GUIDELINES FOR INTEGRATED

MANAGEMENT OF ACUTE
MALNUTRITION IN UGANDA
2020
Contents

Acronyms and abbreviations ix

Foreword xi

Acknowledgement xii

List of contributors xiii

Glossary of terms xiv

1.0 Introduction 1

1.1 Burden and forms of malnutrition 1

1.2 Purpose of the guidelines 2

1.3 History of Integrated Management of Acute Malnutrition guidelines for Uganda 2

1.4 Who should use the Integrated Management of Acute Malnutrition guidelines? 4

1.5 How and when to use the Integrated Management of Acute Malnutrition Guidelines 4

1.6 Components of integrated management of acute malnutrition 4

2.0 Organization of the Integrated Management of

Acute Malnutrition services 6

2.1 Introduction 6

2.2 Actors and their roles at different levels 7

2.3 Organization for in-service training in Integrated Management of Acute Malnutrition

services 11

3.0 Community services 14

3.1 Introduction 14

3.2 Community engagement 14

3.3 Community active screening and referral 16

3.4 Home visits for follow-up 19

3.5 Monitoring, supervision, evaluation and reporting 21

4.0 Health facility identification and classification of acute malnutrition 22

4.1 Introduction 22

4.2 Health facility identification and classification of acute malnutrition in children aged
6–59 months 23

4.3 Health facility identification and classification of acute malnutrition in infants less than
six months and pregnant and lactating women 34

4.4 Health facility identification and classification of acute malnutrition in older persons 41

5.0 Transport of very ill malnourished patients 45

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | i

5.1 Introduction 45

5.2 Transport of malnourished patients from the inpatient therapeutic care facility 45

5.3 Transport of malnourished patients from the outpatient therapeutic care facility 45

5.4 Role of district nutritionist and district health officer in transport of very ill patients 45

6.0 Management of moderate acute malnutrition 47

6.1 Introduction 47

6.2 Management of moderate acute malnutrition in children aged 6–59 months in normal
situations 48

6.3 Management of moderate acute malnutrition in children aged 6–59 months in food
insecure and emergency contexts 55

6.4 Management of moderate acute malnutrition for pregnant and lactating women in
normal situations 67

6.5 Management of moderate acute malnutrition in pregnant and lactating in food insecure
and emergency contexts 71

6.6 Management of moderate malnutrition in older persons in normal situations 72

6.7 Management of moderate acute malnutrition in older persons in food insecure and
emergency contexts 73

7.0 Outpatient therapeutic care for management of severe acute malnutrition without
medical complications 75

7.1 Introduction 75

7.2 Organization of outpatient therapeutic care services 75

7.3 Outpatient therapeutic care for management of severe acute malnutrition in children
aged 6–59 months 78

7.4 Outpatient therapeutic care of infants less than six months with uncomplicated
moderate and severe acute malnutrition 95

7.5 Outpatient therapeutic care for management of severe malnutrition in older persons 98

8.0 Emotional and physical stimulation in Integrated Management of Acute Malnutrition

services 99

8.1 Importance of stimulation 99

8.2 Emotional care and physical stimulation in the OPD, OTC and ITC 99

8.3 Emotional stimulation and play 100

8.4 Physical activity 100

8.5 Methods used in emotional and physical stimulation 100

9.0 Inpatient therapeutic care for management of severe acute malnutrition with medical
complications 102

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9.1 Introduction 102

9.2 Structure and organization of inpatient therapeutic care 103

9.3 Inpatient therapeutic care for management of severe acute malnutrition with medical
complications in children aged 6–59 months 105

9.4 Inpatient therapeutic care for management of severe acute malnutrition with medical
complications in infants less than six months 143

9.5 Inpatient therapeutic management of severe malnutrition in older persons 157

10.0 Integrated Management of Acute Malnutrition services during surge 161

10.1 Introduction 161

11.0 Integrated Management of Acute Malnutrition services in emergency nutrition

response 168

11.1 Key terms 168

11.2 Steps for emergency nutrition response 168

11.3 Program linkages for prevention and management of acute malnutrition in emergencies
170

11.4 Requirements of setting-up an emergency nutrition program 172

12.0 Prevention of malnutrition 173

12.1 Introduction 173

12.2 Key interventions 173

12.3 Creating and strengthening linkages with other programs in MoH or other sectors 175

13.0 Supply chain management in integrated management of acute malnutrition 177

13.1 Introduction 177

13.2 Integrated Management of Acute Malnutrition commodities 177

13.3 Quantification, procurement, storage and distribution of nutrition commodities 178

14.0 Quality improvement, monitoring and evaluation in Integrated Management of Acute

Malnutrition services 181

14.1 Quality improvement in Integrated Management of Acute Malnutrition 181

14.2 Monitoring, evaluation and reporting 188

14.3 Integrated Management of Acute Malnutrition service performance indicators,

coverage, and appropriateness 195

14.4 Evaluation and implementation research priorities for Integrated Management of Acute
Malnutrition 197

ANNEXES 203

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | iii

List of Annexes
Annex 1: Health Management Information System for Nutrition and Related Tools 203

Annex 2: Checking for Bilateral Pitting Oedema and MUAC Assessment 205

Annex 3: Tools used in delivery of IMAM services at different levels 208

Annex 4: Taking body weight and height and determination of WFH/L Z-score 211

Annex 5: Triage of sick children 216

Annex 6: WHO 2006 Z-score Chart 217

Annex 7: Breastfeeding Assessment Tool 219

Annex 8: BMI-for-Age Reference Card for Children 5 to 19 Years 220

Annex 9: Body Mass Index (Adults) (=W/H2) Weight in kg and Height in Metres 224

Annex 10: Infant Young Child Feeding Recommendations 225

Annex 11: Local food recipes used during counselling for appropriate complementary feeding 226

Annex 12: A decision tree for selective feeding in emergencies 230

Annex 13: Preparation and use of the ration and key messages for SFP 231

Annex 14: Food commodities used in management of moderate acute malnutrition 233

Annex 15: Advantages and disadvantages of dry and wet rations 234

Annex 16: Variable RUTF in OTC 235

Annex 17: 5% Weight loss and 5% weight gain 236

Annex 18: Recipes for locally prepared F-75 and F-100 and reconstitution of commercial F-75 and
F-100 237

Annex 19: Diet (F-100 or RUTF) during rehabilitation/recovery phase 240

Annex 20: Amount of F-75 to give during stabilization (or Phase 1) 242

Annex 21: How to insert a naso-gastric tube 243

Annex 22: Amount of RUTF to give in transition phase per 24 hours 244

Annex 23: Amount of F-100 to give during transition; 8 and 6 feeds per day 245

Annex 24: Drug dosages used in the management of severely malnourished children 246

Annex 25: The disadvantages of indwelling cannula 253

Annex 26: Recipes for nutrition-rich mixture of family foods 254

Annex 27: Key nutrition recommendations 255

Annex 28: Standard supply chain monitoring tools 258

Annex 29: Quality improvement journal 261

Annex 30: Health facility supervision and mentorship tool in IMAM service 263

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List of Tables
Table 1: MUAC cut-offs in older persons in the context of emergencies 19

Table 2: Recommended age-specific anthropometric indices to measure 22

Table 3: Classification and admission criteria for acute malnutrition in children aged 6–59 months 25

Table 4: Amount of RUTF to assess the appetite of severely malnourished children 31

Table 5: Classification and admission criteria to inpatient or outpatient care 34

Table 6: Admission criteria for outpatient and inpatient therapeutic care infants less than 6 months 39

Table 7: Classification and admission criteria for outpatient and inpatient care for PLW 41

Table 8: Classification of malnutrition in older children, adolescents and adults 43

Table 9: Criteria for admission to outpatient or inpatient care in older persons 44

Table 10: Trigger actions in management of MAM failure-to-respond 50

Table 11: Routine medication, vaccines, and supplements 53

Table 12: Discharge criteria for children managed for MAM 54

Table 13: Decision making framework for opening a supplementary feeding program 56

Table 14: Guidance on criteria for closing SFP Services 57

Table 15: Supplementary dry ration required per child or PLW for 2 weeks in targeted SFP 62

Table 16: Summary of the routine monitoring in SFP 63

Table 17: Admission and discharge criteria for PLW with MAM 69

Table 18: Routine outpatient medicines for pregnant and lactating women 70

Table 19: Type of discharge for pregnant and lactating women 71

Table 20: Energy needed per day in the context of HIV 73

Table 21: Table of amounts of RUTF to give per day and week in OTC 79

Table 22: Summary of OTC routine systemic medicines and treatment dosages 84

Table 23: Summary of routine monitoring in OTC 86

Table 24: Criteria for diagnosis of failure-to-respond for outpatient therapeutic care 88

Table 25: Discharge criteria for patients in OTC 92

Table 26: Summary of criteria for admission to inpatient therapeutic care 105

Table 27: Summary of antibiotics used in severe acute malnutrition 116

Table 28: Assessment and treatment of dehydration and shock in non-oedematous SAM 125

Table 29: Management of hypernatraemia 128

Table 30: Parameters assessed in stabilization phase 141

Table 31: Diagnosis of failure-to-respond to ITC 141

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | v

Table 32: Amounts of SST-Milk for infants during SST feeding 150

Table 33: Look up table of the amounts of F-100 dilute or F-75 to give for infants not breastfed in the
stabilization, transition and rehabilitation phases 155

Table 34: Dietary requirements for initial treatment of severely malnourished older persons using
local preparations of F-75 and F-100 158

Table 35: Discharge criteria for older children, adolescents and adults 159

Table 36: Descriptive definitions for each phase in surge 165

Table 37: Stakeholders’ roles in emergency response 171

Table 38: Types and frequency of ordering for IMAM commodities and equipment 177

Table 39: Steps in implementing 5S model 182

Table 40: Performance indicators for monitoring effectiveness of IMAM services 195

Table 41: Target levels of quality of IMAM services for children 6–59 months of age 196

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List of Boxes
Box 1: History taking: Medical, dietary and socio-economic situation 32

Box 2: Danger signs or symptoms of severe disease 36

Box 3: Classification of breast-feeding problems 37

Box 4: Mother’s breastfeeding assessment 37

Box 5: Messages on prevention of MAM 51

Box 6: Taking RUTF at home: Key messages for the caretaker 80

Box 7: Causes of failure-to-respond to treatment in outpatient therapeutic care 89

Box 8: ETAT for Children with SAM 108

Box 9: Steps in rehydration of SAM with no oedema using ReSoMal 123

Box 10: Steps for IV rehydration in hypovolaemic shock 130

Box 11: Treatment of toxic/septic shock 131

Box 12: Investigations of the causes of failure-to-respond in inpatients 142

Box 13: Outline for the management for SAM infants less than 6 months of age 145

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List of Figures
Figure 1: Linkages between the components of IMAM 5

Figure 2: Organization of IMAM services 6

Figure 3: IMAM training structure: theory sessions 12

Figure 4: IMAM training structure: Clinical sessions at the health facility 13

Figure 5: Community Services for IMAM 15

Figure 6: Screening for acute malnutrition within the community 18

Figure 7: Activities and processes to classify SAM children at health facility. 25

Figure 8: Identification, classification and admission criteria at a health facility. 28

Figure 9: Process and flow of activities at an SFP site Nutritional Rehabilitation in Supplementary
Feeding Program 60

Figure 10: Diagnosis of failure to respond 67

Figure 11: Nutritional Strategy for Identification, Classification and Treatment for Acute Malnutrition 87

Figure 12: Scheme of Management for Failure to Respond to Treatment 91

Figure 13: Materials for child stimulation. Source: Supplied by Professor S. Grantham-McGregor 101

Figure 14: Feeding Technique 111

Figure 15: Stool Scale 120

Figure 16: Pictures of Children with Sunken Eyes 121

Figure 17: Steps in rehydrating a SAM child with no oedema 124

Figure 18: Fluids in treatment of septic/toxic shock 132

Figure 19: Supplementary suckling technique (© Michael Golden) 151

Figure 20: Surges in caseloads and provision of surge support over time 162

Figure 21: Overview of the IMAM surge approach focusing on the health facility. 163

Figure 22: IMAM Surge Approach as Health Facilities Cross Caseload Thresholds 167

Figure 23: Distribution of nutritional commodities 179

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Acronyms and abbreviations
ANC Antenatal Care
ART Anti-Retroviral Treatment
BCC Behavioural Change Communication
BMI Body Mass Index
CBO Community-Based Organization
CHW Community Health Worker
CME Continuous Medical Education
CMV Combined Mineral Vitamin Mix
CSB++ Corn-Soya Blend Plus
CCC Critical Care Chart
DHIS District Health Information System
DHO District Health Officer
DHT District Health Team
DN District Nutritionist
ETAT Emergency Triage Assessment and Treatment
FBFs Fortified Blended Foods
FSL Food Security and Livelihood
F-75 Formula 75
F-100 Formula 100
F-100dil Diluted F-100
GAM Global Acute Malnutrition
GFD General Food Distribution
ENR Emergency Nutrition Response
HC Health Center
HIV/AIDS Human Immuno-deficiency virus/Acquired Immuno-Deficiency Syndrome
HSS Health System Strengthening
iCCM Integrated Community of Case Management
IEC Information, Education, Communication
IM Intra-Muscular
IMAM Integrated Management of Acute Malnutrition
IMNCI Integrated Management of Neonates and Childhood Illness
ITC Inpatient Therapeutic Care
INR Integrated Nutrition Register
IYCF Infant and Young Child Feeding
IYCF-E Infant and Young Child Feeding in Emergencies
IU International Units
IV Intra-Venous
Kg Kilogram

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | ix

 LBW Low Birth Weight
MAM Moderate Acute Malnutrition
M&E Monitoring and Evaluation
MIYCAN Maternal, Infant, Young Child and Adolescent Nutrition
MNCH Maternal, Neonatal and Child Health
MoH Ministry of Health
MUAC Mid-Upper-Arm Circumference
NACS Nutritional Assessment, Counselling and Support
NAM Not Acutely Malnourished
NCDs Non-Communicable Diseases
NGT Naso-Gastric Tube
NGO Non-Government Organization
NMS National Medical Stores
OTC Outpatient Therapeutic Care
ORS Oral Rehydration Salts
PLW Pregnant and Lactating Women
QI Quality Improvement
ReSoMal Rehydration Solution for Severely Malnourished patients
RMNCH Reproductive Maternal New-born and Child Health
RUTF Ready-to-use Therapeutic Food
RUSF Ready-to-use Supplementary Food
SAM Severe Acute Malnutrition
SCM Supply Chain Management
SFP Supplementary Feeding Program
SST Supplementary Suckling Technique
STDM Specially Diluted Therapeutic Milk
UN United Nations
UNEPI Uganda National Expanded Program in Immunization
VHT Village Health Team
YCC Young Child Clinics
WASH Water Sanitation and Hygiene
WFP World Food Programme
WHO World Health Organization
WHZ Weight-for-Height Z-score
UNAP Uganda Nutrition Action Plan
UNHCR United Nations High Commissioner for Refugees
UNICEF United Nations Children’s Fund

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Foreword
Malnutrition is a major public health problem affecting most of the world’s population from
infancy to old age regardless of their sex. It is responsible for more ill health than any other cause.
Major consequences of malnutrition include increased childhood death, future adult diet-related
non-communicable diseases, enormous economic and human capital costs; justifying the urgent
prioritization of global and countrywide nutrition interventions.
Management of acute malnutrition drew attention in Uganda from 2003/2004 at the peak of the
Lord’s Resistance Army insurgency in the North. Based on existing global recommendations in
2006, the Ugandan Ministry of Health with support from UNICEF and Valid International developed
the first version of the Integrated Management of Acute Malnutrition (IMAM) guidelines to address
the high burden of acute malnutrition in children under five years of age and as a comprehensive
approach incorporating community therapeutic care.
In March 2010, the IMAM guidelines were revised to include pregnant and lactating women
and treatment aspects for malnourished HIV/AIDS children and adults. The guidelines were
further revised in 2015 adapting the WHO 2013 global update that provided evidence and
recommendations for management of SAM. Despite the 2015 IMAM guideline adaptations, key
gaps and concerns emerged over the years affecting service delivery including the use of varying
multiple guidelines affecting universal standardization, monitoring, and quality of care for acute
malnutrition; limited content on management of MAM across all age groups; management of
malnutrition in older persons; emergency of new evidence for management of “mothers at risk
and infants under six months”; and minimal institutionalization of the monitoring of various
IMAM components in the national health management and information system.
This version and revision of the IMAM guidelines addresses the raised gaps and concerns with
multiple changes in all components to strengthen management of acute malnutrition in the
health service delivery for all age groups. The revisions were made through a consultative and
participatory process involving diverse stakeholders and technical experts in nutrition from
Uganda and beyond.
I would like to appeal to all Ugandan health service providers to be mindful of the requirement to
train service providers in management of acute malnutrition using the stipulated procedures and
processes in this guideline for improved quality of care. To the implementing partners together
with the government, your support for the provision of the resources needed to support the
capacity development and supplies for management of children with acute malnutrition is key.
Stakeholders may refer to the guidelines for any other purpose other than to directly implement
IMAM. I call upon all stakeholders involved in the management of malnutrition to apply the
updated instructions and recommendations in this guideline. While some local adaptations may
be made, these should be done in collaboration and with the consent of the Ministry of Health. The
Ministry of Health is committed to ensuring appropriate implementation of these guidelines.

Dr. Henry G. Mwebesa,

Director General Health Services.

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | xi

Acknowledgement
The Ministry of Health (MoH) is greatly indebted to the technical support and guidance provided by
the following organizations in the revision of the IMAM guidelines: The United Nations Children’s
Fund (UNICEF); the World Food Program (WFP); the World Health Organization (WHO); the Office
of the United Nations High Commissioner for Refugees (UNHCR) and the United States Agency
for International Development (USAID). The support from Makerere University Departments of
Paediatrics and Child Health and Food Technology and Nutrition and the School of Public Health is
also acknowledged. The Mwanamugimu Nutrition Unit at Mulago National Referral Hospital; and
the MoH Nutrition Technical Working Group are also acknowledged.
The MoH acknowledges the funding received from UNICEF and WFP that created the enabling
environment for the revisions of this guideline package possible.
The Ministry of Health is grateful to Professor Emeritus Michael H Golden and Dr. Yvonne Grellety
for the technical guidance and providing hands-on training that prepared the Uganda national
core team in the revision of this guideline package. This version of the IMAM guidelines was
revised and updated with adaptations from recent WHO evidence-based recommendations, Prof.
Michael H Golden and Dr. Yvonne Grellety’s 2018 generic guidelines, and review of other past
IMAM guidelines from Uganda, sub-Saharan Africa and South Asia.
The MoH acknowledges the technical support from key individuals in the revision of these
guidelines and the associated training packages: Dr. Ezekiel Mupere, a Paediatrician and medical
Epidemiologist based at School of Medicine, Makerere University led the teams involved in the
process of this revision including field testing and writing the revisions of the IMAM guidelines.
Mupere worked with the following team members in the conceptualization of the revision processes
and development of documents: Dr. Nicolette Nabukeera, Paediatrician at Makerere University
School of Medicine and Dr. Esther Babirekere a Paediatrician at Mwanamugimu Nutrition Unit
Mulago National Referral Hospital. The Nutritionists on this team included Dr. Barbara Kirunda
from the School of Public Health, Ms Sheilla Natukunda, Associate Professor Ivan Mukisa Muzira,
Dr. Robert Mugabi, and Dr. Hedwig Acham from the Department of Food Technology and Nutrition,
Makerere University. From the UNHCR, Isaac Kabazzi, Associate Nutrition and Food Security Officer
provided invaluable input on the team.The team was supervised by Dr. FlorenceTuryashemererwa,
a Nutrition Specialist, and Dr. Cecilia De Bustos, the Nutrition Manager at UNICEF Uganda. From
the Ministry of Health, this work was under the oversight of a number of people including Ms
Samalie Namukose, Principal Nutritionist; Mr Tim Mateeba, Senior Nutritionist; Mr Albert Lule,
Principal Nutritionist; Ms Laura Ahumuza, Senior Nutritionist; Dr. George Upenytho, Commissioner
Community Health; Dr. Jesca Nsungwa, Assistant Commissioner Child Health and Dr. Charles
Olaro, Director Health Services (Clinical and Community).
Finally, the MoH wishes to extend sincere and special recognitions to all stakeholders whether
mentioned by name or not on the list of contributors from the MoH Nutrition Technical Working
Group, implementing partners, academic institutions, national and referral hospitals who in one
way or another, either individually or collectively, contributed to the production of this revised and
update IMAM guidelines. The process would not have succeeded without the tireless efforts and
commitment of everyone passionate about improved delivery of IMAM services.

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List of contributors
Arua Regional Referral Hospital Ministry of Health
Robert Oyaka Dr. Upenytho George, Samalie Namukose,
Tim Mateeba, Albert Lule, Laura Ahumuza,
Fort Portal Regional Referral Hospital Dr. Martin Ssendyona, Dr. Makanga
Aggrey Gwaita, Sr. Dr. Katuutu Euphrasia Livingstone, Dr. Jesca Nsungwa,
Dr. Charles Olaro, Dr. Stanley Bubikiire
Gulu Regional Referral Hospital
Jannan Loum Bishop Moroto Regional Referral Hospital
Simon Ondoga
Hoima Regional Referral Hospital
Albert Mugabi, Dr. Tom Ediamu Didimus Mubende Regional Referral Hospital
Sharon Bagaaya
IBFAN Uganda
Barbra Nalubanga Mulago National Referral Hospital
Sharon Naluwende
Jinja Regional Referral Hospital
Mansur Toko Mwananumugimu Nutrition Unit Mulago
National Referral Hospital
Kabale Regional Referral Hospital Dr. Esther Babirekere, Sr. Julian Eyotaru
Moses Mutabazi
Nutrition Technical Working Group MoH
Kiruddu National Referral Hospital Dr. Hanifa Bachou, Dr. Kiboneka Elizabeth
Amanda Murungi, Wafula Jimmy
UNHCR
Makerere University Department of Isaac Kabazzi
Pediatrics
Dr. Mupere Ezekiel, Dr. Nicolete Nabukeera UNICEF
Dr. Florence Turyashemererwa,
Makerere University Department of Dr. Cecilia De Bustos, Nelly Birungi
Anatomy
Dr. Gerald Tumusiime USAID
Sheilla Nyakwezi, Luwangula Ahmed,
Makerere University Department of Food Dr. Alfred Boyo
Technology and Nutrition
Dr. Hedwig Acham, Sheilla Natukunda, WFP
Prof. Ivan Mukisa, Dr. Robert Mugabi Mary Namanda, Judith Agaba, Mark Lule,
Dr. Robert Ackatia-Armah
Makerere University School of Public Health
Dr. Barbara Kirunda WHO
Dr. Bodo Bongomin
Masaka Regional Referral Hospital
Richard Ninsiima Implementing Partners
Medical Teams International (MTI),
Mbale Regional Referral Hospital International Rescue Committee (IRC), Action
Siraji Kijoogo Against Hunger (ACF), Food for the Hungry
(FH), Real Medicine Foundation (RMF), Save
Mbarara Regional Referral Hospital the Children International (SCI), Lutheran
Dalton Babukiika, Kansiime Noel, World Federation (LWF), Africa Humanitarian
Filda Aheebwa Action (AHA), AVSI, USAID-RHITES, University
Research Council, AMREF.

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | xiii

Glossary of terms
Acute Malnutrition: Mid-upper arm circumference F-75: Also known as Formula 75, is a milk-based
below 12.5 cm or weight-for-height/length diet for the stabilization of children with SAM. It
below minus two standard deviations from contains 75kcal/100ml.
the median of the WHO child growth standards
and or the presence of bilateral pitting oedema. Global Acute Malnutrition (GAM): GAM is a
Acute malnutrition can be severe (severe acute population-level indicator that includes the
malnutrition or SAM) or mild (moderate acute total of severe acute malnutrition and moderate
malnutrition-MAM) acute malnutrition cases.

Anthropometry: Technique that involves body Inpatient care for SAM: Inpatient care is a health
measurements of weight, height and mid- facility-based care for children with SAM that
upper arm circumference. These measurements also have medical complications.
can be used in combination with age or sex to
assess nutrition status of individuals. Integrated Management of Acute Malnutrition
(IMAM): IMAM is defined as the continuum
Bilateral pitting oedema: Swelling from excess care for the management of acute malnutrition
fluid in connective tissue that appears in both feet through: 1) inpatient care for infants less than
and leaves a pit on application of gentle pressure 6 months and children 6–59 months with SAM
with the thumb. Bilateral pitting oedema is a sign and medical complications 2) outpatient care
of severe acute malnutrition and is also known for infants less than 6 months and children
as oedematous malnutrition. 6–59 months with SAM without medical
complications 3) community outreach and 4)
Community Outreach: A continuous process that services or programs for children with moderate
includes several activities such as community acute malnutrition (MAM) that may be provided
assessment, formulating a community outreach depending on the context. In emergencies
strategy, developing and disseminating and areas with high food insecurity MAM
messages and materials, training on community programs are known as supplementary feeding
outreach, community mobilization, active case- programs.
finding and referral, home visits and follow-up,
and linking with other community services, Malnutrition: An abnormal physiological
programmes and initiatives. condition caused by deficiencies, excesses,
or imbalances in a person’s intake of energy
Community Referral: The process of identifying and/or nutrients. Malnutrition encompasses
children with acute malnutrition in the community both over nutrition associated with overweight
or household level and transferring them to the and obesity and undernutrition; referring to
health facility for IMAM services. multiple conditions including micronutrient
deficiencies.
Cured: Recovered from SAM or MAM in
accordance with the discharge criterion that Micronutrient Deficiencies: Reduced or excess
was used for admission. micronutrient intake and/or absorption in
the body. The micronutrients of public health
Dead: Death from acute malnutrition while concern include Vitamin A, iron, iodine, zinc, and
admitted into the program as an in inpatient or folic acid, due to their importance in immune
outpatient. function, organ development, and growth.

Defaulter: Missing treatment for two days while Mid-Upper Arm Circumference (MUAC):
admitted in inpatient therapeutic care or two MUAC is defined as the circumference of the
consecutive visits from outpatient therapeutic arm, usually the left but can also be the right,
care or supplementary feeding programs. measured at the mid-point between the tip of
the shoulder and the tip of the elbow (olecranon
F-100: Also known as Formula 100 is a milk- process and the acromion).
based diet for the nutrition rehabilitation of
children with SAM. It contains 100kcal/100ml.

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Moderate Acute Malnutrition (MAM): MAM is quantities required and preparation methods as
defined as a weight for height Z score less than well as serving sizes/portions.
minus two standard deviation from the median
of the WHO child growth standards (but greater Self-Referral: Self-referral occurs when mothers/
than minus two) and /or MUAC less than 12.5 caregivers bring children to the outpatient care
cm but greater than or equal to 11.5 cm. or inpatient care site without a referral from
outreach workers.
Non-response: Failing to attain discharge
criteria after a pre-defined length of time in the Severe Acute Malnutrition: The presence of
program. bilateral pitting oedema or severe wasting
(weight-for-height below minus three standard
Nutrition education: A process of imparting deviations from the median of the WHO child
validated correct nutrition knowledge to growth standards (WFH < -3 z-score) or MUAC
the public to promote the development and less than 11.5cm.
maintenance of positive attitudes and actual
behaviour and practices (within cultural and Stunting: Also known as chronic undernutrition,
budgetary constraints) that contribute to stunting is defined as low height-for-age z-score
adequate personal health, well-being and below minus two standard deviations from the
productivity. median of the WHO child growth standards.
Stunting is a result of prolonged or repeated
Outpatient care for Management of SAM episodes of undernutrition that may start in
Without Medical Complications: Outpatient utero.
care is an IMAM service that is designed to treat
children aged 6–59 months with SAM without Triage: A selection/sorting of patients into
medical complications through the provision priority/risk groups to fast track treatment and
of routine medical treatment and nutrition increase survival rates.
rehabilitation with RUTF. Children aged 6–59
months attend outpatient care at regular Undernutrition: A consequence of inadequate
intervals (usually once a week) until recovery and/or unbalanced intake and/or absorption
is achieved. Outpatient care also provides of micro- or macronutrients that results into
services for the management of mothers and deficiency of both macro and micronutrients.
their infants under 6 months of age who are
Underweight: A weight-for-age z-score below
severely malnourished but without medical
minus two standard deviations from the median
complications.
of the WHO child growth standards.
Outreach Worker for IMAM: A community
Village Health Team: A person who conducts
health worker or village health volunteer
outreach for community mobilization, screening,
who identifies and refers children with acute
referral and follow-up in the community.
malnutrition from the community to the health
facility and follows up with the children in their
Wasting: Mid-upper arm circumference less
homes when required.
than 12.5 cm and/ or weight-for- height/length
Z score of less than minus two standard
Ready-to-Use Supplementary food (RUSF):
deviations from the median of the of the WHO
RUSF is a specialized nutrient-dense ready-to-
child growth standards.
eat, portable, shelf-stable food that is used for
the prevention and management of moderate
acute malnutrition in infants and children 6–59
months of age.

Ready-to-Use Therapeutic Food (RUTF): RUTF

is defined as an energy-dense, mineral and
vitamin-enriched food specifically designed to
treat SAM in children aged 6–59 months. RUTF
has a similar nutrient composition to F-100.

Recipe: A set of instructions for preparing a

particular dish, including a list of ingredients,

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1.0 Introduction

1.1 Burden and forms of malnutrition

Malnutrition is a major contributor to disease burden, with more than half of global deaths in
children younger than five years of age attributable to undernutrition. Most of these children
are in low-income and middle-income countries. Malnutrition encompasses both overnutrition,
associated with overweight and obesity, and undernutrition referring to multiple conditions
including acute and chronic malnutrition and micronutrient deficiencies. Undernutrition may
result from inadequate food intake or disease, causing a nutrient imbalance or malabsorption,
increasing nutrient requirements or invoking nutrient losses. Overnutrition is the result of excess
intake of nutrients, and includes overweight, obesity and diet-related non-communicable diseases
(such as heart disease, stroke, diabetes and cancer). These guidelines exclusively deal with acute
malnutrition in children and moderate to severe thinness in adults as forms of undernutrition.
The most vulnerable groups to undernutrition include: young children, adolescent girls, pregnant
and lactating women, elderly, people who are ill or immuno-compromised, and indigenous
poor people. Additionally, groups migrating or displaced due to conflicts, droughts, floods and
other natural disasters, famine or land tenure issues are also at acute risk and vulnerable to
malnutrition.
In Uganda, children under five years of age and adults 15 to 49 years of age face multiple burdens
of undernutrition. According to Uganda Demographics and Health Survey 2016, over 266,900
(4 per cent) children less than five years are wasted or have acute malnutrition. Of these, over
86,743 (1.3 per cent) have severe wasting. Uganda is also grappling with high levels of chronic
malnutrition with over 1,935,025 (29 per cent) children being stunted. Among the adults, over
190,296 (2.1 per cent) women are estimated to have moderate to severe thinness or underweight
and among men, over 311,205 (3.8 per cent) have moderate to severe thinness.
The consequences of malnutrition include increased childhood deaths and future adult disability
with its associated diet-related non-communicable diseases (NCDs), as well as enormous economic
and human capital costs.

Forms of undernutrition
Undernutrition is a consequence of inadequate and/or unbalanced intake and/or absorption
of micro or macronutrients that in turn leads to nutritional deficiency. The different forms of
undernutrition include: acute malnutrition (bilateral pitting oedema and/or wasting), stunting,
underweight (combined form of wasting and stunting), and micronutrient deficiencies. All different
forms of undernutrition can appear isolated or in combination, but most often overlap in one
child.

• Wasting is a form of acute malnutrition. Wasting is defined as a Mid-Upper Arm Circumference

(MUAC) less than 12.5 cm and/ or Weight-for-Height less than minus two standard deviations
from the median of the of the WHO child growth standards (WFH < -2 z-score [WHO standards]).
It is associated with a sudden decrease in food consumption/diet quality and/or illness resulting
in sudden weight loss and /or bilateral pitting oedema.
Wasting is also known as acute malnutrition. Acute malnutrition can be in the moderate (moderate
acute malnutrition [MAM]) or the severe form (Severe acute Malnutrition [SAM]). Bilateral pitting
oedema is also a form of SAM. Children with SAM are at higher risk of dying. SAM is classified
as disease according to the International Classification of Disease. The presence of anorexia or
poor appetite and medical complications are clinical signs indicating the severity of disease
progression and classifies SAM as uncomplicated or complicated. The terms marasmus (severe
wasting), kwashiorkor (bilateral pitting oedema) and marasmic-kwashiorkor are used to describe
the clinical manifestations of SAM.

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• Stunting is a form of growth failure or retardation which develops over a long period of time
in children under five years of age. Stunting is also known as ‘chronic undernutrition’. In
children, it is measured using the height-for-age nutritional index. Stunting is associated with
developmental impairments such as delayed motor development, impaired brain function and
poor school performance that have also been associated with a reduced economic potential
later in life. It is largely irreversible after the second year of the child’s life, with minimal catch-
up growth, and represents a significant impediment to human development.
• Micronutrient deficiencies:These have an adverse effect on health, development, and productivity
over the lifespan. Because visible signs are not always present, micronutrient deficiencies are
often referred to as hidden hunger. The micronutrients of public health concern include iron,
zinc, vitamin A, folate and iodine, as they are the most difficult to satisfy without diverse diets.
• Underweight: This is defined by a weight-for-age z–score of below minus two standard
deviations from the median of the WHO child growth standards. This indicator is commonly
used in growth monitoring and promotion (GMP) and child health and nutrition programs
aimed at the prevention and treatment of undernutrition. Underweight is a composite form of
undernutrition including elements of stunting and wasting. In adults, underweight is referred
to as moderate and severe. An adult with a body mass index (BMI) less than 18.5 Kg/m2 is
classified as underweight while a BMI of less than 17kg/m2 but greater than or equal to 16.0kg
is moderate thinness and a BMI less than 16kg/m2 is severe thinness. A BMI less than 16.0
Kg/m2 (severe underweight) is known to be associated with a markedly increased risk for ill
health, poor physical performance, fatigue and even death; this cut-off point is therefore a valid
extreme limit.

1.2 Purpose of the guidelines

The guidelines are aimed at:

• Standardizing the identification, treatment and management of acute malnutrition in Uganda.

• Providing guidance on treatment and rehabilitation of pregnant and lactating women, older
children, adolescents and adults with undernutrition and in chronic illnesses such as HIV/AIDS,
Tuberculosis and in terminal illnesses.
• Pooling adequate resources from all stakeholders for management of acute malnutrition.
• Improving emergency programming for the implementation of any of the IMAM components.

1.3 History of Integrated Management of Acute Malnutrition guidelines

for Uganda
The attention on the management of acute malnutrition became critical to the Government of
Uganda at the peak of the insurgency in Northern Uganda by the Lord’s Resistance Army in
2003/2004. Based on existing global recommendations in 2006, the Uganda Ministry of Health
and with support from UNICEF and Valid International developed the first version of the Integrated
Management of Acute Malnutrition (IMAM) to address the high burden of acute malnutrition in
children under five years of age and as a comprehensive approach incorporating community
therapeutic care.
In March 2010, the IMAM guidelines were launched with addition of pregnant and lactating women
and treatment aspects for malnourished HIV/AIDS children and adults. The guidelines were later
revised in 2015 adapting the WHO 2013 global update with evidence and recommendations for
management of SAM. Despite the 2015 IMAM guideline adaptations, key gaps and concerns
emerged over the years affecting service delivery including:

• Field supervision reports by the Ministry of Health and its implementing partners cited existence
of multiple guidelines in use affecting universal standardization, monitoring, and quality of care
for acute malnutrition.

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• Content gap in management of moderate acute malnutrition for all age groups and management
of malnutrition in older children, adolescents, and adults.
• Need for update and strengthening in management of “mothers at risk and infants under six
months” with recent evidence.
• Limited guidance in previous IMAM guidelines on.
• Continuum of nutrition care across the spectrum of disease severity from normal nutrition to
severe malnutrition at the community and health facility levels.
• Delivery of community component and social mobilization for improved awareness, access and
use of IMAM services.
• Integration of IMAM services with other primary health care services at lower health facilities
(health centre IIIs) and community level to reduce on parallel service delivery.
• Institutionalization of standard monitoring forms into HMIS.
• Persistent and unacceptable low cure rates and high mortality in children with acute malnutrition.
This revision has made multiple changes to strengthen health service delivery for malnutrition to
reduce unnecessary morbidity and mortality including but not limited to:

• Content on the organization, structure, capacity building, and roles for different administrative
units and personnel has been added to improve coordination, planning, and implementation of
IMAM services at national, regional, district, facility, and community levels.
• Guidance on IMAM service outreaches and its integration in primary health care , behavioural
change communication, community engagement, and social mobilization from national to
community levels.
• Guidelines and procedures have been revised to ensure continuum of care for acute malnutrition
for both moderate and severe malnutrition; and the nutrition response in special circumstances
of surge, chronic food insecurity and in emergencies.
• Guidance on management of acute malnutrition for 6–59 months and any child aged ≥60
months whose height is ≤120 cm according to WHO 2006 z–score chart has been systematically
delineated. Addition of any child with age ≥60months whose height is ≤120 cm offers opportunity
to maximize benefit from the therapeutic nutrition intervention to such children whose age may
be above 59 months but shorter than 120 cm.
• Guidelines for management of undernutrition across all age groups including pregnant and
lactating women, older children, adolescents, adults and chronic illness such as HIV/AIDS and
Tuberculosis have been added.
• New processes and procedures for inpatient management of medical complications; and
monitoring and management of patients who fail to respond during outpatient management
of MAM with/or without supplementary feeding program (SFP) services, outpatient therapeutic
care (OTC), and inpatient therapeutic care (ITC) have been added.
• The assessment at the health facility has been aligned to the emergency triage assessment
treatment (ETAT) and integrated management of childhood and newborn illness (IMNCI)
procedures to ensure emergency and priority patients get timely interventions.
• New content for management of medical complications in patients with SAM, outpatient and
inpatient management of infants under six months has been added based on recent evidence
and recommendations.
• A new chapter on prevention has been added to guide integration of IMAM with primary health
care services, nutrition sensitive and specific services, and its delivery in lowest health system
levels.
• New job aids, tally sheets and tools have been introduced to enhance active community
screening, monitoring of patients, data capture and reporting, mentorship and supervision
during IMAM service delivery.

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1.4 Who should use the Integrated Management of Acute Malnutrition
guidelines?
The guidelines should be used by:

• Health care providers responsible for the care and treatment of acutely malnourished individuals, as
a step-by-step guide for health care providers to implement an OTC, inpatient care or supplementary
feeding where it exists, and to ensure appropriate referral and tracking mechanisms.
• Health care providers to inform or train community health workers (CHWs), such as village
health teams (VHTs) in conducting community outreach activities, active case finding, and
referral from the community and follow up.
• Policy makers and program managers including NGOs responsible for designing, implementing
and monitoring programs and policy related to the management of acutely malnourished children.
• Supervisors responsible for monitoring and reporting on any component of IMAM.
• NGOs involved in nutrition rehabilitation during emergencies.

1.5 How and when to use the Integrated Management of Acute

Malnutrition Guidelines
The guidelines provide clear step-by-step actions. Protocols are provided in the annexes. The
protocols can be pulled out and copied so that they are easy to use and follow. These guidelines
should be read in conjunction with the following Ministry of Health (MoH) policy documents
accessed on MoH website (https://www.health.go.ug) where possible as follows:

• Maternal Infant and Young Child Nutrition guidelines 2020

• UNEPI guidelines 2018
• National Tuberculosis and Leprosy Program guidelines 2018
• National Malaria guidelines
• Uganda Nutrition Action Plan II 2020
• Emergency Nutrition Action/preparedness plans
• MoH/WHO IMNCI guidelines
• Consolidated Guidelines for Prevention and Treatment of HIV in Uganda
• Anaemia Policy 2002
• Presidential Initiative for Healthy Eating.
The guidelines should be used during both planning and implementing any of the IMAM
components. The guidelines provide clear steps for implementing the components of the IMAM
program.

1.6 Components of integrated management of acute malnutrition

Integrated Management of Acute Malnutrition (IMAM) is an approach to address acute malnutrition
and focuses on the integration of the management of acute malnutrition into the ongoing routine
health services at all levels. IMAM in Uganda has four arms to address care for acute malnutrition in
children and undernutrition in older persons: Community services, management of MAM with and
without SFP services, outpatient therapeutic care and inpatient Therapeutic Care (see Figure 1).

• Community services involve community engagement, active screening and identification,

referral, and follow-up of the malnourished children, pregnant and lactating women at
community level.
• Management of MAM without SFP services involves nutritional assessment and classification,
counselling and education, treatment of acute illnesses, follow-up and linkage to livelihood
programs, and monitoring failure to respond at community and health facility in all age groups

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 in populations in normal situations. Management of MAM with SFP services involves in addition
food assistance and supplementary feeds to manage and treat MAM in children of 6–59 months
or any child aged 60 months and above with height ≤120 cm according to WHO 2006 z–score
chart, pregnant and lactating women with children <6 months, and other vulnerable groups
with special nutritional needs in populations with high prevalence of wasting or food insecurity
at community or household level such as in emergencies and refugee settings.
• OTC provides home-based management and rehabilitation of SAM patients who have an
appetite and no medical complications.
• ITC is for the management of SAM with medical complications and or no appetite.
Good coordination and communication within and between the different components IMAM is
essential to ensure that patients remain in the system during the management process for acute
malnutrition.

Principles of IMAM
IMAM is implemented with the following core operating principles:

• Maximum coverage and access by making services available and accessible to the highest
possible proportion of acutely malnourished population in need.
• Timeliness by conducting active case-finding and treatment before the prevalence of
malnutrition escalates and additional medical complications occur.
• Appropriate care through provision of simple, effective outpatient care for clients who can be
treated at home and clinical care for those who need inpatient treatment.
• Care for as long as it is needed by maintaining access to treatment to ensure that clients can
stay in the program until they have recovered through building of local capacity and integrating
existing structures or health system for sustainability.
Figure 1: Linkages between the components of IMAM

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2.0 Organization of the Integrated Management of
Acute Malnutrition services

2.1 Introduction
The organization of IMAM services is critical to its success and to ensure efficiency and effectiveness in
service delivery. Implementation of IMAM services requires adequate funding and trained personnel
at each level of organization. All pre-service training institutions should include malnutrition and its
management into their curricula. Involvement of academic institutions should always be part of
the strategy to ensure sustainability given the staff turnover and brain drain. The organization and
planning of IMAM services is aligned to the organizational levels of the health sector including
national, regional or institutional health facility at national, district, health facility/or institutional at
the district, and community levels; and according to the Uganda Nutrition Action Plan II (UNAP II)
strategies coordinated under the Office of the Prime Minister (OPM) (see Figure 2) require increased
coverage in management for acute malnutrition in stable and in emergency situations.

Figure 2: Organization of IMAM services

National Level – Office of the Prime Minister

Multi-sectoral coordination through UNAP with line ministries to address acute malnutrition

Line Sectors: National Level – Ministry of Health Line Sector

Agriculture, Education or
Academic – Nutrition IMAM Policy and Guideline, Standards, Support Functions
Sensitive interventions Leverage with Other Departments UNEPI, MNCH, iCCM,
e.g Food Security and Environmental Health – WASH, Health Promotion
Livelihoods

Districts: Chief
Administrative Officer –
Regions: Hospital Director Accounting Officer
Accounting Officer
Regional Coordinator: Nutritionist
Coordination: DHO,
District Nutritionist or Clinical Team: Focal Point Nurse and Physician as
Focal person and ADHO Paediatrician, Other Specialist or Medical Officer
Support Functions:
District Sectors

Health Facilities Community

Implementation, Focal Workforce – VHTs and Community volunteers
Point, Community
Engagement, Catchment Screening, Identification, Refer, Follow-up
area Catchment Area

Figure 1: Organization of IMAM services

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2.2 Actors and their roles at different levels

National Level
The Office of the Prime Minister
• Coordinates all sector activities in the area of nutrition in the country. Sectors have the key
responsibilities of ensuring that the policies, guidelines and protocols are developed and
implemented at regional, district and lower levels by both public and private institutions.
• Coordinates structure for nutrition activities at local government
• Multisectoral coordination of efforts towards addressing IMAM challenges.

The MoH under the Nutrition Division

The Nutrition Division should:
• Develop, review and disseminate national IMAM protocols, guidelines, tools for implementation
and monitoring.
• Formulate policies to govern IMAM service implementation, strategy and standards.
• Resource mobilization, harmonization and prioritization.
• Provide support functions of implementation and systems strengthening including planning,
forecasting, coordination, capacity building, communication and social mobilization, mentorship
and support supervision, monitoring and evaluation.
• Align IMAM planning and implementation with other community programs in the health sector
and the line government ministries such as Ministry of Education to ensure that IMAM training is
incorporated into the curricula of training institutions of Medical, Nutrition and Nursing and others.

Regional Level
The regional referral hospitals act as national implementing institutions for the MoH at regional
levels in the country with the Medical Directors as accounting officers together with the nutritionist;
the focal point physician who can be a paediatrician, another specialist or medical officer; and
focal point nurse or midwife as core coordinating team.

Regional referral hospitals should:

• Plan, forecast, coordinate, and budget for IMAM service implementation together with nutrition
stakeholders in the region based on MoH policies, strategy and standards.
• Conduct regional resource mobilization, harmonization and prioritization.
• Provide regional support functions of implementation and systems strengthening including
capacity building, communication, mentorship or coaching, support supervision, monitoring
and evaluation.
• Strengthen implementation and quality improvement of the IMAM components at all health
facilities and communities in the region.

District Level
The District Health Officer (DHO), District Nutritionist or focal point person, and the Assistant DHO
form the core coordinating team for IMAM services. Under the Chief Administrative Officer in the
district as accounting officer, the team should:

• Plan, coordinate, and budget for IMAM service implementation together with nutrition
stakeholders in the district based on MoH policies, strategy and standards.
• Forecast stock and drug supplies with an allowance of a 3-month buffer stock for the therapeutic
and supplementary products, routine medicines in treatment of SAM and MAM, and an
adequate stock of other materials and tools needed in delivery of IMAM services.

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• Conduct district resource mobilization, harmonization and prioritization.
• Provide district support functions of implementation and systems strengthening including
capacity building, communication and social mobilization, mentorship or coaching, support
supervision, monitoring and evaluation.
• Strengthen implementation and quality improvement of the IMAM components at all health
facilities and communities in the district.
• Align IMAM planning and implementation with other community health programs in the
district and the district line government sectors and partners. The DHO, District Nutritionist or
focal point, and District Nursing Officer should work together with the District Health Education
Officer as VHT focal person to ensure coordination so that various outreach programs do not
compete or overburden the VHTs.
Active screening for malnutrition should be organized in conjunction with routine community
level services such as immunization, integrated Community Case Management (iCCM), child
health days plus, and world breastfeeding weeks. The data obtained through active screening
should be collated at district level to determine the degree and change in nutritional indicators at
village level and in the district as a whole.

Roles and responsibilities of the District Health Officer and District Nutritionist
The District Health Officer
• Oversees the overall organization of the IMAM services in the district to plan, coordinate,
organize, implement, and control the IMAM services within the district. If there is no nutritionist,
the DHO should appoint an individual to be responsible for the IMAM services from among the
district health team, health sub-district or the general hospital.
• The IMAM focal point person should be a nurse or clinician trained in IMAM theory and practice
with organizational, communication and networking skills.
• Conduct on job training, supervision, monitoring and evaluation, management of the therapeutic
and supplementary products and routine drugs for IMAM services.
The District Nutritionist
The nutrition services are under the District Nutritionist (DN). However, the DN to be in position to
support IMAM services, they should be trained in the IMAM theory and clinical practice. If there
is no DN, the appointed IMAM focal point person should have sufficient clinical skills to train,
supervise and evaluate the clinical management of sick children. The DN or IMAM focal point
person supervises and controls the IMAM services in the District, with the main ITC in the health
facilities providing general medical inpatient services and OTC at health centres, SFP, health posts
and at non-clinical sites or by outreach team.

Roles and responsibilities for the District Nutritionist or IMAM focal point person:
• Is to be part of the District Health Management Team (DHT) to coordinate the IMAM services
together with district staff responsible for other health programs and activities within the
district such as UNUNEPI, IMNCI, TB, HIV, maternal newborn child health (MNCH), Statistics
and Evaluation and Health Management Information System (HMIS).
• Organize quarterly and annual meetings at district level with all stakeholders involved in the
IMAM services. A written report with an overview of the progress of the program, problems and
constraints faced, budget, lessons learnt, plans and changes for new year, and survey/screening
data, etc. should be presented and discussed. The minutes and reports should be shared with the
Nutritionist at the regional referral hospital and Nutrition Division at the MoH.
• Organize monthly coordination meetings at district level with all community, OTC, SFP and ITC
supervisors (issues to discuss include: reports, supplies of therapeutic products, and drugs).
• Assess the needs of the services, forecast, and make requisitions or provision for their
procurement.
• Ensure the availability of transport and fuel to enable regular supervision and meetings.

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• Ensure the flow of therapeutic and supplementary products from the centre to the district,
storage at district level and then transport from the district to the OTC (HC) and SFP site, and
supply to the ITC.
• When a new OTC or SFP is opened, ensure that all materials (tools, RUTF, super cereal plus and
drugs, etc.) are available.
• Ensure mechanisms 1) to transfer patients safely between OTCs and ITC, and 2) to establish
mechanisms for information on the individuals transferred to be passed to the receiving facility
(telephone).
• Ensure regular (monthly) supervision of the quality of service provided by all the facilities (ITC
and OTC, SFP sites) within the district; and coordination between services (ITC versus OTC and
OTC versus SFP site).
• Examine and correct any problems found during supervision (using check-lists) for ITC, OTCs,
SFP, storage facilities, RUTF and RUSF stocks and supplies (charts, registers etc.);
• Identify particularly vulnerable villages for additional support.
• Re-adjust OTC and SFP sites, reassign staff as needed (according to the reports and screening
data).
• Conduct on-job training as necessary and train all newly appointed staff.
• Formulate contingency plans for action in case of increasing hardship.
• Register and give the code to each facility within the district as authorized by the Ministry
of Health (Nutrition Division) and submit the registration details through the regional referral
hospital to MoH.
• Establish a list of clinic day(s) for each OTC and SFP site in the district with the name and
contact phone numbers of the persons in charge and disseminate this list to all IMAM sites.
• Ensure the completion of monthly reports for all IMAM facilities and submit them to DHO.
• Compile, analyse and map the screening tally sheets (in collaboration with the District
Biostatistician/HMIS focal point person) in order to determine the degree and change in
nutritional state at village level and give feed back to the supervisors of the OTC and SFP sites.
• Implement the strategy for community mobilization and facilitate integrated outreach activities.

Health Facility Level

The health facility is the frontline implementing unit of IMAM services. At the health facility level,
the health worker in charge of the Health facility/or IMAM focal person is responsible for:

• Planning and coordination of the IMAM services including routine outreach activities at the
community (at least once a month)
• Training the outreach health workers to conduct active screening using MUAC tapes and
examination for bilateral pitting oedema and follow up of defaulters from the program. These
activities should be integrated with other community-based activities (UNEPI, community
IMNCI, MNCH/Family Planning, and HIV counselling and testing, etc.).
• Conduct monthly health facility staff/VHT meetings to collect the community information and
address any difficulties that arise.
Outreach activities
• Health facilities should conduct both static and mobile integrated outreaches at least monthly.
• For the villages that are more than 5km (or 2 hours walk) away from the OTC site, compliance
with the treatment is much less than for villages close to the OTC site “the catchment area”.
These remote villages must be screened and should have a VHT (volunteer) taught to screen
children, pregnant and lactating women.
• Depending on the accessibility and numbers of SAM children in remote villages, there should
be scheduled visits (weekly) by a nurse aid from the OTC (for example by motorbike), provision
of a mobile team or opening of a new OTC site.

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• SFP sites in emergency and refugee settings should be organized closer to the health facilities
and villages depending mostly on the logistic constraints.

Community Level
Health facility workers or outreach health workers should liaise with the community health workers
or VHTs in the community, to support them and oversee their activities. Where there are no village
focal points/volunteers, the outreach health workers should perform the screening, follow-up and
other outreach activities.

Responsibilities of outreach health workers–Community Health Workers/VHTs

• Sensitize the community about the program before and during its implementation and have the
approval of the community.
• Visit the village or group of villages close together periodically within the catchment area of an
OTC. Visit villages that have problems (excessive defaulting, low rate of weight gain, etc.) or
when requested during a monthly meeting or when the village focal person comes, in rotation,
to help with the OTC and recruit volunteers.
• Inform the community leaders, traditional and modern health practitioners, other members
of civil society and local organizations about the nature and purpose of the program and the
nature of their involvement.
• Using both formal and informal communication to inform the community about malnutrition
and good nutrition practices taking into account literacy levels, who takes care of children, who
determines the use of resources within the household (husband, mother-in-law, etc.), and the
beliefs within the society about the causes of malnutrition as well as their usual health seeking
behaviour.
• Where available, recruit suitable volunteers, particularly where the burden of work is high and
the community is poor.
• Work with the community volunteers and collect the tally sheets from screening, observe any
screening and do any follow-up and home visits required.
• Check with the village elders to maintain their involvement in the program and to provide
feedback about the program.
• Conduct home visits on children that are defaulting or failing to respond to treatment and obtain
any complaints about the program, reasons for defaulting/not responding (program is a low
priority for the family, child has died or moved away, etc.) and determine the outcome of patients.
• Maintain a strong link between the health facility/OTC and the village leaders, village volunteers
and other community workers.
• Coordinate and collaborate with the different partners and programs, in particular, the type and
value of the incentives offered (travel, meal allowance, telephone and credit, clothing, food,
money, etc.) and the subsistence and travel allowances for training/attending meetings.

Support to VHTs or CHWs

Travel: Widely dispersed communities involving travel of long distances to visit villages and
individual houses requires a paid outreach worker with transport provided (e.g. a motorbike and
fuel).
Support: It is critical that village volunteers feel supported and can get help whenever they face
a problem. They should each be supplied with a mobile phone (pre-loaded with all numbers
pertaining to the local program) and/or credit as part of the program where there is a network’s
coverage.
Motivation: Constraints encountered by volunteers should be reduced and incentives provided.
Incentives may include: regular visits, offering a T-shirt and a hat to identify them as being part of
the program or health care system, a mobile phone and a bag to carry and store the materials for
use in the field.

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It is also reasonable to give volunteers some modest incentive such as money for a meal or help
with transport or the equivalent of two hours work (for example, one quarter of the local daily rate
of agricultural labour) per week. VHTs/CHWs should be supported in terms of transportation to
attend regular meetings for volunteers and outreach workers.
Coordination with other partners involved: Where similar programs and several partners/NGOs
exist, especially in emergency situations, it is important to avoid overloading the volunteers,
giving conflicting messages or advice and disparities in incentives.

2.3 Organization for in-service training in Integrated Management of

Acute Malnutrition services
The following guidance has been recommended to standardize in-service trainings and to ensure
IMAM quality service delivery. All participants should be followed after a period of two to four weeks
with mentorship and coaching sessions after the training. It is advisable that IMAM competencies
and knowledge be integrated into curricula and clinical seminar series for academic institutions
to ensure trainee health professionals and health care providers undergo pre-service training.

IMAM participant course

The IMAM participant course is designed to enable participants have a comprehensive
understanding and attainment of the needed knowledge and practical competencies to implement
IMAM services. The IMAM participant course should be conducted in a regional referral hospital
that provides both inpatient and outpatient services for management of severe acute malnutrition.
This is to enable participants have clinical sessions which complement theory sessions learned in
the classroom and an opportunity to develop the required skills to implement IMAM services.

Participants
• The course is designed for healthcare managers and healthcare providers who manage, supervise
and implement IMAM services. These include: clinical specialists (such as paediatricians,
obstetricians, gynaecologists, physicians, surgeons, clinicians (clinical officers, medical doctors,
nurses) and nutritionists who provide clinical and community nutrition services.
• The course should be conducted for a period of eight days including one day of travel. It is
recommended that participants travel on Friday and the training commences on Saturday till
Friday of the following week.

Facilitators
• Each course should be supported by the MoH certified and trained course director, manager,
facilitators and clinical instructors. The course director should be a trained clinical specialist,
medical officer or clinical nutritionist. The clinical instructor can be a trained clinical specialist,
medical officer, nutritionist, or nurse/midwife in clinical practice. Preferably, clinical instruction
should be led by the trained nurse/midwife at the host training site. The course manager can
be a regional referral nutritionist.
• Each course should be supported by at least one facilitator for every six participants and at least
three clinical instructors to support clinical sessions for management of acute malnutrition in
both children and adults.
• Figures 3 and 4 show the organization of both the theoretical and clinical aspects of the IMAM
trainings.

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 Figure 3: IMAM training structure: theory sessions

MINISTRY OF HEALTH (NUTRITION DIVISION)

National coordination and technical oversight

IMAM COURSE MANAGER (Regional Referral Nutritionist)

In charge of logistical planning, budgeting, coordination and management

COURSE DIRECTOR

FACILITATORS
FACILITATORS

CLINICIAN/
NUTRITIONIST CLINICIAN/
PEDIATRICIAN NUTRITIONIST
PEDIATRICIAN
Figure 3: IMAM training structure: theory sessions

PARTICIPANTS- NUTRITIONISTS,
PP PARTICIPANTS- NUTRITIONISTS,
NURSES &
NURSES &
CLINICIANS/PEDIATRICIAN

12 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA

CLINICIANS/PEDIATRICIAN

NOTE: For each IMAM training there is only one course manager and director. However, the number16 of facilitators and participants varies depending on the target number of participants. The ratio of facilitator
to participant should be 1:6. Maximum per table: 10 participants and 2 facilitators. Maximum number of tables: 9.
 Figure 4: IMAM training structure: Clinical sessions at the health facility
MINISTRY OF HEALTH (NUTRITION DIVISION)
National coordination and technical oversight

IMAM COURSE MANAGER (Regional Referral Nutritionist)

In charge of logistical planning, budgeting, coordination and management

COURSE DIRECTOR

CLINICAL INSTRUCTOR GROUP 1 CLINICAL INSTRUCTOR GROUP 2

Together with Two Group Facilitators CLINICAL INSTRUCTOR GROUP 3
Together with Two Group Facilitators
(Clinician and Nutritionist) Together with Two Group Facilitators
(Clinician and Nutritionist)
(Clinician and Nutritionist)

PARTICIPANTS- NUTRITIONISTS,
PARTICIPANTS- NUTRITIONISTS,
NURSES & CLINICIANS PARTICIPANTS- NUTRITIONISTS,
NURSES & CLINICIANS
NURSES & CLINICIANS
Figure 4: IMAM training structure: Clinical sessions at the health facility

NOTE: For each IMAM training there is only one course manager and director. For the clinical sessions a minimum of three clinical instructors are required
to enable swapping of groups during the different clinical sessions. There are four practical sessions over a period of four days. Each session lasts approx.
1.5-2 hours. At any given time, there will be a maximum of three groups in the hospital. The groups will be rotating throughout the day.

17

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 13

3.0 Community services

3.1 Introduction
The community services component focuses on the community engagement, community
active case finding, referral, follow-up, and counselling. Community services for IMAM should
be integrated into ongoing community services. The Village Health teams (VHTs) who are the
primary community health workers together with other community stakeholders should work to
engage communities for better health. The success of the IMAM depends on strong community
engagement and involvement to maximize access and coverage of health services. Many children
with acute malnutrition can be identified early in the community before they develop medical
complications and offered effective treatment on a weekly outpatient basis with simple medical
protocols. This offers an opportunity to decentralize treatment close to people’s homes with
minimal disruption of their existing livelihood and without risk of cross-infection during inpatient
care and resulting into large numbers of children being treated.
The aims of community services for IMAM include:

• Empowering the community by increasing knowledge on acute malnutrition and IMAM services.
• Engaging communities for joint problem solving on barriers to uptake and access of IMAM.
• Strengthening early case-finding and referral of new acute cases, and follow-up of acute cases
with home visits.
• Providing health, nutrition education and counselling.
• Follow-up of risk and problem cases with home visits.
• Strengthening linkage of individuals who have completed treatment to sustainable livelihood
programs and support services in the community.
The components of implementing IMAM community services include (see Figure 5):

• Community engagement
• Community active screening and referral
• Home visits and follow-up
• Monitoring supervision and reporting.

3.2 Community engagement

The goal of community engagement is to improve treatment outcomes and coverage. If community
members are unaware of the service, or the type of children and other vulnerable groups that are
malnourished, or are confused or misinformed about the service, they may not realize the benefits
or become engaged. Promoting understanding is crucial and strategies to engage the community
should be planned and implemented by the health facilities in the catchment area. Community
engagement covers a range of activities designed to:

• Open a dialogue.
• Promote mutual understanding.
• Encourage active, sustained engagement from the community to understand and tackle
malnutrition.
The strategies for community engagement in IMAM services (see Figure 5) should include:

1. Community assessment
This involves interviews and discussions with key community informants such as VHTs, positive
deviant parents, caregivers, model farmers, community health clubs, community leaders, elders
and opinion leaders, parents/women/youth groups and traditional healers.

14 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA

Aim of community assessment:

• Promote and appreciate understanding of acute malnutrition,

• Identify available community resources (people, groups and communication mechanisms),
• Establish formal and informal communication channels in the area
• Establish factors that are likely to affect both service delivery and demand for services.
2. Community sensitization, mobilization and dialogue
This involves discussion with community representatives on the problem of malnutrition and how
it can be easily treated, agreement on what will be done and who will be involved at community
level; and setting up an ongoing dialogue for getting feedback from the community about any
concerns with the services.

3. Development of messages and materials for broader sensitization and mobilization

This process involves development of sensitization messages for malnutrition and the treatment
choices, for one-to-one communication by the community workforce, using handbills/pamphlets,
community radios/television, among others

4. Training community-level actors

Training community level actors like VHTs on modules such as:

• Malnutrition case identification, referral, and follow-up

• Sensitization and effective dissemination of messages,
• Maternal, infant and young child nutrition (MIYCN),
• Using Positive Deviance methodology,
• Integrating nutrition into existing community and home-based health programs
• Collecting and reporting nutrition data.
Figure 5: Community Services for IMAM

Source: Modified from 2015 IMAM

Guidelines

Source: Modified from 2015 IMAM Guidelines

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 15
Figure 5 Community Services for IMAM
3.3 Community active screening and referral
Community active screening and referral for Children aged 6–59 months and pregnant and
lactating women
Active case-finding in communities is important to ensure that children or clients with acute
malnutrition are identified early before the development of medical complications. The primary
activities that take place in the community are:

• Active screening of all children 6–59 months and pregnant and lactating women (PLW) for
severe and moderate acute malnutrition using MUAC and assessing bilateral pitting oedema.
The data should be filled in the HMIS NUT Form 011 Tally sheet (Annex 1).
• The following strategies should be used to identify and refer malnourished children house to
house visit by the VHTs:
• Screening during child health days, growth monitoring, immunization, IMNCI, iCCM,
community development programs, etc.).
• Screening at community meetings, schools, and other available venues
• Self-referrals from the communities as community members.
• Screening by other NGO community activities and services.
• During emergencies, famine, and refugee crises, screening may also include older children,
adolescents and adults.
• Referral of cases with acute malnutrition to the nearest health facility using the referral form.
• Follow up of cases at home that:
• Have defaulted the ITC, OTC or SFP site.
• Have been discharged from ITC, OTC, SFP and have not enrolled in OTC or SFP.
• Have failed to respond to treatment.
• Promoting healthy practices through communication for behaviour change and social norms
and advice/counselling.
• VHTs and other community health workers submitting monthly reports to the supervisor at the
health facility.
During active case finding in the community, MUAC and the presence of bilateral oedema are
used to screen children over 6 months to determine whether they have SAM and MAM or not
(see Figure 6); children aged 6–59 months with a MUAC < 11.5 cm or bilateral pitting oedema are
then referred to the health centre. MUAC is measured with colour-coded tapes (Annex 2) by VHTs.
In some countries, mothers have been trained to measure and monitor their children’s nutrition
status using MUAC and report to VHTs for confirmation and referral where needed.
The community-based health workforce needs to be trained to identify the children affected by
malnutrition using the coloured MUAC tapes and to recognize bilateral pitting oedema.
This workforce comes from and works within the community. It includes:

• Appropriately trained and accredited VHTs as the primary community-based health workforce.
• Trained volunteers (e.g. positive deviant parents, women and youth groups).
• Other community-based organizations that promote health through behaviour change
communications (BCC) and health education and social mobilization;
• Community-level actors engaged by other programs (e.g. water, sanitation, and hygiene
(WASH) through community health club committees; agriculture and food security through
farmer promoters for instance, and education/early childhood development), who contribute
to promoting and improving community health;
• Heads of households and other household decision makers (e.g. mothers-in-law).

16 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 17
Examining for oedema and MUAC assessment should be continuous or conducted monthly to
ensure early identification and referral of cases of acute malnutrition to the nearest health facility.
The VHTs and other community workers should attend the health centre regularly for coordination
meetings and to understand the dynamics of the health facility they are attached to.
The VHTs are also responsible for home visits of defaulters, failure-to-respond children and
potential deaths.The VHTs should undertake follow-up activities as children with acute malnutrition
frequently default and relapse.

Figure 6: Screening for acute malnutrition within the community

Source: Adapted with modifications from Golden H.M. and Y. Grellety (2018), Protocol for Integrated Management of
AcuteSource: Adapted with
Malnutrition modifications
Generic from Golden
Guidelines, H.M.6.3
Version and Y. Grellety (2018), Protocol for Integrated Management of Acute Malnutrition Generic
Guidelines, Version 6.3

Figure 6: Screening
Community activeforscreening
acute malnutrition
and within the community
referral for pregnant and lactating women
Community active screening in pregnant and lactating mothers with infants under 6 months of
age for severe and
Community moderate
active acuteand
screening malnutrition
referral forshould
pregnant be systematically done by trained VHTs
and lactating women
usingCommunity
MUAC (seeactive
Figure 6).
screening in pregnant and lactating mothers with infants under 6 months of
age for severe
• Pregnant and moderate
and lactating women acute malnutrition
(PLW) should
with infants be than
less systematically
6 monthsdone
whobyhave
trained VHTs<
MUAC
using
19.0 cm,MUAC (see Figure
or bilateral pitting6).oedema should be referred to health centre or hospital for further
• Pregnant
investigation. andemergencies
During lactating women
PLW(PLW) with infants
with MUAC less 23.0
less than than cm
6 months
shouldwho have MUAC
be referred <
to the
19.0 cm,
nearest health or bilateral pitting oedema should be referred to health centre or hospital for
facility.
further investigation. During emergency settings PLW with MUAC less than 23.0 cm
Community should be referred
active screeningto theand
nearest healthfor
referral facility.
older persons in the context of food
insecurity and emergencies
Community active screening and referral for older persons in the context of food
Community active screening for undernutrition in older persons including children five years or
insecurity and emergencies
more, adolescents, and adults is not performed routinely in normal situations or populations.
Community active screening for undernutrition in older persons including children five years or
more, adolescents, and adults is not performed routinely in normal situations or populations.
18 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA
However, during emergencies, famine, and refugee crises, screening may also include older
persons using MUAC (see Table 1). It is important to note that the MUAC cut-offs in Table 1 are
However, during emergencies, famine, and refugee crises, screening may also include older
persons using MUAC (see Table 1). It is important to note that the MUAC cut-offs in Table 1 are just
commonly used cut-offs but with no evident standardization or validation and varies from country
to country.

Table 1: MUAC cut-offs in older persons in the context of emergencies

Age category Normal Moderate Acute Severe Acute

Malnutrition (MAM) Malnutrition (SAM)

≥14.5 cm ≥13.5 cm and <14.5 cm <13.5 cm

Children 5–9 years No bilateral pitting No bilateral pitting Presence of bilateral
oedema oedema pitting oedema (rule out
medical causes)

≥18.5 cm ≥16.0 cm and <18.5 cm <16.0 cm

Adolescents
No bilateral pitting No bilateral pitting Presence of bilateral
10–14 years oedema oedema pitting oedema (rule out
medical causes)

≥21.0 cm ≥18.5 cm and <21.0 cm <18.5 cm

Adolescents
No bilateral pitting No bilateral pitting Presence of bilateral
15–17 years oedema oedema pitting oedema (rule out
medical causes)

Adults 18–59 years ≥22.0 cm ≥19.0 cm and <22.0 cm <19.0 cm

No bilateral pitting No bilateral pitting Presence of bilateral

oedema oedema pitting oedema (rule out
medical causes)

Elderly ≥60 years ≥18.5 cm ≥16.0 cm and <18.5 cm <16.0 cm

No bilateral pitting No bilateral pitting Presence of bilateral

oedema oedema pitting oedema (rule out
medical causes)

Source: Food and Nutrition Technical Assistance III Project (FANTA), Compilation of Anthropometric Cut-offs for
Select Countries, Washington, DC: FHI 360/FANTA, 2016. Available at: http://www.fantaproject.org/sites/default/files/
download/FANTA-anthropometric-cutoffs- Feb2016.xlsx . Adapted from: Food and Nutrition Technical Assistance
III Project (FANTA), Nutrition Assessment, Counselling, and Support (NACS): A User’s Guide—Module 2: Nutrition
Assessment and Classification, Version 2. Washington, DC: FHI 360/FANTA, 2016.

