INTEGRATED MANAGEMENT OF MALNUTRITION IN CHILDREN UNDER 5 FINAL[1].pdf

INTEGRATED MANAGEMENT OF
MALNUTRITION IN CHILDREN
UNDER 5
Manual for Health Care Providers
JABATAN KESIHATAN NEGERI PAHANG

1
INTEGRATED MANAGEMENT OF MALNUTRITION IN CHILREN UNDER 5
1.0 INTRODUCTION
1.1 Classification of Malnutrition 3
1.2 Recognizing Severe Malnutrition 4
WHO weight-for-length/height CHARTS
Boy (Weight- for-Length) Birth -2 yrs old 7
Boy (Weight for Height) 2-5 yrs old 8
Girl (Weight for Length) Birth -2 yrs old 9
Girl (Weight for Height) 2-5 yrs old 10
2.0 OUTPATIENT ASSESSMENT AND MANAGEMENT IN
HEALTH CLINICS
2.1 Check for Malnutrition
a. Determine weight for age 11
b. Look for visible severe wasting 12
c. Look and Feel for oedema of both feet 13
2.2 FLOWCHART for Integrated Management of Malnutrition in Children Under 5
in Health Clinics
14
2.3 Feeding recommendations 22
2.4 Assess the child’s feeding 29
2.5 Identify feeding problems 37
2.6 Counsel Feeding 39
2.7 Use good communication skills 43
2.8 Use A Mother’s card 47
MOTHER’S CARD 48
2.9 Referral guidelines for the child with low birth weight by MO/FMS 50
3.0 HOSPITAL MANAGEMENT
3.1 TRIAGE CHART: TRIAGE OF ALL SICK CHILDREN 51
Chart 1: Management of shock in children with severe malnutrition 53
Chart 2: Management of severe or some dehydration without shock 54
Chart 3: Initial Refeeding with starter feed F-75 55
3.2 INPATIENT MANAGEMENT
3.3 Monitoring and treatment of Severe Malnutrition 57
a. Shock 58
b. Hypoglycaemia 58
c. Hypothermia 58
d. Dehydration 59
CONTENTS

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e. Infections 59
f. Parasitic worms and treatment 60
g. Electrolyte Imbalances 60
h. Micronutrient Deficiencies 61
i. Initial Refeeding 63
j. Catch-up Growth Feeding: Chart 4 63
k. Emotional and Sensory Stimulation 64
3.4 Treatment of Associated Conditions
a. Severe Anaemia 64
b. Skin lesions in Kwashiokor 65
c. Continuing Diarrhoea 65
i.Giardiasis 65
ii Lactose Intolerance 65
iii Osmotic Diarrhoea 65
4.0 SEVERE ACUTE MALNUTRITION IN INFANT LESS
THAN 6 MONTHS OLD
66
5.0 DISCHARGE AND FOLLOW UP
5.1 Discharge Criteria 66
5.2 Follow up 67
6.0 COMMUNITY NUTRITIONAL REHABILITATION
6.1 Nutritional Rehabilitation Programme 68
6.2 Notification of the child with severe malnutrition who is admitted into hospital 69
6.3 Follow up of the child with severe malnutrition who is discharged from
hospital
71
6.4 Follow up of the child with severe malnutrition whose parents refuse hospital
admission
74
APPENDICES
Notification form for the child with severe malnutrition who is admitted into
hospital
75
Discharge Checklist 77
Ready to Use Therapeutic Food (RUTF) 78
F-100 Formula 79
F-75 Formula 80
Recipe for ReSoMal 80
REFERENCES 81
ACKNOWLEDGEMENTS 82

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1.0 : INTRODUCTION
Malnutrition is a significant factor in approximately one third of the nearly 8 million deaths in
children who are under 5 years of age worldwide1
.
Severe malnutrition is both a medical and a social disorder. Malnutrition is the end result of
chronic nutritional and, commonly, emotional deprivation by carers who, because of poor
understanding, poverty or family problems, are unable to provide the child with the nutrition and
care the child needs. Successful management of the severely malnourished child requires that
both medical and social problems be recognized and corrected2
.
Children with severe malnutrition are at risk of several life-threatening problems like
hypoglycaemia, hypothermia, serious infection, and severe electrolyte disturbances. Because of
this vulnerability, they need careful assessment, special treatment and management, with regular
feeding and monitoring. Their treatment in hospital should be well organized.
1.1 : CLASSIFICATION OF MALNUTRITION 2
CLASSIFICATION
MODERATE MALNUTRITION SEVERE MALNUTRITION
(Type)
Symmetrical oedema NO YES
(Oedematous Malnutrition, or
kwashiorkor)
Weight-for-Height
(z-score)
-3 < SD score < -2
( z score below -2)
SD score < -3 ( z score below -3)
(Severe Wasting)
Height-for-Age -3 < SD score < -2 SD score < -3
(Severe Stunting)
* Stunted children have a milder, chronic form of malnutrition and usually do not require hospital admission unless
they have a serious illness. They may be satisfactorily managed in the community.

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1.2 : RECOGNIZING SEVERE MALNUTRITION 2,5
Severe malnutrition is characterized by the presence of:
Marasmus - visible severe wasting*, weight for length/ height (z score) of < -3
(refer to Z-score chart) OR
Bipedal oedema (indicating kwashiorkor)
* Visible severe wasting can be recognized by muscle wasting, especially in the gluteal region;
loss of subcutaneous fat; and prominence of bony structures, particularly ribs.
Children with severe acute malnutrition should first be assessed with a full clinical examination
to confirm whether they have any general danger sign, medical complications and an appetite.

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INITIAL ASSESSMENT4
HISTORY TAKING
Assess for general danger signs or emergency signs and take a history concerning:
 recent intake of food and fluids
 usual diet before the current illness
 breastfeeding
 duration and frequency of diarrhoea and vomiting
 type of diarrhoea (watery/bloody)
 loss of appetite
 family circumstances
 cough > 2 weeks
 contact with TB
 recent contact with measles
 known or suspected HIV infection/exposure.
PHYSICAL EXAMINATION
On examination, look for:
 shock: lethargic or unconscious, with cold hands, slow capillary refill (>3sec), or weak (low
volume), rapid pulse and low blood pressure
 signs of dehydration
 severe pallor
 bilateral pitting oedema
 eye signs of vitamin A deficiency:
- dry conjunctiva or cornea,
- Bitot spots
- corneal ulceration
- keratomalacia
(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)
 localizing signs of infection, including ear and throat infections, skin infection or pneumonia
 signs of HIV infection
 fever (temperature ≥ 37.5 °C) or hypothermia (rectal temperature < 35.5 °C)
 mouth ulcers
 skin changes of kwashiorkor:
- hypo- or hyper- pigmentation
- desquamation
- ulceration (spreading over limbs, thighs, genitalia, groin and behind the ears)
- exudative lesions (resembling severe burns) often with secondary infection (including
Candida)

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DETERMINE WEIGHT-FOR-LENGTH/HEIGHT Z-SCORE
The weight-for-length/height is a growth indicator that relates weight to length (for children
less than 2 years old) or height (for children age 2 years and older).
The z-score is a score that indicates how far a measurement is from the median. Also known as
standard deviation (SD) score.
The reference lines on the growth charts (labeled 1, 2, 3, -1, -2, -3) are called z-score lines; they
indicate how far points are above or below the median (z-score 0). Weight-for-height below-3
z-score is a highly specific criterion to identify severely acutely malnourished infants and
children.
To determine weight-for-length/height z-score.
1. Calculate the child's age in years and months.
2. Weigh the child. Babies should be weighed naked and older children should remove all
but minimal clothing, such as their underclothes.
3. Measure the length/height of the child. Depending on a child’s age and ability to stand,
measure the child’s length or height. A child’s length is measured lying down
(recumbent). Height is measured standing upright.
If a child is less than 2 years old, measure recumbent length.
If the child is aged 2 years or older and able to stand, measure standing height.
In general, standing height is about 0.7 cm less than recumbent length. This difference was taken into
account in developing the WHO growth standards used to make the charts in the Growth Record.
Therefore, it is important to adjust the measurements if length is taken instead of height, and vice versa.
- If a child less than 2 years old will not lie down for measurement of length, measure standing height and
add 0.7 cm to convert it to length.
- If a child aged 2 years or older cannot stand, measure recumbent length and subtract 0.7 cm to convert it
to height.
4. To plot weight-for-length/height: (Select the correct age and gender chart)
Plot length or height on a vertical line (e.g.75 cm, 78 cm). It will be necessary to round
the measurement to the nearest whole centimeter (i.e. round down 0.1 to 0.4 and round up
0.5 to 0.9), and follow the line up from the x-axis to wherever it intersects with the
weight measurement.
Plot weight as precisely as possible given the spacing of lines on the chart.
5. Decide where is the point in relation to the z scores lines.
Read points as follows:
 A point between the z-score lines -2 and -3 is z-score “below -2.”
 A point between the z-score lines 2 and 3 is z-score “above 2.”
 A point below the -3 z-score line is z-score “below -3”. This child has weight-for-
length/ height z-score below -3 and therefore has severe malnutrition.

7

8

9

10

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2.0 : OUTPATIENT ASSESSMENT AND MANAGEMENT OF MALNUTRITION IN
CHILDREN UNDER 5 IN HEALTH CLINICS
2.1 : CHECK FOR MALNUTRITION
Assess ALL children for malnutrition by the following:
a) Determine weight for age
b) Look for visible severe wasting
c) Look and Feel for oedema of both feet
a) Determine weight for age.
Weight for age compares the child's weight with the weight of other children who are the same
age and gender. You will identify children whose weight for age is below the bottom curve of a
weight for age chart (red zone in the Child Health Book weight from age growth chart) and those
between the -2 and -3 SD (yellow zone).
The children whose weights are in the yellow zone are low weight for age. They need special
attention to how they are feed and to prevent them from becoming very low weight and
developing severe malnutrition.
The children who are in the red zone are very low weight and they may have severe
malnutrition.
To determine weight for age:
1. Calculate the child's age in months.
2. Weigh the child. Use a scale which you know gives accurate weights. The child should
wear light or clothing when he is weighed. Ask the mother to help remove any coat,
sweater, diapers or shoes.
3. Use the weight for age chart (for girls/ boys) to determine weight for age.
Look at the left-hand axis to locate the line that shows the child's weight.
Look at the bottom axis of the chart to locate the line that shows the child's age in
months.
Find the point on the chart where the line for the child's weight meets the line for the
child's age.
4. Decide if the point is above, on, or below the bottom curve.
- If the point is below the bottom curve (red zone) the child is very low weight for age.
- If the point is above or on the bottom curve, and between -2 SD and -3 SD (yellow
zone) the child is low weight for age.

