1. The document discusses integrated management of acute malnutrition (IMAM), which is a strategy to address acute malnutrition through community mobilization, supplementary feeding programs, outpatient therapeutic care, and inpatient therapeutic care. 2. IMAM aims to decentralize treatment, revise screening and admission criteria, and use ready-to-use therapeutic foods. It brings together outpatient and inpatient care to manage moderate and severe acute malnutrition. 3. Malnutrition is classified as acute or chronic, and can be assessed through anthropometric measurements like weight-for-height, height-for-age, weight-for-age, and mid-upper arm circumference. Z-scores are used to classify nutritional status.

1. INTEGRATED MANAGEMENT OF
MALNUTRITION
OVERVIEW OF MALNUTRITION

2. Nutritional Status of Children
Percent of children under 5
10
3
32
*Based on the new WHO Child Growth Standards

3. Trends in Nutritional Status of Children
Percent of children under age 5
Note: Data for 1999 and 2005-06 are recalculated WHO reference standard to be comparable to 2011 data.

4. Malnutrition and Childhood mortality
in Zimbabwe
Malnutrition
35%
• A child with severe
acute malnutrition
is nearly 10 times
more likely to die
than their well
nourished
counterparts
Source: National Nutrition Survey, 2010

5. Definition of Malnutrition
• Malnutrition literally means “poor nutrition”
• Technically includes both over and under nutrition
• In developing countries, under-nutrition is the main
problem
• Malnutrition in this workshop refers to under-nutrition
unless otherwise stated.

6. Definition of Malnutrition
• “A state in which the physical function of an
individual is impaired to the point where he or
she can no longer maintain adequate bodily
performance processes such as: growth,
pregnancy, lactation, physical work, resisting
and recovering from disease” WFP

7. Causes of
Malnutrition
: Conceptual
Framework
Source: The
Sphere Project

8. IMAM
• Strategy to address acute malnutrition
• Brings together all the components of
outpatient and inpatient care

9. Components of IMAM
• Community mobilization: To increase community
awareness of the problem of malnutrition in order to
improve programme coverage through community
participation.
•
• Supplementary feeding programs: To manage moderate
acute malnutrition.
• Outpatient therapeutic care: To manage uncomplicated
severe acute malnutrition.
• In-patient therapeutic care: To manage complicated severe
acute malnutrition.

10. Integrated Management of Acute Malnutrition
(IMAM)
Acute Malnutrition
With ComplicationsWithout Complications
Moderate to Severe
Inpatient Care
Moderate
Supplementary
Feeding
Severe
Outpatient
Therapeutic Care

11. Linkages of the 3 Components
Source: CTC Field
Manual Valid

12. IMAM - Why?
• IMAM was designed to address these limitations:
– Decentralization of treatment
– Revised screening and admission criteria
– Admission into wards of only cases with complications
– Child able to access treatment without having to stay for long periods
in the ward
• Central to outpatient care is the innovation of
ready-to-use therapeutic food (RUTF)

13. Pathophysiology of
Malnutrition
13

14. Background
• Over 40 nutrients are essential to health
• If any one is deficient then the person will not
be healthy and resist disease
• These nutrients are divided into two groups:
– Type I nutrients
– Type II nutrients
14

15. • Type I –
Functional nutrients
(Fe, I, vit A, D, E, K, …)
 have a body store
 reduces in concentration with
deficiency
 Specific signs of
deficiency
 Growth failure not a
feature
 variable in breast milk
• Type II –
Growth nutrients
(K, Mg, Zn, Na,…)
 have no body store
 stable tissue
concentration
 no specific signs of
deficiency
 Growth failure the
dominant feature
 stable in breast milk
15

16. 16

17. What Happens in Malnutrition
• Malnutrition is characterized by reductive adaptation of all
the organs in the body
• The systems slow down to allow the body to survive on limited
calories
• Appropriate treatment allows the body to slowly learn to
function fully again
• Rapid changes such as rapid feeding or fluids may overwhelm
the systems
• Feeding must be slowly and cautiously increased to always remain
within the physiological capacity of the patient
17

18. Reductive Adaptation
• Whole body
– Activity
• Organs
– Cardiac function
– renal function
– intestinal function
– liver function
– muscle function
• Cells
– Protein synthesis
– Sodium pump
• General
– Temperature
regulation
– immune function
18

19. Cellular function
• Sodium pump activity is reduced and cell
membranes are more permeable than
normal
• Which leads to an increase in intracellular
sodium and decrease in intracellular
potassium and magnesium
• Protein synthesis is reduced
19

20. Renal function in malnutrition
• Kidneys are not functioning at normal capacity
– Fluid and solute excretion are reduced
– Capacity of kidney to excrete excess acid or water
load is greatly reduced
– Giving intravenous fluids including blood can easily
cause fluid overload and heart failure
– Sodium excretion is reduced
– Urinary tract infection is common
20

