30 packets of RUTF at each RHU/BHS
seen during regular clinic hours and services available for appetite testing with RUTF
such as ‘under-five clinics’ or ‘caregiver and child ►► 5 to 10 boxes RUTF at the RHU. Typically
health clinics’. one box of 150 packets (net weight = 13.8kg)
Ideally, the structure or staff should be provided will be required for each treatment episode
with communication facilities allowing contact (see Section 8 for details)
between the medical officer and the local health ►► Registry/ TCL for sick children/Family folder
care team or with the hospital staff in case of
the need to transfer cases with complications to Existing requirements
inpatient care.
►► Routine antibiotics (typically oral amoxicillin –
Staffing one bottle per treatment episode)
►► Registry/ TCL/Family folder
Outpatient treatment services for SAM are ►► Patient treatment record/OTC monitoring
normally implemented within the existing capacity card
of the RHU/BHS. Except in times of emergency, ►► Referral slips
which may require increases in support staffing, ►► Drinking water
there is no requirement to employ specific staff ►► Soap/water for washing hands
for treating cases of SAM. ►► Thermometer
►► Stethoscope (only for clinicians. Not required
to identify danger signs at BHS level)

86 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
Other (or “supplementary”) Initiation of treatment
requirements
Treatment with routine medicines and RUTF
►► Length-Height board (used where staffing and should be initiated as soon as possible after
facilities are available - typically only at RHU) identification. There is no requirement for
– should comply with standard specifications treatment to be delayed in order to ‘validate’
set by the National Nutrition Council measures of MUAC/edema made by community-
►► Child Growth Standards (CGS) charts for based staff (BHW/BNS). It should be ensured
Weight-for-Height /length (WHO, 2006) - only that the staff at various levels are capacitated to
where weight-for-height is used perform the tasks required and that LGUs support
►► BMI for age charts (only where height is the task allocation through updating the relevant
measured and treatment is offered) to children job descriptions.
aged 5 - 19 years)
►► BMI tables for adults where treatment Where RUTF is available and community-based
services are offered for this age group staff are able to assess the appetite for RUTF,
treatment should be initiated as soon as possible
Organization of Services after identification. The midwife should be informed
of the initiation of treatment at the earliest possible
Identification of cases of acute opportunity.
malnutrition
Where the midwife/nurse is not available to
Acute malnutrition may be identified through three make an immediate assessment, children who
independent measures: are obviously sick (e.g. based on IMCI) can be
referred directly to the doctor/medical officer by
►► Mid-Upper Arm Circumference (MUAC) the BHW/BNS in the same way as other sick
►► Bilateral pitting edema of the feet children who do not have SAM. For children
►► Weight-for-height with appetite and no obvious concurrent illness,
treatment with RUTF may be started and the
Children with MAM and SAM are primarily formal clinical assessment and administration
identified in the community setting through the of routine antibiotics may be delayed until the
integration of MUAC and edema measurement next scheduled visit of the midwife/nurse (up to
into routine services both at the community and a maximum of one week). The BHW/BNS should
health service delivery units. perform a follow-up visit at home every two to
three days until the child is seen by a midwife/
Community-level screening and identification nurse/clinician up to a maximum of one week (see
of malnutrition is discussed in Sections 1 and 5. Figure 12).
The measurement of MUAC and checking for the
presence of edema should be done systematically
on ALL children attending ALL treatment services.
Weight-for-height may also be used to identify
cases of acute malnutrition not identified by MUAC
or edema. It is NOT necessary to use weight-for-
height to ‘confirm’ a case identified using MUAC
or edema. Each of these measures indicates
acute malnutrition independently and may identify
different children.

Manual of Operations 87
 Figure 12. Algorithm for identification, initiation of treatment in OTC and referral for SAM

Child is identified with

acute malnutrition

MUAC 115 - 125mm

MUAC less than (11.5 - 12.5cm)
115mm (11.5cm) (RED) (YELLOW)
OR AND
Edema is present Edema absent

• Refer to MAM program

• No IMCI danger • IMCI danger sign
• Refer to IYCF
sign present is present
counseling
• Good appetite for • No appetite for
• Refer to Midwife for
RUTF (PASSED) RUTF (FAILED)
clinical assessment

Are there any minor

illnesses (obvious or
Refer to ITC and inform
reported by caregiver)
Midwife
that require medical
treatment?

Yes No

• Start treatment with RUTF

• Start treatment with RUTF
• Inform Midwife of SAM
• Refer immediately to
case and request clinical
Midwife or CHO/MHO for
assessment/routine
clinical assessment
medicines at next visit*

* If Midwife is unable to perform a clinical assessment within 48 hours of starting treatment with RUTF, a home visit must be made by
the BNS/BHW every two to three days until the Midwife completes the clinical assessment up to a maximum of one week. If the clinical
assessment cannot be completed within one week, the child must be referred to the health center.

88 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
Follow-up treatment (refer to Figure 13) If the child at the BHS/RHU:

Children will normally be identified and receive ►► Fails the appetite test
treatment services through the BHS and RHU ►► Has any IMCI danger sign
under the supervision of the midwife/nurse.
The child must be referred immediately to ITC.
The midwife/nurse/clinician in collaboration with There is no requirement for review by a doctor
the BHW/BNS should identify the best method at the RHU where such a review may delay the
of service delivery. Normally this will require the initiation of emergency care.
caregiver to bring the child to the BHS/RHU to
coincide with scheduled visits of the midwife/ Discharge
nurse every one to two weeks. In rural areas with
difficult access, service delivery may be modified Children may be discharged from care by the
in exceptional circumstances, such that the child’s midwife/nurse when discharge criteria have been
recovery is monitored in the community by the met for two consecutive visits (refer to technical
BHW/BNS. guidelines).

The first follow-up visit for clinical assessment Exceptional care

is ALWAYS made after one week, following the
initiation of treatment. In some exceptional circumstances, access to
routine follow-up by a clinician may be very difficult
If the child assessed at the BHS/RHU: for the caregiver and child. It is preferable to allow
access to care rather than the child default from
►► Has good appetite for RUTF (passes the treatment. In such circumstances and where no
appetite test) mobile team is available, the BNS/BHW may
►► Is gaining weight monitor the child’s progress at home, provide
►► Has no reported illnesses requiring treatment RUTF and subsequently discharge the child from
►► And the clinician agrees to biweekly follow-up care without clinical review only with the express
permission of the responsible medical officer. This
Subsequent follow-up visits may be made may only be implemented if:
every two weeks. The clinician should note this
decision in the child’s clinical record. If at any ►► The BNS/BHW have been trained in the
visit the criteria stated above are not met, the recognition of IMCI danger signs
clinician must review the child weekly. If the twice- ►► The BNS/BHW are able to perform the
weekly clinician follow-up is used, the BNS/BHW appetite test independently
must perform a home visit in between clinical ►► The BNS/BHW can perform a weekly home
assessments. visit
►► The BNS/BHW can contacts the clinician
Children should be given any medicines required responsible by telephone after each weekly
by the protocol, sufficient RUTF to last until the home visit
next follow-up visit and referred to any required ►► The clinician responsible agrees and
complementary care services. documents the decision to delegate
responsibility to the BNS/ BHW
If the child assessed at the BHS/RHU: ►► Adequate supplies of RUTF are available
►► Has not gained weight for two consecutive
visits When cases are monitored and discharged
►► Has reported illnesses requiring medical under these exceptional arrangements, each
treatment individual case must be reported, by the clinician,
to the relevant nutrition committee at monthly
The child should be referred to the doctor/medical coordination meetings.
officer for review.

Manual of Operations 89
 Figure 13. Algorithm for follow-up care in OTC

Child enrolled in OTC

Child referred to ITC for treatment of SAM

• Follow up child at home after 7 Within the first 7 days of enrolment, has the
days child:
• If child has not returned from ITC
inform the midwife/medical officer Received a clinical check up from the
• If child has returned from ITC midwife or medical officer?
ensure child has RUTF and AND
continues treatment in OTC Received routine antibiotics?

Yes No

After 1 week or after return from ITC:

Does the child have a good appetite?

AND/OR
Are IMCI danger signs absent?

Refer to RHU to medical

Yes No officer for further assessment/

treatment

Yes
Measure MUAC & weigh the child:
Has the child gained weight this week?
No Has the child lost weight for 2
consecutive visits?
OR
Yes Has the child’s weight been
the same for 3 visits or more?

Has the child reached discharge criteria

for 2 consecutive visits? No

No Yes

• Give routine medications for OTC as

required
• Give RUTF for 7 days according to • Discharge child from OTC
weight • Complete the register/treatment
• Give RUTF key messages as required record
• Ask the caregiver to return in 7 days • Give IYCF counseling as required
• Complete the register/treatment • Ensure vacci10nation schedule is
record updated
• Give IYCF counseling as needed • Ensure referral to appropriate
• Ensure vaccination schedule is
updated

90 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
Use of Mobile Teams to complementary health and social services
that will continue the child’s healthy growth and
A mobile team may be assembled in order to development and mitigate the risk of relapse. Such
deliver health services to remote areas with little services may include (depending on availability):
or no access to health centers and no appropriate
mechanism of follow-up in the community is ►► IYCF counseling through the BNS/BHW/
available or feasible. The use of mobile teams Midwife at the BHS
should integrate the treatment of acute malnutrition ►► Micronutrient supplementation following
with the delivery of other health services. The national guidelines
team will require all of the essential and existing ►► EPI childhood vaccinations through the
equipment defined earlier in this section for Midwife/Rural Health Nurse/Physician at the
the delivery of treatment for SAM. The use of BHS/BHC
mobile teams may be scaled up in an emergency ►► Pantawid Pamilyang Pilipino Program (4Ps)
depending on the identified need. ►► Facilitate enrollment of father or caregiver in
PhilHealth indigent program if needed
For the purpose of a mobile OTC, a mobile team ►► Supplementary Feeding Program (if available)
will typically require: ►► Food security programming (If available)
►► Caregiver support groups, Promotion of
►► Driver Good Nutrition, routine growth monitoring
►► Midwife/Nurse (to administer protocol through the OPT and Social welfare
medicines/complete treatment record) programs such as Sustainable Livelihood
►► BNS/BHW (for measurements, assisting with and Pantawid Pamilyang Pilipino Programs
appetite test and other health/nutrition related (if eligible), Kapit-Bisig Laban sa Kahirapan-
activities) *one to two measurers (one if Comprehensive and Integrated Delivery of
MUAC only is used, two if weight for height is Social Services (KALAHI -CIDSS) and Self-
also measured) Employment Assistance-Kaunlaran (SEA-K)
Program)
Linkage with Other Services
(Community Mobilization/Referral/ The treatment of SAM is most importantly linked
Post Discharge to other health and nutrition services at the BHS/
Follow-up) RHU level. Families from poor households should
also be referred to the social worker to determine
During treatment and certainly following if beneficiaries may satisfy the DSWD targeting
discharge, the child with SAM should be referred criteria for the 4P’s program.

7.3 Inpatient Therapeutic Care (ITC)

Inpatient treatment for SAM is offered to those monitoring and supervision, the ideal distance
children with: from the ITC to the furthest OTC site should
be less than four hours. As much as possible,
►► Anorexia (fails the appetite test for RUTF) this transport time should be minimized as it is
►► Complications (serious medical conditions, generally the cases of SAM with life-threatening
e.g. IMCI danger signs) complications that require referral to ITC.
►► Children referred from OTC
►► Severe (+3) edema or a combination of Structure
edema and severe wasting
►► All children with SAM where no outpatient Typically the structure for the ITC will be provided
facilities exist within the hospital setting and allow for the
►► Children younger than 6 months with SAM separation of the different phases of SAM care.
If space and staffing allow, the ITC should be
Location separated from the pediatric ward since SAM
patients with complications often have poor
Ideally, the hospital should provide good access immunity and are highly susceptible to cross-
from the catchment areas where outpatient infection. This is particularly important for children
services for SAM are located. As such, the ITC in Phase 1 or Transition Phase care.
will typically be located at the District, Provincial,
or Regional DOH hospitals. For the purposes of

Manual of Operations 91
 which can then be distributed at a later time,
may reduce the workload of staff at night.
Box 23. Typical provisions for an This arrangement may only be used in
ITC unit facilities where the therapeutic milk can be
refrigerated.42 A more practical alternative to
using F100 therapeutic milk in Phase 2 is to
►► Pediatric care spaces which conform to the use RUTF. Children in Phase 2 who cannot
Baby-Friendly Hospital Initiative guidelines be discharged to an OTC can be cared for
►► Storage area for medical/nutritional supplies on a standard pediatric ward as they are less
►► Preparation area for therapeutic milk vulnerable than children in Phase 1 and the
►► Privacy for caregivers (especially when Transition Phase, can eat RUTF and require
breastfeeding) less supervision.
►► A screened area for weighing/assessing 2. Day care ITC units: This arrangement
children should be used only as a very short-term
►► Adequate cooking facilities for caregivers temporary measure where staffing does
►► Adequate toilet/bathroom facilities for not allow 24-hour care. The schedule of
caregivers treatment of children in Phase 1 should
►► Children’s play area with age-appropriate toys minimize the time between the last night
feed and first morning feed of therapeutic
milk. Children in Phase 1 should be fed at
intervals no greater than six to eight hours at
night and must be closely monitored during
the day to ensure that ALL of the therapeutic
In areas of high inpatient caseload or in emergency milk has been taken.43 Children in Phase
situations, the problem of low bed availability or 2 can use RUTF and be monitored on an
poor staffing should first be addressed through the outpatient basis.
establishment of OTC in the outpatient department
of the hospital and at RHUs and BHSs. The OTC Child deaths in ITC typically most frequently occur
should also provide skilled IYCF counseling for at night. The use of day care for children in Phase
caregivers with infants younger than six months 1 with no supervision overnight should never
for whom RUTF is not suitable. be used as a standard form of care. Hospitals
and other health facilities should abide by
In areas where OTC services are extensive and administrative orders requiring minimum staffing
access to the District, Provincial, or Regional levels at all times.
hospital is poor, decentralized ITC care can be
established at RHUs with adequate facilities, staff Where no OTC facilities exist in the community,
and training. In emergencies, it is possible to set children requiring Phase 2 care and who have
up ITC treatment facilities in temporary structures appetite for RUTF may be discharged from
such as tents; however, this need for the treatment inpatient care and treated in the OTC established at
of SAM is unlikely in the Philippine context. the hospital. If the caregiver lives a great distance
from the hospital, compliance with treatment as
Arrangement of Services an outpatient until cure may be facilitated by:

The arrangement of services depends largely on ►► Providing local accommodation allowing the
the facilities and staffing which are available. Child caregiver to remain in the local area
mortality during inpatient care typically occurs at ►► Requesting the attendance of the caregiver at
night as a result of poorly implemented feeding the hospital based OTC every two weeks and
schedules, poor staffing and rotation of staff with provide assistance with transport costs
limited skilled supervision. The implementation of
ITC with reduced hours or staffing (particularly at See “Arrangement of services – Exceptional
night) should be implemented only as a temporary care” in the OTC subsection of Implementation
measure as a necessity (e.g. in emergencies). Arrangements in this operations manual.

1. 24-hour inpatient hospital care: This is the

ideal arrangement that allows for therapeutic
feeding every two to three hours for children
in Phase 1 and Transition Phase that may
be particularly vulnerable. Preparing the
therapeutic milk night feeds during the day,

42 Therapeutic milk should be used within two hours at room temperature or may be kept for a maximum of 16 hours if refrigerated.
43 The risk of nocturnal mortality in Phase 1 due to hypoglycemia may be reduced by ensuring that the whole ration of therapeutic milk has been
taken during the daytime feeding schedule.

92 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
Staffing

►► All ITC medical and nursing staff must be

trained in SAM treatment protocols before
managing SAM patients. The personnel of the
ITC, the OPD and the emergency ward should
be trained in the National Guidelines for the
Management of SAM and undergo retraining
regularly.
►► There should be a minimum number of clinical
staff plus an appropriate number of care
assistants assigned to the ITC unit on every
shift according to the bed capacity of the
hospital.44 (AO -2012 -0012)
►► Senior nursing or medical staff should not be
rotated at the same time as junior staff. Staff
rotation and inadequate supervision of junior
staff may lead to increased child mortality. Record-keeping

Materials

Anthropometry Box 25. Requirements for

record-keeping in ITC

Box 24. Anthropometric ►► The registration book (Annex 50). A separate

register is kept for malnourished patients.
requirements for ITC
►► The Inpatient Therapeutic Care chart (Annex
27) is the primary tool used in ITC. Other
►► MUAC tape charts should not be used. Medical and
►► Weighing scales accurate to 100g (for nursing staff use the same multi-chart to
children 6 - 59 months) record all the information needed to manage
►► Weighing scales accurate to 10g (for Children the malnourished patient – separate charts
younger than 6 months) are not used by different categories of staff.
►► Height board accurate to nearest 1mm ►► The Critical-Care chart (Annex 51) is used
►► Weight for height charts (WHO 2006, for for patients with complications who require
children 0 - 59 months) more intensive monitoring during the
►► BMI for age charts (WHO 2006, for children acute treatment of the complication (e.g.
aged 5 - 19 years) hypovolemic or septic shock, hypothermia).
►► ITC Monthly report form
►► Referral forms (from ITC to OTC)
DIET

Box 26. Dietary Requirements Medicines

in ITC

►► Pre-packaged F75 Therapeutic Milk

►► Pre-packaged F100 Therapeutic Milk Box 27. Medicine requirements
►► Therapeutic Milk look-up tables for ITC
►► Pre-packaged RUTF*
►► Pre-packaged ReSoMal ►► Routine intravenous/oral antibiotics (1st and
►► Cups 2nd line)
►► Nasogastric tubes (Size 5 - 8) ►► Deworming medication
►► Mixer ►► Anti-malarials
►► Drinking water ►► Furosemide
►► Sugar ►► Intravenous fluids, Intravenous glucose,
►► Measuring jugs Intravenous magnesium sulfate

* RUTF should be available in the Emergency Room and Outpatient Department for the purposes of appetite testing.

44 Revised Organizational Structure and staffing standards for Government Hospitals CY 2013 Edition (AO 2012-0012)

Manual of Operations 93
 Equipment

Box 28. Equipment requirement in

ITC

►► Thermometer
Examination equipment ►► Stethoscope
►► Otoscope

►► National Guidelines for the Management of SAM

►► IYCF counseling materials
►► IEC material for health education
►► Age-appropriate toys
►► Beds for caregiver and child (cots should not be used in Phase 1
Other items/ equipment particularly)
►► Impregnated bed nets (for malaria endemic areas)
►► Soap
►► List of OTCs and operating schedules
►► Kitchen equipment for making/refrigerating therapeutic milk
►► Kitchen equipment & eating utensils for caregivers

Linkage of SAM treatment with Referral forms are normally given to the caregiver;
Other Services however, this does not necessarily imply that
the caregiver will be compliant with the referral.
Strengthening of SAM treatment In addition, the midwife/doctor supervising the
service linkages child’s care at the OTC should:

The treatment of SAM provides a continuum ►► Liaise with the referral health facility or
of care. Through this program, children with hospital by phone/fax/email to advise them of
SAM no longer need to go to the hospital for transfer
treatment. However, providing treatment in the ►► Request a BNS/BHW to follow-up the
community brings extra responsibilities in terms of caregiver in the community after referral to
maximizing compliance with treatment, ensuring check on compliance
that children are referred smoothly between the
treatment components when necessary and that If the caregiver has accepted transfer from OTC
onward care after cure is provided to prevent but has not returned for further care, a BNS/
future relapses. BHW should perform a home visit within a week
to follow up on the child and encourage a return
Advocacy should be conducted for standardized to the treatment program if they have not already
referral forms for community workers referring done so.
children to health facilities and between health
facilities. Until such forms are available, the If a caregiver has refused transfer, the BNS/BHW
referral forms currently used in various regions shall advise them that the child’s health is at risk
for referral should be adapted to include the but that, as a minimum, treatment should be
measurement of MUAC and other information continued as an outpatient.
relevant to the treatment of SAM. The MUAC
reading and other information may be indicated Linkages to other Health and
under the ‘Complaints’ section of the referral form. Nutrition services
These may be used where no referral forms
currently exist (e.g. during emergencies). Care during treatment for SAM may involve
However, standard hospital referral forms (and accessing other services, which enhance the
referral from hospital to RHU forms) may be used wellbeing of the child and assist in preventing
provided the relevant information is presented relapses in the future.
(see technical guidelines).

94 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
Some of these services are as follows: be referred to OPT for growth monitoring if not
already enrolled. Caregivers of OTC discharges
Wet Nursing/Cross Nursing/Milk bank: Children should also be encouraged to participate in local
younger than six months may, in some GP activities and receive vitamin A and deworming
circumstances, benefit from prescriptions of breast appropriate to age.
milk obtained from a wet nurse or a milk bank.
Guidelines on milk banking should be consulted Micronutrient supplementation: Micronutrient
for details. supplementation may be recommended by the
clinician but only after discharge from treatment
EPI: Children who have not completed the with RUTF. Giving micronutrient supplementation
schedule of childhood vaccinations should either during treatment with RUTF may interfere with the
be provided with the vaccinations where the nutrient balance required for proper recovery. After
vaccines are available or be referred to the next discharge from treatment for SAM, micronutrient
EPI session in their local community. supplementation of complementary foods is
recommended.
OPT/GP: Children discharged from OTC should

Manual of Operations 95
 8. LOGISTICS AND SUPPLY MANAGEMENT

8.1 Introduction

The provision of sufficient and consistent supplies Adequate supplies promote positive impressions
of diagnostic equipment, medicines and RUTF of the CMAM service in the community, improving
are essential pre-requisites for implementing participation and adherence to treatment, which
quality CMAM services at the community level. leads to reduced child mortality from SAM.

Figure 14. Management cycle for medicines and nutrition supplies

Quality Quality
monitoring
Product selection monitoring

Management Support systems:

• Information system
Rational use,
• Organization and Infrastructure Quantification
monitoring and
• Human resources and Procurement
evaluation
• Planning and budgeting
• Training and supevision
• Monitoring and evaluation

Inventory
Quality management, Quality
monitoring storage, and monitoring
distribution to the
next level

Policy, legal and regulatory

framework

96 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
8.2 Relevant Policies

The relevant policies listed below are based on DOH Regional Offices shall deliver the
existing Laws and Administrative Orders and commodities to the PHOs/CHOs. PHOs and
established systems on Logistics Management CHOs shall ensure the prompt delivery of the
and Procurement. commodities to RHUs/HCs.

1. The overall management of all drug supplies 8. Disposal of expired and damaged medicines
and diagnostic supplies and the development and nutritional supplies shall follow the
and dissemination of corresponding policies government rules and regulations.
and guidelines shall be the responsibility of
the DOH with the support of the Materials 9. The DOH Regional Offices shall be
and Management Division (MMD/DOH) and responsible for the reproduction of all
the local government units (Table 17). forms used in the treatment of SAM to be
distributed to PHOs/CHOs, RHUs.
2. The local government units shall ensure that
policies and guidelines for SAM treatment 10. LGUs shall set aside funds for the
supplies management are implemented emergency procurement of sufficient
properly at their level. They shall also actively quantities of drugs and nutrition supplies
participate in the monitoring and evaluation in times of impending shortage to ensure
of the implementation of these policies and continuous availability of SAM treatment
guidelines. commodities at their service delivery points.

3. DOH shall ensure that medicines and

nutritional products selected for the use
of the program is in accordance to WHO
international guidelines, National Guidelines
for the Management of SAM, registered
with the Philippines FDA and included in
the national formulary. The DOH, with the
support of FDA, shall ensure the quality of
supplies used in the program.

4. Quantification and ordering shall be based

on utilization rate, projected increase of
cases due to strengthened case finding
and provision of buffer stocks. RUTF buffer
stocks should be maintained at 20%.

5. Procurement of SAM treatment supplies

at the national and local government level
shall follow the “Government Procurement
Reform Act” or RA 9184 and the DOH
policies, guidelines and standards for the
procurement of supplies.

6. Medicines and nutrition supplies shall be

stored under appropriate conditions and
accounted for through proper recording and
reporting. Stock status should be reflected
in the National Online Stock Inventory
Reporting System (NOSIRS).

7. The DOH Regional Offices, PHOs and

CHOs shall ensure that drugs and diagnostic
supplies are promptly distributed to the next
level. The DOH central office shall deliver the
commodities to the DOH Regional Offices.

Manual of Operations 97
 Table 17. Management component and responsible unit for managing
SAM treatment commodities
Component Responsible Unit

Selection National Program Management Team (NPMT)

National level for national procurement
Procurement
LGU for local procurement
Allocation:
DOH Regional Office, PHO and CHO
Distribution
Distribution:
MMD, DOH Regional Office warehouse and PHO/CHO warehouse
DOH MMD, DOH Regional Office Warehouses, PHO warehouses
Storage
RHUs
Use RHU/BHS, hospitals

8.3 Considerations in Supply Chain Management

The availability of RUTF at the point of service

delivery is absolutely vital to the successful
Box 29. Considerations in Supply
treatment of children aged 6 - 59 months with
SAM. Chain Management
The supply requires careful management at
each point in the chain. Some considerations are ►► Time taken from order to delivery of stock
identified to the right (see Box 29). ►► Cost of commodities
►► Storage capacity
►► Buffer stock requirements
►► Seasonal fluctuations of SAM
►► Emergency or integrated program
►► Start-up or existing program
►► Efficacy of stock management system
(particularly reordering of stock at point of
service delivery)

8.4 Procedures

The estimation of supplies and medicines

required annually is made from the most recent
National Nutrition Survey data or, if available,
localized prevalence estimates (e.g. from Nutrition
Surveys). The requirement should be based on
the lowest level of data available, i.e. Region/
Province/City or Municipality.

Estimation of Supplies CASELOAD = N x P x K x C

Annex 54 details how the formula
‘Caseload45 = N x P x K x C’, based on a series of
indirect estimates, assumptions and the country’s
current context and capacities, was derived to help
in estimating the number of SAM cases which in
turn can help estimate the RUTF needs.

45 Case load = N × P × K × C (N = size of population aged 6 - 59 months; P = estimated prevalence of SAM; K = correction factor to account for
incident cases over a period of 1 year; C = mean program coverage in 1 year). For startup programs, the following values can be used to estimate SAM
Caseload in the Philippine Context: K = 1.6 and C = 50%. For continuing programs, the various factors (N, P, K and C) may be based on available data
from coverage or nutrition surveys or databases.

98 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
 Table 18. Estimation of supplies required for SAM treatment

Globally Recommended Units for

Supply Calculations
Treatment per Child
SAM Caseload: Total Population x
Outpatient and Inpatient 12.15% x SAM Prevalence x K x
Therapeutic spread, sachet Therapeutic Care Requirements Coverage
92g/CAR-150
1 carton/child # of RUTF Cartons Needed = SAM
Caseload
Inpatient Therapeutic Care SAM Caseload46 x (Estimated or
Requirement actual rate of complicated cases)
F-75 therap. diet, sachet,
102.5g/CAR-120
12 sachets/child; 120 sachets in # F-75 Cartons Needed: (SAM
one carton Caseload X 10%47 X 12)/120
Inpatient Therapeutic Care SAM Caseload45 x (Estimated or
Requirement actual rate of complicated cases)
F-100 therap. diet, sachet,
114g/CAR-90
4 sachets/child; 90 sachets in one # F-100 Cartons Needed: (SAM
carton Caseload X 10%46 X 4)/90
SAM Caseload4545 x (Estimated or
Inpatient Therapeutic Care
actual rate of complicated cases)
ReSoMal,42g sachet for Requirement
1 liter/CAR-100
# ReSoMal Cartons Needed: (SAM
0.2 sachets/child
Caseload X 10%46 X 0.2)/100
Outpatient and Inpatient
MUAC, Child 11.5 Red/PAC- Therapeutic Care Requirements # of MUAC Packs = 10 packs X
50 Number of RHUs/Hospital
10 packs per RHU/Hospital
Outpatient and Inpatient
Amoxici.pdr/oral sus 125mg/ Therapeutic Care Requirements48 # of Amoxicillin bottles Needed:
5mL/BOT-100mL SAM Caseload X 1.5
1 - 2 bottles per SAM child
Mebendazole 500mg
Outpatient and Inpatient
chewable tabs/PAC-100 # of Mebendazole/Albendazole
Therapeutic Care Requirements
Or Packs Needed: (SAM
Albendazole 400mg tabs/ Caseload)/100
1 tablet/child
PAC-100

Acute malnutrition typically shows seasonal of requirement according to nutrition survey data
fluctuations. It is important to remember that should be checked against local wasting and
the calculation is only an estimate. For start- severe wasting data on OPT. If the numbers of
up programs, the correction factor, K, can be cases identified in OTC within a catchment area
assigned the value of 1.6 while the Coverage, C, are greater than the numbers identified by the
can be assigned the value of 50%. Both values are prevalence of the nutrition survey this number
conservative enough for estimating initial RUTF should be used as the ‘prevalence’ (B) in the
needs to be procured in the startup year. However, calculation above.
once nutrition survey data or programming data
are available, the values should be reviewed and If stocks requirements are overestimated, there
revised quarterly based on actual caseloads. may be a need to recall RUTF for redistribution
to other areas prior to expiry of the shelf life.
The number of cases identified in a catchment RUTF which is within three months of its stated
area may be variable depending on the quality of ‘Expiry’ or ‘Best Before’ date should be recalled
screening services to identify SAM. Calculations for redistribution.
46 6 - 59 month children from outpatient care programs. If there is no outpatient program the hospitals should continue using their current supply
routines but could be supplied with an amount of RUTF to treat children >6 months in Phase 2.
47 For start-up calculations, 10% can be used to estimate complicated SAM cases.
48 SAM child with Complications may require other systemic antibiotics.

