guidelines for the integrated management of severe acute malnutrition

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ACF-In Guidelines for the integrated management of SAM In-patient: Transition phase 104 The table gives the amount of F100 (full strength) that should be offered to the patients in transition phase who are not taking RUTF. They should normally be taking 6 feeds during the day and none at night. 2. ROUTINE MEDICINE Routine antibiotic should be continued for 4 more days after acute-phase or until transferred to recovery-phase as an outpatient (patients entering OTP after having been in a facility do not need to be given antibiotics). 3. SURVEILLANCE The surveillance of Acute-phase is maintained in Transition Phase. As the patient is now taking more than maintenance amounts of food, weight gain is expected. Because it takes an average of about 5 kcal to make one gram of new tissue, the expected rate of weight gain, for marasmic patients, during transition phase is about 6g/kg/d, if all the food is taken by the patient and there is not excessive mal-absorption. 4. CRITERIA TO MOVE BACK FROM TRANSITION PHASE TO THE ACUTE PHASE Move the child back to acute-phase: � If there is a rapid increase in the size of the liver � If any other signs of fluid overload develop (increased respiratory rate). � If the patient gains weight more rapidly than 10g/kg/d (this indicated excess fluid retention). � If tense abdominal distension develops (indicates abnormal peristalsis, small bowel overgrowth and perhaps excess carbohydrate intake) � If the patient gets significant re-feeding diarrhoea so that there is weight loss (see separate section). 165 � If a complication arises that necessitates an intravenous infusion (e.g. malaria, dehydration etc.) � If there is any deterioration in the child’s condition (see section on re-feeding syndrome). � If there is increasing oedema (look for unexpected sodium intake, particularly from mother’s diet or drugs – if an extraneous source if sodium is found then it should be eliminated and children with good appetites can remain in transition-phase). � If a child who does not have oedema develops oedema (look for extraneous intake of sodium) 5. CRITERIA TO PROGRESS FROM TRANSITION PHASE TO OTP � A good appetite. This means taking at least 90% of the RUTF (or F100) prescribed for transition phase. � Oedematous patients (kwashiorkor) • should remain in Transition Phase until there is a definite and steady reduction in oedema (now at + level). 165 It is common for the children to get some change is stool frequency when they change diet. This does not need to be treated unless the children lose weight. Several loose stools without weight loss is not a criterion to move back to acutephase.
ACF-In Guidelines for the integrated management of SAM In-patient: Transition phase 105 • Or when their appetite is good (taking all the diet in transition phase - not just in the moderate range) and they have reduced their oedema to ++ � For patients that have been in heart failure, shown signs of fluid overload (and those that have had severe septic shock), or have shown signs of re-feeding-syndrome during the acute phase, treatment should go more slowly and they should remain in transition phase until they are eating well with no signs for fluid overload and all the oedema has subsided. A child that is ready to go to recovery-phase should always be treated at home when there are: 1. a capable caretaker 2. The caretaker agrees to out-patient treatment, 3. There are reasonable home circumstances 4. There is a sustained supply of RUTF. 5. An OTP programme is in operation in the area close to the patient’s home. A child being treated as out-patient that deteriorates or develops a complication should be transferred to in-patient care for a few days before continuing their treatment again as out-patient. The two arms (in-patient and out-patient) of the programme should be integrated so that there is smooth transfer of patients from one to the other mode of treatment. The same registration number is retained throughout the movements (the SAM-Number). A child transferring from one to another mode of treatment is still under the care of the programme for this episode of severe malnutrition; this is not a “discharge” from the in-patient facility but a transfer to another part of the same programme PHASE 2 FOR CHILDREN WHO CAN NOT BE TRANSFERRED TO OTP In some cases (no operational OTP in the area, mother disagrees to go to OTP or not suitable mother, or children refusing RUTF or groundnut intolerance…), the patient will not progress to OTP but will progress to Phase 2 in in-patients care. If the patient cannot go to OTP, he will stay in inpatients but will receive the same treatments than in OTP (cf. section on OTP). If the beneficiary cannot go to OTP because of groundnut intolerance or because he is refusing RUTF, he will be treated with F100. 1. DIET Breastfed children should always get breast-milk before they are given F100 or RUTF and on demand. F100 or RUTF are used in Phase 2. Never give F100 to be used at home, use RUTF. • F100 (100ml = 100 kcal): 200ml/Kg/day of F100 are given. Five feeds par day of F100 should be given. One porridge may be given for patients who are more than 8kg (approximately 24 months of age) but it is not necessary to give it unless the patient asks for it. Alternative recipes of F100 are given in annexe 15. • RUTF: RUTF can be used in both in-patient and out-patient settings. For in-patients, offer the amount of feed given in the table. The children must NEVER be forced fed. After the feed, always propose an additional quantity of F100/RUTF to the patient, until his appetite is satisfied.
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Cover photography: © ACF, Anne-Dom
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guidelines for the integrated management of severe acute malnutrition

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