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b) LOOK for visible severe wasting
A child with visible severe wasting has marasmus, a form of severe malnutrition. A child has
this sign if he is very thin, has no fat, and looks like skin and bones. Some children are thin
but do not have visible severe wasting. This assessment step helps you identify children with
visible severe wasting who need urgent treatment and referral to a hospital.
To look for visible severe wasting, remove the child's clothes:
Look for severe wasting of the muscles of the shoulders, arms, buttocks and legs.
Look to see if the outline of the child's ribs is easily seen.
Look at the child's hips. They may look small when you compare them with the chest and
abdomen.
Look at the child from the side to see if the fat of the buttocks is missing. When wasting
is extreme, there are many folds of skin on the buttocks and thigh. It looks as if the child
is wearing baggy pants.
The face of a child with visible severe wasting may still look normal. The child's abdomen may
be large or distended.

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c) LOOK and FEEL for oedema of both feet
A child with oedema of both feet may have kwashiorkor, another form of severe malnutrition.
Oedema is when an unusually large amount of fluid gathers in the child's tissues. The tissues
become filled with the fluid and look swollen or puffed up.
You must look and feel to determine if the child has oedema of both feet.
Use your thumb to press gently for two (2) seconds on the top side of each foot.
The child has oedema if a dent remains in the child's foot when you lift your thumb.

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EXERCISE A
In this exercise, you will look at still photographs and practice identifying signs of severe
wasting and oedema in children with malnutrition.
Photograph 47: This is an example of visible severe wasting. The child has small hips and thin
legs relative to the abdomen. Notice that there is still cheek fat on the child's
face.
Photograph 48: This is the same child as in photograph 47 showing loss of buttock fat.
Photograph 49: This is the same child as in photograph 47 showing folds of skin ("baggy
pants") due to loss of buttock fat. Not all children with visible severe wasting
have this sign. It is an extreme sign.
Photograph 50: This child has oedema of both feet.

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Photograph 51: This child has NO VISIBLE SEVERE WASTING.
Notes:
Photograph 52: This child HAS VISIBLE SEVERE WASTING.
Notes:

16
Notes:
Notes:

17
Notes:
Notes:

18
Notes:
Notes:

19
Photograph 59: This child has oedema of foot.

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1
Refer
Content
2.1
:
Outpatiient
Management
-
Check
for
Malnutrition
2
Refer
Content
2.4
–
2.8:
Assess
and
Counsel
Feeding
3
Refer
Content
2.9
:
Referral
guidelines
for
the
child
with
low
birth
weight
by
MO/FMS
4
Refer
Content
3.0
:
Hospital
Management
5
Refer
Content
6.0:
Community
Nutritional
Rehabilitation
2.2: FLOWCHART for Integrated Management of Malnutrition in Children Under 5 in Health Clinics

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MANAGEMENT OF CHILDREN WITH MALNUTRITION, VERY LOW WEIGHT
AND LOW WEIGHT.
SEVERE MALNUTRITION
If the child has visible severe wasting or oedema of both feet, classify the child as having
SEVERE MALNUTRITION.
Treatment
Children classified as having SEVERE MALNUTRITION are at risk of death from pneumonia,
diarrhoea, measles, and other severe diseases. These children need urgent referral to hospital
where their treatment can be carefully monitored. They may need special feeding or antibiotics.
VERY LOW WEIGHT
If the child’s weight for age is in the red zone of the weight for age chart and there are no signs
of malnutrition classified the child as very low weight. The child needs to be assessed to see if
he is unwell or well.
Treatment
A child who is very low weight for age and unwell has a higher risk of severe disease and needs
urgent referral to hospital. If the child is well he needs referral to the FMS or MO and PSP for
further assessment and management.
LOW WEIGHT
If the child’s weight for age is in the yellow zone of the weight for age chart, and there are no
signs of malnutrition he is classified as low weight for age.
Treatment.
Assess the child's feeding and counsel the mother about feeding her child according to the
recommendations. The child needs referral to PSP and JT for assessment and counseling.
A child who is low weight should return for follow-up in 14 days.
* Refer FLOWCHART FOR INTEGRATED MANAGEMENT OF MALNUTRITION IN
CHILDREN UNDER 5 pg.20

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2.3 : FEEDING RECOMMENDATIONS
This section will explain the feeding recommendations. You need to understand all of the
feeding recommendations, but you will not need to explain them all to any one mother. You will
first ask questions to find out how her child is already being fed. Then you will give only the
advice that is needed for the child's age and situation.
These feeding recommendations are appropriate both when the child is sick and when the child is
healthy. During illness, children may not want to eat much. However, they should be offered the
types of food recommended for their age, as often as recommended, even though they may not
take much at each feeding. After illness, good feeding helps make up for weight loss and helps
prevent malnutrition. When the child is well, good feeding helps prevent future illness.
Sick child visits are a good opportunity to counsel the mother on how to feed the child both
during illness and when the child is well.
RECOMMENDATIONS FOR AGES UP TO 6 MONTHS
The best way to feed a child from birth to at least
6 months of age is to breastfeed exclusively.
Exclusive breastfeeding means that the child takes
only breastmilk and no additional food, water, or
other fluids (with the exception of medicines and
vitamins, if needed).
Breastfeed children at this age as often as they
want, day and night. This will be at least 8 times in
24 hours.
Breastfeed as often as the child wants, day and
night, at least 8 times in 24 hours
Do not give other foods or fluids
Only if the child is older than 4 months:
shows interest in semisolid foods, or
appears hungry after breastfeeding, or
is not gaining weight adequately
Then add complementary foods (listed under 6
months up to 12 months)
Give 1-2 tablespoon of these foods, 1 or 2 times
per day after the breastfeeding
Up to 6 Months
of Age

23
Most babies do not need complementary foods before
6 months of age.
Breastmilk remains the child's most important food,
but at some time between the ages of 4 and 6 months,
some children begin to need foods in addition to
breastmilk. These foods are often called
complementary or weaning foods because they
complement breastmilk.
The mother should only begin to offer complementary
foods if the child shows interest in semisolid foods,
appears hungry after breastfeeding, or is not gaining
weight adequately. The child may show interest by
reaching for the mother's food, or by opening her
mouth eagerly when food is offered.
By 6 months of age, all children should be receiving a
thick, nutritious complementary food.
It is important to continue to breastfeed as often as
the child wants, day and night. The mother should give
the complementary foods 1-2 times daily after
breastfeeding to avoid replacing breastmilk.

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BENEFITS OF BREAST MILK
Breastmilk contains exactly the nutrients needed by an infant. It contains:
o Protein
o Fat
o Lactose (a special milk sugar)
o Vitamins A and C
o Iron
These nutrients are more easily absorbed from breastmilk than from other milk. Breastmilk
also contains essential fatty acids needed for the infant's growing brain, eyes, and blood
vessels. These fatty acids are not available in other milks.
Breastmilk provides all the water an infant needs, even in a hot, dry climate.
Breastmilk protects an infant against infection. An infant cannot fight infection as well as an
older child or an adult. Through breastmilk, an infant can share his mother's ability to fight
infection. Exclusively breastfed infants are less likely to get diarrhoea, and less likely to die from
diarrhoea or other infections. Breastfed infants are less likely to develop pneumonia,
meningitis, and ear infections than non-breastfed infants.
Breastfeeding helps a mother and baby to develop a close, loving relationship.
Breastfeeding protects a mother's health. After delivery, breastfeeding helps the uterus return
to its previous size. This helps reduce bleeding and prevent anaemia. Breastfeeding also
reduces the mother's risk of ovarian cancer and breast cancer.
It is best not to give an infant below the age of 6 months any milk or food other than
breastmilk. For example, do not give cow's milk, goat's milk, formula, cereal, or extra drinks
such as teas, juices, or water. Reasons:
• Giving other food or fluid reduces the amount of breastmilk taken.
• Other food or fluid may contain germs from water or on feeding bottles or utensils.
These germs can cause infection.
• Other food or fluid may be too dilute, so that the infant becomes malnourished.
• Other food or fluid may not contain enough Vitamins A.
• Iron is poorly absorbed from cow's and goat's milk.
• The infant may develop allergies.
• The infant may have difficulty digesting animal milk, so that the milk causes
diarrhoea, rashes, or other symptoms. Diarrhoea may become persistent.
Exclusive breastfeeding will give an infant the best chance to grow and stay healthy.

25
RECOMMENDATIONS FOR AGES 6 MONTHS UP TO 12 MONTHS
*A good daily diet should be adequate in quantity and include an energy-rich food (for example,
thick cereal with added oil); meat, fish, eggs, or pulses; and fruits and vegetables.
The mother should continue to breastfeed as
often as the child wants.
However, after 6 months of age, breastmilk
cannot meet all of the child's energy needs.
From age 6 months up to 12 months, gradually
increase the amount of complementary foods
given. By the age of 12 months, complementary
foods are the main source of energy.
If the child is breastfed, give complementary
foods 3 times daily.
If the child is not breastfed, give complementary
foods 5 times daily. (If possible, include
feedings of milk by cup. However, milk formula
is not and other breastmilk substitutes are not
as good for babies as breastmilk.)
It is important to actively feed the child. Active
feeding means encouraging the child to eat. The
child should not have to compete with older
brothers and sisters for food from a common
plate. He should have his own serving. Until the
child can feed himself, the mother or another
caretaker (such as an older sibling, father, or
grandmother) should sit with the child during
meals and help get the spoon into his mouth.
An "adequate serving" means that the child
does not want any more food after active
feeding.
Breastfeed as often as the child wants
Give adequate servings of complementary foods:
Thick cereal / thick porridge / bread / biscuit
Fish / chicken / meat / eggs / taufoo
Mashed fruit / bite size fruits
Mashed vegetables / beans / tapioca / sweet
potato / potato / carrots
3 times per day if breastfed
5 times per day if not breastfed
6 Months up to
12 Months

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GOOD COMPLEMENTARY FOODS
Good complementary foods are energy-rich, nutrient-rich, and locally affordable.
Examples in some areas are thick cereal with added oil or milk; fruits, vegetables, pulses, meat,
eggs, fish, and milk products. If the child receives milk formula or any other breastmilk
substitute, these and any other drinks should be given by cup, not by bottle.
Foods that are appropriate in your area are listed in the feeding recommendations and are
described here:
Between 6 months up to 12 months, new foods can be introduced one at a time at least
3 days.
Thick rice porridge can be prepared from already boiled family rice; 4 tablespoons
boiled rice and ¾ cup boiled water.
Mashed green vegetables (boiled and unseasoned) mixed with rice porridge.
Fish steamed, mashed and mixed with rice porridge.
Meat (chicken or beef) steamed or boiled, taufoo / bean curds or eggs can be mixed
with the rice porridge.
Ikan bilis (anchovies) fried, pulverised (½ tsp) and added to porridge.
Ripe fruits like banana, mango and papaya can be mashed or chopped and served to the
child.
Small amount of cooking oil can be added to the food for extra calories.

