IMAM Guideline Kenya June09

MINISTRY OF
PUBLIC HEALTH & SANITATION
National Guideline for

Integrated Management
of Acute Malnutrition
Version 1: June 2009

Foreword
Malnutrition remains an important threat in developing countries. It is estimated that 2.2
million children below five years old die every year of malnutrition. Of importance is the high
infant and under five mortality rates (currently at 77 and 115/1000 live births respectively
in Kenya) of which half has malnutrition as the main underlying cause. Although national
levels of acute malnutrition is at 6% in Kenya, levels of acute malnutrition in Arid and
Semi Arid areas have consistently remained above the emergency threshold of 15%. It is
important to note that HIV and AIDS pose a new and significant challenge in addressing
acute malnutrition as the two are intrinsically related.
Traditionally, the Ministry of Health has rehabilitated severe acute malnourished patients
within inpatient services, mainly through District and Provincial Hospitals. This posed a great
challenge in ensuring successful treatment as malnourished patients were mixed with other
ill patients, increasing the risk of cross infection and as a result of mortality. Experience
from arid districts has shown that this approach also led to low program coverage and high
defaulter rates.
Global emerging evidence has shown that mortality rates could be reduced when patients
presenting with medical complications are admitted as inpatients, while others (with no
complication) are admitted as outpatients and followed-up at community level. This coupled
with active case finding and referral at community level could significantly reduce complicated
cases of acute malnutrition and increase coverage.
The National Guideline for Integrated Management of Acute Malnutrition brings forth a new
approach in the management of severe acute malnutrition for effective care and rehabilitation.
It also addresses management of moderate acute malnutrition and management of acute
malnutrition in the context of HIV and AIDS. The guideline provides an opportunity for all
health care providers to realize the importance of proper management at health facility and
community levels, ensure successful diagnosis and treatment and, consequently address
one of the Millennium Development Goal (MDG) on reducing child mortality.
The Ministries of Medical services and Public Health and Sanitation will provide the necessary
leadership and coordination to all partners in the field of nutrition in addressing the problem
of malnutrition in a holistic manner.
Dr. Francis Kimani Dr. S.K. Sharif OGW, MBChB, M.Med.

Director of Medical Services DLSHTM, MSc
Ministry of Medical Services Ag. Director of Public Health and Sanitation
Ministry of Public Health and Sanitation
Acknowledgements
The National Guideline for Integrated Management of Acute Malnutrition was prepared with
the active participation of nutrition experts from several organizations and institutions in Kenya.
The development of this guideline was carried out under the auspices of Ministry of Public
Health and Sanitation as well as Ministry of Medical Services. In this regard, the support
extended by Dr S.K. Sharif (Ag. Director of Public Health and Sanitation) and Dr F. Kimani
(Director of Medical Services) is gratefully acknowledged.
We wish to thanks UNICEF country office for its consistent support towards the compilation
and development of these guidelines. And, we would like to express sincere gratitude to the
DIFID for the financial support towards this guideline.
Special appreciations and thanks go to the core team, which provided significant support
and contribution in the review of materials, protocols and layouts, comprising of staff from:
Ministry of Public Health and Sanitation: Terry Wefwafwa, (Head, Division of Nutrition), Dr
Anna Wamae (Head, Division of Child and Adolescent Health) and, Gladys Mugambi and
Crispine Ndeda (staff from the Division of Nutrition and Child and Adolesecents); Ministry
of Medical Services: Rosemary Ngaruro (Head, Division of Clinical Nutrition) and Francis
Wambua (staff from the Division of Nutrition); Concern Worldwide: Nicky Dent (Regional
Nutrition Advisor) and Mueni Mutunga (Nutrition Manager); Action Contre la Faim: Erin
McCloskey and Maggy Tiemdjo (former Medical and Nutrition Coordinators) and Habiba
Bishar (Program Manager, Capacity Development). World Health Organization: Dr Assumpta
Murithi (National Professional Officer, Child and Adolescents Health and Nutrition). UNICEF
Kenya: Noreen Prendiville (Chief, Nutrition Section), Ruth Situma and Dolores Rio (Nutrition
Specialists)
We acknowledge and appreciate the support from Mary Corbett and Emily Teshome,
independent nutrition consultants, for the development and drafting of the guideline.
Components of this guideline on nutritional care and support for PLHIV reflects much of the
technical content in the ‘Kenya Guidelines for an Integrated Approach to the Nutritional Care
of HIV-infected children (6 months – 14 years) and was provided by Linda Beyer, Nutrition
Specialist, IYCF and HIV/AIDS, UNICEF Kenya. The formative work was provided by WHO
and acknowledgment goes to Randa Saadeh (WHO Technical Advisor) and Nygel Rollins
(Department of Paediatrics and Child Health, University of KwaZulu-Natal, South Africa).
The following institutions are also greatly acknowledged for their support and contributions:
Ministry of Health-National-Aids and Sexually Transmitted Infection Control Programme
(NASCOP), Save the Children – UK, Merlin, Samaritan Purse Kenya, International Medical
Corps, World Vision Kenya, Islamic Relief, World Food Programs (WFP), UNICEF, Eastern and
Southern Africa Regional Office (ESARO) and UNICEF New York Headquarters
Contents
Acronyms
List of Tables and Figures
Introduction 1
Objectives of the Guidelines 2
Intended Readers 2
How to Use the Guidelines 2
Content of the Guidelines 3
Section One: Overview of Malnutrition 4

Definition of Malnutrition 4
Components of Nutrition 4
Categories of Malnutrition 5
Causes of Malnutrition 6
Diagnosis of Acute Malnutrition 7
Triage of Acute Malnutrition 9
Steps on Admission 12

Appendix 1.1: Checklist to Identify Reasons for Acute Malnutrition 14
Appendix 1.2: Appetite Test 16
Appendix 1.3: Taking Anthropometric Measurements 18
Appendix 1.4: Calculating Weight-for-height 21
Appendix 1.5: Weight-for-Length and Weight-for-Height WHO Charts 2006 (Boys) 22
Appendix 1.6: Weight-for-Length and Weight-for-Height WHO Charts 2006 (Girls) 31
Appendix 1.7: BMI-for-Age WHO Charts 2006 (Boys) 40
Appendix 1.8: BMI-for-Age WHO Charts 2006 (Girls) 41
Appendix 1.9: Weight-for-Height (z-scores) NCHS Chart for children aged 6-59 months 42
Appendix 1.10: Weight-for-Age WHO Chart 2006 (Boys and Girls) 44
Section Two: In-patient Management of Severe Acute Malnutrition

For children over six months, adolescents and adults
Overview 46
Requirement for the In-patient Setting 49
Admission Criteria for In-patient Care 50
In-patient Stabilization and Rehabilitation of Malnourished Patients 51
Contents
Phase One Treatment 52

Nutrition Support: Diet and Frequency 52
Preparation of F-75 52
Feeding Technique for Severely Malnourished Children 53
Routine Medication 54
Malaria Treatment 56
Measles Vaccination 57
De-worming 57
Summary of Medications 57
Surveillance 58
Criteria for Transfer: Phase 1 to Transition Phase 58
Transition Phase Treatment 58
Preparation of F-100 59
Plans for Eventual Out-Patient Care – Use of RUTF 59
Surveillance 61
Criteria for Transfer: Transition Phase to Phase 2 61
Criteria to Return to Phase 1 from Transition Phase 61
Phase Two: Treatment of Severe Acute Malnutrition 62
Preparation of F100 62
Surveillance 64
Discharge 64
Treatment of Medical Complications 65
Hypoglycemia 65
Hypothermia 66
Dehydration 67
Septic (or Toxic) Shock for All Malnourished Patients 74
Absent Bowel Sounds, Gastric Dilatation, Abdominal Distension 75
Heart Failure 76
Severe Anemia 77
Administration of Medication 78
Contents
Appendix 2.1: Multi-Chart 79

Appendix 2.2: Recipes for F75, F100 and ReSoMal using CMV 81
Appendix 2.3: Dietary Requirements for Older Children, Adolescents and Adults 82
Appendix 2.4: Medical History and Examination Patient History 83
Appendix 2.5: Transfer Form 85
Appendix 2.6: Register Format 87
Appendix 2.7: Dehydration 88
Appendix 2.8: Monthly Report Format for Management of SAM (In-patient/Out-patient) 89
Section Three: Management of Acute Malnutrition, Infants Less Than Six Months 90
Infants less Than 6 Months With a Prospect of Being Breastfed
Overview 90
Nutrition Support: Diet, Frequency and Suckling Technique 94
Surveillance 94
Care for Mothers 94
Discharge Criteria 95
Follow-up 95
Infants Less Than 6 Months Without a Prospects of Being Breastfed 95
Overview 95
Admission Criteria 95
Nutrition Suport: Diet and Frequency 96
Preparation of F100 Diluted 96
Surveillance 97
Criteria for Discharge 97
Follow-up 97
Section Four: Out-Patient Therapeutic Care for Severe Acute Malnutrition

Children Over 6 Months 98
Overview 98
Admission Process 98
Requirements for Out-patient Therapeutic Care 99
Admission Criteria 99
Nutrition Support: Diet Frequency 100
Routine medication 100
Registration 101
Contents
Surveillance 102
Discharge Criteria 102
Home Care for the Malnourished Patient 102
Criteria for Transfer: Out-Patient Therapeutic Care to In-patient Phase 1 103
Failure to Respond 104
Estimating RUTF Monthly Requirements for a Health Facility 106
Appendix 4.1: RUTF Specification 107

Appendix 4.2: Admission Card for Outpatient Therapeutic Care 109
Appendix 4.3: Out-Patient Therapeutic Care Ration Card 111
Appendix 4.4: Medical Examination Checklist for OTP 112
Appendix 4.5: Key Messages for OTP 113
Appendix 4.6: Example of OTP Checklist for Field Support Visits 114
Section Five: Management of Moderate Acute Malnutrition 116

Overview 116
Selection Criteria 117
Admission and Discharge Criteria 118
Steps for Managing Moderate Acute Malnutrition 119
Data Collecting and Reporting 121
Requirements for Managing Moderate Malnutrition 122
Monitoring and Evaluation 123
Appendix 5.1:Energy and Protein Values of Commonly Used Foods in Kenya 124
Appendix 5.2: Recipes: Local Recipes 125
Appendix 5.3: Proportions of Premix 128
Appendix 5.4: Preparation of Porridge with Fortified Flour 129
Appendix 5.5: Supplementary Feeding Ration Card 130
Appendix 5.6: Monthly Report Format for Management of Moderate Acute Malnutrition 131
Appendix 5.7 Feeding Programme Stock Card 132
Section Six: Management of Malnutrition for Children in the Context 133

of Hiv and Aids
Overview 133
Patients with HIV & AIDS 133
Objectives and Guidelines for Providing Nutritional Care for PLHIV
(from GoK, MOH, 2007, National Guidelines for Nutrition and HIV and AIDS) 134
Summary of Critical Nutrition Practices for PLHIV 134
Contents
Clinical Guidelines for an Integrated Approach to the Nutritional Care

of HIV-Infected Children (6 months to 14 years) 135
Deciding If and When to Refer a Child with HIV and AIDS 141
The HIV-infected Child with Special Needs 141
Children on Antiretroviral Treatment 143
Appendix 6.1: HIV and Infant Feeding 146

Appendix 6.2: Micronutrient Requirements for Children 147
Appendix 6.3: Nutritional Composition of Fortified Supplementary Blended Foods 148
Appendix 6.4: WHO Clinical Staging of HIV and AIDS for Children (2006) 149
Section Seven: Emergency Nutrition Response 151

Overview 151
Steps for Emergency Response 151
Nutrition Programme Beneficiary Selection Process for Children 154
Implementing Emergency Nutrition Interventions 155
Supplementary Feeding Programme: On-site Feeding and Take-home Feeding 155
Therapeutic Feeding Programme 155
Requirements for an Emergency Nutrition Intervention 156
Monitoring and Evaluation 159
Linking Nutrition Programmes with Other Interventions 159
Appendix 7.1: Stakeholders’ Roles in Emergency Response 160

Appendix 7.2: Coordination Structure 161
Appendix 7.3: Determining Number of Beneficiaries 162
Appendix 7.4: Supply Procurement 163
Appendix 7.5: Performance Indicators for Nutrition Interventions 166
Section Eight: Community Mobilization 167

Overview 167
Community Mobilization 169
Appendix 8.1: Home Visit Checklist 171
Section Nine: Nutrition Information, Education and Communication 173

Overview 173
Contents
Approach to Nutrition Education 173

Channels of Communication 174
Guidelines on Key Nutrition Information 174
Nutrition Subjects and Message Content 175
Nutrition Counselling 178
Monitoring and Evaluation of Nutrition Education 179
Appendix 9.1: Nutrition Messages 180

Acronyms
ALRMP............ Arid Lands Resource Management Project
ASAL............... Arid and Semi Arid Lands
ART................. Anti Retroviral Therapy (treatment course of drugs for HIV)
ARV................ Anti-Retroviral (drugs used against HIV and AIDS)
CBO................ Community Based Organisation
CHC................ Community Health Committee
CHW............... Community Health Worker
CHEW.............. Community Health Extension Worker
DHS................ Demographic Health Survey
DTC................. Diagnostic Testing and Counselling
F75................. Special milk for stabilization of severe malnutrition
F100................ Special milk for catch up growth for severe malnutrition
GM.................. Growth Monitoring
GoK................. Government of Kenya
HIV................. Human Immunodeficiency Virus
IEC.................. Information, Education and Communication
IMAM.............. Integrated Management of Acute Malnutrition
IMCI................ Integrated Management of Childhood Illness
KEPI................ Kenyan Extended Programme of Immunisation
MAM............... Moderate Acute Malnutrition
MoH................ Ministry of Health
MUAC . ........... Mid-Upper Arm Circumference
NCHS.............. National Centre for Health Statistics (USA anthropometric standards)
ORS................ Oral Rehydration Salts
OTP................. Out-patient Therapeutic Programme
PLWHA............ Person Living With HIV /AIDS
ReSoMal.......... Rehydration Solution for Malnourished
RUTF............... Ready to Use Therapeutic Food
SAM................ Severe Acute Malnutrition
SFP................. Supplementary Feeding Programme
TB................... Tuberculosis
UNICEF............ United Nations Children’s Fund
VCT................. Voluntary Testing and Counselling
WFP................ World Food Programme
WHO............... World Health Organisation
Section One
Table 1.1 Characteristics of Marasmus and Kwashiorkor
Table 1.2 MUAC criteria to identify malnutrition of children under five years in the community
Table 1.3 Anthropometric criteria to identify severe, moderate and at risk categories of acute
malnutrition for all age groups and pregnant/lactating women
Table 1.4 Triage to determine treatment of either severe or moderate malnutrition
Table 1.5 Admission criteria to determine in-patient or out-patient care
Table 1.6 Minimum amount of Plumpy’nut per kg of body weight required to pass Appetite Test
Figure 1.1 How to measure MUAC

Figure 1.2 Taking a child’s weight
Figure 1.3 Taking a child’s length
Figure 1.4 Taking a child’s height
Figure 1.5 UNICEF Conceptual Framework: Causes of Malnutrition
Figure 1.6 District level structure required to support management of severe acute malnutrition
Section Two
Table 2.1 Admission Criteria
Table 2.2 Checklist for each phase of the management of acute malnutrition for in-patient treatment
Table 2.3 Quantity of F75 or prepared milk to give during Phase 1, per kg of body weight
Table 2.4 Vitamin A systematic treatment
Table 2.5 Dosage of Amoxycillin, Gentamycin and Chloramphenicol
Table 2.6 Dosage for de-worming, by age group
Table 2.7 Summary of routine medication for in-patient treatment of severe acute malnutrition
Table 2.8 Quantity of F100 to give during Transition Phase, per kg of body weight
Table 2.9 Quantity of RUTF to give during Transition Phase, quantity per kg of body weight
Table 2.10 Quantity of F100 to give during Phase 2, per kg body weight
Table 2.11 Phase 2 surveillance
Table 2.12 Discharge criteria for recovered patients
Table 2.13 Preparation of sugar water (10% dilution)
Table 2.14 Recipes for F-75 Formula
Table 2.15 Recipes for F-100 Formula
Table 2.16 Preparation of ReSoMal Solution with ORS
Table 2.17 Preparation of small quantities
Table 2.18 Preparation of F-100 diluted
Figure 2.1 Feeding technique

Figure 2.2 Treatment of dehydration – assessment
Figure 2.3 Treatment of dehydration – monitoring
Figure 2.4 Diagnosis and treatment of anaemia
Section Three
Table 3.1 Criteria of admission, infants with a prospect of being breastfed
Table 3.2 Quantity of F100 diluted to give to infants with a prospect of being breastfed,
per kg of body weight
Table 3.3 Discharge criteria, infants with a prospect of being breastfed
Table 3.4 Criteria of admission, infants without a prospect of being breastfed
Table 3.5 Quantity of F100 diluted to give to infants without a prospect of being breastfed,
in phase 1, per kg of body weight
Table 3.6 Quantity of F100 diluted to give to infants without a prospect of being breastfed,
in phase 1, per kg of body weight
Table 3.7 Discharge criteria, infants without a prospect of being breastfed
Figure 3.1 Supplemental Sucking Technique
Section Four
Table 4.1 Summary of criteria for admission to out-patient care
Table 4.2 Quantity of RUTF per class of body weight, daily and weekly
Table 4.3 Drug regime for OTP patients
Table 4.4 Surveillance tasks and frequency
Table 4.5 Discharge criteria
Table 4.6 Failure to respond: out-patient criteria
Table 4.7 Checklist: possible causes for failure to respond
Table 4.8 Nutritional composition of RUTF
Table 4.9 Medical examination checklist (OTP to Inpatient Care) for Severe
Acute Malnutrition
Section Five
Table 5.1 Nutritional status classification – use of cut off points
Table 5.2 Indicators for admission and discharge
Table 5.3 Food commodities and ration sizes per patient for 14 days
Table 5.4 Summary of routine medical treatment for children under five
Table 5.5 Summary of routine medical treatment for pregnant and lactating mothers
Figure 5.1 Summary to determine the nutritional status of a patient and the required action
Section Six
Table 6.1
Energy needs of HIV-infected children (kcal/day)
Table 6.2
Assess, clarify and decide a nutritional care plan
Table 6.3
Nutrition Care Plan A (WHO – nutritional care of HIV-infected children, 2006)
Table 6.4
Nutrition Care Plan B (WHO – nutritional care of HIV-infected children, 2006)
Table 6.5
Nutrition Care Plan C (WHO – nutritional care of HIV-infected children, 2006)
Table 6.6
Recommendations for follow-up of a child with HIV and AIDS
Table 6.7
Laboratory parameters for monitoring infants and children at baseline, before and
during ART
Table 6.8 Micronutrient requirements for children 0-6 years
Table 6.9 Nutritional composition of fortified supplementary food
Table 6.10 WHO clinical staging of HIV and AIDS for children with confirmed HIV infection
Section Seven
Table 7.1 Take home (or dry ration) versus on-site feeding (or wet ration)
Table 7.2 Nutritive value of food commodities
Table 7.3 Stakeholders’ roles in emergency response

Table 7.4 Supplementary feeding estimates: commodity requirement
Table 7.8 In-patient centre: semi-solid feeds
Table 7.9 RUTF requirements, estimated for a 10kg child
Table 7.10 Estimates of common drugs used in supplementary feeding centers
Table 7.11 Stock balance sheet (sample)
Table 7.12 Performance indicators for nutrition interventions
Figure 7.1 Flow chart outlining Kenya MOH supply system

Figure 7.2 Coordination structure
Section Eight
Table 8.1 Key community representatives
Table 8.2 Referral criteria for malnourished persons and the relevant actions
Figure 8.1 Levels of care in the Kenya Essential Package of Health (KEPH)
Figure 8.2 Community representation and linkage at the health facility
Figure 8.3 Process of community mobilization
Section Nine
Table 9.1 General guidance on counselling
Figure 9.1 Steps to conduct a nutrition education session

Integrated Management of Acute Malnutrition
Introduction
Introduction
Malnutrition is an important public health issue particularly for children under five years
old who have a significantly higher risk of mortality and morbidity than well nourished
children. Maternal and child under-nutrition is prevalent in low and middle income countries.
New research estimates that the risks related to stunting, severe wasting and intrauterine
growth retardation are linked to 2.2 million deaths and 21% of disability-adjusted life years
worldwide for children under five years. Deficiencies in Vitamin A and zinc are estimated
to be responsible for 600,000 and 400,000 childhood deaths respectively1. Sub-optimum
breast feeding, particularly for infants under-six months, is also a leading factor in childhood
morbidity and mortality.
In Kenya, the infant and the under-five mortality rates are 77 and 115 per 1000 live births
respectively. The national figure for acute malnutrition of children under five years old is
estimated at 6%, however there are huge variations in different regions of the country2.
In the Arid and Semi Arid Areas (ASAL) where food insecurity and natural disaster have
affected the population, rates of acute malnutrition are between 15-20% of children under
five, and sometimes substantially higher.
HIV and AIDS and malnutrition are intrinsically linked. Although the prevalence of HIV in
the general population reduced from 13.5% in 1999 to 5.9% in 20063, the prevalence
among pregnant women is approximately 7.8 %, resulting in an estimated 90,000 children
at risk of mother-to-child (MTCT) transmission of HIV. It is estimated that between 33,500
and 65,500 children in Kenya are becoming infected with HIV from their parents each year,
reversing the previous gains in child survival in the country over the past two decades4.
The Ministry of Health (MoH) in partnership with international and national non-governmental
organizations (NGOs) has addressed the high rates of acute malnutrition in the ASAL areas,
saving many lives and rehabilitating children. The cyclical nature of events in the ASAL calls
for a systematic approach to build government health system capacity to address acute
malnutrition in the long-term. The limited capacity of Government of Kenya (GoK) health
staff to manage the growing burden of malnutrition, however, is a challenge. Therefore,
strengthening the community for an integrated approach to acute malnutrition, especially
to maintain sustainability and increase the access to services, is key in Kenya. To identify
1 Robert E Black et al, “Maternal and Child Under-Nutrition: Global and Regional Exposures and Health Consequences”, The
Lancet 2008; 371: 243-260.
2 The State of the World’s Children 2006, Excluded and Invisible, UNICEF
3. Ministry of Health website, www.health.go.ke
4. ‘Food and Nutrition Handbook’, World Food Programme (2000).
1
malnutrition threats early on and manage malnutrition through existing health structures in
the community is the ideal approach (opening selective feeding programmes should only
occur when the health infrastructure is overwhelmed or has limited capacity to ensure
adequate access and coverage).
There are two basic objectives of the management of acute malnutrition:
Nutritional Assessment
1) to prevent malnutrition by early identification, public health interventions and nutrition

education;
Introduction
2) to treat acute malnutrition to reduce associated morbidity and mortality.
These guidelines address both objectives, with emphasis on the identification and treatment
of acute malnutrition. The Integrated Management of Acute Malnutrition National Guidelines
for Health Workers at the health facilities will be instrumental in building capacity of the MoH
health staff and their partners.
Objective of the Guidelines

The National Guideline for Integrated Management of Acute Malnutrition was developed as a
tool to assist health workers in the assessment and appropriate management with services
and/or counselling for the treatment of acute malnutrition both Moderate Acute Malnutrition
(MAM) and Severe Acute Malnutrition (SAM). Although the guidelines will focus on children
under five years, some information specific to older children, adolescents and adults is also
included. There is no sufficient evidence-based research on the treatment of adult acute
malnutrition to go into elaborate detail, but as evidence becomes available the guidelines
will be updated. To treat acute malnutrition successfully, the guidelines must be used in
their entirety. Strict implementation of the guidelines can significantly contribute towards
reducing the under five mortality rate due to acute malnutrition.
Intended Readers
The National Guideline for Integrated Management of Acute Malnutrition is intended for
use by health managers, clinicians, nutritionists and community workers supported by the
required level of training and with adequate resources to perform the activities and deliver
treatment in a safe and effective manner. Job aids will be developed to assist in the daily
activities in the management of acute malnutrition. The guidelines can also be used by
training institutions to standardize the management of acute malnutrition with new graduates
joining the health force.
The guidelines will also help NGOs involved in nutrition rehabilitation during emergencies
to guide and standardise treatment protocols established by the MoH. Whilst some local
adaptations may be made, these should be done only with the collaboration and consent of
MoH.
The guidelines complement other material developed by the MoH, including the Kenyan
IMCI/IMAI (Integrated Management of Childhood Illness) and the Kenyan National Guidelines
on Nutrition and HIV&AIDS, as well as complement national strategies and policies.
How to Use the Guidelines

The user should adapt The National Guideline for Integrated Management of Acute Malnutrition
to his and her own operational settings, taking into consideration the following:
•• Efforts to manage acute malnutrition must go hand in hand with efforts to curb the
underlying causes of malnutrition in the target area.
2
•• Access to other national guidelines that provide details on specific topics. All of the
national guidelines can be obtained from the MoH.
•• Consult with MoH technical officers for additional technical support if required (i.e.
nutritionists, dieticians, nurses and medical doctors who are familiar with the support
and management of acute malnutrition) and with staff from appropriate humanitarian
agencies; United Nations agencies (UNICEF, WFP, WHO, FAO); and NGOs.
•• Where resources are limited, diets can be modified according to food availability. However
Introduction
macro- and micro-nutrient specific requirements for treatment of acute malnutrition must
be observed.
•• Select the relevant section for the situation. One section may refer to another section for
additional information.
•• Make use of job aids such as posters, counselling cards, and flowcharts to explain aspects
during counselling.
Note that these guidelines are subject to revision and updates. Please inform the Division of
Nutrition (DoN) of the MoH and relevant technical staff of any useful information that may
improve the guidelines
Content of the Guidelines

The guidelines are divided into eight sections, each with a relevant appendix.
Introduction: Gives an overview of malnutrition in Kenya, the purpose of the guidelines, the
intended readers, and steps to use the guidelines.
Section 1: Defines malnutrition, classifications and triage. Also explains the principles of
management of severe acute malnutrition.
Section 2: Guidelines on management of severe acute malnutrition in patients older than 6
months old in the in-patient setting.
Section 3: Guidelines on management of acute malnutrition for infants less than 6 months
old in the in-patient setting.
Section 4: Guidelines on management of severe acute malnutrition in patients older than 6
months in the out-patient setting known as out-patient therapeutic care/programme (OTP).
Section 5: Guidelines on management of moderate acute malnutrition for children, adolescents
and adults through the MoH infrastructure.
Section 6: Guidelines on management of acute malnutrition for children in the context of
HIV and AIDS.
Section 7: Discuss the emergency nutrition response to increased levels of acute malnutrition.
Section 8: Discuss the community structure and the strategy for the management of acute
malnutrition in the community.
Section 9: Discuss nutrition information, education and communication.
3
Section One
Section One:
Overview Of Malnutrition
Definition of Malnutrition
Malnutrition is defined as “a state when the body does not have enough of the required
nutrients (under-nutrition) or has excess of the required nutrients (over-nutrition).
Components of Nutrition
Macronutrients
Protein, fat and carbohydrates are macronutrients that make up the bulk of a diet and supply
the body’s energy. In resource-poor populations, carbohydrates (i.e. starches and sugars) are
often a large part of the diet (80%) and the main source of energy. Fats, also an essential
component in the diet, in resource-poor populations make-up about 10% of the diet. Fats
also supply energy and are important in cell formation. Proteins are required to build new
tissue and are derived mostly from animal origin such as milk, meat and eggs. These animal
by-products contain essential amino acids that cannot be produced by the body but must be
eaten. Protein from cereals and pulses alone do not provide the sufficient balanced essential
amino acids. Therefore, to obtain the correct balance without requiring protein from animal
sources, cereals and pulses must be combined when planning a meal.
Micronutrients
There are around forty different micronutrients that are essential for good health.
Micronutrients are divided into two classes. Most micronutrients are classed as Type I,
which includes iodine, iron, Vitamins A and C. Deficiencies in Type I micronutrients do not
affect growth (i.e. the individual can have normal growth with appropriate weight and still be
deficient in micronutrients) and thus deficiency in Type I micronutrients is not determined by
anthropometric measurement. Deficiencies in Type I micronutrients will cause major illness
such as anaemia, scurvy and impaired immunity.
Type II micronutrients, including magnesium, sulphur, nitrogen, essential amino-acids,

phosphorus, zinc, potassium, sodium and chloride, are essential for growth and tissue repair.
Type II micronutrients are required only in small quantities, but the correct balance is essential
1. The Sphere Project, Humanitarian Charter and Minimum Standards in Disaster Response, 2004
4
for good health. A deficiency in any of the Type II micronutrients will lead to growth failure,
measured by stunting and wasting.
Categories of Malnutrition
There are two categories of malnutrition: Acute Malnutrition and Chronic Malnutrition.
Children can have a combination of both acute and chronic. Acute malnutrition is categorised
into Moderate Acute Malnutrition (MAM) and Severe Acute Malnutrition (SAM), determined
Section One
by the patient’s degree of wasting. All cases of bi-lateral oedema are categorized as SAM.
These guidelines address management and treatment of acute malnutrition.
Chronic malnutrition is determined by a patient’s degree of stunting, i.e. when a child has not
reached his or her expected height for a given age. To treat a patient with chronic malnutrition
requires a long-term focus that considers household food insecurity in the long run; home
care practices (feeding and hygiene practices); and issues related to public health.
SAM is further classified into two categories: Marasmus and Kwashiorkor. Patients may
present with a combination, known as Marasmic Kwashiorkor. Patients diagnosed with
Kwashiorkor are extremely malnourished and at great risk of death. Table 1.1 lists the
characteristics of Marasmus and Kwashiorkor.
Table 1.1: Characteristics of Marasmus and Kwashiorkor
Marasmus Kwashiorkor
•• Severe weight loss and wasting •• Bi-lateral oedema and fluid accumulation
•• Ribs prominent •• Loss of appetite
•• Limbs emaciated •• Brittle thinning hair
•• Muscle wasting •• Hair colour change
•• May have good appetite •• Apathetic and irritable
•• With correct treatment, good prognosis •• Face may seem swollen
•• High risk of death
5
Causes of Malnutrition
The UNICEF conceptual framework, developed in the 1990s and shown below, summarizes
the causes of malnutrition.
Figure1.1: UNICEF Conceptual Framework: Causes of Malnutrition
Malnutrition
Section One
Inadequate Food Intake Disease

Imediate Causes
Access to Health
Household Food Social and Care
Security Environment
Care & the Health Underlying Causes
Environment
National Policies
Formal and Informal Structure Basic Causes
Context and Potential Resources
Imediate Causes of Malnutrition

Lack of food intake and disease are immediate cause of malnutrition and create a vicious cycle
in which disease and malnutrition exacerbate each other. It is known as the Malnutrition-
Infection Complex. Thus, lack of food intake and disease must both be addressed to support
recovery from malnutrition.
Underlying Causes of Malnutrition

Three major underlying causes of malnutrition include:
• Food: Inadequate household food security (limited access or availability of food).
• Health: Limited access to adequate health services and/or inadequate environmental
health conditions.
• Care: Inadequate social and care environment in the household and local community,
especially with regard to women and children.
Basic Causes of Malnutrition

The basic causes of malnutrition in a community originate at the regional and national level,
where strategies and policies that affect the allocation of resources (human, economic,
political and cultural) influence what happens at community level. Geographical isolation
and lack of access to markets due to poor infrastructure can have a huge negative impact
on food security. When conducting an assessment to determine the causes of malnutrition
in a community, it is important to research the actions at each level and how these actions,
or inactions, influence malnutrition rates.
6
Diagnosis of Acute Malnutrition

Selection Criteria for Acute Malnutrition
Admission criteria for acute malnutrition are determined by a child’s weight and height, by
calculating weight-for-height as “z-score” (using WHO Child Growth Standard, 2006)2, and
presence of oedema. All patients with bi-lateral oedema are considered to have severe acute
malnutrition. See Table 1.3 for anthropometric criteria.
Mid-Upper Arm Circumference (MUAC) is often the screening tool used to determine malnutrition
Section One
for children in the community under five years old. A very low MUAC (<11.5cm for children
under five years) is considered a high mortality risk and is a criteria for admission with severe
acute malnutrition. See Table 1.2 below for MUAC criteria for children under-five years.
Table 1.2: MUAC criteria to identify malnutrition of children under five years in the community
Severely Malnourished Moderately Malnourished At Risk of malnutrition
less than 11.5cm 11.5cm to 12.4cm 12.5cm to 13.4cm
The admission criteria for infants below 6 months are substantially different than for infants
over six months. See Section 3 (page 95).
A Note on Admission Criteria for Adolescents and Adults

International guidelines that recognize cut-off measurements to identify moderate acute
malnutrition and severe acute malnutrition in adolescents and adults do not yet exist.
Body Mass Index (BMI) varies considerably in different populations. In the adolescent age
bracket (13 to 18 years) BMI-for-age can be used, but is not applicable in the event of
growth retardation or when age is indeterminate. Adolescents experience growth spurts
(rapid growth), therefore anthropometric measurements to determine wasting can be
difficult.
For adults (older than 18 years), BMI is the main way to identify acute malnutrition,
however it is important to include clinical signs such as bi-lateral oedema and dehydration
that affect BMI results. Other underlying medical conditions, such as TB and HIV and
AIDS, must also be considered. For adults, MUAC in combination with clinical signs can
also identify patients who need specialized nutrition interventions.
During pregnancy MUAC does not change considerably, while a pregnant woman’s weight
should increase. A low MUAC of <21cm during pregnancy can indicate a need for extra
nutritional support due to the pregnancy. A low MUAC for the mother during pregnancy
increases the risk of growth retardation of the foetus3 . Criteria for admission for nutrition
rehabilitation of different age groups is gathered from the sources listed below.4, 5, 6
Table 1.3 presents the criteria to identify at risk, moderate and severe malnutrition using
MUAC, weight-for-height z-score, and BMI for adults. These criteria are used in a health facility
where equipment is available and staff are trained to take weight and height measurements.
2. The WHO Child Growth Standards were introduced in Kenya in 2008. The standards will replace the
NCHS reference for measurement of child malnutrition. See Appendix 1.8 for the NCHS reference.
3. The Sphere Project, Humanitarian Charter and Minimum Standards in Disaster Response, 2004.
4. Woodruff, Bradley A. and Arabella Duffield. “Adolescents: Assessment of Nutritional Status in
Emergency-Affected Populations”, Secretariat of the UN ACC/Sub-Committee on Nutrition, July 2000.
www.unsystem.org/SCN/archives/adolescents/index.htm
5. Adults, Assessment of Nutritional Status in Emergency–Affected Populations, Steve Collins, Arabelle
Duffield and Mark Myatt, July 2000.
6. The Sphere Project, Humanitarian Charter and Minimum Standards in Disaster Response, 2004
7
Table 1.3: Anthropometric criteria to identify severe, moderate and at risk categories of acute
malnutrition for all age groups and pregnant/lactating women
Indicator Severe Acute Moderate Acute At Risk of Acute
Malnutrition (SAM) Malnutrition (MAM) Malnutrition
Infants less than 6 months
W/L W/L < - 3 Z-Score Static weight or losing Static weight or losing
weight at home weight at home
Section One
Z-Score
Oedema Oedema Present Oedema Absent Oedema Absent
Other signs Too weak to suckle or Poor feeding Poor feeding

feed
Children 6 months to 10 years
W/H Z-Scores < -3 Z-Score Between -3 to < -2 Z- Between -2 to <-1
Score Z-Score
MUAC (6 - 59 <11.5cm 11.5 to 12.4cm 12.5-13.4cm
months only)
Adolescent (10 years to 18 years)
MUAC < 16cm N/A N/A
Adults (older than 18 years)

MUAC <16cm irrespective of 16-18.5cm with no N/A
clinical signs relevant clinical signs.
Few relevant social criteria
MUAC 16-18.5cm plus one N/A N/A
of the following:
1) Oedema
2) Inability to stand
3)Apparent
dehydration
BMI <16 (Grade lll chronic 16-17 17-18.5
underweight)
Pregnant & lactating women

MUAC No available criteria < 21cm
*Anthropometric criteria based on WHO Child Growth Standards (2006)
8
Steps to Identify Acute Malnutrition in Children

Children who are malnourished are at high risk of mortality and morbidity. It is important that
malnourished children, or those at risk of malnutrition, are identified and appropriate care
commenced. Community Health Workers (CHWs) may identify children at risk of malnutrition
in the community. Health facility staff can determine if children who are brought for other
reasons are in fact at risk of malnutrition.
Ministry of Health (MoH) programmes such as Integrated Management of Childhood Illness
(IMCI) and Mother & Child Health (MCH) focus on children under five years old, and screening
Section One
for malnutrition is part of the programme process. When nutrition screening is available
in the community, CHWs identify children who are malnourished with anthropometric
measurements (e.g. MUAC) or where oedema is evident. Malnourished children are referred
to the nearest health facility, nutrition unit, health post, or hospital out-patient department.
The child’s anthropometric measurements are re-checked by a nurse or health worker. Those
who appear very sick, weak, emaciated or underweight require fast-track admission.
For detailed information on the community structure in identifying malnourished individuals,
refer to processes of community mobilization in Section Eight, “Community Nutrition Care”
(page172).
Children identified with bi-lateral pitting oedema must be referred to the nearest health
facility.
Triage of Acute Malnutrition

Community Health Workers (CHWs) can screen children in the community using MUAC
and the presence of oedema. They refer those who are malnourished to a health facility.
However, the diagnosis of malnutrition for children under five years old is the responsibility
of health staff at a health clinic, health dispensary, or an out-patient department (OPD) and
hospital casualty department.
The procedure to determine a patient’s medical history, nutritional status and appropriate
treatment is presented in Table 1.4. This procedure conforms to the Kenya IMCI Guidelines.
Table 1.4: Triage to determine treatment of either severe or moderate malnutrition

1. Has there been any weight loss in previous month?
2. Does the patient have an appetite.

ASK:
3. Does the patient have any medical condition that will impair
nutritional status?
4. Is the breast-feeding child suckling well?
LOOK AND FEEL FOR: Visible signs of wasting
MUAC
Weight
CHECK:
Height/length
Bilateral-oedema
DETERMINE: Level of malnutrition using W/H reference charts
LOOK AT SHAPE OF GROWTH CURVE: 1. Has the child lost weight?
2. Is the growth curve flattening?
9
Section One
10
Ask Look & Feel Look & Feel Look & Feel
No Appetite
1. Has there been Visible signs Visible signs Refer patient to
any weight loss in of wasting of wasting inpatient care
previous month? With complications**
Check Severely Acutely Check
2. Does the patient MUAC Malnourished MUAC
Good Appetite Refer or admit
have an appetite Weight, Height/ Weight, Height/
patient for out
length, Bilateral- length, Bilateral-
patient therapeutic
3. Does the patient oedema oedema
No complications** care (OTP)
have any medical
condition that Determine Determine
will impair his BMI or WFH Moderately BMI or WFH Refer or admit
nutritional status? patient for manage-
Actuely
Look at the Look at the ment of moderate
4. Is the breast shape of the Malnourished shape of the malnutrition and
feeding child growth curve or ‘at risk’ growth curve nutrition counselling
suckling well?
1. Has the child 1. Has the child Treat any
lost weight? lost weight? infections.
Healthy Congratulate
2. Is the growth 2. Is the growth the mother and
curve flattening? curve flattening? give nutrition
counselling
**See table 1.5
When severe acute malnutrition is identified, the anthropometric admission criteria are the
same whether the child can access an in-patient facility or out-patient therapeutic care. If
there is no out-patient therapeutic care available, all patients who have a criteria in the red
column (severe malnutrition) of Table 1.3 - with or without complications - are admitted to
the health centre’s in-patient section where they are to stay for each phase of the treatment
of severe acute malnutrition. Also, patients with medical complications and/or ++, +++
oedema and lack of appetite require in-patient treatment of acute severe malnutrition.
When out-patient therapeutic care service is available, the health staffs determine the patients
Section One
who are eligible for it. Patients without complications and with good appetite may go directly
for out-patient treatment. It is important to conduct an Appetite Test (see Appendix 1.2) to
confirm if the child has a good appetite.
Based on the information gathered above, health workers should classify if the patient is
severe acute malnourished (SAM), moderate acute malnourished (MAM) at risk of acute
malnutrition or healthy, and follow criteria below accordingly to determine if severely
malnourished children should receive in-patient or out-patient care.
Table 1.5: Admission criteria to determine in-patient or out-patient care
Factor Criteria for all admissions with severe acute malnutrition

Anthropometric criteria W/H < -3 Z-score
for infants 6 months to MUAC < 11.5cm - 6 months to 5 years only
children 18 years
Anthropometric criteria for BMI <16
adults (older than 18 years) MUAC <16cm OR
MUAC 16.1cm to 18.5cm with clinical complications
Factor In-Patient Care Out-patient Care
Bi-lateral oedema • Bilateral pitting oedema Grade 2 (++) Bilateral pitting oedema
and Grade 3 (+++) Grade 1 (+)
• Both Marasmus and Kwashiorkor
present
Appetite Test Failed or border-line Passed
Caregiver No suitable or willing caregiver Suitable and willing caregiver
Skin Open skin lesions present No open skin lesions
Medical Complications • Severe vomiting • Alert

• Hypothermia with temperature <35°C • No medical complications
(axillary) or <35.5°C (rectal)
• Fever >39°C
• Pneumonia
• Respiration
-> 60 resps/minute under 2 months
- >50 resps/minute from 2-12 months
- 40 resps/minute from 1-5 years
- >30 resps/minute over 5 years old
- Or any chest in-drawing
• Extensive infection
• Very weak, apathetic, unconscious
• Fitting or convulsions
• Severe dehydration based on history
and clinical signs
• Any condition that requires an infusion
or NG tube feeding
• Very pale (severe anaemia)
11
Figure 1.2: District level structures required to support management of severe acute
malnutrition
District or Sub-District Hospital
• Area within a ward to rehabilitate acute malnutrition
• Weekly out-patient therapeutic care at the MCH clinic
(monitoring and food distribution)
• MCH- nutrition screening and paediatric CCC services
Section One
• Out-patient nutrition screening
NOTE: Transfer to hospital all patients

severe acute malnutrition:
-- and/or loss of appetite
-- and/or severe medical complications
-- and/or moderate/severe bi-lateral oedema
(requires in-patient management)
Health Centre/Dispensary
• Weekly out-patient therapeutic care, monitoring,
counselling and food distribution
• MCH nutrition screening
Community
Trained CHWs who:
• Conduct nutrition screening and nutrition education
• Monitor patients being nutritionally rehabilitated in the
community
• Attend MCH on weekly basis for monitoring of
malnourished children and food distribution
Steps on Admission
Step 1: Check for general signs of malnutrition
Health facility staff must check the patient for general signs of malnutrition.
Step 2: Gather patient information

Refer to Appendix 1.3 at the end of this section for anthropometric measurements
Health facility staff:

• Carry-out the patient’s anthropometric measurements.
• Measure weight and height (if the patient’s height is less than 87cms, or if the patient
is younger than two years old, measure length instead), and calculate weight-for-height
(z-score).
• Take a MUAC measurement.
• Check for bi-lateral oedema.
• Record all measurements on patient card and register.
12
Step 3: Identify cause of malnutrition

Fill out a brief checklist to assist to identify why the child is malnourished. See Appendix 1.1
“Checklist to Identify Reasons for Acute Malnutrition” for details.
• Is there an illness that leads to the child’s weight loss?
• Are there economic issues in the family that reduces food availability and/or access?
• Is there dynamics within the household contributing to the situation? (e.g. the mother
sick)
Section One
Step 4 : Conduct Appetite Test
If outpatient therapeutic care is available, conduct the Appetite Test. The Appetite Test is
one of the main criteria to determine if a severe acute malnourished patient requires in-
patient or out-patient treatment. See Appendix 1.2 “Appetite Test” for details.
Step 5: Determine appropriate treatment

A triage process must be established so that the acutely ill are examined and admitted
quickly to the in-patient facility to start treatment immediately. In other words, a “fast track
system” must be in place.
Establish the following parameters:
• Any child older than six months and a MUAC <11.5cm must be admitted to the nutrition
programme for treatment of severe acute malnutrition as low MUAC has a high mortality
risk
• If out-patient treatment of malnutrition is not available, the patient must be admitted to an
in-patient facility for nutrition management. If out-patient management of malnutrition is
available, determine if the patient can be managed in the community or requires admission
to an in-patient facility using Table 1.6 “Admission Criteria to determine in-patient or out
patient care”.
• A child identified as malnourished by the MUAC community screening process but whose
anthropometric measurements taken at the health facility are not considered severely
malnourished is referred for Supplementary Feeding if it is available. (The community
screening process may include higher MUAC cut-offs such as between 11.5 to 13.4cm
for “the moderate” and “at risk” groups.)
SAM patients who are waiting for admission in the health facility waiting area should
receive 50ml glucose 10% to prevent hypoglycaemia (1 rounded 5ml teaspoon of
sugar in 50ml water) by a member of the health staff. See section two, table 2.13
“preparation of sugar water 10% dilution,”
It is important that the parent or caregiver who attends the health facility with a child screened
by a CWH is acknowledged for the visit. This is particularly important when the child is not
considered malnourished by the weight and height anthropometry taken at the health centre.
Otherwise, the community can become disgruntled with the service, particularly if mothers
travel a long distance. It can seriously affect uptake of the services and negatively impact on
coverage. Every mother should be congratulated for taking good care of her child.
If there are consistent errors in the recorded MUACs when children who have been referred
from the community arrive at the health facility, it is necessary to re-train CHWs on the
measurement techniques. This will avoid patients attending health centres unnecessarily.
13
Appendix 1.1: Checklist to Identify Reasons for Acute

Malnutrition
Child Name:
Child Age:
Section One
Illness:
Has the child been sick in the past week? Yes No
If Yes:
What was the sickness?
Did the child go for treatment for the illness? Yes No

If Yes:
Where did the child go for treatment?
What treatment did the child receive?
Nutrition
1. Is the child still breastfeeding? Yes No
If No, when did the breast feeding stop?

If yes:
Has there been a change in breastfeeding pattern in the last 2 weeks?
Feeding less because the child is not interested in breast milk?
Mother has been away from the home so breast milk not available?

List any other reasons:
2. Has the child commenced complementary feeding Yes No
If yes, how often did you feed the child yesterday:

1 time 2 times 3 times More frequently
3. List the foods given yesterday at each meal:

Meal 1:
Meal 2:
Meal 3:
Other meals:
4. Does the child eat from own plate? Yes No
5. Has the feeding pattern of the child changed in the last 1-2 weeks? Yes No
If yes how has it changed?
Why has it changed?
14
Family Illness
Has any other member of the family been ill in the last month? Yes No
If Yes, who was sick?
What was the illness?
Environment
What is your water source?
Piped water/river/stream/pond/deep well/shallow well/other (circle)
Section One
Have you a latrine or access to latrine/toilet? Yes No
Economic Issues
Who is the main income generator?
How does this person make an income?
Has access to work changed in the last month? Yes No
In what way has it changed?
Is there less money for basic foods?

Do you plant anything at home? Yes No
If yes, list what you plant:
When is it harvested?
Have you any domestic animals? Yes No (cows, goats, sheep, camels)
If Yes, how many of each animal:
• Number of Cattle?
• Number of goats?
• Number of sheep?
• Number of camels?
Analysis
What is the main reason for malnutrition for this child?
15
Appendix 1.2: Appetite Test
Why do the appetite test?

