REPORT ON TRAINING COURSE ON THE MANAGEMENT OF SEVERE ACUTE MALNUTRITION AND ORIENTATION ON COMMUNITY-BASED MANAGEMENT CARE OF SEVERE ACUTE

MALNUTRITION

HELD AT SUN LODGE HOTEL, ACCRA, GHANA FROM 31STAUGUST TO 6TH SEPTEMBER, 2009

BY DR BEATRICE C AMADI UNIVERSITY TEACHING HOSPITAL DEPARTMENT OF PAEDIATRICS LUSAKA. ZAMBIA

REPORT ON TRAINING COURSE ON MANAGEMENT OF SEVERE ACUTE MALNUTRITION

INTRODUCTION/BACKGROUND INFORMATION
Severe acute malnutrition is a leading cause of morbidity and mortality in children in the under-five age group in developing countries. Malnutrition contributes over 50% of the 10 - 11 million deaths from preventable causes, which occur annually in this age group. In most developing countries, many severely malnourished children die at home without care, and even when hospital care is provided, case fatality rates are very high, ranging between 30-50%. Factors which contribute to this high case fatality rate include: Inappropriate diets high in protein, sodium and energy given in the acute phase of management Lack of recognizing the fact that all severely malnourished children need to be treated with broad spectrum antibiotics, to treat infection which may not always be apparent Inappropriate use of intravenous fluids, particularly in patients who are not in shock. Equally use of fluids that have high sodium is dangerous Use of iron in the early phase High dose of Vitamin A not given Failure to monitor food intake Lack of feeding at night Non provision of warmth Poor hygiene

Other factors which contribute to poor outcome of hospital management include: Late presentation and delayed referral to inpatient facilities High prevalence of HIV/AIDS Shortage of staff Shortage of essential drugs and supplies e.g. antibiotics, Oral rehydration solution, therapeutic feeds, and medico-surgical supplies. The World Health Organization (WHO) has developed a manual that describes case management guidelines for severely malnourished children. It has been shown that use of appropriate case management protocols based on these WHO guidelines is capable of saving lives of many severely malnourished children with reduction of case fatality rates to less than 5%.

Since 2002, the WHO Training Course materials on Management of Severe Malnutrition have been used in trainings of senior health workers in several Asian and African Countries. Doctors, Nurses and Nutritionists/Dieticians working in inpatient facilities and Ministry of Health including, WHO, UNICEF National Programme Officers and other partners working in the area of childhood nutrition have been trained in case management of severe malnutrition using these guidelines. As per these WHO guidelines all cases of severe malnutrition are admitted and managed as inpatients. Exclusive inpatient management of severe malnutrition does not enable a large of children to be managed due to limited hospital bed capacity. In September 2006, WHO, UNICEF and VALID International held a combined two day meeting on Integrated Management of Severe Acute Malnutrition (IMAM) in Dar es Salaam, Tanzania for East and Southern African countries. This meeting targeted recently trained facilitators on WHO Management of Severe Malnutrition Guidelines, trainees invited to undergo the 6 day Case Management Training Course of Severe Malnutrition, decision makers from Ministries of Health including WHO and UNICEF programme officers from represented countries (Tanzania, Kenya, Uganda, Ethiopia, Eritrea, Namibia, Botswana and Lesotho). This meeting brought WHO, UNICEF and VALID International together to promote the concept of IMAM which at the time was referred to as Community Therapeutic Care (CTC) as way to improve and increase coverage of affected children. At the time, it was noted that CTC had become possible as a new way of managing severely malnourished children due to the development and availability of Ready-to-Use Therapeutic Food (RUTF). Nomenclature has since changed from CTC to Community-based Management of Severe Acute Malnutrition (CMAM). Availability of RUTF has enabled children with severe acute malnutrition without complications to be managed at home with weekly visits to Outpatient Care sites (OPC) for follow up. Only children with complicated severe acute malnutrition are admitted to inpatient facilities for stabilization (Stabilization Care) with an option of early discharge upon improvement of complications. Children with moderate acute malnutrition are managed through a Supplementary Feeding Programme (SFP) with supplies of either dry or wet rations of Maize-Soya Blends and similar fortified food supplements. According to the 2008 Ghana Demographic and Health Survey Report, nutrition indicators for children in the under-5 age are as follows: Underweight 14% Stunting 28%. Wasting 9% Severe wasting 2.2%. This is highest in the Upper West Region (3.9%) followed by Eastern Region (3.7%), Northern (3.4%) and Upper East (2.9%)

In Ghana, acute malnutrition has over the years been managed in hospitals and rehabilitation centres attached to these hospitals. However, results from these facilities have not been encouraging as evidenced by the figures referred to above. Some of the reasons for poor outcome in malnourished children managed in this way are: Lack of training of health workers managing severe malnourished children in these facilities Lack of structured management protocols Lack of therapeutic feeds and other essential supplies

