Mohamed Dahir Abdi

1. Prepared By:- Mohamed Dahir Abdi
Mohameddahir739@gmail.com
Phone:+251910759529

2. Community- Based Management of Acute
Malnutrition (CMAM)
CMAM refers to the management of acute
malnutrition through:
1) inpatient care for children with SAM with medical
complications and all infants under 6 months old
with SAM
2) outpatient care for children with SAM without
medical complications;
3) community outreach; and
4) services or programs for children with moderate
2

3. 3
CMAM:Development,
Concepts …cont’d
ENA

4. 4
Concepts
• Is a public health approach to manage severe
malnutrition
• Aims to integrate emergency nutrition with long-term
programs by establishing structure that can be re-
activated in future emergencies
• Aims to maximize impact and minimize risk
Objectives
• Aims to provide fast, effective and cost efficient
assistance
• Empower the affected communities
• Create platform for longer-term solutions to the
problems of food security and public health
CMAM : Development, Concepts …cont’d

5. 5
CMAM-Development,
Concepts …cont’d
Principles
• Access and coverage – decentralized system
• Timeliness – before the prevalence of malnutrition
escalates, and medical complications develop
• Sectoral integration – health, hygiene, food security
• Capacity building – build on existing structure
Innovations
• Ready to Use Therapeutic Foods (RUTF) : Plumpy
Nut or PB100
• New acute malnutrition classification (Severe with or
without complications)
• Screening and admission using Mid-Upper Arm

7. 1. Check anthropometric criteria
2. Check for bilateral oedema
3. Do appetite test
4. Look for complications
5. Register the patient
6. Fill out the OTP card
7. Take history and P/E
8. Explain to the care taker the procedures of
treatment
7

8. • MUAC and Oedema detection are the
most appropriate anthropometric
techniques to detect Severe Acute
Malnutrition (SAM).
• Weight is used to follow the progress of
the admitted child and decide when to
discharge him/her from the programme.

9. Taking the MUAC
• Mid Upper Arm Circumference (MUAC)
is an alternative measure of thinness
to weight for height with comparative
advantage of being better predictor of
mortality
• Avoiding the need to take height is
also a very important advantage

10. Steps to follow when taking MUAC
1.Ask the mother to remove clothing that may cover
the child’s left arm.
2. Estimate the mid point of the left upper arm while
the child’s left arm is hanging free
3. Wrap the MUAC tape around the midpoint of the
left arm
• Ensure the tape is flat around the skin; nor too tight and
wrinkling/indenting the skin neither too loose and leaving
space between the skin and the tape
• Make sure the numbers are right side up
• Make sure the tape is in correct position on the arm with
correct tension, read and call out the measurement to the
nearest 0.1cm
• Immediately record the measurement

11. Interpretation of MUAC:
Children:
• MUAC >=12 cm, normal , tally and congratulate
• MUAC b/n 11-12, indicate MAM, register and
admit to SFP
• MUAC <11 cm = Severe Acute Malnutrition,
register and admit to OTP , give SFP card
Women:
• MUAC>=23 cm = normal, tally and congratulate
• MUAC <23 cm = malnourished, register and refer
to SFP

12. MUAC measurements Technique

13. MUAC measurements Technique…

14. MUAC Cut offs for Different Actions

15. At community level

16. 2. Checking for Bilateral Oedema
• Bilateral oedema is a sign of Kwashiorkor:
Kwashiorkor is always severe form of acute
malnutrition.
• Children with Kwashiorkor need to be in
therapeutic feeding program with out delay.
• Only children with bilateral oedema are recorded
as having nutritional oedema
• In order to determine the presence of oedema,
normal thumb pressure is applied to the both feet
for 3 seconds
• If a shallow print persists on the both feet then
the child presents oedema

18. 18

19. 19
Grade 1 or +
oedema
Grade 2 or
++ oedema

20. 20
20
Grade 3 or +++ eodema

21. 21

22. 22
Severe Visible Wasting
Ask the mother to
remove all cloth
and look the arm, thigh
and buttocks for loss of
muscle bulk and
sagging of skin