• Malnutrition changes the way infections and other diseases express themselves.
Children who are malnourished and severely affected by a classical childhood illness will
frequently show no signs of disease. However, major medical complications lead to a
loss of appetite.
• Even though the definition and identification of the severely malnourished is
Section One
by anthropometric measurements, there is not a perfect correlation between

anthropometric and metabolic malnutrition. It is mainly metabolic malnutrition that
causes death. Often the only sign of severe metabolic malnutrition is a reduction in
appetite. By far the most important criterion to decide if a patient should be sent to in-
or out-patient management is the Appetite Test.
• A poor appetite means that the child has a significant infection or a major metabolic
abnormality such as liver dysfunction, electrolyte imbalance, and cell membrane
damage or damaged biochemical pathways. These patients are at immediate risk of
death. A child with a poor appetite will not take the diet at home and will continue to
deteriorate or die. As the patient does not eat the special therapeutic food (RUTF) the
family will take the surplus and become habituated to sharing.
How to conduct the Appetite Test

• The appetite test should be conducted in a separate quiet area.
• Explain to the caregiver the purpose of the Appetite Test and how it will be carried out.
• The caregiver washes her hands, and the child’s hands and face, with soap and water.
• The caregiver sits comfortably with the child on her lap and either offers the RUTF from
the packet or puts a small amount on her finger and gives it to the child.
• The caregiver offers the child the RUTF gently, encouraging the child all the time. If the
child refuses, the caregiver continues to quietly encourage the child and takes time over
the test. The test usually takes a short time, but may take up to one hour. The child
must not be forced to take the RUTF.
• The child needs to be offered plenty of water to drink from a cup while he/she is taking
the RUTF.
Results of the Appetite Test

Pass:
• A child who takes at least the minimum amount for their weight in Table 1.8 passes the
appetite test.
• The patient is now seen by the nurse to determine any major medical complication (e.g.
pneumonia, acute watery diarrhoea, etc.). If there is no medical complication, no open
skin lesions, no oedema ++ or +++ (moderate or severe oedema) or wasting and
oedema together, then the patient is normally treated as an outpatient if an out-patient
community nutrition rehabilitation is available.
• Explain to the caregiver the choices of treatment options and decide with the caregiver
whether the child should be treated as an out-patient or in-patient (nearly all caregivers
will opt for out-patient treatment).
• Start admission process and treatment appropriate for out-patient therapeutic care (see
section four, page 98).
16
Table 1.6: Minimum amount of Plumpy’nut per kg of body weight

required to pass the Appetite Test
Plumpy’nut
Body weight (Kg) Sachets
Less than 4 kg to ¼
4 – 6.9 ¼ to
7 – 9.9 to ½
Section One
10 – 14.9 ½ to ¾
15 - 29 ¾ to 1
Over 30 kg >1
Fail:
• A child that does not take at least the amount of RUTF in Table 1.8 is referred for in-
patient care.
• Explain to the caregiver the choices of treatment options and the reasons for
recommending in-patient care.
• Refer the patient to the nearest paediatric unit for Phase 1 management.
• Start the admission process and treatment of Phase 1 and address medical
complications appropriate for in-patients.
Notes
• Even if the caregiver and health worker thinks the child is not taking the RUTF because
of the taste or is frightened, the child still needs to be referred to in-patient care for at
least a short time. If later the child takes sufficient RUTF to pass the Appetite Test then
he can be immediately transferred to the community out-patient treatment.
• The Appetite Test is always performed carefully. Patients who fail the Appetite Test are
always offered treatment as in-patients. If there is any doubt then the patient should be
referred for in-patient treatment until the appetite returns (this is also the main criterion
for an in-patient to continue treatment as an out-patient).
• Ideally, if there is a small weighing scale (the sort used in a domestic kitchen to weigh
portions of food) then the sachet of RUTF is weighed before given to the malnourished
child to check for appetite. At the end of the Appetite Test the RUTF package is
weighed again to calculate how much the child has eaten. When a weighing scale is
not available and commercial RUTF is being used, the amount taken from the package
can be estimated despite risk of accuracies. Table 1.8 is the minimum amount that
must be taken.
• The Appetite Test must be carried out at each visit for patients treated in the
community.
• Failure of an Appetite Test at any time is an indication for full evaluation and probably
transfers for in-patient assessment and treatment.
• 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. It may be necessary to bring a child into
in-patient care to do a simple “trial of feeding” in order to differentiate a metabolic
problem with the patient from a difficulty with the home environment. A trial of feeding
can be the first step to help determine a failure to respond to treatment.
17
Appendix 1.3: Taking Anthropometric Measurements

Taking a Child’s Middle Upper Arm Circumference (MUAC)
MUAC is an alternative way to measure “thinness” (alternative to weight-for-height). It is
especially used for children six months old to five years old.
Figure 1.1: How to Measure MUAC

Section One
•• Ask the mother to remove any clothing covering the child’s left arm.
•• Calculate the midpoint of the child’s left upper arm: first locate the tip of the child’s
shoulder (arrows 1 and 2 in diagram below) with your finger tips.
•• Bend the child’s elbow to make the right angle (arrow 3).
•• Place the tape at zero, which is indicated by two arrows, on the tip of the shoulder
(arrow 4) and pull the tape straight down past the tip of the elbow (arrow 5).
•• Read the number at the tip of the Arm circumference “insertion” tape
0. cm
elbow to the nearest centimetre.
Divide this number by two to cm 6 7 8 9 10 11 12 13 14 15 16 18 19 20 21 22 23 24 25
estimate the midpoint. As an 0. cm
alternative, bend the tape up to

the middle length to estimate the 2 4
midpoint. A piece of string can 1 6
also be used for this purpose; it

is more convenient and avoids 3
5
damage to the tape. 1. Locate tip of 2. Tip of shoulder 4. Place tape at tip of 6. Mark midpoint
shoulder 3. Tip of elbow shoulder
•• Mark the midpoint with a pen on 5. Pull tape past tip of
bent elbow
the arm (arrow 6).
•• Straighten the child’s arm and
wrap the tape around the arm
at the midpoint. Make sure the
7
numbers are right side up. Make
sure the tape is flat around the 7. Correct tape tension
skin (arrow 7).
•• Inspect the tension of the tape
10
on the child’s arm. Make sure
the tape has the proper tension 9 10
8
(arrow 7) and is not too tight
or too loose (arrows 8 and 9). 8. Tape too tight
Repeat any step as necessary

•• When the tape is in the correct
position on the arm with correct
tension, read and call out the 9
measurement to the nearest
0.1cm (arrow 10). 9. Tape too loose 10. Correct tape position for arm circumference
Source:
How to How
weightoand
Weigh and Measure
measure children:Children:
assessing Assessing the Nutritional
the nutritional Statuschildren
status of young of Youngin Children,
UN (1986) United Nations, 1986.
•• Immediately record the
measurement.
18
Taking a Child’s Weight

Children are weighed with a 25 kg hanging sprint scale, graduated to 0.100 kg. Do not
forget to re-adjust the scale to zero before each weighing.
A plastic wash basin should be supported by four ropes that attach (are knotted)
underneath the basin. The basin is close to the ground in case the child falls out and
to make the child feel secure during weighing. If the basin is soiled, first clean it with
disinfectant. The basin is more comfortable and familiar for the child, can be used for ill
Section One
children, and is easily cleaned. In the absence of a basin, weighing pants can be used
although are sometimes inappropriate for very sick children. When the pant is soiled, it can
be cleaned and disinfected to reduce the risk to pass an infection to the next patient.
When the child is steady in the basin or pant, record the measurement to the nearest 100
grams, recording with the frame of the scale at eye level. The scales must be checked for
accuracy by using a known weight on a regular basis, i.e. weekly.
Figure 5.3.Child
Figure 5.3. Child Weight
Weight Measurement
Measurement Using Salter-like Hanging Scale
Figure 1.2: Taking a child’s
Put hands through Grasp feet
weight legholes
Instructions on Taking the 1

2
Weight
1. Before weighing the
child, take all his/her
clothes off
2. Zero the weighing scale
(i.e. make sure the
arrow is on 0) Measurer reads scale at eye level
3. Ensure that the
5
weighing scale is at eye
level Assistant with
4
questionaire
4. Place the child in the
weighing pans
5. Make sure the child
is not holding onto
anything
6. Read the child’s weight.
The arrow must be
steady.
7. Record the weight in kg
to the nearest 100g e.g.
6.6 kg
8. Do not hold the scale 3 Child hangs
freely
when reading the
weight
Source: How to Weigh and Measure Children: Assessing the Nutritional Status of Young Children, UN 1986.
Source: How to Weigh and Measure Children: Assessing the Nutritional Status of Young Children, United Nations, 1986.
31
19
Taking a Child’s Length

Measurer on knees
Figure 1.3: Taking a child’s length 3

Assistant on knees
For children less than 87 cm the measuring 2
board is placed on the ground.

1. The child is placed lying down along the
middle of the board. Arms comfortably straight 5
2. The assistant holds the sides of the
Section One
Hand on knees or
child’s head and positions the head until 8
shins; legs straight
it firmly touches the fixed headboard

with the hair compressed. 9 7 4
3. The measurer places her hands on the Child's feet flat Child flat on board Hands cupped over ears;
against footpiece head against base of board
child’s legs, gently stretches the child
and then keeps one hand on the thighs
to prevent flexion. 1
4. While positioning the child’s legs, the Questionaire and pencil on

clipboard on floor or ground
sliding foot-plate is pushed firmly against

the bottom of the child’s feet. Line of sight perpendicular to base of board 6
5. To read the height measurement, the

foot-plate must be perpendicular to the
axis of the board and vertical.
6. The height is read to the nearest 0.1cm
90o
Source:
Source: How to Weigh and Measure Children: Assessing
Assessing the
the Nutritional
Nutritional Status
Status of
ofYoung
YoungChildren,
Children,UN
United Nations, 1986.
1986.
Figure 1.4: Taking a child’s height

For children taller than 87 cm the measuring
board is fixed upright on level ground. Headpiece firmly on head
1. The child stands, upright against the 15 Measurer on knees
middle of the measuring board. 3
2. The child’s head, shoulders, buttocks, Hand on chin 9
knees, and heels are held against the Shoulders level 10
board by the assistant. Child's hands

and arms at side 11
3. The measurer positions the head and the Left hand on

knees; knees 5
cursor. together
against board
4. The height is read to the nearest 0.1 cm

5. Measurement is recorded immediately
Right hand on shins;

heels against back and
base of board
2
Assistant on knees
12
8
Line
13 of sight
14
1
Questionaire and pencil on

clipboard on floor or ground
7
Source: How to
Source: How toWeigh
Weigh and
and Measure
Measure Children:
Children:Assessing
Assessingthe
theNutritional
NutritionalStatus
Status of
ofYoung
YoungChildren,
Children,UN
United
1986.Nations, 1986.
20
Appendix 1.4: Calculating Weight-for-Height

Refer to Appendix 1.5 and 1.6 for examples below.
Example 1: A child (boy) is 63 cm tall and weighs 6.8 kg.
• Look in the table’s first column for the figure 63 (the height).
• Take a ruler or a piece of card, place it under the figure 63 and look across to the other
figures on the same line.
Section One
• Find the figure corresponding to the weight of the child, in this case 6.8kg.
• Look to see what column this figure is in. In this case it is in the “Weight Normal”
column. In this example the child’s weight is normal in relation to his height. He
therefore has an appropriate weight for height.
Example 2: A child (boy) is 78 cm tall and weighs 8.2 kg.
This child’s weight is between the -3SD and -2SD column. He is too thin in relation to his
height. He is moderately malnourished.
NOTE: It may be that the weight or the height is not a whole number.
Example 3: A child (boy) is 80.4 cm tall and weighs 7.9 kg. These exact figures are not in
the table.
For the height: The height measurement has to be rounded to the nearest 0.5cm, see
example below.
Height in cm
80.0 80.0cm is used for

80.1 and 80.2cm
80.1
80.2
80.3
80.4
80.5cm is used for 80.5cm is used for

80.6 and 80.7cm 80.5 80.3 and 80.4cm.
80.6
80.7
80.8
80.9
81.0cm is used for 80.8, 80.9cm
as well as 81.1 and 81.2 cm
81.0
81.1
81.2
For the weight: Looking at the chart, for a height of 80.5 cm the weight is 7.9 kg, this is
below 8.3 kg. The child is severely malnourished.
21
Appendix 1.5: Weight-for-Lenght and

Simplified field tables
Weight-for-Height WHO Charts 2006 (Boys).
Weight-for-length BOYS
Birth to 2 years (z-scores)
Section One
cm -3 SD -2 SD -1 SD Median 1 SD 2 SD 3 SD
45.0 1.9 2.0 2.2 2.4 2.7 3.0 3.3
45.5 1.9 2.1 2.3 2.5 2.8 3.1 3.4
46.0 2.0 2.2 2.4 2.6 2.9 3.1 3.5
46.5 2.1 2.3 2.5 2.7 3.0 3.2 3.6
47.0 2.1 2.3 2.5 2.8 3.0 3.3 3.7
47.5 2.2 2.4 2.6 2.9 3.1 3.4 3.8
48.0 2.3 2.5 2.7 2.9 3.2 3.6 3.9
48.5 2.3 2.6 2.8 3.0 3.3 3.7 4.0
49.0 2.4 2.6 2.9 3.1 3.4 3.8 4.2
49.5 2.5 2.7 3.0 3.2 3.5 3.9 4.3
50.0 2.6 2.8 3.0 3.3 3.6 4.0 4.4
50.5 2.7 2.9 3.1 3.4 3.8 4.1 4.5
51.0 2.7 3.0 3.2 3.5 3.9 4.2 4.7
51.5 2.8 3.1 3.3 3.6 4.0 4.4 4.8
52.0 2.9 3.2 3.5 3.8 4.1 4.5 5.0
52.5 3.0 3.3 3.6 3.9 4.2 4.6 5.1
53.0 3.1 3.4 3.7 4.0 4.4 4.8 5.3
53.5 3.2 3.5 3.8 4.1 4.5 4.9 5.4
54.0 3.3 3.6 3.9 4.3 4.7 5.1 5.6
54.5 3.4 3.7 4.0 4.4 4.8 5.3 5.8
55.0 3.6 3.8 4.2 4.5 5.0 5.4 6.0
55.5 3.7 4.0 4.3 4.7 5.1 5.6 6.1
56.0 3.8 4.1 4.4 4.8 5.3 5.8 6.3
56.5 3.9 4.2 4.6 5.0 5.4 5.9 6.5
57.0 4.0 4.3 4.7 5.1 5.6 6.1 6.7
57.5 4.1 4.5 4.9 5.3 5.7 6.3 6.9
58.0 4.3 4.6 5.0 5.4 5.9 6.4 7.1
58.5 4.4 4.7 5.1 5.6 6.1 6.6 7.2
59.0 4.5 4.8 5.3 5.7 6.2 6.8 7.4
59.5 4.6 5.0 5.4 5.9 6.4 7.0 7.6
22
60.0 4.7 5.1 5.5 6.0 6.5 7.1 7.8
60.5 4.8 5.2 5.6 6.1 6.7 7.3 8.0
Section One
61.0 4.9 5.3 5.8 6.3 6.8 7.4 8.1
61.5 5.0 5.4 5.9 6.4 7.0 7.6 8.3
62.0 5.1 5.6 6.0 6.5 7.1 7.7 8.5
62.5 5.2 5.7 6.1 6.7 7.2 7.9 8.6
63.0 5.3 5.8 6.2 6.8 7.4 8.0 8.8
63.5 5.4 5.9 6.4 6.9 7.5 8.2 8.9
64.0 5.5 6.0 6.5 7.0 7.6 8.3 9.1
64.5 5.6 6.1 6.6 7.1 7.8 8.5 9.3
65.0 5.7 6.2 6.7 7.3 7.9 8.6 9.4
65.5 5.8 6.3 6.8 7.4 8.0 8.7 9.6
66.0 5.9 6.4 6.9 7.5 8.2 8.9 9.7
66.5 6.0 6.5 7.0 7.6 8.3 9.0 9.9
67.0 6.1 6.6 7.1 7.7 8.4 9.2 10.0
67.5 6.2 6.7 7.2 7.9 8.5 9.3 10.2
68.0 6.3 6.8 7.3 8.0 8.7 9.4 10.3
68.5 6.4 6.9 7.5 8.1 8.8 9.6 10.5
69.0 6.5 7.0 7.6 8.2 8.9 9.7 10.6
69.5 6.6 7.1 7.7 8.3 9.0 9.8 10.8
70.0 6.6 7.2 7.8 8.4 9.2 10.0 10.9
70.5 6.7 7.3 7.9 8.5 9.3 10.1 11.1
71.0 6.8 7.4 8.0 8.6 9.4 10.2 11.2
71.5 6.9 7.5 8.1 8.8 9.5 10.4 11.3
72.0 7.0 7.6 8.2 8.9 9.6 10.5 11.5
72.5 7.1 7.6 8.3 9.0 9.8 10.6 11.6
73.0 7.2 7.7 8.4 9.1 9.9 10.8 11.8
73.5 7.2 7.8 8.5 9.2 10.0 10.9 11.9
74.0 7.3 7.9 8.6 9.3 10.1 11.0 12.1
74.5 7.4 8.0 8.7 9.4 10.2 11.2 12.2
75.0 7.5 8.1 8.8 9.5 10.3 11.3 12.3
23
75.5 7.6 8.2 8.8 9.6 10.4 11.4 12.5
76.0 7.6 8.3 8.9 9.7 10.6 11.5 12.6

Section One
76.5 7.7 8.3 9.0 9.8 10.7 11.6 12.7
77.0 7.8 8.4 9.1 9.9 10.8 11.7 12.8
77.5 7.9 8.5 9.2 10.0 10.9 11.9 13.0
78.0 7.9 8.6 9.3 10.1 11.0 12.0 13.1
78.5 8.0 8.7 9.4 10.2 11.1 12.1 13.2
79.0 8.1 8.7 9.5 10.3 11.2 12.2 13.3
79.5 8.2 8.8 9.5 10.4 11.3 12.3 13.4
80.0 8.2 8.9 9.6 10.4 11.4 12.4 13.6
80.5 8.3 9.0 9.7 10.5 11.5 12.5 13.7
81.0 8.4 9.1 9.8 10.6 11.6 12.6 13.8
81.5 8.5 9.1 9.9 10.7 11.7 12.7 13.9
82.0 8.5 9.2 10.0 10.8 11.8 12.8 14.0
82.5 8.6 9.3 10.1 10.9 11.9 13.0 14.2
83.0 8.7 9.4 10.2 11.0 12.0 13.1 14.3
83.5 8.8 9.5 10.3 11.2 12.1 13.2 14.4
84.0 8.9 9.6 10.4 11.3 12.2 13.3 14.6
84.5 9.0 9.7 10.5 11.4 12.4 13.5 14.7
85.0 9.1 9.8 10.6 11.5 12.5 13.6 14.9
85.5 9.2 9.9 10.7 11.6 12.6 13.7 15.0
86.0 9.3 10.0 10.8 11.7 12.8 13.9 15.2
86.5 9.4 10.1 11.0 11.9 12.9 14.0 15.3
87.0 9.5 10.2 11.1 12.0 13.0 14.2 15.5
87.5 9.6 10.4 11.2 12.1 13.2 14.3 15.6
88.0 9.7 10.5 11.3 12.2 13.3 14.5 15.8
88.5 9.8 10.6 11.4 12.4 13.4 14.6 15.9
89.0 9.9 10.7 11.5 12.5 13.5 14.7 16.1
89.5 10.0 10.8 11.6 12.6 13.7 14.9 16.2
90.0 10.1 10.9 11.8 12.7 13.8 15.0 16.4
90.5 10.2 11.0 11.9 12.8 13.9 15.1 16.5
24
Section One
91.0 10.3 11.1 12.0 13.0 14.1 15.3 16.7
91.5 10.4 11.2 12.1 13.1 14.2 15.4 16.8
92.0 10.5 11.3 12.2 13.2 14.3 15.6 17.0
92.5 10.6 11.4 12.3 13.3 14.4 15.7 17.1
93.0 10.7 11.5 12.4 13.4 14.6 15.8 17.3
93.5 10.7 11.6 12.5 13.5 14.7 16.0 17.4
94.0 10.8 11.7 12.6 13.7 14.8 16.1 17.6
94.5 10.9 11.8 12.7 13.8 14.9 16.3 17.7
95.0 11.0 11.9 12.8 13.9 15.1 16.4 17.9
95.5 11.1 12.0 12.9 14.0 15.2 16.5 18.0
96.0 11.2 12.1 13.1 14.1 15.3 16.7 18.2
96.5 11.3 12.2 13.2 14.3 15.5 16.8 18.4
97.0 11.4 12.3 13.3 14.4 15.6 17.0 18.5
97.5 11.5 12.4 13.4 14.5 15.7 17.1 18.7
98.0 11.6 12.5 13.5 14.6 15.9 17.3 18.9
98.5 11.7 12.6 13.6 14.8 16.0 17.5 19.1
99.0 11.8 12.7 13.7 14.9 16.2 17.6 19.2
99.5 11.9 12.8 13.9 15.0 16.3 17.8 19.4
100.0 12.0 12.9 14.0 15.2 16.5 18.0 19.6
100.5 12.1 13.0 14.1 15.3 16.6 18.1 19.8
101.0 12.2 13.2 14.2 15.4 16.8 18.3 20.0
101.5 12.3 13.3 14.4 15.6 16.9 18.5 20.2
102.0 12.4 13.4 14.5 15.7 17.1 18.7 20.4
102.5 12.5 13.5 14.6 15.9 17.3 18.8 20.6
103.0 12.6 13.6 14.8 16.0 17.4 19.0 20.8
103.5 12.7 13.7 14.9 16.2 17.6 19.2 21.0
104.0 12.8 13.9 15.0 16.3 17.8 19.4 21.2
104.5 12.9 14.0 15.2 16.5 17.9 19.6 21.5
105.0 13.0 14.1 15.3 16.6 18.1 19.8 21.7
105.5 13.2 14.2 15.4 16.8 18.3 20.0 21.9
106.0 13.3 14.4 15.6 16.9 18.5 20.2 22.1
25
Section One
106.5 13.4 14.5 15.7 17.1 18.6 20.4 22.4
107.0 13.5 14.6 15.9 17.3 18.8 20.6 22.6
107.5 13.6 14.7 16.0 17.4 19.0 20.8 22.8
108.0 13.7 14.9 16.2 17.6 19.2 21.0 23.1
108.5 13.8 15.0 16.3 17.8 19.4 21.2 23.3
109.0 14.0 15.1 16.5 17.9 19.6 21.4 23.6
109.5 14.1 15.3 16.6 18.1 19.8 21.7 23.8
110.0 14.2 15.4 16.8 18.3 20.0 21.9 24.1

WHO Child Growth Standards
26
Weight-for-height BOYS
2 to 5 years (z-scores)
65.0 5.9 6.3 6.9 7.4 8.1 8.8 9.6
Section One
65.5 6.0 6.4 7.0 7.6 8.2 8.9 9.8
66.0 6.1 6.5 7.1 7.7 8.3 9.1 9.9
66.5 6.1 6.6 7.2 7.8 8.5 9.2 10.1
67.0 6.2 6.7 7.3 7.9 8.6 9.4 10.2
67.5 6.3 6.8 7.4 8.0 8.7 9.5 10.4
68.0 6.4 6.9 7.5 8.1 8.8 9.6 10.5
68.5 6.5 7.0 7.6 8.2 9.0 9.8 10.7
69.0 6.6 7.1 7.7 8.4 9.1 9.9 10.8
69.5 6.7 7.2 7.8 8.5 9.2 10.0 11.0
70.0 6.8 7.3 7.9 8.6 9.3 10.2 11.1
70.5 6.9 7.4 8.0 8.7 9.5 10.3 11.3
71.0 6.9 7.5 8.1 8.8 9.6 10.4 11.4
71.5 7.0 7.6 8.2 8.9 9.7 10.6 11.6
72.0 7.1 7.7 8.3 9.0 9.8 10.7 11.7
72.5 7.2 7.8 8.4 9.1 9.9 10.8 11.8
73.0 7.3 7.9 8.5 9.2 10.0 11.0 12.0
73.5 7.4 7.9 8.6 9.3 10.2 11.1 12.1
74.0 7.4 8.0 8.7 9.4 10.3 11.2 12.2
74.5 7.5 8.1 8.8 9.5 10.4 11.3 12.4
75.0 7.6 8.2 8.9 9.6 10.5 11.4 12.5
75.5 7.7 8.3 9.0 9.7 10.6 11.6 12.6
76.0 7.7 8.4 9.1 9.8 10.7 11.7 12.8
76.5 7.8 8.5 9.2 9.9 10.8 11.8 12.9
77.0 7.9 8.5 9.2 10.0 10.9 11.9 13.0
77.5 8.0 8.6 9.3 10.1 11.0 12.0 13.1
78.0 8.0 8.7 9.4 10.2 11.1 12.1 13.3
78.5 8.1 8.8 9.5 10.3 11.2 12.2 13.4
79.0 8.2 8.8 9.6 10.4 11.3 12.3 13.5
79.5 8.3 8.9 9.7 10.5 11.4 12.4 13.6
27
80.0 8.3 9.0 9.7 10.6 11.5 12.6 13.7

Section One
80.5 8.4 9.1 9.8 10.7 11.6 12.7 13.8
81.0 8.5 9.2 9.9 10.8 11.7 12.8 14.0
81.5 8.6 9.3 10.0 10.9 11.8 12.9 14.1
82.0 8.7 9.3 10.1 11.0 11.9 13.0 14.2
82.5 8.7 9.4 10.2 11.1 12.1 13.1 14.4
83.0 8.8 9.5 10.3 11.2 12.2 13.3 14.5
83.5 8.9 9.6 10.4 11.3 12.3 13.4 14.6
84.0 9.0 9.7 10.5 11.4 12.4 13.5 14.8
84.5 9.1 9.9 10.7 11.5 12.5 13.7 14.9
85.0 9.2 10.0 10.8 11.7 12.7 13.8 15.1
85.5 9.3 10.1 10.9 11.8 12.8 13.9 15.2
86.0 9.4 10.2 11.0 11.9 12.9 14.1 15.4
86.5 9.5 10.3 11.1 12.0 13.1 14.2 15.5
87.0 9.6 10.4 11.2 12.2 13.2 14.4 15.7
87.5 9.7 10.5 11.3 12.3 13.3 14.5 15.8
88.0 9.8 10.6 11.5 12.4 13.5 14.7 16.0
88.5 9.9 10.7 11.6 12.5 13.6 14.8 16.1
89.0 10.0 10.8 11.7 12.6 13.7 14.9 16.3
89.5 10.1 10.9 11.8 12.8 13.9 15.1 16.4
90.0 10.2 11.0 11.9 12.9 14.0 15.2 16.6
90.5 10.3 11.1 12.0 13.0 14.1 15.3 16.7
91.0 10.4 11.2 12.1 13.1 14.2 15.5 16.9
91.5 10.5 11.3 12.2 13.2 14.4 15.6 17.0
92.0 10.6 11.4 12.3 13.4 14.5 15.8 17.2
92.5 10.7 11.5 12.4 13.5 14.6 15.9 17.3
93.0 10.8 11.6 12.6 13.6 14.7 16.0 17.5
93.5 10.9 11.7 12.7 13.7 14.9 16.2 17.6
94.0 11.0 11.8 12.8 13.8 15.0 16.3 17.8
94.5 11.1 11.9 12.9 13.9 15.1 16.5 17.9
95.0 11.1 12.0 13.0 14.1 15.3 16.6 18.1
28
Section One
95.5 11.2 12.1 13.1 14.2 15.4 16.7 18.3
96.0 11.3 12.2 13.2 14.3 15.5 16.9 18.4
96.5 11.4 12.3 13.3 14.4 15.7 17.0 18.6
97.0 11.5 12.4 13.4 14.6 15.8 17.2 18.8
97.5 11.6 12.5 13.6 14.7 15.9 17.4 18.9
98.0 11.7 12.6 13.7 14.8 16.1 17.5 19.1
98.5 11.8 12.8 13.8 14.9 16.2 17.7 19.3
99.0 11.9 12.9 13.9 15.1 16.4 17.9 19.5
99.5 12.0 13.0 14.0 15.2 16.5 18.0 19.7
100.0 12.1 13.1 14.2 15.4 16.7 18.2 19.9
100.5 12.2 13.2 14.3 15.5 16.9 18.4 20.1
101.0 12.3 13.3 14.4 15.6 17.0 18.5 20.3
101.5 12.4 13.4 14.5 15.8 17.2 18.7 20.5
102.0 12.5 13.6 14.7 15.9 17.3 18.9 20.7
102.5 12.6 13.7 14.8 16.1 17.5 19.1 20.9
103.0 12.8 13.8 14.9 16.2 17.7 19.3 21.1
103.5 12.9 13.9 15.1 16.4 17.8 19.5 21.3
104.0 13.0 14.0 15.2 16.5 18.0 19.7 21.6
104.5 13.1 14.2 15.4 16.7 18.2 19.9 21.8
105.0 13.2 14.3 15.5 16.8 18.4 20.1 22.0
105.5 13.3 14.4 15.6 17.0 18.5 20.3 22.2
106.0 13.4 14.5 15.8 17.2 18.7 20.5 22.5
106.5 13.5 14.7 15.9 17.3 18.9 20.7 22.7
107.0 13.7 14.8 16.1 17.5 19.1 20.9 22.9
107.5 13.8 14.9 16.2 17.7 19.3 21.1 23.2
108.0 13.9 15.1 16.4 17.8 19.5 21.3 23.4
108.5 14.0 15.2 16.5 18.0 19.7 21.5 23.7
109.0 14.1 15.3 16.7 18.2 19.8 21.8 23.9
109.5 14.3 15.5 16.8 18.3 20.0 22.0 24.2
110.0 14.4 15.6 17.0 18.5 20.2 22.2 24.4
110.5 14.5 15.8 17.1 18.7 20.4 22.4 24.7
29 29
Section One
111.0 14.6 15.9 17.3 18.9 20.7 22.7 25.0
111.5 14.8 16.0 17.5 19.1 20.9 22.9 25.2
112.0 14.9 16.2 17.6 19.2 21.1 23.1 25.5
112.5 15.0 16.3 17.8 19.4 21.3 23.4 25.8
113.0 15.2 16.5 18.0 19.6 21.5 23.6 26.0
113.5 15.3 16.6 18.1 19.8 21.7 23.9 26.3
114.0 15.4 16.8 18.3 20.0 21.9 24.1 26.6
114.5 15.6 16.9 18.5 20.2 22.1 24.4 26.9
115.0 15.7 17.1 18.6 20.4 22.4 24.6 27.2
115.5 15.8 17.2 18.8 20.6 22.6 24.9 27.5
116.0 16.0 17.4 19.0 20.8 22.8 25.1 27.8
116.5 16.1 17.5 19.2 21.0 23.0 25.4 28.0
117.0 16.2 17.7 19.3 21.2 23.3 25.6 28.3
117.5 16.4 17.9 19.5 21.4 23.5 25.9 28.6
118.0 16.5 18.0 19.7 21.6 23.7 26.1 28.9
118.5 16.7 18.2 19.9 21.8 23.9 26.4 29.2
119.0 16.8 18.3 20.0 22.0 24.1 26.6 29.5
119.5 16.9 18.5 20.2 22.2 24.4 26.9 29.8
120.0 17.1 18.6 20.4 22.4 24.6 27.2 30.1

30 30
Appendix 1.6: Weight-for-Lenght and

Weight-for-Height WHO Charts 2006 (Girls)
Weight-for-length GIRLS
Section One
45.0 1.9 2.1 2.3 2.5 2.7 3.0 3.3
45.5 2.0 2.1 2.3 2.5 2.8 3.1 3.4
46.0 2.0 2.2 2.4 2.6 2.9 3.2 3.5
46.5 2.1 2.3 2.5 2.7 3.0 3.3 3.6
47.0 2.2 2.4 2.6 2.8 3.1 3.4 3.7
47.5 2.2 2.4 2.6 2.9 3.2 3.5 3.8
48.0 2.3 2.5 2.7 3.0 3.3 3.6 4.0
48.5 2.4 2.6 2.8 3.1 3.4 3.7 4.1
49.0 2.4 2.6 2.9 3.2 3.5 3.8 4.2
49.5 2.5 2.7 3.0 3.3 3.6 3.9 4.3
50.0 2.6 2.8 3.1 3.4 3.7 4.0 4.5
50.5 2.7 2.9 3.2 3.5 3.8 4.2 4.6
51.0 2.8 3.0 3.3 3.6 3.9 4.3 4.8
51.5 2.8 3.1 3.4 3.7 4.0 4.4 4.9
52.0 2.9 3.2 3.5 3.8 4.2 4.6 5.1
52.5 3.0 3.3 3.6 3.9 4.3 4.7 5.2
53.0 3.1 3.4 3.7 4.0 4.4 4.9 5.4
53.5 3.2 3.5 3.8 4.2 4.6 5.0 5.5
54.0 3.3 3.6 3.9 4.3 4.7 5.2 5.7
54.5 3.4 3.7 4.0 4.4 4.8 5.3 5.9
55.0 3.5 3.8 4.2 4.5 5.0 5.5 6.1
55.5 3.6 3.9 4.3 4.7 5.1 5.7 6.3
56.0 3.7 4.0 4.4 4.8 5.3 5.8 6.4
56.5 3.8 4.1 4.5 5.0 5.4 6.0 6.6
57.0 3.9 4.3 4.6 5.1 5.6 6.1 6.8
57.5 4.0 4.4 4.8 5.2 5.7 6.3 7.0
58.0 4.1 4.5 4.9 5.4 5.9 6.5 7.1
58.5 4.2 4.6 5.0 5.5 6.0 6.6 7.3
59.0 4.3 4.7 5.1 5.6 6.2 6.8 7.5
59.5 4.4 4.8 5.3 5.7 6.3 6.9 7.7
31 31
Section One
60.0 4.5 4.9 5.4 5.9 6.4 7.1 7.8
60.5 4.6 5.0 5.5 6.0 6.6 7.3 8.0
61.0 4.7 5.1 5.6 6.1 6.7 7.4 8.2
61.5 4.8 5.2 5.7 6.3 6.9 7.6 8.4
62.0 4.9 5.3 5.8 6.4 7.0 7.7 8.5
62.5 5.0 5.4 5.9 6.5 7.1 7.8 8.7
63.0 5.1 5.5 6.0 6.6 7.3 8.0 8.8
63.5 5.2 5.6 6.2 6.7 7.4 8.1 9.0
64.0 5.3 5.7 6.3 6.9 7.5 8.3 9.1
64.5 5.4 5.8 6.4 7.0 7.6 8.4 9.3
65.0 5.5 5.9 6.5 7.1 7.8 8.6 9.5
65.5 5.5 6.0 6.6 7.2 7.9 8.7 9.6
66.0 5.6 6.1 6.7 7.3 8.0 8.8 9.8
66.5 5.7 6.2 6.8 7.4 8.1 9.0 9.9
67.0 5.8 6.3 6.9 7.5 8.3 9.1 10.0
67.5 5.9 6.4 7.0 7.6 8.4 9.2 10.2
68.0 6.0 6.5 7.1 7.7 8.5 9.4 10.3
68.5 6.1 6.6 7.2 7.9 8.6 9.5 10.5
69.0 6.1 6.7 7.3 8.0 8.7 9.6 10.6
69.5 6.2 6.8 7.4 8.1 8.8 9.7 10.7
70.0 6.3 6.9 7.5 8.2 9.0 9.9 10.9
70.5 6.4 6.9 7.6 8.3 9.1 10.0 11.0
71.0 6.5 7.0 7.7 8.4 9.2 10.1 11.1
71.5 6.5 7.1 7.7 8.5 9.3 10.2 11.3
72.0 6.6 7.2 7.8 8.6 9.4 10.3 11.4
72.5 6.7 7.3 7.9 8.7 9.5 10.5 11.5
73.0 6.8 7.4 8.0 8.8 9.6 10.6 11.7
73.5 6.9 7.4 8.1 8.9 9.7 10.7 11.8
74.0 6.9 7.5 8.2 9.0 9.8 10.8 11.9
74.5 7.0 7.6 8.3 9.1 9.9 10.9 12.0
75.0 7.1 7.7 8.4 9.1 10.0 11.0 12.2
32
75.5 7.1 7.8 8.5 9.2 10.1 11.1 12.3
Section One
76.0 7.2 7.8 8.5 9.3 10.2 11.2 12.4
76.5 7.3 7.9 8.6 9.4 10.3 11.4 12.5
77.0 7.4 8.0 8.7 9.5 10.4 11.5 12.6
77.5 7.4 8.1 8.8 9.6 10.5 11.6 12.8
78.0 7.5 8.2 8.9 9.7 10.6 11.7 12.9
78.5 7.6 8.2 9.0 9.8 10.7 11.8 13.0
79.0 7.7 8.3 9.1 9.9 10.8 11.9 13.1
79.5 7.7 8.4 9.1 10.0 10.9 12.0 13.3
80.0 7.8 8.5 9.2 10.1 11.0 12.1 13.4
80.5 7.9 8.6 9.3 10.2 11.2 12.3 13.5
81.0 8.0 8.7 9.4 10.3 11.3 12.4 13.7
81.5 8.1 8.8 9.5 10.4 11.4 12.5 13.8
82.0 8.1 8.8 9.6 10.5 11.5 12.6 13.9
82.5 8.2 8.9 9.7 10.6 11.6 12.8 14.1
83.0 8.3 9.0 9.8 10.7 11.8 12.9 14.2
83.5 8.4 9.1 9.9 10.9 11.9 13.1 14.4
84.0 8.5 9.2 10.1 11.0 12.0 13.2 14.5
84.5 8.6 9.3 10.2 11.1 12.1 13.3 14.7
85.0 8.7 9.4 10.3 11.2 12.3 13.5 14.9
85.5 8.8 9.5 10.4 11.3 12.4 13.6 15.0
86.0 8.9 9.7 10.5 11.5 12.6 13.8 15.2
86.5 9.0 9.8 10.6 11.6 12.7 13.9 15.4
87.0 9.1 9.9 10.7 11.7 12.8 14.1 15.5
87.5 9.2 10.0 10.9 11.8 13.0 14.2 15.7
88.0 9.3 10.1 11.0 12.0 13.1 14.4 15.9
88.5 9.4 10.2 11.1 12.1 13.2 14.5 16.0
89.0 9.5 10.3 11.2 12.2 13.4 14.7 16.2
89.5 9.6 10.4 11.3 12.3 13.5 14.8 16.4
90.0 9.7 10.5 11.4 12.5 13.7 15.0 16.5
90.5 9.8 10.6 11.5 12.6 13.8 15.1 16.7
33
91.0 9.9 10.7 11.7 12.7 13.9 15.3 16.9

Section One
91.5 10.0 10.8 11.8 12.8 14.1 15.5 17.0
92.0 10.1 10.9 11.9 13.0 14.2 15.6 17.2
92.5 10.1 11.0 12.0 13.1 14.3 15.8 17.4
93.0 10.2 11.1 12.1 13.2 14.5 15.9 17.5
93.5 10.3 11.2 12.2 13.3 14.6 16.1 17.7
94.0 10.4 11.3 12.3 13.5 14.7 16.2 17.9
94.5 10.5 11.4 12.4 13.6 14.9 16.4 18.0
95.0 10.6 11.5 12.6 13.7 15.0 16.5 18.2
95.5 10.7 11.6 12.7 13.8 15.2 16.7 18.4
96.0 10.8 11.7 12.8 14.0 15.3 16.8 18.6
96.5 10.9 11.8 12.9 14.1 15.4 17.0 18.7
97.0 11.0 12.0 13.0 14.2 15.6 17.1 18.9
97.5 11.1 12.1 13.1 14.4 15.7 17.3 19.1
98.0 11.2 12.2 13.3 14.5 15.9 17.5 19.3
98.5 11.3 12.3 13.4 14.6 16.0 17.6 19.5
99.0 11.4 12.4 13.5 14.8 16.2 17.8 19.6
99.5 11.5 12.5 13.6 14.9 16.3 18.0 19.8
100.0 11.6 12.6 13.7 15.0 16.5 18.1 20.0
100.5 11.7 12.7 13.9 15.2 16.6 18.3 20.2
101.0 11.8 12.8 14.0 15.3 16.8 18.5 20.4
101.5 11.9 13.0 14.1 15.5 17.0 18.7 20.6
102.0 12.0 13.1 14.3 15.6 17.1 18.9 20.8
102.5 12.1 13.2 14.4 15.8 17.3 19.0 21.0
103.0 12.3 13.3 14.5 15.9 17.5 19.2 21.3
103.5 12.4 13.5 14.7 16.1 17.6 19.4 21.5
104.0 12.5 13.6 14.8 16.2 17.8 19.6 21.7
104.5 12.6 13.7 15.0 16.4 18.0 19.8 21.9
105.0 12.7 13.8 15.1 16.5 18.2 20.0 22.2
105.5 12.8 14.0 15.3 16.7 18.4 20.2 22.4
106.0 13.0 14.1 15.4 16.9 18.5 20.5 22.6
34
106.5 13.1 14.3 15.6 17.1 18.7 20.7 22.9
Section One
107.0 13.2 14.4 15.7 17.2 18.9 20.9 23.1
107.5 13.3 14.5 15.9 17.4 19.1 21.1 23.4
108.0 13.5 14.7 16.0 17.6 19.3 21.3 23.6
108.5 13.6 14.8 16.2 17.8 19.5 21.6 23.9
109.0 13.7 15.0 16.4 18.0 19.7 21.8 24.2
109.5 13.9 15.1 16.5 18.1 20.0 22.0 24.4
110.0 14.0 15.3 16.7 18.3 20.2 22.3 24.7

35
Weight-for-height GIRLS
65.0 5.6 6.1 6.6 7.2 7.9 8.7 9.7

Section One
65.5 5.7 6.2 6.7 7.4 8.1 8.9 9.8
66.0 5.8 6.3 6.8 7.5 8.2 9.0 10.0
66.5 5.8 6.4 6.9 7.6 8.3 9.1 10.1
67.0 5.9 6.4 7.0 7.7 8.4 9.3 10.2
67.5 6.0 6.5 7.1 7.8 8.5 9.4 10.4
68.0 6.1 6.6 7.2 7.9 8.7 9.5 10.5
68.5 6.2 6.7 7.3 8.0 8.8 9.7 10.7
69.0 6.3 6.8 7.4 8.1 8.9 9.8 10.8
69.5 6.3 6.9 7.5 8.2 9.0 9.9 10.9
70.0 6.4 7.0 7.6 8.3 9.1 10.0 11.1
70.5 6.5 7.1 7.7 8.4 9.2 10.1 11.2
71.0 6.6 7.1 7.8 8.5 9.3 10.3 11.3
71.5 6.7 7.2 7.9 8.6 9.4 10.4 11.5
72.0 6.7 7.3 8.0 8.7 9.5 10.5 11.6
72.5 6.8 7.4 8.1 8.8 9.7 10.6 11.7
73.0 6.9 7.5 8.1 8.9 9.8 10.7 11.8
73.5 7.0 7.6 8.2 9.0 9.9 10.8 12.0
74.0 7.0 7.6 8.3 9.1 10.0 11.0 12.1
74.5 7.1 7.7 8.4 9.2 10.1 11.1 12.2
75.0 7.2 7.8 8.5 9.3 10.2 11.2 12.3
75.5 7.2 7.9 8.6 9.4 10.3 11.3 12.5
76.0 7.3 8.0 8.7 9.5 10.4 11.4 12.6
76.5 7.4 8.0 8.7 9.6 10.5 11.5 12.7
77.0 7.5 8.1 8.8 9.6 10.6 11.6 12.8
77.5 7.5 8.2 8.9 9.7 10.7 11.7 12.9
78.0 7.6 8.3 9.0 9.8 10.8 11.8 13.1
78.5 7.7 8.4 9.1 9.9 10.9 12.0 13.2
79.0 7.8 8.4 9.2 10.0 11.0 12.1 13.3
79.5 7.8 8.5 9.3 10.1 11.1 12.2 13.4
36
80.0 7.9 8.6 9.4 10.2 11.2 12.3 13.6
Section One
80.5 8.0 8.7 9.5 10.3 11.3 12.4 13.7
81.0 8.1 8.8 9.6 10.4 11.4 12.6 13.9
81.5 8.2 8.9 9.7 10.6 11.6 12.7 14.0
82.0 8.3 9.0 9.8 10.7 11.7 12.8 14.1
82.5 8.4 9.1 9.9 10.8 11.8 13.0 14.3
83.0 8.5 9.2 10.0 10.9 11.9 13.1 14.5
83.5 8.5 9.3 10.1 11.0 12.1 13.3 14.6
84.0 8.6 9.4 10.2 11.1 12.2 13.4 14.8
84.5 8.7 9.5 10.3 11.3 12.3 13.5 14.9
85.0 8.8 9.6 10.4 11.4 12.5 13.7 15.1
85.5 8.9 9.7 10.6 11.5 12.6 13.8 15.3
86.0 9.0 9.8 10.7 11.6 12.7 14.0 15.4
86.5 9.1 9.9 10.8 11.8 12.9 14.2 15.6
87.0 9.2 10.0 10.9 11.9 13.0 14.3 15.8
87.5 9.3 10.1 11.0 12.0 13.2 14.5 15.9
88.0 9.4 10.2 11.1 12.1 13.3 14.6 16.1
88.5 9.5 10.3 11.2 12.3 13.4 14.8 16.3
89.0 9.6 10.4 11.4 12.4 13.6 14.9 16.4
89.5 9.7 10.5 11.5 12.5 13.7 15.1 16.6
90.0 9.8 10.6 11.6 12.6 13.8 15.2 16.8
90.5 9.9 10.7 11.7 12.8 14.0 15.4 16.9
91.0 10.0 10.9 11.8 12.9 14.1 15.5 17.1
91.5 10.1 11.0 11.9 13.0 14.3 15.7 17.3
92.0 10.2 11.1 12.0 13.1 14.4 15.8 17.4
92.5 10.3 11.2 12.1 13.3 14.5 16.0 17.6
93.0 10.4 11.3 12.3 13.4 14.7 16.1 17.8
93.5 10.5 11.4 12.4 13.5 14.8 16.3 17.9
94.0 10.6 11.5 12.5 13.6 14.9 16.4 18.1
94.5 10.7 11.6 12.6 13.8 15.1 16.6 18.3
95.0 10.8 11.7 12.7 13.9 15.2 16.7 18.5
37
95.5 10.8 11.8 12.8 14.0 15.4 16.9 18.6

Section One
96.0 10.9 11.9 12.9 14.1 15.5 17.0 18.8
96.5 11.0 12.0 13.1 14.3 15.6 17.2 19.0
97.0 11.1 12.1 13.2 14.4 15.8 17.4 19.2
97.5 11.2 12.2 13.3 14.5 15.9 17.5 19.3
98.0 11.3 12.3 13.4 14.7 16.1 17.7 19.5
98.5 11.4 12.4 13.5 14.8 16.2 17.9 19.7
99.0 11.5 12.5 13.7 14.9 16.4 18.0 19.9
99.5 11.6 12.7 13.8 15.1 16.5 18.2 20.1
100.0 11.7 12.8 13.9 15.2 16.7 18.4 20.3
100.5 11.9 12.9 14.1 15.4 16.9 18.6 20.5
101.0 12.0 13.0 14.2 15.5 17.0 18.7 20.7
101.5 12.1 13.1 14.3 15.7 17.2 18.9 20.9
102.0 12.2 13.3 14.5 15.8 17.4 19.1 21.1
102.5 12.3 13.4 14.6 16.0 17.5 19.3 21.4
103.0 12.4 13.5 14.7 16.1 17.7 19.5 21.6
103.5 12.5 13.6 14.9 16.3 17.9 19.7 21.8
104.0 12.6 13.8 15.0 16.4 18.1 19.9 22.0
104.5 12.8 13.9 15.2 16.6 18.2 20.1 22.3
105.0 12.9 14.0 15.3 16.8 18.4 20.3 22.5
105.5 13.0 14.2 15.5 16.9 18.6 20.5 22.7
106.0 13.1 14.3 15.6 17.1 18.8 20.8 23.0
106.5 13.3 14.5 15.8 17.3 19.0 21.0 23.2
107.0 13.4 14.6 15.9 17.5 19.2 21.2 23.5
107.5 13.5 14.7 16.1 17.7 19.4 21.4 23.7
108.0 13.7 14.9 16.3 17.8 19.6 21.7 24.0
108.5 13.8 15.0 16.4 18.0 19.8 21.9 24.3
109.0 13.9 15.2 16.6 18.2 20.0 22.1 24.5
109.5 14.1 15.4 16.8 18.4 20.3 22.4 24.8
110.0 14.2 15.5 17.0 18.6 20.5 22.6 25.1
110.5 14.4 15.7 17.1 18.8 20.7 22.9 25.4
38
111.0 14.5 15.8 17.3 19.0 20.9 23.1 25.7
Section One
111.5 14.7 16.0 17.5 19.2 21.2 23.4 26.0
112.0 14.8 16.2 17.7 19.4 21.4 23.6 26.2
112.5 15.0 16.3 17.9 19.6 21.6 23.9 26.5
113.0 15.1 16.5 18.0 19.8 21.8 24.2 26.8
113.5 15.3 16.7 18.2 20.0 22.1 24.4 27.1
114.0 15.4 16.8 18.4 20.2 22.3 24.7 27.4
114.5 15.6 17.0 18.6 20.5 22.6 25.0 27.8
115.0 15.7 17.2 18.8 20.7 22.8 25.2 28.1
115.5 15.9 17.3 19.0 20.9 23.0 25.5 28.4
116.0 16.0 17.5 19.2 21.1 23.3 25.8 28.7
116.5 16.2 17.7 19.4 21.3 23.5 26.1 29.0
117.0 16.3 17.8 19.6 21.5 23.8 26.3 29.3
117.5 16.5 18.0 19.8 21.7 24.0 26.6 29.6
118.0 16.6 18.2 19.9 22.0 24.2 26.9 29.9
118.5 16.8 18.4 20.1 22.2 24.5 27.2 30.3
119.0 16.9 18.5 20.3 22.4 24.7 27.4 30.6
119.5 17.1 18.7 20.5 22.6 25.0 27.7 30.9
120.0 17.3 18.9 20.7 22.8 25.2 28.0 31.2

