Interim Natl GL Ghana May12

INTERIM NATIONAL GUIDELINES FOR
COMMUNITY-BASED MANAGEMENT OF
SEVERE ACUTE MALNUTRITION
IN GHANA
February 2010
INTERIM NATIONAL GUIDELINES FOR COMMUNITY-BASED MANAGEMENT OF SEVERE ACUTE MALNUTRITION IN GHANA
TABLE OF CONTENTS
Acknowledgements ...................................................................................................................................................... i
Foreword .......................................................................................................................................................................ii
Acronyms and Abbreviations .................................................................................................................................. iii
CHAPTER I: Introduction .....................................................................................................................................1
1.1 Acute Malnutrition as a Form of Undernutrition .....................................................................................2
1.1.1 What Is Undernutrition? .................................................................................................................2
1.1.2 What Is Acute Malnutrition? ..........................................................................................................2
1.1.3 Assessing Acute Malnutrition .........................................................................................................2
1.2 Principles of the Management of SAM .......................................................................................................4
1.2.1 Community Outreach .......................................................................................................................5
1.2.2 Outpatient Care for Children 6-59 Months................................................................................6
1.2.3 Inpatient Care for Children 0-59 months ....................................................................................6
1.2.4 Supplementary Feeding of Children 6-59 Months and Pregnant and Lactating Women
With MAM....................................................................................................................................6
CHAPTER II: Community Outreach ..................................................................................................................8
STEP 1: Community Assessment ........................................................................................................................9
STEP 2: Formulation of Community Outreach Strategy...............................................................................9
STEP 3: Developing Messages and Materials...................................................................................................9
STEP 4: Community Mobilisation and Training ......................................................................................... 10
STEP 5: Case-Finding and Referral of New Cases With SAM ................................................................ 10
STEP 6: Follow-Up of Children With SAM ................................................................................................ 11
STEP 7: Linking With Other Community Services, Programmes and Initiatives ................................. 12
STEP 8: Continued Community Mobilisation (as in Step 4).................................................................... 12
CHAPTER III: Outpatient Care for the Management of SAM Without Medical Complications ..... 14
STEP 1: Screening Children for SAM ............................................................................................................ 15
STEP 2: Admission Criteria .............................................................................................................................. 16
Admission Procedure................................................................................................................................ 16
STEP 3: Medical Assessment and Decision-Making for Treatment ........................................................ 18
Appetite Test With RUTF .................................................................................................................... 18
STEP 4: Referral to Inpatient Care.................................................................................................................. 19
Upon Admission ....................................................................................................................................... 19
At Follow-On Visits, Referral Based on Action Protocol................................................................ 20
STEP 5: Medical Treatment in Outpatient Care .......................................................................................... 22
New Admission ......................................................................................................................................... 22
Routine Medical Treatment for New Admission .............................................................................. 22
Vaccination Schedule Update ................................................................................................................ 23
STEP 6: Dietary Treatment in Outpatient Care ........................................................................................... 24
Quantities of RUTF to Provide ............................................................................................................ 24

Feeding Procedure ..................................................................................................................................... 24
STEP 7: Counselling, Health, Nutrition and Hygiene Education ............................................................ 25
Upon Admission ....................................................................................................................................... 25
At Follow-On Visits ................................................................................................................................ 25
STEP 8: Individual Monitoring During Follow-On Visits at the Health Facility ................................ 26
Anthropometry .......................................................................................................................................... 26
History and Physical Examination ........................................................................................................ 26
Follow-Up Action..................................................................................................................................... 26
STEP 9: Follow-Up Home Visits for Children Requiring Special Attention........................................ 26
STEP 10: Discharge Criteria ............................................................................................................................. 27
Discharge Procedures ............................................................................................................................... 27
CHAPTER IV: Inpatient Care for the Management of SAM With Medical Complications for
Children 6-59 Months ........................................................................................................................................ 29
4.1 Admission Criteria ........................................................................................................................................ 30
4.2 Admission Procedure.................................................................................................................................... 31
4.3 Stabilisation Phase ........................................................................................................................................ 31
4.3.1 STEP 1: Treat/Prevent Hypoglycaemia ................................................................................... 31
4.3.2 STEP 2: Treat/Prevent Hypothermia ....................................................................................... 32
4.3.3 STEP 3: Treat/Prevent Dehydration ........................................................................................ 33
4.3.4 STEP 4: Correct Electrolyte Imbalance..................................................................................... 34
4.3.5 STEP 5: Treat/Prevent Infection ............................................................................................... 34
4.3.6 STEP 6: Correct Micronutrient Deficiencies ........................................................................... 35
4.3.7 STEP 7: Start Cautious Feeding ................................................................................................. 36
4.3.8 Monitoring During the Stabilisation Phase .............................................................................. 40
4.3.9 Criteria to Progress from the Stabilisation Phase to the Transition Phase ........................ 40
4.4 Transition Phase............................................................................................................................................ 40
4.4.1 Transition Using RUTF............................................................................................................... 40
4.4.2 Transition for Special Cases (Children Who Cannot Consume RUTF) .......................... 42
4.4.3 monitoring During the Transition Phase ................................................................................. 42
4.4.4 Progression From the Transition Phase..................................................................................... 43
4.5. Rehabilitation Phase (Catch-Up Growth) .............................................................................................. 44
4.5.1 Prepare for Follow-Up of Children in Outpatient Care ........................................................ 44
4.5.2 Medical Treatment ......................................................................................................................... 44
4.5.3 Dietary Treatment .......................................................................................................................... 44
4.5.4 Individual Monitoring ................................................................................................................... 47
4.5.5 Criteria to Move Back from the Rehabilitation Phase to the Stabilisation Phase in
Inpatient Care ............................................................................................................................. 47
4.5.6 Progression from the Rehabilitation Phase to Discharge ....................................................... 47
4.6 Provide Sensory Stimulation and Emotional Support .......................................................................... 48
4.7 Failure to Respond to Treatment in Inpatient Care .............................................................................. 48
4.8 Criteria for Discharge from Inpatient Care After Full Recovery ........................................................ 50
4.9 Discharge Procedures ................................................................................................................................... 51
CHAPTER V: Inpatient Care for the Management of SAM in INFANTS 0-6 Months Old ............ 53
5.1 Breastfed Infants 0-6 Months Who Have a Lactating Mother or Caregiver for Wet Nursing ... 54
5.1.1 Routine Medicines and Supplements ......................................................................................... 54

5.1.2 Dietary Treatment .......................................................................................................................... 54
5.1.4 Supportive Care for Mothers ....................................................................................................... 57
5.1.5 Discharge Criteria ........................................................................................................................... 58
5.1.6 Follow-Up After Discharge .......................................................................................................... 58
5.2 Infants 0-6 Months Without the Prospect of Breastfeeding ............................................................... 58
5.2.1 Stabilisation Phase .......................................................................................................................... 58
5.2.2 Transition Phase ............................................................................................................................. 60
5.2.3 Rehabilitation Phase ...................................................................................................................... 61
CHAPTER VI: Monitoring and Reporting..................................................................................................... 63
6.1 Monitoring Tools ......................................................................................................................................... 64
6.1.2 Monitoring of Services .................................................................................................................. 67
6.2 Service Indicators .......................................................................................................................................... 70
6.2.1 Indicators Measuring Output ...................................................................................................... 70
6.2.2 Performance Indicators Measuring Outcome (Effectiveness) ............................................... 70
6.2.3 Additional Indicators Measuring Effectiveness of the Treatment........................................ 71
6.3 Support and Supervision.............................................................................................................................. 72
6.3.1 Quality of Individual Treatment ................................................................................................. 72
6.3.2 Organisation and Management of Services ............................................................................... 72
6.3.3 Performance of Services ................................................................................................................ 73
6.3.4 Feedback System ............................................................................................................................. 73
6.3.5 Quality Control of Monitoring Data ......................................................................................... 73
6.4 Reporting ........................................................................................................................................................ 73
6.4.1 Minimum Reporting Standards................................................................................................... 74
References .................................................................................................................................................................. 75
List of Annexes ......................................................................................................................................................... 77
Annex 1. Planning for Community Outreach ................................................................................................ 78
Annex 2. Community Outreach Messages ...................................................................................................... 85
Annex 3. Admission and Discharge Criteria for the Management of SAM in Children 0-59 Months
.............................................................................................................................................................................. 88
Annex 4. Anthropometric Measurements ....................................................................................................... 90
Annex 5. Guidance Table to Identify Target Weight for Discharge ........................................................ 97
Annex 6. Checklist for Medical History and Physical Examination ......................................................... 98
Annex 7. Routine Medicines Protocols ........................................................................................................... 99
Annex 8. Supplemental Medicines Protocols ............................................................................................... 100
Annex 9. Drug Doses ........................................................................................................................................ 101
Annex 10. Sugar-Water Protocol ................................................................................................................... 106
Annex 11. Dietary Treatment.......................................................................................................................... 107
Annex 12. Alternative Recipes for F75, F100 and ReSoMal Using CMV .......................................... 109
Annex 13. Preparing F75 Milk Using Pre-Packaged F75......................................................................... 111
Annex 14. RUTF Specification ...................................................................................................................... 112
Annex 15. Outpatient Care Action Protocol ............................................................................................... 116
Annex 16. Key Messages Upon Admission .................................................................................................. 117
Annex 17. Messages for Health and Nutrition Education ........................................................................ 118
Annex 18. Play and Stimulation...................................................................................................................... 121
Annex 19. Checklist for Home Visits ........................................................................................................... 123
Annex 20. Inpatient Care Treatment Card (Critical Care Pathway-CCP) ............................................ 124
Annex 21. Outpatient Care Treatment Card ............................................................................................... 130
Annex 22. Outpatient Care RUTF Ration Card ........................................................................................ 132
Annex 23. Health Facility Tally Sheet for the Management of SAM .................................................... 133
Annex 24. Health Facility Monthly Report for the Management of SAM .......................................... 134
Annex 25. District Monthly Report for the Management of SAM ........................................................ 135
Annex 26. Minimal Reporting Guidance for the Management of SAM ............................................... 136
Annex 27. Supervision Checklists ................................................................................................................... 138
Annex 28. Requisition Form for Therapeutic Food .................................................................................. 144
Annex 29. Setup of Inpatient Care and Outpatient Care .......................................................................... 145
Annex 30. Checklist of Materials Needed for Outpatient Care .............................................................. 147
Annex 31. Outpatient Care Staffing .............................................................................................................. 148
Annex 32. Inpatient Care Staffing .................................................................................................................. 151
Annex 33. Checklist of Materials Needed for Inpatient Care .................................................................. 152
Annex 34. Forecasting Nutrition Product Needs ....................................................................................... 153
Annex 35. List of Job Aids .............................................................................................................................. 154
APPENDIX: Clinical Management of SAM with Medical Complications in Inpatient Care.......... 156
List of Tables
Table 1. Indicators and Clinical Signs of Acute Malnutrition With Cut-offs for SAM and MAM........3
Table 2. Classification of SAM for CMAM.........................................................................................................4
Table 3. Admission Criteria for CMAM for Children Under 5 ................................................................... 16
Table 4. Outpatient Care Admission Categories............................................................................................... 17
Table 5. Look-Up Table for Amounts of RUTF to Give to a Child per Day or Week Based on 92 g
Packets Containing 500 kcal ............................................................................................................................. 24
Table 6. Outpatient Care Exit Categories........................................................................................................... 28
Table 7. Stabilisation Phase Look-Up Tables for Volume of F75 for Persons With Severe Wasting
(“Marasmus”) of Different Weights................................................................................................................ 37
Table 8. Stabilisation Phase Look-Up Tables for Volume of F75 for Persons With Severe Bilateral
Pitting Oedema (“Kwashiorkor”) (+++) ...................................................................................................... 38
Table 9. Look-Up Table for Amounts of RUTF to Give to a Child per Day Based on 92 g Packets
Containing 500 kcal ............................................................................................................................................ 41
Table 10. Doses of iron syrup if F100 is used during rehabilitation (catch up growth).......................... 44
Table 11. Inpatient Rehabilitation Phase Look-Up Table for Quantity of F100 to Give to an
Individual Child per Feed ................................................................................................................................... 46
Table 13. Inpatient Care Exit Categories............................................................................................................ 52
Table 14. Look-Up Table for Maintenance Amounts of F100-Diluted to Give to an Individual Infant
per Feed .................................................................................................................................................................. 55
Table 15. Look-Up Table for Amounts of F100-Diluted (Marasmus) or F75 (Kwashiorkor) to Give
to Non-Breastfed Infants in the Stabilisation Phase ..................................................................................... 59
Table 16. Look-Up Table for Amounts of F100-Diluted to Give to Non-Breastfed Infants 0-6
Months or Infants Over 6 Months Weighing Less Than 4.0 kg in the Transition Phase................... 61
Months or Infants Over 6 Months Weighing Less Than 4.0 kg in the Rehabilitation Phase ............ 62
Table 18. Filing System for Outpatient Care Treatment Cards, With a Separation per Discharge
Category ................................................................................................................................................................. 66
Table 19. Summary of Entry and Exit Categories ............................................................................................ 69
Table 20. Outcome Indicators Based on CMAM Guidance and on International Cutoffs as per Sphere
Standards ................................................................................................................................................................ 71
List of Figures
Figure 1. Diagrammatic Representation of Stages of Community Outreach .............................................. 13

Figure 2. Admission and Treatment Flow Chart, Children 6-59 Months With SAM ............................ 21
Figure 3. Timeframe for the Management of SAM in Children (WHO 2003) ....................................... 31
Figure 4. Supplementary Suckling Technique.................................................................................................... 57
List of Boxes
Box 1. Summary Steps in Community Outreach..................................................................................................8

Box 2. Summary Steps in Outpatient Care ......................................................................................................... 14
Box 3. Community Screening and Referral for Treatment ............................................................................. 15
Box 4. Admission Procedure .................................................................................................................................. 17
Box 5. Appetite Test................................................................................................................................................ 19
Box 6. Frequent Causes of Failure to Respond in Outpatient Care .............................................................. 20
Box 7. Information to be Recorded During Referral From Outpatient Care to Inpatient Care ............. 22
Box 8. Iron and Folic Acid ..................................................................................................................................... 23
Box 9. Key Messages at First Visit ....................................................................................................................... 25
Box 10. Criteria and Recommendations for Discharge.................................................................................... 27
Box 11. Additional Guidance ................................................................................................................................ 30
Box 12. Admission Criteria for Inpatient Care for Children 6-59 Months ................................................ 30
Box 13. Reasons for Using an NG tube to Feed the Child During Stabilisation ...................................... 39
Box 14. Frequent Causes of Failure to Respond to Inpatient Treatment .................................................... 49
Box 15. Discharge Criteria From Inpatient Care............................................................................................... 51
Box 16. Admission Criteria for Breastfed Infants ............................................................................................. 54
Box 17. Discharge Criteria for Breastfed Infants ............................................................................................... 58
Box 18. Admission Criteria for Non-Breastfed Infants ................................................................................... 58
Box 19. Discharge Criteria from Inpatient Care Rehabilitation Phase for Non-Breastfed Infants ........ 62
Box 20. Information to be Recorded During Referral from Outpatient Care to Inpatient Care ........... 66
ACKNOWLEDGEMENTS
These Guidelines are the product of collaboration among many people and organisations, all of whom
greatly contributed to the final document.
Ghana Health Service (GHS) would like to thank the Food and Nutrition Technical Assistance II
Project (FANTA-2) for its technical assistance in the production of the Guidelines, with special thanks
to Hedwig Deconinck (Senior Emergency Nutrition Advisor); Anuradha Harinarayan, Dr. Joseph
Akuamoah Somuah, Dr. Sheikh Shahed (Consultants); and Alice Nkoroi (CMAM and Emergency
Nutrition Specialist, Ghana), and the FANTA-2 Communications Unit.
GHS is grateful to the following Severe Acute Malnutrition Technical Committee (SAM TC)
members for their invaluable contributions:
J.G.A. Armah GHS, Nutrition Department
Michael A. Neequaye GHS, Nutrition Department
Dr. Isabella Sagoe-Moses GHS, Child Health Department
Dr. Cynthia Bannerman GHS, Institutional Care Department
Prof. Jennifer Welbeck Korle-Bu Teaching Hospital Child Health Department
Dr. Caroline Jehu-Appiah GHS, Policy Planning Monitoring and Evaluation
Department
Juliana Pwamang USAID/Ghana
Dr. Seth Adu-Afarwuah UNICEF/Ghana
Ernestina Agyapong UNICEF/Ghana
Maina Muthee UNICEF/Ghana
Akosua Kwakye WHO/Ghana
Dr. Mary Brantuo WHO/Ghana
GHS would also like to thank the District Directors of Health Services and Teams in Agona West
Municipality and East Districts in the Central Region and Ashiedu-Keteke Sub-Metro in the Greater
Accra Region, as well as all individuals and agencies that have directly and indirectly contributed to the
experience and learning to-date from which this document has been developed.
Last but not least, GHS wishes to thank USAID/Ghana, UNICEF and WHO for providing financial
assistance and therapeutic supplies for the pilot implementation, and the development, review and
production of the Guidelines.
i
FOREWORD
Malnutrition is a highly complex and multifaceted problem with socioeconomic and cultural aspects
that require a more integrated public health approach. Malnutrition remains a major public health and
developmental challenge in Ghana. The prevalence of acute malnutrition remains high and contributes
to morbidity and mortality of children under five years old in the country. Over the years, management
and treatment of severe acute malnutrition (SAM) has been undertaken in inpatient facilities in
hospitals and Nutrition Rehabilitation Centres (NRCs) attached to health facilities. These Interim
National Guidelines are the first formal comprehensive guidelines for the management and treatment of
SAM cases in Ghana.
It is against this background that the Ghana Health Service (GHS) is adopting the Community-Based
Management of Severe Acute Malnutrition (CMAM) approach to facilitate the management of SAM
beyond inpatient care. The approach is rooted in the public health principles of expanded coverage and
access, timeliness and appropriate care. CMAM involves:
• Inpatient care for the management of SAM with medical complications and for all infants under
six months with SAM
• Outpatient care for the management of SAM without medical complications
• Community outreach for active case-finding and referral and follow-up of problem cases
These Interim Guidelines are designed to be a practical guide for field implementers and policy makers
in Ghana. The Guidelines reflect the most current global knowledge, experience and standards of
CMAM. They were adapted specifically for the Ghanaian health system using lessons learned from the
learning sites in Agona West Municipality and Agona East district in the Central Region and Ashiedu-
Keteke Sub-Metro in the Greater Accra Region, in consultation with local and external experts.
All service providers, including clinicians, nurses, nutritionists, dietitians and other health care providers
involved in the management of SAM in the country, should use these guidelines for the management of
SAM in both inpatient and outpatient facilities. We believe that users will find the Interim National
Guidelines useful. We encourage them to make suggestions for a review that is planned to take place in
one year’s time as part of the finalisation process before endorsing these guidelines as the National
Guidelines for Community-Based Management of SAM in Ghana.
DR. ELIAS K. SORY

DIRECTOR-GENERAL
GHANA HEALTH SERVICE
ii
ACRONYMS AND ABBREVIATIONS

> Greater than
≥ Greater than or equal to
< Less than
≤ Less than or equal to
AIDS Acquired immune deficiency syndrome
ACT Artemisinin-based combination therapy
ART Antiretroviral therapy
ARV Antiretroviral (drug)
AWG Average weight gain
CBO Community-based organisation
CCP Critical Care Pathway
CD4 Cluster of differentiation 4
CHC Child health card
CHN Community health nurse
CHO Community health officer
CHW Community health worker
CHPS Community-Based Health Planning and Services
cm Centimetre(s)
CMAM Community-based management of severe acute malnutrition
CMV Combined mineral and vitamin mix
CTC Community-based therapeutic care
CWC Child welfare clinic
DDNS Deputy Director Nursing Staff
DHMT District Health Management Team
dl Decilitre(s)
ENA Essential Nutrition Actions
EPI Expanded programme of immunisation
F75 Formula 75 Milk
F100 Formula 100 Milk
FANTA-2 Food and Nutrition Technical Assistance II Project
g Gram(s)
GHS Ghana Health Service
Hb Haemoglobin
HEW Health extension worker
HFA Height-for-age
HIRD High Impact Rapid Delivery, Child Survival Programme
HIV Human immunodeficiency virus
HNP Health and Nutrition Policy
IM Intramuscular
IMCI Integrated Management of Childhood Illness
INACG International Nutritional Anaemia Consultative Group
IU International unit(s)
IV Intravenous
IYCF Infant and young child feeding
KAP Knowledge, Attitude and Practice
kcal Kilocalorie(s)
kg Kilogram(s)
L Litre(s)
iii
LOS Length of stay

LSHTM London School for Hygiene and Tropical Medicine
M&E Monitoring and evaluation
M&R Monitoring and reporting
MAM Moderate acute malnutrition
MDG Millennium Development Goal
mg Milligram(s)
MICS Multi Indicator Cluster Survey
ml Millilitre(s)
mm Millimetre(s)
mmol Millimole(s)
MOH Ministry of Health
MT Metric ton(s)
MUAC Mid-upper arm circumference
NCHS National Centre for Health Statistics
NGO Nongovernmental organisation
NGT Nasogastric tube
NHIS National Health Insurance Scheme
NID National Immunisation Day
NRC Nutrition rehabilitation centre
PD Positive Deviance
ORS Oral rehydration solution
PLHIV People living with HIV
RDA Recommended Daily Allowance
ReSoMal Rehydration Solution for Malnutrition
RUTF Ready-to-use therapeutic food
RWG Rate of weight gain
SAM Severe acute malnutrition
SAM TC Severe Acute Malnutrition Technical Committee
SAM SU Severe Acute Malnutrition Support Unit
SCN United Nations Standing Committee on Nutrition
SD Standard deviation(s)
SFP Supplementary feeding programme
TB Tuberculosis
TFC Therapeutic feeding centre
TFU Therapeutic feeding unit
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
WFA Weight-for-age
WFH Weight-for-height
WFP World Food Programme
WHO World Health Organisation
µg Microgram(s)
iv
1. Introduction
CHAPTER I: INTRODUCTION
These guidelines address the management and treatment of severe acute malnutrition (SAM) in Ghana
and focus on community outreach, outpatient care and inpatient care for the Community-Based
Management of Severe Acute Malnutrition (CMAM). They are intended to be used by health and
nutrition care providers working at the national, regional, district, sub-district and facility levels of
health and nutrition system in Ghana. These guidelines provide practical and easy-to-follow guidance
based on current evidence and best practices in the management and treatment of SAM.
The CMAM guidelines seek to improve the management of SAM in children under five years old,
through treatment of SAM cases with medical complications in inpatient care and those without
medical complications in outpatient care. The rationale for managing SAM without medical
complications in outpatient care is that these children do not require hospitalisation and can be
successfully treated at the community level using ready-to-use therapeutic food (RUTF). Home-based
management and treatment of SAM without medical complications make community outreach an
essential component of CMAM. The primary goal of community outreach is to enable the early
detection and referral of severely malnourished children and to increase the number of SAM cases
accessing quality treatment.
The CMAM guidelines have been field-tested in the learning facilities of Agona East District, Agona
West Municipality and Ashiedu Keteke Sub-Metropolitan Area. Adherence to the guidelines will
contribute significantly to improving the performance of the management of SAM as measured in
terms of incread recovery rates; reduced case fatality and defaulter and non-recovery rates; and increased
service access and utilisation (coverage).
The CMAM guidelines will contribute to improved standardised treatment and monitoring and
reporting (M&R). They can also be used as a mobilising force for addressing SAM and strengthening
capacities. They should facilitate the integration of the management of SAM into the primary health
care system, and compliance with the guidelines will contribute to the overall reduction of child
mortality in Ghana.
1
1.1 Acute Malnutrition as a Form of Undernutrition

1.1.1 WHAT IS UNDERNUTRITION?
Malnutrition is a medical (pathological) state resulting from a deficiency in or excess of one or more
essential nutrients. The prefix “mal” means “poor” or “bad.” The condition can result from poor or
bad nutrition. Malnutrition can be either undernutrition or overnutrition.
Undernutrition is caused by inadequate intake or poor absorption of nutrients in the body. There are
four forms of undernutrition: acute malnutrition, stunting, underweight and micronutrient deficiencies.
The four forms can be categorised as either moderate or severe and can appear isolated or in
combination, but most often they overlap in one child or in a population. These guidelines specifically
deal with the identification, treatment and management of SAM.
Undernutrition is identified through anthropometric (body) measurements, clinical signs and

biochemical tests. These body measurements are then compared to a reference value and referred to as
nutrition indices.
Nutrition indicators are the classification of specific measures of nutrition indices based on cut-off
points. They measure the clinical occurrence of undernutrition and are used for making a judgment or
assessment.
There are four common nutrition anthropometric indicators: mid-upper arm circumference (MUAC),
which is used to assess wasting; weight-for-height (WFH), which is also used to assess wasting; height-
for-age (HFA), which is used to assess stunting; and weight-for-age (WFA), which is used to assess
underweight.
1.1.2 WHAT IS ACUTE MALNUTRITION?
Acute malnutrition is caused by a decrease in food consumption and/or illness resulting in bilateral
pitting oedema or sudden weight loss. It is defined by the presence of bilateral pitting oedema or by
wasting.
There are two forms of acute malnutrition:

• SAM, or severe acute malnutrition, is defined by the presence of bilateral pitting oedema or severe
wasting. A child with SAM is highly vulnerable and has a high mortality risk.
• MAM, or moderate acute malnutrition, is defined by moderate wasting.
The following terms are used to describe the clinical manifestations of SAM:
• Marasmus (severe wasting)
• Kwashiorkor (bilateral pitting oedema)
• Marasmic kwashiorkor (mixed form of bilateral pitting oedema and severe wasting)
1.1.3 ASSESSING ACUTE MALNUTRITION
The MUAC measurement and WFH index are used to assess wasting, a clinical manifestation of acute
malnutrition, reflecting the child’s current nutritional status. In the context of Ghana, only the MUAC
measurement is used to assess wasting.
2
MUAC involves measuring the circumference of a child’s left mid-upper arm. MUAC < 11.5 cm for
children aged 6-59 months indicates SAM. MUAC ≥ 11.5 cm and < 12.5 cm for children aged 6-59
months indicates MAM. MUAC is a better indicator of mortality risk associated with acute
malnutrition than WFH z-score (World Health Organisation [WHO] standards). 1 MUAC is used for
children six months and older. A child’s date of birth is assessed based on the caregiver’s proof or recall;
1. Introduction
no proxy of height to assess age is used.
The WFH index shows how a child’s weight compares to the weight of a child of the same height and
sex in the WHO standards. 2 A WFH standard deviation below -2 z-score of the median (WFH < -2
z-score) of the WHO standards indicates wasting. Severe wasting is indicated by a WFH < -3 z-score.
Moderate wasting is indicated by a WFH ≥ -3 and < -2 z-score.
Bilateral pitting oedema is a clinical manifestation of acute malnutrition caused by an abnormal

infiltration and excess accumulation of serous fluid in connective tissue or in a serous cavity. Bilateral
pitting oedema (also called kwashiorkor) is verified when thumb pressure applied on top of both feet
for three seconds leaves a pit (indentation) in the foot after the thumb is lifted.
Table 1. Indicators and Clinical Signs of Acute Malnutrition With Cut-offs for SAM and MAM
Bilateral pitting oedema MUAC WFH z-score
SAM Present < 11.5 cm < -3
MAM Not present ≥ 11.5 cm and < 12.5 cm ≥ -3 and < -2
In most cases, anthropometric measurements or the presence of bilateral pitting oedema alone can
confirm a clinical diagnosis of SAM. Nevertheless, it is essential to assess clinical signs because they will
indicate the severity of illness. In the presence of anthropometric confirmation of SAM, it is essential
to assess the following clinical signs:
• Anorexia, no appetite • Hypothermia

• Intractable vomiting • Severe dehydration
• Convulsions • Lower respiratory tract infection
• Lethargy, not alert • Severe anaemia
• Unconsciousness • Skin lesion
• Hypoglycaemia • Eye signs of vitamin A deficiency
• High fever • Skin lesion
Other clinical signs of wasting may be present without the anthropometric confirmation, e.g., skin on
the buttocks has a “baggy pants” look.
1
See WHO, WFP, UN/SCN and UNICEF 2007 and WHO and UNICEF 2009.
2
The WHO 2006 Child Growth Standards were developed from a multicentre growth reference study that
followed optimal child growth of a cohort of children in Oman, Norway, Ghana, India and the United States.
3
1.2 Principles of the Management of SAM

For a number of years, many countries have treated SAM in inpatient care provided either in paediatric
wards or specialised therapeutic feeding units or centres (TFUs, TFCs), following the WHO 1999
treatment protocol for SAM. 3 However, a new community-based approach was developed following
innovations, such as the invention and use of RUTF, whereby children with SAM without medical
complications can start treatment in outpatient care rather than inpatient care and continue drug and
dietary treatment at home. Meanwhile, children with SAM with medical complications are admitted to
inpatient care but are referred to outpatient care as soon as their medical complication is resolving and
continue treatment until full recovery at home. 4 Table 2 shows the classification of SAM that is used in
the CMAM approach. Another innovation is the use of MUAC as an independent criterion for SAM
for children six months and older. This has made detection of SAM in the community and the health
facility simple and effective.
Table 2. Classification of SAM for CMAM

Management
INPATIENT CARE OUTPATIENT CARE
Approach
SAM without medical
Classification SAM with medical complication complication
Admission Criteria
Children 6-59 months: Children 6-59 months:
Bilateral pitting oedema Bilateral pitting oedema
(+++) ( + + ) or ( +)
or or
Any grade of bilateral pitting oedema with severe wasting Severe wasting (MUAC <
(MUAC < 11.5 cm) 11.5 cm)
Anthropometric
or
and Clinical
SAM with medical complications
Measures
Infants 0-6 months:
Bilateral pitting oedema
or
Visible wasting
Infants ≥6 months who weigh <4.0 kg
Appetite Test Failed Passed
SAM with any of the following medical complications: Clinically well and alert
• Anorexia, no appetite • Hypothermia

• Intractable vomiting • Severe dehydration
Clinical Status • Convulsions • Lower respiratory tract infection
• Lethargy, not alert • Severe anaemia
• Unconsciousness • Skin lesion
• Hypoglycaemia • Eye signs of vitamin A
• High fever deficiency
Caregiver Caregiver willing Caregiver willing
Choice
3
WHO. 1999. Management of Severe Malnutrition: A Manual for Physicians and Other Senior Health
Workers, Geneva 1999.
4
See the WHO 1999 treatment protocol and WHO, WFP, UN/SCN and UNICEF 2007.
4
Management
INPATIENT CARE OUTPATIENT CARE
Approach
SAM without medical
Classification SAM with medical complication complication
Referral/Discharge Criteria
1. Introduction
Children 6-59 months: Discharge if attained 15%
Referral to outpatient care if oedema reducing and/or medical weight gain or more for two
complication resolving, and clinically well and alert consecutive weeks,
no bilateral pitting oedema
Infants 0-6 months: for two consecutive weeks
Discharge when successful re-lactation and appropriate weight and clinically well and alert
gain (minimum 20 gram [g] weight gain per day on
breastfeeding alone for five days) (see other guidance for non-
breastfed children)
Special cases 6-59 months:

Discharge if 15% weight gain is attained for three consecutive
weeks and/or oedema-free for two consecutive weeks and
clinically well and alert
Much evidence accumulated from early studies and field practice in Malawi, Ethiopia and Sudan has
led to the decentralised community-based approach that makes a distinction in severity of the condition
of the child with SAM. The majority of children over six months with SAM who have appetite and no
medical complication can be treated in outpatient care without the need for residential treatment. Small
numbers of children with SAM who have lost appetite or developed medical complications need
inpatient care. The approach is built upon strong community outreach for community mobilisation,
early case-finding and referral, and increasing service access and utilisation (coverage), thereby
decreasing the risk of children developing medical complications. As evidence shows, the impact of this
intervention contributes considerably to reducing mortality associated with SAM.
The following sections provide a brief overview of CMAM services based on a few key principles.
1.2.1 COMMUNITY OUTREACH
Good community outreach is essential to ensure children are detected early and referred for treatment.
The aim is to detect and start the treatment for SAM before the onset of life-threatening
complications.
Community outreach also raises community awareness of the aims of and builds support for the
services. Moreover, it strengthens the community’s awareness of causes, signs and treatment of SAM,
and promotes health and nutrition behaviour change. Through community outreach, community health
workers (CHWs) should better understand the needs of the local community and the factors that
might act as barriers to accessing care, while promoting and supporting infant and child nutrition and
care practices in the community to prevent malnutrition.
It is possible to link community outreach for SAM with existing community health and nutrition
outreach systems or initiatives, such as child welfare clinics (CWCs), community-based growth
promotion, the expanded programme of immunisation (EPI) and others.
5
1.2.2 OUTPATIENT CARE FOR CHILDREN 6-59 MONTHS
Outpatient care is provided to the majority of children with SAM, those without medical
complications and who have appetite. Outpatient care is also provided to children after referral from
inpatient care to continue treatment and nutritional rehabilitation.
Before admission at an outpatient facility, a nutrition and medical assessment carried out by a qualified
health care provider should determine if a child with SAM has good appetite (passed the appetite test,
see Section III, Step 3: Medical Assessment and Decision-Making for Treatment and Box 5) and no
medical complications. On admission to outpatient care, the child should receive routine medication, as
well as a take-home ration of RUTF equivalent to 200 kilocalories (kcal) per kilogram (kg)
bodyweight per day to last until the next weekly health visit. Treatment is managed by a qualified
health care provider at the health facility, Community-Based Health Planning and Services (CHPS)
compound, mobile clinic or decentralised health outreach point. Care then continues at home. The
child returns weekly or biweekly to the outpatient care site for follow up on his/her health and
nutrition progress and to replenish RUTF supplies.
1.2.3 INPATIENT CARE FOR CHILDREN 0-59 MONTHS
Anorexia (loss of appetite), severity of illness and presence of a medical complication are the main
determinants for providing inpatient care to children with SAM. Only small proportions of children
with SAM have poor appetite 5 or will develop medical complications that require intensive medical and
nutrition care. Children requiring inpatient care for stabilisation can be treated in paediatric wards or
specialised facilities that provide intensive 24-hour care or day care by skilled health care providers.
Inpatient care follows the WHO 1999 treatment protocol for SAM 6 but will refer the child 6-59
months to outpatient care as soon as the child’s oedema is reducing, medical condition resolving and
appetite returned. 7 The child then continues treatment in outpatient care in their home, receiving
RUTF until full recovery. Few children less than 59 months remain in inpatient care until full recovery.
All infants 0-6 months with SAM are treated in inpatient care until full recovery.
1.2.4 SUPPLEMENTARY FEEDING OF CHILDREN 6-59 MONTHS AND

PREGNANT AND LACTATING WOMEN WITH MAM
Supplementary feeding programmes (SFPs) or services manage and treat MAM in children 6-59
months and other vulnerable groups. A commonly known supplementary feeding approach in food-
insecure environments or emergencies is targeted supplementary feeding, where a supplementary food
ration, normally a fortified-blended food, is targeted to individuals with MAM in specific vulnerable
groups, such as malnourished pregnant women, lactating women with infants under six months,
individuals with special needs such as people living with HIV (PLHIV), people with tuberculosis (TB)
and the elderly. Specific anthropometric criteria for entry and discharge are usually used. In Ghana,
supplementary feeding is common in the Northern, Upper West and Upper East regions, where food
insecurity is common.
The dietary requirements and programmatic evidence for the management of MAM are under revision
at the global level, and improved guidance is expected shortly.
5
Infection leads to loss of appetite in the acute phase. In addition, liver and metabolic disturbances that
accompany Type 2 nutrient deficiency also lead to loss of appetite in children with SAM.
6
WHO. 1999. Management of Severe Malnutrition: A Manual for Physicians and Other Senior Health
Workers. Geneva: WHO.
7
WHO, WFP, UN/SCN and UNICEF 2007.
6
Note: No guidance or best practices on individual care or population-based strategies for MAM are
provided in these guidelines. Nevertheless, treatment for MAM with an appropriate dietary
supplement is important. Also, children with SAM would benefit after recovery from a dietary
supplement and regular monitoring. It is expected that the management of MAM will be
1. Introduction
addressed in separate guidelines or that this will become part of these guidelines in the future.
7
CHAPTER II: COMMUNITY OUTREACH
Effective community outreach is essential to the early identification and referral of children to CMAM.
Community outreach raises community awareness of the aims of the services, builds support for the
services, and at the same time helps CHWs understand the needs of the local community and the
factors that might act as barriers to accessing care and improving child nutrition.
Community outreach is a critical component of CMAM and can be undertaken individually or

integrated into ongoing community health outreach services, e.g.,
CWC outreach points, EPI outreach facilities or growth monitoring Learning From
facilities. Implementation Site
Continuously review
strategy and, through
The main aims of community outreach for CMAM include:
dialogue, determine ways
• Empowering the community: Increasing knowledge of SAM and of enhancing participation
CMAM and buy-in for CMAM
• Increasing access and service uptake (coverage) of CMAM services services at all levels.
• Strengthening early case-finding/referral of new SAM cases and
follow-up of problem cases
• Strengthening responsibility of the District Health Management Team (DHMT), community
health committees and stakeholders for sustainability and ownership.
BOX 1. SUMMARY STEPS IN COMMUNITY OUTREACH

Planning for Community Outreach
1. Community assessment
2. Formulation of community outreach strategy
3. Developing messages and materials
4. Community mobilisation and training
Conducting Community Outreach
5. Case-finding and referral of new cases with SAM
6. Follow-up of children with SAM
7. Linking with other community services, programmes and initiatives
8. Continued community mobilisation (as above in Step 4)
8
STEP 1: Community Assessment

Community assessment is the first step of community outreach. The assessment is key in determining
II. Community Outreach

the factors that are likely to impact both service delivery and demand for services. The assessment itself
is conducted by district health workers (community health nurses, members of the district health team)
with the objective of answering two main questions:
• What aspects of the community are likely to affect demand for CMAM?
• How can community outreach be organised to meet this demand most effectively?
The following steps form part of Community Assessment: Learning from

• Look for local terms for malnutrition, perceived causes and Implementation Site
Time must be invested in
common local solutions.
understanding key barriers
• Engage with the community in a participatory discussion on the to access and then
magnitude of the malnutrition problem, the causes and possible identifying the health
solutions. This can be done through local social structures, such as workers and volunteers
durbars, 8 or during child welfare outreach services. who are best suited to
• Identify the key community leaders, elders and other influential address these barriers.
people. Traditional healers should be included and might be able
to help screen or refer.
• Gather information on the ethnic groups and most vulnerable groups.
• Identify existing community structures and community-based organisations (CBOs) or groups.
• Identify formal and informal communication channels that are known to be effective.
• Identify health attitudes and health-seeking behaviours.
• Identify available childcare services and resources.
• Review Knowledge, Attitude and Practices (KAP) and coverage surveys or other sociological
studies conducted on health-seeking, care and feeding practices and behaviours.
STEP 2: Formulation of Community Outreach Strategy

• Identify the best mechanisms for community outreach and mobilisation, such as the volunteers who
are most respected in the community and can conduct screening, potential facilities for screening
and the types of screening that will be conducted.
• Negotiate with community opinion leaders, members and stakeholders for the adoption of CMAM
as the approach to manage malnutrition in their community.
• Agree on the relevant structures, groups and organisations to be involved in CMAM.
• Develop clear definitions of roles and responsibilities.
• Once services for the management of SAM have started, continue a dialogue to address concerns,
maintain changes in behaviour and share success stories.
STEP 3: Developing Messages and Materials

Handbills or pamphlets, local radio and television messages, and meetings with community and
religious leaders provide essential information about the CMAM service aims, methods and actors. In
particular, communities must know what the CMAM service will mean to them in practice, i.e., what it
8
Ghanaian traditional rulers sit in state and meet their people at events called “durbars” (an English word that
comes from an Indo-Persian term for "ruler's court").
9
will do, who is eligible, where it will operate, who will implement it, Learning from
how people can access it, and what the overall benefit of the Implementation Site
service/programme is to the community. Steps at this stage include: High default rates and
• Develop handbills (see Annex 2. Community Outreach Messages) absenteeism will be key
and other relevant materials that can help provide information challenges. Assigning clear
about CMAM services to the community and introduce the new responsibility to the
CHWs and volunteers
service.
along with strong
• Developing an orientation and dissemination plan on community supervision is essential to
mobilisation for key members of the health system (e.g., health ensure follow-up home
care providers, health extension workers or other support staff, visits.
managers and supervisors) and outreach workers. What is an effective link
• Ensure that the orientation and dissemination plan includes between the community
specific CMAM-related messages with behaviour change messages and the facility?
that are targeted at key members of the community: opinion
leaders, mothers, other family members and care providers, including traditional healers in the
community.
STEP 4: Community Mobilisation and Training

Community mobilisation aims to raise awareness of CMAM services, Learning from
promote understanding of its methods and lay the foundation for Implementation Site
community ownership in the future. Ensure that CHWs and
other volunteers can fully
comprehend the rationale
Community sensitisation messages are based on the handbill (see
behind CMAM, the
Annex 2. Community Outreach Messages.) Decisions on the importance of the
communication channels and on engagement with different actors community component and
should be based on an understanding of the local community the links with other health
dynamics. Steps include: education activities that
• Discuss service aim and target population. they routinely undertake.
• Discuss basic information on the causes, types, identification and
treatment of malnutrition.
• Practice in the identification of bilateral pitting oedema and wasting (using MUAC).
• Discuss case-finding strategies.
• Discuss case referral and follow-up checklist.
• Define and discuss a health and nutrition education strategy.
• Development of a detailed training plan for key members of the GHS, namely outpatient care
health workers, outreach workers, health volunteers, other support staff, supervisors and data
collectors
STEP 5: Case-Finding and Referral of New Cases With SAM

Case-finding should be carried out with the aim of early identification and referral of children with
SAM in the communities. Active case-finding is important to ensure that children with SAM are
identified before the development of severe medical complications. Identified children are referred to
the nearest health facility that provides treatment for SAM, where a decision is made whether the child
should be admitted to outpatient care or referred to the inpatient care facility.
10
Widespread identification of children with SAM at the community level is achieved through timely
screening using MUAC tapes and assessment of the presence of bilateral pitting oedema. Case-finding
and referral is carried out by CHWs or volunteers who identify children with SAM at all points of
contact with the community.

