2. LEARNING OBJECTIVES
At the end of the module, you will be able to:
• Define Malnutrition
• Different Types and Measurement of Malnutrition
• Causes of Undernutrition and Overnutrition
• Define SAM and MAM and its appropriate management
• Define Obesity
• Common Micronutrient Deficiencies
3. MALNUTRITION
• deficiencies or excesses in nutrient intake, imbalance
of essential nutrients or impaired nutrient utilization
• Undernutrition
⚬ Wasting
⚬ Stunting
⚬ Underweight
⚬ Micronutrient deficiencies
• Overweight
4.
5. • Height-for-age (or length-for-age for children <2 yr) is a measure of
linear growth, and a deficit represents the cumulative impactof adverse events,
usually in the first 1000 days from conception, that result in stunting, or chronic
malnutrition
• Weight-for-height , or wasting indicates acute malnutrition
• Weight-for-age is the most commonly used index of nutritional status, although a
low value has limited clinical significance because it does not differentiatebetween
wasting and stunting
• Mid- upper arm circumference is used for screening wasted children
• BMI- for-age can be used from birth to 20 yr and is a screening tool for thinness
(less than −2 SD), overweight (between +1 SD and +2 SD), and obesity (greaterthan
+2 SD)
GROWTH INDICATORS
7. SGD Target 2.2- Malnutrition
"End all forms of malnutrition, including achieveing
targets on stunting and wasting in under 5 years of age,
and address the nutritional needs of adolescent girls,
pregnant and lactating women and older persons."
SDG GOAL- 2
END HUNGER, ACHIEVE FOOD
SECURITY AND IMPROVED
NUTRITION AND PROMOTE
SUSTAINABLE AGRICULTURE
10. Consequences of
Undernutrition
Consequences for survivors and their families:
(1) increased costs of healthcare, either neonatal care for LBW
babies or treatment of illness for infants and young children
(2) productivity losses associated with smaller stature and
muscle mass
(3) productivity losses from reduced cognitive ability and
poorer school performance
(4) increased costs of chronic diseases associated with fetal
and early child malnutrition
(5) consequences of maternal undernutrition on future
generations
16. 4
th
National
Conference
of
Nutrition
Action
Officers
15-16
November
2016
Cebu
City
Slide 11
3
THE FIRST 1000 DAYS!
• UNICEF: Improving Child Nutrition: The achievable imperative for global progress (NewYork, 2013)
• Global targets to improve maternal, infantand young child nutrition- Policy Brief, 1,000 Days Partnership, n.d., thousanddays.org/wp-
content/uploads/2012/
05/WHO-Targets-Policy-Brief.pelf [accessed 10 May 2015]
18. SEVERE ACUTE MALNUTRITION
Severe wasting
• is extreme thinness diagnosed by a weight-for-
length (or height) < −3 SD of the WHO Child Growth
Standards
19. In children ages 6-59 mo, a mid-upper arm
circumference <115 mm also denotes extreme
thinness: a color- banded tape
SEVERE ACUTE MALNUTRITION
20.
21. Bilateral edema
• is diagnosed by grasping both feet, placing a
thumb on top of each, and pressing gently but
firmly for 10 sec.
• A pit (dent) remaining under each thumb
indicates bilateral edema.
SEVERE ACUTE MALNUTRITION
24. REDUCTIVE ADAPTATION
Malnourished children have adapted to low food intake by:
⚬ Using energy and nutrients more efficiently
⚬ Doing less work.
⚬ The reduced activity affects all the organs and cells in a malnourished
child’s body.
⚬ Causes very profound effects on body functions
Children with malnutrition do not show usual signs and
symptoms and the usual life-saving actions may be
dangerous in the malnourished child.