39
Section One
40
BMI-for-age BOYS
Z-scores (BMI in kg/m2)
Year: Month Month L M S -3 SD -2 SD -1 SD Median 1 SD 2 SD 3 SD
5: 1 61 -0.7387 15.2641 0.08390 12.1 13.0 14.1 15.3 16.6 18.3 20.2
5: 2 62 -0.7621 15.2616 0.08414 12.1 13.0 14.1 15.3 16.6 18.3 20.2
5: 3 63 -0.7856 15.2604 0.08439 12.1 13.0 14.1 15.3 16.7 18.3 20.2
5: 4 64 -0.8089 15.2605 0.08464 12.1 13.0 14.1 15.3 16.7 18.3 20.3
5: 5 65 -0.8322 15.2619 0.08490 12.1 13.0 14.1 15.3 16.7 18.3 20.3
5: 6 66 -0.8554 15.2645 0.08516 12.1 13.0 14.1 15.3 16.7 18.4 20.4
5: 7 67 -0.8785 15.2684 0.08543 12.1 13.0 14.1 15.3 16.7 18.4 20.4
5: 8 68 -0.9015 15.2737 0.08570 12.1 13.0 14.1 15.3 16.7 18.4 20.5
5: 9 69 -0.9243 15.2801 0.08597 12.1 13.0 14.1 15.3 16.7 18.4 20.5
5:10 70 -0.9471 15.2877 0.08625 12.1 13.0 14.1 15.3 16.7 18.5 20.6
5:11 71 -0.9697 15.2965 0.08653 12.1 13.0 14.1 15.3 16.7 18.5 20.6
6: 0 72 -0.9921 15.3062 0.08682 12.1 13.0 14.1 15.3 16.8 18.5 20.7
6: 1 73 -1.0144 15.3169 0.08711 12.1 13.0 14.1 15.3 16.8 18.6 20.8
6: 2 74 -1.0365 15.3285 0.08741 12.2 13.1 14.1 15.3 16.8 18.6 20.8
6: 3 75 -1.0584 15.3408 0.08771 12.2 13.1 14.1 15.3 16.8 18.6 20.9
6: 4 76 -1.0801 15.3540 0.08802 12.2 13.1 14.1 15.4 16.8 18.7 21.0
6: 5 77 -1.1017 15.3679 0.08833 12.2 13.1 14.1 15.4 16.9 18.7 21.0
6: 6 78 -1.1230 15.3825 0.08865 12.2 13.1 14.1 15.4 16.9 18.7 21.1
6: 7 79 -1.1441 15.3978 0.08898 12.2 13.1 14.1 15.4 16.9 18.8 21.2
6: 8 80 -1.1649 15.4137 0.08931 12.2 13.1 14.2 15.4 16.9 18.8 21.3
6: 9 81 -1.1856 15.4302 0.08964 12.2 13.1 14.2 15.4 17.0 18.9 21.3
6:10 82 -1.2060 15.4473 0.08998 12.2 13.1 14.2 15.4 17.0 18.9 21.4
6:11 83 -1.2261 15.4650 0.09033 12.2 13.1 14.2 15.5 17.0 19.0 21.5
7: 0 84 -1.2460 15.4832 0.09068 12.3 13.1 14.2 15.5 17.0 19.0 21.6
7: 1 85 -1.2656 15.5019 0.09103 12.3 13.2 14.2 15.5 17.1 19.1 21.7
7: 2 86 -1.2849 15.5210 0.09139 12.3 13.2 14.2 15.5 17.1 19.1 21.8
Appendix 1.7: BMI-for-age, WHO Charts 2006 (Boys)
2007 WHO Reference
Page 1 of 7
BMI-for-age GIRLS
Z-scores (BMI in kg/m2)
Year: Month Month L M S -3 SD -2 SD -1 SD Median 1 SD 2 SD 3 SD
5: 1 61 -0.8886 15.2441 0.09692 11.8 12.7 13.9 15.2 16.9 18.9 21.3
5: 2 62 -0.9068 15.2434 0.09738 11.8 12.7 13.9 15.2 16.9 18.9 21.4
5: 3 63 -0.9248 15.2433 0.09783 11.8 12.7 13.9 15.2 16.9 18.9 21.5
5: 4 64 -0.9427 15.2438 0.09829 11.8 12.7 13.9 15.2 16.9 18.9 21.5
5: 5 65 -0.9605 15.2448 0.09875 11.7 12.7 13.9 15.2 16.9 19.0 21.6
5: 6 66 -0.9780 15.2464 0.09920 11.7 12.7 13.9 15.2 16.9 19.0 21.7
5: 7 67 -0.9954 15.2487 0.09966 11.7 12.7 13.9 15.2 16.9 19.0 21.7
5: 8 68 -1.0126 15.2516 0.10012 11.7 12.7 13.9 15.3 17.0 19.1 21.8
5: 9 69 -1.0296 15.2551 0.10058 11.7 12.7 13.9 15.3 17.0 19.1 21.9
5:10 70 -1.0464 15.2592 0.10104 11.7 12.7 13.9 15.3 17.0 19.1 22.0
5:11 71 -1.0630 15.2641 0.10149 11.7 12.7 13.9 15.3 17.0 19.2 22.1
6: 0 72 -1.0794 15.2697 0.10195 11.7 12.7 13.9 15.3 17.0 19.2 22.1
6: 1 73 -1.0956 15.2760 0.10241 11.7 12.7 13.9 15.3 17.0 19.3 22.2
6: 2 74 -1.1115 15.2831 0.10287 11.7 12.7 13.9 15.3 17.0 19.3 22.3
6: 3 75 -1.1272 15.2911 0.10333 11.7 12.7 13.9 15.3 17.1 19.3 22.4
6: 4 76 -1.1427 15.2998 0.10379 11.7 12.7 13.9 15.3 17.1 19.4 22.5
6: 5 77 -1.1579 15.3095 0.10425 11.7 12.7 13.9 15.3 17.1 19.4 22.6
6: 6 78 -1.1728 15.3200 0.10471 11.7 12.7 13.9 15.3 17.1 19.5 22.7
6: 7 79 -1.1875 15.3314 0.10517 11.7 12.7 13.9 15.3 17.2 19.5 22.8
6: 8 80 -1.2019 15.3439 0.10562 11.7 12.7 13.9 15.3 17.2 19.6 22.9
6: 9 81 -1.2160 15.3572 0.10608 11.7 12.7 13.9 15.4 17.2 19.6 23.0
6:10 82 -1.2298 15.3717 0.10654 11.7 12.7 13.9 15.4 17.2 19.7 23.1
6:11 83 -1.2433 15.3871 0.10700 11.7 12.7 13.9 15.4 17.3 19.7 23.2
7: 0 84 -1.2565 15.4036 0.10746 11.8 12.7 13.9 15.4 17.3 19.8 23.3
7: 1 85 -1.2693 15.4211 0.10792 11.8 12.7 13.9 15.4 17.3 19.8 23.4
Appendix 1.8: BMI-for-age, WHO Charts 2006 (Girls)
7: 2 86 -1.2819 15.4397 0.10837 11.8 12.8 14.0 15.4 17.4 19.9 23.5
2007 WHO Reference

Page 1 of 7
41
Section One
Appendix 1.9: Weight-for-height (z-scores) NCHS charts

for children aged 6 - 59 months (now replaced by WHO)
The table below is based on the NCHS standards. The height-for-age and weight-for-age
standards were amalgamated to determine the median weight for height. The sexes were
combined when the uni-sex standard is within 1.5% of the body weight of the standard
for either sex.
Section One
Boys’ Weight (kg) Length Girls’ Weight (kg)

-4 SD -3SD -2SD -1SD Median (cm) Median -1SD -2SD -3SD -4SD
1.8 2.1 2.5 2.8 3.1 49 3.3 2.9 2.6 2.2 1.8
1.8 2.2 2.5 2.9 3.3 50 3.4 3.0 2.6 2.3 1.9
1.8 2.2 2.6 3.1 3.5 51 3.5 3.1 2.7 2.3 1.9
1.9 2.3 2.8 3.2 3.7 52 3.7 3.3 2.8 2.4 2.0
1.9 2.4 2.9 3.4 3.9 53 3.9 3.4 3.0 2.5 2.1
2.0 2.6 3.1 3.6 4.1 54 4.1 3.6 3.1 2.7 2.2
2.2 2.7 3.3 3.8 4.3 55 4.3 3.8 3.3 2.8 2.3
2.3 2.9 3.5 4.0 4.6 56 4.5 4.0 3.5 3.0 2.4
2.5 3.1 3.7 4.3 4.8 57 4.8 4.’2 3.7 3.1 2.6
2.7 3.3 3.9 4.5 5.1 58 5.0 4.4 3.9 3.3 2.7
2.9 3.5 4.1 4.8 5.4 59 5.3 4.7 4.1 3.5 2.9
3.1 3.7 4.4 5.0 5.7 60 5.5 4.9 4.3 3.7 3.1
3.3 4.0 4.6 5.3 5.9 61 5.8 5.2 4.6 3.9 3.3
3.5 4.2 4.9 5.6 6.2 62 6.1 5.4 4.8 4.1 3.5
3.8 4.5 5.2 5.8 6.5 63 6.4 5.7 5.0 4.4 3.7
4.0 4.7 5.4 6.1 6.8 64 6.7 6.0 5.3 4.6 3.9
4.3 5.0 5.7 6.4 7.1 65 7.0 6.3 5.5 4.8 4.1
4.5 5.3 6.0 6.7 7.4 66 7.3 6.5 5.8 5.1 4.3
4.8 5.5 6.2 7.0 7.7 67 7.5 6.8 6.0 5.3 4.5
5.1 5.8 6.5 7.3 8.0 68 7.8 7.1 6.3 5.5 4.8
5.3 6.0 6.8 7.5 8.3 69 8.1 7.3 6.5 5.8 5.0
5.5 6.3 7.0 7.8 8.5 70 8.4 7.6 6.8 6.0 5.2
5.8 6.5 7.3 8.1 8.8 71 8.6 7.8 7.0 6.2 5.4
6.0 6.8 7.5 8.3 9.1 72 8.9 8.1 7.2 6.4 5.6
6.2 7.0 7.8 8.6 9.3 73 9.1 8.3 7.5 6.6 5.8
6.4 7.2 8.0 8.8 9.6 74 9.4 8.5 7.7 6.8 6.0
6.6 7.4 8.2 9.0 9.8 75 9.6 8.7 7.9 7.0 6.2
6.8 7.6 8.4 9.2 10.0 76 9.8 8.9 8.1 7.2 6.4
7.0 7.8 8.6 9.4 10.3 77 10.0 9.1 8.3 7.4 6.6
7.1 8.0 8.8 9.7 10.5 78 10.2 9.3 8.5 7.6 6.7
7.3 8.2 9.0 9.9 10.7 79 10.4 9.5 8.7 7.8 6.9
7.5 8.3 9.2 10.1 10.9 80 10.6 9.7 8.8 8.0 7.1
7.6 8.5 9.4 10.2 11.1 81 10.8 9.9 9.0 8.1 7.2
7.8 8.7 9.6 10.4 11.3 82 11.0 10.1 9.2 8.3 7.4
7.9 8.8 9.7 10.6 11.5 83 11.2 10.3 9.4 8.5 7.6
8.1 9.0 9.9 10.8 11.7 84 11.4 10.5 9.6 8.7 7.7
7.8 8.9 9.9 11.0 12.1 85 11.8 10.8 9.7 8.6 7.6
7.9 9.0 10.1 11.2 12.3 86 12.0 11.0 9.9 8.8 7.7
42

8.1 9.2 10.3 11.5 12.6 87 12.3 11.2 10.1 9.0 7.9
8.3 9.4 10.5 11.7 12.8 88 12.5 11.4 10.3 9.2 8.1
8.4 9.6 10.7 11.9 13.0 89 12.7 11.6 10.5 9.3 8.2
8.6 9.8 10.9 12.1 13.3 90 12.9 11.8 10.7 9.5 8.4
Section One
8.8 9.9 11.1 12.3 13.5 91 13.2 12.0 10.8 9.7 8.5
8.9 10.1 11.3 12.5 13.7 92 13.4 12.2 11.0 9.9 8.7
9.1 10.3 11.5 12.8 14.0 93 13.6 12.4 11.2 10.0 8.8
9.2 10.5 11.7 13.0 14.2 94 13.9 12.6 11.4 10.2 9.0
9.4 10.7 11.9 13.2 14.5 95 14.1 12.9 11.6 10.4 9.1
9.6 10.9 12.1 13.4 14.7 96 14.3 13.1 11.8 10.6 9.3
9.7 11.0 12.4 13.7 15.0 97 14.6 13.3 12.0 10.7 9.5
9.9 11.2 12.6 13.9 15.2 98 14.9 13.5 12.2 10.9 9.6
10.1 11.4 12.8 14.1 15.5 99 15.1 13.8 12.4 11.1 9.8
10.3 11.6 13.0 14.4 15.7 100 15.4 14.0 12.7 11.3 9.9
10.4 11.8 13.2 14.6 16.0 101 15.6 14.3 12.9 11.5 10.1
10.6 12.0 13.4 14.9 16.3 102 15.9 14.5 13.1 11.7 10.3
10.8 12.2 13.7 15.1 16.6 103 16.2 14.7 13.3 11.9 10.5
11.0 12.4 13.9 15.4 16.9 104 16.5 15.0 13.5 12.1 10.6
11.2 12.7 14.2 15.6 17.1 105 16.7 15.3 13.8 12.3 10.8
11.4 12.9 14.4 15.9 17.4 106 17.0 15.5 14.0 12.5 11.0
11.6 13.1 14.7 16.2 17.7 107 17.3 15.8 14.3 12.7 11.2
11.8 13.4 14.9 16.5 18.0 108 17.6 16.1 14.5 13.0 11.4
12.0 13.6 15.2 16.8 18.3 109 17.9 16.4 14.8 13.2 11.6
12.2 13.8 15.4 17.1 18.7 110 18.2 16.6 15.0 13.4 11.9
12.5 14.1 15.7 17.4 19.0 111 18.6 16.9 15.3 13.7 12.1
12.7 14.4 16.0 17.7 19.3 112 18.9 17.2 15.6 14.0 12.3
12.9 14.6 16.3 18.0 19.6 113 19.2 17.5 15.9 14.2 12.6
13.2 14.9 16.6 18.3 20.0 114 19.5 17.9 16.2 14.5 12.8
13.5 15.2 16.9 18.6 20.3 115 19.9 18.2 16.5 14.8 13.0
13.7 15.5 17.2 18.9 20.7 116 20.3 18.5 16.8 15.0 13.3
14.0 15.8 17.5 19.3 21.1 117 20.6 18.9 17.1 15.3 13.6
14.3 16.1 17.9 19.6 21.4 118 21.0 19.2 17.4 15.6 13.8
14.6 16.4 18.2 20.0 21.8 119 21.4 19.6 17.7 15.9 14.1
14.9 16.7 18.5 20.4 22.2 120 21.8 20.0 18.1 16.2 14.3
15.2 17.0 18.9 20.7 22.6 121 22.2 20.3 18.4 16.5 14.6
15.5 17.4 19.2 21.1 23.0 122 22.7 20.7 18.8 16.8 14.9
15.8 17.7 19.6 21.5 23.4 123 23.1 21.1 19.1 17.1 15.1
16.1 18.0 20.0 21.9 23.9 124 23.6 21.6 19.5 17.4 15.4
16.4 18.4 20.4 22.3 24.3 125 24.1 22.0 19.9 17.8 15.6
16.7 18.7 20.7 22.8 24.8 126 24.6 22.4 20.2 18.1 15.9
17.0 19.1 21.1 23.2 25.2 127 25.1 22.9 20.6 18.4 16.2
17.3 19.4 21.5 23.6 25.7 128 25.7 23.3 21.0 18.7 16.4
17.6 19.8 21.9 24.1 26.2 129 26.2 23.8 21.4 19.0 16.7
17.9 20.1 22.3 24.5 26.8 130 26.8 24.3 21.8 19.4 16.9
43
Appendix 1.10: Weight for Age WHO Chart 2006 (Boys & Girls)
1.70 2.08 2.46 2.88 3.35 0 3.23 2.79 2.39 2.03 1.67
2.47 2.93 3.39 3.90 4.47 1 4.19 3.64 3.16 2.73 2.30
3.25 3.79 4.32 4.91 5.57 2 5.13 4.50 3.94 3.45 2.95
3.85 4.44 5.02 5.66 6.38 3 5.85 5.15 4.54 3.99 3.45
Section One
4.32 4.94 5.56 6.25 7.00 4 6.42 5.67 5.01 4.43 3.85
4.69 5.34 6.00 6.72 7.51 5 6.90 6.10 5.40 4.79 4.17
4.99 5.67 6.35 7.11 7.93 6 7.30 6.46 5.73 5.09 4.44
5.24 5.95 6.65 7.43 8.30 7 7.64 6.77 6.01 5.34 4.67
5.45 6.18 6.91 7.72 8.62 8 7.95 7.04 6.25 5.56 4.87
5.64 6.39 7.14 7.98 8.90 9 8.23 7.29 6.47 5.76 5.05
5.81 6.58 7.36 8.22 9.16 10 8.48 7.51 6.67 5.94 5.21
5.96 6.76 7.55 8.44 9.41 11 8.72 7.72 6.86 6.11 5.36
6.11 6.93 7.74 8.65 9.65 12 8.95 7.93 7.04 6.27 5.51
6.25 7.09 7.92 8.85 9.87 13 9.17 8.12 7.22 6.43 5.65
6.39 7.24 8.10 9.04 10.10 14 9.39 8.32 7.39 6.59 5.79
6.52 7.39 8.27 9.23 10.31 15 9.60 8.50 7.56 6.74 5.92
6.65 7.54 8.43 9.42 10.52 16 9.81 8.69 7.73 6.89 6.06
6.78 7.69 8.59 9.60 10.73 17 10.02 8.88 7.89 7.04 6.19
6.90 7.83 8.75 9.79 10.94 18 10.23 9.06 8.06 7.19 6.33
7.02 7.97 8.91 9.97 11.14 19 10.44 9.25 8.22 7.34 6.46
7.14 8.10 9.07 10.14 11.35 20 10.65 9.43 8.39 7.49 6.59
7.25 8.24 9.22 10.32 11.55 21 10.85 9.61 8.55 7.63 6.72
7.37 8.37 9.37 10.49 11.75 22 11.06 9.80 8.71 7.78 6.84
7.48 8.50 9.52 10.67 11.95 23 11.27 9.98 8.87 7.92 6.97
7.59 8.63 9.67 10.84 12.15 24 11.48 10.16 9.04 8.07 7.10
7.70 8.76 9.82 11.01 12.35 25 11.69 10.35 9.20 8.21 7.22
7.81 8.89 9.97 11.18 12.55 26 11.89 10.53 9.36 8.35 7.34
7.91 9.01 10.11 11.35 12.74 27 12.10 10.71 9.52 8.49 7.47
8.01 9.13 10.25 11.51 12.93 28 12.31 10.88 9.67 8.63 7.58
8.11 9.25 10.39 11.67 13.12 29 12.51 11.06 9.82 8.76 7.70
8.21 9.37 10.52 11.83 13.30 30 12.71 11.23 9.97 8.89 7.81
8.30 9.48 10.65 11.98 13.48 31 12.90 11.40 10.12 9.02 7.92
8.40 9.59 10.78 12.13 13.66 32 13.09 11.56 10.26 9.14 8.02
8.49 9.70 10.91 12.28 13.83 33 13.28 11.72 10.40 9.26 8.12
8.58 9.81 11.03 12.42 14.00 34 13.47 11.89 10.53 9.38 8.22
8.67 9.91 11.16 12.57 14.17 35 13.66 12.04 10.67 9.50 8.32
8.75 10.02 11.28 12.71 14.34 36 13.85 12.20 10.81 9.61 8.42
8.84 10.12 11.40 12.86 14.51 37 14.04 12.36 10.94 9.73 8.51
8.93 10.23 11.52 13.00 14.68 38 14.23 12.52 11.07 9.84 8.60
9.02 10.33 11.64 13.14 14.85 39 14.41 12.67 11.20 9.95 8.69
9.10 10.43 11.76 13.28 15.01 40 14.60 12.83 11.33 10.06 8.78
9.19 10.54 11.88 13.42 15.18 41 14.79 12.98 11.46 10.16 8.87
9.27 10.64 12.00 13.56 15.35 42 14.97 13.14 11.59 10.27 8.95
9.36 10.74 12.12 13.71 15.52 43 15.16 13.29 11.71 10.37 9.04
44
8.93 10.23 11.52 13.00 14.68 38 14.23 12.52 11.07 9.84 8.60
9.02 10.33 11.64 13.14 14.85 39 14.41 12.67 11.20 9.95 8.69
9.10 10.43 11.76 13.28 15.01 40 14.60 12.83 11.33 10.06 8.78
9.19 10.54 11.88 13.42 15.18 41 14.79 12.98 11.46 10.16 8.87
9.27 10.64
Boys’12.00
Weight13.56
(kg) 15.35 42
Length 14.97 13.14 11.59 (kg)
Girls’ Weight 10.27 8.95
9.36
-4 SD 10.74
-3SD 12.12
-2SD 13.71
-1SD 15.52
Median (cm)
43 15.16 13.29
Median -1SD 11.71
-2SD 10.37
-3SD 9.04
-4SD
9.44 10.84 12.24 13.85 15.68 44 15.34 13.44 11.84 10.48 9.12
9.52 10.94 12.36 13.99 15.85 45 15.52 13.59 11.96 10.58 9.20
9.61 11.04 12.48 14.13 16.02 46 15.71 13.74 12.08 10.68 9.28
9.69 11.14 12.60 14.27 16.18 47 15.89 13.88 12.20 10.78 9.36
Section One
9.77 11.24 12.71 14.40 16.35 48 16.07 14.03 12.32 10.88 9.44
9.85 11.34 12.83 14.54 16.52 49 16.25 14.18 12.44 10.98 9.52
9.92 11.43 12.94 14.68 16.68 50 16.43 14.32 12.56 11.08 9.60
10.00 11.53 13.06 14.82 16.85 51 16.61 14.47 12.68 11.18 9.68
10.08 11.62 13.17 14.95 17.01 52 16.79 14.62 12.80 11.28 9.75
10.15 11.72 13.29 15.09 17.18 53 16.97 14.76 12.92 11.38 9.83
10.23 11.81 13.40 15.23 17.35 54 17.16 14.91 13.04 11.48 9.91
10.30 11.91 13.51 15.36 17.51 55 17.33 15.06 13.16 11.57 9.99
10.38 12.00 13.62 15.50 17.68 56 17.51 15.20 13.28 11.67 10.06
10.45 12.09 13.74 15.64 17.84 57 17.69 15.34 13.40 11.77 10.14
10.53 12.19 13.85 15.77 18.01 58 17.87 15.49 13.51 11.86 10.22
10.60 12.28 13.96 15.91 18.17 59 18.04 15.63 13.63 11.96 10.29
10.67 12.37 14.07 16.04 18.34 60 18.22 15.77 13.74 12.05 10.36
45 45
Section Two:
Section Two
In-patient Management of
Severe Acute Malnutrition
For children over six months, adolescents and adults
Overview
Severe acute malnutrition (SAM) is identified by severe thinness or wasting. Sometimes
patients also present with bi-lateral oedema, called nutritional oedema. Severe acute
malnutrition is often a life-threatening condition. These patients are very fragile, often with
a serious electrolyte imbalance. They do not always present with the typical symptoms
of an illness (e.g. fever, rapid pulse or rapid respirations). Also, it can be very difficult to
diagnose dehydration or anaemia however it is extremely important to do so accurately. A
misdiagnosis can lead to a high risk of mortality.
Traditionally the treatment of severe acute malnutrition has been in-patient, health-
facility based. However, recent research in emergency settings has revealed that severe
uncomplicated acute malnutrition can be treated at home with weekly visits to a health
facility for monitoring and re-placement of specialized food. There must also be a community
component to managing severe acute malnutrition at home. Relevant people in the community
must be aware of the risks of acute malnutrition for children, and how to identify children
with acute malnutrition. There must be Community Health Workers (CHWs) who are trained
on screening procedures for acute malnutrition in the community. They are responsible
for monitoring and supporting children at home who are receiving nutrition support from
Out-patient Therapeutic Care. Specialized food products designed to support nutrition
rehabilitation, referred to as ready-to use therapeutic food (RUTF), must also be available
(see section four for more details on out-patient therapeutic care).
Pathophysiology of Severe Acute Malnutrition

Severe acute malnutrition can result in profound metabolic, physiological and anatomical
changes. Virtually all physiological processes are altered due to severe acute malnutrition.
Every organs and systems are involved in reductive adaptation. Reductive adaptation is the
physiological response of the body to under nutrition i.e. systems slowing down to survive
on limited macro and micro-nutrients intake.
Cardiovascular system:
•• Cardiac output and stroke volume are reduced.
•• Infusion of saline may cause an increase in venous pressure.
•• Any increase in blood volume can easily produce acute heart failure.
46
•• Any decrease will further compromise tissue perfusion.

•• Blood pressure is low.
•• Renal perfusion and circulation time are reduced.
•• Plasma volume is usually normal and red cell volume is reduced.
Gastro-intestinal system
•• Production of gastric acid is reduced.
Section Two
•• Intestinal motility is reduced.
•• Pancreas is atrophied and production of digestive enzymes is reduced.
•• Small intestinal mucosa is atrophied; secretion of digestive enzymes is reduced.
•• Absorption of nutrients is reduced.
Liver function
•• Synthesis of all proteins is reduced.
•• Abnormal metabolites of amino acids are produced.
•• Capacity of liver to take up, metabolize and excrete toxins is severely reduced.
•• Energy production from substrates such as galactose and fructose is much
slower than normal.
•• Gluconeogenesis is reduced, which increases the risk of hypoglycemia during infection.
•• Bile secretion is reduced.
Genitourinary system
•• Glomerular filtration is reduced.
•• Capacity of kidney to excrete excess acid or a water load is greatly reduced.
•• Urinary phosphate output is low.
•• Sodium excretion is reduced.
•• Urinary tract infection is common.
Immune system
•• All aspects of immunity are diminished.
•• Lymph glands, tonsils and the thymus are atrophied Cell-mediated (T-cell) immunity is
severely depressed.
•• IgA levels in secretions are reduced.
•• Complement components are low.
•• Phagocytes do not kill ingested bacteria efficiently.
•• Tissue damage does not result in inflammation or migration of white cells to the affected
area.
•• Acute phase immune response is diminished.
•• Typical signs of infection, such as an increased white cell count and fever, are frequently
absent.
•• Hypoglycaemia and hypothermia are both signs of severe infection and are usually
associated with septic shock.
Endocrine system
•• Insulin levels are reduced and the child has glucose intolerance.
•• Insulin growth factor 1 (IGF-1) levels are reduced.
•• Growth hormone levels are increased.
•• Cortisol levels are usually increased.
47
Circulatory system
•• Basic metabolic rate is reduced by about 30%.
•• Energy expenditure due to activity is very low.
•• Both heat generation and heat loss are impaired; the child becomes hypothermic in a cold
environment and hyperthermic in a hot environment.
Treatment Process
Section Two
Severe acute malnutrition requires specialized treatment to ensure rapid recovery and reduce
the risk of mortality. The management of severe acute malnutrition in the in-patient setting
is divided into three phases: Phase 1, Transition Phase and Phase 2. Phase 1 covers nutrition
and medical stabilization, treatment of medical complications, and commences nutritional
rehabilitation. Transition Phase covers a gradual increase in diet leading to some weight gain
while preventing complications of over-feeding. Phase 2 is a rapid weight-gain phase (catch-
up growth), and covers preparation for discharge.
For children, the in-patient treatment of severe acute malnutrition is conducted in a section of
a ward in the district or sub-district hospital (preferably a pediatric ward). For older patients,
severe acute malnutrition treatment is handled in the adult ward. An in-patient facility can
offer 24 hour care: the patient is admitted and remains in the facility for the entire treatment.
Sometimes a daycare facility is the best approach. The malnourished patient attends daily
for treatment and returns home each evening. This may be preferable during emergency or
insecure situations, or for parents/caregivers who must attend to family demands at home.
For out-patient management of severe acute malnutrition, nutrition recovery is handled
at home and the patient attends a health facility weekly for monitoring and re-placement
food.
Severe malnourished cases with complications, oedema and lack of appetite require admission
to an in-patient facility for initial stabilization. Once recovering in Transition Phase the patient
can be transferred to the Outpatient Therapeutic Programme (OTP) for the remainder of
nutrition rehabilitation.
Phase 1: Nutrition and Medical Stabilization

Patients without an adequate appetite and/or a major medical complication are initially
admitted to an in-patient facility for Phase 1 treatment. Also, when there is limited or no
community capacity to handle out-patient treatment of severe acute malnutrition, and only
in-patient care is available, patients with severe acute malnutrition are admitted to in-patient
for Phase 1 nutrition.
The formula used during this phase (F75) promotes recovery of normal metabolic function
and nutrition-electrolytic balance. In Phase 1, the patient receives F75 formula at 100kcal/
kg/day. Rapid weight gain at this stage is dangerous, that is why the quantities and formula
are formulated so that patients do not gain weight during this stage.
A routine, systematic medical treatment is commenced in Phase 1, and medical complications
are treated. It is important in Phase 1 that oedema, if present, reduces. When oedema
is reduced from +++ to ++, only then can these patients graduate from Phase 1 to
Transition Phase. Patients who initially require intravenous (IV) therapy or naso-gastric (NG)
feeding must have completed these therapies and the tube/cannula removed before transfer
to Transition Phase.
In many of settings in Kenya, HIV testing or Diagnostic Counselling and Testing (DCT) is
considered on admission to care for severe malnutrition in order to identify the need for
chemo-prophylaxis and early assessment for the staging of HIV and AIDS disease progression
and readiness for paediatric ART care. Malnutrition or growth failure can be an important
point of diagnosis for clinical staging of HIV and AIDS in children – particularly in resource
limited settings.
The patient remains in Phase 1 until the medical complications stabilize and until the appetite
48
improves and the patient completes the designated quantity of F75 or equivalent diet at
each mealtime.
Transition Phase: Increase Diet and Prevent Complications

Patients normally remain in Transition Phase for two to three days. This phase is designed to
slowly increase the diet and prevent complications of over-feeding for the stabilized, severely
acute malnourished patient.
F75 is replaced with F100 or a locally made-up milk of the equivalent nutritional value.
Section Two
The patient’s diet is increased from 100kcal/kg/day to 130kcal/kg/day for children. (See
Appendix 2.3 for calorie requirements for other age groups). The quantity of milk remains
the same, but the calorie content changes by changing milk formulas from 75kcal to 100kcal
per 100ml of milk.
The patient in Transition Phase receives around 30% more calories than when in Phase 1.
Daily weight gain can be expected at about 6gm/kg/day. For example, a child who weighs
4kg should gain about 24g a day.
For patients qualified and willing to be discharged from Transition Phase to Outpatient
Therapeutic Care for the remainder of nutrition treatment, the equivalent calories are given
to the patient in the form of Ready-to-Use-Therapeutic Food (RUTF).
: Catch-up Growth and Discharge

In the in-patient setting for the treatment of severe acute malnutrition, patients move from
Transition Phase into Phase 2 when they have a good appetite; are tolerating the diet given;
have no major medical complications; and oedema is resolved. This is usually after about
two to three days in Transition Phase.
In Phase 2, the patient receives F100 at 200kcal/kg/day or the equivalent in the form of
RUTF. Those formulas are designed for patients to rapidly gain weight (more than 8g/kg/
day). Recovered patients are discharged for supplementary feeding if available at the nearest
health facility.
Requirements for the In-patient Setting

Treatment Area
Patients are admitted into the paediatric ward if available or other in-patient ward in the
district or sub-district hospital.
Staff
The management of severe acute malnutrition requires a variety of staff positions. Staff fully
trained in management of acute malnutrition should be available at all times in the ward.
New staff should receive training and be closely supervised until they have the required skills
to take charge or work alone at night. All staff must be familiar with these guidelines and
have received appropriate training.
Individual Roles and Responsibilities

The parent, caregiver, or guardian is the main caretaker of the malnourished patient. He/she
may be the mother, the father, a sibling, a relative or a family friend.
Nutritionists, nurses and nurse assistants are responsible for most of the medical and nursing
care. Their responsibilities include:
• Conduct regular weight and height measurements of malnourished children;
• Prepare diet, calculate the amounts of feeds, and distribute and record the amount of
food taken by the malnourished child;
• Administer oral medication, assess and record clinical signs, and record all information in
the Multi-chart. (See Appendix 2.1 for Multi-chart)
• Support mothers to feed the child.
49
The nurse in charge is the manager who teaches and supervises the medical and nursing
assistants. The nurses are responsible for all technical procedures, such as giving intravenous
medication and other invasive procedures.
The doctor supports the nurses and nutritionists. They work closely together as a team.
The doctor is specifically responsible for the care of the very sick severely malnourished
children, those who are failing to respond to routine management, or are having diagnostic
difficulty.
Section Two
Materials and Equipment

• Medicines and medical equipment including antibiotics, anthelminitics, minerals and
vitamins, NG tubes.
• Therapeutic milks (F75, F100) or the ingredients required to produce locally-made milks
including combined mineral vitamin mix (CMV).
• Anthropometric equipment: height board, salter scales, infant scales, MUAC tapes, baby
scales.
• Laboratory and diagnostic services is important but not essential.
Documentation
For severely malnourished patients admitted to the in-patient facility, health staff should
use the Multi-chart (see Appendix 2.1) to record all medical information, food quantities
and type of diet. All daily activities such as daily weights, measurement of vital signs
(temperature, pulse and respirations) are also recorded in the Multi-chart. Fluid intake and
output is also recorded in the Multi-chart. All staff, regardless of position, should use the
same documentation for the patient to ensure consistency.
Admission Criteria for In-patient Care

Phase 1 treatment is always given in an in-patient setting. This phase of the traeatment is
intended to:
a. Stabilise patients with complications
b. Restore metabolic functions
c. Prevent and/or treat associated conditions and complications and,
d. Intensively monitor patients
Table 2.1: Admission Criteria

Criteria for admission with severe acute malnutrition
Infants 6 months W/H < -3 Z-score
to children 18 years
MUAC < 11.5cm - 6 months to 5 years only
And/or
Bi-lateral Oedema
Adults BMI <16
MUAC <16cm
MUAC 16 cm - 18.5cm with clinical complications
Even if an out-patient therapeutic care service exists for the management of severe acute
malnutrition, patients with the above criteria and lack of appetite and/or severe medical
complications are admitted to the in-patient facility. (See Section One, Table 1.6 “Admission
criteria to determine in-patient or out-patient care” for a detailed list of medical complications).
Check the Appetite Test results to help decide if the patient can be transferred to out-patient
therapeutic care. A poor appetite requires admission to an in-patient facility (see Appendix
1.2 for Appetite Test)
50
In-patient Stabilization and Rehabilitation of Malnourished

Patients
Not all children presenting with severe acute malnutrition will have severe complications.
The ten steps in Table 2.2 are a guide for the stabilization and rehabilitation of severe acute
malnutrition.
When a malnourished patient is admitted to the in-patient facility, particularly during the
initial stabilization phase, check for severe infections as well as hypoglycaemia, hypothermia,
Section Two
and dehydration (Table 2.2, steps 1-3). These usually occur soon after admission and need to
be addressed urgently to prevent death. Infections and electrolyte imbalance may manifest
at any time during treatment (Table 2.2, steps 4-5). If any of these complications present,
refer to the latter part of Section Two “Treatment of Medical Complications” page 70 for
the management of severe medical complications. The remainder of the steps address the
nutrition care at different stages, micro-nutrient support, sensory stimulation and planning
for discharge.
Table 2.2: Checklist for each phase of the management of acute malnutrition for in-patient
treatment
PHASES
Stabilization Rehabilitation
Checklist Days 1-2 Days 3-7 Weeks 2-6
1 Prevent or treat hypoglycaemia
2 Prevent or treat hypothermia
3 Prevent or treat dehydration
4 Correct electrolyte balance
5 Check for infection
No iron supplementation Iron

supplementation
6 Monitor micronutrients
7 Assure cautious feeding
8 Monitor catch-up growth
9 Assure sensory stimulation
10 Prepare for follow-up
51
PHASE ONE TREATMENT
Nutrition Support: Diet and Frequency

When the malnourished patient is in Phase 1, administer a milk diet only: either F75 or an
equivalent locally-produced milk product (see Appendix 2.2). The quantity of milk a child
needs to receive in phase one is equivalent to 130ml/kg/day. For older children and adults,
Section Two
the quantity of milk per kg of body weight is different than for children younger than five
years.
The milk diet is given at regular intervals throughout the day (approximately every two to
three hours). The quantity required for each 24 hour period is determined by the child’s
weight. To determine the amount per feed, divide the 24-hour required quantity by the
number of feeds per day.
In Phase 1 the number of daily feeds is determined by the following:
• In 24-hour care with sufficient trained staff to prepare and distribute the feeds overnight
give: eight (8) feeds per day.
• If night feeds are problematic (e.g. limited night staff available for feeds, lack of kitchen
equipment) give: five to six (5-6) feeds per day. For example, every three hours from 6am
to 9pm.1
• For daycare situations: five to six (5-6) feeds during the day.2
Rarely, if a child has severe vomiting or refuses adequate diet quantities, it may be necessary
to give the diet continuously by NG tube. Occasionally, a patient may have osmotic diarrhoea
and may require more frequent feeds (feed every two to three hours, and overnight).
For severely malnourished patients with severe oedema (+++), reduce the quantity
of F75 by up to 20% until the oedema begins to subside. See Table 2.3 for quantities
of milk to give for different body weights and reduce quantities by 20%.
Breastfed children are always offered breast milk before the diet, and always on
demand.
Preparation of F75
If F75 is available, add one packet (410g) of F75 to two (2) litres of water. (Water must be
boiled and cooled prior to mixing.) If five or less children are being treated for severe acute
malnutrition, less quantities of F75 milk are necessary. Smaller volumes can be mixed using
the red scoop (4.1g) included with the F75 package (20 ml water per red scoop/4.1g of
F75). Prepare enough milk for the next three hours, not longer, to assure that it will not
spoil. If there is access to a refrigerator, milk can be stored for a maximum of 12 hours.
When F75 is not available, refer to Appendix 2.2 for alternative recipes. Recipes can be
made by using either dry skimmed milk (DSM), dried whole milk (DWM), fresh cow’s milk,
fresh goat’s milk, with other ingredients including oil, sugar and cereals. Cereals must be
1. It is better to organize the service so that 5 or 6 feeds are actually given, than to try to give 8 or more
feeds per day and find that the night feeds are not supervised or not given at all. With staff shortages and
junior staff at night, the latter strategy can lead to systematic underfeeding of the children and incorrect
information recorded on the Multi-chart.
2. Hypoglycaemia is only a risk if the daytime intake is very low.
52
cooked. Combined mineral vitamin mix (CMV) must be added to locally made-up milks to
achieve micro-nutrient requirements.
Table 2.3: Quantity of F75 or prepared milk to give during Phase 1, per kg of body weight
Class of Weight (kg) 8 feeds per day 6 feeds per day 5 feeds per day
(ml for each feed) (ml for each feed) (ml for each feed)
2.0 to 2.1 kg 40 ml per feed 50 ml per feed 65 ml per feed
Section Two
2.2 - 2.4 45 60 70
2.5 - 2.7 50 65 75
2.8 – 2.9 55 70 80
3.0 - 3.4 60 75 85
3.5 – 3.9 65 80 95
4.0 – 4.4 70 85 110

4.5 – 4.9 80 95 120
5.0 – 5.4 90 110 130

5.5 – 5.9 100 120 150
6 – 6.9 110 140 175

7 – 7.9 125 160 200
8 – 8.9 140 180 225

9 – 9.9 155 190 250
10 – 10.9 170 200 275

11 – 11.9 190 230 275
12 – 12.9 205 250 300

13 – 13.9 230 275 350
14 – 14.9 250 290 375

15 – 19.9 260 300 400
20 – 24.9 290 320 450
25 – 29.9 300 350 450

30 – 39.9 320 370 500
40 – 60 350 400 500
Feeding Technique for Severely Figure 2.1: Feeding technique
Malnourished Children
Due to muscle weakness and slow swallowing, the risk
of aspiration pneumonia is high for malnourished children.
Therefore, great care must be taken while feeding. The
following information lessens the risk of aspiration
pneumonia.
Sitting Position
The child sits straight up (vertical) on the mother’s lap,
leaning against her chest with one arm behind her back.
The mother’s arm encircles the child. She holds a saucer
under the child’s chin.
53
Appropriate Feeding
• The milk feed is given by cup. Any dribbles that fall into the saucer are returned to the
cup.
• The child is never force fed, never has his/her nose pinched, and never lies back and has
the milk poured into the mouth.
• Meal times are best to be social. The mothers can sit together in a semi-circle around
an assistant who encourages the mothers, talks to them, corrects any faulty feeding
technique, and observes how the children are taking the milk.
Section Two
• Caretakers do not take their meals beside the patient. The child is likely to demand some
of the mother’s meal and this sharing is not recommended as the child’s appetite will
reduce and then the milk will be refused.
Naso-gastric Feeding
Naso-Gastric (NG) tube feeding is required only when a patient is not taking a sufficient diet
orally, which is less than 75% of the prescribed diet per day.
NG tube feeding is required when one or more of the following is true:
• The patient takes less than 75% of the prescribed diet per 24 hours in Phase 1
• The patient presents with pneumonia with a rapid respiration rate
• The patient has painful lesions of the mouth
• The patient has a cleft palate or other physical deformity
• The patient is experiencing disturbances of consciousness
Each day, try patiently to give the patient F75 by mouth before using the NG tube. NG tube
feeding should not exceed three days, and is only used in Phase 1.
Routine Medication
Vitamin A
F75, F100, RUTF and locally-developed milk with CMV provide the adequate amount of
Vitamin A to manage mild Vitamin A deficiency and to replace low liver stores of Vitamin
A during treatment.3 However, many malnourished patients have a serious Vitamin A
deficiency, therefore:
• Administer a dose of Vitamin A to all new admissions except:
 Patients who have received Vitamin A within the last month, or
 For children admitted with oedema:
• administer a single dose of Vitamin A at discharge from in-patient facility after
completion of Phase 2, or
• Administer a single dose of Vitamin A on week four of OTP management, when
the patient is transferred form in patient to out patient care.
• If patient has signs of severe vitamin A deficiency (clinical signs such as night blindness,
conjunctival xerosis with Bibot’s spots, corneal xerosis or ulseration or keratomalacia),
give a dose of vitamin A according to Table 2.4, for two consecutive days, followed by an
additional dose two weeks later.
• Administer a dose of Vitamin A to all in-patients on the day of discharge4 (i.e. completion
of Phase 2). For patients managed at OTP, including those transfered from in-patients,
3. A 10kg child taking maintenance amounts of F75 (1000kcal) will receive 7300 IU (2.2mg) of Vitamin A per
day. The Recommended Daily Allowance (RDA) USA for such a child is 1700 IU (0.5mg) per day.
4. “In-patients” refer to patients admitted to in-patient facility for their entire treatment. It does not refer to
patients transferred to OTP.
54
administer a dose of vitamin A at week four after admission.
Table 2.4: Vitamin A systematic treatment

Age Vitamin A/IU orally on Day 1
6 to 12 months 1 blue capsule 100,000IU = 30,000ug
12 months and older 2 blue capsules 200,000IU = 60,000ug
Section Two
Folic Acid
There is sufficient folic acid in F75, F100 and RUTF to treat mild folate deficiency.5 If
a patient shows clinical signs of anaemia give 5mgs of folic acid. Moderate Anaemia is
identified by palmer paler (very pale palms of the hands), and/or check conjunctiva colour. A
very pale conjunctiva is a sign of moderate or severe anaemia.
Iron Supplementation
High-dose iron tablets are contraindicated as they can increase the risk of severe infection in
severe acute malnourished patients due to the presence of free iron in the blood.
If moderate anaemia is identified:

• For in-patients receiving entire treatment of acute malnutrition in the in-patient health
facility: Add iron to the F100 in Phase 2.
If severe anaemia is identified, see “Treatment of Medical Complications” at the latter part
of this Section (page 70).
Other Nutrients
F75, F100, RUTF and locally-developed milks with CMV contain the micro-nutrients required
to treat the malnourished child. Additional potassium, magnesium or zinc is not administered.
A “double dose”---one coming from the diet and the other prescribed---is potentially toxic.
Additional potassium should never be given with these diets. Even for the severe acute
malnourished patient with diarrhoea, it is not advisable to give additional zinc.
Systematic Antibiotics
All severe acute malnourished children receive antibiotic treatment upon admission,
regardless if they have clinical signs and symptoms of systemic infection or not. Nearly all
these children have infections even if they are not symptomatic. Children who have a poor
appetite and require admission to Phase 1 should be treated blindly for infections.
Small bowel bacterial over-growth occurs in all severe acute malnourished children (including
those with moderate appetite and some with good appetite). Enteric bacteria are frequently
the source of systemic infection by translocation across the bowel wall. This can also cause
mal-absorption of nutrients and failure to eliminate the substances excreted in the bile, fatty
liver, intestinal damage, and can cause chronic diarrhoea. The antibiotic administered for
routine treatment must be active against small bowel bacterial overgrowth. Children with
Kwashiorkor have free iron in their blood: this can lead to bacteria that are not normally
invasive, such as Staphylococcus epidermidis, and “exotic bacteria” to trans-locate and can
cause systemic infection or septicaemia. Amoxycillin is identified in Kenya as the first line
antibiotic to give systematically. If Amoxycillin is not available then the doctor will decide on
the most appropriate antibiotic to give instead. If staphylococcus is suspected, administer
an antibiotic that is active against staphylococcus.
5. A 10kg child taking maintenance amounts of RUTF will receive 400 micrograms of folic acid per day. The
RDA (USA) for such a child is 80 micrograms per day.
55
Antibiotic Regime
First line antibiotic treatment:
Oral Amoxycillin6. (If not available, doctor to decide appropriate alternative)
Second line antibiotic treatment:

• Add chloramphenicol (do not stop amoxycillin) OR
• Add gentamycin (do not stop amoxycillin) OR
Switch to amoxycillin/clavulinic acid (Augmentin®). In in-patient settings where severe
Section Two
infection is common, this may sometimes be considered as the first line antibiotic
combination.
Third line antibiotic treatment:

Third line treatment is at the discretion of the medical doctor and is dependent on each
patient’s medical condition or complications. Frequently, a systemic anti-fungal (fluconazole)
is added for patients who have signs of severe sepsis or systemic candidiasis.
Important note: Co-trimoxazole is not active against small bowel bacterial overgrowth
and is not adequate for the severely malnourished child. If Co-trimoxazole is administered
as a prophylaxis against pneumocystis pneumonia in HIV-positive patients, the above
recommended antibiotics should be administered in addition.
Table 2.5: Dosage of Amoxycillin, Gentamycin and Chloramphenicol
Patient Amoxycillin Gentamycin Chloramphenicol
Weight Dosage Dosage once daily Dosage
Range twice per day IM three times daily
Kg In mg cap/tab In mg In mg cap/tab
<5kg 125mg ½ cap 5mg/kg IM daily 62.5mg ¼ cap
5 - 10kg 250mg 1cap As above 125mg ½ cap
10 – 20kg 500mg 2cap As above 250mg 1 cap
20 – 35kg 750mg 3cap As above 500mg 2cap
>35kg 1000mg 4cap As above 1000mg 4cap
Note: Use the 20mg ampoule of Gentamycin. It is most accurate for small doses for children
with a low body weight. Chloramphenicol should never be used for infants under two (2)
months old, and used only with caution in infants under six (6) months (if other antibiotics
not available).
Duration of Antibiotic Treatment

Antibiotics are administered every day of Phase 1 plus an additional four (4) days or until
transfer to community nutrition care.
Malaria Treatment
Refer to Kenya National Guidelines for Malaria Treatment. Test all malnourished patients
who are at risk of malaria before commencing treatment. The usual signs and symptoms for
malaria may not be present in the malnourished child, therefore in malaria endemic areas all
severely malnourished children are tested for malaria.
6. This is recommended as second-line antibiotic by IMCI. It is given to grossly immuno-compromised

patients who are severe enough to be admitted to a treatment programme. Amoxycillin is active against small
bowel bacterial overgrowth in most patients. Where this is used as the first line antibiotic, metronidazole does
not need to be given. WHO (Technical meeting, Geneva, June 2007) also recommends the use of Amoxycillin
as first line systematic antibiotic therapy on admission for all SAM cases.
56
Never give intravenous infusions of quinine to a severely malnourished patient in the first
two weeks of treatment. Impregnated bed nets should always be used in malaria endemic
regions.
Measles Vaccination
In-patient setting, all children older than six months and also all children above nine months
who do not have a vaccination card are given a measles vaccine both on admission and after
Section Two
a month, or at discharge after Phase 2 (if this is after a month).7
De-worming
Children who play outdoors are susceptible to worm infestation. Deworming is necessary for
in-patient malnourished children, but should be delayed until they are recovering in Phase 2
or discharged to OTP.
Children younger than one year old should not receive anthelminitics. New research by
WHO indicates that all children older than one year can receive a full stat dose of either
Albendazole or Mobendazole for treatment of worm infestation.
Table 2.6: Dosage for deworming, by age group
Children less than one (1) year old Children one year and above
Albendazole Not given 1 dose on admission to Phase 2
1 - 2 Years 200mg
> 2 years 400mg
Mebendazole 500mgs Not given 1 dose on admission to Phase 2
Summary of Medications
Table 2.7 summarizes the routine medications for severely malnourished children. There are
some differences between the in-patient and out-patient drug regime, but in general they
are very similar. The main difference is that iron is not administered to children who receive
RUTF in the out-patient setting, as there is already sufficient iron in the diet.
Table 2.7: Summary of routine medication for in-patient treatment of severe acute
malnutrition
Direct admission to in-patient treatment
Vitamin A 1. One (1) dose at admission (conditional)*

2. One (1) dose on discharge. Do not administer discharge dose when
the patient is transferring from Transition Phase to OTP management.
(It will be given there.)
Folic Acid One (1) dose at admission, if there are definite signs of anaemia
Amoxycillin Everyday in Phase 1, plus four (4) days during Transition/Phase 2
Malaria According to national protocol
Measles Six (6) months and older 1. One (1) vaccine at admission if no vaccination card
2. One (1) vaccine at discharge (after a month)
Iron Add to F100 or milk formula in Phase 2
*Ensure patient has not received Vitamin A within the previous month and do not give to patients with Oedema.
7. The first measles dose often does not give a protective antibody response. It is administered to
ameliorate the severity of incubating measles and partially protects from nosocomial measles. This is usually
unnecessary with out-patient treatment. The second dose, or week four dose, is given to provoke protective
57
Surveillance
Each Day:
• Take patient’s body temperature twice a day.
• Weigh the patient and record the weight. Plot weight on the Multi-chart. (See Appendix
2.1 for multi-chart).
• Assess and record the degree of oedema (0, +, ++, +++).
• Record the patient’s fluid intake and source (oral, NG tube or IV fluids). Record if patient
is absent at mealtime, has refused diet or has vomited. Document the information in the
multi-chart to monitor ongoing progress.
• Assess and note in the Multi-chart standard clinical signs (number of stools passed,
Section Two
vomiting, dehydration, cough, respiration, and liver size).
Once a week, MUAC is measured.
On admission and after 21 days (with each new Multi-chart), measure length for children
who are less than 87cms, or height for children who are greater than or equal to 87cms.
Criteria for Transfer: Phase 1 to Transition Phase

The patient must meet the following criteria to transfer from Phase 1 to Transition Phase:
• Appetite has improved and taking all prescribed quantity of milk.
• Oedema, if present, reduced from severe +++ to moderate++.
• Treatment for any medical complication has commenced and patient is recovering.
• IV fluids and NG feeding completed and cannula/tube removed.
TRANSITION PHASE TREATMENT
A patient usually remains in Transition Phase for two to three days. In this phase the patient
begins to gain some weight slowly. The objective of Transition Phase is to gradually increase
the amount of calorie intake, increasing from 100kcal/kg to 130kcal/kg. This is to prevent
overload and its potential complications. Transition Phase prepares the patient for Phase 2
treatment or, if an out-patient facility for treatment of acute malnutrition exists, for transfer
to the Outpatient Therapeutic Care.

