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OUR MISSION

Relief International is a humanitarian non-profit agency that provides emergency relief, rehabilitation,

development assistance, and program services to vulnerable communities worldwide. Relief

International is solely dedicated to reducing human suffering and is non-political and non-sectarian in its

mission. Relief International's mission is to:

Serve the needs of the most vulnerable - particularly women and children, victims of natural

disasters & civil conflicts, and the poor - with a specific focus on neglected groups and cases.

Provide holistic, multi-sectoral, sustainable, and pro-poor programs that bridge emergency relief

and long-term development at the grassroots level.

Empower communities by building capacity and by maximizing local resources in both program

design and implementation.

Promote self-reliance, peaceful coexistence, and reintegration of marginalized communities.

Protect lives from physical injury or death and/or psychological trauma where present.

Uphold the highest professional norms in program delivery, including accountability to

beneficiaries and donors alike.

_____________________________________________________

OUR PHILOSOPHY

RI dedicates itself to seeking and addressing

the long-term developmental needs of its

beneficiaries even while in the emergency

phase. The agency recognizes that disasters

have the most negative impact on the lives of

the poor; yet disasters, and especially the

movement of the populations, can also bring

about unexpected, positive social change. This

context can therefore serve as a window of

opportunity for eradicating poverty and social

injustice.

Relief International focuses on serving people

who typically have not received due attention,

and in several large-scale crises Relief

International has been the first US-based

agency to provide high-impact development

emergency programming to communities in

need. Relief International believes that as a

humanitarian agency one of its main functions

is to communicate the pronounced needs of the

vulnerable and affected populations to the

international community. Relief International

thus consults closely with the local communities

it serves in order to ensure that its programs do

not impose solutions from the outside but rather

address their needs and requirements for the

long term. This grassroots approach proves

effective in fostering an environment of self-help

and sustainability.

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Table of Contents

A. Abbreviations and Acronyms

B. Introduction

C. Part I: Setting Up a Nutrition Clinic

a. Site Selection

b. Layout

c. Logistics and Special Notes

d. Supplies and Drug List

D. Part II. Admission Criteria/Triage

a. Initial Assessment for both TFC and SFC

b. MUAC Procedures

c. Weight and Height Measurements

d. Signs and Symptoms of Malnutrition

E. Part II: Therapeutic Feeding Centers

a. Phase I

b. Treatment of Complications

c. Transition Phase

d. Phase II or Rapid Weight Gain Phase

e. Phase III or Consolidation Phase

f. Discharge

g. Special Notes for Children under 6 Months

h. Special Notes for Children over 6 Months and under 3kg

F. Part III: Supplementary Feeding Centers

a. TFC Follow Up

b. OTP?

c. Referral Guidelines (same as admission to TFC?)

G. Appendix

a. Quick Reference Tables

b. Forms

c. Checklists

d. References and Additional Resources

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Abbreviations and Acronyms

BMI Body Mass Index

CMAM Community Management of Acute Malnutrition

CMR Crude Mortality Rate

CMV Complex Minerals and Vitamins

CSB Corn Soy Blend

MUAC Mid-Upper Arm Circumference

NGF Naso-Gastric Feeding

ORS Oral Rehydration Salts

OTP Outpatient Treatment Program

ReSoMal Oral Rehydration Solution for severely malnourished patients

SC Stabilization Center

SFC Supplementary Feeding Center

TFC Therapeutic Feeding Center

W/H Weight to Height (%)

W/L Weight for Length (%)

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Introduction

Relief International (RI) is a humanitarian, non-profit, non-sectarian agency that provides emergency

relief, rehabilitation, and development interventions throughout the world. Since 1990, RI’s programs

have linked immediate emergency assistance with long-term economic and livelihood development

through innovative programming at the grassroots level. RI programs—in more than 25 countries

around the world—address a wide range of development issues, including livelihoods, local economic

development, emergency relief, conflict resolution, and education, training and youth initiatives.

From the earliest stage of intervention, RI’s

response activities are designed to help

communities transition from urgent relief to

long-term development for maximum

community impact. For over 20 years, RI has

been implementing these disaster relief and

development assistance projects in

demanding environments across the world,

resulting in the capacity to rapidly respond to

emergencies, as well as an ability to adapt

programs to changing and complex

environments.

Nutrition is a crucial component of health in vulnerable populations. Malnutrition and related disorders

can be caused by a variety of factors including poor agricultural yields, inability to purchase food,

political and economic instability, and other social factors. Severe acute malnutrition is caused by a

significant imbalance between nutritional intake and individual needs. It is most often caused by both

quantitative and qualitative deficiencies. Malnutrition and especially severe acute malnutrition can

rapidly lead to death if left untreated because malnutrition provokes severe physiological disorders and

suppression of the immune system.

This manual covers the basic setup of an emergency nutrition program and establishes standard

nutritional protocols to track a beneficiary from arrival at the health post to admission to discharge and

finally to follow-up. We focus on Therapeutic and Supplemental Feeding Centers and standard

protocols for admission and treatment. Often the beneficiaries of such a program will be refugees or

internally displaced persons. Some special considerations for these populations include the cause of

their migration—it may be caused by food shortage or another factor, access to food based on their

relationship with the local population, and expectations of potential repatriation.

It should be note that the goal of any emergency nutrition program is to provide immediate relief and

assistance, but also to facilitate the implementation of long-term, sustainable solutions within the

community.

_____________________________________________________

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Part I.

Setting Up a Nutrition Clinic

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Site Selection

[Info from other manuals]

Note: Ideally, camps and clinics are set up in areas with a slight incline so that rainwater will

not pool, however this will not be as relevant in areas of drought or low rainfall.

I. Layout When establishing a system for patient flow, the goal is to create an efficient, logical environment for both patients and staff. During examinations, patients should be provided with a covered area for privacy. The typical progression includes: 1. Patient registration 2. Triage/Nutritional Screening 3. Exam Table for Nurse Dressing and Vitals 4. Exam Table for Doctor 5. Dispensary/Drug Table [Get info from Jamila] Example of Efficient Patient Flow

Add a shaded table to hand out time cards/tokens; or add an exit from the Nutrition/Triage area so that

people can leave then return through the Entrance when it is their time

OTP CHECKLIST FOR SET UP:

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PLUMPYNUT (average 20 sachets/child/week) 1 box of 150 sachets per 7 children

ROUTINE MEDICINES

Amoxycillin, fansidar, folic acid, vitamin A, mebendazole

SUPPLEMENTAL MEDICINES (see OTP checklist) esp. ReSoMal, metrondiazole, chloramphenicol, paracetemol (paediatric)

EQUIPMENT (see list)

Thermometers, centigrade x 6 Watches/small clock with second hand (per nurse for counting respirations) OTP CARDS (see templates) x 500 of each

OTP BENEFICIARY CARD: A4, coloured, double-sided, card OTP RATION CARD: coloured card

ID BRACELETS Different colour to SFP, usually red

OTP PROTOCOLS

will follow when do set up at least 1 set per nurse or 8-10 sets in total

BASIC STATIONERY (see OTP checklist) 1 box folder per distribution site plus file dividers Clear plastic envelopes for OTP cards Basic stationery – see list

STABILISATION CENTRE / PHASE I TFC CHECKLIST: F75 PLUMPYNUT ROUTINE MEDICINES – as for OTP SUPPLEMENTAL MEDICINES – as for OTP ADDITIONAL INJECTABLES AND EQUIPMENT – see list SC INPATIENT CARD – use current card or one available if needed MATS, COOKING EQUIPMENT, CUPS ETC

AVERAGE STAFFING REQUIREMENTS:

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MOBILE TEAMS

Number depends on number of distribution sites – usually 2 teams, each team covering 4-5 sites The following is staffing for OTP only – assuming SFP teams already exist (with SCF-US or GOAL)

OTP 2 nurses 1 assistant / translator / educator 1 assistant (to help SFP team with weighing and measuring) 1 outreach worker per kebele (see below)

SFP (if not already in place) usually 7-8 people 1 team leader 1 nurse 1 registrar 2 measurers (weight and height) 1 educator (1 screener) 1 person to distribute Premix

OUTREACH 1 outreach Worker per kebele

STABILISATION CENTRE (minimum per working shift) 1-2 nurses (dependent on beneficiary numbers) 1-2 feeding attendant 1 cleaner and 1 cook (boiling water/making milk, caretaker meals etc)

DISTRIBUTION SCHEDULE:

OTP takes place at every SFP site OTP takes place on a weekly basis (SFP can be a fortnightly basis) Good to avoid changing day of distribution once established Majority of children enter OTP directly; those who are sick or no appetite referred to Stabilisation

Centre SENSITISATION / COORDINATION (pre set up):

National, regional, zonal/district, woreda levels UNICEF, WFP Other NGOs in area Local chiefs, leaders, community structures

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II. Logistics and Special Notes

Waiting Areas It is important to establish a shaded seating area for beneficiaries and caregivers to wait under. Just because they live in a warm climate does not mean they are accustomed to sitting or standing in the sun for long periods of time. They may have been walking for long periods of time, so drinking water should also be available at all times.

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Assigning Appointment Times Upon arrival, each party should receive a colored and numbered card or token indicating when they should return for treatment. This will allow them to leave and come back at their assigned time slot so they will not need to wait all day. Not all beneficiaries will be literate, so this should be explained to each party at the time they are given the card or token. The information may also be posted outside of the health facility. (Can also use Call to Prayer, Meal times, etc to mark times.)

RED – Return at 9am

GREEN – Return at 10am

BLUE – Return at 11am

YELLOW – Return at Noon

III. Supplies and Drug List [RI List of Supplies and Essential Drug List Nutrition Specific!]

- RI Storage and Inventory Protocols (In Appendix?)

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Initial Assessment

General Progression of Patient:

Arrival at Clinic

Fill out Registration Card

Anthropometric Measurements

Height

Weight

MUAC (under 10)

Age

BMI (Adults) Diagnosis/Treatment Assignment

Admit to TFC Admit to SFC General OTP General Distribution

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Admission Criteria

Note: The management of severe malnutrition for infants under 6 months and low weight infant is explained at the end of section II. Arrival:

- Receive soap, water, etc… Upon arrival to the feeding center, pregnant or lactating mothers and children should be examined for signs of malnutrition in a triage area. They should have access to water and shade during this time. Staff will weigh and measure beneficiaries and then they will be admitted to a program based on the following criteria:

Children and adolescents, from 6 months to 18 years: Bilateral oedema And/or weight for height percentage < 70 And/or MUAC < 110 mm for the above 1 year or for a height > 75 cm child.

Adults1 over 18 years:

Bilateral oedema And/or BMI2 < 16 And/or inability to move / to stand up alone.

In order to speed up the admission process, identify patients showing signs whose state is critical:

Rapid triage using MUAC measurements for children.

