guidelines for the integrated management of severe acute malnutrition

ACF-In Guidelines for the integrated management of SAM Out-patient 52
Figure 2: Schema to show the steps to be taken for children that fail to respond
to treatment in OTP
Diagnose Failure-to-response to treatment
Check organisation and application of the protocol
Evaluate the appetite test
Do home visit to check for home circumstances
Residential care for up to 3 days for a trial of supervised feeding
Refer to In-patient facility for full clinical assessment to search
for underlying undiagnosed pathology OR:
Refer to centre with diagnostic facilities and senior paediatric
personnel for assessment and further management: they take
over the future management of the child from the
programme.
� After the diagnosis of failure-to-respond to treatment is made, the organisation and the
application of the protocol are reviewed.
� The appetite test is then evaluated. If the child has a good appetite when tested, but is failing to
gain weight at home, then it is likely that this is a social problem. The hungry child is not getting
the RUTF at home that he will eat willingly at the OTP site. The mother often sees this
demonstrated and realises for the first time that there is a problem. A gentle enquiry into the
home circumstances should then be made. It is very important that this be done in private, out of
earshot of other families, and that the mother is not made to feel guilty – she often does not
realise that there is a problem within the household because of her workload or with the other
children taking the RUTF. The instructions need to be repeated carefully and slowly.
� The next step is to arrange a home-visit. There are often problems with intra-family distribution,
plate sharing and sibling rivalry of which the mother may be quite unaware. Occasionally there is
rejection of a child 66 , parental psychopathology or use of the child’s state to access food and
services for the whole family. These problems are usually not determined from either an
interview with the mother at the distribution point or even during a home visit.
� If the problem is still not determined, the child is admitted to residential care (IPF or residential
health centre) for up to 3 days and fed under careful supervision 67 . If the child gains weight well
66 This is often due to suspicions about paternity or the household head discriminating against the mother for other reasons.
67 When tested with the appetite test at the OTP site the child may not take the food eagerly for various reasons (often such
children are overawed, intimidated or frightened). The child can take several days to relax and become sufficiently familiar
with the staff to take the food readily.