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1. Simplified Approaches for the
Detection and Treatment of Child
Wasting

2. Introduction
The term “simplified approaches” refers to adaptations to the existing national
and global protocols for the management of child wasting and are designed to
improve effectiveness, quality, coverage and reduce the costs of caring for
children with uncomplicated wasting.
The Key Adaptation are:
Family MUAC: caregivers are trained and equipped to screen their own children
for malnutrition by measuring Mid-Upper Arm Circumference and assessing for
nutritional oedema.
 Reduced Frequency of Follow-up Visits: Reducing the frequency of follow-up
visits for wasted children admitted into treatment from weekly to bi-weekly or
monthly.
MUAC and/or oedema only: Use of low MUAC (<115mm) and/or oedema as the
only criteria for admissions and discharge
Modified Dosage: dosage of treatment product is most commonly modified to: 2
sachets/day for severe wasting or nutritional oedema.

3. WASTING and NUTRITIONAL OEDEMA
WASTING and NUTRITIONAL OEDEMA are terms for acute malnutrition
in children aged 6 – 59 months, diagnosed either by low MUAC or oedema.
WASTING may be either severe (severe wasting or SAM) OR moderate
(moderate wasting or MAM). These may be identified by the color obtained
on MUAC measurement with the MUAC tape:
Severe wasting = RED on MUAC tape (<115mm) and / or WHZ <-3
Moderate wasting = YELLOW on MUAC tape (115 - < 125mm) and / or
WHZ < -2
The presence of oedema is referred to as NUTRITIONAL OEDEMA. The
treatment for this is the same as for severe wasting.

4. MUAC/Family MUAC Approach
Family MUAC refers to a community-based approach to screening for
wasting and nutritional oedema in children ages 6 - 59 months, where
caregivers are trained to measure MUAC and check for oedema regularly at
home.

5. Measuring the MUAC
MUAC tape is used to measure the size of the child’s arm. It can be used for
children between the ages of 6 -59months. To measure a MUAC pass the
green end of the tape through the rectangular slit and see which colour
appears in the window
MUAC Tape: Pic 2.
To measure MUAC pass the green end of the
tape through the rectangular slit and see which
colour appears in the window (Pic 2)
To check the exact MUAC measurement in
mm by identifying the measurement aligned
with the arrow in the window.

6. MUAC measurement procedure
Wash your hands or apply hand sanitizer to your hands. Explain that is it
important to do this before you start and at the end of the procedure.
Tell the caregiver that they are going to measure the size of their child’s upper
arm, that it is a quick and painless procedure which will help us determine
whether the child is well nourished and growing well
Measure around the mid-point of the child’s upper arm, i.e. halfway between
the shoulder and elbow. This mid-point can be estimated visually.
Wrap the tape around the doll’s arm / pipe / bamboo and pass the pointed
green end of the tape through the rectangular slit.
In children, the arm should ideally be hanging down and relaxed (refer to the image)
Pass the pointed green end of the tape through the rectangular slit, pull the
tape until it fits snugly against the child’s skin. (continued)

7. MUAC measurement procedure - continued
Explain the tape should not be too loose or too tight (refer to the image)
While holding the white end of the MUAC, read the color
in the window, between the two arrows.
To ensure accuracy, emphasize that the measurement
must be performed twice, to ensure accuracy.
Finally read the measurement in mm that is aligned with
the arrows.