Clinical diagnosis of people showing signs of critical nutritional status and / or obvious illness, including kwashiorkor, marasmus, dehydration, septic shock, loss of consciousness, or other medical emergency.

Images: Testing for Bilateral Oedema

1 A proper medical examination has to be done in order to diagnose pathologies that are not manageable in TFC followed by a

referral to the appropriate structure if needed. 2 These criteria may have to be adapted to the general situation.

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Acute malnutrition is treated differently depending on the severity and whether or not it is accompanied

by other medical complications. The condition will determine whether the patient is admitted to TFC,

OTP, or SFC.

As soon as somebody reaches one of the above criteria, he/she must be admitted. An identification

bracelet must be provided for each beneficiary with his/her name and admission number. A

Therapeutic chart must also be prepared and must be legible. Bracelets may be different colors to

distinguish between TFC, SFC, and OTP patients. Matching bracelet for caretaker?

Overall, each beneficiary is admitted with an adult caretaker preferably the mother. When we cannot do otherwise, an extra child can be allowed to stay within the centre as long as he is suckling or he cannot stay by himself. The caretaker must be briefed on the TFC’s organization and must adhere to the rules. The registrars are in charge of ensuring that all information is passed onto the caretaker.

(For more notes on Caretakers see ___)

Drinking water must be available at all times in the registration room for caretakers and extra children. Patients who do not appear to be in urgent medical emergencies should go through normal procedures for admission.

Acute Malnutrition

Severe acute malnutrition

with medical complications

Therapeutic Feeding (Part II)

Severe acute malnutrition

without medical complications

Outpatient Care (OTP?)

Moderate acute malnutrition

without medical complications

SupplementaryFeeding (Part III)

[Example of ID Bracelets]

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Overview of Admission Criteria:

Admission

In SFC Admission

In TFC

Children from 6 months to 10

years (or from 65 to 130

cm)

W/H , 80% of the median And /or

MUAC < 125 mm

W/H < 70% of the median and/or

Presence of bilateral pitting oedema and/or

MUAC < 110 mm

Adolescents from 10 to 18 years

(> 130 cm)

W/H < 80% of the median And / or

MUAC : not to do , mistakes are common

W/H < 70% of the median and/or

Presence of bilateral pitting oedema

Adults (except pregnant and

lactating women)

MUAC : 160 185 mm MUAC < 160 mm or

Presence of bilateral pitting oedema (Grade 3 or worse) 1

or MUAC < 185 mm and poor clinical condition (Inability to stand, apparent dehydration etc.)

Pregnant and lactating women

MUAC : 170 185 mm

Rem/ at risk of malnutrition 185 210 mm

MUAC < 170 mm and/or

Presence of bilateral pitting oedema (Grade 3 and above) 1

Elderly

( 50-60 years)

MUAC : 160 175 mm MUAC < 160 mm and poor clinical condition

(Inability to stand, apparent dehydration etc.) and/or

Presence of bilateral pitting oedema (Grade 3 or worse) 1

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Weight to Height Measurement Procedures

- Best Weight and Height Method for Infants

- Best Weight and Height Method for Children

- Best Weight and Height Method for Adults

Weight / Height Severe

malnutrition

Moderate

malnutrition

Global

malnutrition

At risk of

malnutrition

Children

6 months 59 months

(5 years)

and/or

65 cm 130 cm of height

< 70 % of

median

< 80% 70 % of

median

< 80% of

median

Adolescent < 70 % of

median

< 80% 70 % of

median

< 80% of

median

Pregnant and Lactating

Women NO NO NO NO

Adults NO NO NO NO

Elderly NO NO NO NO

**See Appendix for detailed Weight-to-Height Charts for Boys and Girls and to determine the

percentage of the median.

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MUAC (Mid-Upper Arm Circumference) Procedures

MUAC is a quick and simple way to determine whether or not a child is malnourished using a simple colored plastic strip. MUAC is suitable to use on children from the age of 12 months up to the age of 59 months. However, it can also be used for children over six months with length above 65 cm.

Steps for taking the MUAC measurement of a child:

1. Determine the mid-point between the elbow and the shoulder (acromion and olecranon) as shown on the picture below.

2. Place the tape measure around the LEFT arm (the arm should be relaxed and hang down the side of the body).

3. Measure the MUAC while ensuring that the tape neither pinches the arm nor is left loose. 4. Read the measurement from the window of the tape or from the tape. 5. Record the MUAC to the nearest 0.1 cm or 1mm.

MUAC Severe

malnutrition

Moderate

malnutrition

Global

malnutrition

At risk of

malnutrition

Children

6 - 59 months and/or

65 - 130 cm of height

< 110 mm 110 125 mm < 125 mm <135 mm

Adolescents (up to 18 years) < 110 mm 110 125 mm < 125 mm <135 mm

Pregnant and Lactating Women < 170 mm 170185 mm < 185 mm 185 210 mm

Adults < 160 mm 160 185 mm < 185 mm

Elderly < 160 mm 160 175 mm < 175 mm

Results:

RED: Patient is Severely Malnourished

ORANGE: Patient is Moderately

Malnourished (Used in RI?)

YELLOW: Patient is At Risk of Malnutrition

GREEN: Patient is Properly Nourished

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Physical Manifestations of Malnutrition [Pictures?]

Wasting is a condition that reflects a recent weight loss or a failure to gain weight as a result of acute

malnutrition. It is a reversible condition that is most prevalent in children ages 12-24 months when

dietary deficiencies and diarrhea are more frequent. You cannot tell if a child is wasted just by looking

at his or her face, but instead must look at the body to diagnose.

Stunting, on the other hand, is a result of chronic malnutrition and is manifest in a height deficit when

compared to standard heights for a particular age group. Stunting is a slow process that develops over

time and it is nonreversible—it has already had an impact on the child’s height potential. It’s prevalence

increases with age, but is highest in children between 24-36 months. Stunting is a consequence of

poor social conditions or repeated exposure to diseases.

Marasmus and Kwashiorkor are both classified as forms of Protein Energy Malnutrition (PEM). The

type of PEM depends on diet and balance of proteins. Marasmus is characterized by gross muscle

wasting, extremely low weight, hunger, no fat under the skin, and sagging skin. Hair should appear

normal. Treatment?

Kwashiorkor is typically characterized by the presence of oedema, bleached hair, and skin lesions. It

is often preceded by measles. Kwashiorkor often accompanies mild anaemia, apathy, low weight, loss

of appetite, thin upper arms, and oedema. Oedemas can be tested for by pressing a finger onto the

swollen area, most often the feet. With oedemas, the affected skin may become very thin and atrophic

with many fine wrinkles. After the oedema has gone away, the skin may appear stretched and too

large. DO NOT give a child with Kwashiorkor too much protein. Their liver has lost much of its function

and will need to be slowly rehabilitated. The large stomach often seen in children with Kwashiorkor is

typically due to a buildup of fat in the liver.

Skin will become darker and then dry, then affected areas will start to crack and peel off to leave pale,

atrophic skin which can be very painful. The lesions typically have no redness, swelling, heat, or pain

even though they are often infected with bacteria because the inflammatory and immune systems are

too weak to respond. Lesions should be treated with the area exposed.

Hair is often a good indicator of nutritional deficiencies, especially for kwashiorkor. Affected hair may

become straight and discolored. Hair growing from the scalp may be white; however this is different

than blond hair. Blonde hair has no prognostic significance, although anemia is common. The ease at

which hair is pulled out is also a good measure of the reduction of protein synthesis and is a useful

sign. Eyelashes may grow to be very long. Fine, downy hair, also known as Lanugo may also be

present in malnourished patients.

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Diarrhea is also a feature of malnutrition. It usually occurs in multiple small green, mucoid stools.

Unlike in proficiently nourished patients, counting of stools... In malnutrition, orange stools can be

oxidized in exposure to the atmosphere and will turn green.

Eyes can reveal a lot in both malnutrition and dehydration. Lid retraction occurs only in true

dehydration, hypoglycaemia, anxiety, anger, etc and is due to activity of the sympathetic nervous

system.

In some areas families may prefer to try traditional medicine before seeking treatment at a medical

facility. If a patient arrives with several signs of traditional healing, it is often a bad sign because they

have come to you as a last resort.

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Overview of Methods for Anthropometric Measures

Method Uses Advantages Disadvantages Common

Thresholds

MUAC Detect wasting and acute malnutrition

Assess risk of death; does not depend on age; rapid, simple, no cumbersome

equipment

Risk of measurement error; lack of agreement on thresholds; does not

take oedemas and dehydration into account

<135 mm: at risk

3Z to < -2Z or 110 to < 125 mm: moderate

malnutrition

<-3Z or <110 mm: severe malnutrition high risk of mortality

Weight- Height

Detect Wasting and acute malnutrition

Does not depend on age

2 measurements needed; ratio is changed by

oedemas and dehydration; no

information on past nutritional status

-3Z to < -2Z or 70% to < 80%:

moderate malnutrition

<-3Z or <70%: severe malnutrition

Weight-Age

Detects a combination of stunting and

wasting, and acute and chronic malnutrition

Used extensively throughout the

world; Height not needed (difficult);

Interesting for monitoring individual

development

Requires age; Confusion in interpreting the

influence of acute and chronic malnutrition;

Oedemas and dehydration modify weight

-3Z to < -2Z or 60% to < 75%: moderate

malnutrition

<-3Z or <60%: severe

Height-Age Detects stunting and chronic malnutrition

Measurements unchanged by acute

malnutrition or by presence of oedemas;

dehydration does not change measures

Need to know age; Measuring height is technically difficult;

Provides no info on the presence of acute

malnutrition

-3Z to < -2Z or 80% to < 90%: moderate

malnutrition

<-3Z or <80%: severe malnutrition

Body Mass Index (BMI)

Used for nutritional assessment in

adults; increasingly used for population

references

Not always accurate; Does not take muscle

mass into account

17-18: At-risk >= 16: malnutrition

Example: An adult female comes into your clinic weighing 49 kg and measuring 1.75m in height.

Is this patient malnourished?

Weight (kg) 49 kg BMI = ------------------ = ------------- = 15.8 or <16

(height)2 m (1.75)2

YES, this patient has a BMI below the

threshold and shows signs of malnutrition.

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DIAGNOSING MEDICAL EMERGENCY [Move to a different section?]

Patients in need of being admitted urgently must be diagnosed quickly and proper treatment must start

as soon as possible.

The conditions considered to be medical emergencies are:

Hypoglycemia

Hypothermia

Acute dehydration

Septic shock

Serious infection (hyperpyrexia)

Cardiac failure

Severe anaemia

Steps for Urgent Diagnosis of Medical Emergnecies:

1. Assess consciousness level in prostrate patients - Response to verbal stimulation - Response to touch: a look, smile, weeping…

6. Refer to Diagnosis and Treatment of Complications for

management of such cases.