Identify and refer malnourished children through the identified strategies:
• House-to-house visits by CHWs and/or community volunteers
• Screening during CWC services at health facilities and satellite service points
• Screening at community meetings, schools, CBOs and other available opportunities
• Self-referrals by communities
• Child assessment for SAM at all health facilities (including Integrated Management of Childhood
Illness [IMCI])
• EPI and National Immunisation Days (NIDs)
• Other nongovernmental organisation (NGO) community activities and services
STEP 6: Follow-Up of Children With SAM

Children with SAM in treatment are monitored to ensure sustained improvement in their condition.
Children discharged from the service should be monitored through regular community screening for
any recurrence of malnutrition. Children with SAM require follow-up
visits in their homes because they are at increased risk of death or Severely malnourished
developing other serious illness. children require follow- up
after discharge as they have
an increased risk of disease
Follow-up home visits are critical for those children with SAM who and death.
are:
• Losing weight, have static weight or whose medical condition is
deteriorating
• Not responding to treatment
• Caregivers have refused inpatient care
• Absent or defaulting
The need for follow-up is identified by the health care provider and discussed with the caregiver. The
health care provider liaises with the CHW by direct contact or through available communication
channels in the community to convey the message to arrange a home visit to high-risk children.
The CHW should follow up on Absentees from outpatient care. It is Learning from
important to gain an understanding of the reason for the absence and Implementation Site
to encourage a return to treatment. The absentee should not be Integrate!
reprimanded as this can discourage return. • Build on existing
knowledge and skills.
Children with SAM in treatment should be linked with a CHW or • Understand current
community volunteer. It is the role of the CHWs to conduct home roles and
responsibilities of
visits and ensure that children with SAM are identified and referred for
CHW, health care
treatment. They also provide feedback to the health facilities on providers, and
problems related to the children’s home environment. integrate messages and
training with current
ongoing programs and
priorities.
11
STEP 7: Linking With Other Community Services, Programmes

and Initiatives
• Identify and link children who are being discharged from the treatment for SAM to programmes
that prevent malnutrition such as Positive Deviance (PD)/Hearth, mother support groups, and
community-based growth promotion and feeding programmes supported by the World Food
Programme (WFP), to name a few examples.
• Children and caregivers should also be linked to other community health or livelihoods
services/programmes in the area that might be complementary to CMAM. These could include
NGO or CBO programmes or other government initiatives. Discuss with health workers and
managers ways to link with CMAM, including involving their community volunteers and CHWs
in education activities.
• Determine which services or programmes children can be referred to upon discharge from
outpatient care.
STEP 8: Continued Community Mobilisation (as in Step 4)

Community mobilisation is an ongoing, not a one-time only activity. Many of the community
interactions take place early in the programme but should be continuously reinforced throughout the
implementation phase to be effective. Community mobilisation should be seen as a process of constant
dialogue in which communities can periodically voice their views and suggest alternative courses of
action.
12
Figure 1. Diagrammatic Representation of Stages of Community Outreach

Planning Phase
1. Community Assessment Building upon strengthening

existing community initiatives
2. Outreach Strategy
4. Training for
Community Outreach
3. Messages and Materials

Implementation Phase
5. Community Mobilization
8. Linking
6. Case Finding and Referral with
Other
Community
Initiatives
7. Home Visits
13
CHAPTER III: OUTPATIENT CARE FOR

THE MANAGEMENT OF SAM WITHOUT
MEDICAL COMPLICATIONS
Outpatient care is aimed at providing home-based treatment and rehabilitation for severely
malnourished children 6-59 months who have an appetite and no medical complications. CMAM
achieves this objective through timely detection, referral and early treatment before the health condition
becomes severe or before the onset of a complication. Effective community mobilisation, active case-
finding, referral and follow-up are essential inputs to successful outpatient care. If the condition of a
child in outpatient care deteriorates or if a medical complication develops, the child should be referred
to inpatient care for stabilisation and return to outpatient care as soon as the medical complication is
resolving.
It is recommended that outpatient care services be carried out on a weekly basis. However, sessions can
be conducted every two weeks when:
1. Poor access or long distance to the health facility increases the opportunity cost for the caregivers
and might prevent weekly participation.
2. Weekly sessions and high case loads overburden health facility schedules or staff at smaller health
facilities. In this case, biweekly sessions could allow for splitting the group of children in two and
alternating by week.
3. Seasonal factors or events that involve caregivers, such as the harvest or planting season, might
prevent caregivers from participating weekly.
4. Other cases as determined by nutrition or health staff.
BOX 2. SUMMARY STEPS IN OUTPATIENT CARE
1. Screening Children for SAM

2. Admission Criteria
3. Medical Assessment and Decision-Making for Treatment
4. Referral to Inpatient Care
5. Medical Treatment in Outpatient Care
6. Dietary Treatment in Outpatient Care
7. Counselling, Health, Nutrition and Hygiene Education
8. Individual Monitoring During Follow-On Visits at Health Facility
9. Follow-Up Home Visits for Children Requiring Special Attention
10. Discharge Criteria
14
STEP 1: Screening Children for SAM

Children 0-59 months with SAM are referred from community screening or are identified at any entry
point of the health services system.
III. Outpatient Care

Screening and referral can occur in a number of ways:
• Referrals by volunteers or CHWs after children are screened for bilateral pitting oedema and low
MUAC at the household level
• Referrals by community health nurses/officers or other health facility staff at any health service,
e.g., CWC outreach, satellite clinic, nutrition rehabilitation centre, outpatient care department,
hospital
• Self referral: Child brought by caregiver to the outpatient care site
• Mother-to-mother referrals within the community
Children in the community and at all points of contact with the health system are checked (see Section
II. Step 5: Case-Finding and Referral of New Cases With SAM):
• MUAC measurements for children 6-59 months are taken using simple, color-coded plastic tapes
designed to measure the arm circumference.
• A clinical check for the presence of bilateral pitting oedema is made by pressing the thumbs for
three seconds on the top side of both feet. If the indentation remains after removing the thumbs,
the child is diagnosed with bilateral pitting oedema, also known as kwashiorkor, a symptom of
SAM (see Annex 4. Anthropometric Measurements).
• Infants under six months with visible wasting and/or bilateral pitting oedema are not measured
using MUAC but referred to the health facility where they are further evaluated. In the absence of a
health card or birth certificate, determination of age of an infant is based on recall of the caregiver.
The height cut-off should not be used as a proxy for age.
All children under five years old should be routinely screened for SAM since it is one of the most
important contributing causes of childhood mortality. Training for screening should be standardised to
ensure uniformity between community volunteers and facility-based health care providers. At the health
facility, the child should be reassessed to confirm that the community volunteer referral is accurate. If
the referred children are regularly inaccurately assessed, action should be taken leading to the retraining
of either the community volunteers or CHWs depending on the source of the inaccuracy. In this way,
children who are correctly screened at the community level will also be admitted to the appropriate
treatment service, leaving no discrepancy between the two systems.
BOX 3. COMMUNITY SCREENING AND REFERRAL FOR TREATMENT
Children are screened and referred for treatment if screening finds:

• Presence of bilateral pitting oedema
• MUAC < 11.5 cm (for children 6-59 months)
Note: Infants under six months with visible wasting and/or bilateral pitting oedema and infants over six
months weighing less than 4.0 kg should be referred to the health facility for investigation.
15
STEP 2: Admission Criteria

The first point of contact with the primary health care system for a child under 5 years old with SAM
will be the health facility providing outpatient care. The trained health care provider will conduct a
medical and nutrition assessment to guide the decision of whether to admit the child 6-59 months to
outpatient care or to refer the child to inpatient care based on certain admission criteria (see Table 3).
Table 3. Admission Criteria for CMAM for Children Under 5

Inpatient Care Outpatient Care
Children 6-59 months Children 6-59 months
Bilateral pitting oedema +++ Bilateral pitting oedema + and ++
Or Or
Any grade of bilateral pitting oedema with severe wasting Severe wasting (MUAC < 11.5 cm)
(marasmic kwashiokor) And
Or • Appetite test passed
SAM with any of the following medical complications: • No medical complication
• Anorexia, no appetite • Child clinically well and alert
• Intractable vomiting
• Convulsions
• Lethargy, not alert
• Unconsciousness
• Hypoglycaemia
• High fever
• Hypothermia
• Severe dehydration
• Lower respiratory tract infection
• Severe anaemia
• Eye signs of vitamin A deficiency
• Skin lesion
Or
• Referred from outpatient care according to action
protocol (see Annex 15. Outpatient Care Action
Protocol)
Infants 0-6 months

• Bilateral pitting oedema
Or
• Visible wasting
• Infants > 6 months and weigh < 4.0 kg
ADMISSION PROCEDURE
The child and caregiver are welcomed at the health facility, and the caregiver is informed about the
admission criteria and procedure. Children who meet the admission criteria for therapeutic feeding
receive a medical assessment, including a history and physical examination that includes an appetite test
(see Box 5). The outcome of the assessment determines if the child will receive treatment in outpatient
care or will be referred to inpatient care. Infants under 6 months with bilateral pitting oedema or visible
wasting should be referred to inpatient care immediately.
16
Additional points to consider during the admission procedure:

• Explain to the caregiver the outcome of the assessment and the treatment, and decide with the
caregiver whether the child will be treated in outpatient or inpatient care. The choice of the
caregiver must be taken into consideration.

• Children who fail the appetite test should always be referred to inpatient care. If, for some reason,
the appetite test is inconclusive, the child should always be referred to inpatient care until the
appetite has been restored.
Table 4. Outpatient Care Admission Categories

Category Definition
New Admission New cases of children 6-59 months with SAM who meet the admission criteria (see
Table 3)
SAM cases are classified according to the type of SAM:
• Marasmus (MUAC < 11.5 cm)
• kwashiokor (bilateral pitting oedema)
New Other New SAM cases not meeting the pre-set admission criteria for SAM, e.g., MUAC
Admissions exactly 11.5 cm, children > 59 months with SAM, etc.
Old Cases Children who are transferred from inpatient care or another outpatient care site,
children who are returning defaulters.
Note: Relapse cases are considered as new cases, as the children were treated successfully before and now have
a new episode of SAM.
BOX 4. ADMISSION PROCEDURE
Welcome the child and caregiver and provide initial care:

• Triage and check critically ill children first.
• Provide sugar-water to all children awaiting screening or examination to avoid hypoglycaemia. Sugar-
water solution should contain approximately 10 percent sugar solution, or 10 g of sugar per 100 ml of
water.
Define nutritional status:

• Check for bilateral pitting oedema and take MUAC. Use admission criteria (see Annex 3. Admission
and Discharge Criteria for the Management of SAM in Children 0-59 Months) to guide decision-
making for admission.
• Indicate the target weight for discharge at 15 percent weight gain (see Annex 5. Guidance Table to
Identify Target Weight for Discharge).
• Register the child and record measurements on treatment card.
Conduct medical assessment:

• Take the child’s medical history, conduct a physical examination, determine if the child has a minor
health problem or a medical complication, and record findings on the treatment card.
• Fast-track children with SAM and medical complications in need of inpatient care and start treatment
(no need for appetite test; administer first dose of antibiotic).
• Test the appetite (see Box 5). The appetite test is a critical criterion for deciding whether a child with
SAM and without medical complications is treated in outpatient care or inpatient care.
• Decide whether to treat the child with SAM in outpatient care or refer him/her to inpatient care.
Provide treatment:
• Provide treatment for underlying infections and decide if treatment for additional health conditions is
needed.
• Provide a weekly or biweekly amount of RUTF, based on a daily ration of 200 kcal of RUTF per kg
17
bodyweight. Fill out the RUTF ration on the ration card for the caregiver.
• Counsel the caregiver on key messages for treatment, the intake of antibiotics and RUTF, and care
practices, and ask her/him to return to the health facility for monitoring sessions or whenever a
problem arises (see Annex 16. Key Messages Upon Admission).
• Link the caregiver with the CHW or volunteer.
• Link the caregiver with other services or initiatives as appropriate.
Note: Children who are identified with SAM during community screening are reassessed at the health
facility. If they fail to fulfil the admission criteria, they should not be admitted, but the caregiver
can be linked with other primary health services or initiatives as appropriate (e.g., nutrition
rehabilitation, PD/Hearth, EPI, CWC, community-based growth monitoring etc.).
STEP 3: Medical Assessment and Decision-Making for Treatment

A qualified health care provider, i.e., a nurse, medical assistant or other clinician assesses the child’s
medical condition, which includes a medical history established through the caregiver and a physical
examination to rule out medical complications that might require inpatient care. Results are recorded
on the outpatient care treatment card (see Annex 21. Outpatient Care Treatment Card).
• Take the medical history and record.

• Conduct a physical examination and record.
• Determine the medical condition (presence or absence of medical complications).
• Perform the appetite test with RUTF (See Box 5).
• Determine if the child needs referral to inpatient care or should be treated in outpatient care.
Verify admission criteria for inpatient care and outpatient care.
• Note: Infants under six months with any grade of oedema and/or visible signs of wasting and
children over six months with a weight less than 4.0 kg should always be referred to inpatient care.
Other exceptional cases can be referred to inpatient care (e.g., caregiver’s choice).
• Check the child’s National Health Insurance Scheme (NHIS) status and facilitate adherence if the
child does not have NHIS coverage.
APPETITE TEST WITH RUTF
Appetite, the ability to eat RUTF, is essential for a child to be admitted to and remain in outpatient
care. Anorexia, or absence of appetite, is considered to reflect a severe disturbance in the metabolism. If
a child has no appetite, he/she will not be able to eat RUTF at home and therefore needs referral for
specialised care in inpatient care for the management of SAM with medical complications.
The appetite test determines if the child is able to eat the RUTF. It tests the appetite, the acceptability
of the taste and consistency, and the ability of the child to swallow (e.g., child is mature or old enough
to swallow solids, child has no lesions that prevent him/her from eating). The appetite test is repeated
at every visit to outpatient care. The repetition of the test for children who are used to RUTF can be
organised in adaptation to the context, e.g., in a group with supervision during waiting times.
Children with SAM who pass the appetite test and have no medical complications are treated in
outpatient care. Those who fail the appetite test are referred to inpatient care. If the appetite test is not
conclusive, the child should be referred to inpatient care until the appetite has been restored. Children
18
who have other medical complications that require referral to inpatient care need not undergo the
appetite test.
BOX 5. APPETITE TEST

Points to Consider When Conducting an Appetite Test
• Conduct the appetite test in a quiet, separate area.
• Provide an explanation to the caregiver regarding the purpose of the appetite test and outline the
procedures involved.
• Observe the child eating the RUTF and determine if the child passes or fails the appetite test.
• Advise the caregiver to:
ο Wash hands before giving the RUTF
ο Sit with the child in his/her lap and gently offer the RUTF
ο Encourage the child to eat the RUTF without force-feeding
ο Offer plenty of clean water to drink from a cup while child is eating the RUTF
Appetite Test
Pass Appetite Test Fail Appetite Test
The child eats at least one-third of a packet of The child does not eat one-third of a packet of
RUTF (92 g). RUTF (92 g).
Note: Many children will eat the RUTF enthusiastically straight away, while others might initially refuse it.
These children need to sit quietly with their caregivers in a secluded place and be given time to
become accustomed to it.
STEP 4: Referral to Inpatient Care

UPON ADMISSION
MUAC measurements, presence or absence of bilateral pitting oedema and medical assessment,
including the appetite test, will determine if a child can be admitted to outpatient care or needs to be
referred for inpatient care. (See Annex 3. Admission and Discharge Criteria for the Management of
SAM in Children 0-59 months.)
Medical complications besides severe bilateral pitting oedema (+++), marasmic kwashiorkor and poor
appetite include:
• Convulsions
• Unconsciousness
• High fever
• Severe anaemia
• Hypoglycaemia
• Hypothermia
• Skin lesion
19
Other cases needing inpatient care are infants over six months and less than 4.0 kg.
If a medical complication is present, the health worker starts life-saving treatment:

• Provide 10 percent sugar-water.
• Refer the child to the closest inpatient care facility, with the caregiver’s consent.
• Record findings and the treatment given in the child’s health record and/or on the referral form.
• Advice is provided to the caregiver. Explain the:
o Severity of the child’s situation and the need for referral to inpatient care
o Need to keep the child warm during transportation
o Need to give frequent, small amounts of breast milk, 10 percent sugar-water or RUTF
during transportation
AT FOLLOW-ON VISITS, REFERRAL BASED ON ACTION PROTOCOL
In case of poor appetite, a developing medical complication or deterioration of the nutritional status
and/or medical condition, a child will be referred to inpatient care for treatment for SAM with
medical complications following the action protocol. (See Annex 15. Outpatient Care Action
Protocol.)
The following medical complications and deterioration of nutritional status require referral:
• No appetite (failed appetite test)
• IMCI danger signs
• Increase in or newly developed bilateral pitting oedema
• Weight loss because of diarrhoea (refeeding or other origin)
• Weight loss for three consecutive weeks
• Static weight (no weight gain) for five consecutive weeks
• Other signs of failure to respond to treatment (see Box 6)
In addition, inpatient care can be requested by the caregiver at any time or by the surrogate in the event
of the caregiver’s absence or death.
If a child is referred to inpatient care as a result of deterioration in his/her condition, a referral form is
provided or the child health record is used to provide basic health and nutrition information, including
treatment and medications already given, reasons for referral, and vaccination status. (See Box 7.)
BOX 6. FREQUENT CAUSES OF FAILURE TO RESPOND IN OUTPATIENT CARE
Problems Related to the Quality of the Treatment

• Inappropriate evaluation of child’s health condition or missed medical complication
• Inappropriate evaluation of appetite test
• Non-adherence to RUTF protocol
• Abrupt weaning of RUTF
• Non-adherence to routine medication protocol
• Inadequate guidance for home care provided
It is recommended that children who are referred to the inpatient care facility due to failure to respond to treatment be
tested for chronic illness such as HIV/AIDS and TB.
20
Problems Related to Home Environment

• Inappropriate frequency of visits to the health facility and reception of RUTF
• Inadequate intake or sharing of RUTF and/or medicines
•

Figure 2. Admission and Treatment Flow Chart, Children 6-59 Months With SAM
Screening:
ADMISSION
Measure anthropometry and check bilateral

pitting oedema
Medical History and Physical Examination:

- Evaluate nutritional status and health condition
- Check for medical complications
- Perform the appetite test
If SAM without medical complication and If SAM with medical complication

passed appetite test and/or failed appetite test
medical complication developed,

Admission to decreased appetite, weight loss or Admission to
Outpatient Care stagnant weight, oedema increase Inpatient Care
or no decrease (See Action
Protocol)
TREATMENT
Referral for continuing treatment in

Treatment outpatient care: Treatment
Appetite returning
(passed appetite test)
Oedema decreasing
Medical complication resolving
SAM treatment completed (based on discharge criteria):

Discharge to home, or refer to supplementary feeding and other services that
address underlying causes of malnutrition
21
BOX 7. INFORMATION TO BE RECORDED DURING REFERRAL FROM OUTPATIENT

CARE TO INPATIENT CARE
• Name and sex of child

• Age of child in months
• Name mother/caregiver
• Health facility referred from
• Date of referral
• Health facility destination
• Admission date (if referral is based on action protocol)
• Referral information; if referred based on action protocol, provide:
ο MUAC
ο Bilateral pitting oedema
ο Medical complication
• Treatment provided to the child
• Referral reason and any other comment
STEP 5: Medical Treatment in Outpatient Care

NEW ADMISSION
• Give routine medicines to all children upon admission to outpatient care regardless of their health
insurance (NHIS) status (see Annex 7. Routine Medicines Protocol).
• Check immunisation status. Refer to EPI for completion of immunisations schedule. Facilitate
measles vaccination for infants six months and older.
• Complete the outpatient care treatment card, provide a registration number and decide the entry
category (see Section VI. Monitoring and Reporting).
ROUTINE MEDICAL TREATMENT FOR NEW ADMISSION
Medicines in addition to those listed below may be prescribed to treat other medical problems based
on the condition of the child.
Antibiotic Treatment with Amoxicillin
• Give oral antibiotic treatment for a period of seven days to be taken at home.
• The first dose should be taken during the admission process under the supervision of the health
care provider. An explanation should be given to the caregiver on how to complete the treatment at
home.
Note: Children who are HIV+ or HIV-exposed should be provided with Cotrimoxazole (Septrin)
and linked for care in line with the National Guidelines for Integrated Management of
Neonatal and Childhood Illnesses and the Guidelines on Nutritional Care and Support for
people living with HIV and AIDS.
22
Malaria Treatment
• Systematically screen all children for malaria in endemic areas upon admission regardless of their

body temperature.
• A child with SAM cannot auto-regulate his/her body temperature well and tends to adopt the
temperature of the environment, thus the child will feel hot on a hot day and cool on a cool day.
• If in clinical doubt, repeat the para-check the following week.
• Treat malaria according to the Ghana national treatment protocol for malaria using artesunate and
amodiaquine combined therapy.
• Ghana is malaria-endemic, so all children with SAM should be provided with insecticide-
impregnated bed nets to prevent malaria.
Vitamin A
• Provide vitamin A if it has not been administered in the past month and if there is no bilateral
pitting oedema (see the child health booklet).
• Give a single dose of vitamin A: For children 6-11 months, give 100,000 international units (IU);
for those 12 months and over, give 200,000 IU.
• Cases with bilateral pitting oedema should receive vitamin A when the oedema has gone.
• Refer any child with signs of vitamin A deficiency to inpatient care, as the condition of their eyes
can deteriorate very rapidly.
Deworming Treatment (Antihelminth)
Give a single dose of albendazole or mebendazole at the second visit, after seven days in outpatient care.
Deworming should be given only to children over two years old. Children under two years who have
worms should be treated according to the national protocol.
Measles Vaccination
Give a single vaccine on the fourth week (fourth visit) for children 9-59 months old if they do not have
a record of a previous vaccination. 9
BOX 8. IRON AND FOLIC ACID
• Iron and Folic Acid should not be given routinely to children in the outpatient care. They are available
in the RUTF.
• Where anaemia is identified according to the IMCI guidelines, children are referred to inpatient care.
• Iron and folic acid should not be provided with a malaria treatment.
VACCINATION SCHEDULE UPDATE
Good collaboration is required between the immunisation programme and outpatient care for updating
the vaccination status of the child. Also, it is important to know the schedule of the Child Health
Weeks and if the child participated to avoid double administration of vitamin A. Vaccinators at other
9
If there is a measles epidemic in the area, provide a measles vaccination upon admission to outpatient care.
23
health facilities should be made aware that vitamin A should not be provided to children with bilateral
pitting oedema and that they should refer children with SAM when identified during campaigns or
regular vaccination sessions.
Children who have been referred from inpatient care or another outpatient care site are not given
routine medicines that have already been administered to them but will continue the treatment that was
started earlier. The child’s records and documentation should be checked for details of medications
already given and, where applicable, with the remaining schedule of medications and supplements,
which should be continued according to this protocol.
STEP 6: Dietary Treatment in Outpatient Care

Children receive 200 kcal per kg bodyweight of RUTF daily, given as a take-home ration. A weekly
supply of RUTF is provided depending on the child’s bodyweight (see Table 5). The dietary treatment
is managed in the home, with the children attending outpatient care sessions on a weekly basis to
monitor the health and nutritional status and replenish RUTF stocks.
QUANTITIES OF RUTF TO PROVIDE
• Provide 200 kcal per kg bodyweight per day of RUTF. Use the RUTF look-up tables (Table 5)
for the amounts of RUTF to give in each weekly session based on the child’s weight. One 92 gram
(g) sachet of RUTF provides 500 kcal.
• Explain to the caregiver the daily amount the child will need to consume.
• Give the required RUTF ration to the caregiver and mark it on the RUTF ration card.
Table 5. Look-Up Table for Amounts of RUTF to Give to a Child per Day or Week Based on 92 g
Packets Containing 500 kcal
Weight of Child Packets per Day
Packets per Week
(kg) (200 Kcal/kg bodyweight/day)
3.5 – 3.9 11 1.5
4.0 – 4.9 14 2
5.0 – 6.9 18 2.5
7.0 – 8.4 21 3
8.5 – 9.4 25 3.5
9.5 – 10.4 28 4
10.5 – 11.9 32 4.5
≥ 12 35 5
FEEDING PROCEDURE
• Advise the caregiver to feed the child small amounts of RUTF, to encourage the child to finish the
allocated daily ration before giving any other foods (with the exception of breast milk) and to
encourage the child to eat as often as possible (every three hours during the day).
• Explain to the caregiver that the breastfed child should be offered breast milk on demand and
before being fed RUTF.
• Explain that safe drinking water should be given after feeding the child RUTF to keep the child
hydrated. Caregivers should be advised not to mix RUTF with liquids as this might foster bacteria
growth.
24
• Key messages on providing RUTF are repeated upon every visit to the health facility and include
breastfeeding first, washing hands before feeding and offering safe water during the feeding (see
Annex 16. Key Messages upon Admission).
• Caregivers should be asked to return empty RUTF packets at each follow-on visit.

STEP 7: Counselling, Health, Nutrition and Hygiene Education
UPON ADMISSION
• Provide messages on the use of medicines and RUTF at home only, limiting the counselling to the
key messages. Explain to the caregiver the principles of the treatment:
o Always breastfeed first
o How to feed RUTF to the child
o When and how to give the medicines to the child
o When to return to outpatient care
o That the child should be brought to the health facility immediately if his/her condition
deteriorates
• Ask the caregiver to repeat the messages to be sure they were understood.
AT FOLLOW-ON VISITS
• Provide individual counselling to caregivers on the progress of the nutritional and medical
condition.
• Provide counselling on breastfeeding, complementary feeding, nutrition care for sick children, basic
hygiene, health-seeking behaviour and any other relevant topics as appropriate.
• If there are more than five cases at one given session, provide group health and nutrition education
during the waiting time at the outpatient care session (see Annex 17. Messages for Health and
Nutrition Education).
BOX 9. KEY MESSAGES AT FIRST VISIT
• RUTF 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 eight meals per day). Your child should have ___ packets per day.
• RUTF is the only food sick/thin children need to recover during their time in outpatient care (however,
breastfeeding should continue).
• For young children, continue to breastfeed regularly.
• Always offer the child plenty of clean water to drink or breast milk while he/she is eating RUTF.
• Wash the child’s hands and face with soap 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. Continue to feed RUTF and (if applicable) breast milk.
25
STEP 8: Individual Monitoring During Follow-On Visits at the

Health Facility
Individual monitoring of children with SAM should be carried out by the health care provider upon
weekly (or biweekly) return visits to the health facility or outreach point. The following parameters are
monitored and recorded on the treatment card during the follow-up visit:
ANTHROPOMETRY
• MUAC
• Weight
HISTORY AND PHYSICAL EXAMINATION
• Degree of bilateral pitting oedema (0, +, ++, +++)

• Weight gain
• The weight is compared with the target weight for discharge (see Annex 5. Guidance Table to
Identify Target Weight for Discharge)
• Children who lose weight or have no weight gain or have their weight fluctuating receive
special attention during the medical examination (see Annex 15. Outpatient Care Action
Protocol)
• Body temperature
• Standard clinical signs: stool, vomiting, dehydration, cough, respiration rate
• Appetite test
• Any illness suffered by the child since the last visit
• Any action taken or medication given in response to a health condition
FOLLOW-UP ACTION
• Follow-up action for home visit or referral for medical investigation

• Tracing of absentees and defaulters
At each follow-on visit, the caregiver should be informed of the child’s progress, and individual and/or
group counselling is provided on health and education messages on hygiene and sanitation,
breastfeeding and appropriate complementary foods following the ENA.
STEP 9: Follow-Up Home Visits for Children Requiring Special

Attention
Upon admission, every child is linked to a CHW or volunteer who covers his/her community of
origin. At least one health worker at each outpatient care site should be responsible for coordinating
follow-up visits with the CHW and volunteers. The same person should coordinate screening at the
community level.
The CHW or volunteer will visit children who require special attention in their homes between the
weekly or biweekly sessions to check the child’s health and the caregiver’s compliance with the RUTF
26
protocol, give any needed guidance and provide additional education messages (see Annex 17. Messages
for Health and Nutrition Education).
As outlined in Section III, Step 6: Dietary Treatment in Outpatient Care, follow-up home visits for
children with SAM are essential in the following cases (see Annex 15. Outpatient Care Action

Protocol):
• Losing weight, static weight or deteriorating medical condition
• Not responding to treatment
• Caregivers have refused inpatient care
• Absent or defaulting
The CHW should record all follow-up home visits in the child health record book and report the
results to the responsible health care provider at the health facility they are linked to.
If home visits could not identify a cause for non-response to treatment and the child’s condition is not
improving, the child is referred for a medical investigation. Refer to Step 4: Referral to Inpatient Care
or the criteria for referral to inpatient care based on the action protocol.
STEP 10: Discharge Criteria

BOX 10. CRITERIA AND RECOMMENDATIONS FOR DISCHARGE
Discharge Criteria for Outpatient Care

• The child has attained 15 percent or more weight gain for two consecutive weeks (see Annex 5.
Guidance Table to Identify Target Weight for Discharge)
• No bilateral pitting oedema for two consecutive weeks
• Clinically well and alert
Additional Recommendations
• Nutrition and health education scheme completed
• Appropriate weaning from RUTF
• Immunisation schedule updated
• Adequate arrangements made for linking caregiver and child with appropriate community initiatives
(e.g., CWCs, community-based growth promotion, NRC) and for follow-up
DISCHARGE PROCEDURES
• Give feedback to the caregiver on the final outcome when the child has reached the discharge
criteria (see below).
• Give a final RUTF ration (one week supply).
• Note the discharge outcome (see Table 6 for exit categories) on the treatment card and ration
card/page.
• Advise the caregiver on good nutrition and caring practices.
• Advise the caregiver to immediately go to the nearest health facility if child refuses to eat or has any
of the following signs:
o No appetite
o Vomiting
27
o Lethargic or unconscious
o Convulsions
o Bilateral pitting oedema
o Losing weight
o High fever
o Diarrhoea or frequent watery or bloody stools
o Difficult or fast breathing
• Caregivers should also be referred to complementary nutrition services such as PD/Hearth, CWCs
or community-based growth promotion, if available in the area, which will reinforce CMAM
behaviour change messages or otherwise continue to improve the child’s nutrition status.
The child’s outcome status is classified per exit category, which is indicated on the treatment card.
Table 6. Outpatient Care Exit Categories

Category Definition
Discharged Cured Child 6-59 months meets discharge criteria (see Box 10)
Died Child dies while in outpatient care
Defaulted Child is classified as defaulter on the third consecutive absence (i.e., three weeks absent)
Non-Recovered Child does not reach discharge criteria after four months (16 weeks) in treatment
(medical investigation previously done)
Referred to Child’s health condition is deteriorating (action protocol)
Inpatient Care
28
IV. Inpatient Care for Children 6-59 Months

CHAPTER IV: INPATIENT CARE FOR THE
MANAGEMENT OF SAM WITH MEDICAL
COMPLICATIONS FOR CHILDREN 6-59
MONTHS
Inpatient care for the management of SAM with medical complications can be provided in a specialised
SAM ward or section of a paediatric or children’s ward in a health facility with 24-hour care. Staff in
these facilities should have been specifically trained in the management of SAM and in recognising and
treating SAM with medical complications.
Children 6-59 months with SAM without appetite or with medical complications and children with
SAM being referred from outpatient care following the action protocol (see Annex 15. Outpatient
Care Action Protocol) should be admitted into inpatient care. Children with SAM may also be
admitted to inpatient care because of the caregiver’s choice. In addition, all infants under six months
with SAM are admitted or weighing less that 4.0 kgto inpatient care (see Chapter V. Inpatient Care
for the Management of SAM in Infants 0-6 Months).
Children, upon admission, should be directly assigned to the specific ward, not treated or kept in an
emergency ward or casualty department, unless their medical staff has specific training in the
management of SAM with medical complications. Critical care for children with SAM differs from the
standard protocols and trained medical staff needs to be involved to reduce the risk of death.
Children 6-59 months admitted to inpatient care will be referred to outpatient care as soon as the
medical complications are resolving, the appetite has returned and/or the oedema is reducing. In special
cases, children complete the full treatment in inpatient care. These special cases include:
• Children who are unable to eat RUTF or who continue to refuse it
Note: A child who refuses RUTF should continue to be offered RUTF at each feed as soon as
appetite has returned.
• Severely malnourished infants 0-6 months or weighing less than 4.0 kg
• When the caregiver refuses outpatient care despite being adequately counselled
29
BOX 11. ADDITIONAL GUIDANCE
This section of the Interim National Guidelines for CMAM should be used alongside:
• WHO. 1999. Management of Severe Malnutrition: A Manual for Physicians and Other Senior Health
Workers. Geneva: WHO.
• WHO. 2006. Management of the Child with Serious Infection or Severe Malnutrition: Guidelines for
Care at the First-Referral Level in Developing Countries. WHO Department of Child and Adolescent
Health. Geneva: WHO.
• WHO. 2004. Guiding Principles for Infant and Young Child Feeding in Emergencies, Geneva:
WHO.
4.1 Admission Criteria
BOX 12. ADMISSION CRITERIA FOR INPATIENT CARE FOR CHILDREN 6-59 MONTHS
Bilateral pitting oedema +++

Or
Marasmic kwashiorkor: Any grade of bilateral pitting oedema with severe wasting (MUAC < 11.5 cm)
Or
Bilateral pitting oedema + or ++ or severe wasting (MUAC < 11.5 cm) with any of the following medical
complications:
• Anorexia, no appetite
• Convulsions
• Unconsciousness
• Hypoglycaemia
• High fever (> 39° C axillary and 38.5 for rectal)
• Hypothermia (< 35° C axillary and 35.5 for rectal )
• Severe anaemia
• Skin lesion
Or
• Referred from outpatient care according to action protocol
• Referred from general paediatrics ward
Infants > 6 months and < 4.0 kg will follow the treatment protocol as infants with SAM < 6 months (see
Chapter V).
30
4.2 Admission Procedure

• Admissions to inpatient care are triaged and the most urgent cases treated first. When first seen,
the child should undergo a nutrition and medical assessment (see Annex 6. Checklist for Medical
History and Physical Examination), and a decision should be made on the treatment to be given.
• Ten percent sugar-water or F75 (5 ml/kg) is offered soon after arrival to prevent the risk of or to
treat hypoglycaemia.
• Treatment should start immediately after the medical history is taken and the physical examination
completed.
• Explain to the caregiver the reasons for admission and the procedures that will be followed.
• Complete the inpatient care treatment card (the Critical Care Pathway [CCP]). Record the child’s
details in the registration book. Use the standard registration numbering system.
• If the child was admitted through outpatient care but referred directly to inpatient care, a referral
note or the child health record should be filled out indicating the anthropometry, medical
assessment outcome, criteria for referral and start of treatment.
• The caregiver should receive counselling, including on the treatment of the child, breastfeeding and
good hygiene practices.
• Children in the stabilisation phase and their caregivers should be physically separated from children
in the transition and rehabilitation phases and from children with other diseases.
Figure 3. Timeframe for the Management of SAM in Children (WHO 2003)

Stabilisation Rehabilitation
(Phase 1) (Phase 2)
Days 1 – 2 Days 3 – 7 Weeks 2 – 6
1. Hypoglycaemia
2. Hypothermia
3. Dehydration
4. Electrolytes
5. Infection No iron With iron
6. Micronutrients
7. Cautious feeding
8. Catch-up growth
9. Sensory stimulation
10. Prepare for follow-up
4.3 Stabilisation Phase

4.3.1 STEP 1: TREAT/PREVENT HYPOGLYCAEMIA
Hypoglycaemia and hypothermia usually occur together and are signs of infection. Check for
hypoglycaemia whenever hypothermia (axillary temperature < 35.0° C; rectal temperature < 35.5° C)
is found. Frequent feeding is important in preventing both conditions.
Treatment
If the child is conscious and Dextrostix shows < 3 mmol/L or 54 mg/dl, give:
• 50 ml of 10 percent glucose or 10 percent sucrose solution (one rounded teaspoon of sugar in 3
31
tablespoons water) orally or by nasogastric tube (NGT), then feed F75 (see Step 7: Start Cautious
Feeding) every 30 minutes for two hours, giving one-quarter of the two-hour feed each time
• Antibiotics (see Step 5: Treat/Prevent Infection)
• Two-hourly feeds, day and night (see Step 7: Start Cautious Feeding)
If the child is unconscious, lethargic or convulsing, give:

• Intravenous (IV) sterile 10 percent glucose solution (5 ml/kg of body weight), followed by 50 ml
of 10 percent glucose or sucrose solution by NGT, then give F75 as above
• Antibiotics
• Two-hourly feeds, day and night
Monitor
• Blood glucose:
o If this is low, repeat Dextrostix, taking blood from finger or heel, after two hours; once
treated, most children stabilise within 30 minutes
o If blood glucose falls to < 3 mmol/L, give a further 50 ml of 10 percent glucose or
sucrose solution and continue feeding every 30 minutes until stable
• Rectal temperature: If this falls to < 35.5° C, repeat Dextrostix
• Level of consciousness: If this deteriorates, repeat Dextrostix
Prevention
• Give two-hourly feeds, start straightaway (see Step 7: Start Cautious Feeding) or rehydrate first if
necessary.
• Always give feeds throughout the day and night.
Note: If you are unable to test the blood glucose level, assume all severely acutely malnourished
children are hypoglycaemic and treat accordingly.
4.3.2 STEP 2: TREAT/PREVENT HYPOTHERMIA
Treatment
If the axillary temperature is < 35.0° C, take the rectal temperature using a low-reading thermometer.
If the rectal temperature is < 35.5° C:
• Feed straightaway (or start rehydration if needed).
• Re-warm the child: Either clothe the child (including head), cover with a warmed blanket and place
a heater or lamp nearby (do not use a hot water bottle), or put the child on the mother’s bare chest
(skin to skin) and cover both of them.
• Give antibiotics (see Step 5: Treat/Prevent Infection).
Monitor
• Body temperature: During re-warming take rectal temperature two-hourly until it rises to > 36.5°
C (take half-hourly if heater is used).
• Ensure the child is covered at all times, especially at night.
• Feel for warmth.
32
• Blood glucose level: Check for hypoglycaemia whenever hypothermia is found.

