This document outlines the setup and operation of a specialist nutrition clinic in Ghana. It discusses the purpose of such a clinic, which is to monitor and treat malnutrition, identify causes, and prevent relapse. It describes the types of malnutrition cases seen, including severe wasting and stunting. Key aspects of running the clinic are detailed, such as the multi-disciplinary team, assessment process, anthropometric measurements, counseling and follow up. Challenges include high rates of defaulting from care. The clinic has helped improve outcomes for malnourished children.

1. Setting up a specialist nutrition clinic
and case reports from the community
By Dr. Mame Yaa Nyarko
1/13/2023
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2. Outline
• Introduction
• Purpose of a malnutrition clinic
• The PML experience
• Challenges
• Lessons learned
• Recommendations
• Conclusion
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3. 1/13/2023 3
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4. Introduction
• Globally malnutrition
continues to contribute to
mortality and morbidity
among children especially
those under 5 years
• For years malnutrition(under-
nutrition) contributes to about
45% of under 5 mortality (1)
• Triple burden of malnutrition
occur globally among
populations and Ghana is
inclusive
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5. Why the malnutrition clinic
• The burden of the problem globally, nationally and locally
• To determine the possible association / cause of the malnutrition
• To identify any long term effect
• To monitor developmental outcomes
• To watch out for relapse and prevent recurrence in other siblings
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6. Why a
malnutrition
clinic?
• Global burden
2018
• 149 million
children under 5
stunted
• 49 million severely
wasted and
17million severely
stunted
• 40 million under 5
overweight
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7. 1/13/2023
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8. UNICEF/WHO DATA
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9. Ghana -2014
• under-five overweight is
2.6%, which has increased
slightly from 2.5% in 2011.
• under-five stunting is
18.8%, which is less than
the developing country
average of 25%.
• under-five wasting
prevalence of 4.7% is also
less than the developing
country average of 8.9%.
Sources: UNICEF global databases Infant and Young Child Feeding,
UNICEF/WHO/World Bank Group: Joint child malnutrition estimates,
UNICEF/WHO Low birthweight estimates, NCD Risk Factor
Collaboration, WHO Global Health Observatory 1/13/2023
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10. Nutritional status of children U5 in Ghana
Indicator on Nutritional
status
2008 GDHS (%) 2014 GDHS (%)
Stunting 28 19
Severe stunting 10 5
Underweight 14 11
Severe underweight 5 2
Wasting 9 5
Severe wasting 1 <1
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11. INPATIENT CASES OF
MALNUTRITION-DISTRIBUTION
BY SEX- 3 year trend in PML
Indicator 2016 2017 2018
Male
168
(50.8%)
259
(48.1%)
272
(47.6 %)
Female
163
(49.2%)
280
(51.9%)
300
(52.4 %)
Total 331 539 572
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12. CONDITIONS MANAGED BY DIETICIANS- HALF
YEAR TRENDS PML data
INDICATORS 2017 2018 2019
Non Oedematous
SAM
99 (38.2%) 121 (49.6%)
181 (56.74%)
Oedematous SAM 15 (5.8%) 12 (4.9%) 15 (4.70%)
MAM &
Underweight
128 (49.4%) 92 (37.7%)
104 (32.61%)
Overweight 5 (1.9%) 9 (3.7%) 7 (2.19%)
Poor feeding 6 (2.3%) 2 (0.8%) 6 (1.88%)
Other 6 (2.3%) 8 (3.3%) 6 (1.88%)
Total 259 244 319 (100)
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13. OUTCOME OF CASES ADMITTED (half year )
INDICATOR 2017 2018 2019
No. treated and
discharged
181 (87.4%) 160 (80.8%)
189 ( 83.2%)
No. absconded 8 (3.9 %) 13 (6.6%) 9 (4%)
No. died 12 (5.8%) 19 (9.6%) 17 (7.5%)
No. referred out 6 (2.9%) 2 (1.0%) 7 (3.1%)
No. still on
admission
0 4 (2.0%)
5 (2.1%)
Total no. of pt.
admitted
207 198
227
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14. MALNUTRITION – BEFORE & AFTER
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15. CASE 2 BEFORE
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16. CASE 2 - AFTER
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17. Pathogenesis
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18. Long term consequences
• Learning difficulties in school
• Earn less as adults, and face barriers
to participation in their
communities.