3.4 Home visits for follow-up

Home visits are carried out by VHTs and other community volunteers. Patients who need follow-
up at home are identified by the staff of the OTC/ITC/SFP. Patients with malnutrition on treatment
require follow-up as they are at an increased risk of disease and death. Patients with malnutrition
should be monitored to ensure sustained improvement in their condition. The follow-up home
visit is necessary for:

• Assessing adherence to treatment (RUTF and medication), and reasons for non-adherence.
• Assessing patients who are not responding to treatment.
• Patients whose caretakers decline admission to the inpatient facility.
• Patients who do not return for appointments (can be due to change of residence, default or
died).
GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 19
• Assessing the caretaker’s understanding of the messages received at the health care centre and
of MIYCN.
• Assessing the availability of water and sanitation facilities, hygiene and food-safety practices.
• Assessing household food security, poverty level, coping mechanisms, social problems and
family dynamics such as many children eating from the same plate.
Follow-up home visits should be determined by the health provider to trace absent or defaulting
clients and with the following activities:

• Measure MUAC, weigh the child and determine weight gain; ask about reasons for defaulting
or non-adherence to treatment, and encourage return to the OTC/SFP. Never reprimand or treat
a defaulter disrespectfully.
• Providing support to caregivers’, family, or patient’s problems; counselling and health education;
give IEC materials during follow-up for patients’ or caretaker’s reference.
• Giving feedback to health providers.
• Linking clients/patients to livelihood/safety net programs available in the community. The
existing structures include: Parish Development Committees, Adult Functional Adult Literacy
Groups, Village Council Executive Committees, Women Council and Parish Councils where
available.

20 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA

3.5 Monitoring, supervision, evaluation and reporting
This mainly involves constant dialogue, in which the communities periodically share their views
and suggest alternative courses of action. It entails regular meetings (monthly and/or quarterly)
with key community representatives, health staff from the nearest health facility, beneficiaries and
other partners to discuss different aspects of the program such as:
Reviewing the selection and motivation of volunteers, the community’s perspective of the program
which may include program success and identifying new barriers to access and joint solutions to
problems limiting the impact of the program. This promotes community ownership of program
development and implementation.
The tools to support the village focal point/volunteer/outreach worker in monitoring, supervision,
and reporting activities are listed in Annex 3.

Data collection
From the tally sheets and during the visit to the village by the outreach worker, the following
information should be collected:

• Village name (GPS coordinates should have been determined and entered in database)
• Names of persons doing the screening
• Date of screening
• Total number of individuals (children and PLW) screened using the HMIS NUT Form 011
Community Tally sheet (Annex 1)
• Number of individuals with oedema.
• Number of individuals in the red band: SAM.
• Number of individuals in the yellow band: MAM.
• Number of individuals in the green band: Normal
• Number of individuals referred and the site to which they were referred.
• Number of individuals who refused to go for IMAM services.
The village tally sheet should then be given to the health worker of the health centre and sent
or given once a month to the nutrition focal point to be analysed and entered into a database.
This information gives a prevalence of SAM and MAM in the screened community at the time
of screening. These results should be mapped to identify pockets of malnutrition. With regular
screening, not only are malnourished children identified but screening forms the basis of a
nutritional surveillance system to define seasonality and determines whether the situation in the
district is deteriorating or improving. This will allow the DHO and District Nutritionist to prioritize
services.

Reporting
One of the key responsibilities of the VHT and other community volunteer members is to maintain:

• Records of screened and referred community members.

• Health education sessions conducted.
• The analysis and submission to health facilities.

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 21

4.0 Health facility identification and classification of
acute malnutrition

4.1 Introduction
A comprehensive evaluation should be performed by a skilled and knowledgeable health worker
in nutrition to determine the nutritional status of an individual at every health facility through:

• Taking anthropometric measurements such as height/length and weight (Annex 4).

• Taking medical and dietary history.
• Conduct of clinical examination, and laboratory tests.
In delivery of IMAM services:

• Anthropometric measurement deficits and/ or the presence of bilateral pitting oedema indicate
acute malnutrition.
• Clinical signs of poor appetite and associated disease indicate severity of disease progress.
• Biomedical assessments may be considered in the contexts of severe disease in tertiary care
and/or research.
• Different anthropometric measurements, indices (Table 2) and clinical signs are used to decide
the severity of acute malnutrition and treatment plan, depending on the individual’s age. Age is
best identified by use of official documents such as an immunisation card and birth certificate or
recall for older persons and for caretakers to estimate the age of the children. When the birth date
is unknown and cannot be verified, the age of the child may be estimated by asking the mother
or caretaker using a local calendar of events.
It is not recommended to use height cut-off as proxy for 6 months of age because in a stunted
population, many infants 6 months or older will have a height less than 65 cm. However, because
of high prevalence of stunting and to maximize benefit from the nutritional intervention, children
aged 60 months and above whose height is ≤120 cm regardless of age in line with the WHO
growth standard chart 2006 limit should be screened and classified together with 6–59 months old
children.

Table 2: Recommended age-specific anthropometric indices to measure

Age Category Anthropometric Indices to Measure Remarks

0–5 Months Weight-for-length, Weight-for-age Z– No standard cut-off for MUAC in this

scores age group. Research still ongoing.

6–59 Months Both MUAC and Weight-for-length/or Recommended by WHO with strong
height (WLZ/ or WHZ), respectively research evidence.

5–19 Years Body Mass Index for age Z-scores Recommended by WHO. No standard
(BMIZ) cut-off for MUAC in this age group.

≥ 19 Years Body Mass Index (BMI) Recommended by WHO

Pregnant and MUAC in all situations No universal standard cut-off but <23.0
Lactating cm is used in Uganda as the only
Women available objective measure to classify
nutritional status in this population.

22 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA

Health facility early identification of acute malnutrition
Screening for malnutrition should be integrated within all other care services at the health facility.
Early identification should be performed for all clients by different cadres of health workers in all
health service structures using measurement techniques (Height, weight, MUAC and examination
of oedema) described in Annex 2 and 4 at all service/contact points of the health facility including:

• Hospital level: Outpatient Department (OPD), Emergency Ward, ITC, Antenatal Care Clinic (ANC)
• Health centre during immunization, IMNCI–Growth Monitoring and Promotion, etc. in Young
Child Clinic (YCC).
• Campaigns: Vitamin A / deworming campaigns, etc.

NOTE: Any patient diagnosed with moderate or severe malnutrition should be referred for
appropriate management (Chapter 6–12).

4.2 Health facility identification and classification of acute malnutrition in

children aged 6–59 months
Activities for health facility early identification of acute malnutrition in children

• First assess and triage children or patients who are obviously severely ill using IMNCI and
emergency triage assessment and treatment procedure (ETAT) (Annex 5) for review by the
clinician and for immediate initiation of treatment intervention as needed (Figure 7).
• Screen all individuals using height/length and weight as indicated in Annex 4.
• Assess all children 6–59 months using MUAC and bilateral pitting oedema and classify according
to Table 3.
• Examine for oedema and other clinical signs of malnutrition including micronutrient deficiencies.
• Record in the respective Health Monitoring Information System (HMIS) registers (the normal
as well as the malnourished) including the daily Nutrition Tally Sheet (HMIS 012), the Integrated
Nutrition Register (INR) (HMIS NUT 001), Nutrition Daily Attendance Summary (HMIS Form
NUT 004) (Annex 1).
• Compile this data periodically (monthly) into Nutrition Monthly Attendance Summary (HMIS
Form NUT 010).

NOTE: The tools used for early identification of malnutrition in children are listed in Annex 3.
The training, equipment and tables to take weight-for-height measurements should be put
in place at all permanent health structures and services.

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 23

24 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA
Figure 7: Activities and processes to classify SAM children at health facility.

1. Waiting Area 2. Anthropometry Area 3. Appetite Test

• RUTF test amount
• Triage using IMNCI • Take MUAC, Weight,
served to SAM patients
and ETAT length/ or height
with no medical
complications
• Nutrition & Health • Patient passes if completes /
Education fails if unable to complete the
RUTF dosage for appetite
test

6. Start: 5. Registration and 4. Clinical Assessment

Counselling on MAM,
• MAM OTC and ITC • Clinical assessment
treatment • Update immunization
• OTC • Qualified patients for HIV counselling and
• ITC MAM, OTC and ITC testing
Registered according to
IMAM guidelines

• Given INR number

Figure 7: Activities and processes to classify SAM children at health facility.

NOTE: The above layout is not a standalone, but these activities can be integrated into
existing outpatient
Note: The clinics
above layout is notsuch as OPD, YCC,
a standalone, MNCH,
but these TB clinics,
activities HIV/ART clinics
can be integrated and other
into existing
care pointsclinics
outpatient at thesuch
facility.
as OPD, YCC, MNCH, TB clinics, HIV/ART clinics and other care points
at the facility.

Classificationof
Classification of acute
acute malnutrition
malnutritionin children
in children
Children who are screened from both the community and the health facility from all service care
Children
pointswho are screened
are classified from
into SAM, both
MAM theacutely
or not community and the
malnourished health
(NAM) facility
using Tablefrom alltable
3. This service care
points are classified into SAM, MAM or not acutely malnourished (NAM) using Table
is used for children 6–59 months and any child with age ≥60 months whose height is ≤120 cm. 3. This table
is used for children 6–59 months and any child with age ≥60 months whose height is ≤120 cm.
Table 3: Classification and admission of acute malnutrition in children 6–59 months

Table
Age3: Classification and admission
Nutritional criteria forModerate
Not Acutely acute malnutrition
Acute inSevere
children aged 6–59 months
Acute
category indicator Malnourished Malnutrition (MAM) Malnutrition (SAM)
Age category Nutritional (NAM) Not Acutely Moderate Acute Severe Acute
Children MUAC cut-off ≥12.5 cm Malnourished
indicator 11.5 cm to 12.5 cm
MalnutritionLess than 11.5 cm
Malnutrition
6–59 in 6–59 months (NAM) (MAM) (SAM)
months W/H or W/L Greater than or Greater or equal to -3 Less than -3 z-score
Children 6–59 MUAC cut-off in ≥12.5 cm 11.5 cm to 12.5 Less than 11.5
(see Annex equal to –2 Z–score z–score and less than (<-3SD)
months 6–59 months cm cm
And any 4.2) (≥-2 SD) -2 z–score (≥ -3 SD &
Andchild
anywith
child W/H or W/L (see Greater<than or
-2 SD) Greater or equal Less than -3
age
with age≥60 Annex
≥60 Bilateral 4) No bilateralequal
pitting pitting toNo
–2bilateral
Z– to -3 z–score
pitting and of bilateral
Presence z-score (<-3SD)
months
months whose oedema oedema score (≥-2 SD)
oedema less than -2 z–
pitting oedema (rule
height
whoseis ≤120 score (≥ out-3 SD & causes)
medical
cm height is < -2 SD)
≤120 cm Bilateral pitting No bilateral No bilateral Presence of
Source: WHO/UNICEF/WFP
oedema 2014, WHO 2013,
pitting Golden H.M. and Y.
pitting Grellety (2018). bilateral pitting
oedema oedema oedema (rule
28 out medical
causes)

Source: WHO/UNICEF/WFP 2014, WHO 2013, Golden H.M. and Y. Grellety (2018).

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 25

Activities to classify acute malnutrition in children 6–59 months and any child with age ≥ 60
months whose height is ≤120 cm
The health worker should give 50ml of sugar water immediately on arrival to obviously ill children
and those that will clearly need inpatient or other medical treatment: approximately 5g (1 teaspoon)
of sugar per 50ml of safe drinking water:

• Take the anthropometric measurements (MUAC at OTC/outreach clinics and both MUAC and
weight and height/Length at health centres/ITC) and check oedema for all patients, including
those referred from the community.
• In health centres /ITCs, check the weight-for-height or length table (Annex 6).
• Examine for oedema and its severity or grade (Annex 2) and take the temperature.
• According to the criteria of admission (see Figure 8), decide if the child should be admitted or
not. If a patient has been referred from the community with a diagnosis of SAM but does not
meet the criteria of admission to the OTC, do not send him/her home without some tangible
benefit as it will undermine the authority and morale of those screening in the community.
• Applaud and encourage the caretaker and provide health education and counsel on
maintaining normal nutrition and health.
• Screen for any illness using IMNCI and treat, or
• Give any due or missed vaccination opportunity, or
• Give vitamin A and deworming tablets if due, or multivitamins that augment the type I
nutritional status of the child.
If the patient has been referred from the community to the SFP services with a diagnosis of MAM,
but does not meet the criteria for admission to the SFP:

• If the patient is a SAM child admit/refer the patient to the closest OTC/ITC for assessment and
admission. Manage the MAM child using guidance in Chapter 6 or send to the SFP site if it is
operational.
• If the patient is not acutely malnourished, do not send him/her home without some tangible
benefit but provide similar interventions as explained above.

NOTE: If there are large number of inappropriate referrals from the community, the
screening teams must be retrained, and the OTC/SFP/health facility staff’s ability checked.
This should be discussed during the regular coordination meetings between the OTC staff
and the screening teams. The error may be with the staff in the OTC as well as the community
screening team.

Tools used to classify acute malnutrition in children into SAM and MAM are listed in Annex 2.

26 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 27
Figure 8: Identification, classification and admission criteria at a health facility.

HEALTH FACILITY NUTRITIONAL CLASSIFICATION, AND ADMISSION CRITERIA

MUAC < 11.5 cm MUAC < 11.5 cm MUAC 11.5 cm to

and presence of or bilateral 12.5 cm MUAC
bilateral oedema oedema and no
+++ +/++ bilateral oedema ≥12.5 cm

Measure weight
and height–W/H Z-
score

W/H < -3 z-score

- W/H ≥-3 to < -2 z-score

Appetite test + Check of

Medical Complications (IMNCI)

Poor appetite Good appetite

and/or and no
medical complications & medical complications The picture can't be displayed.

IMNCI danger signs Education session

Treatment of Illness
(IMNCI)
ITC OTC SFP
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Classification of complicated and non-complicated SAM children for admission in

Figure 8: Identification, classification and admission criteria at a health facility.
inpatient therapeutic care or outpatient therapeutic care
The classification of children with SAM should be made in the OPD of an ITC and in the OTC
(figure 8)

Activities and processes to classify SAM children in OTC

Step 1: The first health worker should do the followed tasks (see Figure 7):
• Assess and triage children or patients obviously severely ill to inpatient treatment without
keeping them waiting or start treatment if the distance is excessive and/or suitable transport is
not available.
• Identify referred patients from the community, ITC, SFP, or other OTC sites.
• Assess and enter all the children eligible for admission into the IMAM services in the INR
(Annex 1), fill in the patient’s chart and give the INR-number.
• Give 50ml of sugar water (1 teaspoon (5g) of sugar in 50 ml of safe drinking water) to any
patients with SAM, suspected to be at risk of hypoglycaemia;
• Perform the appetite test to eligible patients waiting to see the clinician.

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30
The appetite test
Why to do the appetite test?
• Accurate assessment of the appetite is the most appropriate criterion to differentiate a
complicated SAM case from an uncomplicated case.
• The appetite test is done to decide if a patient should be sent for in or outpatient management.
• Reduction in appetite is by far the best sign of severe metabolic-malnutrition (as opposed to
anthropometric-malnutrition).
• A poor appetite means that the patient has a significant infection or a major metabolic
abnormality such as liver dysfunction, electrolyte imbalance, and cell membrane damage or
damaged biochemical pathways, and these patients are at immediate risk for death. Further,
a child with a poor appetite will not take sufficient amounts of the therapeutic diet at home to
prevent deterioration. These children should be admitted in ITC depending on the care takers
decision.
When to do the appetite test
• During initial classification of complicated and non-complicated SAM in children aged 6–59
months.
• When there is poor weight gain at any visit in OTC.
• Failure of an appetite test at any time is an indication for full evaluation and probable transfer
for inpatient assessment and treatment (see Figures 5, 6, and 7).

How to do the appetite test

To the health worker or nutritionist:
• All children who are supposed to have an appetite test are tested together in the same area at
the same time in a separate quiet area such as under a shade.
• Watching other children take the RUTF gives confidence.
• Children who have travelled a long distance should be given water to drink and allowed to rest
first.
• The first step is explaining to the caretakers the purpose of the appetite test and how it will be
done.
• Ask the caretaker to wash her hands and the child’s face and hands.
• Ask the caretaker to sit comfortably with the child on her lap.
• Advise the caretaker to offer the RUTF to the child. The caretaker/mother should first massage
the RUTF sachet to homogenize the content.
• Encourage the mother to feed the child on the RUTF directly from the packet and water to drink
in a cup during the test.

NOTE: The appetite takes usually takes a short time (30 minutes) but may take up to one
hour. The child should not be forced to consume the RUTF. Sometimes a child will not eat
the RUTF because he/she is frightened, distressed or fearful of the environment or staff. This
is likely if there is a crowd, a lot of noise, other distressed children or intimidating health
professionals.

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30 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA
The nurse or nutritionist should evaluate the result of the appetite test:
Pass
A child who takes at least moderate amount as shown in Table 4 passes the appetite test. Or if local
family food or local recipes are used, a child who eats at least three teaspoons.

Fail
A child who does not take at least the “moderate” amount of RUTF fails the test and the health
worker will examine the child and probably refer him/her to the ITC.

NOTE: Even if the child is not taking the RUTF because s/he does not like the taste or is
frightened, the child did not pass the appetite test (and will probably not take sufficient at
home to recover). If local family food or local recipes are used, a child who does not eat at
least three teaspoons.

Table 4: Amount of RUTF to assess the appetite of severely malnourished children

Appetite Test
“Moderate” is the minimum amount that a malnourished child should take to pass the appetite
test
Paste in sachets*(Proportion of whole sachet 92g)
Body weight
Poor Moderate Good
Less than 4 kg <1/8 1/8 –1/4 >1/4
4–6.9 <1/4 1/4–1/3 >1/3
7–9.9 <1/3 1/3–1/2 >1/2
10–14.9 <1/2 1/2 –3/4 >3/4
15–29 <3/4 3/4–1 >1
Over 30 kg <1 >1

Step 2: The Clinician

• The clinician reviews the patient’s anthropometric and the appetite test results (see Figure 7).
• Examines the patient to determine if s/he has a complication using IMNCI criteria (see medical
complications).
• Explains to the caretaker the options for treatment and decides with the caretaker whether the
child should be treated as an outpatient or inpatient.
• Transfers patients that need inpatient treatment for admission to an ITC and patients that can
be treated as outpatients to the OTC site nearest to their home.
• If the triage for malnutrition is made within the OTC and the patient requires ITC treatment, give
the INR-number, register the patient, fill out a transfer form and arrange for the transfer.
• For sick children whose mothers initially refuse inpatient care, give appropriate counselling
and health education. Explain carefully, the benefits of ITC and the risks of OTC to enable the
caretaker make a well-informed decision. Consider the concerns of the caretaker and agree
together on the final decision and arrange appropriate care.
• Start the treatment appropriate for outpatients (see below):
• Review the previous treatment for patients referred/transferred from other clinics to avoid
overdose of routine medicines (see section on routine medications).

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 • Ensure that they continue with the initial treatment.
• Patients on treatment for HIV/AIDS,TB, should be counselled to continue with the medication.
Those diagnosed after admission to OTC should be linked to appropriate program clinic/
health facility for treatment, care and support as the patient continues with OTC.
Tools to classify and manage as OTC or ITC are listed in Annex 3.

Medical history and examination

• On presentation, the clinician or nurse will have recorded results of the anthropometry and
appetite test.
• Record the patient’s history following the criteria in Box 1
• Ask the mother why she has brought the child to the centre or the presenting complaints–i.e.
what she has noticed wrong/changed with the child, when the complaints started and how they
have progressed.
• Ask the systematic questions.

Box 1: History taking: Medical, dietary and socio-economic situation

• Bio-data (age, sex, address, next of kin • Breastfeeding practices

etc.) • Quality types of food (energy giving, body
• Growth milestones with respect age building animal and plant proteins, and
(sitting up, standing, etc.) protective–fruits and vegetables).
• Immunization of the child, right from birth • Quantity–how much
• Attendance of antenatal (tested for HIV • Frequency/ interval of feeding–how often
etc.) • Type of feeding; active or passive
• Birth history, size at birth (small, normal, • When complementary feeding was started
large), (birth weight term/preterm,
• Method of feeding–bottle or cup feeding?
complications at birth)
• Appetite
• Current and past illnesses, drugs,
medications

• Method of cooking/preparation of child’s • Socio-economic history

food • Family size, birth order of the baby etc.,
• Hygiene practices; hand washing with • Family and social situation
clean water and soap, food hygiene, use
• Mother and father’s occupation
of latrine.
• Family resources; land for cultivation
domestic animals
• House ownership
• Parents/caretakers level of education

• Able to drink or breastfeed • Mother’s perception of child’s appetite

• Food and fluids taken in past few days • Has any other reported problem
• Usual diet before current episode of • Immunization history
illness • Illness or contact with TB, HIV, measles (in
• Vomiting everything family)
• Has cough • Family circumstances, (e.g. death of
• Had convulsions siblings, absent or illness of parents, poverty
assessment, etc.)
• Has recent and frequent diarrhoea; type
of diarrhoea (watery/bloody) • Recent change in appearance of face (sinking
of eyes)
• Lethargic or unconscious

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Examination for medical complications (IMNCI)
After anthropometry, conducting the appetite test and history, the nurse/clinician has to examine
the patients to look for complications that need to be managed prior to transfer to the inpatient
facility. Medical or clinical examination involves a more detailed examination of the patient from
head to toe, with emphasis on signs of visible severe wasting, bilateral pitting oedema, and
medical complications; IMNCI danger signs, hypothermia, dehydration/ shock, severe infections,
hypoglycaemia, heart failure, corneal ulcerations, very severe anaemia, dermatosis.
If there is a serious medical complication, then transfer the patient for inpatient treatment if the
patient has any of the following conditions (see Table 5 and Figures 6 and 7):

• Observe the child for movements, alertness, cry, body tone and general appearance. If the
child appears critically ill, look for critical signs, then triage the patient with the consent of the
caretaker using IMNCI and the emergency triage, assessment and treatment plus admission
(ETAT+) procedure (Annex 5).
• Emergency and priority signs:
• Lethargic or unconscious.
• Cold hands.
• Slow capillary refill (>3 seconds).
• Weak (low volume) or rapid pulse.
• Convulsion.
• Pneumonia; rapid or shallow, other difficulty in breathing (e.g. wheeze, stridor). Note–the
respiration rate in SAM children with pneumonia is usually about 5 breaths/minute lower than
in normal children–the cut-off points to classify as pneumonia are:
• 60 breaths/ minute for under 2 months
• 50 breaths/minute from 2 to 12 months
• 40 breaths/minute from 1 to 5 years
• 30 breaths/minute for over 5 year-olds or
• Any chest in-drawing.
• Temperature:
• Hypothermia < 35.5°C (rectal) or < 35° C (axillary)
• Fever > 39.0°C (rectal) or >38.5° C (axillary)
• Diarrhoea and dehydration based on history and change in appearance (clinical signs are
unreliable in the malnourished and should NOT be used to diagnose dehydration)
• Severe vomiting.
• Skin: Open skin sores or infection, rash (measles etc.)
• Anaemia: Very pale (severe anaemia) (Assess palmar pallor if hands are not cold otherwise
assess mucus membranes or conjunctiva.
• Eyes: Clinical vitamin A deficiency signs or eye infection
• Any condition that requires an infusion or nasogastric tube (NGT) feeding
• Signs of abnormality of the ears, mouth and look for mastoiditis
• Tap spine for early signs of Pott’s disease
• Any other general signs or symptoms which the nurse/clinician thinks require investigation or
treatment in an inpatient facility.
If ANY medical complications are present, this indicates that the patient needs inpatient treatment.
The child should be referred to the ITC with the agreement of the caretaker. If the appetite test is
properly and accurately conducted, it should differentiate those oedematous children who should
require ITC treatment from OTC treatment.

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 Table 5: Classification and admission criteria to inpatient or outpatient care

Factor Inpatient care Outpatient care

Appetite Failed Appetite test Passes Appetite test

Bilateral pitting Bilateral pitting oedema Grade 3 Bilateral pitting oedema Grade 1
oedema (+++) to 2 (+ and ++)
Both wasting and oedema (WHZ <
-3 score and bilateral oedema)

Skin Open skin lesions No open skin lesions

Medical Any severe illness, using the IMNCI Alert with no medical
complications criteria–respiratory tract infection, complications
severe anaemia, clinical vitamin-A
deficiency, dehydration, fever,
lethargy, measles rash, etc.

Candidiasis Presence of severe candidiasis or Absence of candidiasis

other signs of severe immune-
incompetence

Caretaker No suitable home circumstances Reasonable home circumstances

or willing caretaker and a willing caretaker

Caretaker Caretaker counselled and Caretaker counselled and

counselled at understands need to start, understands need to start,
every stage of continue or transfer to ITC. continue or transfer to OTC.
management
The caretaker’s concerns must be The caretaker concerns must be
addressed or considered. addressed or considered.

* NOTE: Children with a low MUAC and mild oedema are usually treated as outpatients if
they pass the appetite test. Conversely children with a WHZ < -3 and any degree of oedema
have a very high mortality risk and should be treated in ITC. A careful note must be recorded
in the chart if the caretaker decides to opt to OTC when the state of the child indicates that
s/he should be treated as an inpatient according to these criteria and the situation has been
carefully explained to the caretaker. It is useful in these circumstances to note the reasons
for the choice.

4.3 Health facility identification and classification of acute malnutrition in

infants less than six months and pregnant and lactating women
Infants less than six months may become malnourished if they have never been breastfed or they
have been sub optimally breastfed. There are also other causes of malnutrition in this age group
which may be related to either the mother or the child. Therefore, infants aged less than 6 months
may become malnourished if they have:

• Never been breastfed or have experienced suboptimal breastfeeding practices.

• Received inadequate or unsafe artificial feeds; or complementary feeds are introduced too
early.
• Had recurrent infections.

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• Medical complications.
• Some forms of disability that affects their ability to suckle or swallow, or a developmental
problem affecting feeding; their mothers are dead or absent and no appropriate caregiver is in
place.
• Mothers who are malnourished, traumatized, ill, or unable to respond normally to their infants’
needs.

NOTE: Assessment and screening for an infant aged less than 6 months should always be
considered in conjunction with the mother and family setting. Therefore, assessment of the
physical and mental health status of mothers or primary caregivers should also be conducted
and relevant treatment and appropriate support provided.

Infants should be screened monthly in community-based and facility-based growth monitoring by

VHTs or community health workers and health care workers. Infants identified with the following
should be further assessed for acute malnutrition and adequacy of breastfeeding:

• Danger sign.
• Weight loss.
• Failure to gain weight.
• Suboptimal breastfeeding should be referred with their mothers or caretakers for assessment
and follow-up.
Infants with illness or feeding problems at any contact with the healthcare system should be
systematically screened for adequacy of breastfeeding and acute malnutrition at the health
facility.

Screening and triage at the health facility

At the health facility, the infant and mother or caretaker from the community or self-referral should
receive a comprehensive assessment to decide whether to start treatment in OTC or refer to ITC.
Infants under 6 months of age should be assessed according to IMNCI guidelines, and the mother
or caretaker should receive a breastfeeding assessment, a psychosocial, health and nutrition
assessment. Both outcomes should be considered to decide the severity of illness and treatment
plan.
The assessment steps include:

Infant: Mother:
1. Danger signs or signs of severe disease 1. Nutrition status assessment
2. Nutrition status assessment 2. Breastfeeding assessment
3. Clinical assessment 3. Clinical assessment
4. Breastfeeding assessment 4. Psychosocial assessment for mental health
and general well-being

Infant
1. Danger signs or symptoms of severe disease (see Box 2). Following the same guidance as for
children 6–59 months, checking for general danger signs and any symptoms of severe illness.
Note that respiratory distress in infants 0≤ 2 months of age may be expressed by:

• Slow breathing (respiratory rate < 20 breaths/minute) or

• Fast breathing (respiratory rate > 60 breaths/minute) or

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• Episodes of apnoea (cessation of breathing for > 15 seconds).
• Respiratory distress in infants 2–6 months of age may be expressed by:
• Fast breathing (respiratory rate > 50 breaths/minute).
An infant with danger signs or symptoms of severe disease needs immediate lifesaving
interventions. Complete the assessment and give pre-referral treatment immediately.

Box 2: Danger signs or symptoms of severe disease

• Unable to feed
• Convulsions
• Unconsciousness
• Lower respiratory tract infection
• Dehydration
• Severe anaemia
• Hypothermia
• Intractable vomiting
• Lethargy, not alert
• High fever
• Persistent diarrhoea
• Hypoglycaemia
• Severe skin lesions
• Eye signs of vitamin A deficiency

2. Nutritional status assessment

• Ask about appetite, check for presence bilateral oedema, measure weight and length (WLZ) and
classify weight-for-length z-score using the same guidance as for children 6–59 months.
• Plot the weight on the weight-for-age (WAZ) growth chart on the Child Growth Monitoring Card
and look at the position and any drop across WAZ lines.
• Ask about recent weight loss or failure to gain weight.
• WLZ is not available for infants < 45 cm long (WHO WLZ Tables start at 45 cm). WAZ is used
instead to classify SAM.
3. Clinical assessment should be conducted following the same guidance as for children 6-59
months of age.
4. Breastfeeding assessment of the infant should be conducted by asking the mother questions
(without judging her choice of feeding method and using breastfeed assessment tool in Annex
7) and observing a breastfeeding session to assess any non-breastfeeding, breastfeeding
problems, structural and muscular abnormalities with physical examination. Classify the
breastfeeding problems using Box 3.

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 Box 3: Classification of breast-feeding problems

None Mild Moderate Severe

• No signs of • Breastfeeding • Infant not well • Structural (anatomical)
inadequate difficulties attached abnormalities e.g Cleft lip or palate.
feeding based on • Infant not • Abnormality of tone, posture
• No additional mother’s breast suckling and movement interfering with
issues for conditions effectively breastfeeding
mother-infant • Non-severe • Fewer • Infant’s arms and legs falling to
respiratory than eight the side when infant is held.
difficulties, breastfeeds in • Infant’s body stiff, hard to contain
e.g., nasal 24 hours or move
congestion,
• Infant receiving • Unable to support head or control
interfering with
other foods or trunk
breastfeeding
drinks
• Excessive jaw opening or clenching
• Unwillingness or inability to
suckle on breast
• Coughing and eye tearing while
breastfeeding (sign of unsafe
swallowing)

Source: C-MAMI Tool Version 2.0, 2018

Mother
• Measure MUAC and classify nutrition status (see Figure 6 and Table 7) in this section:
• Check for the presence of bilateral pitting oedema.
• A breastfeeding assessment of the mother should be conducted using Box 4.

Box 4: Mother’s breastfeeding assessment

No Breastfeeding Breastfeeding Difficulties, if ANY indication of need for

Difficulties, if ANY SUPPORT on:
indication of need for
SUPPORT on:

• Re-lactating • Re-lactating
• Meeting the nutritional • Expressing breast milk and cup-feeding
needs of the infant • Breast conditions, e.g., engorgement; sore and cracked
• Working away from nipples; plugged ducts and mastitis; flat, inverted, large or
home long nipples; nipple pain; thrush
• Delegating infant • Perception of not having enough breast milk
feeding and care to • Other concerns, e.g., lack of confidence, concerns about
another diet, working away from home

Source: C-MAMI Tool Version 2.0, 2018.

• The mother should be investigated for any medical problem that needs attention and referral.
• The general well-being should be investigated and identify any mental health problem that
needs action according to mental health guidance, including care and social support.

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Classification and admission criteria for outpatient and inpatient in infants less
than 6 months
The criteria for admission of infants in either outpatient therapeutic care or inpatient therapeutic
care is shown in Table 6. From birth to 6 months of age and for consistency, weight-for-length
z-score (WLZ) cut-offs (see Table 6) are used to assess nutritional status although weight-for-
age (WFA) is the most appropriate measure to assess nutritional status. At this age, failure to
gain weight can be defined as acute malnutrition. WFA is used as a criterion for assessment of
nutritionally vulnerable infants under 6 months. A cut-off of WFA <-2 is used for consistency with
weight-for-length z-score (WLZ) cut-offs.
However, there are premature and small-for-gestational-age babies born who are being exclusively
breastfed and gain weight at a satisfactory rate. Such infants are thriving and do not need admission
to the IMAM services. The best way to differentiate those infants who are thriving from those that
are becoming malnourished is to take repeated weight measures longitudinally and this is the
value of the growth-monitoring program.
Weight loss as a criterion is difficult for a health worker or mother to detect in an infant. Where it
is reported or detected, weight loss in infants should be interpreted alongside the general clinical
condition. A classification cut-off for MUAC in infants <6 months has not yet been established
although there is growing evidence on the use of MUAC to identify nutrition vulnerability in
infants <6 months.

Admission criteria for outpatient care in infants under six months

Severe acutely malnourished Infants aged less than 6 months without medical complications and
all the following criteria may be treated as outpatients only in settings where careful review and
close follow up are guaranteed

• Clinically well and alert

• Gaining weight following the growth curve (serial weight measurements follow consistently
along a “channel” on or between the same percentiles)
• No bilateral pitting oedema
• Adequate social circumstances and support
• Infants whose carers decline admission for assessment and treatment in inpatient care can be
directly enrolled for outpatient care.

Admission criteria for inpatient care in infants under six months

Severe acutely malnourished Infants aged less than 6 months without medical complications and
all the following criteria may be treated as outpatients only in settings where careful review and
close follow up are guaranteed

• General danger signs or serious clinical condition, as outlined for infants aged 6 months or older.
• Recent severe weight loss or failure to gain weight.
• Ineffective breastfeeding (attachment, positioning or suckling) directly observed for 15–20
minutes, ideally in a supervised separated area.
• Any bilateral pitting oedema.
• Any medical problem needing more detailed assessment.
• Any social issue requiring detailed assessment or intensive support (for example, e.g. disability
or depression of caregiver or other adverse social circumstances).
Where the infant has a clinical illness, the mother’s breast-feeding performance is not satisfactory, the
infant appears clinically malnourished. Admit the infant and mother to the ITC ward (see Table 6).

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Table 6: Admission criteria for outpatient and inpatient therapeutic care infants less than 6 months

Classify nutritional status in under six months

Not Acutely Moderate acute Severe acute malnutrition (SAM)

Malnourished malnutrition (MAM)

• WLZ ≥ –2 SD • WLZ ≥ –3 to < –2 SD Bilateral pitting oedema of any degree (+. ++.
• No breastfeeding • No breastfeeding +++),
difficulties difficulties OR weight for length z-score (WLZ) < -3 SD
• Weight gain • Weight gain OR any of the following:
• Alert and well • Alert and well
• Weight loss
• Failure to gain weight
• Drop across the infant’s growth line;
With any danger signs or symptoms of severe
disease according to IMNCI
OR with breastfeeding difficulties after mother’s
counselling.
OR referral from outpatient care according to
action protocol

Admission criteria of SAM infants less than 6 months in OTC or ITC

OTC ITC

• WLZ < -3 with: • Bilateral pitting oedema of any degree (+. ++. +++) weight
for length z-score (WLZ) < –3 SD
ANY of the following:
OR any of the following:
• Moderate weight loss or recent
(days to a week), • Recent severe weight loss within 1 week
• Failure to gain weight in a week, • Prolonged failure to gain weight in weeks to months.
• Sharp drop across the infant’s growth line WAZ
• Moderate drop across WAZ lines
• Moderate, mild or possible WITH any danger signs or symptoms of severe disease
breastfeeding difficulties according according to IMNCI
to Box 4. OR WITH severe breastfeeding problems after mother’s
• Infant not well attached counselling in Box 3 and 4.
• Infant not suckling effectively
• Structural (anatomical) abnormalities e.g. Cleft lip or
• Fewer than eight breastfeeds in 24 palate.
hours • Abnormality of tone, posture and movement interfering
• Infant receiving other foods or with breastfeeding
drinks • Infant’s arms and legs falling to the side when infant is
held.
AND mother-infant pair clinically well
• Infant’s body stiff, hard to contain or move
and alert • Unable to support head or control trunk
Careful review and close follow-up • Excessive jaw opening or clenching
guaranteed • Unwillingness or inability to suckle on breast
• Coughing and eye tearing while breastfeeding (sign of
• Infants whose carers who decline unsafe swallowing)
admission
OR referral from outpatient care according to action
• Referred from ITC after stabilization protocol

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 NOTE: Low-birth-weight babies are not usually severely wasted or oedematous and so are
unlikely to meet the criteria for severe malnutrition. Management of low- birth-weight (LBW)
babies is not well elaborated in this protocol. All mothers of LBW infants should receive
extra support in the following:

• Early initiation of breastfeeding within the first hour after birth. This includes supporting the
mother to express breast milk and feed the newborn breast milk with a cup if newborn is not
able to suckle.
• Keeping the newborn warm, including skin-to-skin contact with the mother (kangaroo technique).
• Counselling on hygiene, especially handwashing.
• Early identification of danger signs and the need for early care seeking and referral.

NOTE: Where available, they should be followed up in a premature clinic to monitor their
weight gain and support breastfeeding.

At the community, LBW babies should be linked to VHTs to support the breastfeeding.

Classification and admission criteria for outpatient and Inpatient for pregnant
and lactating women with infants less than 6 months
Women from the time of confirmed pregnancy or having a breastfeeding infant under 6 months of
age; when attending MNCH for reproductive health interventions or other health services should
be systematically screened for malnutrition by the midwives or other health providers using
MUAC as described in Annex 2. PLW should be classified according to Figure 6 in Chapter Three
and in Table 7.

Classification of nutrition status and admission criteria for OTC and ITC for pregnant and lactating
women for women:

• PLW with MUAC < 19.0 cm and/or bilateral pitting oedema are classified as SAM and are referred
to the clinician for assessment of any medical complications (see Table 7).
• PLW with MUAC ≥ 19.0 cm and < 23.0 cm with no oedema are classified as MAM and are
referred for management as MAM at the health facility and with linkage to community VHT.
• PLW with MUAC ≥ 23.0 cm and no nutritional oedema are classified with a normal nutrition
status and are encouraged to continue monthly community-based and facility-based nutrition
services.

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 Table 7: Classification and admission criteria for outpatient and inpatient care for PLW

Classification of nutritional status in PLW

Not acutely malnourished Moderate acute malnutrition Severe acute malnutrition

(MAM) (SAM)

MUAC ≥ 23.0 cm MUAC ≥ 19.0 cm and < 23.0 Bilateral pitting oedema
No bilateral pitting cm of any degree (+. ++. +++),
oedema No bilateral pitting MUAC < 19.0 cm
oedema

Classify SAM in PLW for OTC and ITC admissions

OTC ITC

MUAC <19.0 cm Bilateral pitting oedema (only in non-

OR Presence of Moderate or mild anaemia pregnant mother)
OR Presence of Moderate or mild depression OR MUAC: <19.0 cm
OR Has no breastfeeding difficulties–see Box 4 OR Severe anaemia
Has social support OR Severe depression
OR Other medical complications
With breastfeeding difficulties
OR Lack of social support.

Source: C-MAMI Tool Version 2.0, 2018; Training Guide for Community-Based Management of Acute Malnutrition
(CMAM): Handouts. Washington, DC: FHI 360/FANTA.

4.4 Health facility identification and classification of acute malnutrition in

older persons
This section provides guidance on how to assess and classify patients with malnutrition as a
consequence of inadequate dietary intake or disease in older children, adolescents and adults.
This is exhibited in form of thinness, weight loss or nutritional oedema. Undernutrition among
adolescents and adults takes the form of moderate and severe thinness. However, for consistency
in IMAM services, moderate and severe thinness are referred to as moderate (MAM) and severe
acute malnutrition (SAM). Significant weight loss is defined as the loss of 5 per cent or more
of the body weight over a period of 6 months. A body mass index of <18.5kg/m2 is defined as
undernutrition, although the definition of malnutrition varies in different settings.
Undernutrition can occur as a primary disorder in older children, adolescents and adults in
conditions of extreme deprivation and famine with consequent inadequate diet. Undernutrition
can also be caused by underlying medical and psychiatric conditions that impairs nutrient intake
or metabolism, including:

• Infectious diseases such as HIV, TB, parasitic infections and other chronic infections
• Cancers
• Intestinal malabsorption and liver diseases
• Endocrine and autoimmune diseases
• Psychiatric and behavioural causes leading to anorexia
• Alcohol and other substance dependence

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• Medications and their side-effects
• Situations of dependency or insufficient diet, for example the elderly, disabled and people in
prisons.
• Undernutrition limits growth in adolescents and the body’s ability to combat disease or to heal
following an injury.

Clinical approach to a patient with undernutrition in older persons

The approach to patients presenting with undernutrition includes assessing and classifying
malnutrition, determining and treating the underlying cause. It is important to assess, classify,
and manage malnutrition, regardless of the underlying cause.
The nutritional status of a patient at the time of presentation is an important indicator of treatment
outcome in many conditions. For example, in persons with HIV, baseline malnutrition has a
higher mortality even following ART initiation, and nutritional interventions support treatment
retention. ART improves nutritional status, but it can also create additional issues with nutritional
implications, such as dyslipidaemia and impaired glucose tolerance.

Step 1: Perform quick check/assess the patient for life-threatening conditions

and treat urgently
Patients with significant undernutrition could present with severe complications of an underlying
systemic disease, or severe complications of malnutrition that require urgent interventions. A quick
assessment should be performed to all adolescents and adults presenting with undernutrition to
identify and manage any emergency conditions.

Step 2: Assess and classify nutritional status using anthropometric measures

and clinical signs of nutritional oedema
The following anthropometric measurements are essential for nutritional assessment and
monitoring response to interventions in older children, adolescents and adults:

• Weight in kg and height in cm

Then determine:

• Extent of unintentional weight loss–compare with prior measurements

• Body mass index (BMI)
Classify the nutrition status/ malnutrition
Body Mass Index (BMI)
BMI is an indicator used to classify underweight, overweight, and obesity in adolescents and
adults (see Table 1). It is defined as the weight in kilograms divided by the square of the height in
metres.

Weight in kilograms
BMI (kg/m²) =
Height in meters2

For children 5 years or older, use of the gender-specific BMI-for-age as the best indicator of
malnutrition and Table 8 and Annex 8 for classification of nutrition status (Annex 8). For adults,
BMI is recommended (Annex 9). BMI requires the accurate measurement of both height and
weight taken using regularly maintained and calibrated equipment. Quality assurance is required
to ensure that reasonable accuracy of the measurements is maintained. BMI can be inaccurate in
several circumstances:

42 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA

• Oedema complicating malnutrition or other disorders. Note that patients with malnutrition
may exhibit nutritional oedema, presenting as bilateral pitting oedema.
• Pregnancy.
Thus, interpretation of BMI for age and BMI results must always be made with consideration of
pregnancy and bilateral pitting oedema status.

Table 8: Classification of malnutrition in older children, adolescents and adults

Severe
Age Nutritional Not Acutely Moderate Malnutrition
Malnutrition or
category indicator Malnourished or Thinness (MAM)
Thinness (SAM)
BMI for age (see
≥-2 SD ≥ -3 SD & < -2 SD < -3 SD
Annex 4 and 8)
Children and
Presence of
adolescents No bilateral
Bilateral pitting No bilateral pitting bilateral pitting
5–19 years pitting
oedema oedema oedema (+ & ++;
oedema
+++)
BMI (see Annex
≥17 kg/m2 ≥16 cm and <17 kg/m2 < 16 kg/m2
Annex 4 and 9)
Adults (>19
Presence of
years) No bilateral
Bilateral pitting No bilateral pitting bilateral pitting
pitting
oedema oedema oedema (rule out
oedema
medical causes)

Source: WHO/UNICEF/WFP 2014; WHO 2013.

NOTE: All patients with (oedema grade + & ++ should be admitted in OTC and those with
+++ in ITC)

Unintentional weight loss

Unintentional weight loss is calculated as the percentage of weight lost from the baseline body
weight (BBW) using the following formula:
per cent of weight lost = [(BBW–current body weight)/BBW] x 100
Significant weight loss is defined as the loss of 5 per cent or more of the body weight over a
period of 6 months.
However, any unintentional weight loss should carefully be investigated for underlying systemic
causes and treated. Percentage of weight loss is used for WHO clinical staging of HIV disease but
is not recommended for classification of malnutrition.

Step 3: Assess for underlying causes of weight loss and undernutrition

Adolescents and adults with undernutrition should be assessed for clinical manifestations of
immunosuppression and opportunistic infections such as chronic diarrhoea, fever, generalized
lymphadenopathy, oral lesions and cough. They should also be assessed for TB.
Patients should be evaluated by taking a history, a thorough physical examination, and performing
relevant laboratory investigations:

• To assess the significance and intentionality of the weight loss and undernutrition,

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 43

• To look for underlying systemic causes of undernutrition and weight loss.
• History should be used to help identify root causes and rate of weight loss and undernutrition.
Adolescents and adults should be examined for bilateral pitting oedema. If present, its cause
must be determined. In addition to malnutrition, other causes of oedema include preeclampsia (in
pregnant women), severe proteinuria (nephrotic syndrome), nephritis, heart failure, acute filariasis
(the limb is hot and painful), and wet beriberi. Non-nutritional causes of oedema can readily be
identified by the history, physical examination and urinalysis.
A detailed nutrition and diet history, as well as an assessment of symptoms associated with weight
loss and under nutrition, helps in identifying any underlying diseases. The availability of adequate
food and household food security should also be assessed.

Step 4: Assess the HIV status

All undernourished adolescents and adults should be screened for HIV according to national
guidelines.

Step 5: Treat undernutrition and its underlying causes

The diagnosis or underlying cause contributing to the undernutrition should be treated plus the
immediate symptoms contributing to undernutrition at all levels. HIV should be staged using the
WHO clinical staging or immunological criteria, and referred to ART clinic for further assessment
initiation of ART.

Classification and admission criteria for outpatient and inpatient in older persons
Older persons with severe malnutrition should be assessed for appetite, medical complications
and danger signs to make the decision for management as outpatient or inpatient (see Table 9).
The initial goal of treatment is to prevent further tissue loss. If they do not have a medical condition
that requires hospital admission, they should be managed in OTC.

Table 9: Criteria for admission to outpatient or inpatient care in older persons

Factor Inpatient care Outpatient care

Appetite Client reports no appetite Client has appetite

Bilateral Bilateral pitting oedema Grade 3 Bilateral pitting oedema

oedema (+++) Grade 1 to 2 (+ and ++)

Medical Any severe illness, hypothermia, No medical complications or

complications weak client with active TB, severe with medical complications and
anaemia, dehydration, fever, etc. walking

Conditions Injuries, burns, surgical procedures, Conditions absent.

causing pregnancy, diarrhoea or diseases of Conditions present but patient
secondary the gastrointestinal tract, thyroid, ambulatory and no medical
malnutrition kidney, liver or pancreas complication

Client Client counselled and understands Client counselled and

counselled at need to start, continue or transfer understands need to start,
every stage of to ITC. Client’s concerns must be continue or transfer to OTC.
management addressed or considered. Client’s concerns must be
addressed or considered.

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5.0 Transport of very ill malnourished patients

5.1 Introduction
Very ill malnourished patients are prone to “transport trauma”; which is one of the main reasons
why both ITCs and OTCs should be established in close proximity with the patient’s villages.
Malnourished patients who are relatively well before transport, deteriorate and die soon after
arrival after a long or difficult journey. When patients with severe malnutrition require to be
transferred to an ITC, public transport is not the best recommended means. It is recommended
that sick patients, where possible, be stabilized at the OTC or nearest health facility prior to being
transported to the nearest health facility.

5.2 Transport of malnourished patients from the inpatient therapeutic

care facility
• The medical staff at the ITC facility should be contacted by telephone.
• The medical staff at the ITC facility should take responsibility and “cover” the nurse while in the
field, or
• Reassure the nurse that it is the correct course of action not to transport the severely
malnourished patient and give advice and support for the management of the patient.
• The telephone call, advice given and the name of the doctor and ITC contacted should be
recorded on the patient’s chart.

5.3 Transport of malnourished patients from the outpatient therapeutic

care facility
The nurse at the OTC must explain to the caretaker that the patient is critically ill.
The danger of transporting the patient to the hospital is greater than trying to stabilize him/her at
the health centre.

NOTE: The caretaker should be counselled to understand the need for transfer or referral and
her/his concerns should be put into consideration.

5.4 Role of district nutritionist and district health officer in transport of

very ill patients
• Mobilize the community about the problem of transport of sick patients from one facility to the
other
• Explore solutions: 1) establish a local ITC to manage/stabilize complicated malnutrition close to
an epicentre of malnutrition, 2) establish a community fund, 3) have an ambulance, 4) establish
a phone consultation to treat patients without transport, 5) use a national or international NGO
• Organize transport of the critically ill transfer-patients
• Payment for transport (lend money, subsidize or pay for transport),
• Essential medical transport (with verification) from the village to the ITC.
• Train staff about care during the transport:
• The vehicle must be driven slowly and not be crowded
• The driver should stop for 5 minutes every 20–30 minutes during the drive to reduce on the
effects of motion sickness

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 45

 • Water must be available during transportation of patients
• Children should be nursed by the mother
• Do not give drugs to sedate or prevent motion sickness (vomiting) to malnourished patients
(this is particularly important).
• Preposition stocks if seasonally impassable roads are anticipated (stocks of RUTF, training of
village volunteers if team cannot travel).
• Consider having an “emergency kit” for ITC-style stabilization of children prior to transport, if
transport difficult/impossible or if mother refuses to travel.
• Regularly evaluate the outcome of patients that have been transported under difficult
circumstances. Detailed analysis of death during and 48 hours after transport should be
undertaken by the DNO and DHO and actions taken (such as opening a satellite ITC).
• The time of leaving and the time of arrival at the destination facility should be noted on the
transfer form and analysed periodically to determine if this is a major problem within the
district;
• Establish regular meetings between the ITC doctors and the OTC staff in order to facilitate
communication between the different teams and give confidence to the ITC about the judgement
of the OTC/community staff;
• Monthly reports should be checked and updated for deaths occurring during transport. Transfer
times reported on the transfer form should be examined and if they are excessive, ways of
resolving the problem should then be explored.

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6.0 Management of moderate acute malnutrition

6.1 Introduction
This chapter covers the principles, design elements and implementation strategies to manage
MAM as an IMAM component at the community and health facility. The purpose of community-
based management of MAM is to provide decentralized services for acute malnourished patients.
Uganda is a relatively food secure country and therefore management of MAM strategies are linked
to national health programs and are incorporated into other service deliveries such as immunization,
growth monitoring, outpatient services, Antenatal Care (ANC) and Reproductive, maternal,
newborn and child health (RMNCH) which form part of the primary health care infrastructure.
The same approach is used in emergency situation when resources for Supplementary Feeding
Program (SFP) services with food assistance are no longer available and/or where the prevalence
of acute malnutrition has been significantly reduced. MAM children should be linked to other
livelihood programs in the community to prevent relapse.
In chronic food-insecure populations, including humanitarian emergency contexts, supplementary
feeding program is used to treat children, PLW and other vulnerable groups with moderate acute
malnutrition. Where there is no functional SFC, clients should be counselled by health workers
to use the locally available foods to improve their nutritional status or meet their nutritional
requirements1 and prevent them from deteriorating to severe acute malnutrition.

Objectives of management of moderate acute malnutrition

• To prevent deterioration to severe acute malnutrition
• Treatment of moderate acute malnutrition
• To have a continuum of care between MAM and SAM treatment services

Components for MAM management

The basic package for MAM management should include:

• Nutrition assessment and classification

• Nutrition counselling and education
• Care or referral for other illnesses/conditions
• Routine medicines
• Supplementary feeding (Where services exists)
• Food assistance
• Follow-up and linkage to livelihood programs
• Monitoring and management of failure to respond
• Monitoring and evaluation
• Follow-up.

1 The WHO endorsed document– “Golden MH, Proposed recommended nutrient densities for moderately malnourished children, Food Nutr
Bull 2009; 30: S267-S342.”

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 47

6.2 Management of moderate acute malnutrition in children aged 6–59
months in normal situations
Principles of MAM treatment for children
Children with MAM do not usually have the profound changes in metabolism, physiology and
immunological status that occur in severely malnourished children. Hence, the treatment protocol
is different from that for children with SAM. The IMNCI criteria, MoH and WHO clinical guidelines
should be used. Children with MAM should be treated with the non-malnourished children when
admitted to hospital.
Following identification and classification of nutritional status at all entry care points in the health
facility, children 6–59 months and any child aged ≥60 months whose height is ≤120 cm with newly
identified MAM in outpatients should receive routine medication and a bi-weekly clinical follow-
up assessment to monitor progress until full recovery.

• Mothers or caretakers who bring children should be encouraged to be involved in care of

the children and should receive counselling and health and nutrition education for improved
feeding and care practices. Caretakers should also receive health and psychosocial support for
themselves. Mother-to-mother support should be encouraged.
Children with MAM should access treatment and attend monthly community-based and facility-
based nutrition prevention services to prevent deterioration. In addition to treatment, mothers or
caretakers should receive infant and young child feeding (IYCF) support–including counselling,
health and nutrition education and food demonstrations. Children under 2 years of age should
undergo growth monitoring and all children under 5 years of age should be screened for acute
malnutrition.

• In general, the WHO does not recommend routine provision of supplementary foods to
moderately wasted infants and children. However, provision of supplementary foods is necessary
in settings where there is a high prevalence of wasting or food insecurity, at community or
household level such as Karamoja sub-region, refugee settings and emergencies (see section
on SFP in this Chapter). As part of the continuum of care for the individual child, services should
include appropriate treatment of clinical conditions and other modifiable factors, provision of
nutritional counselling and subsequent follow-up to assess response.

Service delivery approach for children with moderate acute malnutrition

Children should be screened for acute malnutrition through active community screening
outreaches and through early identification and classification at health facilities (see Chapter 4).

There are two level service care points:

• Management at the health facility site
• Linkage to trained community CHW/ VHT system and livelihood programs.

Health facility site

• A health facility site is managed by a health service provider.
• Children identified as MAM during community screening are given a referral slip to attend the
health facility site on a specific day and to receive guidance on nutritional management and
basic medical treatment every two weeks until discharge.
The facility service provider should link MAM children under management to community VHTs
and any existing livelihood programs.

48 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA

Linkage to trained community CHWs and livelihood programs
• Trained VHTs should support cases of MAM through specific counselling on the use of energy/
nutrient dense local bio-fortified foods such as orange fresh sweat potatoes and iron rich beans
and other fortified products (fortified oil with vitamin A, maize and wheat flour fortified with
iron).

NOTE: The management of MAM should be available every two weeks on a designated day
until discharge.

Procedure for management of children aged 6–59 months with moderate acute
malnutrition
Admission Criteria
• All children aged 6–59 months and any child with age ≥60 months whose height is ≤120 cm with
MAM classified according to Table 3 in Chapter 4 should be admitted at the health facility or SFP
for management
• MAM children should have ability to eat or appetite; and no medical complications according
to the IMNCI criteria or WHO guidelines.
• Assign the INR-number for any child who meets the criteria and complete the section for
monitoring using the INR (HMIS NUT Form 001) (Annex 1).
Assessment and treatment of medical conditions
• Complete the general information for monitoring in the INR.
• Take diet history and assess for danger signs according to the IMNCI and ETAT procedure
Annex 5.
• If any danger sign is present refer the child to the health facility for medical assessment/
treatment according to the Trigger Actions in management of MAM (see Table 10)
• Provide basic medical treatment according to the Routine Medicines for MAM (see Table 11).
Children transferred from the outpatient program for SAM should not be given routine medical
treatment during MAM treatment.
• Deworming and vitamin A supplementation should be done at least every 6 monthly and inter-
current infections or complications should be appropriately treated using IMNCI criteria, MoH
clinical and WHO guidelines (see Table 11).

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 Table 10: Trigger actions in management of MAM failure-to-respond

Indicator Trigger Action

MUAC <11.5 cm without medical Transfer to OTC

complications and has appetite

<11.5 cm with medical Transfer to ITC

complications

Oedema Present Transfer to nearest OTC

Any danger sign of Present Transfer to nearest health

medical condition facility

Weight changes Weight loss in any follow-up visit, Transfer to nearest health
facility
No weight gain for 2 visits or static
weight for 3 visits

Non-response Not recovered after 3 months Transfer to nearest health

facility to investigate possible
underlying cause

Absence Absent for one visit Home visits or phone calls

Default Absent for two consecutive visits Home visits

Counsel on home-based diet to support catch up growth or provide nutritional management if

available

• Counsel the caretaker on the objective of managing children with MAM. Inform the caretaker
that MAM children require additional energy and nutrient density foods to support catch up
growth.
• This can be achieved by adding at least 25 kcal/kg/day above the energy requirements of a well-
nourished child and should be done by encouraging increased intake of home food.
• Explain to mothers/caregivers the necessity of additional energy and nutrients to support catch
up growth of the child using IYCF feeding recommendations and available local food recipes
(Annex 10,11, and Box 5). Provide specific messages on home-based diet following standard
IYCF feeding recommendations (Annex 10).
• Local bio-fortified staple cereals can be used in the diet together with animal source of food
such as fish, egg, milk etc.
• Encourage the caretaker to ensure proper hygiene and sanitation in the household..

NOTE: Children with MAM living in extremely food insecure conditions where the caregivers
may not be able to provide the additional food or children with chronic illness such as HIV/TB
and cancer may have nutritional food assistance or supplementary feeds that ideally provide
700–1000 Kcal/child/day with 25–30 per cent of energy from fat and 10–12 per cent of energy
from protein (See section on SFP).

50 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA

Make the next appointment
• Give the mother/caregiver an appointment for the next visit after two weeks
• Complete the Monitoring section in the INR.
Follow up visits every two weeks until discharge
• Children and their mothers/caregivers should have an appointment every two weeks at the
outpatient site or with the VHT if managed directly at the community level.
At each visit
• The child should be assessed and counselled on the use of energy / nutrition dense local
foods.
• Take MUAC and weight and examine for bilateral pitting oedema
• Children with danger signs should be referred to the nearest health facility.
• If the child has not gained weight after three 2 weekly visits or if the child is losing weight refer
him/her for a medical check-up at the nearest inpatient care or health facility.
• Children who are enrolled as MAM and then deteriorate or develop oedema should be
transferred to the IMAM services for SAM.

Box 5: Messages on prevention of MAM

The following four essential preventive messages must be given (and practiced) in the
integrated management of acute malnutrition for MAM.
• Exclusive breastfeeding (for 6 months)
• Introduction of appropriate energy and nutrient dense foods, including oil and animal
products from 6 months of age (see Annex 10 for IYCF feeding recommendations of
family diet up to 2 years of age and IMNCI feeding recommendations of family diet after
two years of age) with continued breast feeding up to 2 years or more
• Handwashing with soap before eating and after using the toilet
• Recognizing danger signs.

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52 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA
Routine medication for moderate acute malnutrition (MAM)
Recommended routine medications for MAM children are described in Table 11. Before giving any
ROUTINE DRUG, make sure that the patient has not already received it during a mass campaign
OR at the health centre.

Table 11: Routine medication, vaccines, and supplements

WHAT WHEN WHO DOSE DELIVERY

At presentation 6–11 100,000 IU one
according to months blue capsule
national guideline
Vitamin A* Single dose orally
if not given in past 200,000 IU one
supplementation 12–59 at presentation
6 months or health red or two blue
campaigns with months
capsules
evidence
On second visit if <1 Year Not Given None
NOT taken in the
Albendazole** 12–23
last 3 months. ½ Tablet Single Dose
400 mg Months
DO NOT give if
OR
child is from OTC/ ≥2 Years 1 Tablet Single Dose
SFP/ITP

On second visit if
NOT taken in the <1 Year Not Given None
Mebendazole** last 3 months.
500 mg DO NOT give if 12–23
child is from OTC/ ½ Tablet Single Dose
Months
SFP/ITP
≥2 Years 1 Tablet Single Dose
Check the child’s
Measles Rubella health card
9 months Protocol for EPI Protocol for EPI
Vaccinations and update
accordingly

NOTE: * For children who have not received vitamin A supplementation, continue to give Vitamin
A supplementation according to national protocol.
** All children 12–59 months must be routinely treated (every six months) for worm infections
with Mebendazole or Albendazole (or other appropriate anthelmintic).

Iron and folic acid

All Children aged 6–59 months with anaemia should be treated according to WHO and Integrated
Management of Childhood Illness (IMNCI) guidelines; this should include malaria testing and
treatment.

Other treatments
Other medical treatments, including vaccination for measles follow national protocol and expanded
program of immunization (EPI) update, should be provided through referral to clinic services and
administered according to national immunization guidelines.

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 53

Discharge criteria
All Children should be discharged when they meet the following criteria (see Table 12).

Table 12: Discharge criteria for children managed for MAM

Age Group Discharge Criteria

6–59 months and any child MUAC ≥ 12.5 cm (6–59 months) for two consecutive visits.
aged ≥60 months whose
height ≤120 cm WHZ/WLZ ≥ -2 Z-score for two consecutive visits

Procedure of discharge
• As soon as the child reaches the criteria for discharge, s/he can be discharged.
• Give feedback to the caregiver on the treatment outcome of the child.
Record the discharge date - weight–MUAC, Height, WHZ or WLZ score and the Type of discharge
in the INR, SFP chart for clients receiving SFP services (HMIS NUT Form 009) (Annex 1), and the
Integrated Nutrition Ration card (HMIS NUT Form 007) (Annex 1).

• Check that the immunizations are updated and inform the mother/parent that the child is ready
for discharge.
• Counsel the caregiver on hygiene, sanitation, optimal nutrition, and appropriate food preparation
methods.
• Advise the caregiver to immediately go to the nearest health facility if child refuses to eat or has
any of the IMNCI danger signs:

Type of discharges
Cured: MAM patient reaching the criteria of discharge (see Table 12). Children recovering from
SAM followed up after 3 months. And;

• No other severe classification (according to IMNCI)

• No general danger sign or
• Chest in drawing
• Stridor in a calm child
Defaulter: Absence during two consecutive visits
Death: while the patient is registered in the program or within 24 hours of referral to a health
facility (follow up required after referral)

Transfers
• Medical referral: refer to health facility (see Table 10).
• Internal transfer: transfer to another SFP where such services exist.
• Referral to OTC: refer to an OTC (see Table 10).
Non response: It includes individuals who have not reached discharge criteria after a pre-defined
length of time (usually 3 months), and also patients who fulfil the criteria for failure-to-respond to
treatment and fails to respond to all treatment (see Table 10 and Figure 8). 2

2 For MAM children, home visits to determine in the defaulting is real or the child has died is rarely done due to lack of human resources),
but a random selection of these children should be visited at home to determine the usual causes of defaulting. If during the home visit
54 |the beneficiaryFOR
GUIDELINES decides to re-enterMANAGEMENT
INTEGRATED the program, the OF
beneficiary is re-admitted andINthe
ACUTE MALNUTRITION readmission classified as explained above.
UGANDA
6.3 Management of moderate acute malnutrition in children aged 6–59
months in food insecure and emergency contexts
In food insecure populations, including humanitarian emergency contexts, supplementary feeding
program is used to reduce mortality and prevent further deterioration of children’s nutritional
status. The purpose of Supplementary Feeding Program (SFP) services is to treat cases with
moderate acute malnutrition (MAM) and to prevent acute malnutrition (SAM and MAM), thereby
reducing the mortality and morbidity risks in vulnerable groups. SFP is classified as targeted SFPs
or blanket SFPs, depending on the recipients. A blanket approach provides supplemental food to
everyone within a defined population, regardless of whether children are acutely malnourished; a
targeted approach provides supplemental rations only for malnourished. Emphasis is placed on
ensuring a smooth referral process among IMAM components to provide continuum of care to
clients discharged from ITC, OTC, SFP, and management of MAM.

Types of supplementary feeding

Blanket supplementary feeding (BSF)
BSF aims at preventing acute malnutrition or preventing deterioration of nutrition status among
vulnerable groups, through provision of supplementary food rations to all members of groups at
high risk of becoming malnourished based on the MAM decision tree (Annex 12). A supplementary
ration is provided for everyone in an identified vulnerable group for a defined period irrespective
of their nutrition status. BSF services are usually implemented in combination with the General
Food Distribution (GFD). They can also be implemented as a standalone program while waiting
for the GFD to be established.
BSF is provided for, when the prevalence of acute malnutrition in a given area is high i.e. GAM rate
≥15 per cent without aggravating factors or a GAM rate of 10–15per cent with aggravating factors.
BSF involves provision of the basic energy needs from the food ration to the individuals and has
the purpose of averting hunger in a population. BSF is provided under one or a combination of the
following aggravating circumstances:
The aggravating factors can include:

• Inadequate general food ration. Food availability at household level less than the mean energy
requirement of 2,100 kcal/person/day
• Crude mortality rate above 1/10,000/day
• Measles or other emerging epidemics
• High prevalence of respiratory or diarrheal diseases
• Poor sanitation environment.
Targeted supplementary feeding (TSF)
A supplementary ration is targeted to individuals with MAM in specific vulnerable groups.
The vulnerable groups usually include: Children aged 6–59 months and any child with age ≥60
months whose height is ≤120 cm, pregnant and lactating women with children <6 months of age
in situations of food shortage/chronic food insecurity and emergency settings. Other vulnerable
groups in the general population include moderately malnourished people living with chronic
illnesses such as TB/HIV to meet the additional nutrient needs. It aims at treating cases with
MAM through provision of high energy and nutrient dense supplementary food rations, routine
medications and health and nutrition education messages.

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Organization of SFP services
When to open a supplementary feeding centre/site
In an emergency context, where there are rapidly rising numbers of MAM children or the food
security situation is predicted to deteriorate, SFP services should be established when the numbers
of children with MAM exceed the normal health and social services’ ability to respond to their
needs and there is a risk that they will deteriorate to develop severe acute malnutrition.
A decision about whether to open SFP services should take into consideration; malnutrition rates,
contextual factors, public health priorities, available human, material and financial resources and
the objectives of the implementer (see Table 13 and Annex 12).
The decision making framework needs to be used relative to local circumstances.

Table 13: Decision making framework for opening a supplementary feeding program

Finding Action required

Serious situation:
Malnutrition rate (Global General rations (unless situation is limited to vulnerable groups)
Acute Malnutrition-GAM) Blanket supplementary feeding for all members of vulnerable
≥15 % or 10–14 % plus groups, especially children, pregnant and lactating women
aggravating factors
Therapeutic feeding program for severely malnourished
individuals
Risky situation (alert):
No general rations, but
Global Acute Malnutrition)
(GAM) 10–14 % or 5–9 % Targeted Supplementary feeding for individuals identified as
plus aggravating factors malnourished in vulnerable groups
Therapeutic feeding program for severely malnourished
individuals
Food availability at Unsatisfactory situation:
household level < 2100 Improve general rations until local food availability and access
kcal per person per day can be made adequate
Acceptable situation:
Malnutrition rate (GAM)
No need for population interventions
under 10% with no
aggravating factors Attention to malnourished individuals through regular community
services

It is important to have a plan to establish an SFP site for provision of services, monitoring, follow
up and a focal point for creating linkages with other IMAM components and other services such
as food security and livelihood interventions.

When to close a supplementary feeding center

The closure/exit strategy should be planned from the beginning of the program and steps
taken during the whole program period as well as the final decision should always be made in
consultation with all stakeholders including local authorities and community representatives.
Population level assessment of nutrition status should also be part of the decision to close a
program. Criteria for closing blanket and targeted SFPs are summarized in Table 14.

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 Table 14: Guidance on criteria for closing SFP Services

Blanket SFP Targeted SFPs

• General Food Distribution (GFD) is • GFD is adequate (meeting planned

adequate and is meeting planned nutritional requirements).
minimum nutritional requirements if there • Prevalence of acute malnutrition is <10%
is a specific food in the GFD for young without aggravating factors.
children.
• Control measures for infectious diseases
• Prevalence of acute malnutrition is <15% are effective.
without aggravating factors.
• Deterioration in nutritional situation is not
• Prevalence of acute malnutrition is <10% anticipated, i.e. seasonal deterioration.
with aggravating factors.
• Disease control measures are effective.

Source: Adapted from the United Nations High Commissioner for Refugees (UNHCR) and World Food Program (WFP).
2011. Guidelines for Selective Feeding: The Management of Malnutrition in Emergencies.

NOTE:

• In some situations, where GAM is below 10%, but the absolute number of malnourished
children is still considerable, it might not be appropriate to close the targeted SFP.
• The same might apply in unstable and insecure situations where the SFP could be needed
as a household safety net.
• When feasible and appropriate, a gradual process of handover and integration into local
primary health services, community health program like safe motherhood, HIV/ AIDS, PD
Hearth, immunization, integrated management of childhood illnesses (IMNCI) should be
undertaken.

Requirements and process for setting-up a supplementary feeding site

The SFP can be implemented at a site within a health facility or community, provided the following
requirements are in place:

Location
• Presence of a water source: The water source should be nearby for handwashing, cleaning
equipment and the water should be safe for drinking.
• Close to a health facility: The walking distance should be 2 hours or less on foot
Structure
• A suitable existing structure, preferably at a health facility or, existing structures such as a
house, school, church or shade.
• If none of these is available, construct a simple fenced structure big enough to contain room for
registration and taking anthropometric measurements, conducting health education sessions
Toilet or latrines with a water source nearby for hand washing.
Storage facilities
• A solid structure with concrete and cemented floor, well-ventilated and protected from
dampness, rodents and pests and secure from theft
• There must be space allocated for ventilation and aisles for access: about 80% of a warehouse
floor space is for storage. In bags, 1 tonne of food stuff occupies approximately two cubic

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 57

 meters (2m3). Thus one tonne of SFP food commodity stacked two meters high occupies 1 m2
of floor space.
• The facilities should be easily accessible to trucks at all times
• Food items should be stacked on pallets and not directly on the flour
• Products should be kept at least 40cm away from the walls and 10cm off the floor.
• Access to the warehouse is limited to a few authorized individuals.
• Stocks should be rotated on the basis of first-in, first-out.
• Storage facilities should be protected from rodents and insects
• Regularly cleaned/disinfected.
• Food commodities should be separated from the non-food items.
Security measures and procedures in place for transporting logistics and supplies
• Loading the vehicle at the central warehouse
• The quantities necessary for each centre should be established in advance, based on the
stock remaining in the centre and the estimated needs of the period.
• The storekeeper should record the quantity requested for, sign it, and so should the driver
when the vehicle is loaded. This should also be recorded on the stock cards for the central
warehouse
• Destination to the centre
• A trusted driver and a safe route should be used for this task in order to avoid theft
• Delivery to the centre
• The foods delivered (quantities, state of the sacks, etc.) should be noted in a delivery note
and signed by the driver and the supervisor of the centre
• The delivery note should then be checked by the supervisory team, then compared with that
of the warehouse.
Staffing
An adequate number of qualified staff is essential to run an SFP. The essential staff required to run
the programme include:
Supervisor/Nutritionist:To manage the programme; prepare reports; conduct nutrition counselling,
provide technical assistance and organise trainings for health workers and nutrition assistants as
per the protocols and guidelines; coordinate SFP services with stakeholders and support quality
improvement services; Stock control of both food and non-food items.
Nurse/health worker: To assess and treat a sick MAM child following IMNCI protocol and guideline
and give health counselling.
VHTs/CHWs: To conduct nutrition assessment of clients; assist the nutritionist to follow up defaulters
and carry out home visits, support in the preparation of the individual ration (preparation of the
premix and packaging) during distributions or food demonstrations; provide nutrition education
to caregivers.
Storekeeper: Receive, store and dispatch food and supplies; manage the store records and forecast
food needs.
Records assistants/Data clerk: Compile daily and weekly SFP report and submit to the supervisor
Nutrition assistants/Nurse: explains to the mother on management of MAM; registers the child
in the registration book and applies the criteria of admission, discharge and failure to respond to
treatment; identifies the defaulters and the failure to respond to treatment and informs the CHW/
volunteers; supervises and supports the preparation and distribution of the food rations per the
guidelines; gives health/ nutrition education sessions; gives advice to the mother and facilitate

58 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA

enrolment in basic health services in the health facility e.g. (IYCF counselling, micronutrient
supplementation, prenatal check-ups if pregnant, UNEPI, under 5 clinic and services for the other
children and offer family planning counselling).