25. INSUFFICIENT FOOD INTAKE
CONSERVE ENERGY AND
PROLONG LIFE
PHYSIOLOGIC & METABOLIC
CHANGES
• Fat stores are mobilized to provide energy
• Later protein in muscle, skin and GI tract is
mobilized
• Reduction inphysical activityand growth
• Reduction in basal metabolism and
functional reserve of organs and by reducing
inflammatoryand immune response
Reductive Adaptation
26. Acute malnutrition involves internal processes that lead to an
altered metabolism and involving the disruption of:
REDUCTIVE ADAPTATION
• Cardiovascular system
• Gastro-intestinal system
• Liver function
• Genitourinary system
• Immune system
• Endocrine System
• Circulatory system
31. IMMUNE AND INFLAMMATORY FUNCTIONS
•Reduced cell replication
•Impaired immune function (cell
mediated immunity)
Absent usual response to
infection
*Children with malnutrition do not show usual signs and symptoms and the usual life-
saving actions may be dangerous in the malnourished child.
Undiagnosed infection
32.
33. FIG. 57.6 Child with generalized edema.
FIG. 57.5 Child with severe wasting
34. REDUCTIVE ADAPTATION AND TREATMENT
As the child is treated
• The body’s systems must gradually
‘learn’ to function again
• Rapid changes (such as rapid feeding or
fluids) can overwhelm
• Feeding must be slowly and cautiously
increased
37. CHILD > 6 TO 59 MONTHS:
Diagnosis of SAM + any of:
1. Fails appetite test OR
2. Has any medical complications
• Intractable vomiting
• Hyperthermia (T 38C axillary or T 39C rectal)
• Hypothermia (T 35 C axillary or T 35.5 C
rectal)
≥ 50 resp/min from 6 to 12 months
≥ 40 resp/min from 1 to 5 years
≥ 30 resp/min for over 5 year olds
And any chest in-drawing (for kids> 6 mo)
• Anemia
• Extensive superficial infection
• Altered alertness
• Dehydration
• Tachypnea for age
38. CHILD < 6 MONTHS:
Diagnosis of SAM and ANY of:
• recent weight loss/inabilityto gain weight
• any of the medical complications outlined
for 6-59 months of age
• any medical issue needing more detailed
assessment or intensive support (e.g.
disability)
• ineffective feeding (attachment,
positioning and suckling) directly observed
• infant is lethargic and unable to suckle
• Exhausted all optionsfor breastfeeding
• depression of the mother/caregiver or
other adverse social circumstances
39. MUAC for Assessment and Admission
• Identifies children at highest risk of death
• Measures muscle mass (nutrient store)
• Is a transparent and understandable measurement
• Is easy-to-use tool; can be used by all health care providers, also
community-based outreach workers after being trained
19
41. What is an RUTF (Ready-to-Use Therapeutic Food)?
• An energy dense mineral/vitamin enriched food nutritionally
equivalent to F100
• Recommended by WHO (for SAM children > 6 months)
• Meets particular technical and quality specifications for its
compositionand production.
42. 22
READY-TO-USE THERAPEUTIC FOOD
(RUTF)
• Energy- and nutrient-dense lipid-
based paste: 500 kcal/92 g
• Same formula as F-100 (except
it contains iron)
• No microbial growth, even when
opened
• Safe and easy for home use
• Is not given to infants under
6 months
43. Take anthropometric measurements.
• Infants less than 6 mos. of age
• Weight and length measurements.
• Weight-for-length Z-scores.
• Check for edema, temperature and no. of breaths per
min.
• 6-59 mos. of age
• Take MUAC, weight, height/length measurements.
• Weight-for-height/length Z-zcores
• Check for edema, temperature and no. of breaths per
minute
A. INITIAL ASSESSMENT
44. Identify if the child has SAM or MAM.
In children 6-59 mos.
A. INITIAL ASSESSMENT
45. Infants younger than 6 mos.
A. INITIAL ASSESSMENT
Identify if the child has SAM or MAM.
46. For SAM children 6-59 months:
• Do edema test.
• Do appetite test.
• Do medical assessment.
