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Nutrition Manual A Guide to Emergency Therapeutic and Supplemental Feeding Centers

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Nutrition Manual

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Nutrition Manual

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

International has been the first US-based

the long-term developmental needs of its

agency to provide high-impact development

beneficiaries even while in the emergency

emergency programming to communities in

phase. The agency recognizes that disasters

need. Relief International believes that as a

have the most negative impact on the lives of

humanitarian agency one of its main functions

the poor; yet disasters, and especially the

is to communicate the pronounced needs of the

movement of the populations, can also bring

vulnerable and affected populations to the

about unexpected, positive social change. This

international community. Relief International

context can therefore serve as a window of

thus consults closely with the local communities

opportunity for eradicating poverty and social

it serves in order to ensure that its programs do

injustice.

not impose solutions from the outside but rather address their needs and requirements for the

Relief International focuses on serving people

long term. This grassroots approach proves

who typically have not received due attention,

effective in fostering an environment of self-help

and

and sustainability.

in

several

large-scale

crises

Relief

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Nutrition Manual

Table of Contents A. B. C.

D.

E.

F.

G.

Abbreviations and Acronyms Introduction Part I: Setting Up a Nutrition Clinic a. Site Selection b. Layout c. Logistics and Special Notes d. Supplies and Drug List 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 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 Part III: Supplementary Feeding Centers a. TFC Follow Up b. OTP? c. Referral Guidelines (same as admission to TFC?) Appendix a. Quick Reference Tables b. Forms c. Checklists d. References and Additional Resources

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Abbreviations and Acronyms BMI CMAM CMR CMV CSB MUAC NGF ORS OTP ReSoMal SC SFC TFC W/H W/L

Body Mass Index Community Management of Acute Malnutrition Crude Mortality Rate Complex Minerals and Vitamins Corn Soy Blend Mid-Upper Arm Circumference Naso-Gastric Feeding Oral Rehydration Salts Outpatient Treatment Program Oral Rehydration Solution for severely malnourished patients Stabilization Center Supplementary Feeding Center Therapeutic Feeding Center Weight to Height (%) Weight for Length (%)

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Nutrition Manual

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. _____________________________________________________ 7|P a g e


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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

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OTP CHECKLIST FOR SET UP:  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

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AVERAGE STAFFING REQUIREMENTS: 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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Nutrition Manual 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

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

III.

-

RI Storage and Inventory Protocols (In Appendix?)

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Initial Assessment

General Progression of Patient:

Arrival at Clinic

Fill out Registration Card

Height Weight MUAC (under 10)

Anthropometric Measurements

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.

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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Nutrition Manual Images: Testing for Bilateral Oedema Acute Malnutrition

Severe acute malnutrition with medical complications

Severe acute malnutrition without medical complications

Moderate acute malnutrition without medical complications

Therapeutic Feeding (Part II)

Outpatient Care (OTP?)

Supplementary Feeding (Part III)

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?

[Example of ID Bracelets]

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 TFCâ&#x20AC;&#x2122;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. 17 | P a g e


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Overview of Admission Criteria:

Children from 6 months to 10 years (or from 65 to 130 cm) Adolescents from 10 to 18 years (> 130 cm)

Adults (except pregnant and lactating women)

Pregnant and lactating women

Elderly ( 50-60 years)

Admission In SFC

Admission In TFC

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

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

MUAC : 160 185 mm

MUAC : 170  185 mm Rem/ at risk of malnutrition 185  210 mm

MUAC : 160  175 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.) MUAC < 170 mm and/or Presence of bilateral pitting oedema (Grade 3 and above) 1 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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Nutrition Manual 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

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

NO

NO

NO

NO

NO NO

NO NO

NO NO

NO NO

Pregnant and Lactating Women Adults Elderly

At risk of malnutrition

**See Appendix for detailed Weight-to-Height Charts for Boys and Girls and to determine the percentage of the median.

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Nutrition Manual 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.