27
Breastfeed as often as the child wants
Give adequate servings of complementary food
or family foods 5 times per day:
Thick porridge / rice / mee / biscuit / bread
Fish / chicken / meat / eggs / ikan bilis
Tapioca / sweet potato / potato / carrots
Green vegetables / beans
Fruit / bite size fruits
Give small chewable soft items to eat with
fingers. Let the child try to feed himself / herself,
but provide help.
RECOMMENDATIONS FOR AGES 12 MONTHS UP TO 2 YEARS
A good daily diet should be adequate in quantity and include an energy-rich food (for
example, thick porridge with added oil); meat, fish, eggs, or pulses; and fruits and
vegetables (green leafy and yellow vegetables).
By the 12th
month, the child should share the family food.
The growing child needs adequate amount of energy-giving foods like rice, potato and
protein rich sources of foods like fish, chicken, meat, eggs, bean curd, eggs and ikan
bilis.
Dark green leafy vegetables and fruits like papaya and banana (rich sources of vitamins
and minerals).
Cooking oil or margarine is important as an added source of calories.
During this period the mother should continue
to breastfeed as often as the child wants and
also give nutritious complementary foods. The
variety and quantity of food should be
increased. Family foods should become an
important part of the child's diet. Family foods
should be chopped so that they are easy for the
child to eat.
Give nutritious complementary foods or family
foods 5 times a day.
Adequate servings and active feeding
(encouraging the child to eat) continue to be
important.
12 Months up
to 2 Years

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RECOMMENDATIONS FOR AGES 2 YEARS AND OLDER
The growing child of 2 years and older, should be given a variety and adequate amounts from
the family foods in 3 meals per day.
In between meals, 2 snacks of the following foods will give additional nutrients:
Mee / mee hoon / bread / “kuih-muih”
Fruits / soya bean / sweet corn
Taufoo / tapioca / sweet potato / potato / carrots
Sandwich / bun / cake / biscuits
Red beans / green beans / dhal
Oat / sardine / egg
Milk / yogurt / cheese
At this age the child should be taking a variety
of family foods in 3 meals per day. The child
should also be given 2 extra feedings per day.
These may be family foods or other nutritious
foods which are convenient to give between
meals. Examples are listed on the chart and
below.
Give family foods at 3 meals each day. Also, twice
daily, give nutritious snacks between meals, such
as:
Mee / mee hoon / bread/ “kuih-muih”
Fruits / soya bean / sweet corn / taufoo /
tapioca / sweet potato / potato / carrots
Sandwich / bun / cake / biscuits
Red beans / green beans / dhal
Oat / sardine / egg
Milk / yogurt / cheese
2 Years and
Older

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2.4 : ASSESS THE CHILD’S FEEDING
You will assess the feeding of all children who are low weight. In addition assess the feeding
of children who are very low weight but well while awaiting for referral to FMS or Medical
Officer.
To assess feeding, ask the mother the following questions;
How are you feeding your child?
If the infant is receiving any breastmilk, ASK:
- How many times during the day?
- Do you also breastfeed during the night?
Does the infant take any other food or fluids?
- What food or fluids?
- How many times per day?
- What do you use to feed the child?
If low weight for age, ASK:
- How large are the servings?
- Does the child receive his own serving?
- Who feeds the child and how?
During this illness, has the child’s feeding changed?
- If yes, how?
Use the box below to assess feeding and identify feeding problem(s).
Record any CORRECT feeding practices below:
ASSESS CHILD’S FEEDING
Yes____ No ____
If Yes, how many times in 24 hours? __ times. Do you breastfeed during the night? Yes___ No___
Yes___ No ___
If Yes, what food or fluids?
_______________________________________________________________________________
_____________________________________________________________________________________________________
How many times per day? __ times. What do you use to feed the child?
____________________________________________
If low weight for age: How large are servings? ____________________________________________________________
Does the child receive his own serving? ___ Who feeds the child and how?
_______________________________________
During the illness, has the child’s feeding changed? Yes __ No ____
If Yes, how?
__________________________________________________________________________________________
Feeding Problem:

30
Listen for correct feeding practices as well as those that need to be changed. You may look
at the feeding recommendations for the child's age as you listen to the mother. If an answer is
unclear, ask another question. For example, if the mother says that servings are "large enough,"
you could ask, "When the child has eaten, does he still want more?
Assessing breastfeeding requires careful observation.
ASK: Has the infant breastfed in the previous hour?
If so, ask the mother to wait and tell you when the infant is willing to feed again.
If the infant has not fed in the previous hour, he may be willing to breastfeed. Ask the
mother to put her infant to the breast. Observe a whole breastfeed if possible, or observe
for at least 4 minutes.
Sit quietly and watch the infant breastfeed.
LOOK: Is the infant well attached?
The four signs of good attachment are:
- more areola seen above infant's top lip than below bottom lip
- mouth wide open
- lower lip turned outwards
- chin touching breast
If all of these four signs are present, the infant has good attachment.
If attachment is not good, you may see:
- more areola (or equal amount) seen below infant's bottom lip than above top lip
- mouth not wide open, lips pushed forward
- lower lip turned in, or
- chin not touching breast

31
If you see any of these signs of poor attachment, the infant is not well attached.
If an infant is not well attached, the results may be pain and damage to the nipples. Or
the infant may not remove breastmilk effectively which may cause engorgement of the
breast. The infant may be unsatisfied after breastfeeds and want to feed very often or for
a very long time. The infant may get too little milk and not gain weight, or the
breastmilk may dry up. All these problems may improve if attachment can be improved.
A young infant well attached A young infant poorly attached
to his mother's breast to his mother's breast
LOOK: Is the infant suckling effectively? (that is, slow deep sucks, sometimes pausing)
The infant is suckling effectively if he suckles with slow deep sucks and sometimes
pauses. You may see or hear the infant swallowing. If you can observe how the
breastfeed finishes, look for signs that the infant is satisfied. If satisfied, the infant
releases the breast spontaneously (that is, the mother does not cause the infant to stop
breastfeeding in any way). The infant appears relaxed, sleepy, and loses interest in the
breast.
An infant is not suckling effectively if he is taking only rapid, shallow sucks. You may
also see indrawing of the cheeks. You do not see or hear swallowing. The infant is not
satisfied at the end of the feed, and may be restless. He may cry or try to suckle again,
or continue to breastfeed for a long time.
If a blocked nose seems to interfere with breastfeeding, clear the infant's nose. Then
check whether the infant can suckle more effectively.
LOOK for ulcers or white patches in the mouth (thrush).
Look inside the mouth at the tongue and inside of the cheek. Thrush looks like milk
curds on the inside of the cheek, or a thick white coating of the tongue. Try to wipe the
white off. The white patches of thrush will remain.

32
EXERCISE B
Study photographs numbered 66 through 74 of young infants at the breast. Look for each of the
signs of good attachment. Photographs 75 and 76 showed white patches (thrush) in the mouth of
an infant.
Photo
Signs of Good Attachment
Assessment
More areola seen
above infant's top
lip than below
bottom lip
Mouth wide
open
Lower lip
turned
outwards
Chin
touching
breast
66 Yes Yes Yes Yes (almost)
Good
attachment
67
No (equal above
and below)
No Yes No
Not well
attached
Notes:

33
Photo
Assessment
More areola seen
above infant's top
lip than below
bottom lip
Mouth wide
open
Lower lip
turned
outwards
Chin
touching
breast
68 Yes No No Yes
Not well
attached
69 No No No No
Not well
attached
N
No
ot
te
es
s:
:

34
Photo
Assessment
More areola seen
above infant's top
lip than below
bottom lip
Mouth wide
open
Lower lip
turned
outwards
Chin
touching
breast
70 Cannot see Yes Yes Yes
Good
attachment
71
No (equal above
and below)
No Yes No
Not well
attached
N
No
ot
te
es
s:
:

35
Photo
Assessment
More areola seen
above infant's top
lip than below
bottom lip
Mouth wide
open
Lower lip
turned
outwards
Chin
touching
breast
72 Yes Yes Yes Yes
Good
attachment
73 Yes Yes Yes Yes (almost)
Good
attachment
N
No
ot
te
es
s:
:

36
Photo
Assessment
More areola seen
above infant's top
lip than below
bottom lip
Mouth wide
open
Lower lip
turned
outwards
Chin
touching
breast
74 No (more below) No No Yes
Not well
attached
N
No
ot
te
es
s:
:
Photographs 75 and 76 showed white patches (thrush) in the mouth of two infants.

37
2.5: IDENTIFY FEEDING PROBLEMS
It is important to complete the assessment of feeding and identify all the feeding problems before
giving advice.
Based on the mother's answers to the feeding questions, identify any differences between the
child's actual feeding and the recommendations. These differences are problems.
In addition to differences from the feeding recommendations, some other problems may become
apparent from the mother's answers. Examples of such problems are:
Difficulty breastfeeding
The mother may mention that breastfeeding is uncomfortable for her, or that her child
seems to have difficulty breastfeeding. If so, you will need to assess breastfeeding. You
may find that the infant's positioning and attachment could be improved.
Use of feeding bottle
Feeding bottles should not be used. They are often dirty, and germs easily grow in them.
Fluids tend to be left in them and soon become spoiled or sour. The child may drink the
spoiled fluid and become ill. Also, sucking on a bottle may interfere with the child's
desire to breastfeed. However, if the mother has to use a feeding bottle for feeding the
child, the bottles and teats must be cleaned adequately with dishwashing liquid and a
clean brush. The bottles mush be boiled in clean water for 10 to 15 minutes and kept in
the water overnight. Drain off water after cooling down. The bottles must be kept in a
clean tray or rack for use. To reduce risk of contamination, mother should wash her hands
properly before preparing the milk substitutes.
Lack of active feeding
Young children often need to be encouraged and assisted to eat. This is especially true if
a child has very low weight. If a young child is left to feed himself, or if he has to
compete with siblings for food, he may not get enough to eat. By asking, "Who feeds the
child and how?" you should be able to find out if the child is actively being encouraged to
eat.
Not feeding well during illness
The child may be eating much less, or eating different foods during illness. Children
often lose their appetite during illness. However, they should still be encouraged to eat
the types of food recommended for their age, as often as recommended, even if they do
not eat much. They should be offered their favourite nutritious foods, if possible, to
encourage eating.
Next to the assess child’s feeding questions, there is a box labelled "Feeding Problems." Use that
space to record any feeding problem found. You will counsel the mother about these feeding
problems.

38
EXAMPLE: 4-month-old child
1. Breast feeding the child.
2. Breastfeed during the night.
3. No complementary food yet.
4. Mother does not change child’s feeding during illness.
Do you breastfeed your child? Yes__√_ No ____
If Yes, how many times in 24 hours? _5 times. Do you breastfeed during the night? Yes__√_ No___
Does the child take any other food or fluids? Yes__√_ No ___
If Yes, what food or fluids? Milk formula_________________________________________________________________
_____________________________________________________________________________________________________
How many times per day? _3 times. What do you use to feed the child? Feeding bottle___________________________
If low weight for age: How large are servings? No complementary food
yet_____________________________________
Does the child receive his own serving? ___ Who feeds the child and how? _______________________________________
During the illness, has the child’s feeding changed? Yes __ No __√__
If Yes, how? __________________________________________________________________________________________
Feeding Problem:
Not breast fed often
enough
Giving milk formula
Using feeding bottle

39
2.6: COUNSEL FEEDING
Since you have identified feeding problems, you will be able to limit your advice to what is most
relevant to the mother.
Give Relevant Advice
If the feeding recommendations are being followed and there are no problems, praise the
mother for her good feeding practices. Encourage her to keep feeding the child the same way
during illness and health! If the child is about to enter a new age group, the child will need
different feeding recommendations, explain these new recommendations to her. For example, if
the child is almost 6 months old, explain about good complementary foods and when to start
them.
If the feeding recommendations for the child's age are not being followed, explain those
recommendations.
In addition, if you have found any of the problems, give the mother the recommended advice:
- If the mother reports difficulty with breastfeeding, assess breastfeeding.
Show the mother correct positioning and attachment for breastfeeding.
Check and improve positioning and attachment. If the mother has a breast problem, such as
engorgement, sore nipples, or a breast infection, she may need referral to a specially trained
breastfeeding counsellor (such as a health worker who has taken Breastfeeding Counselling
Training Course) or to someone experienced in managing breastfeeding problems, such as a
midwife.