23. 23
Severe visible wasting

24. 24
Baggy pants

25. 25
MEASURING WEIGHT AND
LENGTH/HEIGHT :
•Note: in cases where bilateral pitting oedema and
MUAC are used for admission criteria, it’s optional
to measure height of child.) and note that length is
measured for children under two or with a height
below 85 cm (NCHS) or 87 cm (WHO), while
height is measured for children over two or with a
height above 85 cm (NCHS) or 87 cm (WHO)
•Note that in the case of children over two who are
unable to stand, the measure will be taken lying
down ; In this case an adjustment downward of
0.5 cm is made to the measurement

26. 3. Measuring Weight
Steps to measure weight
1. Explain the procedure to the child’s mother or
caregiver before starting.
2. Install a 25kg hanging salter scale (graduated by
100g). If mobile weighing is needed, the scale can
be hooked on a tree or a stick held by two people.
3. Attach the washing basin/ pants and recalibrate to
zero.
4. Remove the child’s clothes and place him or her
into the basin.

27. Steps to measure weight …
5. Ensure nothing is touching the child and the
basin/pant.
6. Read the scale at eye level (if the child is
moving about and the needle does not stabilize,
estimate weight by using the value situated at
the midpoint of the range of oscillations).
7. When the child is steady record the
measurement to the nearest 100gm.
8. Calibrate the scale with a material with known
weight every week

30. Weight & Height Measurement

31. • An individual child's measurement e.g.
weight is compared with the expected
value of a child of the same height or
age from a reference population
• As a Percentage of the expected
measurement
• As a standard deviation Z score in
relation to the median

32. Reference Population
• The World Health Organization
recommend that International Reference
Value are used known as NCHS,WHO,
CDC reference value
• For example, if the weights of all children
in the sample who were 82 cm in height
were plotted, the distribution curve would
approximately be normal

33. ‘Percentage of Median’ =
Actual weight/Reference Median
Weight x 100
E. g. Height = 82 cm
Reference weight = 11 kg
Weight of child = 9.4 kg
9.4/11 x 100 =85.5%

34. Standard Deviation or Z score
• The child's value is expressed in multiples
of the reference standard deviation value
for a child of the same age or height
• SD score=Actual weight - Reference
median weight Standard deviation of
reference population
•E.g. Weight = 9.4 kg
•Length = 82 cm
•Reference weight =11 kg
ZD= 9.4 -11= -1.6

35. 35
CALCULATING WFH Z-SCORE
• 1. Determine the age of the child in order to decide
whether to use the length tableor the height table.
Remind participants that if a child over the age of 2
(or over 87 cm) must be measured lying down for
whatever reason, subtract 0.5 cm from the
measurement.
• 2. Find the child’s height in the height column if
using the height table or child’s length in length
column if using the length table. Note that length
and height measurements ending on one decimal
are rounded up or down:
– 0.1, 0.2, 0.3, 0.4 are rounded down to 0.0 cm
– 0.5, 0.6, 0.7 0.8, 0.9 are rounded up to 1.0 cm

36. 36
CALCULATING WFH Z-SCORE….
• 3. Looking at the right side of the chart for a girl
or the left side of the chart for a boy, find the
median weight for a child of that height or length.
Determine whether the weight of the child is
above or below -1, -2, -3 or -4 standard
deviations (SDs).
• 4. Calculate the exact z-score by subtracting the
median weight from the child’s weight and
dividing by the SD (in kg).
(Actual child’s weight) – (Standard child’s weight) = z-
score
(one SD)

37. 37
CALCULATING WFH Z-SCORE
Child
Name Sex
Age in
years
Bilateral
Pitting
Oedema
MUAC
(mm or
colour)
Height
(cm)
Weight
(kg)
WFH
Z-Score
Child 1 F 3 No Green 98.2 12.5 < -1 and
> -2
Child 2 M 5 No 123 110.0 14.8 < -2 and
> -3
Child 3 M 5 ++ Yellow 102.2 13.5 < -2 and
> -3
Child 4 F 4 +++ 110 391 9.3 < - 3
Child 5 M 9 months 125 69.9 6.7 < -2 and
> -3
Child 6 F 4 +++ Yellow 105.2 18.0 > median
Child 7 F 8 months + 105 68.2
(Length)
5.0 < -3
Child 8 M 1 No Red 84.3
(Length)
8.9 = -3