5. Check for signs of serious dehydration or septic shock

4. Check for signs of hypothermia or hyperpyrexia - Take the body temperature

3. Check for signs of serious cardiovascular disorder: - Take the radial or jugular pulse (rapid, irregular) - Assess the peripheral circulation by checking how quickly

colors return to skin - Take the blood pressure

2. If there is no response:

- Response to painful stimulation

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Part II.

Therapeutic Feeding Centers

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Introduction:

Therapeutic Feeding Centers (TFC) involve inpatient care for patients with severe acute malnutrition

and other medical complications. These complications include …[Guidelines] TF is broken down into

phases:

1. Phase I or Initial Phase

2. Transition Phase

3. Phase II or Rapid Weight Gain Phase

4. Phase III or Consolidation Phase

5. Discharge and Follow-Up in SFC

Each Phase has particular guidelines for nutritional treatment, systematic medical treatment, specific

medical treatment, and evaluation. All TFC Patients will be followed up at Supplementary Feeding

Centers discussed in Part III.

Goals of TFC:

Recognize and properly diagnose the signs and symptoms of severe acute malnutrition and

related conditions.

Provide the appropriate life-saving treatment to each case

Upgrade the condition of each patient so they can eventually graduate to an outpatient

Supplemental Feeding Center.

The objective of a Therapeutic Feeding Programme (TFP) is to reduce mortality among severely

malnourished patients by providing intensive care until their recovery.

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1 packet

of F-75

premix

2 Liters of Water

2.4 Liters of F-75

Phase I or Initial Phase

In this phase, the vital problems are identified and treated, the deficiencies are corrected, the basic

metabolism is restored and the pathologies are treated.

It is important that the feedings:

Are liquid to be easily consumed by patient, who is usually very weak and with poor appetite.

Are limited in quantity to simply cover basic physiological requirements. Are given in small and frequent quantity to avoid or limit vomiting, to reduce the incident of

diarrhoea and to avoid hypoglycaemia. Occur as soon as possible after admission.

_________________________________________________________

A. Nutritional treatment

The milk to be use is F-75 (130ml = 100kcal). F-75 contains _______ and its purpose is to acclimate

patients with severe acute malnutrition to a normal level of nutrients. Amounts to be given are shown

below according to the age category:

F-75 Energy density: 75 kcal / 100 ml

AGE CATEGORY Amount

(ml / kg of body weight / day) Energy

(Kcal / Kg of body weight / day) 6 months to 10 years 130 100

10 to 18 years 65 50

18 to 75 years 55 40

> 75 years 45 35

Preparation of F-75:

Always dilute with perfectly clean water. Once reconstituted the milk should be used within 2 hours. It should be kept in its original packaging. Once opened, the contents of a sachet must be entirely used up immediately. Destroy milk powder if the color or the smell or the aspect of the milk has changed, even if the expiry date is not yet reached, since there is a risk of organoleptic change of the product.

Added to Yields

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The quantity of milk to be given is calculated on the exact weight of each beneficiary. Meaning it

has to be adapted on daily basis and it is given in 8 meals per day, every 3 hours; spoon-

feeding is prohibited.

Breast-fed children should be offered breast-milk before the feedings and always on demand.

Source: Quantity of milk to be given per feed per 24h per Class of Weight. © M.Golden

Weight

Category (kg)

Daily amount

(ml)

Quantity in ml

8 meals per day

2.0 to 2.1 320 40

2.2 to 2.4 360 45

2.5 to 2.7 400 50

2.8 to 2.9 440 55

3.0 to 3.4 480 60

3.5 to 3.9 520 65

4.0 to 4.4 560 70

4.5 to 4.9 640 80

5.0 to 5.4 720 90

5.5 to 5.9 800 100

6.0 to 6.9 880 110

7.0 to 7.9 1000 125

8.0 to 8.9 1120 140

9.0 to 9.9 1240 155

10.0 to 10.9 1360 170

11.0 to 11.9 1520 190

12.0 to 12.9 1640 205

13 to 13.9 1840 230

14.0 to 14.9 2000 250

15.0 to 19.9 2080 260

20.0 to 24.9 2320 290

25 to 29.9 2400 300

30 to 39.9 2560 320

40 to 60 2800 350

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PHASE 1 FEEDINGS TIMETABLE

AM AM PM PM PM PM PM AM

7.00 10.00 01.00 04.00 06.00 08.00 10.00 01.00

Each feeding must be monitored properly by experienced staff. The quantity eaten by the beneficiary has to be written down on the chart by shading the appropriate part, as well if the beneficiary vomits part of the milk or refusing to eat. The nurse on duty has to be informed [Include feeding chart]

B. Medical treatment

1. Systematic Treatment during Phase I

Age or weight category Dose

VITAMINS

Vitamin A

6 months to 1 year 100 000 IU

> 1 year 200 000 IU

Pregnant and bearing age women

None

At the admission and the following day

Folic acid Every category 5 mg

Single dose at the admission

ANTIBIOTICS

Amoxicillin Every category 60 mg / kg / day

3 times a day throughout the entire phase

ANTIMALARIALS

Chloroquine

Day 1 10 mg/ Kg

Day 2 10 mg / Kg

Day 3 5 mg / Kg

VACCINATIONS

Measles

< 6 months Single vaccination at

admission

6 months to 5 years

One vaccination at admission

One vaccination at discharge

2. Specific Treatment

This treatment is prescribed according to the findings of the medical examination. Refer to the medical

protocol for specific treatment.

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DIAGNOSIS AND TREATMENT OF COMPLICATIONS*

*Adapted from Guidelines for the Management of Severe Acute Malnutrition, Ethiopia Ministry of Health, May 2004

A. HYPOGLYCEMIA All patients who are malnourished can develop hypoglycaemia but this is much less common than was formerly thought.

Diagnosis

One sign of hypoglycaemia is eye-lid retraction

– if a child sleeps with his eyes slightly open,

then he should be woken up and given sugar

solution to drink.

Prevention

Usually by the time when the beneficiaries

reach the TFC they have not eaten for several

hours. As soon as they are admitted they

should received sugared water supplemented

with CMV in the proportion of 5 ml / kg / hour.

Beneficiary with weigh less than 10 kg should

receive 50 ml per hour.

The aim is to minimize the risk of

hypoglycaemia.

Preparation of the sugar water Preparation of the CMV mother solution

1 litre of clean and safe water 50 g of sugar 2 ml of mother solution of CMV

Sugar water has an energy density of 200

kcal / litre.

20 ml of clean and safe water 6.5 g (1 red scoop) of CMV

Treatment

- All malnourished patients with suspected

hypoglycaemia should be treated with

second-line antibiotics.

- Patients who are conscious and able to

drink should be given a 50ml (5-10ml per

kg) of sugar water, or F75 (or F100 if

appropriate) by mouth.

- Patients losing consciousness should be

given 50ml (or 5-10ml per kg) of sugar

water by Naso-gastric tube immediately.

When consciousness is regained give milk

feed frequently.

- Unconscious patients should also be given

sugar water by naso-gastric tube. They

should also be given glucose as a single

intravenous injection (approx. 5ml/kg of

sterile 10% glucose solution).

_______________________________________________

B. HYPOTHERMIA

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Diagnosis

Severely malnourished patients are highly

susceptible to hypothermia. This is defined as a

rectal temperature below

Treatment

- For children with a caretaker, use the

―kangaroo technique‖

- Put a hat on the child and wrap caretaker

and child together.

- Give hot drinks to the mother so her skin

gets warmer (plain water, tea, or other hot

drink).

- Monitor body temperature during re-

warming

- The room should be kept warm, especially

- -

maximum thermometer should be on the

wall during Phase 1 to monitor the

temperature.

- Treat for hypoglycaemia and give second-

line antibiotics.

Note: the thermo-neutral temperature range

-

their mothers/caretakers and not in traditional

hospital child-cots. There should be adequate

blankets and a thick sleeping mat or adult bed.

Most heat is lost through the head; hats should

be worn by malnourished children. Windows

and doors should be kept closed at night.

_______________________________________________

A. DEHYDRATION

Dehydration and septic shock are both difficult

to diagnose and also to differentiate from the

other in severely malnourished patients.

Misdiagnosis and inappropriate treatment

for dehydration is the most common cause

of death in malnourished patients. IV

infusions are rarely used. In malnutrition there

is a particular renal problem that makes the

children sensitive to salt (sodium) overload.

The standard protocol for the well-nourished

dehydrated child should not be used.

A bucket of modified Oral Rehydration Solution

(ORS) or ReSoMal should never freely be

available to caretakers to take for their children

whenever they have a loose stool. Although it

is a common practice, it is very dangerous.

This can lead to failure to lose oedema, re-

feeding oedema, heart failure, and failure to

record significant problems while the diet and

phase remains unchanged.

Diagnosis

Treatment

Whenever possible, a person with severe

malnutrition and dehydration should be re-

hydrated orally. Intra-venous infusions are very

dangerous and are not recommended unless

there is 1) severe shock with 2) loss of

consciousness from 3) confirmed rehydration.

BEFORE starting any rehydration treatment: a) MARK the edge of the liver and the

costal margin on the skin with a permanent marker.

b) RECORD the heart sounds (presence or absence of gallop rhythm) in the notes

c) RECORD the pulse rate in the notes d) WEIGH the child.

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32 | P a g e

The malnourished child is managed entirely by

a) Weight changes and b) Clinical signs of improvement and c) Clinical signs of over-hydration

FLUID BALANCE is measured at intervals by WEIGHING the child.

Give re-hydration fluid until the weight deficit (measured or estimated) is corrected.

Stop as soon as the child is ―re-hydrated‖ to the target weight.

Additional fluid is not given to the malnourished child with a normal circulatory volume to ―prevent‖ recurrence of dehydration.

A total of between 50 and 100 ml of ReSoMal per kg of body weight is usually more than enough to restore normal hydration. Give this amount over 12 hours starting with 5ml/kg every 30 minutes for the first two hours orally or by naso-gastric tube, and then 5 to 10ml/kg per hour. Weigh the child each hour and assess his/her liver size, respiration rate and pulse. After rehydration, for malnourished children from 6 to 24 months give 30ml of ReSoMal for each watery stool that is lost. As the child gains weight, during re-hydration there should be definite clinical improvement and the signs of dehydration should disappear. Make a major reassessment at two hours. If there is continued weight loss then:

Increase the rate of administration of ReSoMal by 10ml/kg/hour

Formally reassess in one hour

Important Notes:

If there is no weight gain then:

Increase the rate of administration of ReSoMal by 5ml/kg/hour

Formally reassess in one hour If there is weight gain and:

Deterioration of the child’s condition with the re-hydration therapy, then the diagnosis of dehydration was definitely wrong. Even senior clinicians make mistakes in the diagnosis of dehydration in malnutrition. Stop and start the child on F75 diet.