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

MUAC Children 6 - 59 months and/or 65 - 130 cm of height Adolescents (up to 18 years) Pregnant and Lactating Women Adults Elderly

Severe malnutrition

Moderate malnutrition

Global malnutrition

At risk of malnutrition

< 110 mm

110 125 mm

< 125 mm

<135 mm

< 110 mm < 170 mm < 160 mm < 160 mm

110 125 mm 170185 mm 160  185 mm 160  175 mm

< 125 mm < 185 mm < 185 mm < 175 mm

<135 mm 185  210 mm

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Nutrition Manual 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 nonreversibleâ&#x20AC;&#x201D;it has already had an impact on the childâ&#x20AC;&#x2122;s height potential. Itâ&#x20AC;&#x2122;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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Nutrition Manual Overview of Methods for Anthropometric Measures

Method

Uses

Advantages

Disadvantages

Common Thresholds <135 mm: at risk

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

3Z to < -2Z or 110 to < 125 mm: moderate malnutrition <-3Z or <110 mm: severe malnutrition high risk of mortality

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

WeightHeight

Detect Wasting and acute 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

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

Height-Age

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

<-3Z or <70%: severe malnutrition -3Z to < -2Z or 60% to < 75%: moderate malnutrition

<-3Z or <60%: severe

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

<-3Z or <80%: severe malnutrition

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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Nutrition Manual 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… 2. If there is no response: - Response to painful stimulation 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 4. Check for signs of hypothermia or hyperpyrexia - Take the body temperature 5. Check for signs of serious dehydration or septic shock

6. Refer to Diagnosis and Treatment of Complications for management of such cases.

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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 â&#x20AC;Ś[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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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:

AGE CATEGORY 6 months to 10 years

10 to 18 years 18 to 75 years > 75 years

F-75 Energy density: 75 kcal / 100 ml Amount Energy (ml / kg of body weight / day) (Kcal / Kg of body weight / day) 130 100 65 50 55 40 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.

1 packet of F-75 premix

Added to

Yields 2 Liters of Water

2.4 Liters of F-75

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Nutrition Manual 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; spoonfeeding 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. Š M.Golden

Weight Category (kg)

Daily amount (ml)

2.0 to 2.1 2.2 to 2.4 2.5 to 2.7 2.8 to 2.9 3.0 to 3.4 3.5 to 3.9 4.0 to 4.4 4.5 to 4.9 5.0 to 5.4 5.5 to 5.9 6.0 to 6.9 7.0 to 7.9 8.0 to 8.9 9.0 to 9.9 10.0 to 10.9 11.0 to 11.9 12.0 to 12.9 13 to 13.9 14.0 to 14.9 15.0 to 19.9 20.0 to 24.9 25 to 29.9 30 to 39.9 40 to 60

320 360 400 440 480 520 560 640 720 800 880 1000 1120 1240 1360 1520 1640 1840 2000 2080 2320 2400 2560 2800

Quantity in ml 8 meals per day 40 45 50 55 60 65 70 80 90 100 110 125 140 155 170 190 205 230 250 260 290 300 320 350

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Nutrition Manual PHASE 1 FEEDINGS TIMETABLE AM 7.00

AM 10.00

PM 01.00

PM 04.00

PM 06.00

PM 08.00

PM 10.00

AM 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

Vitamin A

Age or weight category VITAMINS 6 months to 1 year > 1 year Pregnant and bearing age women

Dose 100 000 IU 200 000 IU None

At the admission and the following day Folic acid

Amoxicillin

Chloroquine

Measles

Every category 5 mg Single dose at the admission ANTIBIOTICS Every category 60 mg / kg / day 3 times a day throughout the entire phase ANTIMALARIALS Day 1 10 mg/ Kg Day 2 10 mg / Kg Day 3 5 mg / Kg VACCINATIONS < 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 Prevention 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.

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

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 hypoglycaemia.

minimize

the

risk

of

Preparation of the CMV mother solution  20 ml of clean and safe water  6.5 g (1 red scoop) of CMV

Sugar water has an energy density of 200 kcal / litre.

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).

_______________________________________________

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B. HYPOTHERMIA Diagnosis Severely malnourished patients are highly susceptible to hypothermia. This is defined as a rectal temperature below C or under arm temperature below 35 C.

-

Monitor body warming

temperature

during

re-

-

The room should be kept warm, especially at night (28 C-32 C): a minimum-maximum thermometer should be on the wall during Phase 1 to monitor the temperature.

-

Treat for hypoglycaemia and give secondline antibiotics.