Manual of Operations 99
 Request and Issuance of Supplies 1. Present duly accomplished Requisition and
by CHO/MHO Issue Slip (see Annex 56) to the PHO/DOH
Regional Office for Approval
Once the respective estimates have been 2. Submits Requisition and Issue Slip to the
calculated, the CHO or MHO will then follow the Supply Office
usual government procedures to request for the 3. Accept/receive the supplies
needed quantities of commodities and supplies
(see Annex 55 for example procedure).

8.5 Receiving of Medicines and RUTF

The point person (e.g. PHN) for drug management Step 3 Record discrepancies noted and send
shall perform the following procedures when feedback to the distributing unit. Record the
receiving medicines and supplies delivered to the quantity of good items and quantity of missing or
facility: damaged on the receipt form.

Procedure Step 4 Sign the receipt form. If possible, have

a fellow health worker verify and sign for the
Step 1 Obtain the supply receipt forms quantities received as well.
accompanying the delivery.
Step 5 Keep a copy of and file the delivery
Step 2 Check for the following: quantities for receipt form for your records.
each item listed, check medicine labels for
name, strength and dosage form, and inspect for Step 6 Encode data into NOSIRS or supply
damages and note the expiry dates. database/logbook being used.

8.6 Storage of Drugs and Nutrition Supplies

►► Maintain clean storeroom with regular ►► Store RUTF boxes under recommended
cleaning, prohibit food consumption where storage conditions:
stocks are kept, remove spoiled products and »» Maximum stack height 2.4m
clean affected areas immediately. Perform »» Temp < 40ºC (Keep in a cool shaded
regular inspections to check for signs of theft, room if no temperature monitoring is
pest, water damage, or deterioration due to available)
high humidity. ►► Store RUTF/medicines only on shelves
►► Organize RUTF/medicine boxes so labels can or pallets, never on the floor. Do not
be easily read (product name, batch number, store medicines near the ceiling where
expiry date). temperatures are higher. Do not stack RUTF
►► Promote air circulation in the storage room – higher than 2.4m.
high ceilings with vents; if feasible, install air ►► Check the expiry date on the label. Practice
conditioner, an exhaust fan, or a window or First Expiring First Out (FEFO) to avoid
air vents. Allow more space between shelves. expired medicines/RUTF and wastage. Alert
Leave adequate space (about 10 - 15cm) the CHO/PHO of any stocks which will expire
between the walls and the shelves or stack of within three months.
medicines for better circulation. Monitor and ►► Remove all expired or damaged items from
record daily the temperature in the storage the usable stocks and place in a clearly
area. marked area for such items. Maintain records
►► Keep medicine containers closed to avoid of expired or damaged medicines/RUTF.
exposure to humid air. Light sensitive ►► Return excess medicines to the provincial/city
products must be kept in their original NTP coordinator for redistribution. Record all
packaging and stored in closed cupboard or in items that were returned.
a shady corner. ►► Access to the storage area must be restricted
and those authorized to handle supplies shall
be accountable for their actions. Fit doors with
security locks and install bars on storeroom
windows. Maintain inventory records for
accountability.

100 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
 Box 30. Expiry and Best Before dates

►► Imported RUTF typically has a shelf life stipulated by the manufacturers of 24 months.
►► The shelf life of RUTF is indicated by an “Expiry” date or a “Best Before” date. Both of these measures indicate the shelf
life of the product.
►► Any RUTF product which is within three months of its Expiry or Best Before date must be recalled and redistributed for
use before the shelf life ends.
►► The nutritional composition of RUTF cannot be guaranteed after the shelf life has passed. In emergencies in the
event of extreme shortages there may be requests to use RUTF beyond its Expiry or Best Before dates. This is not
recommended and must only be done after rigorous further testing of the physical and nutritional properties of the
batch of RUTF. The certification and period of extended shelf life must be endorsed by the FDA.

8.7 Maintaining Records for SAM Treatment Medicines

and Diagnostic Supplies

The facility shall maintain proper records for

medicines and supplies to facilitate monitoring of
available stocks and consumption.

1. Maintain and update medicine and nutrition

supplies stock records in order to track:
a. Supplies ordered
b. Supplies delivered (and condition on
delivery)
c. Supplies consumed (First Expiring, First
Out - FEFO)
d. Supplies loaned to another facility or
returned
e. Expiry date(s)

2. Perform a physical stock check at least

monthly to monitor stock levels. Compare
quantities written on the stock records with
the physical amount in storage.

3. Identify any RUTF which will expire within

three months of the stock check and alert
the CHO/PHO (If there is no immediate
requirement at the facility, stocks which
are soon to expire may be returned and
redistributed to other health facilities).

4. Encode and update in NOSIRS/Supply

Database/Logbook monthly.

Manual of Operations 101

 8.8 Rational Use of Supplies

Preparing and administering treatment to patients amounts of medicines and/or RUTF should be
is the focus of all health care activities in the recorded on patient treatment cards and in the
facility. Treatment must be based on the National treatment records, OTC follow-up forms (or ITC
Guidelines for the Management of SAM for milk monitoring card), TCL and Family Folders.
treatment regimens and administration and the

8.9 Stock and Drugs Delivery

Storage facilities are a necessity at municipal the treatment of SAM and an adequate stock of
level to allow at least 20% buffer-stock for the the other materials and tools needed.
therapeutic products and routine medicines for

8.10 Disposal of Expired Products

RUTF which has expired and has not been tested supplies. Disposal methods should conform to the
for an extended shelf life must be destroyed by environmental laws of the Philippines.
incineration, along with other expired medical

102 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
 9. SUSTAINED FINANCING AND REGULATION
FOR QUALITY SERVICES

9.1 Introduction

The provision of quality SAM treatment services The Food and Drug Administration (FDA)
can contribute to a reduction of mortality in children safeguards the delivery of quality RUTF through
younger than five years. The continuous provision the procurement of supplies that have undergone
of services is largely dependent on the available testing and registration. Regulating the price of
resources that the national and local governments RUTF can likewise facilitate the access of clients
can mobilize for the procurement of RUTF. In order to the micronutrient supplements they need.
to ensure this supply, there is a need to exhaust
all possible schemes that could generate funds to As provided for in the 1991 Local Government
finance SAM treatment. In addition, funds are also Code, the LGUs are primarily responsible for the
needed for the following interventions: provision of basic services to their constituents.
Each LGU must be able to mobilize and establish
►► Orientation and training of staff in the financing schemes to support integrated
management of SAM management of SAM interventions in their
►► Regular conducting of prevalence surveys, respective localities. Financing the integrated
preferably with provincial breakdown, management of SAM can be addressed through
as helpful guide in prioritizing areas and the following five (5) tracks that need to be
population groups to be assisted organized and harmonized to ensure more
►► Supply and maintenance of materials and efficient use of resources:
tools (MUAC tapes, weighing scales and
height boards) 1. Budget allocation for health
►► Design and production of IEC materials and 2. Accreditation to PhilHealth Benefit Packages
conduct of other case finding and health (e.g. Outpatient Benefit Package, Inpatient
promotion activities Benefit Package, Malaria Outpatient Benefit
►► Program implementation review and planning Package, Newborn Care Package)
►► Other operational requirements (e.g. transport 3. Establishing local finance schemes
cost of RUTF, monitoring and evaluation, 4. Provision of DOH grant assistance
coordination meetings, etc.) 5. Mobilization of external donors funds

The role of regulations in the provision of SAM

treatment supplies cannot be overemphasized.

9.2 Local Financing

►► Advocate for local officials to allocate budget

for SAM treatment interventions in their
regular and supplemental budget or in their
20% development fund (as a component of a
comprehensive nutrition strategy).
►► Source additional funds from the provincial
governments including contributions from the
barangays.
►► Design and implement other local financing
schemes in support of interventions as long
as it does not deprive or discourage clients
from accessing and availing themselves of
commodities and services.
►► Mobilize funds directly from other officials
or benefactors within and outside one’s
respective jurisdictions; (e.g. local industries,
balikbayans).

Manual of Operations 103

 ►► Include establishment of programs for them to avail of incentives such as access to
the integrated management of SAM as the Performance Challenge Fund and other
requirements for the Department of Interior national performance-based programs. LGUs
and Local Government’s annual awarding of who want to earn the seal should be able
the Seal of Good Local Governance (SGLG). to comply with the minimum requirements
The SGLG monitors and awards LGUs with as described in the guidelines for the
good performance specifically in the areas management of SAM/ Manual of Operations.
of internal financial housekeeping, social ►► Coordinate with other government offices (e.g.
protection, disaster preparedness, business- DSWD, DepEd, etc.) for technical assistance
friendliness/competitiveness, peace and and other contributions they can provide.
order and environmental management. LGUs
who are awarded with the SGLG will enable

9.3 DOH Assistance

The provision of supplies for the management Prioritize procurement for the following
of SAM is a shared responsibility between the micronutrient supplements requirements through
national and the local governments for severe the LGU budget:
acute malnutrition that has reached levels of public
health significance. For this purpose, it is important ►► Therapeutic dosages of vitamin A for those
to become aware of the local government’s role with xerophthalmia or measles
in as far as procurement of commodities for the ►► Coordinate with DOH, DOH Regional Offices,
management of SAM is concerned. Meanwhile, provincial government units and development
one must be able to mobilize the assistance of partners for a rationalized sharing of
the DOH and other development partners to meet resources for the management of SAM
logistic and supply requirements.

Mobilize the following medicines from the DOH:

►► Amoxicillin syrup 125mg/5mL

►► Amoxicillin tablets 125mg/250mg
►► Albendazole 400mg
►► Mebendazole 500mg

9.4 PhilHealth Reimbursements

►► Primary health care facilities that treat SAM »» Inpatient Benefit Package. Case rate
cases may currently avail of PhilHealth amount shall be deducted by the health
reimbursement as malnutrition is included care facility from the member’s total bill,
in the list of medical case rates (Annex 52); which shall include professional fees of
malnutrition is classified under E40, E41, E43, attending physicians, prior to discharge.
E44.1 – although the revision of definitions The case rate amount is inclusive of
and labels (clearly identify as “SAM”) is hospital charges and professional fees of
suggested for PhilHealth in line with recent attending physician.
changes in the understanding of acute »» Malaria Outpatient Benefit Package. The
malnutrition. supply of drugs and medicines for malaria
►► Maximize the different PhilHealth Benefit clients can also be reimbursed through
Packages to help finance needs for the this benefit package from PhilHealth.
management of SAM. The following are ►► To avail of the above packages, one must
PhilHealth Benefit Packages which can be undertake the following:
tapped: »» Ensure that the facility has met and
»» Outpatient Benefit Package. LGUs can sustained the accreditation requirements
use a portion of the 80% of the capitation of PhilHealth.
funds received from PhilHealth to procure »» Advocate among local officials to
additional needs for the management of enroll indigent clients to the PhilHealth
SAM. Indigency Program or sponsor members

104 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
 from the informal sector to make them the ones listed in the Philippine National
eligible for PhilHealth reimbursements. Formulary (PNF) to make these eligible
»» Ensure that the supplies procured are for reimbursement by PhilHealth.

9.5 Resource Mobilization from Development Partners, NGOs and the

Private Sector

Mobilize resources from the donor community and ►► Mobilize the private sector. Negotiate with the
other development partners. employers (e.g. private companies, private
institutions, HMOs, CBAs, etc.) to finance
►► Develop capability or skills in formulating requirements for the management of SAM.
project proposals which can be forwarded to
the donor community for funding support.

9.6 Regulations for the Management of SAM

The overall purpose of regulatory measures in ►► Pricing of supplies for the management of
support of the integrated management of SAM is SAM
to ensure the quality of SAM services provision »» Coordinate with DTI for the regular
by health care providers and ascertain that the monitoring of RUTF in terms of price/
costs of those services are within the reach of cost to improve clients’ access to these
the clients. Regulatory measures that can be products.
promoted among concerned health offices and ►► Support the implementation of other
stakeholders include the following: regulations that indirectly support the
implementation of integrated management of
►► Procurement of quality supplies for the SAM:
management of SAM »» Health facilities meeting the licensing
»» Ensure that procurement of SAM supplies requirements of DOH
adhere to DOH standards. Patronize »» Adherence of health facilities and health
only supplies that have passed the staff to the Milk Code provision
DOH standards and those listed in the »» Compliance of health facilities and
Philippine National Drug Formulary households with the provisions of the
(PNDF). Environmental Sanitation Code
»» Establish own list of essential drugs which
includes RUTF following the technical
specifications recommended by DOH.
»» Ensure that RUTF which is LGU procured
is reviewed for proper certification by local
FDA committee.

Manual of Operations 105

 10. MANAGEMENT OF SAM IN EMERGENCIES

10.1 Introduction

The Philippines is regularly affected by hazards, The Nutrition Cluster is composed of partner
which may develop into emergencies resulting in agencies from government, the United Nations
the destruction of property, services and the loss and non-government organizations all of whom
of life. It is critical during times of emergency to have active roles and responsibilities for ensuring
ensure that sufficient and timely information is preparedness and response mechanisms for
available to enable the safe management of the nutrition in emergencies. The National Nutrition
proper logistical requirements. Council serves as Chair while UNICEF serves as
co-lead. The cluster’s emergency preparedness
Since 2007, the Philippines has adopted the and response actions are guided by documents
Cluster System in responding to disasters and such as the Policy Guide on Nutrition in
emergencies. Under Republic Act (RA) 10121, the Emergencies, the Policy and Implementing
National Disaster Risk Reduction and Management Guidelines on Reporting and Documentation in
Council (NDRRMC) is the designated coordinating Emergencies and Disasters, Policy and Guidelines
body in charge during emergencies and disasters. on Logistics Management in Emergencies and
Responding to emergency public health issues is Disasters and the Nutrition Cluster Emergency
managed by the Health Cluster, which is one of Preparedness and Response Plan.
eight National Response Clusters chaired by the
Department of Social Welfare and Development Coordination during disasters and emergencies
(DSWD). The Health Cluster is further composed is of the utmost importance and it is vital to
of four sub-clusters: Public Health, WASH, Mental coordinate responses through the cluster system
Health and Psychosocial Services and Nutrition. under the NDRRMC. Key staff should be trained
The Department of Health- Health Emergency in Nutrition in Emergencies, Cluster Coordination,
Management Bureau (DOH-HEMB) was initially IYCF-E and Community-based Management
designated as the government lead for each of of Acute Malnutrition among others.49 Other
these four sub-clusters, but responsibilities have emergency-related laws, plans and policies such
since been reassigned. In 2013, the National as the IYCF-E plan, milk banking in emergencies
Nutrition Council was designated as the new and enforcement of the Milk Code (EO51) should
chair of the National Nutrition Cluster (under be supported during interventions related to the
Department Personnel Order 2007 - 2492-A: management of SAM.
“Creation of Health Emergency Management
(HEM) Clusters”). DOH-HEMB still remains as
overall Health Cluster lead (Quad Cluster) and
representative to the NDRRMC.

10.2 Funding Sources for Emergencies

►► Local Disaster Risk Reduction Management In larger emergencies where international

(LDRRM) Funds assistance is requested, resources may be
►► Quick Response Funds available through UNICEF as Nutrition Cluster
►► Calamity Funds Co-Lead and/or through implementing cluster
►► Government QRF partners though normally these are provided
through supplies or human resource support.

49 Trainings available through DOH-HEMB and DOH-NNC

106 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
10.3 Responsibilities during Emergencies

General reporting and coordination requirements If established, the involved PIMAM Management
follow the Policy and Implementing Guidelines on Teams shall oversee the management of
Reporting and Documentation in Emergencies and the program or request technical assistance
Disasters as governed by Administrative Order from higher levels as needed. Coordination of
2012 - 0014 and enshrined in the Health Emergency activities and reporting of results via the Nutrition
Alert Reporting System (HEARS) managed by Cluster are critical responsibilities of the PIMAM
DOH-HEMB which includes Surveillance in Post Management teams (see section below on ‘Areas
Extreme Emergencies and Disasters (SPEED). where SAM treatment is Implemented’ for details).
The SPEED system monitors 21 common causes If Local/Hospital PIMAM Management Teams are
of morbidity during emergencies and disasters, not yet established/non-functional, coordination of
including acute malnutrition. For details on programming for the treatment of SAM should be
SPEED and the activation of SPEED protocols, done through the relevant local authorities and the
the relevant guidelines should be consulted. Nutrition Cluster under the LDRRMC (see section
below on ‘Areas where SAM treatment is not
Under Rule 11 of Republic Act No 10121, the Local Implemented’ for details).
DRRMC takes the lead based on the following
criteria:

1. The City/Municipal DRRMC if two or more Remi nder s

barangays are affected The responsibilities for action following onset of
2. The Provincial DRRMC if two or more cities/ emergency lie with the following:
municipalities are affected
3. The Regional DRRMC if two or more 1. Municipal Health Office/City Health Office - upon
provinces are affected the declaration of a state of calamity by the Local
4. The National DRRMC if two or more regions or National Government; or 

area affected 2. Provincial Health Office - if the emergency is of
regional and/or provincial concern; or 

The Nutrition Cluster at sub-national level 3. Regional Office for Health - if the emergency is of
(regional, provincial, or LGU) will coordinate with regional concern; or 

the Nutrition Cluster at national level to relay 4. Department of Health Central Office - if the
critical information that will determine necessary emergency is of nationwide concern as declared
emergency nutrition interventions as needed. The by the Office of the President or the National
Nutrition Cluster at national level may provide Disaster Risk Reduction and Management Council
cluster coordination and information management (NDRRMC). If the emergency caused the local and
support as well as other assistance as necessary. regional health sector to be non-functional DOH-
CO may take lead.

Manual of Operations 107

 10.4 Scenarios in an Emergency/Disaster

Nutrition Cluster interventions are guided by the Coordination and Information

Minimum Service Package as outlined in the Management
Emergency Preparedness and Response Plan
(Annex 53). The Philippine Nutrition Cluster remains active
throughout emergency and non-emergency
Rapid and Comprehensive Nutrition situations. A Cluster Coordinator and Information
Assessments Management Officer should be designated to
facilitate coordination and IM mechanisms.
The initial rapid assessment aims to determine Assistance provided by local or international
the current risks and possible scenarios in the NGOs should be coordinated through the relevant
immediate post-emergency period. In areas local nutrition clusters and nutrition committees at
where SAM treatment is implemented, the each level and with at national level with the PMT.
increase in resources to ensure continued access Inter-cluster coordination with Food Security,
and to prepare for a possible surge in number of Health and WASH should be established to
cases should be based on whether an increase in ensure the availability of routine medicines,
SAM caseload over the coming weeks to months supportive services and preventive services for
is anticipated (e.g. where the risk of water-borne high-risk areas.
disease, infectious disease outbreaks, or of
prolonged food insecurity is high). A rapid nutrition A stakeholder analysis should be used to
assessment may include case finding for SAM identify specific partners to support the required
cases using MUAC and edema. interventions.

Care should be taken when interpreting results as Choice of intervention

cases of acute malnutrition may have pre-existed
prior to the emergency or may appear to be ‘new An increase in SAM may be prevented through
cases’ where the current SAM case coverage is the implementation of or support for currently
poor. Results may be cross-checked with existing existing programs that prevent the spread of
databases of SAM cases. Results should also be communicable disease and/or preserve the food
discussed by the local Nutrition Cluster to agree security of the affected communities.
on the appropriate course of action.
Responses specific to supporting the treatment of
Except for the additional deployment of mobile SAM will differ according to whether the treatment
teams for communities cut off from access to service is already implemented in the emergency/
health services, the decision to increase support disaster affected area or is currently not available
for the program shall be made in line with support but will be required.
for other existing health services.

Conducting comprehensive in-depth assessments

that build on secondary data, primary data (now
including purposive and representative sampling) Remi nder
and data from (re)established monitoring systems →→ If members of the local/hospital PIMAM
may also be needed. The level of assessment Management Teams are directly affected by the
may include community-level, complemented emergency/disaster, technical assistance from higher
by household- and individual-level, assessment. levels for augmentation of human resources or
For the Nutrition Cluster, this refers to surveys supplies may be requested via the Nutrition Cluster
that collect data on anthropometrics, access and as needed.
coverage, or KAP surveys with more elaborate
and standardized sampling methods. Such
surveys require a large input of time and resources
and should only be conducted in relation to an
identified need. Before starting a survey, it is
important to identify how the results will be shared
and how they will be linked to action if a problem
is identified.

108 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
 Areas Where SAM Treatment is Implemented

Scale up of support in areas where SAM treatment is already implemented should include:

►► Support for BNS/BHW in screening for cases of SAM in the community. Support should aim to
augment rather than replace current services and care taken in the provision of incentives or
payments so as not to undermine services.
►► Volunteers/assistants may provide ancillary help at the BHS/RHU.
►► The provision of mobile OTC teams for communities unable to access health care.
►► The provision of temporary sites in camps where health centers and/or health staff are
affected by disaster.
►► Additional resources such as medicines and RUTF – based on calculated post-emergency
caseload (note that buffer stocks from regular program may be used to ensure that children
who need it are provided the service immediately upon identification).
►► Implementation of IYCF in emergencies services (especially breastfeeding and
complementary feeding counseling).
►► Emergency ITC if hospital services for cases of SAM with complications where hospital
services become inaccessible.
►► Micronutrient powders for children who are not SAM.
►► If SFP is not normally available but becomes part of the emergency package, ensure proper
screening and referral of children with MAM (refer to MAM guidelines for admission and
discharge criteria).

Caseloads can be managed more efficiently to reduce the workload on health center staff by
providing stable cases with bi-weekly supplies of RUTF provided they have:

►► Good appetite for RUTF

►► Consistent weight gain
►► No illnesses requiring medical treatment
►► Caregiver has previously been compliant with care
►► Instruction is given to return to the health center if any illness or loss of appetite occurs

Areas Where SAM Treatment is Not Implemented

Where no SAM treatment service is currently implemented, the implementation will likely require
the assistance of neighboring local government units or local or international NGOs with previous
experience of SAM treatment in emergencies for the rapid provision of the minimum requirements
for OTC/ITC and community mobilization. Coordination of programming for the treatment of SAM
should be done through the relevant local authorities and the Nutrition Cluster under the LDRRMC.

With the management of SAM public health approach defined in these guidelines, the focus is
on achieving high treatment coverage and early admission to treatment before complications can
develop. As such, community mobilization and OTC services should always be prioritized over
ITC. Before implementation, the emergency program must have a well-defined ‘transition plan’.
Possible scenarios and recommended actions during emergencies are detailed in the SPEED
operations manual. Actions specific to SAM treatment are noted in Table 19.

109
 Table 19. Possible scenarios and recommended actions in emergencies and disasters

Scenario Recommended Options By Whom Time Frame

1. Rapid assessment 3. BNS/BHW/trained 1 - 2 days

Increase of to identify MAM/SAM volunteers via LGUs
malnutrition is using MUAC/edema
reported 2. Coordinate with 4. National/Regional
nutrition cluster DOH, NNC, NGO
1. Plan and coordinate 1. Nutrition Cluster 1 day
with concerned LGU
Health and Nutrition
Staff (length of OTC
program, strategic
location, staffing, how
to transition)
2. Train BNS/BHW/ 2. National/Regional 1 day
volunteers in active DOH, NNC, NGO
case finding
3. Train BNS/BHW/ 3. National/Regional 1 - 2 days
Midwife in SAM DOH, NNC, NGO
OTC required
treatment protocols
4. Establish OTC 4. National/Regional 2 - 5 days
using mobile teams DOH, NNC, NGO
or temporary sites
(safe structure/
tent/evacuation
center) and support
implementation
5. Identify permanent 5. Nutrition Cluster/DOH As early as possible
OTC sites as needed
6. Transition services to 6. Nutrition Cluster/DOH End of response
LGU or close program
1. Plan and coordinate 1. Nutrition Cluster 1 day
with concerned
Hospital Health and
Nutrition Staff (length
of ITC program,
strategic location,
staffing, how to
transition)
2. Train physicians/ 2. DOH/NGO 1 day
nurses (licensed and
in-training) in active
case finding
ITC required 3. Train physicians/ 3. DOH/NGO 1 - 2 days
nurses/midwives/
nutritionist-dietitians
in SAM treatment
protocols
4. Establish ITC 4. DOH/NGO 2 - 5 days
(safe structure/
tent/evacuation
center) and support
implementation 5. Nutrition Cluster/DOH End of response
5. Transition services
to Hospital or close
program

110 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
10.5 Logistics during Emergencies

The Policy and Guidelines on Logistics 3. Define specific roles and responsibilities
Management in Emergencies and Disasters is of all the offices with a stake in logistics
governed by Administrative Order 2012 - 0013. management.
The objectives of this policy are to: 4. Identify innovative and flexible strategies and
potential partners necessary for the provision
1. Ensure the availability of all necessary of logistics in emergencies and disasters.
logistics during emergency and disaster
preparedness and response.
2. Provide standards and guidelines in the
management of goods necessary for
interventions during emergencies and
disasters.

10.6 Reporting in Emergencies

Reporting in emergencies is guided by the The Nutrition Cluster through the Information
Nutrition Cluster monitoring frameworks (based Management Officer should ensure that SAM
on international guidelines). For the management treatment data is shared and included in
of SAM, the same indicators (e.g. number of emergency surveillance systems such as HEARS
children screened, number of admissions) are and SPEED. Standard monthly and quarterly
monitored as in the regular program and the reporting forms are provided in Annexes 44 and
same performance benchmarks are applied (cure, 45.
death, default) or evaluation.

10.7 Transition (Post-emergency)

The transition of the program to treat SAM following In either case, it is absolutely essential that
the emergency should be made according to there is great effort exerted in sensitization of
the ‘transition plan’ which is defined before the the Chief Executives, Local Nutrition Committees
emergency intervention is started. and members of the community in explaining
the transition plan. The transition plan should
If there is no intention to continue the treatment be coordinated through the health and nutrition
service then the program is discontinued typically clusters and ensure that all necessary systems are
when the prevalence of SAM has returned to in place prior to the cessation of the emergency
normal pre-emergency levels. service.

Where it is intended to integrate the service into

routine health services, reference should be made
to the Section 5.2 “Advocacy and Creating an
Enabling Environment” to ensure the appropriate
systems are in place to sustain the SAM treatment,
integrated within local health systems.

Manual of Operations 111

 11. PROGRAM MONITORING AND REPORTING

In order to ensure that the service is achieving effectiveness and coverage will determine the
the objectives of identifying, treating and impact/or program outcome hence:
curing severe acute malnutrition, activities and
outcomes must be monitored. A well-designed
monitoring and reporting system can identify gaps
in implementation of respective components, Treatment
provide information for on-going needs
assessment, advocacy, planning, redesigning and quality
accountability.
+ coverage
Monitoring of the program is comprised of three
major components: program
Assessment of quality of treatment (i.e. proportion of
effectiveness
children treated effectively)

Assessment of program coverage (i.e. proportion of The monitoring system in place to assess
the target group being reached with treatment) and these components must include data capture,
appropriateness of the program for communities. compilation, analysis and feedback if it is to
function effectively. It aims to integrate into current
Assessment of aspects of service delivery (i.e. supply, health management information systems (HMIS)
human resources) which impact the above. to the extent that it is possible i.e. a few selected
indicators.

Even for a service that is achieving good clinical

outcomes (high cure rates and low death rates),
impact is diminished if it only achieves low levels
of coverage. The combination of treatment

11.1 Program Performance Indicators and Standards

Indicators Default rate: The number of children who

defaulted, as a percentage of all discharges
The following program performance indicators during the reporting month. Default is defined as
collected on a monthly basis help in monitoring absent for three consecutive visits in OTC or three
whether the service for management of SAM is days in ITC.
achieving its objectives or not:
Non-cured rate: The number of children
Number of admissions: The total number of discharged as non-cured, as a percentage of
children admitted into the program during the all discharges during the reporting month. Non-
reporting month. cured is defined as not reaching discharge criteria
after four months in the program as long as all
Cure rate: The number of children successfully possible investigations and follow-up have been
discharged cured, as a percentage of all attempted.51
discharges during the reporting month.50
All non-cured cases must be transferred to another
Death rate: The number of children who died health, nutrition, or social service for continuing
during treatment, as a percentage of all discharges care.
during the reporting month.
Human Resources Coverage: Number of

50 Where all discharges is the sum of children recovered + died + defaulted + non-cured
51 Where there is no OTC and full treatment is taking place in ITC this criteria refers to the number of children who are transferred out of the service to
a higher level health facility for further investigation after a period of 40 days in ITC

112 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
health workers who have been trained on SAM
management as a percentage of all health workers
in SAM implementation/target areas
Remi nder s
Treatment Coverage: The percentage of eligible →→ Children referred between inpatient and outpatient
patients (primarily children 6 - 59 months old with components of management of SAM are not
SAM) existing in the area who are reached by the recorded as discharges as they remain within the
service.52 therapeutic service though they are recorded as exits
from a particular facility.
Geographical Access/Coverage: the number of →→ Figures for Inpatient and Outpatient therapeutic care
health facilities in an area which offer management should be combined in order to appropriately assess
of SAM services as a percentage of all health the performance of the service for SAM as a whole.
facilities in SAM implementation/target areas. However, particular indicators may be useful to look
This is a useful measure of the availability of the at separately to assess particular aspects of treatment
service (see Annex 43 for calculations) (e.g. length of stay in inpatient care).