8. Measuring Oedema
Oedema occurs when excess fluid collects under the skin, making the child appear
swollen. There are various causes but one of the most common causes in this age
group is a lack of nutrition, particularly protein. In these children, the presence of
oedema is a sign of nutritional oedema. The treatment is the same as for severe
wasting (i.e. when the MUAC tape result is RED.
For Measuring Oedema:
Wash your hands or apply hand sanitizer .
Inform the caregiver that they are going to check for swelling
of their child’s feet to help determine whether the child
is healthy and well nourished.
Ensure that the child is comfortable.
They can remain in the caregiver’s arms during the check for oedema.
Press both thumbs down on the tops of the child’s feet, for three seconds,
as shown in the picture below:

9. Measuring Oedema (continued…
Use the pads of both thumbs aiming for the soft fleshy area above the 2nd and 3rd
toes. Place the remaining 4 fingers beneath the child’s feet, as shown in the picture.
After three seconds, release both thumbs. If a depression remains in the place where
you have pressed*, three or more seconds after you have released your thumbs, that
means that oedema is present
If there is oedema present in only one foot, the cause may not
be
nutritional oedema, but the caregiver should still be instructed
to
seek medical help as soon as possible.
If the child is distressed, it may not be possible to check both
feet
simultaneously. In that instance, use the following technique to
check one foot at a time: use the non-dominant hand to steady
the
foot and ankle by holding gently but firmly behind the ankle,
and

10. Summary of Findings

11. Reduced Frequency of Follow-Up Visits
Potential benefits to the service:
Reduces pressure on the service e.g. if human resources are limited and / or there is high
demand. Saves time, money and conflict with work and family.
Allows health workers to focus more of their attention on acutely sick children.
Allows health workers in the nutrition treatment center to spend more time in counselling
and educating caregivers on RUTF use in the home, nutrition advice and infants and
young child feeding; more time for reporting and generally improve the quality of care
provided at the center.
Assess for Reduced Frequency of Follow-Up Visits?
Severe or moderate wasting / nutritional oedema (+ / ++) with NO DANGER SIGNS
(listed in the next Slide).
 Pass the appetite test.
The caregiver should be instructed to seek help if they feel that their child is unwell or “not
right” compared to their normal self.
Reduced Frequency of Follow-Up Visits refers to a modified follow-up schedule. MUAC
<115mm or nutritional oedema + / ++ - Follow up required every 4 weeks

12. Danger Signs
DEFINITION OF TERMS: A danger sign is a
problem that the child has that means that
they could be seriously ill.
Danger signs are picked up by asking the
caregiver specific questions and examining
the child for specific abnormalities.
An infant or child with a danger sign should be
urgently referred to the nearest medical facility
that can treat sick children.
Some conditions require pre-referral treatment
by the health worker (refer to national IMCI /
ICCM guidelines).
Some danger signs are:
1. Cough for 14 days or more
2. Diarrhoea for 14 days or more (or > 6 episodes
in 1 day)
3. Blood in stool
4. Fever for 7 days or more
5. Vomits everything
6. Unable to breastfeed or drink
7. Convulsions
8. Chest in-drawing
9. Unconscious or abnormally sleepy
10. Palmar pallor
NUTRITIONAL DANGER SIGNS
11. MUAC < 90mm
11. Oedema +++
12. Oedema (+ / ++ / +++) PLUS wasting (severe /
moderate)

13. Simplified Treatment Protocols for SAM
Simplified treatment protocols use MUAC and edema only as admission and discharge
criteria (no weigh or height), and a modified dosage of RUTF (2 sachets/day).
Objectives of simplified approaches for management of wasting:
Target children with acute malnutrition who are at highest risk of mortality.
Simplify and streamline the admission process for treatment programs; facilitate CHW-
led treatment; align community-based screening methods with program admission
criteria; reduce contact in the context of COVID-19 protocols by suspending weight
and height measurements.
Delivering treatment at dosages that align with growth expectations and energy needs
(modified dosage)
 Ensuring that wasted children do not experience ‘breaks’ in treatment, minimizing
dropouts and loss to follow-up

14. Admission Criteria
< 115mm = RED = severe wasting
 AND/OR mild or moderate bipedal oedema (+/++).
 AND clinically uncomplicated (i.e. passes appetite test, no Emergency / Priority
signs
(Appetite Test: When the child is able to consume 1/3 of the RUTF packet in 30
minutes) other than Malnutrition or Oedema /no serious medical complications).
Note: This protocol is for outpatient nutritional treatment and not suitable for
children with severe oedema +++ ( generalized body oedema), and/or concurrent
wasting by MUAC and oedema (+/++/+++). This should trigger inpatient referral /
admission for resuscitation, stabilisation and inpatient treatment.