Treatment -

For children with a caretaker, use the â&#x20AC;&#x153;kangaroo techniqueâ&#x20AC;?

-

Put a hat on the child and wrap caretaker and child together.

-

Note: the thermo-neutral temperature range 28 C-32 C. Children should always sleep with their mothers/caretakers and not in traditional hospital child-cots. There should be adequate Give hot drinks to the mother so her skin blankets and a thick sleeping mat or adult bed. gets warmer (plain water, tea, or other hot Most heat is lost through the head; hats should drink). 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, refeeding 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 rehydrated 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. 1|P a g e


Nutrition Manual Important Notes: 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 “rehydrated” 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 -

-

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 rehydration.

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). 32 | P a g e


Nutrition Manual -

ReSoMal should no longer be given systematically at admission. 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

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Nutrition Manual Treatment

-

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 nasogastric 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

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Nutrition Manual these first 48 hours will not be valid to diagnose anaemia. 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. 35 | P a g e


Nutrition Manual

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 Palpation of oedema Weight measurement Height measurement Temperature Clinical examination

FREQUENCY Every day Every day The day following the admission Twice a day 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.

AGE CATEGORY 6 months to 10 years

10 to 18 years 18 to 75 years > 75 years

F â&#x20AC;&#x201C; 100 Energy density : 100 kcal / 100 ml Amount Energy (ml / kg of body weight / day) (Kcal / Kg of body weight per day) 130 135 65 65 55 55 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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Nutrition Manual Source: Quantity of milk to be given per feed per 24h per Class of Weight. © M.Golden Weight Category (kg) 2.0 to 2.1 2.2 to 2.4 2.5 to 2.7 2.8 to 2.9 3.0 to 3.4 3.5 to 3.9 4.0 to 4.4 4.5 to 4.9 5.0 to 5.4 5.5 to 5.9 6.0 to 6.9 7.0 to 7.9 8.0 to 8.9 9.0 to 9.9 10.0 to 10.9 11.0 to 11.9 12.0 to 12.9 13 to 13.9 14.0 to 14.9 15.0 to 19.9 20.0 to 24.9 25 to 29.9 30 to 39.9 40 to 60

AM 7.00

Daily amount (ml) 320 360 400 440 480 520 560 640 720 800 880 1000 1120 1240 1360 1520 1640 1840 2000 2080 2320 2400 2560 2800

Quantity in ml 8 meals per day 40 45 50 55 60 65 70 80 90 100 110 125 140 155 170 190 205 230 250 260 290 300 320 350

TRANSITION PHASE – F100 – MEALS TIME TABLE AM PM PM PM PM AM 10.00 01.00 04.00 06.00 08.00 10.00

AM 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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Nutrition Manual B. MEDICAL TREATMENT 1. Systematic treatment

ANTIBIOTIC Amoxicillin

Age category Dose 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 BENEFICIARYâ&#x20AC;&#x2122;S CONDITION

ACTION Palpation of oedema

FREQUENCY 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.

AGE CATEGORY 6 months to 10 years

F – 100 Energy density : 100 kcal / 100 ml Amount Energy (ml / kg of body weight / day) (Kcal / Kg of body weight per day) 200 200

10 to 18 years

100

18 to 75 years > 75 years

80 70

100 80 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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Nutrition Manual

Feeding Guidelines Phase 2 More than 8 Kg Weight Category

3 to 3.4 kg 3.5 to 3.9 kg 4 to 4.4 kg 4.5 to 4.9 kg 5 to 5.4 kg 5.5 to 5.9 kg 6 to 6.9 kg 7 to 7.9 kg 8 to 8.9 kg 9 to 9.9 kg 10 to 10.9 kg 11 to 11.9 kg 12 to 12.9 kg 13 to 13.9 kg 14 to 14.9 kg 15 to 19.9 kg 20 to 24.9 kg 25 to 29.9 kg 30.0 to 30.9 kg 40 to 60 kg

Daily Amount (ml)

Porridge

Plumpy nut

Phase 2 > = 3 kg to < 8 kg Milk (5 meals)

660

720 900 900 1080

Patients of this weight should only be given Milk.