Program Performance Standards

Program performance indicators are compared Table 20. Minimum performance

with standard cut-offs in order to monitor health
standards for the management of
facility performance and take corrective action
SAM53
as needed. They are also used to assess the
performance of the service as a whole (i.e. at Recovery rate > 75%
municipality level or at regional/national level)
using compiled figures from all facilities. Death rate < 10%
Defaulter rate < 15%
The targets indicated in Table 20 were developed
for use in emergency settings, but are currently Coverage > 50 - 70%*
accepted for use in non-emergency settings as
well. Each facility and the program as a whole * Treatment coverage for Rural areas >50%, urban centers
should achieve them. >70%, refugee camps >90%

11.2 Program Process Indicators and Standards

In addition to the monitoring of program Screening and referral

performance there are a number of key program
process indicators that should be monitored. ►► Location of case-finding activities
Tracking these indicators will help to identify the ►► Number of cases of SAM identified in each
cause of poor performance and therefore areas to location
focus attention. ►► Number of cases of SAM admitted for
treatment
Geographical access to treatment ►► Plan for case-finding activities at locations not
visited in the last month
►► Percentage of health facilities providing
treatment for SAM (Geographical coverage – Coordination meetings related to
see Annex 43) community mobilization for SAM
treatment
Sensitization activities
►► Association of Barangay Captains
►► Location and type of sensitization activity ►► City/Municipal Mayor or other Chief
►► Number and type of community members Executives
attending sensitization meetings ►► City/Municipal PMT
►► Plan for sensitization activities in locations not ►► City/Municipal Nutrition Councils
attended that month

52 Note that due to the lack of clear measures of SAM in infants at community level they are not usually included in standard coverage assessment.
Coverage can be assessed for MAM but modifications are required to the standard methodologies to do this.
53 SPHERE 2011. The Sphere Handbook: Humanitarian Charter and Minimum Standards in Humanitarian Response.

Manual of Operations 113

 Facility Formal evaluation activities

►► Percentage of health workers trained on ►► Coverage assessment activities (E.g. LQAS/

Management of SAM SLEAC or SQUEAC)
►► Number/percentage of facilities with stock ►► Feedback from the community regarding the
outs of RUTF (or F75) in the previous three SAM treatment service
months ►► NNC - MELLPI evaluations

11.3 Monitoring Formats and Systems

Monitoring and data collection in order to report In addition, BNS/BHW’s have existing sick child
on the above indicators is performed through reporting formats (Annex 4) which can be used
meetings, registration and reporting from to record the outcome of any follow-up visits.
community and health facility level and through Additional formats for the follow-up of children who
specific assessments conducted at municipality have defaulted are given in Annex 51. One of the
level of coverage. Collation can be performed key responsibilities of the BHS/BHW and/or Rural
at the municipality level and at health facilities. Health Unit/Main Health Center and Municipal
Computers are not required for compilation, but Health office team is to maintain records of the
they can make the process easier. community members screened and referred, any
health education sessions conducted, as well as
Community Level the analysis and submission to health facilities.

On-going monitoring of community sensitization Facility Level

and mobilization efforts is required. This
mainly involves constant dialogue, in which the Monthly reporting formats for the recording of
communities periodically voice their views and admissions and exits according to a number
suggest alternative courses of action. This entails of categories should be filled at each facility
regular meetings (monthly and/or quarterly) with implementing management of SAM.
key community representatives, health staff
from the nearest health facility, beneficiaries and These formats can be completed using a simple
other partners to discuss different aspects of the tally sheet and the patient cards or from the
program, such as: register book where this is in use. Compilation
should occur at municipality level compiling
►► Reviewing the selection and motivation of results for all health facilities implementing the
community workers conducting case-finding management of SAM.
►► The community’s perspective of the program
which may include identifying new barriers to See Annex 44 and 45 for reporting formats for use
access at facility and consolidation (LGU, Regional and
►► Joint solutions to problems limiting the impact National) levels.
of the program. This promotes community
ownership of program development and The responsibilities and schedule for reporting are
implementation. noted in Table 21.

Reporting on case finding is kept simple. As The TCL for Sick Children may be used to record
house-to-house screening or mass mobilization cases of SAM and data entered online.
and screening is not going to be the most
common method of case finding it is not possible Monthly reporting forms for the RHU, City/
to draw conclusions on prevalence or trend in Municipality, Province and Region are provided in
acute malnutrition based on information on cases/ the technical guidelines where the use of TCL for
numbers screened. Therefore, reporting focuses sick children is not possible, or newly established
just on the number of cases of SAM and MAM OTCs not located in health centers or for mobile
identified and referred or counseled (where no teams.
additional treatment for MAM is available) and
who enter treatment. This can be achieved using
existing BNS/BHW reporting.

114 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
 Table 21. Reporting schedule and responsibilities

Focus of Schedule of
Responsibility Recording
Forms Frequency Submission to
Tools
Office Person higher level

every second week

Registry Book/ Facility level (Tuesday)
OTC Chart/TCL Form Monthly
of succeeding month
Midwife/ ITC Chart/ (Annex 44)
BHS (OTC) to City/Municipality
Physician
Critical Care Consolidation every second week
Chart Form (Annex Annually of January to City/
45) Municipality
every third week of
the first month of the
Quarterly
Consolidation succeeding quarter to
PHN/Midwife/ Registry Book/ City/Province
RHU (OTC) Form (Annex
Physician OTC Chart/TCL
45) every third week
Annually of January to City/
Province
every second week
(Tuesday)
Facility level
of succeeding month
Form Monthly
to City/Municipality or
(Annex 44)
DOH Regional Office
(for DOH Hospitals)
Registry Book/
every third week of
OTC Chart/TCL
the first month of the
Hospital Nurse/
succeeding quarter
(ITC) Physician ITC Chart/ Quarterly
to City/Municipality or
Critical Care
Consolidation DOH Regional Office
Chart
Form (Annex (for DOH Hospitals)
45) every second week
of January to City/
Annually Municipality or DOH
Regional Office (for
DOH Hospitals)
every fourth week of
the first month of the
Province/City/ Quarterly
Consolidation succeeding quarter to
PHO/ CHO/ Municipal NAO DOH Regional Office
Form (Annex
MHO or ES/FHSIS
45) every fourth week
Coordinator
Annually of January to DOH
Regional Office
every second week of
the second month of
Quarterly
DOH Regional ESU Consolidation the succeeding quarter
Regional or ND or FHSIS Form (Annex to DOH Central Office
Office Coordinator 45) every second week of
Annually March to DOH Central
Office

Manual of Operations 115

 Treatment Coverage Assessment Defaulter rates and reasons for default. When
a child discontinues treatment against health
Along with all assessment of coverage is the workers’ advice before being cured, the caregiver
identification of major barriers and boosters can be interviewed and a form completed which
to coverage. These two aspects can be best identifies the reasons for stopping treatment. The
assessed fully through the periodic use of the information from the interviews (see Figure 16.)
formal direct coverage assessment methods can be compared with other factors such as MUAC
outlined in Annex 43, in particular a SQUEAC on admission or location to identify difficulties in
assessment. program implementation and assist in adjusting
the program to make treatment more accessible.
It is important to note that barriers to coverage,
though more likely to operate when the service
is already up and running, can also develop
at any time. Therefore in addition to periodic
assessment, data already collected can be tallied Simplified estimation of coverage. A simplified estimation
and used at the health facility and municipality of coverage may be accomplished in order to check that
level on an on-going basis to give an indication children are accessing treatment for SAM. In any community
of whether any major barriers to coverage are the health and nutrition team undertake an activity to find
operating. This can be done through simple tallies all cases of SAM in the community using active case finding
and can be supported during supervision visits. techniques. During case finding, if we find children who
Information can trigger further investigation either are SAM but not attending treatment we can interview the
by assessment or by community focus group caregiver to find out why.
discussion and includes:
For a rural community a ‘good’ coverage is above 50% while
Trends in admissions. Plotted against the for an urban community coverage is expected to be above
seasonal calendar (see Figure 2) – this information 70%. If the proportion of children with SAM undergoing
from the monthly reports can be plotted for the year treatment in the program is above these levels then the
so that any unusual patterns can be identified. coverage can be classified as “high’ or, if the proportion is
An unusual unseasonal drop in admissions may lower, classified as ‘low’. For example:`
indeed be due to a drop in prevalence of SAM,
but it is also likely to be due to the occurrence of a Total number of cases of SAM in the community = 10
particular barrier to coverage. Total number of SAM cases in treatment = 8
Coverage = 8/10 = 0.8 (or 80%)
Spread of MUAC on admission. When a
child has SAM, the condition should ideally be Therefore coverage can be classified as “high” (i.e. above
treated as early as possible. When community 50%).
mobilization for MANAGEMENT OF SAM is
done effectively, the MUAC measurement when
the child starts treatment should be between
110 - 115 mm (11.0 - 11.5cm). This is called This method can only classify coverage as high
‘early’ admission for treatment. If the MUAC or low. It cannot be used to express program
is less than 110mm (11.0cm) then this is ‘late’ coverage as a percentage (in this example we
admission. A late admission means that treatment cannot say coverage is 80%) because the sample
has been delayed and may occur for a number size may be too low).
of reasons (lack of knowledge, long distance or
caregiver’s workload, for example). Delaying
treatment increases the risk of complications,
hospitalization and increases the cost and time
taken for treatment. It may also increase the risk
of death. A simple plot can give this information
(see Figure 15).

Location. It is always worth noting the location

where cases are coming from, since this may
indicate areas where a particular problem with
SAM exists. An absence of cases from a particular
area may also indicate a lack of awareness of
SAM or difficulties in accessing treatment. Other
factors affecting access to treatment such as
distance, difficult terrain or climatic conditions
should be considered.

116 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
 Figure 15. Simple tools for monitoring barriers to access

Number of New admissions

Fever Fever Fever

Disease

ARI ARI
Diarrhea Diarrhea
Food eaten

Figure 16. Defaulter analysis conducted for the CMAM pilot program in Maguindanao
Province 2011, based on home visits and outreach by BHWs and field volunteers

4%
4%

8% 27% Relocated to non-CMAM area

Access (distance,financial)

11% Unknown/no contact

Refusal of one parent

No caretaker for other children

19% 27% Issues with RUTF/meds

Others

Manual of Operations 117

 11.4 Analysis and Feedback

Analysis based on the above information should At provincial, municipal and city levels, reports
focus on: and their interpretation should be shared with
stakeholders and fed back to facilities and to
Treatment coverage and barriers to access. community workers through supervision visits and
To identify any potential actions/modifications meetings. The information should form the basis
that need to be made to the service (e.g. further for focusing supervision, support and resources in
decentralization, increase in number of days particular areas, such as increased supply chain
dedicated to the service due to long waiting times). support, deciding on on-going training focus for
staff, triggering further investigation visits and
Numbers and trends in admissions. To identify potentially further coverage investigation.
seasonal patterns for resource planning, to identify
anomalies in these trends that require further Bottleneck Analysis indicators and steps can be
investigation, to track the effects of mobilization found in Annex 59.
and scale-up efforts and potentially (in programs
with good coverage) to identify deterioration in
the nutrition situation. This information will also
be used to decide on when additional support is
required.

Recovery, default, death and non-recovered.

As a proportion of exits as measures of program
quality. These indicators can identify issues with
adherence to treatment protocols, management
of the service (waiting times, approach to children
and caregivers etc.), sharing of RUTF, insufficient
community mobilization and poor coverage.

Numbers of patients transferred to inpatient

care. As a proportion of admissions; this can
indicate issues with adherence to treatment
protocols, difficulties with referral mechanisms
and/or coverage issues (poor coverage = a lot of
late presentation = large number of referrals).

Numbers and trends in the proportion of

‘other’ admissions. Mainly other age groups; an
indication of the need for further program support
in identification and treatment of those groups.
An increase may also indicate deterioration in the
nutrition situation.

Numbers and locations of referrals This allows

the tracking of the activity of community workers,
identification of areas where additional services
may be justified and to identify areas where
there may be gaps in coverage (low numbers of
referrals may reflect low levels of SAM or poor
identification of cases).

This analysis should also include review of the

program process indicators in Section 11.2 and
the experiences during supervision visits in order
to identify possible causes for the above and to
point towards appropriate remedial actions.

118 National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
Annexes
 LIST OF ANNEXES
Annex 1. Example of local event calendar for calculation of age (Mindanao) 122
Annex 2. Taking measurements 122
Annex 3. IYCF counselling at community and facility level (IMCI) 128
Annex 4. Philippines IMCI & CIMCI (existing formats) 131
Annex 5. WFH tables and checking the z-scores 135
Annex 6. BMI tables for adults and adolescents 138
Annex 7. Identification of acute malnutrition in other groups 139
Annex 8. Infant feeding assessment IMCI 140
Annex 9. Summary Admission criteria for SAM 141
Annex 10. IYCF counselling at community and facility level (IMCI) 142
Annex 11. Routine medicine doses in OTC 143
Annex 12. Antibiotic alternatives for OTC 145
Annex 13. Fever and SAM 145
Annex 14. Ready-to-Use Therapeutic Food (RUTF) 146
Annex 15. Ready-to-use therapeutic food (RUTF) Ration 147
Annex 16. OTC chart 148
Annex 17. Action protocol 150
Annex 18. Routine medicines in Phase 1 inpatient care for SAM 151
Annex 19. Treat / prevent hypoglycemia 153
Annex 20. Treat / Prevent hypothermia 155
Annex 21. Treatment of dehydration / hypovolemic shock 155
Annex 22. Hypernatremic dehydration 160
Annex 23. Treatment of septic shock for all malnourished patients 162
Annex 24. Treatment of severe anemia 163
Annex 25. Treatment of heart failure 164
Annex 26. Absent bowel sounds, gastric dilation and intestinal splash 166
with abdominal distension
Annex 27. Inpatient therapeutic care chart 167
Annex 28. Amount and preparation of F75 milk to be given for children 169
aged 6 - 59 months in Phase 1
Annex 29. Alternate F75 recipes 170
Annex 30. Preparation of diluted F100 170
Annex 31. Procedure for transition to RUTF 171
Annex 32. Amount of F100 milk to be given to children aged 6 - 59 months in transition Phase 172
Annex 33. Amount of F100 to be given in Phase 2 173
Annex 34. Suitable makeshift toys for use in Phase 2 ITC 174
Annex 35. Amount of F100 to be given in Phase 2 175
Annex 36. Diluted F100 (or F75 for cases with edema) for usE with 176
the Supplementary Suckling Technique for infants aged less than 6 months
Annex 37. Express breast milk by hand 177
Annex 38. Amount of Dilute F100 (or F75 for cases of edema) to give to infants 178
Aged less than 6 months with no prospect of being breast fed
Annex 39. Amount of RUTF to be given to the child on transfer to outpatient care 178
Annex 40. Amount of RUTF to be given to the child on transfer to outpatient care 179
Annex 41. Reasons for deterioration in Transition Phase 180
Annex 42. Reassessment of child’s condition 182
Annex 43. Calculation of monitoring indicators 182
Annex 44. Monthly Reporting Format (Facility level) 187
Annex 45. Quarterly/Annual Reporting Format (Consolidation) 188
Annex 46. Example of messages for community sensitization 189
Annex 47. Department Personnel Order 2011 - 2453 190
Annex 48. Roles and Responsibilities of PIMAM stakeholders 193
Annex 49. Role requirements for BHW and BNS 198
Annex 50. Registry Book Example 199
Annex 51. Critical Care Chart Example 201
Annex 52. PhilHealth reimbursements for acute malnutrition (Excerpt) 202
Annex 53. Defaulter form 203
Annex 54. Supervision checklist for OTC 205
Annex 55. Response Actions of National Nutrition Cluster 208
(adapted from Minimum Service Package)
Annex 56. Calculating Case Load for SAM 212
Annex 57. Issuance of Supplies and Materials Procedure (SAMPLE) 215
Annex 58. Supplies RIS Form 215
Annex 59. Bottleneck Analysis 216

121
 ANNEX 1
Example of local event calendar for calculation of age

January February March April May June July August

RAINY SEASON DRY SEASON

Land Preparation -
Land Preparation - Rice Land Preparation - Rice Planting - Rice
Corn (LPC)

Harvest - Land Preparation

Planting - Rice
Corn - Corn (LPC)

Harvest -
Hunger Gap Hunger Gap
Rice

ARI Skin Disease ARI

ANNEX 2
Taking measurements

Checking for bilateral edema

Bilateral edema is the sign of Kwashiorkor. Kwashiorkor is always a severe form of malnutrition. Children
with bilateral edema are directly identified to be acutely malnourished. These children are at high risk of
mortality and need to be treated in a therapeutic feeding program urgently.

In order to determine the presence of edema,

»» Normal thumb pressure is applied to the both feet for at least three seconds.
»» If a shallow print persists on the both feet, then the child has edema.

Only children with bilateral edema are recorded as having nutritional edema.1

You must formally test for edema with finger pressure. You cannot tell by just looking.

© Oxfam/2015/GTeofilo © Oxfam/2015/GTeofilo

1 There are other causes of bilateral edema (e.g. nephrotic syndrome) but they all require admission as an inpatient.

122
 Severity of the edema Recording

Mild Both feet

+

Moderate Both feet plus lower legs, hands and lower arms
Intermediate between mild and severe ++

Severe Generalised edema including both feet, legs, hands, arms and face
+++

Taking MUAC

MUAC is used as an alternative measure of “thinness” to weight-for-height. It is particularly used in children

from one to five years; however, its use has been extended to include children more than 6 months (under
67cm in height).

The technique for taking the MUAC measurement can be seen on page 124.

Step 1 Ask the mother to remove clothing that may cover the child’s left arm.

Step 2 Calculate the midpoint of the child’s left upper arm. This can be done by taking a piece of string (or
the tape itself), place one end on the tip of the child’s shoulder (Arrow 2) and the other on the elbow (Arrow
3), now bend the string up in a loop to double it so the point at the elbow is placed together with the point on
the shoulder with a loop hanging down – the end of the straightened loop indicates the mid-point.

Step 3 As an alternative, place the tape at zero, which is indicated by two arrows, on the tip of the shoulder
(Arrow 4) and pull the tape straight down past the tip of the elbow (Arrow 5). Read the number at the tip of
the elbow to the nearest centimeter.

Step 4 Divide this number by two to estimate the midpoint. Mark the midpoint with a pen on the arm (Arrow
6).

Step 5 Straighten the child’s arm and wrap the tape around the arm at the midpoint. Make sure the numbers
are right side up. Make sure the tape is flat around the skin (Arrow 7).

Step 6 Inspect the tension of the tape on the child’s arm. Make sure the tape has the proper tension (Arrow
7) and is not too tight so that the skin is compressed or too loose so that the tape does not contact the skin
all the way round the arm (Arrows 8 and 9).

Step 7 Repeat any step as necessary.

Step 8 When the tape is in the correct position on the arm with correct tension, read and call out the
measurement to the nearest 0.1cm (Arrow 10).

Step 9 Immediately record the measurement.

Photograph sourced from UNICEF

123
 1 Locate tip of shoulder 6 Mark midpoint

2 Tip of shoulder 7 Correct tape tension

3 Tip of elbow 8 Tape too tight

4 Place tape at tip of shoulder 9 Tape too loose

5 Pull tape past tip of bent elbow 10 Correct tape position for arm circumference

124
Taking the weight

Children may be weighed by using a 25kg hanging sprint scale graduated to 0.100kg or an electronic
balance (e.g. UNISCALE).

Step 1 Do not forget to re-adjust the scale to zero before each weighing.

Step 2 A plastic washbasin should be attached by four ropes that go underneath the basin. The basin needs
to be close to the ground in case the child falls out, and to make the child feel secure during weighing.

Step 3 If the basin is dirtied then it should be cleaned with disinfectant. This is much more comfortable and
familiar for the child, can be used for ill children and is easily cleaned. Weighing pants that are used during
surveys should not be used – they are uncomfortable, difficult to use, inappropriate for sick children and
quickly get soiled to pass an infection to the next patient.

Step 4 When the child is steady, read the measurement to the nearest 100 grams, with the frame of the
scale at eye level. Each day, the scales must be checked by using a known weight.

Photo on right:
Source: Guidelines for the management of the severely malnourished:
version January 2007 by Pr. Michael Golden and Yvonne Grellety, ACF.

Photos on left courtesy of ACF Liberia

125
 Taking the length/height

For children less than 87cm, the measuring board is placed on the ground. The child is placed, lying
along the middle of the board. The assistant holds the sides of the child’s head and positions the head
until it firmly touches the fixed headboard with the hair compressed. The measurer places her hands on
the child’s legs, gently stretches the child and then keeps one hand on the thighs to prevent flexion. While
positioning the child’s legs, the sliding footplate is pushed firmly against the bottom of the child’s feet. To
read the measure, the footplate must be perpendicular to the axis of the board and vertical. The height is
read to the nearest 0.1 centimeter.

1 Questionnaire and pencil on

clipboard on floor or ground

2 Assistant on knees

3 Measurer on knees

4 Hands cupped over ears; head

against base of board

5 Arms comfortably straight

6 Line of sight perpendicular to

base of board

7 Child flat on board

8 Hands on knees or shins; legs

straight

9 Feet flat against footpiece

©Shorr Productions

The longer lines indicate centimetre marking; the shorter lines indicate millimetre.

The child's feet are against this

side of the movable footboard.
This child's length is 66.3cm.

60 61 62 63 64 65 66 68 69 70 71 72 73 74 75

©WHO Growth standard training

126
 1 Questionnaire and pencil on clipboard on
floor or ground

2 Assistant on knees

3 Measurer on knees

4 Hands cupped over ears; head against

base of board

5 Arms comfortably straight

6 Line of sight perpendicular to base of

board

7 Child flat on board

8 Hands on knees or shins; legs straight

9 Feet flat against footpiece

10 Shoulders level

11 Hands at side

12, 13, 14 Body flat against Board

©Shorr Productions
97
96
94
93

The child's head

is against this side
of the movable
headboard. The
92

child's height is
94.2cm
91

©WHO Growth standard training

127
 ANNEX 3
IYCF counselling at community and facility level (IMCI)

Card 6. Tamang Paghakab

»» Ang tamang paghakab ng bibig ng sanggol sa suso ng ina ay nakatutulong sa kapwa ina at
sanggol.

Ang tamang paghakab ay nakatutulong sa maayos na pagsuso ng sanggol at sa patuloy na pagdaloy

ng gatas. Nakatutulong din ito para maiwasan ang mga sugat at bitak-bitak sa utong ng ina. Hindi
dapat masakit ang pagpapasuso.

»» Apat na palatandaan ng magandang paghakab:

1. Malawak ang bukas ng bibig ng sanggol.

2. Makikita ang higit na maitim na balat (areola ng suso) sa itaas ng bibig ng sanggol kaysa sa
ibaba.
3. Ang ibabang labi ng sanggol ay naka-palabas.
4. Nakadikit ang baba ng sanggol sa suso ng ina.

»» Kung ang sanggol ay maayos na nakalapat sa suso ng ina at madali niyang makuha ang gatas, ito
ay senyales na maayos ang pagsuso. Ang ilang pang mga senyales ay:

1. Mabagal ngunit malalim, at minsan pahintu-hinto, na pagsuso ng sanggol. Maaring makita o

marinig siyang lumulunok pagkatapos ng isa o dalawang pagsuso.
2. Ang pagpapasuso ay kumportable at walang sakit para sa ina.
3. Pagkatapos ng pagsuso ay kumportable at walang sakit para sa ina.
4. Ang suso ay mas malambot pagkatapos ng pagpapasuso.

128
 Feeding Recommendations During Sickness and Health

Feeding recommendations FOR ALL CHILDREN during sickness and health, and including HIV EXPOSED children on ARV prophylaxis

Newborn,
1 week up to 6 months 6 up to 9 months 9 up to 12 months 12 months up to 2 years 2 years and older
birth up to 1 week

• Immediately after birth, • Breast feed as often as • Breast feed as often as • Breast feed as often as • Breast feed as often as • Give a variety of foods
put yor baby in skin to skin your child wants. look for your child wants. your child wants. your child wants. to your child, including
contact with you. signs of hunger, such as animal-sourced foods and
beginning to fuss, sucking • Also give thick porridge • Also give a variety of • Also give a variety of Vitamin A-rich fruits and
• Allow your baby to take fingers, or moving lips. or well-mashed foods, mashed foods or finely mashed foods or finely vegetables.
the breast within the including animal-sourced chopped family food, chopped family food,
first hour. Give your • Breastfeed day and night foods and Vitamin A-rich including animal-sourced including animal-sourced • Give at least 1 full cup
baby colostrum, the first whenever your baby fruits and vegetables. foods and Vitamin A-rich foods and Vitamin A-rich (1 cup = 250mL)
yellowish, thick milk. It wants, at least 8 times fruits and vegetables. fruits and vegetables.
protects the baby from in 24 hours. Frequent • Start by giving 2 to 3 • Give 3 to 4 meals each
many illnesses. feeding produces more tablespoons of food. • Give 1/2 cup to 3/4 cup • Give 3/4 to one cup day.
milk. Gradually increase to 1/2 at each meal (1 cup = at each meal (1 cup =
• Breastfeed day and night, cups (1 cup = 250mL) 250mL). 250mL).
as often as your baby • Do not give other foods
• Offer 1 or 2 snacks
between meals.
wants, at least 8 times a or fluids. Breastmilk is all • Give 2 to 3 meals each • Give 3 to 4 meals each • Give 3 to 4 meals each
day in 24 hours. Frequent your baby needs. day. day. day.
• If your child refuses a new
feeding produces more
food, offer “tastes“ several
milk. • Offer 1 or 2 snacks each • Offer 1 or 2 snacks • Offer 1 or 2 snacks
times. Show that you like
day between meals when between meals. The child between meals.
the food. Be patient.
• If your baby is small (low the child seems hungry. will eat if hungry.
birth weight), feed at least • Continue to feed your
• Talk with your child during
every 2 to 3 hours. Wake • For snacks, give small child slowly, patiently,
a meal, and keep eye
the baby for feeding after chewable items that patiently, Encourage ̶ but
contact.
3 hours, if baby does not the child can hold. Let do not force ̶ your child
wake itself. your child try to eat the to eat.
snack, but providel help if
• Do not give other foods needed.
or fluids. Breast milk is
what baby needs. This is
especially important for
infants of HIV-positive
mothers. Mixed feeding
increases the risk of
HIV mother-to-child
transmission compared to
exclusive breastfeeding.

129
A good daily diet should be adequate in quantity and include an energy-rich food (for example, thick cereal with added oil); meat, fish, eggs, or pulses; and fruits and vegetables.
 Recommendation for feeding and care for development

Birth up to 8 months 8 months up to 12 months up to 2 years and older

12 months 2 years

• Exclusively breast feed as • Breast feed as often as • Breast feed as often as • Give adequate amount of
often as your child wants, your child wants. your child wants. family foods at 3 meals a
day and night, at least 8 day.
times in 24 hours. • Add any of the following: • Give adequate amount
Lugaw with oil, mashed of family foods such as: • Give twice daily nutritious
• Do not give other foods or vegatables or beans, rice, camote, potato, fish, food between meals such
fluids. steamed tokwa, flaked chicken, meat, mongo, as: Boiled yellow camote,
fish, pulverized roasted steamed tokwa, pulverized boiled yellow corn, peanuts,
dilis, finely ground meat, roasted dilis, milk and eggs, boiled saba, banana, taho,
eggyolk, bite-sized fruits. (3 dark green leafy and yellow fruits and fruit juices.
times per day if breastfeed, vegetables (malunggay,
5 times per day if not squash), fruits (papaya,
breastfeed) banana). Add oil or
margarine. 5 times per day

• Feed the baby nutritious

snacks like fruits.

Birth up to 4 months 8 months up to 12 months up to 2 years and older

of age 12 months 2 years

• Play: Provide ways for your

child to see, hear, feel and
move. • Play: Give your child clean, • Play: Give your child things • Play: Help your child count,
safe house hold things to to stack up, and to put into name and compare things.
handle, bang and drop. container and take out. Make simple toys for your
4 months to child.
6 months • Commuinicate: Respond • Commuinicate: Respond
to your child's sound and to your child's sound and • Commuinicate: Encourage
interest. Tell your child interest. Tell your child your child to talk and
the names of things and the names of things and answer your child's
people. people. questions. Teach your child
stories, song and games.