Registration and job aids

• Integrated Nutrition Ration card (HMIS NUT Form 007) (Annex 1), referral forms, INR, Supplementary
feeding client card (HMIS NUT Form 009) (Annex 1), stock cards, register for Growth Promotion
Monitoring (at community and health facility levels), list of outpatient and inpatient treatment
sites, laminated posters for the admission and discharge criteria–failure to respond.
• Key messages about the products (RUSF/fortified blended foods) in local languages, dozing
charts, ration distribution charts, information, education and communication materials for
health/nutrition education, dozing charts, ration distribution charts and job aids (Weight for
Height z-score tables) and recipes.

Preparation and distribution of the ration

• Supplemental ration supplies (with secure storage facilities), buckets/basins, salter scale (25kg),
calculator, measuring cup/scoop, soap for washing utensils at the feeding centre, products,
tarpaulin, ropes, safe drinking water, disposable cups, furniture, source of heat, cooking
equipment, thermometer, time watch, scissors, food rations, hygiene and sanitation supplies.
• Routine medicine: Vitamin A capsules; Albendazole/Mebendazole tablets, iron/folic acid tablets
(see Table 11).

Admission criteria and process in SFP

Admission criteria
• Admission criteria for blanket SFPs do not rely on anthropometric indicators. Once the targeted
groups have been defined, individuals who meet those criteria are admitted.
• Admission for targeted SFPs rely on anthropometric indicators of moderate acute malnutrition
in Tables 1 for children in Chapter 4.

NOTE: Children with MAM without medical complications are automatically admitted to
supplementary feeding in emergency situations.

• Children with MAM with medical complications are immediately referred for treatment and/
or further investigation to the appropriate health service and should have access to a nutrient-
dense supplementary food in emergency settings.

Admission process and activities in SFP

Steps in admission process to SFP (see Figure 8)

• Step 1: Conduct triage and fast-track seriously ill patients.

• Give 50 ml of sugar water solution (10per cent sugar solution - one teaspoon of sugar in 50 ml
of safe water.
• Step 2: Take the anthropometric measurements (MUAC, weight and height/length) (Annex 4),
assess for bilateral pitting oedema (Annex 2) and temperature for all patients, including those
referred from the community.
• Check the weight-for-height Z-score (see Annex 6), classify nutrition status based on WFH/L.
• According to the criteria of admission (see Table 3), decide if the child should be admitted in SFP
or OTC.

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 59

• Step 3: Determine if the patient has any signs of a medical problem; if the child has any IMNCI
complications, refer him/her to the nearest health centre immediately for clinical examination
and treatment, “fast track” those obviously ill to the health centre; do not keep them waiting.
• Systematically check for measles vaccination status (if there is a child health card but if no card
available, ask the mother) according to National Guidelines, refer for vaccination.
• Step 4: Explain to the patient how the supplementary feeding intervention functions and how
treatment will be organized, the reasons for admission to the MAM program and expectations.
• Patients will receive medical treatment and a nutrition supplement because s/he is thin for his
height and to prevent him/her deteriorating or getting a complication.
• Explain the expectations and how the caretaker should use the supplement and attend the SFP
(Annex 13).
• Patients on treatment for HIV/AIDS, TB or other chronic illnesses should be counselled to
continue with their medication.
• Step 5: Register the patient information in the INR and give INR-number as per admission
categories. New admission, readmission- defaulter or readmission-relapse (See chapter 14 for
definitions).
• Step 6: Register patient information in the Integrated Nutrition Ration Card (HMIS NUT Form
007) (Annex 1) and give the card to the caretakers.
• Step 7: Dispense routine medications as shown in Table 11.
• Step 8: Link patient to any existing livelihood program within the community
Figure 9: Process and flow of activities at an SFP site Nutritional Rehabilitation in
Supplementary Feeding Program

Ra�on prepara�on area

Entry

A
F
Waiting Area
Food distribu�on area
Triage Exit
Health and nutrition education Food distribu�on
Health and Nutri�on educa�on

B
HIV Counselling and
Anthropometric area
Tes�ng
TB Screen

C D E
Clinical assessment Registra�on point Drug dispensing area

Nutritional Rehabilitation in Supplementary Feeding Program

Figure 10: Process and flow of activities at an SFP site Nutritional Rehabilitation in
Food Supplements usedProgram
Supplementary Feeding in the management of MAM
Supplementary foods must be energy dense, high in protein and rich in micronutrients, culturally
Food Supplements used in the management of MAM
appropriate, easily digestible and palatable.
Supplementary foods must be energy dense, high in protein and rich in micronutrients,
culturally appropriate, easily digestible and palatable.
• In situations where cooking may not be feasible, ready to eat foods or high-energy biscuits
• In situations where cooking may not be feasible, ready to eat foods or high-energy biscuits
can be substituted. However, ready to use foods are not recommended for long-term use but
can be substituted. However, ready to use foods are not recommended for long-term use
but should be provided until the patient has recovered from malnutrition (90 days) or
unless the GAM rate has reduced to less than 15per cent (see section on closing an SFP).
60 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA
• Food supplements are distributed as either ready-to-use foods or fortified blended foods
 should be provided until the patient has recovered from malnutrition (90 days) or unless the
GAM rate has reduced to less than 15per cent (see section on closing an SFP).
• Food supplements are distributed as either ready-to-use foods or fortified blended foods (FBFs).
• Ready to Use Foods can be defined as “energy-dense, mineral and vitamin-enriched foods that
can be eaten directly from the package without being prepared, cooked, or mixed with water.”
Examples of Ready to Use Foods used in MAM include the following:
• Ready-to-use supplementary food (RUSF) is specifically designed to treat MAM in children
6–59 months of age in targeted SFPs. (see Annex 14)
• Lipid-based nutrient spread (LNS) is a term used to describe a type of specialized nutritious
food, i.e., a lipid-based paste. (see Annex 14)
• Fortified Blended Foods (FBFs)3 are a mixture of cereals and other ingredients (such as soya
beans or pulses) that have been milled, blended, pre-cooked by extrusion or roasting, and
fortified with a pre-mix of a sufficient amount and range of vitamins and minerals (UNHCR/WFP
2011 guidelines).
• The improved FBFs now include milk, oil, sugar, a more comprehensive vitamin-and-mineral
profile. Examples include Super Cereal for older children, PLW and adults and Super Cereal
Plus for children aged 6-24 months (see Annex 14).

Types of rations
Supplementary Feeding involves the use of wet and dry rations (see Annex 15). Wet rations are
used in on-site feeding and dry rations are used in take home feeding. Wet rations are used only if
home cooking is impossible and ALL recipients live in vicinity e.g., a refugee camp.
On-site feeding (wet rations) is done through daily distribution of cooked food/meals at feeding
centres SFP and is eaten by the beneficiary in the centre 1–3 times a day. This provides between
500–700 kcals of energy per person per day, including 15–25g of protein (12 per cent) and 15–25g
of fat (30 per cent). On-site feeding is timed so as not to clash with family meals.

Onsite feeding is justified when:

• There is extreme short supply of household foods, firewood, water and cooking utensils
• The security situation does not allow beneficiaries to carry food rations home
• There are a large number of unaccompanied/orphaned children or young adults.
• Wet feeding can be used at the peak of an emergency, when populations have limited access to
fuel and water, where security conditions place people at risk while taking rations home, or for
groups who need additional food but cannot cook for themselves.
Take-home rations (dry rations) are distributed on regular basis (weekly or fortnightly in dry form
or “premix” (i.e. mixture of fortified flour with oil and sugar) to be prepared at home.
Oil and sugar are added to increase energy density and palatability. It must always be mixed with
FBF before distribution.
The frequency of provision will depend on various factors such as the ease of access to SFP sites
and the type of food resources being distributed. Dry rations provide from 1,000 to 1,200 kcals
per person per day and 35–45g of protein (12 per cent) and 34–45g of fat (30 per cent) in order to
account for sharing at home. The ration supplied should enrich the basic diet of the beneficiary
with all essential nutrients to provide the amounts of essential nutrients recommended for the
moderately malnourished child.

3 WFP has renamed its FBFs as follows: CSB+=CSB Super Cereal, CSB++=CSB Super Cereal Plus, WSB+=WSB Super Cereal, WSB++=WSB
Super Cereal Plus, RSB+=RSB Super Cereal, RSB++=RSB Super Cereal Plus

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 61

Supplementary feeding strategies
Escalating strategy
The first strategy is the escalating strategy where the MAM clients are started on Fortified Blended
Foods such as super cereal for PLW and older children and other groups and super cereal plus for
children 6–24 months and their progress carefully monitored.

• Any child that fails to gain weight satisfactorily must be identified early and the food supplement
changed to a product (RUSF) which has a higher nutrient density and whose nutrients are more
readily available with lower levels of anti-nutrients.
• To avoid the inhibitory effects of the anti-nutrients in the normal family food on the absorption
of nutrients from the fortified supplement, these supplementary foods (Lipid based, ready-to-
use-supplementary-food, RUSF) should always be taken between meals and not mixed with
the family food.
A typical basic ration for patients with MAM consists of (see Table 15).

Table 15: Supplementary dry ration required per child or PLW for 2 weeks in targeted SFP

Quantity
Age category Type of Ration Grams/ Person/ Kg/ Person/ Kg/ Person/
Day Week 2weeks
Super-cereal
6–59 months 200 1.4 2.8
Plus
Super-cereal 200 – 250 1.4–1.750 2.8–3.5
PLWS and above Oil 20 0.14 0.28
59 months Sugar 15 0.105 0.21
TOTAL premix4 235 – 285
5
1.65–1.99 3.29–3.99

Source: UNHCR/WFP (2009). Guidelines for selective feeding: The Management of Malnutrition in Emergencies;
Geneva: UNHCR/WFP

• Nutrient-dense supplement strategy

The second strategy is to commence all children on a higher nutrient-dense food such as RUSF
(e.g. RUSF–this is more effective) and monitor the patient–if the patients fail to respond on this
diet then the problem is much less likely to be an unmet nutritional deficiency and may be a social
or underlying medical problem.

• This strategy is particularly suited to the younger MAM child–from 6 months to 24 months.

Routine outpatient medicines used during SFP

• Before giving any ROUTINE DRUG in SFP, make sure that the patient has not already received
it during a mass campaign OR at the health centre. Patients referred from therapeutic care
program already will have received treatment.

4 If ingredients are mixed before distribution, this is known as pre-mix. The aim is to ensure that rations (particularly high-value commodities
such as oil) are not used for the general household or sold. However, pre-mixing can be time consuming, and it reduces the ration’s shelf
life. Once oil and powdered milk are mixed with FBF, the mixture will last a maximum of two weeks before going rancid. Powdered milk is
never distributed alone. It must always be mixed with an FBF before distribution.

5 This contains 1000 Kcal, 36g of protein and 30g of fat.

62 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA

• All patients identified with MAM but who were not referred from the OTC or the ITC should
receive the routine medications.
• The recommended medications in SFP follow the MAM guidance described in Table 11 in this
Chapter. The medications and other treatments should be received either within SFP or through
referral to a health facility.

Routine monitoring
• On admission ensure that there is a record in the register of: the target weight for discharge(for
community outreaches)
• Take the MUAC measurement at each visit (see Table 16).
• Take Weight and height measurements and determine W/HZ scores of children at each visit
(Table 16)
• Assess nutritional status for possible discharge or referral to other services, at each visit.
• Check to see whether the child is progressing normally or requires further referral and treatment
or meets any of the criteria of Failure to respond to treatment.
• Check whether the child has deteriorated to fulfil the SAM criteria (WHZ <-3 Z-score) and if they
do, immediately transfer them to the OTC.
• Ask the mother/caregiver if the child is ill, and if yes refer to the HC for medical check-up
and treatment; if any acute illness, send him/her immediately to the health centre for IMNCI
investigation.
• Record results in the INR and on the integrated nutrition ration card of the patient.
• Give routine treatment at the appropriate visits.
• Conduct health/nutrition education/counselling and explain the change in the nutritional and
medical status to the caregiver.
• Provide counselling on breastfeeding, complementary feeding, nutritional care for sick children,
hygiene, health-seeking behaviours, and other relevant topics, as appropriate.
• Give and record ration at each visit on the ration card of the patient.

Table 16: Summary of the routine monitoring in SFP

Measure Frequency
MUAC is taken Every 2 weeks
Weight is taken using the same/ standardized
Every 2 weeks
scale
Height/Length is measured Every 2 weeks
WHZ or WLZ can be calculated On admission and every 2 weeks
Bilateral pitting oedema Check for bilateral oedema every 2 weeks

Diagnosis and treatment of failure-to-respond

• It is essential to strictly apply the failure-to-respond criteria so that children do not languish in
the SFP for weeks or months without being identified and the cause of failure investigated and
managed.
• It is for this reason that on admission, not only the discharge weight should be calculated but
also the weight at which a criterion for SAM is reached and action needs to be taken urgently.

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 63

64 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA
Criteria for failure to respond to treatment
These are maximum time limits for confirming a patient as a failure to respond to treatment; in
most circumstances action should be taken before these limits are reached.

• Weight loss exceeding 5 per cent of body weight at any time (the same scale must be used)
(Annex 17 for calculating 5 per cent weight loss).
• Any weight loss by the 4th week in the program or at the 2nd visit.
• No weight gains after 6th week in the program or at the 3rd visit.
• Failure to reach discharge criteria after 3 months in the program.

Examine the causes of failure-to-respond and take action!

Reasons for failure to respond
• Problems with the application of the protocol: this should be addressed first.
• Nutritional deficiencies that are not being corrected by the diet supplied in the SFP.
• Home/social circumstances of the patient.
• An underlying physical condition/ illness.
Other causes (see Figure 10).

Step by step procedure for diagnosis failure to respond (see Figure 10)
• Problems associated with application of the protocol; where a substantial proportion of children
fail to respond to treatment (or abandon the program) the proper application of the protocol and
the training of the staff at field level should be systematically reviewed by external evaluation
if possible.
• Any deficiencies should be corrected. Failure to treat the caretakers with due respect is, in most
situations, the commonest cause of defaulting. If it is suspected that “short rations” are being
given or that there is diversion of food, unannounced post-distribution monitoring should be
implemented.
Uncorrected nutritional deficiencies
• When cereal-based fortified blended foods are used (first strategy), the next step is to test
whether the children have an uncorrected nutritional deficiency.
• Change to RUSF (a nutrient dense diet with few anti-nutrients), this is usually done by giving
RUSF in extreme circumstances.
• Explain to the caretaker the importance of not sharing the RUSF.
• Inform the caretaker that RUSF should be taken at least one hour before, or two hours after a
family meal and not mixed with the family food taken by the child.
Social problems
• Where RUSF is being used and the correct instructions have been followed (and the caretaker
confirms that they have been followed), the most likely cause of failure might be social problems
within the household.
• These may include: Influence from family members not to adhere to the feeding protocol,
excessive sharing of the ration with other siblings.
• To test whether any of the social issues are the cause, the child should be fed on the RUSF at
the SFP site and the feeding observed. If the child is eating well or is hungry and yet fails to gain
weight at home, then a major social problem is confirmed.
• Conduct a home visit to hold an in-depth interview with the head/main decision maker in the
household.

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 65

• If the child does not take the test meal and appears not to have an appetite, this may be because
of unfamiliarity with or dislike of the RUSF, then one strategy is to admit the child to day-care
and feed the child under direct supervision for a day or so.
Underlying medical conditions
If the child has no appetite, then there may be an underlying medical problem.

• A careful history and examination should be performed to identify underlying conditions; in

particular, TB, HIV, cerebral palsy, schistosomiasis, other infections, cirrhosis, inborn errors of
metabolism, Down’s syndrome, post-meningitis neurological damage, etc.
Other conditions
If an underlying condition is not found, then the child should be referred to a paediatric facility
with special expertise and diagnostic facilities.

Treatment of the failure to respond to treatment

• After making the diagnosis for failure to respond the next step is to treat the patient. In addition
to your supplementary food commodities such as CSB++ or another blended fortified diet you
will need RUSF which is a higher quality ready to eat supplementary product fortified with all
the nutrients. Follow the steps in chronological order in Figure 6 without omitting any step.
1st step: Give lipid based RUSF, 1000 kcal per day for 2 weeks (2 sachets per day)
This diet will correct all known nutritional deficiencies and in addition, give the additional lacking
nutrients.
2nd step: After 2 weeks, next visit. If he/she now responds to treatment, this means that it was a
nutritional (or social) problem.
Continue the treatment with 2 sachets of RUSF plus the SFP ration for one month. If he/she does
not respond to treatment, this means that the dominant problem is NOT A NUTRITIONAL problem
and that we now have to investigate if it is a social problem.
3rd step: Investigate the home social circumstances; the home visit will pick up some social
problems. It is very important to realize that many/most social problems will NOT be found during
a home visit.

• During the home visit, if a problem is identified that can be alleviated or solved, then deal with
the problem, leave the child at home for follow up and further visits can be made the next
weeks.
• During the home visit, if the identified problem cannot be alleviated or solved at home.
Take any steps necessary to alleviate the problem, such as:

• Admission of the child to a facility.

• Putting more resources into the home.
• Arranging for a different caretaker (relative).
• Getting treatment for the caretaker (e.g. psychiatric/ HIV etc.)
• Link to other sectors such as livelihood /child protection.
During the home visit, if no problem is identified to account for the failure to respond to treatment,
then it is still likely that there is a social problem that has not been identified during the home
visit.

• In this case, admit the child for a trial of feeding for 3 days with feeds under supervision. This
can be in an ITC, in a day-care centre or with “wet feeding” where the child is taken to a health
centre daily to receive food under supervision.

66 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA

• In this case, admit the child for a trial of feeding for 3 days with feeds under supervision. This
can be in an ITC, in a day-care centre or with “wet feeding” where the child is taken to a health
centre daily to receive food under supervision.
4th step: If still the child is not responding to treatment, then he needs to be sent to a facility
4th step: If stillwhere
(hospital) the child is not
there are responding to treatment,that
clinicians/paediatricians thenare
heskilled
needs in
to diagnostics
be sent to aand
facility
have the
facilities to investigate the child.
(hospital) where there are clinicians/paediatricians that are skilled in diagnostics and have the
facilities to investigate the child.
Figure 10: Diagnosis of failure to respond

Failure to respond to treatment

Check the application of the protocol

Change the diet to check for uncorrected nutritional deficiencies

Check for problems with home environment/social problems

Admit for full clinical assessment to search for underlying undiagnosed pathology

Refer to center with diagnostic facilities and senior paediatric personnel for assessment
and further management of the case

Idiopathic–non-response

Discharge criteria in SFP services

Figure 11: Diagnosis of failure to respond
The discharge criteria is described in Table 12 in this Chapter.
Discharge criteria in SFP services
• All the clients should be discharged and followed up by the community workforce–VHTs for 3
The discharge criteria are described in Table 12 and in this Chapter.
months to ensure no relapse.

• All the clients should be discharged and follow-up by the community workforce–VHTs for
NOTE: There is no need to transfer to SFP after OTC services for SAM children as the criteria
3for
months to ensure
discharge is theno relapse.
same. However, during OTC services, if there is a problem with food
security or in an emergency situation a “protection” ration (usually fortified blended foods
Note: There
such isasno need
CSB tofamily
or a transfer to SFP
ration withafter OTC pulse
cereals, servicesandfor
oil)SAM children
should as the
be given to criteria for to
the family
dischargeprevent
is the sharing of the RUTF
same. However, withOTC
during otherservices,
family members.
if there isThe caretaker
a problem must
with besecurity
food told thatorthis
ration is not for the patient but for the rest of the family.
in an emergency situation a “protection” ration (usually fortified blended foods such as CSB or
UNIMIX or a family ration with cereals, pulse and oil) should be given to the family both to assist
this family of a malnourished child and to prevent sharing of the RUTF with other family members.
6.4 Management
The caretaker must be told thatof moderate
this ration is notacute
for themalnutrition forrest
patient but for the pregnant andonly.
of the family
lactating women in normal situations
Acutely malnourished PLW with infants less than 6 months may be enrolled in an outpatient care
where resources permit and capacity is sufficient to manage the caseload. The management of
malnourished PLW options are the same as those for children with MAM.

Principles of care
• Pregnant and lactating women with infants under 6 months of age need additional energy
requirements in addition to the average 2,200–2,400 Kcal (depending on the basal metabolism
69
and physical activities).
• Pregnant women are expected to gain 300 gm per week in the second and third trimester.
• For lactating mothers in the first 6 months the additional energy requirement is estimated at:
• Well-nourished 500 Kcal /day
• Under-nourished 675 Kcal /day.

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 67

68 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA
• Management of MAM in PLW improves maternal nutrition during foetal development and for
the first 6 months of the infant’s life while the mother is breastfeeding the infant, and therefore
is an essential part of the IMAM services.
• Routine assessment of maternal nutrition status of PLW in the community by the VHTs and in
the Reproductive Maternal Newborn and Child Health (RMNCH) clinics is critical.
• Pregnant women should receive maternal nutrition counselling and support during the prenatal
care visits, e.g., micronutrient supplementation, counselling, health and nutrition education,
breastfeeding preparation and screening.
• Lactating women with an infant under 6 months of age should attend monthly nutrition services
in the community and the health facility for growth monitoring, infant and young child feeding
(IYCF)–including counselling, health and nutrition education, and food demonstrations and
screening for acute malnutrition.
• PLW should receive psychosocial support. Mother-to-mother support should be encouraged.
• In circumstances where outpatient management of MAM for PLW is not possible, maternal
nutrition and IYCF should be strengthened at the facility and integrated in community nutrition
services.
• In settings and situations where there is a high prevalence of wasting or food insecurity, at
community or household level, refugee settings and emergencies, PLW identified with moderate
malnutrition should receive a fortified food supplement (Super Cereal) on a monthly basis until
recovery or until the infant reaches 6 months (see SFP for PLW in this section).
• PLW identified with severe malnutrition should receive fortified supplement and referred to
hospital for further investigation as continuum of care.

Management processes of MAM for PLW

• All MAM PLW with infants less than 6 months should be admitted into the program (see Table 17).
• PLW with MUAC < 19.0 cm, or presence of bilateral pitting oedema should be referred to hospital
for further investigation.
• If the woman meets the criteria for admission, assign the INR-number. If SFP services are
available, complete the admission details on the SFP Chart HMIS NUT Form 009 and the
integrated Nutrition ration card HMIS NUT Form 007 (Annex 1).

Table 17: Admission and discharge criteria for PLW with MAM

Admission Criteria Discharge

Pregnant women/ lactating Pregnant women MUAC ≥ 23.0 cm for two consecutive visits,
women with infants less or
than 6 months MUAC ≥
19.0 cm and < 23.0 cm For lactating women with infants less than 6 months: MUAC
≥23.0 or
When Infant reaches 6 months of age.

Nutritional management
• Take a dietary history and determine immunization status and pregnancy care.
• Provide basic medical care according to the Routine Medicines for PLW (see Table 18).
• Provide advice on diet including the need for the following:
• Add an extra meal to your three main meals.

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• Add oil/ghee to your food
• Eat animal foods (fish, eggs, meat, liver and milk), and/or pulses; green leafy vegetables, orange
and yellow fruits and vegetables.
• Give an appointment for the following visit in two weeks
• Complete the INR monitoring section, SFP Chart and the integrated Nutrition ration card.

Table 18: Routine outpatient medicines for pregnant and lactating women

WHAT WHEN Dose Duration

Folic acid In pregnancy 5 mg daily Throughout 1st
Trimester, ideally
before conception
if feasible
Ferrous + Folic acid In pregnancy Ferrous 200 mg + Folic acid Throughout
400 µg one daily pregnancy
Mebendazole In pregnancy 500 mg single doze Second Trimester
Sulphadoxine/or In pregnancy Sulphadoxine/or Every month from
Pyrimethamine: Pyrimethamine single 13 weeks to end of
Intermittent dose (3 tabs) (IPTb) with the pregnancy
preventive treatment an interval of one month
of malaria (IPTp) between doses

Follow-up visits for malnourished PLW

• PLW should have an appointment every two weeks at the outpatient site or with the VHT if
managed directly at the community level.
• At each visit, the PLW should be assessed and receive the advice appropriate diet.
• At each visit MUAC and weight should be taken and recorded.
• Check adherence with medical treatment, dietary advice and discuss any issues.
• Women with any medical complications should be referred to the nearest health facility.
• PLW should stay in the program until the infant is 6 months of age (180 days) and link growth
monitoring.

Discharge procedure for pregnant and lactating women

• Give feedback to the PLW on the treatment outcome (see Table 19).
• Take MUAC measurements and assess for oedema.
• Update the INR and SFP Chart and the integrated Nutrition ration card with the treatment
outcomes (see Table 19).

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 Table 19: Type of discharge for pregnant and lactating women

Type of exit Definition

Cured PLW fully recovers and meets the discharge criteria – MUAC ≥ 23.0 cm and
no oedema for two consecutive visits

Defaulted Absent for 2 consecutive visits

Died Died while enrolled in program

Non cured PLW who have not reached discharge criteria after a pre-defined length of
time (usually 3 months), and also patients who fulfil the criteria for failure-to-
respond to treatment and fails to respond to all treatment.

Transfers Medical referral: refer to health facility

Internal transfer: transfer to another SFP
Referral to OTC: refer to an OTC

6.5 Management of moderate acute malnutrition in pregnant and

lactating in food insecure and emergency contexts
In food insecure and emergency contexts, pregnant and lactating women are managed in
supplementary feeding program. The SFP services, organization and procedures for PLW are the
similar to children 6–59 months’ age.

SFP services for PLW

• Give moderately malnourished PLW superceral (every two weeks )(see Table 15).
• Counsel PLW on the preparation of the porridge using superceral (Annex 13).
• Ensure pregnant women receive iron folate supplementation as a routine (see Table 18).
• Conduct , health and nutrition education sessions
• Refer PLW to health facilities close to their homes for growth monitoring, maternal nutrition
and IYCF education sessions
• Record a new admission in the INR and assign a unique INR-number that should be recorded
on all documents.
• Use the SFP client chart to indicate individual information on assessment, treatment plan and
progress.
• Indicate the amount of food supplement provided on the Integrated Nutrition Ration card.

Monitor progress at follow up

At each visit:
• Take MUAC measurements and monitor progress.
• TConduct nutrition counselling and education sessions.
• TRecord information in the INR and Supplementary feeding chart ANNEX 1.

Discharge criteria
Refer to the Table 17 for discharge criteria.
For the discharge process see section for discharge process for MAM PLW in normal situations.

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6.6 Management of moderate malnutrition in older persons in normal
situations
Moderately malnourished older children, adolescents and adults require an additional 20–30 per
cent caloric intake. In addition to their normal food intake they should consume extra meals
snacks.

Initial assessment and management

• Determine and treat the underlying cause of malnutrition. If the client is HIV positive or
with Tuberculosis, refer to the HIV/AIDS or Tuberculosis clinics for further evaluation and
management, and the Uganda Ministry of Health Consolidated guidelines for Prevention and
Treatment of HIV (2018), and the National Tuberculosis and Leprosy Guidelines.
• Assess dietary intake, food access and provide appropriate support if client has problems.
• Offer nutritional counselling and information for weight gain. Counsel client to consume
• 20–30 per cent more energy from family foods based on current weight.Targeted supplementary
feeding is recommended in HIV and TB or in other similar chronic illnesses because such
illnesses render a person less productive as the infective agents derive energy requirements
from the patient.
However, this does not replace the locally available food to meet the required energy needs.
For all chronically ill clients with MAM, it is important that supplementary feeding is given as
recommended to prevent excessive wasting as well as ensure adherence to treatment at a
rate of 50 Kcal/kg body weight and offering a maximum of 1000–1200 kcal per day. Moderately
malnourished individuals with chronic illnesses, especially in food-insecure situations, may
require food supplements, in addition to antiretroviral therapy, so that appropriate foods are
consumed to support recovery.
• In situations where SFP is available and recommended (emergencies, famine, refugee settings
and HIV/TB or other applicable chronic illnesses), give client available fortified blended flour
(FBF) enriched with oil, vitamins and minerals to meet the daily recommended intakes and to
last until the next visit collection or until the next antenatal visit for pregnant mothers.
• Link or refer to community or home-based nutritional interventions or food security initiatives,
if possible.
• Make an appointment for review after two weeks or at next visit to collect medication as
necessary.
Follow-up
• Monitor weight and changes in eating patterns on each visit.
• Counsel client to increase energy intake (have extra meals and snacks ; add groundnuts paste,
eggs, or milk to enrich food and spices or lemon juice to improve flavour) to enable them meet
their nutrient requirements.
• Give appropriate micronutrient (iron, folate, vitamin A, zinc) supplement as guided by the
clinician.
• Counsel client on 1) the need for monthly weighing, 2) increasing energy density of the diet
at home, 3) managing HIV-related symptoms through diet, 4) medicine-food interactions, 5)
maintaining good sanitation and hygiene, especially safe drinking water, and 6) exercising to
strengthen muscles and improves appetite.
• If the client has not gained weight for 3 months, refer for medical examination or conduct
nutrition assessment, counselling, and support.
• The client attains recovery from moderate malnutrition when the BMI is ≥17.5 kg/m2 or >23.0
cm for pregnant and lactating women and for two consecutive visits, no weight loss, and no
clinical signs of symptomatic disease.

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On recovery during MAM treatment, transition client to normal nutrition plan:
• If client is on ART, ensure s/he is adhering to treatment and managing diet-related symptoms.
If not, counsel client as needed.
• Counsel client to eat enough a variety of adequate and nutritious food to meet the 10 per cent
increase in energy and nutrient needs caused by chronic illness such as HIV/TB (see Table 20). If
it is not possible to eat a variety of nutritious food, give appropriate micronutrient (iron, folate,
vitamin A, zinc) supplement as guided by the clinician.
• Counsel client to eat a variety of foods. If this is not possible, give appropriate micronutrient
(iron, folate, vitamin A, zinc) supplement as guided by the clinician.
• Counsel client on 1) the need for monthly weighing, 2) increasing energy and nutrient density
of the diet at home, 3) managing HIV-related symptoms through diet, 4) medicine-food
interactions, 5) maintaining good sanitation and hygiene, especially safe drinking water, and 6)
exercising to strengthen muscles.
• Pregnant and lactating women with chronic conditions such as HIV/TB are eligible for a
supplementary food at any point in pregnancy and will not be discharged until completion
of pregnancy. Reassessment can be made for lactating women after the six months of the
exclusive breastfeeding period (see Management of MAM in PLW).
• Link client to programs that provide food security or livelihood support.
• Review client’s progress in 2–3 months or earlier if problems arise and ensure community
follow-up.

Table 20: Energy needed per day in the context of HIV

Age in years Energy (kcal) needed per day +20 to 30% because of HIV in
moderately malnourished clients

15–17 2,800 + 700 because of HIV

18+ 2,170 to 2,430 add 525 to 600 because of HIV

Pregnant and post-partum 2,455 to 2,670 add 525 to 600 because of HIV
women
energy (kcal) needed per day + 10% because of HIV in normal
clients

15–17 2,800 + 280 because of HIV

18+ 2,455 to 2,670 add 225 because of HIV

Pregnant and post-partum 2,455 to 2,670 add 225 because of HIV

women

6.7 Management of moderate acute malnutrition in older persons in food

insecure and emergency contexts
• Supplementary feeding program is recommended during emergencies or in chronic food
insecure population and in MAM patients with HIV/TB or other chronic illnesses.
• Admission for targeted SFPs rely on anthropometric indicators of moderate acute malnutrition
in Table 8 in Chapter 4 for older children, adolescents, and adults; and for pregnant lactating
women Table 7.
• Although there are no normative WHO guidelines for use of MUAC among persons older than
5 years of age, the Ministry adopted use of MUAC at community level to assess older children,

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 adolescents, and adults in difficult situations such as during emergencies, famine, or refugee
crises, or when reliable scales and height boards are not available (see Table 1).
• For the health facility level during emergencies or when reliable scales and height boards
are not available for older children, adolescents and adults can be classified as having severe
malnutrition (“severe undernutrition”) and referred to therapeutic feeding if they have a MUAC
<16.0 cm or a MUAC 16.1–18.5 cm plus one of the following (see Table 1):
• Pitting oedema up to the knees on both sides; OR
• Cannot stand; OR
• Sunken eyes
• Evidence/history of recent weight loss.
This can be used to identify patients for admission to therapeutic feeding.

Targeted supplementary feeding in HIV/Tuberculosis and other chronic illness

In situations where SFP is available and recommended (emergencies, famine, refugee settings
and HIV/TB or other applicable chronic illnesses), give client available fortified blended flour (FBF)
enriched with oil, vitamins and minerals to meet the daily recommended intakes and to last until
the next visit collection or until the next antenatal visit for pregnant mothers.
Targeted supplementary feeding (TSF) is recommended if available in HIV and TB or in other
similar chronic illnesses because such illnesses render a person less productive and increases
their energy and nutrient requirement.
TSF does not replace the locally available food to meet the required energy needs.
For all chronically ill clients with MAM, it is important that supplementary feeding is given as
recommended to prevent excessive wasting as well as ensure adherence to treatment at a rate of
50 Kcal/kg body weight and offering a maximum of 1000 -1200 kcal per day.
Moderately malnourished individuals with chronic illnesses, especially in food-insecure situations,
may require food supplements, in addition to antiretroviral therapy, so that appropriate foods are
consumed to support recovery.

NOTE: Children with MAM and without medical complications are automatically admitted to
supplementary feeding in emergency situations.

Children with MAM and with medical complications are immediately referred for treatment
and/or further investigation to the appropriate health service and should have access to a
nutrient-dense supplementary food.

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7.0 Outpatient therapeutic care for management
of severe acute malnutrition without medical
complications

7.1 Introduction
• Outpatient therapeutic care (OTC) aims to provide home-based treatment and rehabilitation for
children with SAM who have an appetite and no medical complications.
• The OTC can function either as a static or mobile service to ensure good access and coverage
so that as many acutely malnourished patients as possible can access treatment within a day’s
walk from and back to their homes.
• Static and mobile OTC services should be integrated into routine service delivery, even in
emergency situations.
• Health facilities or facility outposts should run OTC services on a weekly basis, but sessions can
be conducted every 2 weeks when:
• Poor access or long distance to the health facility increases the opportunity cost for the
caregivers and prevents weekly participation.
• Seasonal factors such as the harvest or planting seasons prevent caregivers from attending
weekly.

7.2 Organization of outpatient therapeutic care services

Location of a Health Centre and its organization

• In a community, OTC should be organized from health centres, health posts or even non-clinical
facilities that are as close as possible to the patients’ homes.
• An ITC should run an OTC for its own facility; however, patients that have been admitted to
the ITC should not be transferred to the associated OTC if there is another OTC closer to the
patient’s home.
• There should be many satellite OTC sites within walking distance of 5 km to 10 km close to or
within the community in places where malnutrition is common to reduce on distance and time
as these factors affect coverage, defaulting rate, and reputation of the whole IMAM services.

Structure of OTC services

• The OTC site requires a physical structure (the health facility) with: 1) a sheltered waiting area,
2) a place to receive the patients and do anthropometry and the appetite test, 3) a place for
the health worker to see and examine the patients and 4) a secure store for the therapeutic
products and a pharmacy;
• Safe drinking water should be easily accessible.
• The OTC is normally conducted in the health facility structure and run for one or two days per
week. However, it can also be established in a school, community centre or private house.
Where there is no suitable structure, OTC can be run from tables set up under shade in the
open, but each function must have its own space. Any established community OTC outpost
should be linked to a nearby health facility.
• Communication facilities: It is important that each structure is able to get in touch with the ITC,
the other OTC teams in the district, the focal points at village level and the District Nutritionist/
Focal Point (up-to-date lists of names, addresses and phone numbers need to be maintained
at district level and distributed to each OTC supervisor, the Outreach workers and village focal
points).

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Process for institutionalizing OTC services at a health facility
• Disseminate the guidelines at the health facility and to the Health Unit Management Committee.
• Build capacity of the key staff in management of acute malnutrition.
• Identify and assign a focal person.
• Identify key stakeholders including community partners
• Identify and mobilize resources including financial, human (knowledgeable and skilled), space,
equipment, supplies, and tools
• Mobilize, sensitize and involve the community
• Make the OTC integrated and functional in all outpatient services at the facility
• Creating linkages within IMAM care points (network)
• Link into the M&E and Quality Improvement (QI) processes.

Organization of the OTC visits

During the OTC days, the Outreach Workers or village volunteers/focal points (at least two) come
from their communities, in rotation, to help the health workers of the centre to:

• Take anthropometric measurements and assess for oedema.

• Perform the appetite tests
• Register the patients
• Receive refresher trainings
For new referrals (see Chapter 4), after the anthropometry and appetite test, the health worker
does:
The medical check-up,

• Discusses with the caretaker the mode of treatment,

• Explains the procedures, and
• Prescribes the RUTF and routine medicines.

Frequency of the visits

• Each OTC site should have an up-to-date list of the day(s) of the week, the hours when the site
is open and functional, the name and phone number of the person responsible.
• The OTC supervisor should have time to visit each village periodically, liaise with the Outreach
workers and volunteers and to run meetings where all the village focal point personnel attend.
• Normally the OTC is run on one or two days per week when children who have been screened
in the community or in OPD care points at the facility are seen at the OTC site.
• For remote villages, two-weekly outreach activities can be arranged. This maintains contact
between the community and the health team and greatly increases compliance with the
treatment.
• The remote villages should be a priority for mapping and screening of malnutrition, and there
should be regular contact with the community volunteers as worst cases of malnutrition are
usually found in these places.

Outreach services or mobile teams during OTC

Where and When
• Where outreach mobile health clinics are operating, especially in an emergency situation and
where the population is widely dispersed, with a relatively low population density, or a nomadic
population, the management of severe acute malnutrition should be done by outreach or mobile
team.

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• A vehicle for mobile services should be equipped with OTC service package as well as, vaccines,
IMNCI medicines and other essential services.
• The staff should essentially be trained in IMNCI/Reproductive Maternal and New-born Health
(RMNCH) and immunization (UNEPI) and should be able to provide these activities as well as
IMAM management and follow up of HIV and TB programs.

Frequency of outreaches
• The team visits pre-arranged sites on a weekly basis.
• Screening is done using only the MUAC tape and checking for oedema.
• Patients fulfilling the admission criteria are assessed and given a weekly RUTF ration (if they
pass the appetite test and medical check).
• Since height is not taken, their weight is taken until they reach their target MUAC.
• A proper referral system and transport is important for the patients that need inpatient care
(see Chapter 5).

Activities and roles and responsibilities of health workers during OTC

A nurse or clinician is responsible for supervision of the program at the OTC site and the
communities within its catchment area.

Prerequisite
• The clinician, if not possible, a trained clinical nurse or nutritionist with skills in clinical aspects
of acute malnutrition, can diagnose the medical complications competently plus appropriate
referral.
• Nurse or nutritionists should only be in charge of OTCs where clinical expertise is readily
available (e.g. urban areas).
• OTCs in more remote sites must be run by a trained clinical nurse qualified to make clinical
decisions as some of the patients need stabilization before transport.

The trained health worker has to:

• Admit the patients according to the criteria of admission (SAM patients with no medical
complications and have passed an appetite test), fill the charts, register (see Chapter 4) and
give the INR-number.
• Give the routine drugs.
• Give the RUTF and inform the caretaker about the proper use of the RUTF.
• Follow up the patients every week.
• Examine the weight changes.
• Fill in the routine follow up sections of the OTC chart and decide if any further action is needed.
• Diagnose the patients who have failure-to-respond and take the appropriate decisions: home
visit, repeat appetite test, supervised feeding trial, and transfer for inpatient treatment if there
is need.
• Participate in monthly coordination meeting at the district level. At this time, the monthly HMIS
105 OPD report of the OTC is given to the District, the therapeutic products needed for the
following month are collected if needed, and other problems should be discussed to ensure
quality of care is maintained and to undertake in-service training and supervision.
• Organize a meeting with all her/his outreach workers each month to learn about and deal with
any problems, collect screening data and to give refresher training.
• Handle the procurements, storage and distribution of commodities.
The tools for OTC services are listed in Annex 3.

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7.3 Outpatient therapeutic care for management of severe acute
malnutrition in children aged 6–59 months
The procedures of admission are explained in Chapter 4. There are two types of admission to the
OTC:

1. New admissions
• New admission from active and early identification or self-referral.
• Readmissions: readmission-Relapse and Readmission- defaulters.
• Relapse (within 2 months or less after previously being discharged as cured within the same
financial year).
• Defaulters: Patients who after default with less than 2 months of absence within the same
financial year.

2. Admissions of patients already under treatment for SAM

• Internal Transfer from another OTC (treatment already started with an INR-number)
• Internal Transfer from an ITC (transfer form with an INR-number and the treatment given)
• Return from an ITC back to the OTC (transfer form with an INR-number, chart & already
registered)

NOTE: There is need for functional communication and referral system between the OTC
site and ITC so that patients can quickly and easily be transferred from ITC to OTC as they
enter the rehabilitation phase (phase 2) and OTC patients that fail to respond appropriately
or who develop a complication can be transferred (temporarily) to ITC. Such transfers are
not “discharges” from the IMAM Services.

A patient should always be treated at home where there is:

• A capable caretaker,
• The caretaker agrees to outpatient treatment,
• There are reasonable home circumstances,
• There is a supply of RUTF,
• An OTC program is in operation in the area close to the patient’s home,
• The classification criteria for home treatment are met.

NOTE:

• If a patient being treated as an outpatient deteriorates or develops a complication, he/

she should be transferred to ITC for a few days before continuing their treatment again in
OTC.
• The In-and-Outpatient services of IMAM should always be integrated and with regular
meetings so that there is smooth transfer of patients from one care to another.
• The same registration number should be retained throughout the movements (the INR–
NUMBER). A patient transferring from one care to another is still under the IMAM services
for this episode of severe malnutrition and should be regarded as an “internal” transfer to
another care of the IMAM services.

Nutritional rehabilitation during OTC

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The nutritional rehabilitation is home based, with the children attending OTC sessions on a weekly
basis to monitor their health and nutritional status and to replenish RUTF stocks.

Amounts of RUTF to give per day and week

• Provide 170 Kcal per kg of bodyweight per day of RUTF. Use the RUTF reference table (see Table
21) to determine the amount of RUTF to give at each weekly visit, based on the child’s weight.
• Explain to the caregiver how much RUTF the child should consume daily.
• Give the required RUTF ration to the caregiver and write the amount on the RUTF ration card.
• Sensitize the mother on the importance of breastfeeding and emphasize that the child should
always get breastmilk before they are given RUTF and also on demand, for children who are
still breastfeeding (Box 6).
• Explain to the caretaker how to give the RUTF at home (Box 6).
• The RUTF can be kept safely for several days (two–three days) after the package is opened
provided it is protected from insects and rodents.
• It is also used in day-care management when RUTF is given for feeding overnight, at weekends
or during staff shortages.

Table 21: Table of amounts of RUTF to give per day and week in OTC

Class of weight (kg) RUTF Paste RUTF Sachets (92g)

Grams per day Grams per week Sachets per day Sachets per week
3.0–3.4 105 750 1¼ 8
3.5–4.9 130 900 1½ 10
5.0–6.9 200 1400 2 15
7.0–9.9 260 1800 3 20
10.0–14.9 400 2800 4 30
15.0–19.9 450 3200 5 35
20.0–29.9 500 3500 6 40
≥ 30.0 650 4500 7 50

NOTE 1: The amount given during the first two weeks can be reduced by about 15 per cent–
20 per cent to reduce on the likelihood of a few children developing complications during the
early phase of treatment (see sections on refeeding diarrhoea and “refeeding syndrome”) as
a potential hazard if a patient who has been taking far less than the requirement suddenly
takes large amounts of the diet, or the mother forces the RUTF that has been dispensed into
her child at the start of treatment. Sudden large increases in intake at the start of treatment
are dangerous and may account for some of the deaths in the OTC program).

NOTE 2: This is equivalent to about 170 Kcal/kg/d. On this amount the child has sufficient
RUTF to gain weight at up to 14 g/kg/d. This is never achieved in outpatient programs where
the rate of weight gain varies from about 2 to 10g/kg/d, indicating a total energy intake by
the child of between 110 and 150kcal/kg/d and extensive sharing within the family. Giving
more RUTF encourages sharing within the family as the other members become habituated
to consuming the “left-overs”, it also increases the cost of the program considerably. If stocks
of RUTF are short, then the amount given could safely be reduced by about 15 per cent–20
per cent. It is better to give all children adequate amounts of RUTF, than excess to some and
none to others. The amount dispensed should never fall below that required to maintain
modest amounts of weight–see Annex 16.

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 Box 6: Taking RUTF at home: Key messages for the caretaker

• For breastfed children, always give breast milk before the RUTF.
• RUTF is a food and specifically packaged medicine for malnourished children only and
thus should not be shared.
• An opened packet of RUTF can be kept safely and eaten at a later time in a protected
container against insects and household rodents.
• Wash the patient’s hands and face with soap before feeding.
• Explain that malnourished children often only have moderate appetite during the first few
weeks and eat slowly. They must be fed separately from any other child in the household.
Attend to the child every 3–4 hours at least and encourage the child or give small regular
meals of RUTF at these times. Tell the mother how much her child should eat each day
(this is given in the reference Table 21).
• Explain that for the first week or two, the child will probably not finish all the RUTF
given. The mother should not be upset by this as excess has been given, but as the child
recovers his/her appetite will improve so that all the diet will be taken later on in recovery.
Uneaten RUTF should not be taken by other members of the family but returned to the
OTC–as the child improves s/he will start to consume nearly all the food.
• Explain that RUTF is the only food the patient needs to recover during her/his time in
the IMAM services. It contains all the ingredients that the patient needs to recover and is
really like a special medicine. It is not necessary to give other foods.
• Tell the caretaker that there are special medical nutrients and milk powder inside the
RUTF, and that it is not just peanut butter. Tell her that all the nutrients are needed by the
child to recover and that if the child does not take sufficient RUTF then they will not get
enough of these medical nutrients. Normal food does not contain the right amounts and
balance of these nutrients.
• Explain that the illness has damaged the child’s intestine so that the normal family food
is not sufficient for the child and may even cause some diarrhoea. Tell the mother that
some common foods will delay the recovery of her child. If the child asks for other foods
small amounts can be given but she should always give the RUTF before other foods
and at a different time from regular family meals.
• Never mix the RUTF with other foods. Most cereals and beans contain anti-nutrients and
inhibitors of absorption that make the special nutrients in the RUTF that the child needs
to recover unavailable for the child. If other foods are given they should be given at a
separate time from the RUTF.
• Explain that the child should NEVER be force-fed and always offer plenty of clean water
to drink while eating RUTF.
• Explain that the caretaker should have an attentive, caring attitude while feeding the
baby; talk, sing and play with the child to stimulate appetite and development (ALWAYS
offer the child WATER with and after the RUTF to satisfy thirst).
• Return to the health facility whenever the child’s condition deteriorates or if the child is
not eating sufficiently.

NOTE: For OTC services, if there is a problem with food security or in an emergency situation
a “protection” ration (usually fortified blended foods such as CSB or UNIMIX or a family
ration with cereals, pulse and oil) should be given to the family both to assist this family
of a malnourished child and to prevent sharing of the RUTF with other family members.
The caretaker must be told that this ration is not for the patient but for the rest of the family
only.

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Procedure for transferring patients from ITC to OTC
• A transfer form should be filled with the INR–NUMBER
• Sufficient RUTF should be given to last until the next day of operation of the OTC site closest to
the child’s home (see Table 21).
• The ITC should inform the OTC site by phone when a transfer is being made.

First direct admission to OTC

The amount of RUTF should be adequate for the next visit to the OTC distribution site (see Table 21).

Routine Medicines
Systemic Antibiotics
• Give systemic antibiotics to severely malnourished patients, even if they do not have clinical
signs of systemic infection to treat the bacterial the small bowel bacterial overgrowth.
• Antibiotics provided to patients in OTC include oral amoxicillin (see Table 22). 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. Co-trimoxazole is
inadequate for the severely malnourished children because it is not active against small bowel
bacterial overgrowth and the levels of resistance reported from most countries are very high.

NOTE: Because many children with bilateral pitting oedema have free iron in their blood,
bacteria that are not normally invasive, such as staphylococcus epidermidis, most enteric
bacteria and “exotic bacteria” can cause systemic infection or septicaemia. If oedematous
children are treated as outpatients, they must receive routine antibiotics.

• Do not give systematic antibiotics to children transferred to the OTC from ITC or have been
transferred from another OTC because such children will have already received a course of
antibiotics.
• There are no recommendations for use of “second-line” antibiotics in outpatient treatment
services as children who require second-line antibiotic treatment have significant infections
and should be treated in ITC (except for some patients whose caretakers refuse to be admitted
for ITC).
• Give the first dose under supervision and tell the mother that the treatment should continue for
a total of 7 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 caretakers (for children < 5kg).
Malaria
• Refer to national guidelines for asymptomatic malaria or malaria prophylaxis.
• Quinine tablets should never be used in the severely malnourished.
• Refer symptomatic malarial cases for inpatient management.
• Where complicated patients refuse admission to inpatients, treat them with the regimen
recommended for inpatients (see section on complications).
• Give insecticide treated bed nets in malaria endemic regions.
Deworming
• Give deworming tablets to patients transferred from ITC to OTC and those admitted directly to
OTC at the 4th outpatient visit at the same time as the measles vaccination (see Table 22).
• Deworming tablets are only given to children aged 1 year and above (who can walk).

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Measles
• Give measles-rubella vaccine to children who do not have a vaccination card during their 4th
visit at 9 months in line with the Uganda National Expanded Program Immunization guidelines
or at over 6 months when there is measles outbreak.
• Give a second dose to those that have been given measles-rubella 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 measles6 and will not be exposed to nosocomial infection.

NOTE: Measles-rubella 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
• Give a single dose of vitamin A on the 4th visit to all children (see Table 22).
• At this time, there should be sufficient recovery to store the massive dose of vitamin A in the
liver. There is sufficient vitamin A in the RUTF to treat sub-clinical vitamin A deficiency.7 Do not
give high doses of vitamin A routinely on admission in OTC.
• 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 to all children vitamin A supplements.

6 If they are incubating measles, they are likely to fail the appetite test.

7 Do not give vitamin A routinely to the severely malnourished on admission to the program. Studies in Senegal and DRC show that there is
an increased mortality in those with oedema and increased respiratory tract infections in both oedematous and wasted children.

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 Table 22: Summary of OTC routine systemic medicines and treatment dosages

Amoxicillin Treatment Dosage

Weight range Amoxicillin (50–100 mg/kg/d) Dosage–twice per day
Kg in mg Cap/tab (250mg)
<5 kg 125 mg * 2 ½ cap.*2
5–10 250 mg * 2 1 cap * 2
10–20 500 mg * 2 2 cap * 2
20–35 750 mg * 2 3 cap * 2
> 35 1000 mg * 2 4 cap * 2
Note: Syrup can be given but check the strength per 5 ml first (there are 2 strengths, 125 mg
and 250 mg). Ampicillin is given in the same dose as amoxicillin.
Deworming Treatment Dosage
Age <1 year 1–< 2 years >= 2years
Albendazole 400 mg Not given ½ tablet 1 tablet
Mebendazole 500 mg Not given ½ tablet 1 tablet
Vitamin A Treatment Dosage
Age Vitamin A IU orally
6 to 11 months One blue capsule (100,000 IU)
12 months and more Two blue capsules or 1 red capsule (200,000
IU)
Drugs Delivery of Routine Medicines
Amoxicillin 1 dose at admission + treatment for 7 days at
home for new admissions only
Albendazole/or Mebendazole 1 dose on the 4th week (4th visit)–all patients
Measles-rubella vaccine (from 9 months old or 1 vaccine on the 4th week (4th visit)–all
6 months during outbreak and repeat dose at patients
9 months)
Vitamin A 1 dose on the 4th week (4th visit)–all patients

Medicines for specific groups of SAM children in OTC

• One dose of Folic acid (5mg) can be given to children with clinical anaemia. There is sufficient
folic acid in the RUTF to treat mild folate deficiency.8
• High dose folic acid should not be given when sulfadoxine (©Fansidar SP) is used to treat
malaria in SAM children.9
• No other supplements should be given

8 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.

9 Giving folic acid within 7 days of Fansidar can make the antimalarial ineffective as the malarial parasite can use folic acid to overcome
the effect of Fansidar

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The RUTF already contains all the nutrients required to treat the malnourished child (The caretaker
should provide the child with sufficient RUTF. The need to give sufficient RUTF to the child and not
to share must be emphasized to the caretaker at admission into the IMAM services 10).
Additional potassium, magnesium or zinc should not be given to the patients. Such a “double dose”,
one coming from the diet and the other prescribed, is potentially toxic. In particular, additional
potassium should never be given with these diets. It is not advisable to give additional zinc for
children with diarrhoea while on RUTF or on other therapeutic food containing zinc as this can
increase the risk for mortality.11

Routine monitoring in OTC

At each weekly visit (see Table 23),

• Measure MUAC, weight and check for oedema.

• Check whether the patient meets the criteria for failure-to-respond to treatment.
• Take body temperature.
• Do the appetite test either routinely for all children or whenever there has been a poor weight
gain;
• Review the child according to the IMNCI protocol.
• Give systematic treatment at the appropriate visits (if a visit is missed, give at the next visit).
• DO NOT give multiple drugs to SAM patients, particularly drugs that could decrease appetite:
• Antiemetics should not be used in OTC (they all depress the nervous system)
• Do not give cough suppressants
• Paracetamol should only be given for documented fever and not simply with a history of fever
(fever >39°C)
• Aminophylline should not be used in OTC.The severely malnourished child does not get asthma
because of the inhibition of the immune system.
• Normal/high dosage metronidazole should not be given and ivermectin must be avoided in any
oedematous child.
• Complete the OTC chart.

10 Large dose vitamin A and folic acid supplements are omitted on admission and additional zinc is not given because the RUTF contains
generous amounts of these nutrients. This simplifies the procedure at the OTC site. It is therefore very important that the patient is actually
given adequate amounts of RUTF at home and that the instructions on use are carefully explained to the caretaker and understood by the
outreach workers and community volunteers.

11 The increase in mortality is probably due to induced copper deficiency with high doses of zinc. This is not a danger with RUTF as the RUTF
contains copper. The zinc tablets given for diarrhoea, however, do not contain additional copper.

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 Table 23: Summary of routine monitoring in OTC

Outpatient Frequency
MUAC is taken Every week
Weight and oedema Every week
Appetite test is done Routinely or whenever there is poor weight
gain
Evaluation of RUTF taken Every week
Body temperature is measured Every week
The IMNCI clinical signs (stool, vomiting, etc.) Every week
Height/Length is measured Every week
Determination of W/H/L Z-score Every week

Criteria for internal transfer to inpatient care

Outpatients who develop any sign of a serious medical complication are transferred to the ITC for
management until they are stabilized or fit to return to OTC. (see Chapter 4 and Figure 11).
Transfer any patient being treated in the OTC to the ITC if they develop any of the followings:

• Failure of the appetite test (see failure-to-respond procedure)

• Increase/development of oedema
• Development of refeeding diarrhoea sufficient to lead to weight loss
• Fulfilling any of the criteria of “failure-to-respond to treatment (see Table 24)
• Major illness or death of the main caretaker and the substitute caretaker is incapable or unwilling
to look after the malnourished patient or requests transfer to inpatient care.

Procedure for transfer

• Write on the patients’ chart, the reason for transfer.
• Complete the transfer form which should contain the summary of the treatment given and the
INR-number (see section on Monitoring and Evaluation).
• Complete the transfer form with a carbon copy. Give the top copy to the patient to take to the
ITC and keep a copy in the OTC with the Client chart (HMIS NUT Form 005) (Annex 1).
• Contact the ITC nutrition supervisor by phone, if possible, to inform the ITC staff about the
transfer and record it on the patient’s chart. The ITC supervisor should arrange for the patient
to be directly admitted to the ward and not processed through casualty or the emergency ward
or department. Such direct admission to the ward should be understood in the ITC’s casualty
department whenever a patient arrives with a transfer form from an OTC.

NOTE: When the patient returns to the OTC, similar contact should be made to avoid losing
the patient during the transfer.

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Figure 11: Nutritional Strategy for Identification, Classification and Treatment for Acute
Malnutrition

Failure-to-respond to treatment in outpatient therapeutic care

For outpatient therapeutic care, a failure to respond to diagnosis usually warrants referral to
inpatient care for full assessment. If inadequate social circumstances are suspected as the
cause, a home visit can be performed before transfer to the inpatient therapeutic care.

NOTE: The full history and examination or laboratory investigations are only conducted
in children who fulfil the criteria for “failure-to-respond” (see Table 24). Most patients are
managed entirely by less highly trained staff (adequately supervised) on a routine basis.

• Skilled staff (senior nurses’ and doctors’) time and resources should be mainly directed to
those few children who fail to respond to the standard treatment or are seriously sick and
complicated for evaluation and supervision.

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 Table 24: Criteria for diagnosis of failure-to-respond for outpatient therapeutic care

Criteria for diagnosis for Failure-to-Respond Time after Admission

Primary Failure to respond*

Failure to gain any weight (non-oedematous children) 21 days

Failure to start to lose oedema 14 days

Bilateral pitting oedema still present 21 days

Weight loss since admission to program (non-oedematous 14 days

children)

Failure to start to gain weight satisfactorily after loss of oedema At any visit

Secondary failure to respond**

Failure of appetite test At any visit

Failure to gain any weight (non-oedematous children) For 21 days

Weight loss of 5% of body weight (non-oedematous children) At any visit

(Annex 17)

Weight loss for two successive visits At any visit

*Primary failure to respond refers to the criterion that has been noticed since admission.
**Secondary failure to respond applies when the child has shown improvement and then later
deteriorates as described by the criteria.

Diagnosis of failure-to-respond in outpatient therapeutic care

• Failure-to-respond to standard treatment can be due to social, nutritional, psychiatric or medical
problems (see Box 7).
• An attempt to diagnose the failure-to-respond should first be made by OTC staff as the ITC staff
have less capacity to investigate social problems than OTC staff.
• Transfer to the ITC should not be the first response when a patient fails to respond. If inadequate
social circumstances are suspected as the main cause of failure in OTC, do an appetite test,
then a home visit or supervised trail of feeding at the health centre (attending daily for 3 days)
before transfer to the ITC.

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 Box 7: Causes of failure-to-respond to treatment in outpatient therapeutic care

Problems with the OTC: Problems of individual children–

psychological:
• Inappropriate selection of patients
to go directly to OTC. • Psychological trauma (witnessing
violence or death, particularly in
• Poorly conducted appetite test or
refugee situations and families
appetite “judged” by inexperienced
living with HIV/AIDS).
personnel or appetite test not
conducted. • Psycho-social deprivation, neglect.
• Inconsistent and inadequate Problems of individual children–
instructions given to caretakers medical:
(especially with respect to sharing
• Initial refusal to go to ITC despite
within the family).
having a medical complication or
• Wrong amounts of RUTF dispensed an inadequate appetite.
to children.
• Undiagnosed vitamin or mineral
• Excessive time between OTC deficiency (particularly if RUTF is
distributions (e.g. two weekly visits shared excessively).
gives significantly worse results
• Malabsorption, small bowel
than weekly visits).
bacterial overgrowth.
Problems of individual children– • Use of traditional medicines/herbs
social: that are toxic or affect appetite.
• Mother refused to go to ITC when • Inappropriately prescribed drugs.
the child has inadequate appetite • Bacterial resistance to routine
or medical complications requiring antibiotics.
ITC investigation and treatment.
• Infection, especially: Diarrhoea,
• Child is given insufficient RUTF. dysentery, pneumonia,
• RUTF taken by siblings or tuberculosis, urinary infection,
caretaker. otitis media, malaria, HIV/AIDS,
• Excessive intake of foods of schistosomiasis, leishmaniosis and
poor quality from family pot or hepatitis/cirrhosis
traditional complementary foods. • Other serious underlying disease
• Use of the child’s illness to access e.g. congenital abnormalities e.g.,
relief or other services for the Down’s syndrome, congenital heart
whole family with attempts to disease), neurological damage
ensure the child remains within the (e.g. cerebral palsy), inborn errors
program. of metabolism, surgical problems
(pyloric stenosis, Hirschsprung’s
disease, etc.)

Management for failure-to-respond to treatment

1. If no failure-to-respond is reported:
• There are always some children who fail-to-respond because of one or more reasons given
above.
• If the centre reports that there are no failures-to-respond, an evaluation visit must be made to
the OTC and the charts individually reviewed by the District Nutrition Officer with the supervisor
to ensure that such cases are being properly identified (see Figure 12).
• Patients who fail to respond are the most likely to default or die. They must not be kept for
long periods in OTC (until they default, die or the staff “give up”) without being identified and
managed appropriately.

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2. If there are a large number of children failing to respond to treatment:
The District Nutrition Officer should review the capacity of the OTC services with the staff to
ensure proper organization of the OTC, staff attitudes, and adherence to the protocol.

3. If there are some children failing to respond:

Evaluate the appetite test and carefully re-examine the child.

4. If the child has a good appetite when tested, but is failing to gain weight at
home:
• It is likely that this is a social problem. The hungry child is not getting the RUTF at home that he
will eat willingly at the OTC site.
• Ask the outreach worker and/or the volunteer to make a home visit and see if he/she can identify
any problem at home.
• Interview the head of the household; this person does not normally attend the OTC and so has
not directly received the advice and instructions given to the immediate caretaker who attends
the OTC.
• Investigate if there are any social problems within the household. These problems are usually
not determined from either an interview with the mother at the distribution point or even during
a home visit.
• For social problems, management may take the form of counselling, family support, support
by the neighbourhood, the village elders or volunteers or a local NGO. Pairing the mother with
another “successful mother” (positive deviance programs).
• As a last resort, plans can be made to find an alternative caretaker for the child where there are
intractable social problems.

5. If the problem is still not determined:

• Have the child come each day for day care (or be resident) at the health centre for up to 3 days
and fed under careful supervision.12

6. If the child gains weight during the supervised feeding but fails to gain weight
at home:
• Then there is a major social problem that was not determined during the home visit.
• A further interview with the whole family including the head of the household should be
undertaken and the results of the “trial of feeding” discussed with the household head as well
as the primary caretaker.
• Psychological trauma (of the caretaker as well as the patient) is particularly hard to deal with
and normally requires a change to a totally supportive safe environment, often with others that
have undergone similar experiences.
• Mental health of the child’s mother is very important for the his/her progess especially during
conflicts. Dramatic improvement is sometimes seen when mothers are given treatment such as
anti-depressants.

12 When tested with the appetite test at the OTC site, the child may not take the food eagerly for various reasons (often such children are
overawed, intimidated or frightened). The child can take several days to relax and become sufficiently familiar with the staff to take the
food readily.

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7. If child still fails to respond with a trial of supervised feeding:
• Refer to an ITC for full medical and psychological evaluation and a search for underlying
pathology.
• Where the investigation indicates no issues, the patient should be further referred to a tertiary
centre where there are more sophisticated diagnostic facilities and senior paediatric/medical
staff.
• Where an underlying medical problem is identified for failure-to-respond to treatment, then
further management of the child should be in the hands of the service/facility that made the
diagnosis.
• Management of such a patient is usually under the control of the specialist and is recorded in
the report as a “medical referral”.
• It is important that children do not languish in OTC for several months, not responding, and
then simply be discharged as “non-responders”. Such a category of outcome should not exist
in an OTC program.

NOTE: Each step in the investigation of failure-to-respond in OTC will involve less children
since the problems are identified and addressed. There should be very few who require
referral to senior paediatricians. Clinically, senior doctors should concentrate on these
failure-to-respond children where their training and skills are best used, rather than on
routine management of the malnourished who respond well to the standard protocols and
can be managed by clinicians, nurses and their assistants.

Figure 12: Scheme of Management for Failure to Respond to Treatment

Check and make a diagnosis of “failure-to-respond” to treatment

Check the organization and application of the protocol

Evaluate the appetite test

Do home visit to check for home and social circumstances interview head

Residential care for up to 3 days for the trial of supervised feeding

Transfer to ITC for full clinical assessment to search for underlying undiagnosed
pathology

Refer to centre with diagnostic facilities and senior paediatric personnel for
assessment and further management: they take over future management of the child
from the program

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Discharge criteria and procedure
Children aged 6–59 months or infants aged 60 months or more with less than 120 cm should be
discharged as cured based on the discharge criteria in Table 25.

Table 25: Discharge criteria for patients in OTC

Age Discharge criteria

6–59 Months WHZ or WLZ ≥ -2 SD on two consecutive visits 13(Two days

AND for inpatients, two weeks for outpatients).
Any child with age ≥60 months Or
whose height ≤120 cm MUAC ≥12.5 cm for children (6–59 months)14
Standard OTC And
No oedema for 14 days (two consecutive visits)
Clinically well and alert.

Outreach or Mobile team: This Target weight gain is achieved

criterion is NOT used in health And
centres or other fixed OTC
No oedema for 14 days15
sites.

Discharge of patients from the mobile OTC outreaches

• The “target” weight should be determined at admission and this weight used as the discharge
weight-for-height criterion.
• When height is re-measured repeatedly, and a new “target” weight calculated, the child may
not attain the discharge criteria because s/he is gaining height quite rapidly. Rapid height gain
is a sign of nutritional well-being and keeping such children in the program is unnecessary and
can overburden the staff and consume resources that are better spent elsewhere.
• All the patients should be discharged and followed up by the community workforce–VHTs for 3
months to prevent relapse.
• The families should be enrolled in social welfare programs.

Discharge procedure
• Applaud the caregiver and give him/her feedback on the patient’s treatment outcome.
• Ensure the parent/caregiver understands importance of follow-up care (supplementary feeding
or other programs).
• When the patient has attained the appropriate exit criteria (see types of discharges), discharge
on last ration (at least 1 week’s supply) and link to livelihood program and complementary
nutrition services where there is no SFP (see Table 25)or transfer the child to SFP if it is available.

13 It is acceptable to discharge the patient if s/he reaches this criterion on one occasion if the weight gain has been steady and the weight
is rechecked before discharge.

14 It is complicated if children have to achieve multiple anthropometric criteria before discharge (X “and” Y, rather than X “or” Y). The
choice of ≥12.5 cm MUAC is based upon the criteria for “normality”–the children should be returned to this range during treatment and
not discharged having just reached the most severe range of MAM. This leaves the difficulty with the short (<67cm) children who do not
readily reach that discharge criterion. For these children, analysis of MUAC-for-Age (WHO Standards) indicates that a MUAC of >11.5 cm
is above the criteria for MAM.

15 See Annex 6: To determine target weight for discharge (Use the height at admission to determine the weight for the WHZ =-2SD)

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• Record the discharge outcome in the INR and the integrated nutrition ration card.
• Advise the caregiver/or patient on good nutrition and caring giving practices.
• Advise the caregiver/or patient to immediately go to the nearest health facility if the child
develops any of the danger signs or IMNCI signs.

Types of discharges
Register the patients discharged in the registration book and chart according to the following
possibilities:

• Cured: the patient has reached the criteria for discharge.

• Dead: if the patient died during treatment in the OTC or in transit to the ITC.
• Defaulter: if the patient has not returned for 2 consecutive visits. It is recommended that a
home visit, neighbour, village volunteer or other reliable source confirms that the patient is not
dead.
• Transfer-OUT: Transfer-out to ITC (they are expected to return) or Transfer-out to another OTC
distribution site (may not return but are still in the program).
When a new OTC distribution site is opened closer to the patient’s home, transfer the patients to
that OTC (internal transfer) but the patient retains their INR-NUMBER and is recorded in the new
OTC as an internal transfer (in) and not as a new admission.

• Non-responders: Non response at discharge should rarely occur in OTC, although this may
arise when a family/caretaker refuses to go to the ITC for diagnosis and treatment or where
there are intractable social problems or an underlying condition for which there is no treatment
available in the ITC (e.g. many cases of cerebral palsy). Where available, further management
of these patients should be transferred to other agencies with expertise in the care of such
cases (medical referral).

Follow-up after discharge

• All patients discharged from OTC should be followed up for a period of 3 months by the
outreach workers and village focal point/volunteers to prevent relapse.
• If there are no outreach workers or village volunteers, and no SFP near to the beneficiaries’
home, organise the follow-up at the nearest RMNCH or health centre.
• The registration book should always record the INR-number of the all discharged patients.