1080

1260 1440 1620 kcal/ 1120 ml of milk 1800 / 1500 ml 1800 / 1500 2100 / 1600 2700 / 2200 2700 / 2200 2700 / 2200 3300 /2800 3900 / 3400 4500 / 3500 5100 / 3600 6000 / 4500

1 1 1 1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1 2 3 3

Milk (7 meals) 95 105 130 130 155 155 180 205

225 300 300 320 440 440 440 560 680 700 720 900

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. 41 | P a g e


Nutrition Manual One sachet provides 500 kcal.

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 CSB OIL SUGAR CMV3

QUANTITY 60 g 10 g 5g 3.4 ml

Kcal Proteins Lipids

338 Kcal 12.8 % 36.2 %

4. Feeding time table AM 07.00

AM 10.00

Milk

Milk

PM 01.00 Porridge or milk

PM 04.00 Milk

PM 07.00 Plumpy nut or milk

PM 10.00

AM 01.00

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. 2|P a g e


Nutrition Manual

B. MEDICAL TREATMENT

1. Systematic treatment

Age Category > 6 months

Iron

Dose 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 < 1 year None 1 to 2 years 250 mg Mebendazole 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

1 2 3 4 5 6 7 8 9 10

2 4 6 8 10 12 14 16 18 20

2.4 4.8 7.2 9.6 12 14.4 16.8 19.2 21.6 24.0

Amount of elemental iron to be added (mg) 36 72 108 144 180 216 252 288 324 360

Amount of iron sulphate tablets to be added (tab) ½ 1 2 2½ 3 3½ 4 5 5½ 6

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Nutrition Manual [Picture] Procedure for Dilution: (Put Procedures and tables at the end of each chapter?) 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 Palpation of oedema

FREQUENCY 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 44 | P a g e


Nutrition Manual ď&#x192;&#x2DC; Ascending weight curve.

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Nutrition Manual

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:

AGE CATEGORY 6 months to 10 years

10 to 18 years 18 to 75 years > 75 years

F â&#x20AC;&#x201C; 100 Energy density : 100 kcal / 100 ml Amount Energy (ml / kg of body weight / day) (Kcal / Kg of body weight per day) 200 200 100 100 80 80 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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Nutrition Manual ITEM CSB OIL SUGAR CMV4

QUANTITY 60 g 10 g 5g 3.4 ml

Kcal Proteins Lipids

338 Kcal 12.8 % 36.2 %

4. Feeding time table AM 07.00

AM 10.00

Milk

Milk

PHASE III FEEDING TIME TABLE PM PM PM PM 01.00 04.00 06.00 08.00 Family meal Plumpy Porridge Milk or milk Nut or milk

AM 10.00 Milk

Feeding Guidelines for Phase III Phase 3 More than 8 Kg Weight Category

3 to 3.4 kg 3.5 to 3.9 kg 4 to 4.4 kg 4.5 to 4.9 kg 5 to 5.4 kg 5.5 to 5.9 kg 6 to 6.9 kg 7 to 7.9 kg 8 to 8.9 kg 9 to 9.9 kg 10 to 10.9 kg 11 to 11.9 kg 12 to 12.9 kg 13 to 13.9 kg 14 to 14.9 kg 15 to 19.9 kg 20 to 24.9 kg 25 to 29.9 kg 30.0 to 30.9 kg 40 to 60 kg

4

Daily Amount (ml) 660 720 900 900 1080

Porridge

Family meal

Plumpy nut

Phase 3 > = 3 kg to < 8 kg Milk (4 meals)

Patients of this weight should only be given milk.

1080

1260 1440 1620 kcal/ 1120 ml of milk 1800 / 1500 ml 1800 / 1500 2100 / 1600 2700 / 2200 2700 / 2200 2700 / 2200 3300 /2800 3900 / 3400 4500 / 3500 5100 / 3600 6000 / 4500

Milk (6 meals) 110 120 150 150 180 180 210 240

Porridge If > 6 months If > 6 months If > 6 months If > 6 months If > 6 months If > 6 months If > 6 months If > 6 months

1

1

1

280

1

1 1 1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 2 3 3

375 375 400 550 550 550 700 850 875 900 1125

1 1 1 1 1 1 1 1 1 1 1

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. 47 | P a g e


Nutrition Manual B. MEDICAL TREATMENT 1. Systematic treatment during Phase III: Age Category > 6 months

