Protocol for the Management of Severe Acute Malnutrition

1 PPRROOTTOOCCOOLL FFOORR TTHHEE MMAANNAAGGEEMMEENNTT OOFF SSEEVVEERREE AACCUUTTEE MMAALLNNUUTTRRIITTIIOONN EETTHHIIOOPPIIAA FFEEDDEERRAALL MMIINNIISSTTRRYY OOFF HHEEAALLTTHH MMAARRCCHH 22000077 AAACCCKKKOOOWWWLLLEEEDDDGGGEEEMMMEEENNNT TTSSS 1 This document is an update of existing guideline for the Management of Severe Malnutrition written by Professor Michael Golden and Dr Yvonne Grellety (Endorsed by the Ministry of Health in May 2004). The present Protocol was edited and compiled by Sylvie Chamois, Michael Golden and Yvonne Grellety. The following persons reviewed these guidelines and contributed significantly during a workshop held on the 12th of April 2006 in Addis Ababa: Anwar Ali (Unicef); Erin Boyd (Goal); Dr Steve Collins (Valid International); Dr Tewoldeberhan Daniel (Unicef); Rebekah Demelash (Unicef); Samson Dessie (Unicef); Teshome Desta (Unicef); Dr Wondwossen Desta (Ethiopian Paediatric Society); Alem Hadera Abay (Goal); Dawit Hagos (Goal); Mulugeta Hailegabriel (Concern); Dr Abel Hailu (Valid International); Jane Keylock (Valid International); Nicola Leadbetter Meades (Goal); Jean Luboya (Unicef); Juan Carlos Martinez Bandera (Unicef).

2 Emily Mates (Concern); Dr Hana Nekatibeb (Linkages); Yohannes Shimeli (Care); Dr Tedbabe Degefie (SC-US); Mekonnen Tesfamariam (Care); Geremew Tesfaye (Unicef) and Dr Belaynesh Yifru (FMoH). The Federal Ministry of Health called a team of national experts on the 29th and 30th of January 2007 in Adama to endorse the final version of the document. This team was composed of: Ato Abdi Ahmed (FMoH); Dr Solomon Amsalu (Gondar University); Dr Tedbabe Degefie (SC-US); Dr Tsinuel Girma (Jimma University); Dr Mesfin Hailemariam (ADRA); Dr Sirak Hailu (WHO) and Dr Hailu Tesfaye (SC-US). UNICEF contributed to the review of this document with technical and financial support.

3 TTTAAABBBLLLEEE OOOFFF CCCOOONNNTTTEEENNNTTT 2 AAACCCRRROOONNNYYYMMMSSS 5 IIINNNTTTRRROOODDDUUUCCCTTTIIIOOONNN 6 FFFRRROOOMMM 666 MMMOOONNNTTTHHHSSS OOOLLLDDD TTTOOO AAADDDUUULLLTTTHHHOOOOOODDD 8 1. IMPLEMENTATION MODALITIES 8 2. ADMISSION CRITERIA 10 3. ADMISSION PROCEDURES 11 4. ROUTINE MEDICINES 17 VITAMIN A 17 FOLIC ACID 17 OTHER NUTRIENTS 17 ANTIBIOTICS 18 MALARIA 20 MEASLES 20 DEWORMING 20 5. PHASE 1 (In-patients only) 22 DIET (F75) 22 SURVEILLANCE 26 CRITERIA TO PROGRESS FROM PHASE 1 TO TRANSITION PHASE 26 6. TREATMENT OF COMPLICATIONS 27 DEHYDRATION 27 SEPTIC (OR TOXIC) SHOCK 33 ABSENT BOWEL SOUNDS, GASTRIC DILATATION AND INTESTINAL SPLASH WITH ABDOMINAL DISTENSION 34 HEART FAILURE 35 HYPOTHERMIA 37 Severe ANAEMIA 37 HYPOGLYCAEMIA 38 HIV 39 OTHER CONDITIONS 39 7.

4 TRANSITION PHASE 41 DIET 41 ROUTINE MEDICINE 44 SURVEILLANCE 45 CRITERIA TO MOVE BACK FROM TRANSITION PHASE TO PHASE 1 45 CRITERIA TO PROGRESS FROM TRANSITION PHASE TO PHASE 2 45 TTTAAABBBLLLEEE OOOFFF CCCOOONNNTTTEEENNNTTT 3 8. PHASE 2 (In- and out-patients) 46 DIET (F100 OR RUTF) 46 ROUTINE MEDICINE 49 SURVEILLANCE 50 CRITERIA TO MOVE BACK FROM PHASE 2 TO PHASE 1 50 9. FAILURE TO RESPOND 52 10. DISCHARGE CRITERIA 56 IIINNNFFFAAANNNTTTSSS LLLEEESSSSSS TTTHHHAAANNN 666 MMMOOONNNTTTHHHSSS 57 1. INFANT WITH A FEMALE CARETAKER 57 ADMISSION CRITERIA 57 PHASE 1 TRANSITION PHASE 2 57 DISCHARGE CRITERIA 62 2.