No improvement in the mood and look of the child or reversal of the clinical signs, then the diagnosis of dehydration was probably wrong: either change to F75 or alternate F75 and ReSoMal.

Clinical improvement, but there are still signs of dehydration then continue with the treatment until the appropriate weight gain has been achieved. Either continue with ReSoMal alone or F75 and ReSoMal can be alternated.

Resolution of the signs of dehydration, then stop re-hydration treatment and start the child on F75 diet.

During re-hydration breastfeeding should not be interrupted. Begin to give F75 as soon as possible, orally or by naso-gastric tube. ReSoMal and F75 can be given in alternate hours if there is still some dehydration and continuing diarrhoea. Introduction of F75 is usually achieved within 2-3 hours of starting re-hydration.

- A patient who needs to be treated for dehydration using ReSoMal MUST goes back to phase 1 and follow up his/her liquid intake and the liquid losses established (as for any re-hydration). See the follow up form attached

- ReSoMal must not be used in any phase other than Phase I. - ReSoMal should only be used at admission of children with watery diarrhoea (see below). All

other children should receive water with sugar (the objective being to prevent hypoglycaemia, not to treat dehydration).

- ReSoMal should no longer be given systematically at admission.

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33 | P a g e

- ReSoMal should therefore be used only for treatment of dehydration in case of watery diarrhoea and / or vomiting. High fever will also increase the risk of dehydration (DHA).

- ReSoMal dosage in case of DHA remains the same.

Differentiation of diarrhoea

WHO recommends conducting the evaluation of diarrhoea according to the number of stools per day. It

is not necessary to evaluate the quantity or the characteristics of the stool. This cannot be applied to

malnourished children in the TFC, because we are feeding them several times a day (up to 6 or 8

times),

IT IS NORMAL THAT MOST PATIENTS HAVE MORE THAN THREE OR FOUR STOOLS PER DAY

AT THE BEGINNING OF TREATMENT (especially small children and elders).

Therefore, diarrhoea must be properly checked (quantity and characteristics of the stools), below is a

proposed classification:

Watery diarrhoea: Stool like water and loss of weight = high risk of dehydration. This is the only case, which should be treated with ReSoMal. (Loss of weight being defined as a decrease in weight during the day after the routine daily weighing.)

Non watery diarrhoea: liquid stools, persistent, often but without loss of weight = non-watery diarrhoea.

No ReSoMal is needed as the risk of dehydration is very low, providing correct hydration.

Re-feeding diarrhoea: Semi-liquid stool without loss of weight. No need for re-hydration, but try to split

up the meal (i.e. smaller meals but more often).

In practice:

- ReSoMal should not be available in the phases, but kept in the pharmacy and used only for treatment.

However WATER must be available everywhere in the phases.

_______________________________________________

B. SEPTIC SHOCK

Diagnosis

Most of the signs of true dehydration are also

seen in septic shock. However, a careful

history and clinical examination can usually

lead to the correct diagnosis and appropriate

treatment.

To diagnose developed septic shock the signs

of hypovolaemic shock should be present:

A fast weak pulse with

Cold peripheries

Disturbed consciousness

Treatment

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All patients of incipient or developed septic

shock should immediately:

- Be given broad-spectrum antibiotics

(second- and first-line antibiotics together)

- Be kept warm to prevent or treat

hypothermia

- Receive sugar water by mouth or naso-

gastric tube as soon as the diagnosis is

made (to prevent hypoglycaemia.

Incipient septic shock: Give the standard F75

diet by naso-gastric tube

Developed septic shock: Give a slow IV

infusion with 15 ml/kg over the first hour of one

of the following solutions (in order of

preference) if patient is unconscious:

- Half-strength Darrow’s solution with 5%

glucose

- Ringer’s lactate solution with 5% glucose

- Half-normal (0.45%) saline with 5% glucose

If available, give a blood transfusion of no more

than 10ml/kg over at least 3 hours. Nothing

should be given orally during a blood

transfusion.

Monitor every 10 minutes for signs of

deterioration, especially over-hydration and

heart failure.

- Increasing respiratory rate

- Development of grunting respiration

- Increasing liver size

- Vein engorgement

As soon as the patient improves (stronger radial

pulse, regain consciousness) stop all IV intake

and continue with F75 diet.

_______________________________________________

C. MARASMUS

D. KWASHIORKOR

E. HEART FAILURE

F. SEVERE ANAEMIA

Severe anaemia, associated with Kwashiorkor

generally indicates a poor prognosis and it is

often difficult to know what to do in this case.

Similarly, an inappropriate treatment of

anaemia with transfusions has an even worse

prognosis!

It seems that many deaths could be due to undiagnosed heart failure when there is fluid overload due to giving excess oral rehydration fluid and of course during transfusion, in association with severe anaemia. Often flaring nostrils are perceived as a sign of respiratory distress due to anaemia, when it is in fact a sign of heart failure (overloading). The difference can be seen by the precise surveillance of the weight. Other potential symptoms of fluid

overload are enlargement of the liver, increase in central venous blood pressure (only when highly qualified staff is on duty). It is important to differentiate the anaemia existing AT admission (before the increase of plasma volume) from the one that develops because of a treatment. Due the nutritional treatment (F75, F-100) the plasma volume is increased, and any Hb measurement can be “diluted”. This is why the Haemoglobin level is a meaningful measure only when measured within 48 hours after admission. The test done after these first 48 hours will not be valid to diagnose anaemia.

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35 | P a g e

If anaemia develops in the absence of haemorrhage or jaundice, and particularly, if this happens at the time of introduction of F100. Then it is likely to be due to haemodilution (and it should not be treated by transfusion, but with a reduction of the quantities of liquids and solutes offered to the patient). Summary: If anaemia is to be treated by transfusion

(according to Hb level) it has to be done

within 48 hours after the admission. The main reason is that because of the nutritional treatment, the plasma volume increases. Therefore the Hb level drops (i.e. is diluted) and laboratory results after 48H will show a very low reading, and an inaccurate picture of anaemia will be given.

For Kwashiorkor, IV infusions should be avoided as much as possible for the same reasons (risks of overload and diagnostic mistakes are extremely high).

At any rate, even if the anaemia has been present since the beginning of the admission (the first 48 hours) the risk of a heart failure (overload) during transfusion is still very high. A decision to transfuse should be taken with care and surveyed to the minute. Unfortunately, transfusions, when available, often happen out of our control (in a Hospital, etc.), where follow-up is weak or non-existent.

_________________________________________

MEDICAL EXAMINATION

The beneficiaries identified as emergency cases as describe in Part B should be treated in priority.

1. Check the patient’s medical history

2. Conduct a proper clinical examination by using the special from, especially look for signs of

hypoglycaemia, Hypothermia , severe acute dehydration and septic shock, infection and

tuberculosis

3. Prescribe systematic treatment according to the protocol

4. Prescribe specific treatment according to the findings of the clinical exam and the complaint and

as explain in the medical protocol.

All the information MUST be written on the chart.

Diagnosis and Treatment of Complications

- Hypoglycaemia - Hypothermia - Dehydration and Septic Shock - Marasmus - Kwashiorkor - Both specific and medical treatment has to be recorded properly on the chart as well medical

examination findings.

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C. MONITORING AND FOLLOW UP OF THE NUTRITIONAL AND MEDICAL CONDITION

The initial phase of treatment is very critical for the beneficiary. A close follow up of each beneficiary is

necessary in order to monitor improvement or deterioration of the medical and nutritional condition and

to be able to take appropriate decision.

ACTION FREQUENCY

Palpation of oedema Every day

Weight measurement Every day

Height measurement The day following the admission

Temperature Twice a day

Clinical examination At least once a day

PROMOTION TO THE TRANSITION PHASE

Beneficiaries are transferred to the Transition Phase as soon as:

They recover the appetite. For Kwashiorkor oedema has started to decrease They are no longer fed via naso-gastric tub They are not seriously ill.

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TRANSITION PHASE

The transition phase has a specific number of days according to the status of the beneficiary at the admission. Length of stay: Marasmus = 2 days

Kwashiorkor = 4 days

The aim of this phase is to accustom the child to F-100.

A. NUTRITIONAL TREATMENT

The milk to be used is F-100 according to the age category and as described below. Beneficiaries

receive the same amount of milk as in Phase I, but will intake more energy from the F-100 milk.

F – 100 Energy density : 100 kcal / 100 ml

AGE CATEGORY Amount

(ml / kg of body weight / day) Energy

(Kcal / Kg of body weight per day) 6 months to 10 years 130 135

10 to 18 years 65 65

18 to 75 years 55 55

> 75 years 45 45

The quantity of milk to be given is calculated on the exact weight of each beneficiary and is

given in 8 meals per day, one every 3 hours. Spoon-feeding is prohibited

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Source: Quantity of milk to be given per feed per 24h per Class of Weight. © M.Golden

Weight

Category (kg)

Daily amount

(ml)

Quantity in ml

8 meals per day

2.0 to 2.1 320 40

2.2 to 2.4 360 45

2.5 to 2.7 400 50

2.8 to 2.9 440 55

3.0 to 3.4 480 60

3.5 to 3.9 520 65

4.0 to 4.4 560 70

4.5 to 4.9 640 80

5.0 to 5.4 720 90

5.5 to 5.9 800 100

6.0 to 6.9 880 110

7.0 to 7.9 1000 125

8.0 to 8.9 1120 140

9.0 to 9.9 1240 155

10.0 to 10.9 1360 170

11.0 to 11.9 1520 190

12.0 to 12.9 1640 205

13 to 13.9 1840 230

14.0 to 14.9 2000 250

15.0 to 19.9 2080 260

20.0 to 24.9 2320 290

25 to 29.9 2400 300

30 to 39.9 2560 320

40 to 60 2800 350

TRANSITION PHASE – F100 – MEALS TIME TABLE

AM AM PM PM PM PM AM AM

7.00 10.00 01.00 04.00 06.00 08.00 10.00 01.00

As for Phase I, each feeding has to be monitored properly by experienced staff. The quantity eaten by the beneficiary has to be written down on the chart by shading the appropriate part, as well if the beneficiary vomits part of the milk or refusing to eat. The nurse on duty has to be informed for each significant event.

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B. MEDICAL TREATMENT

1. Systematic treatment

ANTIBIOTIC Age category Dose

Amoxicillin Every category 60 mg / kg / day

3 times a day throughout the entire phase.

The length of the course should not exceed 10 days.

2. Specific treatment

This treatment is prescribed according to the findings of the medical examination. Refer to the medical

protocol for specific treatment.

If the nutritional or medical condition has deteriorated do not hesitate to demote the child to

Phase I.