Iron

Dose 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 1 2 3 4 5 6 7 8 9 10

Amount of water to be added 2 4 6 8 10 12 14 16 18 20

Amount of F-100 milk obtained 2.4 4.8 7.2 9.6 12 14.4 16.8 19.2 21.6 24.0

Amount of iron sulphate tablets to be added ½ 1 2 2½ 3 3½ 4 5 5½ 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 Weight measurement MUAC Measurement W/H and BMI Temperature Clinical examination

FREQUENCY Twice Weekly Once weekly Twice weekly At least once a day 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

Vitamin A

Age or weight category VITAMINS 6 months to 1 year > 1 year Pregnant and bearing age women

Dose 100 000 IU 200 000 IU None

The day of discharge VACCINATION Measles

9 months to 5 years

One vaccination at the discharge

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Nutrition Manual C. MEDICAL AND NUTRITIONAL FOLLOW UP ACTION Weight measurement Height measurement W/H % MUAC

DAY OF DISCHARGE

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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Nutrition Manual

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:

infection. Hence it is advisable to isolate them and to insure a close and regular monitoring.

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.

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.

These beneficiaries are very fragile and must as far as possible, be protected from risk of

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

Vitamin A Folic acid Amoxicillin

Dose 50 000 IU 5 mg 60 mg / kg / day divided in 3 doses

Days of administration D1, D2 and at discharge D1 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 51 | P a g e


Nutrition Manual D. NUTRITIONAL CARE FOR INFANTS UNDER 6 MONTHS The nutritional protocol has to be adjusted to The milk to be used is diluted F100 as it the physiological needs of these children. The corresponds better to the nutritional needs of objective of the treatment is to increase the this age. 8 meals are given per day following mother’s milk supply whilst giving a supplement the Phase I time table consisting of 130 ml / kg / to the infant until it reaches the stage where the day. mother’s milk alone is sufficient to ensure the child’s growth. 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 Water to add F-100 needed (2/3) (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 52 | P a g e


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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

2 to 2.1 kg 2.2 to 2.4 kg 2.5 to 2.7 kg 2.8 to 2.9 kg

Daily Amount (ml) 320

360 400 440

Diluted F-100 + iron (8 meals a day) 40 45 50 55

[Picture]

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Nutrition Manual Preparation of the Diluted F100 Quantity of diluted F-100 needed 50 100 150 200 250 300 350 400 450 500

F-100 needed (2/3) 33 67 100 133 167 200 233 266 300 334

Water to add (1/3) 17 33 50 67 83 100 117 134 150 166

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 motherâ&#x20AC;&#x2122;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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Nutrition Manual 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 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.

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. 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

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

CSB OIL SUGAR

Quantity (g) 125 20 10

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

CEREAL OIL PULSES SALT

Quantity (g) 300 35 80 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.

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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:

1st month

Weekly visit

2nd month

Fortnightly visit

3rd month

Single visit

1st visit 2nd visit 3rd visit 4th visit 5th visit 6th visit 7th visit

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 ITEM CSB OIL SUGAR

QUANTITY Daily (g) Weekly (kg) 214 g 1.5 kg 30 g 0.210 Kg 14.2g 0.100 kg

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

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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

Quantity for 2 weeks (kg)

3.5 kg

0.5 kg

Quantity per day (g)

250.0

35.7

Kcal per day Protein per day (g) Fat per day (g)

960.0 35.0 17.3

321.3

CSB

WSB

Oil**

Sugar

Total from blended ration per day

1281.3 35.0 53.0

35.7

% energy from protein

10.9

% energy from fat

37.2

Ration 3:

Total from blended ration per day

Famix

CSB

WSB

Oil**

Quantity for 2 weeks

4.0 kg

0.5 kg

Quantity per day (g)

286.0

29.4

Kcal per day Protein per day (g) Fat per day (g)

1087.0 51.5 17.1

264.6 29.4

Sugar

1351.6 51.5 46.5

% energy from protein

15.2

% energy from fat

31.0

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Ration 5:

Famix

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

Protein per day (g)

40.0

Fat per day (g)

