Integrated Management of Acute Malnutrition(IMAM) by Milan Dhakal

1. Integrated Management of
Acute Malnutrition (IMAM)
Milan Dhakal

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5. IMAM in Nepal
● 2008 – Community Based Management of Acute Malnutrition (CMAM) has
been implemented by MoHP with the help of UNICEF since 2008 in 5
districts (Achham, Bardiya, Jajarkot, Kanchanpur and Mugu).
● 2012 – IMAM- Scaled Up in 6 districts (Dhanusa, Jumla, Kapilvastu,
Okhaldhunga, Saptari and Sarlahi).
● 2015 – Emergency Response and Recovery – Earthquake affected 14
districts
● 2073/2074 – Scaled up in 10 MSNP districts (Kalikot, Humla, Dolpa,
Dadeldhura, Bajhang, Bajura, Baitadi, Panchthar, Doti, Parsa)
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6. Objectives of IMAM
The primary objectives of IMAM are:
a) To reduce mortality and morbidity risks in children under five due to acute malnutrition.
b) To rehabilitate children with acute malnutrition to a state of health in which they are able to sustain their
nutritional status upon discharge as cured.
c) To prevent the condition of children with acute malnutrition from deteriorating thus requiring more intensive
treatment.
d) Contribute to the prevention of acute malnutrition in young children in the critical 1000 day window.
e) Prevent micro-nutrient deficiency disorders among under five year old children associated with acute
malnutrition.
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8. Principles of IMAM
a) Maximum coverage and assess: IMAM is designed to achieve the greatest possible coverage by making
services accessible and acceptable to the highest possible proportion of a population in need.
b) Timeliness: IMAM prioritises early case-finding and mobilisation so that most of the cases of acute
malnutrition can be treated before complications develop.
c) Appropriate medical care and rehabilitation: Provision of simple, effective outpatient care for those who
can be treated at home and clinical care for those who need inpatient treatment. Less intensive care is provided
for those suffering from MAM.
d) Care for as long as possible: By improving access to treatment and integrating the service into the existing
structures and health system, IMAM ensures that children can stay in the programme until they have been
cured.
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9. Structure/Component of IMAM
IMAM has four components:
★ Community mobilization
★ Inpatient Therapeutic Care (ITC)/SC
★ Outpatient Therapeutic Care (OTC)
★ Management of Moderate Acute Malnutrition (MAM)=TSFP
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10. Structure/Component of IMAM
★ Community mobilization
➔ involves identification of acutely malnourished children at the community
level on an on-going basis to enable widespread early detection and
referral before the client condition deteriorates further.
➔ aims to increase coverage and maximise the effectiveness of treatment.
➔ provides an opportunity to counsel mothers/caretakers of children under
five years on IYCF practices, as well as prevent future cases of
malnutrition through behaviour change communication activities.
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11. Structure/Component of IMAM
★ Inpatient Therapeutic Care (ITC): involves management of complicated
cases of SAM according to WHO protocols on an inpatient basis at tertiary
level facilities (hospitals) or specialised units (Nutrition Rehabilitation
Homes).
★ Outpatient Therapeutic Care (OTC): involves the management of non-
complicated SAM cases in outpatient care using ready-to-use therapeutic
foods (RUTF) provided on a weekly/fortnightly basis, simple routine
medicines, and monitoring and orientation for the mothers/caretakers.
Outpatient care is offered through decentralized health structures (e.g.
health posts).
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12. Structure/Component of IMAM
★ Management of Moderate Acute Malnutrition (MAM)=TSFP: may take
two forms depending on the household food security level of the district
including in emergency context. It involves either
a) the provision of micronutrient powders (MNPs) ) where available or if the
district is MNP program district and nutrition counselling in areas where
local food is available to provide a nutritious diet for children, or
b) targeted supplementary feeding with fortified blended food plus
nutrition counselling in areas where local foods are not available. In both
cases, individual monitoring and orientation to mothers/caretakers is
provided, plus referral for any medical issues in line with CBIMNCI
protocols.
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15. Community Mobilization/Outreach
Community mobilisation/outreach is a core component of IMAM and is critical for
maximising access and coverage by removing the barriers to community
accessing the service. It must be developed at the planning stage in each district as
there will likely be differences in the structures in place between districts. The process
of community engagement is also essential prior to commencing the service to ensure it
is set up in an appropriate and sustainable manner to avoid issues later on. If mother
has problem on access to the program the FCHV and mother group will discuss and if
the problem being not solved then the issue goes up to monthly meeting of health
facilities level and discussed. Community mobilisation should primarily aim to increase
access and service uptake (coverage) of IMAM services by tapping into community level
resources and structures to make sure that as many children as possible can be
reached at the community level with timely MUAC assessments.