21. Cardiac Function in malnutrition
• The heart muscle is weakened and hence there is
reduced cardiac output
• Blood pressure is low
• Renal perfusion and circulation time are reduced
• Plasma volume is usually normal and red cell volume
is reduced
• Output and stroke volume are reduced
• Any increase in blood pressure can easily produce
acute heart failure
21

22. Intestinal function
• Production of gastric acid is reduced
• Intestinal motility is reduced
• Pancreas is atrophied and production of
digestive enzymes is reduced
• Small intestinal mucosa is atrophied;
secretion of digestive enzyme is reduced
• Absorption of nutrients is reduced
22

23. Muscle function
• The skin and subcutaneous fat and
glands are atrophied, which leads to
loose folds
• Many signs of dehydratation are
unreliable; eyes may be sunken
because of loss of subcutaneous fat
in the orbit
• Many glands including the sweat,
tear and salivary glands are atrophied
23

24. Liver function
• Capacity of the liver to take up, metabolize and
excrete toxins is severely reduced
• Gluconeogenesis is reduced, increasing the risk
of hypoglycemia
• Protein synthesis is reduced
• Fatty infiltration of liver causes hepatomegaly
• Abnormal metabolites of amino acids are
produced
• Bile secretion is reduced
24

25. Immune System
• All aspects of immunity are diminished hence
increased risk of infections
– Signs of severe infections are often masked
– Lymph glands, tonsils and the thymus are
atrophied; T-cell (cell mediated immunity) is
severely depressed
– Individuals with severe infection may not have
a fever
– Tissue damage does not result in inflammation
or migration of white cells to the affected area
– Hypoglycaemia and hypothermia are both signs
of severe infection
25

26. Skin
• Skin and subcutaneous fat are atrophied, which
leads to loose folds of skin
• Many signs of dehydration are unreliable and
may be misleading
26

27. INTERGRATED MANAGEMENT OF
MALNUTRITION
NUTRITION ASSESSMENT

28. NUTRITION ASSESSMENT
• Nutrition status of all children and adults
should be assessed at any point of contact
– At a health facility as part of regular growth
monitoring activities or at community level
• Nutrition screening should take place
alongside nutrition and health education
• Where identified, malnourished individuals
should be referred for HIV counseling and
testing

29. NUTRITION ASSESSMENT
• TARGET?
– All children from 6 to 59 months of age
– Small children and visibly wasted adolescents and adults
• WHERE?
– Screening should be done routinely in all hospitals &
health centres:
• Hospital level: OPD, Emergency Ward , SC
• Health centre: OPD, Immunisation, IMCI, Growth Monitoring
• HOW?
– By using a MUAC tape
– By checking for bilateral oedema
– By taking the weight and height

30. Child Health Card (CHC)
• CHC is a good visual tool
for monitoring growth
trends: Height and weight
overtime
• MUAC is recorded but is
not plotted on a graph
• Weight for height/length
is not plotted on a graph
• To classify acute
nutritional status
interpret MUAC and
weight for length/height
using W/H chart
30

31. Zimbabwe Child Health Card
• Date and weight are recorded
each time the child is seen
• Length/height: every month for
the first two years. Then 4
times a year thereafter.
• The W/H z-score to be checked
for all children
• MUAC is used as a screening
tool
31

32. Age
• Record birth date from official document(s):
• Child Health Card
• Birth Certificate
• ID card
• If official documents are not available, use a local
calendar of events to determine the month and
year of birth
– If child’s height is under 110cm or if s/he is not
able to touch the opposite ear with the opposite
hand, s/he should be taken to be less than 5
years.
32

33. Weight Measurements
• Child should be wearing minimal clothing
• Make sure scale is zeroed
• Weigh child, take reading when measurement is
static/close to static as possible
• Mother child scales-
– Weigh caregiver with no shoes and light clothing
• Standing straight, looking forward
– Zero Tar scale
– Hand caregiver child and take measurement when
reading is static
• Caregiver should hold child in arms close to their body

34. Weighing Children (Salter Scale)
34

35. 68.5
Reading the Screen
35

36. 36
How to take the weight
SALTER SCALE FOR CHILDREN > 8kg
100g precision
SECA SCALE FOR
CHILDREN < 8kg
10-20g precision

37. Height/Length
• Height boards are used to measure height
or length
• Height should be taken for children 2 years
and above (85cm) while standing
• For children less than 2 years or <85cm
length should be taken while the child is
lying down
• Follow the steps below for taking the
height measurements:
37

38. Measuring Height (85cm and above)
40

39. • Assistants Hand Position
• Left hand on knees; knees together against
board
• Right hand on shins; heels against back and
base of board
• Feet flat, heels against the board
Measuring Height (85cm and above)
41

40. Position of Head
Slide board firmly over top
of head
Measuring Height (85cm and above)
42

41. Measuring Length (<85cm)
44

42. Child MUAC
46

43. Measuring MUAC
• 1. Keep your work at
eye level.
• Sit down when
possible. Very young
children can be held by
their mother during
this procedure.
• Ask the mother to
remove clothing that
may cover the child’s
left arm (or least used
arm).
47