• Play: Have large coloful Feeding Recommendation for a child who has PERSISTENT DIARRHEA
things for your child to
reach for, and new things • If still breastfeeding, give more frequent, longer breastfeeding, day and night.
to see
• If taking other milk such as milk supplements:
• Commuinicate: Talk to your - Replace with increase breastfeeding
child and get a conversation - Replace half the milk with nutrient-rich, semi-solid food.
going with sounds or
gestures. • Do not use condensed or evaporated filled milk.

• For other food, follow feeding recommendations for the child's age.

130
 THEN CHECK FOR ACUTE MALNUTRITION
Edema of both feet • Give first dose appropriate antibiotic.
Check for Acute Malnutrition OR • Treat the child to prevent low blood
Classify WFH/L less than -3 Z-scores OR sugar.
nutritional PINK:
Look and Feel: MUAC less than 115mm (11.5cm) AND any • Keep the child warm.
status one of the following: • Refer urgently to hospital.
Complicated
Look for signs of acute manutrition • Medical complication present
ANNEX 4

Severe Acute
or
Malnutrition
Look for edema of both feet • Not able to finish RUTF
Determine the WFH/L* __Z-score. or
Measure MUAC** __mm in a child 6 months • Breastfeeding problem.
or older.

If WFH/L less than -3 Z-scores or MUAC less

WFH/L less than -3 Z-scores • Give oral antibiotics for 5 days.
than 115mm (11.5cm), then:
OR • Continue breastfeeding.
MUAC less than 115mm (11.5cm) • Give ready-to-use therapeutic food if
Check for any medical complication present:
AND YELLOW: available for child aged 6 months or
- Any general danger sign
Able to finish RUTF. more.
- Any severe classification
UnComplicated • Counsel the mother on how to feed the
- Pneumonia with chest indrawing
Severe Acute child.
Malnutrition • Assess for possible TB infection
If no medical complications present:
• Advise mother when to return
- Child is 6 months or older, offer RUTF***
immediately.
to eat.
• Follow up in 5 days.
Is the child:
Not able to finish RUTF portion?
Philippines IMCI & CIMCI (existing formats)

Able to finish RUTF portion?

- Child is less than 6 months, assess WFH/L between -3 and -2 Z-scores • Assess the child’s feeding and
breastfeeding: OR counsel the mother on the feeding
YELLOW:
Does the child have a MUAC 115 up to 125mm. (11.5 up to 12.5cm) recommendations.
breastfeeding problem? • If feeding problem, follow up in 5 days
MODERATE
• Assess for possible TB infection.
Acute
* WFH/L is Weight-for-Height or Weight-for-Length determined by • Advise the mother on when to retun
using the WHO growth standards chart Malnutrition
** MUAC is Mid-Upper Arm Circumference measured using MUAC
immediately.
tape in all children 6 months or older. • Follow up in 30 days.
***RUTF is Ready-to-Use Therapeutic Food for conducting the
appetite test and feeding children with severe acute malnutrition.

WFH/L -2 Z-scores or more • If the child is less than 2 year old,

OR GREEN: assess the child’s feeding and counsel
MUAC 125mm or more. (12.5cm or more) the mother on feeding according to the
NO Acute feeding recommendations.
Malnutrition • Give micronutrient powder supplement.
• If feeding problem, follow up in 5 days.

131
 SICK CHILD RECORDING FORM
(child age 2 months up to 5 years)

Date:____/____/______ BHW:_______________
Temperature:_________ Initial Visit Follow-Up

CHILD’s NAME: ____________________________ ___________________________ AGE:________ ________

First Name Family Name Years Months
BOY GIRL

CAREGIVER’s NAME: __________________________ RELATIONSHIP: Mother/Father/Other: ______________

ADDRESS: ___________________________________________________________________________________

COntact NO.: ______________________________

1. Identify problems
ASK and LOOK Any DANGER SIGN? SICK but NO Danger Sign?

ASK: What are the child’s problems? Encircle each

sign reported. If not reported, then ask to be sure.
Is there Cough? Yes No
 Cough for 21 days or more  Cough (less than 21 days)
If yes, for how long? ____days
Is there Diarrhea (loose stools)? Yes No  Diarrhea for 14 days or  Diarrhea (less than 14
If yes, for how long? ____days more days AND no blood in
Is there blood in stool Yes No  Blood in stool stool)
Is there Fever (reported or now)? □ Yes □ No
If yes, started ____ days ago.
 Fever for 7 days or more
If yes, was there a visit/travel and stayed  Fever less than 7 days
 Any fever in a malaria area
overnight in a malaria area in the past
4 weeks? Yes No
Is there Convulsions? Yes No  Convulsions
Is there Difficulty drinking or feeding? Yes No
 Not able to drink or feed
If yes, Not able to drink or feed anything?
anything
Yes No
Is there Vomiting? Yes No
 Vomits everything
If yes, Vomits everything? Yes No
Is there any other problem? Yes No
See 7 If any OTHER PROBLEMS, refer.
LOOK:
Is there Chest indrawing? Yes No  Chest indrawing
If cough, count breaths in 1 minute: _______ bpm
Fast breathing: Yes No
 Fast breathing
Age 2 months up to 12 months: 50 bpm or more
Age 12 months up to 5 years: 40 bpm or more
 Very sleepy or
Is the child Very sleepy or unconscious? Yes No
unconscious
For child 6 months up to 5 years, MUAC strap colour:
 Red MUAC  Yellow MUAC
RED YELLOW GREEN
Is there swelling of both feet? Yes No  Swelling both feet
If ANY Danger Sign, REFER If NO Danger Sign, treat at
2. Decide: Refer or treat child to health facility home and advise caregiver

132
3. Refer or treat child If ANY Danger Sign, REFER If NO Danger Sign, treat at
(check treatments given and other actions) to health facility home and advise caregiver

If any danger sign, If no danger sign,

REFER URGENTLY to health facility: TREAT at home and ADVISE on home care:

If Child □ Give ORS. Help caregiver give child ORS in front of

Assist referral to health facility: has you until child is no longer thirsty.
Diarrhea □ Give caregiver 2 ORS packets to take home. Advise to
□ Explain why child needs to go to give as much as child wants, but at least 1/2 cup OR
health facility. solution after each loose stool.
□ Give zinc supplement. Give 1 dose daily for 10 days:
□ If the child has diarrhea and can - Age 2 months up to 6 months—½ tablet OR
drink, begin giving ORS solution 1 and ½ bottle caps*
right away. (2.5mL)
- Age 6 months up to 5 years —1 tab OR 3 bottle caps*
□ For any sick child who can drink, (5mL)
advise to give fluids and continue
feeding. □ Help caregiver to give first dose now.

□ Advise to keep child warm, if child * Bottle cap of 60mL zinc syrup
is NOT hot with fever. For ALL □ Advise caregiver to give more fluids and continue
children feeding (kalamansi juice for cough).
□ Write a referral slip. treated □ Advise on when to return. Go to nearest health facility
at home, or, if not possible, return immediately if child
□ Arrange transportation, and help advise on - Cannot drink or feed
solve other difficulties in referral. home care - Becomes sicker
- Has blood in the stool
□ FOLLOW UP child on return at □ Give Paracetamol for temperature of 38.5°C and
least once a week until child is above every 6 hours ( until fever stops).
well.
SYRUP
AGE TABLET (500mg)
(120mg/5mL)
2 months up
1/4 5mL (1tsp)
to 3 years
3 years up to
1/2 10mL (2tsps)
5 years

□ Follow up child in 3 days.

□ For child with YELLOW on MUAC strap, refer to health
center for feeding advice.

133
 Age Vaccine
Advise caregiver, if
4. CHECK Birth  BCG  Hep B1
VACCINES RECEIVED 6 weeks  DPT1  OPV1  Hep B2 WHEN is the next vaccine to
(check vaccines completed, 10 weeks  DPT2  OPV2 be given?
encircle vaccines missed) 14 weeks  DPT3  OPV3  Hep B3
WHERE?
9 months  Measles

5. Check Vitamin A status: Given within the last 6 months? Yes No

(Give Vitamin A if child is 6 months old and is not given within the last 6 months)

6. Check deworming status: Given Mebendazole/Albedazole within the

last 6 months? Yes No
(Give Mebendazole/Albendazole if child is is ≥ 12 months old and has not been given deworming medicine within the
last 6 months.

7. If any OTHER PROBLEM or condition you cannot manage, refer child to health facility,
write referral note, and follow up child on return.

Describe problem: ___________________________________________________________

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

8. When to return for FOLLOW UP (encircle):

Monday / Tuesday / Wednesday / Thursday / Friday / Weekend

9. Note on follow up:

 Child is better—continue to treat at home. Day of next follow up:_________.

 Child is not better—refer URGENTLY to health facility.
 Child has danger sign—refer URGENTLY to health facility.

134
ANNEX 5
WFH tables and checking the z-scores

135
136
Example: a girl is 66cm length and weighs 6.5kg.

»» Take the girls table, look in the 1st column and look for the figure 66cm (= height).
»» Take a ruler or a piece of card place it under the figure 66 and the other figures on the same line.
On this line find the figure corresponding to the weight of the child, in this case 6.8.
»» Look to see what column this figure is in. In this case it is in the MEDIAN WEIGHT column.

In this example the child’s weight is normal in relation to her LENGTH. She therefore has an appropriate
weight for her length.

Example: a boy is 78cm tall and weighs 8.3kg

This child is between the column -2 and -3 Z-score or between MAM and SAM. He is too thin in relation to
his length or less than two and more than three: he is < -two (less) and > -three (more): he is Moderately
Malnourished but NOT Severely Malnourished.

NOTE: It may be that the weight or the height is not a whole number.

Example: length: 80.4cm and weight: 7.9kg. These two figures are not in the table.

For the height/length: The height/length measurement has to be rounded to the nearest 0.5cm, as
it is in the following example.

LENGTH in cm

79.8
79.9
80.0 80.0cm is used for 79.8, 79.9cm as well as for 80.1 and 80.2cm
80.1
80.2

80.3
80.4
80.5 80.5cm is used for 80.3, 80.4cm as well as for 80.6 and 80.7cm
80.6
80.7

80.8
80.9
81.0 81.0cm is used for 80.8, 80.9cm as well as 81.1 and 81.2cm
81.1
81.2

For the weight: Looking at the table, for a length of 80.5cm the weight is 7.9kg. This is between 7.7
and 8.3kg. Conclusion: to express the fact that the child is between these 2 weights, write down that this
child’s Z-score is between -4 and -3 Z-score or <-3 AND >-4 Z-score. The child has SAM.

137
 ANNEX 6
BMI tables for adults and adolescents

bODY MASS INDEX (ADULTS)

(=W / H2) Weight in kg and height in meters

BMI BMI
Height Height
18.5 18 17.5 17 16.5 16 18.5 18 17.5 17 16.5 16
(cm) (cm)
Weight in kg Weight in kg
140 36.3 35.3 34.3 33.3 32.3 31.4 165 50.4 49.0 47.6 46.3 44.9 43.6
141 36.8 35.8 34.8 33.8 32.8 31.8 166 51.0 49.6 48.2 46.8 45.5 44.1
142 37.3 36.3 35.3 34.3 33.3 32.3 167 51.6 50.2 48.8 47.4 46.0 44.6
143 37.8 36.8 35.8 34.8 33.7 32.7 168 52.2 50.8 49.4 48.0 46.6 45.2
144 38.4 37.3 36.3 35.3 34.2 33.2 169 52.8 51.4 50.0 48.6 47.1 45.7

145 38.9 37.8 36.8 35.7 34.7 33.6 170 53.5 52.0 50.6 49.1 47.7 46.2
146 39.4 38.4 37.3 36.2 35.2 34.1 171 54.1 52.6 51.2 49.7 48.2 46.8
147 40.0 38.9 37.8 36.7 35.7 34.6 172 54.7 53.3 51.8 50.3 48.8 47.3
148 40.5 39.4 38.3 37.2 36.1 35.0 173 55.4 53.9 52.4 50.9 49.4 47.9
149 41.1 40.0 38.9 37.7 36.6 35.5 174 56.0 54.5 53.0 51.5 50.0 48.4

150 41.6 40.5 39.4 38.3 37.1 36.0 175 56.7 55.1 53.6 52.1 50.5 49.0
151 42.2 41.0 39.9 38.8 37.6 36.5 176 57.3 55.8 54.2 52.7 51.1 49.6
152 42.7 41.6 40.4 39.3 38.1 37.0 177 58.0 56.4 54.8 53.3 51.7 50.1
153 43.3 42.1 41.0 39.8 38.6 37.5 178 58.6 57.0 55.4 53.9 52.3 50.7
154 43.9 42.7 41.5 40.3 39.1 37.9 179 59.3 57.7 56.1 54.5 52.9 51.3

155 44.4 43.2 42.0 40.8 39.6 38.4 180 59.9 58.3 56.7 55.1 53.5 51.8
156 45.0 43.8 42.6 41.4 40.2 38.9 181 60.6 59.0 57.3 55.7 54.1 52.4
157 45.6 44.4 43.1 41.9 40.7 39.4 182 61.3 59.6 58.0 56.3 54.7 53.0
158 46.2 44.9 43.7 42.4 41.2 39.9 183 62.0 60.3 58.6 56.9 55.3 53.6
159 46.8 45.5 44.2 43.0 41.7 40.4 184 62.6 60.9 59.2 57.6 55.9 54.2

160 47.4 46.1 44.8 43.5 42.2 41.0 185 63.3 61.6 59.9 58.2 56.5 54.8
161 48.0 46.7 45.4 44.1 42.8 41.5 186 64.0 62.3 60.5 58.8 57.1 55.4
162 48.6 47.2 45.9 44.6 43.3 42.0 187 64.7 62.9 61.2 59.4 57.7 56.0
163 49.2 47.8 46.5 45.2 43.8 42.5 188 65.4 63.6 61.9 60.1 58.3 56.6
164 49.8 48.4 47.1 45.7 44.4 43.0 189 66.1 64.3 62.5 60.7 58.9 57.2
190 66.8 65.0 63.2 61.4 59.6 57.8

BMI INTERPRETATION
< 16.0 severe thinness
16.0 - 16.9 moderate thinness
17.0 - 1834 marginal thinness
18.5 - 24.9 normal

Source: WHO (1995) Physical status: the use and interpretation of

anthropometry, Report of a WHO Expert Committee, World Health Organization.

138
ANNEX 7
Identification of acute malnutrition in other groups

Admission

GROUP CRITERIA

• BMI for age < -3 z-scores

Older Children (5 to 9 yrs.) or
• Presence of bilateral pitting edema
• MUAC < 160mm (16.0cm)
or
Adolescents (10 to 18 yrs.) • BMI for age < -3 z-scores, and /or
or
• Bilateral pitting edema
• MUAC < 180mm (18.0cm) with recent weight loss
or
Adults • BMI < 16 with recent weight loss
or
• Presence of bilateral pitting edema

Discharge

GROUP CRITERIA

• WFH ≥ 85% NCHS

More than 120cm HEIGHT to 18
And
years age
• No edema for 14 days
• MUAC ≥ 18.5cm
Or
• BMI ≥ 17.5
Adults And
• No edema for 14 days
And
• Clinically well

139
140
THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE/LENGTH
Use this table to assess feeding of all young infants except HIV-exposed young infants not breastfed. For HIV-exposed non-breastfed young infants see chart “THEN CHECK FOR FEEDING PROBLEM OR LOW
WEIGHT FOR AGE IN NON-BREASTFED INFANTS“

If an infant has no indications to refer urgently to hospital:

Check for Acute Malnutrition Not well attached to breast YELLOW: • If not well attached or not suckling
ANNEX 8

Classify OR effectively, teach correct positioning and

Ask: FEEDING Not suckling effectively FEEDING attachment.
Is the infant breastfed? If yes, how many times in 24 hours? OR PROBLEM - If not able to attach well immediately,
Does the infant usually receive any otehr foods or drinks? if yes, how often? Less than 8 breastfeeds in 24 OR teach the mother to express
If yes, what do you use to feed the infant? hours LOW WEIGHT breastmilk and feed by a cup.
OR • If breastfeeding less than 8 times in 24
Look and Feel: Receives other foods or drinks or hours, advise to increase frequency
OR of feeding. Advise the mother to
Look for signs of acute manutrition Low weight for age/length breastfeed as often and as long as the
OR infant wants, day and night.
Determine the weight for age Thrush (ulcers or white patches in • If receiving other foods or drinks,
Look for ulcers or white patches in the mouth (thrush). mouth). counsel the mother about breastfeeding
more, reducing other foods or drinks,
Infant feeding assessment IMCI

and using a cup.

ASSESS BREASTFEEDING: • If not breastfeeding at all*
- Refer for breastfeeding counselling
Has the infant breastfed in the previous hour? If the infant has not fed in the and possible relactation.*
previous hour, ask the mother to put her infant to the breast. Observe the - Advise about correctly preparing
breastfeed for 4 minutes. breast-milk substitutes and using a
(if the infant was fed during the last hour, ask the mother if she can wait and cup .
tell you when the infant is willing to feed again.) • Advise the mother how to feed and
keep the low weight infant warm at
- Is the infant well-attached home.
not well attached good attachment • Follow-up any feeding problem or
thrush in 2 days.
To check attachment, look for: • Follow-up low weight for age in 14
- Chin touching breast days.
- Mouth wide open
- Lower lip turned outwards GREEN:
Not low weight for age/length and • Advised mother to give home care for
- More areola visible above than below the mouth
no other signs of inadequate the young infant.
(All these signs should be present if the attachment is good) NO
feeding. • Praise the mother for feeding the infant
FEEDING
well.
Is the infant suckling effectively (that, is slow deep sucks, sometimes PROBLEM
pausing)?
not suckling effectively suckling effectively
* Unless not breastfeeding because the mother is HIV positive.

Clear a blocked nose if it interferes with breastfeeeding

ANNEX 9
Summary Admission criteria for SAM

Inpatient management of SAM

Outpatient management of SAM
WHO and CB-IMCI protocols

Severe acute malnutrition with complications Severe acute malnutrition without complications

Children 6 - 59 months Children 6 - 59 months

• Nutritional edema +++ • MUAC < 115mm (11.5cm)
OR OR
• Marasmic-Kwashiorkor (< 115mm with any grade • Nutritional edema + or ++
of edema) OR
OR • WFH< -3 z-scores (where capacity already
• MUAC < 115mm (11.5cm) exists)
OR
• WFH< -3 z-scores with any of the following AND
complications:
- Anorexia, no appetite • Appetite
- Lower Respiratory Tract infection • Clinically well
- High fever • Alert
- Severe dehydration
- Severe anemia
- Not alert (very weak, lethargic,
unconscious, convulsions)
- Hypothermia
- Intractable vomiting

Infants Infants
Infants < 6 months who meet criteria for inpatient Infants < 6 months who meet criteria for outpatient
admission (see Table 8) breastfeeding support (see Table 8 and Section
3.5)

Referral from OTC Referral from ITC

due to deterioration or non-response after stabilization

141
 ANNEX 10
OTC/ITC referral form

Where there are existing two way referral formats in place these should be used and checked/amended
to ensure all the information on the following example is included. If no existing format is in place the form
below may be used/adapted for use.

Referral / Transfer Form (SAM) - Copy for Receiving Facility (OTC/ITC)

Name: _________________________ Sex: ____ Date of Birth: _________________ Age: ______ months/years
Admission information: MUAC: __________ Date of Referral: __________________
Name mother/caregiver (for child): ________________________________________
Registration Number (mother/caregiver):______________________ Contact Number:______________________
Municipality: ___________________ Barangay: _____________ House No.: _____

To be completed by referral focal point (ie. RHU staff - midwife/nurse/doctor)

Referred to/Transfer to: OTC / ITC Date of referral / transfer: _______________________

Weight: _________ Height: _________ WH Z score (if used): ___________ Edema (circle): + ++ +++
Refer/Transfer from: _________________________________ (Name of Brgy/Health Center/OTC/Hospital)
Refer/Transfer to: ___________________________________ (Name of Brgy/Health Center/ OTC /Hospital)
Reason for transfer (circle): Anorexia (no appetite) Complications Edema No weight gain Other: _________
Referred/Transferred by (name of Health Worker):___________________ Contact Number: _________________
Received by (name of Health Worker):__________________________ Contact Number: _________________

Cut along dotted lines

Referral / Transfer Form (SAM) - Copy for Referring Facility (OTC/ITC)

Name: _________________________ Sex: ____ Date of Birth: _________________ Age: ______ months/years
Admission information: MUAC: __________ Date of Referral: __________________
Name mother/caregiver (for child): ________________________________________
Registration Number (mother/caregiver):______________________ Contact Number:______________________
Municipality: ___________________ Barangay: _____________ House No.: _____

To be completed by referral focal point (ie. RHU staff - midwife/nurse/doctor)

Referred to/Transfer to: OTC / ITC Date of referral / transfer: _______________________

Weight: _________ Height: _________ WH Z score (if used): ___________ Edema (circle): + ++ +++
Refer/Transfer from: _________________________________ (Name of Brgy/Health Center/OTC/Hospital)
Refer/Transfer to: ___________________________________ (Name of Brgy/Health Center/ OTC /Hospital)
Reason for transfer (circle): Anorexia (no appetite) Complications Edema No weight gain Other: _________
Referred/Transferred by (name of Health Worker):___________________ Contact Number: _________________
Received by (name of Health Worker):__________________________ Contact Number: _________________

142
ANNEX 11
Routine medicine doses in OTC
Routine Antibiotics

Antibiotics should be given to every severely malnourished patient, even if they do not have signs of systemic
infection as the presence of infection may be masked due to immuno-suppression which limits response
such as fever.

»» Give on admission
»» Give 2 times a day for 5 - 7 days (10 days if needed)
»» The first dose should be given in front of the health worker and an explanation given to the mother
on how to continue this treatment at home.

The antibiotic regimen can be changed according to the resistance pattern of bacteria that arises from time
to time and amoxicillin replaced with another broad spectrum antibiotic.

First line treatment: Amoxicillin2

Medication Route Dose Prescription

4 - 9.9kg 250mg On admission

Amoxicillin Oral 10 - 13.9kg 500mg Twice daily for 5 - 7
14 - 19kg 750mg days

Dosage of Cotrimoxazole prophylaxis for HIV positive children 6 - 59 months (additional)

Medication Route Dose Prescription

40mg Trimethoprim
Cotrimoxazole
Oral 200mg Once daily
Suspension or tablet
Sulfamethoxazole

Malaria

»» Refer to the guidelines of the Philippine Malaria Control Program for asymptomatic malaria or
malaria prophylaxis (except that quinine tablets should not be used in the severely malnourished).
»» Refer symptomatic malarial cases for inpatient management.
»» Where complicated patients refuse admission to inpatients, treat with the regimen recommended
for inpatients.
»» Give insecticide impregnated bed nets in malaria endemic regions.

Deworming

»» This should be coordinated with the Garantisadong Pambata (GP) program

»» Give deworming for both those transferred from ITC to OTC and those admitted directly to OTC at
the 2nd outpatient visit. Worm medicine is only given to children that can walk.

Age <1 year 1 to 2 years ≥ 2years

Albendazole 400mg Not given ½ tablet Once daily

Mebendazole 500mg Not given ½ tablet 1 tablet

2 Amoxicillin is also effective in reducing the overgrowth of bacteria in the GI tract, commonly associated with severe acute malnutrition, and therefore
preferred over Cotrimoxazole which is standard first line antibiotic in Nepal.

143
 Measles

»» This should be coordinated with the Expanded Program of Immunization (EPI) program
»» Give measles vaccine to children over the age of 9 months and without a vaccination card during
their 4th visit; give a second dose to those that have been given measles vaccine as inpatients
when severely malnourished.
»» Do not give measles vaccine on admission to patients directly admitted to OTC, they are unlikely to
be incubating measles3 and will not be exposed to nosocomial infection.

Note: Measles vaccine on admission to OTC is thus omitted except in the presence of a measles epidemic,
because the antibody response is diminished or absent in the severely malnourished. The measles vaccine
is given at a time when there should be sufficient recovery for the vaccine to produce protective antibodies.

Vitamin A

»» Do not keep any child with clinical signs of vitamin A deficiency as an outpatient; the condition
of their eyes can deteriorate very rapidly and they should always be transferred for inpatient
management.
»» If an epidemic outbreak of measles is in progress, give vitamin A to all children.
»» During emergencies/disasters, give additional Vitamin A to 6 - 11 month old infants (100,000 IU)
and 12 - 59 month old children (200,000 IU), unless they have received a similar dose in the past 4
weeks.

Table 1. Vitamin A treatment

Medication Vitamin A IU orally

6 to 11 months One blue capsule (100,000IU = 30,000ug)

12 months and more Two blue capsules or 1 red capsule (200,000IU = 60,000ug)

Medicines for specific groups of SAM children in OTP

One dose of folic acid (5mg) can be given to children with clinical anemia. There is sufficient folic acid in the
RUTF to treat mild folate deficiency.4

3 If they are incubating measles, they are likely to fail the appetite test.
4 This assumes that the patients are receiving the RUTF at home and that the extent of sharing within the family is very small. If there is doubt whether
the child will receive sufficient RUTF then a dose of folic acid can be given.

144
ANNEX 12
Antibiotic alternatives for OTC

Where Amoxicillin resistance is common a short course of metronidazole should be given at a lower
dose than is normally prescribed - 10mg/kg/day (see Annex 19). Alternatively, Amoxicillin/Clavulanic acid
combination could be used (the level of resistance is lower than with amoxicillin alone at the moment) –
this recommendation should be reviewed periodically in light of the prevailing resistance patterns in the
population being treated.

Do not give chloramphenicol to babies of less than 2 months of age and with caution in infants less than
4kg or less than 6 months of age. Because of the danger of OTC staff giving chloramphenicol to these
categories of patient, it should not be used as routine treatment in OTC programs.

ANNEX 13
Fever and SAM

Antipyretics are much more likely to be toxic in the malnourished than in a normal child due to the likelihood
of reduced liver function.

Do not give aspirin to any child under the age of 12 years with fever. This may cause Reye's syndrome.
Other non-steroidal anti-inflammatory medicines (NSAIDS) should not be given in malnutrition due
to the risk of renal toxicity.

Paracetamol should not be given routinely to children with SAM. It is given as a stat dose with
extreme caution under the direction of a clinician only in ITC and OTC. It should never be dispensed
as a take home medicine in OTC. Paracetamol should be used with caution in children receiving
phenobarbitone, phenytoin or rifampicin.

If Paracetamol is prescribed as a stat dose, the oral route is recommended since the absorption of
rectal Paracetamol is highly variable.

For moderate fever up to 38.5°C rectal or 38.0°C underarm:

»» Remove blankets, hat, and enough clothes to expose the back, chest and stomach. Remove any
sources of heat and keep away from windows exposing the child to direct sunlight. If in the open,
keep the patient in the shade in a well-ventilated area.
»» Give frequent sips of cool water to drink.
»» Check for malaria and examine for other sources of infection.

For fever of over 39°C rectal or 38.5°C underarm, where there is the possibility of hyperpyrexia developing,
in addition to the above, also:

»» Place a damp/wet room-temperature cloth over the patient’s scalp, and chest area. Dampen the
cloth whenever it is dry. Use an electric fan or wave a fan over the child to increase the cooling
effect.
»» Monitor the child’s temperature every 30 mins and stop aggressive cooling when the temperature
falls below 38.5°C (rectal) or 38.0°C (axilla).
»» Give the patient frequent sips of cool water. Check with the physician regarding any limits to fluid
intake particularly where there are also IV fluids administered.
»» If the temperature increases or does not reduce, the child should be undressed completely and the
damp/wet cloth can be extended to cover a larger area of the body. A physician should reassess
the status of the child and consider IV antibiotic therapy if not already started.

145
 ANNEX 14
Ready-to-Use Therapeutic Food (RUTF)

Ready-to-Use Therapeutic Food (RUTF) is an energy dense mineral/vitamin enriched food nutritionally
equivalent to F100, which is recommended by the WHO for the treatment of malnutrition and which has
particular technical and quality specifications for its composition and production.5 It is oil-based with low water
activity; thus it is microbiologically safe and can be kept for months in simple packaging. Therefore, with
proper hygiene instruction, RUTF can be safely used for outpatient treatment of Severe Acute Malnutrition.
As it is eaten uncooked, it is an ideal vehicle to deliver many micronutrients that might otherwise be broken
down by cooking. Studies have shown that severely malnourished children given RUTF had a faster rate of
recovery than those given F100.6

While RUTF is a generic name, Plumpy’nut® is the trademark name for the manufactured product from the
French company, Nutriset,7 and Eeezee paste is the trademark name of the manufactured product from
India.

General Description:
Ready-to-Use Therapeutic Food, in individual sachets of 92 grams.

Composition:
Vegetable fat, peanut butter, skimmed milk powder, lactoserum, maltodextrin, sugar, mineral and vitamin
complex. Both GMO Free Certificate and Halal certificates may be obtained from the manufacturer.