40
If the child is less than 6 months old and is taking other
milk or foods:
- Build mother’s confidence that she can produce all the
breastmilk that the child needs.
- Suggest giving more frequent, longer breastfeeds day or
night, and gradually reducing other milk or foods.
If other milk needs to be continued, counsel the mother
to:
- Breastfeed as much as possible, including at night.
- Make sure that other milk is a locally appropriate
breastmilk substitute.
- Make sure other milk is correctly and hygienically
prepared and given in adequate amounts.
- Finish the prepared milk within an hour.
If a child under 6 months old is receiving food or fluids other than breastmilk, the goal is to
gradually change back to more or exclusive breastfeeding. Suggest giving more frequent, longer
breastfeeds, day and night. As breastfeeding increases, the mother should gradually reduce other
milk or food. Since this is an important change in the child's feeding, be sure to ask the mother to
return for follow-up in 5 days.
In some cases, changing to more or exclusive breastfeeding may be impossible (for example, if
the mother never breastfed, if she must be away from her child for long periods, or if she will not
breastfeed for personal reasons). In such cases, the mother should be sure to correctly prepare
breastmilk substitutes (e.g. formula milk) and use them within an hour to avoid spoilage. It is
important to use the correct amount of clean, boiled water for dilution.
If the mother is using a bottle to feed the child:
- Recommend substituting a cup for bottle.
- Show the mother how to feed the child with a cup.

41
A cup is better than a bottle. A cup is easier to keep clean and does not interfere with
breastfeeding. To feed a baby by cup:
- Hold the baby sitting upright or semi-upright on your lap.
- Hold a small cup to the baby's lips. Tip the cup so the liquid just reaches the baby's lips.
- The baby becomes alert and opens his mouth and eyes.
A low-birth weight baby takes the milk into his mouth with the tongue.
A full-term or older baby sucks the milk, spilling some of it.
- Do not pour the milk into the baby's mouth. Just hold the cup to his lips and let him take it
himself.
- When the baby has had enough, he closes his mouth and will not take more.
If mother has difficulty in using the cup a clean feeding bottle and teat should be used.
If the child is not being fed actively, counsel the mother to:
- Sit with the child and encourage eating.
- Give the child an adequate serving in a separate plate or bowl.
This mother is actively feeding her
child.
This child must compete with siblings and
may not get enough to eat.

42
If the child is not feeding well during illness, counsel the mother
to:
- Breastfeed more frequently and for longer if possible.
- Use soft, varied, appetizing, favourite foods to encourage
the child to eat as much as possible, and offer frequent
small feedings.
- Clear a blocked nose if it interferes with feeding.
- Expect that appetite will improve as child gets better.
Even though children often lose their appetites during illness, they should be encouraged to eat
the types of food recommended for their age, as often as recommended. Offer the child's
favourite nutritious foods to encourage eating. Offer small feedings frequently. After illness,
good feeding helps make up for any weight loss and prevent malnutrition.

43
EXERCISE C
In this exercise you will identify feeding problems and relevant advice for written cases.
The health worker has asked the questions to assess feeding. Read the information about feeding
on the recording form. Then describe the correct feeding practices, feeding problem(s) and
relevant feeding advice.
1. The child is 2 months old. The mother has started giving formula milk and is thinking of
stopping breastfeeding soon. She thinks that her child may gain more weight on formula
milk than breastmilk.
Briefly describe the feeding problems in the box on the right of the form.
Do you breastfeed your child? Yes__√_ No ____
If Yes, how many times in 24 hours? _5 times. Do you breastfeed during the night? Yes__√_ No___
If Yes, what food or fluids? Infant formula_____________________________________________________________
____________________________________________________________________________________________________
How many times per day? _2 times. What do you use to feed the child? Feeding bottle_________________________
If low weight for age: How large are servings? No complimentary food yet_____________________________________
Does the child receive his own serving? ___ Who feeds the child and how? ______________________________________
During the illness, has the child’s feeding changed? Yes __ No __√__
If Yes, how? _________________________________________________________________________________________
Feeding Problem:

44
2. The child is 15 months old. The child shares a plate with 3 brothers and sisters and
sometimes does not get much food.
Do you breastfeed your child? Yes___ No __√__
If Yes, how many times in 24 hours? _ times. Do you breastfeed during the night? Yes___ No___
If Yes, what food or fluids? Family food, usually rice and thin soup_________________________________
____________________________________________________________________________________________________
How many times per day? _3 times. What do you use to feed the child? Plate , no bottle_______________________
If low weight for age: How large are servings? _not very much food_____________________________________
Does the child receive his own serving? No Who feeds the child and how? Child feeds himself , shares with
During the illness, has the child’s feeding changed? Yes __ No __√__ siblings
If Yes, how? _________________________________________________________________________________________
Feeding Problem:

45
3. The child is 2 years old.
Do you breastfeed your child? Yes____ No _√_
If Yes, how many times in 24 hours? _____ times. Do you breastfeed during the night? Yes____ No___
If Yes, what food or fluids? Milk formula , 3 meals family
food______________________________________
_______________________________________________________________________________________________________________________________________
How many times per day? _5 times. What do you use to feed the child? Plate , no
bottle____________________
If low weight for age: How large are servings? Until the child does not want it
anymore_______________________
Does the child receive his own serving? YES___ Who feeds the child and how? The mother______________________
During the illness, has the child’s feeding changed? Yes ____ No __√_
If Yes, how? ___________________________________________________________________________________
Feeding Problems:

46
2.7: USE GOOD COMMUNICATION SKILLS
When counselling mothers, it is important to use the following skills:
ASK and LISTEN: You have already learned the importance of asking questions to
assess the child's feeding. Listen carefully to find out what the
mother is already doing for her child. Then you will know what
she is doing well, and what practices need to be changed.
PRAISE: It is likely that the mother is doing something helpful for the child,
for example, breastfeeding. Praise the mother for something
helpful she has done. Be sure that the praise is genuine, and only
praise actions that are indeed helpful to the child.
ADVISE: Limit your advice to what is relevant to the mother at this time.
Use language that the mother will understand. If possible, use
pictures or real objects to help explain. For example, show
amounts of fluid in a cup or container.
Advise against any harmful practices that the mother may have
used. When correcting a harmful practice, be clear, but also be
careful not to make the mother feel guilty or incompetent. Explain
why the practice is harmful.
CHECK
UNDERSTANDING: Ask questions to find out what the mother understands and what
needs further explanation. Avoid asking leading questions (that is,
questions which suggest the right answer) and questions that can be
answered with a simple yes or no.
Examples of good checking questions are: "What foods will you
give your child?" "How often will you give them?" If you get an
unclear response, ask another checking question. Praise the mother
for correct understanding or clarify your advice as necessary.

47
2.8 : USE A MOTHER’S CARD
A Mother's Card is given to each mother to help her remember appropriate food advice. The
Mother's Card has words and pictures that illustrate the main points of advice. The card shows
advice about foods.
There are many reasons a Mother's Card can be helpful:
- It will remind you or your staff of important points to cover when counselling mothers
about foods.
- It will remind the mother what to do when she gets home.
- The mother may show the card to other family members or neighbours, so more people
will learn the messages it contains.
- The mother will appreciate being given something during the visit.
When reviewing a Mother's Card with a mother:
1. Hold the card so the mother can easily see the pictures, or allow her to hold it herself.
2. Explain each picture. Point to the pictures as you talk. This will help the mother remember
what the pictures represent.
3. Circle that is relevant to the mother. For example, circle the feeding advice for the child's
age.
4. Watch to see if the mother seems worried or puzzled. If so, encourage questions.
5. Ask the mother to tell you in her own words what she should do at home. Encourage her to
use the card to help her remember.
6. Give her the card to take home. Suggest that she show it to others in her family.

48

49

50
2.9 : REFERRAL GUIDELINES FOR CHILDREN WITH LOW WEIGHT BY
MEDICAL OFFICER (MO)/ FAMILY MEDICINE SPECIALIST (FMS) IN
PRIMARY HEALTH CARE CLINICS
In primary health-care facilities JM/JT will refer to medical officers/FMS low weight child, very
low weight but well child or the child with suspected malnutrition.
The Medical officers/FMS should assess the weight-for-length/height z-score status of these
children under 5 years of age. They should take a proper history and conduct a proper physical
examination of the child and look for associated illness. (Refer to page 5-10)
Any child:
With a Weight-for-length/height z-score below -2 should be refer to the Family
Medicine Specialist in charge.
With a Weight-for-length/height z-score below -2 AND unwell should be refer to
Hospital with Paediatrician immediately.
With a Weight-for-length/ height z-score below -3, severe visible wasting or have
bilateral pedal oedema (Kwashiokor) should be refer to Hospital with Paediatrician
immediately.

51
3.0 : HOSPITAL MANAGEMENT4
3.1 : TRIAGE CHART - TRIAGE OF ALL SICK CHILDREN
Emergency signs
If any signs positive  Call for help, assess and resuscitate, give treatment, insert IV line and take
blood for emergency laboratory investigations (eg. FBC, BUSE, Random Blood Sugar, BFMP etc.)
ASSESS TREAT
Airway and Breathing
Obstructed breathing or
Apnoea or
Central cyanosis or
Severe respiratory distress
If foreign body aspiration:
- Manage airway in choking child:
Infant: Backslap
Children: Heimlich manoeuvre.
If no foreign body aspiration:
- Manage airway: head tilt chin lift,
suction secretions.
- Give oxygen: nasal prong/catheter.
(If child not breathing, intubate and
ventilate)
- Keep child warm
Circulation
Cold skin with:
Capillary refill longer than 3
secs and,
Weak and fast pulse Check for Severe
malnutrition
Stop any bleeding
Give oxygen
Keep child warm
If no severe malnutrition:
- insert IV line and give fluid rapidly
(20ml/kg normal saline)
- if fail IV line, insert intraosseous line
If Severe Malnutrition:
- Insert IV line, give fluids
Coma
Convulsion
Coma or
Convulsing (now)
Manage airway
If convulsing, give rectal Diazepam
0.5mg/kg
Position the unconscious child (If
trauma, stabilize the neck first)
IV glucose if DXT < 3mmol/L
(D10% 2-4mls/ kg rapid)
CHART 1
Signs positive
If coma/
convulsing
Any sign
positive