38. 38
CALCULATING WFH AS A PERCENTAGE OF
THE MEDIAN.
1. Remember that if a child over the age of 2 (or
over 85 cm) must be measured lying down for
some reason, subtract 0.5 cm from the
measurement.
2. Find the child’s height or length in length column.
Note that length and height measurements
ending on one decimal are rounded up or down:
0.1, 0.2 are rounded down to 0.0 cm
0.3, 0.4 are rounded up to 0.5 cm
0.6, 0.7 are rounded down to 0.5 cm
0.8, 0.9 are rounded up to 1.0 cm

39. 39
CALCULATING WFH AS A PERCENTAGE OF
THE MEDIAN….
• 3. Find the median weight for that child,
irrespective of gender. Determine whether the
weight of the child is above or below 85, 80, 75,
70 or 65 percent.
• 4. Calculate the exact percentage of the median
by dividing the child’s weight by the median
weight.
Actual Child’s weight = percentage of the
median Median reference weight

40. 40
CALCULATING WFH AS A PERCENTAGE OF MEDIAN…
Child
Name
Age in
years
Bilateral
Pitting
Oedema
MUAC
(mm or
colour)
Height
(cm)
Weight
(kg)
WFH as
Percentage
Of Median
Child 1 3 No Green 98.2 12.5 ≥ 80%
Child 2 5 No 123 110.0 14.8 = 80%
Child 3 5 ++ Yellow 102.2 13.5 ≥ 80%
Child 4 4 No 110 391.1 9.3 = 70%
Child 5 9 months No 125 69.9 6.7 <80%
Child 6 4 +++ Yellow 105 18.0 ≥ 80%
Child 7 8 months + 105 68.2
(Length)
5.0 < 70%
Child 8 1 No Red 84.3
(Length)
8.9 < 80%

41. Classification of Acute Malnutrition
MODERATE SEVERE
MUAC 11cm - <12cm <11cm
Oedema No Yes
Z-score Between
–2SD to –3SD
< –3SD
% of Median 70% - 80% < 70%

42. 42
Wasting is a form of acute malnutrition. It is defined by
a MUAC < 120 mm or aWFH < -2 z-score (WHO
standards) orWFH < 80% of the median (NCHS
references).
Weight-for-Age Index (WFA) is used to assess
underweight. It shows how a child’s weight compares to
the weight of a child of the same age and sex in theWHO
standards.
The index reflects a child’s combined current and past
nutritional status.
Weight-for-Height Index (WFH) is used to assess wasting.
It shows how a child’s weight compares to the weight of a
child of the same length/height and sex in theWHO
standards or NCHS references.The index reflects a child’s
current nutritional status.

43. 43
Height-for-Age Index (HFA)-
The HFA index is used to assess stunting. It
shows how a child’s height compares to the
height of a child of the same age and sex in
the WHO standards. This index reflects a
child’s past nutritional status.

44. …
A child with SAM
•MUAC <11
•Oedema
To inpatient
If With
Complication /
with poor appetite
To OTP/Mobile clinic
If Without
Complication/
With good appetite
Discharge
Follow up in hospital
(TFU)

45. 45
Management principles
With the current SAM protocol mortality can
be less than 5%
LOW mortality is achieved by:
1. Stritically using Multichart
2. Restricting the use of fluids, specially IV
3. Treating in phases (Phase-1, Tran & Ph-2)
4. Preventing hypoglycemia and hypothermia
5. “Early” diagnosis and treatment

46. Step 4: Check for complications and
Danger Signs
• This can be done by assessing for
complications and doing appetite test.
• Check for: General danger signs,
Pneumonia, Dysentery, Fever and
hypothermia (low body temperature

47. Complication Referral to in-patient care when:
General Danger
Signs
If one of the following is present: Vomiting
everything, convulsion, lethargy,
unconscious, or unable to feed
Pneumonia/Severe
Pneumonia
Chest in-drawing
Fast breathing:
6 to 12 months 50 breaths / minute and
above
12 months up to 5 years 40 breaths / minute
and above
Dysentery If blood in the stool
Fever or Low body
temperature
T ≥ 37.5 or febrile to touch
T ≤ 350c or cold to touch
Note: If any one of the above complication is present, refer the child
to the nearest health centre/hospital with TFU or SC without
doing Appetite test.