1 sachet = 92 grams of product = 500kcal.

2%

20% 25%
Minerals and Vitamins (CMV)

Peanut Butter

Milk Powder

Sugar

27% Oil
26%

5 WHO/WFP/SCN/UNICEF, 2007. Community-Based Management of Severe Acute Malnutrition. A Joint Statement by WHO, WFP, UNSCN and
UNICEF, May 2007. http://www.unicef.org/publications/files/Community_Based_Management_of_Sever_Acute__Malnutirtion.pdf
6 Diop EHI, Dossou, NI, Ndour MM, Briend A, and Wade S (2003): Comparison of the efficacy of a solid ready-to-use food and a liquid, milk-based diet
for the rehabilitation of severely malnourished children: a randomised trial. Am J Clin Nutr 2003; 78:302-7
7 The company producing other therapeutic supplies such as F100 and F75.

146
 Nutritional value per 100g of product:

Energy: 545kcal
Proteins: 13.6g = 10% protidic calories
Lipids: 35.7g = 59% lipidic calories
(Thus by deduction: 31% carbohydratic calories = 42.2g carbohydrates )

Vitamins: Minerals:

Vitamin A: 910 micrograms

Vitamin D: 16 micrograms Calcium: 320mg
Vitamin E: 20mg Phosphorus: 394mg
Vitamin C: 53mg Potassium: 1111mg
Vitamin B1: 0.6mg Magnesium: 92mg
Vitamin B2: 1.8mg Zinc: 14mg
Vitamin B6: 0.6mg Copper: 1.78mg
Vitamin B12: 1.8 microgram Iron: 11.53mg
Vitamin K: 21 microgram Iodine: 110 microgram
Biotin: 65 microgram Sodium: <290mg
Folic acid: 210 microgram Selenium: 30 microgram
Pantothenic acid: 3.1mg
Niacin: 5.3mg

Shelf life:
24 months from manufacturing date (under well ventilated storage conditions with maximum 40°C
temperature; humidity has no impact)

Packaging and labelling:

Airtight sachet which includes an aluminum layer to protect against UV, light, and humidity.

Local Production of RUTF

Since RUTF has to be imported, the costs are high. With this problem in mind, the development of locally
produced RUTF has been commenced in some countries, in order to try to ensure a cheaper and more
sustainable supply of the product. Any local product must adhere to international specifications and be
subject to national quality control testing and approvals.

ANNEX 15
Ready-to-use therapeutic food (RUTF) Ration

Body Weight Range Ready-to-use therapeutic food (RUTF)

(kg) Sachets per day Sachets per week*

3.0 - 3.4 1 ¼ sachet 8 sachets

3.5 - 4.9 1½ 10
5.0 - 6.9 2 15
7.0 - 9.9 3 20
10.0 - 14.9 4 30
15.0 - 19.9 5 35
20.0 - 29.9 6 40

*Values are rounded off

147
 ANNEX 16
OTC chart

Instructions:
Please fill up needed details and encircle appropriate text or values based on history taking and physical examination

148
149
 ANNEX 17
Action protocol

FACTOR CRITERIA FOR REFERAL TO INPATIENT CARE

Edema Increase of or development of edema

Appetite No appetite or unable to eat RUTF

Deterioration in medical condition to develop any of the IMCI danger signs:

• Vomiting Intractable (empties contents of stomach)

• Temperature: Fever > 38.5°C (101.3°F) axillary

> 39.0°C (102.2°F) rectal

• Hypothermia < 35°C (95°F) axillary

< 35.5°C (96°F) rectal

• Respiration rate ≥ 50 resp/min from 6 to 12 months

≥ 40 resp/min from 1 to 5 years
≥ 30 resp/min for over 5 year olds
Medical
And any chest in-drawing (for children > 6 months)
complications
• Anemia Very pale (severe palmar pallor, roof of the mouth
(oropharynx), nail beds, eye palpebrae), difficulty
breathing

• Superficial infection Extensive skin infection requiring Intra-muscular

antibiotics

• Alertness Very weak, apathetic, unconscious

• Fits/convulsions

• Hydration status Recent history of diarrhea/vomiting with appearance of

sunken eyes
Weight loss for 3 consecutive weighings
Weight changes
Static weight for 5 consecutive weighings
Reported
breastfeeding issues
No improvement after 1 week and continued weight loss of infant
(infants < 6 months
only)

General Other general signs the health worker thinks warrants referral (as per IMCI)

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ANNEX 18
Routine medicines in Phase 1 inpatient care for SAM

If complications are NOT present:

Medication Route Dose Prescription

4 - 9.9kg 250mg On admission

Amoxicillin*
Oral / NGT 10 - 13.9kg 500mg Twice daily for 5 - 7
Oral / NGT
14 - 19kg 750mg days
*Where there is amoxicillin resistance give amoxicillin - clavulanic acid combination

If indicated, Metronidazole (10mg/kg/day) may be used to treat small bowel overgrowth of bacteria not
responding to amoxicillin. Note that the dosage of metronidazole is reduced for children with SAM.

If complications ARE present:

Routine medications for SAM with complications

Medication Route Dose Prescription

On admission
Ampicillin* IM/IV 50mg/kg
6 hourly for 2 days
4 - 9.9kg 250mg
Followed by 10 - 13.9kg 500mg
Orally / NGT Twice daily for 5 days
Amoxicillin 14 - 19kg 750mg

*Where there is amoxicillin resistance give Cefotaxime (IM 50mg/kg once daily) for 2 days then give amoxicillin-clavulanic acid
combination for 5 days

AND

On admission
Gentamycin IM/IV 5mg/kg
Once daily for 7 days

If the child does not improve within 48 hrs or deteriorates within 24 hrs add;

Once daily with

Ceftriaxone* IM/IV 75 - 100mg/kg
Gentamycin

*Care must be taken in reconstituting and administering Ceftriaxone via the IM or IV route. Please refer to the product data sheet for
precautions. Cefotaxime (100mg/kg/day on 1st day followed by 50mg/kg/day on subsequent days) may be preferred in septic shock.

Note: Chloramphenicol for children <1 year should be used with EXTREME caution. Risk for gray baby
syndrome and death are associated with its use.

151
 Other routine medications

Vitamin A

A single dose of vitamin A is given on admission only if the child presents with:
»» Clinical signs of vitamin A deficiency (xeropthalmia, bitot spots)
»» An active case of measles
Or
»» If commercial F75 / F100 / RUTF is not available

Vitamin A schedule for the inpatient treatment of SAM

Medication Age Dose

6 - 12 months 100,000 IU
Vitamin A
Greater than 12 months 200,000 IU

Folic Acid

Folic acid is present in adequate amounts in therapeutic milks and RUTF to treat mild anemia. If moderate
anemia is diagnosed then give a stat dose of 5mg on admission. There is no requirement for daily doses.
For severe anemia see Annex 24.

Measles Vaccination

Children with SAM treated in inpatient care should be vaccinated for measles on admission from 6 months
of age. The dose should be repeated on discharge from inpatient care Phase 2 or when the child reaches
9 months in the outpatient setting.

Antimalarials

Follow national protocol. Impregnated bed nets should also be used on all beds in malaria endemic areas.

Some of the drugs used in treating malaria are potentially more toxic in the malnourished than in well-
nourished patients and should be avoided if possible. Combinations containing amodiaquine should be
avoided in the SAM children until their safety is confirmed in this group of children.

Do NOT give oral or intravenous infusions of quinine to SAM patients for at least the first two weeks of
treatment. In severely malnourished patients quinine often induces prolonged and dangerous hypotension,
hypoglycemia, arrhythmia and cardiac arrest. There is only a small difference between the therapeutic dose
and the toxic dose.

152
Medication NOT to be given in Phase 1

Anthelminthics

Anthelminthics for deworming are not given in Phase 1. These medications are absorbed through the gut
and the active metabolite generated in the liver. Early in treatment poor absorption in the gut and poor liver
function may render the drug ineffective.

Zinc

Zinc is present in F75 and F100 therapeutic milks and in RUTF. Episodes of diarrhea should be treated with
antibiotics and ReSoMal if indicated by the presence of dehydration. If commercially prepared F75 / F100 /
RUTF is not available then zinc should be used in the management of diarrhea.

Iron

Iron is not given in Phase 1. Iron increases the risk of mortality through the increased risk of infection and
sepsis. Iron is given only in Phase 2 where it is added to the therapeutic milk (see Phase 2 care). Iron tablets
do not need to be given to children receiving RUTF as iron is present already present in RUTF in the correct
amounts.

ANNEX 19
Treat / prevent hypoglycemia

Hypoglycemia is a low level of glucose in the blood (less than 3mmol/L or less than 54mg/dL). It is a serious
condition and can cause death. It can occur together with hypothermia and both the conditions are signs
of possible infection. Hypoglycemia may also occur if the malnourished child has not been fed for 4 - 6
hours, sometimes even for lesser duration. For this reason it is always preferable to feed the child every 3
hours (8 times in 24 hours) especially during Phase 1 and Transition Phase. Signs of hypoglycemia include
lethargy, limpness, convulsions and loss of consciousness.

»» If hypoglycemia is suspected but blood glucose cannot be measured, empirical treatment should
be started immediately
»» Consider hypoglycemia whenever hypothermia is detected (axillary temperature less than 35.0ºC;
rectal temperature less than 35.5ºC), or if any signs of hypoglycemia are present.

Measuring blood glucose level

If possible, testing for blood glucose level should be done using glucose paper test strips. When the end of
the paper strip is covered with a blood sample, the strip changes color to indicate the blood glucose level.
Check the expiry date of the strips; if the date is expired, the readings may not be correct. Different testing
kits may have different instructions. In general, instructions are as follows:

»» Touch the paper to the blood sample

»» Wait for an appropriate number of seconds
»» Wash the blood off the strip with running water
»» Compare the test paper to the color scale provided with the strips.

In many cases the color scale for the paper strips may not clearly show the level. For example, it may say
that a certain color corresponds to 2 - 4mmol/L. If a range is given, assume that the child’s blood glucose is
the lower reading (2mmol/L in this case).

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 Treatment

If the child is conscious, give:

»» 50mL bolus of 10% glucose or sucrose solution (1 rounded teaspoon of sugar in 3.5 tablespoons
water) orally or by nasogastric (NG) tube.
»» Feed F75 every 30 minutes for first two hours (giving ¼ of the total recommended two hours’
feed)
»» Keep the child warm
»» Antibiotics

If the child is lethargic, unconscious or convulsing, give:

»» 10% glucose (5mL/kg body weight) intravenously followed by 50mL of 10% glucose or sucrose by
NG tube to prevent rebound hypoglycemia. Then give starter F75 as above
»» If convulsion persists after giving intravenous glucose, give per rectal diazepam (0.5mg/kg body
weight)
»» Keep the child warm; give antibiotics and feed as mentioned above
»» If the child will be given IV fluids for shock, there is no need to follow the 10% IV glucose with an
NG bolus, as the child will continue to receive glucose in the IV fluids.

Prevention of Hypoglycemia

Frequent feeding is important in preventing both hypoglycemia and hypothermia. If possible, feeds during
Phase 1/Stabilization should be given every 3 hours including waking the child during the night. If staff and
facilities are not available to properly feed and monitor the child overnight, the full volume of daily feed
should be given in fewer feeds (5 or 6 times daily). The likelihood of hypoglycemia is reduced if the child is
given the proper amount of feed during the day.

NB: If the number of feeds is reduced for whatever reason, the volume of milk given at each feed must be
increased accordingly.

154
ANNEX 20
Treat / Prevent hypothermia

Hypothermia is a condition with low body temperature (axillary temperature is below 35°C). A rectal
temperature of < 35.5°C is a more reliable indicator of hypothermia. If available, a low reading rectal
thermometer should be used. Check for hypoglycemia whenever hypothermia is detected.

Using a rectal thermometer

»» Shake the thermometer down to below 35°C

»» Position the child on his side or back with legs lifted
»» Insert thermometer in rectum so that the bulb goes in about ½ inch
»» Keep in place for 1 minute and take the reading.

Using an axillary thermometer

»» Shake thermometer down to below 35°C

»» Place thermometer under armpit
»» Keep in place for 3 minutes
»» If below 35°C, take rectal temperature for more accurate reading.

Treatment

»» Re-warm the child by clothing the child (including head), or covering

with a warmed blanket and increasing the room temperature with a
heater or lamp placed nearby, or by putting the child on the mother’s
bare chest (skin to skin) and covering them.
»» Feed the child (or start oral rehydration for dehydration if required)
»» Give antibiotics
»» Do not use hot water bottles for warming due to danger of burning
fragile skin.

Prevention

»» Keep the child covered and away from draughts of air

»» The room temperature should be maintained at not less than 27°C if possible
»» Avoid regular bathing, keep child dry, change wet diapers, clothes and bedding
»» Avoid exposure (e.g. bathing, prolonged medical examinations)
»» Let child sleep with mother/caregiver at night for warmth
»» Feed regularly, give feeds throughout the day and night during Phase 1, if possible, especially for
the first 24 - 48 hours.

ANNEX 21
Treatment of dehydration / hypovolemic shock

Misdiagnosis and inappropriate treatment for dehydration is the most common cause of death of the severely
malnourished patient. It is difficult to diagnose dehydration in children with SAM; the signs of dehydration
such as non-elastic skin and sunken eyes are often present in the severely malnourished patient regardless
of hydration status. It is important to take a detailed medical history and determine if there was a recent fluid
loss from acute diarrhea or vomiting.

Children with SAM usually have reduced cardiac contractility and renal function. Rehydration therapy in
these patients is more cautious than for a normally nourished child as the child cannot compensate for
increased intravascular volumes in the same way, which may quickly precipitate heart failure.

155
 If a child is conscious or has a nasogastric tube in place and the risk of aspiration is low, oral rehydration
solutions are ALWAYS preferable to intravenous rehydration solutions. Intravenous solutions should only
be used when the child is unconscious or is being resuscitated from shock. An intravenous infusion should
never be present in a child who is able to take fluids orally or by nasogastric tube.

NB: The treatment of dehydration and hypovolemic shock differs for children with wasting and children with
edematous malnutrition. A child with edema should not be diagnosed with dehydration although they may
be hypovolemic. The rehydration of children with edema is the same as the treatment of a child with septic
shock

Use of IV lines in ITC

Intravenous access should be maintained only for those children in which it is indicated, i.e.:

»» Children receiving intravenous antibiotics in Phase 1 / Transition Phase

»» Children with decreased consciousness unable to safely tolerate oral fluids
»» Children with hypovolemic / septic shock
»» Children in whom oral or NG tube fluids are contraindicated

IV access which is used intermittently (e.g. for IV antibiotics) must be flushed every 8 hours with 2mL of
sterile normal saline or Heplock®. Peripheral IV access must be cleaned with alcohol at each use.

Intravenous access must not be maintained with slow infusion IV fluids “to keep the line open”. This places
the child with SAM in danger of fluid overload.

All IV access must be removed when there is no indication for its use. IV access should not be left in place
“just in case it is needed”. Peripheral IV access should be removed (and re-sited if needed) every 5 days or
more frequently if signs of phlebitis or infection develop.

Central venous access (including peripherally inserted central cannula/PICC) should be maintained
according to the physician’s instructions.

Assess the dehydration

A diagnosis of dehydration must be made from an examination of the clinical condition with a positive history
of fluid loss, which identifies the cause of dehydration (e.g. persistent vomiting or acute diarrhea). The
assessment of dehydration for children with SAM can be very difficult even for a skilled health staff and can
be confused with other conditions. It is essential to manage the child with extreme caution and be willing to
change the diagnosis if the clinical status of the child does not improve with rehydration. There is a narrow
‘therapeutic window’ for children with SAM and dehydration; overhydration and death can occur quickly.

Clinical signs

»» The skin pinch test is an unreliable sign especially in marasmic children. A positive skin pinch test
may occur in a marasmic child with a normal hydration status.
»» A definite history of significant, recent fluid loss – usually frequent watery diarrhea of sudden
onset (within the past few hours or days). Children with chronic diarrhea may become adapted
physiologically to this state and do not require urgent rehydration therapy.
»» Sunken eyes must be confirmed by an accurate history. The eyes must have become sunken in
the previous few days and a positive history for the cause of dehydration identified. In dehydration
this is due to contraction of the venous plexus behind the eye and occurs acutely. Sunken eyes can
also occur over time in marasmic children due to a loss of fat behind the eyeball.
»» A child’s urine output must also be assessed by an accurate history. The mother or caregiver
should be asked whether or not the child passed urine in the last 6 hours, noting also the urine
color if present.
»» Visibly full superficial veins on the head, neck, and limbs must be absent in a SAM child with
dehydration.
»» A diagnosis of dehydration should ALWAYS be a provisional diagnosis. The response to treatment
must be observed before the diagnosis can be confirmed.
»» Concomitant signs of dehydration may include increased heart rate, temperature, and/or reduced
blood pressure.

156
Patient’s status

1. Weigh the child. The weight should be monitored regularly (at least every hour) during rehydration
to assess the response to treatment. Rehydration therapy should aim to replace the estimated fluid
losses up to a maximum of 5% body weight.
2. Check the heart rate.
3. Check the respiration rate.
4. Feel and note if extremities (hands and feet) are cold.
5. Note the level of consciousness of the child (may range from restless, semi-conscious or lethargic
and difficult to arouse).
6. Palpate the liver and mark the costal margin with indelible ink.
7. Note the absence of jugular venous distension.
8. Note the amount of any edema.

If the following signs are also present:

»» Decreased level of consciousness so that the patient is semi-conscious or cannot be roused

Plus either

»» Cold extremities
»» Slow capillary refill in the nail beds (longer than 3 seconds) OR
»» Fast or weak / absent radial / femoral pulse
- Children 2 to 12 months - pulse rate greater than 160/ min
- Children 1 to 5 years - pulse rate greater than 140 / min

Then hypovolemic shock is provisionally diagnosed (confirmation of the diagnosis is only made following
observation of the response to treatment).

NB: The differential diagnosis of hypovolemic shock and septic shock and is often very difficult in a child
with SAM. If another illness such as viral infection, malaria, or other severe condition is present, septic
shock should be assumed. Septic shock is often seen in individuals who are immunocompromised or have
hospital acquired infections. Mortality due to multiple organ failure may exceed 50%.

Oral Rehydration solutions

1. Rehydration Solution for Malnutrition (ReSoMal) should be used as the standard therapy for children
with SAM diagnosed with dehydration

2. Low Osmolarity Oral Rehydration Solution (LO-ORS) may be used for the treatment of children with
SAM but only for those who have a positive diagnosis of Acute Watery Diarrhea (AWD) or Cholera

3. Standard (full strength) Oral Rehydration Solution (ORS) does not have a suitable formulation for the
treatment of dehydration in children with SAM.

Where ReSoMal is not available, a modified, half-strength solution of LO-ORS may be used with added
potassium and glucose.

NB: Oral Rehydration Solutions such (ORS or ReSoMal) for the treatment of dehydration must NEVER be
freely accessible to caregivers on the hospital ward.

157
 Resomal Formulation:

ReSoMal (ORS for severely malnourished children), 42g sachet to be diluted in 1 liter of purified/boiled and
cooled water.

Technical Specifications:

Contents per sachet of 42 grams:

Sucrose: 25g
Glucose Anhydrous: 10g
Sodium Chloride: 1.75g
Trisodium Citrate, dihydrate: 45g
Potassium Chloride: 2.54g
Tripotassium Citrate: 0.65g
Magnesium Chloride Anhydrous: 0.61g
Zinc Acetate: 0.0656g
Copper Sulphate Anhydrous: 0.0112g
Osmolarity: 300mmol/L

All the ingredients must comply with one of the pharmacopeias:

BP, Ph.Eur, Ph.Int, USP.

Intravenous Rehydration Solutions

1. Ringers Lactate Solution with 5% Dextrose

2. 0.45% Saline with 5% Dextrose

Treatment of Marasmic children with dehydration / hypovolemic shock

Figure 1 below describes the algorithm for the treatment of dehydration in a child with severe wasting.

Figure 1. Treatment of dehydration / hypovolemic shock in a child with severe wasting

Decreased consciousness
Conscious SAM with severe dehydration
and / or Hypovolemic shock

ReSoMal Intravenous Solution

10mL/kg - first 2 hours 15mL/kg - first 1 hour
5 - 10mL/kg - Next 10 hours

Reassess

If conscious: Insert nasogastric If improving:

tube and start ReSoMal 15mL/kg - second hour
(10mL/kg/hr)

Reassess

If not improving:
DIAGNOSE
SEPTIC SHOCK

158
 Monitoring the progress of rehydration therapy

The therapeutic window for rehydration therapy is narrower for a child with SAM than for a normally nourished
child due to the abnormal pathophysiology. The reduced function of the cardiac, renal and abnormal
cardiovascular system results in abnormal responses to an increase in fluid load. It is much easier to quickly
overhydrate the child resulting in heart failure and death, as the increased fluid volume in the cardiovascular
system cannot be excreted normally. A child with SAM in heart failure may not respond well to diuretic
medications. Avoiding over-hydration and heart failure is easier and far preferable to treating them.

Figure 2 below describes the algorithm for monitoring rehydration therapy in a severely wasted patient with
the aim of preventing fluid overload. The goal of rehydration therapy is to improve the child’s clinical status.
This should normally be no more than 5% of the child’s body weight.

Figure 2. Algorithm for monitoring rehydration therapy in a severely wasted patient

Monitor Weight*
Every 30 - 60 mins

Weight Gain Weight stable Weight loss

Increase Increase
Clinically No Clinical
ReSoMal by ReSoMal by
improved improvement
5mL/kg/hr 10mL/kg/hr

Continue to STOP ALL Reassess every Reassess every

target weight REHYDRATION 60 mins until 60 mins
and start F75 FLUIDS target weight is Until target weight
Give F75 and reached is reached
reassess.
Diagnose septic
shock

*The goal of rehydration therapy is based on the improvement of clinical status. A maximum target weight for rehydration therapy
should be no more than 5% of body weight

Monitoring the clinical status during the rehydration of the marasmic child

Every 30 - 60 mins assess:

»» Weigh the patient (and calculate the target weight gain)

»» Heart/Pulse rate, temperature, respiration rate
»» Heart sounds (over-hydration may result in a gallop rhythm)
»» Observe for signs of respiratory distress (chest indrawing, nasal flaring)
»» Observe for vomiting or diarrhea (estimate volumes and correlate with weight loss)
»» Reassess the costal margin of the liver
»» Reassess the absence or presence of jugular venous distension
»» Monitor for presence or absence of urine output and, if present, urine color

159
 During rehydration therapy, breastfeeding should not be interrupted; the child should be breastfed on demand.
Successful rehydration results in an improvement of the clinical status of the child with an improvement in
the level of consciousness, and normal heart/pulse rate and blood pressure.

NB: Rehydration therapy should be stopped immediately if any of the following occur:

»» Target weight for rehydration is achieved (start F75)

»» There is development of edema (start F75)
»» Jugular venous distension is observed
»» Jugular veins become engorged when abdomen is pressed
»» An increase in the costal margin of the liver of 1cm or more
»» Tenderness of the liver on palpation
»» An increase in respiratory rate of 5 breaths per minute or more
»» Increase in pulse/heart rate of 25 beats/min or more
»» Development of grunting expiratory sounds/labored breathing/increased respiratory effort
»» Development of pulmonary rales or crepitations on auscultation
»» Development of a triple rhythm (gallop) in the heart sounds or brachial pulse

Diagnosis of dehydration in children with edema

Patients with bilateral edema are overhydrated and have increased total body water and increased sodium
levels. Edematous patients thus cannot be dehydrated, although they are frequently hypovolemic. The
hypovolemia (relatively low circulating blood volume) is due to a dilatation of the blood vessels with a low
cardiac output.

Treatment of dehydration in children with edema

If a child with edema has watery diarrhea, and the child is deteriorating clinically, then the fluid lost can be
replaced on the basis of 30mL ReSoMal per episode of watery stool.

The fluid management of hypovolemia for a child with edema is the same as the treatment for septic shock.

ANNEX 22
Hypernatremic dehydration

Hypernatremic dehydration (serum sodium concentration greater than 145 mEq/L) is common in areas with
very dry atmosphere particularly if the ambient temperature is also high.

It is most likely to occur in patients that have been transported over long distances to the ITC/OTC under
the sun, without stopping to rest or having something to drink. It is important that those arriving at clinics,
OTC, etc. are given water/sugar-water to drink and not kept waiting under the heat. Hypernatremia can also
occur when the feeds are too concentrated (for example if the mother has been making up infant formula
incorrectly).

Hypernatremia is difficult to treat safely, but is easy to prevent. Malnourished patients, particularly those in
dry and hot environments, should be given continuous access to sufficient plain water.

The conventional treatment of hypernatremia is to give normal saline slowly, either orally or intravenously.
However, this treatment is NOT used in SAM because sodium intake in the severely malnourished child
should be restricted.

160
Diagnosis

The first sign to appear is a change in the texture of the skin;

»» The skin develops a doughy consistency

»» The eyes can be somewhat sunken.
»» The abdomen frequently becomes flat and may become progressively scaphoid or wrinkled.
»» Fever may develop.
»» The patient may become drowsy and progress to unconscious state.
»» Convulsions may follow.

If treatment for hypernatremia is not instituted, this may lead to death. The convulsions are not responsive to
the usual anticonvulsants (phenobarbitone, diazepam). Failure to control convulsions with anticonvulsants
may be the first indication of the underlying diagnosis.

The diagnosis can be confirmed by an elevated serum sodium concentration of more than 150mmol/L.

Treatment

For incipient hypernatremic dehydration, i.e., an alert patient with only skin changes:

»» Breastfeed the child or give breast milk. This can be supplemented with up to 10mL/kg/hr of 10%
sugar-water in sips over several hours until thirst is satisfied. At this early stage, treatment is
relatively safe.
»» Give small amounts of water and have the patient drink slowly over several hours to correct the
dehydration.

For developed hypernatremic dehydration, treatment should be given over 24 - 48hrs

If possible, measure serum sodium:

»» Aim to reduce the serum sodium concentration by about 12mmol/24hrs Rapid correction of
hypernatremia runs the risk for death from cerebral edema.

If it is not possible to measure the serum sodium:

»» Take at least 48 - 72hrs to correct hypernatremic dehydration.

Progress is assessed by serial weight measurements of the patient:

First, put the patient in a relatively humid, thermoneutral (28º to 32ºC) environment – this is the most
important step.
Second, Weigh the patient on an accurate balance and record the weight.

The objective of treatment is to place the patient in a positive water balance of about 60mL/kg/day over
the course of treatment (assessed by weight gain), which is equivalent to 2.5mL/kg/hr of plain water. This
amount should not be exceeded and is continued until the child is awake and alert.

For the child who is conscious, fluid replacement is given orally. If the child is semiconscious or unconscious
and there is no ongoing diarrhea:

1. Insert an NGT and start 2.5mL/kg/hr of 10% sugar-water or breast milk. Do not give F75 at this
stage. Never give F100 or infant formula. Expressed breast milk is the best “rehydrating” fluid
available. (Note that 5% dextrose and 10% sucrose solutions are both isotonic).
2. Reweigh the patient every 2 hours.

161
 If the weight is static or there is continuing weight loss, check the ambient temperature and correct as
necessary to prevent further evaporative water losses. Then, increase the amount of sugar-water intake
to compensate for additional fluid loss from heat (calculated at 2.5mL/kg/hr PLUS the amount of fluid to
replace the additional losses).

If the weight is increasing, continue treatment until the child is awake and alert.

If there is accompanying diarrhea:

»» Give 0.18% normal saline in 5% dextrose orally or by NGT

If the child is unconscious,

»» Give the same volumes of fluid (5% dextrose if there is no diarrhea and 0.18% saline in 5%
dextrose if there is diarrhea) by intravenous infusion.
»» Ideally, there should be an intravenous infusion pump. If not, at the very least, use a pediatric
soluset in order to ensure that that the rate of administration of fluid is not exceeded during
treatment.

When the child is awake and alert and the skin quality returns to normal (or the serum sodium is normal),
start feeding with F75.

ANNEX 23
Treatment of septic shock for all malnourished patients

Septic shock is caused by decreased tissue perfusion and oxygen delivery as a result of infection and
sepsis. It can cause multiple organ failure and death. Children, immunocompromised individuals and the
elderly are most susceptible as their immune systems cannot cope with infection as well as healthy adults
do. The mortality rate from septic shock can be high.

Septic shock presents with some of the signs of dehydration, hypovolemic shock or cardiogenic shock. The
differential diagnosis is often very difficult. If a child diagnosed with hypovolemic shock is not responding to
treatment then septic shock should be diagnosed (see Annex 21). A child with cardiogenic shock may be
hypovolemic or hypervolemic.

Septic shock may present as cold septic shock characterized by low cardiac output and high peripheral
vascular resistance or warm septic shock characterized with low peripheral vascular resistance and variable
cardiac output. Central venous pressure is typically low. If a high central venous pressure, crackles or other
signs of fluid overload are present then the child should be treated for heart failure (Annex 25).