52
Severe Dehydration
(Only in a child with diarrhoea)
Diarrhoea plus any of 2:
Drowsy/ Unconscious
Sunken eyes
Very slow skin pinch
(skin pinch goes back > 2 secs)
Unable to drink or drinks poorly
2 signs positive
Check for Severe
malnutrition
Keep child warm
If no Severe Malnutrition:
- Insert IV line, give fluids according
Plan C (IMCI, WHO)
If Severe Malnutrition:
If in shock (CRT > 3secs, tachycardia,
weak pulse and usually reduced level of
consciousness), refer:
If not in shock, refer:
PRIORITY SIGNS
These children need prompt assessment and treatment:
Malnutrition: Visible severe wasting
Oedema of both feet or face
Severe pallor
Any respiratory distress
Any sick young infant (< 2 months of age)
Restless, continuously irritable, or lethargic
High temperature (>40°C)
Severe Pain
Major burn
An urgent referral note from another facility
Poisoning
Trauma or other surgical condition
Adapted from Hospital care for Children WHO, 2013
Non URGENT
- Proceed with assessment and further treatment
- No Emergency Signs
CHART 2
Diarrhoea
plus:
CHART 1

53
CHART 1
Management of Shock in a Child with Severe Malnutrition
(Give this treatment if the child with severe malnutrition has signs of shock  CRT > 3secs,
tachycardia, weak pulse and usually reduced level of consciousness)
Insert IV line.
Take blood (FBC, BUSE, RBS/ Dextrostix, and (if available) venous blood gas).
While giving fluids, count Respiratory rate (RR) and Heart Rate (HR)  Use as BASELINE.
Count RR and HR every 10 minutes.
Monitor for increase in: RR > 5bpm; HR > 25bpm.
Fluid Resuscitation:
Give IV/IO fluid 15ml/kg over 1 hour.
Solution: 0.45% Normal Saline Dextrose 5%.
* If Dextrostix > 11 mmol/L, give 0.45% Normal Saline or Ringer’s lactate.
Signs of IMPROVEMENT:
(Pulse rate falls, pulse volume increases, RR falls
and no evidence of pulmonary oedema)
A) Hospital without Paediatrician
Discuss further with Paediatrician on call.
KIV may need to repeat IV 0.45% Normal
Saline Dextrose 5% 10ml/kg over 1 hour.
Refer to Hospital with Paediatrician
URGENTLY.
B) Hospital with Paediatrician
KIV may need to repeat IV 0.45% Normal
Saline Dextrose 5% 10ml/kg over 1 hour.
Start Oral/nasogastric Rehydration with
ReSoMal 10ml/kg/hour for 10 hours.
Initiate refeeding with Starter F-75.
Refer
Signs of DETERIORATIONS:
(Increase RR by 5/min or HR by 15/min,
liver enlarges, fine crepitations in lung, JVP
increase, galloping heart rhythm)
Stop bolus infusion as IV fluids can
worsen child’s condition by inducing
pulmonary oedema.
Consult Paediatrician URGENTLY.
CONSULT PAEDIATRICIAN
CHART 3

54
CHART 2
Management of Severe OR Some Dehydration without Shock
Assume that all children with watery diarrhoea or reduced urine output have some
dehydration.
In Hospital without Paediatrician, refer to Hospital with Paediatrician URGENTLY,
giving frequent sips of Resomal/ ORS on the way.
Advice mother to continue breast feeding in a breast fed child.
Give ReSoMal 5ml/kg/feed every 30 minutes.
(Orally or via Nasogastric tube)
Give ReSoMal alternate with F75 formula
- 5 to 10ml/kg/feed Hourly
(The exact amount depends on how much the child wants,
the volume of stool loss and whether the child is vomiting)
If rehydration still require, give F75 formula
- 5 to 10ml/kg/feed Hourly
If no dehydration, see recommended schedule for
refeeding
FIRST 2 HOURS
NEXT 4 to 10 HOURS
(Depends on the severity of dehydration)
AFTER 10 HOURS
Monitor every 30 mins for 2
hours and Hourly for 10hours:
- Respiratory rate
- Heart rate/ Pulse rate
Monitor:
Weight gain
Enlarging liver size
Lungs for crepitations
Strict I/O chart
Urine frequency
Stool frequency
Vomiting
If there is overhydration
(early signs are respiratory rate
increasing by 5/min and pulse rate
by 25/min),
 stop ReSoMal immediately and
reassess after 1 Hour.
CONSULT PAEDIATRICIAN
(for Hospital without Paediatrician)
* Prevention of dehydration from continuing watery diarrhea:
 Give ReSoMal between feeds to replace ongoing stool
losses, eg 50 – 100ml after each watery stool.
CHART 3

55
Initial Refeeding with Starter Feed F75 formula
A cautious approach is required because of the child’s fragile physiological state and reduced
homeostatic capacity.
Refer Dietician
Frequent (every 2 to 3hrly) oral small feeds of low osmolality and low lactose F75.
Nasogastric feeding if child is eating < 80% of amount offered at 2 consecutive feeds.
If child is breast feeding, encourage continued breastfeeding, but make sure prescribed
amounts of starter formula are given:
Days Frequency Volume/kg feed Volume/kg per day
1-2 2 h 11 ml 130 ml
3-5 3 h 16 ml 130 ml
> 6 4 h 22 ml 130 ml
Calories: 100 kcal/kg per day
Protein: 1-1.5g/kg per day
Total Fluid:
No Severe Oedema Presence of Severe Oedema
Total Fluid 130ml/kg/day 100ml/kg/day
Feed from a cup or a bowl. Use a spoon, dropper or syringe to feed very weak children.
If child’s intake does not reach 80kcal/kg per day despite frequent feeds, coaxing and re-
offering  give the remaining feed by nasogastric tube.
Do not exceed 100kcal/kg per day in this initial phase.
Monitor and record:
• amounts of feed offered and left over
• vomiting
• stool frequency and consistency
• daily body weight
CHART 3
MONITOR:
Early signs of Congestive Heart Failure:
(rapid pulse, fast breathing, basal lung crepitations, enlarging liver, gallop heart rhythm, raised
jugular venous pressure).
 If pulse rate (PR) and respiratory rates (RR) increase (RR by 5 breaths/min and PR by 25 beats/min),
and the increase is sustained for 2 successive 4-hourly readings, then:
- Reduce the volume fed to 100 ml/kg per day for 24 h.
Then, gradually increase as follows:
- 115 ml/kg per day for next 24 h
- 130 ml/kg per day for the following 48 h
Thereafter, increase each feed by 10 ml each day.

56
Monitoring Weight Gain
Monitor progress after the transition by assessing the rate of weight gain:
Weigh child every morning before feeding and plot the weight………..
Calculate and record weight gain every 3 days as g/kg/day
If weight gain is:
poor (<5 g/kg/day), child requires full reassessment.
moderate (5-10 g/kg/day), check whether intake targets are being met or if infection has
been overlooked.
good (>10 g/kg/day), continue refeeding.
Good weight gain > 10g/kg/day

57
3.2 : INPATIENT MANAGEMENT 2,4
1) When the child with severe malnutrition is admitted, case must be notified to Pegawai
Sains Pemakanan with Notification Form (Refer Appendix Pg 75)
2) Triage Assessment is performed (Refer to Triage Chart Pg 51)
3) General plan of treatment involve the steps as in Acute Stabilisation Phase and
Rehabilitation Phase as below:
PLAN OF TREATMENT
ACUTE STABILISATION
PHASE
REHABILITATION
PHASE
FOLLOW -UP
STEPS
Day 1-2 Day 3-7 Week 2-6 Week 7-26
Treat & Prevent
Shock
Hypoglycaemia
Hypothermia
Dehydration
Infection
Correct
Electrolyte Imbalances
Micronutrient
deficiencies
No Iron With Iron
Feeding
Initial Feeding
Feeding to achieve catch-
up growth
Emotion and Sensory
stimulation
Preparation for discharge
CHART 1 & 2 CHART 3 CHART 4
Treatment of Shock
and Rehydration
Initial Feeding F75 Catch up Feeding F100
Follow-up Community
Feeding
Time frame for individual components of management of a child with severe malnutrition

58
3.3 : MONITORING AND TREATMENT OF SEVERE MALNUTRITION 4, 7
a) Shock
Refer (Pg. 53)
b) Hypoglycaemia
All severely malnourished children are at risk of hypoglycaemia.
Perform dextrostix immediately.
Diagnosis
Hypoglycaemia is present when the blood glucose is < 3 mmol/litre.
Treatment
Give 50 ml of 10% glucose or sucrose solution orally or by nasogastric tube, followed by the
first feed as soon as possible.
Give the first feed of F-75 therapeutic milk, and then continue with feeds every 2 h for 24 h;
then continue feeds every 2 or 3 h, day and night.
If the child is unconscious, treat with IV 10% glucose at 2-4 ml/kg or,
 If IV access cannot be quickly established, then give 10% glucose or sucrose solution by
nasogastric tube.
 Continue with 2 h oral or nasogastric feeds to prevent recurrence.
Start on appropriate IV or IM antibiotics.
c) Hypothermia
Hypothermia is very common in malnourished children and often indicates coexisting
hypoglycaemia or serious infection.
Diagnosis
If the axillary temperature is < 35 °C or does not register on a normal thermometer, assume
hypothermia. When there’s a low-reading thermometer, take the rectal temperature (< 35.5
°C) to confirm.
Treatment
Treat routinely for hypoglycaemia and infection.
Feed the child immediately and then every 2 h unless they have abdominal distension; if
dehydrated, rehydrate first.
Give appropriate IV or IM antibiotics.
CHART 1

59
Re-warm the child: Make sure the child is clothed (especially the head); cover with a warmed
blanket and place a heater (not pointing directly at the child) nearby, or put the child on the
mother’s bare chest or abdomen (skin-to-skin) and cover them with a warmed blanket and/or
warm clothing.
Monitor rectal temperature every 2 h until it rises to > 36.5 °C. Take it every 30 min if a
heater is being used.
Check for hypoglycaemia whenever hypothermia is found.
Prevent hypothermia by:
− Avoid exposing the child to cold (e.g. after bathing or during medical examinations).
− Change wet nappies, clothes and bedding to keep the child and the bed dry.
− Dry carefully after bathing, but do not bathe if very ill.
− Use a heater with caution.
− Do not use a hot water bottle or fluorescent lamp.
d) Dehydration
Refer (Pg. 54)
e) Infections
In severe acute malnutrition, the usual signs of bacterial infection, such as fever, are often absent,
yet multiple infections are common. Therefore, assume that all children with severe acute
malnutrition have an infection on their arrival in hospital, and treat with antibiotics immediately.
Hypoglycaemia and hypothermia are often signs of severe infection.
Investigate according to clinical assessment:
Blood Culture, BFMP, Urine culture, CXR, Lumbar puncture, Leptospirosis rapid test/
serology, Meliodosis serology.
Treatment
Give all severely malnourished children a broad-spectrum antibiotic.
Choice of Broad Spectrum
Antibiotics
ANTIBIOTIC DURATION
Uncomplicated Oral Amoxycillin 15-25mg/kg TDS 5 days
Complicated (hypoglycaemia,
hypothermia, looks
lethargic/sickly or other medical
complication)
IV C-Penicillin 50 000 U/kg QID or
IV Ampicillin 25-50mg/kg QID
plus
IV Gentamicin 5mg/kg OD
7 days
CHART 2