44. Measuring MUAC
• Calculate the midpoint of
the child’s left upper arm
by first locating the tip of
the child’s shoulder
(Arrows 1 and 2) with
your finger tips.
• Bend the child’s elbow to
make a right angle
(Arrow3).
48

45. Measuring MUAC
• Place the tape at zero,
which is indicated by two
arrows, on the tip of the
shoulder (Arrow 4) and
pull the tape straight
down past the tip of the
elbow (Arrow 5).
49

46. Measuring MUAC
• Read the number at
the tip of the elbow
to the nearest
centimeter.
• Divide this number by
two to estimate the
midpoint.
50

47. Measuring MUAC
• Straighten the child’s arm
and wrap the tape around
the arm at midpoint.
• Make sure the numbers are
right side up. Make sure
the tape is flat around the
skin (Arrow7).
• Inspect the tension of the
tape on the child’s arm.
• Make sure the tape has the
proper tension (Arrow 7)
51

48. Measuring MUAC
• Inspect the tension
of the tape on the
child’s arm.
• Make sure the tape
has the proper
tension (Arrow 7)
and is not too tight
or too loose (Arrows
8-9).
52

49. Measuring MUAC
• Inspect the tension
of the tape on the
child’s arm.
• Make sure the tape
has the proper
tension (Arrow 7)
and is not too tight
or too loose (Arrows
8-9).
53

50. Measuring MUAC
• When the tape is in
the correct position
on the arm with the
correct tension, read
and call out the
measurement to the
nearest 0.1cm.
(Arrow 10).
54

51. Measuring MUAC
• Immediately record the measurement on the
questionnaire and show it to the measurer.
• 8. While the assistant records the measurement,
loosen the tape on the child’s arm.
• 9. Check the recorded measurement on the
questionnaire for accuracy and legibility. Instruct
the assistant to erase and correct any errors.
• 10. Remove the tape from the child’s arm.
55

52. * It is important to note that MUAC
measurements are:
– Almost stable from 12 to 59 months and can be used
without reference to the age or height.
– Used for rapid nutrition assessment in emergency
situation as a good indicator of mortality; and
– Used to screen for malnutrition and referral to the
therapeutic / supplementary feeding centers
particularly at community level
Measuring Mid-upper arm circumference (MUAC)
56

53. Measuring Oedema
• Oedema caused by acute
malnutrition occurs on both feet
and legs, and is known as bi-
lateral pitting oedema
• To assess the presence of bi-
lateral pitting oedema,
apply gentle thumb pressure to
both feet for three seconds ( 3
seconds is approximately the
time necessary to say one
thousand one, one thousand
two, one thousand three)
• If a shallow print or pit remains
on both feet when the thumb is
lifted, then the child has
nutritional oedema
57

54. Classifying Oedema
Severity of the
oedema
Appearance Recording
Mild Both feet +
Moderate:
Intermediate
between mild
and severe
Both feet, plus lower legs,
hands or lower arms ++
Severe
Generalised oedema including
both feet, legs, hands, arms
and face
+++
58

55. Oedema cont…
• Bilateral Pitting Oedema
– Severe Acute oedematous Malnutrition formerly
kwashiokor
• Bilateral Pitting Oedema usually in feet and legs &
Severe Wasting ( as seen by a low MUAC reading)
– Severe Acute oedematous Malnutrition formerly
called Marasmic Kwashiokor

56. Classification of Malnutrition
• Acute
• Chronic

57. Anthropometric index
Combination of different measurements or
combination of a measurement with other data
• Weight-for-height
• BMI-for-age
• Height-for-age
• Weight-for-age
• MUAC-for-height
• MUAC-for-age

58. Anthropometric Indices
Building Blocks
Sex Age
Height/
Length
Weight
1 2 3 4

59. Height
Age
Weight
Height
Using this
information
we can find
out if the child
is “stunted” or
short for his
age (Chronic
malnutrition)
Using this
information
we can find
out if the child
is “wasted” or
thin for his
height (Acute
malnutrition)
Anthropometric Indices
Building Blocks

60. Anthropometric Indices
Which to Use
Nutritional problem Index
Chronic malnutrition (stunting) Height-for-age
Acute malnutrition (wasting) Weight-for-height
Acute/chronic malnutrition
(underweight)
Weight-for-age

61. Classification of Malnutrition
Z-scores
Classification Z-score Values
Normal Z-score ≥ -2 - ≤ +2
Moderately malnourished z-score ≥ -3 and < -2
Severely malnourished z-score < -3

62. Chronic malnutrition
• An indicator of nutritional
status over an extended
period of time
• Also an indicator of
skeletal growth
• Chronically malnourished
children are shorter than
their comparable age
group (stunted)
• Can have long term
developmental effects on
a population

63. Stunting
• More likely to die.
• Fewer years in school.
• Less active, physically
and mentally, as
adults.
• Greater risk that the
next generation will be
stunted.
7 years 7 years 4 years
105 cm 125 cm 100 cm