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16. Community Mobilization: Objectives
- Engage and empower the community by increasing knowledge and understanding on acute
malnutrition and the services available;
- Ensure widespread early case-finding and referral of new SAM and MAM cases;
- Provide appropriate nutrition education and counselling focusing IYCF and care practices;
- Follow-up on particularly at risk and problem cases; and
- Engage communities for joint problem solving on barriers to service uptake.
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17. Community Mobilization: Stages
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18. Community agents involved in case finding in Nepal
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19. Active and Passive case finding
Passive : case finding through existing points of contact within health system
Active: agents at the community level, on an ongoing basis or during existing
health/nutrition campaigns (Vitamin A campaign, immunization) actively seek
out cases.
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21. Assessment and classification of acute malnutrition
1. Assessment of children of 6-59 months
- Step 1: Determine age
- Step 2: Check for bilateral pitting oedema
- Step 3: Measure MUAC, Weight, height
- Step 4: Assessment of appetite and medical complications
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23. Appetite test
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24. RUTF
Ready-to-Use Therapeutic Food (RUTF) is an energy dense mineral/vitamin enriched food
nutritionally equivalent to F100, which is recommended by the WHO for the treatment of
malnutrition. It is oil-based with low water activity; thus it is microbiologically safe and can be
kept for months in simple packaging. Therefore, with proper hygiene instruction, RUTF can be safely
used for outpatient treatment of Severe Acute Malnutrition. As it is eaten uncooked it is an ideal
vehicle to deliver many micronutrients that might otherwise be broken down by cooking.
Composition: Vegetable fat, peanut butter, skimmed milk powder, lactoserum, maltodextrin, sugar,
mineral and vitamin complex.
1 sachet = 92 grams of product = 500 kcal.
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26. Assessment of medical complications
As per CBIMNCI protocal
Examine the symptoms mentioned in the table below
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29. Assessment of infants under 6 months
Clinical signs in infants under 6 months should be assessed in the same way as above according to CBIMNCI
procedures. In addition infants under 6 months may become malnourished if they have:
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32. Management of SAM: Outpatient Therapeutic Care
Outpatient therapeutic care is aimed at providing treatment for children with SAM who have an appetite
and have no medical complications and can therefore be treated at home with simple routine medicines
and RUTF.
Delivered through health facilities(healthpost, PHC, hospitals)
Steps involved in OTC
Step 1: Assessment of nutritional status and medical complication
First sugar water should be given to child to prevent hypoglycemia.
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36. Step 2: Admission or referral based on criteria
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37. Step 3: Medical Management/ Routine medicine
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38. Step 4: Nutrition Management
❖ Nutritional rehabilitation is through the use of Ready-to-Use Therapeutic Food (RUTF).
❖ RUTF provides a complete diet for the SAM child with the exact balance of micronutrients and
electrolytes they require.
❖ The amount of RUTF a child should consume is determined by the need for an intake of 200 kcal/ kg/
day.
❖ The amount given to each patient is therefore calculated according to its current weight and must be
adjusted as weight increases during treatment.
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39. Step 5: Orientation and counseling for the mothers/caretakers
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40. Step 6: Monitoring and follow up
★ Follow up - weekly or fortnightly
★ Things to do:
➢ Weight is measured and recorded to track progress
➢ Degree of oedema (0 to +++) is assessed and recorded
➢ MUAC is taken and recorded to track progress
➢ Medical assessment is completed as per CB-IMNCI guidelines
➢ The mother/caretaker is asked about the progress of the child
➢ Appetite is discussed and RUTF appetite test performed at each follow-up
➢ The weekly ration is calculated according to current weight and provided
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41. Step 7: Discharge from outpatient
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43. Management of SAM: Inpatient Therapeutic care
Inpatient stabilisation should be delivered from tertiary level facilities with capacity for 24 hour care and where
medical capacity is available for the treatment of complications. In some cases it may be possible for the NRH linked
to the hospital to provide this stabilisation care where there is not IMAM program.