48. 4: Check for complications & decide the treatment
If age up to six months and
-Visible severe wasting or
-Oedema of both feet
• If age six months and above and
•MUAC <11cm or oedema of both feet
and
•one of the following Danger sign or
•Fail appetite test or
•pneumonia/severe pneumonia or
• blood in the stool or
• fever/ hypothermia
Severe
Complicated
Malnutrition
Refer urgently to
TFU/SC for an in-
patient management
of the cases
If age six months or above and
•MUAC <11cm or oedema of both feet
and
• pass appetite test
Severe
uncomplicated
Malnutrition
Manage in OTP using
the Health Post OTP
protocol

49. 4: Check for complications ...
Assess Classify Action to take
•If MUAC 11cm to
<12cm and no oedema
of both feet
Moderate
Acute
Malnutrition
Refer to
supplementary
feeding program if
available Counsel
on child feeding/
care
•If MUAC > 12 cm and
no oedema of both
feet
No acute
malnutrition
Counsel the
mother and
congratulate her

50. Step 5: Check for Appetite test
• Appetite is a crucial indicator of any medical
problems. It is important that the test is done
properly and with enough time devoted to it
(up to 30 min).
Preparation:
• RUTF sachet, spoon, drinking water, glass,
table of ’Minimum amount of RUTF’ that
should be taken.

51. • The appetite test should be conducted in a
separate quiet area.
• Explain to the care taker the purpose of the
appetite test and how it will be carried out.
• The care taker should wash his/her hands.
• The care taker should sit comfortably with the
child on his lap and should either offer the RUTF
from the packet or put a small amount on his
finger and give it to the child.
• The care taker should offer the child the RUTF
gently, encouraging the child all the time. If the
child refuses then the care taker should
continue to quietly encourage the child and take
time over the test. The test usually takes a
short time but may take up to thirty minutes.
The child must not be forced to take the RUTF.
• The child needs to be offered plenty of water to
drink from a cup as he/she is taking the RUTF

52. Why do the appetite test?
v By far the most important criterion to decide if
a patient should be sent to in-or out- patient
management is the Appetite Test.
vA poor appetite means that the child has a;
* Significant infection
* Or a major metabolic abnormality such as
-Liver dysfunction,
-Electrolyte imbalance,
-Cell membrane damage or
-Damaged biochemical pathways.
These are the patients at immediate risk of death
52

53. Why do the appetite test?
•Malnutrition changes the way infections and
other diseases express themselves – Children
severely affected by the classical IMCI diseases,
who are malnourished, frequently show no signs
of these diseases
•The major complications lead to a loss of
appetite.
vThe signs of severe malnutrition itself are often
interpreted as dehydration
v It is mainly metabolic malnutrition that causes
death
vThe only sign of severe metabolic malnutrition
is a reduction in appetite
53

54. 1.Should be conducted in a separate quiet area.
2. Purpose of and how test will be carried out.
3- Carer should wash his hands
4-Sit comfortably with the child on his lap and either offer the
RUTF from the packet or put a small amount on his finger
and give it to the child.
5- Offer the child the RUTF gently, encouraging the child all
the time.
-If the child refuses then the carer should continue to quietly
encourage the child and take time over
the test. But not be forced to take the RUTF
- The test usually takes a short time but may take up to
one hour. 6-The child needs to be offered plenty of water
to drink from a cup as he/she is taking the RUTF 54

55. Appetite test table
APPETITE TEST
This is the minimum amount that malnourished patients
should take to pass the appetite test
RUTF BP 100
Body Weight
(Kg
Sachet Body weight
(Kg)
Bars
< 4 ⅛. - ¼ < 5 ¼ – ½
4 up to 10 ¼ - ½ 5 up to 10 ½ – ¾
10 up to15 ½ - ¾ 10 up to 15 ¾ – 1
15> ¾ - 1 > 15 1 – 1 ½

56. 56
Appetite test

57. Pass
1.A child that takes at least the amount shown in the table
(See page13) passes the appetite test.
2- Determine if he has a major complication or if no
medical complications present
3.The choices of treatment option and decide with the
carer, to be treated as either an out or in-patient
4.Give the patient a SAM-unique number and fill
in the registration book and OTP treatment chart
5. Start the Phase 2 treatment appropriate for out-patients
Note:  The appetite test must be carried out at
each follow up visit.
57