60
Treat other infections appropriately:
Meningitis (Do lumbar puncture for confirmation)
IV Cefotaxime 50mg/kg QID or
IV Ceftriaxone 50mg/kg BD
7-21 days
(depends on
organism)
Pneumonia IV C-Penicillin 50 000U /kg QID 5 – 7 days
Diarrhoea/ Dysentry May add IV Metronidazole 15mg/kg first
dose and 7.5mg/kg TDS
7 days
Skin/soft tissue infections IV Cloxacillin 25-50mg/kg QID 5 -7 days
Urinary tract infection IV Cefuroxime 25mg/kg tds 5- 7 days
Leptospirosis IV C-Penicillin 100 000U /kg QID
(Refer to Local Protocol)
7 days
Meliodosis (Refer to Local Protocol)
Malaria (Refer to Local Protocol)
Tuberculosis (Refer to Local Protocol)
f ) Parasitic worms and treatment
If there is evidence of worm infestation, treatment should be delayed until the Rehabilitation
phase.
Do NOT deworm during the initial stabilization phase when child is ill. Albendazole will kill
the worms (especially Ascaris) inside the intestines and may cause worm bolus/ intestinal
obstruction.
Give Syr Albendazole 200mg OD (1-2 years old)/ 400mg OD (> 2 years old) as a SINGLE
DOSE or for 3 DAYS (if there is evidence of Stool infestation), consider repeat dose after 2
weeks to eradicate remaining worms.
g) Electrolyte Imbalances
Sodium
All severely malnourished children have Excess Total Body Sodium even though plasma sodium
may be low. High sodium loads could lead to fluid overload. Don’t give extra sodium, unless
advised by Paediatrician.
When rehydrating, give low sodium rehydration fluid (ReSoMal). Prepare food without added
salt.
Potassium
Correct Hypokalaemia with ReSoMal or Mist KCL. Consider IVI Potassium for severe
symptomatic hypokalemia, if there are ECG changes.
Give Potassium 3-4 mmol/kg/day

61
Magnesium
Give Magnesium 0.4-0.6mmol/kg/day
Phosphate
Correct mild hypophosphataemia (0.6-1 mmol/L) with oral phosphate.
If moderate to severe (<0.6mmol/L) consider IV potassium phosphate.
Give Phosphate 0.1-1.5mmol/kg/day
h) Micronutrient Deficiencies
All severely malnourished children have vitamin and mineral deficiencies.
Treatment
Give:
Vitamin A orally on Day 1 (single dose):
If there are any signs of Vitamin A deficiency like corneal ulceration or history of
measles  repeat dose on Days 2 and 14.
Vitamin K oral/IV 0.3mg/kg (single dose) - If IV Vitamin K, give over 1hour.
Thiamine oral/IV 1-2mg/kg daily for 3 days.
Multivitamin 5ml daily.
Folic acid 5mg on Day 1, then 1mg daily.
Elemental Zinc orally 15mg (or 2mg/kg) daily for 2 weeks.
To be given when child is well and gaining weight (usually in the second week):
Elemental Iron 3mg/kg/day (after 2 days on F-100 catch-up formula. Do not give iron
initially in the stabilisation phase, because iron can make infections worse)
Age < 6 months 50 000 IU
Age 6-12 months 100 000 IU
Age > 12 months 200 000 IU

62
Clinical Manifestation of the Major Micronutrient Deficiencies
Nutrient Essential for production or
function
Manifestations of isolated deficiency
Iron Haemoglobin
Various enzymes
Myoglobin
Anaemia and fatigue
Impaired cognitive development
Reduced growth and physical strength
Iodine Thyroid hormone Goitre, hypothyroidism, constipation.
Growth retardation
Endemic cretinism
Zinc Many enzymes
Immune System
Immune deficiency
Acrodermatitis enteropathica
Increased childhood illness, early death.
Complications in pregnancy, childbirth
Vitamin A Eyes
Immune system
Night blindness, xerophthalmia
Immune deficiency
Increased childhood illness, early death
Contributes to development of anaemia
Vitamin B1
(Thiamine)
Cardiovascular (wet beri-beri)
Nervous system (dry beri-beri)
Tachycardia, cardiomegaly, pulmonary
oedema and cyanosis.
Symmetric peripheral neuropathy
Symmetric paraesthesias (with diminished
touch sensation)
Weakness (starting with feet), Ataxia
Loss of ankle and knee reflexes
Opthalmoplegia
Irritability, forgetfulness
Vitamin D Rickets Bowing of legs, rachitic-rosary
Widened wrist
Hypotonia, protruding abdomen

63
i) Initial Refeeding
Refer (Pg. 55)
j) Catch-up Growth Feeding
Catch-up Growth Feeding - F100 Formula/ High calorie milk
Signs that a child has reached rehabilitation phase for catch-up growth are:
• return of appetite
• no episodes of hypoglycaemia (metabolically stable)
• reduced or disappearance of all oedema
Make a gradual transition from starter F-75 to catch-up formula F-100 or ready to-use
therapeutic food (RUTF) over 2–3 days, as tolerated.
CHART 4
CHART 3
Replace starter F-75 with an equal amount of catch-up F-100 for 2 days.
Start Catch-up Growth
Increase each successive feed by 10 ml until some feed remains uneaten.
The point at which some feed remains unconsumed is likely to be when intake
reaches about 200 ml/kg per day.
After a Gradual Transition, refer dietician and give:
frequent feeds, unlimited amounts
150–220 kcal/kg per day
4–6 g of protein/kg per day
Monitor weight gain
REfer
Day 3 onwards
MONITOR:
Early signs of Congestive Heart Failure:
(rapid pulse, fast breathing, basal lung crepitations, enlarging liver, gallop heart rhythm, raised
jugular venous pressure).
 If pulse rate (PR) and respiratory rates (RR) increase (RR by 5 breaths/min and PR by 25 beats/min),
and the increase is sustained for 2 successive 4-hourly readings, then:
- Reduce the volume fed to 100 ml/kg per day for 24 h.
Then, gradually increase as follows:
- 115 ml/kg per day for next 24 h
- 130 ml/kg per day for the following 48 h
Thereafter, increase each feed by 10 ml each day.

64
k) Emotional and Sensory Stimulation
Provide:
tender loving care
a cheerful, stimulating environment
structured play therapy for 15–30 min/day (work with occupational therapist)
physical activity as soon as the child is well enough
support maternal involvement (eg. comforting, feeding, bathing, playing).
suitable toys and play activities for the child.
3.4: TREATMENT OF ASSOCIATED CONDITIONS 4,7
a) Severe Anaemia
Treatment
Blood transfusion should be given in the first 24 h only if:
Hb is < 4 g/dl
Hb is 4–6 g/dl and the child has respiratory distress.
In severe acute malnutrition, the transfusion must be slower and of smaller volume than for a
well-nourished child. Give:
 Whole blood 10 ml/kg, slowly over 3 h.
 Frusemide, 1 mg/kg IV at the start of the transfusion.
If there are signs of heart failure, give 10 ml/kg of packed cells, as whole blood is likely to
worsen this condition.
* Children with severe acute malnutrition with oedema may have redistribution of fluid leading
to apparent low Hb, which does not require transfusion.
Monitoring
Monitor the pulse and breathing rates, listen to the lung fields, examine the abdomen for liver
size and check the jugular venous pressure every 15 min during the transfusion.
If either breathing (RR) or heart rate (PR) increases (RR by 5 breaths/min or PR by 25
beats/min), transfuse more slowly.
If there are basal lung crepitations or an enlarging liver, stop the transfusion and give IV
frusemide 1mg/kg.
* Do not repeat transfusion even if the Hb is still low or within 4 days of the last transfusion.

65
b) Skin lesion in Kwashiokor
Zinc deficiency is usual in children with kwashiorkor, and their skin quickly improves with zinc
supplementation. In addition:
Bathe or soak the affected areas for 10 min/day in 0.01% potassium permanganate
solution.
Apply barrier cream (zinc ointment, petroleum jelly) to the raw areas, and nystatin cream
to skin sores.
Avoid wet nappies so that the perineum can stay dry.
c) Continuing Diarrhoea
If diarrhoea continues, look for the cause and treat accordingly.
i) Giardiasis
Where possible, examine the stools by microscopy.
If cysts or trophozoites of Giardia lamblia are found, give metronidazole (7.5mg/kg
TDS for 7 days).
Treat with metronidazole if stool microscopy cannot be undertaken or if there is only
clinical suspicion of giardiasis.
ii) Lactose Intolerance
Diarrhoea is only rarely due to lactose intolerance. Intolerance should be diagnosed only if
copious watery diarrhoea occurs promptly after milk-based feeds are begun and if the diarrhoea
clearly improves when milk intake is reduced or stopped.
Starter F-75 is a low-lactose feed.
In exceptional cases:
replace milk feeds with yoghurt or a lactose-free infant formula.
reintroduce milk feeds gradually in the rehabilitation phase.
iii) Osmotic Diarrhoea
Osmotic diarrhoea may be suspected if the diarrhoea worsens substantially with hyperosmolar F-
75 and ceases when the sugar content and osmolarity are reduced. In these cases:
Use cereal-based starter F-75 or, if necessary, a commercially available isotonic starter
F-75.
Introduce catch-up F-100 or ready-to-use therapeutic food gradually.

66
4.0 : SEVERE ACUTE MALNUTRITION IN INFANTS LESS THAN 6 MONTHS OLD 4
Severe acute malnutrition is less common in infants < 6 months than in older children. An
organic cause for the malnutrition or failure to thrive should be considered, and, when
appropriate, treated.
Treatment
Give parenteral antibiotics to treat possible sepsis, and appropriate treatment for other medical
complications.
Re-establish effective exclusive breastfeeding by the mother or other caregiver.
If not possible, give replacement infant formula with advice on safe preparation and use.
For infants with kwashiokor, give infant formula or F-75 or diluted F-100 to supplement
breastfeeding.
For infants with severe acute malnutrition with no oedema, give expressed breast milk
(EBM); and when not possible, infant formula or F-75 or diluted F-100, in this order of
preference.
*Do not use F-100; owing to the high renal solute load and risk of hypernatraemic
dehydration.
5.0 : DISCHARGE AND FOLLOW UP 4,7
Children admitted to hospital with complicated severe acute malnutrition can be transferred to
outpatient care during the rehabilitation phase.
Carefully assess the child and the available community support. The child will require continuing
care as an outpatient to complete rehabilitation and prevent relapse (eg. Klinik Kesihatan Betau
Nutritional Rehabilitation Centre, Feeding centre). Hospital staff will have to liase with Pegawai
Sains Pemakanan (PSP).
5.1 : DISCHARGE CRITERIA
Children should be discharged from hospital to outpatient or a Nutritional Rehabilitation
Programme when:
Completed parenteral antibiotic treatment.
Clinically well and alert.
Medical complications are resolved.
Oedema has resolved.
Their appetite has fully recovered and they are eating well.
Weight-for-length/ height (WHZ) is at least ≥ -2 z score and they have had no oedema for
at least 2 weeks.