WHO steps for management of SAM
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44. Steps involved in ITC
Step 1: Assessment of nutritional status and medical complications
Step 2: Admission or referral based on criteria
Step 3: Medical management
➢ Treat identified medical complications including critical conditions like
shock, dehydration, hypothermia, heart failure
➢ For dehydration, ReSoMal and not ORS is used for SAM cases.
Step 4: Nutrition Management
Step 5: Individual Monitoring and follow up
Step 6: Transition and discharge
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45. Step 4: Nutrition Management
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46. Initial treatment (stabilisation and transition): management of acute medical conditions
for approximately 3-7 days. It consists of medical and nutritional treatment according to WHO
recommended protocol, namely:Inpatient intensive care/medical treatment to control
infection, dehydration and electrolyte imbalance, thereby reducing the mortality risk.
Nutritional treatment which consists of very frequent feeds with F-75 therapeutic milk (10-12
feeds per day) to prevent death from hypoglycaemia and hypothermia. This phase should not
be extended beyond one week because of the limited energy content of the diet. With the
adoption of outpatient care the transition phase includes examining the possibility of
transferring eligible children to outpatient/community-based care using RUTF.
Rehabilitation: to achieve very high intakes and rapid weight gain of >10 g gain/kg/day using
the recommended milk-based F-100 which contains 100 kcal and 2.9g protein/100 ml. (WHO
1999). The “Rehabilitation Phase” can now take place on inpatient or outpatient basis
depending on the outcome of the transition phase.
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47. F75: 0.9g protein/100ml
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50. Step 5: Individual monitoring and follow up
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51. Step 6: Transition and Discharge
Transition
As soon as the medical condition of the patient is stabilised, oedema is reducing and the
complications are resolving, the transition phase is started in preparation for transfer to OTC (or in a
minority of cases to rehabilitation in inpatient care).
Transition is started by feeding the child a test dose of RUTF at alternate feeds retaining the same
feeding schedule.
If the child refuses the RUTF, the mother/caretaker is encouraged to try to get the child to start
eating at every other milk feeding.
In the meantime, F100 is continued until appetite returns and RUTF can be given at every scheduled
feed.
Monitoring continues as for the stabilisation phase and if any of the following develops the client
should return to stabilisation.
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53. Management of SAM in infants <6months
Where there is a possibility of breastfeeding the infant
The main objective is to restore exclusive breastfeeding whether by the mother, a family member or wet-nurse.
Therefore supplement the child’s breastfeeding with therapeutic milk while stimulating and supporting production of
breast milk. This same principle applies in cases where the mother is known to be HIV positive and is able and willing
to breastfeed.
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54. Infant with no possibility for breastfeeding
The aim of the treatment of infants under 6 months with SAM without the prospect of being
breastfed in Nepal is to receive F100-Diluted until they are old enough to take semisolid
complementary food in addition to adapted cow milk.
- Provide F100-Diluted for infants with severe wasting as F100-Diluted has a lower osmolality
than F75 and thus is better adapted to immature organ functions. Also, the dilution allows for
providing more water for the same energy with a better carbohydrate to lipid ratio
- Provide F75 for infants with bilateral pitting oedema and change to F100-Diluted when the
oedema is resolved.
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55. Discharge
The breastfed infant
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56. Management of MAM
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57. Strategies of MAM management
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58. Admission criteria for management of MAM
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59. Assessment of MAM
For Child
FOR PLW
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60. Nutritional Management
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61. Protocol A: Using locally available foods and micronutrients supplements
The dietary management of moderate acute malnutrition should focus on the optimal use of locally
available nutrient-dense foods to enhance the nutritional status of moderately acutely malnourished
children and protect them from becoming severely acutely malnourished. A diet largely based on plant
sources with few animal proteins do not meet these requirements and need to be improved by different
interventions. Multiple micronutrient supplementation represents one of the possible strategies to fortify
food. Similarly, key messages of IYCF should be delivered to both MAM and SAM children’s mothers and
caretakers.
Sarbottam pitho, Poshilo Jaulo
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62. Protocol B: Using Supplementary Food Ration
- Fortified Blended Foods (FBF). Eg. Super Cereals Plus
- Lipid-based Nutrient Supplement (LNS). Eg. RUSF
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63. Medical Management
Mebendazole/Albendazole is given to all children aged 12-59 months on enrolment.
If the child is ≥ 1 years and has not had Albendazole in the previous 6 months, give one dose of Albendazole 200
mg till 2 years then 400 mg after 2 years for possible hookworm or whipworm
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64. Monitoring and follow up
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65. Discharge
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