64. Acute Malnutrition
• An indicator of current nutritional status
• Reflects recent weight changes or disruptions in
nutrient intake
• Classified as Moderate or Severe malnutrition
• Severe Acute malnutrition presents in three ways:
– Marasmus: Non-oedematous malnutrition
– Kwashiorkor
– Marasmic/Kwashiorkor
Oedematous
malnutrition

65. Signs of Severe Acute Malnutrition: Marasmus
• Severe weight loss from
loss of muscular tissue
and subcutaneous fat
• Wizened look
• Prominent ribs
• Apathy and irritability
• Poor appetite

66. Signs of Severe Acute Malnutrition
Kwashiorkor
• Bilateral pitting
oedema
• Dermatitis
• Hair is thin and silky
• Apathy and irritability

67. Signs of Severe Acute Malnutrition
Marasmic Kwashiorkor
• Combines both symptoms of kwashiokor
and marasmus
• Classic signs are wasting with oedema

68. WHO Growth Standard
Girls 24-59 Months of Age (Weight-for-Height)
Standard
deviation
Median
weight (kg)-2 SD weight-3 SD weightHeight (cm)
0.910.99.28.583.0
0.910.89.18.482.5
0.910.79.08.382.0
0.910.68.98.281.5
0.810.48.88.181.0
0.810.38.78.080.5
0.810.28.67.980.0
0.810.18.57.879.5
0.810.08.47.879.0
0.89.98.47.778.5

69. Classification of Malnutrition
Look Up Tables

70. • What is the length-for-age z-score of a girl measuring
57.0cm in length and weighing 3kg
-3SD (Severe)
• What is the length-for-age z-score of a girl measuring
62.4cm in length and weighing 6.4 kg
> -2SD (Normal)
Classification of Malnutrition
Look Up Tables

71. Anthropometry in Children above 5
years, Adolescents & Adults
• Body Mass Index (BMI) - The ratio of weight and height
BMI= Weight (Kg)
[Height(m)]2

72. Classification of Acute Malnutrition –
6 months to 18 years
76
Age Group
Measurement
Index
Classification
Severe Acute
Malnutrition
Moderate Acute
Malnutrition
Children 6 to 59
Months
Weight for Height
(W/H)
<-3 SD (WHO) <-2 & ≥-3 SD (WHO)
Mid-upper Arm
Circumference
(MUAC)
<115 mm <125 & ≥ 115 mm
Bilateral Pitting
Oedema
Yes No
Children and
Adolescents
(6 to 18 Years )
Body Mass Index
(BMI) for Age
<-3 SD (WHO) OR
visible wasting
<-2 & ≥-3 SD (WHO)
Bilateral pitting
oedema
Yes No

73. Classification for adults
Age Group Measurement
Index
Severe Acute
Malnutrition
(SAM)
Moderate Acute
Malnutrition
(MAM)
Adults Body Mass
Index (BMI)
< 16 kg/m2 < 18.5 & ≥ 16
kg/m2
Bilateral Pitting
Oedema
YES NO
Pregnant
&
Lactating
women
Mid-upper arm
circumference
(MUAC)
< 190mm
< 230mm & ≥
190mm
Bilateral Pitting
Oedema
YES NO

74. IMAM MANAGEMENT COMMODITIES

75. What is F-100?
• F-100(Formula 100) is
introduced after the patient
is stabilised and is intended
to rebuild wasted tissues as
quickly as possible.
• Contains an appropriate mix
of protein, sodium & fat to
avoid overwhelming the
patient
• Contains more calories and
protein than F-75
• F-100 is never used
on outpatients

76. What is RUTF?
• RUTF (Ready to use
therapeutic food) has
the same basic
ingredients as the F-100
and is used to support
the recovery of
uncomplicated acute
malnutrition
• Number of sachets for
each child depends on
weight of the child
• Can be administered
to outpatients

77. What is ReSoMal?
• ReSoMal is a powder
for the preparation of
a rehydration solution
exclusively for people
suffering from acute
malnutrition
• The quantity
prescribed depends on
the weight of the
patient.
• ReSoMal is never
used on outpatients

78. What is Therapeutic C.M.V?
• CMV can be used to
prepare F-75, F-100
and ReSoMal
• CMV is never used for
outpatients

79. What is F-75?
• F-75 (Formula 75) is
specially formulated to
meet the needs of the
malnourished patient
without overwhelming
the body.
• F-75 is used in the first
phase of management of
complicated SAM
• Administered until
patient is fully stabilised
(usually 2-7 days)
• F-75 is never used on
outpatients

81. Admission Criteria
STABILISATION CARE

82. Admission into SC
Severe Acute Malnutrition
AND
Medical complications
OR
Poor Appetite

83. Medical Complications - 1
• Intractable vomiting
• Fever > 39°C or hypothermia < 35°C
• Lower respiratory tract infection according to
IMNCI guidelines for age
– > 60 respirations / minute for a child < 2 months
– > 50 respirations / minute for a child 2 – 12 months
– >40 respirations / minute from 1 - 5 years
– > 30 respirations / minute for a child > 5 years.
• Any chest in-drawing

84. Medical Complications - 2
• Difficulty in breathing
• Severe anaemia – very pale (severe palmar pallor)
• Extensive superficial infection requiring parenteral drug
treatment.
• Very weak, apathetic, unconscious, convulsions.
• Severe dehydration.