If septic shock develops after admission, treatment must be carefully reviewed to determine if the treatment
is the cause of the clinical deterioration. Any drugs considered not essential for immediate treatment should
be stopped.

Diagnosis of septic shock

Septic shock is diagnosed when:

»» Tachycardia with weak or absent radial pulses (femoral pulses may also be weak)
»» Cold extremities (capillary refill time more than 3 seconds)
»» Reduced level of consciousness
»» Absent signs of heart failure
»» Possible signs of infection (may be masked in children with malnutrition)

162
NB: The differential diagnosis of hypovolemic shock and septic shock is often very difficult in children with
SAM. If a concomitant illness such as viral infection, malaria or other severe condition is present, septic
shock should be assumed. Septic shock is often seen in individuals with immunocompromisation or hospital
acquired infections.

Treatment of septic shock

Patients diagnosed with septic shock should immediately be given;

»» Give oxygen via face mask or nasal cannula

»» Give broad spectrum, first line / second line antibiotic (see Annex 18)
»» Conscious patients should be started on F75 (or sugar water) orally / NGT (Phase 1 protocols)
»» Treat / prevent hypoglycemia in unconscious patients (Annex 19)
»» Treat / prevent hypothermia (Annex 20)
»» Keep physical disturbance of the child to the minimum required to deliver emergency care

If there is a decreased level of consciousness which is diagnosed to be due to poor cerebral perfusion:

»» Whole blood transfusion 10mL/kg over at least 3 hours

OR
»» Intravenous rehydration solutions at 10mL/kg/hr

NB: Administration of intravenous fluids when septic shock is diagnosed must be done with extreme caution
so as not to induce fluid overload. The patient should be monitored every 10 minutes for signs of clinical
changes. Blood transfusion should be given within 24 hours of admission. During blood transfusion, oral
feeding must be discontinued. When the child regains consciousness and blood transfusion is no longer
required the child may be started on F75. As soon as clinical signs have improved all intravenous fluids
must be stopped.

ANNEX 24
Treatment of severe anemia
When possible, the hemoglobin should be measured on admission in any child that presents with clinical
signs of anemia.

If the hemoglobin is above 4g/100mL or the packed cell volume is above 12%
OR
If the patient has started treatment with F75 for more than 48 hours (preferably 24 hours) and less than 14
days

»» Do NOT give any treatment, apart from a dose of folic acid on admission.

If the hemoglobin concentration is less than 4g/100mL

OR
The packed - cell volume is less than 12% in the first 24 hours after admission

»» The patient has very severe anemia that should be treated.

1. Give 10mL per kg body weight of packed red cells or whole blood slowly over 3 hours.
2. Fast the patient during, and for at least 3 hours after, a blood transfusion.
3. Do not transfuse a patient between 48h after the start of treatment with F75 and 14 days later.
4. Do not give iron during the acute-phase of treatment

If the facilities and expertise exist (neonatal units) it is preferable to give an exchange transfusion to severely
malnourished patients with severe anemia. If a transfusion is necessary during the danger period of 48 hrs
to 14 days after starting dietary treatment or if there is heart failure with very severe anemia then the patient
cannot be given a straight transfusion and needs an exchange transfusion.

163
 If the expertise does not exist locally, then transfer the patient to a center where there are the facilities
and skill to do an exchange transfusion (neonatal unit). 
Heart failure due to anemia is clinically different
from normal heart failure; when the failure is due to anemia alone there is ‘high output’ failure with a
hyperdynamic circulation, easily felt pulse and heartbeat and warm peripheries.

Anemia or a falling hemoglobin, and respiratory distress is a sign of fluid overload and an expanding plasma
volume; the heart failure is not being caused by the anemia per se; the anemia is ‘dilutional’ and the heart
failure is caused by the fluid overload.

Extreme caution should be used in the interpretation of a low hemoglobin level and it should not be
measured subsequently in most circumstances. This is to avoid an inexperienced clinician transfusing the
patient during the danger period of electrolyte disequilibrium (day 2 to 14) in response to a low reading. Do
not give a straight transfusion of blood or even packed cells to these patients.

ANNEX 25
Treatment of heart failure
Signs and symptoms

Heart failure should be considered when there is:

»» Physical deterioration in the presence of weight gain

»» An increase in respiration rate with weight gain
»» An acute increase of more than 5 breaths per minute (particularly during rehydration treatment)
»» Greater than 50 breaths/minute in infants or more than 40 breaths/minute in children 1 - 5 years
»» A sudden increase in liver size (thus, it is important to mark the liver edge on the skin before
starting any infusion)
»» Tenderness developing over the liver
»» Respiration with a “grunting” sound during each expiration
»» Breath sounds indicate crepitations or rales
»» Prominent neck and other superficial veins
»» Engorgement of the neck veins when the liver is pressed
»» Enlargement of the heart (may be very difficult to assess in clinical practice)
»» Appearance of gallop or triple rhythm in the heart rate / pulse
»» An acute fall in hemoglobin concentration or hematocrit (measures quite accurately the degree of
expansion of the intravascular volume)

As heart failure progresses, there is either (1) marked respiratory distress with rapid pulse rate, cold hands
and feet, edema, and cyanosis or (2) sudden, unexpected death. This is cardiogenic shock, and it usually
occurs in the child with SAM after treatment has started.

The underlying cause is excessive intake of sodium from the diet, rehydration fluids, or from drugs. Even if
sodium intake is restricted, heart failure can still occur due to the residual sodium in the diet or the amount
of sodium coming out of the cells as the cells recover. Excess sodium given during the initial treatment of
dehydration can give rise to heart failure several days later when the sodium inside the cells (i.e., intracellular
sodium) enters the vascular space. There is usually weight gain.

Differential diagnosis

Heart failure and pneumonia are clinically similar and very difficult to distinguish.

»» If there is increased respiratory rate AND weight gain, heart failure should be the first
consideration.
»» If there is increased respiratory rate with a loss of weight, pneumonia is more likely the diagnosis.
Pneumonia should never be considered if there has been a gain in weight just before the onset of
respiratory distress.
»» If there is no change in weight (fluid balance), differentiation should be made using other signs of
heart failure.

164
Children with edema can go into heart failure even without a gain in weight. This occurs when the expanded
circulation due to edema fluid is mobilized from the tissues into the vascular space.

Treatment

As edema fluid is mobilized (as in kwashiorkor) and sodium is moving out of the cells (in both kwashiorkor
and marasmus), plasma volume expands but the volume of red cells remains constant. There is thus a
FALL IN HEMOGLOBIN concentration. This DILUTIONAL anemia happens to some extent in nearly all
children as they recover. A substantial fall in hemoglobin, a sign of an expanding circulation is also indicative
of impending or actual volume overload with heart failure. Heart failure here is not caused by anemia per se
but by the expanding blood volume resulting in heart failure. Children with respiratory distress and anemia
should never be transfused.

Figure 3. Algorithm for the differential diagnosis of heart failure and pneumonia

ReSpiratory Distress

Examine daily weights

Weight increase Weight stable Weight decrease

FLUID OVERLOAD
PNEUMONIA
HEART
(ASPIRATION)
FAILURE

When heart failure is diagnosed:

»» Stop all intakes of oral or IV fluids. No fluid or food should be given until the heart failure has
improved even if this takes 24 - 48 hours. Small amounts of sugar-water can be given orally to
prevent hypoglycemia.
»» Review drug regimen and reduce dose or stop those which are given as the sodium salt (see
Annex 28).
»» Give furosemide (1mg/kg/dose). This is generally not very effective and diuretic treatment should
not be relied upon in the malnourished patient to manage heart failure.
»» Optional: Digoxin can be given as a single dose (5 micrograms/kg). A loading dose is not given.
Use the pediatric preparation whenever possible.

165
 ANNEX 26
Absent bowel sounds, gastric dilation and intestinal splash with
abdominal distension
Functional ileus with bacterial overgrowth can present with findings similar to intestinal obstruction. Gram-
negative bacterial translocation is usually observed across the intestine in septicemia. Gastric emptying
is delayed and there may be no intestinal peristalsis. Fluid can subsequently accumulate in the intestinal
lumen. These are very grave signs. This state is often accompanied by severe liver dysfunction and
resembles the “gray baby syndrome” associated with chloramphenicol toxicity. When the condition develops
after admission, all drugs are potentially hepatotoxic and must be discontinued. Apart from drug toxicity,
it is possible that some patients develop this syndrome from super-infection by organisms resistant to
antibiotics or from herbal medicines given by traditional healers. Since there is no gastric emptying, nothing
can be absorbed orally.

»» Warn the mother that the prognosis is not good

The following measures should be taken:

1. Give antibiotics intravenously as outlined for developed septic shock.

2. STOP all other drugs that may cause toxicity (including antiretrovirals).
3. Give an IM injection of magnesium sulfate (4mL of 25% solution) and repeat twice daily until stool
is passed and gastric residuals are reduced.
4. Insert an NGT and aspirate the contents of the stomach, then irrigate the stomach with isotonic
clear fluid (plain normal saline solution). Infuse 50mL of the solution into the stomach and then
gently aspirate all the fluid back again. Repeat this until the gastric fluid becomes clear.
5. Instill 5mL/kg of sugar-water solution (10% sucrose solution) into the stomach and leave it there for
one hour. Aspirate the stomach contents. If the volume retrieved is less than the amount that was
introduced, return the aspirate to the stomach and give additional sugar-water solution to make a
total volume of 5mL/kg.
6. Because gastric and esophageal candidiasis is common, instill oral nystatin suspension or
fluconazole through the naso-gastric tube.
7. Always keep the patient warm.
8. Give intravenous glucose since these children are often unconscious, semiconscious or delirious
(see section on hypoglycemia).
9. Do not insert an intravenous drip at this stage, but monitor the patient carefully for 6 hours without
giving any other treatment. Use the critical care form.
10. Monitor closely to see if there is any improvement in the following:
- Intestinal function when abdominal distension has decreased; visible peristalsis are noted through
the abdominal wall; bowel sounds have returned to normal; and gastric aspirates have reduced in
volume.
- General condition of the child.

If there is intestinal improvement:

»» Start giving small amounts of F75 by NGT (half the quantities given in Table 11). Aspirate the
stomach before each feed.
»» If the volume of gastric residuals is more than 50% of amount instilled, decrease the amount of
F75.
»» If the amount of aspirate is small, the volume to be fed can be gradually increased.

If there is no improvement after 6 hours:

»» Consider putting up an IV drip. It is very important that the fluid given contains adequate amounts
of potassium. Intravenous Potassium Chloride should be added to all solutions that do not contain
potassium at a final concentration of 20mmol/L. Use 0.18% saline in 5% dextrose (D5 0.18%
saline) if it is available; otherwise use Ringer’s lactate in 5% dextrose or 0.45% saline in 5%
dextrose. The drip should be run VERY SLOWLY – the amount of fluid to be given should be NO
MORE THAN 2 to 4mL/kg/hr. A pediatric soluset or infusion pump should be used.
»» When the gastric aspirates decrease so that one half of the fluid given into the stomach is
absorbed, discontinue IV treatment and maintain on oral treatment alone.

166
ANNEX 27
Inpatient therapeutic care chart

Inpatient Details (Front)

Inpatient Facility: ________________________________________________

Referred from: □ OTC________________ □ Others___________ □ Self-Referral

Name: _____________________________________ Age & Sex: ________ Registration Number: ___ /____/____/____

Barangay & Municipality: _______________________________________ Mobile Phone No.: _____________________

Name of Caretaker: ___________________ Relation to Patient: □ Mother □ Father □ Grandmother □ Others________

Contact No.: _________________________

ADMISSION DISCHARGE

Date ___/___/___ Time ______ Date ___/___/___ Time ______

Admission Type Admission Criteria □ Successfully Treated Follow-up ___________

□ New Admission □ SAM □ Died Cause _______________
□ Readmission with Medical Complication______ □ Defaulter/HAMA Cause _______________
□ Relapse □ Edema +++ □ Marasmic Kwashiorkor □ Non-cure Cause _______________
□ Transfer from OTC □ <6 months old □ Poor or No Appetite

167
 Inpatient Details (Back)
DATE

Height (cm)
Anthropometrics

Weight (kg)

WH (Z score)

MUAC (mm)

Edema 0,+,++,+++

0.8
0.6
0.4
0.2
___Kg
0.8
0.6
0.4
Weight Graph

0.2
__Kg
0.8
0.6
0.4
0.2
__Kg
0.8
0.6
0.4
0.2
__Kg
Phase
Product
Feeding

(F75, F100, RUTF)

# Meals/day
Quantity/meal (ml)
Oral, NGT
Meal Time
1

3
Feeding Monitoring

x x x x x x
Amount Taken: 100% 3/4 1/2 1/4
x x x x

168
ANNEX 28
Amount and preparation of F75 milk to be given for children
aged 6 - 59 months in Phase 1

Amount of Milk per feed Amount of Milk per feed

Weight of the child
8 Feeds per day 6 Feeds per day

2.0 - 2.1kg 40mL 50mL

2.2 - 2.4kg 45mL 60mL
2.5 - 2.7kg 50mL 65mL
2.8 - 2.9kg 55mL 70mL
3.0 - 3.4kg 60mL 75mL
3.5 - 3.9kg 65mL 80mL
4.0 - 4.4kg 70mL 85mL
4.5 - 4.9kg 80mL 95mL
5.0 - 5.4kg 90mL 110mL
5.5 - 5.9kg 100mL 120mL
6.0 - 6.9kg 110mL 140mL
7.0 -7.9kg 125mL 160mL
8.0 - 8.9kg 140mL 180mL
9.0 - 9.9kg 155mL 190mL
10.0 - 10.9kg 170mL 200mL
11.0 - 11.9kg 190mL 230mL
12.0 - 12.9kg 205mL 250mL
13.0 - 13.9kg 230mL 275mL
14.0 - 14.9kg 250mL 290mL
15.0 - 19.9kg 260mL 300mL

Preparation of F75 milk

1. Mix one small packet (102.5g) with 500mL of water.

2. Water should be boiled then cooled and preferably filtered.
3. Therapeutic milk should then be made within 30mins of boiling the water. The use of hot water
from dispensers while convenient is not recommended as there is a risk of cross infection and
contamination if the dispensing nozzle is not meticulously cleaned between every use.

169
 ANNEX 29
Alternate F75 recipes

Cereal CMV
Milk Sugar Oil Water
Type of milk powder* red scoop
(g) (g) (g) (mL)
(g) (6.35g)
Dry skim
50 140 54 70 1
milk
Dry whole Add cooled
70 140 40 70 1 boiled water
milk
up to
Fresh cow 2,000mL
560 130 40 70 1
milk
Fresh goat
560 130 40 80 1
milk

*Cereal powder is cooked for about 10 minutes before the other ingredients are added.

To prepare F75

Add the milk, sugar, pre-boiled cereal powder and oil to one liter (L) water and mix. Boil for 5 to 7 minutes.
Allow to cool, add the combined mineral and vitamin mix (CMV) and mix again. Make up the volume to
2,000 milliliters (mL) with cooled boiled water.

Note: Other local recipes for the preparation of F75 have been developed but require the addition of
micronutrient supplementation to the child in place of the CMV in the above.

ANNEX 30
Preparation of diluted F100

1. Add 1 small packet of F100 to 670mL of water instead of using 500mL as usual.
2. If only small quantities are need and F100 has already been prepared for use in Phase 2, take
100mL of F100 and add 35mL of water. This will produce 135mL of diluted F100.

170
ANNEX 31
Procedure for transition to RUTF

1. Encourage the mother to continue breastfeeding on demand.

2. Explain to the caregiver what RUTF is and how to administer it.
3. At each scheduled feeding time (at least 5 times / day in Transition Phase).
4. Prepare F75 formula according to the prescription for the child’s weight.
»» Prepare a packet of RUTF and a glass of clean drinking water for the child.
»» The RUTF packet should be massaged thoroughly for 30 seconds before opening which helps
to mix the ingredients together. This should be done in front of the caregiver to demonstrate the
method. If the RUTF is hard (due to cold temperatures or prolonged storage) first warm the RUTF
gently between your hands.
»» The caregiver should be instructed to wash their hands with soap and water
»» Before offering the F75, offer the child RUTF:
- If the child is capable of holding the packet, the child should feed itself directly from the
packet of RUTF with gentle encouragement from the mother
- If the child cannot eat directly from the packet, the mother may take a small amount
of RUTF on her clean finger and feed it to the child. The amount offered at each mouthful
should be approximately the size of an almond.
»» Table 2 below gives a simple guide to the amount of RUTF that must be taken at each feed and
over 24 hours in Transition Phase.
»» It should be emphasized that the child must NEVER be force fed. It is vital to get a true indication
of appetite so that the child can be safely transitioned to outpatient care.
»» After each mouthful, breast milk or a sip of water should be offered to the child.8
»» UNDER NO CIRCUMSTANCES should the RUTF be mixed with water / F75 or any other liquid
before the child eats it.
»» If the child fails to eat the required amount of RUTF at each feed, the child should finish the feed
by being offered the ration of F75 to drink in addition to any RUTF that has been eaten. The time
taken to eat the RUTF and F75 (if necessary) should be no more than 1 hour.
»» Record the amount of both F75 and RUTF taken on the patients treatment chart.
»» After each feed, the RUTF should be placed in a cool dry place, safe from insects and re-used at
the next scheduled feeding time.
»» The process of offering both RUTF and F75 continues until the child is able to take the required
amount (see below).

If transition is successful, F75 may be discontinued and the child is given only RUTF and breast milk
or water. The amount of RUTF taken by the child should then be increased to the amount of packets
per day indicated in Annex 38. This is the ration the child will be required to eat during recovery as an
outpatient. When at least 75% of this full amount is eaten in 24 hours and there are no other issues identified
during monitoring (see Individual monitoring Section 4.6) the child is judged to be ready to continue their
rehabilitation at home with OTC.

Table 2. Amount of RUTF to be given at the start of the Transition Phase

Number of feeds in Amount of RUTF at Amount to be eaten

Weight of the child
24hrs each feed over 24 hours

< 5kg 5-6 ¼ packet 1 ¼ to 1 ½ packets

> 5kg 6 1/3 packet 1 ¾ to 2 packets

8 RUTF is a thick paste and plenty of clean drinking water should be available for the child to drink. Older children can ask for water when they are thirsty
but young children must be offered the water regularly when taking RUTF. A thirsty child may refuse RUTF, which may be mistaken for poor appetite.
Children over 6 months but with developmental delay in the motor skills associated with chewing food may have some difficulty manipulating the thick
paste in the mouth, sips of water will help.

171
 If the appetite of the child does not improve over 2 - 3 days (i.e. they are not eating the required amount)
reassess the child and change the treatment regimen:

»» If there is deterioration in clinical status return the child to Phase 1

»» If the child is stable but appetite is not improving after 3 days in Transition Phase (the required
amount of each feed is not being taken) with RUTF, change the diet to F100 for Transition Phase
and continue treatment in inpatient care ( transition to Phase 2). Transition onto RUTF can be
attempted again after a couple of days.

ANNEX 32
Amount of F100 milk to be given to children aged 6 - 59 months in
Transition Phase

Weight of the child 6 FEEDS PER DAY 5 FEEDS PER DAY

Less than 3.0kg F100 full strength should not be used

3.0 - 3.4kg 75mL per feed 85mL per feed
3.5 - 3.9kg 80 95
4.0 - 4.4kg 85 110
4.5 - 4.9kg 95 120
5.0 - 5.4kg 110 130
5.5 - 5.9kg 120 150
6.0 - 6.9kg 140 175
7.0 - 7.9kg 160 200
8.0 - 8.9kg 180 225
9.0 - 9.9kg 190 250
10.0 - 10.9kg 200 275
11.0 - 11.9kg 230 275
12.0 - 12.9kg 250 300
13.0 - 13.9kg 275 350
14.0 - 14.9kg 290 375
15.0 - 19.9kg 300 400

172
ANNEX 33
Amount of F100 to be given in Phase 2

Weight of the child F100 (6 feeds per day) in mL F100 (5 feeds per day) in mL

Less than 3.0kg Do not use full strength F100; use diluted F100
3.0 to 3.4kg 110 130
3.5 - 3.9kg 125 150
4.0 - 4.9kg 135 160
5.0 - 5.9kg 160 190
6.0 - 6.9kg 180 215
7.0 - 7.9kg 200 240
8.0 - 8.9kg 215 260
9.0 - 9.9kg 225 270
10.0 - 11.9kg 230 280
12.0 - 14.9kg 260 310

173
 ANNEX 34
Suitable makeshift toys for use in Phase 2 ITC

Ring on a string (from 6 months) Rattle (from 12 months)

Thread cotton reels and other small objects (e.g. cut from the Cut long strips of plastic from coloured plastic bottles. Place
neck of plastic bottles) on to a string. Tie the string n aring, them in a small transparent plastic buttle and glue the top
leaving a long piece of string hanging. firmly.

Drum (from 12 months)

Any tin with a tightly fitting lid
Mirror (from 18 months)
A tin lid with no sharp edges

Posting bottle (from 12 months)

In-and-out toy (from 9 months)
A large transparent plastic bottle with a small neck and long
Any plastic or cardboard container and small objects (not
objects that fit through the neck (not small enough to be
small enough to be swallowed).
swallowed).

Blocks (from 9 months)

Small blocks of wood. Smooth the surfaces with sandpaper
and paint in bright colours, if possible.

Push-along toy (from 12 months)

Make a hole in the centre of the base and lid of a cylindrical- Stacking bottle tops (from 12 months)
shaped tin. Thread a piece of wire (about 60cm long) Cut at least three identical round plstic bottles in half and
through each hole and tie the ends inside the tin. Put some stack them.
metal bottle caps inside the tin and close the lid.

Nesting toys (from 9 months)

Cut off the bottom of two bottles of identical shape but
different size. the smaller bottle should be placed inside
Pull-along toy (from 12 months) the larger bottle.
As above, except that string is used instead of wire.

Puzzle (from 18 months)

Draw a figure (e.g. a doll) in a crayon on a square-
ore rectangular shaped piece of cardboard. Cut the
figure in hald or quarters

Doll (from 12 months)

Cut out the two doll shapes from a piece of cloth and sew
the edges together, leaving a small opening. Turn the doll
inside-out and stuff with scraps of materials. Stitch up the
openinh and sew or draw a face on the doll.

Book (from 18 months)

Cut out three rectangular-shaped pieces of the same
size from a cardboard box. Glue or draw a picture on
both sides of each piece. Make two holes down on
one side of each piece and thread string through to
make a book.

174
ANNEX 35
Amount of F100 to be given in Phase 2

The supplementation is given using a tube the same size as n°8 NGT (a size n°5 tube can be used, but the
therapeutic milk should be strained through cotton wool to remove any small particles that would block the
tube).

Method

1. Diluted F100 is put in a cup and the mother holds it.

2. The end of the NG tube is put in the cup.
3. The tip of the tube is put on the breast at the nipple and the infant is offered the breast in the
normal way so that the infant attaches properly. Sometimes at the beginning the mothers find it
better to attach the tube to the breast with some tape.
4. When the infant suckles on the breast, with the tube in his mouth, the milk from the cup is sucked
up through the tube and taken by the infant. It is like taking a drink through a straw.
5. At first an assistant needs to help the mother by holding the cup and the tube in place. She
encourages the mother confidently. Later the mothers nearly always manage to hold the cup and
tube without assistance.
6. At first, the cup should be placed at about 5 to 10cm below the level of the nipple so the milk
does not flow too quickly and distress the infant. And the weak infant does not have to suckle
excessively to take the milk. As the infant becomes stronger the cup should be lowered
progressively to about 30cm below the breast.
7. The mother holds the tube at the breast with one hand and uses the other for holding the cup.
Some mothers find it more convenient if the tube is held in place with a strip of tape, but this is not
normally necessary.
8. It may take one or two days for the infant to get used of the tube and the taste of the mixture of
milks, but it is important to persevere.
9. By far the best person to show the mother the technique is another mother who is using the
technique successfully. Once one mother is using the SS technique successfully the other mothers
find it quite easy to copy her.
10. The mother should be relaxed. Excessive or officious instructions about the correct positioning
or attachment positions often inhibit the mothers and make her think the technique is much more
difficult than it is. Any way in which the mother is comfortable and finds that the technique works is
satisfactory.
11. If the therapeutic milk is changed (e.g. F75 to Diluted F100) the infant may take a few days to
become used to the new taste. It is preferable to continue with the same supplementary diet
throughout the treatment.

Figure 4. Supplementary Suckling Technique

This infant is suckling the breast and also getting the

Diluted F100 (130mL/kg/d) using the supplemental
suckling technique. Raising or lowering the cup
determines the ease with which the infant gets the
supplement.

For very weak infants it can be at the level of the

infant’s mouth. Never position the cup higher than
this level as the feed can flow into the child’s mouth by
siphoning and expose the child to danger of aspiration.

As the suckling becomes stronger the position of the

cup relative to the child’s mouth may be lowered.
© Save the Children/2011

175
 Cleaning the tube

After feeding the tube is flushed through with clean water using a syringe. It is then spun (twirled) rapidly to
remove the water in the lumen of the tube by centrifugal force. If convenient the tube is then left exposed
to direct sunlight.

Follow up during treatment

The infant should be weighed daily using an infant scale accurate to 10g or 20g.

»» For cases with wasting, if the child takes all of the Diluted F100 but loses weight for 3 consecutive
days, increase the amount of Diluted F100 given by 5mL
»» If the child gains 20g or more per day for 2 days, reduce the amount of Diluted F100 by half and
reassure the caregiver that the child is beginning to breastfeed effectively
»» If the child continues to gain 10g or more per day on the reduced amount of Diluted F100 then stop
giving Diluted F100 and continue breastfeeding alone
»» If the child continues to gain weight on breast milk alone, they may be discharged irrespective of
their WFH/L

ANNEX 36
Diluted F100 (or F75 for cases with edema) for use with the
Supplementary Suckling Technique for infants aged less than 6
months

Amount of Diluted F100

Weight of the child
8 feeds per day

equal or less than 1.2kg 25mL

1.3 - 1.5kg 30mL
1.6 - 1.7kg 35mL
1.8 - 2.1kg 40mL
2.2 - 2.4kg 45mL
2.5 - 2.7kg 50mL
2.8 - 2.9kg 55mL
3.0 - 3.4kg 60mL
3.5 - 3.9kg 65mL
4.0 - 4.4kg 70mL

To prepare the Diluted F100

Add 1 small packet of F100 to 670mL of water instead of using 500mL as usual.
If only small quantities are need and F100 has already been prepared for use in Phase 2, take 100mL of
F100 and add 35mL of water. This will produce 135mL of diluted F100.

176
ANNEX 37
Express breast milk by hand

If the supplementary suckling technique is not working or the skilled staff required to use the SST are not
available, expressing the breast milk by hand and then feeding the infant using a cup is possible.

How to hand express breast milk and cup feed

1. Make sure your hands and utensils are clean

2. Wash your hands with soap and running water
3. Clean and boil the container you will use to collect your breast milk
4. Get comfortable
5. It is sometimes helpful to gently stroke your breasts. A warm cloth may help stimulate the flow of
milk
6. Put your thumb on the breast above the dark area around the nipple (areola) and the other fingers
on the underside of the breast behind the areola
7. With your thumb and first 2 fingers press a little bit in towards chest wall and then press gently
towards the dark area (areola)
8. Milk may start to flow in drops, or sometimes in fine streams. Collect the milk in the clean
container.
9. Avoid rubbing the skin, which can cause bruising, or squeezing the nipple which stops the flow of
milk.
10. Rotate the thumb and finger positions and press/compress and release all around the areola
11. Express one breast for at least 3 to 5 minutes until the flow slows, then express the other breast,
then repeat both sides again (20 to 30 minutes total)
12. Store breast milk in a clean, covered container. Milk can be stored 6 to 8 hours in a cool place and
up to 72 hours in the back of the refrigerator
13. Give baby expressed breast milk from a cup. Bring cup to the baby’s lower lip and allow baby to
take small amounts of milk, lapping the milk with his or her tongue. Do not pour the milk into baby’s
mouth
14. Pour just enough breast milk from the clean covered container into the feeding cup
15. Bottles are unsafe to use because they are difficult to wash and can be easily contaminated
16. Continue with care protocols as described above as if the child was breastfed by SST
17. When the child is gaining weight, give breastfeeding counselling and attempt to re-establish
breastfeeding

Manual of Operations 177

 ANNEX 38
Amount of Dilute F100 (or F75 for cases of edema) to give to infants
aged less than 6 months with no prospect of being breast fed

Phase 1 Transition Phase* Phase 2

Weight of the infant
8 feeds per day (mL) 8 feeds per day (mL) 6 feeds per day (mL)

equal or less than 1.5kg 30 40 60

1.6 - 1.8kg 35 45 70
1.9 - 2.1kg 40 55 80
2.2 - 2.4kg 45 60 90
2.5 - 2.7kg 50 65 100
2.8 - 2.9kg 55 75 110
3.0 - 3.4kg 60 80 120
3.5 - 3.9kg 65 85 130
4.0 - 4.4kg 70 95 140

To prepare the Diluted F100

Add 1 small packet of F100 to 670mL of water instead of using 500mL as usual.
If only small quantities are need and F100 has already been prepared for use in Phase 2, take 100mL of
F100 and add 35mL of water. This will produce 135mL of diluted F100.