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7.4 Outpatient therapeutic care of infants less than six months with
uncomplicated moderate and severe acute malnutrition
This section provides guidance on outpatient management of infants under 6 months with
uncomplicated MAM and SAM in outpatient departments and OTC.

Structure and organization of outpatient care

Special services should be utilized to assist mothers who have difficulty in establishing
breastfeeding. These services should concentrate on addressing all breastfeeding problems–
for the malnourished, to re-establish exclusive breastfeeding and to achieve confidence in the
mother’s ability to produce sufficient milk for their baby to thrive.
Such services should include:

• Having breastfeeding counsellors, trained mother-to-mother support groups.

• The outpatient arm should provide counselling services and provision of one-to-one support
for all mothers who have difficulty with breastfeeding (see Chapter 4).

NOTE: RUTF is NOT recommended for young infants and milk-based feeds should not
be given for home treatment. The nursing care staff should have professional trai ning
in breastfeeding support and counselling as well as skills in care of the neonate and the
malnourished child.

Admission criteria for infants less than six months in OTC

(Refer to Chapter 4, Section 4.3 and Table 6 for details.)

Activities in outpatient care for infants <6 Months with uncomplicated SAM and
MAM
• Take the anthropometric measurements and examine the baby.
• Check the criteria of admission to decide if the child should be admitted in OTC (see Table 6).
• Register the infant in the registration book and INR.
• Explain to the mother the aim of the management, which is to return the infant to exclusive
breastfeeding.
• Advise the mother or caretaker to keep the infant warm. Cover the head and body to prevent
hypothermia.
• Give routine, preventive treatment and other specific treatment based on diagnosis:
• Amoxicillin 40 mg/kg/day two times per day for 5 days
• Drug regimens for infants with weighing ≥ 3 kg are similar to those for infants ≥ 6 months of
age.
• Do not give vitamin A, folic acid, anthelminthic or measles vaccination.
• Counsel and support the mother or caretaker on appropriate care and feeding practices.
• Encourage continued breastfeeding; provide counselling breastfeeding support:
• If the mother is available and breastfeeding is insufficient, counsel and support the mother
to re-lactate as plan A–prospect to breastfeed.
• If the mother is not available, there is no realistic prospect of the infant being breastfed,
consider appropriate, feasible, safe and sustainable replacement feeding.

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• Encourage the mother and child to sleep under impregnated bed nets.
• Monitor the infant’s weight gain weekly and plot WAZ on the Child’s Growth Monitoring Card.
• Verify the mother or caretaker’s health and nutrition status and refer for psychosocial support
if needed.
• Counsel the mother or caretaker on health and nutrition, advise to attend nutrition services in
the health facility and community, and ask to return to the health facility in case of a deterioration
of the infants’ condition.
• Counsel the mother or caretaker on sensory stimulation and emotional support of the child.
• Refer the infant and mother or caretaker to ITC if the infant develops general danger signs
or symptoms of serious disease, does not gain weight or loses weight while the mother or
caretaker is receiving counselling and support for breastfeeding or replacement feeding.

Monitor
Conduct weekly follow-up visits in primary health care services to monitor breastfeeding (or
replacement feeding), weight gain and response to treatment.

• Identify danger signs and non-response to treatment:

1. The development of a complication or deterioration (danger sign, losing, static or faltering
weight, altered feeding) should lead to a referral to ITC.
• Monitor weight and weight gain:
1. Plot the infant’s weight on the WAZ growth chart and evaluate the growth curve. Serial
measurements showing flattening of the curve or unexpected crossing of two or more
Z-score lines downward is considered failure to thrive or growth failure, indicating ineffective
lactation.
• Involve mothers in care:
1. Counsel mothers or caretakers on appropriate breastfeeding and growth.
2. Guide mothers or caretakers to provide sensory stimulation and emotional support for the
infants.
3. Provide health and nutrition education for improved feeding and care practices.
4. Provide psychosocial support to mothers or caretakers.
5. Provide health and nutrition support to mothers or caretakers according to their health and
nutritional status.

Discharge criteria for infants less than 6 months from OTC

Discharge criteria for breastfed infants
• Successful re-lactation with effective suckling established and;
• Weight gain on exclusive breastfeeding is satisfactory (e.g., WAZ above the median of the WHO
growth velocity standards, or more than 5 g/kg/day for at least 3 successive days) or;
• Weight for length Z-score ≥ –2 SD for two consecutive visits.
• Infant has completed age-specific immunization schedules
• Has a mother or caretaker with no ongoing health or psychological conditions requiring
intensive treatment.

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Discharge criteria for infants with no prospect of breastfeeding
• Infant feeding well with replacement feeding and
• Has adequate weight gain or WFH/L z-score ≥ - 2 for 2 consecutive weeks
• Infant has completed age-specific immunization schedules
• Has a mother or caretaker with no ongoing health or psychological conditions requiring
intensive treatment.

NOTE: Mothers or caregivers should then be linked with any necessary community follow-
up and support.

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7.5 Outpatient therapeutic care for management of severe malnutrition in
older persons

First visit
• Treat all medical complications following the Uganda Ministry of Health Clinical Guidelines,
2016 and WHO Guidelines.
• If a client is on ART or anti-tuberculosis drugs and losing weight, refer to the Uganda, Ministry
of Health Consolidated guidelines for Prevention and Treatment of HIV (2018), and the National
Tuberculosis and Leprosy Guidelines.
• Clients with no appetite should be encouraged to consume smaller amounts of family food
more frequently or sip feeding. If this is not successful and client continues to lose weight, it
may be necessary for the client to be admitted in ITC and fed by sip feeding or nasogastric tube.
• If client has appetite and health and social conditions allow home management, counsel clients
to consume energy dense family foods and or supply of locally available fortified blended flour
(FBF) enriched with oil, vitamins and minerals to meet the energy needs per day.
• Explain to the client how to prepare and use nutrient-rich family foods and locally available
fortified blended flour enriched with oil, vitamins and minerals. Counsel on how modify family
foods to improve appetite.
• Counsel on 1) weight monitoring at least once a month, 2) increasing energy density of home
foods, 3) managing HIV/Tuberculosis related symptoms through diet, 4) managing medicine-
food interactions, 5) sanitation and hygiene, especially safe drinking water, and 6) exercise.
• Make an appointment for review after 2 weeks.

Follow-up management
• Continue counselling the client on the use of energy and nutrient dense foods to meet their
daily nutrient needs
• Encourage clients to increase intake of micronutrient rich foods.
• Weigh clients bi-weekly to monitor weight gain.
• If client is not gaining weight or has lost weight for 3 months or has worsening oedema, refer
to a clinician immediately.
• Once the client has been treated for at least 2 months and has BMI for age z-score >-2 SD for
older children and adolescents, BMI ≥16 kg/m2 for adults, or MUAC of >19.0 cm for pregnant
and lactating women, appetite, less mobility, and can eat home foods, follow guidance on
management of moderate malnutrition.

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8.0 Emotional and physical stimulation in Integrated
Management of Acute Malnutrition services

8.1 Importance of stimulation

Emotional and physical stimulation is very important in management of acute malnutrition
because of the following reasons:

• As children become malnourished, they gradually reduce their activity.

• When fully malnourished, they do not play, cry, smile, complain or show normal emotions–they
become lethargic and feeble.
• Malnourished children do not cry when they are hungry, thirsty or distressed, they are usually
unintentionally ignored by both the caregiver and health workers.
• Adults respond to the demands of children, only when the child does not demand for it. This is
one of the main reasons why SAM children should be treated together during ITC and separately
from children with other conditions. This because they do not play or learn. With time, this leads
to delayed mental and behavioural development. If this is not treated, it is the most serious
long-term result of malnutrition.
• Emotional and physical stimulation through play programs that start during rehabilitation and
continue after discharge can substantially reduce the risk of permanent mental and emotional
damage.
• Many children have witnessed events that are very traumatic emotionally. In emergency
situations, they may have witnessed extreme violence to loved ones. Such psychological
trauma frequently leads to post-traumatic stress disorder and, particularly in older children,
can be a major impediment to recovery. The same problems occur in the caretakers. In these
circumstances, they frequently need psychological or psychiatric support or medication.

8.2 Emotional care and physical stimulation in the OPD, OTC and ITC
• Create a friendly supportive atmosphere. Remember that the caretaker is the primary health
provider for the child and you are simply there to provide services to her and her child; to assist
and guide her in giving the best care available.
• Do not punish the caretakers, order them about, demean them or adopt an officious attitude;
never shout or become angry.
• Do not wear imposing uniforms (white coats).
• Provide psychosocial support to children by talking or singing to them and cuddling them.
• Children who do not make eye contact need a lot of attention and care.
• The caretakers should regularly massage the children (with oil such as soya oil).
• In the OPD, OTC and the ITC, organize an educational session that teaches the mothers the
importance of play and exploration as part of the emotional, physical and mental stimulation
that they children need. This is an integral part of treatment.
• Organize sessions where the mothers or caretakers learn to make toys suitable for their children
from cheap or discarded material (see Figure 13).
• In the ITC, keep the mother with the child and encourage her to feed, hold, comfort and play
with him/her as much as possible.
• Toys should be available in the child’s bed and room, as well as the play area (see Figure 13).
Inexpensive and safe toys made from cardboard boxes, plastic bottles, tin cans, old clothes,
blocks of wood and similar materials. They are much better than purchased toys because
mothers learn to make them themselves and continue to make toys for their children after
discharge.

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8.3 Emotional stimulation and play
To avoid sensory deprivation:

• Do not cover the child’s face. The child must be able to see and hear what is happening around
him or her.
• Do not wrap or tie the child. The malnourished child needs interaction with other children during
rehabilitation.
• After the first few days of treatment as the children recover, put them all on large play mats
for one or two hours each day with the mothers or a play guide. There is no evidence that
this increases nosocomial infections. Have the mothers tell stories, sing and play with their
children.
• Teach the mothers how to make simple toys and emphasize the importance of regular play
sessions at home.
• If a child requires a painful procedure (some injections are very painful), do this in a side ward
or out of sight and hearing from the other children.

NOTE: Most nosocomial infection comes from the staff moving from patient to patient without
washing their hands, from the caretakers, from contamination of the diets and storage of
feeds before they are given to the child and from inadequate facilities for washing, and
the disposal of excreta. Putting children together to play does not represent an important
additional danger and is often vital to their recovery. Most faecal contamination in a facility
comes from the young malnourished children themselves. There is a reflex which empties
the bowels about 20 minutes after eating. At this time, children should be automatically put
onto potties. This can also be a communal activity.

8.4 Physical activity

Physical activity itself promotes the development of essential motor skills and may also enhance
growth during rehabilitation.

• For immobile children, encourage mother to do passive limb movements and splashing in a
warm bath.
• For mobile children, encourage mother to do some activities such as rolling or tumbling on a
mattress, kicking and tossing a ball, climbing stairs, and walking uphill and down.
The duration and intensity of physical activities should increase as the child’s condition improves.
There should be a member of staff nominated who has overall responsibility for all these aspects
of care of the malnourished.
The toys shown in the diagram below should be made and used in both the inpatient units and
the homes of the malnourished children.

8.5 Methods used in emotional and physical stimulation

• There must be a caring environment, toys, attention and love.
• There is no place for strict staff, oppressive rules, or blame of the parents.
• The mother is the primary caretaker and her wishes must always be considered.
• Put children who are not acutely ill together on a mat to play during daytime.
• Teach mothers to make toys and the importance of playing with their children during recovery.

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Figure 13: Materials for child stimulation. Source: Supplied by Professor S. Grantham-McGregor

Figure 14: Materials for child stimulation. Source: Supplied by Professor S. Grantham-McGregor
GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 101
100
9.0 Inpatient therapeutic care for management of severe
acute malnutrition with medical complications

9.1 Introduction
Inpatient Therapeutic Care is used for management of Severe Acute Malnutrition with medical
complications and/or a failed appetite test. Inpatient care for SAM patients with complications
is normally needed by around 5 to 20 per cent of the SAM patients identified by community
screening although a higher proportion of patients come to hospital with other illnesses. ITC can
be provided in a nutrition unit or nutrition corner in a health facility with 24-hour care and with ITC
basic requirements.
Successful management of severely malnourished children requires recognition and management
of both social and medical problems. This is because, the medical problems of the children result
partially from the social problems at home. Malnutrition is the result of chronic nutritional and,
frequently, emotional deprivation by caregivers. The caregivers who have a challenge of poor
understanding, poverty or family problems, are unable to provide the required nutritional care
and support for the child.
The purpose of ITC is to concurrently provide medical and nutritional therapy, in addition to other
forms of care (psychosocial, stimulation, play therapy and involving the mother/caregiver in care).
The management of SAM with medical complications or poor appetite is divided into three phases
namely:

• Stabilization or acute phase (Phase 1)

• Rehabilitation or recovery phase (Phase 2)
• Follow-up (Phase 3).

Phases of management for inpatient therapeutic care

1. Stabilization Phase
• The life-threatening problems are identified and corrected during stabilization phase in either a
hospital or a residential care facility.
• Treat and prevent medical complications including deficiencies and metabolic abnormalities
during the first 48–hours of admission to avert death.
• The common medical complications include: infections, dehydration, shock, cardiac failure,
hypothermia, very severe anaemia, hypoglycaemia, severe dermatosis, and other conditions.
• Children in the stabilization phase should be physically separated from the children in the
transition and rehabilitation phases and from children with other illnesses.
• The formula used during this phase (F-75) promotes repair of physiological and metabolic
functions and electrolyte balance.

NOTE: Weight gain during stabilization is dangerous, that is why F-75 is formulated so that
patients do not gain weight.

2. Transition
This is not a phase, but a period designed to prepare patients for rehabilitation phase in OTC.
The transition phase prevents sudden introduction of large amounts of therapeutic milk, before
physiological function is fully restored.This can lead to adverse health outcomes such as electrolyte
disequilibrium and “refeeding syndrome”.

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During this phase, the patients start to gain weight as the diet is changed from F-75 to F-100 or
RUTF. The amount given increases the energy intake by about 30 per cent. The increase in energy
intake should give a weight gain of around 6 g/kg/day.

Rehabilitation phase
During this phase, patients have appetite and have no or reduced medical complications. Patients
are fed on RUTF or F-100 to recover the weight lost or catch up growth. These formulas are
designed for patients to rapidly gain weight (more than 8 g/kg/day) if all prescribed amount is
consumed. Children should be emotionally and physically stimulated, and caregivers/mothers
should be prepared for discharge.

NOTE: Although it is desirable that the rehabilitation phase takes place in outpatient, it may
not be possible under some circumstances such as:

• No capable caretaker or abandoned child

• If RUTF is not available or if the child/caregiver does not accept to be transferred to OTC.

Follow-up phase
After discharge, the patient (child) and the patient’s family are followed to prevent relapse and to
enable continued physical, mental and emotional development of the child.

9.2 Structure and organization of inpatient therapeutic care

ITC structure
• Inpatient therapeutic care requires residential care in a health facility with technical expertise
to monitor and manage medical complications; tools to monitor and manage medical
complications such as the ITC multi-chart, Critical Care Chart and failure-to-respond (HMIS
NUT Forms 008, 003 and 002) (Annex 1), space for storage and preparation of feeds as well as
standard commodities including F-75, F-100, RUTF, and ReSoMal.
• The ITC facility staff should categorize inpatients into the 24-hour feeding schedule of 12 meals
(2-hourly), 8 meals (3-hourly) and 6 meals (4-hourly).
• They should all have full medical monitoring and treatment of complications (see details under
medical complications).

Organization of the ITC

The Nutrition Ward in the ITC needs:

• A space to take the anthropometric measurements, examine the patients, prepare the therapeutic
milk (F-75), toilet and washing facilities and provision for the caretakers to cook (and where
possible, food given to the caretakers), storage facility for drugs and F-75/F-100/RUTF.
• The patients should always be treated together in a separate room or dedicated section of the
ward and NOT mixed with other patients.
• There should be insecticide-treated mosquito nets for each bed. Adult beds are preferred to
baby cots; mothers should sleep with their children to avoid hypothermia, emotional stress and
interruption of breastfeeding so that the mothers themselves do not get exhausted, are able to
make rational decisions and are less likely to default.

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Roles and responsibilities of health workers
• All the human resources should be trained in IMAM for example; doctors, clinical officers,
nurses, nursing aides, nutritionists etc.
• The personnel of the ITC, the OPD and the emergency ward should regularly be re-trained,
supervised and staff turnover should be minimized.
• The health workers involved in ITC should work as a team as they take care of the children
although some tasks are specific to their level of training as indicated below:
The Doctor/Clinical officer
• The doctor’s main duty is to admit, identify and manage patients with secondary malnutrition,
and review patients patients that fail-to-respond to treatment or present diagnostic difficulty
and management of the complications (see section failure-to-respond in this Chapter).
The Nurse/Nutritionist
• Plan, coordinate, and implement ITC IMAM services.
• At admission of a new patient, applies the procedure of triage and admits the SAM patients
with complications to the ITC and transfers those with a good appetite and without medical
complications directly to the OTC.
• Weigh monitor and measure patients according to the protocol.
• Plan and design therapeutic diets for the patients.
• Mix and dispense feeds and give the oral drugs.
• For a transfer from OTC, register the patient using his/her INR-number given by the OTC (if
the SAM patient is referred by other health facilities, the INR-number is given by the facility).
Also give a phone call to the transferring OTC to update them and also discuss any necessary
details.
• Ask the doctor/clinician to examine the patient but do not wait before starting treatment
according to the protocol.
• Start treatment of the stabilization phase and treat the complications according to the protocol.
• At discharge from ITC, take decisions on moving children from stabilization to transition phase
for those who qualify as well as from transition to OTC.
• Teach and supervise the nursing assistants to ensure that they are performing their functions
correctly and accurately.
• Nurse, give or supervises any intravenous treatment and monitor all critical care patients.
• Nutritionists and nurses should ensure adequate supplies, participate in record keeping,
planning and education.
• Nurses should assess the clinical signs and record the results of all the routine information on
the multi-chart (HMIS NUT 008) (Annex 1).

District Nutritionist (DN) and District Health Officer (DHO)

• The supervision of the ITC must include a visit to the emergency/casualty ward and an
assessment of the procedures used in the emergency department to identify, treat and transfer
SAM patients to the staff of the ITC area specifically designated to treat SAM patients.

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9.3 Inpatient therapeutic care for management of severe acute
malnutrition with medical complications in children aged 6–59
months

ITC Admission criteria and process

• It is best for SAM children to be admitted directly to the Nutrition Unit for immediate appropriate
management.
• Avoid admission to the emergency ward for the first 24–48 hours except if the staffs of the
emergency ward have had specific training in the management of the complications seen in
SAM patients.
• The clinical signs and treatment for SAM children differ from those for well-nourished children
and requires specific or specialized management by trained staff.
• SAM children who meet the criteria (Table 26) should be admitted in ITC

Table 26: Summary of criteria for admission to inpatient therapeutic care

Factor Inpatient care

Appetite Failed appetite test

Oedema Bilateral pitting oedema (Grade 3 +++)

Both wasting and oedema Both W/L or W/H Z score <-3 SD and bilateral pitting
oedema (+, or ++, or +++)

Skin Open skin lesions

Medical complications Any severe illness, using the IMNCI criteria–respiratory

tract infection, severe anaemia, dehydration, fever,
lethargy, etc.

Candidiasis Presence of candidiasis or other signs of severe immune-

incompetence

Caretaker No suitable home circumstances or willing caretaker

Caretaker must be counselled Caretaker counselled and understands the need to

and educated at every stage of start, continue or transfer to inpatient treatment. The
management caretaker’s concerns must be addressed or considered.

Types of admissions
New admissions
Patients who come spontaneously or self-referral to the hospital/ITC because of another illness
such as diarrhoea, pneumonia, malaria, etc. and are found to be severely malnourished on
screening or clinical examination (see Chapter 4).

Referral
• Patients referred by a non-OTC health centre or private facility.
• These children are NEW admissions, should be registered with a INR-number and it should be
used throughout the IMAM services.

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Transfer-in from OTC
• Patients who have already been diagnosed in the OTC but have failed their appetite test, have
a complication or failed-to-respond to treatment and fulfil the criteria to be transferred to ITC.
• Transfer-in patients have already the INR-number and a transfer form giving all the information
on the treatment, should any have been already given in OTC.
• Transfer-ins referred to are “Internal Transfers” within the IMAM services.
• A copy of the transfer form (and a phone call) should have been sent with the patient and the
transfer form and should be attached to the multi-chart and the patient registered.

Admission procedures
At admission, conduct the following procedures:
• Conduct triage and fast-track seriously ill patients for assessment and care.
• All patients should be provided with (F-75 or sugar water) shortly after they arrive at the triage
of the ITC.
• Re-measure the weight, height, MUAC and check for oedema to confirm severe acute
malnutrition in children.
• Assess the patient’s medical condition through history taking and physical examination to
identify any medical complications that may require inpatient care.
• Explain the admission process to the mother or caretaker of patients with complicated SAM
and comfort them.
• Do NOT wash or bathe malnourished patients on admission.

Principles of care in ITC

How physiology of SAM affect care of the involved patient
• Management of children with complicated SAM in ITC follows the principles of paediatric
hospital care that shows differences in care of children with SAM and well-nourished seriously
ill children.
• Children with SAM are treated differently because their pathophysiology is abnormal due to
reductive adaptation.
• Reductive adaptation refers to a state of “shut down” of the body’s systems in response to
severe acute malnutrition. The systems slow down and do less in order to allow survival on
limited calories. As the patient is treated, the body’s systems must gradually “learn” to function
fully again. Rapid changes (such as rapid feeding or fluids) would overwhelm the systems and
result in poor treatment outcomes, so feeding must be slowly and cautiously increased.

Treatment protocols for SAM children differ because:

• Children with SAM may not show usual signs of infections because the body does not use
its limited energy to respond in the usual ways such as inflammation or fever.
• The increased iron storage due to a reduced haemoglobin makes iron supplementation to
address anaemia dangerous. The SAM child makes less haemoglobin than usual. Iron that is
not used for making haemoglobin is put into storage. Thus, there is extra iron stored in the
body, even though the child may appear anaemic. Giving iron early in treatment can also
lead to “free iron” in the body which promotes bacterial growth making some infections
worse.
• The disturbed electrolyte balance requires a fluid management with increased potassium
and restricted sodium. Malnourished children already have excess sodium in their cells, so
sodium intake should be restricted.
• All sick children should be assessed and managed for life-threatening conditions using the
emergency triage, assessment and treatment (ETAT+) procedure to verify emergency and

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 priority signs that need urgent attention (Annex 5 and Box 8) and should be monitored for
danger signs related to pulse, respiration and temperature (see Chapter 4).
• ITC aims to stabilize the child’s condition until the child regains appetite and the medical
condition is resolving. The child will then be referred to continued treatment as an outpatient in
OTC and recover at home.
• The duration of hospitalization should always be short to reduce the burden on families and
the health system and the risks of acquiring new infections. If transition to OTC is not possible
because of a social or security issue, the child should remain in ITC until full recovery.
• Careful infection control procedures should be respected, and the room should be kept warm
without draughts.

Emergency triage, assessment and treatment

• The ETAT procedures for the seriously ill children with SAM follow the same procedures as for
the children without SAM with some differences as outlined in Box 8. The principles of ETAT
require that seriously ill children must be checked for emergency signs of:
• Airway (A) and breathing (B),
• Circulation and coma or convulsion (C) and
• Severe dehydration (D), to be treated promptly.
• Health workers should always systematically assess a child’s nutritional status early because
the treatment for positive emergency signs of shock and dehydration differ for children with or
without SAM.
• The health workers should also always make sure the child is warm, with head and body
covered, unless the child has a high fever.
• In the absence of an emergency sign, SAM is always a priority sign, which means that children
with SAM require prompt a full assessment and start of treatment.
• Treatment of the different conditions may overlap, and a return to previous ETAT steps may be
considered based on close monitoring of the child’s condition.
Important things NOT to do and their associated reasons
• Do not give diuretics to treat oedema. The oedema is partly due to potassium and magnesium
deficiencies that may take about 2 weeks to correct. The oedema will go away with proper
feeding, including a mineral mix containing potassium and magnesium. Giving a diuretic will
worsen the child’s electrolyte imbalance and may cause death.
• Do not give iron during the initial feeding phase. Add iron only after the child has been on F-100
for 2 days (usually during week 2). As described earlier, giving iron early in treatment can have
toxic effects and interfere with the body’s ability to resist infection.
• Do not give high protein formula (over 1.5 gm protein per kg body weight daily). Too much
protein in the first days of treatment may be dangerous because the severely malnourished
child is unable to deal with the extra metabolic stress involved. Too much protein could overload
the liver, heart and kidneys and may cause death.
• Do not give intravenous (IV) fluids routinely. IV fluids can easily cause fluid overload and heart
failure in a severely malnourished child. Only give IV fluids to children with signs of shock
(Treatment will be described in the section of Medical Complications).

NOTE: Ensure that the personnel in the emergency treatment area of the hospital knows
these important things NOT to do, as well as what to do.

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 Box 8: ETAT for Children with SAM

First, check for emergency signs in three steps.

• Step 1: If there is any airway or breathing problem manage the airway and give oxygen.
• Step 2: If the child is in shock due to diarrhoea with very severe dehydration start
intravenous (IV) fluid resuscitation and give oxygen.
• Step 3: If the child is unconscious or convulsing, give IV glucose for hypoglycaemia.
• Give an anticonvulsant for convulsions.
If emergency signs are found:
• Call for help, but do not delay starting treatment, assess and resuscitate;
• Measure MUAC for children 6 – 59 months and any child aged more than or equal to 60
months with height ≤120 cm and verify oedema and visible wasting for infants under 6
months of age to determine whether the child has SAM.
• Carry out emergency investigations (blood glucose, blood smear, haemoglobin). Send
blood for typing and cross-matching if the child is in shock, appears to be severely
anaemic or is bleeding significantly
• Give treatment(s)
• After stabilization proceed to assessing, diagnosing and treating the underlying problem.
ETAT procedures in children with SAM In order of emergency, assess and treat the ABCD:

ASSESS TREAT
Airway and breathing (A and B) • Manage the airway
• Give oxygen
• Obstructed or absent breathing or
• Make sure the child is warm (cover the
• Central cyanosis or child’s head and body, apply the kangaroo
• Severe respiratory distress (Head nodding, technique). See Section on for treatment of
grunting, central cyanosis, fast breathing, severe pneumonia.
retractions, not able to feed)
Circulation (for shock) (C) See Section on management of shock
Coldness of extremities or skin with:

• Capillary refill longer than 3 seconds, and

• Weak and fast pulse. If you cannot feel a
radial pulse of an infant (less than 1 year
of age), feel the central pulse. If the room
is very cold, rely on the femoral/carotid
pulse to determine whether the child is in
shock.
Disability “D” Coma/convulsing • Manage the airway.
Level of consciousness: • If convulsing, or SPO2 < 94%, give oxygen
• If convulsing, give diazepam rectally
• Lethargic or in coma (unconscious). Check • Position the unconscious child
level of consciousness on the “AVPU” scale • Give IV glucose
(A alert, V responds to voice, P responds to
pain, U unconscious). See Section on treatment of convulsions.
Or

• Convulsing (now)

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Hypoglycaemia See Section for treatment of hypoglycaemia
Child sleeps with eyelids open

• Child has a low body temperature (Axillary

< 35.0 °C or rectal < 35.5 °C rectal).
limpness and diminution in the level
consciousness
Hypothermia Low body temperature is a sign of
hypoglycaemia and sepsis. Warming the child
• Child has a low body temperature (< 35.0 °C is an emergency treatment.
axillary or < 35.5 °C rectal).
Expose the child -remove blankets and
clothes
• Hyperthermia; Child has a very high body
Tepid sponge if axillary temperature is above
temperature (≥ 38.5 °C rectal or ≥ 38°C
38.5 °C
axillary)
Note: A child with SAM has disturbances of
body temperature regulation and tends to take
the
temperature of the environment. Keeping the
child warm is a routine treatment.
See Section on the management of
hypothermia and hyperthermia/fevers.
Severe anaemia See Section on treatment of very severe
anaemia.
• Child show severe pallor
See Section on treatment of dehydration
• Severe dehydration without shock without shock.
• Child has diarrhoea with recent sunken
eyes. Ask the mother/caretaker whether the
child has had recent and frequent watery
diarrhoea or vomiting and if the face has
changed in appearance.

Therapeutic feeding
Feeding is a critical part of managing severe acute malnutrition; however, due to reductive
adaptation in the severely malnourished patients, feeding must be started cautiously and in
frequent, small amounts. If feeding begins too aggressively, or if feeds contain too much protein
or sodium, the child’s systems may be overwhelmed, and the child may die.
To prevent death, feeding should begin as soon as possible with small amounts of F-75, the “starter”
formula used until the child is stabilized. F-75 is specially made to meet the child’s needs without
overwhelming the body’s systems at this early stage of treatment. When the child is stabilized
(usually after 2–7 days), the “catch-up” formula, F-100 or Ready-to-Use-Therapeutic-Food (RUTF)
is used to rebuild wasted tissues.

Use of F-75 during stabilization phase prevents deaths.

F-75 contains 75 kcal and 0.9 g protein per 100 ml. F-100 is used as a “catch-up” formula to
rebuild wasted tissues.
F-100 contains more calories and protein: 100 kcal and 2.9 g protein per 100 ml.
RUTF provides approximately 500 kcal per sachet of 92 g.
It is nutritionally equivalent and is used as an alternative to F-100 (Annex 19).

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Feeding during stabilization phase
Patients that require inpatient care generally have a poor appetite and usually have medical
complications. Thus, the patients will often require treatment for both the complication and the
malnutrition. The management of acute or life-threatening complications takes precedence over
routine care and may change the way in which the routine care is given.

Diet (F-75)
The diet used in the stabilization-phase of treatment is F-75. In case commercial F-75 is unavailable,
locally prepared F-75 can be used (Annex 17). Recipes for milk-based formula containing 75
kcal/100 ml and 0.9 g protein/100 ml can be prepared and be satisfactory for most children). F-75
is designed for patients with severe complicated acute malnutrition. Patients should NOT gain
weight on F-75. The diet allows their biochemical, physiological and immunological function to
start to recover before they have the additional stress of making new tissues.

Frequency of feeds
• Give 2 to 3-hourly feeds to patients who cannot tolerate the increased volumes and require the
24-hour feeding schedule of eight to twelve meals per day. Such children include:
• Children who are very severely ill,
• Children who have consumed little or none during the day especially new arrivals,
• Children who develop re-feeding diarrhoea on the routine schedule,
• Children who have vomited some or all of their feeds,
• Children who have had an episode of hypoglycaemia,
• Children who have had hypothermia.
• Give stable children 4-hourly feeds (six meals per day).
• Prepare a feeding schedule for children in ITC and post it on the wall where it is visible to staff
and sensitized caretakers.
• Breastfeeding mothers should be supported to breastfeed on demand before giving the F-75.

Criteria for increasing volume and decreasing frequency of feeds:

• If the child is vomiting and has alot of diarrhoea, or poor appetite, continue 2-hourly feeds;
• If there is little or no vomiting, modest diarrhoea (for example, less than five watery stools per
day), and finishing most feeds, change to 3-hourly feeds;
• After a day on 3-hourly feeds: if child is not vomiting, has less diarrhoea, and is finishing most
feeds, change to 4-hourly feeds

NOTE: See Annex 18 for reconstitution of commercial F-75 therapeutic milk powder.

Amounts of F-75 to give

Give the amounts in the Annex 20 to each patient according to their weight and appropriate
schedule of feeding. This comes up to 130ml per kg per day for both oedematous and non-
oedematous children (about 100kcal/kg/day).

NOTE: Patients on F-75 are NOT expected to gain weight (if they gain weight, they are in
danger of refeeding syndrome. F-75 has insufficient phosphorus to allow for new tissue
formation and is very dangerous.)

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 Give the amounts in the Annex 20 to each patient according to their weight and appropriate
schedule of feeding. This comes up to 130ml per kg per day for both oedematous and non-
oedematous children (about 100kcal/kg/day).

Note:
Feeding Patients for
technique on F-75 are NOT
severely expected to gain
malnourished weight (if they gain weight, they are in danger
children
of refeeding syndrome. F-75 has insufficient phosphorus to allow for new tissue formation and is
The muscle weakness, slow swallowing and poor peristalsis of these children makes aspiration
very dangerous.)
pneumonia very common. Therefore, great care must be taken while feeding. Adherence to the
following technique reduces the risk of aspiration pneumonia:
Figure 14: Feeding Technique
Feeding technique for severely malnourished
children
Sitting position
Tell the mother/caretaker to put theslow
The muscle weakness, childswallowing
on her lap against her
and poor
chest, with one arm behind her back.
peristalsis of these children makes aspiration
pneumonia
The mother’s very common.
arm encircles Therefore,
the child and holdsgreat careunder
a saucer must
the child’s
be chin.
takenThewhile
childfeeding.
should be sitting straight
Adherence to the(vertical).
following
technique reduces the risk of aspiration pneumonia:
Appropriate feeding
• Give the appropriate amount of F-75 in a cup, any dribbles
Sitting
that fall into position
the saucer are returned to the cup (see Figure
14). Tell the mother/caretaker to put the child on her lap
against
• Tell the mother hernot
chest, withfeed
to force one the
armchild
behind
andher back.
never to pinch
his/herThe mother’s
nose, squeeze armtheencircles
cheeks tothe child
force theandmouthholds
open a
or lie saucer
back and under
havethe
the child’s chin. into
milk poured Thethechild should be
mouth.
• Meal sitting straightbe
times should (vertical).
sociable. Mothers should sit together in a semi-circle around an assistant
who encourages them, talks to them, corrects any faulty feeding Figure 15: Feeding
technique andTechnique
observes how
the children take the
Appropriate feeding milk.
• Children
• should Givenotthebe given any amount
appropriate other food apartin
of F-75 from the any
a cup, prescribed
dribblesF-75.
that fall into the saucer are
• Caretakers should never take their meals
returned to the cup (see Figure 13).beside the patient. The child is likely to demand some
of the mother’s meal and this sharing is not recommended. Sharing the mother’s meal with
• Tell the mother not to force feed the child and never to pinch his/her nose, squeeze the
the child can be dangerous as the mother’s meal usually has salt or a spice added in sufficient
cheeks to
amounts to provoke force
fluid the mouth
retention and open
heart or lie back
failure and
in the have the milkchild.
malnourished poured into the mouth.
Furthermore, the
• dietMeal
mother’s doestimes should the
not contain be sociable. Mothers
correct balance of should sitto
nutrients together in a semi-circle
treat metabolic around an
malnutrition
and will disturbassistant who encourages
the child’s them,
appetite for the talks to them, corrects any faulty feeding technique and
F-75.
• The only food observes howF-75
apart from the that
children take the
the child milk.receive is breastmilk.
should
• Children should not be given any other food apart from the prescribed F-75.
•
Naso-gastric Caretakers
feeding should never take their meals beside the patient. The child is likely to demand
some of the
Naso-gastric tube (NGT) mother’s
feeding meal
is used andathis
when sharing
patient is taking
is not not recommended.
sufficient dietSharing theThis
by mouth. mother’s
is defined as an intake of less than 75 per cent of the prescribed diet (for children about 75 kcal/kg/
day). The reasons for use of an NG tube are: 110

• Taking less than 75 per cent of prescribed diet per 24 hours

• Pneumonia with a rapid respiration rate
• Painful lesions of the mouth
• Cleft palate or other physical deformity
• Disturbances of consciousness

NOTE: Each day, try patiently to give the patient F-75 by mouth before using the NG tube.
NG tube feeding should not normally exceed three days but may do so in the severely ill
children; and it is only used in Phase 1 (see Annex 21 on how to insert NGT).

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 111

Progress from stabilization, transition, and rehabilitation phases
Criteria to progress from stabilization to transition phase
There is no “fixed” time for a child to remain in the stabilization phase. It is expected that most
of the severely ill children will remain in the stabilization phase for a period longer than average
and the less severely complicated cases and those that respond readily to treatment for a shorter
time. Transfer a patient from stabilization phase to transition phase when all the following are
present:

• Return of appetite (easily finishes 3 to 4 hourly feeds of F-75)

• Reducing oedema (from moderate (++) oedema or mild oedema(+)).

NOTE: Oedema should not be grade 3.

• The patient appears to be clinically recovering.

• The child may also smile at this stage.
Once children are ready to move into the rehabilitation phase, perform an acceptance test for
RUTF (see Chapter 4) and they should transition from F-75 to ready-to-use therapeutic food over
2–3 days, as tolerated. The recommended energy intake during the transition period is 100–135
kcal/kg/day.

Feeding during transition phase

In this phase, the patient begins to gain weight slowly. The objective of transition phase is to
gradually increase the amount of caloric intake from 100 kcal/kg to 135 kcal/kg. Transition phase
prepares the patient for rehabilitation or Phase 2 treatment and transfer to the OTC. The transition
phase usually lasts between 2 and 5 days–but may be longer, particularly when there is another
condition (e.g. TB or HIV, younger and smaller children). A prolonged transition phase is one of the
criteria for failure-to-respond.

Diet used during transition

The ONLY change in diet when moving from stabilization phase to transition phase is that F-75 is
replaced by RUTF, or if the RUTF is not accepted, to F-100.

Transition from F-75 to RUTF

It is preferable to use RUTF in the Transition Phase. All children who are very ill and are going to
continue treatment as outpatients should become habituated to RUTF before they go home. One
advantage of the RUTF is that there is no need for monitoring during the night so that minimum
or no night staff is needed.

Approach for transitioning children from F-75 to ready-to use therapeutic food
Perform an acceptance test to determine if the child will take the RUTF. This test should be
conducted in a quiet and separate corner:

• Counsel the mother to give the child the prescribed amount of ready-to-use therapeutic food
for the transition phase (Annex 22).
• Let the child drink safe water freely. If the child does not take at least half the prescribed amount
of ready-to-use therapeutic food in the first 24 hours, then return to F-75 again and offer the
same amount as at the end of stabilization every 3-4 hours (Annex 20).
• Retry the same approach after another 1–2 days until the child takes the appropriate amount of
ready-to-use therapeutic food to meet energy needs.

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• Give the total amount of RUTF that should be taken during the day according to the child’s
weight (Annex 22).
• Encourage and support breastfeeding mothers to breastfeed on demand before giving RUTF.
• Tell the mother to wash hands before giving the sachet of RUTF to the child.
• Tell the mother to offer plenty of water to the child;
• Advise the mother to put the sachet in a box (insect and rodent proof) when the child has
finished each session of eating.
• CHECK five times during the day, the amount given by the mother. It is important for the
assistant to check regularly and counsel the mother and not assume that the mother will give
all the RUTF to the child. It is useful to have regular “meal times” for the children where the
mothers all gather together in one place to feed their children.

For children that are not taking sufficient RUTF (not gaining any weight)
• Either change to F-100 for a few days and then re-introduce RUTF.
• Or return the child to the stabilization phase for a day or two and give F-75.
• Do NOT give any other food to the patient during this period.
• Do NOT let the caretaker eat in the same room as the malnourished children.
• Check that the caretaker or other children do not consume the patients’ RUTF.
• Make drinking water available both in the ward and also to individual children. The mother must
offer as much water to drink as they will take during and after they have taken some of the RUTF.

Transition from F-75 to F-100

If RUTF is not available, or the child does not readily take the RUTF, then use F-100 (130 ml = 130
kcal).

Approach
• For the first 1–3 days, give the child F-100 every 3–4 hours in the same amounts of F-75 that
were being given in stabilization (Annex 23). Do not increase the amount of F-100 for the first
two days.
• On Day 3, add 10 ml at each meal until the child finishes the meal. If the child does not finish a
meal, offer the same amount for the next meal; if the child finishes, then further increase the
next meal by 10 ml.
• For the following days, continue until the child leaves a bit of most meals (usually when the
volume reaches around 30 ml/kg per meal).
*See Annex 18 for both reconstitution of commercial F-100 therapeutic milk powder and recipe for
locally prepared F-100.
Warning: F-100 should never be given to be used at home. It is always prepared and distributed
in an inpatient unit. The table gives the amount of F-100 (full strength) that should be offered to
the patients in transition phase who are not taking RUTF. They should normally be taking six feeds
during the day and none at night.

NOTE: Re-try RUTF acceptance test before discharge through OTC. Ask mothers to breastfeed
their children, half an hour before giving the feed and always record the amounts given and
taken on the multi-chart.

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Criteria to move back from transition phase to the stabilization phase
The criteria for transferring patients back to stabilization phase is summarized as follows:

• If there is a rapid increase in the size of the liver.

• If any other signs of fluid overload develop (increased respiratory rate).
• If the patient gains weight more rapidly than 10 g/kg/d (this indicated excess fluid retention).
• If tense abdominal distension develops (indicates abnormal peristalsis, small bowel overgrowth
and perhaps excess carbohydrate intake).
• If the patient gets significant re-feeding diarrhoea so that there is weight loss (see separate
section).
• If a complication arises that necessitates an intravenous infusion (e.g. malaria etc.).
• If there is any deterioration in the child’s condition (see section on Refeeding Syndrome)
• If there is increasing oedema (look for unexpected sodium intake, particularly from mother’s
diet or drugs–if an extraneous source if sodium is found then, it should be eliminated and
children with good appetite can remain in transition-phase).
• If a child who does not have oedema develops oedema (look for extraneous intake of sodium).
It is common for the children to get some change in stool frequency when they change diet. This
should not be treated unless the children lose weight. Several loose stools without weight loss is
not a criterion to move back to stabilization phase.

Criteria to move from transition phase to rehabilitation phase

Transfer the patient to the rehabilitation/catch-up phase in OTC:

• If s/he has a good appetite; this means taking at least 90 per cent of the RUTF (or F-100) prescribed
for transition phase.
• For oedematous patients, if there is a definite and steady reduction in oedema.
• If there is a capable caretaker.
• If the caretaker agrees to outpatient treatment.
• If there are reasonable home circumstances.
• If there is a sustained supply of RUTF.
• If an OTC program is in operation in the area close to the patient’s home.

NOTE: Justify a patient transferring from one to another phase of treatment, one as an
inpatient and the other as an outpatient is still under the care of the IMAM program for this
episode of severe malnutrition. This is not a “discharge” from the inpatient facility but an
internal transfer to another part of the same program–nevertheless, the ITC records this as
“successful treatment”.

Rehabilitation Phase or Phase 2

In rehabilitation phase or Phase 2, the main objective is to achieve catch-up growth and resolve
micronutrient deficiencies. Patients can be transferred through OTC (Option 1). Although it is
highly desirable that the rehabilitation phase be managed on an outpatient basis, this is not
always possible.

• If there is no capable caretaker, impossible home circumstances, no other family willing to

care for the child, an abandoned child without an available orphanage, no operational OTC
service or no supply of RUTF, the patient can be managed as an inpatient for rehabilitation until
recovery as Option 2. For patients discharged through OTC as option 1, see Chapter 7 whereas

114 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA

 patients managed in inpatient for rehabilitation phase as Option 2, see guidance hereafter and
in Annex 19.

Refeeding syndrome
“Refeeding syndrome” refers to malnourished patients (and those who have been fasting for more
than one week16) who develop any of the following shortly after they have a rapid, large increase
in their food intake: acute weakness, “floppiness”, lethargy, delirium, neurological symptoms,
acidosis, muscle necrosis, liver and pancreatic failure, cardiac failure or sudden unexpected death.
The syndrome is due to rapid consumption of key nutrients for metabolism particularly if the diet
is unbalanced. There is frequently an acute large reduction in plasma phosphorus, potassium
and magnesium. Other separate problems during early refeeding include refeeding-oedema and
refeeding-diarrhoea (see section on medical complications).

Prevention
It is necessary at the start of treatment to gradually increase caloric intake. On admission,
malnourished patients should never be force-fed excess of amounts prescribed feeds in the
protocol; they should not gain weight when in stabilization phase on F-75; particular care needs
to be taken with those who are being fed by NG Tube. Prevention of refeeding syndrome is the
purpose of the transition phase of treatment. In the OTC protocol, very large amounts of RUTF are
sometimes given at the start of treatment. If any mother forces her child to take all the diet then,
refeeding syndrome is a real possibility.

Treatment
For patients in the rehabilitation phase, if there is deterioration during the rehabilitation or
transition phase of treatment, then the child should be returned to the stabilization phase.
For patients that are in the stabilization phase, reduce the diet to 50 per cent of the recommended
intake until all signs and symptoms disappear and then gradually increase the amount given.
Check to make sure that there is sufficient potassium and magnesium in the diet. If the diet is not
based on cow milk (or the mother is also giving cereals/pulses etc.), additional phosphorus should
be given to prevent refeeding syndrome.

NOTE: Phosphorus is the limiting nutrient in F-75 (breastmilk and cow milk are rich sources
of phosphorus; F-100 contains a lot more phosphorus than F-75. It is appropriate to give
children suspected of refeeding syndrome F-100 dilute (not full F-100 strength) if this is
tolerated.

Routine Medicines
The following are routine medicines provided for children who are admitted in ITC.

• Systemic antibiotics
• Malaria treatment (if test is positive)
• Measles vaccine

16 The syndrome also occurs in obese patients who have been fasting as part of their treatment; they are not wasted but, like the malnourished
patient, have metabolically adapted to a low intake of food.

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Systemic antibiotics
All children with SAM should be given systemic antibiotics.

No signs of infection
Give IV Ampicillin for 2 days followed by Oral Amoxicillin 50–100 mg/kg/d and IV gentamycin once
daily for 7 days (see Annex 24 for doses).

NOTE: Do not mix the two antibiotics or give through the same cannula at the same time.

Signs of infection
• In cases with complications due to very severe infection such as septic shock,
• First line IV antibiotics: IV Ampicillin and IV Gentamycin for 5–7 days (see Table 27 for dosages).
Second line IV antibiotics: IV Ceftriaxone or Cefotaxime (Annex 24 for dosages)

Table 27: Summary of antibiotics used in severe acute malnutrition

IF: Give:

NO COMPLICATIONS Amoxicillin Oral: 25 mg/kg every 12 hours for 5 days

COMPLICATIONS Gentamicin* IV or IM (5 mg/kg) once daily for 7 days,

plus:
(shock, hypoglycaemia,
hypothermia, severe Ampicillin IV or IM (50 mg/kg) every 6 hours for 2 days
dermatosis, infections, IMNCI
danger signs, severe anaemia, Followed by: Amoxicillin Oral: 25 mg/kg every 12 hours for
cardiac failure, and corneal 5 days**.
ulceration)
*May give IV Ampicillin for 5–7 days if overt infections

If there is no improvement In the case of sepsis or septic shock: IV ceftriaxone or

on the first line IV antibiotics Cefotaxime (for children / infants beyond one month: 50
and presence of medical mg / kg every 8 to 12 hours) + oral ciprofloxacin (5 to 15
complications: mg / kg 2 times per day).
If suspected staphylococcal infections: Add: Cloxacillin (12,
5 to 50 mg /kg / dose four times a day, depending on the
severity of the infection).

If a specific infection requires Specific antibiotic on the drug kit (Annex 24). Refer to
an additional antibiotic, ALSO the drug kit for severe acute malnutrition with medical
GIVE: complications.

*If the child is not passing urine, gentamicin may accumulate in the body and cause deafness. Do
not give the second dose until the child is passing urine.
**If amoxicillin is not available, give ampicillin, 50 mg/kg orally every 6 hours for 5 days.

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Administration of antibiotics
• Wherever possible, antibiotics should be given orally or by NG tube (Annex 21).
• In cases with complications due very severe infection such as septic shock, parenteral antibiotics
should be used.
• Infusions containing antibiotics should not be used because of the danger of inducing heart
failure.
• Indwelling cannula should occasionally be used only in very ill children.The indwelling cannulas
should not routinely be used to avoid the risks associated with them (Annex 25).
• Ensure that the cannula site is sterile.

Malaria treatment
Although the national protocol should be followed for asymptomatic malaria in OTC, cases with
symptomatic malaria are admitted to ITC and treated according to the national guidelines.

• For uncomplicated malaria, give artemether-lumefantrine (AL) as the first line treatment using
a six dose regimen (at 0 and 8 hours, then twice daily on each of the following 2 days).
• For complicated malaria (e.g. cerebral malaria)
• For children without diarrhoea, give high dose artemether or artesunate suppositories
• If the suppository is expelled within two hours, repeat the dose.
• For those with diarrhoea, disturbance of consciousness or where suppositories are not
available, give IV artesunate or IM artemether.
• Once responding, change to oral AL to complete the full dose.

NOTE: Avoid use of combinations containing amodiaquine 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, hypoglycaemia, arrhythmia and cardiac arrest. There is only a small
difference between the therapeutic dose and the toxic dose.
Ensure that all beds have mosquito nets in ITC.

Measles-Rubella vaccine update and other vaccines

• All children aged 9 months and above without vaccination cards should be given, measles-
rubella vaccine on admission and a second dose at the 4th week in OTC.,
• In case of a measles outbreak, young children aged 6 months and above should get the measles-
rubella vaccine on admission and a second dose at 9 months.
• All children who are admitted directly to OTC should receive the measles-rubella vaccine at the
4th week.

Medicines given under specific circumstances only

Vitamin A
There is sufficient vitamin A in F-75, F-100 and RUTF to correct mild vitamin A deficiency. High
doses of vitamin A are not required in the child without clinical signs of deficiency.
Give vitamin A supplements only under the following circumstances:

• Where the child has any clinical signs of vitamin A deficiency.

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• In children aged more than 9 months, where there is an active measles epidemic and the child
has not been vaccinated against measles.
Folic acid
There is sufficient folic acid in F-75, F-100 and RUTF to treat mild folate deficiency.
If the child has clinical anaemia, give a single dose of folic acid (5 mg) on the day of admission.

Anti-helminthics
Delay the treatment of anti-helminthic until the patient is admitted in OTC.

Involving mothers in care and integration of psycho-social stimulation in ITC

The mother or caregiver stay with the severely malnourished child in the hospital. Mothers’
or caretakers’ involvement in the care of their children during treatment and recovery of acute
malnutrition is very important (see Chapter 8). It is essential that mothers/caregiver must be
encouraged to feed, hold, comfort, and play with the child as much as possible because;

• The child’s mother/caregiver can provide more continuous stimulation and loving attention
than busy health workers.
• When mothers/caregivers are involved in care at the health facility, they learn how to continue
care for their children at home.
• Mothers/caregivers can make a valuable contribution and reduce the workload of health
workers by helping with activities such as bathing and feeding patients.
There are many ways to encourage mothers’/caregivers’ involvement in hospital care.

• Teaching and encouraging mothers to provide sensory stimulation and physical and emotional
support for their children; for example, playing with children, supervising play session and
making toys.
• Participation of mothers or caretakers in health and nutrition education sessions increases their
knowledge and skills needed in improving feeding, care practices and provides an opportunity
for them to discuss with other mothers and create mother-to-mother support.
• Mothers can be taught how to prepare and feed their children nutritious food.
• Bathe and change children’s clothes and or diapers.

Management of complications
Children with SAM may present with a medical complication or develop it while on treatment.
When a complication develops, always transfer him/her to stabilization phase for treatment
(inpatients are transferred back to stabilization phase if they are in transition phase; outpatients
are referred to the ITC).

1. Treat/prevent hypoglycemia
Hypoglycemia is blood glucose less than 3 mmol/L (54 mg/dl). If possible, health workers should
perform a blood glucose test (Dextrostix, Glucostix or laboratory test) on admission before giving
glucose or feeding.

Causes of hypoglycemia
Inadequate intake of food: Malnourished children may arrive at the hospital hypoglycemic if they
have been vomiting, too sick to eat or if they have had a long journey without food, waiting too
long for admission or if they are not being fed regularly.

118 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA

Prevention of hypoglycemia
• Give 50 mls of sugar water solution to all children on arrival at the facility, particularly those
that have travelled long distances. Make the sugar water solution by adding one rounded tea
spoon of sugar/glucose in 50 ml of safe drinking water.
• If sugar water is not available, assess and start therapeutic feeds (F-75) as soon as possible to
prevent hypoglycemia.
• Give extra sugar to all children who get hypothermia or have septic shock, whether or not they
have low blood glucose. (5ml/kg of 10 per cent dextrose)
• The children who develop hypoglycemia need at least one feed during the night.
Signs of hypoglycemia
There are often no signs at all of hypoglycemia. However, the following signs suggest
hypoglycaemia:

• Lethargy, limpness, loss of consciousness or convulsions.

• Semiconscious with the eyes partly opened (eye-lid retraction) due to overactive sympathetic
nervous system.
• Drowsiness (the only sign before death).
• Hypothermia (axillary temperature < 35 °C or rectal temperature <35.5 °C).
Treatment
• For patients who are conscious and able to drink, give about 50 ml (approximately 5–10 ml/kg)
of sugar water (about 10 per cent ordinary sugar in water), or F-75 by mouth.
• Start feeding F-75 after half an hour after giving glucose and give feeds every half an hour during
the first 2 hours. The amount to give every half-hour is a quarter of the two hourly amount.
• For patients losing consciousness, give 50 ml of sugar water by NG tube immediately. When
consciousness is regained give F-75 feeds frequently.
• For semiconscious and unconscious patients, give sugar water by NG tube immediately. They
should then be given glucose as a single intravenous injection (approximately 5 ml/kg of a
sterile 10 per cent glucose solution).
• Treat all malnourished patients with hypoglycaemia using IV antibiotics.
• The response to treatment is dramatic and rapid. If a very lethargic or unconscious patient does
not respond in this way, then it is urgent that another cause for the clinical condition is investigated
and treated (e.g. cerebral malaria, meningitis, hypoxia, hypernatremia, shock, etc.).

2. Treat/prevent hypothermia
Hypothermia
Severely malnourished patients are highly susceptible to hypothermia. A severely malnourished
child is hypothermic if the rectal temperature is below 35.5°C or if the axillary temperature is
below 35.0°C.

Prevention
• Keep the room warm, especially at night (the thermo-neutral temperature for malnourished is
from 28oC and 32oC).
• Keep windows and doors closed at night.
• Warm your hands before touching the patient.
• Monitor the temperature with a maximum-minimum thermometer on the wall.
• Use adult beds so the children sleep with their mothers.
• Keep bedding/clothes dry and use adequate blankets.
• Dry carefully after bathing (do not bathe if very ill or early in the morning).

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• Avoid prolonged exposure during examinations, weighing and bathing.
• If it is not possible to warm the room, keep the child cuddled up by mother and cover with a blanket.
Treatment
Treat hypothermia if the rectal temperature <35.5 ºC) or auxiliary temperature <35 °C.

• Use the “kangaroo technique”. The child is placed on the chest of the mother skin-to-skin and
the mother’s clothes wrapped around the child.
• Give hot drinks to the mother so that her skin gets warmer (plain water, tea or any other hot drink).
• Cover the child’s head with a hat.
• Stop drought in the room and move the child from the window.
• Monitor body temperature during re-warming (every 30 minutes).
• Treat for hypoglycemia and give intravenous antibiotic treatment.
• Use a heater or incandescent lamp with caution. If heater is used, take temperature every 30
minutes because the child may become overheated.
• Stop rewarming when child’s temperature becomes normal.
• Do not use hot water bottles to rewarm the child due to danger of burning the child’s fragile skin.

3. Treat/prevent dehydration
Dehydration occurs when a patient loses more fluid than is ingested so that the body does not
have enough water and other fluids to carry out its normal functions. Diarrhoea is the commonest
cause of dehydration among children with SAM.

Diarrhoea in SAM
Before assessing for dehydration, the health worker needs to be certain that the child has
diarrhoea. When children start taking therapeutic feeds, their stool changes since most of them
take solid foods and they are changed to a liquid F-75 diet. The mother/caregiver might therefore
report diarrhoea when it is actually not present. Diarrhoea is defined as passing three or more
loose stools. The pictures in the stool scale below have been validated in a study (ProbiSAM)
at Mwanamugimu Nutrition Unit, Mulago National Referral Hospital and can be used by health
workers to ascertain that the child has diarrhoea (see Figure 15). The mothers or other caretakers
are asked to point at the picture which looks like their child’s stool. From that study, it was found
that watery stool (Number 1 in the stool scale below) was associated with dehydration when
compared to the other stool consistencies (see Figure 15).

Figure 15: Stool Scale

1 (Watery) 2 (Abnormally loose)

3 (Loose) 4 (Normal)

120 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA

Figure 16: Stool Scale

Dehydration in the non-oedematous SAM patient
Misdiagnosis and inappropriate treatment for dehydration is the commonest cause of death in the
malnourished patient. Rehydration fluids are never given “routinely” to malnourished patients. With
severe malnutrition the “therapeutic window” is narrow, so that even dehydrated children can quickly
go from having a depleted circulation to over hydration with fluid overload and cardiac failure.
Intravenous infusions are rarely used. In malnutrition (both severely wasted patient and, to a
greater extent, an oedematous patient), there is a particular renal problem that makes the children
sensitive to salt (sodium) overload.

Assessment of dehydration
It is often difficult to determine dehydration status in a patient with SAM as the usual signs of
dehydration such as lethargy, slow skin pinch, sunken eyes/anterior fontanel, may be present and
yet the patient may not be dehydrated. This is because the skin of children with non-oedematous
SAM usually lies in folds and is inelastic so that the “skin pinch” test is usually positive whether
or not the child is dehydrated. The eyes are usually sunken without there being any dehydration
because of wasting and loss of the fat from the orbit which normally fills the space around the
eye (see Figure 16). The consequences of overhydration are very much more serious than slight
dehydration. On the other hand, truly dehydrated children must be appropriately rehydrated if
they are to survive.

Figure 16: Pictures of Children with Sunken Eyes

No.1: Not dehydrated No.2: Dehydrated

The
Thetwotwopictures
picturesabove
above show
show thatthat
sinking of the
sinking of eyes is often
the eyes more more
is often profound in malnourished
profound children who
in malnourished
are NOT who
children dehydrated
are NOT – dehydrated
giving this child rehydration
– giving this childfluid is very dangerous.
rehydration Note
fluid is very that the eyelids
dangerous. Note thatare not
the eyelids
retracted. aresecond
The not retracted.
child is The second
severely child is severely
dehydrated and must dehydrated and must
have rehydration have
fluid. rehydration
Note that this child
fluid.has
also Note that eyes,
sunken this child
but italso
is nothassosunken
profoundeyes,
andbuttheiteyes
is not
haveso aprofound and the eyes
staring appearance (lidhave a
retraction).
staring appearance (lid retraction). This is because more fat in the orbit of the malnourished
This is because more fat in the orbit of the malnourished child is lost in SAM so the eyes are more sunken.
child is lost in SAM so the eyes are more sunken. In dehydration fluid (blood) is displaced from
In
thedehydration fluid– the
orbital veins (blood) is displacedchild
malnourished fromdoes
the orbital
not have veins – the malnourished
sympathetic stimulation child does not
whereas the have
sympathetic
dehydrated stimulation whereas the
child’s sympathetic dehydrated
system child’sleading
is overactive sympathetic
to thesystem is to
eyelids overactive leading
be retracted andto the
eyelids
orbital to be retracted
vessels and orbital
(© Michael Golden) vessels (© Michael Golden) constricted.
constricted.
Figure 17: Pictures of Children with Sunken Eyes

Diagnosis of dehydration in a non-oedematous child

The main diagnosis comes from the HISTORY rather than from the examination. The following
are used to diagnose dehydration in children with SAM:
GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 121

History
Diagnosis of dehydration in a non-oedematous child
The main diagnosis comes from the HISTORY rather than from the examination. The following are
used to diagnose dehydration in children with SAM:

History
A definite history of significant recent fluid loss; usually watery diarrhoea (number one on the
stool scale or like running water, not just soft or mucus stool) that is and with a sudden onset with
in past few hours or days.

• There should also be a HISTORY of a recent CHANGE in the child’s appearance.

Examination
If the eyes are sunken then the mother should confirm that the eyes have just become sunken
since the diarrhoe started.

• Absence of visible “full” superficial veins (look at the head, neck and limbs).
• If in addition to the above, the child is eager to drink or reaches out for the cup when you offer
ReSoMal and has dry mucous membranes, this strengthens the diagnosis of dehydration but
is not definitive without the other features.

NOTE: The child must NOT have oedema. Oedematous patients are overhydrated and
not dehydrated (although they are often hypovolemic from septic, cardiac or other shock)
because they have increased levels of blood nitric oxide which is a potent vasodilator.

Treatment of Dehydration (see Table 28)

• Diarrhoea is not treated with rehydration fluids to “prevent” the onset of dehydration in SAM
children. This leads to overhydration and heart failure. Whenever possible, a dehydrated patient
with severe malnutrition should be rehydrated orally. Intravenous infusions are dangerous and
not recommended unless there is shock and confirmed dehydration.
• ReSoMal, the Rehydration Solution for Malnutrition is used for oral rehydration. It is a
modification of the standard Oral Rehydration Solution (ORS) recommended by WHO. ReSoMal
contains less sodium, more sugar, and more potassium than standard ORS and is intended for
severely malnourished patients with dehydration. Malnourished patients already have excess
sodium in their cells, so sodium intake should be restricted. The management of dehydration is
based on accurate weight measurements of the patient.

NOTE: SAM children often have some refeeding diarrhoea after taking F-75 or other foods
due to malabsorption. They can even malabsorb ReSoMal such that excess can also give
rise to loose stools. It is important to note that here is a difference between dehydration and
diarrhoea. All diarrhoea does not lead to, or mean that the child has, dehydration.

Target weight for rehydration

If the child has been under treatment for SAM and there is a pre-diarrhoeal weight that has been
recorded before the diarrhoea starts:

• If there has been no weight loss with the diarrhoea, then the child is NOT dehydrated and no
rehydration treatment should be given.
• If there has been weight loss, the actual fluid loss is equal to the weight loss and the target
rehydration weight is the pre-diarrhoeal weight. Treatment should not be given to increase the
weight beyond the pre-diarrhoeal weight (Annex 17).
• If the patient is newly admitted, it is extremely difficult to judge the amount of fluid that has
been lost in the child with non-oedematous SAM as all the clinical signs are unreliable.

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• In practice, the weight loss is generally 3 per cent of body weight in most children and in a few
up to 5 per cent.
• Do not attempt to increase body weight by more than 5 per cent.
• If there is weight gain of up to 5 per cent of body weight with rehydration, the truly dehydrated
child will show dramatic clinical improvement and should be out of immediate danger from
death due to dehydration; treatment can then be continued with F-75.

Box 9: Steps in rehydration of SAM with no oedema using ReSoMal

• Weigh the patient before starting rehydration and record the weight (see Figure 17).
• Mark the edge of the liver.
• Record the respiratory rate, pulse rate, capillary refill time and heart sounds.
• Calculate target weight.
• Start with 10ml/kg/h ReSoMal for the first two hours orally or by nasogastric tube and
then adjust according to the weight changes observed.
• Weigh after the two hours.
Reassess for the signs of dehydration after the two hours
Act according to the findings below:
If there is weight gain and deterioration of the child’s clinical condition with the rehydration
therapy;
• The diagnosis of dehydration was definitely wrong.
• Stop ReSoMal and start the child on F-75 diet.
If there is weight gain and clinical improvement, but there are still signs of dehydration;
• Continue cautiously with the treatment until the appropriate weight gain has been
achieved
• Continue with ReSoMal alone until target weight is attained.
If there is continued weight loss, then:
• Give ReSoMal at 20 ml/kg/hour
• Formally reassess in one hour
If there is no weight gain, then:
• Give ReSoMal at 15ml/kg/hour
• Formally reassess in one hour

ReSoMal is given until the weight deficit is corrected. Therefore, do not exceed the target
rehydrated weight.

After rehydration usually, no further treatment is given. However, for malnourished children aged
6 to 24 months, give 30 ml of ReSoMal after each watery stool if it is profuse and likely to dehydrate
them. However, if children are above 2 years on the stool scale give 50mls of ReSoMal after each
stool if they have profuse watery diarrhoea (number 1).
During rehydration, breastfeeding should not be interrupted. Begin to give F-75 as soon as
possible, orally or by nasogastric tube. Introduction of F-75 is usually achieved within 2–3 hours
of starting rehydration.

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 NOTE: Never use a drip in a malnourished child EXCEPT when they are in SHOCK

Figure 17: Steps in rehydrating a SAM child with no oedema

Figure 18: Steps

Monitoring of in rehydrating a SAM child with no oedema
rehydration
The rehydration
Monitoring of a severely malnourished child is managed by monitoring
of rehydration
The rehydration of a severely malnourished child is managed by monitoring
•• Weight
Weightchanges
changes
• Clinical signs of
• Clinical signs ofimprovement
improvement and and
• Clinical signs of overhydration
• Clinical signs of overhydration
Monitoring thethe
Monitoring weight
weight
• Give the rehydration fluid (ReSoMal) until the weight deficit (measured or estimated) is
• Give the rehydration fluid (ReSoMal) until the weight deficit (measured or estimated) is
corrected.
• corrected.
Weigh every hour
•• WeighStop every
as soonhour
as the child is rehydrated to the target rehydrated weight.
Signs of hydration (Have tears returned, is the mouth less dry, is the patient less lethargic?)
• Stop as soon as the child is rehydrated to the target rehydrated weight.
Signs of overhydration
Signs of hydration (Have tears returned, is the mouth less dry, is the patient less lethargic?)
STOP all rehydration (oral or intravenous) therapy immediately if any of the following are
observed:
Signs of overhydration
• The target weight for rehydration has been achieved (give F-75)
STOP all rehydration
• The visible veins become full(oral
(giveor intravenous) therapy immediately if any
F-75) of the following are
observed:
• The development of oedema* (over-hydration – give F-75)
• The development of prominent neck veins*
•• The target
The neck veinsweight
engorgeforwhenrehydration
the abdomenhas (liver)been achieved (give F-75)
is pressed*.
• An increase in the liver size by more
• The visible veins become full (give F-75)than one centimetre. *
• The development of tenderness over the liver. *
• The development of oedema* (over-hydration – give F-75)
• An increase in the respiration rate by 5 breaths per minute or more*
•• The development
The development of prominent
of a “grunting” neck
respiration (thisveins*
is a noise on expiration NOT inspiration). *
• The neck veins engorge when the abdomen (liver) is pressed*.
125
• An increase in the liver size by more than one centimetre. *
• The development of tenderness over the liver. *
• An increase in the respiration rate by 5 breaths per minute or more*
• The development of a “grunting” respiration (this is a noise on expiration NOT inspiration). *
• The development of crackles or crepitation in the lungs*

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• The development of a triple rhythm*
* If these signs develop then the child has fluid overload, an over-expanded circulation and is
going into heart failure

Table 28: Assessment and treatment of dehydration and shock in non-oedematous SAM

Assess, Classify and Treat Dehydration and Shock in a child with Non-oedematous Severe Acute
Malnutrition
Assess Classify Treat
SHOCK • IV 15ml/kg Half Strength Darrows or Ringers
Lactate with 5% Dextrose (1:1) in 1 hour
Lethargic/unconscious and then reassess
has cold hands
• If there is clinical improvement and child is
Plus, either: slow capillary conscious, give ReSoMal 10ml/kg/hr
refill (longer than 3 • If better but not alert, repeat IV fluids 15ml/
seconds) Dehydration with kg in 1 hr then reassess
Or weak or fast pulse Shock • If weight loss or no weight change, repeat
the 15 ml/kg IV fluids in next hr, reassess
And • If there is weight gain with no improvement,
DEHYDRATION STOP IV fluids, look for cause of shock
• After rehydration, no further Resomal is
(see box below)
given EXCEPT if the child is passing profuse
watery stool
History • 10ml/kg/h of ReSoMal for the first 2 hours
orally or by NG tube and then adjust
A history of significant recent according to the weight changes
fluid loss
• If there is weight gain and clinical
HISTORY of a recent CHANGE improvement, continue 10ml/kg/hr but do
in the child’s appearance not exceed target weight then give F-75
• If weight gain but clinically worse, stop
Examination
rehydration
Only examine if the child has • If weight loss, increase to 20ml/kg/hr and
definite significant fluid loss reassess
Any of these: • If no weight gain, increase to 15ml/kg/hr and
Dehydration reassess
• Sunken eyes which Note: Do NOT exceed Target weight
have been noted by the
mother to have changed After rehydration, no further Resomal is given
when the fluid loss EXCEPT if the child is passing profuse watery
started stool then give as below
• No “full superficial veins”
(head, neck and limbs)
• The child is eager to drink
or reaches out for the cup
when you offer ReSoMal
History of fluid loss NO ReSoMal is given EXCEPT in cases of
profuse watery diarrhoea then give: 30ml/
BUT No Dehydration
watery stool for under 24 months. Give 50mls
No signs of dehydration for children above 24 months.

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Management of diarrhea and dehydration in unique situations
Diarrhea and dehydration in the oedematous patient
ALL children with oedema have an increased total body water and sodium and are therefore
overhydrated. Oedematous patients CANNOT be “dehydrated” although they are frequently
HYPOVOLAEMIC with the fluid in the “wrong place”. The hypovolemia (relatively low circulating
blood volume) is due to a dilatation of the blood vessels and a low cardiac output.
If a child with oedematous SAM has definite profuse watery diarrhoea and the child is deteriorating
clinically, then the fluid lost can be replaced on the basis of 30ml of ReSoMal per watery stool for
children aged 6-59 months while in children above 24 months give 50mls of ReSoMal. This is not
mandatory and the clinical state of the child after the oral ReSoMal should be carefully assessed.
The treatment of hypovolemia in oedematous patients is the same as the treatment for septic
shock.

NOTE: Do not give IV fluids to correct shock in children with SAM oedematous.

Persistent or chronic diarrhoea

Children with persistent or chronic diarrhoea (without an acute watery exacerbation) do not need
acute rehydration therapy. They have adapted over the weeks to their altered hydration state and
should not be rehydrated over a few hours. The appropriate treatment of persistent diarrhoea is
nutritional17; it is most often due to nutrient deficiency and will resolve with F-75 and suppression
of small bowel bacterial overgrowth. Small bowel overgrowth is suppressed with most routine
antibiotics used for severely malnourished children; if the diarrhoea persists for 14 days, a course
of metronidazole (10 mg/kg/d) can be given.