A. INITIAL ASSESSMENT
47. Nutritional Edema
• Edema is the retention of water in the tissues of the body.
• Bilateral edema is a sign of kwashiorkor, a form of severe acute
malnutrition.
To diagnose edema, normal thumb pressure is applied to the tops of the feet for
about three seconds.
• If there is edema, an impression remains for some time (at least a few
seconds) where the edema fluid has been pressed out of the tissue.
• The child should only be recorded as edematous if both feet present pitting
edema.
• Nutritional edema always starts from the feet and extends upwards to
other parts of the body.
50. APPETITE TEST
• The appetite test should be conducted in
a separate quiet area.
• Explain to the caregiver the purpose of
the appetite test and how it will be
carried out.
• The caregiver should wash their hands.
• The caregiver should sit comfortably
with the child on their lap and should
either offer the ready-to-use therapeutic
food (RUTF) from the packet or put a
small amount on his finger and give it to
the child.
51. APPETITE TEST
• The caregiver should offer the child
the RUTF gently, encouraging the
child all the time.
• If the child refuses then the caregiver
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 is
taking the RUTF.
59. B. Classify 6-59 mos. old infant/child to OTC or ITC.
Criteria for Admission to ITC or OTC (6-59 months)
60.
61. CRITERIA FOR
ADMISSION TO
ITC OR OTC
(LESS THAN
6 MONTHS)
Factor Inpatient care
Outpatient breastfeeding support (C-
MAMITool, Nov 2015; IMCImedical
treatment, supplementary feeding for
mother, where available)
Anthropometry
Bilateral pitting edema
OR WFL < -3 Z-scores
AND one of the below
WFL < -2 Z-scores
AND none of the complications requiring
inpatient care
History Recent weight loss/ inability to gain weight
Medical
Any of the medical complications outlined for
children 6-59 mos. old;
Any medicalissue needing more detailed
reassessment or intensive support (e.g.
disability)
Feeding practices
Ineffective feeding (attachment,positioning
and sucking) directly observed;
Infant is lethargic and unable to suckle;
No possibility of breastfeeding (e.g. death of
mother)
Condition of
mother
Depression of the mother/ caregiver, or other
adverse social circumstances
OR mother is malnourished or ill
62. • Infant is less than 6 months old.
Provide intensive breastfeeding counseling
to the mother/ caregiver
(C-MAMI Tool, Nov 2015*).
• Child has known peanut allergy.
Refer to ITC for treatment with therapeutic milk
(F75/F100).
• Do NOT give RUTF if:
64. The 10 steps of treatment for severe acute
malnutrition and their approximate time frames.
65. ADMINISTER EMERGENCY CARE AS NECESSARY
• Airway,
• Breathing,
• Circulation and
• Administer life-saving
interventions according
to Pediatric Advanced
Life Support (PALS)
protocols
Check for and immediately treat
life threatening complications
• Hypoglycemia
• Hypothermia
• Dehydration/hypovolemic
shock
• Hypernatremic dehydration
• Septic shock
• Severe anemia
• Heart failure
• Absent bowel sounds
• Gastric dilation and intestinal
66. T a b l e 5 7 . 7
E m e r g e n c y T r e a t m e n t i n S e v e r e M a l n u t r i t i o n
67. T a b l e 5 7 . 7
E m e r g e n c y T r e a t m e n t i n S e v e r e M a l n u t r i t i o n
74. RE-SO-MAL FOR
SAM
Re-So-Mal is a modified rehydration
solutionlow in sodium.
With dehydrationor persistent
diarrhea, replace potassiumbut limit
sodium.
Do not use 0.9 NaCl !
Give magnesium to facilitate
potassiumentry and retentionin cells
75. Table 57.11
Recipe for Rehydration Solution for Malnutrition (ReSoMal)
Table 57.12
Recipe for Concentrated Electrolyte/Mineral Solution*
76.
77. • Normally, cells have a balance of sodium and potassium.