In June 2007, a national workshop for senior health managers and senior clinicians was conducted with support from UNICEF/Ghana and USAID/Ghana. The main focus of this training was the pathophysiology and clinical management of SAM including an orientation of Community-based Management of Severe Acute Malnutrition (CMAM). After this workshop, CMAM learning sites were established in two districts with technical support from Food and Nutrition Technical Assistance Project (FANTA-2) and funding from USAID/Ghana Health Service (GHS). The CMAM project is being implemented by GHS with support from UNICEF which has been providing therapeutic feeds such as RUTF, Therapeutic Milk products (F-75 and F-100) and Combined Mineral and Vitamin Mix (CMV). UNICEF is also providing anthropometric equipment (weighing scales and MUAC tapes). Health workers from the selected districts and regions were trained through several CMAM in-service sessions. Experience from these pilot sites will inform the national strategy for integrating CMAM into the national health system, scaling up services and developing national guidelines for CMAM. Implementation of inpatient management of SAM and follow up outpatient care with RUTF has been limited to a few facilities which participated in the 2007 training. The GHS has now embarked on a programme to roll out improved case management of SAM in the context of CMAM to more facilities in order to address the gaps and poor management outcomes that are currently being recorded in most of the health facilities where children with SAM are admitted. This programme includes community outreach which is aimed at early identification of undernourished children in the community for early intervention, usually associated with improved outcome. In line with the above, the GHS supported by WHO, UNICEF and FANTA-2/USAID organized this training with the following objectives: 1. To develop the training skills of 10 national facilitators in the WHO Training Course on Management of Severe Malnutrition with medical complication admitted for inpatient care based on the CMAM approach 2. To strengthen competencies of 18 clinicians on the inpatient care of SAM with medical complications based on the CMAM approach

I was recruited as Temporary Advisor by WHO (African) Regional Office to undertake the above mentioned assignment and travel arrangements were made in accordance with the training schedule. This report is presented in three sections as follows: I II III IV Facilitator Training Case Management Training in the context of CMAM Course Directors Observations and Recommendations Inpatient Case Management Protocol in the context of CMAM

FACILITATOR TRAINING

1.0 Introduction The Training Course on Management of Severe Acute Malnutrition is designed for senior nurses, doctors, nutritionists/dieticians in hospitals that have or plan to have severe malnutrition wards for children. This training was held at the Sun Lodge Hotel, Accra from 25th to 28th August, 2009. The facilitator training was conducted over a period of 4 days. The focus of the training was mainly on facilitation skills and techniques used in the WHO Training Course on Management of SAM. The second half of the last day was devoted to going through the CMAM protocol and how it fits it with the traditional WHO training materials which mainly focus on inpatient care of children with SAM. During the facilitator training most of the time was spent in the classroom going through the training materials. A planned clinical session was conducted in Reverend Campbell Malnutrition ward at the Princess Marie Louise (PML) Childrens Hospital on the third day of the training. During this session, the trainees visited the kitchen and observed preparation of therapeutic feeds and were shown the schedule of distributing the same to admitted patients.

1.1 Course Materials Each trainee facilitator was given a set of modules all at once in order to allow them to work ahead. However, when they actually facilitate in training, they give the participants modules one at a time. The set of materials given to each trainee included: Introduction Principles of care Initial management Feeding Daily care Monitoring and problem solving Involving mothers in care PHOTOGRAPHS BOOKLET FACILITATOR GUIDE ANSWER SHEETS SET OF FOUR LAMINATED REFERENCE CARDS SAMPLE OF DISCHARGE CARD SET OF 7 MODULES -

The following additional training materials were also provided to each trainee: New 2009 Updates to the WHO Training Course on the Management of Severe Malnutrition, issued by the Nutrition for Health and Development, WHO HQ. Training Guide for CMAM (USAID, AED/FANTA-2, VALID International, Concern Worldwide, UNICEF 2008) Draft Interim Ghana National Guidelines for CMAM 2009 Joint Statement by WHO and UNICEF WHO Child Growth Standards and the identification of severe acute malnutrition in infants and children 2007 Joint Statement by WHO and UNICEF Community-based Management of Severe Acute Malnutrition

1.2

Objectives for Facilitator Training Learn the course content Practice the teaching techniques used with the modules (for example, giving individual feedback, leading group discussions, leading oral drills) Become familiar with the severe malnutrition ward and how clinical practice will be conducted Learn ways to work effectively with a co-facilitator Practice communicating in supportive ways that reinforce learning Discuss problems that may be faced during the course (for example, slower readers, logistical difficulties in the ward, or sections of a module which may be difficult to teach) and prepare to handle these difficulties

1.3 Schedule for Facilitator Training This 4 day training is condensed from the full 6-day case management course. The trainee facilitators were expected to move very quickly through the modules and other relevant aspects of the additional materials with a focus mainly on teaching techniques.