The ONLY change in the diet when transferring from Phase 1 to Transition Phase is that F75
is replaced by either F100 or equivalent made-up milk, ready to use therapeutic food (RUTF),
or a combination of the two. The number of feeds, the timing, and the volume of the diet
remains exactly the same in Transition Phase as in Phase 1 (130ml/kg/day).
The decision whether to give specialized milk or RUTF depends on the patient’s discharge
plan and on availability of specialized foods. If there is only the in-patient option, then milk
can be given alone or a combination of the milk and RUTF. Where the patient will discharge
to the OTP then the child takes RUTF during Transition Phase, in preparation for discharge.
RUTF can be given inter-changeably with F100 depending on the availability of RUTF and
staffing levels. In the in-patient facility, F100 can be given during the day and RUTF given
overnight or on week-ends (especially during times staffing levels are low).
Transition Phase: Feed 5-6 times daily and not overnight
In all cases, breastfed children should always be breastfed before taking F100 or RUTF,
and always on demand.
58
Preparation of F100
Prepare F100 by adding a sachet of F100 milk powder to two (2) litres of boiled cooled wa-
ter. If small quantities of milk are required (few children in need of nutritional rehabilitation),
add one (1) red scoop (4.1g) powder milk to 18ml boiled and cooled water. For small quanti-
ties of locally made-up milk see recipes Appendix 2.2.
Table2.8: Quantity of F100 to give during Transition Phase, per kg of body weight
Section Two
Class of Weight (kg) 8 feeds per day 6 feeds per day 5 feeds per day
F100 full strength should not be given.
Less than 3kg Only F100 Diluted is given.
3.0 to 3.4 kg 60 ml per feed 75 ml per feed 85 ml per feed
3.5 – 3.9 65 80 95
4.0 – 4.4 70 85 110

4.5 – 4.9 80 95 120
5.0 – 5.4 90 110 130

5.5 – 5.9 100 120 150
6 – 6.9 110 140 175

7 – 7.9 125 160 200
8 – 8.9 140 180 225

9 – 9.9 155 190 250
10 – 10.9 170 200 275

11 – 11.9 190 230 275
12 – 12.9 205 250 300

13 – 13.9 230 275 350
14 – 14.9 250 290 375

15 – 19.9 260 300 400
20 – 24.9 290 320 450

25 – 29.9 300 350 450
30 – 39.9 320 370 500

40 – 60 350 400 500
Warning: F100 is never given out for use at home. It is always prepared and distributed in
an in-patient unit. F100 is not kept in liquid form at room temperature for more than three
hours before it is consumed.
Plans for Eventual Out-Patient Care – Use of RUTF

If out-patient management of malnutrition is available, use RUTF in the Transition Phase.
Initially RUTF and F100 meals can alternate with RUTF given every other feed (20g of RUTF
is equivalent to 100ml of F100). If the RUTF is tolerated, the patient’s diet changes to RUTF
for the remainder of Transition Phase. Patients may initially refuse RUTF. If this is the case,
give the patient the F100 diet and offer RUTF again the next day. Discharge to out-patient
treatment of acute malnutrition is only advised when the patient tolerates at least 75% of
the amount of RUTF calculated for the individual child (see Table 2.9).
59
The daily amount of RUTF is given to the caregiver with directions to give small portions of
feeds frequently. The quantity consumed by the child is checked regularly during the day.
Table 2.9 outlines the quantities to give in Transition Phase based on the child’s body weight.
Children who are not taking 75% RUTF are given F100 to make up any deficit in intake. No
other food is given to the patient during this period.
Patients should drink as much clean water as possible while taking and after consumption
of RUTF.
Section Two
Table 2.9: Quantity of RUTF to give during transition phase, per kg of body weight
Class of weight (kg) RUTF (Plumpy’nut®)

sachet per day sachets per week
3.0 - 3.4 1¼ 8
3.5 - 4.9 1½ 10
5.0 – 6.9 2 15
7.0 – 9.9 3 20
10.0 - 14.9 4 30
15.0 – 19.9 5 35
20.0 – 29.9 6 40
30.0 - 39.9 7 50
40 - 60 8 55
Currently in Kenya, Plumpy’nut® is the only product available and is only available for
emergency response programmes. Plumpy’nut® is a commercial product of Nutriset. It
comes in sachets of 500kcal each weighting 92g. However local RUTF may be produced
in Kenya in the future.
Plumpy’nut® is nutritionally equivalent to F100, with the exception that it has an
appropriate amount of iron added for children in Phase 2 or children who pass the
appetite test.
Note: If both F100 and RUTF are being given they can be substituted on the basis that about
100ml of F100 = 20g of RUTF.8
Routine Medication
Routine antibiotic therapy should be continued for four days after Phase 1 or until the patient
is transferred to outpatient therapeutic care or inpatient care phase 2. This is to ensure
that any infection is treated. Patients being discharged to out-patient therapeutic care at
the end of Transition Phase do not need to be given antibiotics on admission into the out-
patient therapeutic care. They already have received a course of antibiotics. Antihemlits are
administered to malnourished children who are one year or older on transfer to either Phase
2 in-patient, or to out-patient.
8. This is an acceptable approximation. If tables are to be constructed then 100 ml of F100 = 18.5g of RUTF:
10g of RUTF = 54ml of F100 should be used and the resulting values rounded to the nearest 5 or 10 ml
60
Surveillance
The surveillance in Transition Phase is the same as surveillance in Phase 1. As the patient is now taking more than
maintenance amounts of food, weight gain is expected. It takes an average of about five (5) kcal to make one (1)
gram of new tissue. Thus, if the patient takes all food and there is not excessive mal-absorption, the expected rate
of weight gain for marasmic patients during Transition Phase is about 6g/kg/day.
Each Day:
Section Two
• Weigh the patient and record the weight. Plot weight on the Multi-chart. (See Appendix 2.1 for multi-chart).
• Assess and record the degree of oedema (0 to +++).
• Record the patient’s fluid intake. Record if patient is absent at mealtime, has refused diet or has vomited.
Document the information in the multi-chart to monitor ongoing progress.
• Assess and note in the Multi-chart standard clinical signs (number of stools passed, vomiting, dehydration,
cough, respiration and liver size).
Once a week, MUAC is measured.
Criteria for transfer: Transition Phase to Phase 2

• If the patient has a good appetite and is taking at least 75% of the RUTF or all F100 prescribed for Transition
Phase, he/she may progress to Phase 2 in the in-patient facility or the out-patient therapeutic care. The daily
ration of RUTF in Transition Phase is the same for a patient of the same weight directly admitted to out-patient
therapeutic care. Therefore, if they are eating at least 75% of the RUTF prescribed, it is a similar calorie amount
as what is given when using F100 in the Transition Phase.
• Oedematous patients (kwashiorkor) discharged to the out-patient management of malnutrition remain in
Transition Phase until there is a definite and steady reduction in oedema (+ level). Patients who remain as in-
patients should remain in Transition Phase until they have lost their oedema entirely.
• Severe medical complications must be resolved before the patient progresses to out-patient therapeutic care or
to Phase 2.
Criteria for Return to Phase 1 from Transition Phase

Move the severely malnourished child back to Phase 1 if any one of the following occurs:
• There is increasing oedema.
• A child who does not have oedema develops oedema.
• There is a rapid increase in the size of the liver.
• Any signs of fluid overload develop.
• Tense abdominal distension develops.
• The patient gets significant re-feeding diarrhoea so that there is weight loss.
• A complication arises that necessitates an intravenous infusion.
If a severe medical complication becomes apparent, such as hypothermia, hypoglycaemia, dehydration, septic
shock, acute vomiting, acute diarrhoea with weight loss and possible reduced bowel sounds/abdominal distension
or heart failure then transfer the patient back to Phase 1.
It is common for some change in stool frequency when there is a change in diet. This does not need to be treated
unless the children lose weight. Several loose stools without weight loss are not a criterion to move back to Phase 1.
61
PHASE TWO TREATMENT
In Phase 2, the main objective is to achieve catch-up growth and resolve micronutrient
deficiencies. However there are some variations in workload. As the patients are recovering
the frequency of meals and some of the routine surveillance is less frequent as in Phase 1
Section Two
and Transition Phase.
Criteria for Transfer to Phase 2 from Transition Phase

• Good appetite (taking all diet in Transition Phase)
• Loss of oedema
• Medical complications have resolved

When patients are transferred from Transition Phase to Phase 2, the main change in the
diet is an increase in the amount of F100 or made-up milk formulas. The volume of milk is
increased from 130ml/kg/day to 200ml/kg/day (equivalent to 200kcal/kg/day). The objective
of Phase 2 is to achieve catch-up growth. Thus, if the child remains hungry after completing a
feed, more milk can be offered. Either F100 or RUTF can be given, or a combination of both.
F100 (100ml = 100 kcal)

• Give five feeds of F100 per day to patients who weigh less than 8kg (see Table 2.10 for
F100 quantities to give for body weight).
• One porridge meal may be given to patients who weigh more than 8kg (approximately 24
months of age); it is not necessary to give porridge unless the patient asks for it.
RUTF: Can be used in the in-patient setting. 20g of RUTF is equivalent to approximately
100ml of F100.
Breastfed children always nurse (receive breast milk) before they are given F100 or
RUTF, and also always on demand.
Preparation of F100
Prepare F100 by adding a sachet of F100 powdered milk (net weight 456gms) to two (2)
litres of boiled, cooled water. See Appendix 2.2 for recipes of locally made milk formulas.
62
Table 2.10: Quantity of F100 to give during Phase 2, per kg body weight
6 feeds/day 5 feeds/day
Class of weight (kg) F100 ml/feed F100 ml/feed
Full strength F100 and RUTF not given to infants who
<3 kg weigh less than 3kg
3.0 to 3.4 110 130
3.5 - 3.9 120 150
Section Two
4.0 - 4.9 150 180
5.0 - 5.9 180 200
6.0 - 6.9 210 250
7.0 - 7.9 240 300
8.0 - 8.9 270 330
9.0 - 9.9 300 360
10.0 – 11.9 350 420
12.0 – 14.9 450 520
15.0 – 19.9 550 650
20.0 - 24.9 650 780
25.0 – 29.9 750 900
30.0 - 39.9 850 1000
40 - 60 1000 1200
Routine Medication
Iron
Iron is given to malnourished children in Phase 2. For convenience and ease for staff it is
added to the F100 diet or locally made-up milk: Crush an iron tablet and add to 4mls of water
and mix well (Iron Solution).
• For one sachet of F100 (makes 2.4 litres of F100), add one (1) crushed tablet of ferrous
sulphate (200mg) in the 4mls of water (Iron Solution).
• For half a sachet of milk (1200ml of F100), add 2mls of the iron solution.
• For 600ml of F100, add 1ml of the iron solution.
If using locally made-up formulas add iron solution as above to the milk. RUTF already
contains the necessary iron.
De-worming
Children that are 1 year old and older are given 1 dose of de-worming medication at the start
of Phase 2.
63
Surveillance
Patient surveillance in Phase 2 is less intensive and less frequent than during Phase 1 and
Transition Phase. However, it is important to routinely monitor progress. See Table 2.11 for
surveillance duties and frequency.
Table 2.11: Phase 2 surveillance
Surveillance Tasks Frequency

Section Two
Check weight and oedema Three (3) times per week
Measure height (length) Every three (3) weeks, with each new Multi-chart
Take body temperature Every morning
Assess standard clinical signs (stool, vomiting) Every day
Take MUAC Every week
Record diet intake Record daily all intake in Multi-Chart
Discharge
Preparation for Discharge
• Throughout in-patient care, keep the patient’s family informed of the patient’s progress
and the discharge plan. Schedule routine health and nutrition education in groups and
individually as necessary.
• If possible, during Phase 2 conduct cooking demonstrations with parents/caregivers on
how to use local foods and maintain balanced diets. This is an effective way to transfer
knowledge, especially where literacy is an issue.
• Discharge patient for Supplementary Feeding if available and with a food ration if possible.
If there is no SFP, schedule a follow-up visit to the mother and child health clinic (MCH)
with the mother/caregiver in order to monitor patient’s progress.
Table 2.12: Discharge criteria for recovered patients9

The patient is... If the following exists...
Cured • < -2 Z-score10.
• MUAC > 11.5cm (6 months - 5 years) and
• No oedema for 10 days.
Medications to Administer on Discharge

• One dose of Vitamin A.
• Measles vaccine if the patient is older 6 months (this needs to be a month apart from the
measles vaccine that was given on admission).
9. Discharge criteria based on percentage of weight gain is currently being developed

10. Ideally, patients should be referred for suplementary feeding once discharged from inpatient and out
patient therapeutic care.
64
TREATMENT OF MEDICAL COMPLICATIONS
This section outlines the most common medical complications associated with severe
malnutrition that require careful diagnosis, management and appropriate treatment. Often
severely malnourished patients have underlying medical conditions that can be asymptomatic
Section Two
on admission. Certain symptoms present early in the treatment of severe malnutrition, others
are masked and present later.
Hypoglycaemia and hypothermia may present in the early stages of recovery. Hypoglycaemia
can be prevented by feeding small amounts of the specialized diet frequently. Hypothermia is
prevented by keeping the patient warm. Dehydration is not common but needs to be treated
correctly if diagnosed. History of fluid loss is an important consideration as other clinical
signs such as non-elastic skin with skin in folds and sunken eyes are often present in the
severely malnourished patient regardless of hydration status.
Infections are common for the malnourished patient. The normal signs and symptoms, such
as fever and increased respiration or increased pulse rate, may not be present. It is extremely
important to closely monitor the medical status of severely malnourished patients by recording
vital signs (such as pulse, temperature, and respiration rate), diet, fluid intake and incidence
of vomiting and/or diarrhoea. It is important to have base-line patient information, such as
vital signs, by recording them on admission and twice daily after admission. If the vital signs
are abnormal or change, it may indicate deterioration in the patient’s condition related to an
underlying medical complication.
If a patient treated by out-patient therapeutic care, or a patient who is transferred out of
Phase 1, develops a serious medical complication always transfer the patient back to Phase
1.
Hypoglycaemia
Though uncommon, severely malnourished patients can develop hypoglycaemia. All children
who have travelled long distances to attend a health centre should be given sugar-water
as soon as they arrive: 1 heaped teaspoon of sugar in 50ml of water. Children who have
hypothermia or septic shock should be given 50-100ml of sugar water, whether or not they
have low blood glucose.
A child who has taken the prescribed quantity of F75 diet each day (with 5-6 feedings per
day) will not develop hypoglycaemia overnight and does not need to be woken for night
time feeding. If the diet is not completely taken during the day (due to vomiting or refusal
of milk), the health worker should encourage the caregiver to give at least one prescribed
quantity of F75 during the night.
Clinical Signs of Hypoglycaemia

• Low body temperature
• Lethargy or limpness
• Possible loss of consciousness
• Eyelid retraction is one sign of over-active, sympathetic nervous system, which starts
before actual hypoglycaemia develops. If a child is sleeping with his eyes slightly open,
wake the child up and give sugar-water to drink. Health staff and caretakers should be
taught to look for this sign during the night.
65
Table 2.13: Preparation of sugar water (10% dilution)

Quantity of Water Quantity of Sugar
100 ml 10g 2 heaped teaspoons
200 ml (average cup) 20g 4 heaped teaspoons
500 ml (small bottle) 50g 10 heaped teaspoons
1 litre 100 g 20 heaped teaspoons
Notes:
Section Two
• Take clean drinking water (slightly warm if possible to help dilution). Add required amount
of sugar and shake or stir vigorously.
• Give immediately to ALL ADMISSIONS IF MILK CAN NOT BE GIVEN IMMEDIATELY.
Treatment of Hypoglycaemia
• Patients who are conscious and able to drink are given about 50ml (approximately
5-10ml/kg) of sugar-water (10% glucose: 1 heaped spoon of ordinary sugar in 50mls of
potable water). Or they can be given F75 diet or F100 (depending on what is immediately
available) orally. The actual amount given is not critical.
• Patients losing consciousness are given 50ml (or 5-10ml/kg) of sugar-water by NG tube
immediately. When consciousness is regained, give milk feed frequently.
• Unconscious patients are given sugar-water by NG tube. They should also be given
glucose as a single intravenous injection (5ml/kg of a sterile 10% glucose solution).
• All severely malnourished patients with suspected hypoglycaemia should be treated with
second-line antibiotics.
Monitoring Hypoglycaemia
The patient response to treatment should be dramatic and rapid. If a very lethargic or
unconscious patient does not respond, it indicates a different cause for the clinical condition
such as an infection. The different source of the lethargy must be determined and treated.
If consciousness drops or temperature falls, re-test the blood glucose level and give another
dose of glucose 50ml by NG tube or IV. (10% glucose as above)
Prevention of Hypoglycaemia
Make sure that the severely malnourished patient receives sugar water on admission, if it is
not close to a feed time or the patient is waiting in the casualty/emergency department for
over one hour
For patients at risk of hypoglycaemia (very sick children with poor appetite, with vomiting or
diarrhoea), give frequent, regular feeds every three (3) hours.
Hypothermia
Clinical signs of Hypothermia
Severely acutely malnourished patients are highly susceptible to hypothermia. Hypothermia
is indicated by a rectal temperature below 35.50C, or an under-arm temperature below
350C.
Treatment of Hypothermia
• Do not bathe severely malnourished patients on admission. Later, when the patient is
stabilized, bathe patient only during the warmest part of the day with warm water. Dry
patients quickly and gently after washing.
• Use the “kangaroo technique” for children with a caretaker. (See box page 82 “Kangaroo
care”.)
• Put a hat on the child and wrap mother and child together.
• Offer hot drinks for the mother to drink to keep her skin warmer (plain water, tea or any
other hot drink).
66
“Kangaroo Care”
Kangaroo care means keeping an infant in continuous skin-to-skin contact with the mother
or adult caregiver. The infant is kept near the mother’s breast.
1. The mother removes inner clothing
2. The infant only wears a nappy and head covering
3. The infant is held close against the mother’s bare chest by wrapping a culturally-
appropriate cloth
4. The mother wears enough usual outer clothing to keep warm, adjusting so that the
Section Two
infant’s face is exposed to the air and the mother can see the infant.
Monitoring Hypothermia
• Monitor a patient’s body temperature during re-warming.
• The room should be kept warm, especially at night (between 280C and 320C). A
maximum-minimum thermometer should be on the wall in the Phase 1 area to monitor
the temperature.
• Treat for hypoglycaemia and give second-line antibiotic treatment.
Note: The thermo-neutral temperature range for malnourished patients is 280C to 320C.
This is often uncomfortably warm for the staff and caretakers who may want to adjust
the room to suit them. Staff and caregivers should not reduce the room temperature as
it will be too cold for severely malnourished children. Children should sleep with their
mothers or caregivers and not in the traditional hospital child-cots/cages. There should be
adequate blankets and a thick sleeping mat or adult bed. Most heat is lost through the
head; hats should be worn by malnourished children. Windows and doors should be kept
closed at night.
Dehydration
Misdiagnosis and inappropriate treatment for dehydration is the most common cause of
death of the severely malnourished patient. It is difficult to diagnose dehydration in these
patients. The signs of dehydration - such as non-elastic skin and sunken eyes - are often
present in the severely malnourished patient regardless of hydration status. It is important
to take a detailed medical history and determine if there was a recent fluid loss from acute
diarrhoea or vomiting.
During treatment of severe acute malnutrition, be aware of the following: The standard
protocol for the dehydrated child (who is not malnourished) should not be used.
A severely malnourished dehydrated child has a different protocol.

• With severe malnutrition, the “therapeutic window” is narrow: even dehydrated children
can quickly go from having a depleted circulation to experiencing over-hydration with
fluid overload and cardiac failure.
• In malnutrition, both marasmus and to greater extent kwashiorkor, IV infusions are rarely
used because there is a particular renal problem that makes the children sensitive to salt
(sodium) overload and at high risk of fluid overload.
• To prevent overuse of oral rehydration salts i.e. ReSoMal, do not leave these products
accessible in the ward for the caretakers to give freely to children. An over-supply of
ReSoMal can lead directly to heart failure, as well as failure to lose re-feeding oedema
with the commencement of re-feeding.
• If there is no dehydration, do not treat diarrhoea with rehydration fluids with the intention
to prevent the onset of dehydration. This will again lead to over-hydration and heart
failure.
67
Diagnosis of Dehydration with the Marasmic Patient

For the patient with marasmus, all the classical signs of dehydration are unreliable and
should not be used to make the diagnosis of dehydration:
• Do NOT use the skin pinch test to diagnose dehydration in malnourished children.
Marasmic skin often lies in folds and is inelastic, thus the “skin pinch” test is generally
positive regardless if the patient is hydrated or not.
• Do NOT assume that patients with marasmic who have sunken eyes are dehydrated.
Marasmic eyes are normally sunken regardless of dehydration11.
Section Two
• Do not make a definitive diagnosis of dehydration. If the child seems to be dehydrated,

make a provisional diagnosis and observe the response to treatment before confirming
the diagnosis.
The diagnosis is determined by the patient’s history rather than by examination.

There needs to be:
• A definite history of significant and recent fluid loss. Usually this is a watery diarrhoea
(not just soft or mucus), frequent, and with a sudden onset within the past few hours
or days.
• There should also be a history noted of a recent change in the child’s appearance.
• If the eyes are sunken, the caretaker must be able to report that the eyes have become
sunken since the diarrhoea started.
• The child must not have any oedema.
Children with persistent or chronic diarrhoea (without an acute watery exacerbation) are not
considered dehydrated.
Treatment of Dehydration for the Marasmic Patient

When possible and feasible, rehydrate the patient orally with ReSoMal. Intravenous infusions
are dangerous and NOT recommended unless there is: 1) severe shock with 2) loss of
consciousness from 3) confirmed dehydration.
The management of dehydration is based on the accurate measurements of a patient’s
weight which is the best measurement of fluid balance. The patient should be weighed
without any items of clothing on (naked).
Before starting any rehydration treatment:

1. Weigh the child;
2. Take and record the child’s pulse;
3. Record the child’s respiration rate and;
4. Mark the edge of the liver and the costal margin on the skin with an indelible marker pen
(skilled staff).
If the staff is qualified to do so, record the patient’s heart sounds (presence or absence of
gallop rhythm).
The marasmic malnourished dehydrated child is managed entirely by:

• Weight changes
• Clinical signs of improvement such as alertness
• Clinical signs of over-hydration (engorged veins, rapid pulse, respiratory distress)
11. The orbit contains the eye, small muscles and nerves, fat, the lachrymal gland and a venous plexus. In
marasmus the fat and lachrymal gland atrophy, so that the eyes sink. In dehydration there is contraction of the
venous plexus forcing blood out of the orbit so that the eyes sink.
68
Step 1: Determine 5% of patient’s body weight

For the severely malnourished, dehydrated child, a maximum of 5% of the child’s body
weight is replaced in the form of fluids. To determine 5% of body weight, equate: body
weight in grams/100 x 5.
Therefore, 5% body weight of a 4kg child equals: 4000g/100 x 5 = 200gm which then
equates to 200ml of re-hydration fluid.
It is estimated that a severely dehydrated marasmic child will lose a maximum of 5% of
body weight so it is important to only replace a maximum of this amount otherwise there is
Section Two
a danger of over-hydration.
Step 2: Administer re-hydration fluid

The fluid must be given slowly over time to prevent complications such as overload or heart
failure.
• Give ReSoMal orally or by NG tube
• Give: 5ml/kg every 30 minutes for first two (2) hours
• Give 5-10mls hourly until weight gain has been achieved
Case Study:
For a 4kg child, over the first two hours give the following orally or by NG tube:
 5ml/kg ReSoMal every 30 minutes for two hours = 20ml x four (there are four 30
minute intervals in two hours) = 80ml. (This is 2% of a 4kg child’s body weight).
 Over the next number of hours give 5 to 10ml/kg/hour ReSoMal until weight gain is
achieved and the patient shows clinical signs of improvement. Therefore for a 4kg
child, give 20 to 40ml per hour after the initial two hours.
It is important to re-assess frequently to make sure that the patient does not become
over-hydrated. Fluid balance is measured at frequent intervals by weighing the child.
69
Step 3: Complete the re-hydration

Give re-hydration fluid until the weight deficit (measured or estimated) is corrected (maximum
of 5% body weight). Stop as soon as the child is re-hydrated, having reached the target
rehydrated-weight.
As the child gains weight during re-hydration, definite clinical improvement should be obvious.
Section Two
The signs of dehydration should disappear. If there is no improvement with weight gain, the
initial diagnosis of dehydration was wrong and rehydration therapy must be stopped.
Figure 2.2: Treatment of dehydration - assessment
Treatment of Dehydration
ONLY Rehydrate until the weight
deficit (measured or estimated)
is corrected and then STOP - Do
not give extra fluid to “prevent
Concious recurrence” Unconcious
Resomal IV Fluid
•• 5ml/30min first 2 hrs
Darow’s solution or
½ saline & 5% glucose or
•• 5 to 10ml/kg/hr, 12 hrs
Ringer lactate & 5% dextrose
at 15ml/kg the first hr & reasses
•• If improving, 15ml/kg 2nd hr

•• If conscious, NGT: ReSoMal
•• If not improving => Septic shock
70
Step 4: After re-hydration

After rehydration, usually no further treatment is given. However, for severe acute
malnourished children from 6 to 24 months, 30ml of ReSoMal can be given for each
incidence of a watery stool. The standard instructions to give 50-100ml for each stool
should not be applied. It may cause fluid overload which is dangerous.
Figure 2.3: Treatment of dehydration - monitoring
Section Two
Rehydration
Monitor Weight
Gain Stable Loss
Clinically Clinically
improved not improved
- STOP ALL - Increase ReSoMal - Increase ReSoMal

Continue
rehydration fluid by: 5ml/kg/hr by 10ml/kg/hr
- Give F75 - Reassess every hr - Reassess every hr
Target weight - Re-diagnose &
assess
F75
Two hours after commencing re-hydration therapy, make a major medical reassessment.
• Check all vital signs such as body temperature, pulse and respiration rate.
• Check heart sounds.
• Check for clinical signs of respiratory distress.
• Check consciousness levels and weight gain.
• Check for vomiting and/or diarrhoea.
71
If there is:
• Continued weight loss: Increase ReSoMal by 10ml/kg/hour and re-assess the patient in
one hour.
• No weight gain: Increase ReSoMal by 5ml/kg/hour and re-assess the patient in one
hour.
• Weight gain and...
 ...deterioration of the child’s condition with the re-hydration therapy:
• The diagnosis of dehydration was definitely wrong. (Even senior clinicians make
Section Two
mistakes in the diagnosis of dehydration in malnutrition.)

• Stop the ReSoMal and start the child on F75 diet.
 ...no improvement in the mood and look of the child, or reversal of the clinical signs:
• The diagnosis of dehydration was probably wrong.
• Change to F75.
 ...clinical improvement, but signs of dehydration:
• Continue with treatment until the appropriate weight gain is achieved.
• Continue with ReSoMal alone. Or F75 and ReSoMal can be alternated.
 ...resolution of the signs of dehydration:
• Stop re-hydration treatment and start the child on F75 diet.
During re-hydration, breastfeeding should not be interrupted.
Begin to give F75 as soon as possible after rehydration has been completed. The F75 can
be given orally or by NG tube. ReSoMal and F75 can be alternated each hour in the case of
a patient with mild dehydration and continuing diarrhoea. The introduction of F75 is usually
achieved within two to three hours after starting the re-hydration process when the patient
should be improving. The re-commencement of F75 will also help to prevent development
of hypoglycaemia
Monitoring Re-hydration
Rehydration (oral or intravenous) therapy must immediately stop if any of the following are
observed:
• The target weight for rehydration is achieved (start F75).
• Visible veins are full (start F75).
• The development of oedema (indicates over-hydration: start F75).
• The development of prominent neck veins.
• The neck veins engorge when the abdomen (liver) is pressed.
• An increase in the liver size by more than one centimetre.
• The development of tenderness over the liver.
• An increase in the respiration rate by 5 breaths per minute or more.
• The development of a “grunting” respiration (this is a noise on expiration not
inspiration).*
• The development of râles or crepitations in the lungs.
• The development of a triple rhythm.
* This sign indicates that the child has fluid overload, an over-expanded circulation, and is
going into heart failure.
Diagnosis of Shock from Dehydration for the Marasmic Patient

The marasmic patient is going into shock when:
• There is definite dehydration determined by the patient’s history and the medical
examination, AND
• There is a weak or absent radial or femoral pulse, AND
• The patient has cool or cold hands and feet (check with back of hand gently for five
seconds).
72
The patient is going into severe shock when, in addition to the above signs, there is a
decrease in the level of consciousness, the patient is semi-conscious or cannot be roused.
The treatment of cardiogenic shock or liver failure is not the same as shock due to dehydration.
With cardiogenic shock or liver failure, fluid given is severely restricted or it can cause serious
deterioration and the treatment itself could lead to death.
Treatment of Shock from Dehydration for the Marasmic Patient

If the patient is definitely dehydrated (a history of fluid loss, a change in the appearance of
Section Two
the eyes), and shows all of the following three bullets, then the patient should be treated
with intravenous fluids:
• Semi-conscious or unconscious and
• Rapid weak pulse and
• Cold hands and feet
The amount of IV fluid given is half or less of that used for nourished, dehydrated children.
Use one of the following solutions:
• Half strength Darrow’s solution
• Ringer-Lactate with 5% dextrose
• Half strength saline with 5% dextrose
Re-hydration needs to be done slowly and monitored closely to prevent over-hydration.

Administer 15 ml/kg IV over the first hour and reassess the child.
• If there is continued weight loss, or the weight is stable, repeat the 15ml/kg IV over
the next hour. Continue until there is weight gain with the infusion. (15mg/kg is 1.5%
of body weight, so the expected weight gain after two (2) hours is up to 3% of body
weight.)
• If the child has gained weight but there is no improvement, assume that the child has
toxic, septic or cardiogenic shock or liver failure. Stop rehydration treatment. Look and
assess for other causes of loss of consciousness.
As soon as the child regains consciousness, or the pulse rate drops to a normal level, then
stop the intravenous fluids and treat the child orally or by NG tube with 10ml/kg/hour of
ReSoMal. Continue with the protocol above for re-hydration of the child orally, using weight
change as the main indicator of progress.
Note: Other Causes of Shock
Apart from the shock related to dehydration, there are four other causes of shock in the
severe acutely malnourished child.
1) Toxic shock12
2) Septic shock13
3) Liver failure
4) Cardiogenic shock.
Diagnosis of Dehydration for the Kwashiorkor Patient

Patients with bi-lateral oedema are over-hydrated and have increased total body water and
increased sodium levels. Oedematous patients thus cannot be dehydrated, although they are
frequently hypovolaemic. The hypovolaemia (relatively low circulating blood volume) is due
to a dilatation of the blood vessels with a low cardiac output. The treatment of hypovolaemia
in kwashiorkor is the same as the treatment for septic shock (see below).
If a child with kwashiorkor has watery diarrhoea, and the child is deteriorating clinically, then
the fluid lost can be replaced on the basis of 30ml of ReSoMal per watery stool.
12. Toxic shock may be caused by traditional medicines, self-treatment with other medication such as aspirin,
paracetamol, metronidazole, etc.
13. Septic shock is a specific type of toxic shock where the damage is caused by overwhelming sepsis.
These are frequently associated with liver failure.
73
Septic (or Toxic) Shock for All Malnourished Patients

Septic shock is a serious medical condition. It is caused by decreased tissue perfusion and
oxygen delivery as a result of infection and sepsis. It can cause multiple organ failure and
death. Children, immuno-compromised individuals, and the elderly are most susceptible as
their immune systems cannot cope with infection as well as healthy adults do. The mortality
rate from septic shock can be as high as 50%.
Septic shock presents with some of the signs of true dehydration and also of cardiogenic
Section Two
shock. The differential diagnosis is often very difficult.

Children who appear very ill may have septic shock, cardiogenic shock, liver failure, poisoning
with traditional medicines, malaria, acute viral infection or other severe conditions. All “very
ill” children should not be automatically diagnosed as having septic shock; the true reason
for the condition should be sought.
If septic shock develops after admission, treatment must be carefully reviewed to determine
if the treatment is the cause of the clinical deterioration. Any unnecessary drugs should be
stopped.
Diagnosis of Septic Shock

To diagnose septic shock, signs of hypovolaemic shock are present. There is a fast, weak
pulse with all three of the following:
• Cold peripheries
• Disturbed consciousness
• Absence of signs of heart failure
Treatment of Septic Shock

All patients with signs of early or developed septic shock should immediately:
• Be given broad-spectrum antibiotics
• Therefore continue first-line antibiotic and add second-line antibiotics. (See “Systematic
Antibiotics” under Routine Medication earlier in Section Two)
For incipient (early) septic shock, give the standard F75 diet by NG tube.
For developed septic shock: Consider third-line antibiotics, antifungal treatment and anti-
staphylococcal treatment. (See “Systematic Antibiotics” under Routine Medication earlier in
Section Two)
• Keep the patient warm to prevent or treat hypothermia.
• Give patient sugar-water (1 teaspoon sugar in 50ml water) by mouth or NG tube as soon
as the diagnosis is made (to prevent hypoglycaemia).
• Do not physically disturb the patient (no washing, excess examination, investigations in
other departments, etc.)
• Do not transport patient to another facility. The stress of transport leads to dramatic
deterioration.
If the patient is unconscious because of poor brain perfusion, then a slow IV infusion of one
of the following can be given:
• Whole blood of 10ml/kg over at least three hours. Nothing is given orally during the blood
transfusion.
• Or 10ml/kg/hour for two hours of the following (do not give if there is a possibility of
cardiogenic shock):
Half-strength Darrow’s solution with 5% glucose
Ringer’s lactate solution with 5% glucose
Half-normal (0.45%) saline with 5% glucose
74
Monitor the patient every ten minutes for signs of deterioration. Especially watch for over-
hydration and heart failure indicated by signs such as:
• Increasing respiratory rate,
• Development of grunting respiration,
• Increasing liver size,
• Vein engorgement.
As soon as the patient improves (stronger radial pulse, regain of consciousness), stop all IV
intake. Continue with F75 diet.
Section Two
Absent Bowel Sounds, Gastric Dilatation, Abdominal
Distension
Bowel sounds in the severe acute malnourished patient may be reduced or absent. The
severe acute malnourished patient will often experience impaired bowel functions, mainly as
a result of bowel infections.
Signs and symptoms of impaired bowel function:
• Abdominal distension
• Loss of bowel sounds
• Vomiting
Treatment
• Give first-line and second-line antibiotic treatment by intra-muscular injection.
• Consider adding third-line antibiotics, at doctor’s discretion.
• Stop all other drugs that may be causing toxicity (such as metronidazole).
• Give a single IM injection of magnesium sulphate (2ml of 50% solution).
• Pass an NG tube, and aspirate the contents of the stomach. Then “irrigate” the stomach
with isotonic clear fluid (5% dextrose or 10% sucrose. The solution does not need to
be sterile). Do this by introducing 50ml of solution into the stomach and then gently
aspirating all the fluid back again. This should be repeated until the fluid that returns from
the stomach is clear.
• Put 5 ml/kg of sugar-water (10% sucrose solution) into the stomach and leave it for one
hour. Then aspirate the stomach and measure the volume that is retrieved. If the volume
is less than the amount that was introduced, either give a further dose of sugar-water or
return the fluid to the stomach.
• There is frequently gastric and oesophageal candidiasis: give oral Nystatin suspension or
Fluconazole
• Keep the child warm.
If the child’s level of consciousness is poor given intravenous glucose:
• Do not put up a drip at this stage. Monitor the child carefully for six (6) hours without
giving any other treatment.
• Improvement is measured first by a change in intestinal function: a decrease in the
distension of the abdomen, visible peristalsis seen through the abdominal wall, return
of bowel sounds, and decreasing size of gastric aspirates. Second, there should also be
improvement in the child’s general condition.
If there is intestinal improvement, begin to give small amounts of F75 by NG tube (half the
quantities given per kg listed in Table 2.3. Subsequently adjust by the volumes of gastric
aspirated).
If there is no improvement after six (6) hours:
• Consider putting up an IV drip. It is crucial that the administered fluid contains adequate
amounts of potassium. Add Sterile Potassium Chloride (20mmol/l) to all solutions that
do not contain potassium. If it is available, use one-fifth normal saline in 5% dextrose,
75
otherwise use Ringer-Lactate in 5% dextrose or half-strength saline in 5% dextrose. The

drip should be run VERY SLOWLY. The amount of fluid that is given should be NO MORE
THAN 2 to 4 ml/kg/hour.
• Start to give the first and second line antibiotics intravenously.
• When the gastric aspirates decrease so that one half of the fluid given to the stomach is
absorbed, discontinue the IV treatment and continue with oral treatment only.
Heart Failure
Section Two
For the severely malnourished patient, congestive heart failure is usually a complication
of over-hydration (when IV fluids or standard ORS solution is given). It can also manifest
when there is very severe anaemia; after a blood or plasma transfusion; or with a diet high
in sodium. It is important to differentiate heart failure from respiratory infection and septic
shock.
Signs and Symptoms of Heart Failure

Heart failure is diagnosed when the patient has a few of the following symptoms (do not
wait for all symptoms to occur, as the patient will continue to deteriorate):
• An increase in respiration rate:
 An acute increase in respiration rate of more than 5 breaths per minute (particularly
during rehydration treatment).
 More than 50 breaths/minute in infants (0-12 months)
 More than 40 in children one to five years old.
• Physical deterioration with a gain in weight.
• A sudden increase in liver size with tenderness developing over the liver. (The liver is
marked before starting any infusion to determine change in size).
• Respiration that has or develops a “grunting” sound during each expiration
• Crepitations or râles in the lungs.
• Prominent superficial and neck veins.
• Engorgement of the neck veins when the abdomen (liver) is pressed.
• Increasing oedema or reappearance of oedema during treatment.
• An acute fall in haemoglobin concentration12. (Requires laboratory).
If heart failure progress, and the patient further deteriorates, there is either
1) Marked respiratory distress progressing to a rapid pulse, cold hands and feet, oedema and
cyanosis; or
2) Sudden, unexpected death.
This is cardiogenic shock. Severely malnourished patients are fragile and can go from
dehydration to over-hydration quickly after treatment has started. Patients can be admitted
with heart failure: it is important that it’s differentiated from shock due to dehydration or
sepsis because the treatment is quite different.
For patients who have already been admitted, there is usually also weight gain. As heart
failure usually starts after treatment, there is nearly always a record of the weight of the
patient that was taken before the onset of heart failure.
Heart failure and pneumonia are clinically similar, and very difficult to tell apart:
• If there is an increased respiratory rate and any gain in weight, then heart failure is the
first diagnosis.
• If there is an increased respiratory rate with a loss of weight, then pneumonia is
diagnosed.
• If there is no change in weight (fluid balance) then the differentiation has to be made
using the v other signs of heart failure.
• Pneumonia is NOT diagnosed if there has been any weight gain before the onset of
respiratory distress.
76
Heart Failure and Oedema

• Children with oedema can go into heart failure without a gain in weight, when the
expanded circulation is due to oedema fluid moving from the tissues to the vascular
space.
• During the initial treatment of severe acute malnutrition, any fluid containing sodium
that has been given will have to be safely excreted later. Initial over-treatment can lead
to death from heart failure several days later, when intracellular sodium (marasmus and
kwashiorkor) and oedema fluid are being mobilised.
Section Two
• As oedema fluid is mobilised (kwashiorkor) and the sodium is coming out of the cells
(both kwashiorkor and marasmus), the plasma volume expands and there is a fall in
haemoglobin concentration. This dilutional anaemia happens to some extent in nearly
all children as they recover. A substantial fall in haemoglobin, as a sign of an expanding
circulation, is also a sign of impending or actual heart failure. These children should never
be transfused.
Treatment of Heart Failure

When heart failure is diagnosed:
• Stop all intakes of oral or IV fluids. No fluid or food is given to the patient until signs of
heart failure are improved which may take 24 to 48 hours. Small amounts of sugar-water
can be given orally to prevent hypoglycaemia.
• Administer frusemide (1mg/kg) stat, as a single dose.
• Digoxin can be given in a single dose of 5 micrograms/kg. Note that this is lower than the
normal dose of digoxin. A loading dose is not given. Use the paediatric preparation, not
small quantities of the adult preparation.
• If the heart failure is associated with severe anaemia, treatment of the heart failure takes
precedence over the treatment of the anaemia.
• A patient with heart failure should never be transfused (unless there are facilities and
experience with exchange-transfusion).
Severe Anaemia
Diagnosis of Anaemia
If the haemoglobin concentration is less than 40g/l, or the packed-cell volume is less than
12% in the first 24 hours after admission, the child has very severe anaemia which can
cause heart failure.
All children have a fall in Hb during the early phase of treatment. This ‘dilutional anaemia’ is
due to the sodium coming of the cells and mobilization of oedema – it must not be treated.
All children have a fall in Hb during the early phase of treatment. This ‘dilutional anaemia’ is
due to the sodium coming of the cells and mobilization of oedema – it must not be treated.
Treatment of Anaemia
• Give 10ml per kg body weight of packed red cells or whole blood, slowly over three (3)
hours.
• The patient fasts during blood transfusion and for at least three (3) hours after blood
transfusion.
• After the start of nutritional rehabilitation with F75, do NOT transfuse a child after 48
hours and up to 14 days.
• Do NOT give iron during Phase 1 and Transition Phase of treatment.
• If the facilities and staff expertise exist (i.e. neonatal units), it is preferable to give an
exchange transfusion to SAM children with severe anaemia.
If there is heart failure with very severe anaemia, transfer the patient to a centre with
facilities to do an exchange transfusion. Heart failure due to anaemia is clinically different
from “normal” heart failure. With anaemia there is “high output” failure with an over-active
77
circulation.
Increasing anaemia and heart failure or respiratory distress is a sign of fluid overload and
an expanding plasma volume. The heart failure is not being “caused” by the anaemia; these
patients should never be given a straight transfusion of blood or even packed cells.
Administration of Medication
Great care should be exercised in prescribing drugs to severely malnourished patients.
Section Two
Severely malnourished patients have: abnormal kidney and liver function; changed levels
of the enzymes that metabolise and excrete drugs; excess enterohepatic circulation (re-
absorption) of drugs that are excreted in the bile; a decreased body fat which increases
the concentration of fat-soluble drugs; and, in kwashiorkor, a possible defective blood-brain
barrier. Few drugs have been examined for pharmocokinetics, metabolism or side effects in
Severe Acute Malnourished (SAM) patients.
It is strongly advised that severe malnutrition is treated first, before standard doses of drugs
are given. Drugs used for HIV and TB can damage the liver and pancreas. HIV and TB are not
considered rapidly fatal (except military TB and TB meningitis) so treatment can be delayed
for up to one week. During that time, nutritional treatment returns the patient’s metabolism
to normalcy.
Common drugs such as Paracetamol do not work for most severely malnourished children
during Phase 1, and can cause serious hepatic damage.
Any required drugs can usually be given in standard doses to patients who are Phase 2 and
out-patients in community nutrient care.
Figure 2.4: Diagnosis and treatment of anaemia
Anaemia
Check Hb at admission if any clinical suspicion of anaemia
Hb >= 40g/l or Hb >= 40g/l or

Packed cell vol>= 12% Packed cell vol>= 12%.
or between 2 and 14 days
after admission.
ONLY during the first 48

hours after admission:
Give 10ml/kg whole or
No acute treatment packed cells 3 hours - No
Iron during phase 2 food for 3 to 5 hours
78
Appendix 2.1 Multi-Chart
INPATIENT THERAPEUTIC FEEDING CARD (Front)
MINISTRY OF
MEDICAL SERVICES
Section Two
79
INPATIENT THERAPEUTIC FEEDING CARD (Back)
Name REG. No
DATE 1 2 3 4 5 6 7 8 9 10 11 12
Antibiotic
Section Two
ROUTINE MEDICINES
Antimalarial
Date Tests
Vitamin A
RESULTS
Albendazole /
Mebendazole on discharge
Measles Vaccine Yes No
TB Cotrimoxazole
ART Yes No Yes No Yes No FBP / Food Support Yes No
Therapy prophylaxis
OTHER MEDICINES
Temperature
MEDICAL CHECKS
Respirations
Stools
Vomit
Clinical Notes
DATE SIGNATURE
Date of Discharge OTP of Discharge
80
Appendix 2.2 Recipes for F75, F100 and ReSoMal using