67
Carer are - sensitized regarding danger signs.
- available for child care.
- have received counselling on appropriate child feeding practices (types,
amount, frequency)
- have the resources to feed the child.
Public Health team and Pegawai Sains Pemakanan (PSP) informed.
(Refer Discharge Checklist Appendix Pg. 77)
Medication on discharge:
Syr Multivitamin
Syr Folic acid
Syr FAC (elemental iron)
5.2 : FOLLOW UP
When a child is discharged to outpatient, make a plan for following up of the child until full
recovery; inform Public Health team and PSP.
The child should be weighed and reviewed:
Weekly then,
2 weekly then,
Monthly for 6 months
(If weight STATIC or DROP, assess and counsel feeding, and review 1-2weekly)
*Refer FLOWCHART FOR INTEGRATED MANAGEMENT OF MALNUTRITION IN
CHILDREN UNDER 5 (Refer Pg. 20)
If the child fails to gain weight over a 2-week period or loses weight between two measurements
(despite proper assessment and counseling) or develops loss of appetite or oedema, or becomes
sick, the child should be referred back to hospital for further assessment.
Once discharged from the nutritional treatment (WHZ > 1), he or she should be periodically
monitored to avoid relapse by primary health team.

68
6.0 : COMMUNITY NUTRITIONAL REHABILITATION
6.1 : NUTRITIONAL REHABILITATION PROGRAMME
The aim of the Nutritional Rehabilitation Programme is to improve the health and nutritional
status of children aged 6 months to 6 years old. Children who suffer from severe malnutrition
and medical complications are admitted into ward for treatment. Through the integrated
management, once the children are discharged from the hospital, they will be incorporated into
the Nutritional Rehabilitation Programme, where they will be registered under either Program
Pemulihan Kanak-Kanak Kekurangan Zat Makanan (PPKZM) or Program Makanan Tambahan
Susu Tepung Penuh Krim (STPK), depending on their eligibility.
They will also to be treated with daily therapeutic feedings such as Ready-to-Use Therapeutic
Food (RUTF), F100 or formula milk which is specially designed for gaining weight or formula
milk with glucose polymer or modular fat. The choice of therapeutic diet is subjected to the
availability of the foods. The activity daily therapeutic feeding they received is depend on where
the children live whether in Community Feeding Centre or Health Clinic.
Under PPKZM, children aged 6 months to 6 years old are supplied monthly with food basket
until they are recovered or reached the age of seven. The food basket comprises of rice, breakfast
cereals, biscuits, margarine, eggs, multivitamin, sardines, anchovies, noodles, chocolate malt
powder, cooking oil, full cream milk powder and special milk for weight gain. There are 13 basic
food combinations that can be supplied to these children. On the other hand, under Program
Makanan Tambahan STPK, children aged 6 months to 6 years old are supplied monthly with 1kg
of full cream milk powder.
Nutrition Officer (Pegawai Sains Pemakaanan PSP) play a crucial role in helping unhealthy
communities to live longer, and more productive lives. There are about 23 Nutrition Officers in
Pahang and each districts have at least one Nutrition Officer and the most is four. In connection
with the nutrition rehabilitation programme, the programmed above will be monitored by
Nutrition Officer in the collaboration with Maternal and Child Health Unit at the district level.

69
6.2: NOTIFICATION OF THE CHILD WITH SEVERE MALNUTRITION WHO IS
ADMITTED INTO HOSPITAL
Flow Chart: Notification of children with severe acute malnutrition from Hospital
Admission: Child with
severe malnutrition
Medical Officer to complete
Notification Form
To fax/ email the notification form
to nearest district Nutrition Officer
(Pegawai Sains Pemakanan)
within 72 hours after admission
To notify by calling the district
Nutrition Officer (Pegawai Sains
Pemakanan) and Liason Officer
when the case being discharged.

70
Standard Operating Procedures for Notifying the Child Admitted with Severe Malnutrition by Hospital
No. Work Process Standard
Person In
Charge
Reference(s) Tool(s)
1 Admit children under 5
with severe malnutrition
1.1 Children under 5
years old admitted to
pediatrics wad for
severe malnutrition
Medical
Officer from
Hospital
WHO Child
Growth
Standards:
Physical
examination &
WLZ or WHZ
2. To Complete the
Notification Form
2.1 To assess nutrional
status by intepreting
growth indicator of
weight-for-
length/height by
determining the z-
score (WLZ/WHZ).
2.2 To complete
Notification Form
Medical
Officer from
Hospital
Notification
Form
(Refer to
Appendix Pg 75)
3 To Fax or Email the
Notification Form to
Nutrition Officer
(Pegawai Sains
Pemkanan) and Liaison
Officer
Nurse assists to fax or
email the notification
form to the nearest
Pejabat Kesihatan
Daerah which brings
to the attention of
Nutrition Officer
(PSP) and Liaison
Officer
Jururawat
Kesihatan /
Jururawat
Masyarakat
4. To Notify Nutrition
Officer (PSP) and Liaison
Officer when the patient is
discharged
Nurse call the
Nutrition Officer
(PSP) and Liaison
Officer from the
respective Pejabat
Kesihatan Daerah
before the patient is
discharged
5. Discharged

71
6.3: FLOWCHART: FOLLOW UP OF THE CHILD WITH SEVERE MALNUTRITION
WHO IS DISCHARGED FROM HOSPITAL BY NUTRITION OFFICER
(PEGAWAI SAINS PEMAKANAN)
Patient with severe
malnutrition discharge
from hospital
To assess the Nutritional
status and counsel feeding
Nutritional Rehabilitation
Programme:
RUTF
PPKZM / FCM
Reassessment after 1 week
WHZ > -3SD
Continue assessment after 2 weeks
WHZ > -2SD
Monthly assessment until WHZ > -1SD
REFER TO FMS/MO
NO
YES
YES
NO
DISCHARGE
D

72
Standard Operating Procedures for Follow up of the child with Severe Malnutrition who is
discharged from hospital by Nutrition Officer (Pegawai Sains Pemakanan)
No. Work Process Standard
Person In
Charge
Reference(s) Tool(s)
1. Children under 5
with severe
malnutrition who are
discharged from
hospital after
treatment
1.1 To notify Nutrition
Officer (PSP) and
Liaison Officer from
the respective Pejabat
Kesihatan Daerah
when the patient is
discharged
Ward Sister
Refer
flowchart in
notification
form
i.Circular From
JKN Pahang;
Bil(42)dlm,JK
N.PHG(S)GS0
5/6/169%
February 2014
Discharge
Checklist :
Discharge
Criteria for the
Child Under 5
with Severe
Malnutrition
2. Assessment on
nutritional status and
nutrition counseling
2.1 To assess nutritional
status by interpreting
growth indicators such
as weight-for-age
(WAZ), height-for-age
(HAZ), BMI-for-age
(BAZ) and weight-for-
height (WHZ).
2.2 To assess food intake
and conduct nutrition
counseling based on the
known issues:
2.2.1 Diet Recall /
FFQ
2.2.2 Recommended
calorie intake =
150% from the
Recommended
Nutrient Intakes
(RNI)
PSP i.Garis Panduan
Program
Pemulihan
Kanak-kanak
Kekurangan
Zat Makanan,
Bahagian
Pemakanan
2014
ii.Garis Panduan
Susu Tepung
Penuh Krim,
Bahagian
Pemakanan
KKM
iii.Garis Panduan
Program
Rehabilitasi
pemakanan
2015
iv.Recommended
Nutrient
Intakes for
Malaysia 2005
i.Buku Rekod
Kanak-Kanak
Kekurangan
Zat Makanan
PPKZMR-101
Pind.1/2014
ii.Buku Rekod
Kesihatan
Bayi dan
Kanak-kanak
(0-6 tahun)
iii.Format
Penyiasatan
Penyebab
KZM mengikut
umur
(Lampiran
1,2,3,4)
3. Nutritional
Rehabilitation
Programme using
therapeutic diet:
- RUTF
- F100
- Formula milk
specially for
weight gain
3.1 Register the case under
NRP and determine
which programme
(PPKZM or FCM) case
is qualified to be
registered under.
Determine whether the
case is under the care of
the centre of
Programme Community
Feeding, Rehabilitation
centre or Klinik
Kesihatan/ Klinik Desa
PSP /
Jururawat
Kesihatan /
Jururawat
Masyarakat
i.Garis Panduan
Pusat
Community
Feeding,
Bahagian
Pemakanan
2014
ii.Garis Panduan
Program
Rehabilitasi
pemakanan
2015

73
3.2 Therapeutic diet will be
given:
3.2.1 RUTF: 1 serving =
300 kcal
3.2.2 F100: 100
ml/kg/day
3.2.3 Formula Milk: 100
kcal / 100 ml
3.2.4 Supplementation of
Glucose Polymer &
Modular Fat
4. Reassessment after
one week
4.1 Nutritional status is
based on Weight for
length (WLZ) or
Weight-for-Height
(WHZ)
4.2 If there is weight
increment, encourage
the parent/ guardian to
continue with correct
feeding practice/
recommendations.
If target weight is not
achievable, study the
cause of such failure
and continue
therapeutic diet.
PSP i.Modul Kursus
Penilaian
Pertumbuhan
Kanak-Kanak:
ii.Modul D
Runding Cara
Pertumbuhan
dan Pemberian
Makanan
WHO Child
Growth
Standards:
Weight-for-
Height (WHZ)
5. Continue assessment
after two weeks
5.1 Nutritional status is
based on Weight- for -
length (WLZ ) or
Weight-for-Height
(WHZ)
5.2 If there is weight
increment, the body
weight of the child will
be assessed monthly
PSP WHO Child
Growth
Standards:
Weight- for -
length (WLZ )
Weight-for-
Height (WHZ)
6. Refer to Family
Medicine Specialist
or Medical Officer
If there is no increment in
weight or the increment of
weight is not satisfactory,
refer to Family Medicine
Specialist/ Medical Officer
PSP
7. Reassessment after
one month
7.1 The target increment of
body weight is
determined by the
growth indicator of
Weight- for -length
(WLZ ) or Weight-for-
Height (WHZ) until the
Z-scores >-1 SD
PSP WHO Child
Growth
Standards:
Weight -for -
length (WHZ)
and Weight-for-
Height (WHZ)

74
6.4: FLOW CHART: FOLLOW UP FOR THE CHILD WITH MALNUTRITION
WHOSE PARENTS REFUSE HOSPITAL ADMISSION
CASE REFERRED
WHZ < -3SD
YES
NO
TO REGISTER
PPKZM / FCM
PROGRAMME
NUTRITIONAL REHABILITATION
PROGRAMME:
RUTF and
PPKZM / FCM
Assessment Weekly
Assessment Biweekly
IWEEKLY
DISCHARGE
D
WHZ >-3SD
REFER TO FMS/MO
NO
YES
WHZ >-2SD
NO
YES
To assess Nutritional
Status and Counsel feeding
Monthly Assessment until
WHZ > -1SD