1.4 Facilitator Guide Trainees learnt to use the Facilitator Guide during this training. A description of the roles and responsibilities of a facilitator are given in the Facilitator Guide. The major duties of a facilitator include: To introduce the modules To answer questions and assist trainees while they work To provide individual feedback on completed exercises To do demonstrations and give explanations of certain steps To conduct oral drills To lead and summarize video exercises and group discussions To coordinate role plays To summarize the modules To assist with clinical practice as requested by the clinical instructor

Trainee facilitators were urged to learn to follow Procedures as described in the Facilitator Guide to assist them effectively train participants on case management of SAM.

1.5 Method of Work The schedule of the facilitator training followed that in the Course Directors Manual including additional topics on CMAM and new (2009) WHO updates on CMAM The training commenced by mid morning of Tuesday 25th August 2009 after addressing all the relevant administrative issues. There was a practical session during which the trainees prepared ReSoMal. Therapeutic Feeds were not prepared during the facilitator training, this was to be done during the case management training. The last half of 4th day was devoted to going through CMAM guidelines including how this is being implemented in the learning sites (Agona East and West of Central Region and Ashiedu Keteke sub Metro of Greater Accra Region) and in the Northern Region. Trainee Facilitators were taken through some sections of CMAM Module 5 Training Guide. This was done as a power point presentation and some handouts from the CMAM Training Manual were given out to the trainees. A schedule of the Facilitator training is attached (Annex 1).

1.6 Trainee Facilitators A total of 12 trainees facilitators were in attendance during the Facilitator Training. Two of these were also trained as co-Course Director and Clinical Instructor respectively. The trainee facilitators included: o A Professor of Paediatrics from Korle Bu Teaching Hospital o Two Paediatricians, from local hospitals, one was the co-course director, while the other was trained a clinical instructor o Three Nutrition Programme Officers working for WHO, UNICEF including the CMAM Specialist working with FANTA-2. o One Programme Manager for Nutrition Rehabilitation (also CMAM focal person) working with GHS o One nutritionist, Training Administrative Assistant o Four Medical officers working in inpatient facilities and 1 Assistant Medical Officer. The full list of Trainee facilitators is attached (Annex 2)

1.7 Expected Outcome Skilled and knowledgeable facilitators who will spearhead CMAM training and participate in the final development and implementation of the new CMAM guidelines which were currently in draft form. These Facilitators will form a core team which will take on the responsibility of conducting more facilitator and case management trainings so that the country will have a critical mass of dedicated health workers well trained in CMAM guidelines to oversee the rolling out of this important programme throughout the country.

1.8 Opening Ceremony The Training was officially opened by Dr Isabella Sagoe-Moses, Child Health Coordinator for Child Health Service in GHS. Dr Sagoe-Moses welcomed the participants to the training and gave a brief background on the problems of malnutrition at National level. She reiterated GHSs commitment to supporting such trainings in order to have trained facilitators who will take the lead in training other health workers in order to ensure wider implementation of CMAM in the country. Trainee facilitators were counseled on the importance of maintaining standards taught in this course and to ensure that they do not cut corners as they set about training the countrys health cadres in CMAM guidelines. Attainment of the Millennium Development Goals (MDGs) was a priority for the country, however, attainment of some of the MDGs would be possible, only if malnutrition was addressed at national level. This was a great challenge to all the health workers in the country to put in their best in order to make these desired achievements, including reduction of in children under-5 years. She ended by thanking the partners, WHO, UNICEF and FANTA-2/FANTA for their continued support to GHS for the technical, material and financial support being rendered to the country through GHS and specifically for making this training possible. Mrs Okwabi, GHS Infant and Young Child Feeding Coordinator Nutritionist informed the trainees facilitators that the current training and many other associated activities were all long overdue, hence the need to move very quickly so that the CMAM programme is implemented throughout the country. She ended by thanking the partners, WHO, UNICEF and FANTA-2/USAID for their continued support.

1.9 Preparation for the workshop The following observations were made on the preparations of the facilitator training: The venue for the facilitator training had been secured at the Sun Lodge Hotel which was about 20-30 minutes drive from Princess Marie Louise (PML) Childrens Hospital, where the inpatient training including practical sessions was going to be held The course materials comprising training modules and the manual including the additional training materials were delivered before the training. However, the training Video provided by WHO HQ was defective. A copy brought by the Course Director was used. Several copies were made from this DVD for use in future trainings. Supplies for the facilitator trainees (stationery, pens, pencils, highlighters, calculators etc) and secretarial services were available within the classroom. The Sun Lodge Hotel provided all the meals during training (lunch, midmorning and afternoon snacks and drinks). There were no complaints from the trainee facilitators as regards the quality of food. The ingredients for preparation of the ReSoMal, Therapeutic Feeds (F-75 and F100) and a box of RUTF had all been procured utensils and weighing scales were available. A familiarization tour of PML Childrens hospital was not undertaken by the Course Director prior to the training. However, site visit had been conducted and all the necessary permission obtained for the use of the hospital for training and clinical sessions by the local team comprising Akosua Kwakwye ( Nutrition Programme Officer, WHO country office) Alice Nkoroi (CMAM and Emergency Nutrition Specialist) and Michael Neequaye (Programme Manager, Nutrition Rehabilitation) The course director arrived 2 days before the training and met with the local team the following day for briefing and finalizing of the training preparations. It was gratifying to note that all the necessary preparation had been put in place for the following days training. Training schedules, registrations forms were prepared by the course director Almost all the participants were accommodated at the Sun Lodge Hotel except for 3 who live in Accra. The morning sessions started at 0830 hours and ended at 1730hours. It was commendable that all the participants worked very hard throughout the training and kept to time.