CMV
Table 2.14: Recipes for F-75 Formula
CMV**
red
Milk Sugar Cereal scoop
Section Two
Type of milk (g) (g) Oil (g) flour* (g) = 6.35g Water (ml)
Dry Skim Milk 50 140 54 70 1 Up to 2000
Dry Whole Milk 70 140 40 70 1 Up to 2000
Fresh cow milk 560 130 40 70 1 Up to 2000
Fresh goat milk 560 130 40 80 1 Up to 2000
* Cereal flour is cooked for about 10 minutes and then the other ingredients added.
** CMV = Special Mineral and Vitamin mix adapted to severe acute malnutrition treatment (® Nutriset)
To prepare the F75 diet, add the dried skim milk, sugar, cereal flour, and oil to some water
and mix. Boil for 5 to 7 minutes. Allow to cool, then add the mineral mix and vitamin mix
and mix again. Make up the volume to 1000ml with water.
Table 2.15: Recipes for F-100 Formula

Type of milk Milk (g) Sugar (g) Oil (g) CMV** Water (ml)
red scoop
= 6.35g
Dry Skim Milk 160 100 120 1 Up to 2000
Dry Whole Milk 220 100 60 1 Up to 2000
Fresh cow milk 1800 100 50 1 Up to 2000
Fresh goat milk 1800 100 60 1 Up to 2000
Table 2.16: Preparation of ReSoMal Solution with ORS

Standard WHO-ORS One litre packet
CMV (mineral and vitamin mix) 1 Red scoop (6.35g)
Sucrose (Sugar) 50g
Water 2000ml
Table 2.17: Preparation of small quantities

To make smaller quantities of ReSoMal, F75 or F100, using the red scoop in the container:
Product One red scoop Water to add

ReSoMal 5.9 g 140 ml
F75 (powder) 4.1 g 20 ml
F100 (powder) 4.1 g 18 ml
Table 2.18: Preparation of F-100 diluted

1 sachet Add 2.8 L clean water
½ sachet Add 1.4 L clean water
1 red scoop Add 25ml of clean water
81
Appendix 2.3: Dietary Requirements for Older Children,

Adolescents and Adults
Initial Treatment for Adolescents and Adults
Critically sick severe acute malnourished adolescents and adults who are admitted to a
health facility require careful nutritional management as well as medical treatment to prevent
further weight loss and increased levels of malnutrition. Adolescents and adults are given
Section Two
the same formula feeds (F75, F100, or a locally-made equivalent) as children. The initial goal
of treatment is to prevent further loss of weight. See Table 2.16 below for precise dietary
requirements.
Table 2.19: Dietary requirements for initial treatment of SAM adolescents and adults14
Age (years) Total energy requirement Volume of diet over a 24 hour period
(Kcal/kg of bodyweight/ (ml/kg of bodyweight/hour)
day) F75 F100
7-10 75 4.2 3.0
11-14 60 3.5 2.5
15-18 50 2.8 2.0
19-75 40 2.2 1.7
>75 35 2.0 1.5
If an adult or adolescent is anorexic (refuses food or shows no appetite), the patient may
require NG tube feeding for the first feeds. For adolescents and adults, large quantities of milk
or formula can be difficult to tolerate (a 50kg adult in Phase 1 requires 2.64 litres of F75 milk
over each 24 hour period). Often milk is not considered a full meal by adult and adolescent
patients, and once the patient has stabilized it may be possible to give a combination of milk
and RUTF which sometimes is better tolerated.
Example: A 60-year-old adult, with a weight of 45kgs in Phase 1, requires:

2.2mls (from F75 column, Table 2.16) x 45kg x 24 hours = 2,376 ml of F75
2,376ml/100*75 = 1,782 Kcal a day
1782 /45kgs = 39.6 kcal/kg/day.
The second column “Total Energy Requirement” shows that a 60-year-old needs 40kcal per
kg of body weight each day.
14. The Management of nutrition in major emergencies, World Health Organization, Geneva 2000
82
Appendix 2.4: Medical History and Examination

Patient History
Medical History
What are the complaints and how long has each been present?
1.
Section Two
2.
3.
4.
Breast feeding alone for how long?
Age stopped breast feeding:
How has the patient been eating and drinking?
Appetite good poor none
Diarrhoea yes no
Stools per day: Normal watery soft blood mucus green pale
Vomiting yes no
Number of times per day:
Breathing: normal fast noisy difficult for how long:
Cough:
Fever:
Convulsions: yes no
Unconsciousness: yes no
83
Medical Examination
In-patient and out-patient In-patient only
Does the patient look: not-ill / ill / very ill / comatose
Mood and behaviour Normal / apathetic / inactive / repeated movements

irritable /
Eyes normal / sunken / staring / xerosis / keratomalacia mild, moderate,
conjunctivitis severe
Section Two
Ears normal / discharging
Mouth normal / sore / red / candida smooth tongue / herpes / angular stomatitis
Membrane colour normal / pale / jaundiced / cyanosed
Gums normal / bleeding
Breathing normal /noisy / asymmetrical /

laboured / wheeze / indrawing
Chest normal / asymmetric / pigeon / sulcus
Oedema none / + / ++ / +++ pretibial / hands / face / generalised
Hydration normal / dehydrated / shock /

uncertain
Passing urine yes / no
Peripheries normal / warm / cold
Pulse rate min / normal / strong / weak
Heart sounds normal / gallop / murmur
Stool not seen / normal / soft / watery / green /

pale / mucus / blood
Abdomen normal / distended / tender / visible /
peristalsis
Bowel sounds normal / active / quiet / absent
Splash no / yes
Liver …..cm below costal margin, normal / firm /

hard / smooth / irregular
Spleen not felt / felt / large – normal / firm / hard –
tender / painless
Tone normal / stiff / floppy
Meninges normal / stiff neck / Brudzinski / fontanelle

bulging
Reflexes normal / increased / decreased / absent
Skin change none / mild / mod / severe peeling / raw / ulcers / infection / cuts /
bruises
Perineum normal / rash / raw / candida
Purpura no / yes
Hair black / brown / red / blond normal / easily

plucked / balding
Scabies none / local / generalised
Lymph nodes none / groin / axilla / neck tender /

painless soft / firm / hard / fixed
Rib ends normal / swollen / displaced
84
Appendix 2.5: Transfer Form

Outpatient to In-Patient Care
Transfer Form: Outpatient Therapeutic Care to Inpatient Therapeutic Care
Name:
Section Two
Age: Sex: Date of Admission:

Admission Data: Weight (kg): MUAC (cm): Facility:
Height (cm): WHZ:
Oedema: (circle) + ++ +++ REG. No:
Date of Transfer:
Criteria for Transfer: Anorexia Acutely Ill Oedema No Weight Gain Other:
Treatment given:
Comments:
85
In-Patient to Out-patient Care

Transfer Form: Inpatient Therapeutic Care to Outpatient Therapeutic Care
Name:
Age: Sex: Date of Admission:

Section Two

Admission Data Weight (kg): MUAC (cm): Facility:
Height (cm): WHZ:
Oedema: (circle) + ++ +++ REG. No:

Date of Transfer:
Criteria for Transfer: (circle) Good appetite

Medically stable
Oedema reduced to +
Weight Gain
Other:
Treatment given:
Comments:
86
ADMISSION DETAILS EXIT DETAILS
+
o. Physical Address / Mobile Age Sex Admission Serostatus / TB
REG. N Admission Date Name Exit Date Exit Outcome^ Observations
No. (months) (M/F) Criteria* status
Appendix 2.6: Register Format

In-Patient and Out-patient Therapeutic Care
* Admission criteria can be: KWASH. (kwashiokor), MAR.(Marasmus: W/H and/or MUAC), OTHER, OLD CASES (returned from inpatient care, returned defaulters)
^ Outcome can be: Cured, Defaulter, Death, Transfer to Inpatient or another OTP (indicate centre), Non-respondent
.+Serostatus can be 0=negative, 1=positive, 2=exposed 3=unknown (exposed infant under 18 months whose biological mother is HIV positive)
87
Section Two
Appendix 2.7: Dehydration
Dehydration Protocol
• RECENT history of significant fluid loss (vomiting/watery diarrhoea)

• RECENT change in appearance (since onset of fluid loss)
• No oedema
Section Two
• Normal signs of dehydration DO NOT apply (because non-elastic skin & sunken
eyes are often present in malnourished child even when there is no dehydration)
RECORD weight AND pulse AND respiration rate – progress is assessed by these indicators
CHECK FOR SHOCK GIVE IV fluids:

• Half-strength Darrow’s solution OR
• Cold hands plus pulse weak/absent Yes
• Half-strength saline with 5% dextrose OR
AND/OR • Ringer lactate with 5% dextrose AT 15ml/
• Decreased consciousness kg for 1 hour and reassess
No
ReSoMal AT 5ml/kg over 30 mins for 2 hrs Weight STABLE
Increase ReSoMal
by 5ml/kg/hr
Weight GAIN Reassess every hr
Weight STABLE
OR
Weight LOSS
Clinical No clinical Weight LOSS
improvement improvement
Increase ReSoMal
by 5ml/kg/hr
STOP therapy Reassess every hr
Give F75 if conscious
Reassess and Weight GAIN &
re-diagnose no improvement
Continue until
Repeat 15 ml/kg IV
target weight is
over 1 hr, continue
reached
until there is weight
gain with infusions
F75 feeds
STOP immediately all rehydration therapy if any of the following are observed:
• Vein engorgement*
• Development or increase of oedema
• Increase in liver size (>1cm) and/or liver tenderness*
• Increase in respiration rate by ≥ 5 breaths per minute*
• Development of grunting respiration*
• Development of râles or crepitations in the lungs*
• Development of triple rhythm*
*If these signs develop then the child has fluid overload, an over-expanded circulation and is going into heart
failure
88
REPORTING FORMAT - MANAGEMENT OF SEVERE ACUTE MALNUTRITION
PROVINCE IMPLEMENTING PARTNER(S)
DISTRICT
MONTH
HEALTH FACILTY
YEAR
OUTPATIENT NAME & POSITION OF REPORTING OFFICER
INPATIENT Signature
Date
ESTIMATED TARGET malnourished <5's
(based on latest survey data and admission criteria)
ESTIMATED COVERAGE
(from coverage survey or estimated from target and admissions)
SAM (inpatient/outpatient)
RUTF Consumption (Boxes)
NEW CASES (B) NEW CASES (C ) Discharges (E) Transfers (F)
Total at
Total end of
beginning of TOTAL NEW TOTAL EXITS (G) =
From Outpatient reporting period
reporting 6-59m (According Other (adults, CASES (D) (B+ C) (E + F)
or Inpatient care CURED DEATH NON-RECOVERED To inpatient or (A+D-G=H)
period (A) to admission infants, DEFAULTER (E3)
Returned (E1) (E2) (E4) outpatient care
criteria)(B1) adolescents)(B2)
defaulters
% % % %
TARGET (Sphere Standards) >75% <10% <15%
NB: Old Cases and Transfers are excluded from national/programme reporting as they are movements within the programme rather than entries and exits
E1: Cured = reaches discharge criteria
Appendix 2.8: Monthly Report Format for Management of
E3: Defaulter = absent for 3 consecutive visits
E4: Non recovered = does not reach the discharge criteria after 4 months in OTP
89
Section Two
Section Three:
Section Three
Management of Acute
Malnutrition
Infants Less Than Six Months
Infants Less Than Six Months with a

Prospect of Being Breastfed
Overview
Mothers should exclusively breastfeed their babies for the first six months of life. This means
that the babies should not get any other milks, foods or liquids, not even sips of water. After
six months breast milk alone is not enough. Babies need to gradually start eating a variety
of foods to continue growing well. Breast milk continues to be an important part of the diet
until the baby is at least two years. Mothers who are HIV-positive should be referred to a
health worker for appropriate support and counselling on infant feeding options. Exclusive
breastfeeding is recommended for HIV-infected women for the first six months of life unless
replacement feeding is acceptable, feasible, affordable, sustainable and safe (AFASS) for them
and their infants before that time. When replacement feeding is acceptable, feasible, affordable,
sustainable and safe, avoidance of all breastfeeding by HIV-infected women is recommended1.
Children younger than six months who are malnourished are always treated in an in-patient
unit. They should not be admitted to an out-patient treatment facility. RUTF is not suitable for
infants less than six months.
Infants who are malnourished are weak and often do not suckle strongly enough to stimulate
an adequate production of breast milk. The mother often thinks that she herself has insufficient
breast milk and is apprehensive about her ability to adequately feed her child. The low output
of milk is due to inadequate stimulation by the feeble infant. Breast milk supply is demand-led,
the more the baby breastfeeds, the more breast milk the mother will produce.
The objective of treatment of acute malnourished infants less than six months is to return
them to full exclusive breast feeding.
1. HIV AND Infant Feeding: New Evidence and Programmematic Experience. Report of a technical consultation
held on behalf of the Inter-agency Task Team (IATT) on Prevention of HIV Infections in Pregnant Women, Mothers
and their Infants, Geneva, Switzerland, 25–27 October 2006 (WHO, UNICEF, UNAIDS, UNFPA).
90
For children under the age of six months, the main admission criterion is failure of effective breast feeding and the
main discharge criterion is gaining weight on breast milk alone.
Table 3.1: Criteria of admission, Infants with a prospect of being breastfed

AGE ADMISSION CRITERIA
Infant less than 6 months The infant is too weak or feeble to suckle effectively (independently of
Section Three
or his/her weight-for-length)
less than 3kg being breast-fed or
The infant is not gaining weight at home or
W/L is -3 z-scores
or
Presence of bilateral oedema
Nutrition Support: Diet, Frequency and Suckling Technique

The aim of nutrition rehabilitation is to stimulate breast-feeding and to supplement the breast milk until the breast
milk is sufficient enough alone to allow the child to grow properly. Breast milk output is normally stimulated by the
baby feeding at the breast. When the baby has not been feeding well and lactation has reduced, there is a need
to support breastfeeding with the Supplemental Suckling (SS) technique (see figure 3.1). It is important to put the
infant to the breast as often as possible.
• Breastfeed every three hours for at least 20 minutes, more often if the child cries or seems to want more.
• Between 30 minutes and one hour after a normal breastfeed give maintenance amounts of F100 Diluted using
the SS technique.
• F100 Diluted: 130ml/kg/day (100kcal/kg/day), divided in eight meals (see Table 3.2).
• Infants should be nursed in a separate space from the older malnourished children. This can be in a “breast-
feeding corner”. It is important not to admit infants into the in-patient facility where the severely complicated
cases are admitted. It is important that these infants are not put at high risk of cross infection from older sick
children.
There are no separate phases in the treatment of infants with the SS technique. There is no need to start with F75
and then switch to F100 Diluted unless the infant has severe oedema.
Preparation of F100 Diluted

When the ready made-up formulas are available: Dilute F100 (one packet) into 2.7l litres of water (instead of 2
litres) to make F100 Diluted.
To make small quantities of F100 Diluted:

1. Use 100ml of F100 already prepared and add 35ml of water, then you will get 135ml of F100 Diluted. Discard
any excess waste. Don’t make smaller quantities.
2. If you need more than 135ml, use 200ml of F100 and add 70ml of water, to make 270ml of F100 Diluted and
discard any excess waste.
If F100 Diluted is not readily available, the infant can be fed with the same quantities of commercial infant formula,
diluted according to the instructions on the tin.
However, infant formula is not designed to promote rapid catch up growth. Unmodified powdered whole milk
should not be used.
Quantity of F100 Diluted

It is important to feed these children often as they are small and will only take small quantities. Feed every three
hours. The quantity of F100 diluted to give to a malnourished infant is calculated depending on the body weight
(see Table 3.2). The quantity is NOT increased as the infant starts to gain weight.
91
Table 3.2: Quantity of F100 Diluted to give to infants with a prospect of being breastfed,
per Kg of body weight
Class of Weight (kg) ml of F100 Diluted per feed (8 feeds/day)

Wt of Child Diluted F100
>=1.2 kg 25 ml per feed
1.3 to 1.5 kg 30
Section Three
1.6 – 1.7 35
1.8 – 2.1 40
2.2 - 2.4 45
2.5 - 2.7 50
2.8 - 2.9 55
3.0 - 3.4 60
3.5 – 3.9 65
4.0 – 4.4 70
Children less than six months with oedema are started on F75 and not on F100 Diluted.
When the oedema has resolved and the child suckles strongly, he/she is changed to F100
Diluted or infant formula.
Note: F100 undiluted is never used for infants less than 3kg.
Regulating Quantity of F100 Diluted

The child’s progress is monitored by his/her daily weight:
• If the child loses weight over three consecutive days yet seems hungry and is taking all
the F100 Diluted, add 5mls to each feed.2
• In general the supplementation is not increased during the stay in the centre. If the child
grows regularly with the same quantity of milk, it means the quantity of breast milk is
increasing.
• If after some days, the child does not finish all the supplemental food, but continues to
gain weight, it means that the breast milk is increasing and that the child has enough.
• Weigh the child daily with a scale graduated to within 10g or 20g.
When a baby is gaining weight at 20g per day (whatever his weight):
• Decrease the quantity of F100 Diluted to one half of the maintenance intake.
• If the weight gain is maintained (10g per day whatever his weight) then stop supplemental
suckling completely.
• If the weight gain is not maintained then increase the amount given to 75% of the
maintenance amount for two to three days and then reduce it again if weight gain is
maintained.
• If the mother is agreeable, it is advisable to keep the child in the centre for a further few
days on breast milk alone to make sure that s/he continues to gain weight. If the mother
wishes to go home as soon as the child is taking the breast milk greedily then they should
be discharged.
• When it is certain that the child is gaining weight on breast milk alone s/he should be
discharged, no matter what his current weight or weight-for-length.
2. The Supplemental Suckling feed is giving maintenance amounts. If it is being taken and there is weight
loss, either the maintenance requirement is higher than calculated or there is significant mal-absorption.
92
Supplemental Suckling Technique

The supplementation is given using a tube the same size as n°8 NGT (a size n°5 tube can
be used, but the milk should be strained through cotton wool to remove any small particles
that would block the tube). Cut the tip of the NG tube back beyond side ports on the tube,
if these ports exist
1. F100 Diluted or formula milk is put in a cup. The mother holds it.
2. The end of the tube is put in the cup.
3. The tip of the tube is put on the breast at the nipple and the infant is offered the breast
Section Three
in the normal way so that the infant attaches properly. Sometimes at the beginning the
mothers find it better to attach the tube to the breast with a piece of tape.
4. When the infant suckles on the breast with the tube in his mouth, the milk from the cup
is sucked up through the tube and taken by the infant. It is like taking a drink through a
straw.
5. At first an assistant needs to help the mother by holding the cup and the tube in place.
She encourages the mother confidently. Later the mother nearly always manages to hold
the cup and tube without assistance.
6. At first, the cup should be placed at about 5 to 10cm below the level of the nipple so
the milk does not flow too quickly and distress the infant, and so the weak infant does
not have to suckle excessively to take the milk. As the infant becomes stronger the cup
should be lowered progressively to about 30cm below the breast.
7. The mother holds the tube at the breast with one hand and uses the other for holding
the cup.
Notes:
• It may take one or two days for the infant to get used of the tube and the taste of the
mixture of milks, but it is important to persevere.
• By far the best person to show the mother the technique is another mother who is using
the technique successfully. Once one mother is using the SS technique successfully the
other mothers find it quite easy to copy her.
• The mother should be relaxed. Excessive or officious instructions about the correct
positioning or attachment positions often inhibit the mother and make her think the
technique is much more difficult than it is. Any way in which the mother is comfortable
and finds that the technique works is satisfactory.
• If the formula diet is changed then the infant normally takes a few days to become
used to the new taste. It is preferable to continue with the same supplementary diet
throughout the treatment.
Figure 3.1: Supplemental Suckling Technique
This infant is suckling the breast and

also getting the F100 Diluted (130ml/
kg/day) by the Supplemental Suckling
(SS) technique.
Raising or lowering the cup determines
the ease with which the infant gets the
supplement: for very weak infants it can
be at the level of the infant’s mouth. If
it is above this level the feed can go into
the child by siphonage when there is a
danger of aspiration
Cleaning the tube:

After feeding is completed the tube is flushed through with clean water using a syringe. It is
then spun (twirled) rapidly to remove the water in the lumen of the tube by centrifugal force.
If convenient the tube is then left exposed to direct sunlight.
93
Routine Medication
Vitamin A: 50,000UI at admission only
Folic acid: 2.5mg (1/2 tab) in one single dose
Ferrous sulphate: when the child suckles well and starts to gain weight. Use the F100,
which is enriched with ferrous sulphate (phase II). Dilute it with 1/3 water to obtain the
correct dilution. There are relatively few children younger than six months so it is easier
Section Three
and safer to use the F100 prepared for the older patients than to calculate and add ferrous
sulphate to very small amounts of diet.
Antibiotics: First line: Amoxycillin (from 2kg): 30mg/kg two (2) times a day (60mg/day).
Second line if required: Gentamycin for severe infections (do not use Chloramphenicol in
young infants).
Surveillance
Each Day:
• These children must be seen by a nurse everyday because they are vulnerable.
• Weigh the patient and record the weight. Plot weight on the Multi-chart. (See Appendix
2.1 for Multi-chart).
• Assess and record the degree of oedema (0, +, ++, +++).
• Record the patient’s fluid intake and source (oral, NG tube or IV fluids). Record if patient
is absent at mealtime, has refused diet or has vomited. Document the information in the
multi-chart to monitor ongoing progress.
• Assess and note in the Multi-chart standard clinical signs (number of stools passed,
vomiting, dehydration, cough, respiration and liver size).
Care for the Mother

As the aims are to increase breast milk and for the mothers learn from each other, and
because the treatment is different from older patients, the infants should be together in a
specific room that can be monitored and kept quiet.
• Check mother’s MUAC and the presence of oedema.
• Explain to the mother what the aim of treatment is and what is expected of her.
• Do not make the mother feel guilty for the state of her child or blame her for giving other
foods.
• Strongly reassure the mother that the technique works and that she will produce enough
milk herself to make her baby better.
• Be attentive to her and introduce her to the other mothers in the phase.
• She should drink at least two (2) litres of fluids per day.
• She must eat enough - about 2500kcal/day (one porridge in the morning, one or two
family meals, one porridge in the afternoon).
• The mother who is admitted in the centre with her child receives Vitamin A:
1. If the child is below 1 month old 200.000IU (there should be no risk of pregnancy)
• Micronutrients’ supplementation must also be given to the mother. The quality of the
milk depends upon the mother’s nutritional status. It is critical that the mother receives
meals while the child is an in-patient. The mother’s diet is important for the recovery of
the infant from malnutrition.
• The length of stay in the in-patient facility should be as short as possible.
94
Discharge Criteria
Table 3.3: Discharge criteria, infants with a prospect of being breastfed
AGE DISCHARGE CRITERIA
Infant less than 6 months • It is clear that he/she is gaining weight on breast milk alone after the
or Supplemented Suckling technique has been stopped.
less than 3kg being breast-fed • There is no medical problem.
Section Three
Note: there are no anthropometric criteria for discharge of the fully breast-fed infant who is
gaining weight.
Follow-Up
The follow-up for these children is very important. The mother should be enrolled for a
supplementary feeding programme if it exists and receive high quality food ration to improve
the quantity and quality of breast milk. It is also important to monitor the infant’s progress,
support exclusive breastfeeding and inform the mother on when to introduce appropriate
complementary food at the age of six months.
Infants Less Than Six Months without

Prospect of Being Breastfed
Overview
There are special circumstances where a child less than six months can not be exclusive
breastfed (these include abandonment, a child being orphaned, medical conditions or when
a mother who is HIV positive meets the criteria for and chooses exclusive replacement
feeding). The criteria for exlcusive replacement feeding - Accessible, Feasible, Acceptable,
Safe and Sustainable (AFASS) - is detailed in national job aids, counselling cards and IEC
materials on Infant Feeding and HIV.
When there is no prospect of being given breast milk then severely malnourished, less than six
month old infants are treated according to the standard protocols of management of severe
acute malnutrition in Phase 1, Transition and Phase 2 detailed in Section Two. However,
the following dietary modifications explained here must be applied. The admission criteria
are the same as the other malnourished infants; however discharge criteria are different, as
explained below.
Admission Criteria
Table 3.4: Criteria of admission3, infants without a prospect of being breastfed
AGE ADMISSION CRITERIA
Infants less than six months old W/L (weight-for-length ) < -3 Z scores
or or
less than 3kg with no prospect of being breast-fed Presence of bilateral oedema.
3. There are no standards for infants below 49cm and the increments to judge nutritional status require
precise scales that are not generally available. The in-patient therapeutic unit is not appropriate for treating
premature and low-birth-weight non-breast-fed infants below 49cm in length. These infants should be
referred to the nursery and given infant formula.
95

Phase 1
• Wasted, marasmic infants of less than six months old can be given F100 Diluted in
Phase 1.
• Oedematous infants of less than six months are always be given F75 in Phase 1.
Table 3.5: Quantity of F100 Diluted or F75 to give to infants without a prospect of being
Section Three
breastfed in Phase 1, per kg of body weight

Class of Weight (kg) ml of F100 per feed in Phase 1 (8 feeds/day)
Wt of Infant Diluted F100
=< 1.5 kg 30 ml per feed
1.6 to 1.8 kg 35
1.9 – 2.1 40
2.2 - 2.4 45
2.5 - 2.7 50
2.8 – 2.9 55
3.0 - 3.4 60
3.5 – 3.9 65
4.0 – 4.4 70
Children less than six months, with oedema, should be given F75 and not F100 Diluted.
Transition Phase
During Transition Phase, only F100 Diluted is used. The volume of the diet is increased by
one third. These small infants are not treated with full-strength F100.
Phase 2
During Phase 2, double the volume of F100 Diluted that was given during Phase 1.
Table 3.6: Amounts of F100 to give to infants without a prospect of being breastfed in
Phase 2, per kg of body weight
Class of Weight (kg) ml of F100 per feed in Phase 2 (8 feeds/day)
Diluted F100
=< 1.5 kg 60 ml
1.6 to 1.8 kg 70
1.9 – 2.1 80
2.2 - 2.4 90
2.5 - 2.7 100
2.8 – 2.9 110
3.0 - 3.4 120
3.5 – 3.9 130
4.0 – 4.4 140
Preparation of F100 Diluted

See section 2, Appendix 2.2 for instructions to make F100 Diluted.
96
Routine Medication
Routine medicine is the same as for infants under six months who are breastfed. See page
99 for details.
Surveillance
Surveillance is the same as for phase 1, in-patient care. Please see 62, Section Two.
Section Three
Criteria for Discharge
Table 3.7: Discharge criteria, infants without a prospect of being breastfed
AGE DISCHARGE CRITERIA
Infant less than six months When infant reaches weight-for-length is > -2 Z-scores,
or he/she can be switched to infant formula.
less than 3 kg with no prospect of being
breast-fed
Follow - up
Follow up for these children is very important and needs to be organized between the carer
and the health staff at the MCH clinic. With the absence of breast-milk, other milks need to
be included in the diet to prevent relapse. Nutrition counselling for the mother or caregiver
is essential. A child that has been exposed to HIV through the perinatal period, should be
tested for HIV at six weeks of age (through DNA PCR testing), receive close follow-up for
prevention and growth monitoring, prophylaxis and early referral to assess the need for ART
support.
97
Section four:
Section Four
Out-patient Therapeutic Care

for Severe Acute Malnutrition
For Children Over Six Months
Overview
Under certain conditions, patients with severe acute malnutrition can be treated as out-
patients in the community. However the relevant community members must be informed and
confident on issues related to acute malnutrition, treatment, and how outpatient therapeutic
care or out-patient therapeutic programme (OTP) assists in the management of acute
malnutrition.
The objective of out-patient management of severe acute malnutrition is a more widespread
access to treatment, establishing the appropriate facilities within or closer to more
communities. Community Health Workers (CHWs) and other community volunteers must
be trained to screen, monitor and follow-up malnourished children in the community.
Uncomplicated cases of severe malnutrition - patients who have a good appetite; are free
from medical complications; and do not have moderate/severe oedema - can be treated with
routine drugs and the relevant quantity of ready to use therapeutic food (RUTF) at home.
Out-patients attend a health facility weekly for monitoring and to replenish RUTF supply.
Health staff at the health facility must be trained on the treatment of severe acute malnutrition
in the community.
Admission Process
Assessment
• Take the patient’s weight and height, and calculate weight-for-height (Z-scores).
• Check for oedema
• Measure and record MUAC.
• Assign special registration number and register in the registration book.
• Check immunisation status.
• Give routine medications according to Table 4.3.
• Complete the OTP ration card (Appendix 4.3).
• Fill in the ration card (See Appendix 4.3 for ration card).
98
Requirements for Out-patient Therapeutic Care

Health Facility Requirements
• A health worker trained in the management and treatment of acute malnutrition in the
community, ideally a qualified nurse.
• The health staff at the health facility must have the capacity to conduct weekly assessment,
monitoring, and treatment services for patients with severe acute malnutrition.
• Medical and anthropometric equipment including weighing scales, height boards, weight-
Section Four
for-height reference charts, and MUAC tapes.
• Routine medicines including antibiotics, antihelminths and vitamin A. Medical equipment
such as a thermometer and a stethoscope or clock to count respirations.
• OTP registration book, patient cards for recording patient information and monthly
statistical forms
• An adequate supply of ready-to-use therapeutic food (RUTF) (see “Estimating RUTF
Monthly Requirements for a Health Facility” at the end of Section Three to calculate
monthly requirements depending on number of patients).
Community Requirements
• Community members who are committed and who understand the risks of acute
malnutrition; the importance of nutrition rehabilitation for malnourished children; and the
benefits of out-patient treatment of acute malnutrition in the community.
• Well-trained, motivated CHWs.
Admission Criteria
The anthropometric criteria that determines the extent of severe acute malnutrition is
consistent, irrespective of whether the patient is then admitted to an in-patient or out-
patient facility.
Having determined the patient’s medical situation, one is eligible for out-patient therapeutic
care when the patient has:
• A good appetite (conduct the Appetite Test, Appendix 1.2)
• No medical complications
• No severe oedema (do not have ++ or +++ Oedema)
In-patients who are recovering sufficiently and meet the above criteria may be transferred to
out-patient therapeutic care after completing Transition Phase.
Table 4.1: Summary of criteria for admission to out-patient therapeutic care
Criteria for admission Out-patient therapeutic care

Anthropometric criteria • W/H < -3 Z-score
6 months to 18 years • MUAC < 11.5cm (age >6 months)
Anthropometric criteria • BMI <16
Adults • MUAC <16cm
• MUAC 16.1cm to 18.5cm with clinical complications
Bi-lateral oedema Bi-lateral pitting oedema
Grade 1 (+) only
Appetite Test Passes Appetite Test
Home care situation Reasonable home circumstances and a willing caregiver
Skin No open skin lesions
Medical complications Alert and no medical complications
Others Visually emaciated second twin, HIV positive child losing weight, infants
< 6 months for monitoring purposes
99

Nutrition rehabilitation in the community is effective when the patient receives a weekly
supply of take home Ready to Use Therapeutic Food (RUTF). This is a specialized food
developed specifically for the recovery of severe malnutrition at home. It is an energy-dense,
mineral/vitamin-enriched product that is equivalent to F100 with added iron. It contains the
required energy and micronutrients to meet the nutritional needs of the severely malnourished
child. RUTF is an oil-based, ready-to-use product that has a low risk of contamination. It
Section Four
provides approximately 530Kcal per 100g. The ration given to a severely malnourished child
is based on the intake requirement of between 150-200 kcal/kg/day. The amount of RUTF to
be consumed per day is based on the weight of the child (see Table 4.2).
Preparation of RUTF
RUTF is pre-cooked thus does not require preparation. It can be eaten directly from the
container or packet.
Quantity of RUTF
The caregiver is given a week’s supply of RUTF at each weekly health facility visit. The
caregiver is informed how much to give daily. See Table 3.2 for quantities of RUTF to feed
for class of body weight. It is better to give the whole packet/sachet to the child rather than
taking it out and putting on a plate or other container. Cut the top of the packet and the
child can eat directly from the packet. This is safer and more hygienic. Encourage the child to
take the RUTF slowly through the day and to drink plenty of water. If the child is still breast
feeding, breastfeed before giving RUTF.
Table 4.2: Quantity of RUTF per class of body weight, daily and weekly1
RUTF (Plumpy’nut®) * RUTF (BP - 100)

Class of weight
(kg) sachet per day sachet per week Bars per day Bars per week
3.5 - 3.9 1 .5 11 2 14
4.0 – 5.4 2 14 3 21
5.5 – 6.9 2.5 18 4 28
7.0 – 8.4 3 21 5 35
8.5 – 9.4 3.5 25 6 42
9.5– 10.4 4 28 7 49
10.5 – 11.9 4.5 32 8 56
≥ 12 5 35 9 63
*Table from Community-based Therapeutic Care, A Field Manual, first edition, 2006
Routine Medication
Give routine medication to all severe acutely malnourished children admitted to out-patient
therapeutic care (see Table 3.3). Where possible, medications are given as a single-dose
treatment so that the health worker can observe administration and avoid problems with
compliance. The one exception is the first-line antibiotic (amoxycillin): the first dose should
be given in front of the health worker who explains to the parent/caregiver how to continue
treatment at home.
Additional medication may be prescribed to treat other medical problems as required.
1. Quantities may vary and will be raised when RUTF will be produced and supplied locally.
100
Table 4.3: Drug regime for OTP patients
Direct admission to out-patient therapeutic care

Vitamin A One (1) dose on the fourth week (fourth visit)
Do not give to children with oedema
Amoxicyllin Give first dose at the health facility and
give remainder of treatment to the parent/caregiver with instructions
to give twice daily for seven days at home
Malaria According to national protocol
Section Four
Measles 1 vaccine on the fourth week (fourth visit)
(children 6 months and older)
Deworming 1 dose (Mebendazole or Albendazole) on the second week (second
(children >1 year old) visit)
Iron and Folic Acid: Not to be given routinely. Where anaemia is identified according to IMCI
guidelines, treatment should begin after 14 days care and not before. It should be given
according to National/WHO Guidelines. For severe anaemia, refer to inpatient care.
Antibiotic: First line choice is amoxicyllin as effective against small bowel overgrowth
associated with malnutrition. If a child is on catrimoxizale prophylaxis, this should continue
throughout at the same dose, while amoxycillin one-week-dose is added.
Registration
All admission and discharges should be noted in the register (see Appendix 2.6). The
observation column should be used to add information about the home situation (e.g. orphan,
twin, IDP) or additional medical information (e.g. HIV status, if on TB treatment).
A unique registration number is given to each child when the child is first admitted for
supplementary feeding, out-patient therapeutic care or inpatient therapeutic care. Each
registration number is made of 3 parts, for example:
NYL/003/0TP
- NYL: refers to the name of the health facility (or site) where treatment is provided
- 003: is the number allocated to the child (this runs in sequence from the previous child
registered at that health facility or site)
- OTP: refers to the programme component where the child entered. This could equally be
Inpatient or SFP.
To ensure that the children can be tracked, the full number allocated when a child enters a
programme is retained until the child is discharged
To facilitate tracing and follow-up in the community, all registrations should follow this
numbering system. It should be quoted on all records concerning the child i.e. OTP, SFP
cards, registration books, ration cards, transfer slips and identity bracelets if any.
Returning defaulters retain the same number that they were first given, as they are still
suffering from the same episode of malnutrition. Their treatment continues on the same
monitoring card.
Readmissions after relapse are given a new number and a new card as they are suffering
from a separate episode of malnutrition and therefore require full treatment again.
101
Surveillance
Table 4.4: Surveillance tasks and frequency
Task Frequency
Patient attends health facility weekly
Patient receives replacement RUTF weekly
Health worker checks weight weekly

Section Four
Health worker checks MUAC weekly
Health worker checks height monthly
Health worker checks vital signs: temperature, respiration rate weekly
Health worker conducts Appetite Test weekly
Health worker does medical check and history weekly
Health worker fills in OTP card and ration card weekly
Discharge Criteria
Table 4.5: Discharge criteria
The patient If:
is:
Cured2 • MUAC >11.5cm and
• No oedema for two consecutive visits.
• W/H -2 Z-score
• Children admitted on MUAC, are discharged from outpatient therapeutic care after a
minimum of two months.
Defaulted Absent for three consecutive visits
Died Died while registered in the out-patient therapeutic care
Non-recovered Has not achieved discharge criteria within four months.

Link the child to other programmes e.g. IMCI, OVC, HBC, ART Clinics, or targeted food
distributions.
Discharge Procedures
• Give feedback to the parent/caregiver on the patient’s final outcome.
• Ensure the parent/caregiver understands importance of follow-up care (supplementary
feeding or other programme).
• Give a final ration of seven (7) packets as a weaning off ration.
• Fill in date of discharge on the register.
• Advise parent/caregiver on good nutrition and cooking practices.
• Advise parent/caregiver to return to the health facility if child becomes sick or is losing
weight again.
• Refer patient to the nearest supplementary feeding programme if available.
Home Care for the Malnourished Patient

The Role of the Parent or Caregiver
Discuss with the parent/caregiver the following points, and make sure they feel confident of
their role.
• The quantity of RUTF to give the patient daily.
• The severely malnourished patient must eat the RUTF ration before other family food is
offered.
• Wash patient’s hands and face with soap before giving RUTF.
2. Discharge criteria based on percentage of weight gain is currently being developed.
102
• Each morning give a sachet of RUTF to the child and encourage child to take small
amounts frequently during the day. Once the sachet is finished give the remainder of the
quantity of RUTF prescribed for the day depending on the child’s body weight. (See Table
4.2 for quantities of RUTF per kg of body weight.)
• Give plenty of safe drinking water to the child throughout the day (on demand).
• RUTF is never shared with other members of the family.
• Seek the CHW if concerned with the patient’s condition (not eating, losing weight,
vomiting, diarrhoea, sick, increasing oedema); or go directly to the health centre for
Section Four
medical review and advise.
• Give routine medicines as advised by the health worker.
• Attend the health centre weekly for monitoring and to receive more RUTF supplies.
• Return empty RUTF containers weekly to replenish RUTF.
• Malnourished children need to be kept warm (ensure child wears plenty of clothes).
• Children with diarrhoea should continue to feed and drink plenty of water.
Role of Health Workers - General Reminders

• Look over the child’s monitoring card with the assigned CHW and highlight areas that will
require special attention during the home visits.
• Conduct group health/nutrition education with all the patients attending for weekly review
and replacement food before seeing each patient individually.
• Link with other community-based support programmes.
• Promote RUTF as medicine and NOT as food to be shared.
• A child who has been in the programme for four weeks with no weight gain, or with
weight fluctuating between small gains and losses should be investigated further for
medical or social reasons. Special attention must be paid to these children during medical
assessment. (See table 4.6 “Failure to Respond” page 92 Section Three)
• If a child has any clinical signs that suggest HIV and AIDS, encourage the parent or
caretaker to bring the child to early referral for VCT or TB screening.
Note: If there is food insecurity in the area, or there is an emergency situation, a “protection”
ration (usually CSB or UNIMIX-equivalent to a supplementary feeding ration) should be
given to the severely malnourished patient’s family. This is to assist the family and also
minimize the risk that the RUTF is shared with other family members as well as the patient.
It is important that the family is registered for a general ration if present (in an emergency
context). The parent/caretaker must be reminded that the general ration is not for the patient
but only for the rest of the family.
Criteria for Transfer: Out-Patient Therapeutic Care to In-

patient Phase 1
Patients who develop any sign of a serious medical complication during out-patient therapeutic
treatment should be transferred to in-patient Phase 1 until stabilized. Medical complications
are listed in Section One, Table 1.6.
If the patient develops any of the following, he/she is transferred to the in-patient facility:
• Failure of the Appetite Test.
• Increase or development of oedema.
• Development of re-feeding diarrhoea sufficient enough to lead to weight loss.
• Weight loss for three consecutive weighing, or two weeks.
• Weight loss of more than 5% of body weight at any visit.
• Static weight for three consecutive weighing.
• Fulfilling any of the criteria of “failure to respond” in Table 4.6.
103
Phase 1 protocol is followed when a patient is transferred back to the in-patient unit (see
Section 2).
Failure to Respond
For out-patient therapeutic care, a failure to respond diagnosis usually warrants referral to
in-patient care for full assessment. If inadequate social circumstances are suspected as the
cause, a home visit can be performed before transfer to the in-patient facility.
The CHW should discuss with the parent/caregiver the conditions of the home environment
Section Four
that may be affecting the child’s recovery progress. At each visit to the health facility, the
health staff will routinely take vital signs (temperature, pulse and respiration rate) and weight
and conduct the Appetite Test. They will note any issues and work to resolve problems.
A follow-up home visit is essential when:
• The caregiver/parent has refused admission to in-patient care despite advice.
• The caregiver/parent does not bring the patient for scheduled appointments at the out-
patient programme.
Table 4.6: Failure to respond: out-patient criteria

Out Patient Therapeutic Care
Criteria for failure to respond Time admitted
Primary failure to respond
Failure to gain any weight (non-oedematous children) 3 weeks
Failure to start to lose oedema 3 weeks
Oedema still present 3 weeks
Weight loss since admission to programme (non-oedematous children) 2 weeks
Secondary failure to respond

Failure of Appetite test At any visit
Weight loss of 5% of body weight At any visit
Weight loss for two successive visits 2 weeks
Primary Failure to Respond

For every unexplained primary failure to respond, a detailed history and examination is
performed. In particular, check carefully for infection as follows:
1. Examine the child carefully. Re-measure all vital signs including the temperature and
respiration rate for signs of infection or underlying medical conditions.
2. Depending on patient’s signs and symptoms of illness or disease, the following examinations
can be considered as appropriate and where laboratory facilities exist. Routine urinalysis
and culture to examine urine for infection; hemotology, blood, spinal fluid and/or sputum
cultures for infection; screening sputum or tracheal aspirate for signs of TB; do radiography
and chest x-ray.1 Further, with specific symptoms of enteric conditions, examination of
the stool for blood, ova, parasites or culture for type of infection needs to be considered.
Examine stool for blood, look for trophozoites or cysts of Giardia; culture stool for bacterial
pathogens. Further, diagnostic counselling and testing (DCT) for HIV (or infantile diagnosis
using DNA PCR testing), haematological screening for malaria should be considered with
related clinical symptoms. HIV, Tuberculosis or Kala Azar can underline malnutrition.
1. Gastric aspirates are very rarely positive in the malnourished child with active TB, particularly if there is
overnight feeding; this test should not be relied on, is difficult to perform well and is traumatic for the child. If
it is used, overnight feeds should not be given.
104
Secondary Failure to Respond

Secondary failure to respond is considered when there is a deterioration in the patient’s
condition after an initial response to recovery.
Common causes of a secondary failure to respond:
• Inhalation of diet into the lungs. There is a poor neuro-muscular coordination between
the muscles of the throat and the oesophagus in malnutrition. It is common for a child to
inhale food into the lungs during recovery. An advantage to RUTF is that it is less likely to
Section Four
be force-fed and thus inhaled.
• An acute infection contracted or infections limiting food intake and nutrients absorption.
• Sometimes as the immune and inflammatory systems recover, there appears to be
“reactivation” of infection during recovery. This means that initially the illness is
asymptomatic, but as the child starts to recover these signs become present. This may
present with increased temperature, fevers, increased respirations and increased pulse
rate. In other words an underlying infection is initially masked but becomes evident after
starting a therapeutic diet. Malnourished children often do not have the same immune
responses to disease until nutrition rehabilitation is in progress.
• A limiting nutrient in the body that has been “consumed” by the rapid growth, and is
not supplied in adequate amounts by the diet. This is not common with F100 or RUTF,
but may occur with home-made diets or with the introduction of other foods. Frequently,
introduction of “family plate,” UNIMIX, or CSB will slow the recovery rate of a severely
malnourished child. Recovery rate may slow if the child at home is given family food
(the same food that the child was taking when malnutrition developed) or traditional
complementary foods such as a watery porridge
• For children in the out-patient setting, administering of traditional medicine or a change
in home circumstances can significantly deter recovery.
It is important to systematically determine the cause of the child’s failure to recover from
severe acute malnutrition. Table 4.8 (following page) is a checklist of possible reasons for
failure to respond. When a child fails to respond to treatment, the common causes must be
investigated first.
Table 4.7: checklist: possible causes for failure to respond

Out-patient therapeutic care
Inappropriate for patient to go directly to out-patient therapeutic care
Poorly conducted Appetite Test
Inadequate instructions given to parent/caretaker
Inaccurate quantity of RUTF dispensed to children
Health facility long distance from child’s home thus patients are unable to attend regularly (high rates of
absence)
The Patient
Insufficient food received
Sharing RUTF with other siblings or caregiver
Sharing parent/caregiver’s food
Vitamin or mineral deficiency
Mal-absorption
Psychological trauma (particularly refugee situations and families living with HIV and AIDS)
Rumination
Infection, especially: malaria, diarrhoea/enteric conditions, respiratory infections/conditions/pneumonia/
tuberculosis, HIV and AIDS, urinary infection/ otitis media, skin or oral conditions/lesions.
Other serious underlying disease: congenital abnormalities (e.g. Down’s syndrome), neurological damage
(e.g. cerebral palsy), inborn errors of metabolism.
Unwilling parent/caregiver
Parent/caregiver overwhelmed with other work and responsibilities
Children who fail to respond to the out-patient therapeutic care are followed up at home to
105
determine the family circumstances, and if there are concerns with the care or sharing of
food. After three months of non-response to treatment, these patients are referred for further
medical review and laboratory tests as required. This will assist in diagnosing underlying
illnesses if present. Discharged, non-recovered children must be sent for supplementary
feeding, if available, or other support programmes. For children who are HIV positive, care
and support for HIV and AIDS is an important part of recovery (see section 7).
A General Failure to Respond

Section Four
When failure to respond is common among severe acute malnourished patients in one health
facility, the potential causes in Table 3.7 must be systematically examined to determine and
rectify any sweeping problems.
• Review staff qualifications and conduct refresher training as required.
• Re-calibrate scales and length-boards.
• Visit centre to assess routine procedures carried out by staff.
• Monitor routine procedures such as taking weights and heights, giving medications and
taking vital signs (temperature, pulse, respirations).
Health workers should be aware of the possible co-existence of HIV, tuberculosis or,
in someareas of the countries, Kala Azar, when assessing children and screen more
systematically in areas of high prevallence.
Estimating RUTF Monthly Requirements for a Health Facility

It is important to accurately estimate the RUTF monthly requirements in each health facility
to manage severe acute malnutrition. The health facility should not run out of RUTF stocks
or end up with a large surplus of stock.
In general, estimate the stock requirement by assuming 10kg is the average weight of a
child admitted with severe acute malnutrition. Therefore, each child will require 112 sachets
of RUTF a month. Round this up to 120 sachets required monthly. (Each sachet weighs
92gms.) There are 150 sachets in a carton of RUTF (Plumpy’nut). A health facility requires
at least three months buffer stock as well. Therefore, five severely malnourished children
will require four cartons of RUTF per month, and there should be a buffer stock of 8 to 12
cartons of RUTF.
106
Appendix 4.1: RUTF Specification

Ready to Use Therapeutic Food (RUTF)
Severely malnourished children and adults require specialised therapeutic food to recover,
such as Formula 100 (F100), Formula 75 (F75), or milk made with recommended formulas
according to WHO protocol. Ready-to-use therapeutic food (RUTF) is an integral part of out-
patient therapeutic care as it allows children and adults to be treated at home rather than by
milks in a health facility. RUTF is an energy dense mineral/vitamin enriched food, which is
Section Four
equivalent to Formula 100 (F100).
There are currently two commercial types of RUTF used in Kenya: Plumpy’nut® and BP 100®.
Several countries produce a local RUTF that are nutritionally the same as F100, and similar
to both F100 and the commercial RUTFs. Plans for local production of RUTF (peanut-based
paste) are being discussed for Kenya.
Plumpy’nut®
Plumpy’nut is a RUTF spread, presented in individual sachets. It is a paste of groundnut,
composed of vegetable fat, peanut butter, skimmed milk powder, lactoserum, maltodextrin,
sugar, mineral and vitamin complex.
Instructions for use: Clean drinking water must be available to children during consumption
of RUTF spread. The product should only be given to children who can express their thirst.
RUTF is contra-indicated for children who are allergic to cow’s milk, proteins or peanuts, and
asthmatic people (due to risk of allergy).
Recommendations for use: In the management of severe acute malnutrition in therapeutic
feeding, it is recommended to use the product in Phase 2. In Phase 1, use a milk-based diet
(F75).
Storage of Plumpy’nut: Plumpy’nut has a shelf life of 24 months (two years) from
manufacturing date. Keep stored in a cool and dry place.
Packaging: Plumpy’nut is presented in sachets of 92g. Each carton (around 15.1kg) contains
150 sachets. One sachet = 92 g = 500 Kcal.
BP-100
BP-100 is a compressed (RUTF) food product for us in the rehabilitation and treatment phase
of severely malnourished children and adults. It is developed for use in feeding centres or
direct to families as a take home ration. It is especially useful in contaminated environment
and in cases where no therapeutic feeding facilities can be established. The nutrition
specification is very similar to the therapeutic WHO formula F-100. The major nutritional
difference between F-100 and BP-100 is that BP-100 contains iron (10mg per 100g).
BP-100 can be eaten as a biscuit directly from the pack, or crumbled into clean water
and eaten as porridge, especially for children between 6 and 24 months and age. To make
porridge use 2dl of boiled drinking water per ‘meal pack’ consisting of two BP-100 tablets.
The intake of BP-100 should not be mixed in the same meal with local food items as the
latter may contain components inhibiting the absorption of vitamins and minerals.
107
Table 4.8: Nutritional composition of RUTF3

