guidelines for the integrated management of severe acute malnutrition

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ACF-In Guidelines for the integrated management of SAM Infant less than 6 months old 108 INFANTS LESS THAN 6 MONTHS OLD One day observation may be necessary to determine the treatment according to the evaluation of breast-feeding practices and breast-feeding possibilities with the mother or other caretaker. However, depending mainly of the state of the child, this observation may need to be much quicker. Beast-feeding will always be the preferred option in most contexts. Few reasons can prevent a mother from breast-feeding her child (refer to “Acceptable medical reason of use of breast-milk substitute” WHO, 2009 and “Infant feeding Module 1”, page 28 for HIV and breast-feeding and Module 2 Infant Feeding in Emergencies 166 ). - Based on WHO recommendations of December 2009 167 , any HIV positive woman should either practice exclusive breast-feeding until 6 months of the child and receive ART treatment or when breast-milk substitute is AFASS (accessible, feasible, affordable, sustainable and safe) avoid all breastfeeding and choose another feeding option. - Breast-feeding can be proposed to any female caretaker who is willing to breast-feed and take care of the infant (“wet nursing” for example). ACF IFE position paper gives some guidelines in the management of infant feeding in a therapeutic programme. “ACF teams should be prepared to discuss all of the different options with the infants’ caretakers, including, as a priority, wet nursing and re-lactation.” “However this principle does not exclude the use of BMS – these circumstances call for a pragmatic and responsible view. This may involve the decision to provide an appropriate BMS. Use of BMS may be temporary or for full artificial feeding of an infant for whom there is no access to breast-milk. After assessment and analysis of the situation, ACF will procure appropriate (preferably generic) BMS, labelled in local language when it is necessary and in line with the International Code for Marketing of BMS. Distribution will be done in a responsible manner, treating each case on an individual basis, providing support and follow up to the caretakers and the infants, discussing alternatives on a regular basis and ensuring a continuous unbroken supply of appropriate BMS for those children that need it, until at least the age of 12 months old. ACF will ensure that the families of these infants have access to the necessary resources, such as fuel, clean water and water containers, to be able to artificially feed the infants.” Infant with a Female Caretaker These children should always be treated in an in-patient unit and should not be admitted to out-patient treatment. RUTF is not suitable for infants and milk based feeds should not be given for home treatment. Infants who are malnourished are weak and do not suckle strongly enough to stimulate an adequate production of breast milk. The mother often thinks that she herself has insufficient milk and is apprehensive about her ability to adequately feed her child. The low output of milk is due to 166 http://www.ennonline.net/resources/4 167 “Mothers known to be HIV-infected (and whose infants are HIV uninfected or of unknown HIV status) should exclusively breastfeed their infants for the first 6 months of life, introducing appropriate complementary foods thereafter, and continue breastfeeding for the first 12 months of life. Breastfeeding should then only stop once a nutritionally adequate and safe diet without breast milk can be provided.” HIV and infant feeding – Revised Principles and Recommendations- Rapid Advice – November 2009 – WHO - http://whqlibdoc.who.int/publications/2009/9789241598873_eng.pdf
ACF-In Guidelines for the integrated management of SAM Infant less than 6 months old 109 inadequate stimulation by the feeble infant. The objective of treatment of these patients is to return them to full exclusive breast feeding. Thus, the admission criterion is failure of effective breast feeding and the discharge criterion is gaining weight on breast milk alone (anthropometry is not used as primary admission criterion). 1. Organisation It is inappropriate to admit young infants to most general paediatric or nutrition wards. There should be a completely separate ward/section for these infants. This is best integrated with a special service/programme to assist mothers who have difficulty breast feeding. The aim of such a service would be to re-establish exclusive breast feeding and achieve confidence in their ability to produce sufficient milk for their baby to thrive for any mother. It’s out-patient arm would counsel and provide one-to-one support for mothers who have difficulty with breast-feeding; the in-patient arm would be for mothers whose children are not “thriving” and become malnourished. If such a service does not exist then the programme should be part of the neonatal service. The staff should be female and have professional advanced training in breast-feeding support and counselling as well as skills in care of the neonate. In most cultures, the ward/room where these infants are managed should be adequately screened and private; unannounced arrival of males in the section should be forbidden. The mothers must be confident that they will not be disturbed or surprised by men arriving in the ward. Rounds by male doctors should be announced in advance. There should be a separate visiting room where mothers can meet with their husbands without them being admitted to the service. 2. Admission criteria The only admission criterion is failure of satisfactory breast feeding so that the child is not gaining weight and developing normally. This is normally assessed by longitudinal measures of weight (growth monitoring programmes). A single weight-for-height measurement is not a satisfactory admission criterion. This is particularly difficult to measure in small infants, is unreliable at this age without accurate equipment and skill, and, if normal, is an inappropriate measure of “thriving” in the less than 6 months old child. MUAC is not used in the small infant as it changes rapidly in the first 6 months of life (children under 65 cm of length). From birth to 6 months of age weight-for-age is the most appropriate measure to assess nutritional status. At this age, failure to gain weight can be defined as acute malnutrition. However, there are premature or small-for-gestational-age babies born who are being exclusively breast fed and gain weight at a satisfactory rate 168 ; they follow their “channels” of growth and even catch-up, crossing centile lines despite the fact that their current weight-for-age may still be much below “normal”. Such children are thriving and do not need admission to the programme. The best way to differentiate those infants who are thriving from those that are becoming malnourished is to take repeated weight measures longitudinally; this is the value of the growth-monitoring programme. Where there is a growth-monitoring programme: • all infants who are not following the weight-for-age growth channels should be considered for admission; 168 In the first 6 months of life birth weight is the dominant determinant of current weight. Birth weight is statistically related to current weight up to 18 months of age, but beyond 6 months other factors become statistically more important.
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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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