Prevention
• Give two-hourly feeds, start straightaway (see Step 7: Start Cautious Feeding).
• Always give feeds throughout the day and night.
• Keep the child covered and away from draughts.
• The health care provider or caregiver should warm his/her hands before touching the child.
• Keep the child dry; change wet nappies, clothes and bedding.
• Avoid exposure (e.g., bathing, prolonged medical examinations).
• Let child sleep with mother/caregiver at night for warmth.
• Maintain room temperature 25° C to 36.5° C (77° F to 86° F).
Note: If a low-reading thermometer is unavailable and the child’s temperature is too low to register
on an ordinary thermometer, assume the child has hypothermia.
4.3.3 STEP 3: TREAT/PREVENT DEHYDRATION
Note: Low blood volume can coexist with oedema. Do not use the IV route for rehydration except in
cases of shock and then do so with care, infusing slowly to avoid flooding the circulation and
overloading the heart.
Treatment
The standard oral rehydration solution (ORS) (90 mmol sodium/L) or low osmolarity ORS
(75mmol sodium/L) contains too much sodium and too little potassium for children with SAM.
Instead, give special Rehydration Solution for Malnutrition (ReSoMal) (see Annex 12. Alternate
Recipes for F75, F100 and ReSoMal Using CMV for the recipe). It is difficult to estimate
dehydration status in a child with SAM using clinical signs alone. Therefore, assume that all children
with watery diarrhoea may have dehydration and give ReSoMal 5 ml/kg every 30 minutes for two
hours, orally or by NGT, then ReSoMal 5-10 ml/kg/hour for the next four to 10 hours. The exact
amount to be given should be determined by how much the child wants, stool loss and vomiting.
In Case of Bilateral Pitting Oedema
Replace the ReSoMal doses at four, six, eight and 10 hours with F75 if rehydration is continuing at
these times, then continue feeding F75 (see Step 7: Start Cautious Feeding).
During treatment, rapid respiration and pulse rates should slow down and the child should begin to
pass urine.
Monitor the Progress of Rehydration
Observe the child every 30 minutes for two hours, then hourly for the next six to 12 hours, recording:
• Pulse rate
• Respiratory rate
• Urine frequency
• Stool/vomit frequency
33
Return of tears, moist mouth, eyes and fontanel appearing less sunken, and improved skin turgor 10 are
also signs that rehydration is proceeding. It should be noted that many children with SAM will not
show these changes even when fully rehydrated. Continued rapid breathing and pulse during
rehydration suggest coexisting infection or overhydration. Signs of excess fluid (overhydration) are
increasing respiratory and pulse rates, increasing oedema and puffy eyelids. If these signs occur, stop
fluids immediately and reassess after one hour.
Prevention
To prevent dehydration when a child has continuing watery diarrhoea:

• Keep feeding with F75 (see Step 7: Start Cautious Feeding).
• Replace the approximate volume of stool losses with ReSoMal. As a guide, give 50-100 ml after
each watery stool.
(Note: It is common for severely acutely malnourished children to pass many small unformed
stools. These should not be confused with profuse watery stools and do not require fluid
replacement.)
• If the child is breastfed, encourage the caregiver to continue.
4.3.4 STEP 4: CORRECT ELECTROLYTE IMBALANCE
All severely acutely malnourished children have excess body sodium even though plasma sodium might
be low (giving high sodium loads will kill). Potassium and magnesium deficiencies are also present and
might take at least two weeks to correct. Oedema is partly due to these imbalances. Do NOT treat
oedema with a diuretic.
Give:
• Extra potassium (3-4 mmol/kg/day)
• Extra magnesium (0.4-0.6 mmol/kg/day)
• Low sodium rehydration fluid (e.g., ReSoMal) when rehydrating
• Food prepared without salt
The extra potassium and magnesium can be prepared in a liquid form and added directly to feeds
during preparation. When the combined mineral and vitamin mix (CMV) for SAM is available
commercially, the CMV replaces the electrolyte/mineral solution and multivitamin and folic acid
supplements mentioned above (see Annex 12. Alternative Recipes for F75, F100 and ReSoMal Using
CMV). However, a large single dose of vitamin A and folic acid on Day 1 and iron daily after weight
gain has started should still be given.
4.3.5 STEP 5: TREAT/PREVENT INFECTION
In SAM, the usual signs of infection, such as fever, are often absent and infections are often hidden.
Therefore give routinely on admission:
• Broad-spectrum antibiotic(s) and
• Measles vaccine if the child is over six months and not immunised (delay if the child is in shock
and there is bilateral pitting oedema)
Note: Some experts routinely give, in addition to broad-spectrum antibiotics, metronidazole (7.5
10
Skin turgor is a sign commonly used by health workers to assess the degree of fluid loss or dehydration.
34
mg/kg eight-hourly for seven days) to hasten repair of the intestinal mucosa and reduce the

risk of oxidative damage and systemic infection arising from the overgrowth of anaerobic
bacteria in the small intestine.
Choice of broad-spectrum antibiotics (see Annex 9. Drug Doses):

• If the child appears to have no complications, give oral amoxicillin for five to seven days according
to the national protocol.
• If the child is severely ill (apathetic, lethargic) or has medical complications (hypoglycaemia,
hypothermia, skin lesions, respiratory tract or urinary tract infection) give:
o Ampicillin 50 mg/kg intramuscular (IM)/IV six-hourly for two days, then oral
amoxicillin 15 mg/kg eight-hourly for five days or, if amoxicillin is not available, continue
with ampicillin but give orally 50 mg/kg six-hourly
And
o Gentamicin 7.5 mg/kg IM/IV once daily for seven days
• If the child fails to improve clinically within 48 hours, add chloramphenicol 25 mg/kg IM/IV
eight-hourly for five days.
Where specific infections are identified, add:

• Specific antibiotics if appropriate
• Antimalarial treatment if the child has a positive blood film for malaria parasites
If anorexia persists after five days of antibiotic treatment, complete a full 10-day course. If anorexia still
persists, reassess the child fully, checking for infection and potentially resistant organisms, and ensure
that vitamin and mineral supplements have been correctly given.
4.3.6 STEP 6: CORRECT MICRONUTRIENT DEFICIENCIES
All children with SAM have vitamin and mineral deficiencies. Although anaemia is common, iron
should not be given until the child has a good appetite and starts gaining weight (usually by the second
week in outpatient care), as giving iron can make infections worse. Make sure the child is tested and
treated for malaria before providing iron.
For children who show signs of deficiency, provide vitamin A orally on Day 1 (for age > 12 months,
give 200,000 IU; for age 6-12 months, give 100,000 IU; for age 0-5 months, give 50,000 IU) unless
there is definite evidence that a dose has been given in the past month. If bilateral pitting oedema is
present, provision of vitamin A is delayed until the oedema is resolved.
Give the following daily:

• Multivitamin supplement
• Folic acid 1 mg/day (give 5 mg on Day 1)
• Zinc 2 mg/kg/day
• Copper 0.3 mg/kg/day
• Iron 3 mg/kg/day but only when the child starts gaining weight and is tested and treated for
malaria; iron supplementation is not needed if the child consumes RUTF
Adding a half levelled scoop of CMV to 1 L of feed will supply the zinc and copper needed, as well as
potassium and magnesium. Annex 12. Alternative Recipes for F75, F100 and ReSoMal Using CMV.
Note: When CMV for SAM is available commercially, it replaces the electrolyte/mineral solution
and multivitamin and folic acid supplements mentioned in Step 4 correct electrolyte imbalance
35
and step 6, correct micronutrient deficiencies, but the large single dose of vitamin A and folic
acid on Day 1 and iron daily after weight gain has started should still be given.
4.3.7 STEP 7: START CAUTIOUS FEEDING
A cautious approach is required in the inpatient phase because of the child’s fragile physiological state
and reduced homeostatic capacity. Feeding should be started as soon as possible after admission and
should be designed to provide just sufficient energy and protein to maintain basic physiological
processes.
The essential features of feeding in the inpatient phase are:
• Small, frequent feeds of low osmolarity and low lactose
• Oral or nasogastric feeds (never parenteral preparations)
• 100 kcal/kg/day, 1-1.5 g protein/kg/day
• 130 ml/kg/day of fluid (100 ml/kg/day if the child has severe oedema) (Tables 7 and 8 provide
look-up tables for volumes of F75.) If the child is breastfed, encourage continued breastfeeding but
give the prescribed amounts of F75 following breastfeeding to make sure the child’s needs are met.
The suggested therapeutic diet and feeding schedules (see sub-sections below) are designed to meet the
daily requirements for the child. Milk-based diets, such as F75, containing 75 kcal/100 ml and 0.9 g
protein/100 ml, are satisfactory for most children. Give milk from a cup. Very weak children may be
fed by spoon, dropper or syringe.
For children with a good appetite and no oedema, the stabilisation phase can be completed in two to
three days. Tables 7 and 8 show the volume/feed already calculated according to body weight. Use the
Day 1 weight to calculate how much to give, even if the child loses or gains weight in this phase.
During the stabilisation phase, feeds should be provided at least every three hours (eight feeds per day)
to prevent hypoglycaemia. It is important that feeds be provided to the child during the day and night.
Breastfed children should be offered breast milk on demand before being fed F75.
36
Table 7. Stabilisation Phase Look-Up Tables for Volume of F75 for Persons With Severe Wasting

(“Marasmus”) of Different Weights
Weight of Volume of F75 per feed (ml)a Daily total 80% of daily totala
child (kg) Every 2 Every 3 hours c Every 4 hours (130 ml/kg) (minimum)
hours b
(8 feeds) (6 feeds)
(12 feeds)
2.0 20 30 45 260 210
2.2 25 35 50 286 230
2.4 25 40 55 312 250
2.6 30 45 55 338 265
2.8 30 45 60 364 290
3.0 35 50 65 390 310
3.2 35 55 70 416 335
3.4 35 55 75 442 355
3.6 40 60 80 468 375
3.8 40 60 85 494 395
4.0 45 65 90 520 415
4.2 45 70 90 546 435
4.4 50 70 95 572 460
4.6 50 75 100 598 480
4.8 55 80 105 624 500
5.0 55 80 110 650 520
5.2 55 85 115 676 540
5.4 60 90 120 702 560
5.6 60 90 125 728 580
5.8 65 95 130 754 605
6.0 65 100 130 780 625
6.2 70 100 135 806 645
6.4 70 105 140 832 665
6.6 75 110 145 858 685
6.8 75 110 150 884 705
7.0 75 115 155 910 730
7.2 80 120 160 936 750
7.4 80 120 160 962 770
7.6 85 125 165 988 790
7.8 85 130 170 1,014 810
8.0 90 130 175 1,040 830
8.2 90 135 180 1,066 855
8.4 90 140 185 1,092 875
8.6 95 140 190 1,118 895
8.8 95 145 195 1,144 915
9.0 100 145 200 1,170 935
9.2 100 150 200 1,196 960
9.4 105 155 205 1,222 980
9.6 105 155 210 1,248 1,000
9.8 110 160 215 1,274 1,020
10.0 110 160 220 1,300 1,040
a
Volumes in these columns are rounded to the nearest 5 ml.
b
Give two-hourly feeds for at least the first day. When there is little or no vomiting, diarrhoea is modest (< 5
watery stools per day) and the child is finishing most feeds, change to three-hourly feeds.
c
After a day on three-hourly feeds, if there is no vomiting, less diarrhoea and the child is finishing most feeds,
change to four-hourly feeds.
37
Table 8. Stabilisation Phase Look-Up Tables for Volume of F75 for Persons With Severe Bilateral
Pitting Oedema (“Kwashiorkor”) (+++)
Weight with Volume of F75 per feed (ml) a Daily total 80% of daily
+++ oedema Every 2 (100 ml/kg) total
Every 3 hours c Every 4 hours
(kg) hours b (minimum)
(8 feeds) (6 feeds)
(12 feeds)
3.0 25 40 50 300 240
3.2 25 40 55 320 255
3.4 30 45 60 340 270
3.6 30 45 60 360 290
3.8 30 50 65 380 305
4.0 35 50 65 400 320
4.2 35 55 70 420 335
4.4 35 55 75 440 350
4.6 40 60 75 460 370
4.8 40 60 80 480 385
5.0 40 65 85 500 400
5.2 45 65 85 520 415
5.4 45 70 90 540 430
5.6 45 70 95 560 450
5.8 50 75 95 580 465
6.0 50 75 100 600 480
6.2 50 80 105 620 495
6.4 55 80 105 640 510
6.6 55 85 110 660 530
6.8 55 85 115 680 545
7.0 60 90 115 700 560
7.2 60 90 120 720 575
7.4 60 95 125 740 590
7.6 65 95 125 760 610
7.8 65 100 130 780 625
8.0 65 100 135 800 640
8.2 70 105 135 820 655
8.4 70 105 140 840 670
8.6 70 110 145 860 690
8.8 75 110 145 880 705
9.0 75 115 150 900 720
9.2 75 115 155 920 735
9.4 80 120 155 940 750
9.6 80 120 160 960 770
9.8 80 125 165 980 785
10.0 85 125 165 1,000 800
10.2 85 130 170 1,020 815
10.4 85 130 175 1,040 830
10.6 90 135 175 1,060 850
10.8 90 135 180 1,080 865
11.0 90 140 185 1,100 880
11.2 95 140 185 1,120 895
11.4 95 145 190 1,140 910
11.6 95 145 195 1,160 930
11.8 100 150 195 1,180 945
12.0 100 150 200 1,200 960
a
Volumes in these columns are rounded to the nearest 5 ml.
b
Give two-hourly for at least the first day. When there is little or no vomiting, diarrhoea is modest (< 5
watery stools per day) and the child is finishing most feeds, change to three-hourly feeds.
c
After a day on three-hourly feeds, if there is no vomiting, less diarrhoea and the child is finishing most feeds,
change to four-hourly feeds.
38
Feed Preparation

• For a large number of children:
Add one packet of F75 to 2 L of water. The water needs to be boiled and cooled prior to mixing.
• For few children:
Smaller volumes can be prepared by measuring small amounts of F75 using the red scoop. Add 20
ml boiled and cooled water per one red scoop of F75 powder.
If pre-packaged F75 is not available, use one of the recipes to prepare F75 using locally available
ingredients and (imported) CMV (see Annex 12. Alternative Recipes for F75, F100 and ReSoMal
Using CMV).
Feeding Procedure
Feed by cup and saucer. Only feed with a NG tube when the child is unable to take sufficient F75 by
mouth. A sufficient amount is defined as intake of 80 percent of the milk. The use of the NG tube
should not exceed three days and should only be used in the stabilisation phase.
BOX 13. REASONS FOR USING AN NG TUBE TO FEED THE CHILD DURING
STABILISATION
An NG tube should be used if the child:

• Takes less than 80 percent of the prescribed diet per 24 hours during stabilisation
• Has pneumonia (rapid respiration rate) and difficulty swallowing
• Has painful lesions/ulcers of the mouth
• Has a cleft palate or other physical deformity
• Is very weak and shows difficulty remaining conscious
Feeding Technique
Aspiration pneumonia is very common in severely malnourished children due to muscle weakness and
slow swallowing. Therefore, applying the correct feeding technique is important to ensure the child has
an adequate milk intake.
The child should be on the caregiver’s lap against his/her chest with one arm behind his/her back. The
child should be sitting straight (vertical). The caregiver’s arm should encircle the child and the caregiver
should hold a saucer under the child’s chin. The F75 is given by cup, and any dribbles that fall into the
saucer are returned to the cup. The child should never be force-fed, have his/her nose pinched or lie
back and have the milk poured into his/her mouth.
Meal times should be sociable. The caregivers should sit together in a semi-circle around an assistant
who talks to the caregivers, encourages them, corrects any faulty feeding technique and observes how
the child takes the milk.
The meals for the caregivers should be organised by the health facility. The caregivers’ meals should
never be taken beside the child. Sharing of the meal with the child can be dangerous given their delicate
pathophysiology. If the caregiver’s meal has added salt or condiments, it can be sufficient to provoke
heart failure in children with SAM.
39
4.3.8 MONITORING DURING THE STABILISATION PHASE
Individual monitoring of children with SAM in the stabilisation phase should be done continuously.
Based on improvement in the child’s condition, a decision can be made on progression to the next
phase of treatment. The following parameters should be monitored daily:
• Weight is measured at the same time (before or after feeds), and entered and plotted on the
inpatient treatment card (the CCP).
• The degree of oedema (0, +, ++, +++) is assessed.
• Body temperature, pulse and respiration is measured every four hours.
• Standard clinical signs (stool, vomiting, dehydration, cough ) are monitored, and skin condition
and peri-anal lesions are assessed and noted on the CCP.
• MUAC is taken upon admission and thereafter on each seventh day.
• A record is taken (on the24 hour food intake form) if the patient is absent, vomits or refuses a
feed, and whether the patient is fed by NG tube or is given an IV infusion or transfusion. There
are appropriate places for these to be recorded each day.
During the inpatient phase, diarrhoea should gradually diminish, and children with bilateral pitting
oedema should start losing weight. If diarrhoea continues despite cautious re-feeding or worsens
substantially, re-evaluate the child.
4.3.9 CRITERIA TO PROGRESS FROM THE STABILISATION PHASE TO THE

TRANSITION PHASE
• The appetite has returned (the child easily finishes all F75 milk during three-hourly feeds).
• Bilateral pitting oedema is resolving (accompanied by weight loss).
• No serious medical problems, such as vomiting, watery diarrhoea, dehydration, naso gastric feeding,
respiratory distress or any complication that requires IV infusion, are present.
4.4 Transition Phase

4.4.1 TRANSITION USING RUTF
The transition phase prepares the child for outpatient care and can last up to three days. RUTF is
gradually introduced in this phase. The acceptability of RUTF is tested by offering it to the child at
every feeding. When the child eats at least 75 percent of the required amount of RUTF, then the child
is ready for discharge to outpatient care to continue treatment.
Once the child can meet his/her nutritional needs on RUTF alone, has regained appetite and the
medical complications are resolving, he/she will be ready for referral to outpatient care and continue
treatment at home. Before referring the child to outpatient care, he/she should be observed for at least
24 hours eating RUTF to ensure he/she does not develop complications. The child should start
gaining weight. If a child’s medical condition requires referral to another medical facility, he/she
should continue his/her nutritional treatment there. A supply of RUTF is provided.
40
Medical Treatment During Transition

If routine medicines and supplements are provided, follow the schedule as described in outpatient care.
Routine antibiotic therapy should be continued for four more days after stabilisation. If a child has to
complete his/her antibiotic schedule while in outpatient care, then this should be noted on the child’s
referral from inpatient to outpatient care card, which will be used to continue treatment in outpatient
care.
Dietary Treatment During Transition
Mixed feeds are introduced during the transition phase. Gradual introduction of RUTF is promoted as
soon as appetite has returned. Some children might initially refuse the RUTF; continue to offer RUTF
at every feed until they eat the full diet.
The diet should provide an average increase in energy intake of about one-third daily over the amount
given during the stabilisation phase, i.e., 150 kcal/kg bodyweight/day.
Table 9. Look-Up Table for Amounts of RUTF to Give to a Child per Day Based on 92 g Packets
Containing 500 kcal
Weight of the Child Packets per day 75% of daily prescribed amount
(kg) (200 kcal/kg bodyweight/day) (150 kcal/kg bodyweight/day)
3.5 – 3.9 1½ 1¼
4.0 – 4.9 2 1½
5.0 – 6.9 2½ 2¼
7.0 – 8.4 3 2½
8.5 – 9.4 3½ 2¾
9.5 – 10.4 4 3¼
10.5 – 11.9 4½ 3½
≥12 5 4
RUTF Quantities
• RUTF look-up tables provide RUTF quantities of the individual child per day according to the
child’s weight.
• A full day’s amount of RUTF is given to the caregiver and the amount taken should be checked
five times during the day.
• When the child is taking more than 75 percent of the daily prescribed amount of RUTF, he/she
should be referred to outpatient care and continue treatment at home (see Section 4.4.3).
Feeding Procedure
• Provide the RUTF to the caregiver to feed the child.

• The caregiver should be encouraged to provide small, frequent RUTF feeds every four hours (five
to six times per day).
• Breastfed children should be offered breast milk on demand before being fed RUTF.
• Children should be offered as much water to drink as they will take during feed and after they have
taken some of the RUTF.
41
4.4.2 TRANSITION FOR SPECIAL CASES (CHILDREN WHO CANNOT

CONSUME RUTF)
In rare cases, some children will not consume RUTF. In these circumstances, children should be put on
F100 according to the 1999 WHO treatment protocol.
Quantities of F100 for Children Who Do Not Take RUTF
• The volume of feeds remains the same as in the stabilisation phase.

• Give 130 ml of F100 (150 kcal) per kg bodyweight per day.
• Use the F100 look-up table (Table 10) for the volume of F100 to give per feeding according to
the child’s bodyweight.
Feed Preparation of F100

Add one packet of F100 to 2 L of water (the water needs to be boiled and cooled prior to mixing).
• For few children:
Smaller volumes can be prepared by measuring small amounts of F100 using the red scoop (add 18
ml water per red scoop of F100 powder).
If pre-packaged F100 is not available, use one of the recipes given (see Annex 12. Alternative Recipes
for F75, F100 and ReSoMal Using CMV) to prepare F100 using locally available ingredients and
CMV.
Feeding Procedure
• Procedures and timing of F100 feeds in the transition phase are the same as in the stabilisation
phase.
• Breastfed children should be offered breast milk on demand before being fed F100.
• Never force-feed the child.
4.4.3 MONITORING DURING THE TRANSITION PHASE
In the transition phase, individual monitoring of severely malnourished children is done daily. Based on
improvements in the child’s condition, a decision should be made on progression to the next phase:
referral to outpatient care to continue rehabilitation or maintenance in inpatient care until full recovery.
Patients with bilateral pitting oedema (kwashiorkor) should remain in the transition phase until there is
a definite and steady reduction in oedema.
The following parameters should be monitored daily and entered on the inpatient treatment card
[Critical Care Pathway (CCP)]:
• Weight
• Degree of oedema (0 to +++)
• Body temperature, pulse and respiration
• Standard clinical signs; stool, vomiting, dehydration, cough, respiration and liver size
• MUAC is taken each week
• Other record: e.g., absent, vomits, refuses a feed
42
• Mood or smile

4.4.4 PROGRESSION FROM THE TRANSITION PHASE
Recovering children 6-59 months can progress to outpatient care. Very few remain in inpatient care,
only those who cannot eat RUTF. Infants under six months will remain in inpatient care until full
recovery. Children with problems are returned to the stabilisation phase.
Criteria to Progress from the Transition Phase to the Rehabilitation Phase
From the Transition Phase to Outpatient Care
• A good appetite: The child passes the appetite test and takes more than 75 percent of the daily
RUTF ration
• Oedema reducing to moderate (+ +) or mild (+)
• Resolving medical complication
From the Transition Phase to the Rehabilitation Phase in Inpatient Care (for the Very Few Exceptions
Who Cannot Transition to RUTF)
• A good appetite: The child takes at least all of the F100 prescribed for the transition phase (150
kcal/kg/day)
• Oedema reducing to moderate (+ +) or mild (+)
• Resolving medical complication
Criteria to Move Back From the Transition Phase to the Stabilisation Phase
The child should be moved back to the stabilisation phase if there is:
• Weight gain of more than 10 g/kg/day in association with an increase in respiratory rate: this is
indicative of excess fluid retention
• Increasing or developing oedema
• Rapid increase in the size of the liver
• Any signs of fluid overload
• Tense abdominal distension
• Significant refeeding diarrhoea leading to weight loss
Note: It is common for children to have some change in stool frequency when they change diet.
This does not need to be treated unless the children lose weight. Having several loose stools
without weight loss is not a criterion to move back to the stabilisation phase.
• A complication that necessitates an intravenous infusion
• A need for feeding by NG tube
43
4.5. Rehabilitation Phase (Catch-Up Growth)

4.5.1 PREPARE FOR FOLLOW-UP OF CHILDREN IN OUTPATIENT CARE
Some children progressing from the transition phase will still require inpatient care and should be
moved to the inpatient rehabilitation phase. This phase is associated with full recovery and rapid catch-
up of lost weight.
Children progressing to the rehabilitation phase who are on an RUTF diet can be discharged from
inpatient care to outpatient care and monitored weekly in the outpatient department of the same health
facility if there is no possibility to refer the child to a health facility with outpatient care in or close to
his/her community. (Chapter III. Outpatient Care for the Management of SAM Without Medical
Complications provides details on weekly and biweekly monitoring.)
4.5.2 MEDICAL TREATMENT
Routine medicines and supplements should follow the schedule as described in outpatient care.
The medical part of the treatment for SAM is likely to be completed at this stage. There should be no
serious medical complications, and the child should have a good appetite. The child is expected to be
consuming large amounts of his/her diet and gaining weight rapidly.
Routine medicines (See Section III, Step 5: Routine Medications in Outpatient Care and Annex 7.
Routine Medicines Protocols):
• De-worming medicine (anti-helminth) if the child is more than 24 months (two years)
• Measles vaccination at week four
• If the child is rehabilitating on F100: Iron sulphate is added to F100 (one crushed tablet – 200 mg
of iron sulphate – is added to 2-2.4 L of F100) or provide daily doses of Iron syrup orally
• If the child is on RUTF: Do not give additional iron as it already contains the necessary iron.
Table 10. Doses of iron syrup if F100 is used during rehabilitation (catch up growth)
Weight of child Doses of Iron Syrup:
Ferrous Fumarate, 100mg per 5 ml
(20g elemental iron per ml)
3 up to 6 kg 0.5 ml
6 up to 10 kg 0.75 ml
10 up to 15 kg 1 ml
Note that the amounts in the above dosages are very small (less than ¼ teaspoon) and will need to be
measured with a syringe
4.5.3 DIETARY TREATMENT
• Children who are not taking RUTF as inpatients are fed F100.
• Provide F100 according to child’s bodyweight.
• Give four-hourly feeds of F100 per day.
• Breastfed children over 6 months old should be offered breast milk on demand before being fed
F100.
44
• Note: Children weighing less than 4 kg must be given F100-Diluted. They should never be given

full-strength F100. (See regimen in Chapter V. Inpatient Care for the Management of SAM in
Infants 0-6 Months Old.)
Quantities of F100
• Give 200 ml of F100 (200 kcal) per kg bodyweight per day.

• Use the look-up tables (Table 11) for the volume of F100 to give per feed in the inpatient
rehabilitation phase according to child’s bodyweight.
45
Table 11. Inpatient Rehabilitation Phase Look-Up Table for Quantity of F100 to Give to an
Individual Child per Feed
Weight of Range of volumes per Range of volumes per Range of daily volumes of F-100
child (kg) three-hourly feed of F- four-hourly feed of F-100
100 (6 feeds daily) *
(8 feeds daily) *
Minimum Maximum Minimum Maximum Minimum (150 Maximum (220
ml ml ml ml ml/kg/day) ml/kg/day)
2.0 40 55 50 75 300 440
2.2 40 60 55 80 330 484
2.4 45 65 60 90 360 528
2.6 50 70 65 95 390 572
2.8 55 75 70 105 420 616
3.0 55 85 75 110 450 660
3.2 60 90 80 115 480 704
3.4 65 95 85 125 510 748
3.6 70 100 90 130 540 792
3.8 70 105 95 140 570 836
4.0 75 110 100 145 600 880
4.2 80 115 105 155 630 924
4.4 85 120 110 160 660 968
4.6 85 125 115 170 690 1,012
4.8 90 130 120 175 720 1,056
5.0 95 140 125 185 750 1,100
5.2 100 145 130 190 780 1,144
5.4 100 150 135 200 810 1,188
5.6 105 155 140 205 840 1,232
5.8 110 160 145 215 870 1,276
6.0 115 165 150 220 900 1,320
6.2 115 170 155 230 930 1,364
6.4 120 175 160 235 960 1,408
6.6 125 180 165 240 990 1,452
6.8 130 180 170 250 1,020 1,496
7.0 130 195 175 255 1,050 1,540
7.2 135 200 180 265 1,080 1,588
7.4 140 205 185 270 1,110 1,628
7.6 145 210 190 280 1,140 1,672
7.8 145 215 195 285 1,170 1,716
8.0 150 220 200 295 1,200 1,760
8.2 155 225 205 300 1,230 1,804
8.4 158 230 210 310 1,260 1,848
8.6 160 235 215 315 1,290 1,892
8.8 165 240 220 325 1,320 1,936
9.0 170 250 225 330 1,350 1,980
9.2 175 255 230 335 1,380 2,024
9.4 175 260 235 345 1,410 2,068
9.6 145 265 240 350 1,140 2,112
9.8 185 270 245 360 1,470 2,156
10.0 190 275 250 365 1,500 2,200
* Volumes per feed are rounded to the nearest 5 ml.
46
Preparation of F100

Add one packet of F100 to 2 L of water (the water needs to be boiled and cooled prior to mixing).
• For a small number of children:
Smaller volumes can be prepared by measuring small amounts of F100 using the red scoop (add 18
ml water per one red scoop of F100 powder).
If pre-packaged F100 is not available, use one of the recipes given (see Annex 12. Alternative Recipes
for F75, F100 and ReSoMal Using CMV) to prepare F100 using locally available ingredients and
CMV.
Feeding Procedure
• Feed by cup and saucer.

• Breastfed children should be offered breast milk on demand before being fed F100.
• After the feed, always offer an additional quantity to the child if he/she takes all the feed given
quickly and easily. The child should be able to take as much as F100 as he/she wants.
4.5.4 INDIVIDUAL MONITORING
Individual monitoring of the recovering child in the inpatient care rehabilitation phase is done daily.
The following parameters should be monitored daily and recorded on the inpatient treatment card
(CCP):
• Weight
• Degree of oedema (0 to +++)
• Body temperature, respiration and pulse
• Standard clinical signs: stool, vomiting, dehydration, cough, respiration
• MUAC each week
• Other records, e.g., absent, vomits, refuses a feed
• A full medical examination is done every two days
4.5.5 CRITERIA TO MOVE BACK FROM THE REHABILITATION PHASE TO

THE STABILISATION PHASE IN INPATIENT CARE
If a child develops any signs of a medical complication while receiving treatment in outpatient care,
he/she should be referred back to the stabilisation phase in the inpatient care facility. Routine drugs
are individually prescribed depending on what has already been given and the cause of the referral (see
Annex 15. Outpatient Care Action Protocol).
4.5.6 PROGRESSION FROM THE REHABILITATION PHASE TO DISCHARGE
Based on the child fulfilling the discharge criteria, a decision can be made to discharge the child to
his/her home or for referral to other health, nutrition and livelihood services that seek to address some
of the underlying causes of malnutrition at the household level.
47
4.6 Provide Sensory Stimulation and Emotional Support

Children with SAM have delayed mental and behavioural development. To address this, sensory
stimulation should be provided to the children throughout the period they are in inpatient care.
Provide:
• Tender loving care
• A cheerful, stimulating environment
• Structured play therapy for 15-30 minutes per day (See Annex 18. Play and Stimulation)
• Maternal involvement when possible for, e.g., comforting, feeding, bathing, play
4.7 Failure to Respond to Treatment in Inpatient Care

Some children undergoing inpatient care might show failure to respond to treatment or exhibit
deterioration in their condition at different stages of the treatment. The most frequent causes of failure
to respond to inpatient treatment are listed in Box 14. Failure to achieve initial improvement at the
expected rate is termed primary failure to respond to treatment. Primary failure to respond can be
attributed to unrecognised infection or drug-resistant infections such as bacterial (TB), viral (measles,
hepatitis B, HIV) or parasitic (malaria) infections. On the other hand, deterioration in a child’s
condition when a satisfactory response has been established is termed secondary failure to respond to
treatment. Secondary failure might be due to acute infection contracted during inpatient care,
reactivation of infection as immune and inflammatory responses recover, as well as insufficiency in
essential nutrients in the diet provided to the child.
Table 12. Criteria for Failure to Respond to Treatment

Criteria Time after admission
Primary failure to respond
Failure to regain appetite Day 4 – 7
Failure to start to lose oedema Day 4 – 7
Oedema still present Day 10
Failure to gain at least 5 g/kg bodyweight Day 10
Secondary failure to respond
Failure to gain at least 5 g/kg bodyweight/day for 3 During inpatient care - rehabilitation
successive days phase
A child undergoing treatment for SAM and who meets any of the above criteria should be diagnosed as
failing to respond to treatment. When such a diagnosis is made, it is essential that an extensive medical
evaluation of the child be carried out (i.e., medical history, physical examination, laboratory
investigations of urine and stool samples). Overall case-management practices of these children should
be reviewed (e.g., evaluation of adherence to treatment protocol, availability of trained staff).
“Failure to respond to treatment” should be recorded on the individual treatment chart and the child
should be scheduled to be seen by more senior and experienced staff. Furthermore, corrective measures
should be taken to strengthen specific areas that need improvement in the practice of managing SAM
while ensuring that treatment protocols are adhered to and that adequate supervision is given to staff.
48
Frequent Causes of Failure to Respond

The most frequent causes of failure to respond to inpatient treatment are listed in Box 14.
BOX 14. FREQUENT CAUSES OF FAILURE TO RESPOND TO INPATIENT TREATMENT
Problems related to the health facility:

• Poor environment for malnourished children
• Lack of adherence to treatment protocols for SAM
• Failure to treat malnourished children in a separate area
• Failure to complete the individual treatment card (multi-chart) correctly, resulting in gaps in data for
monitoring the child’s progress
• Insufficient staff (particularly at night) or inadequately trained staff
• Inadequate supervision and constant rotation of staff in the treatment facility
• Inaccurate weighing machines
• Food prepared or given incorrectly
Problems related to the individual child:

• Insufficient feeds given
• Vitamin and mineral deficiencies
• Malabsorption
• Psychological trauma (particularly in refugee situations and families living with HIV)
• Rumination
• Infection, especially diarrhoea (amaebiasis, giardiasis, dysentery), pneumonia, TB, urinary
infection/otitis media, malaria, HIV/AIDS, schistosomiasis, Kalazar/Leishmaniasis and/or
hepatitis/cirrhosis
• Other serious underlying disease: congenital abnormalities (e.g., Down’s syndrome), neurological
damage (e.g., cerebral palsy), inborn errors of metabolism
Care for Children Failing to Respond to SAM Treatment
When a child shows signs of failure to respond to treatment, the causal factors contributing to this
situation should be thoroughly investigated and the child treated appropriately according to
recommendations provided in these guidelines.
Primary Failure to Respond
Every child with unexplained primary failure to respond should have a detailed medical history and
examination performed. In particular, the child should be assessed carefully for infection as follows:
• Examine the child carefully. Measure the temperature, pulse rate and respiration rate.
• Where appropriate, examine urine for pus cells and culture blood. Examine and culture sputum or
tracheal aspirate for TB, examine the fundi for retinal TB and do a chest x-ray. 11 Examine stool for
blood and look for trophozoites or cysts of Giardia. Culture stool for bacterial pathogens. Test for
HIV, hepatitis and malaria. Culture and examine the cerebrospinal fluid.
11
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.
49
Secondary Failure to Respond
Secondary failure to respond to treatment is a deterioration/regression in condition after having

progressed satisfactorily to the rehabilitation phase with a good appetite and weight gain. It is usually
due to:
• Inhalation of diet into the lungs: Severely malnourished children often have poor neuromuscular
coordination between the muscles of the throat and the oesophagus. It is quite common for
children to inhale food into their lungs during recovery if they are: 1) force-fed, particularly with a
spoon or pinching of the nose; 2) laid down on their back to eat; and 3) given liquid diets.
Inhalation of part of the diet is a common cause of pneumonia in all malnourished patients.
Patients should be closely observed while being fed by the caregiver to ensure that the correct
feeding technique is being used. One of the advantages of ready-to-use therapeutic food (RUTF) is
that it is much less likely to be force-fed and inhaled.
• An acute infection that has been contracted in the health facility from another patient (called a
nosocomial infection) or at home from a visitor/sibling/household member: At times, as the
immune and inflammatory system recovers, there appears to be a “reactivation” of infection during
recovery. Acute onset of malaria and TB (e.g., sudden enlargement of a cervical abscess or
development of a sinus infection) might arise several days or weeks after starting a therapeutic diet.
• A limiting nutrient in the body that has been “consumed” by the rapid growth and is not being
supplied in adequate amounts by the diet: This is very uncommon with modern diets (F100 and
RUTF), but might occur with homemade diets or with the introduction of other foods.
Frequently, introduction of the family diet slows the rate of recovery of a severely malnourished
child. The same can occur at home when the child is given family food or traditional weaning
foods that are inadequate in Type 1 and Type 2 nutrients.
Action Required When a Child Fails to Respond to Treatment
• Keep accurate records of all children who fail to respond to the treatment and of those who died.
These records should include, at a minimum, detail of the child’s age, sex, date of admission,
MUAC on admission, principal diagnosis, treatment, and, where appropriate, date and time of
death, and apparent cause of death.
• Always systematically examine the common causes of failure to respond and death, and identify
areas where case management practices should be improved to rectify the problems.
• If these actions are not immediately successful, then an external evaluation by someone experienced
with the inpatient care for SAM should be conducted. An investigation into the organisation and
application of the protocol for treatment should be carried out as part of the evaluation.
• Review the supervision of staff with refresher training, if necessary.
• Recalibrate scales (and length-boards).
4.8 Criteria for Discharge from Inpatient Care After Full Recovery
Children who meet the discharge criteria (see Box 15) are discharged as cured.
Other children who are discharged but did not meet the discharge criteria (thus did not recover) are
children who:
• Died while in treatment.
• Defaulted (absent on the third consecutive follow-up visit in outpatient care).
• Did not recover or did not meet the discharge criteria after four months (16 weeks) in treatment
50