• A “pump” functions to take sodium outside and potassium into the cells.
• This is critical for correct distribution of water in, around cells and in
blood.
• In reductive adaptation, the ‘pump’ that usually controls the balance of
potassium and sodium does not function properly.
Sodium in cells Potassium as it leaks out of cells
Fluid accumulation outside of the cells (edema)
NOTE: ELECTROLYTE BALANCE IN SAM
78. FOR NON-EMERGENCY CASES
New SAM patients:
• Conduct IMCI medical
check
• Medical history
• Appetite test
• Anthropometry
• Record all information
REFER to the OTC if
• no medical complications
• good appetite
• record all information on the
patient record and ITC chart
SAM patients already on
treatment and
transferred:
• Review record
• Continue with same
registration number
• Check information/new issues
on referral document
• Record all information
79. ROUTINE MEDICATIONS FOR SAM IN PHASE 1 / STABILIZATION
Medication Route Dose Prescription
Amoxicillin* Oral / NGT
4 - 9.9kg = 250 mg
10 - 13.9kg = 500 mg
14 - 19kg = 750 mg
On admission
Twice daily for 5 - 7 days
*Where there is amoxicillin resistance give amoxicillin - clavulanic acid combination
Oral medications for SAM without medical
complications
• Nearly all children with SAM have bacterial infections.
• With reductiveadaptation,the usual signsof infection are not apparent
• With limited energythere is no typical response, such as inflammationor
fever
80. ROUTINE MEDICATIONS FOR SAM IN PHASE 1 / STABILIZATION
Medication Route Dose Prescription
Ampicillin* IM/IV 50mg/kg
On admission 6 hourly for 2
days
Followed by
Amoxicillin
Orally / NGT
4 - 9.9kg = 250mg
10 - 13.9kg = 500mg
14 - 19kg = 750 mg
Twice daily for 5 days
Parenteral medications for SAM with medical complications
Gentamicin IM/IV 5mg/kg On admission once daily for 7 days
*Where there is amoxicillin resistance give Cefotaxime (IM 50mg/kg once daily) for 2 days then give
amoxicillin-clavulanicacid combination for 5 days
81. • These regimens should be adapted to local resistance
patterns.
• If specific infections are identified, add appropriate antibiotics.
• For persistent diarrhea or small bowel overgrowth, add Metronidazole, 7.5
mg/kg PO every 8 hr for 7 days.
82. OTHER ROUTINE MEDICATIONS IN PHASE 1
Vitamin A
• Present in therapeutic amounts in F75/ F100 /
RUTF
• Give:
⚬ As single dose on admissionif child has clinical Vit A
deficiency
⚬ When child has active measles
⚬ When commercial F75/ F100/ RUTF not available
Folic Acid
• Present in therapeutic amounts in F75/ F100/
RUTF
• Indicated for moderate to severe anemia
83. OTHER ROUTINE MEDICATIONS IN PHASE 1
Measles vaccination
• On admission for children from 6 months old
• Repeat dose upon discharge from Phase 2 or
• When child is 9 months old in the OTC
Antimalarials
• Follow national protocol
• Caution: some antimalarials are toxic in the SAM child – avoid amodiaquine
• NO Quinine in the first two weeks of treatment
84. Anti-helminthics
• Absorbed through gut and generates active metabolites in the liver
• Would be ineffective as SAM child with poor gut and liver function
Iron
• Increases risk of death by increasing risk of sepsis
• Given only in Phase 2
Zinc
• Only given in Phase 1 if commercial therapeutic feeds not available
AND
• Child has diarrhea
MEDICATIONS NOT FOR PHASE 1
85. TEST YOURSELF!!
True or False.
1. SAM patients need sodium supplementation.
2. All children with SAM are presumed to have a bacterial infection.
3. Iron supplementation is given during Phase 1 treatment in ITC.
How did you do?