Both specific and medical treatment has to be recorded properly on the chart as well medical

examination findings.

C. NUTRITIONAL AND MEDICAL FOLLOW UP OF THE BENEFICIARY’S CONDITION

ACTION FREQUENCY

Palpation of oedema Every day until they disappear

Weight measurement Every day

Height measurement The day of promotion

MUAC Measurement Once weekly

W/H and BMI Twice weekly

Temperature Twice a day

Clinical examination At least once a day

PROMOTION TO PHASE II or RAPID WEIGHT GAIN PHASE

After 4 days in the transition phase for kwashiorkor and 2 days for marasmus and as long as the

nutritional and medical conditions are satisfactory, patients may be promoted to Phase II.

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PHASE II or RAPID WEIGHT GAIN PHASE

During this phase, the beneficiary should gain weight rapidly. The risk of developing infections is less

compared to Phase I and Transition phase, but nevertheless regular clinical care is necessary.

Particular attention is needed for the first 3 days of this phase where the mortality rate seems to be still important. Duration: 15 – 20 days

A. NUTRITIONAL CARE

1. Therapeutic Milk

The milk to be used is F-100 according to the age category and as described below. Beneficiaries in

Phase II receive an increased amount of milk as their bodies are more used to the amount of nutrients

provided.

F – 100 Energy density : 100 kcal / 100 ml

AGE CATEGORY Amount

(ml / kg of body weight / day) Energy

(Kcal / Kg of body weight per day) 6 months to 10 years 200 200

10 to 18 years 100

100

18 to 75 years 80 80

> 75 years 70 70

The quantity of milk to be given is calculated by weight category as described below. (Source: Quantity

of milk to be given per feed per 24h per Class of Weight. © M.Golden)

For children « special cases » less than 3 Kg, please refer to the appropriate chapter

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Feeding Guidelines

Phase 2 More than 8 Kg

Phase 2 > = 3 kg to < 8 kg

Weight Category

Daily Amount (ml)

Porridge

Plumpy

nut

Milk

(5 meals)

Milk

(7 meals)

3 to 3.4 kg 660

Patients of this weight should

only be given Milk.

95

3.5 to 3.9 kg 720 105

4 to 4.4 kg 900 130

4.5 to 4.9 kg 900 130

5 to 5.4 kg 1080 155

5.5 to 5.9 kg 1080 155

6 to 6.9 kg 1260 180

7 to 7.9 kg 1440 205

8 to 8.9 kg 1620 kcal/ 1120 ml of milk 1 1 225

9 to 9.9 kg 1800 / 1500 ml 1 1 300

10 to 10.9 kg 1800 / 1500 1 1 300

11 to 11.9 kg 2100 / 1600 1 1 320

12 to 12.9 kg 2700 / 2200 1 1 440

13 to 13.9 kg 2700 / 2200 1 1 440

14 to 14.9 kg 2700 / 2200 1 1 440

15 to 19.9 kg 3300 /2800 1 1 560

20 to 24.9 kg 3900 / 3400 1 1 680

25 to 29.9 kg 4500 / 3500 1 2 700

30.0 to 30.9 kg 5100 / 3600 1 3 720

40 to 60 kg 6000 / 4500 1 3 900

2. Ready to Use Product (RTUP)

Plumpy Nut could be introduced in this

phase to replace one milk feeding preferably

when the beneficiary is above 2 years and

has no oedema.

Plumpy Nut is distributed in the Phase II. The

sachet is opened and given to the

beneficiary together with one cup of water.

Make sure that Plumpy Nut and water are

not mixed together in the cup. Water is given

to facilitate the absorption of Plumpy Nut as

it is a thick food. Empty sachets have to be

collected at the end of the feeding.

One sachet provides 500 kcal.

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3. Porridge

Semi-liquid food (like porridge) is introduced for

the above 1 year. The porridge should provide

300 to 350 Kcal of which 10 % to 15 % are

provided as proteins and 30 to 35 % as lipids.

This porridge is enriched with CMV (vitamins

and minerals complex). The porridge to be

given is the same whatever the age or weight

category.

As for milk and Plumpy Nut, the quantity eaten

has to be recorded properly on the therapeutic

chart by shading.

ITEM QUANTITY

CSB 60 g Kcal 338 Kcal

OIL 10 g Proteins 12.8 %

SUGAR 5 g Lipids 36.2 %

CMV3 3.4 ml

4. Feeding time table

AM AM PM PM PM PM AM

07.00 10.00 01.00 04.00 07.00 10.00 01.00

Milk Milk Porridge or milk

Milk Plumpy nut or milk

Milk Milk

Porridge and Plumpy Nut should never be given in the same time as milk.

3 The preparation of the mother solution is explain in the admission chapter. 20 ml CMV mother solution fortified 2000 Kcal.

The number of ml of mother solution to add has to be calculated accordingly.

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B. MEDICAL TREATMENT

1. Systematic treatment

Age Category Dose

Iron > 6 months 3 mg / kg / day

Throughout the whole phase diluted in

F100 milk ANTIBIOTIC

Amoxicillin Every category 60 mg / kg / day

3 time a day if it has not gone beyond 10 days.

TREATMENT TO ELIMINATE PARASITIC INFESTATION

Mebendazole < 1 year None

1 to 2 years 250 mg

Single dose

2 years 500 mg

D1, D2, D3

Dilution of iron sulphate in HEM

At this stage, Iron sulphate is added to the F-100 milk [WHY?]

Number of F-100 sachets

Amount of water to be

added

Amount of F-100 milk obtained

Amount of elemental iron to be added

(mg)

Amount of iron sulphate tablets

to be added (tab)

1 2 2.4 36 ½

2 4 4.8 72 1

3 6 7.2 108 2

4 8 9.6 144 2 ½

5 10 12 180 3

6 12 14.4 216 3 ½

7 14 16.8 252 4

8 16 19.2 288 5

9 18 21.6 324 5 ½

10 20 24.0 360 6

[Picture]

Procedure for Dilution: (Put Procedures and tables at the end of each chapter?)

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1. Measure the water needed for the preparation of the milk 2. Prepare the number of tablets to be added in the F-100 according to the number of milk

sachets. Crush the tablets and mix it with a small quantity of water already measured for the preparation of F-100 milk.

3. Mix the crushed in water tablet with the total of water measured 4. Mix the F100 powder with the amount of water prepared.

3. Specific treatment

This treatment is prescribed according to the findings of the medical examination. Refer to the medical

protocol for specific treatment.

C. NUTRITIONAL AND MEDICAL FOLLOW UP

ACTION FREQUENCY SCHEDULE

Palpation of oedema Every day until they

disappear

Weight measurement Every two days

In case of static or decreasing weight not due to oedema the weight has to be check

the following day

Height measurement Once weekly

MUAC Measurement Once weekly

W/H and BMI Twice weekly

Temperature At least once a day

Clinical examination At least every two days

If the nutritional or medical condition has deteriorated the child has to be demoted to Phase 1 or

Transition Phase. The decision has to be made by the SECHN, the supervisor or the expatriate

in charge after proper checking.S

PROMOTION TO PHASE III or CONSOLIDATION PHASE

W/H > or = 85 % No oedema since 2 to 3 days Oedema have started to subside since 15 days Ascending weight curve.

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PHASE III or CONSOLIDATION PHASE

The aim of this phase is to prepare for the discharge of the beneficiary. Discharged beneficiaries will

be referred to the Supplemental Feeding Centers (SFC).

Duration: 3 days to one week

A. NUTRITIONAL TREATMENT

1. Therapeutic Milk

As for phase II the milk to be used is F-100 according to the age category and as described below:

F – 100 Energy density : 100 kcal / 100 ml

AGE CATEGORY Amount

(ml / kg of body weight / day) Energy

(Kcal / Kg of body weight per day) 6 months to 10 years 200 200

10 to 18 years 100 100

18 to 75 years 80 80

> 75 years 70 70

The quantity of milk to be given is calculated by weight category.

2. Ready To Use Product (RTUP)

If Plumpy Nut has been introduced to the patient it should continue to replace one milk feeding if the

beneficiary is above 2 years and has no oedema.

Plumpy Nut is distributed in the Phase II. The sachet is opened and given to the beneficiary together

with one cup of water. Make sure that Plumpy Nut and water are not mixed together in the cup. Water

is given to facilitate the absorption of Plumpy Nut as it is a thick food. Empty sachets have to be

collected at the end of the feeding.

One sachet provides 500 kcal.

3. Porridge Corn-Soy Blend (CSB) porridge is continued for the above 1 year. The porridge should provide 300 to

350 Kcal of which 10 % to 15 % are provided as proteins and 30 to 35 % as lipids. The porridge to be

given is the same whatever the age or weight category.

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ITEM QUANTITY

CSB 60 g Kcal 338 Kcal

OIL 10 g Proteins 12.8 %

SUGAR 5 g Lipids 36.2 %

CMV4 3.4 ml

4. Feeding time table

Feeding Guidelines for Phase III

4 The preparation of the mother solution is explain in the admission chapter. 20 ml CMV mother solution fortified 2000 Kcal.

The number of ml of mother solution to add has to be calculated accordingly.

PHASE III FEEDING TIME TABLE

AM AM PM PM PM PM AM

07.00 10.00 01.00 04.00 06.00 08.00 10.00

Milk Milk Porridge Family meal

or milk Milk

Plumpy

Nut or milk Milk

Phase 3

More than 8 Kg

Phase 3

> = 3 kg to < 8 kg

Weight Category Daily Amount

(ml) Porridge

Family

meal

Plumpy

nut

Milk

(4 meals)

Milk

(6 meals) Porridge

3 to 3.4 kg 660

Patients of this weight should only be

given milk.