• Never develop their full cognitive
potential
• Developmental delays
Levels and trends in child malnutrition UNICEF
/ WHO / World Bank Group Joint Child
Malnutrition Estimates Key findings of the
2019 edition
Chronic /
acute
malnutrition
Stunting/
wasting
Recurrent
infections/ poor
weight gain/
weight faltering
Long term
cognitive/
intellectual
impairment
Adult
potential
not
achieved
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19. Who runs the clinic
• Team approach
• Doctor led vrs Dietician led
• Paediatrician( general/ public health/
gastroenterologist/nutritionist)
• Dietician
• Nurse
• Nutrition Officer
• Community health nurse
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20. What do you
do at the
clinic ?
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21. What is
done at
the clinic
History
Anthropometry
Physical
Assessment
Counselling
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22. Assessment tool
• General Information
• Date of first visit: ……/…/…… Clinic Number: ……………….. Folder
number…………………
• Name of Child: ……………………………………………………….………
• (i) Child's date of birth :……../………../……….( day/month/year) [ ] Not known
• (ii) Child's age (years to the nearest 6months)……………………………….
• (iii) Child's gender [ ] male [ ] female
• (iv) child's father’s ethnic background
• [ ] Akan ( Asante, Fante, Akwapim, Kwahu, Bono, Nzema, Other)
• [ ] Northern Tribes (Dagbani,
• [ ] Ga / Adangbe [ ] Ewe
[ ] Other (please specify
• (V)child’s mother’s ethnic background
• [ ] Akan ( Asante, Fante, Akwapim, Kwahu, Bono, Nzema, Other)
• [ ] Northern Tribes (Dagbani,
• [ ] Ga / Adangbe [ ] Ewe
• [ ] Other (please specify)…………………………..
• (v) Caregiver’s (person currently looking after child)religious background.
• [ ] Christianity [ ] Islam
• [ ] African Traditional Religion
• [ ] Other (pls specify)………………
• (vi) Birth order of this child (e.g. 1st, 2nd etc): ……………………………
• (vii) Birth weight (from child health records) ………………………………
• Birth weight (child health records not available)……………………….
• Do not know birth weight [ ]
• (viii) Number of children born alive by mother including this child: …………
• (ix) Immunisation history: complete for age [ ] Yes [ ] No
•
Remarks:………………………………………………………………………………………………
….
• (x) Is this child in school? [ ] Yes [ ] No
• If yes, [ ] Preschool [ ] School age
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23. Assessment tool
• B. Social History
• (i) Who is the main person completing this form?
• 1. [ ] Mother 2. [ ] Father
• 3.[ ] Other adult female (please specify relationship to child) ………………….
• 4.[ ] Other adult male(please specify relationship to child) …………………..
• (ii) Do both parents of this child live together? [ ] Yes [ ] No
• (iii) Do both parents contribute to this child’s upkeep? [ ] Yes [ ] No
• (iv) Are the primary caregivers the biological parents of this child [ ] Yes [ ] No
• (v) If no, please specify the relation. ……………………………………..
• (vi) Age of mother (in years) [ ]
• (vii) if mother in unavailable current caregiver’ s age [ ]
• (viii) Father’s occupation……………………………………………
• (ix) Educational background of father [ ] primary/ JHS [ ]
secondary/SHS/Vocational [ ] Tertiary
• (x ) Mother’s occupation …………………………………………………
• (xi) Educational background of mother [ ] primary/ JHS [ ]
secondary/SHS/Vocational [ ] Tertiary
• (xii) Primary caregiver’s occupation (if it is not the parents)
…………………………………………………..
• (xiii) Educational background of primary caregiver
• [ ] primary/ JHS [ ] secondary/SHS/Vocational [ ]
Tertiary
• (xiv) Income of father/male caregiver
• 1. GHC< 100 2. GHC100-200 3. GHC >200-500
• 4. GHC >500-1000 5. GHC >1000-5000 6. GHC
>5000
• 7. Do not know
• (xv) Income of mother/female caregiver
• 1. GHC< 100 2. GHC100-200 3. GHC >200-500
• 4. GHC >500-1000 5. GHC >1000-5000 6. GHC
>5000
• 7. Do not know
•
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24. Assessment tool
c. Admission history (from folder or at time of
admission)
• (i) Presenting compliant……………………………………
• (ii) Reason for admission:
……………………………………………………………………
• Severe vomiting
• Hypothermia ( temp<35°C axillary and <35.5°C rectal)
• Fever >38.5°C
• Respiratory – pneumonia, tachypnea, dyspnea
• Extensive infections
• Very weak, apathetic and unconscious
• Convulsions
• Severe dehydration from both history and clinical features
• Severe pallor
• Any condition that requires IV infusion or NGT feeding
• Other conditions
(specify)…………………………………………………………….
