guidelines for the integrated management of severe acute malnutrition

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ACF-In Guidelines for the integrated management of SAM Triage 32 4. The assistant conducting the test should be cheerful and relaxed. The mother initially allows her child to play with an RUTF packet or pot and become familiar with the environment. This sometimes helps the child become confident. Watching other children take the RUTF also gives confidence. 5. The caretaker should sit comfortably with the child on her lap and offer the RUTF to the child. The RUTF can be given from the packet itself or it can be dispensed into small pots or cups 31 . The mother either gives the RUTF directly or puts a small amount on her finger and gives it to the child. The caretaker must not actually consume any of the RUTF herself, although it usually helps if she pretends to take some as this is the best way to encourage the child. 6. The caretaker should offer the child the RUTF gently, encouraging the child all the time. If the child refuses then she should continue to quietly encourage the child and take time over the test. The test usually takes a short time, about fifteen minutes, but can take up to one hour in a shy or upset child or one with a marginal appetite. The child must not be forced to take the RUTF. 7. The child MUST to be offered plenty of water to drink from a cup during the test. The appetite test needs a particular follow up. It is helpful if the person conducting the appetite test has been trained on care practices component, specifically on mother and child interactions, observation techniques, child development, and communication skills 32 . During the appetite test a deeper observation of mother and child relationship must be done to avoid difficulties at home to follow the treatment. A special support at home by the home visitor team can sometimes be proposed or, when it is available a follow up in the centre. This observation will determine if there is a need for the beneficiary to be referred to in patient. The result of the appetite test • Pass 1. A child that takes at least the amount shown in the moderate/good column of the table below passes the appetite test. 2. The patient is now seen by the nurse to determine if s/he has a complication using IMCI criteria (e.g. pneumonia, acute watery diarrhoea, etc.). If s/he has no medical complication, has not got open skin lesions, oedema +++ or severe wasting and oedema together then s/he should be treated at home. 3. Explain to the caretaker the choices of treatment options and decide with the caretaker whether the child should be treated as an out-patient or in-patient (nearly all caretakers will opt for out-patient treatment). If the mother opts for the in-patient treatment, refer to IPF with request of treatment to start in transition phase. 4. Start the treatment appropriate for outpatients (see below) 31 Graduated 20 or 25ml medicine cups are the most convenient. The packet of RUTF normally holds almost 100g of the paste. If the child has a poor appetite giving a whole packet to each child can lead to waste, and is difficult for the staff to judge the amount taken. With small cups one package can be used for about 4 tests and it is much easier to judge the amount taken from a small cup than from the packet itself. The cups should be pre-prepared before the start of the OTP; this is so that the mothers do not see the food being dispensed from the sachets and think that the RUTF should be emptied from the packet to be given at home. 32 Refer to “Manual for the integration of child care practices and mental health within nutrition programmes” for details on how to do this observation page 120
ACF-In Guidelines for the integrated management of SAM Triage 33 • Fail 1. A child that does not take at least the “moderate” amount of RUTF shown in the table should be referred for in-patient care if there is no danger from transport trauma (see section on transport). 2. Explain to the caretaker the choices of treatment options and the reasons for recommending inpatient care; decide with the caretaker whether the patient will be treated as an in-patient or outpatient. When in-patient care is needed, the nurse has to explain carefully the benefits of inpatient care and risks of out-patient care. The nurse must accept the decision of the caretaker and not “pressure” the mother into a decision one way or the other. 3. Refer the patient to the nearest in-patient facility for acute (acute-phase) management. 4. At the in-patient facility the nurse has to register the child using his/her SAM number given by the OTP (if the SAM child is referred by other health facilities or the ER, the SAM-number is given by the facility); the details are entered into the registration book (see annex 7) and Multi-chart (see annexes 8, 9 and 10). 5. Start treatment of the acute-phase using F75 and treat the complications appropriate for inpatients. � Even if the caretaker/health worker thinks the child is not taking the RUTF because s/he doesn’t like the taste or is frightened, the child still needs to be referred to in-patient care for at least a short time. In that case, while starting the F75, retry the appetite test in better conditions. If it is found that the child actually takes sufficient RUTF to pass the Test then they can be immediately transferred to out-patient treatment (if no complications); the appetite test is the main criterion for an in-patient to continue treatment as an out-patient. � At the in-patient facility, sometimes a child will not eat the RUTF because he is frightened, distressed or fearful of the environment or staff. This is particularly likely if there is a crowd, a lot of noise, other distressed children or intimidating health professionals (white coats, awe-inspiring tone). The appetite test should be conducted in a separate quiet area. If a quiet area is not available then the appetite can be tested outside the in-patient facility. The following table gives the MINIMUM amount that should be taken 33 . 33 Where there is a small scale a more accurate appetite test can be performed. The sachet/cup is weighed before and after the test and the amount taken compared with the weight given in the table in the appendix. This test can be performed in facilities where there are adequate staff and an appropriate scale. It has been noted that the amount taken in the first 20mins is usually at more than 90% of the total amount that will be taken if the test is prolonged. There is a close correlation between the rate at which the child starts to take the RUTF and the total amount taken.
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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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