86. General Guide to
the Essential
Management
Steps towards
successful
treatment of
severe acute
malnutrition
87. PHASE 1. STABILIZATION
• If clinical assessment is delayed
for any reason, and the child is
able to take oral fluids
⚬ Give 10% sugar water
solution (10g or 1 tablespoon
of sugar in 100mL of water) to
prevent hypoglycemia.
88. PHASE 1. STABILIZATION -- FEEDING
• Feed the SAM child with F 75 (75 kcal, also low protein, 0.9
g/100ml and low sodium)
• Meet the child’s needs without overwhelming the body’s systems
• High in carbohydrate, and provides much-needed glucose
What you need to do:
• Calculate amount of F 75 needed
• Prepare F75
• Plan the frequency of feedings
89. PHASE 1. STABILIZATION -- FEEDING
• Calculate amount per feeding based on
weight
• S/he needs: 100 kcal/kg/day OR 130
ml/kg/day of F75
• Plan to feed 6-8 times per day
• Compare manual calculation, refer to to
look up table
Preparation of
F 75
• O r u s e b o i l e d w a t e r ;
p r e p a r e F 7 5 w i t h i n 3 0
m i n u t e s o f b o i l i n g
• S t o r e i n f u n c t i o n a l
r e f r i g e r a t i o n
• R e - w a r m b y d i p p i n g i n
90.
91. WHEN F75 IS NOT AVAILABLE
• There are alternative recipes.
• Or use diluted F100
• Commercial milk formula is NOT a suitable substitute.
Strongly advise against the use of commercial milk
formula for the child with SAM.
92. HOW TO FEED A SAM CHILD
Feed
• Orally by cup and saucer
• Nasogastric tube if warranted
• Breastfed children aged 6 - 59 months
should always be offered to breastfeed
before the diet and should always be given
on demand.
• Children with SAM have weak
muscles and swallow slowly.
• They are prone to choking and
developing aspiration pneumonia.
• Remove the NG tube when the child
takes:
⚬ More than 75% of the day’s
amount orally; or two
consecutive feeds fully by
mouth.
93. TRANSITION PHASE
Ready to transition when:
• Medical complications are resolving
• Appetite returns
• Edema is reducing
• Amount of energy is increased by 30% (to 130kcal/kg/day) and the amount of
protein is increased
Transition may be divided into two distinct management approaches:
• Transition to outpatient therapeutic care (OTC) for SAM where it is available
• Transition to Phase 2 inpatient care where outpatient care for SAM is not
available
94. TRANSITIONING TO OTC USING RUTF
(where OTC is available)
• Counsel on, encourage and support breastfeeding
• Explain what RUTF is to the caregiver
• Feed RUTF 5 times per day, always follow with water
or breastfeeding
• Do not mix RUTF with liquids
Weight of the
Child
Number of
feeds/24 hours
Amount of
RUTF in each
feed
Amount to be
eaten over 24
hours
<5kg 5 - 6 ¼ packet
1 ¼ to 1 ½
packets
>5kg 6 ⅓ packet
1 ¾ to 2
packets
Transition Phase
95. RE-ASSESS, RE-ASSESS
Change the treatment regimen if the child’s
appetite does not improve over 2-3 days
(they do not eat the required RUTF amount)
• If there is clinical deterioration, return the child
to Phase 1.
• Change the diet to F100 if the child is stable
but the appetite does not improved after 3
days in the Transition Phase →continue to
Phase 2 inpatient care.
Transition Phase
96. FULLY TRANSITIONING TO OTC
The child is ready to continue nutritional
rehabilitation at home with OTC when:
• At least 75% of full RUTF amount is
eaten in 24 hours
• No other issues identified during
monitoring
So, discontinue F 75 and give RUTF plus
water or breastfeeding
Refer to OTC or back to the OTC which
referred the child.