75
APPENDICES
NOTIFICATION
FORM
Reminders:
1. Please send/ fax/ email one (1) copy of completed notification form to the nearest
Pejabat Kesihatan Daerah
2. Keep one (1) copy in respective facility (blue color)
Nutrition Unit,
Public Health Division,
State Health Department of Pahang

76
NOTIFICATION FORM OF THE CHILD WITH SEVERE MALNUTRITION
Hospital: Date:
Wad:
1. Name: ………………………………………………………………………………………………………………………………
2. MyKid number: ………………………………………………………… …………………………………………………….
3. Name of parent/ guardian: ….…………………………..………………………………………………………………
4. MyKad of Mother: ……………………………………………………………………….…………………………………..
If above not available Mykad of father/guardian……………………………………………………………..
5. Date of birth: ………………………………………. Age: …………Year(s) …………. Month(s)
6. Gender: Male/ Female
7. Current Address: Contact number: ………………………………..
………………………………………………………………………………………………………….…….……………………………
…………………………………………………………………………:…………………………………………………
8. Date of admission (day/month/year): …….. /….… /….….
9. Body weight:………………(kg); Length/Height: …………….(cm);
WLZ / WHZ Z-SCORE: …………………… on admission
10. Diagnosis:
………………………………………………………………………………………………………………………………………..
………….……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………….
Reported by:
Name: Position:

77
DISCHARGE CHECKLIST: DISCHARGE CRITERIA FOR CHILDREN WITH SEVERE MALNUTRITION
(Please check all boxes before discharge)
HOSPITAL :
NAME:
AGE:
Weight _____kg Length/ Height _____cm WLZ/WHZ z-score on Admission: ______
Weight _____kg Length/ Height _____cm WLZ/WHZ z-score on Discharge : ______
CRITERIA √- YES - NO
1 Well and has no fever, tachycardia, tachypneoa and oedema.
No refeeding syndrome.
2 Good weight gain (Weight-for-Length/ Height Z-score > -2 SD
No oedema for at least 2 weeks.
3 Good appetite and eating well.
4 Deworming done.
5 Immunization completed/ planned at KK.
6 Dietician plan/ Appropriate feeding practices and hygiene counseling
given to parents/ caretaker.
7 Pegawai Sains Pemakanan (PSP) informed again upon discharge, and
ensure patient enroll into the nutritional rehabilitation programme.
8 Bakul Makanan KZM/ Therapeutic Diet provided by PSP upon discharge.
9 Follow up appointment and condition of patient informed to Liason
Officer in PKD and recorded.
10 Case informed to Nutritional Rehabilitation Centre (If patient is
discharged to the centre for continuation of care).
11 Memo/letter to Klinik Kesihatan prepared.
12 Discharge summary done.
13 Child Health Care Book updated.
14 Carers sensitized regarding danger signs.
15 Medication given to parents/carers. Parents taught.
16 Follow up appointment given to parents/carers.
* Patient can only be discharged if every box is ticked √ ( YES).
Checked by,
______________________
(Medical Officer In Charge)
Sign and Stamp

78
FOOD FOR CHILDREN WITH SEVERE MALNUTRITION
A. READY TO USE THERAPEUTIC FOOD (RUTF)
RUTF are energy dense food (>300 kcal), enriched with nutrients and used as a therapeutic food. Typical
ingredients of RUTF are peanuts, vegetable oil, sugar and powdered milk. It usually contains a mixture of
protein, carbohydrate, fat and vitamins and minerals. RUTF are designed to be eaten straight from the
packaging, not easily spoiled by bacterial contamination and able to maintain its consistency over time.
In Malaysia, RUTF has been used in Community Feeding Program (PCF) by Ministry of Health to treat
Orang Asli children with low and severely low body weight.
Ingredients:
1. Full cream milk powder 30% weight
Can be replaced with skimmed milk powder with higher contents of protein.
2. Icing Sugar 28% weight
Commercially available granulated white or brown sugar can be used. However, the texture
needs to be refined so the particle size is less than 200 micron.
3. Vegetable oil 15% weight
Oil from soybean, cottonseed, rapeseed are preferred as they contain a balanced proportion of
different types of fatty acids.
4. Peanut butter 25% weight
Can be prepared by roasting and blending the dry peanuts without adding any fat, salt or
preservatives.
5. Vitamins and mineral 1.6% weight (Optional)
Refined powder or liquid form of vitamins and minerals can be added to fortify the blend.
Nutrition facts (1236 kcal of energy per serving):
Nutrient Weight
Carbohydrate 118.5 g
Protein 37.1 g
Fat 68.4 g
Vitamin A 17.2 mg
Vitamin B1 1.0 mg
Vitamin B2 2.6 mg
Niacin 8.6 mg
Calcium 1.1 g
Iron 4.2 g
Fiber 4.4 g
* Adapted from nutrient analysis for RUTF Hulu Perak, Perak

79
B. F-100 FORMULA
F-100 are milk-based therapeutic food designed as “catch up formula” for malnourished children. The
formula is used in therapeutic feeding centers where children are hospitalized for treatment. The figure
means that the product contains 100 kcal for every 100 ml of the mixture. Main ingredients for F-100 are
full cream milk or skimmed milk powder, sugar, vegetable oil and water. Refined cereals are often added
to improve the taste and nutrient contents. In Malaysia, F100 and F75 are widely used in hospitals, either
in pre-packed form or prepared separately by the dietitians. The dosage is given based on the child
weight.
Ingredients (approx. 500 ml):
Ingredients Weight
Without cereals With cereals
Full cream milk powder 32.0 g 20.0 g
Granulated sugar 16.0 g 25.0 g
Corn or vegetable oil 18.0 g 15.0 g
Cereals (Red rice by Cerelac) - 40.0 g
Water 500 ml 500 ml
How to prepare (F-100 without cereals approx. 500 ml):
1. Add 3 tablespoons of full cream milk powder (32 g) together with 1 tablespoon of sugar (16 g)
and 1 tablespoon of vegetable oil (18 g). Pour in cooled boiled water slowly and mix thoroughly
using spoon until the mixture reached 500 ml.
2. Stir the mixture using the blender until no visible layer of oil on the top. The formula is now
ready to be consumed within 2 hours in room temperature.
Nutrition facts
For every 500 ml, F 100 contains 30.7 g of proteins and 507 kcal of energy.
Tips for preparation
1. Apply hygiene at all level.
2. Mix oil well so that it does not separate. If oil floats to the top of the mixture, there is a risk that
some children will get too much and others too little.
3. Be careful to add the correct amount of water to make up 500 ml of formula to prevent over
dilution of the mixture. Use a container with marking.
4. It is important to use cooled, boiled water even for recipes that involve cooking. The water should
be cooled because adding boiling water to the powdered ingredients may create lumps.
5. It is best to consume the formula immediately after mixing. The oil tends to float again if left too
long and increase the risk of bacterial contamination.
6. The best way to feed the child is by using cup or spoon to eliminate poor suckling, contamination
and nipple confusion issues if using feeding bottle.

80
C. F-75 FORMULA
RECIPE FOR F-75
RECIPE FOR ReSoMal (Rehydration Solution for Malnutrition)
1) Mixed 4 packets of ORS
2) Measure and add in 50g Glucose.
3) Filter 45mls of Inj. Potassium Chloride (KCL) (1g/10ml) with 5 micron filter.
4) Add water till an amount of 2000ml.
5) 2000ml = 8 bottles of ReSoMal (250ml/bottle).
6) ReSoMal bottle maybe keep in refrigerator (Temp 4°C) for a maximum of 1 month.
(Ensure expiry date is written)
Contents of Modified F75 formula for local use Quantity This formula
contain:
Nutrition
Dry skim milk 2.0 g Energy (kcal) 78 kcal
Sugar 5.0 g Protein (g) 1.5 g
Cereal 7.0 g Lactose (g) 0.026 g
Vegetable oil 3.0 g
Water 100 ml

81
REFERENCES
1.
World Health Organization (2013) Guideline: Updates on the management of severe
acute malnutrition in infants and children. Geneva: World Health Organization.
2.
World Health Organization (2000) Management of the child with a serious infection or
severe malnutrition. Guidelines for the care at the first-referral level in developing
countries. (IMCI) Geneva: WHO.
3.
World Health Organization, & UNICEF. (2009). WHO child growth standards and the
identification of severe acute malnutrition in infants and children: joint statement by the
World Health Organization and the United Nations Children's Fund.
4.
World Health Organization (2013). Pocket book of Hospital Care for children:
Guidelines for the Management of Common Childhood Illness with limited resources. 2nd
Edition.
5.
Bhan, M. K., Bhandari, N., & Bahl, R. (2003). Management of the severely malnourished
child: perspective from developing countries. BMJ: British Medical Journal, 326(7381),
146-151.
6.
Malnourished Orang Asli Protocols. (2009). Paediatric department, Hospital Raja
Permaisuri Bainun, Ipoh.
7.
Clinical Management Protocol of A Sick Malnourished Orang Asli Child. (2010).
Paediatric Department, Hospital Sultan Haji Ahmad Shah (HOSHAS), Temerloh,
Pahang.
8.
Paediatric Protocols for Malaysian Hospital 3rd
Edition (2013).

82
ACKNOWLEDGEMENTS
CHAIRPERSON
DR. CHIN CHOY NYOK
Senior Consultant Paediatrician and Neonatologist,
Hospital Tengku Ampuan Afzan, Kuantan
MEMBERS
DR. SURYATI BT. ADNAN
Senior Consultant Infectious Disease Paediatrician
Hospital Sultan Haji Ahmad Shah, Temerloh
DR. AZMI B. ABDULLAH
Consultant Paediatrician
Hospital Pekan
DR. KELVIN CHIA CHEONG YUNG
Paediatrician,
Hospital Kuala Lipis
DR. RAHIMI BT. HASSAN
Public Health Physician
Kuala Lipis District Health Office
DR. WAN ABDUL RAHIM B. WAN
MUHAMMAD
Jerantut District Health Office
DR. MOHD RAHIM B. SULONG
Rompin District Health Office
DR. NOR AZAM B. KAMARUZMAN
Family Medicine Specialist
Rompin Health Clinic
DR. ISKANDAR FIRZADA B. OTHMAN
Jaya Gading Health Clinic, Kuantan
DR. ABDUL KHALEK B. ABDUL RAHMAN
Benta Health Clinic, Kuala Lipis
PN. ZAHARIAH BT. MOHD NORDIN
Senior Principal Assistant Director (Nutrition)
Nutrition Unit,
Pahang State Health Department
PN. HAR RASYIDAH BT. MOHD IRANI
Nutrition Officer
Bandar Mentakab Health Clinic,Temerloh
EN. ABU HANIFAH B. SULONG
Nutrition Officer
Sungai Koyan Health Clinic, Kuala Lipis
CIK NORFAIEZAH BT. AHMAD
Nutrition Officer
Jerantut Health Clinic, Jerantut
CIK HALIMATUS SAADIAH BT. MD. JABIR
Nutrition Officer
Muadzam Shah Maternal and Child Health Clinic,
Muadzam Shah.
EN. LAI WAI KENT
Nutrition Officer
Tanah Rata Health Clinic, Cameron Highlands

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