5 INFANT WITHOUT ANY PROSPECT OF BEING BREAST-FED 63 ADMISSION CRITERIA 63 PHASE 1 TRANSITION PHASE 2 63 DISCHARGE CRITERIA 64 PPPLLLAAAYYY,,, EEEMMMOOOTTTIIIOOONNNAAALLL WWWEEELLLLLLBBBEEEIIINNNGGG AAANNNDDD SSSTTTIIIMMMUUULLLAAATTTIIIOOONNN 65 CCCOOOMMMMMMUUUNNNIIITTTYYY MMMOOOBBBIIILLLIIISSSAAATTTIIIOOONNN 67 INTRODUCTION 67 ASSESSING COMMUNITY CAPACITY 67 COMMUNITY SENSITISATION 67 CASE FINDING THE IDENTIFICATION OF SEVERELY MALNOURISHED CHILDREN IN THE COMMUNITY 68 FOLLOW-UP 70 HHHIIIVVV///AAAIIIDDDSSS AAANNNDDD MMMAAALLLNNNUUUTTTRRRIIITTTIIIOOONNN 71 HHHEEEAAALLLTTTHHH AAANNNDDD NNNUUUTTTRRRIIITTTIIIOOONNN IIINNNFFFOOORRRMMMAAATTTIIIOOONNN 73 RRREEECCCOOORRRDDDIIINNNGGG AAANNNDDD RRREEEPPPOOORRRTTTIIINNNGGG 74 1.

6 ATTRIBUTING THE UNIQUE SAM NUMBER 74 2. FILLING THE REGISTRATION BOOK 75 3. RECORDING IN THE INDIVIDUAL FOLLOW-UP CHART 77 4. PREPARING THE MONTHLY STATISTIC REPORT 77 TTTAAABBBLLLEEE OOOFFF CCCOOONNNTTTEEENNNTTT 4 AAANNNNNNEEEXXXEEESSS 82 1. ANTHROPOMETRIC MEASUREMENT TECHNIQUES 82 2. WEIGHT-FOR-LENGTH AND WEIGHT-FOR-HEIGHT TABLES 88 3. WEIGHT-FOR-HEIGHT CHARTS FOR ADOLESCENTS 91 4. IN-PATIENT MULTI-CHART 93 5. OUT-PATIENT RECORD CARD 94 6. TARGET WEIGHT FOR DISCHARGE 96 7. TRANSFER FORM FROM TFU TO OTP AND OTP TO TFU 98 8. HOME VISIT RECORD FORM 99 9. COMMUNITY WORKERS REFERRAL SLIP 99 10. RECIPES OF F75, F100 AND RESOMAL USING CMV 100 11.

7 HISTORY AND EXAMINATION 101 12. INFORMATION ON BREASTFEEDING 103 13. INFORMATION ON NUTRITION AND GROWTH 107 14. FLOW CHART FOR MALARIA DIAGNOSIS AND TREATMENT 111 AAACCCRRROOONNNYYYMMMSSS 5 ART Anti Retroviral Treatment BMI Body Mass Index (Kg weight per height in metres squared Kg/m2) CBC Community Based Care (OTP plus community mobilisation plus TFU) CMV Combined Vitamins and Minerals (used in preparing therapeutic diets) F75 Therapeutic milk used only in Phase 1 of treatment for SAM F100 Therapeutic milk used in Transition Phase and Phase 2 of treatment of SAM (for in-patients only)

8 HIV Human Immunodeficiency Virus IMCI Integrated Management of Childhood Illness IU International Units MUAC Mid Upper Arm Circumference NCHS National Centre for Health Statistics of USA (anthropometric standards) NGT Naso-Gastric Tube NRU Nutrition Rehabilitation Unit (same as TFU) OPD Out Patient Department (of health facility) ORS Oral Rehydration Salt OTP Out-patient Therapeutic Programme (treatment of SAM at home) RDA Recommended Dietary Allowances ReSoMal Oral REhydration SOlution for severely MALnourished patients RUTF Ready-to-Use Therapeutic Food RWG Rate of Weight Gain SAM Severe Acute Malnutrition (wasting and/or nutritional oedema) SFP Supplementary Feeding Programme TB Tuberculosis TFU Therapeutic Feeding Unit (in hospital, health centre or other facility)

9 TFP Therapeutic Feeding Programme W/H Weight for Height W/L Weight for Length IIINNNTTTRRROOODDDUUUCCCTTTIIIOOONNN 6 Improving nutrition is essential to reduce extreme poverty. Since the famine of the mid-eighties, the images of Severe drought and large scale starvation have become inexorably linked with Ethiopia. Malnutrition can best be described in Ethiopia as a long term year round phenomenon due to chronic inadequacies in food instance combined with high levels of illness.

10 It is not a problem found uniquely during drought years, but a year round chronic problem found in majority of households across all regions of the country. More than half of all deaths in children have stunting and wasting as the underlying cause: that is, they are too thin or too short for their age because they have not had sufficient type II nutrients (the growth nutrients that are required to build new tissue) to grow properly and many have lost weight. These children would have recovered from other illnesses if they had not been malnourished, but because they are malnourished they die.