85. Admission into SC
• Automatic entries into the SC
– Oedema +++
– Marasmic -Kwashiorkor
– Severely malnourished infants < 6 months
• Any of the three criteria below
– Moderate acute malnutrition associated with
• Bilateral pitting oedema
• No appetite
• Medical complications

86. Other Admissions
• If the care-giver refuses outpatient care
– Moderate cases without complications are not stabilized in
inpatient facilities but treated according to IMNCI protocols with
nutritional support (diet: F100/RUTF/CSB etc.)
• Referrals
– From OTP due to:
• Severe medical complication or anorexia
• Worsening oedema
• Weight loss for three consecutive weeks
– Non response after 3 weeks in OTP
• Readmission
– initially discharged as a defaulter
• Relapse
– previously cured but returns meeting criteria for
admission

87. Three Phases of Management

88. 3 phases of management
1. Initial Treatment
– Life threatening problems are identified and treated
– Specific deficiencies are corrected
– Metabolic abnormalities are reversed
– And feeding is begun
2. Rehabilitation
– Intensive feeding given to recover lost weight.
– Emotional and physical stimulation increased
– Caregiver trained to continue care at home
– Preparations for discharge
3. Follow-up
– Child and family followed up to prevent relapse and
– Ensure continued physical, mental and emotional development

89. Nutritional Rehabilitation of SAM with
complications
(STABLISATION/IN-PATIENT CARE)

90. Overview
• Reductive adaptation that occurs in malnutrition results
in the body failing to cope with large amounts of
nutrients
• The body then needs small amounts of protein &
sodium but LARGE amounts of carbohydrates
• 2 formula diets are used for management of severe acute
malnutrition
– F-75 – 75calories/100ml Protein – 0.9g/100ml
– F-100 or RUTF– 100cal/100ml Protein – 2.9g/100ml

91. Nutritional rehabilitation in SC
• This is phased into 3 parts:
–Phase 1- stabilisation phase
• The patient is stabilized both medically and
nutritionally
• They normally do not gain weight
–Transition phase
• The process of catch up growth is
commenced
–Phase 2- rehabilitation phase

92. Feeding on Admission
• Explain to the caregiver from the beginning
the type of feed, its importance, and the likely
duration of stay
• Provide small frequent feeds to avoid
overloading liver, intestines & kidneys
– Interval can be every 2/3/4 hours day and night
– Amount should be not more than 100kcal/kg and not less than
80kcal/kg
• More results in metabolic disorders
• Less results in continued tissue deterioration
• Use a nasogastric tube for those unwilling or
unable to eat
• If vomiting, reduce to a smaller tolerable
amount

93. Feeding on Admission
• Encourage the patient to eat, through
persuasion and being patient
• Feed formula from a cup - DO NOT USE
FEEDING BOTTLES
• Hold children in a secure sitting position
for feeding
• Those too weak to sit and consume may
be fed using a syringe, dropper, or
nasogastric tube
• Frequent breastfeeding should be
encouraged and actively supported

94. Stabilisation phase
–Give F-75 according to patient’s weight –
use look up charts
–Nothing other than F-75 and breast milk,
where relevant, should be provided to the
patient
–Feed with a cup and / or spoon

95. Indications for NGT feeding
– Use naso-gastric feeding under the following conditions:
• Consuming less than ¾ of prescribed diet
• Has pneumonia with respiratory distress (making inhalation of
feed likely)
• Has painful lesions in the mouth
• Has a cleft palate or other physical deformity interfering with
feeding
• Disturbances of consciousness (making inhalation of feed likely)
• NG feeding should end as soon as feasible
• At each feed, the patient should consume as much as
possible orally – only then should the feed be
continued through NG tube

96. Naso-gastric Feeding
• NG tube should be removed as soon as patient is able to
finish ¾ of feed orally
• If over the next 24 hours the patient fails to take in ¾ of
feeds, the tube should be reintroduced
• NG tube should always be aspirated before fluids are
administered.
• Aspiration is used to
– check if the previous feed has been absorbed
– confirm that the tube is in the stomach. Check pH of
aspirated contents (acidic if coming from the
stomach)
• Feeding should always be supervised by experienced
staff

97. • Return of appetite (i.e. finishes feeds easily)
• The only change is a change from F75 to F100.
– The number of feeds, timing and volume remains
exactly the same as in phase 1.
• RUTF may be introduced at this stage in addition to F100 so
patients are familiar with it when they reach phase two.
– Give 3 sachets of RUTF over the 2 day transition
period as a test dose.
Phase I to Transition Phase