• If under nutrition (move to question (iii),
• (iii) Feeding : [ ] well [ ]
poorly [ ] not at all
• (iv) What feed is the child on?
• [ ] breast milk only [ ] RUTF
[ ] Modified family foods
• [ ] Infant formula
• [ ] cereals e.g. koko, tombrown, cerelac [ ]
Others, pls specify ………………
• Is child taking adequate amounts? [ ] Yes [ ]No
• Any food taboos? If yes, please
specify……………………………………………………………………
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25. Assessment tool
Item 1x/day 2x/ day 3x/day 4x/day
Main meals
Snacks
Sugary drinks
Fruits
Vegetables
d. Physical activity
• How many hours per week does your
child spend on the following?
(i) Screen time (TV, Laptop, Tablet) [ ]
<2hrs/day [ ] 3-5hr/day
• [ ] 1-3hr/3days/wk[ ] <2hr/week
(i) Moderate exercise (e.g. brisk walking,
cycling, jumping, ampe)
• [ ] <60mins/ day [ ] 60mins/ day
[ ] > 60mins/day
(i) Vigorous exercise (sports e.g. football,
track sports)
• [ ] < 30 mins/day [ ] >30mins/day
[ ]60mins/day
if over nourished move to question (vii)
(vii)How many times does your child take the
following:
(viii)Examples of snacks
……………………………………………………………………….
(ix) Examples of fast food
……………………………………………………………………
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26. Assessment tool
(i) Developmental history:(Refer to developmental milestone chart)
• Gross Motor skills:
…………………………………………………………………………………………………………
• ……………………………………………………………………………………………………………
• Appropriate for age? [ ] Yes [ ] No
•
• Fine motor skills:
………………………………………………………………………………………………………….
• …………………………………………………………………………………………………………………
• Appropriate for age? [ ] Yes [ ] No
•
• Speech and Language:
………………………………………………………………………………………………..
• …………………………………………………………………………………………………………………
• Appropriate for age? [ ] Yes [ ] No
•
• Vision and Hearing:
………………………………………………………………………………………………………..
• …………………………………………………………………………………………………………………
…………………….
• Assessment:
• (vi)Diagnosis at admission:
………………………………………………………………………………….
•
• (vii) Anthropometric Measurement at time of admission:
• Weight: [ ][ ]. [ ] kg Length/Height: [ ][ ]. [ ] cm MUAC: [ ][ ]. [ ] cm
• WFL/WFH z score ………… BMI:
• (viii) Date of admission ……………………..
• (ix)Duration of stay: ……………………… (in days)
• (x) Final diagnosis ……………………………………………………….
• Follow up: [ ] Yes [ ] No
• (Please follow up for the first 5 years of life. Initial visits can be 1-2 weekly
and then monthly and increase interval as child remains more stable)
• e. Additional Information
i. Any other co morbidities? If yes, please
specify………………………………………………………….
…………………………………………………………………………………………………………………
ii. Examples: referral to other specialists and other disciplines
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………
iii. Record any laboratory tests done at admission and any further interventions e.g.
Anaemia- transfused or haematinics given; monitor response.
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27. New visit
• Please fill current history form at each visit.
• New visit (undernutrition)
• f. Current history and assessment
• Date: ……………….
i. Scheduled visit: [ ] Yes [ ] No If no reason for today’s visit
………...............
ii. Weight [ ][ ]. [ ] kg Length [ ][ ]. [ ]
MUAC [ ][ ]. [ ]cm
iii. Feeding: [ ]Yes [ ]No
iv. What feed is the child on?
• [ ] breastmilk only [ ] RUTF [ ] Modified family foods
• [ ] Infant formula
• [ ] cereals e.g. koko, tombrown, cerelac [ ]Other’s pls specify
………………
(i) Is child taking adequate amounts? [ ] Yes [ ]No
(ii) Any food taboos? If yes, please specify
………………………………………………………………..
(i) Developmental history:(Refer to developmental milestone
chart)
• Gross Motor skills:
………………………………………………………………………………………
• ………………………………………………………………………………………
• Appropriate for age? [ ] Yes [ ] No
•
• Fine motor skills:
………………………………………………………………………………………
• ………………………………………………………………………………………………
……………………………………..