It is recommended that the following steps be considered at discharge:
• Health and nutrition education scheme is completed.
• Immunisation schedule is updated.
• Adequate arrangements for linking the caregiver and child with appropriate community initiatives
and for follow-up are made.
BOX 15. DISCHARGE CRITERIA FROM INPATIENT CARE
1. Discharged and Referred to Outpatient Care

Appetite returned (passed appetite test for RUTF – the child is eating more than 75 percent of daily
prescription of RUTF) and start of weight gain
And
Medical complication resolving
And
Bilateral pitting oedema decreasing
(If marasmic kwashiorkor admission: bilateral pitting oedema resolved)
And
Clinically well and alert
2. Discharged from Inpatient Care After Rehabilitation Phase (full recovery in inpatient care)
• 15 percent weight gain for two consecutive weeks
• No bilateral pitting oedema for two consecutive weeks
4.9 Discharge Procedures

The following should be addressed before the child is discharged:
• Provide feedback to the caregiver on the final outcome of treatment.
• Counsel the caregiver on good feeding and care practices, including on providing and preparing
appropriate complementary food.
• Ensure the caregiver understands the importance of follow-up care to prevent relapse.
• Note discharge the outcome in the register and on the treatment card.
• Advise the caregiver to immediately go to the nearest health facility if the child refuses to eat or has
any of the following signs:
o High fever
o Frequent watery or bloody stools, or diarrhoea lasting more than four days
o Difficult or fast breathing
o Vomiting
o Not alert, very weak, unconscious, convulsions
o Bilateral pitting oedema
The child’s outcome status is classified per exit category and is indicated on the treatment card.
51
Table 13. Inpatient Care Exit Categories

Category Definition
Discharged Cured Child 6-59 months who is discharged after rehabilitating in inpatient care
Infant 0-6 months who meets inpatient care discharge criteria
Referred to Child’s health condition is improving/stabilised and is referred to outpatient care to
Outpatient Care continue treatment
Died Child dies while in inpatient care
Defaulted Absence from inpatient care for three consecutive follow-up visits in outpatient care
Non-Recovered Child does not reach discharge criteria after four months (16 weeks) in treatment
(medical investigation previously done)
52
V. Inpatient Care for Infants 0-6 Months

CHAPTER V: INPATIENT CARE FOR THE
MANAGEMENT OF SAM IN INFANTS 0-6
MONTHS OLD
Treatment for infants 0-6 months with SAM or infants over six months with a weight less than 4.0 kg
should be done within the context of infant and young child feeding (IYCF) recommendations. 12
Breastfeeding support is an integral component of therapeutic care for severely malnourished infants.
This support includes protection and support for early, exclusive and continued breastfeeding, as well
as reducing the risks of artificial feeding for non-breastfed infants. Infants who are not breastfed and
who are particularly at risk also need to be ensured of protection and support.
Problems related to feeding that lead to SAM in infants include, among other factors:
• Lack of breastfeeding
• Partial breastfeeding
• Inadequate, unsafe artificial feeds
• Mother dead or absent
• Mother malnourished and/or traumatised, ill and/or unable to respond normally to infant’s needs
• Disability that affects the infant’s ability to suckle or swallow, and/or a developmental problem
affecting infant feeding
Severely malnourished infants need special care. The main objective of treatment of these infants is to
improve or re-establish breastfeeding and provide temporary or longer-term, appropriate therapeutic
feeding, as well as provision of nutrition, psychological and medical care for their caregivers. Ideally
these infants should be admitted to a separate section, away from where older, severely malnourished,
sick children are admitted. Infants 0-6 months with malnutrition should always be treated in inpatient
care. RUTF is not suitable for infants 0-6 months as the reflex of swallowing is not yet present.
In this section, guidance is provided on treatment of two categories of children 0-6 months as outlined
below:
1. Breastfed infants: Infants 0-6 months with a lactating caregiver
2. Non-breastfed infants: Infants 0- 6 months without the prospect of being breastfed
Infants over six months with a bodyweight less than 4.0 kg will fall in these categories, as well.
12
As outlined in WHO and UNICEF 2003 and IFE Core Group 2007.
53
5.1 Breastfed Infants 0-6 Months Who Have a Lactating Mother or

Caregiver for Wet Nursing
BOX 16. ADMISSION CRITERIA FOR BREASTFED INFANTS
Breastfed infants 0- 6 months or less than 4.0 kg, if the infant has:
• Visible wasting
And the infant is:
• Too weak to suckle effectively (independently of weight-for-length), or
• Not gaining weight satisfactorily at home
5.1.1 ROUTINE MEDICINES AND SUPPLEMENTS
Antibiotics
Amoxicillin is provided to infants weighing a minimum 2 kg at a rate of 15 mg/kg three times per day
for five days in association with Gentamicin. Do not use chloramphenicol on infants less than two
months of age.
Vitamin A
Give 50,000 IU in a single dose upon admission only.
Folic Acid
Give 2.5 mg (½ tablet) in a single dose.
Ferrous Sulphate
Ferrous sulphate is added to F100 (one crushed tablet – 200 mg of ferrous sulphate – is added to 2-
2.4 L of F100) before diluting the F100 to make F100- Diluted. Alternatively, provide daily doses of
Iron syrup orally; refer to Table 10 for drug dosages.
5.1.2 DIETARY TREATMENT
The objective is to supplement the child’s breastfeeding with therapeutic milk while stimulating breast
milk production.
• The infant should be breastfed as frequently as possible. Breastfeed every three hours for at least 20
minutes (more if the child cries or demands more).
• Between 30 minutes to one hour after a normal breastfeeding session, give maintenance amounts of
therapeutic milk.
• Provide F100-Diluted for children without oedema (see Feed Preparation below).
• Provide F75 for infants with oedema and change to F100-Diluted when the oedema is resolved.
54
Quantities of F100-Diluted

• F100-Diluted is given at 130 ml/kg/day, distributed across eight feeds per day (3 hourly feeds).
• Use the look-up tables (Table 14) for F100-Diluted maintenance amounts to give to infants
during feeding using the supplementary suckling technique (see Feeding Technique below). The
quantity of F100-Diluted is not increased as the child starts to gain weight.
Table 14. Look-Up Table for Maintenance Amounts of F100-Diluted to Give to an Individual Infant
per Feed
Bodyweight (kg) F100-Diluted per feed
if 8 feeds per day (3 hourly feeds)
≥ 1.2 25 ml per feed
1.3 – 1.5 30
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
Regulation of Amount of F100-Diluted Given
The progress of the infant is monitored by daily weighings.

• If the infant loses weight over three consecutive days but continues to be hungry and is taking all
his/her F100-Diluted, add 5 ml extra to each feed. 13
• In general, supplementation is not increased during the stay in the health facility. If the infant
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 feed but continues to gain weight,
it means the intake from breast milk is increasing and the infant is taking adequate quantities to
meet his/her requirements.
• The infant should be weighed daily with a scale graduated to within 10 g (or 20 g).
When an infant is gaining weight at a rate of 20 g per day (absolute weight gain):
• Decrease the quantity of F100-Diluted by one-quarter and gradually to one-half of the
maintenance intake so that the infant gets more breast milk.
• If the weight gain is maintained, stop supplementary suckling completely.
• If the weight gain is not maintained, increase the amount given to 75 percent of the maintenance
amount for two to three days and then reduce it again if weight gain is maintained.
• If the caregiver is agreeable, it is advisable to keep the infant in the centre for a few more days on
breast milk alone to make sure that he/she continues to gain weight. If the caregiver wishes to go
home as soon as the infant is taking the breast milk with increased demand, they should be
discharged and followed at the nearest CWC in the community.
13
Maintenance amounts of F100-Diluted are given using the supplemental suckling technique. If the volume of
F100-Diluted being taken results in weight loss, either the maintenance requirement is higher than calculated or
there is significant malabsorption.
55
Feed Preparation

Add one packet of F100 to 2.7 L of water instead of 2 L. This is referred to as F100-Diluted.

ο Add 35 ml of water to 100 ml of F100 already prepared, which will yield 135 ml of
F100-Diluted. Discard any excess milk after use. Do not make smaller quantities.
ο If you need more than 135 ml, add 70 ml of water to 200 ml of F100 to make 270 ml of
F100-Diluted and discard any excess milk after use.
ο If pre-packaged F100 is not available, use one of the recipes given (see Annex 12. Alternative
Recipes for F75, F100 and ReSoMal Using CMV) to prepare F100 using locally available
ingredients and CMV. Add 700 ml of water to 2 L of already prepared F100 to make F100-
Diluted.
Feeding Procedure
• Ensure good breastfeeding through good attachment and effective suckling. Avoid distractions and
let the infant suckle the breast at his/her own speed.
• Build the mother’s confidence to help milk flow.
• Encourage more frequent and longer breastfeeding sessions to increase milk production and remove
any interference that might disrupt breastfeeding.
• Use the supplementary suckling technique to provide F100-Diluted maintenance amounts.
Feed with an NG tube only when the infant is not taking sufficient milk by mouth. The use of an NG
tube should not exceed three days and should be used in the stabilisation phase only.
Feeding Technique
Use the supplementary suckling technique to re-establish or commence breastfeeding, and also for
providing maintenance amounts of F100-Diluted to severely malnourished infants. This technique
entails the infant sucking at the breast while also taking supplementary F100-Diluted from a cup
through a fine tube that runs alongside the nipple. The infant is nourished by the supplementary F100-
Diluted while the suckling stimulates the breast to produce more milk.
The steps required in using the supplementary suckling technique are simple. The caregiver holds a cup
with the F100-Diluted. The end of an NG tube (size nº8) is put in the cup and the tip of the tube is
placed on the breast, at the nipple. The infant is offered the breast with the right attachment. The cup
is placed 5-10 cm below the level of the nipple for easy suckling. When the child suckles more
strongly, the cup can be lowered to up to 30 cm.
56
Figure 4. Supplementary Suckling Technique

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 to kill bacteria.
The following parameters are key and should be monitored daily and entered on the inpatient
treatment card (CCP):
• Weight
• Degree of oedema (0, +, ++, +++)
• Standard clinical signs: stool, vomiting, dehydration, cough, respiration, liver size
• Any other record, e.g., absent, vomits or refuses a feed, whether the patient is fed by NG tube or is
given an IV infusion or transfusion
5.1.4 SUPPORTIVE CARE FOR MOTHERS
Supportive care for breastfeeding should be provided to mothers, especially in very stressful situations.
Focus needs to be directed at creating conditions that will facilitate and increase breastfeeding, such as
establishing safe “breastfeeding corners” for mothers and infants, one-on-one counselling and mother-
to-mother support. Traumatised and depressed women might have difficulty responding to their
infants and require mental and emotional support, which should also support an increase in
breastfeeding. It is also important to assess the mother’s nutritional status (MUAC and oedema).
Explanation should be provided to the mother on the different treatment steps her child will go
through, and efforts should be made to strengthen the mother’s confidence and discourage self-
criticism for perceived inability to provide adequate breast milk. Alert the mother of the risk of a new
pregnancy during this period.
Adequate Nutrition and Supplementation for Breastfeeding Mothers
Breastfeeding women need about 450 kcal per day of extra energy. Essential micronutrients in breast
milk are derived from the mother’s food or micronutrient supplement. Therefore, it is important that
the mother’s nutrient and energy needs be met. The mother should consume at least 2,500 kcal per day.
It is suggested that the health facility provide nutritious food for the mother. The mother should also
receive vitamin A (200,000 IU, unless there is a risk of pregnancy) if the infant is under two months.
57
Dehydration might interfere with breast milk production; therefore it is therefore important to ensure
that the mother drinks at least 2 L of water per day.
5.1.5 DISCHARGE CRITERIA
BOX 17. DISCHARGE CRITERIA FOR BREASTFED INFANTS
For a breastfed infant under six months or weighing less than 4.0 kg on admission:
• Successful re-lactation with effective suckling = minimum 20 g weight gain per day on breast milk
alone for five days
• No bilateral pitting oedema for two weeks
• Clinically well and alert and has no other medical problem
Additional recommendations: Mother has been adequately counselled and has received the required
amounts of micronutrient supplements during the stay at the health facility and for use at home
5.1.6 FOLLOW-UP AFTER DISCHARGE

Follow-up for these children is very important. In areas where services are available, the mother should
be included in the SFP and receive high-quality food with the right balance of nutrients to improve the
quantity and quality of breast milk. It is also important to monitor the infant’s progress and support
breastfeeding and the introduction of complementary food at the appropriate age of six months.
5.2 Infants 0-6 Months Without the Prospect of Breastfeeding
BOX 18. ADMISSION CRITERIA FOR NON-BREASTFED INFANTS
Non-breastfed infants 0-6 months or non-breastfed infants over six months and weighing less than 4.0 kg:
• Presence of bilateral pitting oedema
• Visible wasting
5.2.1 STABILISATION PHASE
Routine Medicines and Supplements
Antibiotics
Give amoxicillin (for infants weighing a minimum 2 kg) at 15mg/kg three times per day for five days
in association with Gentamicin. Do not use chloramphenicol on infants 0-2 months of age.
Vitamin A
Give 50,000 IU in a single dose upon admission only.
Folic Acid
Give 2.5 mg (1/2 a tablet) in a single dose.

58
Ferrous Sulphate

Ferrous sulphate is added to F100 (one crushed tablet – 200 mg of ferrous sulphate – is added to 2-
2.4 L of F100) before diluting the F100 to make F100-Diluted. Alternatively, provide daily doses of
Iron syrup orally. Refer to Table 10 for the dosages of iron syrup.
Dietary Treatment
• Infants 0-6 months with wasting (marasmus) should be given F100-Diluted in the stabilisation
phase. Never provide F100 full-strength.
• Infants 0-6 months with oedema (kwashiorkor) should always be given F75 in the stabilisation
phase.
Use the look-up table (Table 15) for amounts of F100-Diluted or F75 to give non-breastfed infants in
the stabilisation phase.
Table 15. Look-Up Table for Amounts of F100-Diluted (Marasmus) or F75 (Kwashiorkor) to Give
to Non-Breastfed Infants in the Stabilisation Phase
Bodyweight (kg) F100-Diluted or F75 (ml per
feed), 8 feeds per day,
no breastfeeding (3 hourly feeds)
≤ 1.5 30
1.6 – 1.8 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
Feed Preparation

Add a packet of F100 to 2.7 L of water instead of 2 L to make F100-Diluted.
ο Add 35 ml of water to 100 ml of F100 already prepared to make 135 ml of F100-
Diluted. Discard any excess milk after use. Do not make smaller quantities.
ο If you need more than 135 ml, use 200 ml of F100 and add 70 ml of water to make 270
ml of F100-Diluted. Discard any excess milk after use.
ο If pre-packaged F100 is not available, use one of the recipes given (see Annex 12. Alternative
Recipes for F75, F100 and ReSoMal Using CMV) to prepare F100 using locally available
ingredients and CMV. Add 700 ml of water to 2 L of prepared F100 to make F100-Diluted.
Feeding Procedure
• Feed by cup and saucer or an NG tube by drip (using gravity not pumping).
• Feed with an NG tube only when the infant is not taking sufficient milk by mouth.
• The use of an NG tube should not exceed three days and should be used in the stabilisation phase
only.
59
Feeding Technique
Apply the correct feeding technique (see Feeding Technique in Section 4.3.7). It is important to ensure
the infant has adequate intake.
Individual Monitoring
The following parameters should be monitored daily and entered on the inpatient treatment card
(CCP):
• Weight
• Degree of oedema (0, +, ++, +++)
• Standard clinical signs: stool, vomiting, dehydration, cough, respiration, liver size
• Any other record, e.g., absent, vomits or refuses a feed, whether the patient is fed by an NG tube or
is given IV infusion or transfusion
Criteria to Progress from the Stabilisation Phase to the Transition Phase
The criteria to progress from the stabilisation phase to the transition phase are both:
• Return of appetite
• Beginning of loss of oedema, which is normally judged by an appropriate and proportionate weight
loss as the oedema starts to subside (children with severe oedema [+++] should remain in the
stabilisation phase until their oedema has reduced to moderate [++], as they are particularly
vulnerable)
5.2.2 TRANSITION PHASE
Routine Medicines and Supplements
Routine antibiotic therapy should be continued during transition or until the child is transferred to the
rehabilitation phase.
Dietary Treatment
Use the standard protocol for older children in the transition phase with the following modifications:
• Only F100-Diluted should be used.
• The volume of the F100-Diluted feeds is increased by one-third in comparison with the
stabilisation phase.
• Refer to Table 16 for the amounts of F100-Diluted to give to non-breastfed infants in the
transition phase.
60
Months or Infants Over 6 Months Weighing Less Than 4.0 kg in the Transition Phase

Bodyweight (kg) F100-Diluted (ml per feed),
8 feeds per day,
no breastfeeding (3 hourly feeds)
≤ 1.5 45
1.6 – 1.8 53
1.9 – 2.1 60
2.2 – 2.4 68
2.5 – 2.7 75
2.8 – 2.9 83
3.0 – 3.4 90
3.5 – 3.9 96
4.0 – 4.4 105
Continue surveillance as outlined in the stabilisation phase.
Criteria to Progress from the Transition Phase to the Rehabilitation Phase
The criteria to progress from the transition phase to the rehabilitation phase are all of the following:
• A good appetite: Taking at least 90 percent (almost all) of the F100-Diluted prescribed for the
transition phase
• Complete loss of oedema (kwashiorkor)
• Minimum stay of two days in the transition phase for wasted patients
• No other medical problem
5.2.3 REHABILITATION PHASE
Dietary Treatment
Use the standard protocol for older children in the rehabilitation phase with the following
modifications:
• Only F100-Diluted should be used.
• Infants receive twice the volume per feed of F100-Diluted than was given during the stabilisation
phase.
• Refer to Table 17 for the amounts of F100-Diluted to give to non-breastfed infants in the
rehabilitation phase.
61
Months or Infants Over 6 Months Weighing Less Than 4.0 kg in the Rehabilitation Phase
Bodyweight (kg) F100-Diluted (ml per feed),
6 to 8 feeds per day,
No breastfeeding
≤ 1.5 60
1.6 – 1.8 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
Continue with rehabilitation phase surveillance as outlined in the standard protocol for older children
using the CCP.
Criteria for Discharge from the Rehabilitation Phase
BOX 19. DISCHARGE CRITERIA FROM INPATIENT CARE REHABILITATION PHASE FOR
NON-BREASTFED INFANTS
Discharge criteria for infants under six months or weighing less than 4.0 kg with no prospect of being
breastfed:
• 15 percent weight gain for two consecutive weeks
• No oedema for two consecutive weeks
• Clinically well and alert, no medical problem
Other recommendations:
• At discharge, the infant can be switched to infant formula or other breast milk substitutes per the Ghana
IYCF recommendations.
• Caregiver should have been provided adequate counselling on care and feeding practices, danger signs
and when to return to the health centre, and follow-up
Follow-Up
Continuity of care after discharge is important. Follow-up with these infants is needed to supervise the
quality of recovery and progress and to educate the caregivers. It is also important to support the
introduction of complementary food at the appropriate age of six months.
62
VI. Monitoring and Reporting

CHAPTER VI: MONITORING AND
REPORTING
A well-designed monitoring and reporting (M&R) system is an essential component in the

management of SAM. The objective of monitoring is to compare service performance against a set of
objectives and to make adjustments to the service or programme based on an analysis of routine data.
With well-informed monitoring, data aspects of the management of SAM that need improvement can
be identified in a timely manner. Appropriate action can then be taken to improve individual care,
organisation of care and quality of care. The M&R system for the management of SAM in Ghana
follows the Ghana Health Information Management system at the district, regional and national levels.
Implementation of an M&R system for inpatient and outpatient care involves timely collection of
relevant information; aggregation and disaggregation at the facility, district, regional and national levels
of the system; and subsequent analysis and reporting. Monitoring is used to measure monthly
performance and to report on effectiveness. Performance indicators of interest are the recovery, death, ,
default and non-recovered rates. Barriers to access to care and the degree of service uptake are expressed
in the coverage rate, which measures how well the service or programme is reaching the target
population and meeting needs.
Standardised M&R forms and tools are used for collection and aggregation of community outreach,
outpatient care and inpatient care monitoring data. This will facilitate comparability of data across
different facilities and is for ease of data aggregation at the district, regional and national levels. The
definition of indicators and entry and exit categories should be the same.
As part of the M&R system, it is important to focus attention on the training of health managers and
health care providers in data collection, analysis and reporting to ensure accurate information at
prescribed periods of time and to ascertain both the quality of information and its usage for
strengthening the quality of community outreach, inpatient care and outpatient care. (See training
responsibilities in Section 6.3.2.)
63
6.1 Monitoring Tools

Registration
Every child who comes to any health facility should be registered in the outpatient department, after
which the clinician or other senior health care provider determines whether the child should be treated
in outpatient care or inpatient care.
Basic patient information is maintained in a register book at the outpatient or inpatient care site.
Unique Registration Numbering System
Every new admission is assigned a unique SAM registration number. This unique registration number
should be maintained even if a child is transferred to another health facility. It helps in tracking a child
across different services (inpatient care and outpatient care) and for information sharing. The unique
SAM registration number should be used on all monitoring and referral documents pertaining to the
child.
The standard numbering system uses the following format, which is compatible with the health
information management system as follows:
66/77/8888/999/XXX
66 = Two-digit code for the region

77 = Two-digit code for the district
8888= Four digit code for the health facility. In the case where the facility does not know
the four digit code, a three letter abbreviation representing the facility is used.
999 = Child’s individual number
XXX = Three-letter code indicating in which service the child started treatment:
Outpatient Care (OPC) or Inpatient Care (IPC)
When the health facility does not know its four-digit facility code, an abbreviation of three letters
is used to represent the facility. For example, SWD/001/OPC represents the first child admitted
to outpatient care in Swedru health facility. It is important to note that at the health facility, only
the facility code/three letter abbreviation, the child’s individual number and service in which the
child started treatment will appear on the treatment card.
Individual Cards
Individual monitoring of children with SAM who are receiving treatment is important to determine the
progress of treatment and, in case of a sudden deterioration, to respond with a life-saving intervention.
Intensive monitoring is needed for the child with SAM in inpatient care. A detailed inpatient care
treatment card, or multi-chart, is updated daily. In outpatient care, the child with SAM is in better
condition and does not need the same level of health monitoring. Here, key information on the health
and nutritional condition of the child is recorded on the outpatient care treatment card, which is
updated during the weekly or biweekly monitoring sessions. Analysis of the individual treatment cards
helps to identify and highlight problems which might contribute to failure to respond to treatment.
64
Inpatient Care Treatment Card (CCP)

(See Annex 20)

The child’s information should be entered on the inpatient care treatment card along with the
unique SAM registration number. All daily surveillance should be recorded on the treatment card.
This helps monitor the child’s progress and inform decision-making during treatment.
• When a child is discharged from treatment, referred or moved, the health care provider (or person
responsible) should tally the number of exits on the tally sheets and in the ationregistration book, if
one is being used.
• It is important to systematically review the individual treatment cards during supervision visits to
ensure that proper treatment is given and protocols are being adhered to.
Outpatient Care Treatment Card

(See Annex 21)
• The child’s information should be entered on the outpatient care treatment card upon admission
and upon each visit to the health facility along with the unique SAM registration number. This
helps monitor the child’s progress and inform decision-making during treatment.
• When a child is discharged from treatment, referred or moved, the health care provider (or person
responsible) should tally the exit on the tally sheets and in the registration book, if one is being
used.
• It is important to systematically review the individual treatment cards during supervision visits to
ensure that proper treatment is given and that protocols are being adhered to.
Referral Document
• If the child is referred from inpatient care to outpatient care, the caregiver is given an outpatient
care treatment card that is a different colour than that used in outpatient care (usually yellow). The
card is clearly marked “referred from inpatient” together with instructions on how and when to go
for treatment at the outpatient care facility. When the caregiver arrives at the outpatient care site,
he/she presents the card to the health care provider. This card is used to continue treatment in the
outpatient care site.
• If the child is referred from outpatient care to inpatient care, a referral form is given to the
caregiver along with instructions on how and when to go for treatment at the inpatient care facility.
The referral form used is the same form that is used for referral of patients from one facility to
another; however, key information for the management of SAM is noted on the form (see Box 20).
65
BOX 20. INFORMATION TO BE RECORDED DURING REFERRAL FROM OUTPATIENT

CARE TO INPATIENT CARE
• Name and sex of child

• Age of child (in months)
• Name mother/caregiver
• Health facility referred from
• Date of referral
• Health facility destination
• Admission date (if referral is based on action protocol)
• Referral information –If referred based on action protocol, the following information should be
recorded on the referral document:
ο MUAC
ο Bilateral pitting oedema
ο Medical complication
• Treatment provided to the child
• Referral reason and any other comment
RUTF Ration Card

(See Annex 22)
The RUTF ration card includes basic information on the child, including the admission and weekly
anthropometry, weekly RUTF supplies and target weight. The caregiver keeps it. The RUTF ration
card is in the form of a sticker that should be attached on the child’s health record. If the child does
not have a child health book, the card should be given to the caregiver.
Filing System
A filing system for treatment cards containing three files is kept at the health facility. The first file
contains the treatment cards of those currently in treatment, including those who are absent or were
transferred to inpatient care. Two other files contain treatment cards of those who have been
discharged: one for those discharged cured and the other for those who died, defaulted or did not
recover.
Table 18. Filing System for Outpatient Care Treatment Cards, With a Separation per Discharge
Category
File 1: Currently in Outpatient Care File 2: Discharged - 1 File 3: Discharged – 2
• Currently in Outpatient Care • Cured* • Deaths
• Absentees • Defaulters*
• Referrals to Inpatient Care • Non-Recovered
(awaiting return)
* If defaulters return for treatment, monitoring continues with the same card/registration number.
66
6.1.2 MONITORING OF SERVICES
Health Facility Tally Sheet

(See Annex 23)
Health facility tally sheets are completed by a health care provider at the end of each outpatient care
session or weekly at the inpatient care facility. Monthly summaries are provided per health facility in
the health facility monthly report, which is a compilation of the routine quantitative data (see next
section). A supervisor checks the tally and reporting sheets for accuracy and as an indication of service
performance. Each health facility should send the health facility tally and site reporting sheets to the
District Health Office monthly.
Tally sheets provide information on total admissions, total discharges and total under treatment, which
helps service planners see whether services are reaching the target population, there is a need to change
implementation strategies, or supply and human resources need to be adaptated.
Admissions
• New admissions 6-59 months

• Other new admissions: Infants under six months, children over five years, adolescents and adults
• Referrals from inpatient care, outpatient care or other facilities and/or returned defaulters
Details on the entry category can be added, such as bilateral pitting oedema, MUAC and gender can
help identify differences in affected age groups and types of SAM.
Discharges
• Cured
• Died
• Defaulted
• Non-recovered
Discharges are monitored to assess performance; identify changes in the number of cured, died,
defaulted or non-recovered cases; and identify areas that require investigation.
Referrals to Another Site (Inpatient Care or Outpatient Care)
Referrals are children leaving the specific treatment site and are counted in a separate exit category.
Children who are referred are not counted as discharged, as they have not ended or abandoned
treatment.
Health Facility Monthly Report

(See Annex 24)
The health facility monthly report is completed with inputs from the health facility tally sheet and
provides performance indicators for each site, including the proportion of children who are discharged
cured, died, defaulted or non-recovered; total admissions; new admissions; old cases; total exits; and
total under treatment. This report is generated monthly (or for longer periods, if of interest).
67
Note: It is important to report by calendar month to ensure accuracy in data aggregation and
disaggregation.
Additional information that might be collected and marked on the health facility reporting form
includes averages calculated on a sample of treatment cards of cured beneficiaries who are discharged
from the service that month on indicators such as average weight gain (AWG) and average length of
stay (LOS).
The health facility tally sheets and health facility monthly report are sent to the District Health Office
on a monthly basis. The reports from individual facilities are compiled monthly into a district monthly
report (see Annex 25) combining inpatient care and outpatient care, which reports overall performance
on the management of SAM. Analysis of site and district reports provides information about the
performance the management of SAM services for individual health facilities and the district as a
whole. The results are compared to international standards (see Table 20 with adapted Sphere
Standards). Reports from the districts are compiled into district, regional and national SAM data
repositories at each level.
Other Information Collected
Additional information can be gathered from community outreach workers and through discussions
with caregivers and other community members.
Readmissions After Discharge (or Relapse)
This can help service planners understand the situation outside of the service. Interventions might be
needed at the household level to avoid high readmission rates. High readmission rates also might mean
children are discharged too soon. Relapse is recorded on the child’s treatment card and can be tallied
monthly or yearly.
Cause of Death
This should be recorded on the child’s treatment card. Assessing and compiling this information can
help identify problems with treatment and use of action protocols, and determine where training and
supervision might be needed.
Reasons for Absentees, Default, Non-Response to Treatment and Non-Recovery
Compilation of this information can help identify common reasons for default or non-response to
treatment. Reasons for non-response might include a high TB and/or HIV prevalence sharing food in
the household; or poor water, sanitation and hygiene. This might indicate a need for stronger service
linkages with other sectors.
68
Table 19. Summary of Entry and Exit Categories

Outpatient Care
Inpatient Care
for the Management of
SAM Without Medical Complications

SAM With Medical Complications
for Children 6-59 months
Entry Categories
1. New admission: 1. New admission:
New cases of children 6-59 months who meet admission New cases of children 6-59 months who meet
criteria admission criteria
- Including relapse after cure - Including relapse after cure
2. Other new admissions: 2. Other new admissions:

New cases of infants, children, adolescents or adults (< 6 New cases not meeting pre-set admission criteria
months or ≥ 5 years) who need treatment for SAM in who need treatment for SAM in outpatient care
inpatient care (children ≥ 5 years, children with a MUAC exactly
at 11.5 cm, etc.)
3. Referral from outpatient care:
Child’s condition deteriorated in outpatient care 3. Referral from inpatient care:
(according to action protocol) and child needs inpatient Cases discharged from inpatient care to continue
care treatment in outpatient care
Or
Returned after defaulting or
Moved in from other outpatient care site
Exit Categories
1. Discharged cured: 1. Discharged cured:
(Child 6-59 months meets discharge criteria, i.e., special Child 6-59 months meets discharge criteria
cases that were not referred to outpatient care earlier)
Infant < 6 months meets discharge criteria
Child ≥ 5 years meets discharge criteria
2. Died: 2. Died:
Child dies while in inpatient care Child dies while in outpatient care
3. Defaulted: 3. Defaulted:
Child is absent on the third consecutive day (three days Child is absent on the third consecutive week (three
absent) weeks absent)
4. Non-recovered: 4. Non-recovered:
Child who remained in inpatient care does not reach Child does not reach discharge criteria after four
discharge criteria after four months (16 weeks) in months (16 weeks) in treatment – medical
treatment – medical investigation should have previously investigation should have previously been done.
been done
5. Referred to outpatient care: 5. Referred to inpatient care:

Child’s condition stabilised and child is referred to Child’s condition deteriorated and child is referred
outpatient care to continue treatment to the inpatient care according to the action
protocol
Note: Performance indicators for inpatient care
facilities are only calculated for those who
remain in inpatient care until full recovery
69
6.2 Service Indicators

6.2.1 INDICATORS MEASURING OUTPUT
• # Functioning inpatient care and outpatient care facilities

• # Health care providers trained in inpatient care and treatment of SAM with medical
complications (plus gender distribution)
• # Health care providers trained in outpatient care and referral based on action protocol (plus
gender distribution)
• # CHWs trained in community outreach (plus gender distribution)
• # Volunteers trained in community outreach (plus gender distribution)
• # Communities mobilised (number of meetings)
6.2.2 PERFORMANCE INDICATORS MEASURING OUTCOME

(EFFECTIVENESS)
Monthly
• Total numbers of new admissions

• Total numbers of discharges*
• Total number of children under treatment
• Information on new admissions: Proportion of children admitted for bilateral pitting oedema, low
MUAC, low WFH
• Gender distribution admission
• % Cured
= proportion of children discharged cured out of total discharged
• % Died
= proportion of children who died when under treatment out of total discharged
• % Defaulted
= proportion of children recorded as absent for three consecutive visits out of total discharged
• % Non-recovered
= proportion of children who do not meet the discharge criteria after four months under treatment
out of total discharged
* Total number of discharges = cured + died + defaulted + non-recovered; total number of exits = cured +
died + defaulted + non-recovered + referred
Periodic Indicators to be Collected Biannually
• Average daily weight gain

—calculated on sample of cured discharges for kwashiorkor and marasmus (see Section 6.2.3)
= sum of weight gains/number of cards in sample
• Average LOS
—calculated on sample of cured discharges for kwashiorkor and marasmus (see Section 6.2.3)
= sum of LOS/number of cards in sample
• % Coverage
= proportion of children with SAM under treatment out of total number of children with SAM
identified in the community
70
6.2.3 ADDITIONAL INDICATORS MEASURING EFFECTIVENESS OF THE

TREATMENT

Additional indicators can be calculated on a random sample of children (new admissions only) enrolled
in outpatient care who are discharged cured. Kwashiorkor and marasmus cases are calculated separately.
Average Daily Weight Gain of Discharged Cured
AWG in outpatient care is expected to be greater than 4.0 g/kg/day. A low AWG might indicate high
absence rates, default, ineffective treatment, sharing of RUTF or non-compliance to the treatment
protocol.
(Note: The Sphere minimum standards of AWG based on traditional centre-based inpatient care is
greater than 8 g/kg/day).
Calculation:
Weight gain (g/kg/day) = [discharge weight in g – minimum weight in g] divided by
[minimum weight in kg x number of days between minimum weight and discharge day]
AWG = sum of weight gains (g/kg/day) divided by number of cards in sample
Average LOS of Discharged Cured
The average LOS in outpatient care is expected to be 60 days and four to seven days in inpatient care.
A long average LOS might be the result of a high proportion of children who do not respond to
treatment (non-responders or non-recovered), frequent absences, default, sharing the RUTF and/or
unresolved illness. A short average LOS might indicate that children are discharged too soon. If there is
a high relapse rate, this might be a possible cause.
Calculation:
Average LOS = sum of LOS divided by number of cards in sample
Coverage
Coverage is an indicator expressing SAM service availability and uptake. Coverage indicates how well a
service is meeting needs. The coverage ratio is a population-based indicator, expressed as a percentage.
Table 20. Outcome Indicators Based on CMAM Guidance and on International Cutoffs as per Sphere
Standards 14
Indicator Outpatient care Inpatient care until full recovery
Cured > 75 % Not applicable
Defaulted < 15 % < 15 %
Died < 10 % < 10 %
Average LOS 60 days 4-7 days
Average daily weight gain > 4 g/kg/day Not applicable
Coverage > 70 % Camp: > 90%; Urban: > 70%; Rural: > 50%
14
Sphere Standards version 2004 in revision, expected in 2010.
71
6.3 Support and Supervision

Supervisors should perform regular support and supervision visits, and use a checklist to cover aspects
to assess and address systematically. At the same time, the supervisor is a mentor and he/she should
support health workers and community outreach workers with technical support based on identified
needs.
Supervision of the quality of protocol implementation entails monitoring admission and discharge
trends and adherence to protocols. Accurate recording and compilation of information regarding
admissions, readmissions, referrals, and discharges from outpatient care or inpatient care facilities are
important. Analysis of the data from the outpatient care and inpatient care facilities is essential for the
supervisor to know and check, as it provides important information about the performance of
individual facilities and for ensuring actions are taken to strengthen quality.
6.3.1 QUALITY OF INDIVIDUAL TREATMENT
Support and supervisory visits should include reviewing treatment cards, particularly of those children
who defaulted, died, did not respond to treatment or did not recover. This should ensure that
weaknesses in the delivery of the services or in the management of SAM in individual children are
identified so that improvements can be made in both.
Supervisors should check that admissions and discharges are carried out according to the national
guidelines and that routine medicine and therapeutic diets are administered correctly. They must also
check that oedema is properly assessed, deterioration in the condition of the child is identified and
acted upon according to protocols, and transfers and absentees are noted and followed up.
The supervisors should also review with health workers the care provided to children with static weight
or weight loss or those who have not recovered after three months. Any deaths should also be reviewed.
Discussion on the review findings should be done with implementing health care providers so that
necessary improvements can be made.
Supervisors should review:

• Completion of the treatment cards, ration cards and other health documents
• Adherence to medical treatment and nutritional rehabilitation protocols
• Progress of individual children, checking for consistent weight gain
• Community follow-up of problem cases or referral
• Quality of health and nutrition counselling
(See Annex 27. Supervision Checklists.)
6.3.2 ORGANISATION AND MANAGEMENT OF SERVICES
To best monitor the organisation and management of services, supervisors should review:
• Organisational structure of service delivery
• Crowd management
• Supply flow and stock management for medicines and therapeutic foods
• Organisation of human resources
• Quality of health and nutrition group sessions
• Links with community outreach
72
• Links with other community services