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2.0 Activities during the training days The training started soon after the mid-morning tea break. The trainees were given the course outline including how the course was to be conducted: Day 1: Introductions Introduction to Facilitator Training: o Context of Facilitator Training o Materials needed o Objectives of Facilitator Training o Teaching Methods o Schedule for Facilitator training o Introduction to Facilitator Guide o Modules: Introduction Principles of Care Day 2: o Module: Initial Management Day 3: o Module: Feeding o Clinical Session visit to Princes Marie Louise Childrens Hospital Day 4: o Module: Daily Care Monitoring and Problem Solving Involving Mothers in Care

o o o o

Overview of CMAM Practical arrangements for the course Teams of facilitators discuss plans for the first day of training Closing Remarks to the newly trained facilitators by Course Director

After a power presentation to review the purpose of the course, the course director introduced the use of Facilitator Guide and gradually took the trainees through it pointing out the relevant sections which gave instructions on how to conduct the facilitator techniques and skills including preparation required for specific tasks taught in the course. Initially the course director demonstrated to the trainees how the various facilitator techniques and skills were performed at the first instance. Thereafter, trainees took turns to practice the already demonstrated techniques and skills with emphasis on effective use of the Facilitator Guide as the course progressed. While one trainee practiced a particular technique or skill, the others observed closely and gave feed back at the end of the session. Positive feedback was given first followed by areas which could be improved upon. The use of Facilitator Guide was continuously emphasized throughout

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the facilitator training and the areas to be improved upon by each participant were highlighted. The course director maintained a Practice Assignment Grid to ensure that all the trainee facilitators were given a chance to practice the various facilitator techniques and skills equally. The facilitator techniques and skills taught in the course are as follows: o o o o o o o o o o o Introducing a module Leading a discussion Adapting for nurses groups Individual Feedback Oral Drills Video Activity Summarizing a module Conducting a Demonstration Coordinating role plays While participants are working Group Discussion

The trainee facilitators continued with practicing of the various facilitator techniques and skills throughout the course. By the end of the course trainees had mastered the facilitator skills and techniques taught in the course. No clinical session was conducted during facilitator training. The following observations were made during the visit to PML childrens hospital on the 3rd day of the training: o The kitchen is located in the old building of the hospital adjacent to the new building housing Reverend Campbell malnutrition ward situated on the same floor. o Participants had an opportunity to observe preparation of feeds by the diet cook supervised by the Dietician. The feeds are prepared hygienically. There were recipes for preparation of F-75 and F-100 using full cream milk on the wall. The names of patients admitted on the ward and the amount of feed was also put up on the kitchen wall. o However, it was noted that the recipe for F-75 was incorrect. Instead adding 100gm or sugar, 70 grams was being added. There was obviously a mix up with the recipe for preparation of cereal based F-75 (70 grams of sugar is added with 35 grams of cereal powder). This was brought to the attentions of the Dietician and the recipe was corrected immediately. o The patients are started on 4 hourly feeds during the stabilization phase and this is continued through to the rehabilitation phase. The patients are only fed during the day, receiving the last feed at 18.00 hrs. Thereafter the kitchen is closed for the night to re-open at 07.30 hours the following day.

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o The amount of feed for each patient is measured by the kitchen staff who then give to the patients. At times mothers go to the kitchen to collect the feeds. Each cup is labeled with the childs name. o The malnutrition ward had 3 children with SAM admitted on the day of the visit. o There was a much older version of MUAC tape by the Nurses desk (showing severe wasting <12mm and wasting <13mm). The ward has a new manual infant scale, a plastic as well as a locally made wooden length boards. There was a stand-on scale with an attached stadiometer used to measure weight and height of older children . o There is Nutrition Rehabilitation Centre is located behind the new hospital wing but on another plot separated by a wall fence. Outpatient care sessions of SAM are conducted every week on Fridays. The Centre has a kitchen where mothers with moderately malnourished children prepare feeds. Usually the children receive 3 meals during each visit.. There is a play room with a lot of toys for children. There are a few cots where children are put to sleep. The centre is clean and well kept. Staff are very friendly and welcoming to mothers o Growth monitoring and immunization sessions are held at the centre weekly The trainee facilitators successfully completed the classroom work on the 4th day with a session on CMAM. The CMAM Specialist (Ms Alice Nkoroi) presented an overview of CMAM, which was followed by a discussions on how this programme was being implemented in the country. The various monitoring and reporting forms were presented and discussed. Each trainee was given a sachet of RUTF to taste.