19.7

CSB

WSB

Oil**

Sugar

Total from blended ration per day

1362.6 40.0 49.1

29.4

% energy from protein

11.7

% energy from fat

32.4

Ration 7:

Famix

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

Protein per day (g)

44.9

Fat per day (g)

22.1

CSB

WSB

Oil**

Sugar

1497.6 44.9

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) 3.5 - 3.9 4.0 - 5.4 5.5 - 6.9 7.0 - 8.4 8.5 - 9.4 9.5 - 10.4 10.5 - 11.9 >12

Ration per weekly distribution 11 14 18 21 25 28 32 35

Ration per day

Ration per meal

1.5 2 2.5 3 3.5 4 4.5 5

¼ sachet ¼ sachet ½ sachet ½ sachet ½ sachet ½ sachet ½ sachet 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

Adults (except pregnant and lactating women)

Pregnant and lactating women

Elderly ( 50-60 years)

MUAC : 160 185 mm

MUAC : 170  185 mm Rem/ at risk of malnutrition 185  210 mm

MUAC : 160  175 mm

W/H < 70% of the median and/or Presence of bilateral pitting oedema 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.) MUAC < 170 mm and/or Presence of bilateral pitting oedema (Grade 3 and above) 1 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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Nutrition Manual 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 Malnutrition Moderate Severe Height 100% 85% 80% 75% 70% 60% (cm) In Kg in Kg in Kg in Kg in Kg in Kg 49.0 49.5 50.0 50.5 51.0 51.5 52.0 52.5 53.0 53.5 54.0 54.5 55.0 55.5 56.0 56.5 57.0 57.5 58.0 58.5 59.0 59.5 60.0 60.5 61.0 61.5 62.0 62.5 63.0 63.5 64.0 64.5 65.0 65.5 66.0 66.5

3.2 3.3 3.4 3.4 3.5 3.6 3.7 3.8 3.9 4.0 4.1 4.2 4.3 4.4 4.6 4.7 4.8 4.9 5.1 5.2 5.3 5.5 5.6 5.7 5.9 6.0 6.2 6.3 6.5 6.6 6.7 6.9 7.0 7.2 7.3 7.5

2.7 2.8 2.9 2.9 3.0 3.1 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.8 4.9 5.0 5.1 5.2 5.4 5.5 5.6 5.7 5.9 6.0 6.1 6.2 6.4

2.6 2.6 2.7 2.7 2.8 2.9 3.0 3.0 3.1 3.2 3.3 3.4 3.5 3.5 3.6 3.7 3.8 3.9 4.0 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 5.0 5.2 5.3 5.4 5.5 5.6 5.7 5.9 6.0

2.4 2.5 2.5 2.6 2.6 2.7 2.8 2.8 2.9 3.0 3.1 3.2 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 5.0 5.1 5.2 5.3 5.4 5.5 5.6

2.3 2.3 2.4 2.4 2.5 2.5 2.6 2.6 2.7 2.8 2.9 2.9 3.0 3.1 3.2 3.3 3.4 3.4 3.5 3.6 3.7 3.8 3.9 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 5.0 5.1 5.2

1.9 2.0 2.1 2.2 2.3 2.5 2.6 2.8 2.9 3.1 3.2 3.4 3.5 3.7 3.9 4.0 4.2 4.4

Height (cm) 67.0 67.5 68.0 68.5 69.0 69.5 70.0 70.5 71.0 71.5 72.0 72.5 73.0 73.5 74.0 74.5 75.0 75.5 76.0 76.5 77.0 77.5 78.0 78.5 79.0 79.5 80.0 80.5 81.0 81.5 82.0 82.5 83.0 83.5 84.0 84.5

WEIGHT-FOR-LENGTH Malnutrition Moderate Severe 100% 85% 80% 75% 70% 60% in Kg in Kg in Kg in Kg in Kg in Kg 7.6 7.8 7.9 8.0 8.2 8.3 8.5 8.6 8.7 8.9 9.0 9.1 9.2 9.4 9.5 9.6 9.7 9.8 9.9 10.0 10.1 10.2 10.4 10.5 10.6 10.7 10.8 10.9 11.0 11.1 11.2 11.3 11.4 11.5 11.5 11.6