Re-feeding diarrhoea after admission

The intestine of the malnourished child is atrophic and the capacity to absorb large amounts of
carbohydrate is limited; there is also frequently pancreatic atrophy so that carbohydrate, fat and
protein digestion is compromised.
When the child starts on F-75, there is often an increase in the stool output and it becomes less
formed. There is usually no loss of weight so that the child is not dehydrated and treatment should
continue.
Do NOT give ReSoMal for simple “re-feeding diarrhoea” without weight loss.
Usually, the diarrhoea can be ignored, as the amoxicillin suppresses the small bowel overgrowth
and the intestine repairs with the improved nutrition in F-75 so that mild osmotic diarrhoea
subsides after a few days.

Re-feeding diarrhoea appears to be more common in children with oedematous malnutrition.

The correct treatment is to change the diet.
Commercial F-75 has much of the sugar replaced by dextrin maltose so that it is much less likely to
cause osmotic diarrhoea. If F-75 is locally prepared in the facility, then use the recipes containing
starch (particularly rice starch), if possible, add some germinated grain flour to add amylase which
reduces the viscosity.

17 Check for mucus and blood in the stool, amoebiasis and shigella dysentery

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 If this does not suffice or there is weight loss,
• Then divide the diet into many smaller volume feeds, so that they do not overwhelm the
limited capacity for digestion and absorption.

For a few children this is insufficient as the intestine or pancreas is sufficiently damaged
that even small amounts of F-75 can provoke osmotic diarrhoea initially.
• Change the diet to one where the F-75 is fermented or based upon yoghurt instead of
unfermented milk
• Change to a cow’s milk-free diet like lactose-free soy-based milk or goat’s milk
• Add pancreatic enzymes directly to the feed just before it is given. These are available
commercially and are normally used to manage cystic fibrosis of the pancreas
(mucovisidosis).
• If there is mucus and blood in the stool, check for and treat amoebiasis or shigella
dysentery

NOTE: Re-feeding diarrhoea appears to be more common in children with oedematous

malnutrition. Weight loss can be due to resolution of oedema.

Hypernatraemia dehydration
Hypernatraemic dehydration is common in areas with a very dry atmosphere particularly, if there
is also a high temperature. Hypernatraemic dehydration is most likely to occur in children that
have been carried for long distances to the ITC/OTC in the sun or hot environment, without the
mother/caregiver stopping to rest or give the child something to drink. It is recommended to
give sugar water to all children on arrival at the ITC/OTC facility. The triage area in the OTC/ITC
facility should have a shade. Hypernatraemic dehydration also when the therapeutic feeds are
over concentrated.

NOTE: In areas where the humidity is very low and the daytime temperature is very high,
ALL the children must be offered water to drink at frequent intervals. If F-100 is used in
transition phase and rehabilitation phase, then it should be further diluted, and the intake
table adjusted for the additional volume required to be given at each feed.

Diagnosis
The first sign to appear is a change in the texture and feel of the skin.

• The skin develops plasticity similar to the feel of dough (flour and water mixed for bread/
chapatti making).
• The eyes can appear sunken.
• The abdomen frequently then becomes flat and may progress to become progressively sunken
and wrinkled (so called “scaphoid abdomen” or “prune belly”).
• The child may develop fever.
• The child becomes progressively drowsy and then unconscious.
• Convulsions follow and if treatment for hypernatremia is not commenced this leads to death. The
convulsions are not responsive to the normal anticonvulsants (phenobarbitone, diazepam etc.).
• Failure to control convulsions with anticonvulsants may be the first indication of the underlying
diagnosis.

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The diagnosis can be confirmed by finding elevated serum sodium more than 150 mmol/l.
Management of Hypernatraemia (see Table 29)

Table 29: Management of hypernatraemia

Incipient • Breastfeed the child. This can be supplemented with up to about 10

hypernatraemic ml/kg/h of 10% sugar-water in sips (little by little) over several hours
dehydration until the thirst of the child is satisfied. At this early stage treatment is
relatively safe.
• Give water slowly over several hours to correct the mild
hypernatraemic dehydration.
Developed • First, put the child in a relatively humid, thermo-neutral (28˚ to 32˚
hypernatraemic C) environment – this is the most important step and must not be
dehydration omitted. Use an incubator If it is available. Incase, the neonatal
incubator is unavailable use the same “tent” that is often used for
children with pneumonia.)
• Measure serum sodium, the aim is to reduce the serum sodium
concentration by about 12 mmol/24h. To correct the hypernatremia
more quickly than this, risks death from cerebral oedema.
• If it is not possible to measure the serum sodium, take at least 48
hours to correct hypernatraemic dehydration. The treatment should
start slowly and as the serum sodium approaches normality, the rate
of replenishment can be increased.
• Progress is assessed by serial weighting of the child every 2 hours.
The child is • The same volumes of fluid 2.5 ml/kg/h (5% dextrose if there is no
unconscious diarrhoea and one fifth normal saline in 5% dextrose if there is
diarrhoea) can be given by intravenous infusion.
If the child is • Then, pass an NGT and start 2.5 ml/kg/h of 10% sugar water or breast
conscious or milk. Do not give F-75 at this stage. Re-weigh the child every 2 hours.
semi-conscious • If the weight is static or there is continuing weight loss, recheck the
and there is no immediate environment to try to prevent on-going water losses. Then
diarrhoea increase the amount of sugar-water intake to compensate for the on-
going weight loss (calculated as g/h and increase the intake by this
amount).
• If the weight is increasing continue treatment until the child is awake
and alert.
If the child is • If there is accompanying diarrhoea, then give 2.5 ml/kg/h of one
conscious or fifth normal saline in 5% dextrose orally or by NG-tube. (ratio of 1: 4
semi-conscious Normal saline to 5% Dextrose
and there is
accompanying
diarrhoea,

NOTE: Start feeding the child with F-75 when the child is awake and alert and the skin quality
returns to normal (or the serum sodium is normal if there are facilities to measure sodium).

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4. Management of shock
Shock is a dangerous condition with cold extremities, slow capillary refill (longer than 3 seconds)
and fast, weak pulse. There are several common causes of shock in the child with SAM. There is
need for differentiating the different causes of shock because treatment for one pathology can
worsen another. The common causes of shock include:

• Dehydration (acute body fluid loss–diarrhoea) (see section above on dehydration).

• Hypernatraemic dehydration (water loss/over concentrated feeds).
• Toxic shock (traditional medicine, drug toxicity, aflatoxins, etc.)
• Septic shock (bacterial, viral, fungal infection, severe malaria).
• Cardiogenic shock (fluid overload, high sodium intake, blood transfusion, refeeding syndrome).
• Liver failure.

NOTE: In very severely affected children, there are usually several contributing factors, for
example, septic/ toxic shock or liver failure also affect cardiac function.

Signs of shock
The severely malnourished patient is considered to have shock if he/she:
• is lethargic or unconscious and
• has cold hands

PLUS either:
slow capillary refill* (longer than 3 seconds)
or
weak or fast pulse

*To check capillary refill:

• press the nail of the thumb or big toe for 2 seconds to produce blanching of the nail bed
• Count the seconds from release until return of the pink colour.
• If it takes longer than 3 seconds, capillary refill is slow.
Hypovolaemic shock
Shock from dehydration and sepsis are likely to coexist in severely malnourished patient. They are
difficult to differentiate on clinical signs alone. Patients with dehydration will respond to IV fluids.
Those with septic shock and no dehydration will not respond to IV fluids. The amount of IV fluids
given must be guided by the child’s response. Overhydration can cause heart failure and death.

Fluids for hypovolaemic shock in SAM

The choice of fluids is based on the electrolyte abnormalities in children with SAM (Hypokalaemia
and Hypernatraemia). The aim is to provide fluids containing potassium, lower in sodium than
normal and containing glucose. Use one of the following solutions:

• Ringers-Lactate with 5 per cent dextrose at a ratio of 1:1

• Half strength Saline with 5 per cent dextrose*
• Half Strength Darrrow’s

NOTE: If Half Strength Saline is used, add sterile potassium chloride (20mmol/l).

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Steps in IV rehydration for shock in a child with non-oedematous SAM
The box below summarizes the steps involved in intravenous rehydration of a child with non-
oedematous SAM.

Box 10: Steps for IV rehydration in hypovolaemic shock

1. Weigh the patient

2. Calculate the target weight
3. Give 15 ml/kg IV over the first hour and
4. After one hour, reassess the child for signs of improvement and weight
Next actions depend on the findings after 1 hour;
• If the child has regained consciousness and the pulse rate drops towards a normal level,
then stop the drip and treat the child orally or by NG-Tube with 10 ml/kg/hour of ReSoMal
• If improving after one hour but not alert, repeat the 15 ml/kg IV over the next hour.
• If there is continued weight loss or there is no change in weight, repeat the 15 ml/kg IV
over the next hour. (15 mg/kg is 1.5% of body weight, so the expected weight gain after
2 hours is from 0% up to 3% of body weight)
• If there is no clinical improvement after the second infusion and the child has gained
weight, then assume that the child has toxic, septic or cardiogenic shock or liver failure.
STOP rehydration treatment and ASESS for other causes of loss of consciousness and
shock.

5. Septic shock
Children with septic shock normally present with very severe illness. If the condition develops after
admission, then it is more likely to be cardiogenic shock, or an adverse reaction to the treatment
that is being given.
Septic/toxic shock presents with some of the signs similar to dehydration which are often
accompanied with some degree of cardiogenic dysfunction and also frequent liver dysfunction.
The differential diagnosis is often very difficult, and treatment must take into account the possibility
of multiple defects.

• Children who appear “very ill”, may have septic shock, ordinary dehydration, hypernatraemic
dehydration, cardiogenic shock, liver failure, or toxic shock from poisoning with traditional
medicines or overdose of therapeutic drugs, aspirin poisoning, malaria, acute viral infection or
other severe conditions–or combinations of these problems. All “very ill” children should not
be automatically diagnosed as having dehydration or septic shock; the actual reason for the
condition should be sought.
Shock developing after admission
Children with septic shock normally present with very severe illness, if the condition develops after
admission then it is more likely to be cardiogenic shock, or an adverse reaction to the treatment
that is being given.
If the child deteriorates after admission to the inpatient facility, then:

• Review the treatment given to the child to determine if the treatment is the cause of the clinical
deterioration.

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• Review the fluid (sodium) intake, particularly any treatment given in the emergency ward during
admission (if there is excessive treatment for cardiogenic shock/heart failure).18
• Examine the daily weight changes as this may indicate cardiogenic shock; do not diagnose
septic shock in a very ill child if the patient has gained weight during the preceding 24 hours:
treat for heart failure.
• Stop any drugs being given that are not included in the protocol.
• Check the dose of drugs given to ensure that they have been adjusted for the malnourished
state.
Diagnosis of toxic/septic shock
To make a diagnosis of developed septic shock, it requires the signs of hypovolemic shock to be
present. These include:

• A fast, weak pulse with all the four signs.

• Cold peripheries.
• Slow capillary refill in the nail beds (more than 3 seconds).
• Disturbed consciousness.
• Absence of signs of heart failure.
Treatment of toxic/septic shock
All patients with signs of early or developed septic shock should immediately be given a broad
spectrum of antibiotics. Box 11 summarizes the treatment of toxic/septic shock in children with SAM.

Box 11: Treatment of toxic/septic shock

• Give 2nd line IV broad-spectrum antibiotics; Cefotaxime or Ceftriaxone 100 mg/kg/d.

• Add Ciprofloxacin orally 30 mg/kg/d in three doses or inject Gentamicin 5 mg/kg/day
once daily.
• May add Metronidazole 10 mg/kg/d orally or rectally.
• If there are extensive, open skin lesions or signs suggestive of pulmonary abscesses,
add Cloxacillin IV: Children: 100–200 mg/kg/d.
• Keep the child warm to prevent or treat hypothermia.
If there is no improvement in 24 hours, then add Fluconazole orally 3 mg/kg/d once daily.
• Give sugar water by mouth or NG tube as soon as the diagnosis is made to prevent
hypoglycaemia.
• Avoid physical disturbance (no washing, excess examination, investigations in other
departments, etc.).
• Do not transport to another facility unless there are proper facilities to safely transport
the patient.
• Fluid management is shown in the following section:

Fluid management in septic/toxic shock

For Incipient septic shock:
Give the standard F-75 diet by NG tube. If gastric residues are aspirated from the NG tube, start
with half the recommended quantity of F-75 until there are no gastric aspirates (see Figure 18).

18 In some areas, the drinking water contains appreciable concentrations of sodium. Ensure that the patient has not been taking the mother’s
food.

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For developed septic shock, if the patient is semiconscious or unconscious because of poor brain
perfusion, the results of the FEAST study indicate that bolus infusion increases mortality. ANY
POSITIVE FLUID BALANCE increases MORTALITY. A blood or albumin transfusion should not be
given.19
A cautious slow IV infusion can be given as summarized in Figure 18. (Do not give if there is a
possibility of cardiogenic shock and never give a bolus infusion).
Monitor every 10 minutes (gently) for any signs of deterioration, especially overhydration and
heart failure.

• Increasing respiratory rate

• Development of grunting respiration
• Increasing liver size
• Vein engorgement
Figure 18: Fluids in treatment of septic/toxic shock

19 Ford N, Mortality After Fluid Bolus in Children with Shock Due to Sepsis or Severe Infection; a Systematic Review and Meta-Analysis,
PloS.
Ford N, Mortality After Fluid Bolus in Children with Shock Due to Sepsis or Severe Infection; a Systematic Review and Meta-Analysis,
PloS.
Andrews, B, Effect of an early resuscitation protocol on in-hospital mortality among adults with sepsis and hypotension, RCT JAMA
318[13], 1233, 2017.
Bachou, H et rm., Risk factors in hospital deaths in severely malnourished children in Kampala, Uganda. BMC Paediatrics 6[1], 7. 2006.
Boyd, JH et rm., Fluid resuscitation in septic shock a positive fluid balance and CVP are associated with increased mortality, Critical Care
Medicine, 39[2], 259, 2011.
Byrne, L, Unintended Consequences Fluid Resuscitation Worsens Shock in an Ovine Model of Endotoxemia, Am J Resp Critical Care Med,
2018.
Sadaka, F, Fluid resuscitation in septic shock effect of increasing fluid balance on mortality, J Intens Care Med 29 213, 2014

132 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA

6. Acute abdomen caused by paralytic ileus or electrolyte imbalance
Septic shock can complicate other systems including the gut, causing gastric dilation. The signs of
gastric dilation include:

• Sudden abdominal distension

• Absent bowel sounds
• Intestinal splash.
Paralytic ileus can occur as a result of autonomic disruption, concomitant ischaemia or as a
result of a complication of hypokalaemia, hypomagnesaemia, abdominal trauma or sepsis. There
is a functional ileus with bacterial overgrowth similar to that with intestinal obstruction. In this
situation, there has normally been gram-negative bacterial translocation across the intestine with
septicaemia.
It is possible that some patients develop this syndrome from “super-infection” by emergence of
organisms resistant to the antibiotic regime being used or “traditional/herbal medicines” given
by traditional practitioners. Nothing will be absorbed orally as the stomach is not emptying.

Management of paralytic ileus in children with SAM

• Warn the mother that the dangers and prognosis are not good.
• Do NOT feed the patient anything by mouth/orally.
• Give oxygen, keep warm and treat hypoglycaemia.
• Give antibiotics intravenously as outlined for septic shock (see Box 11).
• STOP all other drugs that may be causing toxicity.
• Give an IM injection of magnesium sulphate (2 ml of 50 per cent solution) and repeat twice
daily until stool is passed and gastric aspirations drop.
• Pass an NG tube and aspirate the contents of the stomach, then “irrigate” the stomach with
isotonic clear fluid (5 per cent dextrose or 10 per cent sucrose).
• Put 5 ml/kg of sugar water (10 percent sucrose solution) into the stomach and leave it there for
one hour.
• Then aspirate the stomach and measure the volume that is retrieved. If the volume is less than
the amount that was introduced, then return the aspirate to the stomach and make up the
volume to 5 ml/kg with more sugar water.
• There is frequently gastric and oesophageal candidiasis, put oral nystatin suspension, or
fluconazole down the NG tube.
• Do not put up a drip at this stage but monitor the child carefully for 6 hours, without giving any
other treatment.
• Monitor continuously using the Critical Care Chart (CCC) (HMIS NUT Form 003) (Annex 1) to
see if there is any improvement.
If there is intestinal improvement,
• Then start to give small amounts of F-75 by NG tube (half the quantities given in the F-75 table).
• Aspirate the stomach before each feed.
• If the volume of residual feed remaining is large, then decrease the amount of F-75.
• If the amount of aspirate is small, then the amount can be gradually increased.
If there is no improvement after 6 hours, then:
• Consider putting up an IV drip with fluid containing adequate amounts of potassium or add
Sterile Potassium Chloride (20 mmol/l).
• Give Ringer-Lactate in 5 per cent dextrose or half-strength saline in 5 per cent dextrose VERY
SLOWLY; NO MORE THAN 2 to 4 ml/kg/h (using a paediatric burette).

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• When the gastric aspirates decrease so that one half of the fluid given to the stomach is
absorbed, discontinue the IV treatment and continue with oral treatment only.
Respiratory distress
When a child with SAM presents with respiratory distress, it is important to differentiate between
pneumonia and heart failure.

NOTE: On admission, the most likely diagnosis is pneumonia. Heart failure (or inhalation
pneumonia) is more likely if the child has developed respiratory distress while on thenward
after starting F-75 (day 2–5), or after an IV infusion, transfusion or ReSoMal or ORS.

7. Severe Pneumonia
Diagnosis:
Children with SAM may have very severe pneumonia if they have a cough or difficult breathing
plus at least one of the following:

• central cyanosis
• severe respiratory distress
• chest wall in-drawing.
However, those signs may also occur with pulmonary oedema or heart failure.
In SAM, the absence of fast breathing does not exclude severe pneumonia because, when muscle
wasting is severe, there may not be an increase in respiratory rate at all. Chest auscultation signs
of pneumonia may also be absent, the swallowing reflex in SAM children is compromised and
oesophageal peristalsis is slow. Aspiration of feeds particularly solid or peanut containing foods
is dangerous and a common cause of sudden death in children who seem to be recovering well.
The children must never be force-fed by mouth. The caretakers or mothers must be taught the
appropriate feeding technique.

Treatment
Follow the Uganda National protocol for the management of very severe pneumonia. If the child
does not show signs of rapid improvement (maximum delay 48 hours) on recommended therapy
then staphylococcal pneumonia is suspected (chest X-ray is particularly useful for this condition
as pulmonary abscesses may occur) then switch to gentamicin 7.5 mg/kg IM or IV once a day and
cloxacillin 50 mg/kg IM or IV every 6 hours.

8. Heart failure
Cardiac failure is the inability of the heart to pump sufficiently to maintain blood flow to meet the
needs of the body. The common cause of cardiac failure leading to sudden death is hypervolemia
due to overhydration, overfeeding, blood transfusion and high sodium diet. Others include:Severe
malnutrition, severe anaemia, and severe pneumonia.

Signs and symptoms of heart failure

Heart failure should be diagnosed when there is:

• Physical deterioration with weight gain

• Increasing or reappearance of oedema.
• An increase in respiration rate with weight gain.
• An acute increase in respiration rate of more than five breaths per minute (particularly during
rehydration treatment;

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 1. More than 50 breaths/minute in infants.
2. More than 40 breaths/minute in children 1–5 years.
• Increasing pulse rates of 25 beats/minute from baseline along with confirmed increase
respiratory rate.
• A sudden increase in liver size (this is why the liver is marked before starting any infusion).
• Tenderness developing over the liver.
• Respiration that has or develops a “grunting” sound during each expiration.
• Crepitations in the lungs.
• Prominent superficial and neck veins.
• Engorgement of the neck veins when the abdomen (liver) is pressed.
• Enlargement of the heart (very difficult to assess in practice).
• Appearance of triple/gallop rhythm (difficult to assess in practice).
• An acute fall in haemoglobin concentration or haematocrit (needs laboratory but measures
quite accurately the degree of expansion of the intravascular volume).
As the heart failure progresses there is either;
1) marked respiratory distress progressing to a rapid pulse, cold hands and feet, oedema and
cyanosis or,
2) sudden, unexpected death.
This is cardiogenic shock; it usually occurs in a severely malnourished patient after treatment
has started. There is usually also weight gain. As heart failure usually starts after (and is due to)
treatment, there is nearly always a record of the weight of the patient that was taken before the
onset of heart failure.

Differential diagnosis
Heart failure and pneumonia are clinically similar and very difficult to differentiate

• If there is an increased respiratory rate AND any gain in weight, then heart failure should be the
first diagnosis.
• If there is an increased respiratory rate with a loss of weight, then pneumonia can be diagnosed.
• If there is no change in weight (fluid balance) then the differentiation has to be made using the
other signs of heart failure.
• Pneumonia should NOT be diagnosed if there has been a gain of weight just before the onset
of respiratory distress.
Children with oedema can go into heart failure without a gain in weight, if the expanded circulation
is due to oedema fluid being mobilised from the tissues to the vascular space.

Treatment of heart failure

Children with dilutional anaemia and cardiac failure should never be transfused. The heart failure
is not caused by the anaemia; the increasing anaemia is a sign of the expanding blood volume
causing the heart failure. Additionally, children with respiratory distress and anaemia should not
be transfused.

When heart failure is diagnosed,

• Position the individual to an upright sitting position
• Give oxygen if possible
• 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.

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• Give sugar water 5ml/kg orally to prevent hypoglycaemia.
• Review drug regimen and reduce dose or stop those which are given as the sodium salt.
• Give furosemide (1 mg/kg)
• Closely monitor a patient in cardiac failure.
Close monitoring of a patient in cardiac failure is essential during treatment. Important parameters
should be taken frequently and recorded in the Critical Care Chart (HMIS NUT Form 003) (Annex 1).
These include:

• Pulse rates every 30 minutes

• Respiratory rates every 30 minutes
• An assessment of the engorgement of the neck vein
• An assessment of the liver size and tenderness
• Oxygen circulation, if possible.
Preventing congestive cardiac failure in severe malnutrition
• Feed cautiously; only give the prescribed amount of feeds.
• Avoid blood transfusion and only transfuse, if patient is very severely anaemic (Hb < 4 g/dl)
before 48 hours of admission.
• Rehydrate cautiously as described earlier.

9. Management of very severe anaemia

Very severe anaemia refers to haemoglobin level below 4g/dl or packed cell volume <12 per cent.
Measure the haemoglobin on admission in any patient that is clinically anaemic. Haemoglobin
should not be measured subsequently in most circumstances. This is to avoid a person identifying
a low haemoglobin level and transfusing the patient during the “danger” period of electrolyte
disequilibrium (day 2 to 14) when anaemia is Dilutional.

Dilutional anaemia
As oedema fluid is mobilised (oedematous SAM) and the sodium is coming out of the cells (both
oedematous and non-oedematous SAM), the plasma volume expands but the volume of red cells
remains constant so that there is a FALL IN HAEMOGLOBIN concentration. This DILUTIONAL
anaemia happens to some extent in nearly all children as they recover. A substantial fall in
haemoglobin is a sign of an expanding circulation, and is also a sign of impending or actual
volume overload with heart failure.

Treatment of severe anaemia

If the haemoglobin concentration is less than 4 g/100 ml or the packed-cell volume is less than 12
per cent in the first 48 hours after admission, the patient has very severe anaemia that should be
treated.

• Give 5–7 ml per kg body weight of packed red cells or 10 ml/kg whole blood slowly over 3
hours.
• Give Furosemide at 1 mg/kg body weight
• Do not feed the patient during, and for at least 3 hours after a blood transfusion.
Dilutional anaemia: If the haemoglobin is above 4 g/dl or the packed cell volume is above 12 per
cent, OR if the patient has started treatment with F-75 for more than 48 hours (preferably 24 hours)
and less than 14 days,

• Do not transfuse. Do not give iron during the stabilization phase of treatment.
• If the facilities and expertise exist (neonatal units), it is preferable to give an exchange transfusion
to severely malnourished patients with very severe anaemia.

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If a transfusion is necessary during the “danger” period of 48 hours to 14 days after starting
dietary treatment or if there is heart failure with very severe anaemia, then the patient cannot be
given a straight transfusion he or she needs an exchange transfusion. If the expertise does not
exist locally, then transfer the patient to a centre that has the capacity and skills in terms to do an
exchange transfusion (neonatal unit).
Heart failure due to anaemia is clinically different from “normal” heart failure; when the failure is
due to anaemia alone there is “high output” with an overactive circulation, an easily felt pulse
and heart beat and warm peripheries.
Anaemia or a falling haemoglobin, and respiratory distress is a sign of fluid overload and an
expanding plasma volume. The heart failure is not being “caused” by the anaemia, rather the
apparent anaemia is “dilutional” and is caused by the fluid overload. Do not give a straight
transfusion of blood or even packed cells to these patients.20

10. Management of skin conditions

Oedematous dermatosis
In oedematous SAM, there are often open skin lesions where the epidermis has stripped away
to leave raw weeping wounds that resemble burns. The lesions can be treated in the same way
as burns. Serum may be lost through the lesions. There is also an increased loss of heat by
evaporation and hypothermia is common and must be prevented.
The lesions usually become overgrown with bacteria and candida under usual ITC conditions.
Normally these patients do not have an inflammatory reaction, pus formation or fever due to their
deficient inflammatory and immune function; an inflammatory reaction can occur later during
treatment as the nutritional status of the patient improves.

Treatment of oedematous dermatosis

• Put the patient onto second- or third-line systemic antibiotics, including fluconazole for possible
staphylococcal or other bacteria and fungal infections.
• Monitor body temperature; do not wash the child unless the environmental temperature is
high.
• If possible, expose the lesions directly to the atmosphere during a hot day so that they dry
(form a crust), do not cover with occlusive dressings.
• If available, dress with Silver sulfadiazine impregnated tulle or cream (1 per cent) once per day,
if unavailable dress with Zinc Oxide ointment (10 per cent).
• At night and in cold conditions, dress with sterile paraffin gauze.
• Gently massage oil (e.g. mustard or soya oil) into the areas of unaffected skin to prevent further
breakdown of the skin.
• If the patient has candidiasis, apply miconazole cream to the skin lesions until they are dry.
Other common skin conditions include perineal excoriation, fungal infections of the skin, impetigo
(Bacterial skin infections) and cancrum-oris.

11. Treatment for convulsions

Convulsions are not common in SAM children, even those with a high fever. One common cause
is hypernatraemic dehydration, which must always be considered in any SAM child who has
convulsions. The serum sodium concentration should be measured in all SAM children that have
had a convulsion. Some traditional medicines cause convulsions.

20 Some guidelines advocate transfusion of children with a haemoglobin higher than 4 if there is respiratory distress. This advice should
not be followed; it is very dangerous in the severely malnourished patient as the respiratory distress is usually due to heart failure in this
situation.

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Convulsions are treated similarly in children with or without SAM. BUT, as drugs affecting the brain
are all lipid-soluble, in children with low body-fat, the concentration that will occur in the brain
with standard doses can be excessive and may even affect vital centers such as the respiratory
center. Nevertheless, it is critical to stop the convulsions and to determine the underlying cause.

• Turn the child into the left lateral position and manage the airway and breathing.
• Gain circulatory access.
• If there is hypoglycaemia, give 10 per cent glucose solution 5 ml/kg IV. If it is not possible to
measure blood glucose, give empirical treatment with glucose.
• If the convulsion does not stop in 2 minutes, give diazepam, 0.2 mg/kg IV or 0.5 mg/kg rectally.
• If convulsion continues after 5 minutes, give a second dose of diazepam IV or rectally.
• If convulsion continues after another 5 minutes, give phenobarbital, 15 mg/kg IV.
• If the child has a high fever, tepid sponge with (lukewarm) water to reduce the fever.
• Do not give oral medication until the convulsion has been controlled, because of the danger of
aspiration. If there is hypocalcaemia, symptoms may settle if the child is given 2 ml/kg of 10 per
cent calcium gluconate as a slow IV infusion.
• Rule out central nervous system infection (e.g. TB meningitis) and cerebral malaria. Treat if
present.

Eye Signs
Treatment of eye signs
If the child with SAM has dry conjunctiva or cornea, corneal clouding or ulceration, Bitot’s spots,
or keratomalacia:

• Give vitamin A immediately on day 1 (< 6 months give 50,000 IU, 6–12 months give 100,000 IU,
and > 12 months give 200,000 IU) and repeat on day 2 and day 15.
• For corneal ulceration, instil 1 drop of Atropine (1%) into the affected eyes three times a day to
relax the eye and to prevent the lens from being pushed out.
• Cover the affected eye with a damp gauze pad (dampen with 0.9% saline) and bandage to hold
the pad in place.
o If necessary, put mittens or bandages on the child’s hands to prevent him/her from touching
his/her eyes.
• If there is pus or inflammation: Administer Chloramphenicol eye drops every 3 hours or apply
1% Tetracycline eye ointment 4 times a day for 7 days and bandage the child’s eyes when he/
she is stable.

NOTE: Children with vitamin A deficiency are likely to be photophobic and will keep their
eyes closed. It is important to examine the eyes very gently to prevent corneal rupture.

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Other specific conditions

HIV/AIDS
Children with severe acute malnutrition who have HIV/AIDS should be started on antiretroviral drug
treatment as soon as possible after stabilisation phase - stabilization of metabolic complications
and sepsis or start 14 days after admission in patients failing to respond. HIV infected children
with severe acute malnutrition should be given the same antiretroviral drug treatment regimens,
in the same doses, as children with HIV who do not have severe acute malnutrition (Refer to the
National HIV Care guidelines for the details).
Children with severe acute malnutrition who are HIV infected should be managed with the same
therapeutic feeding approaches as children with severe acute malnutrition who are not HIV infected.
The children should also be particularly screened for TB at the time of HIV testing, as co-infection
is particularly common. TB, HIV and SAM are linked and frequently appear in the same patients.
HIV/AIDS infected children with severe acute malnutrition generally respond slower to nutritional
rehabilitation and therefore need close monitoring. When they are started on antiretroviral
drug treatment, they should be monitored closely in the first 6–8 weeks following initiation of
antiretroviral therapy, to identify early metabolic complications and opportunistic infections.
HIV/AIDS infected SAM children with persistent diarrhoea even after standard management should
be investigated to exclude carbohydrate intolerance and infective causes which may require
different management such as; modification of fluid and feed intake, or antibiotics.

NOTE: Avoid Amphotericin B in SAM patients with HIV because of its high toxicity.

Treatment of tuberculosis and SAM

All severely malnourished children should be screened for TB. Screening includes thorough history,
physical examination and tests including sputum for GeneXpert. Tuberculin skin test and chest X-ray
should be done. If TB is diagnosed, treatment should be according to the national protocol.

Fever
Severely malnourished children are unable to regulate their body temperature adequately. They
may have fever or hypothermia due to the surrounding environment.

Treatment of fever
For moderate fevers, up to 38.5°C rectal or 38.0°C axillary
• Do not treat with paracetamol.
• Remove blankets, hat and most clothes and keep in the shade in a well-ventilated area.
• Do laboratory tests to check for malarial parasites and other infections.
• Conduct physical examination to identify any focus of infection. Treat the cause of fever.
Fevers of over 39°C rectal or 38.5°C axillary:
There is the possibility of hyperpyrexia developing. In addition to the above, also:

• Tepid sponge with luke warm water over the child’s scalp, re-dampen the cloth whenever it is dry.
• Monitor the rate of fall of body temperature.
• If the temperature does not decline, tepid sponge an extended to cover a larger area of the body.
• When the temperature falls below 38°C rectal, stop active cooling. There is a danger of inducing
hypothermia with aggressive cooling.

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 NOTE: Do not use Antipyretics; they are much more likely to be toxic in the malnourished
than a normal child.

Underlying medical causes of malnutrition

Sometimes malnutrition is caused by congenital defects like cardiac disease, cleft lip and palate,
disabilities like cerebral palsy and a variety of surgical conditions as well as inborn errors of
metabolism. All these need to be referred appropriately for management of the underlying
condition otherwise nutritional rehabilitation alone may not result in cure.

Selection of appropriate drugs

Great care should be exercised in prescribing all drugs to severely malnourished patients. For
most drugs, the dose recommended for normal children is either toxic or ineffective in the
malnourished child. Drugs which affect the central nervous system such as anti-emetics and those
where the side effects include adverse effects on the liver, pancreas, kidney, heart, circulation
or intestine and those which cause loss of appetite should not be used, or only used under very
special circumstances.
It is advised that:

• For other conditions that are not rapidly fatal, the malnutrition is treated for at least one week,
but preferably two full weeks (whilst the nutritional treatment returns the metabolism of the
patient towards normal) before standard doses of drugs are given.
• Many drugs should be avoided altogether until there is research to show that they are safe
and how the dosage should be adjusted for the malnourished state. Common drugs such as
paracetamol do not work in most malnourished children during the stabilisation phase and can
cause serious hepatic damage.
Routine monitoring during inpatient therapeutic care
The following should be monitored regularly during ITC:

• Pulse, respirations, and temperature, and watch for danger signs.

• Weight is measured, entered and plotted on the multi-chart each day.
• The degree of oedema (0 to +++) is assessed each day.
• Body temperature is measured twice per day.
• The standard clinical signs (stool, vomiting, dehydration, cough, respiration and liver size) are
assessed and noted in multi-chart each day.
• MUAC is taken each week.
• A record is taken (on the intake part of the multi-chart) if the patient is absent, vomits or refuses
a feed, and whether the patient is fed by Naso-Gastric Tube (NGT) or is given an IV infusion or
transfusion. There are appropriate places for these to be recorded each day.
• Record results of monitoring on the multi-chart (HMIS NUT Form 008) (Annex 1).
Measure pulse count respirations and measure temperature every 4 hours, before feeding. This
monitoring is very important because an increase in pulse rate or respiratory rate can signal a
problem such as an infection, or heart failure from over-hydration due to feeding or rehydrating
too fast. An increase or decrease in temperature to above or below normal can indicate infection.
It is critical to monitor the patient closely (every four hours) during initial treatment and during
transition to RUTF or F-100. After the patient is stable and has started rehabilitation phase, you
may decrease monitoring of pulse, respirations, and temperature to once a day as long as the
patient is gaining weight (see Table 30). If there is no weight gain, or if the patient loses weight,
resume monitoring every four hours.

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 Table 30: Parameters assessed in stabilization phase

Monitoring in ITC Frequency

Weight and oedema Every day

Body temperature is measured Every morning

The standard clinical signs (stool, vomiting, etc.) Every day

MUAC is taken Every week

Appetite is judged from the amount taken Intake record is kept on chart

Failure-to-Respond to treatment (ITC)

Diagnosis
Children who fulfil the criteria for “failure-to-respond” should have an extensive history and
examination or laboratory investigations conducted. Skilled staff, time and resources should be
mainly directed to training, supervision and diagnosis and management of the few children who
fail-to-respond to the standard treatment.
Failure-to-respond to standard treatment is a “diagnosis” in its own right (see Tables 31 and Box
12). For OTC, the most common reasons for failure are social; social and psychological reasons
can also cause failure to respond in inpatients although, this is less likely.

Table 31: Diagnosis of failure-to-respond to ITC

Criteria for failure to respond Time after admission

Failure to improve/regain appetite Day 4
Failure to start to lose oedema Day 4
Oedema still present Day 10
Failure to fulfill the criteria for rehabilitation phase Day 10
(OTC)
Clinical deterioration AFTER admission At any time

Note that the day of admission is counted as day 0, so that day 1 is the day after admission.

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 Box 12: Investigations of the causes of failure-to-respond in inpatients

Problems with the treatment facility:

• Failure to adhere to the protocol
• Poor environment for malnourished children
• Excessively intimidating, strict or cross staff
• Failure to treat the children in a separate dedicated area
• Failure to complete the multi-chart correctly (or use of traditional hospital records only)
• Insufficient staff (particularly at night)
• Poorly trained staff; excessive staff turnover or untrained senior medical staff
• Inaccurate weighing machines (of failure to take and plot the weight change routinely)
• F-75 not prepared or given correctly
• An expectation by the staff that a high mortality is inevitable, in line with their previous
experience.
Problems of individual children:
• A severe medical complication (see section on complications)
• Drug toxicity (see section on drugs)
• Insufficient food given (criteria for NGT not applied)
• Food taken by siblings or caretaker
• Sharing of caretaker’s food
• Malabsorption
• Psychological trauma
• Rumination (and other types of severe psychosocial deprivation)
• Infection, especially viral, bacteria resistant to the antibiotics being used, fungal,
diarrhoea, dysentery, pneumonia, TB, urinary infection/ Otitis media, malaria, HIV/AIDS,
Schistosomiasis/ Leishmaniosis, Hepatitis/ cirrhosis
• Other serious underlying diseases: congenital abnormalities (e.g. Down’s syndrome),
neurological damage (e.g. cerebral palsy), inborn errors of metabolism

When a child deteriorates after having progressed satisfactorily initially, it is usually due to:

• Electrolyte imbalance with movement of sodium from the cells and an expansion of the
circulation to give fluid overload or to the refeeding syndrome.
• Inappropriate dosage of drugs or use of drugs not recommended in the severely malnourished
child.
• Aspiration of feeds into the lungs.
• An acute infection that has been contracted in the centre from another patient (called a
“nosocomial” infection) or from a visitor/sibling/household member.
• Sometimes as the immune and inflammatory system recovers, there appears to be “reactivation”
of an existing infection during rehabilitation.
• A limiting nutrient in the body that has been “consumed” by the rapid growth and is not being
supplied in adequate amounts by the diet. This is uncommon with commercially produced (F-
100 and RUTF) but may well occur when they are made in the facility or where untried recipes
are introduced or sharing of the mother’s food (see refeeding syndrome).
Required actions when children fail to respond to treatment in ITC
• Record the diagnosis and refer the child to more senior and experienced staff.
• Take a detailed history and fill the clinical history and examination form.

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• Examine the child carefully. Measure the temperature, pulse rate and respiration rate accurately.
• Where appropriate, examine urine for pus cells and culture blood, culture sputum or tracheal
aspirate for TB; examine the retina in a low light for retinal tuberculosis.
• Do a chest x-ray.
• Examine stool for blood, look for trophozoïtes or cysts of giardia; culture stool for bacterial
pathogens. Test for HIV, hepatitis and malaria.
• Examine and culture Cerebral Spinal Fluid (CSF).
• Check if parents are giving traditional medicines and other treatments brought into the facility.
• Systematically consider the common causes listed in the Box 12.
• If this is not immediately successful, then consult someone with experience of running a
program for the treatment of severe malnutrition.
• Review of the supervision of staff with refresher training if necessary.
• Re-calibration of scales (and length-boards).
• Refer children with chronic diseases (Congenital heart disease, neural tube defects, cerebral
palsy, Broncho-pulmonary dysplasia, chronic renal failure, etc.) to the appropriate paediatric
ward under the care of the paediatrician. These patients are referred out of the program and all
further management decisions and treatment will be under the direction of another service.
Discharge procedure
• Register the patient in the registration book as successfully treated, dead, defaulter or a medical
referral.
• Complete the ITC multi-chart (HMIS NUT 008) (Annex 1) and fill in a transfer form with the INR-
number and give all the required information about the treatment.
• Call the health worker at the OTC to give them notice about the patient returning home.
• Give the mother a copy of the transfer form, the name and address of the OTC and the day of
the consultation and a provision of RUTF until the next appointment in the OTC.
• Write in the child’s health card the treatment given and the weight.

9.4 Inpatient therapeutic care for management of severe acute

malnutrition with medical complications in infants less than six
months
The management of SAM with medical complications in infants less than 6 months differs from
the older children and other age groups. This is because at less than 6 months of age, physiological
processes, including thermoregulation, renal and gastrointestinal functions, are relatively
immature and may require modified management approaches or clinical interventions. Clinical
signs of infection and dehydration may also be more difficult to identify and interpret.
Infants less than 6 months old with SAM should always be treated in an inpatient unit until
discharge. The objectives of ITC are to:

• Establish or re-establish, effective exclusive breastfeeding;

• Provide temporary or longer-term appropriate therapeutic feeding for the infants; and
• Provide nutrition, psychological, and if needed, medical care for the caregivers.
Principles of care
Exclusive breastfeeding is the optimal feeding for infants under 6 months of age to thrive and
be protected against infections (see Box 13). However, development of SAM in infants under 6
months commonly reflects sub-optimal breastfeeding practices and re-establishing satisfactory
breastfeeding is at the core of treatment. Sub-optimal breastfeeding is associated with low birth
weight, pre-term birth, recurring infections, persistent diarrhoea, chronic diseases, disability and
social problems.

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All infants should be screened systematically for malnutrition on arrival, at the time that is most
appropriate in the assessment, depending on the child’s condition and presence of emergency
signs. When infants with their mothers or caretakers arrive at the hospital either because of referral
or self-referral, they should receive ETAT and IMNCI procedure assessments (see Chapter 4 and
Principles of Care in this Chapter).
The potential benefits of inpatient care should be carefully weighed against potential risks such as
nosocomial infections and opportunity costs for the mother and the health system. Management
of acute malnutrition in infants under 6 months of age is based on the severity of both the infant’s
and the mother’s condition. The mother or caretaker should be involved in care of the infant and
receive counselling, health and nutrition education. Psychosocial support; mother-to-mother
support should be encouraged.
Management of SAM in infants under 6 months of age is aligned with the Integrated Management
of Neonatal and Childhood Illness (IMNCI) approach, paediatric hospital care and management of
SAM in children 6–59 months of age.

Box 13: Outline for the management for SAM infants less than 6 months of age

Initial assessment and Weigh and measure infant and diagnose and treat complications
Treatment such as hypothermia, hypoglycaemia, dehydration, infections and
septic shock.
Give the infant initial Feed the infant with appropriate milk feeds for initial recovery and
re-feeding metabolic stabilization
Feed and care for the If the mother is available, feed and care for her physically and
Mother psychologically, to help restore her health, her ability to produce
milk, and her ability to respond to her baby.
Keep mother and infant Keep mother and infant together, to help the mother care for and
together respond to the baby, and to give skin-to-skin contact (Kangaroo care)
to warm the baby. Beds or mats are better for this than cots.
Continue and improve Breastfeeding is an integral part of management. Continue
or re-establish and improve or start to re-establish breastfeeding as soon as
breastfeeding possible from the beginning of treatment, if necessary using the
supplementary suckling technique. A mother may need to express
breast milk, if the infant is too weak to suckle. Show her how to do
this.
Feed the infant for As the infant starts to recover, feed him/her to achieve rapid catch-
catch-up growth up growth, (nutrition rehabilitation). Give supplementary milk feeds
using a breastfeeding supplement if needed, as long as necessary,
until exclusive breastfeeding is re-established.
Give adequate breast If breastfeeding is not possible, give adequate breast milk substitute
milk substitute if in accordance with local agreed criteria.
breastfeeding is
impossible
Discharge when weight Discharge the infant from the nutrition ward/unit when gaining weight
gain on either exclusive more than 5g/kg/day for at least 3 successive days or when gaining
breastfeeding or weight for 5 days on breastfeeding alone (regardless of original body
replacement feeding is weight) or when the infant has changed completely to adequate
satisfactory breast milk substitute when breastfeeding is not possible.

Structure and organization of inpatient care

Special services should be utilized to assist mothers who have difficulty re-establishing
breastfeeding. These services concentrate on all breastfeeding problems; for the malnourished, to

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re-establish exclusive breastfeeding and to achieve confidence in the mother’s ability to produce
sufficient milk for their baby to thrive. Such services include:

• Having breastfeeding counsellors, trained mother-to-mother support groups.

• It is inappropriate to admit young infants to most general paediatric or nutrition wards. It should
be a specific section of the ITC devoted to the management of the malnourished young infant
if possible. The ward where these infants are managed should be adequately screened and
private. The nursing care staff should have professional training in breastfeeding support and
counselling as well as skills in care of the neonate and the malnourished child.

Activities in ITC for infants less than 6 Months

• Take the anthropometric measurements and examine the baby, check the criteria of admission
(see Table 6 in Chapter 4) or management, register in the registration book and the chart.
• Explain to the mother, the aim or plan of the management.
• Manage the infants using the Supplemental Suckling Technique (SST) as appropriate for ITC.
• Prepare the appropriate therapeutic milk, teach and demonstrate the techniques to the mother
or caretaker.
• Monitor and follow the baby and the mother as appropriate in ITC.
• Discharge the baby and the mother as appropriate in ITC.

Registration
• Register the infant in the registration book and INR
• Fill in the infant SST-chart (HMIS NUT Form 006) (Annex 1).
• Explain to the mother the aim of the management, which is to return the infant to exclusive
breast feeding.

Management
Routine Care
• These children have to be seen by a nurse every day because they are exceptionally vulnerable.
Antibiotics
• Give routine antibiotics, preventive and other specific treatment based on diagnosis. Routine,
preventive and other specific treatment based on diagnosis of infants weighing 4 kg or more
is similar to that for children 6 months of age or older, except, do not give vitamin A, folic acid,
anthelminthic or measles vaccination.
• Give Antibiotics: Amoxicillin 30 mg/kg, twice a day (60 mg/day) together with Gentamicin once
daily (3 to 5mg/kg/d).
• Children or infant less than 4kgs should be treated in the category of neonates.

NOTE: Never use Chloramphenicol in young infants) during the first four to five days.

Micronutrient supplementation
The infant should receive the following micronutrients supplements:

Vitamin A
Give a dose of 50,000 IU to every infant at the time of discharge from the nutrition unit/ward.

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 NOTE: Infants less than 6 months of age with SAM should be given a dose of 50,000IU
of Vitamin A on admission only if they are given therapeutic milk that is not fortified as
recommended in WHO specifications and Vitamin A is not part other daily supplements

Iron
• Iron supplement should be given when the infant starts to gain on weight.
• Give 3 mg/kg/day into two divided doses (crush the tablet and dilute it in the milk).
Folic acid
• Give 2.5 mg (one tablet) as a single dose on admission if an infant is being fed on diluted
F-100 or F-75.

• If an infant is being fed on infant formula, give 2.5mg of folic acid on the first day and a smaller
dose (1mg) on subsequent days.
• The infant should be sent home with at least a week’s supply of folic acid on discharge.
• When a child returns for follow up, more can be given.
Prevent hypothermia
• Encourage breastfeeding immediately and then feed every 2–3 hours (clarify on feeding), day
and night.
• Keep the infant warm.
• Cover the child’s head with a hat, apply the kangaroo technique and cover the body with a
blanket.
• Place the infant in an adult bed to let the mother sleep with the infant (under insecticide-treated
bed nets).
• Avoid exposing the child to cold, e.g., after bathing or during medical examinations.
• Dry the infant carefully after bathing, but do not bathe if very ill.
• Change wet nappies, clothes and bedding to keep the infant and the bed dry.
• Never use a hot water bottle.

Routine Monitoring
Monitoring progress of with infants with medical complication or factors is similar to that for older
children.
Monitor the infant and write details on the infant chart:

• Verify danger signs and non-response to treatment.

• Continuous monitoring of key vital signs is daily care practice.
• Weight is measured daily and plot on the SST multichart (HMIS NUT Form 006) (Annex 1).
• Body temperature is measured twice per day.
• Assess and record the degree of oedema (0, +, ++, +++).
• The standard clinical signs are assessed and noted in multi-chart each day;
• Respiration rate
• Stool
• A record is taken (on the fluid intake part of the SST multi-chart if the patient is absent, vomits
or refuses a feed.

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Individual monitoring
The importance of close monitoring during each phase of treatment must be emphasized, and
staff may need training to understand that this is a priority. The following parameters should be
monitored daily and recorded on the critical care pathway chart:

• Record and review the total intake of supplementary milk feeds and/or number of breastfeeds
per 24 hours.
• Monitor weight gain, urinary output, activity level and other signs that breast milk is being
produced.

Monitoring weight gain

• Infants should be weighed daily USING appropriate scales; preferably with an accuracy to 20g.
• It is important to check that scales are being properly used (e.g. calibrated to zero after each
measurement).
• Infants should be weighed entirely naked; weight of clothes can make a big difference to the
small changes in weights seen in such small infants.
• Using a basin to weigh young infants when using a salter scale, it is more practical for small,
sick infants, and easier to clean than hanging pants.
• Weight gain needs to be calculated as grams per kilogram body weight per day. However, a
useful rule of thumb for minimum acceptable weight gain during catch-up growth in young
infants (weighing less than 4kgs on admission) is 20 g every day.

Monitoring urine frequency

Ask how often the baby passes urine. Frequent urination (six or more wet nappies daily for babies
aged under six months) with pale, dilute urine, is a useful day-to-day sign of adequate fluid intake
in the exclusively milk-fed infant.

Monitoring infant’s level of activity

Ask about the infant’s level of activity.
An infant is probably getting enough feeds if s/he:

• Wakes spontaneously every two to three hours demanding a feed.

• Feeds vigorously.
• Is lively and interacts socially in a way appropriate to his/her age.
An infant who is not getting enough feeds may be very quiet and undemanding because s/he lacks
the energy to insist on being fed.

Nutritional rehabilitation for infants below 6 Months with prospect of breast

feeding
Infants with complicated SAM are very weak and do not strongly suckle to adequately stimulate
the breast to enable adequate production and let down of breast milk. The mothers often perceive
that they do not have insufficient milk to adequately feed their children. The low output of milk
is due to inadequate stimulation by the weak infant. Attempts to put such infants to the breast
repeatedly fail, the infant continues to lose weight and the mother s continuously perceives that
exclusive breastfeeding will not work.
On the other hand, treating the infant with artificial diets rapidly leads to weaning and the mother
sees that the “formula” is the only way to allow her child to recover. A weaning infant carries a
high risk of mortality and is not recommended.

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The objective of treatment of these patients is to return them to full exclusive breastfeeding. This
is achieved by stimulating breastfeeding at the same time as supplementing the child during
breastfeeding until the infant becomes stronger and breast milk production is sufficient to allow
the child to grow properly.
Breast milk output is stimulated by the Supplemental Suckling technique (SST). It is important to
put the child to the breast as often as possible. The SST is time consuming and requires skill but is
the only technique that works in practice. If the SST is not working or skilled staff is not available,
support the mother to express breast milk by hand and feed the infant using a cup.

Diet
The SST milk can be made by diluting F-100 to make F-100-dilute.

NOTE: Full strength F-100 should NEVER be used for small infants of children less than 3 kg
or infants less than 6 months. The renal solute load is too high for this category of child and
could provoke hypernatraemic dehydration.

Type of milk
• For oedematous infant: Give F-75 or expressed breast milk until the oedema has resolved or for
a few days and then switch to F-100 dilute and use SST for feeding the child.
• For non-oedematous infant: Give F-100-dilute, locally known as Specially Diluted Therapeutic
Milk (SDTM) or breast milk.

Preparation of feeds in Table 32

For F-100 dilute,
• Add 4 blue-levelled scoops of F-100 to 100 ml of safe drinking water to make 116 ml of F-100.
• Use only 100 ml of F-100 already prepared and add 35 ml of water, then you will get 135 ml of
F-100 diluted.
• Give excess milk to the lactating mother to drink.
• If you needed more than a total of 135 ml of F-100 diluted, use 200 ml of F-100 reconstituted and
then add 70 ml of water, etc.
• Don’t make smaller quantities.
Amounts to give by SST
• Encourage the mother to breastfeed every 3 hours for at least 20 minutes, more often if the
infant cries or demands to breastfeed.
• After (30 to 60 minutes) of normal breastfeeding, return the infant to the breast and help the
mother to give the F-100 diluted using the SST.
• Give the amount of SST F-100 diluted milk at 130ml/kg/day divided in 8 feeds according to the
look up table (see Table 32).
• Do NOT increase the amount given, this is because the infant subsequently starts to regain
strength and sufficiently suckles and gains weight.
• Encourage the mother to continue breastfeeding when the infant is gaining weight and tell her,
that “the recovery is due to her own breast milk.
• Write the information on the infant chart.
There are no separate phases in the treatment of infants with the SS technique. There is no need
to start with F-75 and then switch to F-100 dilute (can be used for infants with oedema for a few
days).

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 Table 32: Amounts of SST-Milk for infants during SST feeding

Class of Weight (kg) ML per feed (for 8 feeds/day)

Infant formula or F-100-diluted
>=1.2 25
1.3–1.5 30
1.6–1.7 35
1.8–2.1 40
2.2–2.4 45
2.5–2.7 50
2.8–2.9 55
3.0–3.4 60
3.5–3.9 65
4.0–4.4 70

Supplementary Suckling Technique (SST)

The supplemental suckling technique (SST) entails the infant suckling at the breast while also
taking the milk supplement from a cup through a fine tube that runs alongside the nipple (see
Figure 19). The infant is nourished by the milk supplement while suckling stimulates the breast
to produce more milk. The amount of the supplement is just sufficient for the baby to maintain
weight, even if the mother is producing no milk.

At the beginning of the SST:

• Use a tube the same size as gauge 8 NGT. (A gauge 5 tube can be used and is better for the
infant, but the milk should be strained through cotton wool to remove any small particles that
block the tube).
• Put the appropriate amount of SST milk in a cup and hold it.
• Put the end of the tube in the cup.
• Put the tip of the tube on the breast at the nipple. On the first days, apply tape to hold the NGT
to the breast and tell the mother to offer the breast in the normal way so that the infant attaches
properly.
• 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.
• Help the mother at first by holding the cup and the tube in place.
• Build confidence of the mother to conduct the SST technique.
• Place the cup at first about 5 cm to 10 cm below the level of the nipple so that SST-milk can be
taken with little effort by a weak infant.
NEVER place the cup above the level of the nipple, or it will flow quickly into the infant’s mouth by
siphonage with a major risk of aspiration.

• Tell the mother to relax. Excessive or interfering 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.
• It may take one or two days for the infant to get used to the tube and the taste of the mixture of
milks, but it is important to persevere.
• Retry the SST more than once to restore exclusive breastfeeding if it fails.

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Note: At the beginning, the mothers find it better to attach the tube to the breast with some tape,
later as she gets experience this is not normally necessary.

NOTE:as
Later, Atthe
the infant
beginning, the mothers
becomes find it better to attach the tube to the breast with some
stronger;
tape, later as she gets experience this is not normally necessary.
• Lower the cup progressively to about 30 cm below the breast.
• Later when the mothers are more confident, ask if they want to manage to hold the cup
Later, as the infant becomes stronger;
and tube without assistance. The mother, instead of the assistant, can hold the tube at the
• Lowerbreast
the cupwith
progressively
one handtoand about
the30other
cm below
holdsthe
thebreast.
infant and the cup. In this way she can
• Later when the mother is confident, ask
perform SST feeding without assistance. if they want to hold the cup and tube without assistance.
The mother, instead of the assistant, can hold the tube at the breast with one hand and the
• other Use
holdsanother mother
the infant and the who isInusing
cup. the she
this way technique successfully
can perform to help.
SST feeding without assistance.
Try to mother
•• Use another have thewho mothers
is usingtogether at thesuccessfully
the technique same timetousing help. the SST. Once one mother is
• Ensure using
that the SST successfully
all mothers conduct the theSST
otherat mothers
the sameare greatly
place and encouraged and find
time. This builds it relatively
mothers’
easy especially
confidence to copy her.when they observe one of them successfully conducting the SST.
•• If the IfSST
the milk
SSTformula
milk formula is changed
is changed suddenly,
suddenly, then thethen the infant
infant normallynormally
takes atakes
few a fewtodays to
days
become familiar with the new taste. It is preferable to continue with the same supplementary
become used to the new taste. It is preferable to continue with the same supplementary
diet throughout the treatment.
diet throughout the treatment.
Figure 19: Supplementary suckling technique (© Michael Golden)

Figure
This20:infant
Supplementary suckling
is suckling the technique (© Michael
breast and Golden)the SST milk (130 ml/kg/d) by the
also getting
supplemental suckling technique. Raising or lowering the cup determines the ease with
which the infant gets the supplement. For very weak infant, it can be at the level of the
This infant is suckling the breast and also getting the SST milk (130 ml/kg/d) by the supplemental
infant’s mouth. If it is above this level, the feed can go into the child by siphonage when
suckling
there istechnique.
a danger ofRaising or lowering the cup determines the ease with which the infant gets
aspiration.
the supplement. For very weak infant, it can be at the level of the infant’s mouth. If it is above this
level, the feed can go into the child by siphonage when there is a danger of aspiration.
NOTE: NEVER place the cup above the level of the nipple, or it will flow quickly into the
infant’s mouthplace
Note: NEVER by siphonage with athe
the cup above major
levelrisk of aspiration.
of the nipple, or it will flow quickly into the infant’s
mouth by siphonage with a major risk of aspiration.

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 151

152
152 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA
Cleaning the tube
• After feeding, flush the tube through with clean water using a syringe. Then spin the tube
rapidly to remove the water in the lumen by centrifugal force, and inspect to ensure that no
water remains in the tube. If convenient, the tube is then left exposed to direct sunlight. The UV
rays in sunlight penetrate the plastic and can effectively sterilize the tube if it is already clean
and all opaque matter is removed.

Progress and follow-up

Monitor the progress of the infant by taking daily weight with a scale graduated within 10 g (or 20
g) and write on the infant chart.

Regulating the amount of F-100 diluted

• If the child loses weight over 3 consecutive days but seems hungry and is taking all his F-100
dilute, add 5 ml extra to each feed.
• The Supplemental Suckling feed is giving maintenance amounts. If it is being taken and there is
weight loss, either the maintenance requirement is higher than calculated or there is significant
malabsorption.
• In general, the supplementation is not increased during the stay in the centre. If the child grows
regularly with the same quantity of milk, it means the quantity of breast milk is increasing.
If after some days, the child does not finish all the supplemental food, but continues to gain
weight
Tell the mother that the breast milk is increasing and that the infant is getting enough to fully
recover.
Reduce the amount of SST-milk given at each feed by the amount not taken.

When a baby is gaining weight at 20 g per day for 2 consecutive days (whatever her/his weight)
Decrease the quantity of SST milk given at each feed to a half of the maintenance intake.
If, on half the SST intake, the weight gain is maintained at 10 g per day for 2–3 consecutive days
(whatever her/his weight). Then stop supplement suckling completely. Tell the mother that her
breast milk is adequate to meet the child’s needs.
If the weight gain is not maintained when the SST milk intake is cut in half, then change the
amount given to 75 per cent of the maintenance amount for 2 days and then reduce it again if
weight gain is maintained.
If the mother wishes to go home as soon as the child is breastfeeding properly and gaining
weight, they should be discharged.
If the mother agrees, keep the child in the centre for a further 2 days on breast milk alone to
confirm that her infant continues to gain weight on breast milk alone. Then discharge the infant,
no matter what his current weight for age or weight for length.

Care for the mothers

Since the aim is to increase breast milk, the mother’s health and nutritional status are critical for
the nutritional repletion of the infant.

• Check mother’s nutrition status and manage any deficits.

• Explain to the mother the aim of treatment and what is expected of her.
• Do not make the mother feel guilty for the state of her child or blame her for giving other foods.

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• Introduce her to the other mothers in the centre and introduce her to the staff personally. Make
her feel “at home” in a friendly and relaxing atmosphere.
• Agree with her that she may not have enough milk at present, but strongly reassure the mother
that the technique works and that enough milk will “come into” her breasts as her baby recovers.
She will then be able to feed the baby with her own milk to make her baby better.
• Tell her and encourage her to drink at least 3 litres of water per day.
• Make the necessary arrangement for the mother so she can eat about 2500 Kcal/day of a high
quality diet.
• Decrease as much as possible the length of stay in the facility.
• Refer mothers to mental health counselling where necessary.
• Link the mother or caretaker to community-based health and nutrition support groups and
community-based initiatives prior to discharge.

Follow up
The follow-up after discharge for these children is crucial. Advise the mother to come to the
RMNCH clinic regularly (weekly to start with and then every two weeks if the infant is thriving).
The mother should be enrolled in Supplementary Feeding Program (SFP) service if it exists
and receive high quality food ration to improve the quality of breast milk. It is also important to
monitor the infant’s progress, support exclusive breastfeeding and inform the mother on when to
introduce appropriate complementary food at the age of six months.

Nutritional rehabilitation for infants without any prospect of being breastfed

There are special circumstances where a child less than six months cannot be exclusive breastfed.
These include abandonment; a child being orphaned, among others. These young infants are
particularly vulnerable because they have neither a mother nor the protection of breast milk.
When there is no prospect of being given breast milk then severely malnourished, less than six
month old infants are treated according to the following modified protocol.
Anthropometry in these small infants is difficult and imprecise. There are no standards for infants
below 45 cm and the increments to judge nutritional status require precise scales that are not
generally available. Use the growth monitoring program to admit infants that are losing weight
or have crossed WAZ lines because their weight is static and presence of oedema or IMNCI signs
(see admission criteria for infants less than 6 months in ITC in Section 4.3).
If there is no realistic prospect of being breastfed, infants with severe acute malnutrition should be
given appropriate replacement feeding. Severely malnourished infants without oedema should
be fed using F-100 diluted. Infants with oedema should be fed with F-75 until the oedema has
resolved and should then switch to infant formula or F-100 diluted.

Stabilization phase
• Infants less than 6 months give F-100 diluted to non-oedematous infants) at 130 ml/kg/day,
distributed across 8 feeds per day (every 4 hours) (see Table 33).
• Infants less than 6 months with oedema should be fed on F-75 in stabilization phase (see Table
33 (9).

NOTE: The criteria for using an NG tube and passage to transition phase are the same
as for older children. The infants must have antibiotics routinely and the management of
complications is the same as for older infants and children.

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Transition Phase
During transition phase, only F-100 diluted is used. If the infant has been taking F-75 during the
stabilization phase, then this is changed to F-100 diluted during the transition phase. Otherwise,
there is no change in the diet given, but the volume offered is increased by about one third
providing 110‑130 kcal/kg/day.

NOTE: Do NOT feed infants on full strength F-100.

Rehabilitation phase
During Phase 2, double the volume of F-100 diluted that was given during stabilization phase (see
Table 33). This is a large amount to encourage rapid catch-up growth. Infants must NEVER be force
fed. The frequency of feeding can be reduced to 6 times per day.

Table 33: Look up table of the amounts of F-100 dilute or F-75 to give for infants not breastfed in the
stabilization, transition and rehabilitation phases

Stabilization Phase Transition Phase Rehabilitation Phase

Class of Weight (kg) Amount (ml) of F-100 dilute/ SDTM or F-75 (if oedematous) to give per
feed
Frequency 8 feeds/day (3 8 feeds/day (3 6 feeds/day (4
hourly) hourly) hourly)
=< 1.5 30 40 60
1.6 – 1.8 35 45 70
1.9 – 2.1 40 55 80
2.2 – 2.4 45 60 90
2.5 – 2.7 50 65 100
2.8 – 2.9 55 76 110
3.0 – 3.4 60 80 120
3.5 – 3.9 65 85 130
4.0 – 4.4 70 95 140
Children less than six months, with oedema, should be given F-75 and not F-100 diluted.

Follow-up
Follow-up after discharge for these infants and their caretakers is very important and should be
organised by the outreach worker in conjunction with the Village Health Teams/Person. Nutrition
counselling for the mother or caregiver is essential.

Special support for low birth weight infants

Low birth weight (LBW) infants, especially those born earlier than term or small for their gestational
age, need additional care to survive and stay healthy. This care includes providing greater support
to keep them warm, initiating early and exclusive breastfeeding and preventing infections.

NOTE: Low birth weight infants are not usually severely wasted or oedematous and so are
unlikely to meet the criteria for SAM. Therefore, they should be managed according to the
WHO guidelines specifically for “Low birth weight babies” but linked to community health
workers for follow-up.

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Discharge of infants less than 6 months from ITC to OTC
Prepare for discharge and continue support in OTC according to the following discharge criteria:
Write in the registration book, the infant SST chart, and on the health card (passport) of the child.
Discharge criteria for infants less than 6 months from ITC to OTC

• All medical complications including oedema are resolved.

• Weight gain on either exclusive breastfeeding or replacement feeding is satisfactory at 20g/d,
with the weight curve following the WAZ growth line for three consecutive days
• Child’s Weight for length Z-score equal to or more than -2.0 SD (applies only to children with no
prospect to breastfeed).
Note that there are no anthropometric criteria for discharge of the fully breastfed infant who is
gaining weight.

• The infant has good appetite and is clinically well and alert
• The immunization schedule and other routine interventions have been completed.
• The mother has been adequately supplemented with vitamins and minerals, so that she has
accumulated body stores of the type 1 nutrients.
• For infants with no prospect to breast feed, the health worker is confident that the mother/
caregiver can prepare safely the appropriate breast milk substitute and feed the child the
appropriate amount.

NOTE: Infants less than 6 months should only be discharged from all nutritional care only
when they fulfill the discharge criteria as indicated in OTC (Section 7.4) :

Advise the mother or caretaker on for safe feeding at home

Mothers or caretakers who are expected to give replacement feeding (without prospect to
breastfeed) to their infants after they are discharged from ITC need clear guidance on safe
preparation and use of replacement feeds.

• The guidance should be acceptable, feasible, affordable, sustainable and safe (AFASS) for the
caretaker and their infants.
• Counselling and support for optimal IYCF should be provided, based on general recommendation
for feeding infants and young children, including for low birth weight infants by the health
workers.
• Whenever formula milk is provided as part of management of SAM in infants, it should not
confuse or compromise the wider public health message concerning exclusive breastfeeding
for infants under 6 months of age. Early introduction of complementary foods for older infants
could be considered depending on maturity of swallowing.
• Encourage the mother or caretakers to attend monthly health facility or integrated outreach
growth monitoring and primary health care services and advise them to return to the health
facility in case of a health problem.

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9.5 Inpatient therapeutic management of severe malnutrition in older
persons

Introduction
This section provides guidance needed for inpatient management of older children (> 5 years),
adolescents and adults with severe malnutrition.

Principles in management
The physiological changes and principles of management of older persons with severe
undernutrition are similar to children.The guidelines for management of children with SAM should
be followed; however, differences in classification of malnutrition, amount of food required and
drug dosages.
Adolescents and adults rarely associate wasting or oedema with their diet except in famine
conditions resulting in disbelief that altering their diet will help them. Even in famine conditions,
they are often very reluctant to eat anything except traditional foods, which they view as perfectly
satisfactory. Moreover, the foods they are allowed are often restricted by family values, cultural
and religious beliefs. They are often reluctant to take formula feeds unless they can be persuaded
that such feeds are a form of medicine. This problem is one of the most difficult aspects of treating
adolescents and adults.
The clinical approach to a patient with undernutrition, including nutritional classification and
outpatient management in older persons has been detailed in Chapter Four.

Inpatient management of adolescents and adults with severe malnutrition

Stabilization
Adolescent and adult patients who have severe malnutrition should be assessed for co-existing
medical conditions and provided with appropriate treatment.

• Treat all medical conditions following the Uganda Ministry of Health Clinical Guidelines 2016.
• For management of medical complications, contextualize content in ITC.
• Care should be taken when administering intravenous feeds (where applicable) and fluids
to patients with unknown cardiac status and albumin levels, as severe oedema (including
pulmonary oedema) may result.
• In patients with HIV and on antiretroviral medication, do not stop ART during stabilization
phase. For a patient who has not yet received ARVs before admission, do not initiate ART during
stabilization phase. Initiate ART after stabilization phase. When possible, find out what might
be causing the undernutrition and manage accordingly. Use the HIV guidelines to ascertain
possible underlying cause of undernutrition while on antiretroviral therapy.

Feeding during stabilization phase

Give the patients locally prepared therapeutic feeds of F-75 (Annex 18) according to kilocalories
per kilogram body weight (see Table 34).

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 Table 34: Dietary requirements for initial treatment of severely malnourished older persons using
local preparations of F-75 and F-100

Age (years) Daily energy requirementsa Volume of diet required (ml/kg per
hour)
(Kcal /kg) (KJ/kg) F-75b F-100b
7–10 75 315 4.2 3.0
11–14 60 250 3.5 2.5
15–18 50 210 2.8 2.0
19–75 40 170 2.2 1.7
>75 35 150 2.0 1.5

a Individual needs may vary up to 30 per cent from these figures depending on sex, activity
level, infections and other factors.
b F-75 and F-100 are locally prepared therapeutic milk products. See Annex 18 for recipes. The
designations mean that the preparation contains respectively 75 and 100 kcals per 100 ml.
For example:
A 60-year-old adult, with a weight of 45 kgs in Phase 1, requires:
2.2mls (from F-75 column, Table 34) x 45 kg x 24 hours = 2,376 ml of F-75
This adult will require 2376mls per 24 hours. In terms of caloric intake:
2,376ml/100*75 = 1,782 Kcal a day;
1782 /45kgs = 39.6 kcal/kg/day.
The “Total Energy Requirement” shows that a 60-year-old needs 40 kcal per kg of body weight
each day based on second column (see Table 34).

• Demonstrate sip feeding for clients who are too ill to eat by themselves. Naso-gastric tube
feeding should only be used when there is no alternative in severely anorexic clients. The
amount of food given per kg of body weight is much less for adults than for children and
decreases with increasing age reflecting the lower energy requirements of older persons (see
Table 34). These amounts will meet all nutrient requirements of adolescents and adults.
• If a client has confirmed lactose intolerance, alternative F-75 recipes made of fermented milk to
meet the daily energy needs (see Annex 18).
• If client has or gains appetite, they are ready for transition phase.

Feeding during transition phase

For adolescents and adults, large quantities of therapeutic milk or formula can be difficult to
tolerate. Moreover, often milk is not considered a full meal by adolescent and adult patients.
Therefore, once the patient has stabilized, gradually introduce or give a combination of F-100 and
locally available fortified blended flours enriched with oil, vitamins and minerals or nutrient-rich
family foods (Annex 26) which sometimes are better tolerated to provide the recommended daily
intake as tolerated.