6.3.3 PERFORMANCE OF SERVICES
Supervisors should assess the performance of the services by reviewing:

• Completion of tally sheets and reporting forms
• Results of site reports
6.3.4 FEEDBACK SYSTEM
Health care providers and supervisors at outpatient care and inpatient care facilities should hold regular
meetings to discuss performance using the monitoring data. Aggregated monitoring data should also be
analysed and discussed at the district, state and national levels. Experiences should be shared, feedback
given and action plans for improving performance developed and discussed. In outpatient care settings,
feedback can be provided to the community through focus group discussions andcommunity
mobilisation activities.
It is recommended that feedback be provided to the community on a regular basis to gain trust and
confidence in the new treatment and empower community members to participate in the treatment of
children with SAM. This can be done through regular focus group discussions. Focus groups should be
carefully selected to ensure that specific issues are discussed with appropriate community
representatives. These can be community leaders, teachers, beneficiaries or non-beneficiaries, for
example. Discussions should be a two-way process to allow for explanation of service protocols or
specific issues and for the community to provide input into the services. Discussion topics could cover
perceptions of therapeutic feeding, reasons mothers/caregivers do not bring children to the outpatient
sessions or health facilities, and how these issues can be improved.
6.3.5 QUALITY CONTROL OF MONITORING DATA
Indicators collected from inpatient care and outpatient care need to be continuously and systematically
reviewed to ensure quality information is collected. Quality checks should be conducted to identify
whether indicator levels have fallen below the established standards. A level of action should be
determined based on the context, the specific indicator that is faltering and whether or not aggravating
factors were present. Minimum standards should not be taken as absolute, but as flexible levels for
warning that vary depending on the aforementioned factors.
6.4 Reporting
Quantitative and qualitative data are reviewed to triangulate information, better interpret findings and
provide a more detailed assessment of service performance.
The analysis and triangulation of the information from community discussions, supervisory checklists
and monitoring of services enables health managers, health care providers and CHWs, in collaboration
with supervisors and the community, to strengthen the quality of services for the management of SAM.
73
6.4.1 MINIMUM REPORTING STANDARDS
A minimum reporting checklist is proposed (see Annex 26. Minimal Reporting Guidance for the
Management of SAM).
74
REFERENCES
References
Ashworth, A. 2001. “Treatment of severe malnutrition.” Journal of Pediatric Gastroenterol Nutrition
32 (5): 516-8. www.jpgn.org
Note: A review article with a summary of pathophysiology of SAM and its main complications;
suitable for health workers with an interest in physiopathology
Collins, S. 2004. “Community-based therapeutic care: A new paradigm for selective feeding in
nutritional crisis.” Humanitarian Practice Network Paper 48, ODA. www.validinternational.org
FANTA, UNICEF, Valid International and Concern Worldwide. 2008. Training Guide for
Community-Based Management of Acute Malnutrition. Washington, DC: FANTA.
http://fantaproject.org/cmam/training.shtml
Golden, M. H. 1996. “Severe Malnutrition.” Oxford Textbook of Medicine. 3rd edition. Oxford,
United Kingdom: Oxford University Press. pp. 1278-1296.
Note: Later editions of Oxford Textbook of Medicine do not include this chapter; the most
comprehensive explanation of acute malnutrition physiopathology; suitable for health workers with
an interest in physiopathology
Gross, R., and P. Webb. 2006. “Wasted time for wasted children: severe child undernutrition must be
resolved in non-emergency settings.” The Lancet 367: 1209-1211. www.thelancet.com.
UNICEF, University of Aberdeen and UNICAL. .2000. Severe Malnutrition: A model patient
application. www.capgan.org/unical.
Note: An interactive tutorial (CD-ROM or internet) on physiopathology and management of
severe malnutrition; suitable for health workers
Valid International, 2006. Community-based Therapeutic Care: A Field Manual. Oxford, United
Kingdom: Valid International. www.validinternational.org or
http://www.fantaproject.org/ctc/manual2006.shtml
Note: Field manual with extensive information in outpatient care and many aspects of programme
setup and management; suitable for managers and health workers
Wellcome Trust. 2000. Topics in International Health: Nutrition. London: Wellcome Trust.
www.talcuk.org/cd-roms/topics-in-international-health-nutrition.htm
75
Note: Cost £10; interactive CD-ROM with tutorials and exercises on the physiopathology and
medical and nutrition management of SAM; suitable for health workers
WHO. Guidelines for Community-based Management of Severe Acute Malnutrition. Geneva: WHO.
Note: Pending publication; focuses on integrating therapeutic care in primary health programmes
WHO. 2004. Guiding Principles for Infant and Young Child Feeding during Emergencies. Geneva:
WHO. www.who.int/nutrition/publications/guiding_principles_feedchildren_emergencies.pdf.
WHO. 2002. Training course on the management of severe malnutrition. Geneva: WHO.
www.who.int/nutrition/publications/severemalnutrition/en/manage_severe_malnutrition_training_fl
y_eng.pdf
Note: Seven modules for participants with one clinical instructors guide, one facilitator guide and
one course director guide; handouts and visuals (slides, video/DVD) on medical and nutrition
management of SAM; answer sheets; suitable for health workers
WHO. 2000. Management of the child with a serious infection or severe malnutrition: Guidelines for
care at first referral level in developing countries. Geneva: WHO. http://www.who.int/child-
adolescent-health/publications/referral_care/Referral_Care_en.pdf
Note: Guidelines for medical and nutrition management of SAM and for IMCI programmes;
suitable for health workers
WHO. 1999. Management of severe malnutrition: A manual for physicians and other senior health
workers. Geneva: WHO.
www.who.int/nutrition/publications/severemalnutrition/en/manage_severe_malnutrition_eng.pdf.
Note: Guidelines for medical and nutritional management of SAM; extensive information in
management of complications; suitable for health workers.
WHO and LSHTM. 2003. Guidelines for the inpatient treatment of severely malnourished children.
Geneva: WHO. www.who.int/nutrition/publications/severemalnutrition/guide_inpatient_text.pdf
WHO, WFP, UN/SCN and UNICEF. 2007. Community-Based Management of Severe Acute Malnutrition:
A Joint Statement by the World Health Organisation, the World Food Programme, the United Nations System
Standing Committee on Nutrition and the United Nations Children’s Fund. Geneva: WHO.
www.who.int/nutrition/publications/severemalnutrition/978-92-806-4147-9/en/index.html
WHO, WFP, UN/SCN and UNICEF. 2006. Informal consultation on the community-based
management of severe malnutrition in children. Food and Nutrition Bulletin, Vol. 27, No. 3
(supplement). Geneva: UN/SCN.
www.who.int/nutrition/publications/severemalnutrition/FNB_0379-5721/en/index.html
76
LIST OF ANNEXES
Community Outreach
1. Planning for Community Outreach
2. Community Outreach Messages
Annexes
Outpatient and Inpatient Care
3. Admission and Discharge Criteria for the Management of SAM for Children 0-59 Months
4. Anthropometric Measurements
5. Guidance Table to Identify Target Weight for Discharge
6. Checklist for Medical History and Physical Examination
7. Routine Medicines Protocols
8. Supplemental Medicines Protocols
9. Drug Doses
10. Sugar-Water Protocol
11. Dietary Treatment
12. Alternative Recipes for F75, F100 and ReSoMal Using CMV
13. Preparing F75 Milk Using Pre-Packaged F75
14. RUTF Specification
15. Outpatient Care Action Protocol
16. Key Messages Upon Admission
17. Messages for Health and Nutrition Education
18. Play and Stimulation
Monitoring and Reporting Tools

19. Checklist for Home Visits
20. Inpatient Care Treatment Card (Critical Care Pathway-CCP)
21. Outpatient Care Treatment Card
22. Outpatient Care RUTF Ration Card
23. Health Facility Tally Sheet for the Management of SAM
24. Health Facility Monthly Report for the Management of SAM
25. District Monthly Report for the Management of SAM
26. Minimal Reporting Guidance for the Management of SAM
27. Supervision Checklists
28. Requisition Form for Therapeutic Food
Management Tools
29. Setup of Inpatient Care and Outpatient Care
30. Checklist of Materials Needed for Outpatient Care
31. Outpatient Care Staffing
32. Inpatient Care Staffing
33. Checklist of Materials Needed for Inpatient Care
34. Forecasting Nutrition Product Needs
35. List of Job Aids
Appendix
Clinical Management of SAM With Medical Complications in Inpatient Care
77
Annex 1. Planning for Community Outreach

1. Planning and Orientation Workshop
Objectives:
• To highlight the importance of community outreach in community-based management of severe
acute malnutrition (CMAM)
• To help Ghana Health Service (GHS) staff at the outpatient care site understand the barriers to
service utilization and acceptance in the community
• To develop a plan for information gathering on the key barriers to community outreach from the
client base (mothers, community leaders and community-based volunteers), including skills training
on conducting community meetings or group discussion
Participants: Health workers including community outreach coordinators, community health nurses
(CHNs), community health officers (CHOs), field technicians, health extension workers (HEWs)
Agenda: 5 to 6.50 hours

Topics for discussion Time Facilitators
Introduction to planning and orientation 15 min District Director-
DHMT*, Agona
Overview of community outreach for CMAM (Visualization of 1 hr
community outreach activities to health workers through
discussion and visual aids)
Overall current practices in community outreach activities 30 min
Resources to explore to better engage in community outreach 30 min
activities
Break
Linking community outreach with the CMAM services 30 min
Community outreach tools 1.5 hrs
Roles and responsibilities for community outreach 1 hr
Role play (to better understand community assessment 1 hr
activities)
Close of planning and orientation 10 min
* District Health Management Team
2. Guidance for Community Meetings

Five meetings will be held in each community, with different groups of participants in each meeting.
Objectives of the meetings:

• To help participants understand their children’s health status
• To understand current health care practices in the community
• To inform the community about the services and involve it in planning
Time for each meeting: One to 1.5 hours
Number of days required: Two days
78
Type of meeting participants:

• Women (two groups)
ο Young mothers
ο Older mothers and grandmothers caring for young children in their homes
• Men
• Community leaders and elders
Annexes
• HEWs: CHWs/volunteers
Expected number of participants in each meeting: Seven to 10 participants
Venue: A comfortable and quiet place in the village to facilitate discussion without any interruption
Sitting arrangement: All participants including moderator/interviewers should sit in a “U” pattern so
that everyone can communicate easily.
Ensure equal participation in discussion: Facilitate the discussion to ensure participation from each
participant as much possible; try to restrain individuals from dominating the discussion.
Number of people involved in facilitating each meeting: One interviewer and one note-taker for each
meeting
Language for facilitation: Local dialect
Tips for facilitators:

• Greet the participants and briefly explain the meeting objectives
• Ask questions gently and prompt discussion
• Identify a note-taker for the discussion
The following questionnaires are examples and can be adapted as needed:
Questionnaire: HEWs Group (CHWs and volunteers)
Local disease classification for severe forms of malnutrition:

1. Did you see any children under 5 years old present as very thin/wasted or swollen (legs, hands,
face) in this community?
2. Does this condition have a name? If so, what you do call/name them?
3. What do you believe are the causes of this disease/condition?
4. Are all children likely to get it?
5. What can be done to treat it?
Attitude toward existing Ministry of Health (MOH) health services:

1. Where do most families in your village go to seek health care for themselves? For their children?
2. Does the MOH health centre/outreach site function regularly? When is it open/closed?
3. Do you think community members like to seek services at the health centre? Is the treatment
provided at the MOH health centre of good quality? At the outreach site?
4. Is treatment for children under 5 years free of cost at MOH health centre and outreach site?
5. What are the major problems to access care at the MOH health centre?
79
Health-seeking behaviour of the villagers:

1. What do the villagers do when their children are sick?
2. Where do they seek health care?
3. Where do they go for emergency treatment (children are ill in the late afternoon or at night)?
Other barriers to accessing health service:

1. How far is the health facility from your village/community?
2. Is distance a problem? For whom?
Other means/paths of treatment available in the community:

1. Are there any treatment facilities available (other than MOH) in your village/community?
2. Are there good healers to your community? Do the families in your community like to seek care
there?
3. What do you call/name them?
4. How about the cost of treatment from these points? Are they cheaper or more convenient than the
MOH health centre/outreach site?
Participation in health-related activities or programmes in the community:

1. How do you support health-related activities in your community?
2. How do you link villagers with health service centres/outreach?
3. How much time do you spend doing these voluntary activities in a week?
4. What do you do to engage and motivate mothers to participate?
5. Who are the other volunteers involved directly/indirectly with health related activities?
6. What about others in the village? Who listens to your advice? Who doesn’t?
7. How do you think information on health services could be spread effectively in your community?
8. How is your work being supervised in the village/community? Who from the MOH is involved
with your work?
Homogeneity/heterogeneity of the community:

1. How many ethnic groups reside in this community?
2. Is there a common language used in this village/community? What is it?
3. Does this have an effect on how volunteers are selected and managed in your village?
Questionnaire: Women and Men Groups
Local disease classification for severe forms of malnutrition (show pictures):

face) in this community/village (like this picture)?
2. Is this a disease/condition? If so, how you do call/name it?
3. What do you believe causes this disease/condition?
4. Is there a specific time when this disease is more common, such as the time of the year, rainy season
or summer, or according to the age of the child?
5. Are all children likely to get this condition, or only some? Why are some children more likely to
get this condition?
6. How do you manage or treat this disease in your community?
Health-seeking behaviour of mothers/caregivers:

1. What do you do at the time of any sickness of your children?
2. Where do you seek health care? How far is it?
3. Are there any other treatment facilities (traditional treatments) available in your
village/community?
80
4. Where did you receive treatment last time your child was sick? Why did you choose to go there?
5. Where do you go for emergency treatment (illness of children in late afternoon or at night)?
6. Who usually accompanies your child he/she goes for treatment?
Attitude toward existing MOH health services:

1. How do you feel about the treatment facility at the health centre?
2. When was the last time that you visited the health centre?
Annexes
3. Do you attend the outreach services offered by the health centre?
4. When did you go last?
5. Were you satisfied with the services provided by the the health centre team?
6. How do you get information about the outreach services? Where and when they are held?
7. Who else gives you information about health services in your community?
Other means/paths of treatment available in the community:

1. What are the other treatments available in your community? What do you call/name them?
2. How often do you receive treatment for your child from the traditional healer?
3. Do most of the villagers get treatment from these service points?
4. How about the cost of treatment from these points? Are they cheaper and more convenient than
the health centre/outreach?
Other barriers to access:

2. Are the location and distance of the health centre feasible to reach?
3. What is the type of transportation available?
4. How far is the outreach site from your village?
Homogeneity/heterogeneity of the community:

1. What is the common language used in this village/community?
2. How many ethnic groups are residing in this community?
Questionnaire: Community Leaders and Elders Group
Local disease classification for severe forms of malnutrition: (show pictures)

face) in this community/village (like this picture)?
2. Is this a disease/condition? If so, what do you call/name it?
3. What do you believe causes this disease/condition?
4. Is there a specific time when this disease is more common, such as the time of the year, rainy season
or summer, or according to the age of the child?
5. Are all children likely to get this condition, or only some? Why are some children more likely to
get this condition?
Health-seeking behaviour of the villagers:

1. What do you do when your children get sick?
2. Where do you seek health care? How far is it?
3. Are there any other treatment facilities (traditional treatment) available in your village/community?
Attitude toward existing MOH health services:

1. How do you feel about the treatment facility at health centre?
2. When was the last time that you visited the health centre?
3. Were you satisfied with the services provided by the team at the health centre?
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4. Does your village receive outreach services? Where are they held and at what time?
5. Do you know the different community-based health volunteers in your village?
6. Who else gives you information about health services in your village?
Other means/paths of treatment available at community:

1. What are the other treatments available in your community/village? How do you call/name them?
2. Do most of the villagers get treatment from these service points?
3. How about cost of treatment from these providers? Are they cheaper and more convenient than the
health centre/outreach?
Other barriers to access:

2. Is the location and distance of the health centre feasible to reach?
3. What is the transportation you use to get there?
4. How far is the outreach site from your village?
3. Strategy Formulation
Objective
At the end of the session you should have:

1. Identified the best candidate to carry forward community mobilisation and screening
2. Determined a strategy with the most potential for success
3. Identified a cost-effective training strategy (who, where and how) for the staff who will be engaged
in community mobilisation and screening
4. Developed an understanding of the key barriers to the success of CMAM and prepared to develop
a communication strategy
5. Developed a training plan
Participants: GHS staff members (CHN or CHO, disease surveillance officers) who participated in
conducting the community meetings
Agenda
9.00- 11.00 Briefing and data collection: Facilitate discussion with the CHN, CHO and other health
am workers. Fill out Worksheet 1 and agree on implications for strategy.
Use the following questions to fill worksheet 1: One hour

• What is the understanding of malnutrition and SAM in the community?
• What are the main health-care-seeking practices in the community (government
services, other)?
• What are some of the key barriers to seeking health care in general in the community?
• Are there children from some families/groups at higher risk of malnutrition? How
would you describe them?
11.30- 1.00 Group work: 45 minutes
pm • Keeping the implications in mind, fill out Worksheet 2
• Identify ways the implications for strategy (e.g., low knowledge, lack of trust in the
GHS) can be addressed when the case-finding candidate selection is done .
2.00- 3.00 Final discussions on training and preparation for integration of services:
pm • Discuss the best training strategy, where and how; fill out Worksheet 3
• Discuss whether the CHO is able to conduct some of the trainings or needs support,
and plan for training (when, where, who, how)
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Worksheet 1. Community Outreach Strategy

Key Findings Implications for Strategy
1.
2.
3.
4.
Annexes
83
Worksheet 2. Selection of Candidates for Case-Finding

Names Job Description Proximity Salary/Stipend Breadth Accessible/ Can Accept Capable of Could Be
(including to Cases Paid by of Coverage Amenable Additional Measuring Relied Upon
supervised by) (exist in every to Training Work MUAC for
village or Follow-Up
catchment)
Existing health extension workers and health volunteers
Other extension workers and volunteers
Important village figures
XXX = high XX = medium X = low
Worksheet 3: Training Plan for Community Outreach

Community Number of Type of Trainer Date Place Resources
groups outreach outreach
workers workers
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Annex 2. Community Outreach Messages

Examples from Agona
To All District and Community-Based Organisations
Annexes
Date:
Postal Address/Name of Institution:
Dear Sir/Madam,
Re: New Treatment for Children with Severe Acute Malnutrition
A new treatment is now available at Swedru hospital and Kwanyako, Abodom, Duakwa and Nsaba
health centres under Agona District Health Directorate for children who are very thin or have swelling
(signs of severe acute malnutrition, or SAM). These children need referral to the health centre, where
they receive an assessment. If a child with SAM has good appetite and no medical complications, the
child does not have to go to the hospital; he/she is given medicines and a weekly supply of the
nutritional food called Plumpy’nut® and followed up through weekly health centre visits. If a child with
SAM has no appetite or has a medical complication, then he/she will be admitted to the hospital for a
short time until the complication is resolving and then will receive further treatment at the health centre
and at home. Children under six months who are very thin or have swelling will need specialised care in
Swedru hospital.
To determine whether a child is eligible for this treatment, his/her arm is measured in the community
to see if s/he is too thin and both feet are checked for swelling. The arm measurement is taken with a
tape similar to the cloth tape tailors use in the marketplace and can be taken by many types of persons.
Community health workers or volunteers are being trained in communities around the above-
mentioned health facilities so a person the child or his/her family knows can take the measurement.
If you know a child who is very thin or whose feet are swollen, tell the parents or guardians about this
new treatment. They can ask around their neighbourhood for a community health worker or volunteer
or someone else trained to take the arm measurement, or they can go directly to these health facilities.
We are confident that this new treatment will significantly improve the district’s ability to support the
recovery of malnourished children, and we look forward to your cooperation. Please do not hesitate to
contact me for more information or clarification.
Yours faithfully,
District Director of Health
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To All District Health Facilities:

Date:
Postal Address:
Dear Sir/Madam,
Re: Community-Based Management of Severe Acute Malnutrition (CMAM)
As part of its mandate to improve the quality and accessibility of health services in Agona District, the
Ghana Health Service (GHS) has introduced a new treatment for children under five years with a
severe form of acute malnutrition (bilateral pitting oedema or severe wasting). This service is called
Community-Based Management of Severe Acute Malnutrition (CMAM). It brings the treatment of
children with severe acute malnutrition (SAM) much closer to the family, making it possible for
children and their mothers/caregivers to avoid the long stays at the Paediatric Ward or the Nutrition
Rehabilitation Centre, which customarily have been necessary for treating undernutrition.
Children in the communities and health facilities are checked for bilateral pitting oedema and screened
for severe wasting based on a mid-upper arm circumference (MUAC) measurement with a specially
marked tape (MUAC tape) for referral and admission to the CMAM service at the health centre.
At the health facility, the child with SAM receives a medical evaluation. If a child with SAM has good
appetite and no medical complications, s/he can be treated at home and followed up through weekly
health centre visits. If a child with SAM has no appetite or has a medical complication, then s/he will
be admitted to inpatient care at Swedru Hospital for a short time until the medical complication is
resolving and then receive further treatment at the health centre and at home. Children under six
months who are very thin or have swelling will need specialised care in inpatient care at Swedru
Hospital. Early detection of cases and referral for treatment is essential to avoid medical complications.
The treatment, which is free of charge, provides antibiotic, antihelminth and malaria drug treatment,
vitamin A supplementation and a ready-to-use therapeutic food (RUTF) called Plumpy’nut® at the
health centre level, which the families of eligible children can take home.
We would like to involve a variety of health practitioners and service providers, including private
clinics, to help us identify children with SAM so that they can be treated at an early stage. Currently,
the services are provided in five facilities (Swedru Hospital and Kwanyako, Abodom, Duakwa and
Nsaba Health Centres) under Agona District Health Directorate, but it is hoped that the services will
be extended to other health centres in Agona District. We are writing therefore to kindly request that
your health facility brief all staff members, especially those in the outpatient department, and have them
refer children with bilateral pitting oedema and severe wasting to any of the above-mentioned health
centres for treatment.
The GHS SAM team would be pleased to provide your clinic with MUAC tapes and train your staff in
identifying and treating children with bilateral pitting oedema and severe wasting.
We are confident that the CMAM services will significantly improve the District’s ability to support
the recovery of malnourished children, and we look forward to your cooperation. Please do not hesitate
to contact us for more information or clarification.
Yours faithfully,
District Director of Health
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To All Mothers/Caregivers With Children Between 6-59 months:

A new treatment is now available for children under five years who are very thin or have swelling. These
children have severe acute malnutrition (SAM)and need a specific treatment with medicines and a
nutritional food that will be provided at the health centre after a medical check. If a child with SAM
has good appetite and no medical complications, he/she can be treated at home and followed up
through weekly health centre visits. These children do not have to go to the hospital but can stay at
Annexes
home with their families. If the child with SAM has no appetite or has developed a medical
complication, then he/she will be admitted to hospital for a short time until the complication is
resolving. The child will continue treatment at the health facility and at home. Children under six
months who are very thin or have swelling will need specialised treatment in inpatient care at Swedru
Hospital.
How to Know Whether Your Child Needs this Treatment
Some people within your community have been trained to take an arm measurement of children with a
small tape and check if both feet are swollen.
The Treatment
All children found to be thin or swollen are referred to the health centre, where the arm measurement
and swelling are checked again. If the children have appetite and are clinically well, they are given
medicines and a weekly supply of a nutritional food called Plumpy’nut®. Only the children who are
very small or very ill will need referral to inpatient care.
If you know a child who appears to be very thin or whose feet are swollen, tell his/her parents or
guardians about this new treatment. They can ask around their neighbourhood for a community health
worker, volunteer or someone else trained to take the arm measurement. Or, they can go directly to the
health centres to have their child measured any day. Follow-up service days in the health centres are:
• Swedru Hospital on Monday
• Kwanyako Health Centre on Wednesday
• Abodom Health Centre on Wednesday
• Nsaba Health Centre on Friday
• Duakwa Health Centre on Friday
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Annex 3. Admission and Discharge Criteria for the Management of

SAM in Children 0-59 Months
Outpatient Care
Inpatient Care
for the Management of SAM
Without Medical
SAM with Medical Complications
Complications
Admission Criteria
Bilateral pitting oedema +++ Bilateral pitting oedema + and
Or ++
Any grade of bilateral pitting oedema with severe wasting (MUAC < 11.5 Or
cm) Severe wasting (MUAC <
Or 11.5 cm)
SAM with any of the following medical complications:
• Anorexia, no appetite And
• Intractable vomiting • Appetite test passed
• Convulsions • No medical complication
• Lethargy, not alert • Clinically well
• Unconsciousness • Alert
• Hypoglycaemia
• High fever
• Hypothermia
• Severe anaemia
• Skin lesion
Or
• Referred from outpatient care according to action protocol
Infants 0- 6 months
• Infants 0-6 months with bilateral pitting oedema or
• visible wasting (or e.g., insufficient breastfeeding in vulnerable
environment)
• Other: e.g., infants ≥ 6 months who weigh < 4.0 kg
Discharge Criteria
Referred to outpatient care: Discharged cured:
Appetite returned (passed appetite test) - The child has attained 15%
and weight gain or more for two
medical complication resolved consecutive weeks
and - No bilateral pitting oedema
bilateral pitting oedema decreasing for two consecutive weeks
and - Child clinically well and alert
clinically well and alert
(If bilateral pitting oedema and severe wasting: bilateral pitting oedema
resolved)
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Outpatient Care
Inpatient Care
for the Management of SAM
Without Medical
SAM with Medical Complications
Complications
Children ≥ 5 years
See discharge criteria outpatient care
Annexes
Infants < 6 months
Discharged cured if successful re-lactation and appropriate weight gain
(minimum 20 g weight gain per day on breastfeeding alone for five days)
and clinically well and alert
(if no access to breastfeeding, alternative method of replacement feeding
based on national guidelines is required).
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Annex 4. Anthropometric Measurements

Bilateral Pitting Oedema
Bilateral pitting oedema, or kwashiorkor, can be verified when thumb pressure applied on top of both
feet for three seconds leaves a pit (indentation) in the foot after the thumb is lifted. The pit will remain
in both feet for several seconds. Bilateral pitting oedema usually starts in the feet and ankles. It is
important to test both feet; if the pitting is not bilateral, the oedema is not of nutritional origin. The
presence of bilateral pitting oedema is confirmed by a second person who repeats the test.
There are three grades of bilateral pitting oedema. When there is no bilateral pitting oedema, the grade
is “absent.” Grades of bilateral pitting oedema are classified by plus signs.
Grades of bilateral pitting oedema Definition

Absent Absent
Grade + Mild: Both feet/ankles
Grade ++ Moderate: Both feet, plus lower legs, hands or lower arms
Grade +++ Severe: Generalised bilateral pitting oedema, including both
feet, legs, arms and face
Pictures of Bilateral Pitting Oedema
Grade +
In this child, there is bilateral pitting oedema in both

feet. This is grade + oedema (mild); however, the
child might have grade ++ or +++, so legs and face
will also need to be checked.
90
Grade ++
In this child, both feet plus the lower legs, hands and
lower arms are swollen. This is grade + + bilateral
pitting oedema (moderate).
Annexes
Grade +++
This child has +++ bilateral pitting oedema

(severe). It is generalised, including both feet, legs,
arms, hands and face.
Mid-Upper Arm Circumference (MUAC)

MUAC is used for children age 6-59 months. It is essential to use the age cutoff of 6 months for the
use of MUAC. Never use a height cutoff as proxy to determine age. If the birth date is unconfirmed,
use the recall of the mother/caregiver to estimate the young child’s age.
How to Measure MUAC
(See photo)
• MUAC is always taken on the left arm.
• Measure the length of the child’s upper arm, between the bone at the top of the shoulder and the
elbow bone (the child’s arm should be bent).
• Mark the middle of the child’s upper arm with a pen.
• The child’s arm should then be relaxed, falling alongside his/her body.
• Wrap the MUAC tape around the child’s arm, such that all of it is in contact with the child’s skin.
It should be neither too tight nor too loose.
• Read the MUAC in centimetres (cm).
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For numbered tapes, feed the end of the tape down through the first opening and up through the third
opening. The measurement is read from the middle window where the arrows point inward. Read the
number in the box that is completely visible in the middle window. For the example below, it is 12.4
cm.
For the simple three-colour tape (red, yellow, green), slide the end through the first opening and then
through the second opening. Read the colour that shows through the window at the point the two
arrows indicate.
Photo Credit: WHO-Tanzania, training on the management of severe acute malnutrition, September 2006 (Valid International).
92
Annexes
93
Weight
To increase accuracy and precision, two people are always needed to measure weight. Weight can be
measured using a Salter-type hanging spring scale (as is commonly found in the field) or an electronic
scale such as the United Nations Children’s Fund (UNICEF) UNISCALE, which is more precise and
allows a child to be measured in the mother/caregiver’s arms.
Hanging Spring (Salter) Scale
A 25 kg hanging spring scale, graduated by 0.100 kg, is most commonly used. In the field setting, the
scale is hooked to a tree, a tripod or a stick held by two people. In a clinic, it is attached to the ceiling
or a stand.
Weighing pants (or a weighing hammock for smaller infants) are attached to the scale. Culturally
adapted solutions, such as a mother’s wrap, basin or grass basket, might be preferable to use to weigh
the child. These are suspended from the lower hook of the scale, and the scale is readjusted to zero.
How to use the Salter Scale:

(See picture)
• Before weighing the child, take all his/her clothes off.
• Zero the weighing scales (i.e., make sure the arrow is on 0.)
• Place the child in the weighing pants/hammock, making sure the child is touching nothing.
• Read the child’s weight. The arrow
must be steady and the
weight/scale should be read at eye
level.
• Record the weight in kg and to the
nearest 100 g (e.g., 6.4 kg).
Considerations when using the Salter

scale:
• Make sure the child is safely in the
weighing pants or hammock with
one arm in front and the other arm
behind to help maintain balance.
• In cold climates or in certain
cultures, it might be impossible or
impractical to undress a child
completely. The average weight of
the clothes should be estimated and
deducted from the measure. It is
helpful to retain similar clothing for
girls and boys during weighing to
help to standardize the weight
deductions.
• When the child is steady and
settled, the weight is recorded to
the nearest 100 g. If the child is
moving and the needle does not
94
stabilise, the weight should be estimated by recording the value at the midpoint of the range of
oscillations. The measurer announces the value read from the scale, the assistant repeats it for
verification and records it on the clinic form or child health card (CHC). The child is then dressed.
• The scale should be checked daily against a known weight. To do this, set the scale to zero and
weigh objects of known weight (e.g., 5 kg, 10 kg, 15 kg). If the measure does not match the weight
to within 10 g, the scale should be replaced or the springs must be changed.
Annexes
Measuring Weight Using an Electronic Scale “Tared Weighing”
“Tared weighing” means that the scale can be re-set to zero (“tared”) with the person just weighed still
on it.
Explain the tared weighing procedure to the mother as follows. Stress that the mother must stay on the
scale until her child has been weighed in her arms.
Be sure that the scale is placed on a flat, hard, even surface. Since the scale is solar powered, there must
be enough light to operate the scale.
Mother's weight alone. Taring the scale. Baby's weight appears on display.
• To turn on the scale, cover the solar panel for a second. When the number 0.0 appears, the scale is
ready.
• Check to see that the mother has removed her shoes. You or someone else should hold the naked
baby wrapped in a blanket.
• Ask the mother to stand in the middle of the scale, feet slightly apart (on the footprints, if
marked), and remain still. The mother’s clothing must not cover the display or solar panel.
• Remind her to stay on the scale even after her weight appears, until the baby has been weighed in
her arms.
• With the mother still on the scale and her weight displayed, tare the scale by covering the solar
panel for a second. The scale is tared when it displays a figure of a mother and baby and the
number 0.0.
• Gently hand the naked baby to the mother and ask her to remain still.
95
• The baby’s weight will appear on the display. Record the weight. Be careful to read the numbers in
the correct order (as though you were viewing while standing on the scale rather than upside-
down).
If the child is 2 years or older, you will weigh the child alone if the child will stand still.
96
Annex 5. Guidance Table to Identify Target Weight for Discharge

Guidance Table to Identify the Target Weight
for Children 6-59 Months
Target weight: Target weight:
Weight on admission* Weight on admission*
15% weight gain 15% weight gain
4.1 4.7 10.7 12.3
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4.3 4.9 10.9 12.5
4.5 5.2 11.1 12.8
4.7 5.4 11.3 13.0
4.9 5.6 11.5 13.2
5.1 5.9 11.7 13.5
5.3 6.1 11.9 13.7
5.5 6.3 12.1 13.9
5.7 6.6 12.3 14.1
5.9 6.8 12.5 14.4
6.1 7.0 12.7 14.6
6.3 7.2 12.9 14.8
6.5 7.5 13.1 15.1
6.7 7.7 13.3 15.3
6.9 7.9 13.5 15.5
7.1 8.2 13.7 15.8
7.3 8.4 13.9 16.0
7.5 8.6 14.1 16.2
7.7 8.9 14.3 16.4
7.9 9.1 14.5 16.7
8.1 9.3 14.7 16.9
8.3 9.5 14.9 17.1
8.5 9.8 15.1 17.4
8.7 10.0 15.3 17.6
8.9 10.2 15.5 17.8
9.1 10.5 15.7 18.1
9.3 10.7 15.9 18.3
9.5 10.9 16.1 18.5
9.7 11.2 16.3 18.7
9.9 11.4 16.5 19.0
10.1 11.6 16.7 19.2
10.3 11.8 16.9 19.4
10.5 12.1 17.1 19.7
* Or weight free of oedema
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Annex 6. Checklist for Medical History and Physical Examination

Medical History
• Diet before current episode of illness

• Breastfeeding history
• Food and fluids taken in the past few days
• Recent sinking of eyes
• Duration and frequency of vomiting or diarrhoea, appearance of vomit or diarrhoeal stools
• Time when urine was last passed
• Contact with people with measles or TB
• Any deaths of siblings
• Birth weight
• Milestones reached (e.g., sitting up, standing)
• Immunisations
Physical Examination
• Mid-upper arm circumference (MUAC), weight, length or height

• Appetite test: anorexia
• Enlargement or tenderness of the liver, jaundice
• Abdominal distension, bowel sounds, “abdominal splash” (a splashing sound in the abdomen)
• Severe pallor
• Signs of circulatory collapse: cold hands and feet, weak radial pulse, diminished consciousness
• Temperature: hypothermia or fever
• Thirst
• Eyes: corneal lesions indicative of vitamin A deficiency
• Ears, mouth, throat: evidence of infection
• Skin: evidence of lesion, infection or purpura
• Respiratory rate and type of respiration: signs of pneumonia or heart failure
• Appearance of stool
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Annex 7. Routine Medicines Protocols

Name of Medication When Age / Weight Prescription Dose
6 months to 12 months 100,000 IU
Single dose on admission
At admission (except children > 12 months 200,000 IU
VITAMIN A* (for children with bilateral pitting
with oedema) DO NOT USE with oedema-single dose on discharge)
bilateral pitting oedema
ANTIBIOTIC
At admission All beneficiaries See Protocol 3 times a day for 5-7 days
Amoxicillin
At admission
ANTIMALARIAL: Test on admission. Artesunate 4 mg/kg bodyweight +
Artesunate 50 mg
Artesunate + Repeat test later if initial test All beneficiaries Amodiaquine 10 mg/kg bodyweight in
Amodiaquine 50 mg
Amodiaquine is negative and malaria is two divided doses for 3 days 15
suspected
Less than 24 months DO NOT GIVE NONE
ANTIHELMINTH
On second visit 24 months
Mebendazole ** 500mg Single dose on second visit
or over
MEASLES
On week 4 From 6 months Standard
VACCINATION
*VITAMIN A: Do not give if child has already received vitamin A in the past month. Do not give to children with oedema until they are discharged, unless there are signs
of vitamin A deficiency.
** MEBENDAZOLE or other antihelminth can be given after 3 months if signs of re-infection appear.
IRON and FOLIC ACID are not to be given routinely in Outpatient Care for Managing SAM without medical complications. Where anaemia is identified
according to Integrated Management of Childhood Illness (IMCI) Guidelines, treatment should begin after 14 days in the outpatient care programme and not
before. When iron and folic acid are given, they should be given according National/World Health Organization (WHO) Guidelines (INACG 1998). For
severe anaemia, refer the child to the inpatient care.
No paracheck (Rapid Diagnostic Test) is undergone routinely for malaria treatment in the health centre. Treatment is advised on a presumptive diagnosis in absence of
15
microscopy or paracheck in the National Guidelines.