6.5 6.6 6.7 6.8 7.0 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.9 8.0 8.1 8.2 8.2 8.3 8.4 8.5 8.6 8.7 8.8 8.9 9.0 9.1 9.1 9.2 9.3 9.4 9.5 9.6 9.6 9.7 9.8 9.9

6.1 6.2 6.3 6.4 6.6 6.7 6.8 6.9 7.0 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8 7.9 7.9 8.0 8.1 8.2 8.3 8.4 8.4 8.5 8.6 8.7 8.8 8.8 8.9 9.0 9.1 9.2 9.2 9.3

5.7 5.8 5.9 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 6.9 7.0 7.1 7.2 7.3 7.4 7.4 7.5 7.6 7.7 7.8 7.8 7.9 8.0 8.1 8.1 8.2 8.3 8.4 8.4 8.5 8.6 8.7 8.7

5.3 5.4 5.5 5.6 5.7 5.8 5.9 6.0 6.1 6.2 6.3 6.4 6.5 6.5 6.6 6.7 6.8 6.9 6.9 7.0 7.1 7.2 7.2 7.3 7.4 7.5 7.5 7.6 7.7 7.7 7.8 7.9 7.9 8.0 8.1 8.2

4.6 4.7 4.9 5.1 5.2 5.4 5.5 5.7 5.8 5.9 6.1 6.2 6.4 6.5 6.6 6.7 6.8 6.9

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

Height (cm) 85.0 85.5 86.0 86.5 87.0 87.5 88.0 88.5 89.0 89.5 90.0 90.5 91.0 91.5 92.0 92.5 93.0 93.5 94.0 94.5 95.0 95.5 96.0 96.5 97.0 97.5 98.0 98.5 99.0 99.5 100.0 100.5 101.0 101.5 102.0 102.5 103.0 103.5 104.0 104.5 105.0 105.5 106.0 106.5 107.0

100% in Kg 12.0 12.1 12.2 12.3 12.4 12.5 12.6 12.8 12.9 13.0 13.1 13.2 13.3 13.4 13.6 13.7 13.8 13.9 14.0 14.2 14.3 14.4 14.5 14.7 14.8 14.9 15.0 15.2 15.3 15.4 15.6 15.7 15.8 16.0 16.1 16.2 16.4 16.5 16.7 16.8 16.9 17.1 17.2 17.4 17.5

WEIGHT-FOR-HEIGHT Malnutrition Moderate Severe 85% 80% 75% 70% 60% in Kg in Kg in Kg in Kg in Kg 10.2 9.6 9.0 8.4 7.2 10.3 9.7 9.1 8.5 10.4 9.8 9.1 8.5 7.3 10.5 9.8 9.2 8.6 10.6 9.9 9.3 8.7 7.4 10.6 10.0 9.4 8.8 10.7 10.1 9.5 8.8 7.6 10.8 10.2 9.6 8.9 10.9 10.3 9.7 9.0 7.7 11.1 10.4 9.7 9.1 11.1 10.5 9.8 9.2 7.9 11.2 10.6 9.9 9.2 11.3 10.7 10.0 9.3 8.0 11.4 10.8 10.1 9.4 11.6 10.8 10.2 9.5 8.2 11.6 10.9 10.3 9.6 11.7 11.0 10.3 9.7 8.3 11.8 11.1 10.4 9.7 11.9 11.2 10.5 9.8 8.4 12.0 11.3 10.6 9.9 12.1 11.4 10.7 10.0 8.6 12.2 11.5 10.8 10.1 12.4 11.6 10.9 10.2 8.7 12.5 11.7 11.0 10.3 12.6 11.8 11.1 10.3 8.9 12.7 11.9 11.2 10.4 12.8 12.0 11.3 10.5 9.0 12.9 12.1 11.4 10.6 13.0 12.2 11.5 10.7 9.2 13.1 12.3 11.6 10.8 13.2 12.4 11.7 10.9 9.4 13.3 12.6 11.8 11.0 13.5 12.7 11.9 11.1 9.5 13.6 12.8 12.0 11.2 13.7 12.9 12.1 11.3 9.7 13.8 13.0 12.2 11.4 13.9 13.1 12.3 11.5 9.8 14.0 13.2 12.4 11.6 14.2 13.3 12.5 11.7 10.0 14.3 13.4 12.6 11.8 14.4 13.6 12.7 11.9 10.1 14.5 13.7 12.8 12.0 14.6 13.8 12.9 12.1 10.3 14.8 13.9 13.1 12.2 14.9 14.0 13.1 12.3 10.5