ANNEX 39
Amount of RUTF to be given to the child on transfer
to outpatient care

Weight of the child (kg) Packets per week Packets per day

3.5 - 3.9kg 11 1.5

4.0 - 4.9kg 14 2
5.0 - 6.9kg 18 2.5
7.0 - 8.4kg 21 3
8.5 - 9.4kg 25 3.5
9.5 - 10.4kg 28 4
10.5 - 11.9kg 32 4.5
≥12kg 35 5

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ANNEX 40
Amount of RUTF to be given to the child on transfer to outpatient
care

Recording milk intake

It is vital to record milk intake accurately. On the Inpatient Therapeutic Care Sheet (Annex 27), an area of
the chart is designated for monitoring milk intake.

Each feed time is associated with a box of 4 squares [see figure 5]. Each large square represents one feed
at the indicated time of day and each small square represents ¼ of the feed given at each meal.

Figure 5. Example of how to record the milk intake for one feed

x x
x v

In the example in Figure 5 above, the child took all of the milk (x) but vomited (v) back approximately 25%
(the amount is estimated by the nurse with the help of the caregiver. The chart should be completed AFTER
the feed has been given.

Figure 6 below gives an example of feeds between 0600 and 1500 hrs over 2 days. (NB: Feeds are offered
throughout the 24hrs, the chart provided only offers an example of how to complete a portion of the form!)

On Day 1 the child is fed 100% of the 0600hrs feed using an HG tube. At 0900hrs, the child was able to
take 50% orally (represented by the “x”) and 50% by NG tube. The 1200 /1500 hrs feeds were taken entirely
orally.

On Day 2, at 0600 the child took the feed orally but vomited 25% of the feed. The child took the rest of the
feeds 100% orally without any problems.

In this example, the child has taken all of the milk with almost no losses through vomiting. The appetite has
improved since Day 1 and the milk is taken orally. A child in Phase 1 should have the NG tube removed
and be could be considered for Transition Phase based on the return of the appetite provided there are no
other complications.

Figure 6. Example of a milk-monitoring chart for 2 days

Time Day 1 Day 2

A=Absent NG NG x x
0600
V=vomiting NG NG x x
R=refused
NGT=Naso gastric tube x x x x
0900
IV=IV infusion NG NG x x

Volume taken x x x x
1200
100% - x x x x x x x x
75% - x x x
50% - x x x x x x
1500
25%- x x x x x

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 ANNEX 41
Reasons for deterioration in Transition Phase

If a child has deteriorated after progressing to Transition Phase it is usually due to one of the following:
»» Re-feeding syndrome
»» Re-activation syndrome
»» Osmotic diarrhea resulting from a change in diet (less common with low osmolarity feeds)
»» Aspiration of the diet through improper feeding technique
»» Nosocomial infection
»» Inappropriate prescription / use of medications

Re-feeding syndrome

Re-feeding syndrome is a complex metabolic reaction that occurs when the energy or nutrient load on the
body causes a rapid shift of electrolytes and fluid between intracellular and extracellular compartments in
the body. The condition may occur when malnourished patients (and those who have been fasting for more
than one week)9 develop any of the following shortly after rapid and large amounts of food are ingested:

»» Acute weakness or “floppiness”

»» Lethargy
»» Delirium
»» Neurological symptoms
»» Acidosis
»» Muscle necrosis
»» Liver and pancreatic failure
»» Cardiac failure
»» Sudden unexpected death

The syndrome is due to rapid consumption of key nutrients for metabolism particularly if the diet is
unbalanced. Frequently, there is a great reduction in plasma phosphorus, potassium, and magnesium.

Prevention

It is necessary at the start of treatment not to provide large amounts of food intake in the malnourished
state. On admission, these malnourished patients should never be force-fed amounts in excess of the diet
prescribed in this protocol. Particular care must be taken for those who are fed by NGT.

Treatment

For re-feeding syndrome among patients in the recovery or Transition Phase:

»» Return to Phase 1 of treatment and feed with F75
»» Assess the child for heart failure and treat according to Annex 25

For re-feeding syndrome among patients in the acute phase:

»» Reduce the diet to 50% of the recommended intake until all signs and symptoms disappear; then
gradually increase the amount to be given by 10% each day as long as the child remains symptom
free
»» Assess the child for heart failure and treat according to Annex 25

Check to ensure that there is sufficient potassium and magnesium in the diet. If the diet is not based on
cow’s milk (or if the patient is also receiving cereals/pulses, etc.), additional phosphorus should be given.

9 The ref-eeding syndrome also occurs in obese patients who have been fasting as part of their treatment. While they are not wasted like the malnourished
patient, they too have metabolically adapted to a low intake of food.

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Re-activation syndrome

Reactivation syndrome occurs when a previously undiagnosed infection becomes apparent. This may occur
as a result of the recovery of the immune and/or inflammatory system rather than the development of a
newly acquired infection. Treatment for disease conditions which become apparent is according to national
protocol except where modified by other protocols in these guidelines.

Osmotic diarrhea

Osmotic diarrhea results from an excess of non-absorbable and osmotically active solutes in the gut lumen.
This differs from secretory diarrhea in which the activity of the mucosa exceeds its absorption capacity and
may be caused by pathogens. Osmotic diarrhea is usually investigated by examination of the carbohydrates
or fecal osmolar gap (FOG) in stool specimens. The FOG does not, however, reveal the pathological
mechanism.

Osmotic diarrhea in children undergoing treatment for SAM usually occurs following a change in diet from
F75 to F100 in the Transition Phase or increasing the amount of F100 between Transition Phase and Phase
2. When diarrhea occurs after a change in diet the diagnosis of osmotic diarrhea can be presumptive,
however it is normal for some increase in frequency of stools to occur when the diet is increased. An
increased frequency of stools without weight loss does not require any treatment. Confirmation of the
diagnosis of osmotic diarrhea is made when symptoms resolve within 3 days of reducing the diet.

Diarrhea may occur during the first week of treatment with RUTF in the outpatient setting but may also be
related to enteropathogens and or the use of antibiotics on admission. RUTF contains zinc and the diarrhea
normally resolves within the first or second week of treatment. Osmotic diarrhea should not be presumed
in the outpatient setting and RUTF should not be reduced until enteropathic causes have been eliminated
through treatment with antibiotics.

Prevention

Protocols for feeding in Transition Phase and Phase 2 should follow the guidance in this protocol. Osmotic
diarrhea is more common when non-commercial preparations are used. Commercial F75, F100 and RUTF
contain maltodextrin instead of sugar and thus have a lower osmolarity.

Treatment

Treatment for osmotic diarrhea is based on a presumptive diagnosis and the condition should resolve within
3 days. If it does not resolve despite adherence to protocols then a pathogenic cause may be presumed and
treated empirically with antibiotics.

»» Use commercially produced F75 / F100 where possible

»» In Phase 1 maintain the required daily intake but give F75 in smaller volumes with each feed and
increase to 8 - 12 feeds per day
»» In Transition Phase return to Phase 1 using F75 milk
»» In Phase 2 return to Transition Phase protocols using F100 milk

Where osmotic diarrhea has been diagnosed, the diet in Transition Phase should be increased from 130kcal/
kg/day by 10 - 20kcal/kg/day daily until the target energy intake of 200kcal/kg/day of Phase 2 is reached.
The energy intake should only be increased as long as the child remains free of further symptoms.

Osmotic diarrhea caused by lactose intolerance

Diarrhea is rarely a result of lactose intolerance. Treat children for lactose intolerance only if the continuing
diarrhea is preventing general improvement. Starter F75 is a low-lactose feed. In exceptional cases,
substitute milk feeds with fermented milk such as yoghurt or with a lactose-free infant formula.10 Before the
child is discharged from hospital, milk-based feeds can be given to determine whether the intolerance has
resolved.11

10 WHO Pocket book of hospital care for children: guidelines for the management of common illnesses with limited resources. 2nd Edition. 2013 (p140)
11 WHO, Management of Severe Malnutrition: A Manual for Physicians and Other Senior Health Workers, Geneva 1999.

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 ANNEX 42
Reassessment of child’s condition

In any case of failure to respond or deterioration of the child’s condition in any phase, a thorough reassessment
is needed. The physician should consider:

»» A detailed recent history

»» Accuracy of previous record keeping
»» Full medical examination and review of nutritional status
»» Review previous medical and nutritional therapy
»» Chest x-ray / laboratory investigations
»» Use of un-prescribed medicines or food
»» A review of the care environment (hygiene, staffing, milk preparation)
»» Appropriate use and / or recalibration of measurement equipment
»» Referral may be required to a specialist pediatric service

ANNEX 43
Calculation of monitoring indicators

Treatment performance

Discharges Total children leaving the program; whether discharged cured, or due to
death, defaulting, non-cure

Cure rate No. of children successfully discharged (cured) / No. of discharges

Death rate No. of deaths during registration in the program / No. of discharges

Defaulter rate No. of defaulters / No. of discharges

Non-cure rate No. of non-recovered cases after 4 months of treatment / No. of

discharges

DeFinitions

Defaulters Absent from the program for 3 consecutive visits (or days in inpatient care)

Non-cure rate Children who have not been cured after 4 months in the program although all
actions have been taken according to the protocols for non-response.

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Mean length of stay (LOS)

This indicator should be calculated for ONLY the recovered patients.

Mean length of stay = Sum of (No. of days for each recovered patient) / No. of recovered patients

Geographical Coverage

Geographical coverage is commonly defined as the ratio of health facilities12 in a program area that deliver
CMAM services to the total number of health facilities in the program area:

Geographical coverage = Health facilities delivering CMAM services/total health facilities

Geographical coverage can be interpreted as the maximum coverage that a program can achieve (potential
coverage or availability coverage). Geographical coverage calculated as above at facility level should be
the “headline” figure reported for geographical coverage. There may, however, be benefits to assessing
geographical coverage at other levels, i.e. by districts and regions (see table below).

Treatment Coverage

An estimate of coverage made by finding cases and ascertaining whether they are in or not in a suitable
treatment program. This can be best done through the periodic use of the assessment/investigation
techniques detailed below.

CSAS (Centric Systematic Area Sampling)

CSAS was developed in 2002 as part of the CTC research program. It was used for program monitoring
and evaluation for several years. However, it was deemed too expensive to be used routinely and has now
been superseded by the less resource intense SQUEAC and SLEAC methods for routine monitoring and
evaluation purposes.

Design

CSAS uses a two-stage sampling design. First stage is a systematic spatial sample of the entire program
area to select the communities to survey. The sample is therefore representative of the whole program area.
Second stage is an active and adaptive case-finding (also called snowball or chain-referral) method that
find all or nearly all SAM cases in the communities being surveyed. Hence, sample is representative of the
communities surveyed.

Results

CSAS yields the following results:

»» Overall coverage estimate
»» Local coverage estimates which can be represented as a coverage map
»» Ranked list of barriers

Figures 7 & 8 show typical CSAS outputs from a coverage assessment using CSAS of an NGO-delivered
CMAM program undertaken in two neighboring health districts in Niger.

12 ‘Health facilities’ refer to primary health care facilities as well as secondary and tertiary facilities offering either outpatient or inpatient care for the
treatment of SAM

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 Figure 7. Map showing the spatial distribution of Figure 8. Barriers to service access and uptake
point and period coverage in a CMAM program in a CMAM program reported by caregivers of
produced using the CSAS method non-covered cases produced using the CSAS
method

Semi-Quantitative Evaluation of Access and Coverage (SQUEAC)

SQUEAC is a semi-quantitative method that provides in-depth analysis of barriers and boosters to coverage.
It is designed as a routine program monitoring tool through the intelligent use of routine monitoring data
complemented by other relevant data that are collected on a “little and often” basis.

Design

SQUEAC is more an investigation than a survey. SQUEAC is made up of three stages:

»» Stage 1: Semi-quantitative investigation into factors affecting coverage using the SQUEAC toolkit
»» Stage 2: Confirm areas of high and low coverage identified in Stage 1 through small studies and
small-area surveys
»» Stage 3: Estimating overall coverage using Bayesian techniques. Likelihood survey is conducted
as part of this stage. This survey utilizes a systematic spatial sample as with all the other coverage
survey methods. Stage 3 of SQUEAC is optional and is done if the reporting of an overall coverage
estimate is a key information requirement in addition to the rich information on barriers and
boosters to coverage already gained from Stages 1 and 2.

Results

SQUEAC provides the following results:

»» Mapping of coverage using small area surveys through a “risk mapping” approach
»» Estimation of coverage using Bayesian techniques
»» Concept map of barriers and boosters to coverage

Figure 9 shows the relations between factors influencing coverage and effectiveness in a MoH-delivered
CMAM program in Sierra Leone. Figure 10 shows coverage mapping through a risk mapping approach.

184
 Figure 9. Relations between factors influencing Figure 10. Coverage mapping by risk mapping
coverage and effectiveness produced by a
SQUEAC assessment

Simplified Lot Quality Assurance Sampling Evaluation of Access and Coverage

(SLEAC)

SLEAC is a rapid low-resource survey method that classifies coverage at the service delivery unit (SDU)
level such as the district. A SLEAC survey identifies the category of coverage (e.g. “low coverage”, “moderate
coverage” or “high coverage”) that describes the coverage of the service delivery unit being assessed. The
advantage of this approach is that relatively small sample sizes (e.g. n ≤ 40) are required in order to make
an accurate and reliable classification.

SLEAC can also estimate coverage over several service delivery units hence ideal for coverage survey of
wide areas. Coverage is still classified for individual service delivery units. Then, data from individual service
delivery units are combined and coverage for this wider area is estimated from this combined sample.

SLEAC was originally developed as a companion method for SQUEAC but has recently been used for
mapping of coverage classes in service delivery units over very wide-areas.

Design

SLEAC uses a systematic spatial sample similar to that used in CSAS. Only small sample sizes (n ≤ 40) are
required for each service delivery unit in which coverage is being classified.

Results

SLEAC yields the following results:

»» Overall coverage classification
»» Can be used over wide areas to provide local coverage classifications with a coverage map and a
wide area estimates
»» Ranked list of barriers

185
 Figure 11 shows a map of coverage class for all administrative districts in a MoH-delivered CMAM program
in Sierra Leone. SLEAC also provides output similar to Figure 8. It is typical to use SLEAC to identify areas
for further investigation using the SQUEAC method (Figure 12a & 12b).

Figure 11. Map of per-district coverage produced by the SLEAC method

Figure 12a. Using SLEAC and SQUEAC in failing service delivery units

Figure 12b. Using SLEAC and SQUEAC in succeeding and failing service delivery units

186
ANNEX 44
Monthly Reporting Format (Facility level)

187
 ANNEX 45
Quarterly/Annual Reporting Format (Consolidation)

188
ANNEX 46
Example of messages for community sensitization

IMPORTANT MESSAGE TO ALL CAREGIVERS AND FAMILIES WITH CHILDREN

AGED BETWEEN 6 MONTHS AND 5 YEARS

A new treatment is now available at Rural Health Units and Barangay Health Stations for the
treatment of children between six months and five years who are very thin, or who have swollen
feet. Children with these features suffer from a severe form of malnutrition. The families with such
children now do not have to stay in the hospital for a long time but can treat the child at home under
the supervision of the local health team.

To be eligible for this treatment, the child has the arm measured with a special tape (called a MUAC
tape) to see if he/she is thin. The feet are also checked to see if they have begun to swell. If the
arm is too thin or there is swelling of the feet, the child visits the closest RHU or BHS to their home.

Many types of person can do the measurement. The Barangay Nutrition Scholar or Barangay
Health Worker will check the measurement to ensure it is correct and will then initiate the treatment
with the assistance of the local midwife / nurse. The child will receive antibiotics and a special
treatment for severe malnutrition called RUTF. RUTF is a special ”medicinal food”, like a sweet
peanut butter, containing all of the nutrition the child needs to recover. The child may be required to
visit the doctor in some circumstances to be prescribed extra medicines.

The child will visit the RHU / BHS weekly or two weekly to assess recovery and to receive more
supplies of RUTF. The health team will determine how much RUTF the child should eat each day /
week. Full recovery takes approximately 6 to 8 weeks.

If you know a child who is very thin, or whose feet have started to swell, let his parents or guardians
and any pregnant or lactating caregivers know about this new treatment. They can inquire with the
Barangay Captain or Barangay Nutrition Committee for the name of the person trained in the arm
measurement, or they can go direct to the RHU or BHS.

All members of the community, with children who are eligible for treatment, may access this service;
no one is excluded.

*For Muslim communities it may be added that RUTF is Halal*

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 ANNEX 47
Department Personnel Order 2011 - 2453

190
191
192
ANNEX 48
Roles and Responsibilities of PIMAM stakeholders

1. Department of Health:

The Heads of the Office for Technical Services and Office for Health Operations, shall oversee that
these guidelines are implemented in the different offices of the Department.

DOH-Central Office shall:

a. Create the National Program Management Team (NPMT) and serve as the policy-making body
and leader in promoting the importance of standardized PIMAM services both during development
and times of emergencies and disasters among the government and private sector including
planners, decision makers, policy makers and the general public.
b. Formulate, in coordination with members of the Health Sector, and implement policies, guidelines,
protocols and standards and service packages and integrate all related programs to allow a holistic
approach, not just focusing on malnutrition.
c. Provide assistance and guidance to all implementing agencies in strengthening and financing
service delivery.
d. Provide training on the guidelines/protocol to relevant stakeholders; conduct dialogues with
relevant stakeholders and review the implementation of the program
e. Spearhead the conduct of studies, management of information, and documentation of best
practices to support and initiate evidence-based reforms.

193
 Disease Prevention and Control Bureau (DPCB) shall:
a. As the NPMT lead, ensure that all of the functions set by the NPMT shall be carried out effectively
and efficiently.
b. Regularly convene the NPMT to plan and address issues and other concerns that may arise during
the course of the scale-up and program implementation and provide members with the program
technical and administrative updates.
c. Generate additional membership of potential partners for an enhanced program implementation.
d. Lead in the integration, standardization, and dissemination of indicators, tools, and recording and
reporting forms.
e. Facilitate the report (number and status of cases, interventions done, utilization of logistics)
generation and analysis per facility and generate evidences and studies based on programming
data and coordinate with relevant DOH Bureaus/Offices for integration.
f. Ensure that storage facilities have at least a 20% buffer stock of therapeutic products and routine
medicines for the treatment of SAM and other materials and tools to last for 3 months.
g. Address possible issues and concerns on procurement or production of logistical needs (RUTF/
RUSF, MUAC tapes, weighing scales, height boards, standard weights for calibration - 2kg).
h. Facilitate the development of system for inventory, transport and tracking of necessary logistics to
the end-user.

Health Emergency Management Bureau (HEMB) shall:

a. Serve as the lead coordinating office for the Quad cluster during times of emergencies and
disasters and provide support to the National Nutrition Cluster.
b. Facilitate the coordination of response activities and information sharing among DOH Offices and
Bureaus and cluster partners during emergencies.
c. Coordinate the augmentation of human resource and logistics in emergencies when assistance
from the national government is needed.
d. Ensure the integration of PIMAM indicators in the SPEED and HEARS reporting systems for
emergencies and disasters.

Health Promotion and Communication Service (HPCS) shall:

a. Lead in the advocacy and promotion activities.
b. Develop and produce appropriate advocacy and communication strategies, IEC materials and
collaterals.
c. Support the NPMT in the dissemination of the IEC materials and collaterals.
d. Provide technical assistance in the local version translation of the IEC materials.

Epidemiology Bureau (EB) shall:

a. With the NPMT, facilitate the integration and consequent updating of PIMAM indicators under the
FSHIS and regular reporting systems of the department.
b. Support enhancement of surveillance systems and facilitate information sharing among DOH
Bureaus and Units and cluster partners especially on cases of communicable diseases.

Epidemiology Bureau (EB) shall:

a. With the NPMT, facilitate the integration and consequent updating of PIMAM indicators under the
FSHIS and regular reporting systems of the department.
b. Support enhancement of surveillance systems and facilitate information sharing among DOH
Bureaus and Units and cluster partners especially on cases of communicable diseases.

Bureau of Local Health Systems Development (BLHSD) shall:

a. Support the advocacy for the implementation of PIMAM program in all LGUs.
b. Spearhead the integration of PIMAM program performance indicators in the LGU scorecard and to
provide technical assistance in the conduct of M&E.

Health Facility Development Bureau (HFDB) shall:

a. Facilitate the setting up and/or dedication of ITC areas in all hospitals with due priority for DOH
Hospitals.
b. Provide technical support to ITCs through the dietary department in all hospitals.
c. Facilitate the organization and conduct of the capacity development for ITC.

194
 Health Facilities and Services Regulatory Bureau (HFSRB) shall identify specific PIMAM
requirements that will be incorporated in the checklist for routine licensing applications (new and
renewal of license) of health facilities and PHILHEALTH accreditation.

Knowledge Management Information Service (KMIS) shall provide technical assistance to the
NPMT in ensuring the functionality, maintenance, and integration of PIMAM into existing health
information management systems (iClinicsys, PHIE, FHSIS, PIDSR, disease registries, and others).

Pharmaceutical Division shall expedite the registration of PIMAM commodities in the PNDF and
issuance of clearance for commodities, drugs and medicines as needed.

Food and Drug Administration (FDA) shall:

a. Provide technical assistance in the acceptance of international and local donations, especially food
and drugs.
b. Facilitate the acceptance and clearance of food, drugs and supplies which are necessary for
PIMAM program implementation.

Health Human Resource Development Bureau (HHRDB) shall:

a. In coordination with other NPMT members, standardize the training of trainers (PIMAM, active
screening, Essential Nutrition Action, Breast feeding community Initiative, mother-to-mother
network group).
b. Develop or conduct other related learning and educational development activities.

Health Policy Development and Planning Bureau (HPDPB) shall, in coordination with other
NPMT members, review and provide technical assistance in the development of the PIMAM protocol.

2. National Nutrition Council (NNC) shall:

a. As NPMT co-lead, provide assistance to the DPCB in the in the fulfillment of the functions set for
PIMAM implementation in the country.
b. Provide both Technical / Management support.
c. Utilize the existing Philippine Plan of Action for Nutrition (PPAN) strategy for enhancing the
effective PIMAM program implementation, specifically it shall incorporate the program’s screening
activity in the conduct of the regular Operation Timbang (OPT) and annual Monitoring and
Evaluation of Local Level Program Implementation (MELLPI).
d. Generate support from the council members to facilitate the effective and efficient PIMAM program
implementation.

3. DOH Regional Offices and National Nutrition Council Regional Offices

The DOH Regional Directors shall directly oversee the implementation and adoption of these policies
within their Regions, create Regional PIMAM management teams, and provide feedback, suggestions, and
policy recommendations to the Secretary of Health.

The Regional PIMAM Management Teams, led by the Family Health Medical Officer, shall be responsible
for the implementation and adoption of these guidelines in their respective regions.

The Regional Offices for Health, being the lead of the PIMAM Regional Management Team,
and Regional National Nutrition Councils, as co-lead, shall:
a. Formulate plans, procedures and protocols to implement this policy and guidelines.
b. Provide and implement a mechanism of coordination and collaboration with hospitals (both
government and private), LGUs, partners, and other stakeholders, to ensure the timely and
effective service delivery.
c. Support monitoring and evaluation activities.
d. Provide technical assistance and logistics support to implementing agencies and regions. Design,
update, and conduct necessary training to enhance capabilities of PIMAM implementers.
e. Conduct studies and facilitate technical resource development that will contribute to improving
service delivery.
f. Identify, develop and enhance capacity of the members of the health and nutrition sector.

195
 g. Plan for and manage supplies efficiently and effectively.
h. Develop/improve and sustain a safe and efficient referral system of children with acute
malnutrition.
i. Through the respective Development Management Officers, ensure the supportive supervision,
monitoring, and coordination of PIMAM implementation at the LGU level including logistics
coordination.

4. Local Government Units

The Provincial/Municipal/City Chief Executives shall directly oversee the implementation and adoption
of these policies within their locality, create Local PIMAM Management Teams, and provide feedback,
suggestions, and policy recommendations to the Regional Offices for Health.

The Local PIMAM Management Team, led by the Provincial/City/Municipal Health Officer, shall be
responsible for the implementation and adoption of these guidelines in their respective locality. They shall
report to the Provincial/City/Municipal Chief Executive.

The LGUs shall:

a. Institutionalize (structure, organization and policies, people, resources, systems, partners) health
emergency management in their responsible areas.
b. Formulate plans, procedures and protocols to implement their policy and guidelines
c. Enforce existing local policies and guidelines.
d. Consider the principles set in this policy in their respective health and nutrition plans and systems.
e. Identify, develop and enhance capacity of the members of the health and nutrition sector.
f. Plan for and manage supplies efficiently and effectively.
g. With support from the Regional Offices for Health, develop/improve and sustain a safe and efficient
referral system of children with acute malnutrition in their respective LGUs.

5. Hospitals

The Medical Center Chiefs/Chief of Hospitals shall administer these regulations and support all the
policies and guidelines mentioned in this Order. He/she shall lead in the dissemination of these guidelines,
their integration of the same in the hospital and the creation of Hospital PIMAM Management Teams. He/
she shall ensure the availability of personnel and funds to support all the needed training and responses.
He/she shall submit reports to the respective Regional Office, LGU, or DOH-CO.

The Hospital PIMAM Management Team, led by the Chief of Clinics, shall directly oversee the
implementation of these guidelines in their respective hospitals. He/she shall report to the Chief of Hospital/
Medical Center Chief.

Hospitals shall:
a. Formulate plans, procedures and protocols to implement this policy and guidelines.
b. Implement all policies, and adhere to all standards, requirements and systems.
c. Provide and implement a mechanism of coordination and collaboration with hospitals (both
government and private), LGUs, partners, and other stakeholders, to ensure the timely and
effective service delivery.
d. Support monitoring and evaluation activities.

6. Philippine Health Insurance Corporation shall develop strategies to ensure coverage for
children requiring treatment of severe acute malnutrition including, but not limited to: outpatient treatment
with routine medicines and therapeutic food provided in capacitated health facilities, inpatient treatment
of severe acute malnutrition with medical complications, reimbursements, point-of-care service delivery in
non-PhilHealth accredited institutions/health service providers during emergencies and disasters.

196
7. Other Government Agencies shall

a. Adopt these guidelines in their offices and provide feedback and report to LGU, Regional Office for
Health, or DOH Cluster where they belong.
b. Adhere to and observe all requirements and standards on public health especially those needed to
respond to emergencies and disasters in accordance to the thrust of the Department of Health.
c. Coordinate and participate in inter-agency activities with the Department of Health on Health
Emergency Management.
d. Support the DOH/LGUs/Hospitals in providing technical assistance (through the conduct of
assessment or trainings) and logistics support.

8. Academe and Professional Societies shall

a. Adopt these guidelines in their institutions/organizations and provide feedback and report to LGU,
Regional Office for Health, or DOH.
b. Adhere to and observe all requirements and standards on public health especially those needed to
respond to emergencies and disasters in accordance to the thrust of the DOH.
c. Coordinate and participate in inter-agency activities with the DOH.
d. Support the DOH/LGUs/Hospitals in providing technical assistance (through the conduct of
assessment or trainings) and logistics support.
e. Support the DOH/LGUs/Hospitals/Universities/Schools in ensuring that all curricula relevant to
PIMAM are updated and implemented and that bodies of evidence on PIMAM are generated and
disseminated.

9. Non-Government Organizations/Agencies, Development Partners Private

Sector and Civil Society Groups shall

a. Adopt these guidelines in their locality and provide feedback and report to LGU, Regional Office for
Health, or DOH Cluster where they belong.
b. Participate in information dissemination, advocacy activities and training.
c. Adhere to and observe all requirements and standards needed to respond to emergencies and
disasters in accordance to the thrust of the Department of Health.
d. Provide development/technical assistance to strengthen capacities and systems during scale-up
and implementation of the program consistent with the above principles.
e. Coordinate with appropriate DOH Offices for assistance in the implementation of this policy and
services during development and emergencies.