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At the end of the training, planning for the following weeks case management training was done. Twenty participants were expected for this training. A decision was made to have two groups of 10 participants in each group. The facilitators were thus divided into the two groups as follows: Group A: Jennifer Welbeck, Prof. Clement Adams Isaac Abban, Dr Alice Nkoroi

Group B: Memuna Tanko, Dr, Kwabena Sarpong, Dr Rev. Sister Patricia Zaghe Catherine Adu-Asare Akosua Kwakye Clinical Instructor: Matildah Agyemang, Dr Co-course Director: Thelma Brown, Dr Michael Neequaye was to be involved with administrative duties.

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II
1.0

CASE MANAGEMENT COURSE

Introduction

The WHO case management course on Management of SAM is a 6 day training which is designed for in-service, providing training to health workers who have already finished their basic medical training and are working and treating sick children. The course has a variety of methods of instructions, including reading, written exercises, discussions, role plays, video exercises and demonstrations including practice in a real inpatient malnutrition ward. Small groups of participants are led and assisted by facilitators as they work through the course modules which include: Module 1 Module 2 Module 3 Module 4 Module 5 Module 6 Module 7 Introduction Principles of Care Initial Management Feeding Daily Care Monitoring and Problem Solving Involving Mothers in Care

The following additional training materials were given to each participant: New 2009 Updates to the WHO Training Course on the Management of Severe Malnutrition, issued by the Nutrition for Health and Development, WHO HQ. Training Guide for CMAM (USAID, AED/FANTA-2, VALID International, Concern Worldwide, UNICEF 2008) Draft Interim Ghana National Guidelines for CMAM 2009 Joint Statement by WHO and UNICEF WHO Child Growth Standards and the identification of severe acute malnutrition in infants and children 2007 Joint Statement by WHO and UNICEF Community-based Management of Severe Acute Malnutrition RUTF look-up charts MUAC tapes Weight-for-length/height tables based on WHO Growth Charts

Updates and additional information from these additional materials was included in the appropriate WHO training modules by the participants assisted by Facilitators. This way, the participants had updated modules to work through during the course. As mentioned above, the WHO training course of management of SAM is based on inpatient care of all severely malnourished children. However, recent developments and innovations, specifically the new classification of SAM and the development of RUTF

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has made it possible to successfully manage severely malnourished children with no complications and a good appetite as outpatients with regular, usually weekly visits to the health facility for evaluation and supplies of RUTF. CMAM has improved case management of SAM in terms of increased coverage, good outcome as evidenced by high cure rates and reduced case fatality rates of <4% in OPC facilities (experience from Zambias Lusaka District Health Management Board Outpatient Therapeutic Centres). CMAM has four components which should be implemented for maximum positive impact of the programme. These components are: Community Outreach with early identification of undernourished children in the community Supplementary Feeding programme (SPF) Outpatient Care (OPC) Inpatient Care

RUTF is required in order to implement CMAM. Currently RUTF is imported from Nutriset, France, however, local production of RUTF is being advocated in countries where CMAM is being implemented. RUTF is equivalent to F100, the catch up milk feed which has traditionally been used during inpatient care of patients with SAM. Use of F100, requires that patients remain admitted in hospital for 4-6 weeks or longer, particularly in children with HIV disease. Prolonged hospital admission impacts negatively on the family, particularly younger siblings left at home while the mother cares for the severely malnourished child admitted for inpatient care. Inpatient care is labour intensive and expensive requiring a large number of specialized health workers (doctors, nurses and nutritionists/dieticians) and is usually associated with high risk of cross infection among admitted children, particularly if they share beds. In such a situation, case fatality rate is much higher when compared to case management in the context of CMAM, where SAM patients without complications are managed as outpatients, while only those with complications get admitted into hospital.

1.2 Expected Outcome The expected outcome is to have knowledgeable and dedicated doctors, nurses, nutritionists and dieticians required to spearhead the implementation of protocols for appropriate and correct case management of children with complicated cases of SAM throughout the country. These trained health workers will be able to initiate RUTF during inpatient care of children with SAM with an option of early discharge to continue care from home. This improved management of complicated cases of SAM with the option of early discharge to continue care in outpatient centre will contribute to reduction of case fatality rates.

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1.3. Training Site The training was held at PML Childrens Hospital in the Administrative block of the hospital and Reverend Campbell malnutrition ward, were the clinical sessions were held daily All the logistics and supplies for the case management training were in place including training modules and additional materials referred to above. Most of the participants and facilitators were accommodated at the Sun Lodge, except for a few who live within Accra. A bus was hired to ferry participants and facilitators to and from the PML hospital. Sun Lodge hotel provided take away meals - lunch, mid morning and afternoon snacks with water and a variety of soft drinks. There were no complaints from the participants regarding the quality of the food, except on 2 occasions when lunch was delivered late, but this did not disrupt the training.