Moisture content 2.5 % maximum
Energy 520-550 kcal/100g
Proteins 10% - 12% total energy
Lipids 45%-60% total energy
Sodium 290mg/100g maximum
Potassium 290mg/100g maximum
Calcium 300-600mg/100g
Section Four
Phosphorus 80 – 140 mg/100g

Magnesium 10- 14mg/100g
Iron 11-14mg/100g
Zinc 1.4-1.8mg/100g
Copper 20-40µg
Iodine 70-140µg/100g
Vitamin A 0.8-1.1mg/100g
Vitamin D 15-20 µg/100g
Vitamin E 20mg/100g minimum
Vitamin K 15-30 µg/100g
Vitamin B1 0.5mg/100g minimum
Vitamin B2 1.6mg/ 100g minimum
Vitamin C 50 mg/ 100g minimum
Vitamin B6 0.6mg/ 100g minimum
Vitamin B12 1.6 µg/100g minimum
Folic acid 200 µg/100g minimum
Niacin 5mg/100g minimum
Panthotenic acid 3mg/100g minimum
Biotin 60 µg/ 100g minimum
N-6 fatty acid 3% - 10% of total energy
N-3 fatty acid 0.3% - 2.5% of total energy
Local Production of RUTF

The ingredients required are the four basic ingredients of RUTF:
• Sugar
• Dried Skim Milk (DSM)
• Oil
• A vitamin and mineral supplement
In addition, up to 25% of the product’s weight can come from vegetable sources such as
oil-seeds, groundnuts or cereals such as oats.
In addition to good nutritional quality (protein, energy, and micronutrients), RUTF should
have the following attributes:
1. Taste and texture suitable for young children
2. No additional processing required, such as cooking before consumption
3. Resistant to contamination by micro-organisms and a long shelf-life without sophisticated
packaging
4. Ingredients that are low cost and readily available in developing countries
Information on how to produce RUTF locally is available at:

http://www.who.int/child-adolescent health/New_Publications/NUTRITION/CBSM/tbp_4.pdf
3. WHO/WPP/SCN and UNICEF Joint Statement on Community based Management of Severe Acute
Malnutrition available at: http://www/unicef.org/nutrition/index _ 39468.html
108
Appendix 4.2: Admission card for out-patient therapeutic

care
ADMISSION CARD: OUTPATIENT THERAPEUTIC CARE
Name
Physical
Section Four
Caretaker
address
Age Date of
Sex M F
(months) Admission
General Food Distribution
Receiving Family Receiving Supplementary
Yes No Yes No
Food Support Food
Admission Anthropometry
Weight Height MUAC
Other
(kg) (cm) (cm)
Admission MUAC <-3 WHZ Readmission

Oedema Yes No
Criteria <11.5 cm (Relapse)
Diarrhoea Yes No Stools / Day 1-3 .4-5 >5
Vomiting Yes No Passing Urine Yes No
Cough Yes No If oedema, how long swollen?
Appetite Good Poor None Breastfeeding Yes No
Reported
Problems
Physical Examination
Respiration Rate Chest
<30 30 - 39 40 - 49 50 - 59 60+ Yes No
(# min) Indrawing
Temperature
0 Conjunctivae/Palmar Coloration Normal Pale
( C)
Eyes Normal Sunken Discharge Dehydration None Moderate Severe
Ears Normal Discharge Mouth Normal Sores Candida
Lymph Nodes None Neck Axilla Groin Disability Yes No
Skin Changes None Scabies Peeling Ulcers / Abscesses Extremities Normal Cold
Routine Admission Medication & Immunisation

Admission: Drug Date Dosage (& type) 2nd visit: Date Dosage
Albendazole/
Antibiotic
mebendazole
Antimalarial
(coartem) I m m m unisation Measles Yes No
Vitamin A Fully Immunised Yes No
Other Treatment
Type Other Drugs Date Dosage
ART Yes No
TB therapy Yes No
FBP / Food
Yes No
Support
Cotrimoxazole
Yes No
prophylaxis
109
Section Four
110
Appendix 4.3: Out-Patient Therapeutic Care Ration Card

OTP RATION CARD
Hospital /
Health REG.N
o
Facility
Section Four
Name Age Sex M F
Date Weight (kg) Height (cm) WHZ MUAC (cm) Oedema RUTF CSB /
(# units) Unimix
OTP RATION CARD

Hospital /
Health REG.N
o
Facility
Name Age Sex M F
Date Weight (kg) Height (cm) WHZ MUAC (cm) Oedema RUTF CSB /
(# units) Unimix
111
Appendix 4.4: Medical Examination Checklist for OTP

Table 9: Medical Examination Checklist (OTP -> Inpatient Care) for
Severe Acute Malnutrition
Examination Criteria for referral to inpatient care
Oedema Grade ++ +++
OR Increasing oedema
Section Four
OR Marasmus-Kwashiorkor
Special cases Severely malnourished infants < 6 months or children ≥6 months and weight <3kg
Appetite Anorexia/no appetite or unable to eat
Has difficulty swallowing the RUTF
Vomiting Persistent/intractable
Temperature (axilary) Fever ≥ 39oC
Hypothermia < 35oC
Respiratory Rate* Cough and fast breathing i.e.
≥ 50 respirations/minute from 2 to 12 months
≥ 40 respirations/minute from 1 to 5 years
≥ 30 respirations/minute for over 5 years
OR Any chest in-drawing
Anemia Very pale, severe palmar pallor
Hydration status Severe dehydration based on recent history of fluid loss (watery diarrhea/vomiting)
with associated weight loss
Alertness Extremely weak and lethargic, unconscious
Fitting/convulsions
Superficial Infections Open skin lesions, extensive infection requiring intramuscular treatment
*≥60 respirations/minute for <2 months; but all infants should be referred to inpatient
care
Any condition requiring an infusion or nasogastric feeding requires inpatient care
112
Appendix 4.5: Key message OTP

(Uncomplicated Severe Acute Malnutrition)
•• RUTF (eg Plumpynut) is a food and medicine for very thin children only. It should not be
shared.
•• Sick children often do not like to eat. Give small regular meals of RUTF and encourage the
child to eat often (if possible 8 meals/ day).
Section Four
•• RUTF is the only food sick/thin children need to recover during their time in OTP.
•• For young children, continue to put the child to the breast regularly.
•• Always offer the child plenty of clean water to drink while he or she is eating RUTF.
•• Use soap for children’s hands and face before feeding if possible.
•• Keep food clean and covered.
•• Sick children get cold quickly. Always keep the child covered and warm.
•• When a child has diarrhoea, never stop feeding. Give extra food and extra fluids.
•• Play, sing and talk with your child as this helps their recovery.
Notes:
Ready to Use Therapeutic Food (RUTF) e.g. Plumpynut is not for infants less than 6 months
old: malnourished infants need to be referred to inpatient care for therapeutic/specialised
milk.
The carer should be asked to repeat back to check that the messages have been correctly
understood.
These key messages can be supplemented with more details and more messages if time
allows.
Where a ration of supplementary food is given to avoid sharing of the RUTF, the message
should be made clear that it is for the other children in the family not the severely malnourished
child.
As the child nears the end of their treatment in OTP, other foods (supplementary food, local
food) can start to be given in addition to the RUTF.
113
Appendix 4.6: Example of OTP Checklist for Field Support Visits

Name of health facility……………………………………..Date………………………
Key areas Assessment Comments / observations

1.SCREENING Yes/No
Are anthropometric measurements taken and
Section Four
recorded correctly?
Is testing and grading of oedema done cor-
rectly?
Is Weight for Height Z scores calculated ac-
curately?
2. ADMISSION PROCEDURE Yes/ No
Are children admitted according to criteria?
Is history taken correctly?
Is physical examination of child done cor-
rectly?
Is appetite test done at every visit?
Is rapid examination checklist assessment
form used to identify referrals?
Is ID number assigned to each child?
Is every child assigned a community health
worker?
3. MEDICAL MANAGEMENT Yes/No
Are the routine drugs (Amoxycillin, Vitamin
A, deworming) given according to protocol?
Is immunization status checked?
Are slow responders checked for possible
underlying causes? (eg tuberculosis, HIV,
KalaAzar)
4. NUTRITIONAL MANAGEMENT Yes/No
Is RUTF ration given according to child’s
body weight?
5. DOCUMENTATION Yes/No
Is information / data correctly documented
on:
i. admission card
ii. OTP ration card
iii. OTP Register
iv. OTP reporting forms
v. report forms
6. HEALTH EDUCATION Yes/No
Is general information on OTP procedures
given to caretaker on admission?
i. Reason for admission
ii. Principles of treatment
iii. RUTF messages
iv. Frequency of return visits
v. Reasons for weekly return visits
114
Key areas Assessment Comments / observations

7. DISCHARGE PROCEDURES Yes/No
Are children discharged according to OTP
criteria?
8. MONITORING Yes/No
Is child’s progress monitored on every visit?
Section Four
(appetite, anthropometric measurements, ill-
nesses reported by caretaker, attendance)
Is programme effectiveness monitored (i.e.
admissions, exits, number in programme,
weight gain, length of stay in programme)
against Sphere standards?
10. REPORTING
Are report accurately compiled?
Is the reporting channel followed?
12. STORES MANAGEMENT Yes/No
Are stock cards maintained and updated?
Are stocks of RUTF available and adequate?
Is the storeroom clean and tidy?
13. COMMUNITY MOBILISATION Yes /No
Is community mobilization conducted?
How many community mobilization sessions
are conducted each month?
Is feedback on the programme given to com-
munity?
Are absentees and defaulters followed up?
Is feedback given to health facilities on
cases followed up?
Feedback given to health centre team……Yes /No
Agreed action points:

1. ………………………………………………………………………………………
2. ………………………………………………………………………………………
3. ………………………………………………………………………………………
4. ………………………………………………………………………………………
5. ………………………………………………………………………………………
Mentoring team:
Name………………………….Organisation…………………Date………….Sign………
115
Section Five:
Section Five
Management Of
Moderate Acute Malnutrition
Overview
This section covers the principles, design elements and implementation strategies to manage
moderate acute malnutrition at the health facility. In Kenya, management of moderate acute
malnutrition strategies are linked to national health programmes and are incorporated into
Mother and Child Health programmes (MCH) which form part of the primary health-care
infrastructure.
The main aim of managing moderately malnourished people is to meet the additional nutritional
needs of the malnourished individuals of a vulnerable group, or prevent deterioration of
nutritional status of those at-risk (e.g. infants, children, pregnant and lactating mothers;
including guidance to adolescents and adults). This is basically done with supplementary
feeding, nutrition counselling, and treatment of common ailments at the health facility
(or centres designed to manage individuals that are moderately malnourished or at risk).
Managing moderate malnutrition includes encouraging pregnant and lactating mothers to
attend antenatal clinics and mothers to practice regular growth monitoring of children under
five years.
In some communities, children between three and six years old are enrolled in Early Childhood
Development (ECD) centres. According to the National Early Childhood Standard Guidelines,
ECD centres should establish feeding programmes that provide nutritious snacks and lunch
to alleviate short term hunger, and hence improve the capacity of the children.
In areas where HIV and AIDS prevalence is high, nutritional support and care is essential for
people living with HIV and AIDS.
In areas where malnutrition rates are low, adults and children who present with moderate
acute malnutrition can be treated at the health facility or at a community centre run by
Community Health Workers (CHWs). In these centres, health workers measure children and
adults, make nutritional diagnosis, offer counselling and provide necessary nutritional and
medical treatment for malnourished individuals. Activities for managing moderate acute
malnutrition can be undertaken at the MCH clinic.
116
Selection Criteria
When a malnourished individual attends a health facility, it is important that the health
worker makes the right diagnosis and gives appropriate treatment. Initial assessment of an
individual in a health facility includes taking the anthropometric measurements, the patient’s
history and a medical examination of the health and feeding practices of the individual.
Based on that information, the health worker can determine if the patient is moderately,
severely malnourished, or at-risk. See Table 5.1 for cut-off points.
Section Five
Note: Refer to Section 2, 3 and 4 for detailed information on the management of severe
acute malnutrition.
Table 5.1: Nutritional status classification – use of cut off points1
Indicator Well nourished At-risk Moderate

malnutrition malnutrition
Oedema No No No
Weight-for-height (+2 to -1SD) (<-1 to -2SD) (<-2 to >-3SD)

(6 months to 18 years)
Height-for-age (+2 to -1SD) (<-1 to -2SD) (<-2 to >-3SD)
(6 months to 18 years)
Weight-for-age (6 to 59 months) (<-2 to >-3SD)
Weight –for –age (<6 months old)2
MUAC for children (6-59 months) ≥13.5cm 12.5-13.4cm 11.5-12.4cm
MUAC for PLW >23cm 21-23cm <21cm
MUAC for adults (PLWHA) >23.3cm <23.3cm
BMI for adults ≥18.5 17-18.4 16-16.9
BMI for adults (PLWHA) <18.5
In addition to the cut-off points in Table 5.1, children presenting with chronic diseases
(e.g. lung disease), HIV and AIDS, tuberculosis, Kala Azar, measles, persistent diarrhea
and vomiting are at risk of becoming malnourished. In addition, health workers should also
check the children’s growth curve, a decline or a static curve indicates that the nutritional
statues of the child is not improving. These categories should as well be considered for
supplementary feeding, especially in food insecure areas, in order to intervene early and
prevent further deteriorations. The flow chart below summaries the processes for a health
worker to determine the status of the individual and the required actions.
Figure 5.1: Summary to determine the nutritional status of a patient and

the required actions
Conduct individual assessment Health worker
Classify
nutritional Moderately malnourished Severely malnourished At-risk malnourished
status
1. Nutrition treatment 1. If severe with 1. Medical treatment

complications, refer to
2. Medical treatment 2. Nutrition counselling
inpatient care
Action 3. Nutrition counselling 3. Nutrition treatment
2. If severe with no
4. Follow-up visits complications, refer to 4. Follow-up visits
out patient nutrition
care
1. Adapted from WFP. Food and Nutrition handbook, Rome 2001

2. For moderately malnourished children <6 months old, admit mother in programme
117
Decision Matrix
This decision matrix can come in handy as a guide to enable a health worker makes
the correct decisions.
Step 1: Take anthropometric measurements
• Check weight, height and age.
• Calculate weight-for-height or weight-for-age for children less than five years. (Refer
to Section 1, Appendix 1.4)
Section Five
• Calculate BMI for adults where applicable.

• Or, take MUAC measurement of children older than six months pregnant mothers
and adults.
• Record measurements on patient card. If a child is enrolled in a growth monitoring
programme, record measurement in the Child Welfare Card (CWC).
• Use cut-off points in Table 5.1 to determine the level of moderate malnutrition (at-
risk or moderate).
Step 2: Conduct a causal assessment
Check the patient’s record in the CWC. For children, discuss with the parent/caregiver
the child’s growth by showing them the child’s growth curve. Inquire from parent/
caregiver the reasons for deterioration of nutritional status.
Health status
• Ask about the patient’s general health and any history of illness: use check Section,
Appendix 1.1.
• For children, check child’s immunization status and Vitamin A supplementation.
• For pregnant and lactating mothers, check for iron deficiency anemia and other
micronutrient deficiencies, such as iodine.
Food consumption and care practices
• For children younger than 24 months, ask parent/caregiver if the child is
breastfeeding.
• Ask caregiver what food the child eats, and how many times a day.
• Ask who feeds the child most often, and how the child is fed.
• For adult patients, ask what food they eat and frequency of consumption.
Step 3: Determine treatment
• If the patient is moderately malnourished or at-risk, refer for nutrition treatment,
medical treatment and nutrition counselling.
• If there is inadequate food at household level: refer the patient to a food-based
programme. If there is no food-based programme in or near to the health facility,
provide nutritional counselling and/or refer the patient to social groups for food or
cash assistance.
• If the patient is sick, requires immunization, or suffers from micronutrient
deficiencies, refer to the relevant health services.
• If the problem is feeding practice, give the caregiver information on recommended
feeding practices for the child’s age, and discuss how they can adjust their feeding
practices by using available resources. (Refer to Section nine for details on relevant
counselling topics).
Admission and Discharge Criteria

When a patient is identified as moderately malnourished, the health worker takes the necessary
steps to enroll him/her in a programme where he/she can receive nutrition support and care.
It is important that the health worker understands the discharge criteria while admitting the
patient. This will help the health worker determine the possible length of stay of the patient in
the programme. Table 5.3 gives a summary of admission and discharge criteria.
118
Table 5.2: Indicators for Admission and Discharge

Admission criteria Discharge criteria
Moderately malnourished Moderately malnourished
• Children with a weight-for-height <-2 to >-3SD and/ • Children maintain a weight-for-height >-2SD
or MUAC between 11.5cm and 12.4cm. - and/or MUAC ≥12.5cm for a period of two
• Pregnant and lactating mothers with a MUAC that is consecutive weighs/measurements
<21 cm • Pregnant and lactating mothers attain a MUAC
• PLWHA with a MUAC that is < 23.3cm that is above 23cm
• Other adults with a MUAC of < 18.5cm • PLWHA attain above 23.3cm
Section Five
• Other adults BMI < 18.5 • Other adults attain a MUAC of above 18.5cm
• Other adults BMI above 18.5
At risk group At risk group

• Chronically ill children (TB, HIV and AIDS, Malaria, • Child has recovered from illness
persistent diarrhoea, vomiting, Kala Azar measles) • Child’s growth curve is steadily increasing
• Children with the growth chart showing a decline in
growth.
Steps for Managing Moderate Acute Malnutrition

Registration
1. Register the patient in the registration book. If possible, have a separate register for
children under five years, pregnant women, lactating women, and adults.
2. Provide the patient with a clinic or ration card. Health workers can modify the Supplementary
Feeding Ration card in Appendix 5.4 accordingly.
3. Explain how treatment will be organizead, and the reasons for admission to a nutrition
programme.
Nutrition support
Provide food rations
Every community relies on a staple food or has a particular food familiar to the beneficiaries.
Local food habits, tastes and preferences are taken into account when determining food
rations and designing the food basket. A typical food basket will comprise of a cereal, pulses,
oil and sometimes sugar. The ideal dry ration for supplementary food provides 1000 to 1200
Kcal; 35g to 45g of protein; and fat supplies 30% of required energy. The recommended
amounts of each commodity as for the premix are shown in Table 5.3.

Table 5.3: Food commodities and ration size per patient for 14 days
Food items Quantities per child <5 years old (kg)
CSB/unimix 3.5
Vegetable oil 0.35
Total 4.5
Food Items Quantities per adult (kg)

Maize 3.2
Pulses 0.56
Vegetable oil 0.18
Iodized salt 0.07
Total 4.55
For a take-home dry ration, prepare a premix by mixing the appropriate ingredients together
in a big basin. Avoid distributing separate ingredients for take home rations. They may be
used for other purposes, such as being sold in a market or shared with other household
119
members. During distributions, blended food can be mixed with oil and other dry ingredients
such as sugars into a premix. See Appendix 5.3 to determine the proportions of premix.
The oil in a premix will become rancid if the premix is made more than two weeks before
eating; therefore it is important that ration distributions are either weekly or bi-weekly. After
allocating the correct amounts of rations to the patient, explain when the next feed will be
given.
• For those taking home dry ration based on blended foods such as CSB, conduct a cooking
demonstration for new patients and caregivers. Explain how to make and serve the
Section Five
porridge see Appendix 5.2 for instructions.

• Remind patients and caregivers that the ration is only for the patient. Explain to them how
long the ration should last (usually for one to two weeks, depending on the quantity).
• Follow-up visit. Carefully explain to the patient or caregiver what is expected for the next
visit. Weight or MUAC measurement will be taken and recorded in the register and in the
ration or clinic card at each visit. Height measurements will be taken monthly. Explain
that this measurement will be taken in order to check nutritional progress.
Routine Medication
Supplementary Feeding always covers medical protocols such as provision of anti-helminths;
vitamin A, iron and folic acid supplementation; and immunizations. Table 5.4 and 5.5
summarize routine medical treatment for children, people with HIV and AIDS, adolescents,
and adults. Details regarding specific treatments can be obtained from the IMCI guidelines.
Table 5.4: Summary of routine medical treatment for children under five
Name of Product When Age Prescription Dose
Vitamin A* At admission <6 months 50,000IU Single dose
on admission
6 months to 100 000IU
<1year
>1 year of age 200000IU
Abendazole At admission <1 year Do not give
1 year and above 400mgs 1 tab on

admission
Mebendazole** At admission <1 year Do not give
1 year and above 500mg Single dose

on admission
Iron /folate*** At admission 6 to 24 months 12.5mg Daily dose
(low birth weight iron/50µg folic from 6 to 12
and infants) acid months of
age
2 to 5years 20-30mg Daily dose
6 to 11 years 30-60mg Daily dose
Adolescents and 60mg Daily dose

adults
Measles vaccination At admission >9 months - Once
* Do not repeat the dosage of Vitamin A if the child has already received a supplement of Vitamin A during
the previous 30 days (e.g. during a national campaign or following recovery from SAM).
** Dose can be given again after 3 months if signs of re-infection appear.
*** Give one dose of 6mg/kg of iron daily for 14 days.
120
Table 5.5: Summary of routine medical treatment for pregnant and lactating mothers
Name of When Physiological Prescription Dose
Product status
Vitamin A Within first 4 weeks Post partum 200000IU Single
after delivery dose on
admission
Mebendazole Second trimester Pregnant 500mg Single dose
Iron/ Folic acid On admission During pregnancy and 60mg iron/400µg folic Daily dose
Section Five
lactation acid
Albendazole is not recommended after 2nd trimester of pregnancy
Nutrition counselling
• The patient or caregiver must receive adequate information about the cause of their
malnutrition, and how to avoid a relapse. Annex 9.1 outlines key topics, messages and
action points to assist a patient or caregiver improve his/her condition.
• Some patients may require both nutrition counselling and food rations. Ensure that they
receive both.
• After counselling, ask caregiver or adult patient to explain what they will do at home. This
is to make sure they understand the new practices.
• Inform the community worker about the counselling messages for follow-up purposes.
Follow-up
1. Make an appointment with the caregiver or patient for follow-up. Encourage caregivers or
patients to come to the next nutrition counselling and food ration allocation sessions.
2. Explain the expected progress from the child and likewise the adult patient e.g. increased
weight gain, good appetite.
3. Explain to the patient or caregiver that a CHW is likely to visit his/her home for follow-up.
Introduce the CWH if she/he is present.
4. Ask the adult patient or caregiver to refer friends, acquaintances, family, etc. with similar
problems to the health facility.
Data Collection and Reporting

Ration cards can be used at the health facility level to record information related to nutritional
status, nutrition and medical treatment and type of nutrition education issued to all patients
admitted to the programme. The cards keep a record of attendance, type and amount of
rations, and treatment and nutrition counselling received.
• The card’s information is similar to the health facility register.
• Counsel caregivers to ensure that the cards are kept in good condition.
• The cards are presented at each health facility visit and shown to the CHW when visiting
a patient’s home.
Health workers keeps a monthly attendance report as well to record new admissions,
attendance, discharge, deaths, default and transfers. (Annex 5.5 and 5.6 are samples of a
monthly reporting formats and balance stock sheets). Monitoring data and other information
can be slotted into the existing Child Health and Nutrition Information System (CHANIS)
programme. Records are also kept for supplies of food and drugs, storage and staffing
position. The monthly reports and stock balances are shared at coordination forums such as
district health sector group meetings, District Steering Groups (DSGs), and with the relevant
provincial and national departments.
3. Where the exact number of weeks cannot be determined, patient must be referred to the MCH for prescription
121
Requirements for Managing Moderate Malnutrition

Regardless of the number of malnourished patients that will attend the MCH clinic, a solid
plan is essential to establish an intervention programme for the effective allocation of
resources, and to assure good performance of any intervention.
Collect Information
Section Five
In planning a programme, the district nutritionists need detailed information about all
the health facilities in the district. The required information includes: the population by
catchment health facility (disaggregated by age and sex); staffing positions; storage space,
available modes of transportation and road conditions; supply chain for immunization and
documentation of all intervention processes. This detailed information can be adapted from
that used in an emergency context (Section 7) though on a smaller scale of operation.
Procure Equipment and Documentation

First, the district nutritionist ensures that the necessary equipment is available and in good
condition. The anthropometric equipment required includes:
• height boards;
• weighing scales (25kg Salter scale and adult weighing scale);
• MUAC tapes, both child and adult;
• clinic cards, ration cards, and register books.
The health workers must keep a register of the patients enrolled in the programme. This
is useful for tracking the number and type of patients and for monitoring supplies. The
nutritionist ensures that nutrition education and training materials; counselling cards; monthly
report sheets; and request forms are available for the programme.
Allocate Staff
An adequate number of qualified staff is essential to run the programme. If staff is limited,
existing health staff may have to multi-task to ensure that the work is done. For example, a
CHW can assist the nutritionist in taking measurements, distributing dry rations, and with
counselling.
The essential staff required to run the programme include:
• 1 nutritionist to manage the programme, give nutrition counselling, provide technical
assistance and organize refresher courses as protocols and guidelines are revised;
• 1 nurse to assess patients for common ailments and give health-related counselling;
• 1 store keeper to manage supplies and make returns or compile stock reports
• 1 cook (only for wet feeding programme);
• 1 Community Health Worker (CHW) to assist nutritionist and conduct follow-up.
• All staff must be trained to conduct their tasks with the utmost professionalism.
Calculate Expected Patient Load

Estimating the number of expected patients helps the health workers plan resources
accordingly, and aids with supply distribution equitably among centres. The district nutrition
officer can estimate the expected number of moderately acute malnourished patients by
using the nutritional data recorded at each health facility to calculate average patient loads
expected per health facility. It is therefore important that each health facility maintains good
records for malnourished patients.
122
Calculate Quantity of Required Supplies

An accurate estimate of supplies is essential to avoid supply shortages or over-supply that
result in wastage. See Appendix 7.4 for detailed information and steps to calculate the required
quantity of supplies.
Supply Handling and Health Centre Management

Proper handling of supplies is of utmost importance as damage leads to waste. The health
centre forwards requests to the national office and receives supplies from headquarters. This
Section Five
supply chain is similar to that described in Section 7 page 157.
Distribution of Food and Drugs

There are commercial food items such as fortified blended food such as CSB, sugar, and
oil that can be distributed to moderately malnourished patients. Ration amounts and food
commodities for this type of distribution are shown in Table 5.3. In the absence of these
food commodities, nutritionists can use locally available food and prepare them in the most
appropriate way to provide the recommended daily allowances. The nutrient content of each
food or meal can be calculated to ensure that the required energy, proteins and fats are
met.
Monitoring and Evaluation

Monitoring and Evaluation activities assess the appropriateness, efficiency, effectiveness
and impact of a nutrition support programme. For instance a supplementary feeding
programme is monitored continuously so that health facility managers and staff can detect
and immediately act on day-to-day problems at any level of programme implementation.
An evaluation is a one-off exercise that may be conducted on a regular basis and/or when
the project period is extended. Evaluations measure outcomes and impacts. Generally, a
nutritional assessment can be conducted in the district or division to determine the impact
of the nutrition programme on the health and nutrition of the population. An evaluation
gathers, organizes and presents information to use to improve future interventions as well as
offer information to determine what other types of interventions are required to contribute
towards reduction of malnutrition on the affected community.
Data collection and reporting

All nutrition programmes should keep a record of basic information for each patient admitted
(see Supplementary Feeding ration cards and report forms in Annex 5.4 and 5.5 ). The
records include a patient’s registration number, name, age, sex, height, weight, date of
admission and date of discharge. Children enrolled for supplementary feeding programme
can wear a plastic bracelet, a metal tag, or a strap of cloth marked with a permanent pen
with their name and registration number. as identification.
123
Appendix 5.1: Energy and Protein Values of Commonly Used

Foods in Kenya
common foods energy protein g possible con- Nutrient output per meal
kcal per per 100 g sumption per energy protein(g)
100g meal (g) (kcal)
cereals whole maize meal 370 9 50 185 5
Section Five
maize grain 370 9 50 185 5

rice 359 8 75 270 6
wheat flour 340 11 50 170 6
wheat flour whole grain 334 17 50 167 9
millet 335 9 60 202 6
sorgum 306 8 60 183 5
roots and tubers cassava 375 2 75 281 2
arrow roots 125 2 75 94 2
sweet potatoes 131 6 75 98 98
irish/english potatoes 81 2 60 49 1
bananas raw (matoke) 109 1 60 65 1
others cane sugar 375 . 20 75 .
cooking fat 900 . 20 180 .
animal source foods fish fillet 244 72 50 122 36
meat beef 180 20 75 135 15
chicken 163 25 75 122 19
egg 154 12 100 154 12
cow whole milk 73 3 200ml 150 6
plant source foods green grams 352 24 50 176 12
lentis 350 24 50 175 12
beans 347 18 50 173 9
cow peas 297 23 50 151 12
soya 429 30 50 215 15
pigeon peas 399 23 50 199 11
fruits avocado 128 1 100 128 1
banana ripe 94 1 50 47 1
oranges 89 1 40 36 .
passion 87 1 40 35 .
mangoes 60 1 60 36 .
pawpaw 32 0.4 40 12 0.2
nuts and seeds ground nuts 554 10 50 277 5
coconuts 544 6 50 314 17
cashew nuts 569 21 50 265 11
simsim 544 20 50 272 10
vegetables spinach 32 3 200 64 6
cabbage 24 2 150 36 3
kales(sukuma wiki) 52 4 150 73 6
cow peas leaves 43 6 100 43 6
amaranth(terere) 45 5 100 45 5
pumpkin leaves 36 5 100 36 5
124
Appendix 5.2: Local Recipes 4
Blended foods
Corn Soya Blend porridge
1 cup CSB
3 cups water
Method
Section Five
Use one cup of CSB/premix and three cups of water, cook the mixture until it has boiled for
5 to 10 minutes (not more).
Soya-sweet potato
Ingredients
•• ¾ cup fine Soya grits or mash
•• 1¾cup diced sweet potatoes
•• 1½ taste spoon sugar
•• Pinch of salt
Method
1. Blanch the grits by dropping in boiling water and simmer for 10 minutes;
2. Drain off water, rinse in hot water, add cold water plus de-hull by rubbing between the
hands;
3. Add 1cup of water to the grits, add pealed plus diced sweet potatoes and cook for 15
minutes;
4. Grind the mixture or blend it to fine peeled slurry;
5. Re-heat the slurry to boiling point cool plus serve warm.
Variation: Replace sweet potatoes with pumpkin, green bananas, Irish potatoes, arrow
roots.
Soya wimbi (millet) porridge
Ingredients
5 cups of water
½ cup of maize maize meal
¼ cup wimbi flour
¼cup raw Soya flour
3 table spoon sugar
Juice from 2 lemons (optional)
Method
1. Bring 3 cups of water to the boil;
2. Blend maize meal plus wimbi flour into a paste with the remaining 2 cups of water;
3. While stirring, add the paste to the boiling water, continue to stir until the mixture starts
to thicken;
4. While stirring, sprinkle raw soya flour;
5. Reduce heat plus cook for about 25 minutes; and
6. Add sugar and stir to dissolve;
7. Add lemon juice and remove from fire;
8. Cool and serve.
Variations: Replace wimbi flour with sorghum or bulrush millet.
Note: Omit lemon juice if the porridge is cooked for a child.
4. Recipes from Ministry of Agriculture, department of home extension :

Kenya Soya cook book and Nutrition manual for Kenya
125
Bean porridge
Ingredients
1 cup of beans
1cup maize meal
1\2 teaspoon of margarine
Method
1. Soak beans and remove skin;
Section Five
2. Fry the beans until dry and pound into flour;

3. Mix the beans flour with the maize meal and cook into a porridge;
4. Add margarine and serve;
How to calculate energy and nutrients in a meal
The following steps can assist the nutritionist calculate the nutrients in the meal that contains
several ingredients:
Step 1: Weigh all raw ingredients
Step 2: Calculate the different nutrients in each ingredient
Step 3: Add up quantities of calories, proteins plus other nutrients in all the ingredients to
determine whether the quantities provide the recommended kcals per person in a
day.
Case study: Saidia Nutrition Centre, Kinoti location
Saidia health centre runs a wet feeding programme targeting 50 moderately malnourished
< 5 years old children. The centre provides two porridge meals a day. Fatuma, the district
nutritionist knows that the required kcals for wet feeding is 500-700kcals and 15g-25g of
protein per day, and the fat should provide 30% of the total energy. However, she needs to
verify that the meal provides the recommended kcals per person per day. The ingredients of
the porridge meal per person are;
Ingredients
40gms groundnuts
70gms of maize flour
10gms sugar
1\2 an orange
1\2 liter of water
Method
- Roast groundnuts to remove the skin, pound until fine then sieve.
- Boil water in a saucepan.
- Make a smooth paste of maize flour, sugar plus cold boiled water.
- Place the mixture in the saucepan back on the fire and continue to stir until mixture is
smooth and cooked.
- Add the sifted groundnut flour while stirring to avoid formation of lumps.
- Remove from the fine and when cool add the fruit juice from half the orange.
- Cool to a desirable temperature.
- Serve the child.
126
From the nutrient content table ( Appendix 5.1), select the food item and check how much
energy, protein and fat content is available per item. Note that the nutrient content is per
100gm
The following is calculated per 100g
•• 100g maize flour has 368kcal energy , 9.4g protein and 1.0g fat
•• 100g groundnut has 567kcal, 25.8g protein, 45g of fat,
•• 100g Sugar has 400 kcal
•• Protein contain 4.0kcal /g
Section Five
•• Fat contain 9.0kcal/g
The following formulas can be used to calculate the energy and nutrients available in any
meal:
Formula 1: Energy (kcal) =Amount of Commodity (g) x Amount of energy in Commodity
(kcal) /100g
Formula 2: Protein (g) = Amount of Commodity (g) x Amount of Protein in Commodity
(g)/100g
Formula 3: Fat (g) =Amount of Commodity (g) x Amount of fat in Commodity (g)/100g
Formula 4: Total energy in fat (%) =Total amount of fat in all commodities (g) x Amount
of Energy in fat (kcal/g) / Total amount of energy from all food items (kcal ) x
100
127
Appendix 5.3: Proportions of Premix

Premix preparation for 1, 5, 10 and 20 persons – children < 5 years old
Quantities for X Persons (kg)

Food Item 1 5 10 20
CSB 3.9 19.3 39 77
Vegetable Oil 0.3 6.0 11.9 23.9

Section Five
Sugar 0.3 1.8 3.6 7.2
Total 4.5 27.0 54.0 108.0
Measuring rations for caregivers or P/L women

Quantities for X Persons (kg)
Food Item 1 5 10 20
Maize Meal 3.50 17.5 35.0 70.0
Beans 1.05 5.25 10.5 21.0
Total 4.55 22.75 45.5 91.0
Rations for Supplementary Feeding

Commodity Ration 1(g) Ration 2 (g) Ration 3 (g)
On- site supplementary feeding
Blended food fortified 100 - -
Cereal ( e.g. maize flour) - 125 60
DSM - - 45
Pulses - 30 -
Oil 30 20 30
Sugar 20 - 15
Salt - 5 -
Energy ( Kcal) 725 700 700
Protein (% of energy) 10 11 12.5
Take home supplementary feeding
Blended food fortified 200 140 250
DSM - 50 -
Pulses 20 50 25
Sugar 15 30 20
Energy ( Kcal) 1000 1250 1250
Protein (% of energy) 14 14.5 14.5
WHO 2000, The management of nutrition in major emergencies
128
Appendix 5.4: Preparation of Porridge

with Fortified Flour
UNIMIX (or CSB) is a special food for children 6 months to 5 years and others with special
nutritional needs such as pregnant women and breast-feeding mothers. UNIMIX is a supple-
mentary food that is meant to be eaten in addition to the normal family food to improve the
diet of children and other vulnerable groups. To increase the energy density and taste, oil,
seasonal fruits and vegetables and or any local nuts can be added. UNIMIX is pre-cooked
Section Five
but is not an instant product. It should be cooked for 5-10 minutes, but not longer. Before
starting to cook, please ensure that the water which is used is safe before mixing into por-
ridge and wash your hands thoroughly before preparing the porridge.
1 cup of UNIMIX
3 cups of water
2
Nutrition value of 100g of CSB /UNIMIX

Energy-380 Kcal Fat -6g . Carbohydrates-60g Vitamin A – 1700 I.U, Riboflavin – 0.5mg, Pantothenic acid --3mg
Phosphorous – 600mg, Sodium – 300mg, Protein-18g, Vitamin D – 200, Niacin – 8mg Folacin – 0.2mg Magnesium-
100mg Potassium -700mg Vitamin E -8 I.U Vitamin B6 – 0.7mg Ascorbic acid – 40mg Iron – 18mg Iodine
– 50mcg Thiamin -0.7mg Vitamin B12- 4mcg Calcium – 800mg Zinc – 3mg
129
Appendix 5.5: Supplementary Feeding

Ration Card
Card No: SUPPLEMENTARY FEEDING CARD FOR CHILDREN < 5 yrs

District :Health Facility:
Card No:
General Information
Section Five
Child Name: Village/address:
New Admission Yes /No Mother/Caregiver’s Name:
Re- Admission Yes/ No
Age (months): Sex: Male / Female
Medication/Supplementation
Albendazole Vitamin A
Measles Iron tablets

Vaccination
Other drugs
Follow-up
Distribution Ration Date Weight Height W/H Target MUAC Iron/
(kg) (cm) W/H (cm) Folic
Admission
2
3
4
5
6
7
Discharge
CuredT ransferred No Response
Defaulted Dead
This card can be modified for Pregnant and lactating women
130
MONTHLY REPORT FORMAT - MANAGEMENT OF MODERATE ACUTE MALNUTRITION
PROVINCE IMPLEMENTING PARTNERS
DISTRICT MONTH
HEALTH FACILITY YEAR
NAME & POSITION OF REPORTING OFFICER
Signature
Date
ESTIMATED TARGET malnourished <5's
(based on latest survey data and admission criteria)
CSB/UNIMIX consumption (kg)
Oil consumption (L)

of Moderate Acute Malnutrition
New Cases (B) Old Cases (C) Discharges (E) Transfer (F)
Total TOTAL Total end of the

According to From TOTAL EXITS (G)
beginning of ADMISSION (D) month (H) (A+D-
admission Outpatient or To Inpatient (E+F=G)
the month (A) Other (at risk) (B+C=D) CURED DEATH NON-RECOVERED G=H)
criteria (W/H, Inpatient Care, DEFAULTER (E3) or Outpatient
(B2) (E1) (E2) (E4)
MUAC, BMI) or Returned Care
(B1) Defaulters
<5years
PLM
Adult/Adol
TOTAL
Appendix 5.6: Monthly Report Format for Management
For < 5yrs % % % %
For PLM % % % %
For Adult/Adol % % %
E1: Cured = reaches discharge criteria TARGET (Sphere Standards) >75% <3% <15%
131
E3: Defaulter = absent for 3 consecutive visits
E4: Non recovered = does not reach the discharge criteria after 4 months in OTP
H: Total end of the month (H) = Total beginning of the month (A) + Total admissions (D) - Total discharges (G)
Section Five
Section Five
Stock card
132
Provice: ___________________ District: ___________________ Health facility: ___________________
_
Reporting Month:______________ Year: ___________________ Period starting from Date___________ to ___________
Numbers
beneficiaries Total Males Females Food Items Opening stock Receipts Distribute Losse Closing stock
children<5yrs Severe Inpatient CSB/UNIMIX (kg)
children<5yrs Severe Outpatient Oil (kg)
children<5years Moderate RUTF ( Boxes)
P/L mothers moderate mal F-75 ( Boxes)
Adolescents severe mal F-100 ( Boxes)
Adolescents moderate mal Others
Adults severe mal
Adults moderate mal
Total
Note:
1. closing stocks quantity of food items left after distributing and losses (Closing Stock= (Opening stocks +Receipts) -(dist ributed + Losses)
2. the specification of male/female (does not apply for p/L women)
3. the quantities are mainly measured in kg (a part from oil that is measured in Liter)
Name
Signature
Date
Appendix 5.7: Feeding Programme Stock Card
Section Six:
Section Six
Management of Malnutrition
for Children in the Context of
HIV and AIDS
Overview
According to the 2007 Kenya AIDS Indicator Survey (KAIS), Kenya has seen an increase in
the overall prevalence of HIV from 6.7 per cent in 2003 to 7.8 per cent in 2007 -translating
to 60,000 to 100,000 new infections a year. In accord with the 2005-2010 Kenyan National
HIV and AIDS Strategic Plan, the Government of Kenya has identified good nutrition as a
key component of the national response to the HIV and AIDS epidemic. This is keeping with
global recognition that good nutrition is essential for the promotion of health and quality of
life of all people, particularly people living with HIV and AIDS (PLHIV).
By the end of 2007 in Kenya, there were an estimated 234 facilities offering paediatric ART
treatment (NASCOP, 2008). While PMTCT services have expanded rapidly, the prevalence
among pregnant women is approximately 9.6%, resulting in an estimated 90,000 children
at risk of Mother-to-Child (MTCT) transmission of HIV and an estimated 34,000 to 45,000
new HIV infections every year. Tragically the majority of these children die within two years
without being diagnosed. While 60,000 children are estimated to be in need of ART only
20,000 are known to be receiving treatment, reversing the previous gains in child survival in
the country over the past two decades.
HIV-infected children’s energy needs increase by 20-30%; children experiencing weight
loss increase their energy needs by 50-100%. A number of studies have shown that
growth faltering by age 3-4 months was observed while progressive stunting appeared to
be more typical than wasting. Disturbances in growth are detectable well before the onset
of opportunistic infections or other manifestations. In children with HIV and AIDS, growth
failure is noted from several international studies and wasting being more prominent in
children who are HIV positive after one year of age. Height growth or lean body mass is
affected in children and is significantly linked to survival.
Patients with HIV & AIDS

This section details some of the broad principles for in-patient and out-patient nutritional
management of children with HIV and AIDS. This section provides a comprehensive approach
and will be cross referenced with other sections. Objectives, critical interventions as well as
key nutritional requirements are detailed below. The general management for severe acute
malnutrition needs to follow the protocols and principles of care highlighted in Section
133
Two: ‘Inpatient Management and Treatment of Severe Acute Malnutrition’ and Section Four:
‘Out-patient therapeutic Care for Severe Acute Malnutrition’ as well as other sections that
pertain to care of children less than six months of age (Section Three: Management of Acute
Malnutrition in Infants Less than Six Months).
Objectives and Guidelines for Providing Nutritional Care

for PLHIV (from GoK, MOH, 2007, National Guidelines for
Section Six
Nutrition and HIV and AIDS)

Providing nutritional care and support for adults and children with HIV and AIDS serves to:
• Improve the quality of life through improved nutritional status, promote food-based
strategies, reduce food and water-borne infections, enhance resistance to opportunistic
infections and enhance better management of HIV related illnesses.
• Increase adherence to ARV treatment through nutritional management of side-effect(s)
from medicines.
• Increase participation in programmes through food incentives that promote adherence to
evidenced based care.
• Address micronutrient deficiencies that may prevent HIV disease progression and delay
adverse pregnancy outcomes.
• Improve the nutritional assessment and care in all levels of service provision (e.g. PMTCT,
ART, VCT and TB care).
• Increase the capacity of government and key NGO/CBO partners to provide nutritional
care as part of PMTCT and home based care.
• Promote choice and action on optimal infant feeding practices. This would include
minimizing mixed feeding and increasing exclusive breastfeeding where there are no
alternatives that are acceptable, feasible affordable, sustainable and safe (AFASS).
• Establish and strengthen monitoring and evaluation systems that would guide further
planning for optimal care of those living with and affected by HIV and AIDS.
The role of nutritional assessment is fundamental to effectively planning for the nutritional
needs of PLHIV and assists in:
• Confirming an adequate nutrient intake, improve eating habits, and help build and maintain
stores of essential nutrients.
• Confirming correct weight status, and maintain a healthy weight by preventing overall
weight loss particularly of muscle mass (lean body mass, LBM) or development of
obesity.
• Confirming absence of illnesses that aggravate nutritional wasting, and assist the patient
in assessing treatment for illnesses that reduce food intake.
• Adjusting meals and meal plans for other chronic illnesses associated with HIV.
• Facilitating the provision of therapeutic nutritional care and support during advanced
stages of HIV and AIDS.
Summary of Critical Nutrition Practices for PLHIV

• Have periodic nutritional status assessments, especially the weight, at least every second
month for symptomatic clients and every third month for asymptomatic clients.
• Increase energy needs for the disease stage through consumption of balanced diet.
Severely malnourished patients (BMI<16) should be supported with therapeutic and
supplementary foods, where this is available.
• Patients with no AIDS symptoms require 10% more energy (one snack) per day than
the recommended daily allowance for HIV-negative individuals of the same age, sex,
134
physical activity level and physiological state. Patients with AIDS symptoms require 20-
30% more energy (2-3 snacks) per day than the recommended daily allowance for HIV-
negative individuals. Children with weight decline or faltering need 50-100% more energy
than HIV-negative children of same age, sex. The additional energy can be achieved by
consuming sufficient amounts of balanced food, including one or more snacks in between
the meals in the course of the day,
• Maintain high levels of sanitation, food hygiene, and food/water safety at all times. If living
in hookworm endemic areas one should be de-wormed bi-annually with an appropriate
Section Six
broad-spectrum anti-helminthic drug, like Albendazole or Mebendazole.
• Practice positive living behaviours, including practicing safer sex, avoiding or moderating
use of alcohol, cigarettes and non-prescription drugs, moderating consumption of junk
foods, and management of depression and stress.
• Carry out physical activity or exercises to strengthen or build muscles, increase appetite
and health.
• Drink plenty of clean safe water (8 glasses in a day). All water used to swallow medicines
and to prepare juices should be clean and safe (e.g. filtered and boiled).
• Seek prompt treatment for all opportunistic infections and other diseases, and dietary
manage symptoms especially those that may interfere with food intake, absorption and
utilization.
• Those on medicine, including ARVs, should manage the drug-food interactions and side-
effects by following the drug-food schedule, use dietary approaches to manage side-
effect symptoms. If taking traditional remedies (herbs, medicines) or other nutritional
supplements, the clinician should be informed.
• Children (below 6 months) born to HIV+ mothers whose mothers/caregivers have opted
for exclusive replacement feeding, should be supplemented with 50,000 IU of Vitamin A
and if not on commercial infant formula, put on multivitamins every day.
Clinical Guidelines for an Integrated Approach to the Nutritional

Care of HIV-Infected Children (6 months to 14 years)
WHO (2007) clinical guidelines for nutritional management of children with HIV and AIDS
(age 6 months to 14 years) are detailed in job aids for health care providers. The following
is an excerpt from these draft guidelines.
The nutritional needs of HIV-infected children vary according to their age, stage of disease,
the presence of acute and/or chronic infections and the treatments they receive. Nutritional
needs are best met through balanced and varied diets. When these are not available, or
demands are high, then additional support may be needed.
The energy and protein needs of HIV-infected children depend on their age, and growth
patterns and the long-term effects of HIV disease such as acute/chronic infection or other
complications (see table below). Improving the diet alone, though, may not result in normal
growth, weight recovery or improvement in clinical status. Children who are not growing
well may require additional medical interventions such as TB therapy or antiretroviral
treatment (ART); these children should be referred to a health facility that is capable of
skilled assessment if they are not already under follow-up. Children starting and remaining
on ART also need additional energy and protein to build up their muscles, grow again and to
be active and playful as the infection comes under control.
135
Table 6.1: Energy needs of HIV-infected children (kcal/day)
Daily energy HIV infected and HIV infected 20% Severely

needs of HIV asymptomatic and poor weight additional malnourished and
uninfected 10% additional gain or other energy HIV infected50-100%
children* energy symptoms additional energy**
6–11 mths 690 760 830 150-220 kc al/kg/day
12-23 mths 900 990 1080 150-220 kcal/kg/day

Section Six
24-59 mths 1260 1390 1510 150-220 kcal/kg/day
6-9 yrs 1650 1815 1980 75-100 kcal/kg/day
10-14 yrs 2020 2220 2420 60-90 kcal/kg/day
* Based on average of total energy requirements for light and moderate habitual physical activity levels for
girls and boys by age group. Joint FAO/WHO/UNU Expert Consultation, October 2001. ftp://ftp.fao.org/docrep/
fao/007/y5686e/y5686e00.pdf
** Management of Severe Malnutrition: a manual for physicians and other senior health workers. WHO. 1999.
Most HIV-infected children do not need any more protein than uninfected children, but they
should rather have a balanced diet where protein contributes about 10-15% of energy intake.
HIV-infected children frequently have low levels of vitamins and other micronutrients. They
may not be receiving enough from their diet or their bodies are using up more to fight the
HIV infection itself or opportunistic infections. Vitamin A supplements, as in children without
HIV infection, reduce diarrhoeal morbidity and mortality especially in young children. Zinc
supplements also help HIV-infected children to recover from diarrhoeal illnesses which is
consistent with national IMCI guidelines for management of diarrhoeal illness in children 5
years and under.
Micronutrient intakes at recommended levels need to be assured in HIV-infected children
through varied diets, fortified foods, and micronutrient supplements when adequate intakes
cannot be guaranteed through local foods. At present, all WHO recommendations for
micronutrient supplementation in the general population (e.g. vitamin A, zinc and iron) are
the same as for HIV-infected children.
In summary, adequate and appropriate nutrition from the early stages of HIV infections and
also in the advanced stages is necessary to optimise health outcomes; however nutrition
support alone, macro- and/or micronutrients, are not an alternative to comprehensive HIV
treatment including antiretroviral drugs.
National indicators for monitoring of programme implementation and impact have been detailed
in other national guidelines and training documents on Nutrition and HIV and AIDS.
National reference documents include:
GoK - Ministry of Health: Kenyan National Guidelines on Nutrition and HIV and AIDS,
January 2007
GoK - Ministry of Health: Kenyan National Training Curriculum on Nutrition and HIV and
AIDS, January 2007
GoK – Ministry of Health: Kenya Nutrition and HIV and AIDS Strategy (Draft) February
2007.
The following pasges provide reference to portions of a broader job aid that provides a
stepwise approach to providing nutritional care to children infected with HIV from 6 months
to 14 years of age. The following table highlights assessment and classification which
remains similar to that of a child who is not infected with the exceptions of clinical wasting
for a child with severe malnutrition (Care Plan C); weight loss or chronic health conditions
identifying a child that is in need of supplementary food support (Care Plan B) or increased
nutritional needs of a child that demonstrates normal growth (Care Plan A). The following
plans of care are based on the macronutrient and also the micronutrient needs of children
based on assessment and classification.
136
Table 6.2: Assess, clarify and decide a nutritional case plan
2006-11-07 WHO - Nutritional care of HIV-infected children
ASK LOOK and FEEL SIGNS CLASSIFY AS TREAT

Ask mother/caregiver 1. Look for signs of severe Signs of severe visible wasting, or
(or check the medical visible wasting
SEVERE NUTRITION
records) Oedema present in both feet, or MALNUTRITION CARE PLAN
• Loss of muscle bulk
C
1. Has the child lost weight • Sagging skin/ buttocks Weight-for-height < 70% expected
during the past month? median, or
2. Feel for oedema of both feet
3. Check the weight and height MUAC less than:
2. Does the child have: • Is the weight-for-height < 70% • 110mm in infants 6mo-12mo
• chronic lung disease, expected median? • 110mm in infants 1yr-5yrs
including LIP, • Is the child very low weight (less • 136mm in infants 6yrs-9yrs
bronchiectasis than 60% exp wt for age)?
• TB • 160mm in infants 10yrs-14yrs
• Is the child underweight (less than
rd
• Persistent diarrhoea 3 centile)? Reported weight loss, or POOR WEIGHT NUTRITION
4 Very low weight (less than 60% exp GAIN CARE PLAN
curve Assess wt for age), or B
• Has the child lost weight since the growth rd
last visit? (Confirm current weight Underweight (less than 3 centile), or
in all
by repeating measurement)
children Confirmed weight loss (>5%) since
Ask all questions • Is the child’s growth curve the last visit, or
and complete all flattening?
assessments with • Is the child gaining weight? Growth curve flattening, or
each child 5. Check the MUAC MUAC less than:
Infants 6mo-12mo • 115mm in infants 6mo-12mo
• Is MUAC less than 110mm?
• 135mm in infants 1yr-5yrs
Gaining • Is MUAC less than 115mm?
• 155mm in infants 6yrs-9yrs
weight Children 1yr-5yrs
10yrs
• Is MUAC less than 110mm?
• Is MUAC less than 135mm? Child is gaining weight GROWING NUTRITION
137
Growth Children 6yrs-9yrs APPROPRIATELY CARE PLAN
curve • Is MUAC less than 135mm? A
flattening • Is MUAC less than 155mm?
Children 10yrs-14yrs Chronic lung disease, or CONDITION WITH NUTRITION
• Is MUAC less than 160mm? TB, or INCREASED CARE PLAN
Losing
• Is MUAC less than 185mm? Persistent diarrhoea NUTRITIONAL B
weight
NEEDS
Section Six
2006-11-07 WHO - Nutritional care of HIV-infected children
Table 6.3: Nutrition Care Plan A (WHO - Nutritional care of HIV-infected children, 2006)
1. Ask about general condition and if child is on any treatment including ART and TB medicine?
Also check re. immunizations (Step 7)
Is the child at school?
If child is on ART then also complete Step 10
2. Check mother’s health (+ need for ART) and care of other children
3. Nutrition counselling
Encourage mother/caregiver that the child is growing well. Explain growth chart and how to follow progress
Ask, have there been any major changes in the child’s circumstances from the last visit that might put the care of the child at
Section Six
risk, including access to food?