Rehabilitation
• An improving appetite indicates the beginning of rehabilitation. During rehabilitation, it is usual
for adolescents and adults to become very hungry, sometimes refusing the specialized foods
and requesting enormous amounts of other foods. When this happens, a diet should be given

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 that is based on family foods, but with added oil, mineral mix, and vitamin mix. Provide a wide
variety of nutrient-dense foods and allow the patient to eat as much as s/he desires.
• Give homemade mixture of nutrient-rich foods plus three high-energy nutritious snacks a day
to meet the energy needs per day (see Annex 26).

Criteria to moving back to stabilization phase

• If any signs of fluid overload develop.
• Development of abdominal distension.
• If the patient gets significant re-feeding diarrhoea associated with is weight loss.

Criteria for discharge

Severely malnourished adolescents and adults can be discharged and transferred to outpatient
care when:

• No grade +++ for 2 consecutive days

• They are eating well (family foods) or gaining weight
• They have a reliable source of nutritious food at home
• Any other health problems have been diagnosed and treatment has begun.
• Can return for review and supplementary food after 14 days
Adults should continue to receive a nutrient dense diet as outpatients until their BMI is >18.5 kg/
m2 for older children and adolescents, their diets should be supplemented until their BMI for age
z-score is > -2 Z-score (see Table 35).

Table 35: Discharge criteria for older children, adolescents and adults

AGE DISCHARGE CRITERIA

Children and adolescents 5 – 19 years, and any BMI for age > -2 Z scores
child aged ≥5 years whose height >120 cm And
No oedema for 14 days
Adults BMI ≥17.5kg/m2
And
No oedema for 14 days
Pregnant and Lactating Women 6 months after MUAC >23.0 cm
delivery

Failure-to-respond to treatment
Failure to respond to treatment in adults and adolescents is usually due to an unrecognized
underlying illness or refusal to follow the treatment regimen.

Usual causes of failure-to-respond

Problems with the treatment facility:

• Poor sanitary environment

• Inaccurate weighing equipment
• Inadequate amounts of food quantity and quality.
Problems of individual patients:

• Insufficient quantity and quality of food consumed.

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 159

• Vitamin or mineral deficiency.
• HIV and/or other opportunistic diseases.
• Malabsorption.
Other serious conditions and underlying diseases can delay weight gain, especially, diarrhoea,
tuberculosis, and hepatitis/cirrhosis, particularly where these have not been recognized or
successfully treated. Cancer patients, burns victims, HIV and TB infected patients in general have
higher energy requirements and therefore their recovery may be slower.

Discharge from nutrition care

In preparation for discharge (once patients have met the discharge criteria (see Table 35);

• Nutrition education and counselling should be provided using the Ministry of Health tools.
• Nutrition education and counselling can be conducted as part of group sessions, or with
individual patients and their guardians.
• Linkages should be made with institutions and organisations providing other services. Other
referrals may include social welfare, targeted food distribution.

Prevent malnutrition or relapse

• Encourage the sick person to eat, but do not use force as the body may not be able to accept it,
and the patient may vomit.
• Offer smaller, attractive meals of what the sick person likes more frequently.
• Let the sick person choose the foods she or he desires to eat from what is available.
• Encourage the patient to eat nutrient-dense foods that are locally available.
• Monitor weight and address causes of weight loss before the patient develops malnutrition.

Advice to patient on care seeking

• Seek help from a trained health worker if you notice rapid weight loss or if the sick person
consistently refuses to eat any food or is not able to swallow.
• Community nutrition delivery mechanisms have shown to be effective in many programs.
Community-based feeding programs and home-based care share many common components,
including emphases on physical care, a continuum of care, health education, local capacity-
building, ensured access, sustainable support, and community-based case-finding strategies.
• Enrol the person in a care service for nutritional assessment, counselling, and support, including
supplementary feeding.
• Offer nutritional counselling and information for weight gain.
• Determine and treat underlying causes of malnutrition.
• Encourage small and frequent meals. Treat nausea, thrush, and diarrhoea when indicated.
• Link or refer to community or home-based nutritional interventions or food security initiatives,
if available.
• To prevent malnutrition in PLHIV, where feasible, recommend home care for all adolescents
and adults living with HIV.

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10.0 Integrated Management of Acute Malnutrition
services during surge

10.1 Introduction
This chapter provides guidance in two special situations when acute malnutrition or undernourished
cases increase beyond usual proportions for regular health care system to handle during surge
and in emergencies.

• The Surge Approach was developed as a holistic approach to managing acute malnutrition
over time by helping the health system in partnership with external actors to better prepare for
and respond to episodic peaks in admissions of malnourished children.
• The surge approach is introduced in a non-emergency time to help prepare and strengthen
existing capacity.
• The IMAM Surge approach introduces a process and an evolving set of practical tools to help
government health teams to appropriately manage services for acute malnutrition over time.
Specifically, the approach focuses on improving planning and management of treatment
services during seasonal spikes or surges in caseloads of acute malnutrition.
• Surge approach can be adapted to address both severe and moderate acute malnutrition where
appropriate.

10.2 The surge approach

The IMAM Surge approach introduces a process and an evolving set of practical tools to help
government health teams to appropriately manage services for acute malnutrition over time.
Specifically, the approach focuses on improving planning and management of treatment services
during seasonal spikes or surges in caseloads of acute malnutrition. It can be adapted to address
both severe and moderate acute malnutrition where appropriate.

Components of the IMAM surge approach

Risk analysis and capacity assessment
• Each health facility should analyse the likely drivers of acute malnutrition in their catchment
area and particularly the factors resulting in more children with acute malnutrition arriving at
the facility for treatment.
• The aim is to establish what a ‘normal’ caseload looks like and when and to what degree surges
occur throughout the year. For example, in clinic X, the SAM caseload in July is usually double
that in January because it is the hunger gap and malaria and diarrhoea increase due to the rains
(leading to weight loss in children). In such a period, teams should begin by listing factors that
might contribute to malnutrition as well as factors influencing health seeking behaviours such
as the weeding season when mothers are often too busy to bring children to clinics or biannual
Child Health Days which might include MUAC screening and lead to more referrals.
• General patterns of performance indicators should be plotted using the health facility
performance charts as a wall charts to see where key factors occur at the same time. These are
cross-checked against admission data from previous years to identify months that are most
likely to see significant surges in admissions. Trends may be quite localized within the district;
thus, this analysis must be done separately for each facility, involving staff and key community
informants and, ideally, led by the District Health Team.
• A basic capacity assessment in key areas required for IMAM services should also be undertaken
for each facility. This ideally combines a more standardized assessment conducted by e.g. the
District Health Officer as well as a more subjective self-assessment by the health facility team.
Examples of capacity criteria include the number and type of staff currently working in the

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 161

king in the facility, storage space (e.g. for prepositioning RUTF), number
uld be assessed per hour and number of staff trained in MUAC
facility, storage space (e.g. for prepositioning RUTF), number of cases that could be assessed
per hour and number of staff trained in MUAC measurement.
esholds to trigger
Set facility caseloadsurge response
thresholds to trigger surge response
acity assessment
• Based on theand previous
capacity assessmentexperience,
and previousaexperience,
set of caseload thresholds
a set of caseload thresholds are
agreed for each health facility. Thresholds are equal to the number of cases of severe acute
h healthmalnutrition
facility. Thresholds areperequal
seen in the facility month,to thewhich
above number of cases
the health of severe
facility would need to modify
seen in the facility per month, above which the health facility would support
their normal clinic procedures (usually the ‘alert’ threshold) and/or receive external
from the District Health Office (usually the ‘serious’ or ‘emergency’ threshold).
eir normal
• Thisclinic
forwardprocedures
planning allows(usually the teams
health facility ‘alert’tothreshold)
plan a numberand/or receiveto normal
of modifications
rom theprocedure
District(e.g.Health
staff do Office
not book (usually
leave during the ‘serious’
the hunger gap) or
that ‘emergency’
will reduce the need for
external support (see Figure 20).

ning allows
How tohealth
calculate facility teams to plan a number of modifications to
thresholds?
(e.g. staff do not
Thresholds bookAlert,
(Normal, leave during
Serious, the hunger
Emergency): gap)
Indicate that will
a critical reduce
number (this the
number is a
format of a range) of monthly cases at a health facility, above which the type and scale of support
support (see Figure 19).
changes.
Triangulate data from the risk analysis, to estimate the expected caseload (over different times of
the year); reflect on the facility’s year trends.
ds?
Figure 20: Surges in caseloads and provision of surge support over time
ert,
cy):
ber
of a
at a
ich
port

the
the
ver
ar);
ear

The IMAM Surge Approach is particularly suited for situations where there are frequent
fluctuations in the prevalence of undernutrition and demand for services for the management of
acute malnutrition, in more extreme cases often interpreted as being an “emergency”.

Figure 21: Surges in caseloads and provision of surge support over time

d: This is set based on the capacity of the health facility to offer IMAM
n number of children without compromising quality of services. This
d to be the normal threshold, e.g. 0–15 caseloads.
162 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA
 Implementing the surge approach focusing on the health facility
The surge approach is made up of 8 steps (see Figure 20) that can be divided into 2 main stage
• The set-upthe
Implementing stage
surge approach focusing on the health facility and district level
• TheAsurge
permanent
approachstage ofup
is made real-time
of 8 stepsmonitoring andthat
(see Figure 21) action,
can bewith regular
divided into 2periods of reflectio
main stages:
andset-up
• The adaptation.
stage
• A permanent stage of real-time monitoring and action, with regular periods of reflection and
adaptation.
Figure 21: Overview of the IMAM surge approach focusing on the health facility.

Implementation of surge approach

Figure 22:1:Overview
Step of the IMAM surge approach focusing on the health facility.
Risk analysis
Health facility level: Health facility staff, in-charges, nutrition focal person/nutritionist, community
Implementation
health workersof surge
should approach
play a big role in risk analysis.
StepThis
1: Risk analysis
step should involve:
Health facility level: Health facility staff, in-charges, nutrition focal person/nutritionist, communi
• Analyses of trends in the caseloads within a health facility and then,
health workers should play a big role in risk analysis.
• Analyses of factors that influence access to health care and health seeking behaviour.
This step should involve:
The focus should be on the health facility and its catchment area.
• Analyses of trends in the caseloads within a health facility and then,
During this step, health facility staff and stakeholder should become:
• Analyses of factors that influence access to health care and health seeking behaviour.
The focus
• More should be on
conscious the health
of seasonal facility
trends and, and its catchment area.
During this step,
• Risks for thehealth
trends.facility staff and stakeholder should become:
• • Other
More factors that
conscious influence health
of seasonal trendscare seeking behaviours, known as drivers of caseload or
and,
demand for services. This information should then be used to look forward to anticipating how
• Risks forfactors
these the trends.
are likely to evolve and may impact upon the caseload of IMAM in the months
ahead.
16
GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 163
District level
The district health team should conduct analysis of:

• Admission trends in the context of SAM and MAM caseload reported in the district using DHIS2
data.
• Analysis of drought early warning information and food security should be collected, analysed
and reported on a monthly basis by DHO and DN, and
• Analysis of prevalence of acute malnutrition using SMART surveys and rapid nutrition
assessments, if available.

Step 2. Capacity assessment

Health facility level: The health facility staff should undertake a self-review of their capacity
generally with an emphasis on IMAM services, to identify factors that affect appropriate service
delivery during normal times with the lens that weaknesses identified will become more important
in the event that IMAM caseloads increase.
District level: This review should help the district and the partners, under the leadership of the
DHTs to plan how the district will meet the gaps in capacity to deliver services effectively during
surges, especially in terms of human resource, service delivery, therapeutic supplies and financing
options, in order to support the health facilities to respond to IMAM surges. Partners should be
part of the capacity review process.

Step 3: Threshold setting

Threshold setting is a process whereby the surge stakeholders of each health facility should:

• Bring together the information from the Trends and Risk Analysis (Step 1) as well as
• Their capacity to handle the workload of patients that they have (Step 2) and
• Consider when they may need help to respond to any increase in demand for IMAM services.
Since the capacity of a health facility can vary greatly, thresholds should be defined by each facility
individually with careful consideration of different factors that influence their capacity, i.e. staffing
(number and qualification), equipment, the presence of community workers, etc. Thresholds
should be set for four phases, starting from a normal situation and increasing to alert, alarm and
emergency phase. Descriptive definitions for each phase are provided in Table 36.

164 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA

 Table 36: Descriptive definitions for each phase in surge

Description of phases for the Health Facility

Phase Description for the Health Facility

• Normal threshold – This is set based on the capacity of the health
facility to offer IMAM services to a given number of children without
NORMAL compromising quality of services.
• Health workers are engaged in a discussion based on their previous
experience on the caseloads they would comfortably deal with at their
health facility without compromising quality of services (IMAM) and
other services offered at their health facility.
• This number is deemed to be the normal threshold, e.g. 0 – 15 caseloads.

• This is set to be the caseloads between the normal and serious threshold
(a range was given) Alert threshold will be in the range, 16 – 44.
ALERT
• Health facility staff members begin to be overstretched due to increased
demand for IMAM services but can handle the situation by reorganizing
to focus on key priorities with minimal external support
• Entails a slight simplification of procedures or some task shifting aimed
at being more efficient. HF should be able to access additional supplies
easily as needed.
• This is set to be the highest number of caseloads in a given month for
the previous year. For example, if 45 were the highest caseloads in the
SERIOUS previous year, then this is set to be the serious threshold for the current
year. Serious threshold will be in the range, 45 – 89.
• When the HF staff is overstretched from the increased caseload
and requires additional support from the DHT/partners in order to
appropriately meet the additional demands
• Re-organizing within the HF and mobilization of the HF’s own resources
are insufficient to handle the situation.
• This is set to be 100% increase (or double) the serious threshold e.g. ≥
90.
EMERGENCY
• HF staff is overstretched to the point where even greater additional
support is required from the District and partners in order to:
• a) ensure that services for SAM are functioning effectively and at full
capacity and
• b) the population is able to access appropriate services in a timely
manner.
• Significant resource inputs from partners are likely (i.e. additional human
resource, supply chain support, infrastructure and equipment).
• Additional partner support will ideally be provided via the DHT, but if the
DHT is overwhelmed itself, direct support to HFs may be required.

At district level, the threshold setting is based on: Proportion of facilities surpassing alarm or
emergency phase, food insecurity, SMART surveys, if done in the preceding three months.

Step 4: Defining and costing surge actions

The surge actions to be implemented should be defined to ensure that the health facility has the
capacity to respond to the caseload of acute malnutrition at all times, whether during a normal

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 165

situation or when thresholds are passed into the alert, alarm or emergency phase (see Figure 21
and Table 36). The actions that are defined may consist of things that the health facility can do
themselves or that they need support from other actors.
Actions should be suggested by health facilities and then finalized at the district level.
Once guidance for actions has been established, costs for this package must be estimated.
This is done for each phase and is estimated as a cost per health facility. Many of these costs
should be part of routine health and nutrition service delivery, especially IMAM services. Only
additional activities should be highlighted for costing. Afterwards, these actions and costs must
be incorporated into health facility and district work plans and budgets.

Step 5: Formalizing agreements and statements

This step should ensure that:

• All key actors have the same understanding about the package of surge actions,
• When they will occur and
• Who is responsible for each aspect?
It is also to ensure that there is confirmed commitment to this support and that it is both budgeted
and funded. The absence of this formalizing agreements step can translate into delays in action
when a higher phase is activated. Within this step, the focus should be on the standard operating
procedure.

Step 6: Monitoring caseloads against set thresholds

There are three key activities for surge that should be done routinely within the health facility:

• Monitoring of the thresholds–through the IMAM registers as new admissions arrive and
through the wall charts on a monthly basis;
• Monthly planning for the upcoming three months, based on the knowledge of the previous
years;
• Reporting of data and/or surge phase.
• As a final session during the set up at the HF level, stakeholders should learn how to use both
of these methods to monitor the IMAM caseload, plan for the coming period, and what to do
when a threshold is crossed.
Each month, plotting new admissions and data reported in HMIS on the health monitoring performance
chart on the wall as an opportunity to review charts from the previous years to see if any surges can
be anticipated in the coming three months so that they are planned for.

Step 7: Scaling up and down surge support

Scaling up
As soon as the health staff notice that a threshold for SAM admissions has been crossed for
either MAM or SAM, the Health Facility In-Charge should be informed. At this point, the health
facility staff review the situation quickly and consider potential reasons why there has been an
increase in the number of admissions and any immediate steps to respond. The health facility In-
Charge should then call the Nutrition Focal Point to inform him/her of the situation. The district
focal person should then discuss the issue with the rest of the DHT during a routine or a specially
called meeting, confirm activation of specific surge actions. Once a decision to scale up has been
agreed, the health facility should also inform key community representatives.
During scale up: Through the DHT and other stakeholders, a comprehensive surge appropriate
action and support package should be delivered to the health units.

166 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA

Given the main support planned for IMAM, the thresholds should be set according to the number
of, when crossing a threshold into a lower phase, surge actions should be scaled down, whereby
when there is a normal situation, the health facility returns to their normal way of functioning.
During scale down
Once SAM admissions and caseloads have decreased and/or health facility capacity is adequate
to manage current SAM caseload, the same mechanism is used to scale down surge actions in line
with the thresholds.

• First, within the health facility, the situation should be discussed and communicated to the DHT
focal point,
• The DHT focal point in turn shares with the rest of the DHT and partners, and
• The DHT and partners approves systematic scale down plan accordingly.
Consideration should be given on how information moves promptly between the health facilities
and DHT as well as to other actors who have committed support.
Ultimately, caseloads and external support are expected to return to ‘normal’ pre-surge levels
(see Figure 22). This is especially important if reporting frequency is increased during serious and
emergencyUltimately,
phases. caseloads and external support are expected to return to ‘normal’ pre-surge levels
(see Figure 21). This is especially important if reporting frequency is increased during serious and
emergency phases.
Step 8: Reflect: Regular review and adaptation
Regular review
Step 8:ofReflect:
the approach should
Regular review beadaptation
and conducted to ensure that the surge approach is
functioningRegular
appropriately and is achieving its
review of the approach should be purpose to improve
conducted to ensurethe
thathealth facility’s
the surge capacity
approach is
to managefunctioning
periodic increases in admissions of acute malnutrition without undermining
appropriately and is achieving its purpose to improve the health facility’s capacity health
to
services for other illnesses.
manage This is ainreflection
periodic increases admissionsperiod for malnutrition
of acute health facility and undermining
without district health staff
health
after the ‘surge season’ has passed by regarding:
services for other illnesses. This is a reflection period for health facility and district health staff
after the ‘surge season’ has passed by regarding:
• How the scale up of support worked and how the actual caseload trends differed from the
• How the scale up of support worked and how the actual caseload trends differed from the
trends predicted;
trends predicted;
• Whether• thresholds
Whetherwere appropriate;
thresholds and
were appropriate; and
• How surge
• actions or surge
How surge support
actions should
or surge beshould
support revised.
be revised.
This reviewThis
andreview and revision
revision can alsocanbealso be performed
performed midway
midway through
through theyear
the yearand/or
and/or when
whenany
anymajor
major
changes inchanges
capacityinoccur.
capacity occur.

Figure 22: IMAM Surge Approach as Health Facilities Cross Caseload Thresholds

Figure 23: IMAM Surge Approach as Health Facilities Cross Caseload Thresholds
GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 167
11.0 Integrated Management of Acute Malnutrition
services in emergency nutrition response
Introduction
This chapter provides guidance in emergency situations including steps for emergency nutrition
response and requirements for emergency nutrition intervention

11.1 Key terms

Emergency: This is an extraordinary, urgent and sudden situation that requires immediate
intervention to avert stress, morbidity and death. Emergencies may be either manmade disaster,
such as an exacerbation of an ongoing conflict with population displacement (e.g. massive land
evictions, war, etc.) or due to environmental issues such as a serious drought or severe flooding/
landslides. The local infrastructure may not have the capacity to respond due to limited resources
particularly financial, human, logistical, structural limitations and/or geographical isolation. There
is a need to rapidly respond to prevent increased and/or excessive morbidity and mortality.
Complex emergency: This is a relatively acute situation affecting large civilian populations, usually
involving a combination of war or civil strife, food shortages and population displacement,
resulting in significant excess mortality.
Nutritional Emergency: This occurs when there are abnormally high rates of acute malnutrition
resulting from a crisis event where:
Global acute malnutrition rate >10 per cent21or
Crude mortality rate >1 death/10,000 persons per day in presence of aggravating factors.
Emergency Nutrition Response:This should be an intervention that primarily aims to protect the
nutrition status of the most vulnerable groups, prevent individuals with MAM from becoming
severely malnourished and to treat all forms of acute malnutrition during nutritional emergencies.

11.2 Steps for emergency nutrition response

Step 1: Coordination and information sharing

• This involves coordination of all the emergency activities at all levels and among all implementing
partners to ensure effectiveness.
• It prevents duplication of programs and identifies gaps that have not been addressed in each
sector.
In Uganda, Ministry of Disaster Preparedness and Refugees together with the Office of the Prime
Minister have the responsibility of coordinating emergencies including nutrition emergency
response. A government task force should be set up to oversee the coordination.

Step 2: Rapid needs and nutrition assessment

The following should be performed:

• Jointly plan and conduct an initial assessment to understand the situation and identify the extent
of the threat to people’s lives, their coping strategies and access to services such as health, safe
drinking water/sanitation and basic diet using national standardized tools or guidelines.

21 UNHCR, 2011

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• Conduct a multi-sectoral assessment, to understand the different factors affecting malnutrition
i.e. the immediate, underlying and basic causes. This will ensure a holistic approach to the
management of acute malnutrition.
• Review existing interventions where an existing humanitarian response is in place but there
is deterioration in the situation, and identify needs required to increase capacity to meet the
demands of a deteriorating situation.
• Carry out ongoing rapid nutrition surveys periodically during the program to monitor
effectiveness of the response.

Step 3. Select appropriate emergency nutrition responses (ENR)

After assessing and there is a problem, there is need to respond. The response should include:

• A holistic approach to programming and addressing identified needs.

• Protection of lives and livelihoods.
• Integrating screening and referral for acute malnutrition at all health facility and community
contact points and/or RMNCH and ensure medical nutritional follow up of MAM & SAM clients
without complications and admission of severely malnourished with complications to inpatient
wards.
• Relief/humanitarian services that are equitably and impartially provided. Typical responses to
nutritional emergencies include (Annex 12):
• Curative, e.g. therapeutic care.
• Preventative, e. g. improving water supply and sanitation to prevent disease epidemics.
• Food and non-food interventions.
• The vulnerable groups such as under five age group, pregnant and lactating women, elderly
and chronically ill especially People Living with HIV/AIDS (PLWHA) and TB patients are usually
the primary target in emergency nutrition interventions.

Step 4. Planning an emergency nutrition response

• Establishing an emergency response team with defined roles and responsibilities.
• Selecting nutrition program sites; the program sites are identified depending on:
• Population size affected, planned geographical coverage and accessibility.
• The population needs (small, medium or big needs) and the capacity of the implementing
partner.
• The area can be defined by using administrative boundaries such as village, parish, sub-
county, county and district etc.
• Maximizing positive coverage and impact by being aware of competition for scarce resources/
increased resources, misuse or misappropriation of supplies. It is important to have a good
logistics system to ensure there is no break in the pipeline.
• Joint planning and implementing with local authorities and the health sector at all levels

Step 5: Implementing the Emergency Nutrition responses

• Emergency nutrition intervention works to stabilize the nutrition and food security situation.
• Prevents deterioration in acute malnutrition.
• Ultimately reducing high rates of malnutrition among the vulnerable populations.
• It requires substantial resources to be set up and monitored with Non-Government Organizations
supporting MoH.

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 169

11.3 Program linkages for prevention and management of acute
malnutrition in emergencies
Preventing and addressing undernutrition requires multi-sectoral action and other program
linkages such as infant and young child feeding in emergencies (IYCF-E), health, education,
protection, water, sanitation and hygiene and food security.

Acute malnutrition:
• Integrate MAM and SAM services wherever possible.
• Linkages at the health facility and community levels are essential in emergencies to take care
of the increased numbers of acutely malnourished children.
• Community sensitization and mobilization, active case finding and referral systems should be
established jointly for MAM and SAM management.
The following are possible programs an emergency nutrition response program can be linked to;
these fall generally under one of the following categories;

• Income generating/livelihood promotion; seeks to increase household income and assets through:
• Wage labour; local or migratory labour formal employment or casual labour, and payment in
cash or kind.
• Self-employment; agricultural production, agro processing, small scale manufacturing, service
provision, and trading.
• Risk reduction and loss management.

Infant and Young Child Feeding in emergencies (IYCF-E)

• It is important to address IYCF-E as part of the prevention of acute malnutrition, particularly to
emphasize exclusive and continued breastfeeding and optimal complementary feeding in children
aged 6–23 months and management of artificial feeding for infants with no possibility to breastfeed.
• Routine Growth Monitoring and Promotion for children aged 0–23 months should be emphasized.
• It is also important to include basic information on infant and young child feeding and other
exceptional circumstances.

Health, water, hygiene and sanitation

• Early and accelerated management of water sources, sanitation, hygiene, and health program
for common childhood illness (e.g. diarrhoea, measles) should augment the management of
acute malnutrition during an emergency.
• Feeding centres and distribution sites should include access to safe water for drinking, as well
as clean water and soap for handwashing.

Food security and livelihood (FSL) program

Household food insecurity has a significant impact on the effectiveness of prevention and
management of acute malnutrition.
Where food insecurity is a result of an emergency or existed prior to the emergency, resources
should be spent on nutrition interventions for prevention of acute malnutrition or treatment of
MAM only when a general food distribution or equivalent transfer in cash or voucher is in place.

Exit strategy for emergency nutrition response

• An exit strategy should be developed right at the beginning of the ENR program through a
coordinated involvement of relevant stakeholders with leadership of government.

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• An exit strategy indicates when an emergency intervention should be phased out or closed
down.
• When program closure is envisaged, it must be progressive, over a recommended period of
3–6 months. It is desirable to start with a reduction in the rations, stopping new admissions,
establishing handover solutions, and training of identified focal person(s) for the specific
programs (see Chapter 6 Guidance on SFP services).

Factors to consider when closing or handing over a program

• Malnutrition rates are <10 per cent with no aggravating factors.
• Net reduction in the number of children attending the centres (through improvement in the
nutritional status or the displacement of the population etc.
• Depletion of food stock without being renewed.
• Epidemiological control of infectious diseases is effective.
• Crude mortality rates <1/10,000/day.
• Improved climatic conditions.

Table 37: Stakeholders’ roles in emergency response

Agency Role

Ministry of • Technical support to implementing partners such as NGOs and CBOs

Health • Technical support in conducting nutritional and health assessments.
• To ensure that critical health and nutrition needs are addressed
• Technical support in nutrition and health education
• Provide staff, materials/equipment, food and drugs
• Monitor and evaluate emergency nutrition programmes
• Provide information for decision making and policy formulation
• Advocate for interventions in affected areas
• Coordinate health and nutrition interventions

OPM • Coordinate sectors to provide emergency preparedness and nutrition

response activities in affected areas
• Identify key response areas
• Avail information for decision making

UN Agencies • Support Government of Uganda (GoU) in coordination and response to

emergencies through;
• Technical and financial support to government departments and
implementing partners for emergency preparedness and response

NGOs/CBOS • Support GoU in responding to emergencies through;

• Provision of technical and logistical support to existing infrastructures
• Set-up and implement emergency interventions programmes
• Conduct health and nutrition assessment
• Support coordination structures, at national and sub-national levels

Other • Provide other humanitarian services such as water and sanitation,

Government shelter and clothing and education for school children
Departments

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11.4 Requirements of setting-up an emergency nutrition program
• Qualified and skilled personnel.
• Space; office for conducting emergency nutrition response activities and for storage of
commodities.
• Supervisory structures.
• Supply-chain management structure.
• Monitoring and evaluation system.
• Transportation facilities; trucks, fuel, maintenance.
Several different staff positions are required to implement an emergency nutrition programme,
Including managers and technical staff (doctors, nurses, nutritionists and health assistants). The
local aid worker must have the relevant technical qualifications, be fluent with the local language
and culture of the beneficiaries and be familiar with the area’s geography. Some of the staff must
be trained prior to commencing an emergency nutrition intervention and have experience with
the different roles, responsibilities and procedures.
The following staff is needed on site

• Overall program manager.

• A supervisor may be required to oversee an implementation site.
• Community field workers: to conduct food distributions to affected population. Personnel hired
to support food distribution, cooking and other support tasks are recruited from among the
beneficiaries on a clearly defined cash or food-for-work basis.
• Registry clerks and assistants (number hired will depend on the size of the operation).
• Storekeepers and food supervisors trained in food safety.
• Guards for guarding food stocks (security may be provided by the government).
• VHTs/ Community Health Workers (CHWs)/ Community Volunteers.

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12.0 Prevention of malnutrition

12.1 Introduction
Tackling malnutrition in all its forms requires that nutritional needs are addressed at key life stages
through the entire life-course. Addressing nutrition through the life-course also requires a more
holistic view and integrated provision of health and nutrition services by health care systems. This
section provides practical guidelines for the prevention of all forms of malnutrition in vulnerable
groups and general population. The key interventions listed below include essential nutrition
actions for healthier populations over the life-course.

12.2 Key interventions

Infants (0–6 months)

• Promote early initiation of breastfeeding (immediately after birth within an hour) and exclusive
breastfeeding for the first 6 completed months of the infant’s life.
• Promote optimal feeding for low birth weight babies.
• Encourage kangaroo care for low birth weight babies.

Children aged 6–23 months

• Encourage mothers to introduce nutritionally adequate, safe and appropriate complementary
foods at 6 completed months of the infant’s age while they continue breastfeeding for up to 2
years or beyond.
• Children should receive a diversified diet with a variety of locally available foods from the main
food groups i.e. energy-giving foods (cereal grains and tuber, oils and sugar), body-building
foods (plant and animal proteins) and protective foods (vegetables and fruits).
• Promote hygiene and handwashing.
• Encourage consumption of iron and folate fortified cereal food products.
• Promote biannual periodic vitamin A supplementation for the prevention and control Vitamin A
deficiency disorders.
• Promote growth monitoring and prevention.
• Promote iron and folic acid supplementation to control and/or prevent iron deficiency and
anaemia in children.
• Promote therapeutic zinc supplementation in management of diarrhoea.
• Encourage periodic deworming.
• Encourage consumption of iodized salt among all household members.
• Prevention and treatment of moderate acute malnutrition.
• Promote treatment of severe acute malnutrition using therapeutic foods.
• Promote appropriate IYCF in emergencies.

Adolescents
• Promote iron and folic acid supplementation to adolescent girls in line with the national anaemia
policy guidelines.
• Promote the use of iodized salt among adolescents for the prevention and control of iodine-
deficiency disorders micro-nutrient deficiencies.
• Counsel adolescents on healthy eating habits to prevent obesity and undernutrition.
• Provide periodic deworming treatment to control and/or prevent iron deficiency and anaemia
in adolescents.

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• Encourage adolescents to engage in moderate-to-vigorous-intensity physical activity for 30
minutes daily.
• Encourage girls to remain longer in schools to prevent teenage pregnancies.
• Educate and counsel on family planning and delay first pregnancy till at least 18 years of age.

Maternal nutrition
• Promote healthy eating behaviour during pregnancy and lactation.
• Promote iron and folic acid supplementation.
• Provide nutrition counselling and education on consumption of foods rich in iron, folic acid.
• Prevention of iodine deficiency diseases through use of iodized salt.
• Malaria control through use of insecticide-treated mosquito nets and intermittent preventive
treatment (IPT) for malaria.
• Deworming in the 2nd and 3rd trimesters.
• Encourage consumption of fortified foods e.g. cooking oil fortified with vitamin A, wheat flour
with iron etc.

12.3 Creating and strengthening linkages with other programs in MoH or

other sectors
It is important to note that each intervention/program is most effective when combined or
integrated with other strategies. A number of the measures should be undertaken through the
PHC system to promote and strengthen the integration of nutrition specific interventions in the
relevant programs of the MoH, and in the activities of other sectors:

• Health or nutrition education, information, and counselling should be used as some of the
modalities for promoting some of the above program or interventions (see Annex 27).
• The community and public health promotion messaging should do awareness creation on the
causes, signs and symptoms, identification, treatment, and prevention of malnutrition.
• Linking with other health programs such as NACS, IMNCI, iCCM, EPI, ANC/Reproductive Health,
TB and HIV, among others.
• Linking with Food Security and Livelihood (FSL) to ensure families with malnourished children
under 5 years and PLW are targeted and supported with agricultural inputs e.g. seed distribution
or re-stocking and other livelihood projects.
• Linking with the agriculture sector to empower the public with knowledge, skills and capacity
for adequate food production.
• Linking with the education sector to ensure:
• School curricula development includes adequate nutritional training,
• School health programs integrate nutrition services such as screening and referral for
treatment of cases identified with acute malnutrition,
• Pre-service training through which health personnel are equipped with knowledge and skills
to prevent, identify, and manage acute malnutrition.
• Linking with WASH sector to ensure that:
• Provision of water and sanitation services in nutrition centres is prioritized wherever WASH
projects are implemented;
• The community (beneficiaries) is equipped with adequate knowledge, skills, and capacity for
optimal hygiene and sanitation practices.

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13.0 Supply chain management in integrated
management of acute malnutrition

13.1 Introduction
It is critical to have a reliable supply chain for delivering basic nutrition supplies and equipment
for quality IMAM services. An efficient system for ordering and managing nutrition supplies and
equipment prevents stock-outs and reduces time loss, thereby building confidence in service
management. This Chapter outlines the goals, type of supplies and their sources, and stock
management at different levels of the health system

What is supply chain management (SCM)?

SCM refers to control of the supply chain process starting with procurement, storage, distribution
and use from manufacture to supplier through wholesaler to retailer and finally to consumer.
SCM for IMAM involves the physical movement of nutrition supplies, data that goes along with
the commodities and the actual individuals that handle the commodities from stage to stage of
the supply chain. Delivery of quality IMAM services heavily depends on an efficient integrated
nutrition supply chain.
The IMAM nutrition commodities should follow the logistic cycle for the Ministry of Health through
the National Medical Stores (NMS). The cycle involves commodity selection, quantification,
procurement, warehousing and distribution, ordering and reporting.

Goals of SCM for IMAM commodities

• To prevent stock outs.
• To reduce time loss or to have timely response.
• To build confidence in service management.

13.2 Integrated Management of Acute Malnutrition commodities

The RUTF and other nutrition commodities (see Table 38) were put on the 2016 essential medicines
and health supplies list of Uganda and should follow the MoH logistic cycle.

Table 38: Types and frequency of ordering for IMAM commodities and equipment

Type Examples When to order

Therapeutic
F-75, F-100, RUTF, CMV and ReSoMal NMS cycle
feeds
Corn Soya Blend (CSB), lipid based nutrient
Supplementary
supplement, Fortified blended foods (Super Cereal NMS cycle
foods
and Super Cereal Plus), BP-100, BP-5, RUSF
Anthropometric MUAC tapes, weighing scales, height or length Based on
equipment boards need
Data collection HMIS NUTRITION Forms and Registers, monthly Based on
tools and quarterly reports at different care points need
Routine
medicines and Annex 3 (drugs section) NMS cycle
supplements

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13.3 Quantification, procurement, storage and distribution of nutrition
commodities
Nutrition commodities are quantified, procured, distributed and stored under standards
established by the National Medicine Policy of Uganda. Therefore, quantification and forecasting,
ordering, receiving, storing, dispensing, recalling and monitoring of supplies should be integrated
with other supplies at all levels and aligned with the Essential Medicines Manual 2018. Similarly,
management of stock-outs should follow the existing protocols.

Managing stocks
• Involves quantification of supplies using standard end user monitoring tools (see Annex 28).
• The projections for nutrition supplies are done regularly in order to ensure effective programming
and minimize on stock outs.
• Calculations are based on case-loads and target populations and should include buffer stock
estimates.
• Consumption estimates of the nutrition supplies are derived from total number of new admitted
cases multiplied by the recommended quantities of the therapeutic supplies used for treating a
client.

Quantification Process
• Quantification is the process used to determine how much of the specific essential medicine is
needed for procurement for a specific period. For example, if the procurement plan is to cover
a twelve months’ period, the consumption data for the past twelve months should be reviewed,
if available.
• Essential medicine can be quantified using one or a combination of the standard methods that
include consumption, morbidity and proxy method.
• There are two procurement systems for public health facilities in Uganda; the push and pull
system.
• Higher level health facilities pull logistics from NMS through their bimonthly orders whereas
lower level health facilities receive kits as a push from NMS.
• Prior to the new financial year, all public health facilities conduct annual procurement planning
for the health commodities including nutrition commodities required for next financial year.
This then become the basis for the bi-monthly order quantity for higher level facilities (health
centre IV to National Referral Hospitals) and kit for the lower health facility.
• It is required that during this process, all departments/ units are represented to provide
information such that a more accurate forecast is established.

Ordering of supplies
• Ordering of nutrition commodities and essential drugs should be done based on the NMS cycle,
except anthropometric equipment in order to ensure effective programming and minimizing
stock outs.
• Calculations are based on case-loads, target populations and consumption. It should include
buffer stock estimates.
• In case the consumption records are not available, you can estimate the requirements using
morbidity data.
• To determine the quantity to order, the following parameters should be established:
• Average monthly consumption,
• Maximum stock and
• Stock on hand/physical count.

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Quantity to order = maximum stock-stock at hand.
Where, maximum stock = 4 x average monthly consumption.
The quantity to order is then calculated using the formula below factoring in a 2-month buffer.
BufferQuantity
stockto order = maximum stock-stock at hand.
Buffer Where,
stock is defined
maximum stock = 4 xas reserve
average supplies to safeguard against unfor
monthly consumption.
demands.
Buffer stock
• It is stock used over and above the actual stock required or needed t
Buffer stock is defined as reserve supplies to safeguard against unforeseen shortages or demands.
IMAM services.
• It is stock used over and above the actual stock required or needed to run the program or IMAM
• Itservices.
is obtained by calculating 10 per cent of the stock needed for the p
• It is obtained by calculating 10 per cent of the stock needed for the program.

Transportation
Transportation and
anddistribution
distribution
Transportation
Transportationand
and distribution of nutrition
distribution of nutrition commodities
commodities to health
to health facilities facilities
is integrated with is
other district commodities. However, given the bulky nature of some of the commodities e.g.
districtsupplementary
commodities. However,
foods, they givenandthe
may be transported bulky
distributed usingnature ofThesome
hired trucks. Figure 23of th
below shows the distribution system of nutritional commodities in Uganda.
supplementary foods, they may be transported and distributed using hired tr
below Figure
shows 23: Distribution of nutritional commodities
the distribution system of nutritional commodities in Uganda.

Central
Warehouse

Health Facility

Community
Client (Outreach)

Supply Audit
• The aim of supply audit is to identify bottlenecks in supply chain management to inform actions
and to optimize supply chain procedures.
• The methods, tools, and indicators used depend on the objective of the inquiry (which questions
to answer) and use of information in line with the SCM procedures.
Figure 24: Distribution of nutritional commodities
• Information to be in diagnostics for supply chain management are shared in coordination
meetings and performance reports to inform decision making for resource allocation and
improvement strategies.
Supply Audit
• The aim of supply audit is to identify bottlenecks in supply chain ma
actions and to optimize supply chain procedures.
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Storage and record keeping
Nutrition commodities are stored within the health facility stores. Stock is properly recorded on
stock cards and/or in the stock book so as to track its movement from the storeroom/warehouse
to the health facility store. This helps staff understand the flow of supplies into and out of the
facility.

Dispensing
The objective of dispensing is to ensure that the right form of the right medicine is given to the
right patient in the right dosage and quantity with the right instructions and in the right packaging
by the right care provider. Nutrition commodities are dispensed in a similar way as other drugs
and medications.

NOTE: Avoid parallel dispensing.

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14.0 Quality improvement, monitoring and evaluation
in Integrated Management of Acute Malnutrition
services

14.1 Quality improvement in Integrated Management of Acute

Malnutrition
Quality refers to performance according to standards or expectations to satisfy stated or implied
needs of a person/ or population. Therefore, this Chapter focuses on systematically improving
quality of IMAM services by bridging the gaps between services actually provided and desired
quality service standards. Provision of IMAM services should also meet the reasonable needs of
the clients.
Provision of IMAM services is expected to be responsive to the attributes and dimensions of
quality improvement (QI) which are stated and elaborated in the Quality improvement framework
and strategic plan 2015/16–2019/20 for MoH. In brief, integration of the principles of QI in IMAM
using the QI Journal (Annex 29) should include:

• Client focus: IMAM services should be designed to meet the needs and the reasonable
expectations of the clients or community in order to improve service uptake and utilization.
• Focus on systems and processes: As indicated by the evidence of focusing on systems and
processes, we encourage analysis of IMAM Service delivery systems and development of flow
charts. The flow charts should clearly show the steps in every service.
.
The flow charts will help;

1. To clarify complex processes.

2. Give team members a shared understanding of the process.
3. Identify steps that do not add value to the internal or external customer.
4. Analyse gaps and identifying causes of poor performance.
• Team work: Improvement is achieved through the team approach to problem solving and
quality improvement. Quality Improvement teams should have an officer in charge of nutrition.
• Testing changes and emphasizing the use of data: Quality Improvement teams at all levels
should be encouraged to select and monitor QI projects on provision of IMAM services using
documentation journals.
QI interventions in all health facilities implementing IMAM should embrace the plan, do, study,
and act cycle (PDSA) model and 5S model which isas the foundations for quality of health care
in IMAM services and as stipulated in the 2015 MoH Quality improvement framework (see Table
39).

The PDSA model

The PDSA model allows teams to systematically try out ideas to improve before deciding to
implement. Changes are tried on a small scale before they are implemented on a larger scale.
The cycle allows teams to know quickly whether the change will work and helps to gather data
to convince colleagues whether the suggested changes work or not. The QI team should use the
PDSA cycle to identify the gaps, test changes to bridge the gaps, study the tested changes, and
adapt changes that have caused improvement in nutrition service delivery as best practices.

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Steps in the PDSA Cycle
Plan (P): Develop a plan of change, What changes will occur and why?
Do: Test the change (intervention)
Study (S): Verify that the change was implemented according to the plan i.e. Compare the data
with the baseline information to determine whether there was improvement.
Act (A): Summarize and communicate what was learnt from the previous steps. Implement the
change as standard procedure if it proved to be successful. Monitor the change over time to check
for improvements and problems.

The 5S model
The 5S is an acronym standing for: Sort (S1), Set (S2), Shine (S3), Standardize (S4), Sustain (S5).
The 5S model is the foundation and initial step towards implementation of all QI interventions in
the Health Sector. The 5S has to be implemented in all nutrition service delivery centres.

Table 39: Steps in implementing 5S model

A. SORT Removing unnecessary items from the workplace.

B. SET Arrange in order and label all items used in the working place
C. SHINE Clean all the working place used for IMAM including tools,
instruments and other items used for service delivery.
D. STANDARDISE Can scale up 5S model to be implemented in all the other units
involved in Nutrition and beyond.
E. SUSTAIN Continuous review, support supervision, mentorship training and
monitoring implementation of 5S. Capacity building has to be
sustained in order to operationalize 5S.

Service standards in quality improvement in IMAM

Service Delivery Standards (SDS) are the minimum levels of performance in nutrition service
delivery that should meet the expectations of the clients consuming the services. The following
are pertinent service standards for IMAM and include:

Staffing
Qualified health service providers depending on level of healthcare service delivery:

• Inpatient therapeutic care facilities should be run by an experienced and trained Medical Officer
and above in IMAM together with a Nutritionist, Nurse/Midwife with experience in paediatric
and/or general nursing, Dispenser, and Social Worker. Other support staff should be available
to run the chores of an inpatient ward.
• Inpatient care can be established at any of the available health centre IV and above health
facility with appropriate staffing and serving a community with high burden of SAM.
• All health facilities providing ITC services should provide or support OTC and community
services.
• Outpatient care and community components should be conducted by trained clinicians–Medical
Officer/or Clinical Officer, Nurses/Midwives, Nutritionists, and VHTs.
• Outpatient care and community components should be established at all lower health centre
III/or any existing health centre IIs with appropriate staffing and serving a community with

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 high burden of acute malnutrition. All health facilities providing ITC should establish OTC and
community IMAM components.
• The health facilities should link with the community through VHTs to engage and work with the
community in follow up and screening for eligible clients.

Supplies
• All health facilities providing inpatient, outpatient, supplementary, and community IMAM
services should plan and stock the recommended nutrition commodities, essential drugs, and
functional equipment as guided in Chapter 12.
• All referral hospitals at the district, region, and national levels should plan and provide the
necessary laboratory services for the IMAM services.

Service delivery
• Active and routine screening: Health facilities should conduct early community case finding,
health facility identification and initiation of treatment before the onset of complications.
• Accurate anthropometrics: Service providers should ensure frequent calibration of height/
length and weight scales and use of appropriate tools for accurate body measurements.
• Correct procedures for calculating quantities, weighing, measuring, mixing, cooking, storing
and monitoring the quality of the food should be ensured. In ITC, any reconstituted therapeutic
milk must be used within 6 hours and leftovers discarded.
• Monitoring of response to treatment: Ensure health workers adhere to treatment protocols for
diagnosis and treatment of failure-to-respond.
• Standard of care: Children receive comprehensive care according to their needs and diagnosis
made by the Clinician. Children should be followed up over time and across services and
referred to other care as needed. Referral or movement of children from or to the community
or between services is tracked, and a communication and/or transportation system is ensured.
• Involvement of mothers or caretakers in care: Mothers or child caretakers should actively be
engaged in care and receive specific counselling on their children’s condition including hygiene
and nutrition education.

Quality Improvement Implementing Teams

The QI implementation is the responsibility of the Work Improvement Team (WIT) in a health
facility. Depending on the circumstances, the Community engagement, SFP service, OTC and ITC
should form the implementation units for QI at health facility level as outlined below:

Community Engagement
All health facilities should have engagement with the community through the VHT system as the
primary CHWs to ensure community assessment and mobilization are performed. The facility QI
team should develop a community outreach strategy, messages, materials, and training of VHTs.
The following pertinent functions and activities should be considered in community engagement
and conduct of outreaches:

• Have capable and motivated VHTs with appropriate competencies, time, tools and equipment
to perform activities according to their job description.
• Have sensitized and empowered communities that are aware and understand the IMAM
services to generate service demand and use, and to empower communities to adopt healthy
practices and behaviours.
• Conduct active and routine screening for early case finding and early start of treatment before
the onset of complications.

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• Conduct home visits by VHTs to trace defaulters and other problem cases to understand reasons
for absenteeism, mortality or non-response to treatment.
• Conduct accurate anthropometric measurements by trained VHTs.
• Responsiveness to community needs and expectations as it generates satisfaction, trust,
service utilization by service users.

Supplementary feeding program service

SFP services are provided commonly in emergency situations or in areas with chronic food
insecurity as an intervention for management of moderate acute malnutrition.

• The involved staff and organizations should design and tailor the approach based on context,
underlying causes of malnutrition, and available resources.
• The services should not be implemented in isolation but part of the broader multisector
program including infant and young child feeding (IYCF) support in emergencies; livelihoods;
food security; health and water, sanitation, and hygiene (WASH) interventions.
• A referral system between community, OTC and ITC should be established.
Team: The supervisor (Nutritionist, Nurse) is the in-charge, assisted by the Nutrition Counsellor/
Social Worker, Nutrition Assistant. The nutritionist and counsellor organize health and nutrition
education and food demonstrations with the support of the health facility team and supervisor.
Routine screening is conducted monthly by the health workers and health workers reporting to
the supervisor.
Equipment and nutrition supplies such as fortified blended flours or RUSF, job aids and forms:
Fortified blended flours and RUSF supplies are forecasted annually and requested quarterly using
the standard forms. Annual forecasting guides quarterly requests, which may be adjusted for
expected changes in caseload. The quarterly requirement for Super Cereal depends on treatment
duration and is based on the monthly supplement

Outpatient therapeutic care (OTC)

OTC is established from HC III to Regional Referral Hospital (RRH) level and it is responsible for
basic nutrition patient care and support for health service delivery. This includes diagnosis of
patients with SAM and their enrolment into care. Those with complications are referred to the next
level of service delivery for further management.
OTC staff include a Clinician, Nurse, Nutritionist (applies to General Hospital to RRH), Dispenser
(applies to General Hospital to RRH), counsellor and support staff. Additional staff may be co-
opted to support and strengthen the QI functions as the situation may require.

Functions of OTC include:

• Assess the quality of individual care and services, focusing on appropriate admission, progress
of management and treatment outcome, which reflects adherence to guidelines and adequate
organization of care.
• On admission and each follow-up visit, the clinician or nurse records information in the register
and on the treatment card to monitor individual clinical care until the end of treatment. The
treatment card indicates what to assess and what to monitor during progress and at the end of
treatment. A unique registration number is provided and recorded on all forms.
• Referral of patient with acute malnutrition: Referral slips track movement of children with SAM
and MAM between the community and health facilities and/or services.
• Adaptation to care: On each visit, health workers adapt health and nutrition counselling to
the client’s health and nutritional status, progress and needs. If nutritional status stagnates or
worsens, a history and clinical examination may reveal the causes, or referral to hospital may
be necessary.

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• If a client does not return to the health facility, the VHT leader may ask the VHT to do a defaulting
and mortality audit.

Inpatient Therapeutic Care (ITC)

• ITC is located in General Hospitals, RRH level and other institutions such as HC IV with basic
amenities which include: admission space for malnourished children with complications and
trained staff in IMAM.
• Key staff should include a Specialist for Children/Paediatrician, Nutritionist, Medical Officer,
Nurse/Paediatric Nurse, Dispenser and support staff including a Cleaner to maintain a sanitary
condition and appropriate space for mixing and storage of feeds, access to safe and adequate
water supply.
• The team is responsible for diagnosis of patients with acute malnutrition with complication and
making sure the patient is enrolled into care and support.
• The responsible health worker, with support from the team (clinician, nurses, midwife, and
nutrition counsellor) monitor the quality of individual care and services, focusing on danger
signs, assessment, progress of treatment and treatment outcome, reflecting adherence to
guidelines and adequate organization of care.
• Documentation: The physician or nurse records individual information in the register on
admission and on the treatment record during treatment to monitor individual clinical care
until the end of treatment.
• The treatment card indicates what to assess at the start of treatment, during treatment and at
the end of treatment. A unique registration number is provided and recorded on all forms.
• Monitoring danger signs and treatment progress: Quality care includes closely monitoring
danger signs and treatment progress, which are essential for the child’s recovery. Any failure to
diagnose and immediately treat life-threatening and other medical complications, infections or
serious underlying diseases can adversely affect treatment outcome by causing development
of a more serious condition, delay in response, non-response, relapse or death.
• Health workers should perform mortality audits for any child who dies while receiving treatment
within the CMAM programme. Any child death needs to be audited to understand the cause
and what elements of care need improvement.
• Feeding of the child: Sufficient time must be allocated to feed each child, and adequate staff
should be allocated for this task, day and night. Feeding a malnourished child takes more
time and patience than feeding a normal child. If it takes about 15 minutes to feed each child
and therapeutic food is given every 3 hours, one person is needed, day and night, to feed 12
children.
• When therapeutic food is given every 2 hours, more staff are needed. If there are not enough
staff, treatment of a child may fail because insufficient time is taken for feeding.
• Referral tracking: Referral slips track movement of children with SAM and MAM between the
community and health facilities and/or services.

NOTE: It is not enough to merely conduct death audits. Health service providers ought to
demonstrate that they are learning from each death that is audited to prevent similar deaths
from occurring in future.

QI functions for community, SFP, OTC and ITC

The four components (Community, SFP where applicable, OTC, and ITC) of IMAM services should
be integrated and the teams should work together as one unit for quality improvement in a health
facility. In a situation where these structures don’t exist, the QI focal person should take lead to
work with other exiting committees to address QI functions for nutrition health services.

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The key functions are:

• Implement PDSA and 5S as outlined above.

• Identify key service delivery standard gaps that need to be addressed and monitored.
• Document progress made in implementing QI interventions using a standard QI documentation
journal.
• Hold weekly meetings to assess progress made in implementing QI interventions in nutrition
(track the indicator you have agreed to monitor). The team involved in nutrition should develop
a culture of internally sharing results on a regular basis.
• Make monthly reports which should be shared with the health facility in-charge and the health
facility QI Committee which meets on a monthly basis.

The health facility QI committee

Every health unit should create a QI committee which meets on a monthly basis to deliberate
implementation of QI from the different departments in the health unit (HC III upwards). The
Nutrition QI implementing Unit (Community, SFP where applicable, OTC, and ITC) should submit
monthly reports to the health facility QI committee to be guided on proper implementation process.
This interaction is important to build capacity for QI in nutrition at the health facility.
The composition of the health facility QI Committee:
The health facility QI committee is comprised of the following:

• The health facility in-charge is the chairperson,

• Representative of the hospital board or health unit management committee,
• Health facility administrator (where applicable in case of larger centres: Hospitals),
• Heads of departments (smaller departments are merged to avoid having very big meeting).
• Medical records officer / health information assistant.
• Representatives from health implementing partner supporting implementation of QI in Nutrition.
• Health consumers (Community/Patient) representatives (one male, one female).
(Ref: Health Sector Quality Improvement Framework & Strategic Plan 2015/16 to 2019/29).

Responsibilities for the health facility QIT

• Plan and guide the resource mobilization process for QI particularly, nutrition. The team should
generate a costed work plan for the nutrition functions.
• Review health facility QI action plan for nutrition. This should indicate clear roles and
responsibilities particularly for regular capacity building using continuous medical education
(CME) sessions and other available opportunities for QI training, support supervision, etc.
• Conduct QI supervision, coaching and mentorship in nutrition activities in the health facility.
The reports for this activity should be well documented, indicating clearly the actions to be
taken and responsible person.
• Receive and review department monthly QI reports on key performance data/indicators from
the identified QI gaps and the actions taken (this is normally reflected in the documentation
journal).
• Compile and submit facility QI reports to the HSD and District QI Committee
• Recognize and reward good performance.
• Organize and hold regular monthly health facility QI Committee meetings.
The health facility in-charge receives a consolidated QI report which is discussed at the district
QI meetings, where broad strategic planning for nutrition actions takes place. The district QI
Committee meetings take place on a quarterly basis and provide opportunity to plan for QI in

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nutrition and other related issues for the entire district. The DHO chairs this meeting at the district
and should be supported to be regular and give adequate attention to QI.
The districts are expected at regional level to conduct quarterly QI Committee meeting involving
the all the districts in the region at the Regional Referral Hospital (RRH). QI in nutrition issues
are further discussed at the regional level before critical issues can be identified for the National
Steering Committee sitting at the MoH headquarters.
Nutrition focal persons are resource persons that work in districts and RRHs. They are expected to
plan and support the implementation of QI in nutrition work plan at the respective levels of service
delivery important.

Continuous quality improvement (CQI)

Continuous Quality Improvement is done by the team of care providers and supportive supervision
team.

• The aim is to promote quality of care in everyday work by testing small improvements to
address identified problems, discussing with team members how problems were addressed
and further improving identified solutions.
• Team members meet regularly to discuss problems and think through opportunities for
solutions and improvements, and continually test improvements.
• Tools used include treatment records to determine the quality of care by assessment, diagnosis,
treatment, response to treatment and treatment outcome. Deeper analysis of monthly reports of
quality of care and performance of services, problem solving, quality improvement discussions
and case study discussions are also undertaken.
• Monitoring tools and indicators are used and targets for improvement are set by mutual
agreement.

Supportive supervision and mentorship

• Aim: Promote quality of care by strengthening relationships between health workers and
supervisors to work together to set goals, monitor performance, identify and correct problems
and proactively improve quality of service. Supportive supervision and mentorship also creates
opportunities to encourage good practices and help health workers maintain high-quality
service delivery.
The following activities assess the quality of care and inform actions for improvements:
• Identifying weaknesses in IMAM services and care organization and the causes that need
correction and providing guidance for problem solving.
• Strengthening the technical capacity of health workers through discussion and on-the-job
mentoring during visits or planning tailored refresher trainings.
• Motivating staff by encouraging good practices and appraising performance.
• Supportive supervisors and mentors’ visits may be conducted four weeks after the initial IMAM
training of the health staff and every 6 months or more often to ensure that the quality and
organization of clinical care meet standards.
• Discuss and solve identified problems, observe care provision and verify the quality of records.
During supervision, gaps and discrepancies should be identified in consultation with the team
and, as much as possible, with representatives of the community.
• Immediate feedback should be given to allow joint discussion of possible solutions to problems
identified.
• All regional hospitals should be supervised by the MoH Nutrition Division with support from
national referrals and implementing partners. All district general hospitals by regional teams
and lower health facilities should be supervised by the DHTs and supporting implementing
partners.

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• The IMAM supportive supervision and mentorship visits may be integrated with other health
services.
• Tools: Supportive supervision tools include registers, treatment records, stock cards, monthly
reports and supervision checklists. Health Facility Supervisory and Mentorship Checklists
(Annex 30) have been developed to collect the data.

NOTE: Personnel conducting supervisory visits should also review the treatment or monitoring
charts, particularly those of children who have defaulted, died, or are not responding to
treatment.

Indicators: The following indicators are monitored to assess the quality of clinical IMAM care:

• Proper completion of register, monitoring cards, ration cards, records and monthly reports.
• Adherence to IMAM and other medical protocols.
• Proper community follow up and referral.
• Proper completion of stock cards for medicine and nutrition supplies.
• Status on admission recorded and tallied.
• Adherence to guidelines for assessment, diagnosis, treatment, and monitoring of condition
and progress.
• Verification of failure-to-respond to treatment.
• Tracing and follow up of absentee and defaulters.
• Mortality audits for all children who died while on treatment.
• Progress of individual children, checking for consistent weight gain, length of stay and at end
of treatment.
• Person-centred care provided.
• Team-based care provided.
• Adherence to hygiene standards.
• Mother or caretaker received care, involved in care, informed, and linked with peers.
• Other procedures according to the supervision checklist.

14.2 Monitoring, evaluation and reporting

Introduction
The purpose of this sub-section is to ensure that monitoring and evaluation (M&E) is an integral
part of all IMAM services. Monitoring is the systematic or periodic check on all aspects of the
IMAM services during implementation to establish if inputs, processes and outputs are proceeding
according to plan so that timely action can be taken to correct deficiencies detected.
It is important to monitor IMAM activities to ensure quality service delivery, effective use of
resources and strengthen accountability.
Evaluation: Measure outcomes and impacts as a one-off exercise which may be conducted on a
regular basis and/or when a certain period is completed to gather information to improve future
IMAM interventions or to determine other types of interventions required to reduce malnutrition
in affected communities. The monitoring and evaluation activities assess the:

• Appropriateness
• Efficiency
• Effectiveness
• Impact of the nutrition support program

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The data from monitoring and evaluation activities is critical for the following: Planning services,
opening and closing ITCs, OTCs, SFPs, and community involvement; ordering supplies and
knowing where additional training or help is required. It also forms part of the surveillance system
to assess the nutrition status of the communities where IMAM services are provided. Indicators
should be graphed using the health performance unit charts to help in interpreting trends during
IMAM implementation in health facilities.

Monitoring comprises of three major components:

• Monitoring of individual treatment to assess patient’s progress.
• Monitoring to assess effectiveness of treatment interventions (i.e. proportion of acutely malnourished
patients treated effectively) and community-level activities for mobilization and case-finding.
• Assessment of service coverage (i.e. proportion of the target group being reached with
treatment) and appropriateness of the programme for communities.

Key definitions in monitoring and evaluation

INR-number: This is a unique number assigned to each patient DIAGNOSED with either MAM or
SAM admitted for treatment in ITC, OTC and SFP. It is assigned in addition to any other numbers
that may be given by a registered IMAM facility.
The INR-number must be used on all internal transfer forms and documents related to that patient
(Critical care pathway chart, ITC multi-charts, SS multi-charts, OTC and SFP chart, integrated
nutrition register and integrated ration card).
The INR-number should normally take the following format:
Health district code (letter or number)/Facility name or Number/Individual Number

NOTE:This can be changed at national level and should be as simple as possible. Where there is
an alternative unique national number for each individual, this can replace the INR-number.

The District nutritionist with the DHO and the DHT:

• Liaises with any other agencies or NGOs that collaborate in the government’s IMAM services.
• Assigns the code and register each facility whether it is an OTC site or an ITC before the site
is opened and informs the MoH nutrition division through the most senior nutritionist at the
regional referral of the facility’s registration details.
The patient keeps this same INR-number during ALL internal transfers. The individual health
facilities can also give their own registration number (a site-specific number) to the patient for
internal use and filing but they must use the INR-number on all transfer forms and documents
related to that patient.

NOTE: Sometimes a patient has a third number. For example, if there is an ITC attached to
an inpatient facility providing 24-hour medical services and the patient has been transferred
from OTC as an outpatient, then the patient will have: 1) a INR-number assigned by the
OTC site, 2) an inpatient sequential registration number for the malnutrition unit, and 3) a
facility registration number; these registration numbers must be kept distinct and marked in
different places on the charts and transfer forms.

The critical number is the INR-number. This INR-number is assigned where the patient is first
DIAGNOSED; whether this is an OTC site or in the ITC. This number is unique and should always
be denoted as the INR-number. In all the documents relating to the patient, i.e. for inpatient
care, on critical care pathway chart, INR book and transfer forms; for outpatient care, on the OTC

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chart, registration book and transfer forms. Where there is a child health card or other monitoring
documents, then the INR-number and the admission must be entered into that document retained
by the caretaker.
Facility registration number: This is a registration number assigned by the facility. It should
normally take the form of a number followed by the year (e.g. 0234/2011). This number is used
for internal filing and sorting records within the facility on the critical care pathway chart and is
different from the INR in the ITC and the OTC chart, but is not used for constructing a database of
patients.
For clarity: The sequence of numbers will not be the same; this is because, internal transfers may
be given a new facility registration number but should NOT be given a new INR-number–they
retain the same INR-number from facility to facility.
New admission: A new admission is defined as a patient with SAM or MAM who has not been
under treatment elsewhere for this episode of SAM or MAM and has not been assigned an INR-
number in the current financial year. This category includes relapsed cases (child relapsed within
a period of two months or more of ending treatment of previous episode within the same financial
year).
Relapse: Relapse is a patient diagnosed as MAM or SAM after being previously discharged as
cured within the same year financial year. A relapse should be counted as a “new admission” if
they relapse within 2 months of ending treatment of a previous episode within the same financial
year.

NOTE: A period of 2 months or more indicates recovery of the same episode of illness.

INR-number and relapse: They should give a postfix to her/his INR-number thus: xxxx-2 to denote
that this is the second episode of SAM for this patient. If the original INR-number cannot be found,
a new INR-number should be given, but it should always have xxx-2 to denote a second admission
to the program. The INR-number will not change every financial year.
Clients who have relapsed are particularly vulnerable and the fact that they are relapses should be
noted in the “Major Problem” section of their charts.
Readmission: A readmission is either a Readmission defaulter (R-D) or Readmission Relapse (R-
R). A readmission defaulter is defined as a patient who returns to either OTC or ITC or SFC after
missing two consecutive visits for OTC and/or SFC and two days for ITC to resume treatment
within of a period of two months or less. The R-R / R-D patient is not a new admission and is
reassigned his/her original INR-number.
A readmission relapse is a patient diagnosed as SAM or MAM after being discharged as cured
within a period less than 2 months within the same financial year.
Transfer: Transfer is defined as a patient who arrives because s/he has been transferred from
another facility (from OTC to ITC, OTC to another OTC, or ITC to OTC) after receiving the INR-
number. Such transfers are recorded in both the entry and exit sections of the register and report.
If it is necessary to differentiate transfers between facilities, then the terms transfer-in and transfer-
out can be applied as follows.

• Transfer-in: Is a patient arriving from another facility (OTC or ITC).

• Transfer-out: Is a patient sent to another facility to continue treatment (OTC or ITC).
• Internal transfer: Is a patient who moves from one department to another within the same
health facility.
Other admission: Other admission is defined as a patient that is admitted to the facility for
whatever reason but does not fulfil any of the criteria of SAM (e.g. a twin, etc.); these patients are
not counted in the facility’s monthly report statistics and are not given an INR-number.

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Error of admission: Error of admission should not be recorded in either admission or discharges
in the monthly statistics; their INR-number should be reassigned to the next patient and crossed
out from all their records.
For clarity: These patients are not considered as part of IMAM services and are not counted in the
report. If they have used considerable amount of resources, this can be recorded.

NOTE: Review IMAM services of health facilities that have frequent errors of admission.

Cured: Cured is defined as a patient reaching the criteria for discharge. Patients are discharged as
cured from nutrition therapy only in OTC and SFP.

NOTE: Discharge through the SFP is not considered as a transfer, but as a discharge from the
service for severe malnutrition and the patient is referred to the SFP.

Successfully treated: This term is used for 1) patients in the ITC who successfully complete Phase
1 (stabilisation phase) of treatment and are transferred to OTC to continue their treatment, and 2)
for infants less than 6 months who are discharged gaining weight on exclusive breastfeeding.
For clarity: When the patients exit the ITC to continue treatment in the OTC, they are still in the
services and have not reached the criteria for discharge that is they are not yet “cured”. However,
the ITC has successfully “graduated” the patient and fulfilled their role in treatment properly.
Length of stay: This is the time from admission to the time of reaching “cured” status (OTC) or
successful treatment (ITC) and not the time of physical exit of the facility.
For clarity: Patients may remain in the services after they have reached the criteria for “cure”,
particularly in an ITC where transport or escort arrangements have to be made; this time is not
counted in the length of stay or rate of weight gain calculations.

NOTE: It is not recommended that the length of stay for individual patients in the ITC be
added to the length of stay in the OTC to obtain the total length of stay for that individual.
This data can, if desired, be obtained during evaluations, as well as the length of stay and
rate of weight gain of children who were first treated in ITCs before transfer to the OTC
separately from those who were treated wholly in the OTC.

Died or dead: Died or dead is defined as a patient who dies during treatment the after they have
been assigned an INR-number.
For clarity: This includes patients who die in transit from one facility to another. Where a patient
with SAM dies during transit from an OTC to an ITC, the death should be recorded as death in the
OTC report similarly in SFP.
If the child was previously reported as “defaulter unconfirmed” and is subsequently found to have
died, this should be notified in a subsequent monthly report in the “change of category section”. A
note is made in the INR registration book and the ITC/OTC chart.
Defaulter-confirmed: A defaulter-confirmed is defined as a patient who is absent, without making
any arrangements with the staff, for two consecutive visits (14 days in OTC and 2 days in an ITC)
and without being officially discharged, who is known to be still alive (from home visit, neighbour,
volunteer or outreach worker’s feedback).
Defaulter-unconfirmed: A Defaulter-Unconfirmed is defined as a patient that fulfils the definition
for defaulter, but that it is uncertain whether they are in fact alive or dead.

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In the reports, the defaulters are recorded as defaulting when they have failed to return. In OTC,
this will normally mean that they are recorded in the month following the actual time that they
were last seen, and to a lesser extent for ITC. If any calculations are made on defaulters (e.g.
rates of weight gain before defaulting etc.), then 14 days should be subtracted from the “date of
defaulting” for OTC patients and 2 days for ITC patients.
Non-response (to standard treatment): Non-response to treatment is defined as a patient in either
OTC or ITC or SFP who fulfils the criteria set out in the guidelines as failure-to-respond to treatment
and fails to respond to all treatment and whose caretaker refuses referral or referral to a doctor to
take over the case is impossible.
For clarity: This includes all children who do not respond for any reason (social, psychological and
medical) and is not restricted only to those who have suspected underlying medical conditions
requiring transfer or referral.
Medical-referral: Medical-referral is defined as a patient who has a serious underlying illness that
requires treatment beyond the scope of the ITC (or is suspected of having such a condition that
requires diagnostic tests beyond the capacity of the ITC) and is referred to another service which
takes over the complete management of the child. This is counted as the patient leaving the IMAM
services for management by another service.
Refusal-of-transfer: Refusal of transfer is defined as a patient who fulfils the criteria for admission
to an ITC (according to the triage criteria) but declines the invitation for transfer from the OTC.
For clarity: This is not a reason for discharge from the OTC where the patient remains for continued
treatment. A note is made in the register and the chart to say that the patient declined transfer. This
is not recorded in the monthly report. But since it can be an explanation for mortality in the OTC,
it should be periodically examined for the annual report and evaluations; if frequent, this should
signal the need for investigation of the reasons (distance to the ITC, reputation of the ITC, etc.) and
remedial action to be taken.
Exit: An exit is defined as a patient leaving a facility. It is the sum of patients cured/successfully
treated, died, defaulted, medical referral, and transfers. For the OTC, this represents the sum of
discharges and transfers. For the ITC this is the sum of successfully treated patients, discharges
and transfers.
Discharge: A discharge is defined as a patient who leaves the facility with IMAM services because
they are cured, died, defaulted, or medically referred.
Missing-patients: Missing-patients are defined as those patients that are transferred to another
facility and fail to attend the receiving facility to which they have been transferred within a
reasonable space of time (several days). This statistic is not recorded in any of the documents but
can be calculated from the collated reports of the OTCs and ITCs within a district.

IMAM monitoring tools, reports, charts and indicators

There are various tools used for individual and program level monitoring in implementation of
IMAM services and these have been summarized in Annex 1.

Registration
Integrated nutrition register (INR): Every OTC and ITC should have the Integrated nutrition register.

NOTE: Where applicable, use one INR for all service points within each facility. Some services
do not use INR, but rely on the charts themselves to enable reporting, monitoring and
evaluation. This is not considered a safe or satisfactory procedure because of the problem of
missing charts and there should always be an INR.

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The register for IMAM should be maintained separately from other registers (such as IMNCI) and must
contain all the information necessary to also calculate the length of stay, weight gain and permit all the
data to be differentiated by gender, for compilation of the annual (or more frequent) report.