99
Annexes
Annex 8. Supplemental Medicines Protocols

Name of Product When to Give Prescription Special Instructions
CHLORAMPHENICOL To be given as second-line antibiotic for See separate protocol Continue for 7 days
children not responding to amoxicillin:
continued fever that is not due to malaria
TETRACYCLINE EYE For treatment of eye infection Apply 3 times a day: morning, afternoon Wash hands before and after use; wash
OINTMENT and at night before sleep eyes before application; continue for 2
days after infection is gone
NYSTATIN For treatment of candida 100,000 units (1 ml) 4 times a day after Continue for 7 days
food (use dropper and show caregiver
how to use it)
PARACETAMOL For children with fever over 38.5° C See separate protocol Single dose only - do not give to take
home
BENZYL BENZOATE For treatment of scabies Apply over whole body; repeat without Avoid eye contact; do not use on broken
bathing on following day; wash off 24 or secondary infected skin
hours later
WHITFIELDS For treatment of ringworm or other Apply twice a day Continue treatment until condition has
fungal infections of the skin completely resolved
GENTIAN VIOLET For treatment of minor abrasions or Apply on lesion Can be repeated at next visit and
fungal infections of the skin continued until condition resolved
QUININE 2nd-line antimalarial treatment for See separate protocol
children who have not responded to
fansidar
FERROUS SULPHATE/ FOLATE Treatment of anaemia identified According to WHO protocols (INACG To be given only after 14 days in the
according to Integrated Management of 1998 and Donnen et al, 1998) programme
Childhood Illness (IMCI) Guidelines
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Annex 9. Drug Doses

Antibiotics
Antibiotics should be given to every severely malnourished child even if he/she does not show clinical
signs of systemic infection. Small bowel bacterial overgrowth is frequently the source of systemic
Annexes
infection. Moreover, in some severely malnourished children, bacteria such as Staphylococcus
epidermidis can cause systemic infection or septicaemia.
First-line antibiotics are always provided in outpatient care and inpatient care. If second-line antibiotics
are needed in outpatient care, the child with severe acute malnutrition (SAM) is referred to inpatient
care.
Box 1. Antibiotic Regimen
First-Line
Oral amoxicillin (use ampicillin if amoxicillin is not available)
Second-Line
Add chloramphenicol (do not stop amoxicillin)
or
Add Gentamicin (do not stop Amoxicillin)
or
Change to amoxicillin/clavulanic acid (Augmentin)
Third-Line
Individual medical decision
Notes:
• A systemic antifungal (fluconazole) is frequently added if there are signs of severe sepsis or
systemic candidiasis.
• Co-trimoxazole is not active against small bowel bacterial overgrowth. It is inadequate for the
severely malnourished child. If it is being given for preventive therapy in HIV-positive
children, the other antibiotics should be given first and the prophylactic co-trimoxazole after
one week.
Box 2. Duration of Antibiotic Treatment
Inpatient Care (stabilisation phase)

Every day in Phase 1 plus four more days or until referral to outpatient care
Outpatient Care (stabilisation and rehabilitation phases)

For a total of seven days
Note: Paediatric antibiotic formulation is preferred. For children < 5 kg, antibiotic tablets should be
used and cut in half by the health care provider before they are given to the caregiver to give to
the child.
101
Amoxicillin Doses
Give amoxicillin 15mg/kg bodyweight three times per day for five days.
Table 1. Amoxicillin Doses

Weight of the
child Syrup – 125 mg / 5 ml Syrup – 250 mg / 5 ml Tablets – 250 mg
Dosage – give three times a day
≤ 9.9 kg 125 mg (5 ml) 125 mg (2.5 ml) 125 mg (½ tablet)
10.0 - 30.0 kg 250 mg (10 ml) 250 mg (5 ml) 250 mg (1 tablet)
> 30.0 kg give tablets give tablets 500 mg (2 tablets)
Chloramphenicol Doses
Use chloramphenicol for second-line antibiotic treatment for children who have not responded to
amoxicillin, e.g., have a continued fever that is not due to malaria. Give three times per day for seven
days. Always complete the course.
Note: Always check label on bottles for dosages and dilution of syrups, as this can change between
different manufacturers.
Table 2. Chloramphenicol Doses

Weight of the
child Syrup – 125 mg / 5 ml Capsules – 250 mg
Dosage – give three times a day
2.0 – 5.9 kg 62.5 mg (2.5 ml) Give syrup
6.0 - 10.0 kg 125 mg (5 ml) 125 mg (½ capsule)
10.0 - 30.0 kg 250 mg (10 ml) 250 mg (1 capsule)
Co-trimoxazole for children with confirmed or suspected HIV infection or children who are HIV
exposed.
Co-trimoxazole should be given to children starting at 4-6 weeks old to:

• All infants born of mothers who are HIV-infected until HIV is definitively ruled out
• All infants <12 months with confirmed HIV infection or those with stage 2,3 or 4 disease or
• Asymptomatic infants or children (stage 1) if CD4 <25%
Table 3. Co-trimoxazole dosage – single dose per day

Age Single strength
5ml syrup Single strength adult tablet paediatric tablet
40mg/200mg 80mg/400mg 20mg/100mg
0-6 months 2.5ml ¼ tablet 1 tablet
6-59 months 5ml ½ tablet 2 tablets

5-14 years 10ml 1 tablet 4 tablets
>15 years NIL 2 tablets -
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Malaria Treatment
All severely malnourished children should be systematically screened for malaria. If in clinical doubt,
repeat the test in the days or weeks following the initial test. A persistently negative test excludes p.
falciparum malaria.
Notes:
Annexes
• The malaria load in oedematous children might be low at testing.
• The usual clinical signs and symptoms of malaria might be absent in severely malnourished
children as they might lack the ability to mount an acute phase inflammatory response as a
result of pathophysiological changes in their bodies.
• Care should be taken not to give intravenous (IV) infusions of quinine to severely
malnourished children within two weeks of treatment.
• Provision of insecticide-treated bednets is essential to protect children with SAM,
especially in areas where malaria is endemic.
Artesunate + Amodiaquine Doses
Give artesunate 4 mg per kg bodyweight plus amodiaquine 10 mg per kg bodyweight in two divided
doses for three days.
Table 3. Artesunate and Amodiaquine Doses

Artesunate 50 mg Amodiaquine 150 mg
Weight
Dose Dose
< 5 kg ¼ ¼
5 - < 10 kg ½ ½
10.0 - < 14 kg 1 1
14 - < 19 kg 1 1
Quinine Doses
Give quinine three times per day for seven days. Always complete the course.
Table 4. Quinine Doses

Weight Dose
< 5 kg 0
5 - < 10 kg ¼ tablet every 8 hours
10.0 - < 14 kg ½ tablet every 8 hours
14 - <19 kg ½ tablet every 8 hours
Deworming Treatment
Inpatient Care
For children remaining in the rehabilitation phase in inpatient care, the deworming medicine is
given at the start of rehabilitation phase.
103
Outpatient Care
For children admitted directly to outpatient care as well as those who have been transferred from
inpatient care, deworming medicine is given at the second visit to outpatient care (i.e., after one week).
Table 5. Anthelmintic Drug Therapy Doses for Children With SAM

Age or weight of the child Albendazole 400 mg Mebendazole 500 mg
Under 1 year Not given Not given
< 10 kg 200 mg or ½ tablet 250 mg or ½ tablet
once Once
≥ 10 kg 400 mg or 1 tablet 500 mg or 1 tablet
once Once
Note: In Ghana, anthelmintics should only be given to children over 24 months old.
Measles Vaccination
Inpatient Care
All children 6 months and older should be vaccinated if they cannot give evidence (vaccination card) of
previous vaccination. Vaccination should be given upon admission and discharge.
Note: The first measles vaccination given upon admission often does not give a protective antibody
response in a severely malnourished child undergoing inpatient treatment. It is given because it
ameliorates the severity of incubating measles and partially protects from nosocomial measles.
The second dose provokes protective antibodies.
Outpatient Care
All children six months and older should be vaccinated if they cannot give evidence (vaccination card)
of previous vaccination. Vaccination should be given on the fourth week of treatment. Children
referred from inpatient care should also be vaccinated on week four of treatment if the repeat
vaccination was not provided.
Note: Provision of two vaccinations (upon admission and discharge) is usually unnecessary with
outpatient treatment as there is limited risk of crowding and thus of transmission, except in
case of a measles epidemic or if the child was under 12 months when the first vaccination was
given.
Paracetamol
Paracetamol is given for the treatment of children with fever, given as a single dose. Start antibiotic
and/or malaria treatment immediately. Children with SAM with a fever over 38.5°C are referred to
inpatient care.
Paracetamol Doses
Give a single dose of paracetamol for symptomatic treatment of fever.
Use extreme caution for children with SAM. Give treatment one time only and start antibiotic or
antimalarial immediately. Monitor the child: If the fever is greater than 39° C, refer the child to
104
inpatient care where possible. If inpatient care is not possible, give a single dose of paracetamol and a
tepid sponge bath to the child until the fever subsides. Return the child to the clinic if a high fever
continues at home.
Note: Always check the label on bottles for doses and dilution of syrups, as this can change between
different manufacturers. Give one dose only and start antibiotic or antimalarial.
Annexes
Table 6. Paracetamol Doses
Weight of the child Syrup – 125 mg / 5 ml Capsules – 250 mg
Dose – one-time treatment only
< 4.0 kg 25 mg (1 ml) 25 mg (¼ tablet)
4.0 – 8.0 kg 60 mg (2.5 ml) 50 mg (½ tablet)
8.0 - 15.0 kg 120 mg (5 ml) 100 mg (1 tablet)
> 15.0 kg 240 mg (10 ml) 200 mg (2 tablets)
105
Annex 10. Sugar-Water Protocol

Sugar Water (10 Percent Dilution)
Quantity of Water Quantity of Sugar
100 ml 10 g 2 heaped teaspoons

200 ml (average cup) 20 g 4 heaped teaspoons
500 ml (small bottle) 50 g 10 heaped teaspoons
1L 100 g 20 heaped teaspoons
Notes:
• Use clean drinking water (slightly warm if possible to help dilution). Add the required
amount of sugar and shake or stir vigorously.
• Give immediately to all children refusing ready-to-use therapeutic food (RUTF) or being
referred to inpatient care.
• If possible, especially when very hot, give to all children in outpatient care while they are
awaiting treatment.
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Annex 11. Dietary Treatment
Overview of Dietary Treatment
F75 Therapeutic Milk Inpatient care – stabilisation phase

(100 kcal/kg/day)
Annexes
F100 Therapeutic Milk Inpatient care – transition and rehabilitation
(150 and 200 kcal/kg/day) phase
F100-Diluted Therapeutic Milk Infants under 6 months (no oedema) in inpatient care –
stabilisation phase to complement breastfeeding
(130 kcal/kg/day)
Infants with oedema in stabilisation phase will take F75 and

change to F100-Diluted when the oedema is resolved
RUTF Inpatient care transition and rehabilitation phase or outpatient

care (200 kcal/kg/day)
Therapeutic Milk
F75 and F100 are therapeutic products that are available commercially as powder formulations. The
formulas can also be prepared using basic ingredients of dried skim milk, sugar, cereal flour, oil,
combined mineral and vitamin mix (CMV) for severe acute malnutrition (SAM). (See Annex 12.
Alternative Recipes for F75, F100 and ReSoMal Using CMV.)
F75 Therapeutic Milk
• F75 therapeutic milk has 75 kcal per 100 ml. F75 has the correct balance of Type 1 and Type 2
nutrients, a greater nutrient density and bioavailability, lower osmolarity and renal solute load. It is
designed to restore hydration, electrolyte and metabolic balance, provide the necessary calories and
nutrients for maintenance needs and start the process of restoration of adequate immune function.
• F75 is provided in inpatient care (stabilization phase only).
• Quantities to give of F75: 100 kcal/130 ml/kg/day.
F100 Therapeutic Milk
• F100 therapeutic milk has 100 kcal/100 ml. F100 has the correct balance of Type 1 and Type 2
nutrients, and a greater nutrient density and bioavailability. The F100 diet is designed to provide
adequate calories and nutrients to promote catch-up growth in children recovering from SAM.
• F100 should never be given for use at home or in outpatient care.
• F100 is provided in inpatient care – transition and rehabilitation phase.
• Quantities to give of F100 inpatient care – transition phase: 130 kcal/130 ml/kg/day.
• Quantities to give of F100 inpatient care –rehabilitation phase: 200 kcal/200 ml/kg/day, in case
ready-to-use therapeutic food (RUTF) cannot be taken.
107
F100-Diluted Therapeutic Milk
• F100-Diluted therapeutic milk has 66 kcal/100 ml, as one-third of water is added to the F100
mixture.
• F100-Diluted is provided in inpatient care (all phases for infants under 6 months or below 4 kg, if
no oedema).
• Quantities to give of F100-Diluted: 100 kcal/130 ml/kg/day.
Ready-to-Use Therapeutic Food (RUTF)

RUTF are soft foods or pastes that have been developed specifically with the right mix of Type 1 and
Type 2 nutrients and are of adequate caloric composition to treat a child over 6 months with SAM.
RUTF is easy for children to consume and requires no preparation and no mixing with water or other
foods. RUTF has similar nutrient and caloric composition to the F100 therapeutic milk but has very
low water activity, meaning that bacteria cannot grow in it. This allows it to be given as a take-home
ration in outpatient care. RUTF can also be provided in the inpatient transition and rehabilitation
phase. Plumpy’nut® is a commercial RUTF product manufactured by Nutriset. It comes in sachets of
500 kcal weighing 92 g. RUTF can also be produced locally using dried skim milk, sugar, oil, CMV
and peanut paste.
92 g Packets Containing 500 kcal (average treatment based on 200 kcal/kg bodyweight/day)
Weight of Child (kg) Packets per Week Packets per Day
3.5 – 3.9 11 1.5
4.0 – 4.9 14 2
5.0 – 6.9 18 2.5
7.0 – 8.4 21 3
8.5 – 9.4 25 3.5
9.5 – 10.4 28 4
10.5 – 11.9 32 4.5
≥ 12 35 5
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Annex 12. Alternative Recipes for F75, F100 and ReSoMal Using
CMV
Recipes for F75 Formula – Cooking Recipe
Cereal CMV
Annexes
Milk Sugar Oil powder* red scoop = Water
Type of milk (g) (g) (g) (g) 6.35g (ml)
Dried skim milk 50 140 60 70 1 Up to 2,000
Dried whole
70 140 40 70 1 Up to 2,000
milk
Fresh cow milk
or full –cream
600 140 40 70 1 Up to 2,000
(whole) long life
milk
*Cereal powder is cooked for about 10 minutes and then the other ingredients are added.
To prepare the F-75 diet, add the dried skim milk, sugar, cereal flour and oil to water and mix. Boil for
5-7 minutes. Allow to cool, then add the CMV and mix again. Make up the volume to 2,000 ml with
water.
Alternative Recipes for F75 Formula – No Cooking

CMV
Milk Sugar Oil red scoop = Water
Type of milk (g) (g) (g) 6.35g (ml)
Dried skim milk 50 200 60 1 Up to 2,000
Dried whole milk 70 200 40 1 Up to 2,000
Fresh cow milk or full
–cream (whole) long 600 200 40 1 Up to 2,000
life milk
Recipes for F100 Formula

CMV
Milk Sugar Oil red scoop = Water
Type of milk (g) (g) (g) 6.35g (ml)
Dried skim milk 160 100 120 1 Up to 2,000
Dried whole milk 220 100 60 1 Up to 2,000
Fresh cow milk or full –
cream (whole) long life 1,760 150 40 1 Up to 2,000
milk
109
Rehydration Solution for Malnutrition (ReSoMal)

ReSoMal is a rehydration solution for children with SAM provided in inpatient care only after careful
diagnosis of dehydration based on history and clinical signs. It is made of a CMV for use in the dietetic
treatment of severe malnutrition. CMV is packed in an airtight metallic tin. Each tin contains a
measuring scoop equalling 6.35 g of mineral and vitamin mix to be added to 2 litres (L) of self-
prepared F75, F100 or ReSoMal.
Recipe for ReSoMal using standards ORS (90 mmol sodium/L)
Ingredient Amount
Standard WHO ORS One L packages
CMV 1 red scoop or 6.35 g
Sugar 50 g
Water 2,000 ml
Recipe for ReSoMal using low osmolarity ORS (75 mmol sodium/L)
Ingredient Amount
Low osmolarity WHO ORS 500 ml package
CMV ½ levelled red scoop or
3.175 g
Sugar 20 g
Water 850 ml
CMV should have a moderate positive non-metabolisable base sufficient to eliminate the risk of
metabolic acidosis. The non-metabolisable base can be approximated by the formula: estimated
absorbed millimoles (sodium +potassium + calcium + magnesium) - (phosphorus + chloride). The
CMV reproduced has a suitable positive non-metabolisable base.
The composition of the therapeutic CMV complies with the recommendations for mineral and vitamin
enrichment in the dietetic treatment of severe malnutrition. It can be used to prepare ReSoMal (from
the current ORS [standard or low osmolarity] + sugar + water) and prepare enriched high energy milk
(F100 or F75).
The shelf life is 24 months from manufacturing date.
Nutrition Value for 6.35 g (1 Levelled Measuring Spoon) of Product

Vitamins: Minerals:
Vitamin A: 3,000 µg Potassium: 2,340 mg
Vitamin D: 60 µg Magnesium: 146 mg
Vitamin E: 44 mg Zinc: 40 mg
Vitamin C: 200 mg Copper: 5.7 mg
Vitamin B1: 1.4 mg Iron: 0 mg
Vitamin B2: 4 mg Iodine: 154 µg
Vitamin B6: 1.4 mg Selenium: 94 µg
Vitamin B12: 2 µg
Vitamin K: 80 µg
Biotin: 0.2 mg
Folic acid: 700 µg
Pantothenic acid: 6 mg
Niacin: 20 mg
110
Annex 13. Preparing F75 Milk Using Pre-Packaged F75

Quantity (Red Scoop ) Quantity of water (ml) Amount of F75 milk prepared (ml)
1 20
2 40
3 60
Annexes
4 80
5 100
6 120
7 140
8 160
9 180
10 200
Quantity of water to add
Quantity of F75 (g) (ml) Amount of F75 milk prepared (ml)
¼ sachet (102.5 grams) 500 600
½ sachet (205 grams) 1,000 1,200
1 sachet (410 grams) 2,000 2,400
111
Annex 14. RUTF Specification

Severely malnourished children require specialised therapeutic food to recover, such as F100 and F75
therapeutic milk, according to the WHO protocol recommendations. Ready-to-use therapeutic food
(RUTF) is an integral part of outpatient programmes as it allows children to be treated at home rather
than at inpatient treatment centres. RUTF is an energy-dense mineral- and vitamin-enriched food that
is equivalent to F100 therapeutic milk.
There are currently two commercial types of RUTF: Plumpy’nut® and BP 100®. Several countries are
producing their own RUTF using recipes that are adapted to locally available ingredients, and the
product produced has similar nutritional quality as F100. It has also been shown to be physiologically
similar to both commercial forms of F100 and RUTF.
Plumpy’nut®
Plumpy’nut® is a ready-to-eat therapeutic spread, presented in individual sachets. It is a paste of
groundnut composed of vegetable fat, peanut butter, skimmed milk powder, lactoserum, maltodextrin,
sugar and combined mineral and vitamin mix (CMV).
Instructions for Use
Clean drinking water must be made available to children during consumption of ready-to-eat
therapeutic spread. The product should only be given to children who can express their thirst.
Recommendations for Use
• In the dietetic management of SAM in therapeutic feeding, it is recommended to use the product
in the rehabilitation phase (phase two). In the stabilisation phase (phase one), use a milk-based diet
(F75).
• Plumpy’nut® is contraindicated for children who are allergic to cow’s milk, proteins or peanut, and
also for people with asthma (due to risk of allergic response).
Storage
Plumpy’nut® has a shelf life of 24 months from the manufacturing date. Keep it stored in a cool and
dry place.
Packaging
Plumpy’nut® is presented in sachets of 92 g). Each carton (around 15.1 kg) contains 150 sachets. One
sachet = 92 g = 500 kcal.
112
Table 1. Mean Nutrition Value of Plumpy’Nut®

Nutrients For 100 g Per sachet of 92 g Nutrients For 100 g Per sachet of 92 g
Energy 545 kcal 500 kcal Vitamin A 910 µg 840 µg
Proteins 13.6 g 12.5 g Vitamin D 16 µg 15 µg
Lipids 35.7 g 32.86 g Vitamin E 20 mg 18.4 mg
Calcium 300 mg 276 mg Vitamin C 53 mg 49 mg
Phosphorus 300 mg 276 mg Vitamin B1 0.6 mg 0.55 mg
Annexes
Potassium 1,111 mg 1,022 mg Vitamin B2 1.8 mg 1.66 mg
Magnesium 92 mg 84.6 mg Vitamin B6 0.6 mg 0.55 mg
Zinc 14 mg 12.9 mg Vitamin B12 1.8 µg 1.7 µg
Copper 1.8 mg 1.6 mg Vitamin K 21 µg 19.3 µg
Iron 11.5 mg 10.6 mg Biotin 65 µg 60 µg
Iodine 100 µg 92 µg Folic acid 210 µg 193 µg
Pantothenic
Selenium 30 µg 27.6 µg 3.1 mg 2.85 mg
acid
Sodium < 290 mg < 267 mg Niacin 5.3 mg 4.88 mg
Local Production of RUTF

Required ingredients for producing RUTF:
• Basic ingredients: sugar, dried skim milk, oil, and a vitamin and mineral supplement
• Up to 25 percent of the weight of the product can come from vegetable sources, such as oil-seeds,
groundnuts or cereals such as oats
In addition to good nutrition quality (protein, energy and micronutrients), RUTF should have the
following attributes:
• Taste and texture suitable for young children
• Does not need additional processing, such as cooking before consumption
• Is resistant to contamination by microorganisms and a long shelf life without sophisticated
packaging
• Ingredients are low cost and readily available in developing countries
WHO/UNICEF/WFP/SCN Specifications
Recently, WHO, the United Nations Children’s Fund (UNICEF), the World Food Programme
(WFP) and the United Nations Standing Committee on Nutrition (SCN) produced draft
specifications for RUTF. They are as follows:
RUTF is a high nutrient- and energy-dense ready-to-eat food suitable for the treatment of severely
malnourished children. This food should be soft or crushable, palatable and easy for young children to
eat without any preparation. At least half of the proteins contained in the product should come from
milk products.
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Table 2. Nutrition Composition of RUTF 16

Moisture content 2.5% maximum
Energy 520-550 kcal/100 g
Proteins 10 to 12% total energy
Lipids 45 to 60% total energy
Sodium 290 mg/100 g maximum
Potassium 1100 to 1400 mg/100 g
Calcium 300 to 600 mg/100 g
Phosphorus (excluding phytate) 300 to 600 mg/100 g
Magnesium 80 to 140 mg/100 g
Iron 10 to 14 mg/100 g
Zinc 11 to 14 mg/100 g
Copper 1.4 to 1.8 mg/100 g
Selenium 20 to 40 µg
Iodine 70 to 140 µg/100 g
Vitamin A 0.8 to 1.1 mg/100 g
Vitamin D 15 to 20 µg/100 g
Vitamin E 20 mg/100 g minimum
Vitamin K 15 to 30 µg/100 g
Vitamin B1 0.5 mg/100 g minimum
Vitamin C 50 mg/100 g minimum
Vitamin B12 1.6 µg/100 g minimum
Folic acid 200 mcg/100 g minimum
Niacin 5 mg/100 g minimum
Pantothenic acid 3 mg/100 g minimum
Biotin 60 µg/100 g minimum
n-6 fatty acids 3 to 10% of total energy
n-3 fatty acids 0.3 to 2.5% of total energy
Note: Iron is already added to RUTF, but not to F100.
Safety
The food shall be kept free from objectionable matter. It shall not contain any substance originating
from microorganisms or any other poisonous or deleterious substances, like anti-nutrition factors,
heavy metals or pesticides, in amounts that may represent a hazard to the health of severely
malnourished patients.
• Aflatoxin level: 5 parts per billion maximum

• Microorganism content: 10,000/g maximum
• Coliform test: negative in 1 g
• Clostridium perfringens: negative in 1 g
• Yeast: maximum 10 in 1 g
• Moulds: maximum 50 in 1 g
• Pathogenic Staphylococci: negative in 1 g
16
Reference document for F100 composition: WHO. 1999. Management of Severe Malnutrition: A Manual
for Physicians and Other Senior Health Workers. Geneva: WHO. Available at
www.//www.who.int/nutrition/publications/severemalnutrition/9241545119/en/.
114
• Salmonella: negative in 125 g

• Listeria: negative in 25 g
The product should comply with the International Code of Hygienic Practice for Foods for Infants
and Children of the Codex Alimentarius Standard CAC/RCP 21-1979. All added mineral and
vitamins should be on the Advisory List of Mineral Salts and Vitamin compounds for Use in Foods
for Infants and Children of the Codex Alimentarius Standard CAC/GL 10-1979.
Annexes
The added minerals should be water-soluble and should not form insoluble components when mixed
together. This mineral mix should have a positive non-metabolisable base sufficient to eliminate the
risk of metabolic acidosis or alkalosis. 17
Information on how to produce RUTF in-country is available at: http://www.who.int/child-

adolescent health/New_Publications/NUTRITION/CBSM/tbp_4.pdf.
17
The non-metabolisable base can be approximated by the formula: estimated absorbed millimoles (mmol)
(sodium + potassium + calcium + magnesium) - (phosphorus+chloride). The mineral mix recommended for
F100 by WHO is an example of mineral mix with suitable positive non-metabolisable base.
115
Annex 15. Outpatient Care Action Protocol

Sign Referral to Inpatient Care Home Visit
GENERAL
Deteriorating
CONDITION
Grade +++
Any grade of bilateral pitting oedema with severe wasting (marasmic
BILATERAL kwashiorkor)
PITTING OEDEMA
Increase in bilateral pitting oedema
Bilateral pitting oedema not reducing by week 3
ANOREXIA * No appetite or unable to eat – Failed appetite test
VOMITING * Intractable vomiting
Ask mother/caregiver if the child had convulsions since the previous
CONVULSIONS *
visit
LETHARGY, NOT Child is difficult to awake
ALERT *
UNCONSCIOUS- Child does not respond to painful stimuli
NESS *
A clinical sign in a child with SAM is eyelid retraction: Child sleeps Child is absent or
HYPOGLYCAEMIA with eyes slightly open defaulting
Low level of blood glucose < 3 mmol/l
Severe dehydration based primarily on recent history of diarrhoea,
DEHYDRATION vomiting, fever or sweating and on recent appearance of clinical signs
of dehydration as reported by the mother/caregiver Child is not
Axillary temperature ≥ 38.5° C, rectal temperature ≥ 39° C, taking gaining weight or
HIGH FEVER losing weight on
into consideration the ambient temperature
Axillary temperature < 35° C, rectal temperature < 35.5° C, taking follow-up visit
HYPOTHERMIA
into consideration the ambient temperature
≥ 60 respirations/minute for children under 2 months
≥ 50 respirations/minute for children 2 to 12 months Child
RESPIRATION returned from
≥ 40 respirations/minute for children 1 to 5 years
RATE inpatient care or
≥ 30 respirations/minute for children over 5 years refused
Any chest in-drawing referral to inpatient
care
ANAEMIA Palmer pallor or unusual paleness of skin
SKIN LESION Broken skin, fissures, flaking of skin
SUPERFICIAL
Any infection requiring intramuscular antibiotic treatment
INFECTION
Below admission weight on week 3
WEIGHT
Weight loss for 2 consecutive visits
CHANGES
Static weight for 3 consecutive visits
Mother/caregiver requests treatment of child in inpatient care for
REQUEST
social reasons (decided by supervisor)
Child who is not responding to treatment is referred to inpatient care
NOT or hospital for further medical investigation.
It is recommended that children who are referred to the inpatient care
RESPONDING
facility due to failure to respond to treatment are tested for chronic illness
such as HIV/AIDS and TB.
* Integrated Management of Childhood Illness (IMCI) danger signs
116
Annex 16. Key Messages Upon Admission

1. RUTF is a food and medicine for very thin children and children with swelling only. It should not
be shared.
2. Sick children often don’t like to eat. Give small regular meals of RUTF and encourage the child to
Annexes
eat often (if possible eight meals a day). Your child should have _______ packets a day.
3. For young children, continue to breastfeed. Offer breast milk first before every RUTF feed.
4. RUTF is the only food sick and thin/swollen children need to recover during their time in
Outpatient Care. Always give RUTF before other foods, like porridge (“Koko”).
5. Always offer plenty of clean water to drink while eating RUTF. Children will need to drink more
water than normal.
6. Use soap to cleanse child’s hands and face before feeding. Keep food clean and covered.
7. Sick children get cold quickly. Always keep the child covered and warm.
8. Never stop feeding if a child has diarrhoea. Give extra food and extra clean water.
Note: Ask the caregiver to repeat the messages to check if they have been correctly understood. Upon
the next visits to the health facility, the health and nutrition messages are expanded (see Annex
17. Messages for Health and Nutrition Education).
117
Annex 17. Messages for Health and Nutrition Education

Key Points
1. At six months, babies need more nutrients than breast milk alone can provide, and they are also
physically ready to eat foods.
• They can sit, hold their heads up and steady.
• They can swallow food more easily without spitting.
• Their stomach is matured enough to digest foods properly.
2. Babies sometimes reject food because the new taste and texture are different from the breast milk
they are used to.
• Mothers need to take time to teach babies to eat “new” food by continuing to offer it to
them. You will have to be patient and keep trying until baby likes the food.
• It sometimes takes more than five times before a baby likes a food.
3. Forcing your baby to eat might cause feeding problems, such as the baby constantly rejecting the
food.
4. Keeping your hands clean when preparing food or feeding your baby is essential. Wash your hands
with soap and water to prevent diarrhoea-causing germs from getting to your baby.
5. Babies at this age often put their hands in their mouth. Washing their hands with soap and water
helps them stay healthy.
6. Babies should be fed from their own bowl. Don’t give leftovers to the baby.
7. Cooked foods should not be saved from one day to the next unless they are refrigerated.
• Foods should always be reheated to boiling and cooled before serving.
• Cooked food should not be given to the baby after two days in the refrigerator
Meeting Baby’s Food Needs Starting at Six Months

1. At six months, breast milk alone is not enough for the health and growth of your baby.
2. Babies like a variety of foods, just like adults. There are many foods that babies like, such as Koko,
rice, weanimix, beans, yams, kenkey and sweet potatoes.
3. A small spoon makes it easier for a child to learn how to swallow food.
4. As a baby gets older, the thickness of foods should increase.
5. Thicker foods mean the baby will get more nutrients in each spoonful and feeding will take less
time for you.
6. Your baby has a small stomach. When food is thin and watery, they are getting water but less of
the nutrients they need.
7. Frequent breastfeeding continues to provide protection and nourishment to your baby.
Helping Your Baby to Grow Strong

1. From six months on, babies need more than one type of food at each feeding if they are going to
maintain their health and grow well.
2. Fats/oil should be added to each meal. Any fat you have at home is OK for the baby. A small
amount, such as one teaspoonful of fat/oil, is packed with energy.
3. Babies accept fats easily at six months.
4. Beans, fish, eggs, fish powder and meats help babies grow. Babies who eat them one to two times a
day have good blood and are protected from illness.
118
5. All mothers are concerned about the cost of feeding their family, but luckily babies only need a
small amount of animal protein. As part of a feeding, include a matchbox-size amount (or at least
one tablespoonful) of mashed or chopped meat, egg or fish every other day to help your baby grow.
6. The same amount of mashed beans, ground nuts, agushi or fish powder is needed on the days you
don’t give animal protein.
7. Remember that frequent breastfeeding is still very important for your baby.
Annexes
Vegetables and Fruits: Protecting Your Baby from Illness
1. From six months on, babies need more than one type of food at each feeding if they are going to
maintain their health and grow well.
2. Many families think that fruits are not good for babies because they cause diarrhoea. This is not
true.
• Babies need small quantities of fruits at a time.
• Many fruits contain nutrients that are essential for good health and, in fact, protect babies
from getting sick.
3. Fruits that are orange are especially high in needed vitamins. They are also plentiful and
inexpensive, like mangoes or pawpaw.
4. Babies love the sweet taste of fruits.
5. Vegetables also add variety, vitamins and minerals to your baby’s meals. Cooked greens, pumpkins,
squash or orange sweet potato will give important vitamins.
6. Babies need fruits one to two times each day and vegetables one to two times each day.
7. Fruits and vegetables should be washed very well.
8. Frequent breastfeeding is still very important for your baby.
How Much and How Often?

6 Months Old
1. 1 soup ladle of porridge at a meal

2. Feed the baby two times each day
3. Frequent breastfeeding day and night
7-8 Months Old
1. Babies at this stage have learned about eating and can start to eat more at each meal and eat more
frequently.
2. The baby should eat three times a day.
3. Each meal should contain the following:
• 1 soup ladle of a thick porridge with 1 teaspoon of oil/groundnut paste and fish
powder/egg/soya bean powder or
• ½ soup ladle of staple (e.g., yam, rice, soft banku) and 1 stew ladle of stew/thick soup
containing 1 tablespoon of mashed fish, meat or beans
And
• 2 tablespoon of mashed fruits or vegetables
4. Breastfeed frequently day and night.
119
9 Months to 1 Year Old
1. Most babies have some teeth and like to start chewing.

2. Your baby still needs to be fed three times a day but now also needs a snack.
3. At least one snack each day is important for babies at this age.
4. Snacks should be chosen wisely so they are not too sweet. Fruits, Koose, buttered bread and
doughnuts (bofrot) are good choices for snacks.
5. Babies eat better if a variety of foods are fed each day.
6. The amount of food increases to:
• 2 soup ladles of a thick porridge with 1 teaspoon of oil/groundnut paste and fish
powder/egg/soya bean powder or
• 1 soup ladle of staple (e.g., yam, rice, soft banku) and 1 stew ladle of stew/thick soup
containing 1 tablespoon of mashed fish, meat or beans
And
• 2 tablespoon of mashed fruits or vegetables
7. Frequent breastfeeding is still very important for your baby.
120
Annex 18. Play and Stimulation

Structured Play Activities
Play therapy is intended to develop language skills and motor activities and is aided by simple toys. It
should take place in a loving, relaxed and stimulating environment.
Annexes
Language Skills
At each play session:
• Teach local songs and finger and toe games.
• Get the child to laugh and vocalise, repeat what he/she says.
• Describe all activities.
• Teach action words with activities (e.g., “bang bang” as he/she beats a drum, “bye bye” as he/she
waves).
• Teach concepts at every opportunity.
Motor Activities
Encourage the child to perform the next motor milestone:
• Bounce the child up and down and hold him/her under the arms so that his/her feet support
his/her weight.
• Prop the child up, roll toys out of reach and encourage the child to crawl after them.
• Hold hands and help the child to walk.
• When the child is starting to walk alone, give a “push-along” toy and later a “pull-along” toy.
Activities With Toys

Simple toys can easily be made from readily available materials. These toys can be used for a variety of
different motor activities.
“Ring on a String”
• Swing the ring within reach and tempt the child to grab it.
• Suspend the ring over the crib and encourage the child to knock it and make it swing.
• Let child explore the ring, then place it a little distance from child with the string stretched toward
him/her and within reach. Teach the child to retrieve the ring by pulling on the string horizontally.
• Sit the child on your lap. Holding the string, lower the ring toward the ground. Teach the child to
get the ring by pulling up on the string vertically. Also teach the child to dangle the ring.
“Rattle and Drum”
• Let the child explore the rattle. Show child how to shake it while saying “shake shake.”
• Encourage the child to shake the rattle by saying “shake” but without demonstrating.
• Teach the child to beat the drum with the shaker while saying “bang bang.”
121
• Roll the drum out of reach and let the child crawl after it while saying “fetch it.”
• Get child to say “bang bang” as he/she beats the drum.
“In and Out” Toy with Blocks
• Let the child explore blocks and the container. Put the blocks into the container and shake it, then
teach child to take them out one at a time while saying “out” and “give me.”
• Teach the child to take the blocks out by turning the container upside down.
• Teach the child to hold a block in each hand and bang them together.
• Let the child take the blocks in and out of container while saying “in” and “out.”
• Cover the blocks with the container while saying, “Where are they? They are under the cover.” Let
the child find them. Then hide them under two and then three covers (e.g., pieces of cloth).
• Turn the container upside down and teach the child to put blocks on top of the container.
• Teach the child to stack blocks; first stack two, then gradually increase the number. Knock them
down while saying “up up” then “down.” Make a game of it.
• Line up blocks horizontally: first line up two, then more. Teach the child to push them along while
making train or car noises. Teach older children words such as “stop” and “go,” “fast” and “slow,”
and “next to.” After this, teach children to sort blocks by colour, first two then more, and teach
high and low building. Make up games.
Posting Bottle
• Put an object in the bottle and shake it. Teach the child to turn the bottle upside down and to take
the object out while saying, “Can you get it?”
• Then teach the child to put the object in and take it out. Later try with several objects.
Stacking Bottle Tops
• Let the child play with two bottle tops. Teach the child to stack them while saying, “I’m going to
put one on top of the other.” Later, increase the number of tops.
• Older children can sort tops by colour and learn concepts such as high and low.
Books
• Sit the child on your lap. Get the child to turn the pages, pat pictures and vocalise. Later, let the
child point to the picture you name. Talk about pictures and obtain pictures of simple familiar
objects, people and animals.
• Let older children name pictures and talk about them.
Doll
• Teach the word “baby.” Let the child love and cuddle the doll. Sing songs whilst rocking the child.
• Teach the child to identify his/her own body parts and those of the doll when you name them.
Later s/he will name them.
• Put the doll in a box as a bed and give it sheets. Teach the words “bed” and “sleep,” and describe
the games you play.
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Annex 19. Checklist for Home Visits

Community Health Worker’s Name: _____________________________
Date of Visit: ______________________________________________
Annexes
Child’s Name: _____________________________________________
Note: If problems are identified, please list any health education or advice given in the space below or
on the other side of the page. Return this information to the health facility.
Feeding
Is the ration of ready-to-use therapeutic food (RUTF) present in the home? Yes No
If not, where is the ration?
Is the available RUTF enough to last until the next outpatient care session? Yes No
Is the RUTF being shared or eaten only by the sick child? Shared Sick child
only
Yesterday, did the sick child eat food other than RUTF? Yes No
If yes, what type of food?
Yesterday, how often did the child receive breast milk?
(for children < 2 yrs)
Yesterday, how many times did the sick child receive RUTF to eat?
Did someone help/encourage the sick child to eat? Yes No
What does the caregiver do if the sick child does not want to eat?
Is clean water available? Yes No
Is water given to the child when eating RUTF? Yes No
Caring
Are both parents alive and healthy?
Who cares for the sick child during the day?
Is the sick child clean? Yes No
Health
What is the household’s main source of water?
Is there soap for washing in the house? Yes No
Do the caregiver and child wash hands and face before the child is fed? Yes No
Is food/RUTF covered and free from flies? Yes No
What action does the caregiver take when the child has diarrhoea?
Food Security
Does the household currently have food available? Yes No
What is the most important source of income for the household?
COMMENTS:
123
Annex 20. Inpatient Care Treatment Card (Critical Care Pathway-

CCP)
See following pages.
124
Name: _________________________________________________________________ Page ____ of _____
INITIAL MANAGEMENT Comments on pre-referral and/or emergency treatment already given:

SIGNS OF MALNUTRITION Severe wasting? Yes No SIGNS OF SHOCK None Lethargic/unconscious Cold hand Slow capillary refill (> 3 seconds) Weak/fast pulse
Bilateral Pitting Oedema? 0 + ++ +++ If lethargic or unconscious, plus cold hand, plus either slow capillary refill or weak/fast pulse, give oxygen. Give IV glucose as described under Blood Glucose
Dermatosis? 0 + ++ +++ (raw skin, fissures) (left).
Weight (kg): Height/length (cm): Then give IV fluids: Amount IV fluids per hour: 15 ml x ____ kg (child’s wt) = __________ml
WFH z-score: MUAC (mm): Start: Monitor every 10 minutes *2nd hr Monitor every 10 minutes
TEMPERATURE: o
C rectal axillary Time *
If rectal < 35.5o C, or axillary <35o C, actively warm child. Check temperatures every 30 minutes. Resp. rate *
BLOOD GLUCOSE (mmol/l) Pulse rate *
If <3mmol/l and alert, give 50 ml bolus of 10% glucose or sucrose (oral or NG). *If respiratory & pulse rates are slower after 1 hour, repeat same amount IV fluids for 2nd hour; then alternate ReSoMal and F-75 for up to 10 hours as in
If <3 mmol/l and lethargic, unconscious, or convulsing, give sterile 10% glucose IV: 5 ml x ___kg right part of chart below. If no improvement on IV fluids, transfuse whole fresh blood. (See left, Haemoglobin.)
(child’s wt) = ___ml Then give 50 ml bolus NG.
Time glucose given: Oral NG IV
HAEMOGLOBIN (Hb) (g/l): or Packed cell vol (PCV): DIARRHOEA
Blood type: Watery diarrhoea? Yes No If diarrhoea, circle signs present: Skin pinch goes back slowly Lethargic
If Hb <40 g/l or PCV<12%, transfuse 10 ml/kg whole fresh blood (or 5-7 ml/kg packed cells) Blood in stool? Yes No Thirsty
slowly over 3 hours. Amount: Time started: Ended: Vomiting? Yes No Restless/irritable Dry mouth/tongue No tears
Sunken eyes
EYE SIGNS None Left Right
Bitot’s spots Pus/Inflammation Corneal clouding Corneal ulceration If diarrhoea and/or vomiting, give ReSoMal. Every 30 For up to 10 hours, give ReSoMal and F75 in alternate hours. Monitor every hour. Amount
If ulceration, give vitamin A & Atropine immediately. Record on Daily Care page. If no ulceration, minutes for first 2 hours, monitor and give:* of ReSoMal to offer:*
give vitamin A upon discharge. 5 ml x ____ kg (child’s wt) = ____ ml ReSoMal 5 to 10 ml x ____ kg (child’s wt) = _____ to _____ ml ReSoMal
Record on Comments/Outcome page.
Oral doses of Vitamin A: < 6 months 50 000 IU Time Start
6 – 12 months 100 000 IU Resp. rate
>12 months 200 000 IU Pulse rate
MEASLES Yes No Passed urine? Y N
Number stools
FEEDING Begin feeding with F-75 as soon as possible. (If child is rehydrated, reweigh before Number vomits
determining amount to feed.
Hydration signs
New weight: ______ kg)
Amount for 2-hourly feedings: ____ ml F75* Time first fed: ______ Amount taken (ml) F75 F75 F75 F75 F75
* If hypoglycaemic, feed ¼ of this amount every half hour for first 2 hours; continue until blood
* Stop ReSoMal if: Increase in pulse & resp. rates Jugular veins engorged Increase in oedema, e.g., puffy eyelids
glucose reaches 3 mmol/l.
** If bilateral pitting oedema, give ReSoMal 30 ml after each watery stool only.
Record all feeds on 24-hour Food Intake Chart.
ANTIBIOTICS (All receive) Drug/Route Dose/Frequency/Duration Time of 1st Dose
MALARIA TEST Type/Date/Outcome Antimalarial: Dose/Frequency/Duration Time of 1st Dose

HIV TEST Type/Date/Outcome
125
DAILY CARE Week 1 Week 2 Week 3

DAYS IN HOSPITAL 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Date
Daily weight (kg)
Weight gain (g/kg) Calculate daily after on RUTF or
F100
Bilateral pitting oedema 0 + ++ +++
Diarrhoea/Vomit O D V
FEED PLAN: Type feed
# daily feeds
Volume to give per feed
Total volume taken (ml)
NGT Y N
Breastfeeding Y N
Appetite test with RUTF F failed P passed
ANTIBIOTICS List prescribed antibiotics in left column. Allow one row for each daily dose. Draw a box around days/times that each drug should be given. Initial when given.
ANTIMALARIAL (note type of drug)
FOLIC ACID (if not on RUTF) 5mg 1mg
* Give day 1, 2 and 15 if child admitted with eye sign or recent measles. Else, give routinely single dose on
VITAMIN A week four or upon discharge unless evidence of dose in past month
Drug for worms (note type of worms)
IRON (if not on RUTF) 2 x daily Begin iron after 2 days on F100. Do not
give when on RUTF.
FOR EYE PROBLEMS After 7-10 days, when eye drops are no longer needed, shade boxes for eye drops.
Tetracycline or Chloramphenicol 1 drop 4 x daily
Atropine 1 drop 3 x daily
Dermatosis 0 + ++ +++
Stool appearance
Ear problems
Mouth or throat problems
Bathing, 1% permanganate
OTHER
126
Name: _________________________________________________________________ Page ____ of _____
MONITORING RECORD
Monitor respiratory rate, pulse rate and temperature 4-hourly until after transition to RUTF or F100 and patient is stable. Then monitoring may be less frequent (e.g., twice daily).
RESPIRATORY RATE
Breaths/
minute
PULSE RATE
Beats/
minute
TEMPERATURE
39.5
39.0
38.5
38.0
37.5
37.0
36.5
36.0
35.5
35.0
34.5
Danger Signs: Watch for increasing pulse and respirations, fast or difficult breathing, sudden increase or decrease in temperature, rectal temperature below 35.5°C, and other changes in condition. See
Danger Signs listed on back of WHO F100 Reference Card. See normal ranges of pulse and respiratory rates also on back of WHO F100 Reference Card.
127
Annexes
WEIGHT CHART
Weight on admission: _______ kg
Height / length: _______ cm
Bilateral pitting oedema on

admission:
0 + ++ +++
Desired weight at discharge based on

15% weight change:
Weight (Use appropriate scale.)