110 If > 6 months

3.5 to 3.9 kg 720 120 If > 6 months

4 to 4.4 kg 900 150 If > 6 months

4.5 to 4.9 kg 900 150 If > 6 months

5 to 5.4 kg 1080 180 If > 6 months

5.5 to 5.9 kg 1080 180 If > 6 months

6 to 6.9 kg 1260 210 If > 6 months

7 to 7.9 kg 1440 240 If > 6 months

8 to 8.9 kg 1620 kcal/ 1120

ml of milk 1 1 1 280

1

9 to 9.9 kg 1800 / 1500 ml 1 1 1 375 1

10 to 10.9 kg 1800 / 1500 1 1 1 375 1

11 to 11.9 kg 2100 / 1600 1 1 1 400 1

12 to 12.9 kg 2700 / 2200 1 1 1 550 1

13 to 13.9 kg 2700 / 2200 1 1 1 550 1

14 to 14.9 kg 2700 / 2200 1 1 1 550 1

15 to 19.9 kg 3300 /2800 1 1 1 700 1

20 to 24.9 kg 3900 / 3400 1 1 1 850 1

25 to 29.9 kg 4500 / 3500 1 1 2 875 1

30.0 to 30.9 kg 5100 / 3600 1 1 3 900 1

40 to 60 kg 6000 / 4500 1 1 3 1125 1

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B. MEDICAL TREATMENT

1. Systematic treatment during Phase III:

Age Category Dose

Iron > 6 months 3 mg / kg / day

Throughout the whole phase diluted in F100 milk Dilution of iron sulphate in Therapeutic milk (HEM)

Number of F-100 sachets

Amount of water to be

added

Amount of F-100 milk obtained

Amount of iron sulphate tablets

to be added

1 2 2.4 ½

2 4 4.8 1

3 6 7.2 2

4 8 9.6 2 ½

5 10 12 3

6 12 14.4 3 ½

7 14 16.8 4

8 16 19.2 5

9 18 21.6 5 ½

10 20 24.0 6

Procedure for Dilution:

1. Measure the water needed for the preparation of the milk 2. Prepare the number of tablets to be added in the F-100 according to the number of milk

sachets. Crush the tablets and mix it with a small quantity of water already measured for the preparation of F-100 milk.

3. Mix the crushed in water tablet with the total of water measured 4. Mix the F100 powder with the amount of water prepared.

3. Specific treatment According to the clinical exam and the prescription

C. MEDICAL AND NUTRITIONAL FOLLOW UP

ACTION FREQUENCY

Weight measurement Twice Weekly

MUAC Measurement Once weekly

W/H and BMI Twice weekly

Temperature At least once a day

Clinical examination At least twice a week

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DISCHARGE

A. CRITERIA

Children and adolescents (6 months to 18 years) W/H > 85 % And MUAC >= 120 mm And no bilateral oedema for at least 15 days. And absence of medical problem.

Adults BMI > 17.5 And no bilateral oedema for at least 15 days And ascending weight curve And absence of medical problem

Beneficiary should not be discharged if under medication.

As much as possible each discharged beneficiary should be referred to TFC follow up.

B. SPECIFIC TREATMENT

Age or weight category Dose

VITAMINS

Vitamin A

6 months to 1 year 100 000 IU

> 1 year 200 000 IU

Pregnant and bearing age women

None

The day of discharge VACCINATION

Measles 9 months to 5 years One vaccination at the discharge

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C. MEDICAL AND NUTRITIONAL FOLLOW UP

ACTION

DAY OF DISCHARGE

Weight measurement

Height measurement

W/H %

MUAC

The TFC team is in charge of preparing the TFC follow up chart [EXAMPLE]. It is advisable to write the

admission and discharge information and the under five chart as well.

The SFC team usually does the TFC follow up. Nevertheless the TFC team has to properly inform the

caretaker of the discharged about:

The closest distribution point. The day and frequency of the distribution. The TFC follow up timetable.

Sometimes the caretaker has no way to reach one of the distribution points. In that particular case, a

double ration (2 weeks ration) is given and the mother is encourage to make a regular checking at the

closest health facility.

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SPECIAL CARE FOR INFANTS UNDER 6 MONTHS [Picture]

A. ADMISSION

Infants under 6 months of age are admitted in

TFC if they meet the following criteria:

The infant is too weak to suck effectively

The mother is not producing enough milk.

Prior to admission the following has to be

checked properly:

A proper clinical examination has to be conducted

Check the presence of milk by carefully pressing the mother’s breast.

These beneficiaries are very fragile and must

as far as possible, be protected from risk of

infection. Hence it is advisable to isolate them

and to insure a close and regular monitoring.

As for other beneficiaries the infant is admitted

with a caretaker. As mothering for infant is one

of the key points of the treatment, mother is

admitted as caretaker / lactating woman. In

case of orphan infant the grandmother is

admitted. If it is not possible - even it is not in

the habit – we have to encourage a lactating

woman among the relatives to stay with the

infant.

B. STEPS

Conduct a medical examination Daily weight of the child Prescribe the systematic treatment Prescribe specific treatment Encourage the breast-feeding and cares to the mothers

C. MEDICAL CARE

a) Systematic treatment

Dose Days of administration

Vitamin A 50 000 IU D1, D2 and at discharge

Folic acid 5 mg D1

Amoxicillin 60 mg / kg / day divided in

3 doses

From D1 to D10

Chloroquine

b) Specific treatment

The specific treatment is prescribed according to the medical examination findings and complaints.

Keep in mind that these beneficiaries are very fragile

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D. NUTRITIONAL CARE FOR INFANTS UNDER 6 MONTHS The nutritional protocol has to be adjusted to the physiological needs of these children. The objective of the treatment is to increase the mother’s milk supply whilst giving a supplement to the infant until it reaches the stage where the mother’s milk alone is sufficient to ensure the child’s growth.

The milk to be used is diluted F100 as it corresponds better to the nutritional needs of this age. 8 meals are given per day following the Phase I time table consisting of 130 ml / kg / day.

No iron has to be added in the diluted F100 for children under 6 months.

Diluted F-100 Energy density: 100 kcal / 100 ml Quantity given: 130 ml / kg of body-weight / day

Quantity of diluted F-100 needed

F-100 needed (2/3)

Water to add (1/3)

50 33 17

100 67 33

150 100 50

200 133 67

250 167 83

300 200 100

350 233 117

400 266 134

450 300 150

500 334 166

The supplement is not increased during the

stay, so any increase in weight signifies an

increase in the infant consumption of breast

milk. However, the quantity of diluted F100 is

adapted according to the daily weight.

In case the breast milk production is sufficient

but the child is unable to suck, the breast milk

has to be manually extracted and given

immediately with a cup.

Particular attention has to be paid to the

mother. She should be listened to, reassured,

and encouraged to breast-feed.

The lactating women have to receive 2500 Kcal

/day. An additional porridge has to be

distributed.

The stay at the TFC should be as short as

possible as the environment can be dangerous

to the health of these infants. 15 days should be

a maximum.

1. Preparing for discharge

If the weight curve is ascending for 10 days: Cut the quantity of milk to be given by half and ensure the weight is still increasing After 3 days, if the curve is ascending, stop the supplementation with diluted F-100. Keep the child under observation for 3 days

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SPECIAL CARE FOR INFANTS OVER 6 MONTHS WEIGHING LESS THAN 3 KG

The objective is to get the mother to continue breastfeeding while giving the infant the supplements

required at this stage of development. In a child more than 6 months old who weighs less than 3 kg,

growth is seriously retarded. At the beginning of the treatment the child is treated in the same way as

infant less than 6 months old.

1. Nutritional

The nutritional protocol consists of three phases:

An initial treatment phase during which the energy intake is progressively increased. A rapid gain weight phase while the infant still weighs less than 3 kg A further rapid gain weight phase once the infant has reached 3 kg. At the start of the treatment and until the infant reach 3 kg the diet is based on diluted F-100.

Weight Category

Daily Amount (ml)

Diluted F-100 + iron

(8 meals a day)

2 to 2.1 kg 320 40

2.2 to 2.4 kg 360 45

2.5 to 2.7 kg 400 50

2.8 to 2.9 kg 440 55

[Picture]

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Preparation of the Diluted F100

Quantity of diluted

F-100 needed

F-100 needed

(2/3)

Water to add

(1/3)

50 33 17

100 67 33

150 100 50

200 133 67

250 167 83

300 200 100

350 233 117

400 266 134

450 300 150

500 334 166

1. Give diluted F-100 one hour after each breastfeeding:

2. Calculate the quantity of diluted F-100 according to the actual weight of the infant,

rounding up the quantity of milk to the nearest 5 ml.

3. Measure out the quantity with a syringe

4. Supplementary suckling technique

Supplementary suckling technique

Tell mother to put the infant to the breast every 3 hours for at

least 20 minutes. Since suckling stimulates the production of

milk, it is important to put the infant to the breast as often as

possible, and always before giving the diluted F-100 milk.

The diluted F-100 is given to the infant by using a gastric tube,

one end of which is placed on the mother’s nipple and the

other, which has been cut about 1 cm from the small holes, into

a cup of diluted F-100 milk. Do not forget to remove the

stopper.

When the infant suckles it takes in milk from the cup via the

tube together with the breast milk. The mother must hold the

cup about 10 cm lower than the breast, so that milk is not

sucked up too quickly.

It may require 2 or 3 days before the infant becomes used to

this technique. In the first few days, if the infant does not suck

all the milk from the cup through the tube, the balance should be given using the cup.

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2. Rapid weight gain phase:

When the child reaches 3 kg, the usual protocol needs to be followed. That means transition phase

with F100 – 8 meals a day during 4 days and then promoted to Phase 2. According to his weight,

the porridge will be given or not.

Close monitoring must be organized at the beginning of Phase II.

3. Discharge:

The child is cured when

W/H > 85 % The weight curve is ascending No medical problems

The child is referred to SFC for Follow Up.

E. MEDICAL AND NUTRITIONAL FOLLOW UP

ACTION FREQUENCY SCHEDULE

Weight measurement Every days

A baby scale is used, 10 to 20 g precision

Height measurement Once weekly

W/H and BMI Twice weekly

Temperature At least once a day

Clinical examination Once daily

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SPECIAL NOTES ON THE CARETAKERS

Beneficiaries in TFC cannot stay by their own

hence a caretaker has to assist them. The

caretaker must be an adult, preferably the

mother, as mothering is crucial. When this is

not possible, somebody who is close to the

beneficiary should stay as the caretaker.

The treatment of severe malnutrition will not be

effective if we did not have the support of the

caretaker. Moreover the relationship between

the beneficiary and the caretaker is very

important. It should be strong (e.g.: a

beneficiary who is usually with the mother but

admitted in TFC with the grandmother may

refuse feeding because of lack of attention/

mothering).

The caretaker has to be briefed on the purpose

of TFC and its regulations. At the admission

non- food items are given:

mosquito net sleeping mat blanket cup spoon plate

These items are under their responsibility until

the discharge. Bathing and laundry soap are

distributed on a weekly basis.

The registrars have to explain how TFC is

organized and what we are expecting from

caretakers. They have to be involved in their

own food preparation and in the cleaning of the

entire centre. It is up to the team to organize the

caretakers by groups and to encourage them to

elect a caretaker leader.

The caretaker has to attend the health

education session according to the planning.

Because caretakers have to stay in TFC until

the discharge of the beneficiary they must be

fed as well. Most of the time they cannot

organize their own food provision and feeding

helps to limit defaulting of the beneficiary.

We have to provide them enough food to cover

their daily needs (2100 Kcal). Their daily food

ration is made of porridge and family meal.

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The porridge should provide 600 to 700 Kcal of which 35 % is lipids and 11 % is proteins.

The family meal should provide 1400 to 1500 Kcal of which 25 to 30 % of lipids and 10 to 12 % of

proteins.