The charts
There are five types of charts: The critical care pathway charts (CCC) (ITC) (HMIS NUT Form 003),
ITC multi-chart (HMIS NUT Form 008) and the infant SST-chart (ITC) (HIMS NUT Form 006), the
OTC chart (HIMS NUT Form 005), SFC chart (HMIS 009) and the Integrated Nutrition Ration chart
(HMIS NUT Form 007).

• Inpatient CCC and multi-chart are the primary tools for managing very sick inpatients in ITC.
It should be filled for each patient. It is the primary tool for managing malnutrition and is
recommended for all facilities managing inpatients.
• The chart is designed so that it allows proper control of all aspects of the care of the patient (from
admission to follow-up and throughout his/her stay in the inpatient facility). All the staff use the
same chart. All the essential information is recorded systematically in the same predetermined
part of the chart. The information can thus be found easily and quickly for each patient.
• Infant SST-chart is the primary tool for managing the less than 6 months’ infants in ITC.
• OTC chart is a single A4 double-sided sheet upon which all the OTC information is recorded.
• SFC chart is used for monitoring patients enrolled for supplementary feeding program.

Reports
Each facility’s data for IMAM services (SFP, OTC and ITC) should be entered into the district
database which is linked to the National Level database (see Figure 24). The reports are used to
assess the quality of services provided at facility level.
The monthly reports from each district are also collated together to give an overall picture of
the quality of service and magnitude of the problem of SAM at district level. The district health
information system (DHIS2) can be used to analyse nutrition IMAM data at district, regional
andlevel
and national national
tolevel
givetooverall
give overall information on
information onoror
reporting rates of
reporting IMAM
rates ofdata
IMAMelements
dataand
elements and
indicators. The results of the analysis are reported back to the SFP, OTC and ITC supervisors
indicators. The results of the analysis are reported back to the SFP, OTC and ITC supervisors during
during themeeting.
the next monthly next monthly meeting.

In additionIntoaddition to the standard

the standard monthly monthly
HMIS HMIS reports
reports (HMIS105
(HMIS 105and
and 108),
108), there
there should
shouldbe;be;
1) 1) quarterly
quarterly facility report (HMIS 106a), 2) (Village quarterly report HMIS 097c 3)
facility report (HMIS 106a), 2) (Village quarterly report HMIS 097c 3) a three-yearly external a three-yearly
evaluationexternal
of the evaluation
IMAM servicesof the IMAM services
in each in each district.
district.
Figure 23: Reporting of IMAM services

Figure 26: Reporting of IMAM services

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14.3 Integrated Management of Acute Malnutrition service performance
indicators, coverage, and appropriateness
The following performance indicators help in monitoring the effectiveness of IMAM services
(Table 40).

Table 40: Performance indicators for monitoring effectiveness of IMAM services

A: OTC, SFP
Indicator Definition
1 Cure rate Number of patients cured as a percentage of total discharges during
reporting month.
Discharges include cured, defaulters, deaths and non-respondents)
(Total discharged as cured/Total discharges x100).
2 Default rate Number of patients who defaulted as a percentage of all discharges during
the reporting month (Default/Total discharges x 100).
3 Non-respondents’ Number of patients who are non-respondents as a percentage of total discharges
rate during the reporting month (Total non-cured/Total discharges x 100).
4 Coverage Number of eligible cases who are enrolled in IMAM program divided by total
number of eligible x 100.
5 Death rate The number of patients who died as a percentage of total discharges during
the reporting month (Total Died/Total discharges x 100)
B: ITC
1 Case fatality a
Number of patients who died as a percentage of all new admissions for the
reporting month(s) (Total Died/Total new admissions x 100).

New admissions also include readmissions and defaulters.

2 Defaulter rate Number of patients who defaulted as a percentage of all new admissions for
the reporting month(s). (Total defaulted/Total new admissions x 100).
3 Failure to Number of patients who failed to respond as a percentage of all new
respond admissions for the reporting month(s). (Total failure to respond/Total new
admissions x 100).
4 Transfer rates to Number of patients transferred to OTC as a percentage of new admissions for
OTC the reporting month(s) (Total transfers to OTC /Total new admissions x 100).
a
Case-fatality rate of >20 per cent is unacceptable; 11–20 per cent poor; 5–10 per cent moderate
and <5 per cent is acceptable.

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 Table 41: Target levels of quality of IMAM services for children 6–59 months of age

Indicators Acceptable Alarming

SFP OTC ITC SFP
Cure rate >75% >75% >75% <50%
Death rate < 3% < 10% <10% > 10%
Defaulter rate < 15% < 15% <15% >30%
Coverage >50 per cent in
rural areas

>70 per cent in

urban areas

>90 per cent in

a camp

Average length of stay <90 days <60 days 7–8 days

for cured patients
Distribution of centres >90% target population lives within 1 day return walk from
centre.
Cure and death rate, average length of stay are indicators of quality of care: Defaulter rate is an
indicator of accessibility/acceptability. Source: Sphere standards, 2018.

Monitoring coverage of IMAM services

• Coverage refers to the number of individuals receiving treatment as proportion of of the number
of people who need treatment.
• IMAM coverage refers to the extent to which the treatment of acute malnutrition is available to
the clients in the community who are acutely malnourished.
• If performance is good (high cure, low mortality and default rates) but coverage is poor, then
there is low impact at population level.
• Where cure rates are lower, higher coverage rates are needed to effect a given GAM reduction
at population level.
Percentages below show coverage needed in order to achieve a reduction in global acute
malnutrition (GAM) at population level, at 75% cure rate

GAM reduction aim Minimum coverage needed

100% Not possible with a cure rate of 75%
75% 100%
50% 66.7%
25% 33.3%
Note: 75% cure rate is constant

• Coverage is one of the most important indicators of how well the implementation of services is
meeting a need.
• A “met need” is the product of coverage rate and cure rate. A high coverage but lower cure
rates may be better at meeting the need, than one with high cure rate and a low coverage.
• For example: A programme with 75% coverage and 70% cure rate will have a 53% met need.
i.e. 75% coverage X 70% cure rate= 53%. A programme with 80% cure rate and 25% coverage
will have a 20% met need. i.e. 80% cure rate X 25% coverage = 20%.

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Monitoring Appropriateness of IMAM Services
• Refers to a correct intervention implemented at a correct time and acceptable both culturally
and socially
• Quantitative indicators such as mortality, default and cure rates are complemented by qualitative
information collected from the community.
• This two-way process helps to identify issues affecting the implementation at a community
level as well as to strengthen the community sense of ownership of the services.
• Two kinds of community level monitoring can be used: focus group discussions (FGDs) and
interviews with key members of the community (KIIs).
• The purpose of these discussions and interviews is to uncover potential barriers to components
of IMAM in order to improve its delivery.

14.4 Evaluation and implementation research priorities for Integrated

Management of Acute Malnutrition

IMAM evaluation and collaborative research

Addresses two main questions:
• Are the results those that were intended?
• And are they of value?
• Aims at strengthening the on-going and future IMAM interventions.
• This can be achieved by generating and disseminating evidence on experiences in IMAM
through the use of both qualitative and quantitative information related to processes, outputs,
outcomes (including adherence to global standards and quality of services), coverage and
scaling up options.
• Evaluation is performed using the existing databases collected over time or through specific
evaluation studies designed and conducted at base line, midterm and at the end of the
programme.
• The lessons and recommendations from the evaluation are used by central and local governments
and partners to strengthen existing programmes as well as advocate for leveraging resources
for effective IMAM strategies and interventions in areas of need.
• The tools required for evaluating IMAM services include:
• A health facility checklist
• Focus group discussion interview guide for VHTs and other community resource persons
• Focus group discussion interview guide for beneficiary caregivers and other community
members
• An individual interview guide for health and nutrition programme managers (including
health facility, district, national and implementing partners)
• Questionnaire for health facility workers (Doctors, Nurses, Nutritionists and other clinical
staff).
Evaluation is done by:

• Monitoring performance indicators (cure, default, non-respondent and death rates, rate of
weight gain)
• Using other evaluation indicators that cannot routinely be monitored
• Coverage and appropriateness
• The impact of the implementation of services in terms of reduction in numbers of patients
with acute malnutrition
• The efficient use of resources and management for IMAM services

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 • The cost effectiveness of the services

Collaborative Learning
• The IMAM coordination and technical working committees at the MoH Nutrition Division,
regional, district and health facility levels should prepare monitoring, evaluation and feedback
reports to share with stakeholders, affiliated support organizations and department staff.
• The feedback should be conducted through regular quarterly and annual reports, reflection
and learning workshops, research dissemination workshops, publication of study findings, and
direct interaction with stakeholders and facilitators during implementation.

Implementation and Operational Research Questions

Identification, risk classification , Screening and monitoring
• Which anthropometric and non-anthropometric measures or combinations of measures among
children with acute malnutrition best predict the risk of mortality, serious morbidity or longer
term adverse outcome?
• How can early detection and treatment of acute malnutrition be integrated into primary health
services effectively, efficiently, while ensuring quality of care?
• Which measures, or combination of measures, best predict immediate response to treatment(s),
risk of relapse and sustained recovery during, and after treatment, and can also be used for
monitoring IMAM services delivery in the local context?
• How can existing interventions (e.g. growth monitoring, IMCI) better detect and support children
0-59 months of age who are failing to thrive?
• How can community health workers or Ugandan VHTs be more directly involved in finding,
treating and following- up children with uncomplicated wasting in the communities?
• What are the most effective and cost-effective models for integration of diagnosis and treatment
of acute malnutrition into decentralized, community-based platforms in Uganda?
• What community and environmental factors (e.g. prevalence food insecurity, seasonality,
health system quality and coverage, humanitarian emergencies) best characterise populations
to inform appropriate wasting prevention strategies in children?
• What are the best practices, facilitators and bottlenecks for IMAM guideline implementation
and institution that need to be addressed to generate evidence-based lessons and
recommendations for expansion and sustainability of IMAM service coverage in the country
at all levels.
• What are the most effective and cost-effective models for integration of diagnosis and treatment
of acute malnutrition into decentralized, community-based platforms in Uganda?
• How can health system support functions of coordination, governance, planning, supervision
and monitoring, and implementation, capacity development, and information or data
management be effectively strengthened in a decentralized approach to improve results of
IMAM services delivery in the local context.

Management
• Can local formulations/or recipes achieve comparable/improved recovery outcomes and/or at
a reduced cost than commercial RUTF formulations used in treatment of SAM?
• What are the most acceptable and cost-effective local formulations/or recipes for use in
treatment of acute malnutrition in all age groups?
• How can key commodities for the treatment of acute malnutrition be integrated into national
supply chain systems effectively and efficiently?
• What is the most effective and cost-effective dosage of RUFs to ensure optimum treatment and
recovery outcomes in the local context?

198 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA

• What is the cost-effectiveness of different IMAM interventions in averting morbidity and
mortality for acute malnutrition at national and sub-national levels.
• Under what circumstances can community health workers provide appropriate and safe care
for children with wasting?
• What is the decentralized level of relevance, appropriateness, efficiency and quality of IMAM
services in different settings in Uganda.?

Prevention
• What is the effect of a pre-pregnancy and pregnancy maternal health intervention on the
prevention of low birth weight?
• What is the effect of an integrated package of care for LBW infants in reducing stunting, wasting
and underweight in the first 2 years of life?
• What is the impact of interventions for managing growth failure among infants less than 6
months of age on the risk of acute malnutrition between 6-24 months?
• In populations where children are at risk of acute malnutrition, what programmatic approaches,
according to population context, are most effective at improving quality complementary
feeding?

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 199

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Uganda. BMC Paediatrics 6[1], 7, 2006.
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malnutrition in infants <6 months (MAMI), Oxford, ENN, 2015. p. https://www.ennonline.net/
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MAMI-June-2017_Final-SHARE.pdf, 2017.
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155012-3, Geneva, World Health Organization, 2017.
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management of common childhood illnesses, 2nd ed., Geneva, WHO, 2013.
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• World Health Organization, United Nations High Commissioner for Refugees, International
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202 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA

ANNEXES

Annex 1: Health Management Information System for Nutrition and

Related Tools
Check HMIS Nutrition and Related Tools Package for detailed standard forms, registers, and
charts

HMIS Deadline Responsible

S/N NAME DESCRIPTION
CODE person(s)
Tool used in active screening to Monthly
identify all cases of malnutrition
Nutrition in the community
HMIS NUT
1 Tally Sheet - Used to facilitate counting and
011
Community summarizing of clients assessed
for nutritional status in the
community.
To record detailed information Monthly
of clients screened for acute
malnutrition using MUAC.
HMIS VHT VHT/ ICCM Community
2 To record detailed information
006 register Health
of clients referred to health
Workers
facilities for nutrition and other
health services as well as those
followed up
Used by VHTs and other Daily
Community
HMIS VHT community health and nutrition
3 Referral
001 providers to refer patients within
Form
IMAM services and vice versa
Quarterly
Health Facility To summarize VHT/ICCM
HMIS VHT
4 Quarterly VHT household data received from
008
Summary VHTs in the village

To facilitate counting and Daily OPD staff

summarizing of client records
with a focus on those provided
HMIS NUT Nutrition Tally with nutrition services such as
5
012 sheet nutrition assessment, therapeutic
care, counselling and cases
identified, enrolled into care and
the respective outcomes.
Health Daily OPD staff -
To facilitate counting of clients
HMIS NUT Nutrition Daily Incharge
6 attended for nutritional status at
004 Attendance
the health facility
Summary
Health Monthly OPD staff – In-
To facilitate summarizing of
HMIS NUT Nutrition charge
7 clients assessed for nutritional
010 Monthly
status at the health facility
Summary

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 203

 Tool used to record detailed Daily and In-Charges of
information about each at every OTC/ITC/SFC
Integrated client enrolled in any feeding visit
HMIS Nutrition program for example Outpatient
8
001 Register Therapeutic Care (OTC), and
(INR) Supplementary Feeding Centre
(SFC) at each visit and Inpatient
Therapeutic Care
Weekly OPD/OTC
Integrated Used to capture and follow-
HMIS NUT Incharge with
9 Nutrition up supplies for OTC and SFP
007 support of OPD/
Ration Card clients
OTC staff
Supplementary Weekly SFC Incharge
HMIS NUT Feeding Used to monitor and follow-up and staff
10
009 Service Client SFP clients
card
Outpatient Weekly OTC Incharge
HMIS NUT Used to monitor and follow-up and staff
11 Therapeutic
005 OTC clients
Care Chart
History and Daily OTC, ITC staff
diagnosis
To identify and diagnose clients
HMIS NUT for failure
12 failing to respond in OTC and
002 to respond/
SFP services
complicated
malnutrition
Tool used to report the monthly Monthly
data for OPD attendances, Facility In-
Outpatient
HMIS diagnoses, MCH, HIV/AIDS Charge,
13 Monthly
105 services, laboratory, stock status Records
Register
of essential drugs and supplies assistant
and finances among others
Used to track the movements Weekly Store or
HMIS and balance of all commodities dispensing
14 Stock Card staff
015 stored at any place in the health
unit for more than a week
Used when a patient or client For each
HMIS OPD is being referred for further individual Facility In-
15 Referral Note management to a case
003 Charge
higher-level health Centre

Captures initial vital signs and

HMIS NUT Critical Care Emergency and
16 complications of patients with Daily
003 Chart ITC staff
SAM

Facilitates documentation of
HMIS NUT the initial intervention and
17 Multi-chart Daily ITC staff
008 monitoring of SAM patients in
ITC

To facilitate quantification
HMIS Daily Ward ITC staff and
18 of needed per day feeds to Daily
XXX Feed Chart In-charge
inpatients

204 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA

 Suckling
Technique Facilitates documentation of
HMIS NUT Chart for the initial intervention and
19 Daily ITC staff
006 Infants less monitoring of infant less than six
than six months in ITC
month
Health Unit Monthly Facility In-
HMIS Inpatient Facilitates summarizing Charge,
20
108 Monthly inpatients Records
Report assistant
To facilitate delivery of
recommended feeding during
HMIS Discharge
21 sickness and health and danger Daily ITC staff
XXX Card
signs for caretakers to note on
discharge
IMAM Standard Weekly Store or
Used for monitoring Stock
HMIS Form Supply Chain dispensing
22 conditions, stock status,
XXX Monitoring staff
reporting, and quality
Tool
Quarterly Facility In-
Journal
HMIS Facilitates processes for quality Charge,
23 for Quality
XXX improvement. Records
Improvement
assistant
IMAM Standard
District and Used for support supervision,
HMIS Health Facility mentorship and monitoring
24 Quarterly DHT
XXX Supervision of IMAM services across the
and Mentorship continuum
Tool

Annex 2: Checking for Bilateral Pitting Oedema and MUAC Assessment

Checking for bilateral Pitting oedema

• Bilateral oedema is the sign of severe acute malnutrition. Children with oedematous acute
malnutrition oedema are at high risk of mortality and need to be treated in a therapeutic feeding
program urgently.
In order to assess for bilateral pitting oedema, follow these steps:
Step 1. Hold the child’s feet and apply gentle pressure on top of both feet for 3 seconds and then
lift your thumbs.

NOTE: If no pit shows or if a pit only shows in one foot, the child does not have bilateral
pitting oedema. If a pit shows in both feet, (see Table 1 A) go to Step 2.

Step 2. Continue the same test on the lower legs, hands, and lower arms. If no pitting appears in
these areas, then the child is said to have Grade+, or mild, bilateral pitting oedema. Mild bilateral
pitting oedema only shows in the feet. If pitting appears in these other areas, go to Step 3.
Step 3: Look for swelling in the face, especially around the eyes. If no swelling appears in the face,
then the child is said to have Grade ++, or moderate, bilateral pitting oedema. If swelling appears
in the face, the child is said to have Grade +++, or severe, bilateral pitting oedema.

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 205

• Only children with bilateral oedema are recorded as having nutritional oedema.22 Oedema is
commonly graded from 0 (no oedema) to grade 3/+++ (severe) (see Table 1).

Table 1A: Grading of bilateral pitting oedema

Observation Grade

No oedema (0)

Bilateral pitting oedema in both feet (below the ankles) + / (Grade 1) mild

Bilateral pitting oedema in both feet and legs, (below the knees) ++ / (Grade 2) moderate
hands or lower arms
Intermediate between mild and severe

Bilateral pitting oedema observed on both feet, legs, arms, face +++ / (Grade 3) severe

Note: It is important to interpret oedema with caution as it may be a sign of underlying medical
NOTE: It is important to interpret oedema with caution as it may be a sign of underlying
condition (e.g. nephritic syndrome, severe anaemia, other renal or heart conditions) or
medical condition (e.g. nephritic syndrome, severe anaemia, other renal or heart conditions)
physiological
or physiologicalchanges such
changes as in
such aspregnancy afterafter
in pregnancy ruling-out eclampsia).
ruling-out A clinician
eclampsia). shouldshould
A clinician take
detailed
take history,
detailed physical
history, examination
physical and where
examination possible
and where biochemical
possible tests. tests.
biochemical

Apply pressure for 3 seconds Pitting in both feet (bilateral pitting oedema)

MidMid upper-armcircumference
upper-arm circumference measurement
measurement
MUAC
MUACshould be be
should measured
measuredwhile
whilethe
thearm
arm is hangingdown
is hanging downthe
the side
side of of
thethe
bodybody
and and relaxed.
relaxed.
TheThe
tapetape
should
should be placed at the midpoint between the shoulder and the tip of the elbow. It is It is
be placed at the midpoint between the shoulder and the tip of the elbow.
recommended to use a string instead of the MUAC tape to find the midpoint
recommended to use a string instead of the MUAC tape to find the midpoint

Note: Rule out bilateral pitting oedema prior to taking MUAC measurements
NOTE: Rule out bilateral pitting oedema prior to taking MUAC measurements
For children, ensure a MUAC tape with the correct cut-off points is used. Discard any other
MUAC bands. The MUAC band for children should indicate:
RED or less than 11.5cm To indicate SAM
YELLOW or 11.5cm to less than 12.5cm
22 There are other causes of bilateral oedema (e.g. nephritic syndrome) but To indicate
they MAM as an inpatient.
all require admission
GREEN or equal or greater than 12.5cm
206 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA
To indicate normal.
 •The individu
be relaxed, f
her body.
For children aged 6-59 months, ensure a MUAC tape with the correct cut-off points is used. Discard
any other MUAC bands. The MUAC band for children should indicate: •Wrap the M
RED or less than 11.5cm To indicate SAM individual’s m
YELLOW or 11.5cm to less than 12.5cm To indicate MAM is in contact
GREEN or equal or greater than 12.5cm To indicate normal. skin [7]. The
In order to measure MUAC, follow the steps below: too
In order to measure MUAC, follow the steps tight [8] n
below:
•Remo
• Remove the individual’s clothing to expose the
to expo
the less active arm.
•Meas
• Measure the length of the individual’s upper individu
arm, between the bone at the top of the shoulder the bon
[2] and the tip of the elbow [3] (the individual’s [2] and
arm should be bent to easily locate the tip). individu
• Find the midpoint of the upper arm by placing easily l
the tape from the top of the shoulder [4] to the •Find
tip of the elbow [5], mark it [6]. It is easier to use arm by
a string instead of the MUAC tape to find the top of
midpoint. the elb
to use
• The individual’s arm should then be relaxed, •Feed thetapeento
falling alongside his or her body.
• Wrap the MUAC the first
tape opening
around theand then through the second opening. The mea
individual’s
•The i
be rela
midpoint sothe that window where
all of it is in contactthe
witharrows
the point inward [10]. her bod
individual’s skin [7]. The tape should be neither •Wrap
too tight [8] nor too loose [9]. individu
is in c
skin [7]
too tigh

•Feed
the first opening and then through the second opening. Th
• MUAC reading at the arrow. the window where the arrows point inward [10].
• Feed the end of the tape through the first opening and then through the second opening. The
measurement is read from the window where the arrows point inward [10].
• reading
• MUAC Record the MUAC reading with a precision of 1mm (0.1cm).
at the arrow.
• Record the MUAC reading with a precision of 1mm (0.1cm).
Note: Measuring MUAC in older children and adults follow the same pr

NOTE: Measuring MUAC in older children, PLW and

• adults
MUAC follow the
reading same
at the procedures.
arrow.

• Record the MUAC reading with a precision of 1mm (0.1cm

Note: Measuring MUAC in older children and adults follow the sa

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 207

Annex 3: Tools used in delivery of IMAM services at different levels

Level Tools and Supplies

Community Colour coded MUAC tapes (including spare tapes)

by Village Screening tally sheets (see Annex 1)
Focal Point in
Referral slips in line with the Integrated Case management (ICM)
Screening
Pencils, exercise books, pencil sharpener, eraser
Bag
List of key telephone numbers. Written simple guidelines (in the local
language) adapted to the level of education of the village focal point. It
should be given even if the focal point/volunteer is unable to read. This
will avoid humiliation and s/he will nearly always have someone in the
village who can read for them if they are illiterate.
Counselling cards

Community by MUAC tapes

Village Focal Weighing scales
Point and
Safe water for drinking (jug and cups)
Outpatient site
in Management Water and soap for handwashing
of MAM Key messages
Essential medicines
Monitoring card for MAM
Nutritional supplement (if applicable)
Materials on use of energy/nutrient dense local foods
IEC materials on IYCF

Early MUAC tapes (including spare tapes)

identification Length board/height board
of malnutrition
Weighing Scale within at least 100g precision
in children at
Health Facility Screening tally sheets or INR register
Referral slips
Pencils, pens, exercise books, pencil sharpener, eraser
Weight/Height tables for children, BMI-for-age for adolescents and BMI
table for adults see Annexes 5 and 6.

Classification MUAC tapes,

of acute Scale,
malnutrition
Length/height board,
in children
into MAM and Weight-for-height table,
SAM Registration book and INR register,
Patient cards/charts,
Pencils, pens.

208 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA

Tools for MUAC tapes
OTC/or ITC Scale, length board, weight-for-height table
Classification
Registration book, patient charts
Anthropometric Reference charts
Sugar, safe drinking water, medical measuring cup or scale (5g
precision)
Water and soap to wash hands
Thermometer
Examination tools such as stethoscope and otoscope
Transfer forms

Tools for OTC MUAC tapes

services Scale, length board, weight-for-height table, 5% weight loss table, weight
gain table to reach discharge criteria, weight gain over 14 days’ table
Registration book, OTC charts, box for the OTC charts & for archive, stock
cards
Reference table for RUTF and key messages
RUTF, sugar, safe drinking water, medical measuring cups or scale (5g
precision) for the appetite test
Water and soap to wash hands
Thermometer, calculator, pencils, pens, rubber, etc.
Examination tools (stethoscope, otoscope, etc.)
Drugs: Amoxicillin; Anti-malarial; Vitamin A; Anti-helminths; Measles
vaccination.
Transfer forms, stock cards, monthly reports
Communication tools (phone, etc.), Poster on transport
recommendations, list of the OTCs & ITC

Records INR, ITC Multichart, CCC, transfer forms, registration book, monthly
reports

Feeds F-75, F-100 and RUTF

Drugs

Routine medicines (amoxicillin, ampicillin, gentamicin, anti-malarial,

measles vaccine), and specific drugs for complications (ReSoMal,
vitamin A, folic acid, anti-fungal, furosemide, glucose, burn creams,
Ceftriaxone, Cefotaxime, Ciprofloxacin etc.)

Anthropometric MUAC tapes, height/length board, weighing scale with 100g precision,
measurements a scale with 10g–20g precision for children and infants less than 8kg.
Laminated reference charts for weight-for-height, BMI for age, BMI, feed
volumes to dispense.

Job aids Wall charts for triage, standard treatment, management of common
complications

Examination Stethoscope, otoscope, thermometers, calculator

tools

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 209

 Feeds Boiled drinking water, clean water and soap, cups, mixer, sugar,
preparation measuring jugs, nasogastric tube for children

Psychosocial Toys for children

support

Others A list of the OTC sites, the name and phone numbers of the persons in
charge and the days and hours that the OTCs operate.
Copies of the IMAM protocol, IEC materials, Flip charts and lesson plans
for education sessions

Tools in OTC Registration book;

for infants <6 Scale with a precision of 10 g;
months
Diet: Generic infant formula, meals for the mother;
Drugs: for systematic treatment and food/nutrients for the mother;
Others: posters to encourage breastfeeding, flip charts to show
technique.

Tools used in Registration book;

ITC for infants Infant SST- chart (Annex 1);
<6 months
Material for SST: NGT size 8, cups, material to clean the tube, measuring
jug (Do not use a feeding bottle);
Scale with a precision of 10 g;
Diet: F-100-Dilute (STDM) or F-75, meals for the mother;
Drugs: for systematic treatment and food/nutrients for the mother;
Others: posters to encourage breastfeeding, flip charts to show
technique, look up table for the feeds.

210 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA

Annex 4: Taking body weight and height and determination of WFH/L
Z-score

Taking the Weight

• Make sure the weighing scale is calibrated to Zero before each measurement is taken.
• Clients should be weighed with minimum of clothing and no jewellery.
• The weight reading should be done as soon as the indicator on the scale has stabilized.
• Weight is recorded to the nearest 0.1 kg (100 g).

Annex 4: Taking body weight and height and determination of WFH/L Z-score
NOTE: Weighing scales should be standardized after every 100 measurements using a known
Taking the Weight
weight.
• Make sure the weighing scale is calibrated to Zero before each measurement is taken.
• Clients should be weighed with minimum of clothing and no jewellery.
• The weight reading should be done as soon as the indicator on the scale has stabilized.
• Children may
• be weighed
Weight byto using
is recorded a 25
the nearest kg(100
0.1 kg hanging
g). sprint scale graduated to 0.100 kg or an
electronicNote:
balance (e.g. UNISCALE).
Weighing scales should be standardized after every 100 measurements using a known
weight.
• Children may be weighed by using a 25 kg hanging sprint scale graduated to 0.100 kg
For the hanging SALTER
or an scale,
electronic balance (e.g. UNISCALE).
• For children, a basin which is more hygienic, practical, less traumatic and with which the child
For the hanging SALTER scale,
is familiar.• For children, a basin which is more hygienic, practical, less traumatic and with which
• Put 2 ropes underneath the basin, cross them and pass the 4 rope-ends through holes in the
the child is familiar.
• Put 2 ropes underneath
basin’s rim at equal distance from the basin,
eachcross them
other andtie
and passthe
the 44 rope-ends through holes
ends together to hang on the scale’s
in the basin’s rim at equal distance from each other and tie the 4 ends together to hang
hook.
on the scale’s hook.
• The basin• should The bebasinno more
should than
be no more10than
cm10height
cm heightfrom thefloor
from the floor
(but (but not touching
not touching the the floor).
floor).
• Tare the basin to zero the scale.
• Tare the basin to zero the scale. severely malnourished: version January 2007 by Pr. Michael Golden
Photo on right: Source: Guidelines for the management of the
d ll h l f f b

Weighing children under 2 years of age Using an electronic scale (Seca electronic UNISCALE)
If the child is under 2 years of age or is unable to stand, you will do tared weighing.
207
Explain the
tared weighing procedure to the mother as follows:
Stress that the mother must stay on the scale until her child has been weighed in her arms.
Place the scale on hard flattened even surface and follow the steps in the figure below with Seca
electronic scale.

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 211

 Measuring length/height
With Depending
Seca electronic scaleage and ability to stand, measure the child’s length or height. A child’s
on a child’s
length is measured lying down (recumbent). Height is measured standing upright.

Measuring length/height
• If a child is less than 87 cm, measure recumbent length.
Depending on aischild’s
• If the child 87 cm orage
moreand
and ability to stand,
able to stand, measuremeasure
standingthe child’s length or height. A ch
height.
• In general, standing height is about 0.7 cm less than recumbent length. This difference was
length taken
is measured lying down (recumbent). Height is measured standing upright.
into account in developing the WHO growth standards used to make the charts in the
• If a child
Growth is less
Record. thanit87
Therefore, cm, measure
is important to adjustrecumbent
the measurementslength.
if length is taken instead
of height, and vice versa.
• If the child is 87 cm or more and able to stand, measure standing height.
• If a child less than 2 years old will not lie down for measurement of length, measure standing
• In general,
height and addstanding height itistoabout
0.7 cm to convert length.0.7
If acm
childless
agedthan recumbent
2 years length.
or older cannot This differe
stand,
measure recumbent length and subtract 0.7 cm to convert it to height.
was taken into account in developing the WHO growth standards used to make
• Make sure the child is barefoot and has no head gear.
charts
• Make sureinthethe Growth
head, Record.blades,
back of shoulder Therefore,
buttocks it
and isheels
important
touch theto adjust
surface theheight/
of the measuremen
length
length is taken
board; instead
knees should be of height,
fully straightand vice stretched
and arms versa. on the sides; and neck should
be straight with eyes looking straight ahead with the headpiece placed firmly in position.
• If a child less than 2 years old will not lie down for measurement of length, meas
• The measurement is read to the nearest 0.1 cm.
standing
• Whether heightlength
measuring and add 0.7 the
or height, cmmother
to convert
should itbeto length.
nearby If asoothe
to help childandaged 2 years or o
comfort
cannot
the child. stand, measure recumbent length and subtract 0.7 cm to convert it to heig

212 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA

To measure length:
• Use a measuring board with a headboard and sliding foot piece.
• Lay the measuring board flat, preferably on a stable, level table (see Fig 2a).
• Cover the board with a thin cloth or soft paper to avoid causing discomfort and the baby sticking
to the board.
• Measurement will be most accurate if the child is naked; diapers make it difficult to hold the
infant’s legs together and straighten them. However, if the child is upset or hypothermic, keep
the clothes on, but ensure they do not get in the way of measurement. Always remove shoes
and socks.
• Undo braids and remove hair ornaments if they interfere with positioning the head. After
measuring, re-dress or cover the child quickly so that he does not get cold.
• Remove the child’s shoes.
Work with another person preferably the mother/caregiver. Tell the mother/caregiver to stand or
kneel behind the headboard. Then help the mother/caregiver to:

• Position the child lying on his back on the measuring board, supporting the head and placing it
against the headboard.
• Position the crown of the head against the headboard, compressing the hair.
• Hold the head with two hands and tilt upwards until the eyes look straight up, and the line of
sight is perpendicular to the measuring board.
• Check that the child lies straight along the center line of the measuring board and does not
change position.
• You (skilled health service provider)
should stand alongside the measuring
board and support the child’s trunk as
the child is positioned on the board.
• Place one hand on the shins or knees
and press gently but firmly.
• Straighten the knees as much as
possible without harming the child.
• With the other hand, place the foot
piece firmly against the feet. The soles
of the feet should be flat on the foot
piece, toes pointing up. If the child
bends the toes and prevents the foot
piece touching the soles, scratch the
soles slightly and slide in the foot piece
when the child straightens the toes.
• Measure length to the last completed
0.1 cm and record immediately in the
child’s visit notes (e.g. child health card)
or other appropriate tools. The longer
lines indicate centimetre marking; the
shorter lines indicate millimetre.
Figure 2a: Measuring length
Figure 1: Measuring length

©Shorr

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 213

The longer lines indicate centimetre marking; the shorter lines indicate millimetre.
 Figure 1: Measuring length

©Shorr
©Shorr

The longer lines indicate centimetre marking; the shorter lines indicate millimetre.
The longer lines indicate centimetre marking; the shorter lines indicate millimetre.
©WHO Growth standard training
©WHO Growth standard training

To measure standing height

• Use a stadiometer with a vertical 210
back board, a fixed base board, and a
movable headboard. A stadiometer
(height board) is a device used
to measure standing height. The
stadiometer should be placed on a
hard-flattened floor.
• The mother/caregiver should remove
the child’s socks and shoes for accurate
measurement. Also remove hair
ornaments and undo braids if they
interfere with measurement.
The mother/caregiver should then kneel
or crouch near the child’s feet and:

• Help the child stand with back of the

head, shoulder blades, buttocks, calves
and heels touching the vertical board.
• Hold the child’s knees and ankles to
keep the legs straight and feet flat to
prevent the child from standing on their
toes.
• Young children may have difficulty
standing to full height. If necessary,
gently push on the tummy to help the
child stand to full height.
You (skilled health service provider)
should bend to level of the child’s face Figure 2b: Measuring height
and:

• Position the head so that the child is looking straight

Figure ahead
2: Measuring (line of sight is parallel to the base
height
of the board).
• Place thumb and forefinger over the child’s chin to help keep the head in an upright position.
• With the other hand, pull down the headboard to rest firmly on top of the head and compress
hair.
• Measure the height to the last completed 0.1 cm and record it immediately on the child’s visit
notes or appropriate tools.

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 Determination of the weight/height Z-score using WHO 2006 Z-score table

For the height/length: The height/length measurement has to be rounded to the nearest
0.5cm, as itofisthe
Determination in the following example.
weight/height Z-score using WHO 2006 Z-score 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.

Forweight:
For the the weight: Looking
Looking at the
at the table(Annex
table (Annex6),
6),for
for a length
length ofof80.5
80.5cm.
cm.
Assuming
Assuming it’s ait’s
boya boy with
with 7.9kg.
7.9kg.
Lookthe
Look for forweight
the weight
(7.9(7.9
kg) kg)
on on
thethe
leftleft column.The
column. Theweight
weight falls
fallsbetween
between7.6kgs and
7.6kgs 8.3kgs
and 8.3kgs
CheckCheck
for the forZthe Z score
score at the
at the toptop
of of
thetherow.
row.The
Thechild’s
child’s weight
weight lies
liesbetween
between these 2 weights,
these 2 weights, write
downwrite
that down
this child’s
that thisZ-score is between
child’s Z-score -4 and-4-3and
is between Z-score or <-3
-3 Z-score orAND >-4 Z-score
<-3 AND OROR
>-4 Z-score child is less
than -3SD.
child is less than -3SD.

213

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Annex 5: Triage of sick children

EMERGENCY SIGNS:

• Obstructed breathing
Airway & • Central Cyanosis
breathing • Severe Respiratory distress
• Weak/absent breathing Immediate transfer to
emergency area:
• Start life support
procedures
Cold hands with any of:
• Capillary refill > 3 seconds • Give oxygen
Circulation • Weigh if possible
• Weak + fast pulse
• Slow (<60bpm) or absent
pulse

Comma /convulsing/confusion: AVPU = ‘P or U’ or Convulsions

Diarrhoea with sunken eyes →assessment/ treatment for severe dehydration

PRIORITY SIGNS
• Tiny-Sick infant aged < 2months
• Temperature very high >390
• Trauma-major trauma
• Pain-Child in severe pain
• Poison-mother reports poisoning
• Pallor- severe palmer pallor
• Restless/Irritable/Floppy
• Respiratory distress
• Referral-has an urgent referral letter
• Malnutrition:
o visible severe wasting
o Bilateral pitting oedema Front of the Queue - Clinical
• Burns- severe burns review as soon as possible:
• Weigh
• Baseline observations
MEDICAL COMPLICATIONS IF SEVERE
ACUTE MALNUTRITION
• Hypoglycaemia (Blood Sugar <3mml/dl)
• Hypothermia Temp ≤35.50C, axillar
• Severe infections
• Diarrhea and Severe dehydration
• Shock
• Very severe anemia (Hb ≤ 4g/dl)
• Cardiac failure
• Severe dermatosis
• Corneal Ulceration

NON URgENT- CHILDREN WITH NONE OF THE ABOVE SIGNS/MEDICAL COMPLICATIONS

JANUARY 2016

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Annex 6: WHO 2006 Z-score Chart

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Annex 7: Breastfeeding Assessment Tool

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Annex 8: BMI-for-Age Reference Card for Children 5 to 19 Years
3C: BMI-FOR-AGE REFERENCE CARD FOR CHILDREN 5 TO 19 YEARS

Boy’s BMI (kg/m2) Age Girl’s BMI (kg/m2)

Year:
-3SD -2SD -1SD Median Months Median -1SD -2SD -3SD
Months
12.1 13.0 14.1 15.3 5:1 61 15.2 13.9 12.7 11.8
12.1 13.0 14.1 15.3 5:2 62 15.2 13.9 12.7 11.8
12.1 13.0 14.1 15.3 5:3 63 15.2 13.9 12.7 11.8
12.1 13.0 14.1 15.3 5:4 64 15.2 13.9 12.7 11.8
12.1 13.0 14.1 15.3 5:5 65 15.2 13.9 12.7 11.7
12.1 13.0 14.1 15.3 5:6 66 15.2 13.9 12.7 11.7
12.1 13.0 14.1 15.3 5:7 67 15.2 13.9 12.7 11.7
12.1 13.0 14.1 15.3 5:8 68 15.3 13.9 12.7 11.7
12.1 13.0 14.1 15.3 5:9 69 15.3 13.9 12.7 11.7
12.1 13.0 14.1 15.3 5:10 70 15.3 13.9 12.7 11.7
12.1 13.0 14.1 15.3 5:11 71 15.3 13.9 12.7 11.7
12.1 13.0 14.1 15.3 6:0 72 15.3 13.9 12.7 11.7
12.1 13.0 14.1 15.3 6:1 73 15.3 13.9 12.7 11.7
12.2 13.1 14.1 15.3 6:2 74 15.3 13.9 12.7 11.7
12.2 13.1 14.1 15.3 6:3 75 15.3 13.9 12.7 11.7
12.2 13.1 14.1 15.4 6:4 76 15.3 13.9 12.7 11.7
12.2 13.1 14.1 15.4 6:5 77 15.3 13.9 12.7 11.7
12.2 13.1 14.1 15.4 6:6 78 15.3 13.9 12.7 11.7
12.2 13.1 14.1 15.4 6:7 79 15.3 13.9 12.7 11.7
12.2 13.1 14.2 15.4 6:8 80 15.3 13.9 12.7 11.7
12.2 13.1 14.2 15.4 6:9 81 15.4 13.9 12.7 11.7
12.2 13.1 14.2 15.4 6:10 82 15.4 13.9 12.7 11.7
12.2 13.1 14.2 15.5 6:11 83 15.4 13.9 12.7 11.7
12.3 13.1 14.2 15.5 7:0 84 15.4 13.9 12.7 11.8
12.3 13.2 14.2 15.5 7:1 85 15.4 13.9 12.7 11.8
12.3 13.2 14.2 15.5 7:2 86 15.4 14.0 12.8 11.8
12.3 13.2 14.3 15.5 7:3 87 15.5 14.0 12.8 11.8
12.3 13.2 14.3 15.6 7:4 88 15.5 14.0 12.8 11.8
12.3 13.2 14.3 15.6 7:5 89 15.5 14.0 12.8 11.8
12.3 13.2 14.3 15.6 7:6 90 15.5 14.0 12.8 11.8
12.3 13.2 14.3 15.6 7:7 91 15.5 14.0 12.8 11.8
12.3 13.2 14.3 15.6 7:8 92 15.6 14.0 12.8 11.8
12.4 13.2 14.3 15.7 7:9 93 15.6 14.1 12.8 11.8
12.4 13.3 14.4 15.7 7:10 94 15.6 14.1 12.9 11.9
12.4 13.3 14.4 15.7 7:11 95 15.7 14.1 12.9 11.9
12.4 13.3 14.4 15.7 8:0 96 15.7 14.1 12.9 11.9
12.4 13.3 14.4 15.8 8:1 97 15.7 14.1 12.9 11.9
12.4 13.3 14.4 15.8 8:2 98 15.7 14.2 12.9 11.9
12.4 13.3 14.4 15.8 8:3 99 15.8 14.2 12.9 11.9
12.4 13.4 14.5 15.8 8:4 100 15.8 14.2 13.0 11.9
12.5 13.4 14.5 15.9 8:5 101 15.8 14.2 13.0 12.0

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 Boy’s BMI (kg/m2) Age Girl’s BMI (kg/m2)
Year:
-3SD -2SD -1SD Median Months Median -1SD -2SD -3SD
Months
12.5 13.4 14.5 15.9 8:6 102 15.9 14.3 13.0 12.0
12.5 13.4 14.5 15.9 8:7 103 15.9 14.3 13.0 12.0
12.5 13.4 14.5 15.9 8:8 104 15.9 14.3 13.0 12.0
12.5 13.4 14.6 16.0 8:9 105 16.0 14.3 13.1 12.0
12.5 13.5 14.6 16.0 8:10 106 16.0 14.4 13.1 12.1
12.5 13.5 14.6 16.0 8:11 107 16.1 14.4 13.1 12.1
12.6 13.5 14.6 16.0 9:0 108 16.1 14.4 13.1 12.1
12.6 13.5 14.6 16.1 9:1 109 16.1 14.5 13.2 12.1
12.6 13.5 14.7 16.1 9:2 110 16.2 14.5 13.2 12.1
12.6 13.5 14.7 16.1 9:3 111 16.2 14.5 13.2 12.2
12.6 13.6 14.7 16.2 9:4 112 16.3 14.6 13.2 12.2
12.6 13.6 14.7 16.2 9:5 113 16.3 14.6 13.3 12.2
12.7 13.6 14.8 16.2 9:6 114 16.3 14.6 13.3 12.2
12.7 13.6 14.8 16.3 9:7 115 16.4 14.7 13.3 12.3
12.7 13.6 14.8 16.3 9:8 116 16.4 14.7 13.4 12.3
12.7 13.7 14.8 16.3 9:9 117 16.5 14.7 13.4 12.3
12.7 13.7 14.9 16.4 9:10 118 16.5 14.8 13.4 12.3
12.8 13.7 14.9 16.4 9:11 119 16.6 14.8 13.4 12.4
12.8 13.7 14.9 16.4 10:0 120 16.6 14.8 13.5 12.4
12.8 13.8 15.0 16.5 10:1 121 16.7 14.9 13.5 12.4
12.8 13.8 15.0 16.5 10:2 122 16.7 14.9 13.5 12.4
12.8 13.8 15.0 16.6 10:3 123 16.8 15.0 13.6 12.5
12.9 13.8 15.0 16.6 10:4 124 16.8 15.0 13.6 12.5
12.9 13.9 15.1 16.6 10:5 125 16.9 15.0 13.6 12.5
12.9 13.9 15.1 16.7 10:6 126 16.9 15.1 13.7 12.5
12.9 13.9 15.1 16.7 10:7 127 17.0 15.1 13.7 12.6
13.0 13.9 15.2 16.8 10:8 128 17.0 15.2 13.7 12.6
13.0 14.0 15.2 16.8 10:9 129 17.1 15.2 13.8 12.6
13.0 14.0 15.2 16.9 10:10 130 17.1 15.3 13.8 12.7
13.0 14.0 15.3 16.9 10:11 131 17.2 15.3 13.8 12.7
13.1 14.1 15.3 16.9 11:0 132 17.2 15.3 13.9 12.7
13.1 14.1 15.3 17.0 11:1 133 17.3 15.4 13.9 12.8
13.1 14.1 15.4 17.0 11:2 134 17.4 15.4 14.0 12.8
13.1 14.1 15.4 17.1 11:3 135 17.4 15.5 14.0 12.8
13.2 14.2 15.5 17.1 11:4 136 17.5 15.5 14.0 12.9
13.2 14.2 15.5 17.2 11:5 137 17.5 15.6 14.1 12.9
13.2 14.2 15.5 17.2 11:6 138 17.6 15.6 14.1 12.9
13.2 14.3 15.6 17.3 11:7 139 17.7 15.7 14.2 13.0
13.3 14.3 15.6 17.3 11:8 140 17.7 15.7 14.2 13.0
13.3 14.3 15.7 17.4 11:9 141 17.8 15.8 14.3 13.0
13.3 14.4 15.7 17.4 11:10 142 17.9 15.8 14.3 13.1
13.4 14.4 15.7 17.5 11:11 143 17.9 15.9 14.3 13.1
13.4 14.5 15.8 17.5 12:0 144 18.0 16.0 14.4 13.2

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 Boy’s BMI (kg/m2) Age Girl’s BMI (kg/m2)
Year:
-3SD -2SD -1SD Median Months Median -1SD -2SD -3SD
Months
13.4 14.5 15.8 17.6 12:1 145 18.1 16.0 14.4 13.2
13.5 14.5 15.9 17.6 12:2 146 18.1 16.1 14.5 13.2
13.5 14.6 15.9 17.7 12:3 147 18.2 16.1 14.5 13.3
13.5 14.6 16.0 17.8 12:4 148 18.3 16.2 14.6 13.3
13.6 14.6 16.0 17.8 12:5 149 18.3 16.2 14.6 13.3
13.6 14.7 16.1 17.9 12:6 150 18.4 16.3 14.7 13.4
13.6 14.7 16.1 17.9 12:7 151 18.5 16.3 14.7 13.4
13.7 14.8 16.2 18.0 12:8 152 18.5 16.4 14.8 13.5
13.7 14.8 16.2 18.0 12:9 153 18.6 16.4 14.8 13.5
13.7 14.8 16.3 18.1 12:10 154 18.7 16.5 14.8 13.5
13.8 14.9 16.3 18.2 12:11 155 18.7 16.6 14.9 13.6
13.8 14.9 16.4 18.2 13:0 156 18.8 16.6 14.9 13.6
13.8 15.0 16.4 18.3 13:1 157 18.9 16.7 15.0 13.6
13.9 15.0 16.5 18.4 13:2 158 18.9 16.7 15.0 13.7
13.9 15.1 16.5 18.4 13:3 159 19.0 16.8 15.1 13.7
14.0 15.1 16.6 18.5 13:4 160 19.1 16.8 15.1 13.8
14.0 15.2 16.6 18.6 13:5 161 19.1 16.9 15.2 13.8
14.0 15.2 16.7 18.6 13:6 162 19.2 16.9 15.2 13.8
14.1 15.2 16.7 18.7 13:7 163 19.3 17.0 15.2 13.9
14.1 15.3 16.8 18.7 13:8 164 19.3 17.0 15.3 13.9
14.1 15.3 16.8 18.8 13:9 165 19.4 17.1 15.3 13.9
14.2 15.4 16.9 18.9 13:10 166 19.4 17.1 15.4 14.0
14.2 15.4 17.0 18.9 13:11 167 19.5 17.2 15.4 14.0
14.3 15.5 17.0 19.0 14:0 168 19.6 17.2 15.4 14.0
14.3 15.5 17.1 19.1 14:1 169 19.6 17.3 15.5 14.1
14.3 15.6 17.1 19.1 14:2 170 19.7 17.3 15.5 14.1
14.4 15.6 17.2 19.2 14:3 171 19.7 17.4 15.6 14.1
14.4 15.7 17.2 19.3 14:4 172 19.8 17.4 15.6 14.1
14.5 15.7 17.3 19.3 14:5 173 19.9 17.5 15.6 14.2
14.5 15.7 17.3 19.4 14:6 174 19.9 17.5 15.7 14.2
14.5 15.8 17.4 19.5 14:7 175 20.0 17.6 15.7 14.2
14.6 15.8 17.4 19.5 14:8 176 20.0 17.6 15.7 14.3
14.6 15.9 17.5 19.6 14:9 177 20.1 17.6 15.8 14.3
14.6 15.9 17.5 19.6 14:10 178 20.1 17.7 15.8 14.3
14.7 16.0 17.6 19.7 14:11 179 20.2 17.7 15.8 14.3
14.7 16.0 17.6 19.8 15:0 180 20.2 17.8 15.9 14.4
14.7 16.1 17.7 19.8 15:1 181 20.3 17.8 15.9 14.4
14.8 16.1 17.8 19.9 15:2 182 20.3 17.8 15.9 14.4
14.8 16.1 17.8 20.0 15:3 183 20.4 17.9 16.0 14.4
14.8 16.2 17.9 20.0 15:4 184 20.4 17.9 16.0 14.5
14.9 16.2 17.9 20.1 15:5 185 20.4 17.9 16.0 14.5
14.9 16.3 18.0 20.1 15:6 186 20.5 18.0 16.0 14.5
15.0 16.3 18.0 20.2 15:7 187 20.5 18.0 16.1 14.5

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 Boy’s BMI (kg/m2) Age Girl’s BMI (kg/m2)
Year:
-3SD -2SD -1SD Median Months Median -1SD -2SD -3SD
Months
15.0 16.3 18.1 20.3 15:8 188 20.6 18.0 16.1 14.5
15.0 16.4 18.1 20.3 15:9 189 20.6 18.1 16.1 14.5
15.0 16.4 18.2 20.4 15:10 190 20.6 18.1 16.1 14.6
15.1 16.5 18.2 20.4 15:11 191 20.7 18.1 16.2 14.6
15.1 16.5 18.2 20.5 16:0 192 20.7 18.2 16.2 14.6
15.1 16.5 18.3 20.6 16:1 193 20.7 18.2 16.2 14.6
15.2 16.6 18.3 20.6 16:2 194 20.8 18.2 16.2 14.6
15.2 16.6 18.4 20.7 16:3 195 20.8 18.2 16.2 14.6
15.2 16.7 18.4 20.7 16:4 196 20.8 18.3 16.2 14.6
15.3 16.7 18.5 20.8 16:5 197 20.9 18.3 16.3 14.6
15.3 16.7 18.5 20.8 16:6 198 20.9 18.3 16.3 14.7
15.3 16.8 18.6 20.9 16:7 199 20.9 18.3 16.3 14.7
15.3 16.8 18.6 20.9 16:8 200 20.9 18.3 16.3 14.7
15.4 16.8 18.7 21.0 16:9 201 21.0 18.4 16.3 14.7
15.4 16.9 18.7 21.0 16:10 202 21.0 18.4 16.3 14.7
15.4 16.9 18.7 21.1 16:11 203 21.0 18.4 16.3 14.7
15.4 16.9 18.8 21.1 17:0 204 21.0 18.4 16.4 14.7
15.5 17.0 18.8 21.2 17:1 205 21.1 18.4 16.4 14.7
15.5 17.0 18.9 21.2 17:2 206 21.1 18.4 16.4 14.7
15.5 17.0 18.9 21.3 17:3 207 21.1 18.5 16.4 14.7
15.5 17.1 18.9 21.3 17:4 208 21.1 18.5 16.4 14.7
15.6 17.1 19.0 21.4 17:5 209 21.1 18.5 16.4 14.7
15.6 17.1 19.0 21.4 17:6 210 21.2 18.5 16.4 14.7
15.6 17.1 19.1 21.5 17:7 211 21.2 18.5 16.4 14.7
15.6 17.2 19.1 21.5 17:8 212 21.2 18.5 16.4 14.7
15.6 17.2 19.1 21.6 17:9 213 21.2 18.5 16.4 14.7
15.7 17.2 19.2 21.6 17:10 214 21.2 18.5 16.4 14.7
15.7 17.3 19.2 21.7 17:11 215 21.2 18.6 16.4 14.7
15.7 17.3 19.2 21.7 18:0 216 21.3 18.6 16.4 14.7
15.7 17.3 19.3 21.8 18:1 217 21.3 18.6 16.5 14.7
15.7 17.3 19.3 21.8 18:2 218 21.3 18.6 16.5 14.7
15.7 17.4 19.3 21.8 18:3 219 21.3 18.6 16.5 14.7
15.8 17.4 19.4 21.9 18:4 220 21.3 18.6 16.5 14.7
15.8 17.4 19.4 21.9 18:5 221 21.3 18.6 16.5 14.7
15.8 17.4 19.4 22.0 18:6 222 21.3 18.6 16.5 14.7
15.8 17.5 19.5 22.0 18:7 223 21.4 18.6 16.5 14.7
15.8 17.5 19.5 22.0 18:8 224 21.4 18.6 16.5 14.7
15.8 17.5 19.5 22.1 18:9 225 21.4 18.7 16.5 14.7
15.8 17.5 19.6 22.1 18:10 226 21.4 18.7 16.5 14.7
15.8 17.5 19.6 22.2 18:11 227 21.4 18.7 16.5 14.7
15.9 17.6 19.6 22.2 19:0 228 21.4 18.7 16.5 14.7

This table has been constructed using the WHO reference tables for BMI-for-age z-scores for 5 to
19 years.

152 GUIDELINES FOR NTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA JANUARY 2016

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Annex 9: Body Mass Index (Adults) (=W/H2) Weight in kg and Height in
Metres
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 – 18.4 Marginal thinness
18.5 – 24.9 Normal

Source: WHO (1995) Physical status: the use and interpretation of anthropometry, Report of a WHO expert committee,
WHO

224 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA

Annex 10: Infant Young Child Feeding Recommendations
IYCF Feeding Recommendations of Family Diet Up to 2 Years of age

Amount of at
Texture
Frequency (per Each Serving
Age (Thickness/ Variety
day) (In addition to
Consistency)
Breast Milk)
Start with 2–3 Breastfeeding +
Thick porridge/
6 months At least 2 times spoons per feed encourage mothers to
Mashed pap/
(181 days) to Mashed family and increase feed their children at
pureed family
8 months food gradually to ½ least one type of locally
foods
bowl (250 ml) available food from
At least 3 times Finely chopped the three main food
9–11 foods and to 2 ½ bowl (250 family foods, groups:
months times nutritious ml) finger foods (Energy-giving foods),
snacks sliced foods Carbohydrates/fats/oils-
e.g. rice, maize, millet
etc.
At least 3 times (Bodybuilding), plant/
12–24 foods and 1 to 2 1 bowl (250 Family foods animal protein egg fish,
months times nutritious ml) Slice foods meat, milk, beans, peas
snacks etc.
(Protecting foods) and
vegetables and fruits.
Responsive
Active Be patient and encourage your baby to eat actively.
feeding
Feed your baby using a clean cup and spoon, never use a bottle as this is
difficult to clean and my cause your baby to get diarrhoea.
Hygiene
Wash your hands with soap and water before preparing food, before eating
and before feeding young children.

IYCF feeding recommendations of family diet after 2 years of age

Age Frequency (per Amount of at Texture Variety

day) Each Serving (Thickness/
(In addition to Consistency)
Breast Milk)
2 years and 3 to 4 times Give at least 1 Family foods Animal-source
older foods and 1 to 2 bowl (250 ml) at foods and
times nutritious each meal vitamin A
snacks rich fruit and
vegetables.
If your child refuses a new food offer “tastes” several times. Show that you
like the food. Be patient.
Talk with your child during a meal and keep eye contact.

A good daily diet should be adequate in quality and in quantity and include an energy-rich food
(For example: thick cereal with added oily, egg, fish, or pulses; and fruits and vegetables.

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Annex 11: Local food recipes used during counselling for appropriate
Annex 11: Local food recipes used during counselling for appropriate complementary
feeding complementary feeding

225

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 226
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 227
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 228
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Annex 12: 12:
Annex A decision tree for
A decision selective
tree feeding in
for selective emergencies
feeding in emergencies

230 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA 229

Annex 13: Preparation and use of the ration and key messages for SFP
The child should receive a porridge two or three times each day.
Annex 13: Preparation and use of the ration and key messages for SFP

Preparation of rations:
The child should receive a porridge two or three times each day.
Preparation of rations:
• Prepare a premix by mixing thoroughly the appropriate quantities of ingredients together in a
• Prepare a premix by mixing thoroughly the appropriate quantities of ingredients together in a
big basin. The ration should be prepared before the distribution in the most hygienic way, to
big basin. The ration should be prepared before the distribution in the most hygienic way, to
decrease as much as possible the risk of bacterial contamination.
decrease as much as possible the risk of bacterial contamination.
• Distribute
• a fortnightly
Distribute (2 week)
a fortnightly ration
(2 week) totothe
ration thepatients basedonon
patients based their
their ageage group.
group. Each Each
ration ration
should be given in a clean family container.
should be given in a clean family container.
• Clear
• information should
Clear information be given
should onon
be given thethehygienic
hygienic use ofthe
use of theration
ration
andand on how
on how and when
and when it it
should be consumed.
should be consumed.
• Conduct
• a cooking
Conduct demonstration
a cooking demonstrationforfor
new
newcaretakers (seeAnnex
caretakers (see Annex15)15)forfor preparation
preparation methodmethod
and key and
messages)
key messages)

How to prepare super cereal at home

How to prepare super cereal at home
Preparation of super cereal at Home
Preparation of super cereal at Home
1. It is a fortified blended food made of maize and soya flour, vitamins and minerals that is given to pregnant
1.and
It is a fortified
lactating women.blended food made
It is pre-cooked but of maize
is not and soya
an instant flour,
product. vitamins
It should and minerals
be cooked that isbut
for 10 minutes,
given
not longer. to pregnant and lactating women. It is pre-cooked but is not an instant product. It
should be cooked for 10 minutes, but not longer.
2. Before starting to cook super cereal, wash your hands thoroughly and ensure the water used to prepare
2. Before starting to cook super cereal, wash your hands thoroughly and ensure the water
the porridge is safe.
used to prepare the porridge is safe.
3.3.The
The ratio
ratio ofofwater to super
water cereal
to super is 4:1.isFor
cereal example;
4:1. 4 cups of4water
For example; cupsshould be added
of water shouldto 1be
cup of super
added
cereal
to 1flour.
cup First mix the
of super superflour.
cereal cerealFirst
with some cold super
mix the water to make with
cereal a paste, thencold
some add the rest to
water of the
makewater
and then cook the mixture until it boils for 10 minutes (NOT MORE).
a paste, then add the rest of the water and then cook the mixture until it boils for 10
minutes (NOT MORE).

230

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KEY MESSAGES FOR SFP
• The ration is designed for the enrolled MAM child.
• The ration should be given 2 to 3 times a day between the family meal (if working and other
commitments allow this to happen). It is only a supplement for the child who should continue
to get family meals – on his own plate – not a communal dish from which all the family/children
eat.
• Continue breastfeeding until 24 months (this should be emphasized. It is very important. If the
mother is breastfeeding, then you should tell her that she should share the supplement with
the child; half-half).
• Wash your hands before preparing the food and before you feed your child. Wash the child’s
hands.
• The water used should be safe drinking water.
• The premix should not be kept more than 2 weeks.
• The prepared porridge should not be kept for more than 2 hours at room temperature.
• Store the food in a sealed/covered container.
• Do not stop feeding the child and do not stop breastfeeding, especially if the child has diarrhoea.
• To avoid the inhibitory effects of the anti-nutrients in the normal family food, supplements
(RUSF) should not be mixed with food or taken with family meals (It should be taken 1 hour
before a family meal or 2 hours after a family meal).
• Supplement not to be sold.
• Follow-up is every 2 weeks: weight, height/length MUAC are taken.

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 Annex 14: Food commodities used in management of moderate acute
malnutrition

231
Annex 14: Food commodities used in management of moderate acute malnutrition
Follow-up is every 2 weeks: weight, height/length MUAC are taken.
•

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Annex 15: Advantages and disadvantages of dry and wet rations
Type of Advantages Disadvantages
ration
Dry • Dry feeding requires fewer resources • There is no guarantee that the
ration (personnel, structure) than wet feeding beneficiary will receive the ration.
and there is no evidence to show that • Monitoring of the use of ration
wet feeding is more effective than dry foods and nutritional status of the
feeding. beneficiary is less frequent.
• A greater number of beneficiaries can • More difficult to hold educational
be supported. activities.
• Less disruption of the family’s rhythm as • Requires more food per
the distribution requires that the mother beneficiary.
or caretaker are away from home for a
shorter time leading to better coverage
and lower defaulter rates.
• It keeps responsibility for preparation
and feeding within the home.
• It is more appropriate for dispersed
populations.
• Less risk of cross infections.
• It is quicker to put in place a dry feeding
centre
Wet • Useful when firewood and cooking • Disruption of family tasks due to
ration utensils are so difficult to find that the daily presence at SFP.
household has difficulties in preparing • Increased risk of transmission of
meals. diseases having malnourished
• It is easier to ensure that the beneficiary children concentrated together all
receives the food s/he requires. (Less day.
sharing of the food). • The centre requires many more
• It is easier to ensure that the ration is staff than a dry centre.
prepared correctly and that the hygiene • The centre requires more
is good. infrastructure than a dry centre.
• It is possible to use the mothers’ time in • The capacity for rapid reaction to
the centre to do nutrition and hygiene changes in the situation is lower.
education with them.
• There is a possibility that the
• Bringing staff and beneficiaries together food in the centre will be used to
possible. substitute for the beneficiaries
share of food in the household
defeating the purpose of the
supplementary ration.

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Annex 16: Variable RUTF in OTC
Week RUTF Paste - grams per week RUTF Sachets (96g)
of treat-
CRITICAL Absolute Inter- STAN- CRITICAL Absolute Inter- STAN-
ment
stock Mini- mediate DARD stock Mini- mediate DARD
short- mum (Week ration short- mum (Week ration
age (Week two) age (Week two)
one) one)
Class of 100 kcal/ 135 kcal/ 150 kcal/ 170 kcal/ 100 kcal/ 135 kcal/ 150 kcal/ 170
weight kg/d kg/d kg/d kg/d kg/d kg/d kg/d kcal/
(kg) kg/d
3.0 – 3.4 440 600 660 750 5 6 7 8
3.5 – 4.9 530 720 800 900 6 8 9 10
5.0–6.9 830 1100 1250 1400 9 12 13 15
7.0–9.9 1060 1430 1600 1800 12 15 17 20

NOTE: This table can be used if there is a limited supply of RUTF due to a pipeline break
(not planned), or if the children have marginal appetites at the start of treatment and the
OTC wants to discourage sharing because of a large surplus before the child regains a full
appetite. The amount given should NEVER fall below 135 kcal/kg/week. If the amount falls
below 100 kcal/kg/d, the children will lose weight and deteriorate.

NOTE the relatively small difference between the Critical and Standard amounts to be dispensed.
It is the “little” extra which gives the impetus for growth; this is why sharing in the family can lead
to low recovery rates and this needs to be explained to the caretaker and her family.

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Annex 17: 5% Weight loss and 5% weight gain
5% weight loss (for failure-to-respond in OTC) 5% weight gain (for treatment of dehydration)
1st Loss 2nd 1st Loss 2nd Initial Gain Final Initial Gain Final
week week week week
4.0 0.2 3.8 8.0 0.4 7.6 4.0 0.2 4.2 8.0 0.4 8.4
4.1 0.2 3.9 8.1 0.4 7.7 4.1 0.2 4.3 8.1 0.4 8.5
4.2 0.2 4.0 8.2 0.4 7.8 4.2 0.2 4.4 8.2 0.4 8.6
4.3 0.2 4.1 8.3 0.4 7.9 4.3 0.2 4.5 8.3 0.4 8.7
4.4 0.2 4.2 8.4 0.4 8.0 4.4 0.2 4.6 8.4 0.4 8.8
4.5 0.2 4.3 8.5 0.4 8.1 4.5 0.2 4.7 8.5 0.4 8.9
4.6 0.2 4.4 8.6 0.4 8.2 4.6 0.2 4.8 8.6 0.4 9.0
4.7 0.2 4.5 8.7 0.4 8.3 4.7 0.2 4.9 8.7 0.4 9.1
4.8 0.2 4.6 8.8 0.4 8.4 4.8 0.2 5.0 8.8 0.4 9.2
4.9 0.2 4.7 8.9 0.4 8.5 4.9 0.2 5.1 8.9 0.4 9.3
5.0 0.3 4.8 9.0 0.5 8.6 5.0 0.3 5.3 9.0 0.5 9.5
5.1 0.3 4.8 9.1 0.5 8.6 5.1 0.3 5.4 9.1 0.5 9.6
5.2 0.3 4.9 9.2 0.5 8.7 5.2 0.3 5.5 9.2 0.5 9.7
5.3 0.3 5.0 9.3 0.5 8.8 5.3 0.3 5.6 9.3 0.5 9.8
5.4 0.3 5.1 9.4 0.5 8.9 5.4 0.3 5.7 9.4 0.5 9.9
5.5 0.3 5.2 9.5 0.5 9.0 5.5 0.3 5.8 9.5 0.5 10.0
5.6 0.3 5.3 9.6 0.5 9.1 5.6 0.3 5.9 9.6 0.5 10.1
5.7 0.3 5.4 9.7 0.5 9.2 5.7 0.3 6.0 9.7 0.5 10.2
5.8 0.3 5.5 9.8 0.5 9.3 5.8 0.3 6.1 9.8 0.5 10.3
5.9 0.3 5.6 9.9 0.5 9.4 5.9 0.3 6.2 9.9 0.5 10.4
6.0 0.3 5.7 10.0 0.5 9.5 6.0 0.3 6.3 10.0 0.5 10.5
6.1 0.3 5.8 10.1 0.5 9.6 6.1 0.3 6.4 10.1 0.5 10.6
6.2 0.3 5.9 10.2 0.5 9.7 6.2 0.3 6.5 10.2 0.5 10.7
6.3 0.3 6.0 10.3 0.5 9.8 6.3 0.3 6.6 10.3 0.5 10.8
6.4 0.3 6.1 10.4 0.5 9.9 6.4 0.3 6.7 10.4 0.5 10.9
6.5 0.3 6.2 10.5 0.5 10.0 6.5 0.3 6.8 10.5 0.5 11.0
6.6 0.3 6.3 10.6 0.5 10.1 6.6 0.3 6.9 10.6 0.5 11.1
6.7 0.3 6.4 10.7 0.5 10.2 6.7 0.3 7.0 10.7 0.5 11.2
6.8 0.3 6.5 10.8 0.5 10.3 6.8 0.3 7.1 10.8 0.5 11.3
6.9 0.3 6.6 10.9 0.5 10.4 6.9 0.3 7.2 10.9 0.5 11.4
7.0 0.3 6.6 11.0 0.5 10.5 7.0 0.3 7.3 11.0 0.5 11.6
7.1 0.4 6.7 11.1 0.6 10.5 7.1 0.4 7.5 11.1 0.6 11.7
7.2 0.4 6.8 11.2 0.6 10.6 7.2 0.4 7.6 11.2 0.6 11.8
7.3 0.4 6.9 11.3 0.6 10.7 7.3 0.4 7.7 11.3 0.6 11.9
7.4 0.4 7.0 11.4 0.6 10.8 7.4 0.4 7.8 11.4 0.6 12.0
7.5 0.4 7.1 11.5 0.6 10.9 7.5 0.4 7.9 11.5 0.6 12.1
7.6 0.4 7.2 11.6 0.6 11.0 7.6 0.4 8.0 11.6 0.6 12.2
7.7 0.4 7.3 11.7 0.6 11.1 7.7 0.4 8.1 11.7 0.6 12.3
7.8 0.4 7.4 11.8 0.6 11.2 7.8 0.4 8.2 11.8 0.6 12.4
7.9 0.4 7.5 11.9 0.6 11.3 7.9 0.4 8.3 11.9 0.6 12.5
8.0 0.4 7.6 12.0 0.6 11.4 8.0 0.4 8.4 12.0 0.6 12.6

236 | GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA

se one of the following recipes for F-75 (note that cooking facilities are needed):
Dried whole milk 35 g
Sugar 70 g
you have Annex
dried whole Cereal flour
18: Recipes for locally prepared F-75 and F-100 35 andg reconstitution of
lk commercial F-75 and F-100
Vegetable oil 20 g
Alternatives Ingredient Amount For F-75
Complex Mineral and Vitamin mix* ½ levelled
Use one of the following recipes for F-75 (note that cooking facilities are needed):
scoop
Water
If you have dried to whole
Dried makemilk1000 ml 1000 35ml**
g
whole milk
Milk Sugar 300 ml 70 g
Cereal flour 35 g
you have fresh cow’s Sugar Vegetable oil
70 g 20 g
lk, or full-cream Cereal flour Mineral and Vitamin mix*
Complex 35 g ½ levelled scoop
hole) long life milk Vegetable Water tooil
make 1000 ml 20 g 1000 ml**
If you have fresh Milk 300 ml
Complex
cow’s milk, or full- Sugar
Mineral and Vitamin mix* ½ levelled
70 g
scoop
cream (whole) Water to make 1000 ml 1000 35ml**
Cereal flour g
long life milk
se one of the following recipes for F-100:
Vegetable oil 20 g
Fresh cow’sMineral
Complex milk, orandfull- cream
Vitamin mix*(whole) 880 ml ½ levelled scoop
Water to make 1000 ml 1000 ml**
you have fresh
Use one cow’s Sugar
of the following recipes for F-100: 75 g
lk, or full-cream
If you have fresh Fresh cow’s milk, or full- cream (whole) long life
Vegetable
cow’s milk, or full- milk oil 20 g 880 ml
hole) longcream
life milk
(whole)
long life milk Complex Mineral and Vitamin mix* ½ levelled
Sugar 75 g scoop
Vegetable oil 20 g
Water to make
Complex 1000
Mineral andml
Vitamin mix* 1000 ½ml**
levelled scoop
Water to make 1000 ml 1000 ml**
Dried
If you have dried Driedwhole
wholemilk
milk 110 g110 g
you have dried whole Sugar
whole milk Sugar 50 g 50 g
lk Vegetable oiloil
Vegetable 30 g 30 g
Complex Mineral and Vitamin mix* ½ levelled scoop
Complex Mineral and Vitamin mix*
Water to make 1000 ml
½ levelled scoop
1000 ml**
*Where CMV is Water to make
not available, 1000
prepare mlenergy milk (HEM).
high 1000 ml**
here CMV is**Important
not available,note
prepare
abouthigh energywater:
adding milk (HEM).
Add just the amount of water needed to make 1000 ml of
mportant note about adding water: Add just the amount of water needed to make 1000 ml of formula. (This
formula. (This amount will vary from recipe to recipe, depending on the other ingredients.)

ount will varyDofrom recipe to recipe, depending on the other ingredients.)

not simply add 1000 ml of water, as this will make the formula too dilute. A mark for 1000 ml
should be made on the mixing container for the formula, so that water can be added to the other
ingredients up to this mark.
o not simply add 1000 ml of water, as this will make the
Directions for making cooked F-75 with cereal flour (top recipes).
rmula too dilute. A mark for 1000 ml should be made on the
You will need a 1-litre electric blender or a hand whisk (rotary
xing container
whiskfor
or the formula,
balloon whisk),soa that water
1-litre can bejug,
measuring added to pot,
a cooking
e other ingredients uportohot
and a stove thisplate.
mark. Amounts of ingredients are listed on
the previous page. Cereal flour may be maize meal, rice flour, or
whatever is the staple cereal in the area.
rections for
It is making
importantcooked F-75 boiled
to use cooled, with water
cerealeven
flour (top that
for recipes
involve cooking. The cooking is only 4 minutes of gentle boiling,
cipes). and this may not be enough to kill all pathogens in the water.
The water should be cooled because adding boiling water to the
powdered ingredients may create lumps.
ou will need a 1-litre electric blender or a hand whisk (rotary
hisk or balloon whisk), a 1-litre measuring jug, a cooking pot,
GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 237
d a stove or hot plate. Amounts of ingredients are listed on
If using an electric blender:

• Put about 200 ml of the boiled, cooled water into the blender. (If using liquid milk instead of
milk powder, omit this step.)
• Add the flour, milk or milk powder, sugar, oil and blend.
• Add boiled, cooled water to the1000 ml mark and blend at a high speed.
• Transfer the mixture to a cooking pot and boil gently for 4 minutes while stirring continuously.
(This makes quite a glutinous mix unless a source of amylase has been added.)
• Some water will evaporate while cooking, so transfer the mixture back to the blender after
cooking and add enough boiled, cooled water to make 1000 ml. Add the CMV and blend again.
If using a hand whisk:

• Mix the flour, milk or milk powder, sugar and oil in a 1-litre measuring jug. (If using milk powder,
this will be a paste.)
• Slowly add boiled, cooled water up to 1000 ml mark.
• Transfer to cooking pot and whisk the mixture vigorously.
• Boil gently for 4 minutes while stirring continuously.
• Some water will evaporate while cooking, so transfer the mixture back to the measuring jug
after cooking and add enough boiled cooled water to make 1000 ml. Add the CMV and whisk
again
Directions for making non-cooked F-100 recipes
If using an electric blender:

• Put about 200 ml of the boiled, cooled water into the blender. (If using liquid milk instead of
milk powder, omit this step.)
• Add the required amounts of milk or milk powder, sugar, oil, and CMV.
• Add boiled cooled water to the 1000 ml mark and then blend at high speed.
If using a hand whisk:

• Mix the required amounts of milk powder and sugar in a 1-litre measuring jug; then add the
oil and stir well to make a paste (If you use liquid milk, mix the sugar and oil, and then add the
milk.)
• Add CMV, and slowly add boiled, cooled water up to 1000 ml mark, while stirring all the time23.
Whisk vigorously.
If CMV is not available, prepare HEM or use mineral mix.
Mineral mix is included in each recipe for F-75 and F-100. It is also used in making ReSoMal. The mix
contains potassium, magnesium, and other essential minerals. It must be included in F-75 and F-100
to correct electrolyte imbalance. The mineral mix may be made in the pharmacy of the hospital.