98. Transition Phase to Phase I
• The following reasons indicate need to return to Phase I treatment
protocol:
– Weight gain more than 10g/kg/d (this indicates that there is excess
fluid accumulation – there is not enough energy in F100 to gain
weight so quickly)
– Worsening or reappearance of oedema
– Rapid increase in the size of the liver or liver tenderness
– Any sign of fluid overload, heart failure or respiratory distress
– If tense abdominal distension develops
– Re-feeding diarrhoea causing dehydration or weight loss (some loose
stools normally occur but do not cause loss of weight)
– Development of complications that require intravenous infusion of
drugs or fluids
– Loss of appetite

99. Transition Phase to Phase II
• Wasted patients should be in the transition
phase for at least 2 days
• Oedema should be resolving
• Medical complications should be resolved or
controlled
• The patient should have appetite – they
should be able to consume at least ¾ of RUTF
ration as observed for 24hrs
• Phase 2 = Outpatient therapeutic care (OTP)

100. Phase II- Rehabilitation

101. Phase II
• F-100 or RUTF is given to promote rapid catch
up growth and restore normal weight
• Patient should receive unlimited quantities,
but should consume a minimum of 150
ml/kg/day and a maximum of 220ml/kg/day
– refer to look up charts
– Extra consumption should be recorded on the multi-chart
– Feeds should occur every 3 hours initially & can be changed to
every four hours over time
• Preferred consumption is 200kcal/kg/ day
• Patients will not always consume the entire
amount at each feed – this is Ok

102. Introduction of Other Foods
• Other foods should be introduced when patient is able to finish all prescribed
meals
• Danger comes when other foods are consumed at the expense of F-100 because:
– They have lower energy content
– They are relatively deficient in vitamins and minerals
– And may contain substances that inhibit absorption of
Zinc, Copper, and Iron
• Where other foods are introduced:
– They should provide at least 1kcal/g of body weight
– Oil or margarine should be added to increase energy
content
– Where possible, use fortified foods
– Provide meals between F-100

103. Introduction of RUTF
• If the patient can consume ¾ of the recommended RUTF, the
patient can be discharged to outpatient care with a one week
supply of RUTF (In exceptional cases a two week ration can be
provided)
• The quantity of RUTF required is dependent upon the
patient’s weight – refer to look up tables in Quick Reference
Guide for exact quantities pg 18

104. Other considerations
• Moderately malnourished children referred to
SC
– if they do not have a good appetite give
F75
– If appetite is good give RUTF immediately to
prevent nutritional deterioration
• Referrals to SC due to static/loss of weight
without complications
– give RUTF if they already have an appetite.
• It is therefore important to conduct a medical
check on admission in order to prescribe the
correct diet.

105. Criteria to move back from phase 2 to
phase 1
• If re-feeding oedema occurs move back to
transition and phase 1
• If major illness occurs during phase 2
particularly during the first week
• If milk re-feeding diarrhoea occurs do not
treat unless associated with loss of weight

106. Milk Intolerance
• How do we diagnose it?
– Watery diarrhoea which occurs promptly after
giving a milk based feed
– The diarrhoea improves when milk intake is
reduced/stopped
– Recurs when milk is given
– Acidic feaces (pH <5)
• It is managed by replacing with sour
milk/yoghurt/commercial lactose free
formula

107. Composition of F75 and F100/RUTF
Nutrient F75/100ml F100/100ml RUTF/92g-100g
Energy 75cal 100cal 535 -500cal
Protein 0.9g 2.9 13.4g – 12g
Fat 2.6g 5g 31g – 28.5g
Vitamin A 137ug 152ug 0.95mg
Zinc 1.9mg 2.1mg 12.5 – 11.5
Iron <34ug < 38ug 12mg

108. Management of Severe Acute Malnutrition
Infants Under 6 Months of Age

109. Management of Severe Acute Malnutrition
Infants Under 6 Months of Age
• This age group poses the
highest mortality risk as
compared to any group in
the <5 years category
• Management objective is
very different from the
other age groups
• The aim is to re-establish
full and exclusive breast
feeding

110. Risk factors for SAM in infants< 6 mo
• Not exclusively breastfeeding
• Low birth weight
• Persistent diarrhoea
• Chronic underlying disease or
disability

111. Infants Under 6 Months of Age
Admissions Criteria
• Bilateral pitting oedema any grade
OR
• Weight for length less than – 3SD
OR
• Infant too weak or feeble to suckle
OR
• Mother reports breastfeeding failure AND
infant is not gaining weight

112. • Prepare the mother psychologically to breast feed
• Keep mother and baby together – encourage skin to
skin contact (kangaroo care)
– soothing for mother and baby
– helps stabilise baby’s condition (e.g. heart rate and
temperature)
– helps breastfeeding
• Put infant to the breast – proper attachment and
positioning
Management of Acute Malnutrition
Infants Under 6 Months of Age

113. Infants Under 6 Months of Age
Supporting Breastfeeding
• Frequent feeding (the more the baby suckles the more milk is
produced)
• Good Positioning
• Baby’s head and body in line
• Baby held close to mother’s body
• Baby’s whole body supported
• Baby approaches breast, nose to nipple
• Good Attachment
• Baby’s mouth is wide open
• Baby’s chin touches the breast
• More areola (brown around the nipple) shows above than below the nipple
• Baby’s lower lip is turned outwards (may be hard to see)