Advise mother/caregiver why additional food (energy) is needed in children (and adults) with HIV infection (approx 10%)
Counsel on continued breastfeeding if mother is well (Check national guidelines and age of the child)
Counsel on complementary feeding and replacement feeding (frequency of meals, amount & type of food per meal,
responsive feeding – see Appendices VI and VII). Reinforce and encourage good practices.
Counsel on feeding a variety of foods such as milk/ maas, fruit, vegetables, wholegrains, cereals & meat/ chicken or fish
based on local diets i.e. food sources that are high in vitamin A, iron, calcium, etc. and other locally produced foods
Review safe food preparation, food and water storage methods and hygiene issues (keep hands, utensils and food prep
area clean; separate raw and cooked foods; cook food thoroughly; keep food at safe temperature; use safe water and food)
Check if there are other sources of good foods such as through garden projects or other community resources
4. Meet age-specific needs and additional 10% food (energy) based on actual weight
Examples of ways to increase energy intake by 10% using food
GIVE IN ADDITION TO THE MEALS AND SNACKS APPROPRIATE FOR THE CHILD’S AGE
6 months - 11 months [100kcal]
• Local adaptation
E.g. 2 tsp marg/ oil & 1 tsp sugar to porridge add other examples of switches
12 months - 23 months [100kcal]
E.g. 2 tsp marg/ oil & 1 tsp sugar to porridge add other examples of switches
2 years - 5 years [150kcal]
E.g. Extra cup of full cream milk/ fermented milk add other examples of switches
E.g. Extra cup of full cream milk/ fermented milk add other examples of switches
E.g. Extra cup of fruit yoghurt or cheese sandwich add other examples of switches
See Appendix II for suggested daily food quantities to increase energy intake by ~10% for different ages.
5. Ensure adequate micronutrient intake

If the child’s diet is not balanced and does not contain a variety of animal sourced foods, fruits and vegetables then give
a daily micronutrient supplement that provides 1 Recommended Daily Allowance of a wide range of vitamins and other
micronutrients. Refer to national guidelines.
6. Vitamin A supplements every 6 months
<6 months 50,000IU 6-12 months 100,000IU >12 months, 200,000IU
Do not give if child has received dose within the past month e.g. from hospital
7. De-worm every 6 months (Step 7)

Albendazole (oral) 400mg single dose every 6 months after first year of life
8. Cotrimoxazole prophylaxis (Step 7)

Provide from 6 weeks of age 5mg/kg/day
9. Ensure mother/caregiver understands care plan and ask if she/he has any questions
10. Review in 2-3 months (Tell caregiver to return earlier if problems arise)
138
Table 6.4: Nutrition Care Plan B (WHO - Nutritional care of HIV-infected children, 2006)
1. Clinically stage the child (Appendix I). Assess for ART, clinical and immunological response to
ART including adherence and refer if indicated. If child is on ART then also complete Step 10.
3. Nutrition counselling
• What does the child eat and drink? (Step 4)
• Who gives the child their food and how does the child eat? (Step 5)
• Is there food at home? (Step 6)
• Advise mother/caregiver why additional food (energy) is needed in children (and adults) with HIV + complications (25-30%)
Section Six
• Review safe food preparation, food and water storage methods and hygiene issues (Step 7)
• Ask, have there been any major changes in the child’s circumstances from the last visit that might put the care of the child at
risk, including access to food? (Step 6)
4. Meet age-specific needs and additional 25 - 30% food (energy) based on actual wt
These needs may be met either through a food-based approach or through specific nutritional supplements – either
form of support should be provided by the service/programme
Food-based approach Nutritional supplement

GIVE IN ADDITION TO MEALS AND SNACKS GIVE IN ADDITION TO MEALS AND SNACKS
6 months- 11 months [230 -275 kcal] 6 months- 1year [230 - 275kcal]
• 2 tsp marg/ oil to porridge/ food & 1 tsp sugar to • equivalent local adaptation / recommendation (examples in
porridge/ food - aim to add to 3 foods per day Appendix III)
OR
• *1 extra cup of full cream yoghurt or milk
12 months - 23 months [425 - 500kcal] 1 year – 6 Years [425 - 500kcal]
• 2 tsp marg/ oil to porridge/ food & 1 tsp sugar to • or equivalent local adaptation / recommendation (examples
porridge/ food - aim to add to 3 foods per day in Appendix III)
• *1 extra cup of enriched full cream milk
OR
• 1 Cheese/ peanut butter/ egg sandwich [2 slices]
2 years – 5 years [425 - 500kcal]
6 years – 9 years [550 - 650kcal]
10 years - 14years [550 - 650kcal] 7 - 14years [550 - 650kcal]

• 2 tsp marg/ oil to porridge/ food & 1 tsp sugar to • or equivalent local adaptation / recommendation (examples
porridge/ food - aim to add to 5 foods per day in Appendix III)
• 1 Extra cup of full cream milk/
OR
• 3 Cheese/ peanut butter/ egg sandwich [6 slices]
*To enrich milk add 4 tablespoons (60g) full cream milk powder to 500ml milk/fermented milk [605kcal & 30.7g protein]
See Appendix III for examples of nutritional support to provide additional 20-30% energy for different ages

If the child’s diet is not balanced then give a daily micronutrient supplement that provides 1 RDA of a wide range of
vitamins and other micronutrients. Refer to national guidelines.
If recent diarrhoeal illness, give Zinc supplement (20mg daily for 2 weeks)



10. Review 1st visit 1-2wks. If responding, then every 1-2 months depending on response
139
Table 6.5: Nutrition Care Plan C (WHO - Nutritional care of HIV-infected children, 2006)
1. Assess if the child needs to be admitted

Assess if there are signs of a concurrent opportunistic infection or dehydration,
Assess if there have been any major changes in the child’s circumstances? (Step 6)
Assess if the child wants to eat – Conduct a test feed. (Step 4)
If the child will not eat then admit and manage as per WHO Management of Severe Malnutrition.
If the child eats well then plan home management according to table below. Prescribe feeds.
2. Clinically stage the child (Appendix I). Assess for ART, clinical and immunological response to
ART including adherence and refer if indicated.
Section Six
All severely malnourished children or those with recent severe weight loss should be assessed for possible ART and to
exclude opportunistic infections such as TB
4. Meet age-specific needs and additional 50-100% food (energy) based on actual wt
Therapeutic feeding
Provide 150-220kcal/kg/day (do not rely on home foods being available)
6 months - 11 months [150-220kcal/kg/day = ~900 - 1300kcal]
12 months - 23 months [150-220kcal/kg/day = ~900 - 1300kcal]

• F100 – give volumes CHECK VOLUMES ETC or
• RUTF [40g/kg/day]
2 years - 5 years [150-220kcal/kg/day = ~1,700 – 2,300kcal]

• F100 – give volumes CHECK VOLUMES ETC or
6 years - 9 years [150-220kcal/kg/day = ~900 - 1300kcal]

• F100 or
10 years – 14 years [150-220kcal/kg/day = ~2200 – 3,300kcal]

• F100 or
See Appendix IV for composition of different Therapeutic feeding interventions.

A child receiving F100 or RUTF will receive all the micronutrients that they require through the feeds
A child that receives therapeutic feeding based on local foods is unlikely to receive all micronutrients in the required
amounts and may therefore need a separate, additional vitamin-mineral supplement that meets defined standards. In
addition, many commercial vitamin-mineral supplements do not contain adequate amounts of zinc and separate
supplements of zinc may also be needed.
If recent diarrhoeal illness, give Zinc supplement (20mg daily for 2-4 weeks)



10. If managed at home, then review in 1 week to ensure weight gain of at least 5gm/kg/d. If
gaining weight then review every 1-2 weeks until recovery and change to plan A. If not gaining
weight then consider admission.
140
Deciding If and When to Refer a Child with HIV and AIDS

The following table identifies general recommendations for follow-up of a child with HIV
and AIDS. Judgment should always be exercised depending on the social situation and
mechanisms of support for each child.
Table 6.6: Recommendations for follow-up of a child with HIV and AIDS
Condition Review interval Comment
Section Six
The child who is well and growing 2-3 months Unless needing to attend to receive routine
appropriately cotrimoxazole/ micronutrient or other
support/treatment
The child on antiretroviral Three monthly If gaining weight and no other problems
treatment (ART)
2-4 weekly If failing to gain weight
The child who has chronic 2-3 months Tell caregiver to return earlier if problems
increased nutritional needs but arise.
investigated and no other active
problems
Child starting on Nutrition Care First visit 1-2wks Tell caregiver to return earlier if problems
Plan B Then 1-2 months arise
The child who is unwell and/or 2-4 weeks May require more frequent visits depending
showing signs of growth faltering on clinical status and support offered or
or has had recent diarrhoeal illness being provided
When the child is malnourished Weekly Only if fulfils criteria for management
+/- other signs of disease at home and no other investigations
progression e.g. history of recent immediately required that require
severe weight loss or recent hospitalization
diarrhoea illness
When a child is severely Admit for investigation
malnourished or has very low
weight and no explanation/
diagnosis has been identified
The HIV-infected Child with Special Needs

Management of acute malnutrition can be met through supplementary or therapeutic foods
detailed in sections two, three, four and five in these guidelines. Ensuring nutritional care is
integrated with clinical and medical management of HIV and AIDS, opportunistic infections,
chemo-prophylaxis and management of side effects of ART and other medicines will ensure
optimal growth and prevention of weight loss in PLHIV. Key areas of intervention include
nutritional support when recovering from a period of illness, poor appetite (anorexia), sore
mouth/throat, change in taste, diarrhoeal illness and nausea and/or vomiting. Within the job
aids for health workers, WHO has detailed interventions on:
•• How to add extra energy and protein to everyday foods
•• What to try if the child does not feel like eating
•• What to try if the child has a sore/dry mouth or throat
•• What to try if the child has a change in taste
•• What to try if the child has diarrhoea
•• What to try if the child has nausea and/or vomiting
A. Eating during and when recovering from an illness – see Suggestion sheet 11
It is often difficult to encourage children to eat during a febrile illness or when otherwise
unwell e.g. difficulty breathing. During these acute illnesses, HIV-infected children are likely
to lose weight. If this weight is not recovered in the weeks after the illness, then the child’s
1. Suggestion sheets can be found in the Kenya Guidelines for Integrated Approach to the Nutritional Care of
HIV-infected Children (6 months - 14 years), chart booklet for healthcare providers, 2008.
141
growth curve is likely to drop to a lower level in the long term. Hence it is important to
optimize intake during illnesses if possible (in hospital this may require inserting a nasogastric
tube) and targeting the recovery period to recover lost weight by ensuring the best care and
nutritional intake. In the recovery period it is important to:
•• increase the energy and protein using everyday foods,
•• ensure that food is available day and night so that if the child is hungry then he/she has
something appropriate to eat, and
•• encourage the child in simple and loving ways.
Section Six
Some of the ways to encourage a child to eat include the following:

•• Make the child comfortable.
•• Be patient and feed slowly.
•• Feed small amounts frequently. Children may tire easily while eating, making it difficult
to eat sufficient food at a sitting. Offering feeds frequently may be needed to increase
food intake.
•• Give foods that the child likes.
•• Give a variety of foods and extra fluids.
•• If the child is thirsty give fluids that have some energy e.g. milk, rather than juices or fizzy
drinks that have very little energy value.
•• Pay attention to the child and make feeding a happy time.
Sick children need extra drinks and food during illness, for example if they have fever or
diarrhoea. A sick child may prefer breastfeeding to eating other foods. Do not withhold food
from a sick child unless there is a medical reason.
B. Poor appetite (Anorexia) – see Suggestion sheet 2

Children and adults with HIV infection frequently experience loss of appetite. This may be
due to sores in the mouth or because HIV infection itself can cause a loss of appetite.
C. Sore mouth or throat – see Suggestion sheet 3

A sore mouth or throat can make it difficult to eat. Thrush, herpes, infections and other
conditions may cause a sore mouth or throat. Some conditions may respond to treatment;
refer to a doctor if not sure whether there is such an infection. Mouth hygiene such
as rinsing the mouth with clean water before and after meals and cleaning the teeth, is
important and can help the child to feel better.
D. Change in taste – see Suggestion sheet 4

A child may find that they have a taste in their mouth or their food tastes different because
of side-effects of medication or infections; this may be just temporary. Children may also be
more aware of the texture or feel of foods in their mouth. They may even develop cravings
for certain foods.
E. Children with diarrhoea – see Suggestion sheet 5

When a child passes a loose or watery stool three or more times a day, he/she has diarrhoea.
It can be a side effect of medicines or a symptom of disease. Diarrhoea is often caused by
contamination of water or food from poor hygiene and sanitation.
Most diarrhoea will cease after a few days. A child should be seen at the clinic if the
diarrhoea lasts for more than three days or if there is a fever or blood in the stool. An infant
or young child who is not able to drink or breastfeed or is drinking poorly, becomes sicker
and weak, has blood in the stool or develops a fever should be seen by a health worker
immediately. A child should be referred to hospital if the diarrhoea lasts more than 14 days
and there is loss of weight.
142
Zinc supplements – any child with diarrhoea (acute, persistent or dysentery) should receive
zinc as followed:
<6 months: 10mg daily for 2 weeks >6 months: 20 mg daily for 2 weeks
Vitamin A supplements - children with diarrhoea should also receive an extra dose of vitamin
A if they have not received their routine supplement in the previous month. This dose helps
protect against serious later relapses of diarrhoea.
Section Six
F. Nausea and/or vomiting – see Suggestion sheet 6
Nausea can be caused by infection, stress, certain foods, hunger, lack of water, unpleasant
smells or a side-effect of some medications or treatments. Nausea may also reduce the
appetite.
G. Anaemia
Anaemia is common in HIV-infected children and may be due to chronic opportunistic
infections or direct effects on the bone marrow. Even in areas with high prevalence of worm
infestation and iron deficiency, anaemia in HIV-infected children cannot be assumed to be
due to iron deficiency.
Children with palmar or severe palmar pallor should be referred for investigation. Iron
supplements should only be started if iron deficiency is confirmed.
Children on Antiretroviral Treatment

The following provides an overview of planning for assessment and follow-up for a child on
anti-retroviral treatment.
If the child is on ART, then ask:

1. Has there been any change in eating patterns or appetite since the last visit?
2. Has the child vomited? If yes, has there been any fast breathing/fever? – see below
3. Since the last visit has the child been taking any other medicines from a doctor/pharmacy/
programmes, or from other sources including traditional medicines?
4. Have you noticed any change in body shape or appearance of the child?
What to do if a child on ART is gaining weight well

Most children will gain weight once started on ART. Remember to:
• Encourage the mother/father or caregiver that the child’s health is improving
• Check the health of the mother/father and assess if any of them needs ART
• Check if doses of ART need to be increased with increasing weight
• Review ART adherence and remind mother/father or caregiver of signs of OIs
What to do if a child on ART is not gaining weight

If a child on ART is not gaining weight the healthcare worker should be thinking of:
• Failure to take ART correctly – either non-adherence or vomiting. (Severe wasting with
other symptoms such as abdominal pain, vomiting or fast breathing may be a sign of
lactic acidosis)
• Early side effects of ART e.g. nausea
• Development of the immune reconstitution syndrome (only to be expected in first 3
months of starting ART)
• Presence of an opportunistic infection e.g. TB
• Late ART related side effects e.g. lactic acidosis or lipodystrophy
• Inadequate food intake
• Other nutritional problem e.g. inadequate food supply or preparation or caregiving
• Possible early sign of treatment failure if the child has been on ART for more than 6 months
143
If persisting very low weight or visible severe wasting or oedema of both feet then refer
urgently.
Depending on available resources the healthcare worker should:
i. Assess ART adherence.
ii. If possible, repeat the CD4 to check whether there is immunological deterioration
iii. Investigate and treat for any opportunistic infection or underlying disease – TB is
especially important.
iv. Assess dietary intake and food security. Make appropriate referral to dietician, welfare
Section Six
or social worker if necessary.

v. If these resources are not available then refer to an ART referral site for investigation
and management. If resources are available then review every 2-4 weeks and monitor
growth until cause of poor weight gain is identified and managed.
vi. If the child continues to lose weight then refer urgently to an ART referral site.
Note: Children who are referred for weight loss should be followed up after discharge from
the referral centre, and growth monitoring done on a regular basis (at least monthly, although
it may be necessary to bring the child back more frequently or admit for observation in
hospital).
What to do if the child has nausea and vomiting when taking antiretroviral drugs
1) All children who present with nausea and vomiting should be assessed using IMCI
guidelines to assess and classify severity of the vomiting and to look for any danger signs.
The presence of danger signs should also alert to possible lactic acidosis. (See below)
2) If the child vomits doses for more than 2 days or complains of increased fatigue or
difficulty breathing then refer urgently; missed doses may make their ART stop working
so well.
3) Check if there has been a recent change in treatment.
4) If the child does not need urgent referral or other care e.g. rehydration, then manage as
if the nausea and vomiting are related to their antiretroviral drug therapy:
• If the child vomits their ART within 30 minutes of the dose, the dose should be
repeated.
• Nausea and vomiting may be related to the taste of the medicines. The following
suggestions may be helpful to control these symptoms:
i. Take ART drugs separately from other medications such as cotrimoxazole or TB
treatment
ii. Do not mix all the ART syrups together.
iii. If dissolving capsules (e.g. Stavudine) reduce the amount of fluid used to dissolve.
iv. If the child complains of the taste, then instruct mother or caregiver to place the
syringe near the back of mouth to give the medicine (to avoid the child tasting the
medicine)
v. Advise mother or caregiver to keep syrups in fridge to make more palatable (ritonavir
cannot be refrigerated)
vi. Reassure the mother or caregiver that nausea and vomiting are common side effects
of ART especially in the first few weeks. The symptoms usually settle, but if she is
concerned or the child does not respond within two days she should return to the
clinic.
vii. Advise on use of fluids, ORS and prevention of dehydration
Routine monitoring of children on ART for metabolic disorders

Children on ART require regular monitoring of the viral and immune response as well as for
possible metabolic and other adverse effects.
144
Table 6.7: Laboratory parameters for monitoring infants and children at baseline, before and
during ART
Diagnosis and Baseline (at At initiation Every six As required
monitoring entry into of first-line or months or symptom-
laboratory tests care) second-line directed
ARV regimen
HIV diagnostic √ - - -
testing: virological
Section Six
and Ab testing
Haemoglobina √ √ - √
WBC and differentialb √ √ - √
%CD4+ or absolute √ √ √ √
CD4 cell countc
Pregnancy testing in - - - √
adolescent girlsd
Full chemistry - - - √
(including, but not
restricted to, ALT,e
liver enzymes, renal
function, glucose,
lipids, amylase,
lipase and serum
electrolytes)f
HIV viral load - - - √
measurementg
a Haemoglobin monitoring at weeks 4, 8 and 12 after initiation of ART is recommended by some experts if AZT
is used.
b Monitoring at weeks 4, 8 and 12 after initiation of ART is optional.
c Children not yet eligible for ART should be monitored with CD4 every six months. For infants and children who
develop new or recurrent WHO stage 2 or 3 events or whose CD4 approach threshold values the frequency
of CD4 measurement can be increased. %CD4+ is preferred in children <5 years of age.
d Pregnancy testing may be needed for adolescent girls prior to initiating a regimen containing EFV.
e The predictive value of pre-emptive liver enzyme monitoring is considered very low by some experts. WHO
recommends liver enzyme monitoring in a symptom-directed approach. However, regular monitoring during
the first three months of treatment and symptom-directed measurement of liver enzymes thereafter has
been considered by some experts for children on nevirapine-based regimens, or for adolescent girls with
CD4 values over 250 cells/mm3 and for infants and children coinfected with hepatitis B or hepatitis C virus
or other hepatic disease.
f Regular monitoring (every six months) of full chemistry, particularly lipid levels, liver enzymes and renal
function, should be considered for infants and children on second-line drugs.
g At present, viral load measurement is not recommended for decision-making on the initiation or regular
monitoring of ART in resource-limited settings. Tests for assessment of HIV RNA viral load can also be
used to diagnose HIV infection, and to assess discordant clinical and CD4 findings in children suspected of
failing ART.
145
Appendix 6.1: HIV and infant feeding

New evidence and programmematic experience : report of a technical con-
sultation held on behalf of the Inter-agency Task Team (IATT) on Preven-
tion of HIV Infections in Pregnant Women, Mothers and their Infants, Ge-
neva, Switzerland, 25-27 October 2006 (WHO, UNICEF, UNAIDS, UNFPA)
Updated Recommendations on HIV and Infant Feeding

Section Six
Based on the new evidence and experience, the group agreed on the following recommen-
dations for policy-makers and programme managers. These are intended to supplement,
clarify and update existing United Nations guidance and do not replace it. An update of the
relevant United Nations guidance incorporating these additional recommendations is avail-
able.
•• The most appropriate infant feeding option for an HIV-infected mother should continue
to depend on her individual circumstances, including her health status and the local
situation, but should take greater consideration of the health services available and the
counselling and support she is likely to receive.
•• Exclusive breastfeeding is recommended for HIV-infected women for the first six
months of life unless replacement feeding is acceptable, feasible, affordable, sustainable
and safe for them and their infants before that time.
•• When replacement feeding is acceptable, feasible, affordable, sustainable and safe,
avoidance of all breastfeeding by HIV-infected women is recommended.
•• At six months, if replacement feeding is still not acceptable, feasible, affordable,
sustainable and safe, continuation of breastfeeding with additional complementary
foods is recommended, while the mother and baby continue to be regularly assessed.
All breastfeeding should stop once a nutritionally adequate and safe diet without breast
milk can be provided.
•• Whatever the feeding decision, health services should follow up all HIV exposed infants,
and continue to offer infant feeding counselling and support, particularly at key points
when feeding decisions may be reconsidered, such as the time of early infant diagnosis
and at six months of age.
•• Breastfeeding mothers of infants and young children who are known to be HIV-infected
should be strongly encouraged to continue breastfeeding.
•• Governments and other stakeholders should revitalize breastfeeding protection,
promotion and support in the general population. They should also actively support HIV-
infected mothers who choose to exclusively
•• breastfeed, and take measures to make replacement feeding safer for HIV infected
women who choose that option.
•• National programmes should provide all HIV-exposed infants and their mothers with
a full package of child survival and reproductive health interventions2 with effective
linkages to HIV prevention, treatment and care services. In addition, health services
should make special efforts to support primary prevention for women who test negative
in antenatal and delivery settings, with particular attention to the breastfeeding period.
•• Governments should ensure that the package of interventions referenced above, as well
as the conditions described in current guidance, are available before any distribution of
free commercial infant formula is considered.
•• Governments and donors should greatly increase their commitment and resources
for implementation of the Global Strategy for Infant and Young Child Feeding and
the United Nations HIV and Infant Feeding Framework for Priority Action in order to
effectively prevent postnatal HIV infections, improve HIV-free survival and achieve
relevant UNGASS goals.
2 UPDATED RECOMMENDATIONS ON HIV AND INFANT FEEDING

For the full package of interventions, see: WHO. Antiretroviral drugs for treating pregnant women and preventing HIV
infection in infants in resource-limited settings. Geneva, 2006; WHO. The World Health Report: Make every mother and child
count. Geneva, 2005.
146
Appendix 6.2: Micronutrient Requirements for Children

Table 6.8: Micronutrient requirements for children 0 - 6 years
Target 0-3 4-6 7-9 10-12 1-3 4-6
micronutrient months months months months years years
Vitamin A (µg RE) 375 375 400 400 400 450
Vitamin B1 (mg) 0.2 0.2 0.3 0.3 0.5 0.6
Vitamin B2 (mg) 0.3 0.3 0.4 0.4 0.5 0.6
Section Six
Vitamin B3 (mg) 2 2 4 4 6 8
Vitamin B6 (mg) 0.1 0.1 0.3 0.3 0.5 0.6
Vitamin B12 (µg) 0.4 0.4 0.5 0.5 0.9 1.2
Vitamin C (mg) 25 25 30 30 30 30
Vitamin D (µg) 5 5 5 5 5 5
Vitamin E (mg) 2.7 2.7 2.7 2.7 5 5
Folic acid (mg) 80 80 80 80 160 200
Vitamin K (µg) 5 5 10 10 15 20
Calcium (mg) 300 300 400 400 500 600
Iodine (µg) 15 15 135 135 75 110
Iron (mg) a a a 10 6 6
Zinc b (mg) 2.8 2.8 4.1 4.1 4.1 5.1
Magnesium (mg) 26 26 53 53 60 7.3
Selenium (µg) 6 6 10 10 17 21
Source: Food and Agricultural Organization of the United Nations and World Health Organization: Human vita-
min and mineral requirements. Report of a joint FAO/WHO consultation. Bangkok, Thailand 1998.
NB: Bioavailability is the degree to which a nutrient is absorbed or becomes available at the
site of physiological activity after intake.
a Neonatal iron stores are sufficient to meet the iron requirement for the first six months
in full term infants. Premature infants and low birth weight infants require additional iron.
Based on 15% bioavailability. b Based on high dietary bioavailability
147
Appendix 6.3: Nutritional Composition of Fortified

Supplementary Blended Foods
Table 6.9: Nutritional composition of fortified supplementary blended food
Name of Insta Health Builder Insta Health Builder UNIMIX (CSB) 10 %
Product - Advantage – First Food Sugar
Nutrient Unit Per 100g Per 100 g Per 100g
Section Six
Energy Kcal 440 435 400

Protein % 16 12 14
Fat % 12 11 6
Carbohydrate % 60 64
Fibre % 4 4 12 %
Vitamin A IU 1050 920 2300
Vitamin B1 mg 0.29 0.25 0.28
Vitamin B2 mg 0.44 0.38 0.82
Niacin (B3) mg 3.17 2.75 5.0
Vitamin B5 mg 1.60 1.39
Vitamin B6 mg 0.17 0.15 0.165
Vitamin B12 mcg 0.52 0.52 1.3
Folate mcg 136 108 0.2 mg
Vitamin C mg 28.0 24 60
Vitamin D IU 90.0 80 200
Vitamin E mg 3.60 3.15 7.5 iu
Vitamin K mcg 11.9 7.25
Ca-d-pantothenate mg 0.28
Iodine mcg 20.1 18.2
Copper mg 0.32 0.28 0.7
Iron mg 6.50 5.18 8.0
Zinc mg 5.50 4.80 12
Phosphorus mg 322 240
Magnesium mg 146 112
Calcium mg 155 128 260
Manganese mg 0.84 0.67
Potassium mg 561 400
Selenium mcg 6.45 4.45
Sodium mg 200 160 650
Chloride mg 180 155
148
Appendix 6.4: WHO Clinical Staging of HIV and AIDS for

Children (2006)
Table 6.10: WHO clinical staging of HIV and AIDS for children with confirmed HIV infection
Clinical Stage 1
Asymptomatic
Persistent generalized lymphadenopathy
Section Six
Clinical Stage 2
Unexplained persistent hepatosplenomegaly
Papular pruritic eruptions
Extensive wart virus infection
Extensive molluscum contagiosum
Fungal nail infections
Recurrent oral ulcerations
Unexplained persistent parotid enlargement
Lineal gingival erythema
Herpes zoster
Recurrent or chronic upper respiratory tract infections (otitis media, otorrhoea, sinusitis or tonsillitis)
Clinical Stage 3
Unexplained a moderate malnutrition not adequately responding to standard therapy
Unexplaineda persistent diarrhoea (14 days or more)
Unexplained persistent fever (above 37.5°C intermittent or constant, for longer than one month)
Persistent oral candidiasis (after first 6-8 weeks of life)
Oral hairy leukoplakia
Acute necrotizing ulcerative gingivitis or periodontitis
Lymph node tuberculosis
Pulmonary tuberculosis
Severe recurrent bacterial pneumonia
Symptomatic lymphoid interstitial pneumonitis
Chronic HIV-associated lung disease including brochiectasis
Unexplained anaemia (<8.g/dl), neutropaenia (<0.5 x 10 9 per liter) and/or chronic thrombocytopaenia (<50
x 10 9 per liter)
Clinical Stage 4b
Unexplained severe wasting, stunting or severe malnutrition not responding to standard therapy
Pneumocystis pneumonia
Recurrent severe bacterial infections(such as empyema, pyomyositis, bone or joint infection or meningitis
but excluding pneumonia)
Chronic herpes simplex infection (orolabial or cutaneous of more than one month's duration or visceral at
any site)
Extrapulmonary tuberculosis
Kaposi sarcoma
Oesophageal candidiasis (or candidiasis of trachea, bronchi or lungs)
Central nervous system toxoplasmosis (after one month of life)
HIV encephalopathy
149
Cytomegalovirus infection: retinitis or cytomegalovirus infection affecting another organ, with onset at age
older than one month
Extrapulmonary cryptococcosis (including meningitis)
Disseminated endemic mycosis (extrapulmonary histoplasmosis, coccidiomycosis)
Chronic cryptosporidiosis
Chronic isosporiasis
Disseminated non-tuberculous mycobacterial infection

Section Six
Cerebral or B-cell non-Hodgkin lymphoma
Progressive multifocal leukoencephalopathy
Symptomatic HIV-associated nephropathy or HIV-associated cardiomyopathy
a - Unexplained refers to where the condition is not explained by other causes.

b - Some additional specific conditions can also be included in regional classifications (such as reactivation of
American trypanosomiasis [meningoencephalitis and/or myocarditis] in the WHO Region of the Americas,
penicilliosis in Asia and HIV-associated rectovaginal fistula in Africa).
150
Section Seven
Section Seven:
Emergency Nutrition Response
Overview
An important component of any response to a humanitarian crisis in Kenya are the health and
nutrition activities geared toward a resident population, an internally displaced population, and/or a
refugee population. In Kenya, the humanitarian health and nutrition actors include the Government
of Kenya (GoK), the ministries of the Office of the President; the Ministry of Health; the Ministry
of Agriculture and Livestock; and the Ministry of Education. UN agencies (WHO, WFP, UNICEF,
UNHCR, OCHA) work with the Red Cross, Non-Governmental Organizations (NGOs), Community
Based Organizations (CBOs), religious groups and co-operations. (See Appendix 7.1 for the roles
of stakeholders).
Often NGOs play a major role in nutrition response during emergency situations. Even so, all
emergency nutrition response activities are conducted under the umbrella of the Health and
Nutrition Sector Working Group chaired by the MoH. Under the health and nutrition sector working
group, the Nutrition Technical Forum (NTF) coordinates all the nutrition activities. The MoH works
through its health and nutrition programmes implemented in all of Kenya’s districts. All implementing
partners and support agencies are required to channel their plans and/or implementing strategies to
the MoH for guidance and approval. The Arid Lands Resource Management programme (ALRMP)
under the Office of the President coordinates all emergency preparedness and response activities
to ensure that gaps are identified and response is timely.
Steps for Emergency Response

Coordination
Coordination of all the emergency activities is the key to success of any response. All emergency
nutrition response and preparedness must be linked to the NTF and the Health and Nutrition
Sector Working Group, which is the technical arm of the Kenya Food Security Sector Working
Group (KFSSG) in health and nutrition matters (see “Coordination Structure” Appendix 7.1). The
mandate of the Health and Nutrition Sector Working Group is to coordinate local and international
assistance to Kenya to assure that the health and nutritional needs of vulnerable populations in
emergencies are addressed in a timely and appropriate manner. In particular, the NTF assesses,
identifies and priorities nutritional issues of relevance to Kenya in order to provide a planned and
coordinated strategy to address these issues. This forum was established to improve the efficiency
of nutrition interventions in emergency as well as non-emergency settings.
151
The Health and Nutrition Sector Working Group and NTF address:
• Preparedness by promoting readiness and the ability to cope and respond to emergencies at all
levels.
• Prevention of emergency situations to the extent possible.
• Mitigation by minimizing the effects of the emergency.
• Response and relief by meeting the needs of people affected by the emergency situation in a
coordinated, efficient and timely manner.
Section Seven
How does it work?

The Working Group is chaired by the MOH and co-chaired by UNICEF Country Office.
• At national level, the groups meet regularly in a forum to exchange information, discuss subjects
such as updates on emergency interventions, health and nutrition needs, and identification of
gaps that may require support.
• At the district level, the Sector Working Group is the technical arm of the District Steering
Group (DSG) that reports to the KFSSG. The District Medical Officer (DMO) chairs the meeting
while the District Nutrition Officer (DNO) co-chairs. These meetings are held once a month.
The Sector Working Group discusses specific health and nutrition issues at the district level,
including food ration distributions, integrated nutritional assessments, response strategies, and
pockets of interventions.
Detailed information regarding the Sector Working Group can be downloaded from website www.
kenyafoodsecurity.org
Identifying main nutrition and health problems

For any emergency, an initial assessment is conducted to understand the situation and to be able
to analyze the extent of threat to life, dignity, health, and livelihoods. All the assessments should
be coordinated through the Health and Nutrition sector group. To gather nutrition information,
standardized assessment reports are disseminated to relevant stakeholders. The assessment will
determine the nature of the response required, and whether an external response is necessary.
For the assessment to yield robust results, the following factors must be considered:
• Use a detailed, comprehensive and context-specific checklist and/or a questionnaire. The tools
are available in the Health and Nutrition sector working group.
• Conduct the assessment as soon as feasible after the disaster occurs; write up and disseminate
the report quickly.
• An assessment team must be multi-disciplinary, comprised of relevant technical specialists.
Each individual of the team must have clear terms of reference.
• The community must be actively involved in the assessment process including developing
tools, training, and data collection. Their local knowledge of the area is important.
• Clear objectives must be set so that process of collecting information is clear and well understood
by the user.
• Sources of information should be varied for validity and reliability; therefore both secondary and
primary data must be reviewed.
If possible, conduct a multi-sectoral assessment to understand the different factors affecting
malnutrition: the immediate, underlying and basic causes of malnutrition. This will ensure a holistic
approach to the treatment of acute malnutrition.
• Where existing nutrition interventions are in place, it is best to conduct a rapid programme
review.
• Data collected must be presented in a logical manner and disaggregate by age, gender,
occupation, livelihood and vulnerability. This will help to plan an appropriate response and
effective actions to address malnutrition.
152
Setting up response programmes and targeting
Planning a programme
An emergency response programme is required when the relevant authorities are unable or unwilling
to respond to the identified needs of the population; or when the assessment and analysis proves
that the population’s general nutritional needs are unmet.
Emergency programmes should have thefollowing characteristics:
• Programmes are designed to support and strengthen existing systems (e.g. Health infrastructures,
Section Seven
coordination mechanisms)
• Programmes are designed to protect lives of people and to promote livelihood.
• Programmes are most effective when they are well coordinated, with a good flow of information
between stakeholders (making gaps known).
• Programmes must maximize positive impact and do no harm (i.e. competition for scarce
resources/increased resources, misuse or misappropriation of supplies).
• Programmes ensure that humanitarian services are provided equitably and impartially.
It is important that the implementing partner works with local authorities, in particular the MoH
and the district administrators. The implementing partner must be familiar with programme
requirements.
Community participation in the initial assessment and the programme plan and design will lead to
the emergency response programme’s success. Establish a committee of community/beneficiary
representatives to secure the community’s full participation. In districts where a Village Health
Committee (VHC) exists, the committee can be used as a venue to the community. If there is
no formal committee, meet with a contact representative of the community (a village elder or
chief). The committee or contact person can meet and discuss with the responsible officers food
distribution and other issues (immunization schedules, programme adjustments/changes, official
visits).
The targeting criteria outlined below must be based on thorough, astute analysis of the
community’s vulnerability. Critical needs will arise when a targeting system fails to reach all of the
vulnerable people. The criteria must be known to the VHC, contact person, affected population
and implementing partners.
Selecting programme sites

Whenever existing infrastructures have reached their maximum capacity or do not ensure adequate
coverage,additional progamme sites would be considered to provide adequate services and ensure
good coverage. The affected area or emergency area in a district must be mapped in consultation
with the district health and nutrition coordination group. The affected area can be defined by
administrative boundaries such as district lines or a division, or by livelihood zones such as agro-
pastoralists, pastoralists and fisher folks. A programme site can then be identified. The size of the
programme will depend on the capacity of implementing partner and resources available. The site
must easily be accessible to the vulnerable population. Once the area is identified, nutrition service
delivery sites are established. The following is taken into consideration while selecting a feeding
centre:
• A feeding centre is ideally located within walking distance of the target population, especially
for small children, pregnant and lactating mothers. It is also ideally close to a health facility.
• In a large displacement camp a number of small centres is best. Small centres are easier to
manage and more pleasant for children, mothers and other malnourished patients. The centres
should also provide a good working environment for staff.
• For wet feeding intervention, the feeding site is located in a clean and secure environment, near
adequate safe drinking water.
• The feeding centre or distribution site must have an organized layout; be fenced and protected;
have formal entry and exits, marked well; have adequate space to prevent over-crowding; and
provide a shelter (temporary or permanent) that is safe.
153
Nutrition Programme Beneficiary Selection Process for Children

The selection criterion for children has two phases:
1. Initial screening is conducted in the community. MUAC is measured for children between 6-59
months. Children with a MUAC measurement <13.5cm are referred to a health centre or
feeding centre for further measurements of weight and height. Presence of oedema is an
indicator of severe acute malnutrition and a child with oedema is referred to an existing in-
patient or a out-patient therapeutic care programme, see details in Sections Two and Section
Section Seven
four.
2. Second screening is conducted in the health centre or feeding centre by taking the weight and
height measurement of children already screened by MUAC. The weight-for-height indicator
is a more accurate estimate of body wasting, and is usually the preferred index for nutritional
status in emergencies.
Implementing Emergency Nutrition Interventions

In an emergency setting, emergency nutrition interventions are programmes set-up to 1) manage
acute malnutrition, 2) provide other critical nutrition services (i.e. growth monitoring, micronutrient
supplementation, protection of infant and young child feeding practices) and, 3) provide food to
a population that does not have access to food. In essence, the emergency nutrition intervention
works to reduce high rates of acute malnutrition of large, vulnerable populations.
There are three types of nutritional interventions: general feeding programme, supplementary
feeding programme, and therapeutic feeding programme. The supplementary feeding programme
(SFP) is an ideal nutrition intervention for management of moderately acute malnourished patients
whereas the therapeutic feeding programmes (TFP) is ideal for management of severely acute
malnourished patients. Emergency nutrition interventions require substantial resources to set-
up and monitor, and NGOs often support the MoH with implementation. An effective nutrition
intervention is one that is comprehensive and provides a holistic approach in managing acute
malnutrition. The intervention should identify a vulnerable population, distribute food, offer basic
medical treatment, micronutrient supplementation and if possible nutrition education.
General Feeding Programme

This programme provides a food ration to households highly affected by food insecurity. Organization
and coordination is the key to success of a food distribution operation. If the population is entirely
depending on general food rations as a source of food, then the rations must provide at least
2100kcal per person per day. General food rations are usually provided as dry rations for people
to cook in their homes. The local community’s food habits, tastes and preferences must be taken
into consideration when distributing general food rations. World Food Programme (WFP) has set
standards for distributing general food to the affected population1.
Supplementary Feeding Programme

The goal of a supplementary feeding programme (SFP) is to rehabilitate individuals affected by
Moderate Acute Malnutrition or at risk of becoming malnourished by providing a supplementary
food ration which is highly nutritious. There are two types of SFP: targeted and blanket.
Targeted Supplementary Feeding Programme

This programme is set up when:
• There are large numbers of mild and moderately acute malnourished individuals.
• A large number of children are likely to become mildly or moderately acute malnourished due
to aggravating factors like serious food insecurity or high levels of disease.
• There are children discharged from an existing therapeutic feeding programme.
• A high prevalence of people with HIV and AIDS.
• A high prevalence of micronutrient deficiencies.
• There is short-term hunger among preschoolers.
1. WFP (2000) Food and Nutrition Handbook
154
Blanket Supplementary Feeding Programme

The main aim of a blanket SFP is to prevent widespread acute malnutrition and to reduce excess
mortality among those at-risk by providing a food/micronutrient supplement for all members of the
vulnerable group (e.g. children under five, people with HIV and AIDS, elderly and the chronically
ill).
Blanket SFPs may be set up under one or a combination of the following circumstances:
• At the onset of an emergency when general food distribution systems are not adequately in
place.
Section Seven
• Problems in delivering/distributing the general ration.
• When large numbers of mild and moderately acute malnourished individuals are likely to become
severe due to aggravating factors.
• Anticipated increase in rates of acute malnutrition due to seasonally induced epidemics.
• In case of micronutrient deficiency outbreaks, to provide micronutrient-rich food to the target
population.
Supplementary Feeding Programme: On-site Feeding

and Take-home Feeding
There are two ways to distribute food commodities during emergencies: on-site feeding (or wet
ration) and take-home (or dry ration). The ideal dry ration supplementary food provides 1000
to 1200Kcal; 35g to 45g of protein; and fat supplies 30% of required energy. On-site feeding
supplementary food provides 500 to 700Kcal per beneficiary per day; includes 15g to 25g of
protein; and fat supplies 30% of required energy.
Table 7.1 Take-home (or dry ration) versus on-site feeding (or wet ration)
Take-home or dry ration On-site feeding or wet ration

This is the preferred option: a regular (weekly or A daily distribution of cooked food/meals at a
bi-weekly) distribution of food in dry form that is health facility or feeding centre is one method of
prepared at home. Generally, the take-home or dry supplementary feeding. It is only considered for
ration option should be considered first as it requires extreme situations as it is time consuming and also
fewer resources and less hardship on the patients. undermines the family’s ability to take responsibility.
There is no evidence that on-site SFPs are more It may also create population movements into centres,
effective. which is not recommended. When it is conducted, the
number of meals provided varies, but usually two to
Other advantages of dry ration are: three meals are provided each day.
• Serves more patients. An on-site feeding may be justified when:
• There is less risk of cross-infection as malnourished
• Food supply in the household is extremely limited,
and sick children do not sit in close proximity while
increasing the risk that a moderately malnourished
feeding. patient’s take-home ration is distributed to all family
• It takes less time to establish (on-site feeding members (some sharing is to be expected).
programmes require setting-up and equipping • Firewood, water, and cooking utensils are in serious
centres). short supply making it almost impossible to prepare
• Is less time consuming for mothers who attend meals in the household.
every week or fortnight instead of daily. As a result, • The security situation is extremely serious and
the take-home option leads to better coverage and beneficiaries are at-risk of being looted when
lower default rates. returning home carrying weekly supplies of food.
• Keeps the feeding responsibility in the family.
• Dispersed populations do not have to travel long
distances to attend daily.
• The dry-ration option prevents displacement in
famine situations.
Therapeutic Feeding Programme

The therapeutic feeding programme deals with the management of severe acute malnourished
patients. In these guidelines, the management of severely acute malnourished patients has two
components, in-patient and outpatient therapeutic care. Detailed information is provided in Section
Two, three and four.
155
Requirements for Emergency Nutrition Intervention

Personnel
Several different staff positions are required to implement an emergency nutrition programme,
including managers and technical staff (doctors, nurses, nutritionists and health assistants). The
local aid worker must have the relevant technical qualifications, be fluent with the local language
and culture of the beneficiaries, and be familiar with the area’s geography. Some of the staff must
be trained prior to commencing an emergency nutrition intervention and have experience with the
Section Seven
different roles, responsibilities and procedures.