Transition Phase
98. TRANSITION TO PHASE 2 USING F100
DO THIS WHEN:
• child is on RUTF in preparation for outpatient care, clinically stable
but appetite is not improving
• no outpatient treatment available → the child must be treated and
cured of SAM entirely within the inpatient care setting
• Increase to 130kcal/kg/day using F100 therapeutic milk. F100
contains 100kcal/100mL of milk
• Continue breastfeeding by demand
• When 90% of F100 ration taken orally and no other
issues → Phase 2
99. PHASE 2- REHABILITATION PHASE
Caloric intake increased to 200kcal/kg/day using F100
therapeutic milk
Iron is added to the therapeutic milk as follows:
• 200mg Ferrous Sulfate (1 tablet) in 2 liters therapeutic milk
• 100mg Ferrous Sulfate (1/2 tablet) in 1 liter therapeutic milk
• If smaller quantities of milk are being given, crush 100mg
(1/2 iron tablet) and mix thoroughly in 10mL of water
(ensure the tablet is well crushed and leaves no sediment)
• Add 10mg Ferrous Sulfate (1mL of 10mL Iron solution) in
each 100mL of therapeutic milk
100. RESPONSIVE FEEDING AND EMOTIONAL STIMULATION
• Support play and emotional stimulation
as an aid to psychological recovery by:
⚬ Encouraging the caregiver to talk to
the child with good eye contact
during feeding.
⚬ Providing a brightly colored ward
environment.
⚬ Providing toys suitable for children
of various ages
• In addition to nutritional management in Phase 2, while in a
hospital environment
101. DETERMINE THAT THE CHILD IS READY FOR DISCHARGE
AS CURED FROM PHASE 2 ITC WHEN:
For those admitted based on MUAC, edema OR both MUAC and WFH
Z-score:
• MUAC > 12.5 cm for 2 consecutive days AND
• No edema for 10 days AND
• Clinically well
For those admitted based on WFH Z-score only:
• WFH or WFL > -2 Z-scores for two consecutive days AND
• No edema for 10 days AND
• Clinically well
102. TEST YOURSELF!!
1. What therapeutic food is used during Phase 1 Stabilization for SAM children > 6 months old??
• Diluted F100
• F75
• RUTF
2. What findings would indicate readiness for transition?
• Bipedal edema
• Patient is tachypneic
• Appetite has returned
3. Phase 2 treatment is opted for when
• Patient has stable weight but appetite is unimproved
• OTC is not available
• a and b
103. Carry out the nutritional management of a SAM
infant <6 months of age
104. CONTINUE TO ENCOURAGE AND SUPPORT BREASTFEEDING
• An exclusively breastfed infant will always
be healthy.
• When an infant becomes malnourished, it is
usually preferable to attempt to improve the
breastfeeding practices or to re-establish
them if they have been discontinued.
• Inpatient staff should encourage and help /
support re-establish breastfeeding.
105. NUTRITIONAL MANAGEMENT < 6 MONTHS OLD
Step 1
• Ask what the infant is fed with
• If breastfed, ask about other food being given
• When possible, observe and assess position and
latch as she breastfeeds
• Encourage skin to skin contact
• At ITC start, breastfeed every one to three hours
and then on demand as the infant’s appetite
improves
• Assistthe infant by expressingbreast milk
directly into his/hermouth if the child is unable
to empty the breast fully
107. ENCOURAGE/SUPPORT BREASTFEEDING IN A SAM INFANT <6 MONTHS
Step 2
Where mothers are still trying to re-establish
breastfeeding, options for feeding the infant include:
• ‘wet nursing’ by a female member of the family
• ‘cross nursing’
• Use donor human milk if available.
Observe proper guidelines on storage.
• Alternatively feed the infant by cup
The aim of treatment:
⚬ to stimulate breastfeeding, re-establish
and sustain it
108. DILUTED F100 MILK
• As necessary, supplement the infant’s diet with Diluted F100 therapeutic milk
until breastfeeding is re-established
To prepare:
• Add 1 small packet
of F100 to 670mL of
water instead of using
500mL as usual
*Use F75 for those with nutritional
edema using these same volumes
109. STEP 3 CONTINUE TO PRAISE EFFORTS AT
BREASTFEEDING
STEP 4 INFANTS SHOULD BE NURSED AT A
SEPARATE SPACE FROM THE OLDER
MALNOURISHED CHILDREN.