114. Infants Under 6 Months of Age
Dietary management for the Breastfed
• Encourage the mother to breast feed as often as
possible
• Let the baby feed as needed & come off the
breast by themselves. Then offer the second
breast
• If the mother is unable to breastfeed she should
use expressed breast milk or dilute F100 and
feed the child using
– a cup or
– the Supplementary Suckling Technique (SST)
• SST helps to stimulate breast milk production

115. Supplementary Suckling Technique (SST)
• Options include use of
• a syringe,
• a dropper,
• dripping milk on to the
breast so that it trickles
down into the baby’s mouth,
OR
• Use of a cup and nasogastric tube
• Only use NG tube, syringe, dropper
where equipment can be sterilised
The goal of supplemental suckling is to gradually replace supplementary
milks with mother’s breast milk

116. Dietary management for the Non- Breastfed Infant < 6
mo with SAM
• If there is no realistic prospect of being breastfed
– Give diluted F100 initially
– In phase II give double the amount of dilute
F100 then
– Give appropriate replacement feeds i.e
commercial infant formula with relevant
support to enable safe preparation and use
including at home when discharged
• Assessment of physical and mental health status of
mothers or caretakers should be promoted and
relevant treatment or support provided.

117. Preparing Dilute F100
• For supplementary suckling use F100 diluted as follows
– Dilute 100 ml of F-100 + 35 ml of water every 3 hours
or 200ml F-100 + 70 ml of water
– Do not make quantities less than 135ml of F100 Diluted
• Discard any excess waste
• Use look up chart to determine the appropriate quantities
of feed to administer

118. Dietary Management Infants with Oedema
• For infants with oedema, give
– F-75 as a supplement to breast milk until oedema is resolving
– Then give F100 dilute
• Infants should not be given un-diluted F-100 at any time because
of the high renal solute load and risk of hypernatraemic
dehydration.

119. Routine Medicines
• Folic acid stat dose
• Ferrous sulphate 3-5mg/kg/day when the
child starts to suckle well and starts to grow.
• Antibiotics: Amoxycillin (for children > 2 kg
body weight)
• If they are not receiving F-75, F-100 or RUTF
that comply with the WHO specifications give
– zinc in the same way as children who are not
severely malnourished and
– high dose of vitamin A (50,000 IU)

120. Monitoring infants with SAM below 6 months
• Weigh daily with no clothing using
a precision scale of 10-20g
• If infant gains 20g/day it means
breast milk quantity is increasing;
reduce F-100 Dilute

121. Discharge Criteria

122. IMAM
MANAGEMENT OF SAM WITHOUT
COMPLICATIONS
OTP

123. Admission Criteria
Severe Acute Malnutrition
AND
No medical complications: if there
is a medical complication -> refer the child
to the hospital (SC)
AND
Good Appetite: if a patient cannot eat
enough at home, s/he will most probably
deteriorate -> refer the child to the hospital (SC)
127

124. Types of admission to OTP
1. New admission: spontaneous, referred by CHW, from
screening
2. Relapse (also a new admission)
3. Re-admission: return of a defaulter (less than 2
months after defaulting)
4. Transfer IN
– from SC (Return)
– from another OTP
5. Choice: Caregiver refuses inpatient care despite
advice and the child is admitted to OTP instead
128

125. Registration process
• Take the patient's weight and height, and calculate the
weight-for-height
• Measure and record MUAC
• Calculate the target weight for discharge (if admission
on W/H criteria)
• Register the patient in the registration book
• Do an appetite test
• Check immunisation status
• Give routine medications
• Complete the OTP treatment card (OTP chart)
• Fill in details in the patients admission book
129

126. What is the Target weight or the
discharge weight?
• The target weight is the weight the patient should
reach to be discharged as cured (if admitted on
W/H)
• The target weight is equal to the weight
mentioned in the -1.5 z-score column in the W/H
table
• The target weight should be reached and
maintained for 2 consecutive visits (two weeks)
before the patient can be discharged as cured
130

127. Outpatient Therapeutic Programme
Nutritional Treatment
• Achieved through the use of Ready-to-Use Therapeutic Food (RUTF)
• Child should consume about 170 kcal per kilogram of body weight per
day (170 kcal/kg/day)
• Contains all the nutrients needed to treat acute malnutrition
– -> no need to give extra vitamin (except vitamin A), or minerals (no Zinc!)
• Continue breastfeeding
• Sufficient (even eaten alone at first) to begin rehabilitation
• RUTF is both a medicine and a food
• Patients need to drink water when eating RUTF
• The ration should be given according to the table below
131