______ kg
[Desired weight based on weight-

for-height -1 z-score:
_____kg]
Actual weight at referral to

outpatient care:
______ kg
[Actual weight at discharge if

treatment until full recovery in
inpatient care
______ kg]
DAY 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
128
Name: _________________________________________________________________ Page ____ of _____
COMMENTS/OUTCOME
COMMENTS SPECIAL DISCHARGE AND FOLLOW-UP INSTRUCTIONS
TRAINING GIVEN TO PARENTS/ CAREGIVERS
PATIENT OUTCOME
DATE CIRCUMSTANCES/COMMENTS
Referral to Outpatient Care Site:
IMMUNISATIONS
Immunisation card? Yes No In case of treatment until full recovery in Inpatient
Circle immunizations already given. Initial and date by any given in hospital. Care, Circle Outcome:
Discharge based on 15% weight change Discharge weight equal or above 15% weight
[or based on weight for height -1 z-score] gain: Y N
[Weight for height Z-score: _______]
Immunization First Second Third Booster Early Departure (against advice) Discharge weight equal or above 15% weight
gain: Y N
BCG At birth Optional: > 6 __ __ Early Discharge Discharge weight equal or above 15% weight
months gain: Y N
Polio At birth 2 months 3 months 12 months Referral for Non Response to Treatment Discharge weight equal or above 15% weight
gain: Y N
DPT 3 months 4 months 5 months 12 months Death Number of days after admission (circle):
< 24 1-3 days 4-7 days >7 days
Approximate time of death: Day Night
Measles 6 to 9 __ __ __ Apparent cause(s):
months Had child received IV fluids? Yes No
129
Annexes
Annex 21. Outpatient Care Treatment Card

ADMISSION DETAILS: OUTPATIENT CARE
ADMISSION INFORMATION
Name Reg. No / /
Age (months) Sex M F Date of admission

Community,
Time to travel to site
Locality
House location Father alive Mother alive
Name of caregiver Total number in household

Direct from Referred from Referred from Readmission
Admission Yes / No
community heath facility inpatient care (relapse)
Admission anthropometry
Oedema ( +,
MUAC (cm) Weight (kg)
++, +++)
Bilateral MUAC
Admission criteria pitting < 11.5 cm (6 months and Other, specify
oedema above)
Medical history
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
Additional
information
Physical examination
Respiratory rate
<30 30 – 39 40 - 49 50+ Chest indrawing Yes No
(# per min)
Temperature 0
C Conjunctiva Normal Pale
Eyes Normal Sunken Discharge Dehydration None Moderate Severe
Ears Normal Discharge Mouth Normal Sores Candida

Enlarged
None Neck Axilla Groin Hands & feet Normal Cold
lymph nodes
Skin changes None Scabies Peeling Ulcers / Abscesses Disability Yes No
Additional
information
Routine medicines upon admission
Drug Date Dosage Drug Date
Amoxicillin Malaria test Results:
Vitamin A (if not in
Date Dosage
last 1 months)
Measles
Yes No Malaria treatment
Immunization date
2ND VISIT: Fully immunised Yes No
Drug Date Dosage
Mebendazole
Other medicines
Drug Date Dosage Drug Date Dosage
130
MONITORING INFORMATION
NAME REG No. /OPC
Week ADM. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Date
Anthropometry
15% Target
Annexes
Weight
Bilateral Pitting
Oedema
(0, +, ++, +++)
MUAC
(cm)
Weight
(kg)
Weight loss *
(Y/N) * *
* If below admission weight on week 3, refer for home visit; if no weight gain by week 5, refer to inpatient care
History
Diarrhoea
(# days)
Vomiting
(# days)
Fever
(# days)
Cough
(# days)
Physical examination
Temperature
(0C)
Respiratory
rate(# /min)
Dehydrated
(Y/N)
Anaemia / palmer
pallor
(Y/N)
Superficial skin
infection (Y/N)
Appetite check / feeding
RUTF test
Passed/Failed
RUTF
(# units given)
Action / follow-up
ACTION
NEEDED (Y/N)
Other medication
(see front of card)
Name examiner
VISIT
OUTCOME**
** OK=Continue Treatment A=Absent D=Defaulted (3 absences) R=Referral RR=Refused Referral C=Cured NR=Non-Recovered HV= Home Visit X=Died
Action taken during follow-up home visit (include date)
Name of Community Volunteer:
131
Annex 22. Outpatient Care RUTF Ration Card
Outpatient Care RUTF Ration Card
NAME of CHILD:
OUTPATIENT CARE SITE: REG. NO: /OPC
MUAC
ADMISSION CRITERIA Bilateral Pitting Oedema < 11.5 cm Other
Oedema MUAC RUTF (#
Date (0, +, ++, +++) (cm) Weight (kg) units given) Comments
Notes:
OUTCOME: Cured Died Defaulted Referred Non-recovered

Comments/Home visits
132
Annex 23. Health Facility Tally Sheet for the Management of SAM
HEALTH FACILITY: _______________________________________________ DISTRICT:_______________________________
FACILITY TYPE (Inpatient or Outpatient): _______________________________ MONTH: ________________________________
Week 1 2 3 4 5 TOTAL
Date
Total start of week (A)
New Cases 6-59 m (Oedema) (B1)
New Cases 6-59 m (MUAC < 11.5 cm) (B2)
New Cases Other (< 6 months, > 59 months with MUAC <11.5 or Oedema) (B3)
Old Cases: Referred from other outpatient or inpatient care, or returned defaulter (C)
TOTAL ADMISSIONS (D=B1+B2+B3+C)
Cured (E1)
Died (E2)
Defaulted (E3)
Non-Recovered (E4)
Total Discharges (E=E1+E2+E3+E4)
Referrals to other outpatient or inpatient care (F)
TOTAL EXITS (G= E+F)
Total end of week (A+D-G)
ADDITIONAL INFORMATION
Males
Females
RUTF Quantities (Issued during the week) -In sachets/pots
RUTF Quantities (Balance at the end of the week) -In sachets/pots
133
Annexes
Annex 24. Health Facility Monthly Report for the Management of SAM
REGION MONTH/YEAR
DISTRICT TYPE OF MANAGEMENT (CIRCLE) Inpatient Outpatient
FACILITY
ESTIMATED MAXIMUM CAPACITY
ESTIMATED TARGET malnourished < 5s

(based on latest survey data and admission criteria)
Sachets/pots kg equivalent
RUTF QUANTITIES (Received)
RUTF QUANTITIES (Issued)
RUTF QUANTITIES (Balance)
New Cases (B) Discharges (E)

Total Old Cases (C) Total end of
beginning Other (< 6, >59 Returned referral TOTAL Referral (F) TOTAL the month
6-59 m 6-59 m months with
of the from outpatient or ADMISSION to inpatient EXITS (G) (H)
(oedema (MUAC < MUAC < 11.5 NON-
month cases) 11.5 cm) cm or Oedema) inpatient care, or (D) CURED DIED DEFAULTED RECOVERED or outpatient
(A) (B1) (B2) (B3) returned defaulters (B+C=D) (E1) (E2) (E3) (E4) care (E+F=G) (A+D-G=H)
% % % %
TARGET >75% <10% <15%
(Sphere standards)
E1: Cured = meets discharge criteria
E3: Defaulted = absent for three consecutive sessions
E4: Non-recovered = does not meet discharge criteria after four months in treatment (medical investigation done)
134
Annex 25. District Monthly Report for the Management of SAM
NUMBER OF OUTPATIENT IMPLEMENTING

REGION CARE FACILITIES PARTNER(S)
NUMBER OF INPATIENT
DISTRICT CARE FACILITIES
ESTIMATED MAXIMUM REPORTING PERIOD

CAPACITY (MONTH/YEAR)
ESTIMATED TARGET
Children with SAM <5 years of age in a given period
ESTIMATED COVERAGE
Sachets/ pots Kg equivalent
RUTF QUANTITIES (RECEIVED)
RUTF QUANTITIES (ISSUED)
RUTF QUANTITIES (BALANCE)
Total New Cases (B) Discharges (E)

Total end of
6-59 m 6-59 m Other (children >
beginning of the month
(Oedema (MUAC < 59 months, infants NON-
the period cases) 11.5 cm) <6 m) TOTAL ADMISSION CURED DIED DEFAULTED RECOVERED TOTAL DISCHARGES (H)
(A) (B1) (B2) (B3) (B) (E1) (E2) (E3) (E4) (E) (A+B-E=H)
% % % %
TARGET >75% <10% <15%
(Sphere standards)
E1: Cured = meets discharge criteria
E3: Defaulted = absent for three consecutive sessions
E4: Non-recovered = does not meet discharge criteria after four months in treatment (medical investigation done)
135
Annexes
Annex 26. Minimal Reporting Guidance for the Management of

SAM
The monthly, quarterly or yearly report presents key quantitative and qualitative information and
analysis, and interprets the information in a comprehensive manner. The report should include the
following essential information:
Introduction
• Author of report
• Date and period of reporting
• Geographical catchment area and population
• Name of health facilities with outpatient care and/or inpatient care
• Starting date of services
Performance and output indicators for the management of SAM in inpatient care and outpatient care
combined, per time period
• Number of new admissions
• Number of discharges
• Number of beneficiaries in treatment
• Number and percentage cured
• Number and percentage died
• Number and percentage defaulted
• Number and percentage non-recovered
• Number of referrals to inpatient care or hospital
• Number admitted from community outreach referral
• Number of sites
• Number of new sites added
• Number of staff (e.g., health managers, health workers, community health workers [CHWs],
volunteers) trained
Figures
• Figure (graph) with trends of key performance and output indicators:
 Bars with new admissions, discharges, beneficiaries in treatment
 Lines for cured, died, defaulted and non-recovered rates
• Figure (graph) for monthly average length of stay (LOS) and average weight gain (AWG) per
category of admission criteria
• Figure (pie chart) with distribution of admission criteria
• Figure (pie chart) with distribution of discharge categories
Death records: Date, sex, age, reported cause of death, LOS in service
Default records: Date, sex, age, reported/presumed reason for defaulting, LOS in service
Interpretation of overall progress

• Interpret findings on performance and coverage and any qualitative information that was obtained
through community meetings, focus group discussions, etc.; then, triangulate the information.
136
• Discuss challenges, opportunities, lessons learned.

• Add success stories.
Annexes
137
Annex 27. Supervision Checklists
SUPERVISION CHECKLIST
OUTPATIENT CARE
Health Centre: Date:
Quality Discussed Comment

1 – Done correctly Nurse/Health
2 – Done, but needs Extension
work Worker
3 – Not done or Supervisor
done incorrectly (Y/N)
Number of staff present Staff:
Staff greet the mothers/caregivers and are

friendly and helpful
Registration numbers assigned correctly
Registration numbers written on all

documentation
Grade of bilateral pitting oedema
measured accurately
Mid-upper arm circumference (MUAC)
measured accurately
Weight measured accurately
Admission is done according to correct

criteria (spot check monitoring cards)
Medical history recorded accurately
Physical examination performed accurately
Child’s appetite assessed using ready-to-

use therapeutic food (RUTF) (on
admission and at all follow-on visits)
Routine medications given according to
protocol and recorded accurately
Amount of RUTF needed is correctly
calculated
Appropriate education given to mothers of Note topic:
outpatient care beneficiaries
Follow-on medicines given according to
protocol and recorded accurately
Non-responders are identified according
to the definition for follow-up
138
Priorities for follow-up home visits are

discussed with a outreach worker if needed
Beneficiaries discharged according to
protocol
Correct number of absentees/defaulters
passed to outreach worker for follow-up
Outpatient care tally sheets, register and
Annexes
RUTF stock cards correctly completed
(spot check)
All absentees/defaulters from previous
week followed up
Outreach follow-up form filled in
correctly and information noted on ration
card
Appropriate education (according to
education message sheet) given to
mothers/caregivers at home
Mother/caregiver referred for additional
care or services if appropriate
Timely and appropriate referral to the
clinician made for non-responders
Volunteer/outreach worker returns
follow-up visit checklists or observations
to health centre
Volunteer/outreach worker feedback
provided on a timely basis (before the next
outpatient session)
Volunteer/outreach worker has a helpful,
positive attitude with caregivers
139
SUPERVISION CHECKLIST
COMMUNITY OUTREACH
Health Centre:_____________________________ Date:_________________

Quality Discussed Comment
1 – Done supervisor
correctly (Y/N)
2 – Done, but
needs work
3 – Not done or
done incorrectly
All absentees/defaulters from previous
week followed up
Outreach follow-up conducted and
information noted on ration card
Appropriate education (according to
education message sheet) given to
mothers/caregivers at home
Mother/caregiver referred for additional
care or services if appropriate
Timely and appropriate referral to the
clinician made for non-responders
Outreach worker returns follow-up home
visit checklists or observations to health
centre
Outreach worker feedback provided on a
timely basis (before the next outpatient
care session)
Outreach worker has a helpful, positive
attitude with mothers/caregivers
140
INPATIENT CARE
SUPERVISION CHECKLISTS
Annexes
Checklist for Monitoring Food Preparation
OBSERVE YES NO COMMENTS
Are ingredients for the recipe available?
Is the correct recipe used for the ingredients that
are available?
Are ingredients stored appropriately and discarded
at appropriate times?
Are containers and utensils kept clean?
Do kitchen staff (or those preparing feeds) wash
hands with soap before preparing food?
Are the recipes for F75 and F100 followed
exactly? (If changes are made due to lack of
ingredients, are these changes appropriate?)
Are measurements made exactly with proper
measuring utensils (e.g., correct scoops)?
Are ingredients thoroughly mixed (and cooked, if
necessary)?
Is the appropriate amount of oil remixed in (i.e.,
not left stuck in the measuring container)?
Is CMV added correctly?
Is the correct amount of water added to make up
a litre of formula? (Staff should not add a litre of
water, but just enough to make a litre of formula.)
Is food served at an appropriate temperature?
Is the food consistently mixed when served (i.e.,
oil is mixed in, not separated)?
Are correct amounts put in the dish for each
child?
Is leftover prepared food discarded promptly?
Other
Checklist for Monitoring Ward Procedures

Feeding
Are correct feeds served in correct amounts?
Are feeds given at the prescribed times, even on
nights and weekends?
Are children held and encouraged to eat (never
left alone to feed)?
Are children fed with a cup (never a bottle)?
Is food intake (and any vomiting/diarrhoea)
recorded correctly after each feed?
Are leftovers recorded accurately?
Are amounts of F75 kept the same throughout
141
the initial phase, even if weight is lost?

After transition, are amounts of F100 given freely
and increased as the child gains weight?
Warming
Is the room kept between 25 and 30 degrees C
(to the extent possible)?
Are blankets provided and children kept covered
at night?
Are safe measures used for rewarming children?
Are temperatures taken and recorded correctly?
Weighing
Are scales functioning correctly?
Are scales standardised weekly?
Are children weighed at about the same time each
day?
Are children weighed about one hour before a
feed (to the extent possible)?
Do staff adjust the scale to zero before weighing?
Are children consistently weighed without
clothes?
Do staff correctly read weight to the nearest
division of the scale?
Do staff immediately record weights to the
nearest division of the scale?
Do staff immediately record weights on the
child’s Critical Care Pathway (CCP)?
Are weights correctly plotted on the Weight
Chart?
Giving antibiotics, medications, supplements
Are antibiotics given as prescribed (correct dose at
correct time)?
When antibiotics are given, do staff immediately
make a notation on the CCP?
Is folic acid given daily and recorded on the CCP?
Is vitamin A given according to schedule?
Is a multivitamin given daily and recorded on the
CCP?
After children are on F100 for two days, is the
correct dose of iron given twice daily and
recorded on the CCP?
Ward environment
Are surroundings welcoming and cheerful?
Are mothers offered a place to sit and sleep?
Are mothers taught/encouraged to be involved in
care?
Are staff consistently courteous?
As children recover, are they stimulated and
encouraged to move and play?
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Checklist for Monitoring Hygiene

Handwashing
Are there working handwashing facilities in
the ward?
Do staff consistently wash hands thoroughly
with soap?
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Are their nails clean?
Do they wash hands before handling food?
Do they wash hands between each patient?
Mothers’ cleanliness
Do mothers have a place to bathe, and do
they use it?
Do mothers wash hands with soap after using
the toilet or changing diapers?
Do mothers wash hands before feeding
children?
Bedding and laundry
Is bedding changed every day or when
soiled/wet?
Are diapers, soiled towels and rags, etc. stored
in a bag, then washed or disposed of properly?
Is there a place for mothers to do laundry?
Is laundry done in hot water?
General maintenance
Are floors swept?
Is trash disposed of properly?
Is the ward kept as free as possible of insects
and rodents?
Food storage
Are ingredients and food kept covered and
stored at the proper temperature?
Are leftovers discarded?
Dishwashing
Are dishes washed after each meal?
Are they washed in hot water with soap?
Toys
Are toys washable?
Are toys washed regularly, and after each
child uses them?
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Annex 28. Requisition Form for Therapeutic Food
Requisition Form for Therapeutic Food

REGION:……………………………………………………………………...
DISTRICT:……………………………………………………………………
SUB-DISTRICT/FACILITY:………………………………………………..
1. NUMBER OF BENEFICIARIES
OUTPATIENT INPATIENT TOTAL
NUMBER OF FACILITIES
NUMBER OF
BENEFICIARIES
2. REQUEST
Products Number of Number of Months Current Stock Quantity Requested
Beneficiaries Requested Levels (MT)* (MT)*
* MT = metric tons
REQUESTED FOR A PERIOD OF……………………………………………………….
PREPARED BY:……………………………DESIGNATION:……………………………
DATE OF REQUEST:………………………………………………………………………
QUANTITY APPROVED AND SUPPLIED:………………………………………………………
APPROVED BY:…………………………………DESIGNATION:………………………......
144
Annex 29. Setup of Inpatient Care and Outpatient Care

Inpatient Care
Inpatient care is intended for the treatment of severe acute malnutrition (SAM) with medical
complications and all infants under 6 months with SAM, as well as for those who cannot benefit from
Annexes
outpatient care due to distance or lack of caregivers. It is organised as residential care (24 hours, with
the patients staying overnight). The decision between one or the other depends on available resources
(particularly human resources for night shifts), security conditions (protection of the patients) and
quality of care and follow-up of the patients (most severe and complicated cases should not be
transported unless really necessary).
Inpatient care can be established at the paediatric ward or a specially assigned ward at the hospital or
health facility, or as an independent structure if there is case overload. In the latter case, it is often set
up as a semi-permanent structure (e.g., in refugee camps). In all cases, the inpatient care facility should
have a good permanent supply of clean, potable water (for preparing the milk, washing and cleaning the
wards).
Experience shows that, on average, 10 to 20 percent of children with SAM will need stabilisation at
inpatient care. This figure may be much higher at the beginning of the intervention, if the setup of
outpatient care is not covering all the area of origin of beneficiaries or if early detection of cases is
deficient (late presentation). Children with SAM and medical complications are usually kept in a
separate room from patients in the rehabilitation phase or other hospital patients. On average, patients
in stabilisation care stay for three to 10 days. Those who need to complete treatment in inpatient care
stay an average of 30 days. The majority can be treated on an outpatient basis directly (at the outpatient
department) or referred to outpatient care once stabilised after a few days in a health facility with
inpatient care (primary health care clinic or hospital).
Staff Needs
Clinical Care Staff
This includes senior nurses and junior nurses. The presence of a physician is recommended but is not
always necessary. Only clinicians who have received specific training on the management of SAM
should treat these patients, as many treatments normally given to children that are not malnourished
might be dangerous for the malnourished child.
Feeding Assistants
Feeding assistants play a major role. They are in charge of weighing the child, supervising the meals,
interacting with the caregivers, monitoring clinical warning signs and filling in most of the information
on the patient's card. A ratio of one staff per 10 patients is considered appropriate in emergency
inpatient care facilities. Other staff in this category might be in charge of the emotional and physical
stimulation programme.
145
Support Staff
Cleaners and kitchen staff play a key role in maintaining a tidy environment and preparing therapeutic
milks and food for caregivers. In large centres, a person in charge of the logistics and transport will be
necessary. Guardians, storekeepers and other ancillary staff might be needed depending on the context
and size of the facility.
Supervisors
One supervisor is needed for each ward with inpatient care (usually, but not necessarily, a clinician).
Outpatient Care
Outpatient care is intended for children presenting SAM without medical complications and for
patients who have recovered in inpatient care after they have recovered appetite. Outpatient care can be
set up in a health facility or can be organized at health outreach sites. It is always advisable to have a
store, a covered waiting area and a separate protected area for clinical assessment of patients even if the
centre is established in a provisional structure.
Outpatients visit the health facility once per week or once every two weeks. The number of patients
attending an outpatient care facility can vary from 10 to 20 per session to several hundreds. When too
many children are attending on the same day a decision should be taken as to whether it would be more
appropriate to open new sites or increase the number of service days for existing facilities.
A nurse or health care provider is sufficient to take on the outpatient care (or several, depending on
size). Health care providers need to be trained and able to identify danger signs and decide when and
whether referral for inpatient care is necessary. They should be able to identify anorexia and assess
progress of children, calculate indicators for monitoring and evaluation of patients (e.g., weight-for–
height [WFH], weight gain, mid-upper arm circumference [MUAC]), fill in registration books and
patient's treatment cards, and manage stores and supplies of food and drugs.
Where there are problems of access, or insufficient staff, mobile outpatient clinics can be planned for a
limited period of time. One mobile team can visit up to five sites in a week (implementing weekly
outpatient care once per week in each site).
146
Annex 30. Checklist of Materials Needed for Outpatient Care

Item Amount per clinic
Outpatient care file for treatment cards 1
Stapler and box of staples 1
Pens 4
Scissors 1 pair
Annexes
Small clock or watch with second hand 1
Bucket with lid 2
Soap for handwashing 1 bar
Small bowl 1
Small jug 1
Hand towels 2
Water jug (with lid) 2
Plastic cups 10
Small metal spoons 4
Thermometer 3
Salter scale (25k g) plus pants 1
Mid-upper arm circumference (MUAC) tape 2
Copies of community-based management of severe acute malnutrition 1 of each
(CMAM) protocols
Other Items Minimum amount, for the
treatment of 500 children
Outpatient care treatment cards 500
Outpatient care ready-to-use therapeutic food (RUTF) ration cards 500
Tally and reporting sheets
Drinking water 1 jerry can per site
Sugar to make 10 percent sugar water solution 5 kg
RUTF (500 children) 500 x 12 kg
Copies of protocols and guidelines
Routine Medicines Amount
Amoxicillin syrup 125 mg/5 ml 500 bottles
Albendazole 100 mg 4 tins
Paracheck (malaria rapid test) 200
Antimarlarial treatment 200
Antihelminth treatment 500
Vitamin A capsules 1 tin
Supplemental Medicines Amount
Add if needed
Note:
• All medicines must be clearly labelled.
• Stock should be reviewed after each outpatient care session following the first month
as requirements will vary depending on admissions.
• Children with severe acute malnutrition (SAM) and severe diarrhoea and/or
dehydration are referred to inpatient care where they will receive rehydration solution
for malnutrition (ReSoMal). ReSoMal is never given in outpatient care.
147
Annex 31. Outpatient Care Staffing

Outpatient Care
Appoint in each health facility (and plan rotations if appropriate):
• A qualified health worker (community health nurse [CHN], community health officer [CHO],
nurse or medical assistant)
• One assistant (if needed due to caseload)
Community Outreach
Each health facility has established links with:
• A community outreach coordinator
• A team of community outreach workers: community health workers (CHWs) and/or volunteers
Training should be provided to all health workers and outreach workers. An orientation is given at the
start of the service followed by continuous training (e.g., refresher training, mentoring, feedback
meetings).
Staff Roles and Responsibilities

District Health Manager or District Nutritionist as Community-Based Management of severe Acute
Malnutrition (CMAM) Focal Point/Coordinator
• Resource mobilisation and allocation (human resources, infrastructure, supplies, transportation,

training)
• Planning of services
• Support and supervision
• Monitoring and evaluation (M&E)
• Training of health workers
District Community Outreach Coordinator
• Community assessment and mobilisation

• Support and supervision
• Training of outreach workers
Health Worker (CHO, CHN, nurse, medical assistant)
• Evaluation of the medical condition (anthropometry, medical history, physical examination,

appetite test)
• Admission
• Referral to inpatient care
• Treatment of severe acute malnutrition (SAM) (prescription of medicines and ready-to-use
therapeutic food [RUTF])
• Monitoring progress of children
• Health and nutrition counselling
• Organisation and supervision of outpatient care admission and follow-on sessions
148
• Discharge of children
• M&R of service (site tally sheets and monthly reporting)
• Monitoring of equipment and supplies
• Training of outreach workers
CHW
Annexes
• Health facility-based health and nutrition education
• Community-based health and nutrition education and individual counselling
• Community screening and referral
• Follow-up home visits for problem cases
• Training of volunteers
Volunteers
• Community-based nutrition and health education and individual counselling

• Community screening and referral
• Follow-up home visits for problem cases
Detailed Responsibilities
Position Responsibilities
Organise setup of outpatient care and ensure smooth flow of patients
CHO/CHN/Nurse Record registration information on treatment and ration cards
Investigate medical history through caregiver interview
One CHO should be Carry out initial physical examination
responsible for overall Review child’s growth and health at each follow-up outpatient care session
supervision and case Record medical history and physical examination results on outpatient care
management at the treatment card
outpatient care service Refer children for further medical care/inpatient care treatment if necessary
site. Prescribe routine and additional medicines according to protocol
Identify non-responders for follow-up
Identify absentees and defaulters for follow-up
Link mother/caregiver to the nearest outreach worker for follow-up
Allocate duties to staff
Supervision of outpatient care staff
Manage logistics (stock management, transport for referrals, storage and supply of
RUTF)
Maintain good filing system
Track children in-between and across services
Review accuracy of treatment cards at the end of the outpatient care session
Complete, review, consolidate and submit site tally sheets and monthly reports to
the District Health Office
Monitor performance indicators at the health facility level
Provide health and nutrition education sessions to mothers/caregivers at outpatient
CHWs care sessions
Weigh and check mid-upper arm circumference (MUAC) and oedema for all
children attending outpatient care sessions
Distribute RUTF ration
Discuss follow-up cases with assigned volunteer/outreach worker
Review follow-up visit checklists and report results to CHO
Coordinate regular meetings with volunteers/outreach workers to refresh training,
149
share information and discuss performance

Give feedback to community leaders or committee on performance of CMAM and
of volunteers
Involve influential community groups in case-finding (women’s groups, community-
based organisations [CBOs], religious groups)
Case-finding in the community: check for oedema and measure MUAC
Outreach Worker Refer cases to the nearest outpatient care service
Visit absentees or defaulters in their homes; encourage absentees and defaulters to
return to outpatient care/inpatient care
Follow-up children who are not responding in their homes; investigate issues and
advise
Record home visits and report to CHO on a timely basis
Conduct community sensitisation meetings
Give monthly verbal feedback to community leaders or committee on number of
CMAM beneficiaries, on cure, defaulter and death rates, and on other issues
150
Annex 32. Inpatient Care Staffing

Inpatient Care Staff Needs 18
• Qualified clinician, at least one per shift for 24-hour care (nurse, medical assistant, physician,
paediatrician)
Annexes
• Nutrition assistant or assistant cook
• Support staff
• Liaison staff
Staff Roles and Responsibilities

Staff in the inpatient care centre will be responsible for managing the child with severe acute
malnutrition (SAM) with medical complications on a 24-hour basis.
The recommended staff ratio in comparison with the number of beds is one to seven.
Experienced staff who are experts in the treatment of SAM with medical complications understand the
needs of a child with SAM and are familiar with community-based management of severe acute
malnutrition (CMAM) services and aspects that are essential for a well-functioning treatment facility.
It is important, therefore, that loss of experienced staff be avoided wherever possible. Disruption of
ongoing services should not happen.
Example: Princess Marie Louise Hospital

There are about five doctors in rotational duties for the management of SAM in inpatient and
outpatient care. All nursing staff are trained in CMAM. There are about 15 beds, and six nurses, one
health extension worker (HEW) and one ward assistant are deployed to manage inpatient care with 24-
hour rotation duties. Nursing staff rotation is managed by the Deputy Director Nursing Staff (DDNS)
and takes into consideration minimal changes for nurses trained in the management of SAM. As a
result there is no disruption of the quality of the service. One dietician and two diet cooks are
responsible for preparing formula milk in the kitchen; they also serve the milk. There is laboratory
support on a 24-hour basis.
18
If outpatient care is functioning well, the inpatient caseload should be low (normally five to 10 patients per
district inpatient care, depending on the catchment area and prevalence of SAM).
151
Annex 33. Checklist of Materials Needed for Inpatient Care

Item Amount per Ward
Inpatient care file for treatment cards 2
Stapler and box of staples 1
Pens 6
Scissors-small 1 pair
Scissors- large 1 pair
Micropore 2 dozen
Small clock or watch with second hand 1
Bucket with lid 2
Soap for handwashing 10 bars
Small bowl 1
Small jug 1
Hand towels 10
Water jug (with lid) 10
Plastic cups 20
Small metal spoons 6
Thermometer 3
Salter scale (25 kg) plus pants 2
MUAC tape 2
Copies of community-based management of severe acute malnutrition (CMAM) 1 of each
protocols
Dextrostix 2 dozen
Glucometer 1
Small torch 2
Saline stand According bed number
Intravenous (IV) cannula 20
Transfusion set
Source of clean water
Central oxygen supply (or oxygen cylinder)
Infusion set
Stethoscope 2
X-ray box 1
Diagnostic set
Adult beds for child and mother/caregiver
Therapeutic milk: F75 (2 L/child) and F100 (60 L/child)
Or equivalent in ingredients
Combined mineral and vitamin mix (CMV) and oral rehydration solution (ORS)
for rehydration solution for malnutrition (ReSoMal)
Routine and supplemental medicines
Kitchen Supply
Item Amount
Refrigerator 1
Cooking utensils for boiling water 1
Spoon large 12
Spoon small 12
Stirrer 12
Measuring cup 20
Soap 2 Dozen
Gas cylinder 2
Food for mother/caregiver
A well-equipped kitchen with a source of clean drinking water is needed.
152
Annex 34. Forecasting Nutrition Product Needs

Inpatient Care
• Assuming a duration of treatment of 10 days, 2 kg (five packets) of dry F75 per child can be used
for planning. This is equivalent to 6 kg per month of dry F75 for each paediatric bed dedicated for
Annexes
the management of complicated case of severe acute malnutrition (SAM).
If F75 is prepared locally, needs for ingredients needed to prepare this quantity of F75 can be
calculated: preparation of 6 litres (L) of F75 will require 19 g of combined mineral and vitamin
mix (CMV) (three levelled scoops) and 150 grams (g) of dried skim milk or 210 g of dried whole
milk, plus 420 g of sugar, 162 g of vegetable oil and 210 g of cereal flour.
 Usually less than 5 percent of children admitted for SAM with medical complications (or less than
1 percent of all SAM cases) will not be able to eat ready-to-use therapeutic food (RUTF) during
the rehabilitation phase and will require F100. For these children, a planning figure of 12 kg of
F100 per child for the whole rehabilitation phase can be used.
 RUTF is needed for a few days for every child in the transition phase and all children in inpatient
care (any phase) with appetite.
Outpatient Care
• One treatment of a child with SAM based on +- 200 kcal/kg/day of RUTF diet corresponds
approximately to 30 to 40 g/kg/day for 60 days, or 12 kg per treatment of a child with SAM.
• The total requirement of RUTF will depend on the duration of the treatment and on the weight of
the child at the beginning of treatment, but for planning purposes, an average requirement of 12 kg
RUTF per child treated can be assumed.
Estimating the Quantities of Nutrition Products Needed for the Management of SAM for Planning
Therapeutic When needed Proportion of Duration of Total quantity Total quantity
food children with treatment needed to treat needed to treat
SAM admitted one child 100 children
needing the
product (kg) (kg)
F75 Inpatient care 15% 5-10 days 2 30
(stabilisation
phase)
F100 Inpatient care < 5% 4-6 weeks 12-15 60-75
(recovery phase)
RUTF Outpatient care > 95% 6-8 weeks 12 1,200
and inpatient care
(transition/
recovery phase)
153
Annex 35. List of Job Aids

For Community Outreach Workers
• Messages for community outreach

• Health and nutrition education messages
• M&R tools: referral slip, home visit report
For Health Care Providers in Inpatient Care

Distribute the following as desk or wall charts, or forms to be filled in at health facilities with inpatient
care.
• Manual and guidelines on the community-based management of severe acute malnutrition

(CMAM)
• Admission and discharge criteria chart
• Appetite test chart
• Entry and exit categories chart
• Routine medicines protocols chart
• Supplementary medicines protocols chart
• Dietary treatment protocols and tables for the use of F75, F100 and ready-to-use therapeutic food
(RUTF)
• Alternative recipes for F75, F100 and rehydration solution for malnutrition (ReSoMal) using
combined mineral and vitamin mix (CMV)
• Key messages upon admission
• 15 percent weight gain look-up table
• Weight-for-height (WFH) look-up table
• List of sites with their catchment areas, service days and outreach workers’ names
• M&R tools: inpatient care treatment cards (Critical Care Pathway [CCP]), Road to Health cards,
referral forms, site tally and reporting sheets, supervision checklists, supply checklists
For Health Care Providers in Outpatient Care

Distribute the following as desk or wall charts, or forms to be filled in at health facilities with
outpatient care.
• Manual and guidelines on CMAM

• Admission and discharge criteria chart
• Appetite test chart
• Entry and exit categories chart
• Routine medicines protocols chart
• Supplementary medicines protocols chart
• Dietary treatment protocols and tables for the use of F75, F100 and RUTF
• Alternative recipes for F75, F100 and ReSoMal using CMV
• Key messages upon admission
154

• Action protocol for outpatient care chart
• 15 percent weight gain look-up table
• WFH look-up table
• M&R tools: outpatient care treatment cards, Road to Health cards, referral forms, home visit
Annexes
forms, site tally and reporting sheets, supervision checklists, supply checklists
For Health Managers
• Manual and guidelines on CMAM

• Packages of job aids and M&R tools for community outreach, inpatient care and outpatient care
• M&R tools: inpatient care treatment cards (CCP), outpatient care treatment cards, Road to Health
cards, referral slips, referral forms, home visit forms, site tally and reporting sheets, supervision
checklists, supply checklists
• Data repository
• Minimal reporting guidance
• Job descriptions
• Training packages for community outreach, inpatient care and outpatient care
155
APPENDIX: Clinical Management of SAM with Medical

Complications in Inpatient Care
Box 1. Acknowledgement
The Ghana Health Service (GHS) is grateful to Professor Michael Golden and Dr. Yvonne Grellety for
permission to copy their original material in this section. This material is reproduced on the understanding
that it can be taken and used by national governments of developing countries and their teaching institutions
without payment of any fees or the need to obtain further permission, provided that the material is not
edited, abstracted or altered. Those from developed countries and those who wish to abstract or edit the
material should seek permission from the copyright holders.
All children with severe acute malnutrition (SAM) with medical complications should be managed in
inpatient care in a health facility with bed capacity and with staff trained in the special management of
SAM with medical complications. These children should not be treated upon admission in the
emergency ward but transferred to a special SAM ward where skilled health care providers will start
life-saving treatment. The following paragraphs detail the diagnosis and treatment of the most common
medical complications that occur in children with SAM.
Dehydration
Misdiagnosis and inappropriate treatment for dehydration is the most common cause of death for
malnourished children. The appearance of a severely wasted child who is not dehydrated is similar to a
normal child who is dehydrated; therefore an untrained clinician may easily misdiagnose dehydration in
SAM. With SAM, the “therapeutic window” is narrow so that even dehydrated children can quickly go
from having a depleted circulation to over-hydration with fluid overload and cardiac failure.
Intravascular infusions are therefore rarely used in children with SAM. In malnourished children, both
marasmus and to a greater extent kwashiorkor, there is a particular renal problem that makes the
children sensitive to sodium overload. The standard rehydration protocol for a well-nourished
dehydrated child should therefore not be used.
Access to Rehydration Solution for Malnutrition (ReSoMal) should be restricted and must never be
freely available for the caregivers to give to their children whenever they have a loose stool. Although a
common practice, it is very dangerous to freely give ReSoMal or oral rehydration solution (ORS) to
these children. This can lead directly to heart failure, as well as failure to lose oedema, development of
refeeding oedema, and failure to report and record significant problems while the diet and phase
remains unchanged. If there is no dehydration, diarrhoea must not be treated with rehydration fluids as
a means of “preventing” the onset of dehydration. This again can lead to over-hydration and heart
failure.
Dehydration in Children with Marasmus
All the classical signs of dehydration (i.e., skin pinch test, sunken eyes) are unreliable in marasmic
children and should therefore not be used to make the diagnosis of dehydration in these patients.
• The skin of marasmic children normally lies in folds and is inelastic such that the “skin pinch” test
is usually positive without there being any dehydration.
Do NOT use the skin pinch test to diagnose dehydration in malnourished children.
156
• Eyes of marasmic children are normally sunken 19 without there being any dehydration.
Do NOT assume that malnourished patients with sunken eyes have dehydration.
The diagnosis of dehydration in marasmic children is therefore much more uncertain and difficult than
in normal children. Incorrect and over-diagnosis is very common and treatment is often given
inappropriately. It is good practice not to make a definitive diagnosis of dehydration: If you think the
child is dehydrated then make a provisional diagnosis and observe the response to treatment before
Appendix
confirming the diagnosis.
Box 2. Diagnosis of Dehydration in the Marasmic Patient
The main diagnosis of dehydration in marasmic children comes from the history rather than from physical
examination.
There needs to be:

• A definite history of significant recent fluid loss - usually diarrhoea which is clearly watery (not just
soft or containing mucus) and frequent with a sudden onset whose occurrence is within the past few
hours or days.
• There should also be a history of a recent change in the child’s appearance.
• If the eyes are sunken, the caregiver must confirm that the appearance of the eyes has changed to
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 dehydrated
and do not need acute rehydration therapy. They have adapted over the weeks to their altered hydration
state and should therefore not be rehydrated over a few hours or days.
Diagnosis of Shock With Dehydration in the Marasmic Patient
• When there is definite dehydration diagnosed from both the history and examination and there is
presence of a weak or absent radial or femoral pulse and cool or cold hands and feet (check with
back of hand gently), the patient is going into shock.
• Severe shock occurs when, in addition to the above signs, there is also a decrease in the level of
consciousness so that the patient is semiconscious or cannot be aroused.
• There are other causes of shock in the severely malnourished child, in particular: 1) toxic shock, 20
2) septic shock, 3) liver failure and 4) cardiogenic shock.
• Treatment of cardiogenic shock or liver failure based on the assumption that the patient has shock
due to dehydration is very dangerous and the treatment itself may then lead to death.
19
The orbit contains an eye, small muscles and nerves, fat, the lachrymal gland and a venous plexus. In
marasmus, the fat and the 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.
20
Toxic shock may be caused by traditional medicines or self-treatment with other medicine such as aspirin,
paracetamol, metronidazole, etc. Septic shock is a specific type of toxic shock where the damage is caused by
overwhelming sepsis. These are frequently associated with liver failure.
157
Treatment of Dehydration in the Marasmic Patient
Whenever possible, a dehydrated patient with SAM should be rehydrated orally. IV infusions are very
dangerous and are not recommended unless there is severe shock with loss of consciousness from
confirmed dehydration. The management of the rehydration process is based upon accurate
measurements of weight (this is the best measurement of fluid balance). The weight measurements
should be taken using an infant scale or, in the case of older children, a hanging scale to which a basin
is attached with rope. 21 The basin hangs close to the ground and is easily cleaned. The patients should
be weighed naked.
Monitoring Rehydration in the Marasmic Patient
Before starting any rehydration therapy, do the following:

• Weigh the child
• Mark the edge of the liver and the costal margin on the skin with an indelible marker pen
• Record the respiration rate
In addition, the following can be recorded if staff has the necessary skill:
• Record the heart sounds (presence or absence of gallop rhythm) on the treatment card
• Record the pulse rate on the treatment card
Box 3. Rehydration in the Marasmic Patient
Rehydration of the child with SAM is managed entirely on the basis of the following:
• Weight changes
• Clinical signs of improvement
• Clinical signs of over-hydration
Fluid balance is measured at intervals by weighing the child.

