guidelines for the integrated management of severe acute malnutrition

ACF-In Guidelines for the integrated management of SAM In-patient 59
IN-PATIENT CARE
The procedure for implementing an in-patient therapeutic programme is detailed in the ACF manual
(staffing, material, general organisation) 72 . In integrated programme it will be crucial to evaluate the
workload nutrition activities will represent and plan accordingly for added staff.
Patients that require in-patient care have a poor appetite and usually have a complication such as
diarrhoea, dehydration, sepsis, pneumonia, severe anaemia, etc. Thus, the patients will often require
treatment of both the complication and their routine dietary and medicine section. The management of
the complications take precedence over routine care and may change the way in which the routine
care is given; the two sections should be read in conjunction with each other.
The principles of the management of In-Patient care
� Acute-phase. Patients with an inadequate appetite and/or an acute major medical complication
are initially admitted to an in-patient facility for acute-phase treatment. The formula used during
this phase (F75) promotes repair of physiological and metabolic functions and electrolyte balance.
Rapid weight gain at this stage is dangerous, that is why F75 is formulated so that patients do not
gain weight.
� Transition Phase. A transition phase is then introduced because sudden change to large
amounts of diet, before physiological function is fully restored, can be dangerous and lead to
electrolyte disequilibrium and “recovery syndrome”. During this phase the patients start to gain
weight. RUTF (or F100) is introduced. The quantity of RUTF given increases the energy intake
by about 30%. The increase in energy intake should give a weight gain of around 6g/kg/d; this is
less than the quantity given and rate of weight gain expected, in the recovery phase.
� Transfer to OTP or Return to OTP. Whenever patients have a good appetite and no acute
major medical complication, they are given RUTF and transferred to OTP. These formulae are
designed for patients to rapidly gain weight (more than 8 g/ kg/ day). The look-up tables are
scaled so that the same tables can be used to treat patients of all weights and ages.
Structure used for in-patient care:
� In-patient: management of severe malnutrition in hospitals and major health centres.
- Patients that are admitted can be treated on a 24/24 hour basis. Actual treatment at night is
only required for very ill children, those that get re-feeding diarrhoea and those that have not
taken food during the day. These patients receive the diet 8 meals per 24 hours with full
medical surveillance and treatment of complications (there needs to be adequate staff at night).
- Patients are admitted to a 24/24 hour facility, but are only actively treated during the day with
no treatment being offered at night when there is a shortage of trained staff – they are given 6
feeds during the day.
- Patients can equally be treated on a Day Care system (receiving 5 or 6 meals during the day).
• Those from far away sleep in the facility in a separate room or a separate local
structure, on beds or even mattresses on the floor 73 . Such treatment is called
“residential day care”. There is no provision of staff, surveillance or treatment during
72 “TFC Manual 2007” by Michael Golden and Yvonne Greletty; Action Contre la Faim; Version 3.4 page 117, How to
implement the treatment in a Nutrition Rehabilitation Centre
73 It is important to avoid cots (small beds) that prevent mothers sleeping with their children and putting children at risk of
hypothermia, emotional stress and interruption of breast feeding; this applies to all facilities.