15. Assessment for Medical Complication(s)
Emergency
 obstructed or absent breathing
severe respiratory distress
 signs of shock
Reduced Level of Consciousness’
Convulsions
 Signs of severe dehydration in a child with diarrhoea (advise caution is
assessing hydration status in children with wasting or oedema
If Malnutrition or Oedema are present on triage, but no other danger signs, progress to the next step
of the protocol which will be to assess the degree of wasting or oedema

16. Appetite Test
For wasting or nutritional oedema admission, give all children an appetite test on
admission to find out whether they can eat RUTF (1/3 of the sachet). For wasting
or nutritional oedema at follow-up, administer appetite tests during subsequent
treatment visits if there is reason to believe the child does not have a good
appetite.
Failed appetite test = referral to nearest nutrition centre / inpatient treatment at
the same facility.

17. Treatment Frequency
RED MUAC (<115mm and/or bipedal oedema (+/++)
Every 4 weeks for children admitted with wasting until discharge ( Refer to the
reduced frequency vistis)
Note: Emphasize weekly at-home MUAC and oedema assessment and timely care
seeking in the event of any MUAC deterioration or illness that occurs between
scheduled follow-up visits.

18. Nutritional treatment with RUTF/Dosage
For severe wasting or nutritional oedema, the patients may be on a weight-based
or modified regimen of RUTF.

19. Transition from severe wasting to moderate wasting
When a child improves from severe
wasting or nutritional oedema to
moderate wasting, for two
consecutive measurements, at or
above 115mm and no oedema, they
will be given Ready to Use
Supplementary Food as per
protocols and Visits will be scheduled
accordingly.
However, if the child regresses to severe
wasting or develops oedema or the MUAC
goes below 115mm mark the Health Care
Worker may transfer for additional nutrition
assessment and transfer back to SAM
treatment

20. Routine Medical Treatments
For child admitted with severe wasting and/ or nutritional oedema:
RED MUAC (<115mm and/or bipedal oedema (+/++)
Amoxicillin: Give first dose at health facility and then give remainder to caregiver
with instructions to give twice daily for 7 days
6-11 months: 250mg
12-59 months: 500mg
Deworming: Single dose (albendazole) on the second visit (children >1 year)
12-23 months: 200mg
24-59 months: 400m

21. Discharge Criteria
Cured MUAC <115mm and no oedema
Default Absent on monthly Visit)
Non- recovered Has not achieved discharge criteria within 16 weeks ( 4 months)
Referred Danger sign or other medical complication detected.
Referral could be to the inpatient department / resuscitation area of
the
same facility or to the “next-level” facility (with ability to treat higher
acuity patients +/- specific pediatric expertise).
Transfer Health center may refer patients to a Stabilization center/inpatient
care at district or provincial hospital.
Following this further assessment at the nutrition center, a health
worker may recommend that the child is transferred back to the
original facility to resume treatment.

22. Discharge Criteria
Transfer
Criteria:
Transfer to the nearest stabilization centre is recommended for
children ‘not responding to treatment’.
This can be defined as: Severe wasting or nutritional oedema with :
 Weight loss since admission: 7 days.
Failure to gain weight (non-oedematous): 14 days.
 Weight loss (non-oedematous children) on monthly visit.
No reduction of oedema: 14 days
Failure of the appetite test: any visit.
Oedema still present: 21 days
Moderate wasting
No weight gain after 6 weeks.
 Weight loss for more than 4 weeks
Discharge: MUAC and oedema assessment, danger signs and care-seeking,
and other health education as appropriate.
Transfer to MAM