58. Appetite Test
• A child that does not take at least the
amount of RUTF should be referred for in-
patient care (Refer to the nearest TFU for
phase1management).
• Give SAM-unique number in the
registration book and multichart are filled
• Start treatment of Phase 1, and
complications appropriate for in-patients.
58

59. Most vulnerable with high risk of
mortality
• Bilateral odema, grade +++ or
• Marasmic kwashiorkor or
• MUAC <110mm (red) or
• WHZ <-3 or WHM < 70
• No appetite
• Severe medical complications
Children to be treated at In-patient care
59

60. Admission Criteria to OTP for SAM
without complications
• MUAC < 11cm in children with age 6
months and 5 years
• W/H < 70%
• Presence of bilateral Oedema of grade +
&++
• Pass appetite test
• Reasonable home circumstances and a
willing carer
• No open skin lesions/infection
• Alert with no medical complications

61. AGE ADMISSION CRITERIA
< 6 months 1. Visible severe wasting or
2. Presence of bilateral
pitting oedema of feet
6 months to 5 years 1. MUAC < 11 cm or
2. Presence of bilateral
pitting oedema of feet

62. Recording and Reporting
• Understand the importance of
registration and recording for OTP
• Be able to fill OTP card, Registration
book, and weekly reporting format
properly
NB:Fill all the necessary information in
the OTP card and the registration
book if the child is eligible for OTP.

63. Importance of the record keeping
This OTP card should be filled for each patient. It is
the primary tool for managing malnutrition and is
recommended for all facilities looking after these
patients. Other documents should not be used
It gives detailed information for each individual
case’s progression changes
1. in health and nutritional status,
2. medical treatments,
3. clinical signs, temperature, etc

64. Continue…
• The information can be found easily and
quickly.
• Inspection of the charts allows the HEWs
to quickly see if a patient needs special
attention and allows all supervisors to
control the quality of work of the staff.
• The charts and registration book contain all
the information needed to analyse and
report the results of the OTP in a standard
way.

65. How To fill The Registration Book
The information that should be filled by the
HW/HEWs are:
• Identification information, e.g. the child’s name,
• the father’s name,
• kebele and gotte.
Anthropometric information, e.g. MUAC, Weight;
oedema.
• Diagnosis and outcome, e.g. defaulters, discharge
cured, death, transfer out to in-patient care, and
non-responder.
• The registration book is filled at admission and
during discharge only

66. Fill the OTP card for Semira Ali
• Semira Ali is a 36 months old girl admitted
four weeks back with MUAC 10.2cm. She
was 9kg at admission and did not have
oedema. She was being followed using the
opportunity of weekly mobile clinic. Semira
came this week with weight 12kg, the same
weight as last week. Her mother reported
that she has diarrhoea but no fever, no
blood in the stool.
• What will you ask? What will you feel/check?

67. Fill out the OTP Record Card
67

68. Fill out the OTP Record Card
68

69. Failure to Respond
N.B. If failure to respond, refer to in-patient treatment whenever possible

70. Management of SAM in OTP
The OTP treatment includes:
• The patient should come to OTP site weekly to
receive weekly Ready to Use Therapeutic Food
(RUTF): Plumpy’Nut, or BP 100 biscuit bar and
• Routine drugs:
-7 days course of oral Amoxicillin,
- De-worming tablets: Albendazole, Mebendazole,
- folic acid, and vitamin A
- measles vaccination, and
- If appropriate, anti-malarial

71. OTP Treatment
• Feeds
– RUTF (Ready to Use
Therapeutic Food)
• Plumpynut or BP-100
• 1 sachet of plumpy Nut
– 92 gm, 500Kcal
– As frequent as possible to
finish the daily ration
– See the look up table
• How to do an appetite test
– Make sure the child is
calm
– Give the mother 1 sachet
of Plumpy Nut
– Evaluate how much he
takes in a maximum of 30
minutes

72. Amount of RUTF to Give
Week supply of RUTF based on the child weight
Class of weight
(kg
PLUMPY’NUT® BP100®
sachet
per day
sachet per
week
bars per day bars per
week
3.0 - 3.4 1 ¼ 9 2 14
3.5 - 4.9 1 ½ 11 2 ½ 18
5.0 – 6.9 2 14 4 28
7.0 – 9.9 3 21 5 35
10.0 - 14.9 4 28 7 49
15.0 – 19.9 5 35 9 63