1.4 Participants Twenty participants were expected for the case management training, however, on the first day, only 12 participants were available. Letters had been sent and followed up with phone calls, so it was not clear why some of the invited participants did not turn up. On the second day, 2 participants joined the course while 1 participant from the Eastern Region joined midmorning on the 3rd day. The facilitators worked with the late comers who were able to catch up with the rest of the group. Altogether 15 participants were trained, 8 in Group A and 7 in Group B. Full list of participants is attached as Annex 3

1.5 Opening Ceremony The training started at 0950 hours on Monday 31st August, 2009 with a prayer, followed by introductions. The GHS Deputy Director of Public Health opened the training. In his welcome remarks, the DDPH informed the participants that the programme to improve management of SAM started 2 years ago, with support from several partners, namely, WHO, UNICEF, FANTA-2 and USAID. Consultants were brought in to conduct training on CMAM. It was emphasized that in order to attain the MDGs, something needed to be done about malnutrition, specifically, early identification and correct management of cases in hospital and in the community. In order to achieve the above, there was need to improve management skills on management of SAM and have standardized protocols all over the country. This was going to be possible with the decision to implement training course on management of SAM.

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The course director gave a brief overview of the training course and shared experience from Zambia which had implemented the WHO guidelines since 2003 and communitybased management of SAM in Lusaka District Health Teams Health Centres since 2005, starting with 5 and scaling up to 26 sites, where over 350 children were being treated in the Outpatient centres with RUTF.

1.6 Conduct of the training The course followed the following schedule: Day 1: Monday 31st August, 2009 The course started after the tea break at 11 hours. After group introductions, the participants settled to work on the modules and the additional materials as follows: Modules: Video Clinical Practice: Introduction/updates Principles of Care/MUAC as a measure of wasting/updates Transformations Tour of the ward

Day 2: Tuesday 1st September, 2009 Modules: Video: Clinical Practice: Initial Management/updates Making ReSoMal Emergency Care Clinical Signs/measuring MUAC Weighing admitted children with SAM

Day 3: Wednesday 2nd September, 2009 Modules: Kitchen: Clinical Practice: Initial Management/updates (finish) Feeding/updates. Introduce RUTF reference card Making F-75 and F-100/show RUTF and discuss composition Initial Management CCP chart/measuring MUAC//feeding F-75

Day 4: Thursday 3rd September, 2009 Modules: Clinical Practice: Feeding/updates (finish) Daily Care/updates Initial Management/Feeding /Transition to RUTF. Situations requiring Transition to F100 were explained

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Day 5: Friday 4th September, 2009 Visit to Nutrition Rehabilitation Centre Daily Care/updates (finish) Monitoring and Problem Solving/updates Monitoring Patients on RUTF/use of CCP charts to monitor Progress. Criteria for early discharge

Modules: Clinical Practice:

Day 6: Saturday 5th September, 2009 Modules: Video: Presentations: Involving Mothers in Care/updates Teaching Mothers about home feeding Malnutrition and mental development Overview of CMAM and its implementation in Ghana CMAM in general and sharing Implementation of CMAM in District Health Management Clinics in Lusaka, Zambia Way Forward

The training was conducted over 6 days. The facilitators guided the participants through the training modules, including updates and new information on CMAM contained in the additional materials given to each participant. The modules were introduced one at a time by the facilitators who used the techniques and skills they had learn during the facilitator training. The course director guided the facilitators and provided counsel as and when required, including addressing questions which arose during the training. Co-course director and the clinical instructor worked closed with the course director who reinforced their knowledge and skills on how to conduct the training. During the practical sessions, the participants had an opportunity to manage and follow up a severely malnourished child who was transitioned from F-75 to RUTF with good response within two days. There was another child with a feeding problem which had not been noticed by the ward staff. Participants were able to appreciate the importance of assessing and observing a feed in all patients on admission in order to establish whether there was a feeding problem or not. It is equally important to assist and teach mothers how to feed a severely malnourished child with a feeding problem, this includes insertion of a naso-gastric tube if the child is unable to take adequate amounts of a feed orally. A third child admitted with poor appetite was successfully fed via a nasogastric tube until the child was able to take F-75 by mouth on the second day.

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During the sessions in the Rehabilitation Centre, participants observed several children with uncomplicated SAM being fed with RUTF. Two children with complications (one with high fever and the other with marasmic-kwashiorkor) were identified and referred for inpatient care in the malnutrition ward as per CMAM protocol of inpatient care. During the clinical sessions, participants had an opportunity to learn and practice how to effectively use the various daily monitoring charts to assess response to therapeutic and medical care and use the same charts to identify and manage poor responders to management. The participants had adequate practice on measurement of MUAC and checking for oedema including monitoring of patients on OPC.