• Appropriate for age? [ ] Yes [ ] No
•
• Speechand Language:
……………………………………………………………………………………………
• Appropriate for age? [ ] Yes [ ] No
• Vision and Hearing:
………………………………………………………………………………………………
………..………………………………………………………………
• Assessment:
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28. PML experience
• The malnutrition clinic was started on the 6th of February, 2018 to follow up on
growth and development of children who have been treated for malnutrition,
especially Severe Acute Malnutrition (SAM) up to the age of 5 years.
• Enrolled in the clinic currently are children who have been stabilized, some of
whom are still undergoing nutrition rehabilitation on outpatient basis and a few
who have successfully been rehabilitated.
• End of 2018- 48 registered clients between the ages of 6 months and greater
than 5 years.
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29. PML experience
• Majority (43.8 %) of them are between 6 months and 11 months. Only 4 % of
them are older than 5 years.
• Females (62.5 %) are more than males (37.5 %).
• More clients were registered in March (20.8%) and April (22.9%) than the other
months.
• Three (3) of the children who were enrolled in the clinic in 2018 died. Two (2)
of them were retro positive and one (1) had Congenital Heart Disease.
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30. MALNUTRITION CLINIC
Clinic is run every Friday
with the doctors, dietitians,
nutritionists and nurses at
RC ward
This half year
recorded a total of
21 patients
12 active for visits,
9 inactive
Reasons for inactivity are; no tracking
contacts, no responses to visit calls, travelling,
not in catchment area, etc.
In addition o the previous
years’, we have a total of
90 patients
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31. GCPS CPD 1/13/2023 31

32. 1/13/2023
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33. CHALLENGES
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34. STAFF STRENGTH
RANK 2017 2018 2019
PRINCIPAL DIETITIAN 1 1 1
DIETITIAN 0 0 1
INTERN DIETITIANS 3 2 2
DIET COOK
SUPERVISOR
2 2 1
TOTAL 6 5 5
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35. CHALLENGES
1. Staff attrition
2. Non availability of
RUTF
3. Lack of appropriate
developmental
assessment tools
4. Funding for parents/
caregivers
5. No tracking of contacts
6. No responses to calls
for follow up
7. Travelling, not in
catchment area
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36. Pt MA,8 months, who lives with both parents at Domi , is the 2nd born of both parents. came in with a
MUAC of 7.6cm, wt 4.06kg, stayed for 3 weeks and went home with a weight of 5.04kg and MUAC of 10.5
cm.
BEFORE STABILISATION AFTER STABILISATION
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37. Pt JO, an 8 months who lives with mother at Madina, is the only child of both parents. Came in
with a MUAC of 8.7cm, weight 4.92kg, stayed for 3 weeks and went home with a weight of 5.05
kg and MUAC of 8.9 cm
BEFORE STABILISATION AFTER STABILISATION
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38. Lessons learned
• Dedicated team is key to success of the clinic
• Social support to many families will provide better
outcomes
• Need for country specific developmental milestones or
adapt one from similar setting(Malawi study- MDAT)
• Dietician or nutritionist led clinic is an option if there
aren’t many paediatricians or doctors
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39. Recommendations
• Malnutrition clinic is important in the management of nutritional problems in
children because
1. Gives a better understanding of the nutritional problems that confront us
2. Helps us monitor the progress of the children during rehabilitation phase
3. Helps us to identify any neurodevelopmental challenges or delays
• A team approach is the best
• Include CHN to help in home visits and follow up
• There should be support for caregivers who are assessed as needy
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40. Conclusion
‘Good nutrition
allows children
to survive, grow,
develop, learn,
play, participate
and contribute –
while
malnutrition robs
children of their
futures and
leaves young
lives hanging in
the balance. ‘
(Joint Malnutrition estimates 2019)
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41. Acknowledgement
• Ms. Susan Combey
• Ms. Priscilla Tette- Donkor
• Ms. Charity Acheampong
• Dr. Edem Tette
• Children and caregivers PML hospital who allow us to care for them and allow
us to take pics
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42. References
1. Levels and trends in child malnutrition UNICEF / WHO / World Bank Group Joint Child Malnutrition
Estimates Key findings of the 2019 edition
2. Gladstone M, Lancaster GA, Umar E, Nyirenda M, Kayira E, et al. (2010) The Malawi Developmental
Assessment Tool (MDAT): The Creation, Validation, and Reliability of a Tool to Assess Child
Development in Rural African Settings. PLoS Med 7(5): e1000273.
doi:10.1371/journal.pmed.1000273
3. PML annual report 2018 and half year report fro Jan-Jun 2019
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43. Thank you
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