Vitamins
Vitamins are also needed in or with the feed. The vitamin mix described below cannot be made in
the hospital pharmacy because amounts are so small.Thus, children are usually given multivitamin
drops as well. Recommended vitamins to be included in the multivitamin preparation are listed
in table below. The multivitamin preparation should not include iron. If CMV is used, separate
multivitamin drops are not needed.

23 Whether using a blender or a whisk, it is important to measure up to the 1000 ml mark before blending/whisking. Otherwise, the mixture
becomes too frothy to judge where the liquid line is.

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Reconstitution of commercial therapeutic milk powder (F75 and F100).
• It is recommended to reconstitute it just before the feeding.
• Wash hands and sterilize equipment and utensils, clean and disinfect the work surface. Wash
equipment and utensils thoroughly with soap and hot water if sterilization is not possible.
• Boil drinking water.
• Take care not to burn; pour into a cup the required amount of boiled water cooled to 70 degrees
Celsius. If there is no thermometer, use boiled and cooled water for 3–5 minutes.
• In the cup, add the required number of levelled spoons of powder and immediately replace the
spoon without washing it.
• Mix with using a clean whisker.
• Cool to room temperature and feed the child.
• Discard unused milk within 2 hours.
• Clean the utensils.

NOTE: If the commercial therapeutic milk powder is not available , use one of the above local
recipes

Preparation F-75 & F-100

Level dosing spoons Water quantity (ml) Volume of reconstituted therapeutic milk
(ml)
F-75 F-100
1 25 ≈28 ≈29
2 50 ≈56 ≈58
4 100 ≈112 ≈117
6 150 ≈170 ≈180
8 200 ≈224 ≈234
10 250 ≈280 ≈290
20 500 ≈560 ≈580
Whole tin of 400 g 1850 ml (F100) ≈2480 ≈2158
2200 ml (F75)
24 tins 44 litres F (100) ≈59.5 litres ≈52 litres
9.6kg (net weight) ≈52.8 litres (F75)

NOTE: Always follow the manufacturer’s instructions

GUIDELINES FOR INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN UGANDA | 239

Annex 19: Diet (F-100 or RUTF) during rehabilitation/recovery phase
Although it is highly desirable that the rehabilitation phase be managed on an outpatient basis,
this is not always possible.

• If there is no capable caretaker, impossible home circumstances, no other family willing to care
for the child, an abandoned child without an available orphanage, no operational OTC service
or no supply of RUTF;
Then patients may have to be kept in the ITC until fully recovered.
The principles of the treatment in the facility and in the community are exactly the same; however,
the diet, organisation and documentation differ.

• It is not efficient to keep children and caretakers in an acute hospital ward for the rehabilitation
phase. They should be resident in a separate structure.
• Breastfed children should always get breast milk before they are given F-100 or RUTF and also
on demand.
• In the Recovery Phase (Phase 2), the patients have an unlimited intake (but should never take
more than 200 kcal/kg/d).
• Either F-100 or RUTF are used in Phase 2 in ITC; they are nutritionally equivalent (except that
F-100 does not have added iron, RUTF does contain adequate iron) and one can substitute for
the other.
F-100 (100 ml = 100 kcal): Six feeds of F-100 are given. One porridge (ideally nutrient-rich and
fortified such as used in SFP) may be given for patients who are more than 24 months of age
(approximately 8 Kg). It is neither necessary nor desirable to give porridge but many children
demand food with which they are familiar; then it can be given as a separate meal and used as an
inducement for the child to take the therapeutic food. It is better to give the porridge as the last
feed in the evening to ensure that adequate F-100 is taken during the day and to give time for the
porridge to digest overnight.
RUTF can be used for inpatients. The advantages of use in the ITC are that it requires less staff time
and supervision, no preparation is necessary, the food can be taken throughout the day and the
mother can feed the child by herself overnight; there is also no need to give the child additional
iron.
Give the amounts shown in the table. If the patients take the whole amount, then more should be
offered.

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Dosing chart for RUTF and F-100 in rehabilitation
Class of weight /Kg 6 feeds /day Whole†day
F-100 RUTF RUTF
ml/feed g/feed g/day
<3 kg Full strength F-100 and RUTF are not given below 3kg: use F-100 dilute
3.0 to 3.4 110 20 120
3.5 – 3.9 125 20 130
4.0 – 4.9 135 25 150
5.0 – 5.9 160 30 175
6.0 – 6.9 180 35 200
7.0 – 7.9 200 35 220
8.0 – 8.9 215 40 235
9.0 – 9.9 225 40 250
10.0–11.9 230 45 260
12.0–14.9 260 50 290
15.0–19.9 300 55 330
≥ 20.0 370 65 400

†One sachet of commercial RUTF contains about 92 g and 500 kcal (one gram = 5.4 kcal)
When RUTF is given, water should also be given to the child to satisfy his/her thirst. Because
RUTF can be kept safely, the amount for the whole day can be given once per day. This is then
eaten at the patient’s leisure, in his/her own time. But the health worker should periodically check
on the amount taken, assess the child’s appetite and ensure that the caretaker does not consume
the RUTF.

NOTE: Iron is added to the F-100 in the rehabilitation phase (Phase 2). Add 1 crushed tablet
of ferrous sulphate (200 mg) to each 2 litres to 2.4 litres of F-100. For lesser volumes: 1000 to
1200 ml of F-100, dilute one tab of ferrous sulphate (200 mg) in 4 ml of water and add 2 ml
of the solution. For 500 to 600 ml of F-100, add 1ml of the solution. Alternatively, if there are
few children, iron syrup can be given to the children. RUTF already contains the necessary
iron.

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Annex 20: Amount of F-75 to give during stabilization (or Phase 1)
Class of Weight (kg) 12 feeds per day ml 8 feeds per day ml 6 feeds per day ml
for each feed (Every 2 for each feed (Every 3 for each feed (Every 4
hours) hours) hours)
2.0 – 2.1 25 40 50
2.2–2.4 30 45 60
2.5–2.7 33 50 65
2.8–2.9 35 55 70
3.0–3.4 38 60 75
3.5–3.9 40 65 80
4.0–4.4 43 70 85
4.5–4.9 48 80 95
5.0–5.4 55 90 110
5.5–5.9 60 100 120
6.0–6.9 73 110 140
7.0–7.9 83 125 160
8.0–8.9 93 140 180
9.0–9.9 103 155 190
10–10.9 113 170 200
11–11.9 126 190 230
12–12.9 137 205 250
13–13.9 153 230 275
14–14.9 166 250 290
15–19.9 173 260 300
20–24.9 193 290 320
25–29.9 200 300 350
≥30 213 320 370

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Annex 21: How to insert a naso-gastric tube
• Choose the appropriate size tube (range is 6, 8 or 10 FG). Lie infants on their back, swaddled in
a small blanket as a mild restraint.
• Measure the tube from the child’s ear to the tip of the nose and then to just below the tip of the
sternum (for pre-terms and neonates, measure from the bridge of the nose to just beyond the
tip of the sternum). Hold or mark this position so that you know how far to insert the tube.
• Lubricate the catheter with a jelly type lubricant, Vaseline or at least water and insert through
the nose bending the tube slightly upwards to follow the nasal passage.
• Bend the head slightly backwards to extend the neck. Insert the catheter smoothly and quickly
at first pushing upwards (not just backwards) so that the catheter bends in one loop downwards
along the back of the throat. Do not push against resistance (if you cannot pass the tube through
the nose, pass it through the mouth instead). Take care that the tube does not enter the airway.
• If the child coughs, fights or becomes cyanotic, remove the tube immediately and allow the
patient to rest before trying again. It is vital to check that the tube is in the stomach before
anything is put down the tube. This should be re-checked before each feed is given in case the
tube has been dislodged from the stomach. Note that sick, apathetic children and those with
decreased consciousness can have the tube passed directly into their lungs without coughing.
It is not a guarantee that the tube is in the right place just because it has passed smoothly
without complaint from the child.
• The best way to test that the tube is fully in the stomach is to aspirate some of the stomach
contents and test for acid with litmus paper. The stomach contents in normal children are acid
and turn blue litmus paper red. However, the malnourished frequently have achlorhydria (lack
of gastric acid). In the absence of litmus paper and in the malnourished child, check that there
is the characteristic appearance and smell of stomach contents (sour or like vomit).
• Also check the position by injecting 0.5–1 ml of air into the tube whilst listening over the stomach
with a stethoscope. A “gurgling” or bubbling sound can be heard as air enters the stomach.
• It is always best to ask someone else to check if you are not sure the tube is in the right place, to
avoid the risk of milk going onto the lungs. Before each feed, aspirate the tube to check that the
previous feed has left the stomach; this may be slow and gentle in very sick children as strong
suction can damage the stomach lining. It is important not to cause gastric distension by giving
a new feed on top of an old one. The flow of the feed should be slow.
• Attach the reservoir (10 or 20 ml syringe) and elevate it 15–20 cm above the patient’s head. The
diet should always be allowed to flow into the stomach by gravity and not pushed in with the
plunger. When the feed is complete, irrigate the NGT with a few ml of plain water and stopper
the tube (or clamp it). Place the child on his/her side to minimize regurgitation and aspiration.
Observe the child after feeding for vomiting, regurgitation or abdominal distension.
• In an ITC, the tube should be changed every 3–5 days.

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Annex 22: Amount of RUTF to give in transition phase per 24 hours
Class of Weight Paste Paste Total
In grams Sachets Kcal
3.0–3.4 90 1 500
3.5–3.9 100 1 550
4.0–4.9 110 1¼ 600
5.0–5.9 130 1½ 700
6.0–6.9 150 1¾ 800
7.0–7.9 180 2 1000
8.0–8.9 200 2 1100
9.0–9.9 220 2½ 1200
10–11.9 250 3 1350
12–14.9 300 3½ 1600
15–19.9 370 4 2000
≥20 450 5 2500

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Annex 23: Amount of F-100 to give during transition; 8 and 6 feeds per day
Class of Weight (kg) 8 feeds per day 6 feeds per day
(3 hourly) (4 hourly)
Less than 3.0 F-100 full strength should not F-100 full strength should not
be used be used
3.0–3.4 60 75 ml per feed
3.5–3.9 65 80
4.0–4.4 70 85
4.5–4.9 80 95
5.0–5.4 90 110
5.5–5.9 100 120
6.0–6.9 110 140
7.0–7.9 125 160
8.0–8.9 140 180
9.0–9.9 155 190
10.0–10.9 170 200
11.0–11.9 190 230
12.0–12.9 205 250
13.0–13.9 230 275
14.0–14.9 250 290
15.0–19.9 260 300
≥20.0 290 320

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Annex 24: Drug dosages used in the management of severely
malnourished children

Antibacterials
Amoxicillin (first line antibiotic, routine treatment OTC and ITC)
Administer oral oral oral oral
Dose 50 – 100 mg/kg/d
suspension suspension capsule capsule
Presentation
125mg/5ml 250mg/5ml 250mg 500mg
3 – 5 Kg 125 mg * 2 5ml x 2 2.5ml x 2 ½x2
5 – 10 kg 250 mg * 2 10ml x 2 5ml x 2 1x2 ½ x2
10 – 20 kg 500 mg * 2 − 10ml x 2 2x2 1 x2
20 – 35 kg 750 mg * 2 − − 3x2 1½ x2
> 35 kg 1000 mg * 2 − − 4x2 2 x2
• Dose not normally critical can be doubled.
• Amoxicillin is supplied as sodium salt – care in case of sodium sensitivity
• Resistance to amoxicillin is common.
• May be adverse reactions with some viral infections (Epstein-Bar virus, CMV and possibly HIV)

Ampicillin (need for IV penicillin)

Administer IV, IM
Dose 100-200 mg/kg/d
Presentation 500mg /1g vials
times/day 4
3 – 5 kg 250mg X 4
5 – 10 kg 500mg x 4
10 – 20 kg 1g X 4
20 – 35 kg 2g x 4
> 35 kg 3g x 4
• IV preferred over IM: injection painful
• Give by perfusion over at least 30mins, reduce dose with renal impairment
• DO NOT give alongside Gentamicin (separate IV by at least one hour) or give gentamicin IM
as it inactivates the gentamicin
• Presented as the Sodium salt – use as low a dose a possible in case of sodium sensitivity
(especially in oedematous SAM and heart failure)
• In severe infections use second/third line antibiotics in view of widespread resistance and
high sodium administration with large doses

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Gentamicin (first/second line, with signs of infection)
Administer 5mg/kg/d once daily IM/IV IM/IV
Presentation 10 mg/ml 40 mg/ml
2ml vial 2ml vial
<=3 kg 10mg 1 ml x1 0.25 ml x1
3.1-5.0 kg 20mg 2 ml x1 0.5 ml x1
5.1 – 10 kg 40mg 4 ml x1 1 ml x1
10.1 –15 kg 60mg 6 ml x1 1.5 ml x1
15.1 - 20 kg 80mg 8 ml x1 2 ml x1
20-35 kg 140mg 14 ml x1 3.5 ml x1
>35 kg 200mg 20 ml x1 5 ml x1
• IM or IV. IM preferred if Penicillins/cefotaxime given IV
• May result in antibioma with poor absorption in severely wasted children
• Approximately 5mg/kg/d once daily but young infants 3.5mg/kg
• Danger of nephrotoxicity and ototoxicity
• Do not give IV at the same time as amoxicillin, ampicillin, cloxacillin, cefotaxime (separate
by at least one hour as they inactivate gentamicin) in very severely oedematous children,
give by estimated oedema free weight
• Precaution – if magnesium sulphate is given by IM injection together with gentamicin may
cause neuromuscular blockage - monitor respiratory function

Cefotaxime (first/second line, with signs of infection)

Administer IM/ IV
Dose 50-100 mg/kg/d
Presentation 250 mg/ vial
2 times/ day
3 – 5 Kg 100 mg x 2
5 – 10 kg 200 mg x 2
10 – 20 kg 400 mg x2
20 – 35 kg 800 mg x 2
> 35 kg 1g x 2
• Preferred to ceftriaxone particularly for gram-negative septicaemia
• Do not give in same infusion as gentamicin -separate by at least one hour; cefotaxime can
inactivate the gentamicin
• IM injection is very painful use lidocaine containing diluent
• IV injection do not dilute with lidocaine
• May deplete vitamin K in liver, if prolonged usage considered give vitamin K
• In severe infections frequency can be increased to 4 times daily
Ciprofloxacin (second line, septicaemia, septic shock)
Administer dose oral IV
Presentation 30mg/kg/d 250mg 2mg/ml
3 times/ day tablet vial
3 – 5 Kg 50 mg x 3 1/4 tab x3 25 ml x3
5 – 10 kg 100 mg x 3 1/2 tab x3 50 ml x3
10 – 20 kg 200 mg x 3 1 tab x3 100 ml x3
20 – 35 kg 400 mg x 3 2 tab x3 200 ml x3

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> 35 kg 800 mg x 3 3 tab x3 400 ml x3
• Very well absorbed orally - give oral or by NGT on empty stomach if possible - IV reserved
for vomiting and very severe infection
• ORAL give either before or after food
• Absorption reduced by dairy products (e.g. F-75, F-100), antacids, calcium, iron and zinc salts
- do not give with Zinc tablets
• Avoid giving with AL (artemether+lumefantrine)
• DO not give IM
• IV Infusion concentration not to exceed 2mg/ml
• Infuse slowly over at least 60mins
• COMBINE with cefotaxime to prevent emergence of resistance

Cloxacillin (staphylococcal infection)

Administer Dose Oral Oral Oral IM/IV
100-200 mg/
Presentation 125mg/ml 500mg 1g 500mg/vial
kg/d
3 times/ day suspension capsule capsule vial
3 – 5 Kg 62.5-250mg
2ml x 3 1/2 x 3 -- 250mg x 3
x3
5 – 10 kg 100-300mg
3ml x 3 1x3 1/2 x 3 500mg x 3
x3
10 – 20 kg 250-750mg
8ml x 3 2x3 1x3 1g x 3
x3
20 – 35 kg 1g - 1.5g x3 -- 3x3 2x3 2g x 3
> 35 kg 2-6g x3 -- 3x3 2x3 2g x 3
• For suspected or diagnosed systemic staphylococcal infection (especially staph. Pneumonia)
• Parenteral therapy preferred for severe infection
• Supplied as the sodium salt
• Do not give IV at the same time as gentamicin – separate by at least 1 hour and flush
cannula

Metronidazole (small bowel overgrowth, amoebiasis, giardia)

Administer Dose Oral Oral IV
Presentation 10-12 mg/kg/d 40 mg/ml 200 mg 500 mg
1-2 time/ day suspension tablet 100 ml vial
3 – 5 Kg 30-60 mg x1 1 ml x 1 5 ml x 1
5 – 10 kg 60-100 mg x1 2 ml x 1 1/4 x 1 10 ml x 1
10 – 20 kg 120-200 mg x1 4 ml x 1 1/2 x 1 10 ml x 2
20 – 35 kg 250-350 mg x1 10 ml x 1 1x1 30 ml x 2
> 35 kg 400-500 mg x1 10 ml x 1 1x2 50 ml x 2
• Very high bioavailability: oral route strongly recommended. Well absorbed rectally
• Can give a double dose as the first loading dose
• Use suspension if possible
• Do not give for more than 7 days
• WHO recommends reduction of standard dose (30mg/kg/d) to 1/3 with hepatic impairment –
in SAM maximum dose is 10-12mg/kg/d by pharmacodynamics studies
• Take suspension before food and tablets with or after food

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Antifungals
Nystatin (gastro-intestinal candidiasis)
Administer oral
Dose 400,000 IU / d
4 times/ day
3 – 60 Kg 100,000 x 4
• Not for systemic candidiasis. For Oral, oesophageal, gastric and rectal candidiasis only
• Dose can be safely increased to 500,000 IU 4 times daily to treat severe gastrointestinal
candidiasis
• Give after meals

Fluconazole (systemic candidiasis and fungal infection)

Administer Dose Oral IV
Presentation 3-6mg/kg/d 50mg 2mg/ml
1 time/ day capsule vial
3 – 5 Kg 15mg/d 1/3 x 1 5ml x 1
5 – 10 kg 30mg/d 1/2 x 1 10ml x 1
10 – 20 kg 60mg/d 1x1 20ml x 1
20 – 35 kg 120mg/d 2x1 40ml x 1
> 35 kg 200mg/d 4x1 50ml x 1
• Bioavailability of oral preparation is excellent
• Avoid giving with AL (artemether +lumefantrine)
• Oral preparation contains sodium benzoate
• IV preparation give by SLOW infusion over at least one hour
• A double dose can be given on the first day of treatment
• Young infants – give same dose but on alternate days

Miconazole (cutaneous ringworm, candidiasis and other fungal infections)

Presentation Cream or ointment
2%
2 times/ day
3 – 60 kg topical x2
• Apply twice daily to dry skin lesions
• Continue for at least 10 days.
• Can be used for all ages.
• Do not apply to ulcerated skin lesions or mucus membranes.
• Supplied as the nitrate.

Anti-Malarials
Artemether + Lumefantrine (AL) Oral Malaria treatment
Administer initially 8h 24h 48hr Total tablets
3 – 5 Kg 1/2 tab 1/2 tab 1/2 tab x 2 1/2 tab x 2 3
5 – 10 kg 1 tab 1 tab 1 tab X2 1 tab X2 6
10 – 20 kg 2 tab 2 tab 2 tab X2 2 tab X2 12
20 – 35 kg 3 tab 3 tab 3 tab x2 3 tab x2 18
> 35 kg 4 tab 4 tab 4 tab x2 4 tab x2 24

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• Dispersible tablets 20mg/120 mg per tablet
• 6-dose regimen = initial dose followed at 8, 24, 36, 48 and 60 hrs by further doses
• Avoid giving with Ciprofloxacin, Fluconazole, erythromycin
• Tablets can be crushed
• If dose is vomited within 1 hour repeat the dose
• If AL not available, use Artemether-amodiaquine tablets at the same dose (not recommended
because of hepatotoxicity)

Artemether (IM - initial treatment for severe malaria)

Administer IM IM IM IM
day 1 only - loading dose subsequent days (max 7)
Presentation dose 20mg/ml 40mg/ml dose 20mg/ml 40mg/ml
1 time/day ampoule Ampoule ampoule ampoule
3 – 5 Kg 10-15mg 0.7 ml X 1 0.4ml x 1 5-8mg 0.4ml x 1 0.2ml x 1
5 – 10 kg 15-30mg 1.2 ml x 1 0.6 ml x 8-15mg 0.6ml x 1 0.3ml x 1
1
10 – 20 kg 30-65mg 2.5ml x 1 1.2 ml x 1 15-30mg 1.2 ml x 1 0.6 ml x
1
20 – 35 kg 85-110mg 4.5ml x 1 2.2 ml x 1 30-65mg 2.2 ml x 1 1.1 ml x 1
> 35 kg 110-170mg 7.0ml x 1 3.5ml x 1 85-110mg 3.5 ml x 1 1.8ml x 1
• Dose 3.2mg/kg initially then 1.6 mg/kg x1, until patient can take oral medication
• USE 1ml syringe to measure and give small doses
• NOTE there are 20, 40 and 80mg/ml preparations available, do not use the 80mg/ml for small
children
• Maximum length of treatment 7 days
• Always follow Artemether with complete (6-dose) oral course of AL
• may affect plasma potassium levels and cardiac function
• AVOID use with ciprofloxacin, Fluconazole and Erythromycin
• The solution is made up in peanut oil

Artesunate (initial treatment severe malaria)

Administer rectal Rectal IM or IV IM or IV
Presentation 50mg 200mg 60mg ampoule 60mg ampoule
day 1
Suppository Suppository daily
0 and 12hr
3 – 5 Kg 1 sup 1/4 sup 10mg x 2 10mg x 1
5 – 10 kg 1 sup 1/4 sup 20mg x 2 20mg x 2
10 – 20 kg 2 sup 1/2 sup 40mg x 2 40mg x 1
20 – 35 kg 4 sup 1 sup 60mg x 2 60mg x 1
> 35 kg 6 sup 2 sup 100mg x 2 100mg x 1
• Rectal dose can be used initially
• Rectal dose approximately 10mg/Kg for ill children
• NOTE IV/IM preparation prepared in 5% Sodium bicarbonate solution
• For IV use further dilution in 5% glucose before IV infusion
• Use with caution in oedematous SAM and heart failure because of sodium content
• IV give 2.4mg/kg at 0, 12, 24hr and then daily until oral treatment can be given
• Always follow with a full 6-dose course of AL.

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Scabicide
Permethrin (scabies/lice – ectoparasites)
Presentation Cream Lotion
5% 1%
3 – 60 kg Once once
• Apply over whole body, wash off after 12 hours.
• If washed with soap within 8 hours repeat.
• Ensure webs between fingers and toes, wrists, axilla, perineum and buttocks are covered.
• Do not apply to mucus membranes, or ulcerated skin
• Same chemical as used in Impregnated bed nets

Heart Failure
Furosemide / Frusemide (only for use in heart failure)
Administer Dose Oral oral IV/IM
Presentation 0.5-2 mg/kg/dose suspension tablet 10 mg/ml
2-3 times/ day 4 mg/ml 40 mg 2 ml ampoule
3 – 5 Kg 2 ml 1/4 1 ml
5 – 10 kg 5 ml 1/2 2 ml
10 – 20 kg 10 ml 1 4 ml
20 – 35 kg 15 ml 1 5 ml
> 35 kg 20 ml 2 7.5 ml
• Only use for HEART FAILIURE
• NEVER give for oedema mobilisation (it can exacerbate oedema which is related to
potassium deficiency)
• For children normal oral dose 0.5-1mg/kg
• Maximum oral dose 3 x 4mg/kg = 12mg/kg (80mg) per day
• Normal IV dose 0.5-1mg/kg
• Maximum IV dose 3 x 4 mg/kg
• Causes loss of potassium, magnesium etc. as well as sodium and water
• Not ever effective in Heart failure in SAM – can use higher doses.

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Alternate Drugs that may be used when recommended drugs are unavailable
Ceftriaxone
Administer IM/ IV
Dose 50-100mg/kg/d
Presentation 250mg/ vial
2 times/ day
3 – 5 Kg 100mg x 2
5 – 10 kg 200mg x 2
10 – 20 kg 400mg x2
20 – 35 kg 800mg x 2
> 35 kg 1g x 2
• Prefer cefotaxime if available
• CAREFUL: incompatible with Ringer Lactate and any calcium containing fluid - cefotaxime
precipitates
• Very painful if given IM
• Can cause electrolyte disturbance,
• Supplied as sodium salt
• Gives false positive urinary glucose (reducing substances) and Coomb’s test
• For children maximum dose 1g

Amoxicillin + Clavulanic acid (Augmentin)

Administration Dose Oral Oral Oral
Preparation 25 - 50 mg/kg/d 125mg/5ml 250mg/5ml 500 mg
3 x per day suspension suspension tablet
3 – 5 Kg 62.5 mg x3 2.5 ml X 3
5 – 10 kg 125 mg x3 5 ml X 3 2.5 ml x 3 1/4 x3
10 – 20 kg 250 mg x3 10 ml X 3 5 ml X 3 1/2 X3
20 – 35 kg 500 mg x3 1x3
> 35 kg 750 mg x3 1x3
• Exact dose not critical: can be doubled in case of severe infection with sensitive organisms
• Ratio is fixed at 1mg of amoxicillin with 0.25mg clavulinic acid - dose expressed in terms of
amoxicillin content
• The risk of acute liver toxicity has been estimated to be about six times higher with
amoxicillin+clavulanic acid than with amoxicillin alone
• The preparation contains sodium
• The pharmacology of clavulinic acid has not been ascertained in SAM

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Annex 25: The disadvantages of indwelling cannula
• They give access to the circulation for antibiotic-resistant bacteria in these immuno-compromised
patients.
• The dressings quickly become dirty in conventional hospital settings.
• They often become colonised with Candida and can give rise to fungal septicaemia.
• They require fluid or anticoagulants to keep the vein open but these children have impaired
liver function (bleeding tendency) and are very sensitive to fluid overload.
• They require skilled health persons to insert, re-site and maintain the cannula: staff time is the
limiting factor in most resource poor settings.
• The administration of IV drugs takes more time, from higher grades of staff, than giving oral
drugs.
• IV preparations are much more expensive than oral preparations and the cannula itself is
expensive.
• Insertion of the cannula is painful and distressing for the child and they frequently need to be
re-inserted.
• The cannula restricts the movements of the child and impairs feeding, washing, play and care.
• Extravasations into the tissue can cause skin necrosis and other complications.

Example
Example of fluid
of fluid extravasation
extravasation withwith scalp
scalp necrosis
necrosis and and resisting
resisting of cannula
of cannula several
several times.
times.

Annex 26: Recipes for nutrition-rich mixture of family foods

Recipes for different types of nutrient-rich family foods (Kitoobero)
• Beans, Meat and Matooke
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Annex 26: Recipes for nutrition-rich mixture of family foods
Recipes for different types of nutrient-rich family foods (Kitoobero)
• Beans, Meat and Matooke
Ingredients:

• Palm of dry beans (90g)

• Fist of meat (60g)
• Fingers of Matooke (300–500g)
• 1 pinch of salt
• ½ mug of water (250ml)
Method:
• Measure the dry beans and soak overnight or for about 6 hours. Remove the skin and wash
them. The skinned beans having expanded become 2 full palms (180g).
• Scrape the meat, mix it with clean water which had been boiled and cooled, in a container and
try to separate the particles of meat.
• Peel the Matooke, cut them into small pieces and wash them.
• Mix the skinned beans, scraped meat, pieces of Matooke, water and salt into a clean saucepan.
Cover and steam for 3 hours, when the food is ready, mash and divide it into two; one half for
lunch and the other half for supper. Prepare and serve the child.

NOTE: Any other tuber (irish potatoes, sweet potatoes, cassava, yams) can be prepared the
same way as Matooke whereas dry peas can be prepared the same way as dry beans.

Ground nuts, powdered nkejje (small fish powder) and maize flour
Ingredients:

• Palm of raw ground nuts (90g)

• Teaspoonful of nkejje powder (10g)
• Palms of maize flour
• 1 mug of water (500ml)
• 1 pinch of salt
Method:
• Get raw ground nuts, sort and pound well. After pounding, the ground nuts become two palms.
• Sun-dry the nkejje, and then pound and sieve into fine powder.
• Mix the ground nut and nkejje powders plus the maize flour, in a clean sauce pan. Add water
and a pinch of salt into the mixture, mix well, cover and steam. When food is ready, prepare and
serve the child as in recipe 1 above.

NOTE: Silver fish (mukene) can be prepared in the same way as nkejje

Selection of Triple Mix (kitoobero)

Carbohydrate Animal Proteins Plant Proteins

Sweet potatoes Fish (Nile perch) Peas
Cassava Silver fish Beans
Yams Meat Ground nuts
Rice Chicken
Millet

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Annex 27: Key nutrition recommendations
Topic Recommendation
Optimal • Early initiation of breastfeeding within one hour of birth for the baby to
Breastfeeding benefit from colostrum (first yellowish milk).
• Exclusive breastfeeding for the first 6 completed months.
• Breastfeed on demand (as long as the infant wants, at least 8–12 times
during day and night).
• Appropriate positioning and attachment.
• Continued breastfeeding up to 2 years or beyond OR
• Continued breastfeeding up to 12 months of life if the mother is HIV
positive and the infant is HIV negative, the mother is on HAART and the
infant receive ARV prophylaxis.
• Continued breastfeeding during illness and express breast milk if the
baby is not able to breastfeed
Optimal • At 6 completed months start appropriate complementary foods while
Complementary continuing to breastfeed.
feeding • Give a variety of foods to include energy giving foods (GO), body
building foods (Grow) and protective foods (Glow).
• Ensure:
• Proper hygiene during food storage, preparation and serving.
• Growth monitoring and promotion monthly.
• Vitamin A supplementation every 6 months.
• Immunization.
Feeding of the sick • Increase frequency of breastfeeding and offer additional food (small
child (or an adult frequent meals).
where applicable) • A sick child should be given a diet high in energy, protein and
micronutrient especially iron, zinc and vitamins in a form that is easy to
eat and digest.
• The feeds must be easy to eat and digest.
• To achieve high energy intakes: 1) feed the child frequently, at least
six times a day 2) add oil, honey, margarine, butter, sugar. Use fat rich
foods like groundnuts.
• To achieve high protein intakes, use milk, or locally available staple
mixed with legumes, meat or fish.
Maternal Nutrition • Increase food intake by eating one extra meal during pregnancy, two
extra meals during lactation in addition to eating the regular meals.
• Ensure iron and folic acid supplementation, intermittent presumptive
treatment and prevention of malaria.
• Eat plenty of fruits and vegetables with every meal.
• Drink enough liquids every day (8 glasses or 3 NICE cups).
• Emphasize the use of iodized salt and other fortified foods.
• Pregnant mothers should be discouraged from alcohol consumption,
smoking and other un-prescribed medication that may harm the baby.
• Take the weight, height and MUAC of all pregnant women and record
it in the mother/ child passport/ ANC register and other relevant data
collecting tools.
• Encourage mother to ensure that all children aged five years and below
and pregnant women sleep under insecticide treated mosquito nets,
for preventing anaemia because malaria.

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Control of Vitamin Children
A deficiency • Vitamin A is safe for children and boosts their immunity.
(VAD)
• Promote consumption of vitamin A rich foods e.g. mangoes, green
leafy vegetables, wild red and orange fruits and foods such as egg
yolk, liver, milk and other fortified foods such as vegetable oil.
Control of Vitamin • Vitamin A supplementation
A deficiency • Children 6–59 months should be given vitamin A every 6 months as it
(VAD) protects them from diseases such as night blindness, diarrhoea, acute
respiratory infections and reduces deaths.
• All non-breastfed infants less than six months should be given vitamin
A
• Children sick with measles, certain problems, severe malnutrition may
need additional vitamin A according to the treatment schedule (refer to
ITC).
Mothers
• Encourage pregnant women and lactating mothers to consume
balanced diet and foods rich in vitamin A such as liver, eggs, orange
flesh sweet potatoes, pumpkin dark green leafy vegetables, lactating
mothers should not be given vitamin A routinely.
Control of anaemia • Emphasize consumption of iron rich foods such as liver, red meat,
eggs, fish, whole grain bread, legumes and iron fortified foods.
• Promote consumption of vitamin C rich foods such as oranges, green
vegetables as they enhance the absorption of iron.
• Provide advice on food items and medicines that should not be taken
together with iron supplements since they may inhibit absorption such
as milk, antacids, tea and coffee.
• Malaria control.
• Deworming routinely.
• Malnourished children with nutritional anaemia (commonly due to iron
or folic acid deficiency).
• Give one dose at 6mg/kg of iron daily for 14 days for children not in ITC
and receiving RUTF.
• Children with SAM and severe anaemia should be managed following
ITC protocols.
• Avoid iron in children known to suffer from sickle cell anaemia.
• Avoid folate until 2 weeks after a child has completed the dose of
sulphur based drugs (Fansidar, Septrin and others).
Mothers
• Give all pregnant women a dose of 200mg of iron and 5 mg of folate
once a day (combined with ferrous sulphate Bp 200mg and folic acid
0.4mg)
• Treat anaemia for 3 months.
• Refer severe cases of anaemia to the nearest higher level of care
• Promote use of antimalarial interventions such as long lasting
insecticide treated mosquito nets to prevent malaria which may cause
anaemia.

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Hygiene and Personal hygiene, domestic and environmental hygiene
sanitation • Promote good hygienic practices in the preparation and handling of
food.
• Hand washing with soap and clean, running water.
• Protect foods from contamination with insects, pests and other
animals.
• Keep all food preparation premises, utensils, and equipment clean.
• Cook food thoroughly or re-heat it thoroughly.
• Keep food at safe temperatures.
Deworming • Use safe water and raw materials
• Give 250 mg of Mebendazole or 200mg of Albendazole for children 1–2
years and 500 mgs Mebendazole or 400 mgs Albendazole if > 2years as
a single dose. Note: DO NOT administer if child is less than 1 year.
Growth monitoring • Children aged 0–2 yeas should be weighed every month, their weights
and promotion plotted on the growth chart in the Child Health Card or Mother Child
(GMP) Passport. Explain to the mother the child’s progress.
• Lengths for these children should be measured at specified intervals
as per GMP guidelines. Assess and explain to the mother the child’s
progress (based on length for age).
• Children 2 to 5 years should have weights and heights measured every
6 months to determine if they are growing adequately.
• When children come for GMP, check for their immunization, and
vitamin A supplementation status.
• Children whose growth is faltering are at high risk and should be
monitored closely by health facility staff.
Immunization • Encourage all children 0–5 years, adolescents and pregnant mothers
to receive the recommended vaccinations as per the national
immunization schedule.
• Explain to the mother the importance of immunization and the national
schedule, barriers to immunization and how to overcome them and
Access to immunization services.
• Make immunization safe (i.e. check expiry date, use sterile disposable
needles, observe cold chain, use trained personnel).

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Annex 28: Standard supply chain monitoring tools
Date of Visit
Data Collector
District
Name of Facility
Respondent(s)
Name Title Contact

Stock conditions

Please assess the place where nutrition supplies are Yes/No Note
primarily stored at this facility on the criteria below.

Cartons and products are in good condition (not

crushed, perforated, stained, or otherwise visibly
damaged).

There is evidence of rodents or insects in the storage

area. (Visually inspect the storage area for evidence
of rodents (droppings) or insects that can damage or
contaminate the products.)

Nutrition supplies are stored in a dry, well-lit, well-

ventilated storeroom. (Visually inspect roof, walls, and
floor of storeroom.)

Cartons and products are protected from direct

sunlight.

Storage area is dry and free of water penetration.

Cartons stored on shelves or pallets off the floor.

Expired, damaged or other unusable commodities are

stored away from usable commodities.

RUTF are stored and organized to enable FEFO (First-

to-expire, first-out) procedures and are accessible for
counting and general stock management.

Nutritional products are likely to be exposed to the over

40 degree centigrade temperature.

Storage area is secured with a lock and key but is

accessible during normal working hours. Access is
limited to authorized personnel.

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Stock Status
RUTF F-75 F-100 ReSoMal Note
What is the physical count of usable
(undamaged, unexpired) nutrition supplies
today?
Is there any nutrition supply at this facility
that is expired as of today’s visit?
Is there any nutrition supply at this facility
that is damaged as of today’s visit? (sachet
ripped, perforated, opened, nibbled by
pests, or otherwise damaged so as to be
unusable)?
Is there a stock card or stock ledger for
nutrition supplies?
Does the stock card or stock ledger have
complete records for the most recent three
months?
According to the stock card or stock ledger
how many days in the most recent three
months have nutrition supplies been
stocked out?
Is there a register or tally that records
consumption of nutrition supplies?
Does the register or tally contain complete
records of nutrition supply consumption
for the most recent three months?
According to the tally, what quantity of
each nutrition supply was consumed (used
at the facility or dispensed to patients/
caregivers from this site) during the most
recent three months?
(If the answer to 7 is No) Does the stock
card or stock ledger contain complete
records of nutrition supplies removed
from stock or distributed to patients/
caregivers for the most recent three
months?
Who is in charge of receiving/managing/
issuing nutrition supplies at this facility?
Are nutrition supplies kept in the
same storage as other pharmaceutical
supplies?

Data Reporting
RUTF F-75 F-100 ReSoMal Note
Do the stock position data on DHIS2 for
the last three months match with the
records at the health facility?
Do the supply utilization data on DHIS2
for the last three months match with the
records at the health facility?

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Do the supply expiry data on DHIS2 for the
last three months match with the records
at the health facility?
Do the records at the health facility match
with the records at the DHO store for the
last three stock movements?
Do the SAM admissions data on DHIS2
for the last three months match with the
records at the health facility?
How many supplies are utilized in the # of SAM
last month? What is the number of SAM admissions:
admissions in the same month?
How many supplies are utilized two # of SAM
months ago? What is the number of SAM admissions:
admissions in the same month?
How many supplies are utilized three # of SAM
months ago? What is the number of SAM admissions:
admissions in the same month?
Any Other Comments
Other: Quality, Diversion, Comment
Has the mixing become easier with the
new packaging and the use of a scoop
provided in a tin?
Where do you store the scoop after mixing
milk?
Are you facing any challenge with storing
F-100/F-75 in the new packaging due to the
increase in volume?
Have you seen or heard of anyone selling
or exchanging nutrition supplies at home
or in the local market?
Other
What are the main challenges in supply
chain management for nutrition (e.g.,
requisitioning, storage, distribution and
issuing/dispensing)?
What do you see as benefits and concerns
of integrating nutrition supplies into
NMS?
Is there any challenges faced in relation to
distribution of other EMHS from NMS?

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Annex 29: Quality improvement journal

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Annex 30: Health facility supervision and mentorship tool in IMAM service

Supervision Checklist for The District Nutrition Officer/Focal Point

Period: From ____/_____/______to ___/_____/_____/ Region: ____________ District: __________
N° OTCs Visited: ....... Functioning: ........ N° HC Visited: ......... Functioning: .........
N° ITC Visited......... Functioning: ..... N° Hospitals Functioning: ..... N° district’s OTCs using
the ITC.....
Total Population: ..................... % of Catchment pop: ....... (<5km)
New OTC: Yes / No if Yes, Name......... Code............... OTC Closed: Yes / No if Yes, Name.........
Code....
New Staff Expected Yes / No Allocated Yes / No If Yes, No.......
Reason for visits–routine / results of reports / staff problems / logistic problems / patient complaints
High defaulting / high death / screening results / coverage low / other...................................

Activities Yes No Comments

1.Protocol applied in all the OTCs %
1.Protocol applied in the ITC
2.Supervision of the OTC No of OTC visited:
2.Supervision of the ITC No:
3. Transfer system in place Transport Free–Paid by …................
3. Transfer form, communication N° transfer...... Death during transfer......
between OTC/ITC working, etc.
Not arriving.....................
Other.....................
3.SAM-Number used for Internal Y/N
transfer
4.On job Training activities needed for If Yes, which OTC & how many?
OTC
4.On job Training activities needed for If Yes, which ITC & how many?
ITC
4.On job Training during the Period If Yes, where & how many?
4. New staff appointed in OTC
4. New staff appointed in OTC Trained
4. New staff appointed in ITC
4. New staff appointed in ITC Trained
5. Monthly Reports a) Received from a) No Received: No Expected:
the OTC Last month, b) Transmitted
to the HMIS b)Transmitted to HMIS:
6. Material lacking in any OTCs? If yes, Name of the OTC:

Action taken:
6. RUTF lacking in any OTCs? If yes, Name of the OTC:
Action taken:
6. F75-F100-RUTF lacking in ITC? If yes, Products:

Action taken:

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6. Systematic Treatment lacking in OTC If yes, Name of the OTC:

Action taken:
6. Systematic Treatment lacking in ITC If yes, Name of the drug:

Action taken:
7. Staff Paid last month in OTC / ITC
8. Meeting last month with the OTC/ Last date:
ITC supervisors
8. Meeting last month with the DHMT Last date:
8. Meeting with the other team
members in the district (for
community mobilisation)
9. Any activities for Community If yes, which?
Mobilisation at district level
9. Community Mobilization Evaluated
9. Regular Meetings of CHW in each
OTC
9. Are there adequate CHWs in each Total no: Expected no:
OTC
9. Training Material distributed to the
HC for Community Mobilisation
9. District Storage in Good Condition
for the Therapeutic food?
9. ....for Drugs
9. Stock Cards Updated in District/
OTCs/ ITC
9. Rupture of RUTF in previous 2 If yes, explain
months at district level
9. Rupture of Drugs in previous 2 If yes explain
months at district level
9. Any Delivery/Transport Problems of
supplies (e.g. RUTF) to OTC?
10. OTC Structures in bad shape
10. OTC Structures with NO
insufficient Water
Conclusion and actions taken for the next month:

Joint the monthly reports of the months and the supervision of the OTC / ITC

Name, surname Position Qualification e-mail Phone

Date: Position: Signature:

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FORM XXX: UGANDA OTC AND ITC SUPERVISION FORM
Objective: This tool is to be used for supervision and mentorship of OTC and ITC processes.
DISTRICT: _____________________________ HSD: ______________________________
FACILITY NAME: ________________________ MONITORING DATE: ____/____/ _____
Day Month Year
SUPERVISOR’S NAME: ________________________________CONTACT _____________________

HEALTH FACILITY STAFF MET

SNO. NAME CADRE TELEPHONE EMAIL

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A. General health facility management
To be answered by the health facility manager or his/her appointee(s). Circle the coding
corresponding to the correct/observed response. Observe and verify records accordingly.

No. Question and filters Response Coding COMMENTS

A01 Level of health facility Regional Referral 1
Hospital 2
District Hospital 3
Health Centre IV 4
Health Centre III 5
Health Centre II
A02 Health facility Government 1
ownership Private not-for-profit 2
(PNFP) 3
Private for profit
(PFP)
A03 Does the health facility OTC 1
have an ITC 2
Both 3
A04 Is (Are) the OTC/ITC/Both Yes 1
currently functional? No (Skip to A07) 2
A05 Does the health facility Yes 1
have staff in charge of No (skip to A07) 2
nutrition?
A06 Has the person in charge Yes 1
of nutrition services No 2
received any in-service
training in nutrition in the
past two years?
A07 Does the OTC/ITC/Both Yes 1
get regular (at least once No (skip to A09) 2
per quarter) integrated
support supervision that
includes nutrition from
the national/regional or
district levels? (Verify with
records)
A08 Does the OTC/ITC/Both Yes 1
get regular feedback from No 2
the support supervision
teams? (Verify with
records)
A09 Does the OTC/ITC/Both Yes 1
receive regular support No 2
supervision from Ministry
of Health specific to
nutrition (at least once
per quarter; verify with
records)?

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No. Question and filters Response Coding COMMENTS
A10 Does the OTC/ITC/ Yes 1
Both receive regular No 2
support supervision from
the Regional/District
Nutritionist (at least once
per quarter; verify with
records)?
A11 Does the health facility Yes 1
have an updated (bi- No 2
annual) equipment
inventory? (HMIS 092)
A12 Nutrition screening done 1= OPD
at entry points, 2= YCC
3= EPI
If not done, why for 4= ART clinic
each? 5= Antenatal clinic
6=Paediatric ward
7=Emergency ward
8= other (specify)
9=Not done
A13 Does the OTC/ITC/Both Yes 1
provide caregivers and No 2
children with access to
safe water?
A14 Are there accessible Yes 1
handwashing facilities No 2
with soap?
A15 Is the ward kept as free
as possible of insects and
rodents?
A16 Is trash disposed of
properly?

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B. Provision of nutrition services
To be answered by nutrition service providers. Circle the coding corresponding to the correct/
observed response. Observe and verify records accordingly

No. Question and filters Response Coding COMMENTS

This section is to be filled by both OTC ITC OTC
and ITC
B01 Taking mid-upper arm circumference Yes 1 1
(MUAC) correctly and accurately No 2 2
(observe)
B02 Age of client recorded Yes 1 1
No 2 2
B03 Taking height/length correctly and Yes 1 1
accurately (observe) No 2 2
B04 Taking weight correctly and accurately Yes 1 1
(observe) No 2 2
B05 Do staff adjust the scale to zero before Yes 1 1
weighing? No 2 2
B06 Checking for oedema correctly Yes 1 1
No 2 2
B07 Use of growth reference charts and Yes 1 1
classification of acute malnutrition using No 2 2
WFH
B08 Interpretation of growth reference Yes 1 1
charts No 2
2
B09 Haemoglobin estimation Yes 1 1
No 2 2
B11 Infant and young child feeding and Yes 1 1
support. No 2 2
B12 Follow-up of children admitted (review Yes 1 1
records) No 2 2

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C. Tools/materials and supplies
To be answered by nutrition service providers and the assessor should verify the availability and
use of the respective materials, equipment and supplies.
For each question, refer to the response format row in order to either write coded responses (1
= Yes if the item is available and 2 = No if the item is not available) and to specify appropriate
numeric values where indicated.

No. Questions response Coding Comments

Current guidelines/guides/standards24 (to be answered by the health facility manager or his/her
appointee[s])
C01 Is there a copy of the current Integrated Yes 1
Management of Acute Malnutrition (IMAM) No 2
Guideline accessible?
C02 Infant and Young Child Feeding Policy Yes 1
Guidelines No 2
Counselling cards/job aids
C03 Infant and Young Child Feeding National Yes 1
Counselling Cards for Health Workers No 2
(flipchart)
C04 Question and Answer Guide: Infant and Young Yes 1
Child Feeding with a Special Focus on HIV/ No 2
AIDS: Reference Tools for Counsellors
C05 Are there IEC materials (posters, take home Yes 1
brochures, flipcharts) on management of No 2
severe malnutrition
Additional OTC/ITC job aids/tools
C06 Integrated Nutrition Register Yes 1
No 2
C07 HMIS reporting forms (105) Yes 1
No 2
C08 OTC/ITC quarterly report form (Comment on Yes 1
their use) No 2
C09 RUTF reference cards Yes 1
No 2
C10 Are RUTF appetite dosing charts available? Yes 1
No 2
Nutrition status indicator reference charts/growth monitoring and promotion charts/equipment
C11 Functional Weighing scales Yes, 1
Specify number adequate 2
Yes, not 3
adequate
(specify
number)

24 The supervisor should be aware of the current guidelines, guides, and standards.

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No. Questions response Coding Comments
C12 Functional Height/length boards Yes, 1
adequate 2
Yes, not 3
adequate
(specify
number)
C13 Functional MUAC tapes for 6–59 months Yes, 1
adequate 2
Yes, not 3
adequate
(specify
number)
C14 Functional MUAC tapes for adults Yes, 1
adequate 2
Yes, not 3
adequate
(specify
number)
C15 Are scales standardised weekly?
C16 Weight-for-height z-score tables for children Yes 1
less than 5 years available? No 2
C17 Weight-for-age tables/child health growth Yes 1
charts? No 2
C18 Mother-child passport/child health card Yes 1
available? No 2
This section to be filled by ITC ONLY
C19 Are Multi-Charts available and used? Yes 1
No 2
C20 Are SS Infant Charts available and used Yes 1
No 2
C21 Are Critical Care Chart available and used? Yes 1
No 2
C22 Are look up tables or F-75 and F-100 Yes 1
available? No 2
Nutritional commodities and supplies
C23 Sugar water Yes 1
No 2
C24 Routine medicines Yes 1
No 2
C25 RUTF Yes 1
No 2
This section to be filled by ITC ONLY
C26 F-75 Yes 1
No 2

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No. Questions response Coding Comments
C27 F-100 Yes 1
No 2
C28 ReSoMal Yes 1
No 2
C29 Does the health facility have functional Yes 1
equipment for estimating Hb? (Consult the No 2
laboratory where applicable)
C30 Blood transfusion Yes 1
No 2
C31 Laboratory/radiology facilities Yes 1
No 2
C32 Toys for children Yes 1
No 2
C33 Kitchen Yes 1
No 2
C34 Utensils (feeding cups, spoons, mixing Yes 1
bowls) No 2
C35 Safe water supply/drinking water Yes 1
No 2
C36 Running water Yes 1
No 2
C37 Soap for hand washing Yes 1
No 2
Other tools
C38 Referral forms available? (Comment on their Yes 1
use) No 2

Any other comments:

___________________________________________________________________________________
___________________________________________________________________________________
____________________________________________________________________

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D. Nutrition services specific to OTC
To be answered by nutrition service providers. Write the coding corresponding to the correct/
observed response. Observe and verify records accordingly

ACTIVITIES WRITE OBSERVATION ACTION TAKEN

APPROPRIATE
RESPONSE

SPECIFIC TO OTC ONLY Yes 1

No 2
Staff greet mothers/caregivers and
D01
are friendly and helpful
Child’s appetite tested using RUTF,
D02
upon admission?
Is the admission and discharge
D03 criteria followed correctly according
to the protocol?
Registration of clients in INR & INR-
D04
number recorded
D05 OTC chart filled correctly
D06 WFH classification done correctly
D07 Temperature taken & written?
Medical history and Physical
D08 examination performed and
recorded accurately
Are correct quantities of RUTF
D09
distributed?
Child’s appetite tested using RUTF
D10 during outpatient care follow-up
sessions where necessary?
Routine medication given
D11 according to protocol and recorded
accurately
Systemic. Treatment given &
D12
documented
D13 # Sachets given & recorded
Health and nutrition Education
D14
sessions held
D15 Other specific drugs given
Failure to Respond to treatment
D16
diagnosed and managed?
Type of discharge written on the
D17
chart and register
Home Visit of the Unconfirmed
defaulter written on chart and
D18
communicated to Community
Outreach Workers?

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 Home Visit of the absent patients
done and written on the chart and
D19
communicated to Community
Outreach Workers?
D20 Stock card of RUTF updated
Stock card of routine drugs
D21
updated
Internal Transfer noted in the
D22
register? Form with chart?
D23 Transfer back from ITC?
Transfer form attached to the
D24
chart?
Monthly report (Form 105)
D25 adequately filled in and sent on time
through appropriate channels
D54 Monthly report sent on time
Charts securely stored in order by
D55
INR No and registration No

Any other comments:

___________________________________________________________________________________
___________________________________________________________________________________
____________________________________________________________________

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E. Nutrition services specific to ITC
To be answered by nutrition service providers. Write the coding corresponding to the correct/
observed response. Observe and verify records accordingly

Activities WRITE Observation Remarks /

APPROPRIATE comments
RESPONSE
Welcome and ward environment
Yes 1
No 2
Do the Staff greet the caregivers and
E01
are friendly and helpful?
Are mothers taught/ encouraged to be
E02
involved in care?
Caregivers do not wait for too long
E03
before they are attended to?
Admissions
Is the admission criteria followed
E04
correctly according to the protocol?
Are the Medical History & examination
E05 performed and forms filled
appropriately?
E06 Is the Appetite Test conducted?
Do the health staffs provide
E06
counselling to the clients?
Are children consistently weighed
E07
without clothes?
Are weights correctly plotted on the
E08
multi Chart?
3. Is the patient information recorded
E09 in Register, multichart & INR No
given.
Management in stabilisation phase
Are children weighed at about the
E10
same time each day?
E11 Are children Breastfed before feeds
Do kitchen staff (or those preparing
E12 feeds) wash hands with soap before
preparing feeds?
Are F75 Feeds prepared appropriately
E13
(based on protocol)
Are children fed according to the
schedule, observed and recorded
E14
correctly? Including night and
weekend

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 Are correct feeds served in
E15 correct amounts and recorded on
multichart?
Frequency of feeding in stabilization 1= 2 hourly
phase 2= 3 hourly
E16 3= 4 hourly
4= other
(specify)
Frequency of preparation of feeds 1= 2hourly
during day 2= 3hourly
3= 4hourly
E17
4= >4hours
5= Not done
6=NA
Frequency of preparation of feeds 1= 2hourly
during night 2= 3hourly
3= 4hourly
E18
4= >4hours
5= Not done
6=NA
E19 Is feeding supervised?
Is the Systemic treatment protocol
E20
followed and recorded?
Are dishes washed after preparing
E21
feeds
Is the Multichart filled used and filled
E22
appropriately
Is the Critical care charts used and
E23
filled appropriately?
E24 Are other specific drugs given?
Is the Criteria for Transition phase
E25
followed (based on protocol)
Is Failure-to- Respond in ITC
E26
recognised and managed?
Is weight taken and Recorded daily on
E27
charts?
Health worker has adequate
E28 knowledge on diagnosis and
management of dehydration
Knowledge on preparation of ReSoMal
E29
from WHO standard ORS
Is monitoring done while child is
receiving ReSoMal? e.g. target
E30
rehydration weight, respiratory rate,
pulse rate
Is care for the skin done?
E31
If yes , How?

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 Are recipes displayed for preparation
E32 of therapeutic feeds from locally
available milk?
Transition Phase & exit
Is the transfer of patients from
E33 transition to rehabilitation phase done
correctly according to the protocol?
Are correct amounts of RUTF given
E34
and recorded
Are correct feeds served in correct
E35
amounts and time?
E36 Is F-100 available
E37 Are F100 reference cards available?
Are correct amounts of F100
E38
prescribed?
Are there any other nutrient dense (specify
E39 foods provided to achieve catch up foods)
growth?(specify)
E40 Is clean water available?
Are Health and nutrition education
E41 sessions held (ask for documentation
of talks)
Is the Type of exit written on the chart
E42
and register completed
As children recover, are they
E43 stimulated and encouraged to move
and play?
Are mothers involved in play &
E44
stimulation of their children? How?
Is the environment cheerful &
E45
stimulating?
Less than 6 months
E46 Is the SST- Chart used & filled-in
E47 Is F100 dilute prepared appropriately
Is the position of the mother & infant
E48
during SS-T proper?
E49 Systemic treatment provided?
Do caregivers come back for follow
E50
up?
Monitoring
Is the Internal Transfer noted in the
E51 register? Form attached to the OTC
chart?
E52 Is the Transfer Criteria applied?

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 Is the Monthly report (HMIS 105) from
E53
last month filled in correctly
Is the Monthly report sent on time to
E54
the appropriate channels?
Are the Charts kept securely in order
E55
by INR No and registration No
Coordination
Do staff attend regular meetings with
E56
IMAM team
Is the list of health centres providing
E57 outpatient Management of SAM
available?
Does the ITC/health facility provide
E58
OTC services?
E59 Good communication with OTCs
Is transport arranged with the district
E60
for patients and products?
Does the ITC/health facility provide
E61
SFP services?

Any other comments:

___________________________________________________________________________________
___________________________________________________________________________________
____________________________________________________________________

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F. Store Management
To be observed and records checked by assessor. Health facilities will be assessed or graded
based on whether they stock nutrition commodities or not. Write codes 1 = Yes and 2 = No.

No. Question and filters Commodities and Supplies

Nutrition Essential
Comments
commodities25 medicines
and other
supplies

F01 The storage room/area is clean and

dry.

F02 Ventilation is adequate.

F03 Lighting is adequate.

F04 The storage area is free from vermin

and rodents

F05 Are order forms used to request

commodities and supplies?26

F06 Stock cards are used to account for

commodities and supplies.

F07 Stock cards for commodities and

supplies are updated at the time of
visit.

F08 Nutrition commodities and supplies

are managed within the general
health facility store.

F09 Has there been a stock out reported

in last 12 months?

F10 Is there a current stock-out of any

of F75, F100, or RUTF (if OTC is
linked)?
If yes, specify.

F11 Commodities and supplies are

stored according to FEFO/FIFO (first
expiry first out/first in first out)
procedures.

F12 Commodities and supplies are

protected from sunlight throughout
the day.

25 Nutrition commodities include therapeutic foods and supplementary foods.

26 Order forms are only available in HCIV and above

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 F13 Commodities and supplies are
stored on pallets or shelves and
away from walls to protect them
from dampness.

F14 Is the dispensing of nutrition

commodities through the dispensing
area that is used to dispense other
medicines?

Any other comments:

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

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F. Monitoring and Evaluation for Nutrition
To be answered by the person in charge of records/health management information system
(HMIS). For this section, circle the coding corresponding to the correct/observed response.
(The assessor should verify responses)

No. Questions and filters response Coding Comments

F01 Does the health facility have a designated Yes 1
person for HMIS data? No 2
F02 Do you register and report clients receiving Yes 1
nutrition services? No 2
F03 Does the health facility collect data on Yes 1
nutrition? No 2
F04 Does the health facility HMIS person compile Yes 1
data on nutrition? No 2
F05 Does the health facility analyse and display Yes 1
data on nutrition? No 2
F06 Is the register complete for all nutrition Yes 1
indicators? List those incomplete and why No 2
F07 Are the monthly HMIS report 105 and Yes 1
108 being completed correctly? List those No 2
incomplete and why
F08 Are the quarterly HMIS 106a reports being Yes 1
completed correctly? If not, why No 2
SPECIFIC TO ITC ONLY
F09 Is CCC used on the nutrition unit Yes 1
No 2
F10 Adequate knowledge on use of CCC? Yes 1
No 2
F11 Is the multichart used on nutrition unit? Yes 1
No 2
F12 Adequate knowledge on use of multichart Yes 1
No 2

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Action plan matrix for the health facility
Based on the identified findings and recommendations, develop an action plan for addressing the
gaps.
Health Facility: ________________________________District: __________________________
Date: _______________________

GAPS Activity/ Responsible Timing Means of Verification

observed Recommendation Person

Source: Adapted from MoH (2015) Nutrition Service Delivery Assessment Tool for National Referral, Regional Referral,
and General Hospitals

Date Signature of person interviewed

____________________________ ____________________________

Signature of Evaluator

__________________________________

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FORM XXX: SUPPLEMENTARY FEEDING PROGRAM (SFP) SUPERVISION FORM
Objective: This tool is to be used for supervision and mentorship of SFP processes.

Name of Outpost: ____________________________ Village: ____________________________

Parish: ____________________________ Sub County: ____________________________

District: ____________________________ Health Centre ____________________________

Date of Monitoring/supervision Visit: ____________________________

Supervisor’s name: _______________________________________

EALTH FACILITY/OUTPOST STAFF MET

SNO. NAME CADRE TELEPHONE EMAIL

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Circle the coding corresponding to the correct/observed response. Observe and verify records and
availability of tools and equipment accordingly.

QUESTION RESPONSE CODING COMMENT

A Screening, Referrals, Assessments, Enrolment Action taken
and Follow-up-Observe and check appropriate
tools
Admission
A01 Are referral slips used to refer clients Yes 1
from the communities to the outpost No 2
available?
A02 Are clients referred from the communities Yes 1
followed up by the VHTs? No 2
A03 Did referrals from OTCs come with referral Yes 1
slips? No 2
A04 Are referral slips used to refer clients to Yes 1
OTCs/ITCs available and used? No 2
A05 Were all clients referred from OTCs Yes 1
enrolled? No 2
A06 Were clients last referred to OTCs followed Yes 1
up? No 2
A07 Are defaulters followed up with a home Yes 1
visit? No 2
A08 Are the admission criteria for various Yes 1
age categories adhered to according to No 2
protocol?
A09 Is a copy of the admission criteria chart Yes 1
pinned up? No 2
A10 Are health workers involved in assessment Yes 1
of clients? 2
A11 Functional weighing scales 1.Yes, 1
Specify number adequate 2
2. Yes, not
adequate
3.No (specify
number)
A12 Functional weighing scales Yes, 1
Specify number adequate 2
Yes, not 3
adequate
No (specify
number)
A13 MUAC tapes for children 6–59 months Yes, 1
Specify number adequate 2
Yes, not 3
adequate
No (specify
number)

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A14 MUAC tapes for adults Yes, 1
adequate 2
Yes, not 3
adequate
No (specify
number)
A15 Use of growth reference charts and Yes 1
classification of acute malnutrition No 2
A16 Interpretation of growth reference Correct 1
charts? Incorrect 2
A17 Taking mid-upper arm circumference Yes 1
(MUAC) correctly and accurately No 2
(observe)?
A18 Age of client recorded? Yes 1
No 2
A19 Taking height/length correctly and Yes 1
accurately (observe)? No 2
A20 Taking weight correctly and accurately Yes 1
(observe)? No 2
A21 Checking for oedema correctly? Yes 1
No 2
A22 Categorization of nutrition status Yes 1
correctly? No 2
A23 Infant and young child feeding and Yes 1
support? No 2
A24 Are there any problems with adherence to Yes 1
the admission criteria? No 2
A25 Mother-child passport/child health card Yes 1
available? No 2
Is there a copy of the current Integrated Yes 1
Management of Acute Malnutrition (IMAM) No 2
Guideline accessible?
A26 Infant and Young Child Feeding National Yes 1
Counselling Cards for Health Workers No 2
(flipchart) available?
A27 Question and Answer Guide: Infant and Yes 1
Young Child Feeding with a Special Focus No 2
on HIV/AIDS?
A28 Are there IEC materials (posters, Yes 1
take home brochures, flipcharts) on No 2
management of severe malnutrition
A29 Integrated Nutrition Register available? Yes 1
(Comment on their use) No 2
A30 HMIS reporting forms available? Yes 1
(Comment on their use)? No 2
A31 OPD quarterly report forms available? Yes 1
(Comment on their use)? No 2
A32 Are the monthly HMIS report 105 being Yes 1
completed correctly? List those incomplete No 2
and why
A33 Are the quarterly HMIS 106a reports being Yes 1
completed correctly? If not, why No 2

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A33 Any On job Training activities for SFC? Yes 1
No 2
A34 Is the Integrated nutrition ration card filled Yes 1
appropriately? No 2
B Progress Monitoring
B01 Is progress monitoring of the clients Yes 1
done? No 2
B02 Is progress monitoring data for the client’s Yes 1
up to-date on the client charts and SFC No 2
registers?
B03 Are there any problems with filling in Yes 1
the SFC registers and client’s cards and No 2
charts?
B04 Is the discharge criteria adhered to Yes 1
according to protocol? No 2
B05 Is a copy of the discharge criteria chart Yes 1
pinned up at the outpost? No 2
B06 Are discharged clients given discharge Yes 1
cards? No 2
B07 Is Failure to Respond to treatment Yes 1
diagnosed and managed? No 2
B08 Type of discharge written on the chart and Yes 1
register? No 2
B09 Home visit (HV) of the absent patients Yes 1
done and written on the chart and outreach No 2
health workers informed?
B10 Home visit of the Unconfirmed defaulter Yes 1
written on chart and communicated to No 2
outreach workers?
B11 Charts securely stored in order by INR No Yes 1
and registration No? No 2
B12 Monthly report sent on time? 1
2
B13 Did health and nutrition education Yes 1
sessions take place? No 2
B14 Did the topic presented to the beneficiaries Yes 1
focus on any of the following? Nutrition, No 2
childcare, immunization, GMP, seeking
health services, hygiene, IYCF, acute
malnutrition?
B15 Is routine medication and services Yes 1
provided and recorded? No 2
B16 Are IEC materials displayed at the Yes 1
outpost? No 2
B17 Is the approved food basket adhered to? Yes 1
No 2
No
B18 Is the approved ration adhered to? Yes 1
No 2
B19 Is the recommended ration days per Yes 1
distribution adhered to? No 2

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B20 Is food given to the right beneficiary Yes 1
category? No 2
B21 Is distribution done using ration cards? Yes 1
No 2
B22 Are pre-mixing and other handling Yes 1
processes hygienic? No 2
B23 Is distribution process supervised? Yes 1
No 2
B24 Did the distribution end by mid-day? Yes 1
No 2
B25 Are there accessible hand washing Yes 1
facilities with soap? No 2
F Storage
F01 The storage room/area is clean and dry. Yes 1
No 2
F02 Lighting is adequate. Yes 1
No 2
F03 The storage area is free from vermin and
rodents
F04 Is storage space adequate? Yes 1
No 2
F05 Commodities and supplies are stored on Yes 1
pallets or shelves and away from walls to No 2
protect them from dampness?
F06 Does the store have stock cards? Yes 1
No 2
F07 Does the store have other stock movement Yes 1
records? No 2
F08 Are stock store records up-to-date at the Yes 1
time of visit? No 2
F09 Are there problems with maintaining stock Yes 1
records? No 2
F10 Has there been a stock out reported in last Yes 1
12 months? No 2
F11 Commodities and supplies are stored Yes 1
according to FEFO/FIFO (first expiry first No 2
out/first in first out) procedures.
F12 Commodities and supplies are protected Yes 1
from sunlight throughout the day. No 2

Summary of key findings:

For each capacity area, identify the key findings, and recommendations. To be filled in by the
Assessor.

Key finding RECOMMENDATIONS

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This work was funded by