Quantity (g)

CEREAL 300

OIL 35

PULSES 80

SALT 5

This family meal is accommodated with local food as cassava leaves, dry fish, hot pepper and other

condiments.

The beneficiary porridge and family meal can be fortified with CMV.

Quantity (g)

CSB 125

OIL 20

SUGAR 10

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Part III.

Supplementary Feeding Centers

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Introduction:

Supplementary Feeding Centers involve screening and treatment of acute moderate

malnutrition, screening and referrals for acute severe malnutrition, Outpatient Treatment

Programs (OTP), and food distribution. OTP involves home-based treatment for patients with

severe acute malnutrition, but NO other complications.

Goals of SFC:

Recognize and properly diagnose the signs and symptoms of severe malnutrition and

related conditions.

Provide the appropriate life-saving treatment to each case

Upgrade the condition of each patient so they can eventually graduate to an outpatient

Supplemental Feeding Center.

The objective of a Supplementary Feeding Centre ( SFC) is to avoid that a child already

moderately malnourished becomes severely malnourished with the risk to death in the

days.

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FOLLOW UP

The aim of TFC Follow Up is to insure a surveillance of the discharged beneficiary for a 3-month period

and preventing the relapses. The TFC Follow up is usually conducted by SFC team nevertheless the

TFC team should be aware of the aim and protocol of TFC follow up.

A screening is conducted at each visit and a single premixed ration is distributed as for SFC

beneficiaries. The schedule is as explain below:

Along the TFC Follow up there are 7 contacts with the beneficiary. Defaulter is considered after 2

consecutive absences. Even after an absence, the schedule has to be strictly followed (e.g.: a

beneficiary which misses the 2nd visit and coming after absence will be registered as 3rd visit.

Beneficiary with stable or decreasing weight can be asked to come one week after for new screening.

Beneficiary reached SFC criteria has to be referred to SFC

All information regarding TFC Follow up is collected in a special register.

1st month

Weekly visit

1st visit

2nd visit

3rd visit

4th visit

2nd month Fortnightly visit 5th visit

6th visit

3rd month Single visit 7th visit

ITEM QUANTITY

Daily (g) Weekly (kg)

CSB 214 g 1.5 kg

OIL 30 g 0.210 Kg

SUGAR 14.2g 0.100 kg

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Options for ration composition for a targeted, dry supplementary feeding programme

A daily, take-home supplementary ration should provide:

1200-1600 kcal/day

10-12% energy from protein*

30-35% energy from fat*

*nb. protein provides 4 kcal/g, fat provides 9 kcal/g

Example rations:

Ration 1: Famix CSB WSB Oil** Sugar

Total from

blended ration

per day

Quantity for 2 weeks (kg)

3.5 kg

0.5 kg

Quantity per day (g) 250.0

35.7

Kcal per day 960.0

321.3

1281.3

Protein per day (g) 35.0

35.0

Fat per day (g) 17.3

35.7

53.0

% energy from protein

10.9

% energy from fat

37.2

Ration 3: Famix CSB WSB Oil** Sugar

Total from

blended ration

per day

Quantity for 2 weeks

4.0 kg

0.5 kg

Quantity per day (g)

286.0

29.4

Kcal per day

1087.0

264.6

1351.6

Protein per day (g)

51.5

51.5

Fat per day (g)

17.1

29.4

46.5

% energy from protein

15.2

% energy from fat

31.0

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Ration 5: Famix CSB WSB Oil** Sugar

Total from

blended ration

per day

Quantity for 2 weeks 4.0 kg

0.5 kg

Quantity per day (g) 286.0

29.4

Kcal per day 1098.0

264.6

1362.6

Protein per day (g) 40.0

40.0

Fat per day (g) 19.7

29.4

49.1

% energy from protein

11.7

% energy from fat

32.4

Ration 7: Famix CSB WSB Oil** Sugar

Total from

blended ration

per day

Quantity for 2 weeks 4.5 kg

0.5 kg

Quantity per day (g) 321.0

29.4

Kcal per day 1233.0

264.6

1497.6

Protein per day (g) 44.9

44.9

Fat per day (g) 22.1

29.4

51.5

% energy from protein

12.0

% energy from fat

30.9

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Plumpynut OTP Ration Guidelines

Weight of Child (kg) Ration per weekly

distribution Ration per day Ration per meal

3.5 - 3.9 11 1.5 ¼ sachet

4.0 - 5.4 14 2 ¼ sachet

5.5 - 6.9 18 2.5 ½ sachet

7.0 - 8.4 21 3 ½ sachet

8.5 - 9.4 25 3.5 ½ sachet

9.5 - 10.4 28 4 ½ sachet

10.5 - 11.9 32 4.5 ½ sachet

>12 35 5 ¾ sachet

Give small amount every few hours (day and night)

ALWAYS offer water to drink while eating Plumpynut.

ALWAYS offer breastmilk first if the child is still breastfeeding

Follow the appetite of the child – NEVER force food On discharge, amount given should be ―ration/day‖ x ―number of days‖ until next SFP distribution date.

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Appendix

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Quick Reference Tables

Overview of Admission Criteria:

Admission

In SFC Admission

In TFC

Children from 6 months to 10

years (or from 65 to 130

cm)

W/H , 80% of the median And /or

MUAC < 125 mm

W/H < 70% of the median

and/or Presence of bilateral pitting oedema

and/or MUAC < 110 mm

Adolescents from 10 to 18 years

(> 130 cm)

W/H < 80% of the median And / or

MUAC : not to do , mistakes are common

W/H < 70% of the median and/or

Presence of bilateral pitting oedema

Adults (except pregnant and

lactating women)

MUAC : 160 185 mm

MUAC < 160 mm or

Presence of bilateral pitting oedema (Grade 3 or worse) 1

or MUAC < 185 mm

and poor clinical condition (Inability to stand, apparent

dehydration etc.)

Pregnant and lactating women

MUAC : 170 185 mm

Rem/ at risk of malnutrition 185 210 mm

MUAC < 170 mm and/or

Presence of bilateral pitting oedema (Grade 3 and above) 1

Elderly

( 50-60 years) MUAC : 160 175 mm

MUAC < 160 mm and poor clinical condition (Inability to stand, apparent

dehydration etc.) and/or

Presence of bilateral pitting oedema (Grade 3 or worse) 1

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Weight-for-length tables for boys and girls below 85 cm, in % of the NCHS median

*Children measuring BELOW 85 cm should be measured lying down.

WEIGHT-FOR-LENGTH WEIGHT-FOR-LENGTH

Malnutrition Malnutrition

Moderate Severe Moderate Severe

Height 100% 85% 80% 75% 70% 60% Height 100% 85% 80% 75% 70% 60%

(cm) In Kg in Kg in Kg in Kg in Kg in Kg (cm) in Kg in Kg in Kg in Kg in Kg in Kg

49.0 3.2 2.7 2.6 2.4 2.3 1.9 67.0 7.6 6.5 6.1 5.7 5.3 4.6

49.5 3.3 2.8 2.6 2.5 2.3 67.5 7.8 6.6 6.2 5.8 5.4

50.0 3.4 2.9 2.7 2.5 2.4 2.0 68.0 7.9 6.7 6.3 5.9 5.5 4.7

50.5 3.4 2.9 2.7 2.6 2.4 68.5 8.0 6.8 6.4 6.0 5.6

51.0 3.5 3.0 2.8 2.6 2.5 2.1 69.0 8.2 7.0 6.6 6.1 5.7 4.9

51.5 3.6 3.1 2.9 2.7 2.5 69.5 8.3 7.1 6.7 6.2 5.8

52.0 3.7 3.1 3.0 2.8 2.6 2.2 70.0 8.5 7.2 6.8 6.3 5.9 5.1

52.5 3.8 3.2 3.0 2.8 2.6 70.5 8.6 7.3 6.9 6.4 6.0

53.0 3.9 3.3 3.1 2.9 2.7 2.3 71.0 8.7 7.4 7.0 6.5 6.1 5.2

53.5 4.0 3.4 3.2 3.0 2.8 71.5 8.9 7.5 7.1 6.6 6.2

54.0 4.1 3.5 3.3 3.1 2.9 2.5 72.0 9.0 7.6 7.2 6.7 6.3 5.4

54.5 4.2 3.6 3.4 3.2 2.9 72.5 9.1 7.7 7.3 6.8 6.4

55.0 4.3 3.7 3.5 3.2 3.0 2.6 73.0 9.2 7.9 7.4 6.9 6.5 5.5

55.5 4.4 3.8 3.5 3.3 3.1 73.5 9.4 8.0 7.5 7.0 6.5

56.0 4.6 3.9 3.6 3.4 3.2 2.8 74.0 9.5 8.1 7.6 7.1 6.6 5.7

56.5 4.7 4.0 3.7 3.5 3.3 74.5 9.6 8.2 7.7 7.2 6.7

57.0 4.8 4.1 3.8 3.6 3.4 2.9 75.0 9.7 8.2 7.8 7.3 6.8 5.8

57.5 4.9 4.2 3.9 3.7 3.4 75.5 9.8 8.3 7.9 7.4 6.9

58.0 5.1 4.3 4.0 3.8 3.5 3.1 76.0 9.9 8.4 7.9 7.4 6.9 5.9

58.5 5.2 4.4 4.2 3.9 3.6 76.5 10.0 8.5 8.0 7.5 7.0

59.0 5.3 4.5 4.3 4.0 3.7 3.2 77.0 10.1 8.6 8.1 7.6 7.1 6.1

59.5 5.5 4.6 4.4 4.1 3.8 77.5 10.2 8.7 8.2 7.7 7.2

60.0 5.6 4.8 4.5 4.2 3.9 3.4 78.0 10.4 8.8 8.3 7.8 7.2 6.2

60.5 5.7 4.9 4.6 4.3 4.0 78.5 10.5 8.9 8.4 7.8 7.3

61.0 5.9 5.0 4.7 4.4 4.1 3.5 79.0 10.6 9.0 8.4 7.9 7.4 6.4

61.5 6.0 5.1 4.8 4.5 4.2 79.5 10.7 9.1 8.5 8.0 7.5

62.0 6.2 5.2 4.9 4.6 4.3 3.7 80.0 10.8 9.1 8.6 8.1 7.5 6.5

62.5 6.3 5.4 5.0 4.7 4.4 80.5 10.9 9.2 8.7 8.1 7.6

63.0 6.5 5.5 5.2 4.8 4.5 3.9 81.0 11.0 9.3 8.8 8.2 7.7 6.6

63.5 6.6 5.6 5.3 5.0 4.6 81.5 11.1 9.4 8.8 8.3 7.7

64.0 6.7 5.7 5.4 5.1 4.7 4.0 82.0 11.2 9.5 8.9 8.4 7.8 6.7

64.5 6.9 5.9 5.5 5.2 4.8 82.5 11.3 9.6 9.0 8.4 7.9

65.0 7.0 6.0 5.6 5.3 4.9 4.2 83.0 11.4 9.6 9.1 8.5 7.9 6.8

65.5 7.2 6.1 5.7 5.4 5.0 83.5 11.5 9.7 9.2 8.6 8.0

66.0 7.3 6.2 5.9 5.5 5.1 4.4 84.0 11.5 9.8 9.2 8.7 8.1 6.9

66.5 7.5 6.4 6.0 5.6 5.2 84.5 11.6 9.9 9.3 8.7 8.2

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Weight-for-height tables for boys and girls above 85 cm *Children measuring 85 cm and ABOVE should be measured standing.