73. Routine Medication
Drug Treatment
Vitamin A - 1 dose at admission
Folic Acid - 1 dose at admission
Amoxicillin - 1 dose at admission + give
treatment for 7 days to take home
-The first dose should be given in
the presence of the supervisor
Deworming - 1 dose on the 2nd week (2nd visit)
Malaria - According to national protocol
Measles (from 9 months
old)
- 1 vaccine on the 4th week (4th visit)

74. Key Messages
1. Should not be shared
2. Give small regular meals to finish the daily ration
3. Give plumpynut before other foods
4. Continue breastfeeding
5. Offer plenty of clean water to drink
6. Use soap for child’s hand and face before feeding
7. Keep the child covered and warm
8. With diarrhea never stop feeding
NB – Ask the mother to repeat the messages to
check her understanding

75. Characteristics / Advantages of RUTF
• RUTF is Ready to Use Therapeutic Food that can be
consumed easily by children straight from the packet or
pot without any cooking;
• Is a high-energy, nutrient-dense food with a nutritional
profile similar to F100;
• It is easy to use and store. It can be kept in simple
packaging for several months without refrigeration. It
can be kept for several days even when opened;
• BP-100 and Plumpy’nut are the commonly known RUTF
preparations
• If you have both products, for younger children (under 2
years age), give either plumpy’nut or crush BP-100 and
make porridge

76. Advantages of OTP …
• High coverage and good access
• Decreased inpatient load
– Health worker load
– Hospital resources
• Convenient for the family
– Home environment (familiar environment)
– Mother able to care for the whole family
– Able to take care of the cattle and other
things important to them

77. Refer to in patient care if there is one of
the following:
• Develop complication
• Fail appetite test
• Increase/development of oedema
• Weight loss for 2 consecutive visit
• Failure to gain weight for 3 consecutive visit
• Major illness or death of the main caretaker so
that the child can’t be managed at home.

78. Sign Referral to Inpatient
Grade +++or
Marasmic kwashiorkor (Both
MUAC <11 and oedema)
Oedema Increase in Edema
Appetite Poor
General danger sign Present
Diarrhoea Persistent
Dysentry Present
Pneumonia Present

79. • Deworming and measles vaccination
• Weekly ration of Plumpy’Nut or BP 100
• Appointment for next follow up
• Record the information on the OTP card
If the child is absent for any follow up visit:
• Ask the community Volunteer to do home
visit and report back to the HEW

80. Discharge:
• Discharge the patients from OTP follow up if
the following criteria are fulfilled:
A. For those who were admitted based
on oedema: - discharge if there is no
oedema for 2 consecutive visits (14
days).
B. For those who were admitted
without oedema: - discharge when
the patient reaches the discharge
target weight.
C. If the child fails to reach the discharge
criteria after 2 months of OTP treatment,
refer for inpatient care

81. On discharge make sure:
• Counselling on child feeding and care is
given to the mother/caretaker
• Give a discharge certificate to the
caretaker and referral to Supplementary
Feeding Program (Whenever available)
• A child is registered appropriately on the
registration book on date of discharge

82. • All children with Severe Acute Malnutrition
deserve to access treatment for
Malnutrition
• In principle, all Health Centers and
Hospitals are expected to treat Severe
Acute Malnutrition as an integrated service
of routine health care delivery
• Severe Acute Malnutrition is diagnosed
using anthropometric measurements
• Marasmic and Kwashiorkor patients can be
treated using the same dietary formula
and protocol

83. …
• Majority of Severely malnourished children
can be treated on out-patient basis (OTP)
using MUAC and Oedema identification
• Assessment and classification of
malnutrition
• Admission procedure and criteria of
admission
• How to use OTP/TFU cards
• Therapeutic foods and routine medicines
• What to monitor in a malnourished child
• Recording and reporting

84. Conclusion
• Protecting the nutrition status of children
and access to treatment is a basic child
right
• Earlier detection/presentation is key for
treatment success
• Increase capacity by integration into
primary health care services
• successful management of severe malnutrition
does not require sophisticated facilities and
equipment, neither highly qualified personnel.
It does, however require that each child be
treated with proper care and affection!

85. Proper treatment output
Discharge