guidelines for the integrated management of severe acute malnutrition

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ACF-In Guidelines for the integrated management of SAM Triage 34 Table 1: The amount of RUTF that should be taken to assess the appetite of severely malnourished children APPETITE TEST To pass the appetite test, malnourished patients should eat at minimum an amount above “poor”. Body weight Paste in sachets Paste in cups (Proportion of whole sachet 96g) (ml or grams ) poor moderate good poor moderate good Less than 4 kg ¼ 25 4 – 6.9 ⅓ 35 7 – 9.9 ½ 50 10 – 14.9 ¾ 75 15 - 29 1 150 Over 30 kg 1 150 Note: if cups are used then a new table should be constructed, depending on the size of the cup (often 25ml). The table should be in the number of cups the child should take for his category of weight. The majority of children will be from 4 to 6.9kg so the minimum test to differentiate a poor appetite would then be one level cup (of 25ml). � The appetite test should be carried out at each visit for out-patients (particularly those who do not gain weight steadily). � Failure of an appetite test at any time is an indication for full evaluation and probable transfer for in-patient assessment and treatment. � During the second and subsequent visits the intake should be in the “good” range of table if the patient is to recover reasonably quickly. � If the appetite is “good” during the appetite test and the rate of weight gain at home is poor then a home visit should be arranged because this indicates a social problem at household level or extensive sharing of the RUTF. If the home visit is not possible, it may be necessary to bring a child into residential care to do a simple “trial of feeding”, where the intake of the child is directly observed by the staff, to differentiate: • a difficulty with the home environment • a metabolic problem with the patient; Such a trail-of-feeding, in a structured environment (e.g. day-care, IPF), is also used to investigate failure to respond to treatment. 3. Medical complications (IMCI) After anthropometry and conducting the appetite test the patients are seen by the nurse to look for complications that need to have treatment started before transfer to the in-patient facility. If there is a serious medical complication then the patient should be referred for in-patient treatment 34 – these complications include the following 35 : 34 The same criteria are used for transfer of a child from out-patient treatment to in-patient treatment. 35 If the patients have any of these conditions they will almost certainly have failed the appetite test.
ACF-In Guidelines for the integrated management of SAM Triage 35 � Severe vomiting � Hypothermia < 35°C � Pneumonia • >60 breaths/ min for under 2 months • >50 breaths/ minute from 2 to 12 months • >40 breaths/minute from 1 to 5 years 36 • >30 breaths/minute for over 5 year-olds or • Any chest in-drawing � Extensive infection � Weak, apathetic or unconscious � Fitting/convulsions � Severe dehydration based on history & change in appearance (clinical signs are unreliable in the malnourished and should NOT be used to diagnose dehydration) � Any condition that requires an infusion or NG tube feeding. � Fever > 39°C � Very pale (severe anaemia) � Other general signs, the clinician thinks requires transfer to the in-patent facility The first consultation at admission is the best time to investigate the possible underline causes of malnutrition and to have opportunity to discuss history with the caretaker. Decision in type of treatment in or out patient should meet the child’s best interest. Medical consultation is good opportunity for TB 37 and/or HIV suspicious patient to be referred to adequate centre to be diagnosed and to receive adequate treatment. In high HIV prevalence context and where there is an effective Voluntary Testing and Counselling (VCT) programme then VCT should be systematically offered to all newly admitted patients with severe malnutrition and their caretakers. Specificity for HIV/TB patient The treatment of the malnutrition is the same whether the patient is HIV positive or negative 38 . They can be treated in “in” or “out” patient setting, following the same nutrition protocol than other malnourished children in combination with referrals for VCT, ART and any other relevant HIV service to address the child situation. However, we can expect in the programme higher mortality rate and 36 Respiratory rate can be judged with a small home-made pendulum. Such a pendulum can be easily made locally from string and a small weight – it is quicker, easier and much less expensive than a watch. Knots should be tied at 43 and 66 centimetres for 50 and 40 breaths/swings per min respectively. The appropriate knot is held and the pendulum swung in front of the child – if the child is breathing faster than the pendulum then a diagnosis of respiratory distress should be made. 37 “Malnutrition and TB” ACF November 2004, different diagnosis approach of the TB in malnourished children and clinical signs 38 Refer to “ACFIN HIV SAM research summary report” for conclusion and recommendations
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Cover photography: © ACF, Anne-Dom
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