WEIGHT-FOR-HEIGHT WEIGHT-FOR-HEIGHT

Malnutrition Malnutrition

Moderate Severe Moderate Severe

Height 100% 85% 80% 75% 70% 60% Height 100% 85% 80% 75% 70% 60%

(cm) in Kg in Kg in Kg in Kg in Kg in Kg (cm) in Kg in Kg in Kg in Kg in Kg in Kg

85.0 12.0 10.2 9.6 9.0 8.4 7.2 107.5 17.7 15.0 14.1 13.3 12.4

85.5 12.1 10.3 9.7 9.1 8.5 108.0 17.8 15.2 14.3 13.4 12.5 10.7

86.0 12.2 10.4 9.8 9.1 8.5 7.3 108.5 18.0 15.3 14.4 13.6 12.7

86.5 12.3 10.5 9.8 9.2 8.6 109.0 18.1 15.4 14.5 13.6 12.7 10.9

87.0 12.4 10.6 9.9 9.3 8.7 7.4 109.5 18.3 15.6 14.6 13.7 12.8

87.5 12.5 10.6 10.0 9.4 8.8 110.0 18.4 15.7 14.8 13.8 12.9 11.0

88.0 12.6 10.7 10.1 9.5 8.8 7.6 110.5 18.6 15.8 14.9 14.0 13.0

88.5 12.8 10.8 10.2 9.6 8.9 111.0 18.8 16.0 15.0 14.1 13.1 11.3

89.0 12.9 10.9 10.3 9.7 9.0 7.7 111.5 18.9 16.1 15.1 14.2 13.3

89.5 13.0 11.1 10.4 9.7 9.1 112.0 19.1 16.2 15.3 14.3 13.4 11.5

90.0 13.1 11.1 10.5 9.8 9.2 7.9 112.5 19.3 16.4 15.4 14.4 13.5

90.5 13.2 11.2 10.6 9.9 9.2 113.0 19.4 16.5 15.5 14.6 13.6 11.6

91.0 13.3 11.3 10.7 10.0 9.3 8.0 113.5 19.6 16.7 15.7 14.7 13.7

91.5 13.4 11.4 10.8 10.1 9.4 114.0 19.8 16.8 15.8 14.8 13.8 11.9

92.0 13.6 11.6 10.8 10.2 9.5 8.2 114.5 19.9 16.9 16.0 15.0 14.0

92.5 13.7 11.6 10.9 10.3 9.6 115.0 20.1 17.1 16.1 15.1 14.2 12.1

93.0 13.8 11.7 11.0 10.3 9.7 8.3 115.5 20.3 17.3 16.2 15.2 14.2

93.5 13.9 11.8 11.1 10.4 9.7 116.0 20.5 17.4 16.4 15.4 14.3 12.3

94.0 14.0 11.9 11.2 10.5 9.8 8.4 116.5 20.7 17.6 16.5 15.5 14.5

94.5 14.2 12.0 11.3 10.6 9.9 117.0 20.8 17.7 16.7 15.6 14.6 12.5

95.0 14.3 12.1 11.4 10.7 10.0 8.6 117.5 21.0 17.9 16.8 15.8 14.7

95.5 14.4 12.2 11.5 10.8 10.1 118.0 21.2 18.0 17.0 15.9 14.9 12.7

96.0 14.5 12.4 11.6 10.9 10.2 8.7 118.5 21.4 18.2 17.1 16.1 15.0

96.5 14.7 12.5 11.7 11.0 10.3 119.0 21.6 18.4 17.3 16.2 15.1 13.0

97.0 14.8 12.6 11.8 11.1 10.3 8.9 119.5 21.8 18.5 17.4 16.4 15.3

97.5 14.9 12.7 11.9 11.2 10.4 120.0 22.0 18.7 17.6 16.5 15.4 13.2

98.0 15.0 12.8 12.0 11.3 10.5 9.0 120.5 22.2 18.9 17.8 16.7 15.5

98.5 15.2 12.9 12.1 11.4 10.6 121.0 22.4 19.1 17.9 16.8 15.7 13.4

99.0 15.3 13.0 12.2 11.5 10.7 9.2 121.5 22.6 19.2 18.1 17.0 15.8

99.5 15.4 13.1 12.3 11.6 10.8 122.0 22.8 19.4 18.3 17.1 16.0 13.7

100.0 15.6 13.2 12.4 11.7 10.9 9.4 122.5 23.1 19.6 18.4 17.3 16.1

100.5 15.7 13.3 12.6 11.8 11.0 123.0 23.3 19.8 18.6 17.5 16.3 14.0

101.0 15.8 13.5 12.7 11.9 11.1 9.5 123.5 23.5 20.0 18.8 17.6 16.5

101.5 16.0 13.6 12.8 12.0 11.2 124.0 23.7 20.2 19.0 17.8 16.6 14.2

102.0 16.1 13.7 12.9 12.1 11.3 9.7 124.5 24.0 20.4 19.2 18.0 16.8

102.5 16.2 13.8 13.0 12.2 11.4 125.0 24.2 20.6 19.4 18.2 16.9 14.5

103.0 16.4 13.9 13.1 12.3 11.5 9.8 125.5 24.4 20.8 19.6 18.3 17.1

103.5 16.5 14.0 13.2 12.4 11.6 126.0 24.7 21.0 19.7 18.5 17.3 14.8

104.0 16.7 14.2 13.3 12.5 11.7 10.0 126.5 24.9 21.2 19.9 18.7 17.5

104.5 16.8 14.3 13.4 12.6 11.8 127.0 25.2 21.4 20.1 18.9 17.6 15.1

105.0 16.9 14.4 13.6 12.7 11.9 10.1 127.5 25.4 21.6 20.4 19.1 17.8

105.5 17.1 14.5 13.7 12.8 12.0 128.0 25.7 21.8 20.6 19.3 18.0 15.4

106.0 17.2 14.6 13.8 12.9 12.1 10.3 128.5 26.0 22.1 20.8 19.5 18.2

106.5 17.4 14.8 13.9 13.1 12.2 129.0 26.2 22.3 21.0 19.7 18.4 15.7

107.0 17.5 14.9 14.0 13.1 12.3 10.5 129.5 26.5 22.5 21.2 19.9 18.6

130.0 26.8 22.8 21.4 20.1 18.7 16.1

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Overview of Methods for Anthropometric Measures

Method Uses Advantages Disadvantages Common

Thresholds

MUAC Detect wasting and acute malnutrition

Assess risk of death; does not depend on age; rapid, simple, no cumbersome

equipment

Risk of measurement error; lack of agreement on thresholds; does not

take oedemas and dehydration into account

<135 mm: at risk

3Z to < -2Z or 110 to < 125 mm: moderate

malnutrition

<-3Z or <110 mm: severe malnutrition high risk of mortality

Weight- Height

Detect Wasting and acute malnutrition

Does not depend on age

2 measurements needed; ratio is changed by

oedemas and dehydration; no

information on past nutritional status

-3Z to < -2Z or 70% to < 80%:

moderate malnutrition

<-3Z or <70%: severe malnutrition

Weight-Age

Detects a combination of stunting and

wasting, and acute and chronic malnutrition

Used extensively throughout the

world; Height not needed (difficult);

Interesting for monitoring individual

development

Requires age; Confusion in interpreting the

influence of acute and chronic malnutrition;

Oedemas and dehydration modify weight

-3Z to < -2Z or 60% to < 75%: moderate

malnutrition

<-3Z or <60%: severe

Height-Age Detects stunting and chronic malnutrition

Measurements unchanged by acute

malnutrition or by presence of oedemas;

dehydration does not change measures

Need to know age; Measuring height is technically difficult;

Provides no info on the presence of acute

malnutrition

-3Z to < -2Z or 80% to < 90%: moderate

malnutrition

<-3Z or <80%: severe malnutrition

Body Mass Index (BMI)

Used for nutritional assessment in

adults; increasingly used for population

references

Not always accurate; Does not take muscle

mass into account

17-18: At-risk >= 16: malnutrition

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Forms

- Registration cards - Initial Assessment cards - Meal Trackers - Weight tracker -

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Check Lists

- Set up

- TFC - SFC/OTP

- Personnel - Supplies - Drugs - Actions Diagnosis, treatment, etc - Systematic treatment at each stage

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References and Additional Resources Action Against Hunger, Strategic Programming for Community Nutrition Interventions. 2007. http://www.actionagainsthunger.org/sites/default/files/publications/ACF-Community-Nutrition-Guide.pdf Medecins San Frontieres, Clinical Guidelines: Diagnosis and Treatment Manual. 2010. http://www.refbooks.msf.org/MSF_Docs/En/Clinical_Guide/CG_en.pdf Medecins San Frontieres, Essential Drugs. 2010. http://www.refbooks.msf.org/MSF_Docs/En/Essential_drugs/ED_en.pdf Medecins San Frontieres, Rapid Health Assessment of Refugee or Displaced Populations. 2006. http://www.refbooks.msf.org/MSF_Docs/En/Rapid_health/RAPID_HEALTH_en.pdf Medecins San Frontieres, Refugee Health. 1997. http://www.refbooks.msf.org/MSF_Docs/En/Refugee_Health/RH.pdf World Health Organization, Guidelines for the Inpatient Treatment of Severely Malnourished Children. 2003. http://www.who.int/nutrition/publications/severemalnutrition/guide_inpatient_text.pdf World Health Organization, Management of Severe Malnutrition: A Manual for Physicians and Other Senior Health Workers. 1999. http://www.who.int/nutrition/publications/severemalnutrition/en/manage_severe_malnutrition_eng.pdf World Health Organization, Management of the Child with a Serious Infection or Severe Malnutrition: Guidelines for Care at the First-Referral Level in Developing Countries. 2000. http://whqlibdoc.who.int/hq/2000/WHO_FCH_CAH_00.1.pdf World Health Organization, Manual for the Health Care of Children in Humanitarian Emergencies. 2008. http://whqlibdoc.who.int/publications/2008/9789241596879_eng.pdf