• This area may be useful to bring
breastfeeding mothers together for mutual
support and counseling by staff.
Step 5 Give counseling and support for any issues
identified during monitoring in relation to attachment
and feeding of the infant
110. On the use of commercial milk formula as
alternative
• Ensure that acceptable medical reasons exist for its provision
• The packaging must be free of any markings for brand recognition
• Follow instructions on reconstitution and give volume as appropriate for the
age.
⚬ Ensure that formula milk use complies with ALL the following:
Acceptable Feasible
Affordable Sustainable
Safe
⚬ Teach the caregiver on the proper preparation and dilution of the formula
milk
⚬ Caution against over dilution
111. Assess for discharge ofinfants <6months
old
￭ There is weight gain more than 5g/kg/day while completely
on breastmilk or as last resort, therapeutic or formula milk
for 3 consecutive days
￭ Edema is absent
￭ All medical issues have resolved
￭ Immunizations checked and updated
112. Testyourself!!
• What is the optimum source of nutrition for SAM infants
< 6 months old?
• F 75
• Diluted F 100
• Breastfeeding
• Commercial milk formula
2. What alternative feeding method is recommended?
• Feed by nasogastric tube
• Feed by cup
• Feed by supplemental suckling technique
• b and c
114. Criteria to start Transition Phase to OTC:
Category Criteria
Child aged 6 to 59 months
Medical complications resolved (or chronic
conditions controlled)
AND
edema subsiding (must have reduced to at
least +2)
AND
appetite for RUTF (must be able to eat at least
75% of outpatient ration)
*There is no anthropometriccriterionfor dischargewhen transitioningfromITCto OTC because nutritional
rehabilitationis continuedand completed in OTC.
115. Category Discharge Criteria from Transition to OTC
Child aged
6 to 59
months
Medical complications resolved
(or chronic conditions controlled)
AND
For patients with edema at least
+1 or
With good appetite (taking all diet
in transition phase) and edema ++
AND
Good appetite (must be able to
eat at least 90% of RUTF or F100
ration)
PLUS
• Clinically well and alert
• Recovery phase at home
when:
⚬ There is a capable
caretaker
⚬ The caretaker agrees
to out-patient
treatment
⚬ There is a sustained
supply of RUTF
⚬ An OTP is in operation
in the area close to the
patient’s home
116. Criteria for Discharge cured from ITC Phase 2
Category DischargeCriteria
Child aged 6 to
59 months
Admitted on MUAC,
edema, or both
MUAC and WFH Z-
score
MUAC ≥ 125mm (12.5cm) for 2 consecutive visits
AND
No edema for 10 days AND Clinically well
Admitted on
WFH Z-score only
WFH or WFL ≥ -2 Z-scores for two consecutive days AND
No edema for 10 days AND
Clinically well
Infants < 6 months
Child is gaining weight more than 5g/kg/day on breast
milk for 3 consecutive days**
AND
edema is absent
AND
Clinically well & childhood immunizations have been
117. B. CLASSIFY THE INFANT/CHILD’S OUTCOME OF TREATMENT.
Cured Reached the criteria for discharge cured
Dead Died during treatment in the OTC or in transit to the ITC
Defaulter
Not returned for three consecutive visits and
a home visit, neighbor, village volunteer, or other reliable source confirms
that the patient is not dead
Discharged as non-
cured
Does not reach the discharge criteria within four months and all referral
and follow-up options have been tried (e.g. home visit conducted and
household situation assessed)
Refer for assessment of possible medical complications if not yet done
(e.g. TB) and link with the MAM program where possible and to social
support systems.
