guidelines for the integrated management of severe acute malnutrition

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ACF-In Guidelines for the integrated management of SAM Out-patient 42 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. During the weekly visits 48 and specifically during the appetite test, it is essential that the staff understand the emotional needs of these children and create a friendly supportive atmosphere. Caretakers must never be chastised and the staff should never shout or become angry. Unsmiling children need to be comforted, spoken to and played with. There must be an educational and play session that shows the mothers how to play with her child and the importance of play and exploration as part of the emotional, physical and mental stimulation that the children need. This is an integral part of treatment. In out-patient settings it is critical that the mothers understand the importance of this aspect of treatment. 49 Weekly visit to the centre of the beneficiaries and caretaker remain opportunity of targeted nutrition and health promotion with topic being adapted according to the prevailing issue. Diet There are various commercial types of RUTF: they are nutritionally the same as F100, except the fact that RUTF has iron and F100 does not. Several countries are producing their own RUTF and product and formula need to be validated by UNICEF and MSF to make sure they fulfil the nutritional requirement (refer to the ‘UN statement on CMAM and product’ 50 and to the ACF general information document on RUTF and F100 in annex 12). But whatever the product used, let’s remember that in out-patients, an important part for the success of the treatment is the quality of the caretaker education. Breast-fed children should always get breast-milk before they are given RUTF and also on demand. Explain to the caretaker how to give the RUTF at home: � For breast-fed children, always give breast milk before the RUTF, for at least 20-30 minutes. Breastfed children must continue to receive breast milk 8 to 10 times per day, decreasing with increasing age � RUTF is a food and a medicine for malnourished children only. It should not be shared with the other family members even if the child does not consume all the diet offered. Opened packets of RUTF can be kept safely and eaten at a later time – the other family members should not eat any that is left over at a particular meal. 51 � Wash the child’s hand and face with soap before feeding. � These children often only have moderate appetites during the first few weeks and eat slowly. They must be fed separately from any other children in the household. The child can keep the RUTF with him/her to eat it steadily throughout the day – it is not necessary to have set meal times if the food is with the child all the time. However, the caretaker should attend to the child 48 Or fortnightly in some circumstances 49 Refer to “Manual for the integration of child care practices and mental health within nutrition programmes” page 50 child development and page 62 Mother and child relationship 50 http://www.unscn.org/files/Statements/Community_Based__Management_of_Severe_Acute_Malnutrition.pdf 51 It’s recommended to ask the carers to bring back empty packets every week.
ACF-In Guidelines for the integrated management of SAM Out-patient 43 every 3-4 hours at least and encourage the child, or give small regular meals of RUTF at these times. Tell the mother how much her child should eat each day (this is given in the look-up table). � Explain that for the first week or two the child will probably not finish all the RUTF given 52 . The mother should not be upset by this as excess has been given, but as the child recovers his/her appetite will improve so that all the diet will be taken later on in recovery. Uneaten RUTF should not be taken by other members of the family – as the child improves s/he will start to consume nearly all the food. � Explain that RUTF is the only food the child needs to recover during his time in the programme. It contains all the ingredients that the child needs to recover and is really like a special medicine. It is not necessary to give other foods. � Explain that the illness has damaged the child’s intestine so that the normal family food is not sufficient for the child and may even cause some diarrhoea. Tell the mother that a lot of other foods will delay the recovery of her child. If the child asks for other foods small amounts can be given but she should always give the RUTF before other foods and at a different time from regular family meals: Never mix the RUTF with other foods. Most cereal or pulse based foods contain anti-nutrients and inhibitors of absorption that make the nutrients in the RUTF unavailable for the child. If other foods are given they should be given at a separate time from the RUTF. � When RUTF is given abundant clean water must be offered during and after the feed (to satisfy the patient’s thirst). For OTP programmes, if there is a problem with food security or in an emergency situation a “protection” ration 53 could be given to the family both to assist this family of a malnourished child and prevent sharing of the RUTF with other family members. The caretaker must be told that this ration is not for the patient but for the rest of the family only. For children who are being transferred to an OTP from an in-patient facility, a transfer form needs to be filled in with the SAM-Number of the child. The child should be transferred with sufficient RUTF to last until the next day of operation of the OTP site closest to the child’s home. The IPF should inform the OTP site and the district focal point by phone when a transfer is being made 54 . For children that are first admitted directly into OTP, the amount of RUTF should be enough for the next visit to the OTP distribution site. • Amounts to give The children must NEVER be force fed. 52 NGOs that counsel the mother thoroughly and give 170kcal/kg/d achieve higher rates of weight gain than those that dispense excess and fail to give adequate advice on its use. There are very good physiological reasons for restricting the amount given during the first 2 weeks to about 130 kcal/kg/d (see section on re-feeding syndrome and reasons for introduction of the transition phase in the in-patient section) although this can complicate the OTP protocol slightly. 53 ACF recommendation: This ration can be given as a family ration, or social safety net projects can be promoted as fresh food voucher... 54 In all transfers the time of leaving should be noted on the form – and the time of arrival at the destination facility. These transfer times should be analysed periodically to determine if this is a major problem within the district. If transfer times are excessive then a meeting should be held to explore ways of resolving the problem.
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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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