Height (cm) 107.5 108.0 108.5 109.0 109.5 110.0 110.5 111.0 111.5 112.0 112.5 113.0 113.5 114.0 114.5 115.0 115.5 116.0 116.5 117.0 117.5 118.0 118.5 119.0 119.5 120.0 120.5 121.0 121.5 122.0 122.5 123.0 123.5 124.0 124.5 125.0 125.5 126.0 126.5 127.0 127.5 128.0 128.5 129.0 129.5 130.0

WEIGHT-FOR-HEIGHT Malnutrition Moderate Severe 100% 85% 80% 75% 70% 60% in Kg in Kg in Kg in Kg in Kg in Kg 17.7 15.0 14.1 13.3 12.4 17.8 15.2 14.3 13.4 12.5 10.7 18.0 15.3 14.4 13.6 12.7 18.1 15.4 14.5 13.6 12.7 10.9 18.3 15.6 14.6 13.7 12.8 18.4 15.7 14.8 13.8 12.9 11.0 18.6 15.8 14.9 14.0 13.0 18.8 16.0 15.0 14.1 13.1 11.3 18.9 16.1 15.1 14.2 13.3 19.1 16.2 15.3 14.3 13.4 11.5 19.3 16.4 15.4 14.4 13.5 19.4 16.5 15.5 14.6 13.6 11.6 19.6 16.7 15.7 14.7 13.7 19.8 16.8 15.8 14.8 13.8 11.9 19.9 16.9 16.0 15.0 14.0 20.1 17.1 16.1 15.1 14.2 12.1 20.3 17.3 16.2 15.2 14.2 20.5 17.4 16.4 15.4 14.3 12.3 20.7 17.6 16.5 15.5 14.5 20.8 17.7 16.7 15.6 14.6 12.5 21.0 17.9 16.8 15.8 14.7 21.2 18.0 17.0 15.9 14.9 12.7 21.4 18.2 17.1 16.1 15.0 21.6 18.4 17.3 16.2 15.1 13.0 21.8 18.5 17.4 16.4 15.3 22.0 18.7 17.6 16.5 15.4 13.2 22.2 18.9 17.8 16.7 15.5 22.4 19.1 17.9 16.8 15.7 13.4 22.6 19.2 18.1 17.0 15.8 22.8 19.4 18.3 17.1 16.0 13.7 23.1 19.6 18.4 17.3 16.1 23.3 19.8 18.6 17.5 16.3 14.0 23.5 20.0 18.8 17.6 16.5 23.7 20.2 19.0 17.8 16.6 14.2 24.0 20.4 19.2 18.0 16.8 24.2 20.6 19.4 18.2 16.9 14.5 24.4 20.8 19.6 18.3 17.1 24.7 21.0 19.7 18.5 17.3 14.8 24.9 21.2 19.9 18.7 17.5 25.2 21.4 20.1 18.9 17.6 15.1 25.4 21.6 20.4 19.1 17.8 25.7 21.8 20.6 19.3 18.0 15.4 26.0 22.1 20.8 19.5 18.2 26.2 22.3 21.0 19.7 18.4 15.7 26.5 22.5 21.2 19.9 18.6 26.8 22.8 21.4 20.1 18.7 16.1

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Nutrition Manual Overview of Methods for Anthropometric Measures

Method

Uses

Advantages

Disadvantages

Common Thresholds <135 mm: at risk

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

3Z to < -2Z or 110 to < 125 mm: moderate malnutrition <-3Z or <110 mm: severe malnutrition high risk of mortality

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

WeightHeight

Detect Wasting and acute 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

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

Height-Age

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

<-3Z or <70%: severe malnutrition -3Z to < -2Z or 60% to < 75%: moderate malnutrition

<-3Z or <60%: severe

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

<-3Z or <80%: severe malnutrition

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 ď&#x192; 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-NutritionGuide.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_e ng.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

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RI Nutrition Manual (9/2/2011)  

Updated 9/2/2011