128. Amount
s to give
132
Age Group
Patient
Weight (Kg)
RUTF
Sachet/Day
Sachet/Wee
k
Children < 6
months
Do NOT provide RUTF
Children 6 to
59 Months
(170
kcal/kg/day)
Children
above 5-12 if
less than 20kg
3.0– 3.4 1 ¼ 8
3.5 – 4.9 1 ½ 10
7.0 – 9.9 3 21
10 -14.9 4 ½ 30
15 – 19.9 5 35
Children and
Adolescents
(12 to 18
Years)
20 - 21 2 ½ 18
22 - 28 3 21
29 -30 3 ½ 25
31 - 41 4 28
42 - 48 4 ½ 32
Adults
(Above 18
Years)
25 - 28 2 14
29 - 32 2 ½ 18
33 - 41 3 21
42 - 44 3 ½ 25
44 - 60 4 28
Pregnant or
Lactating
Women
Any weight
5 35
6 42

129. Criteria of transfer to SC
• Transfer any patient being treated in the OTP to the SC if they develop any
of the following:
– Failure of the appetite test (see failure-to-respond procedure)
– Increase/development of œdema
– Development of refeeding diarrhoea sufficient to lead to weight loss
– Fulfilling any of the criteria of “failure to respond to treatment”:
Weight loss for 2 consecutive weightings
Weight loss of more than 5% of body weight at any visit
Static weight for 3 consecutive weightings
• Major illness or death of the main caretaker so that the substitute
caretaker is incapable or unwilling to look after the malnourished patient
or requests transfer to in-patient care
133

130. Failure-to-Respond to treatment
134
CRITERIA FOR FAILURE TO RESPOND
TIME AFTER
ADMISSION
Failure to gain any weight (non-oedematous children) 3 weeks
Weight loss since admission to program (non-oedematous children) 2 weeks
Failure to start to lose œdema 2 weeks
Œdema still present 3 weeks
Failure of Appetite test At any visit
Weight loss of 5% of body weight (non-œdematous children) At any visit
Weight loss for two successive visits At any visit
Failure to start to gain weight satisfactorily after loss of oedema
(kwashiorkor) or from day 14 (marasmus) onwards.
At any visit

131. OTP discharge criteria
Age group Discharge from OTP to home
Children < 6 months DO NOT GIVE RUTF
Children 6-59
months
 Z Score > -1.5 for two consecutive visits; or
 MUAC > 12.5cm; and
 No bilateral pitting oedema for 2 consecutive visits
Adolescents from
120cm height to 18
years of age
 W/H > 85% NCHS for one occasion; or
 BMI for age > -1SD for two consecutive visits; and
 No bilateral pitting oedema for 2 consecutive visits
Adults (above 18
years)
 BMI > 17.5; or
 MUAC ≥18.5 and
 No bilateral pitting oedema for 2 consecutive visits
Pregnant and
lactating woman
 MUAC >230mm and infant ≥6months; and
 No bilateral pitting oedema for 2 consecutive visits, and
135

132. Introduction
• Adults and adolescents have considered at low risk of
developing malnutrition;
– Hence excluded from most nutrition programmes
• Malnutrition has become common among adolescents and
adults because of HIV/ AIDS, TB and related infections
• The same principles used for the management of children
apply for adolescents and adults.
• Body Mass Index (BMI) is used when measuring the
nutritional status of adults.
• BMI for Age tables are available for adolescents

133. Admission Criteria
Acute Malnutrition
With ComplicationsWithout Complications
Moderate or Severe
Inpatient Care
Moderate
Supplementary
Feeding
Severe
Outpatient
Therapeutic Care

134. Classification of Malnutrition

135. Example of BMI for AGE Tables for
Girls

136. MANAGEMENT OF SAM IN
ADOLESCENTS AND ADULTS
• Manage them the same way as children.
– BMI for screenings
– Requirements are calculated using mls/kg
– Progress is measured using weight
– Same commodities and same methods
• Watch out for:
– Issues with palatability of plumpy nut
– Underlying conditions (HIV)

137. SUMMARY
• Assess
– Weight for Height
– MUAC
– Complications
– Appetite Test
• Classify
– SAM
• SC
• OTP
– MAM
• SFP (no programs so IYCF)
• Treat
– F75
– F100
– Plumpy Nut

138. Care & Emotional Environment

139. Play Activities
• Interaction with other children is
important during rehabilitation
• Mothers can be trained as play
guides and how to make the toys
• Feeding can take place in the play
area
• Children in the same phase can
be fed together
• Curriculum for play activities
should aim at development of
both motor and language skills
• 15-30 minutes play with each
child every day

140. Physical Activities
• Promote the development of essential motor skills
• May also enhance growth during rehabilitation
• Immobile children can splash in a warm bath
• Generally, duration and intensity should increase as
nutrition status and general condition improves
– Examples include walking, climbing stairs, running,
throwing and catching a ball

141. Play Therapy for Malnourished
Children

142. • Play is an important part of every child’s development
• Play helps them learn skills and develop self confidence and
imagination
• Most children develop some play themselves
• All children benefit from adult help in their play
• In particular their language improves when mothers and
fathers play with them
• Play is particularly important as part of the management
for children who have been ill or who are malnourished

143. Play for the Malnourished Child
• This little girl has
Kwashiorkor. She is very
suspicious of all the staff
• This picture shows the
same child only 5 days
later after play had been
introduced