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 ANNEX 49
Role requirements for BHW and BNS

Barangay Health Workers Barangay Nutrition Scholars

The BHWs are selected based on Section 3 The Barangay Nutrition Scholars are selected
Rule IV Qualifications for Registration stipulated based on Section 4 Qualifications as stipulated in
in the Implementing Rules and Regulations of Presidential Decree 1569 otherwise known as the
the Republic Act 7883 otherwise known as the Strengthening the Barangay Nutrition Program by
Barangay Health Workers Benefits and Incentives Providing for a Barangay Nutrition Scholar in Every
Act of 1995. Barangay, Providing Funds Therefore, and Other
Purposes.
Requirements:
Requirements:
1. Have completed the DOH basic training
course for BHWs conducted by an accredited 1. Bonafide residence in the barangay for at least
government agency or NGO four (4) years and the ability to speak the
2. Be at least eighteen (18) years of age as of dialect
the date of the filing of the application for 2. Possession of leadership potential and the
registration initiative and willingness to serve the people
3. Have rendered voluntary primary care service for a least one (1) year
for at least one (1) year immediately preceding 3. Willingness to learn, and to teach what he has
the date of the filing of application for learned to the members of the barangay
registration in his/her barangay as certified by 4. At least a primary school graduate
the Rural health Midwife assigned to his/her 5. Physical and mental fitness
barangay, or by a duly authorized 6. At least eighteen (18) years old but not greater
representative of an NGO operating in the than sixty (60) years old
barangay who has personal knowledge about
the BHW’s performance and by the head of
his/her association
4. Be physically and mentally fit
5. Perform activities under the supervision of the
Rural Health Midwife
6. Primarily conduct active screening and assist
the BNS – as part of the community-IMCI
assessment of children

198
 Entry to Facility
Patient’s Patient’s Transfer
Name Name/ Address & from
Reg. # SAM No. Type of Sex DOB Age Date Wt Ht WH Edema MUAC
(surname, Caregiver’s Phone No.
ANNEX 50

first name) name Entry Code of the F/M mm/dd/yy (months) mm/dd/yy (kg) (cm) Z 0,1,2,3 (mm)
OTC/ITC

3
Registry Book Example

10

11

12

13

14

15

16

17

18

19

20

199
200
Exit to Facility Type of Exit
Date of
Transfer out Minimum
minimum
Date Wt Ht WH Edema MUAC weight Observation
Type weight
mm/dd/yy (kg) (cm) Z 0,1,2,3 (mm) (kg)
Code of the OTC/ mm/dd/yy
ITC

10

11

12

13

14

15

16

17

18

19

20
 CRITICAL CARE CHART

Patient’s Name: Reg. No. Sheet No. Diagnosis:

Check the vital signs that are to be monitored in the “check” column and
Age: SAM-No. Edema: 0 + ++ +++
write in the times in the time row (only check those that are needed)
IPF/emergency ward/casualty/pediatr ward/other: - attach graph for graphing critical signs if necessary.

Date: Nurse in Charge: Dr. in Charge:

ANNEX 51

Check the patient every ..........min/hour Time started ....................am/pm

TIME Hr Check Initial Eval.
EXAMINATION
Level of Consciousness
Weight - Kg.g
Capillary refill (nail bed) - secs

Cold extremities Yes No

Respiration rate - per min
Critical Care Chart Example

Pulse - per min

Liver (cm below costal margin)
Stool (liquid/semi/solid) number
Vomit - number
Passed urine Yes No
Temperature (axilla/rectal)
Eyelids (retract/sleep eyes/open)
Other
Other
TREATMENT GIVEN
ResSoMal........................................mL
IV-fluid.............................................mL
Blood/pack cells..............................mL
F75/sugar water..............................mL
IV glucose 10%..............................mL
Oxygen
Wet cloths
Kangaroo-rewarming
stat Drug
stat Drug
stat Drug

201
 ANNEX 52
PhilHealth reimbursements for acute malnutrition (Excerpt)
ICD Code Description Case Rate Professional Health Care
Fee Institution Fee
B65.8+ J17.3* Pneumonia in schistosomiasis due to 15,000 15,000 10,500
Schistosoma intercalatum; mattheei; mekongi
B65.9 Schistosomiasis, unspecified 2,800 840 1,960
B65.9+ J17.3* Pneumonia in schistosomiasis 15,000 4,500 10,500
B77.8+ J17.3* Pneumonia in ascariasis 15,000 4,500 10,500
B77.9 Ascariasis 2,800 840 1,960
B82.0 Intestinal helminthiasis, unspecified 2,800 840 1,960
B82.9 Intestinal parasitism, unspecified 2,800 840 1,960
E16.2 Hypoglycemia 2,800 840 1,960
E40 Kwashiorkor 8,190 2,457 5,733
E41 Nutritional marasmus; Severe malnutrition with 8,190 2,457 5,733
marasmus
E43 Unspecified severe protein-energy malnutrition 8,190 2,457 5,733
E44.1 Mild protein-energy malnutrition 8,190 2,457 5,733
E86.1 moderate dehydration 2,800 840 1,960
E86.2 severe dehydration 2,800 840 1,960
E87.0 Hyperosmolality and hypernatraemia; Sodium 2,800 840 1,960
[Na] excess; Sodium [Na] overload
E87.1 Hypo-osmolality and hyponatraemia 5,950 1,785 4,165
E87.2 Acidosis; Acidosis NOS; Lactic Acidosis; 5,950 1,785 4,165
Metabolic Acidosis; Respiratory Acidosis
E87.3 Alkalosis; Alkalosis NOS; Metabolic Alkalosis; 5,950 1,785 4,165
Respiratory Alkalosis
E87.4 Mixed disorder of acid-base balance 5,950 1,785 4,165
E87.5 Hyperkalaemia; Potassium [K] excess; 5,950 1,785 4,165
Potassium [K] overload
E87.6 Hypokalaemia; Potassium [K] deficiency 5,950 1,785 4,165
E87.7 Fluid overload 5,950 1,785 4,165
E87.8 Other disorders of electrolyte and fluid balance, 5,950 1,785 4,165
not elsewhere classified; Electrolyte imbalance
NOS;
Hyperchloraemia; Hypochloraemia; Other
metabolic disorders

202
ANNEX 53
Defaulter form

Defaulter Details (Front)

Name of Child ________________________ Registration number ______________
Health Centre ________________________ Today’s date ____________________
Child’s MUAC: ____________ mm

Name of Caregiver: ____________________ Contact No.: ____________________

If MUAC < 115mm ask;

DO YOU THINK YOUR CHILD IS MALNOURISHED?
 YES  NO

For all defaulters ask:

WHY IS YOUR CHILD NOT CURRENTLY ENROLLED IN TREATMENT?

 Too far (How long does it take to walk? ……..hours)

 No time / too busy. What is the parent doing instead?________________________
 Mother is sick
 The mother cannot carry more than one child
 The mother feels ashamed or shy about coming
 Security problems
 There is no one else who can take care of the other siblings
 The amount of RUTF was too little to justify the journey
 My husband refuses
 I do not think the program can help my child (prefer traditional healer, etc.)
 The child wasn’t improving
 Condition improved and didn’t need treatment anymore (in mother’s opinion)
 Condition improved and was discharged by staff
 Child died
 Other reasons: ___________________________________________________
_________________________________________________________________

Additional notes:

203
 Defaulter Details (Back)
For each defaulter please take the following information from the OTC card:

Name:

Registration number:

Date of enrolment into study

Date of last attendance:

MUAC on admission:

Weight on admission:
MUAC on last attendance
before default:
Weight on last attendance
before default:
Number of weeks attended
OTC:
 < 30 mins  30 - 60 mins  1 - 2 hours
Distance / time taken to walk
to HC (tick)  2 - 3 hours  > 3 hours

Additional notes / significant information

204
 ANNEX 54
Supervision checklist for OTC

Preparation

Activity Yes No Remarks

RUTF stock checked and reconciled
OTC Inventory
• Digital scale
(scales must be accurate to 100g minimum)
• Height Boards
• WFH tables (WHO 2006)
• MUAC tapes
• OTC follow up cards
• OTC protocols
• OTC Medications
• Clean drinking water
• Cups, spoons
• Soap/water (for hand washing)
• Carrying bags (for RUTF)

Screening

Activity Yes No Remarks

BHW / BNS deployed for MUAC / edema
measurement in community
Appropriate number of MUAC tapes are available in
good condition
BHW / BNS aware of the cut off points for selection of
children;
6 - 59 months
• MUAC (for children > 6 months)
• MUAC < 115mm (11.5cm) refer to OTC
• Children < 6 months referred to OTC
BHW / BNS conducting MUAC / edema measurements
appropriately
Individual beneficiary’s MUAC and edema clearly
indicated on a piece of paper along with name/age/sex
(if referred from community)
Eligible children clearly directed toward OTC clinic by
BHW / BNS
BHW / BNS clearly explaining to caregivers reason
why ineligible children were not selected

205
 Final screening of new arrivals and follow up of OTC cases

Activity Yes No Remarks

Height measurement procedure is appropriate (where
height measurement is used)
Weight measurement procedure is appropriate
MUAC measurement procedure is appropriate
WFH appropriately identified using weight for height
chart
MUAC / edema measured for all OTC cases
Measurements clearly indicated in the OTC cards.
BHW / BNS / Midwife / Medical Officer explains the
findings to mothers

Medical Consultation

Activity Yes No Remarks

Sufficient amount of routine medicines are available
Thermometer is available and in good condition
OTC cards are available in sufficient amount
Sufficient arrangement made for sitting of beneficiaries
Clinical examination of every OTC case done
appropriately following protocol
Findings of the clinical examination clearly indicated in
the OTC card
Appetite test performed appropriately
Routine medicines for OTC cases are provided to each
child and indicated in cards
SAM with complications or lack of appetite identified
appropriately and referred to ITC
Appropriate amount of RUTF distributed and clearly
explained to mothers
Mothers counselled on disadvantages of sharing
RUTF
Discharges from OTC made appropriately
Absent OTC children are searched for (by outreach
workers / volunteers)
Record keeping is appropriate
Staff are sympathetic to mothers and children

206
 RUTF Distribution

Activity Yes No Remarks

Soap is available
Caregiver washes hands before giving RUTF to child
RUTF education given to all new OTC mothers
Caregiver is able to explain how to use RUTF correctly
for her/his child
Record keeping is appropriate

Conclusion

Activity Yes No Remarks

Nurse completes RUTF stock record sheet (if
appropriate)
Nurse completes the TCL / Family Folder
OTC file properly organized
OTC cards for discharged patients are returned to
clinic for filing except referrals to ITC
Names of OTC children for follow up in the community
including absentees and defaulters are provided to
BHW / BNS workers to find during the week
Adequate stock and buffer stock in place for caseload
RUTF stock reconciled with storekeeper

207
 ANNEX 55
Response Actions of National Nutrition Cluster (adapted from
Minimum Service Package)

Actions of the Nutrition Cluster at the national level will depend on the extent of the disaster. This section
proposes actions that must be taken by the National Nutrition Cluster for 3 scenarios:

a. National Cluster Actions for functional LGU Nutrition Cluster

b. National Cluster Level Actions augmenting functional Regional/LGU Nutrition Cluster
c. National Cluster Level Actions taking over for non-functional Regional/LGU Nutrition Cluster

A. National Cluster Actions for functional LGU Nutrition Cluster

Timeline Nutrition
1. Pre-Emptive 1.1 Update resource inventory/mapping of micronutrients
Evacuation
Phase 1.1.1 Tents
1.1.2 Vitamin A capsules
1.1.3 Multiple micronutrient powders
1.1.4 Multiple Micronutrient supplements for pregnant women
1.1.5 IECs for Nutrition
1.1.6 MUAC Tapes
1.1.7 Weighing scale
1.1.8 Weight for height reference table
1.1.9 Height Board
1.1.10 Ready-to-Use Therapeutic Food (RUTF)
1.1.11 Ready-to-Use Supplementary Food (RUSF)
1.1.12 Antibiotics, deworming tablets (for routine acute malnutrition management, to be
coordinated with the health office/centers)
1.1.13 Human milk banks (inform them ahead for proper coordination)
1.1.14 Breastfeeding Kit (container/katsa, feeding cup with cover, food container with
spoon and fork, 1 liter glass tumbler with cover, IEC materials, birth registration
form)

1.2 Mapping of partners (4Ws - Who, what, when, where)

1.3 Coordination with partners on the following:

1.3.1. Conduct of general and blanket supplementary feeding for 6 to 59 months old
children, and pregnant and lactating women
1.3.2. Setting-up of mother-baby friendly areas in evacuation center for IYCF counseling
and complementary feeding

1.4 Alert notification to health facilities with capacities for SAM (severe acute malnutrition
“severe wasting” management), ensure functional referral systems

1.5 Activation

1.5.1. Joint Rapid Nutrition Assessment Teams, if necessary

1.5.2. Infant feeding/ Breastfeeding Support Groups, if necessary

1.6 Intra/InterCluster Coordination Meetings

2. Within First 24 2.1 Coordinate/Facilitate team deployment by LGU
hours of Impact
2.2 Assist LGU in establishing contacts, gathering critical information (baseline) and
25 to 71 hours
identifying immediate priorities to include areas that situation may worsen, especially
regarding support for IYCF and EO 51 monitoring

2.3 Support LGU in the conduct of gap analysis and in the prioritization and planning/
scheduling of nutrition interventions

2.4 Facilitate and coordinate the preparation and submission of daily situation report

208
 Timeline Nutrition
3. More than 72 3.1 Provision of technical assistance on the following:
hours
3.1.1 Implementation of nutrition interventions
3.1.2 Information management (e.g. 4Ws, use of data tracking matrix of DSWD, situation
reports)
3.1.3 Monitoring and evaluation
3.1.4 Documentation

3.2 Support LGU in policy monitoring of EO51 and reporting of violations

3.3 Lead/facilitate cluster coordination initiatives

3.4 Assist LGU in the advocacy for nutrition services related to mental health and psychosocial
care, water, sanitation and hygiene, health, and others

3.5 Activation of 4Ws

3.6 Technical assistance for “exit” strategy

B. National Cluster Level Actions augmenting Functional Regional/LGU Nutrition Cluster

Timeline Nutrition
1. Pre-Emptive 1.1 Update resource inventory/mapping of micronutrients by Nutrition Clusters at all levels
Evacuation
Phase 1.1.1 Vitamin A capsules
1.1.2 Multiple micronutrient powders
1.1.3 Ferrous sulfate and iron with folic acid
1.1.4 IECs for Nutrition
1.1.5 MUAC Tapes
1.1.6 Weighing scale
1.1.7 Weight for height reference table
1.1.8 Height Board
1.1.9 Ready-to-Use Therapeutic Food (RUTF)
1.1.10 Ready-to-Use Supplementary Food (RUSF)
1.1.11 Antibiotics, deworming tablets (for routine acute malnutrition management, to be
coordinated with the health office/centers)
1.1.12 Human milk banks (inform them ahead for proper coordination)
1.1.13 Breastfeeding Kit (container/katsa, feeding cup with cover, food container with
spoon and fork, 1 liter glass tumbler with cover, IEC materials, birth registration
form)

1.2 Mapping of partners (4Ws- Who, what, when, where) by Nutrition Clusters at all levels

1.3 National/Regional Nutrition Clusters providing augmentation to LGU Nutrition Clusters on

the following:

1.3.1 Conduct of general and blanket supplementary feeding for 6 to 59 months old
children, and pregnant and lactating women
1.3.2 Setting-up of mother-baby friendly areas in evacuation centers for IYCF counseling
and complementary feeding

1.4 Support LGU in giving alert notification to health facilities with capacities for SAM (severe
acute malnutrition “severe wasting” management)

1.5 Augment activation of the following:

1.5.1 Joint Rapid Nutrition Assessment Teams, if necessary

1.5.2 Infant feeding/ Breastfeeding Support Groups, if necessary

1.6 Support LGU in the conduct of Intra/InterCluster Coordination Meetings

209
 Timeline Nutrition
2. Within First 24 2.1 Augment team deployment by LGU
hours of Impact
2.2 Assist LGU in establishing contacts, gathering critical information (baseline) and identifying
25 to 71 hours
immediate priorities to include areas that situation may worsen.

2.3 Support LGU in the conduct of gap analysis and in the prioritization and planning/
scheduling of nutrition interventions

2.4 Support LGU in the preparation and submission of daily situation report
3. More than 72 3.1 Augment LGU’s logistics on the following:
hours
3.1.1 Implementation of nutrition interventions
3.1.2 Information management (e.g. 4Ws, use of data tracking matrix of DSWD)
3.1.3 Monitoring and evaluation
3.1.4 Documentation

3.2 Support LGU in policy monitoring of EO51 and reporting of violations

3.3 Support LGU in the conduct of Intra/Inter-Cluster Coordination Meetings

3.4 Assist LGU in the advocacy for services related to mental health and psychosocial care,
water, sanitation and hygiene, health, and others

3.5 Technical assistance for “exit” strategy

C. National Cluster Level Actions taking over for non-functional Regional/LGU Nutrition Cluster

Timeline Nutrition
1. Pre-Emptive 1.1 Updating of inventory of resources and mobilization/mapping of micronutrients
Evacuation
Phase 1.1.1 Vitamin A capsules
1.1.2 Multiple micronutrient powders
1.1.3 Ferrous sulfate and iron with folic acid
1.1.4 IECs for Nutrition
1.1.5 MUAC Tapes
1.1.6 Weighing scale
1.1.7 Weight for height reference table
1.1.8 Height Board
1.1.9 Ready-to-Use Therapeutic Food (RUTF)
1.1.10 Ready-to-Use Supplementary Food (RUSF)
1.1.11 Antibiotics, deworming tablets (for routine acute malnutrition management, to be
coordinated with the health office/centers)

1.2 Coordinate the conduct of general/blanket supplementary feeding

1.3 Conduct of targeted supplementary feeding for 6 to 59 old months children, and pregnant
and lactating mothers

1.4 Distribute Vitamin A to RHUs for 6 to 59 months children

1.5 Coordinate the setting up of mother-baby friendly areas in evacuation centers for IYCF
counseling and complementary feeding

1.6 Team Activation

1.6.1 Joint Rapid Nutrition Assessment Teams

1.6.2 Infant feeding/ Breastfeeding Support Groups

1.7 Referral of SAM (Severe Acute Malnutrition “severe wasting”) with complications to
Integrated Management of Acute Malnutrition (IMAM) referral hospitals

1.8 Cluster Coordination Meeting

210
 Timeline Nutrition
2. Within First 24 2.1 Assessment Team Deployment
hours of Impact
2.2 Rapid nutrition assessment
25 to 71 hours
2.3 Infant feeding in emergencies assessment
* the following
activities will not
2.4 Cluster coordination
only be delivered
in the evacuation
2.5 Planning for Intervention
center
3. More than 72 3.1 Implementation of the following nutrition interventions:
hours
3.1.1 Rapid screening for acute malnutrition using mid-upper arm circumference (MUAC)
tape
3.1.2 Blanket and targeted supplementary feeding
3.1.3 Integrated Management of Acute Malnutrition (IMAM) activity components

3.1.3.1 Screening and identification of severe acute malnutrition (SAM or “severe

wasting”) and moderate acute malnutrition (MAM or “wasting”) using MUAC (or
weight-for-height if capacity exists) as basis and checking of bilateral pitting
edema
3.1.3.2 Enrolment/admission
3.1.3.3 Growth monitoring and promotion
3.1.3.4 Standard case management
3.1.3.5 Case referral
3.1.3.6 IMAM crash course for health staff and volunteers

3.1.4 Promotion, protection, and support of infant and young child feeding in emergencies

3.1.4.1 Policy (Milk Code) active monitoring and advocacy

3.1.4.2 Establishment/setting up of breastfeeding areas/corners/tents in evacuation
centers/camps/temporary shelters
3.1.4.3 Organization and orientation of breastfeeding support groups
3.1.4.4 Infant feeding in emergencies assessment and counseling
3.1.4.5 Provision of breastfeeding support services

3.1.4.5.1 Transport and storage of pasteurized human breastmilk in coordination

with human milkbank
3.1.4.5.2 Identification of wet nurses
3.1.4.5.3 Organization of relactation sessions
3.1.4.5.4 Distribution of breastfeeding kits

3.1.5 Micronutrient Intervention

3.1.5.1 Provision of vitamin A capsules (VAC)

3.1.5.2 Iron and folic acid supplementation
3.1.5.3 Multiple micronutrient powder (MNP) supplementation
3.1.5.4 Supplementary Feeding

3.2 Information Management

3.2.1 Monitoring, supervision and evaluation:

3.2.1.1 Service delivery

3.2.1.2 Resource mobilization and use
3.2.1.3 Emerging needs, e.g. need for “Diskwento” caravan
3.2.1.4 Anthropometric survey/surveillance

211
 Timeline Nutrition
3.2.2 Documentation and information sharing

3.2.2.1 from the LGU to the National office (DOH)

3.2.2.2 within LGUs
3.2.2.3 between and among partners
3.2.2.4 clusters
3.2.2.5 others

3.3 Referral of psychosocial high-risk or positive cases to mental health and psychosocial
support (MHPSS) interventions and activities

3.4 Referral to WASH, Health Clusters, and other interventions

3.5 Cluster coordination

3.6 Policy monitoring of EO51 and reporting of violations

3.7 Develop “transition” strategy

ANNEX 56
Calculating Case Load for SAM

How do we estimate case load for SAM and / or MAM in children 6 - 59 months
in a given time period?
Adapted from the article of Mark Myatt, Consultant Epidemiologist, Brixton Health, CMAM Forum

A common approach to is to use the formula:

case load = N × P × K × C
where:

N is the size of the population in the program area. This is usually the population aged between 6 and
59 months which, in low income countries, is commonly estimated as 20% of the total population. In the
Philippines, this population is estimated to be 12.15%.

P is estimated prevalence of SAM or MAM. This is usually estimated using a nutritional anthropometry
survey (e.g. Operation Timbang Plus, the National Nutrition Survey, or a SMART survey). It is important
that prevalence is estimated for the program's admitting case-definition based on MUAC measurements,
Weight-for-height/length (W/H or W/L) SD Scores and edema.

In PIMAM, the admitting case definitions for SAM are:

1. MUAC < 115mm (11.5cm)

2. Presence of bilateral pitting edema
3. W/H or W/L < -3 SD

K is a correction factor to account for new (incident cases) over a given time period.

C is expected mean program coverage over a given time period. Program coverage may range from
10% to 90%. It should be noted that programs that place emphasis on using weight-for-height in admitting
case-definitions tend to achieve considerable lower levels of coverage than programs that place emphasis
on using MUAC in admitting case-definitions.

212
Deciding appropriate input values for N, P, K, and C

An appropriate value for N is usually derived from census data. In some settings, certain factors may lead
to census data not being accurate (e.g. political manipulation, the absence of a functioning civil society,
population displacement, and poor security). Population estimates should, therefore, be corrected by
the application of estimates of population growth, for displacement, migration, and mortality in the target
population.

An appropriate value for P for SAM is usually estimated with poor relative precision. For example, a SMART
survey with a sample size of 600 and a design effect of 1.5 may return an estimate of SAM prevalence
of 1.25% with a 95% confidence interval (CI) of 0.41% to 2.89%. On average, 10 - 20% of the total GAM
prevalence can estimate SAM prevalence if no available data can be used. Existing prevalences for GAM
and MAM are, however, usually estimated with better relative precision.

K is estimated from:

prevalence
incidence =
average duration of untreated disease

The average duration of episodes of untreated SAM and MAM is usually taken to be 7.5 months.

This yields:

t
incidence = prevalence x
7.5 months
where t is the time period specified in months.

12 months
incidence = prevalence x = prevalence x 1.6
7.5 months
Need can be estimated as the sum of prevalent cases and incident cases:

t
need = prevalence + (prevalence x )
7.5
Thus K can be estimated as:

t
K=1+
7.5
For a year this is:

12
K=1+ = 2.6
7.5

213
 C is the mean coverage that is expected to be achieved by the program over the time period. This depends
on the type of program and how well the program operates in terms of case-finding, recruitment, and
retention.

For start-up programs, the correction factor, K, can be assigned the value of 1.6 while the Coverage, C, can
be assigned the value of 50%. The correction factor of 1.6 is the most commonly used globally but other
studies indicate that it is variable according to context (may be as high as 5). Both values are conservative
enough for estimating initial RUTF needs to be procured in the start-up year. However, once nutrition survey
data or programming data are available, the values should be reviewed and revised quarterly based on
actual caseloads.

An example calculation:

Population : 121,400
N = 121,400 × 0.1215 = 14,750
Proportion 6 - 59 months : 12.15%
Prevalence of SAM : 1.34% P = 0.0134
Time period (Start-up) : 1 year K = 1.6
Expected coverage : 50% C = 0.50

The expected case load is:

case load = N × P × K × C
case load = 14,750 × 0.0134 × 1.6 × 0.50 = 158

A 95% confidence interval could be calculated using the upper and lower 95% confidence limits for P in the
formula. Confidence intervals will usually be very wide for SAM. This is due to the lack of precision in the
estimate of SAM prevalence available from typical nutritional anthropometry surveys.

The overall caseload for SAM can also be used to estimate the need for inpatient (stabilisation) care. At the
start of a program there may be a large number of complicated cases. In this context, the need for inpatient
care will be high (e.g. 10 - 15% of prevalent cases). For the Philippines, a value of 10% for complicated
cases is a conservative figure for start-up programs.

Using the example data:

Initial inpatient demand = 14,750 × 0.0134 × 0.10 × 0.50 = 10
The need for inpatient care should, in a well CMAM functioning program, decline over time and not
exceed 5% of estimated case-load over the specified time-period. Using the example data:
Ongoing inpatient demand = 158 × 0.05 = 8
It should be noted that this is an approximate method. This is due to uncertainty in all of the variables.

____________________________________________________________________________________
This document was drafted by Mark Myatt (Consultant Epidemiologist, Brixton Health) on 30th May 2012
and revised accordingly for the Philippine SAM guidelines on May 14 2015.
References:

Garenne M, Willie D, Maire B, Fontaine O, Eeckels R, Briend A, Van den Broeck J, Incidence and duration of severe wasting in two African populations, Public Health Nutr. 2009
Nov;12(11):1974-82
Anon, WHO, UNICEF, WFP and UNHCR Consultation on the Programmatic Aspects of the Management of Moderate Acute Malnutrition in Children under five years of age 24-
26 February 2010, WHO, Geneva, 2010
MacMahon B, Pugh TF, Epidemiology Principles and Methods, Little Brown & Company, Boston, USA, 1970
Miettinen O, Estimability and estimation in case-referent studies, American Journal of Epidemiology, 1976;103(2):226–235

214
ANNEX 57
Issuance of Supplies and Materials Procedure (SAMPLE)

Steps End-user Service Provider Person in charge Fees Form

1 Present duly Determine the City/Municipal None Requisition and
accomplished necessity of the Health Officer/Chief required Issue Slip
Requisition and Issue Supplies requested of Clinics
Slip then return to the end
to the PHO/DOH user with signature.
Regional Office for
Approval
2 Submits Requisition and Check the inventory Provincial/Regional None Requisition and
Issue Slip to the Supply for availability Storekeeper/ Supply required Issue Slip
Office Officer
3 Record in the stock Provincial/Regional None Requisition and
card Storekeeper/ Supply required Issue Slip
Officer
4 Accept/receive the Releases supplies Provincial/Regional None Requisition and
supplies and materials Storekeeper/ Supply required Issue Slip
requested Officer
END OF TOTAL
TRANSACTIONS

ANNEX 58
Supplies RIS Form

REQUISITION AND ISSUE SLIP

(Agency)
Division :       Responsibility Center RIS No.       Date:      
Office: Code    SAI No.       Date:    
Requisition Issuance
Stock No. Unit Description Quantity Unit Value Remarks

Purpose      

Requested by: Approved by: Issued by: Received by:

Signature
Name
Designation
Date

215
 ANNEX 59
Bottleneck Analysis

Periodic evaluation of the CMAM program through bottleneck analysis (BNA) can help identify obstacles
to service delivery in order to address impediments and improve coverage of services. The program areas
are evaluated across seven determinants across a specific time period: commodity availability, human
resources availability, geographic availability, community mobilization activities, utilization of services,
continuity of services, and quality of services. The BNA is recommended to be performed every 3 months.

Indicator Numerator/Denominator
COMMODITY: Numerator: Number of health facilities with no stock outs
% of health facilities that did not
have stock outs of RUTF in the Denominator: Total number of health facilities offering CMAM
last 3 months services in area monitored

HUMAN RESOURCES: Numerator: Number of health workers trained in CMAM

% of health workers who have
been trained on CMAM Denominator: Total number of health workers in area monitored

Numerator: Number of health facilities offering CMAM treatment in

GEOGRAPHICAL ACCESS: area monitored
% of health facilities offering
CMAM treatment Denominator: Total number of health facilities in area monitored

OUTREACH: Numerator: Number of community health workers trained in CMAM

% of CHWs who have been
trained on CMAM Denominator: Total number of community health workers in area
monitored
Numerator: Number of children < 5 newly admitted for SAM
UTILIZATION: treatment
% of children < 5 with SAM
admitted for treatment Denominator: Number of children expected to have SAM for period
monitored
Numerator: Number of children < 5 years newly admitted for
CONTINUITY: treatment of SAM minus defaulters
% of children < 5 who did NOT
default from treatment Denominator: Total number of children expected to have SAM in
area monitored for the period monitored
Numerator: Number of children with SAM who were cured in area
QUALITY: monitored
% of children < 5 with SAM who
were cured Denominator: Total number of children expected to have SAM in
area monitored for period monitored

Once the above figures are obtained, it may be helpful to plot this data in graphs to evaluate and compare
trends. Visualization of data trends may help programme areas identify constraints or bottlenecks and work
towards improving service delivery. The following figure is a sample BNA in an area across 4 quarters.

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