1.7 Facilitators meeting The facilitators held daily meetings at the close of each day. During these meetings, facilitators presented progress reports including any questions from the participants regarding course materials or any issues relating to the course. During the training the following questions were raised: Vitamin A in children with oedema and eye signs Provision of additional zinc in children with SAM presenting with diarrhea The Course Director gave some guidance and provided literature on studies on Vitamin A in children with oedematous SAM. Children with oedematous SAM should not be given Vitamin A until after the resolution of oedema An exception to this rule was a child with oedematious SAM with eye signs, suggestive of Vitamin A deficiency who should receive 3 therapeutic doses of Vitamin A to prevent blindness On the issue of additional zinc for severely malnourished children with diarrhea, the course director provided guidance that all the therapeutic feeds (F-75, F-100 and RUTF) and ReSoMal had a lot of zinc, hence there was no need to give additional zinc supplements

1.8 Outcome of training The two groups worked almost at the same pace on the first day. However, from day 2, Group A took the lead but by a small margin. The participants worked well and went through all the modules as per course schedule which is attached in annex 4 and Annex 5.

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III COURSE DIRECTORS OBSERVATIONS AND RECOMMENDATIONS

OBSERVATIONS:
The training was generally well organized. The Hotel where most of the participants and facilitators were accommodated was good, comfortable with professional and courteous staff. All the rooms had internet connection free of charge. The meals as mentioned were satisfactory and there were no significant complaints from the participants on quality of the meals. Transport was arranged for the pick from the hotel in the morning and evenings from PML Childrens hospital. However, since there was only one bus, participants who finished classes earlier had to wait for the facilitators to join after their meeting. This probably inconvenienced the participants, even though no one complained. The journey back to the hotel took much longer due to heavy traffic The classroom work generally went on well with no major problems. The two groups of participants had the video sessions together after which they held group discussions in their respective classrooms. PML Childrens hospital had made efforts to implement inpatient management guidelines of SAM after the 2007 training. The hospital has separate ward for children with SAM and mothers are allowed to say by their childrens bedside 24 hours a day. All the admitted patients are given broad spectrum antibiotics on admission with provision to go to second line in case of non response Baseline investigations (Full Blood Count, Malaria test) and HIV testing in some patients are carried out during inpatient admission. Other investigations are carried out as indicated. All the patients receive broad spectrum antibiotics including Vitamin A and Zinc Supplements. Generally the hospital has good record keeping, with all patients given case management files which are stapled together to avoid loss of the notes There is a day room on the same floor where mothers have their meals, receive visitors and spread out on the floor to lie down for a quick nap. However, the hand wash basins are non functional and need to be replaced.

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There is no sharing of beds, this is good in that it prevents direct correct infection from one patient to another Hospital stay is free of charge for the first 5 days, after which a charge is imposed for patients staying longer There is an ablution block on the same floor of the ward for patients and caregivers F75 is incorrectly reconstituted since the amount of sugar added is less than recommended in the recipe given in the training modules. This puts patients at risk of hypoglycaemia. Some of the monitoring charts are maintained well and completed every day, these are: drug, feed (only amount given, not amount taken), temperature and weight charts (though all the weights recorded were incorrect). There were some problems identified on the implementation and overall management of admitted children with SAM. Among these are: 1. Admission to the malnutrition ward is based on clinical signs. Even though there was an old MUAC tape found at the Nurses post, none of the admitted children had MUAC measured on admission to determine presence of severe wasting. Children are weighed with clothes on. This resulted in recording a higher than the actual weight of the patient. This was evident during the training when patients were weighed correctly by the participants all the patients had higher than the actual weight recorded on the charts. 2. Generally the management of admitted children was poor, feeding of the children is not assessed. During the training one of the admitted patients with SAM had feeding problems and needed a naso-gastric feed. But this was not done and the patients continued to feed poorly with poor response

3. Ghana has adopted MUAC as a measure of wasting and this is reflected in draft National Guidelines which have been developed to address SAM in children aged under-5 years. However, it is unusual for children aged 5 years and above to present with SAM, particularly in relation with HIV/AIDS and other chronic illnesses e.g. tuberculosis. MUAC as a measure of wasting is only applicable for use in children aged 6 59 months. In infants aged <6months and children aged 5 years and above weight-for-length/height SD score is an appropriate measure of wasting.

22

During the case management training, a child aged six and half years was admitted with SAM on the malnutrition ward. This child needed to have weight-for height measured to determine the presence of severe wasting In view of the above, there is need for GHS to consider including measurement of length/height in children outside the age range covered by MUAC in order to correctly measure wasting in these children by way of weight-for-length/height SD scores. . 4. Vitamin A was given routinely to children with oedema on admission 5. All children were given zinc supplements despite being on therapeutic feeds which already contained a lot of zinc. Such practice may lead to zinc toxicity. ReSoMal also contained zinc, hence there is not need to give additional zinc SAM children presenting with diarrhoea 6. Feeding was not regular, children were started on 4 hourly feeds on admission from morning till 18.00 hours when the kitchen was closed for the night. Even during the daytime, some of the feeds are missed 7. Admitted children are given other foods, mainly a light porridge (pap) and some family foods from home when they should be exclusively on therapeutic milk feeds 8. Generally the care of admitted SAM patients is poor, there is no observation and supervision of feeds. This results in non identification of children with poor feeding 9. SAM children with diarrhea are given WHO formulation of Oral Rehydration Solution which is unsuitable and dangerous for children with SAM as it contains a lot of sodium, less potassium and inadequate amounts of glucose. ReSoMal is never prepared despite the hospital having Combined Mineral and Vitamin Mix (CMV) in the pharmacy. The pharmacy is supposed to make ReSoMal but this is not done. 10. As mentioned above, the F-75 prepared in the kitchen contains less glucose putting newly admitted SAM patients at risk of hypoglycaemia 11. The pharmacy dispenses CMV in small quantities to make 1 litre of feed, however, on cross checking, the amounts dispensed are more than half a scoop which is the amount required to make one litre of milk feed