The following staff are needed on site:
• Overall programme manager.
• A supervisor may be required to oversee an implementation site.
• Community field workers: to conduct food distributions to affected population. Personnel hired
to support food distribution, cooking and other support tasks are recruited from among the
beneficiaries on a clearly defined cash- or food-for-work basis.
• Registry clerks and assistants (number hired will depend on the size of the operation).
• Store-keepers and food supervisors trained in food safety.
• Guards for guarding food stocks (security may be provided by the government).
• Community health workers (CHWs).
• Community volunteers.
• Village Health Committee members.
Supervision and Management

Quality, experienced supervision ensures effective programme implementation:
• Managers are accountable for decisions, ensuring adequate security and compliance to the
codes of conduct.
• Each member of the staff must have a written job description with clear reporting lines and a
periodic performance assessment.
• Staff must be provided with necessary training, resources, and logistical support in order to
fulfill their responsibilities.
• Staff must clearly understand the programme objectives and activities required and receive
subsequent feedback on their performance.
• Staff must be oriented on health and safety issues.
Office Space
An emergency nutrition response team requires an office with basic equipment: office furniture
(table and chairs); stationary; where possible a computer, photocopying machine and paper; registry
books; relevant documentation (national guidelines, population sizes, a map of the area or camp
with the livelihood zones, sectors and facilities); a chart or a blackboard indicating the number of
inhabitants in each sector; a clear and complete list of all personnel, equipment, transport; and
stock record book. The office should have a sheltered porch for waiting visitors, and is always be
locked after working hours. Security personnel can be provided to safe guard the equipment and
emergency supplies.
Supply Chain Management

Ration planning
Rations for general food distribution are planned according to the standard initial planning
requirements for energy, protein, fat and micronutrients for each individual or for the affected
community. The materials required for planning rations include spreadsheets and instructions
for calculating the nutritional content of a ration compared to the average bodily requirement.
The nutrition manger may also require a spreadsheet for calculating the tonnage of different
commodities required for the feeding centre. (See Appendix 7.4).
156
When determining the amounts of rations, make adjustments to suit the local situation. For
example, if the standard requirement is 2100kcal/person/day and an assessment shows that the
local population acquires 40% of kcal from local or personal resources, the ration should be
allocated to provide 2100kcal - 850kcal = 1250kcal/person/day.
Similar calculation are considered for protein and fat. The total amount of food required is based
on the ratio combination. In this case, the ration combination in Table 7.2 is best suited for the
programme beneficiaries.
Section Seven
Note: Food rations should be acceptable by the population and cost effective.
Table 7.2: Nutritive value of food commodities

Commodity Nutrition value Amount (g)
Energy (kcal) protein (g) fat (g)
Blended food (CSB) 950 22.5 15 250
Oil 220 - 25 25
Sugar 80 - - 20
Energy (Kcal) 1250
Protein (% of energy) 14.5
Sourcing and Procurement

In any emergency response, an assessment must be conducted to determine the local food supply,
its availability and reliability. It also must include the implications that an emergency programme
will have on local production and market systems before sourcing from outside. The programme
manager must try to tap into an existing supply system. This will save on time and resources.
Emergency supplies for selective feeding interventions are channeled through MOH and health
facilities. See Appendix 7.4 for guidelines to calculate supplies for feeding centres. The figure
below outlines the MOH supply system.
Figure 7.1: Flow chart outlining Kenya MoH supply system
District Nutrition
Officer
(Health Facility)
Nutrition 1. Reviews supply requests, Division of Nutrition

Programme compiles and forwards to (Headquarters)
Manager partner Reviews requests
2 In-charges of logistics and 2. Supply
(Implementing agency)
follow-up of supplies with Division of 3. Monitor supply
1. Compile monthly partners Nutrition distribution, by
supply requests 3. Coordinates and monitors (Provincial reviewing monthly
2. Forward to DNO distribution of supplies reports and give
4. Compiles district report
Office)
3. Compile monthly appropriate feedback
reports and forward to and disseminates to 4. make field visits
DNO and share with DSG, partners, provincial
district DSG and national nutrition
departments
157
Transportation2
Problems with transportation of foodstuff, which is bulky, is often the cause of bottle-necks
and delays in relief operations. Considerations include the following:
• Transporting the full dry ration (36,000 kg) for one week for 10,000 people requires 12
three-tonne trucks.
• A jeep or a minibus can carry about 500kg of food, plus a small team of personnel for
food distribution and surveillance; 500kg represents the daily general ration for 1,000
Section Seven
people (200 families) or the supplementary ration for 5,500 children.

• Transportation is also needed for supervisory personnel on a full-time basis.
• In bad weather conditions, at least one out of every ten vehicles will be immobilized at
any given time for maintenance or repair.
• Delays due to bad weather, poor roads, and vehicle breakdown are common.
Storage3
Bulky cereals (grain or flour) occupy the most space yet have a short shelf life. Careful
storage and handling can minimize waste. The following rules should be followed:
• The store should have a good roof and be dry, well ventilated, and as cool as possible.
Using modern buildings, where possible with concrete floor and walls, as warehouses
minimizes the problem of rodents, insects, etc.
• Products are kept at least 40cm away from the walls and 10cm off the floor. Bags must
lie on pallets, boards, heavy branches, bricks, or a layer of clean dry polyethylene bags or
tarpaulins – not directly on the floor.
• Damaged bags must be kept apart from the undamaged (possibly in a separate area); a
reserve of good empty bags should be kept so that goods from damaged bags can be
repacked.
• Bags should be stacked two by two (i.e. two bags in one direction, then two more on top
at 900 to the first two) to allow ventilation. They will also be stable and easier to count.
• Stacks should be no higher than two meters (2m). This makes handling easier and reduces
the risk of stacks falling.
• Each product is stored separately and has its own stock card.
• Access to the warehouse is limited to a few authorized individuals. The store must have
a lock that the storekeeper keeps and is responsible for.
• The balance on the stock cards should be checked periodically by counting the actual
number of items in the store.
• Stocks should be rotated on the basis of first-in, first-out. New deliveries are not to
be stacked on top or in front of old stock. Old stocks should be issued before new
supplies.
• Labourers are trained and supervised. This will reduce damage from careless handling.
Calculating storage space

There must be space allocated for ventilation and aisles for access: about 80% of a warehouse
floor space is for storage. In bags, 1 tonne (2205lbs or 1000kg) of cereals or processed
food occupies approximately two cubic meters (2m3). Thus one tonne of grain stacked two
meters high occupies 1 m2 of floor space.
Example: For 30 000 people using 400g of grain/person/day for 60 days:
30 000 x 400 x 60 = 720 000 000g = 720 tonnes
• The volume of this grain is 1440 m3.
• Stacked two meters high requires a surface of area of 720m2 + 20% access and
ventilation = 864m2.
• A building 43 m x 20 m would provide 860 m2.
• A building 50 m x 18 m would provide 900 m2.
2. WHO 2000. The Management of Nutrition in Major Emergencies

3. WHO 2000, The Management of Nutrition in Major Emergencies
158
Monitoring and Evaluation

In order to determine the actual performance of the nutrition relief programme, it is
recommended that a nutritional assessment is conducted at the end of the programme period
to determine the extent that nutritional problem has been reduced. An nutritional assessment
is generally the best way to determine the impact of the relief programme. However, care
should be taken while interpreting the results of nutritional assessment as programme
Section Seven
performance can be influenced by many other factors. The following set of indicators are
collected and used as a guide to determine the effectiveness of the programme:
• Recovery rate: the number of children successfully discharged in the previous month as
a proportion of the number of children registered at the beginning of that month.
• Attendance rate: the number of children who attend the programme as a proportion of
the number of children enrolled in programme.
• Default rate: the proportion of children who drop out of the SFP each month (i.e. did not
attend for two consecutive sessions).
• Mortality rate: the number of children who died after admission to the SFP.
• Coverage rate: the number of children enrolled in the SFP as a proportion of the estimated
number of the target group.
• Mean length of stay: the mean amount of time it takes a child to attain the discharge
weight.
See Appendix 7.5 for indicators of a successful nutrition programme.
Linking Nutrition Programmes with Other Interventions

Emergency nutrition interventions are more effective when a population is entirely dependent
on outside intervention for all basic needs and relief programmes are already in place. The
most effective and efficient care first ensures that potable water and general food needs
are met while rapidly establishing disease control measures such as measles vaccination
and adequate sanitation. Providing shelter and essential non-food items (water containers,
blankets and possible fuel sources for cooking) is the next priority. To ensure a smooth
operation and correct priorities, the various implementing agencies must coordinate their
work.
The emergency nutrition programme must be connected with the existing community health
services from the onset of the emergency. This will facilitate referral from the feeding centre
to the health services whenever a malnourished patient has medical complications. Also,
it may be more efficient to manage beneficiaries through the existing health structure if
the vulnerable population is small enough. For instance, in the absence of a relief nutrition
intervention, individual attention should always be given to malnourished children through
other community health services. See Section eight for detailed information on out-patient
nutrition care strategy.
159
Appendix 7.1: Stakeholders’ Roles in Emergency Response

Table 7.3: Stakeholders’ roles in emergency response
Agency Role
Ministry of Health • Technical support to implementing partner such as NGOs and CBOs
• Technical support in conducting nutritional and health assessments.
To ensure that critical health and nutrition needs are addressed
• Techincal support in nutrition and health education
Section Seven
• Provide staff, materials/equipment, food and drugs

• Monitor and evaluate emergency nutrition programmes
• Provide information for decision making and policy formulation
• Advocate for interventions in affected areas
• Coordinate health and nutrition interventions
ALRMP • Coordinate emergency preparedness and response activities in arid
and semi arid areas
• Identify key response areas
• Avail information for decision making
UN-agencies Support GOK coordination and response to emergencies through
1. Technical and financial support to government departments and
implementing partners for emergency preparedness and response
NGOs/CBOs Support GOK in responding to emergencies through;
2. Provision of technical and logistical support to existing
infrastructures
3. Set-up and implementing emergency interventions programmes
4. Conduct health and nutrition assessment and share information
5. Support coordination structures, at national and sub-national
levels
Other Government Departments Provide other humanitarian services such as:
• Provide water and sanitation
• Shelter and clothing
• Education for school children
160
Appendix 7.2: Coordination Structure

Figure 7.2: Coordination Structure
Section Seven
National Food Security Executive Committee
Chaired by the Head of State
National Food Security Coordinating Committee

Chaired by Head of Public Service
Kenya Food Security Meeting (KFSM)
Sector working groups
Disaster Management
Sub-committees:
Nutrition Technical
Health and Nutrition
Data and Information Forum
DISK
Kenya Food Security
Steering Group Education
(KFSSG)
Food Aid
Agriculture and Livestock
Water and Sanitation
District Sectoral
District Steering Group
Working Groups
Community
161
Appendix 7.3: Determining Number of Beneficiaries
Determining number of beneficiaries for admission in a targeted SFP

Based on the findings of a nutritional assessment, the population of a targeted SFP can be
estimated as follows:
Population of vulnerable group x moderate acute malnutrition rates = total number of
malnourished group
Section Seven
Example: In order to determine the number of moderately malnourished children 6-59 months
who can be admitted in a targeted SFP programme in district X, the targeted population can
be estimated as:
• Total population of district X= 200,000
• Population aged 6-59 months (20% of total population) = 40,000
• Prevalence of moderate acute malnutrition (z-scores)= 10%
Estimated number of moderately malnourished children is 40,000 x 10%= 4,000
If the programme plans to attain 80% coverage, then the estimated number of beneficiaries
to be registered in the programme will be; 4,000 x 80%= 3,200
Determining number of beneficiaries for admission in a blanket SFP

• All children younger than five years old are used as as a cut-off point. Population size of
children under five years can be estimated as 20% of the total population in the target
area.
• All pregnant women from the time of confirmed pregnancy, and lactating mothers until
maximum six months after delivery. Population size can be estimated as 6% of total
population in the target area.
• All adults showing signs of acute malnutrition.
• All the elderly and the chronically sick.
The population figures can be obtained from the district statistic office, district medical
officer and district arid lands resource management project offices.
162
Appendix 7.4: Supply Procurement

How to calculate food and drugs for procurement
While calculating the actual amount of food and drugs required, it should be noted that:
1. Additional estimates need to be made for carers and added in the total request.
2. The list should not be used as a reference document for drugs.
3. Each month, the number of children should be adjusted accordingly.
Section Seven
4. The total amount of food required is calculated as follows:
Quantity per person per day x No. of beneficiaries to be covered x expected duration
in days = Total supplies
5. Care should be taken that the total supplies are presented in metric tones.
6. The tables below give examples of therapeutic and supplementary feeding calculation.
These spread sheets work best in an excel programme, but in the absence of a computer
software, a calculator will be handy. The final request sheet should be a summary of each
food item.
Table 7.4: Supplementary feeding estimates: commodity requirement

Food Commodity kcal/100g Quantity Number Expected Total kcal Total
(g)/ of Duration /person/ Quantity
person/ Children of Stay day Procured
day Covered (days) (MT)
Unimix 400 230 500 60 920 6.9
Oil 900 28 500 60 252 0.8
Sugar 400 28 500 60 112 0.8
Table 7.5: In-patient centres: formula requirement

Commodity Kg/litre Formula Number of Days/Child on Sub-total
Children Formula Quantity
Admitted in Required (MT)
Programme
F75 0.205 100 5 0.13
F100 0.228 100 25.00 1.14
Table 7.6: In-patient centres: starter formula - high energy milk (using DSM, oil and sugar)
Commodity Kg/litre formula Number of Days/child on Sub-total
Children Starter Formula Quantity
Admitted in Required (kg)
Programme
DSM 0.025 200 5 25.00
Sugar 0.100 200 5 100.00
Oil 0.027 200 5 27.00
CMV 0.003 200 5 3.30
Table 7.7: In-patient centre: catch up formula - High energy milk

Commodity Kg/litre formula Number of Days/child Sub-total
Children on Catch-up Quantity
Admitted in Formula Required (kg)
Programme
DSM 0.080 200 25 800.00
Sugar 0.050 200 25 500.00
Oil 0.060 200 25 600.00
CMV 0.003 200 25 33.00
163
Table 7.8: In-patient centre: semi-solid feeds

Commodity Kg/litre formula Number of Days/Child on Sub-total
Children Solid Meal Quantity
Admitted in Required (kg)
Programme
Sugar 0.020 200 20 0.08
Oil 0.030 200 20 0.12

Section Seven
UNIMIX 0.100 200 20 0.40
Table 7.9: RTUF requirements, estimated for a 10kg child

Commodity Quantity per day One Month
Plumpy’nut Per 10kg child 3 sachets (1 sachet = 92g) 90 sachets I carton = 150 sachets
BP - 100 per 10kg child 7 bars 210 bars. 1 carton = 216 bars
Table 7.10: Estimates for common drugs used in supplementary feeding centres
Please note that this list of drugs is not exhaustive and may vary depending on the nature of complication.
Drug Unit Size Units pd Days of Estimated No. of Total Units

pc (10kg Treatment Proportion Children Procured
child) of Treated
Children
ORS sachet per 1000ml 1.00 3 0.30 500 450
Mebendazole 100mg tab 2.00 3 1.00 500 3000
Vitamin A 200,000 IU 1.00 1 0.80 500 400
Vitamin A 100,000 IU 1.00 1 0.20 500 100
Benzyl benzoate 25% 1 litre bottle 0.01 2 0.50 500 5
Tetracycline eye 1% 5g tube 0.20 5 0.30 500 150

ointment
Paracetamol 100mg tab 8 2 0.25 500 2000
Measles vaccine plus equipment 1.00 1.00 1.00 500 500
* malaria treatments should be according to national protocols

** syrups require a source of clean bottles for dispensing to out patients
164
MOH STOCK POSITION: WAREHOUSE
Table 7.11: Stock balance sheets (sample)

MOH STOCK POSITION: WAREHOUSE
Reporting period:
OPENING STOCK IN OUT
Quantity Date of WR Quantity Release Date
Description Unit Bal. received receipt location released order # out Destination Bal.
Section Seven
Stock balance sheet (sample)
District: Name of health facility or implementing partner:
Reporting Month. Total Number of beneficiaries :
Type of Selective Commodity Opening Receipts Distributed Losses Closing Closing
Feeding Programme Type Stock Stock Stock (in
(Kg) MT)
165
Appendix 7.5: Performance Indicators for Nutrition

Interventions
Table 7.12: Performence indicators for nutrition interventions
Key indicator Target levels
Coverage rate >50% in rural, >70% in urban and >90% in camp
Section Seven
situation
Distribution of SFP centres More than 90% of target population is within <1 days
return walk (including time for treatment) of distribution
centre for dry ration and not more than 1 hour for wet
feeding
Mortality rate <3% of individuals in programme have died
Recovery rate >75% of those admitted have recovered and

successfully been discharged from programme
Defaulter rate < 15 defaulted in the programme
Mean weight gain 5 and 10gm per kg of their body weight per day.
166
Section Eight
Section Eight:
Community Mobilization
Overview
Community Nutrition Care refers to the nutritional support and care for out-patient severely
malnourished patients, moderately malnourished patients and those at-risk. Nutrition support
is managed by the patient’s household members, community members and Community
Health Workers (CHWs). Household members are in general actively involved in preventive
and promotive health care. They also often manage the clinical care of the critically and
chronically ill. It is therefore essential to work with households, to give household members
a chance to influence how care is delivered and to regain the people’s confidence in a
given health system. To ensure nutrition care at community level, it is important to focus
on enhancing household capacity and to have discussions that enable household members
make informed decisions both for health and for nutritional needs.
MOH is at the forefront of the effort to ensure that the community is actively involved in
preventive and promotive health care, clearly stipulated in the National Health Sector Strategic
Plan (NHSSP II) 2005-2010. The NHSSP II has the mandate to scale up community-based
interventions and link with the referral systems. One objective of NHSSP II is to involve
communities in addressing downward spiral of determining health status. Since NHSSP II
applies a broader approach in service delivery, the Kenya Essential Package of Health (KEPH)
was initiated to represent the integration of all health programmes into a single package that
focuses its intervention towards improving health at different phases of human cycle such
as age groups and levels of care (see Figure 8.1)1. Essential packages that specifically target
the communities are referred to as Community-Based Kenya Essential Package for Health
(CB-KEPH)
1. National Health Sector Strategic Plan (NHSSP II) 2005-2010 policy paper
167
Figure 8.1: Levels of care in the Kenya Essential Package of Health (KEPH)
6
Tertiary
hospitals
Inpatient
5 Management of severe acute malnutrition
Secondary hospitals
4
Primary hospitals
Section Eight
3
Health centres, maternities, nursing homes
Management of moderate and at-risk
2
malnourished patients,
Dispensaries, clinics
Outpatient therapeutic care, referal of
severe malnourished patients to
level 4,5 and 6
INTERFACE
1 Screening, Out-patient therapeutic care,

Communities, villages, households, families, individuals nutrition counselling, case
finding and follow-up.
The foundation of service delivery is the community level (Figure 8.1, level one). The
community defines its own priorities, and services are provided based on the priorities which
creates ownership and commitment. A Village Health Committee (VHC) is a community
structure essential to the process. Households and individuals participate in the VHC and
contribute to their own health and that of their village. Figure 8.2 shows the community
representation at the health facility and how they link. Community representatives relay
health- and nutrition-related issues affecting the community to the health facility management
committee. Information from the health facility is then channelled back to the community.
Figure 8.2: Community representation and linkage at the health facility
HEALTH
FACILITY Chief or DO, Technical
officer incharge,
nuturitionist
comminuty
representatives.
Community representative
(VHC–Chairman, CHW)
Village Health Committee (VHC)

(Sub-chiefs, CHW, Community Volunteer, Village elder, TBAs,
Religious leaders)
168
Community Mobilization
“Community mobilization”2 is a term used to cover a range of activities that, in this case,
help nutrition programme implementers (i.e. nutritionists, managers and health workers) build
a relationship with the community and foster people in the community to use the nutrition
programme. In turn, community mobilization helps health workers better understand the
affected communities they’re working in. It is central to the success of the management of
malnutrition.
Section Eight
In essence, the goals of community mobilization are to:
• Provide a link for the community and the existing health facilities
• Create awareness on the treatment of malnutrition
• Provide early detection for and treatment of malnourished individuals
• Promote community participation
There are two phases and five essential steps in conducting community mobilization. See
Figure 8.3 for an overview of the community mobilization process. The planning phase
involves the assessment of community capacity to determine gaps and levels of participation.
The implementation phase is the actual community participation; the implementation of the
nutritional support and care programme; and sensitizing the community members on the
importance of nutrition.
Figure 8.3: Processes of community mobilization

Planning Phase Implementation phase
Assessing
Community Ongoing
community Case finding Follow-up
sensitization sensitization
capacity
Step 1: Assess community capacity

To assess the community’s capacity, first identify the community representatives and
community groups and organizations that will help to: inform communities about nutrition
and malnutrition; identify and screen malnourished individuals; and conduct treatment and
case follow-up.
Establish the formal and informal channels of communication in the area. The informal (e.g.
market places, women gathering at water points, ceremonies such as weddings, funerals,
etc.) and formal (e.g. posters, megaphones, community meetings such as the local chief’s
baraza) are good venues for health workers to share information and to open up dialogue
with the community members.
Table 8.1: Key community representatives

Groups Key representatives
Administrative Leaders Councillors, chiefs, sub-chiefs and village elders
Community workers from Village health volunteers, Community Health Workers (CHW), community
the MoH and other other vaccinators, agricultural extension workers and social workers
government departments
Religious leaders Priests, pastors, sheikhs/Imam and traditionalists
Traditional health practitioners Traditional Birth Attendants (TBAs), traditional healers/herbalists
Community groups and Women groups, relief committees, youth groups, adult literacy schools
organisations (Subaru) and school teachers/children
2. Valid International 2006, Community-based Therapeutic Care (CTC), A Field Manual. Oxford, UK
169
Step 2: Community sensitization

Community sensitization is a way to reach out to people in the community and teach the
causes, signs and symptoms of malnutrition, and teach how to seek treatment opportunities.
Community sensitization is summarized in three steps:
1. Plan messages that are simple and explicit in local terms on the following:
• What is malnutrition? What are the signs of malnutrition?
Section Eight
• Available treatment services and methods used for treatment.

• Access points for the treatment services.
• Those who benefit from the treatment of malnutrition.
2. Make a sensitization plan

Decide who to inform, and how to best get the information out. Always share and discuss
the information messages with a few community figures first to make sure the messages are
culturally appropriate and inoffensive.
3. Disseminate the messages

• Sensitize the community representatives, groups and organizations through the most
effective communication channels identified.
• Use pictures of malnourished children to strengthen the messages. Pictures for Marasmic
and Kwashiorkor will assist communicating the messages better.
Step 3: Case finding

CHWs and community volunteers will screen and identify malnourished individuals based on
MUAC measurement and the presence of nutritional oedema. Screening takes two different
forms:
Mass screening
CHWs at the health facility or in the village screen vulnerable groups in the population (i.e.
children under five years, pregnant and lactating mothers, the chronically ill and the elderly).
Often, the sick and vulnerable may not attend the mass event and remain in the house. It is
important to find out during the screening if people know of thin or sick individuals in their
locality (use pictures or posters and local terms to ensure understanding).
Active Case Finding

CHWs screen at the households and the health facility, actively seeking out sick and
malnourished individuals. Consultation with community groups (see Table 7.1) will help
identify the vulnerable households and narrow and expedite the search.
Table 8.2: Referral criteria for malnourished persons and the relevant actions
MUAC CATEGORY ACTION
<11.5cm for children Severe malnutrition Refer urgently to health facility for immediate
<18cm for adults assistance.
11.5 to <12.4cm for children Moderate malnutrition Refer to health facility where services for
18 to 21cm for adults management at risk and moderate malnutrition
are available.
<21cms for P/L women
170
Step 4: Follow-up
CHWs conduct home visits on a regular basis. Home visits focus on households where
children or adults:
• Are not recovering
• Have deteriorating medical conditions
• Are not responding to the treatment, should be admitted for inpatient care
• Are not presenting for follow-up visits at the health facility
• Need constant monitoring of new practices taught during nutrition counselling sessions
Section Eight
It’s sometimes easier during a home visit to gently inquire the reasons why a patient has
defaulted or is showing poor response. It’s also an opportunity to encourage a patient to
return to treatment or to provide support to the caregivers to ensure recovery.
Home visits are done with a standard checklist (see Appendix 8.1) which will ensure that
key areas of follow-up are covered.
Step 5: On-going sensitization

Community sensitization is an on-going process. Community members, by attending meetings,
can regularly voice their views and suggest alternative courses for action. The Community
Own Resource Persons (CORPS) and other community workers maintain regular contact with
the community to identify problems and work together to provide timely solutions. A regular
means of maintaining contact with the community should be established as soon as the
programme becomes operational. During design stage, information collected on appropriate
channels, individuals and forums in which to conduct this dialogue can be useful to the
process.
171
Appendix 8.1: Home Visit Checklist

The following are issues to focus on during a home visit.
Feeding
• Is the Premix/RUTF eaten only by the sick child?
• Is food other than Premix/RUTF given to the sick child? If yes, what food?
• Is Premix/RUTF finished before other food is given?
• How is the child given the Premix/RUTF? (eg. mixed with other food, with water)
Section Eight
• How much Premix/RUTF does the child eat each day?

• How many times per day is the sick child given food/RUTF to eat?
• Does anyone encourage/help the sick child to eat?
• What does the parent/caregiver do if the sick child does not want to eat?
• Observe child eating one meal of Premix/RUTF.
Caring
• Does the parent/caregiver feel that their child is improving? If not, why not?
• Have they visited the traditional healer to help this child?
• Who cares for the sick child during the day?
• Is the sick child clean?
• Is anyone in the household sick or has anyone recently died? How does this affect the
caring of the child?
• Any other household circumstances that affect the caring of the child?
Health
• What is the households main source of water?
• Do they use soap in the household?
• Does the parent or caregiver and the sick child wash hands and face before feeding?
• Is Premix/RUTF, other food and water covered and free from flies?
• Does the parent or caregiver know what causes diarrhoea?
• What action does the parent or caregiver take when the sick child suffers from diarrhoea?
(include any action involving foods, medicines, fluids)
• If any medicines have been prescribed, are they being given correctly?
• If there is a particular medical problem that has been identified by the out-patient care
team, how is the child progressing? Is there a need for an extra clinic visit?
• Observation of diarrhoea or vomiting.
Food Security
• What is the most important source of food for the household?
• What is the most important source of income for the household?
• Is the family currently receiving General Ration? and for how many people?
172
Section Nine
Section Nine:
Nutrition Information,
Education and Communication
Overview
Information, education and communication about nutrition are the means to help people
maximize their use of food and health resources and adapt to a changing environment.
Section Nine is a framework for Community Health Workers (CHWs) to use to deliver
nutrition-related information in a consistent way that will reduce cases of malnutrition.
For success in this endeavor, the community must be involved and understand the causes
of malnutrition in their situation so they are more open to change negative food-related
behaviour.
Behaviour change depends on many factors. A successful nutrition education endeavour
will:
• Consider the motivation of the people being reached.
• Recognize that people have strong and established beliefs about their food and will not
assume that a community is a “blank slate” on which new ideas are written.
• Be based on a participatory assessment and analysis of the nutrition problem, and a
carefully thought-out plan of action.
• Rely on observed behavioural practices, not on anecdotal evidence.
• Target a specific group and communicate a clear message.
Approach to Nutrition Education

Figure 9.1: Steps to conduct a nutrition education session
2. Prioritize the 3. Identify the 4. Build consensus about the 5. Select relevant
problem target group problem with community nutrition notes
1. Identify the
problems 7. Assess and select
8. Evaluate 6. Identify blocks
appropriate communication
your work. (e.g lack of
channel of communication:
(What was resources,
(demonstration, songs,
useful, new?) beliefs)
poem, and counselling)
173
Health promotion and health education activities rely on a variety of well-designed and
effective information, education and communication (IEC) materials. IEC materials, including
training materials, are provided at clinics to community-based workers and supervisors. IEC
materials are most useful to health workers when there is proper training and follow-up
on how to use them. Every brochure, poster, videotape or other piece of IEC material is
supported by research, to deal with a specific health concern, and to be well-received and
persuasive among a specific audience.
Section Nine
Channels of Communication
There are two main methods to communicate nutritional messages: face-to-face and with
mass media. In many successful approaches, a combination of methods is applied. Harnessing
skills of different personnel and special training of local personnel may be necessary. The
knowledge and skills of local personnel or influential community members involved in nutrition
IEC will be a major factor in determining the method and success of the interventions
Face-to-face/Interpersonal Communication
Interpersonal communication, counselling and discussion about nutrition and health related
issues is useful to reach individuals who have specific nutrition-related problems (e.g.
parents with malnourished children) and also for reaching sub-groups. Such communication
is enriched by the use of printed materials (wall charts, flip charts, brochures and posters)
and practical demonstrations.
Mass Media Communication

Mass media communication can be successful for public information campaigns. It uses all
types of media (for example radio and print) to address a single problem or behaviour, and
to communicate a single message clearly and in a positive way. Messages can be relayed
though popular media such as storytelling, participatory theatre, puppet theatre, song and
dance. These forms combine entertainment with education.
Guidelines on Key Nutrition Information

Many packages and guidelines have been developed to assist in IEC. The following are
recommended:
The “Essential Nutrition Actions Package” developed by the MoH and UNICEF covers the
following:
1. Optimal breastfeeding;
2. Optimal complementary feeding;
3. Feeding sick and/or malnourished children;
4. Maternal nutrition;
5. Control of anaemia; and
6. Control of iodine deficiency.
Other packages cover subjects such as vitamin A supplementation, growth monitoring,
immunization, hygiene and sanitation and de-worming.
For each of the above essential nutrition actions, there are either guidelines, policies or
protocols that are used for nutrition counselling at different points of contact with individuals
or groups.
Other resources on nutrition counselling and education are available at the Ministry of Health,
Department of Child Health, Division of Nutrition;
• Integrated Management of Childhood Illness (IMCI) National Guidelines
• Health Worker Guidelines on Infant Young Child Feeding
• Policy on Infant Young Child Feeding
• Health worker guidelines on the code for marketing of breast milk substitutes
174
• Summary of Kenyan code for marketing of Breast Milk substitute

• FAQ on breastfeeding/Maternal nutrition
• Guidelines on implementation on Baby Friendly Hospital initiative (BFHI)
• Kenyan National Guidelines on Nutrition and HIV and AIDS
• Kenyan National Curriculum on Nutrition and HIV and AIDS
• Nutrition counselling cards for nutritional care for support for PLWHA
• MOH Community strategy to deliver KEPH at level one
Section Nine
See Appendix 9.1 for a summary of key messages and action points.
Nutrition Subjects and Message Content

Infant and Young Child Feeding
Information covers appropriate feeding practices for infants less than six months; adequate
dietary intake during introduction of complementary feeding at six months; the prevention
and care of infections; and reasons to be attentive to the care of a child.
Optimal Breastfeeding
The best and safest method to feed infants for the first six months of life is exclusive
breastfeeding. Exclusive breastfeeding means giving an infant no other food or drink, not
even water, apart from breast milk (including expressed breast milk), with the exception of
drops or syrups consisting of vitamins, mineral supplements or medicines. During pregnancy
expectant mothers are to be counselled on infant feeding options, irrespective of HIV status.
There are national job aids, counselling cards and IEC tools to support counselling on infant
feeding and HIV.
Message content
Step 1: Counsel all expectant mothers on:
• Information on benefits of breastfeeding
• Prevention and management of breastfeeding problems
• Appropriate complementary feeding
• Good maternal nutrition and self-care
• Child spacing
• Prompt treatment of infections
• Reduction of risk of HIV infections
• Information on counselling and HIV testing
• Reinforcing risk reduction to couples
Step 2: Provide counselling and encourage testing for mothers in areas where HIV prevalence
is high:
• Reinforce reduction of the risk of HIV transmission (national counselling cards and IEC
materials available for infant feeding and HIV).
• Reinforce risk reduction to couples
Optimal Complementary Feeding

After six months, breast milk and other forms of milk alone are not adequate to meet the
infant’s nutritional requirements. Complementary foods are introduced after six months with
continued breastfeeding or replacement feeding until a nutritionally adequate diet can be
sustained without breast milk. Abrupt cessation of breast feeding is discouraged to avoid
undue traumatic effects on both the mother and the infant. Milk continues as an important
component of the diet, providing up to half or more of the nutritional requirements for
children between 6-12 months old, and up to one third of the requirements for children aged
12-24 months.
175
Message content
• When to start complementary feeding
• What food to give and when
• How to prepare complementary foods hygienically
• Food variation to ensure nutrition adequacy
Immunization and De-worming

Section Nine
Immunization
Vaccines are available for certain major infectious childhood diseases including measles,
poliomyelitis, tuberculosis, diphtheria, tetanus, whooping cough (pertussis), mumps and
rubella. Education on immunization is essential to avoid outbreaks of these diseases that
could be fatal or cause complications such as blindness, partial paralysis and stunting.
Message content
• Importance of immunization
• Barriers to immunization
• Overcoming barriers to immunization
• Access to immunization services (lobbying for improved access)
• Making immunization safe (i.e. check expiry date, use disposable needles, sterilize syringes,
use of trained personnel)
De-worming
Intestinal parasitic infections are a major cause of anaemia among children, pregnant and
lactating mothers. In communities where these parasites are endemic, education on treatment
and prevention measures is useful.
Message content
• Types of helminthes
• Causes and consequences
• Symptoms and signs
• Care, prevention and treatment
Growth Monitoring and Promotion

Growth monitoring is to periodically measure the weight and height of a child to assure
adequate growth. Growth monitoring is also useful for targeting resources, in that resources
are allocated to improve health and nutritional status of identified malnourished patients;
increase participation of patients; mobilize communities; and track progress in reducing
malnutrition. Growth promotion is motivates caregivers, families, communities and health
workers to practice behaviour that supports adequate growth (height and weight gain) in
young children.
Message content
Growth monitoring
• Monitoring weight beginning from birth
• Involvement of caretakers in monitoring
• Adequate weigh gain rather than nutritional status as an indicator of action
• Use of growth chart to record child’s growth process
• Interpretation of information in a child’s growth chart
• Analysis of the causes of inadequate growth leading to feasible options for action
• Guidelines on how to monitor growth.
176
Growth promotion
• Adequate pre-conception and prenatal nutrition for mothers
• Exclusive breastfeeding for the first six months
• Appropriate complementary feeding with continued breastfeeding for 24 months
• Adequate nutritional care during illness and severe malnutrition
• Adequate micronutrient intake
Protein and Energy Malnutrition (PEM)
Section Nine
Protein-Energy Malnutrition is a general terminology that refers to deficiencies of protein
and energy in the body. Two types of PEM are kwashiorkor and marasmus. PEM is a major
health problem that affects children between six months and five years. It is a cause, directly
or indirectly, of death. Health workers and community members require information on
management of PEM to be able to counsel caregivers adequately.
Message content
• Basic understanding of the forms of PEM
• Causes and consequences
• Symptoms and signs
• Care prevention and treatment
• Alternative supplementary food for the malnourished individuals
Hygiene and Sanitation

Poor hygiene and a unsanitary environment contribute to malnutrition. Information on
hygiene and sanitation helps a community and health workers decide on the best and most
appropriate interventions for their community health problems.
Message content
General health
• Factors that influence health with focus on environment, awareness of health issues,
personal hygiene and health care
• Identifying health problems and establishing priorities through assessing community
perceptions about health and
• Identifying causes of health problems and possible solutions
Food handling and storage

• Food safety during preparation and cooking
• Food storage
• Care for kitchen utensils and cooking surfaces
• Proper child feeding practices and care
Water
• Water sources
• Household water treatment
• Safe handling of water
• Monitoring of water quality
• Managing community water resources
Message content
• Disposal of waste
• Problems caused by poor drainage
• Methods of improving drainage
• Solid waste management and chemical safety
• Personal, domestic and community hygiene
• assessing hygiene practices
177
Micronutrient Deficiencies
Micronutrient deficiencies cause permanent or long-lasting disability, and often increase risk
of morbidity and mortality.
• Basic understanding of the major nutrients: Vitamin A, Iron, Iodine, Zinc, Folic Acid and
Vitamin C.
• Micronutrient deficiency disorders:
Types
Causes
Section Nine
Clinical manifestation
Care, prevention and treatment
Nutrition Counselling
Nutrition counselling is integral to the management of acute malnutrition. It is essential
at discharge for acutely malnourished individuals who are managed at home by family
members or those discharged from facility-based programmes. Caregivers must know the
proper feeding practices at home to avoid patient relapse or deterioration in nutrition status.
Alongside counselling, follow-ups by the health workers are conducted to ensure that the
malnourished individuals are adequately cared for.
CHWs may not be able to follow-up each child, however, owing to limited staff capacity and
distance. This, therefore, calls for thorough understanding by the family members on the
need for proper care and nutritional support of malnourished or discharged individuals. Table
8.1 is a summary on proper feeding of malnourished individuals, focusing on children less
than five years old and pregnant and lactating mothers.
Table 9.1: General guidance on counselling

Who does the nutrition Nutritionists, nurses, clinicians, Community Health Workers
(CHWs) and extension workers
counselling?
When to do the nutrition During management, discharge, and follow-up of malnourished

individuals
counselling
Who are the clients? • Parent or caregiver of child

• Community groups
• Pregnant and lactating mothers
• Adults who are malnourished or chronically ill
Materials and methods • Depending on the topic, use national MoH guidelines such as the
IMCI, guidelines on IYCF, Nutrition and HIV and AIDS
• Draw examples from local events and materials
• Use simple language that is easily understood
• Use pictures and posters to explain symptoms
178
Monitoring and Evaluation of Nutrition Education

Programmes
Monitoring a nutrition education programme is essential to determine its progress towards
achieving the set objectives. Qualitative data can be collected continually to determine its
appropriateness, effectiveness and the coverage of nutrition education programmes. At
the onset of the programme the implementers should develop a monitoring and evaluation
plan. The plan should be well understood by information collectors and be specific to the
Section Nine
programme. Examples of monitoring indicators are:
• Number of trainings conducted
• Number of programme supervisors and managers trained
• Number of community groups/individuals trained
• Number of peer educators trained
• Number of active peer educators
• Number of “trainers of trainers” trained
• Number of BCC materials developed
It is also important that the monitoring and evaluation plan schedules the evaluation, and sets
out the methodology, resources and the type of indicators. Often an evaluation will address
two main question: Are the results those that were intended? And, are they of value?
The following indicators are considered.
• The impact of the programme in terms of behavioural change. For example, the increase
in the number of mothers exclusively breastfeeding
• The efficient use of resources and management of programme
• Cost effectiveness of the programme
• Programme coverage (e.g. number of specific groups a message reaches of those
targeted)
All information obtained is shared with all stakeholders to improve practices, scale-up
interventions, revise guidelines and inform policy.
179
Appendix 9.1: Nutrition Messages

Topic Key messages/ action points
Optimal breastfeeding • Timely initiation of breastfeeding (within one hour of delivery)
and giving of colostrum.
• Importance of continuing to breastfeed for at least two years.
• Importance of ensuring proper hygiene in food preparation
and feeding.
Section Nine
• Give appropriate information to mothers to support exclusive

and continued breastfeeding.
• Children 0-6 months should be exclusively breastfed: No
feeds (including water) other than breast milk only
• Breastfeeding should be on demand (as long as the infant
wants).
• Encourage breastfeeding during illness. If child is not able to
breast feed, encourage expression of breast milk and feed by
cup.
Optimal complementary • Encourage continued breastfeeding beyond 6 months
feeding together with appropriate complementary feeding.
• Explain body building, energy giving, and protective foods.
Body building foods responsible for building and repairing our
body (e.g. Meat, beans, milk eggs).
• Explain energy giving foods provide energy to our body to
enable us to carry out daily activities like, working, thinking,
running, playing etc (sorghum, maize, oil,).
• Explain protective foods enable the body to protect against
infection and fight diseases (e.g. Green vegetables, Mangoes,
Carrots).
• Encourage increased fluid intake, including breastfeeding, day
and night for children with diarrhea or vomiting.
• Discourage withholding of feeds during illness and instead
encourage intake of small frequent enriched feeds daily or
give an extra meal above child ’ s usual daily feeds.
• Encourage mothers to bring all their children below 5 years
old to the nearest health facility for growth monitoring
monthly as well as for vitamin A supplementation every 6
months.
• Feeding of the sick and or malnourished children
• If the child is still breastfeeding, encouraged mother to
continue.
• The child at this stage requires: 1. High energy intake (150
-200 kcal/kg body weight) 2. Sufficient protein 4-5g/kg body
weight/day 3. Micronutrients especially potassium, iron, zinc
and vitamins
• The feeds must be easy to eat and digest.
• To achieve high energy intakes: 1. feed the child frequently,
at least six times a day 2. Add oil, honey, margarine, butter,
sugar 3. Use fat rich foods like groundnuts, avocado, un-
diluted buffalo milk, sheep’s milk.
• To achieve high protein intakes: Use milk, or locally available
stable mixed with legumes, meat or fish
180
Maternal nutrition • Take the weight (in kg) of all pregnant women and record it
on the maternal clinic card.
• Counsel mothers on appropriate diet for pregnant women
using locally available foods.
• Encourage consumption of a balanced diet rich in vitamins
and minerals.
• Emphasize on use of iodised salt.
• Encourage mother to ensure that all children aged five years
Section Nine
and below and pregnant women sleep under insecticide
treated mosquito nets, for preventing anemia because malaria
is often a major underlying factor.
• Counsel mothers on diet during lactation emphasizing
importance of extra food while lactating using list of locally
affordable foods.
Vitamin A Children
supplementation • All children aged 6 to 59 months need a vitamin A capsule
every 6 months.
• Vitamin A supplementation is safe for children and protects
them from diseases such as diarrhea, acute respiratory
infections and also reduces deaths.
• Children should be fed as often as possible with vitamin A
rich foods (mangoes, green leafy vegetables, wild red and
orange fruits, egg York, liver, milk, etc.)
• Children sick with measles, certain eye problems, severe
diarrhoea or severe malnutrition should visit health centres
because they may need additional Vitamin A according to the
treatment schedule.
Mothers
• Give mothers a dose of 200,000 IU of vitamin A if baby is 8
weeks old or less.
• Ensure that the capsule is swallowed on site.
• Encourage the mother to consume a balanced diet using
locally available foods and a variety of foods rich in vitamin
A such as liver, eggs, oranges, yellow sweet potatoes,
pumpkins, dark green leafy vegetables.
• Record in register mother who have received high dose
vitamin A supplementation. Also indicate in Child Card that
mother has been supplemented with vitamin A.
181
Iron and folate Children

• Give one dose at 6 mg/kg of iron daily for 14 days.
• Avoid iron in a child known to suffer from sickle cell anemia
• Avoid folate until 2 weeks after child has completed the dose
of sulfa based drugs
Mothers
• Give all pregnant women a standard dose of 200mg iron
(Feso4) tablets three times a day + 5 mg folate once daily.
Section Nine
• Promote use of anti-malarial interventions such as bednets

for preventing anaemia because malaria is often a major
underlying factor.
• Provide advice on food items and medicines that should not
be taken together with iron supplements since they may
inhibit absorption such as milk, antacids, tea, coffee.
• Treat anemia with treatment doses of iron for 3 months.
• Refer severe cases of anaemia to the nearest higher level of
care if they are in the last month of pregnancy, have signs of
respiratory distress or cardiac abnormalities such as oedema.
• Provide advice on a balanced diet and emphasize on
consumption of iron rich foods such as liver, red meats, eggs,
fish, whole-grain bread, legumes and iron fortified foods.
• Promote consumption of vitamin C rich foods such as
oranges, green vegetables, as they enhance the absorption of
iron.
Hygiene and sanitation • Store uncooked food in a safe dry place
• Protect food from insects, rodents and other animals
• Avoid contact between raw food stuffs and cooked food
• Keep areas where children are fed or play free from human
and animal faeces
• Keep all food preparation premises clean
• Wash hands before preparing food for feeding children
• Wash cooking utensils Wash fruits and vegetables
• Use clean water Cook food thoroughly
• Avoid storing cooked food, instead, prepare food often If
cooked food is saved, keep it as cool as possible If previously
food is to be eaten reheat it thoroughly before eating
• Wash the child ’ s hands before feeding
• Use open feeding cups
• Feed actively, that is supervise the child and continue
offering food until the child has enough
De-worming •Give 500mg mebendazole or 400mg albendazole as a single
dose in clinic if the child is 2 years of age or older and if the
child has not had any in the previous 6 months
Growth monitoring • Children aged 0-2 years need to be weighed every month.
• Children 0-59 months need to be weighed often enough to
determine if they are growing adequately.
• When children come for weighing , also check for their
immunization and vitamin A supplementation status
• Children whose growths are faltering are at high risk and
should be monitored closely by health facility staff.
182
MINISTRY OF
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IMAM Guideline Kenya June09

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MINISTRY OF

PUBLIC HEALTH & SANITATION

National Guideline for

Version 1: June 2009

Dr. Francis Kimani Dr. S.K. Sharif OGW, MBChB, M.Med.

Section One: Overview of Malnutrition 4

Section Two: In-patient Management of Severe Acute Malnutrition

Phase One Treatment 52

Appendix 2.1: Multi-Chart 79

Section Four: Out-Patient Therapeutic Care for Severe Acute Malnutrition

Appendix 4.1: RUTF Specification 107

Section Five: Management of Moderate Acute Malnutrition 116

Section Six: Management of Malnutrition for Children in the Context 133

Clinical Guidelines for an Integrated Approach to the Nutritional Care

Appendix 6.1: HIV and Infant Feeding 146

Section Seven: Emergency Nutrition Response 151

Appendix 7.1: Stakeholders’ Roles in Emergency Response 160

Section Eight: Community Mobilization 167

Appendix 8.1: Home Visit Checklist 171

Section Nine: Nutrition Information, Education and Communication 173

Approach to Nutrition Education 173

Appendix 9.1: Nutrition Messages 180

Figure 1.1 How to measure MUAC

Figure 2.1 Feeding technique

Figure 3.1 Supplemental Sucking Technique

Table 7.3 Stakeholders’ roles in emergency response

Figure 7.1 Flow chart outlining Kenya MOH supply system

Figure 9.1 Steps to conduct a nutrition education session

1) to prevent malnutrition by early identification, public health interventions and nutrition

2) to treat acute malnutrition to reduce associated morbidity and mortality.

Objective of the Guidelines

How to Use the Guidelines

Content of the Guidelines

Type II micronutrients, including magnesium, sulphur, nitrogen, essential amino-acids,

Table 1.1: Characteristics of Marasmus and Kwashiorkor

Figure1.1: UNICEF Conceptual Framework: Causes of Malnutrition

Inadequate Food Intake Disease

Imediate Causes of Malnutrition

Underlying Causes of Malnutrition

Basic Causes of Malnutrition

Diagnosis of Acute Malnutrition

A Note on Admission Criteria for Adolescents and Adults

Oedema Oedema Present Oedema Absent Oedema Absent

Other signs Too weak to suckle or Poor feeding Poor feeding

Oedema Oedema Present Oedema Absent Oedema Absent

Adults (older than 18 years)

Pregnant & lactating women

*Anthropometric criteria based on WHO Child Growth Standards (2006)

Steps to Identify Acute Malnutrition in Children

Triage of Acute Malnutrition

Table 1.4: Triage to determine treatment of either severe or moderate malnutrition

2. Does the patient have an appetite.

LOOK AND FEEL FOR: Visible signs of wasting

DETERMINE: Level of malnutrition using W/H reference charts

LOOK AT SHAPE OF GROWTH CURVE: 1. Has the child lost weight?

2. Is the growth curve flattening?

Table 1.5: Admission criteria to determine in-patient or out-patient care

Factor Criteria for all admissions with severe acute malnutrition

Caregiver No suitable or willing caregiver Suitable and willing caregiver

Skin Open skin lesions present No open skin lesions