• Give rehydration fluid until the weight deficit (measured or estimated) is corrected.
• Stop as soon as the child is “rehydrated” to the predetermined target rehydrated weight.
• Additional fluid is not given to the malnourished child with a normal circulatory volume in order
to “prevent” recurrence of dehydration.
• Normally much less ReSoMal is sufficient to restore adequate hydration in malnourished children
than in normally nourished children (e.g., a total of 50 millilitres per kilogram (ml/kg) bodyweight
- 5 percent bodyweight).
• Begin rehydration therapy with a volume of 5 ml/kg bodyweight given at 30-minute intervals for
the first two hours orally or by nasogastric tube (NGT; 2 percent bodyweight), and then adjust the
volume of ReSoMal according to the weight changes observed. Weigh the child each hour and
assess his/her liver size, respiration rate and pulse.
• After the rehydration therapy is completed usually no further treatment is given; however, for
malnourished children aged 6-24 months, 30 ml of ReSoMal can be given for each watery stool
that is lost. The standard instructions to give 50-100 ml for each stool should not be applied – it
is dangerous.
21
Hanging pants used for surveys should not be used to weigh sick children in health facilities or those likely to
soil the pants and pass infection to the next child.
158
• As the child gains weight, during rehydration there should be a definite clinical improvement and
the signs of dehydration should disappear; if there are no signs of improvement accompanying the
weight gain then the initial diagnosis was wrong and rehydration therapy should be stopped.
• Make a major reassessment at two hours.
If there is continued weight loss:
Appendix
• Increase the rate of administration of ReSoMal by 10 ml/kg bodyweight/hour
• Formally reassess in one hour
If there is no weight gain:

• Increase the rate of administration of ReSoMal by 5 ml/kg bodyweight/hour
• Formally reassess in one hour
If there is weight gain and deterioration of the child’s condition with the rehydration therapy:
• The diagnosis of dehydration was definitely wrong. It must be noted that even senior clinicians also
make mistakes in the diagnosis of dehydration in malnutrition.
• Stop the ReSoMal and commence the child on the F75 diet.
If there is no improvement in the mood and look of the child or reversal of the clinical signs:
• The diagnosis of dehydration was probably wrong.
• Either change to F75 or alternate F75 and ReSoMal.
If there is clinical improvement but there are still signs of dehydration:

• Continue with the treatment until the appropriate weight gain has been achieved.
• Either continue with ReSoMal alone, or F75 and ReSoMal can be alternated.
If there is resolution of the signs of dehydration:

• Stop rehydration treatment and commence the child on F75 diet.
Target Weight for Rehydration With Watery Diarrhoea in the Marasmic Patient
1. If the child has been under treatment for SAM and there is a known pre-diarrhoeal weight just
before the diarrhoea starts:
• If there has been no weight loss with the diarrhoea, rehydration treatment should not be given.
• If there has been weight loss, the actual fluid loss is equal to the weight loss and the target
rehydration weight is the pre-diarrhoeal weight. Treatment should not be given to increase the
weight beyond the pre-diarrhoeal weight. “Prophylactic” administration of ReSoMal to
prevent recurrence of dehydration is not given.
2. If the patient is newly admitted, it is extremely difficult to judge the amount of fluid that has been
lost in the child with marasmus. Because of the narrow therapeutic window and the danger of going
from underhydration to overhydration, the estimated weight deficit should be very conservative. It
is better and much less dangerous to slightly underestimate the amount of weight deficit than to
overestimate the weight deficit.
• In practice, the weight loss is generally 2 to 5 percent of bodyweight.
• Do not attempt to increase bodyweight by more than 5 percent in conscious children.
159
• If there is weight gain of up to 5 percent of bodyweight with rehydration, the truly dehydrated
child will show dramatic clinical improvement and be out of immediate danger from death due
to dehydration; treatment can then be continued with F75.
3. Breastfeeding should not be interrupted during rehydration. Begin to give F75 as soon as possible,
orally or by NGT. ReSoMal and F75 can be given in alternate hours if there is still some
dehydration and continuing diarrhoea. Introduction of F75 is usually achieved within two to three
hours of starting rehydration.
Figure 1. Rehydration in the Marasmic Patient

F75
MONITOR WEIGHT
Gain Stable Loss
Clinically Clinically
improved not
Continu • STOP ALL • Increase • Increase

e rehydration fluid ReSoMal: 5 ReSoMal by 10
• Give F75 ml/kg/hr ml/kg/hr
• Re-diagnose & • Reassess every • Reassess every
Target assess hour hour
Weight
F75
Treatment of Shock from Dehydration in the Marasmic Patient
If there is definite dehydration (e.g., a history of fluid loss, a change in the appearance of the eyes) and
the patient is semiconscious or unconscious AND has a rapid weak pulse AND has cold hands and
feet, the patient should be treated with IV fluids. The amounts given should be half or less of that used
in normally nourished children.
Use one of the following solutions:

• Half-strength Darrow’s solution
• Ringer-Lactate with 5 percent dextrose
• Half-strength saline with 5 percent dextrose
160
Management:
• Give 15 ml/kg bodyweight intravascular over the first hour and reassess the child.
• If there is continued weight loss or the weight is stable, repeat the 15 ml/kg intravascular over the
next hour. Continue until there is weight gain with the infusion. (15 mg/kg is 1.5 percent of
bodyweight, so the expected weight gain after two hours is up to 3 percent of bodyweight.)
• If there is no improvement and the child has gained weight, then assume that the child has toxic,
Appendix
septic or cardiogenic shock or liver failure. Stop rehydration treatment. Search for other causes of
loss of consciousness.
• As soon as the child regains consciousness or the pulse rate drops toward a normal level, stop the
drip and treat the child orally or by NGT with 10 ml/kg/hour of ReSoMal. Continue with the
protocol (above) for rehydration of the child orally using weight change as the main indicator of
progress.
• There should never be a drip present in a malnourished child who is able to drink or is absorbing
fluid adequately from an NGT.
Figure 2. Treatment of Dehydration in the Marasmic Child
DEHYDRATED CHILD
ONLY rehydrate until the

weight deficit (measured or
estimated)
Conscious Unconscious
ReSoMal IV fluid
- 5 ml/kg /30 min first 2 hrs Darrow’s solution
- 5 to 10 ml/kg/hr 12 hours or 1/2 saline & 5% glucose
or Ringer lactate & 5% dextrose
at 15 ml/kg the first hr & reassess
- If improving, 15 ml/kg 2nd hr;

- If conscious, NGT: ReSoMal
- If not improving => Septic shock
Monitoring Rehydration
All rehydration (oral or IV) therapy should be stopped immediately if any of the following are
observed:
• The target weight for rehydration has been achieved (change to F75)
• The visible veins become full (change to F75)
• The development of oedema (over-hydration – change to 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 (cm)*
• The development of tenderness over the liver*
161
• An increase in the respiration rate by five breaths per minute or more*

• The development of a “grunting” respiration (this is a noise on expiration not inspiration)*
• The development of crepitations in the lungs
• The development of a triple rhythm
* If these signs develop, the child has fluid overload, an over-expanded circulation and is going into heart failure.
Diagnosis of Dehydration in a Child with Kwashiorkor
All children with oedema have increased total body water and sodium levels. In other words, they are
over-hydrated. Oedematous patients 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.
Diagnosis
If a child with kwashiorkor has definite watery diarrhoea and the child is deteriorating clinically, then
the fluid lost can be replaced on the basis of 30 ml of ReSoMal per watery stool.
Treatment
The treatment of hypovolaemia in kwashiorkor is the same as the treatment for septic shock.
Hypernatraemic Dehydration 22
Hypernatraemic dehydration is common in areas with a low relative humidity (very dry atmosphere),
particularly if there is also a high temperature. 23 It is caused by loss of water without loss of salt,
leading to pure water deficiency. This is because water is lost through the skin and breath at a high rate
under these conditions. If solutions high in sodium or other osmolyte that is not metabolised are given,
then water will still be lost while leaving the osmotically active solute in the body. Also, in areas where
bottle feeding is common, mothers frequently over-concentrate infant formula; 24 this can lead to
hypernatraemic dehydration even in wet or cold climates and is lethal in hot and dry climates and
seasons. The malnourished child is particularly at risk because he/she has a very low renal-
concentrating ability and a high surface area relative to his/her body mass.
During development of the high plasma osmolarity, there is a balancing increase in intra-cellular
osmolytes to prevent water being drawn out of the cells. During treatment, if the extracellular fluid
osmotic pressure is reduced too quickly leaving a high intracellular osmotic pressure, sudden cellular
swelling occurs that can lead to swelling of the brain to a sufficient degree to give convulsions and
death.
22
This is the same as “hyper-osmolar syndrome” and other synonyms that denote that the plasma osmolarity is
increased above normal. The increased osmoles can be urea if a very high protein diet has been taken or there is
inadequate renal function or it can be glucose in patients with glucose intolerance.
23
The dry atmosphere is the more important feature. Where the climate is very hot and wet, much less water is
lost so that the child presents first with fever because of an inability to excrete the heat generated during
metabolism.
24
All infant formulae have a very much-higher renal solute load than breast milk. In very hot and dry climates
even correctly made up infant formulae can result in hypernatraemic dehydration. This is a real danger that arises
from the failure of breastfeeding in such climates. Because of the low renal solute load of human breast milk,
exclusive breastfeeding is the best way to avoid hypernatraemic dehydration.
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Although hypernatraemia is difficult to treat safely, it is easy to prevent safely. Malnourished children,
particularly those in dry and hot environments should have continuous access to sufficient water
without a high ion content that requires renal excretion to fulfil their requirements for water.
The first sign of hypernatraemic dehydration is a change in the texture and feel of the skin, which
develops a plasticity similar to the feel of dough (flour and water mixed for bread making). The eyes
can sink somewhat. The abdomen then frequently becomes flat and may progressively become sunken
Appendix
and wrinkled (so-called “scaphoid abdomen or “prune belly”). The child may then develop a low-grade
fever if there is insufficient water to evaporate to excrete the heat generated during normal metabolism.
The child becomes progressively drowsy and then unconscious. Convulsions follow this stage, which
leads to death if treatment for hypernatraemia is not instituted. The convulsions are not responsive to
the normal anti-convulsants (e.g., phenoparbitone, diazepam).
Failure to control convulsions with anti-convulsants may be the first indication of the underlying
diagnosis. The diagnosis can be confirmed by finding an elevated serum sodium: normally
hypernatraemia is diagnosed when the serum sodium is greater than 150 millimoles per litre (mmol/L).
For insipient hypernatraemic dehydration – a conscious, alert child who is only showing changes in the
texture and feel of the skin – breast milk is the best diet. This can be supplemented with up to about
10 ml/kg/hour of water that should be given as a 10 percent sugar-water solution in sips over several
hours until the thirst of the child is satisfied. At this early stage – when impending water deficiency
should be recognised and treated – treatment is relatively safe.
Treatment must be slow for developed hypernatraemic dehydration. If it is possible to measure serum
sodium, aim to reduce the serum sodium concentration by about 12 mmol every 24 hours. Trying to
correct the hypernatraemia quicker than this risks death from cerebral oedema. If it is not possible to
measure the serum sodium, aim to correct hypernatraemic dehydration over at least 48 hours. The
treatment should start slowly, and as the serum sodium approaches normality, the rate of repletion can
increase.
The textbook treatment of hypernatraemia is to slowly give normal saline either orally or intravenously.
This is dangerous in the severely malnourished child and should not be used, as it is based upon the
premise that the excess sodium given can be safely excreted by the kidneys, which is not the case in the
severely malnourished child.
Treatment progress is assessed by serial weighting of the child:

• First, put the child in a humid, thermoneutral (28˚ to 32˚C) environment. This is critical to
prevent further water loss as well as hyperthermia if the humidity in the air is increased in a hot
environment. 25
• Weigh the child on an accurate balance and record the weight.
25
If the child is small, this can be in an incubator similar to that used for neonates. It can also be achieved with
aerosol sprays into the atmosphere or a humidifying tent, such as that used to treat bronchiolitis. If such facilities
are not available, hanging wet sheets in the room or spraying the walls with water intermittently will both
humidify and cool the atmosphere. Wet clothes should not be placed directly onto the child unless he/she has a
high fever. In one study in Chad (daytime climate of 43 ˚ C with 15 percent humidity), the turnover of water in
malnourished children was one-third of body water per day (250 ml/kg/day). It is critical to prevent this
ongoing excessive water loss, otherwise it is very difficult to judge the amount of fluid to give the child that is
needed for slow rehydration, which is a relatively small faction of the requirements for replacing ongoing losses,
which are unmeasured and very difficult to assess with any accuracy. The only way to judge ongoing losses and
the rate of rehydration is with serial accurate weights.
163
The objective of treatment is to put the child into a positive water balance of about 60 ml/kg/day, 26
which is equivalent to 2.5 ml/kg/hour of plain water. This amount should not be exceeded until the
child is awake and alert.
• If the child is conscious or semi-conscious and there is no diarrhoea, put down an NGT and start
2.5 ml/kg/hour of a 10 percent sugar-water solution. 27 Do not give F75 at this stage, as it gives a
renal solute load (mainly as potassium). Never give F100 or infant formulae.
• Reweigh the child every two hours.
ο If the weight is static or there is continuing weight loss, recheck the environment to try to
prevent ongoing water losses then increase the amount of sugar-water intake to compensate
for the ongoing weight loss (calculated as g/hour and increase the intake by this amount).
ο If the weight is increasing, continue treatment until the child is awake and alert.
• If there is accompanying diarrhoea, give one-fifth the normal saline in 5 percent dextrose orally or
by NGT.
• If the child is unconscious, the same volumes of fluid (5 percent dextrose if there is no diarrhoea
and one-fifth normal saline in 5 percent dextrose if there is diarrhoea) can be given by IV infusion.
There should be a peristaltic pump or accurate paediatric burette in order to ensure that that the
rate of administration of fluid is not exceeded during treatment.
• When the child is awake and alert, recommence feeding with F75.
Septic (or Toxic) Shock

Septic shock presents with some of the signs of true dehydration and also of cardiogenic shock; the
differential diagnosis is often very difficult.
Children that 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 this develops after admission to inpatient care, the treatment given to the child should be
carefully reviewed to determine if the treatment is the cause of the clinical deterioration. Any “unusual”
drugs should be stopped.
Diagnosis of Septic Shock
Diagnosis of developed septic shock requires that the signs of hypovolaemic shock be present. They
include a fast weak pulse with:
• Cold peripheries
• Disturbed consciousness
• Absence of signs of heart failure
26
The extracellular fluid volume is about 250 ml/kg, depending on the level of body fat and the extent of
cellular atrophy. If the extracellular sodium concentration is about 160 mmol/L and this is to be reduced by 12
mmol/day, the extracellular fluid should be expanded by about 0.75 percent per day. However, the extra water
given will be distributed in both the intra- and extracellular compartments, so it is necessary to have a positive
water balance of 0.75 percent of body water per day. There is a higher body water percentage in malnourished
children than in normal children. Therefore, the daily positive water balance should be about 60 ml/kg/day,
which equals 2.5 ml/kg/hour.
27
Sugar-water should be used rather than plain water. It is isotonic and so empties from the stomach, and is
absorbed more quickly. The treatment will last for about 48 hours. Sugar water prevents hypoglycaemia in these
children.
164
Treatment of Septic Shock
All patients with signs of incipient or developed septic shock should immediately be:
1. Given broad-spectrum antibiotics
a. Second-line and first-line antibiotics should be given together.
b. For developed septic shock, consider third-line antibiotics, antifungal treatment and anti-
staphylococcal treatment.
Appendix
2. Kept warm to prevent or treat hypothermia
3. Given sugar-water by mouth or NGT as soon as the diagnosis is made (to prevent hypoglycaemia)
4. Be physically disturbed as little as possible (e.g., no washing, no excess examination, no
investigations in other departments)
5. Never be transported to another facility – the stress of transport leads to dramatic deterioration
For Incipient (Early) Septic Shock
Give the standard F75 therapeutic diet by NGT.
For Developed Septic Shock
If the patient is unconscious because of poor brain perfusion, a slow intravascular infusion of one of
the following can be given:
• Whole blood of 10 ml/kg over at least three hours – nothing should be given orally during the
blood transfusion
Or
• 10 ml/kg/hour for two hours of one of the following (do not give if there is a possibility of
cardiogenic shock):
ο Half-strength Darrow’s solution with 5 percent glucose
ο Ringer-Lactate solution with 5 percent glucose
ο Half-normal (0.45 percent) saline with 5 percent glucose
Monitoring Treatment
Monitor the child every 10 minutes for signs of deterioration, especially overhydration and heart
failure, including:
• Increasing respiratory rate, development of grunting respiration
• Increasing liver size
• Vein engorgement
As soon as the patient improves (e.g., stronger radial pulse, regain of consciousness) stop all
intravascular intake and continue with an F75 diet.
If there are absent bowel sounds, gastric dilatation and intestinal splash with abdominal distension:
• Give first- and second-line antibiotic treatment by intramuscular (IM) injection.
• Consider adding third-line antibiotics.
• Stop all other drugs that may be causing toxicity (such as metronidazole).
• Give a single IM injection of magnesium sulphate (2 ml of 50 percent solution).
• Pass an NGT and aspirate the contents of the stomach. Then “irrigate” the stomach with isotonic
clear fluid (5 percent dextrose or 10 percent sucrose – the solution does not need to be sterile). Do
165
this by introducing 50 ml 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 percent sucrose solution) into the stomach and leave it there for
one hour. Aspirate the stomach and measure the volume that is retrieved. If the volume is less than
the amount that was introduced then either a further dose of sugar water should be given or the
fluid returned to the stomach.
• There is frequently gastric and oesophageal candidiasis. In this case, give oral nystatin suspension or
fluconazole.
• Keep the child warm.
If the child’s level of consciousness is poor, given IV glucose:

• Do not put up a drip at this stage. Monitor the child carefully for six hours, without giving any
other treatment.
• Improvement is measured first by a change in intestinal function (i.e., decrease in the distension of
the abdomen, visible peristalsis seen through the abdominal wall, return of bowel sounds,
decreasing size of gastric aspirates) and secondly by improvement in the general condition of the
child.
If there is intestinal improvement, start to give small amounts of F75 by NGT (half the quantities
given in the stabilisation phase look-up table – subsequently adjust by the volumes of gastric aspirates).
If there is no improvement after six hours:

• Consider putting up an IV drip. It is very important that the fluid given contains adequate amounts
of potassium. Sterile potassium chloride (20 mmol/L) should be added to all solutions that do not
contain potassium. If it is available, use one-fifth normal saline in 5 percent dextrose, otherwise use
Ringer-Lactate in 5 percent dextrose or half-strength saline in 5 percent dextrose. The drip should
be run very slowly – the amount of fluid that is given should not be more than 2 to 4 ml/kg/hour.
• Start to give the first- and second line antibiotics intravenously.
• When the gastric aspirates decrease such that one half of the fluid given to the stomach is
absorbed, discontinue the IV treatment and continue with oral treatment only.
Heart Failure
Diagnosis
Heart failure should be diagnosed when there is:

• Physical deterioration with a gain in weight: This is the most common way of making the diagnosis
and does not require any equipment or particular clinical skill
• A sudden increase in liver size (this is why the liver is marked before starting any infusion)
• Tenderness developing over the liver
• An increase in respiration rate
ο An acute increase in respiration rate of more than five breaths per minute (particularly
during rehydration treatment)
ο > 50 breaths/minute in infants
ο > 40 breaths/minute in children aged 1-5 years
• Respiration that has or develops a “grunting” sound during each expiration
• Crepitations in the lungs
• Prominent superficial and neck veins
166
• Engorgement of the neck veins when the abdomen (liver) is pressed

• Enlargement of the heart (very difficult to assess in practice)
• Appearance of triple rhythm (very difficult to assess in practice)
• Increasing oedema or reappearance of oedema during treatment
• An acute fall in haemoglobin (Hb) concentration 28 (needs laboratory)
Appendix
During the last stage of heart failure development, 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 known as cardiac shock; it commonly occurs in the severely malnourished child after treatment
has started. It has to be differentiated from shock due to dehydration or sepsis because the treatment is
quite different.
Heart failure is usually preceded by 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, heart failure should be the first diagnosis. If there is an
increased respiratory rate with a loss of weight, pneumonia can be diagnosed. If there is no change in
weight (fluid balance), the differentiation has to be made using the other signs of heart failure.
Pneumonia should not be diagnosed if there has been a gain of weight just before the onset of
respiratory distress.
Children with oedema can go into heart failure without a gain in weight if the expanded circulation is
due to oedema fluid being mobilised from the tissues to the vascular space. During the initial treatment
of SAM, any sodium containing fluid that has been given will have to be safely excreted later. Initial
over-treatment can lead to death several days later from heart failure when intracellular sodium
(marasmus and kwashiorkor) and oedema fluid are being mobilised.
As oedema fluid is mobilised (in kwashiorkor patients) and the sodium is coming out of the cells (both
kwashiorkor and marasmus), the plasma volume expands and there is a fall in Hb concentration. This
dilutional anaemia happens to some extent in nearly all children as they recover. A substantial fall in
Hb as a sign of an expanding circulation is also a sign of impending or actual heart failure. These
children should never be transfused.
28
All children have a fall in Hb during the early phase of treatment. This “dilutional anaemia” is due to the
sodium coming out of the cells and mobilisation of oedema – it must not be treated.
167
Figure 3. Diagnosis of Heart Failure

RESPIRATORY DISTRESS
Examine daily weights
Weight increase Weight decrease
Weight stable
Heart failure Pneumonia

Fluid overload (Aspiration)
Treatment of Heart Failure
When heart failure is diagnosed:

• Stop all intakes of oral or IV fluids. No fluid or food should be given until the heart failure has
improved. This may take 24 to 48 hours. Small amounts of sugar water can be given orally to
prevent hypoglycaemia.
• Give frusemide (1 mg/kg).
• Digoxin can be given in single dose (5 micrograms per kilogram [µg/kg] – note that this is lower
than the normal dose of digoxin. A loading dose is not given. Use the paediatric preparation and
not small quantities of the adult preparation).
If heart failure is associated with severe anaemia, the treatment of the heart failure takes precedence over
the treatment of the anaemia. A patient in heart failure should never be transfused (unless there are
facilities and experience with exchange-transfusion).
Monitoring Treatment of Heart Failure
The following parameters should be monitored:

• Weight
• Respiration rate and sound
• Pulse rate
• Jugular vein or visible vein engorgement
• Liver size
• Heart sounds
168
Hypothermia
Severely malnourished patients are highly susceptible to hypothermia (rectal temperature below 35.5°C
or under arm temperature below 35°C).
Diagnosis
Appendix
• Check the temperature of the room (28-32ºC).
• Check if the child sleeps with his/her caregiver.
• Check the temperature of the patient: rectal temperature < 35.5ºC; axillary temperature < 35ºC.
Management
• Care should be taken not to bathe malnourished patients on admission. Bathing should be done
after the child has stabilised. Bathe patients during the warmest part of the day using warm water.
Drying of patients should be done quickly and gently after washing.
• Use the “kangaroo technique”: put the naked child on the naked skin of the caregiver, put a hat on
the child and wrap caregiver and child together, give hot drinks to the caregiver so her skin gets
warmer (plain water, tea or any other hot drink).
• Monitor body temperature during re-warming.
• The room should be kept warm, especially at night (between 28-32°C): a maximum-minimum
thermometer should be on the wall in the stabilisation phase area to monitor the temperature.
• Treat for hypoglycaemia and give second-line antibiotic treatment.
Note: The thermo-neutral temperature range for malnourished patients is 28-32°C. This is often
uncomfortably warm for the staff and caregivers who may adjust the room to suit themselves.
Children with SAM should always sleep with their caregivers and not in 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.
Severe Anaemia
Diagnosis
A child has very severe anaemia if the Hb concentration is less than 40 grams per litre (g/L) or the
packed-cell volume is less than 12 percent in the first 24 hours after admission.
Management
Transfusion is a radical treatment and extremely dangerous for children with SAM who often present
with cardiac dysfunctions, reduction in renal function and with iron-carrier protein deficiency.
• Give 10 ml/kg bodyweight of packed red cells or whole blood slowly over three hours.
• All children should fast during the procedure and for at least three hours after a blood transfusion.
• Do not transfuse a child between 48 hours after the start of treatment with F75 until 14 days later.
169
• Do not give iron during the stabilisation phase of treatment.

• If the facilities and expertise exist (neonatal units), it is preferable to give an exchange transfusion
to severely malnourished children with severe anaemia.
If there is heart failure with very severe anaemia, transfer the patient to a health facility with the
capacity to perform an exchange transfusion. Heart failure due to anaemia is clinically different from
“normal” heart failure. In heart failure due to anaemia, there is “high output” failure with an overactive
circulation. Increasing anaemia and heart failure or respiratory distress is a sign of fluid overload and an
expanding plasma volume. It should be borne in mind that 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.
Figure 4. Diagnosis of Anaemia

ANAEMIA
Check Hb at admission if any clinical signs of anaemia
-Hb<=40g/l or -Hb<40g/l or
-Packed cell volume >=12% -Packed cell volume <12%
Or between day 2 and 14 after
admission
No acute treatment ONLY the first 48 hours after

Iron is given during admission: Give 10ml/kg
rehabilitation phase of whole or packed cells over 3
treatment hours
No food for 6 hours
Hypoglycaemia
Children with SAM can develop hypoglycaemia, though it is a very uncommon medical complication.
All children who have travelled for long distances or have waited a long time for attention should be
given sugar water as soon as they arrive (approximately 10 percent sugar solution: 10 g of sugar per
100 ml of water).
Children who are at risk of hypothermia or septic shock should be given sugar water whether or not
they have a low blood glucose level.
A child who has taken the diet during the day will not develop hypoglycaemia overnight and does not
need to be woken for night-time feeding. If the diet has not been taken during the day, the mother
should give at least one feed during the night.
Diagnosis
There are often no clinical signs of hypoglycaemia. One sign that does occur in malnutrition is eyelid
retraction – if a child sleeps with his eyes slightly open.
170
Management
• If a child sleeps with his /her eyes slightly open, then he/she should be woken up and given sugar
solution to drink.
• Patients who are conscious and able to drink should be given about 50 ml (approximately 5 to 10
ml/kg bodyweight) of sugar water (about 10 percent ordinary sugar in potable water) or F75 (or
Appendix
F100) milk by mouth. The actual amount given is not critical.
• Patients losing consciousness should be given 50 ml (or 5-10 ml/kg bodyweight) of sugar water by
NGT immediately. When consciousness is regained, give milk feed frequently.
• Unconscious patients should be given sugar water by NGT. They should also be given glucose as a
single IV injection (approximately 5 ml/kg bodyweight of a sterile 10 percent glucose solution).
• All patients with SAM with suspected hypoglycaemia should be treated with second-line
antibiotics.
• The response to treatment is dramatic and rapid. If a very lethargic or unconscious patient does not
respond in this way, then there is another cause giving rise to the clinical condition that has to be
identified and treated.
SAM and HIV or Tuberculosis (TB)

Dietary management of children with SAM with HIV does not differ from dietary treatment of
children with SAM who are HIV-negative. HIV-infected children are likely to present more often with
associated infection, and therefore rates of weight gain and recovery may be lower than in HIV-negative
children.
The management of SAM in HIV-infected patients should take into account:

• High prevalence of TB: Always consider diagnosis of TB in HIV-infected patients. The signs are
the same as those in children without HIV infection.
• Cotrimoxazole prophylaxis: Prophylactic doses of Cotrimoxazole should be given to patients when
HIV is suspected, and provision should be indefinite in situations where antiretroviral therapy
(ART) is not yet available. This antibiotic is added to the other systematic antibiotics for treatment
of SAM given at the start of treatment.
• ART should be considered for HIV-positive patients with SAM where available: ART is potentially
toxic for the child with SAM as it takes several weeks or months before having an impact on the
cluster of differentiation 4 (CD4) cell count. Therefore, it is safe to wait until recovery of
nutritional status (at least the end of inpatient care) to commence ART treatment. The most
appropriate schedule for commencement of ART treatment for children with SAM and HIV
infection is, however, not yet established and is currently being investigated.
• Voluntary testing and counselling of children with SAM and their parents in high HIV prevalence
areas: Testing for HIV in children with SAM is advised in areas with a high HIV prevalence. It has
implications for the treatment of SAM and it may lead to detection of HIV in the accompanying
parent, with implications for counselling and treatment. If families of HIV-infected children are
food-insecure, they will also need special nutrition support.
Although guidelines for the management of SAM are considered appropriate for HIV-infected patients
with the minor adaptations described above, extensive research is currently under way to further adapt
protocols for these patients. These include, among other considerations:
• Comparison of recovery rates of HIV-infected and HIV-negative children with SAM treated in
CMAM
• Development of nutrition products specifically designed for HIV-infected malnourished patients
171
• Use of micronutrient supplementation for HIV-infected individuals

• Development of nutrition support for PLHIV in ART
• Studies of the interaction between ART and nutritional status of the patient
• Assessment of SAM in HIV-infected adults
• Impact of nutrition support on HIV-infected individuals
• Integration of HIV programmes with CMAM
Until such a time where the evidence base is established, it is advised to treat SAM in HIV-infected
patients with this standard treatment protocol for SAM, combined with prophylaxis (Cotrimoxazole)
and start of antiretrovirals (ARVs), if necessary, only after initial recovery of nutritional status.
Other Medical Complications

Children diagnosed with SAM may also be suffering from other underlying illnesses. In such
circumstances these children should be treated according to this standard protocol for SAM. Those
who fail to respond to treatment need further investigation for an underlying condition that makes
them fail to respond to treatment.
Great care should be exercised in prescribing drugs for patients with SAM. They have abnormal kidney
and liver function, altered levels of the enzymes necessary to metabolise and excrete drugs, excess
entero-hepatic circulation (reabsorption) of drugs that are excreted in the bile, decreased body fat
which increases the effective concentration of fat-soluble drugs and, in kwashiorkor, there may be a
defective blood-brain barrier. Moreover, very few drugs have had their pharmacokinetics, metabolism
or side effects examined in patients with SAM.
The following considerations are strongly advised:

• The underlying malnutrition should be treated first before standard doses of drugs are given. Drugs
used for HIV and TB can damage the liver and pancreas. These diseases do not usually cause
immediate death (except military TB and TB meningitis) so treatment should normally be delayed
for up to one week while the nutritional treatment returns the metabolism of the patient back to
normal.
• If it is critical that a particular drug be given at the start of treatment for SAM, then it should
initially be administered in reduced doses.
• Many drugs should be avoided altogether until there is research to show that they are safe and
guidance is provided on the dosage appropriate for the malnourished child. Common drugs, such
as paracetamol, do not function well in most children with SAM being treated in the stabilisation
phase and can cause serious hepatic damage. Metronidazole should be avoided if at all possible, and
ivermectin or other drugs that are dangerous if they cross the blood-brain barrier should never be
given to oedematous patients.
172

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INTERIM NATIONAL GUIDELINES FOR

Quantities of RUTF to Provide ............................................................................................................ 24

5.1.1 Routine Medicines and Supplements ......................................................................................... 54

Figure 1. Diagrammatic Representation of Stages of Community Outreach .............................................. 13

Box 1. Summary Steps in Community Outreach..................................................................................................8

DR. ELIAS K. SORY

ACRONYMS AND ABBREVIATIONS

LOS Length of stay

1.1 Acute Malnutrition as a Form of Undernutrition

Undernutrition is identified through anthropometric (body) measurements, clinical signs and

1.1.2 WHAT IS ACUTE MALNUTRITION?

There are two forms of acute malnutrition:

1.1.3 ASSESSING ACUTE MALNUTRITION

Bilateral pitting oedema is a clinical manifestation of acute malnutrition caused by an abnormal

• Anorexia, no appetite • Hypothermia

1.2 Principles of the Management of SAM

Table 2. Classification of SAM for CMAM

• Anorexia, no appetite • Hypothermia

Special cases 6-59 months:

1.2.1 COMMUNITY OUTREACH

1.2.2 OUTPATIENT CARE FOR CHILDREN 6-59 MONTHS

1.2.3 INPATIENT CARE FOR CHILDREN 0-59 MONTHS

1.2.4 SUPPLEMENTARY FEEDING OF CHILDREN 6-59 MONTHS AND

CHAPTER II: COMMUNITY OUTREACH

Community outreach is a critical component of CMAM and can be undertaken individually or

BOX 1. SUMMARY STEPS IN COMMUNITY OUTREACH

STEP 1: Community Assessment

II. Community Outreach

The following steps form part of Community Assessment: Learning from

STEP 2: Formulation of Community Outreach Strategy

STEP 3: Developing Messages and Materials

STEP 4: Community Mobilisation and Training

STEP 5: Case-Finding and Referral of New Cases With SAM

II. Community Outreach

STEP 6: Follow-Up of Children With SAM

STEP 7: Linking With Other Community Services, Programmes

STEP 8: Continued Community Mobilisation (as in Step 4)

Figure 1. Diagrammatic Representation of Stages of Community Outreach

II. Community Outreach

3. Messages and Materials

CHAPTER III: OUTPATIENT CARE FOR

BOX 2. SUMMARY STEPS IN OUTPATIENT CARE

1. Screening Children for SAM

STEP 1: Screening Children for SAM

III. Outpatient Care

BOX 3. COMMUNITY SCREENING AND REFERRAL FOR TREATMENT

Children are screened and referred for treatment if screening finds:

STEP 2: Admission Criteria

Table 3. Admission Criteria for CMAM for Children Under 5

Infants 0-6 months

Additional points to consider during the admission procedure:

III. Outpatient Care

Table 4. Outpatient Care Admission Categories

BOX 4. ADMISSION PROCEDURE

Welcome the child and caregiver and provide initial care:

Define nutritional status:

Conduct medical assessment:

STEP 3: Medical Assessment and Decision-Making for Treatment

• Take the medical history and record.