23

12. The scale on the ward is not digital and difficult to caliberate 13. The length board on the ward is made according to the correct specification but this is rarely since length/height is not routinely measured on admission and during hospital stay. The plastic length measuring mat is wavy and does not stretch out smoothly

14. The ward is not free of draughts and is cold at night 15. The hospital does not provide individual Insecticide Treated Mosquito nets 16. Mothers are not given food while in hospital 17. There is no facility for hand washing for mothers in the ward and in the day room. There are two sinks which are non functional 18. The Fische chart is not fully and correctly filled out for each individual admitted patient with SAM. MUAC is not measured on admission and and oedema is not monitored as required on the monitoring chart 19. There is a Rehabilitation Centre behind PML where RUTF is being given to children with uncomplicated SAM. However, children admitted for inpatient care of SAM are not started on RUTF as per CMAM guidelines. This probably results in prolonged hospital stay since patients are transitioned to F-100 on the malnutrition ward

During the training participants picked out the correct and incorrect practices of inpatient management of SAM during the clinical practice sessions. The incorrect practices were discussed in class with the facilitators. Corrections were made and communicated to the ward staff, dietician and the medical officer in charge of the hospitalto effect change. Some action points were discussed with the hospital in charge.

Discussions and suggestions were made to the hospital in-charge and dietician
(both were participants in the case management training) to give 3 hourly feeds of F-75. A discussion was held with the dietician, specifically on the incorrect recipe of F-75. A change was made immediately to correct this situation Suggestions were made to ensure day and night provision of therapeutic feeds. Some suggestions were made as follows: (i) consider changes to enable kitchen staff work shifts (long term). (ii) Hospital to purchase thermos flasks where feeds could be stored so that patients are fee 3 hrly at night after the kitchen closed (immediate)

24

Consider involving nurses on the malnutrition ward to warm refrigerated feeds and give the same to the patients overnight when the kitchen closed. This would be achieved if more nurses on the ward were trained in case management of SAM One of the admitted patients was successfully transitioned from F-75 to RUTF with a possibility of early discharge as soon as the medical complications were under control

(iii)

Identified a severely malnourished child whose poor feeding had not been
identified by the ward staff. A nasogastric tube was inserted for feeds with appropriate counseling to the mother.

Course director prepared a protocol for inpatient management of SAM

malnutrition with input from the co-course director and clinical instructor. This attached at the end of this report as Annex 6

25

COURSE DIRECTOR SUMMARY

Training Course on Community-based Management of Severe Acute Malnutrition Location of course: Sun Lodge Hotel/Princess Marie Louise Childrens Reverend Campbell Malnutrition Ward, Accra. Ghana Facilitator Training: Dates of Facilitator training: Number of full days: Number of Facilitators trained

25/08/2009 - 28/08/2009 4 10 + 1 trained as Clinical Instructor + 1 trained as Co-Course Director

CMAM Course: Dates of course: Number of full days: Total number of hours worked in course: Total number of participants trained: Clinical Sessions: Number of sessions conducted Number of hours( per group) devoted to Clinical sessions

31/08/1009 - 5/09/2009 6 40 15

5 5 hours

Modules Completed: All the participants completed all the 7 Modules, including the updates to The training modules and additional materials provided on CMAM Each of the participants received a copy of the course materials and manual to Take home including all the additional materials provided during the course Number of facilitators serving at the course: 9 One of the trained facilitators, Mr Neequaye involved in administrative assignment course. Ratio of facilitator to participant: 1: 2

26

RECOMMENDATIONS
1. There is need to effectively use the Course Directors Guide to ensure adequate preparation of the facilitator and case management trainings. This includes guidance on selection of inpatient facility including all the necessary equipment and supplies

2. The inpatient and Outpatient training facility should have all the necessary functional anthropometric equipment. Preferably mother-infant SECA scales, digital infant weighing scales, MUAC tapes, length/height measuring boards should be made available

3. The National guidelines should include guidelines on management of SAM in children 5 years and above 4. There is need to train more facilitators who should be selected from the pools of health workers who have been trained in case management. 5. There is need to quickly conduct case management training to enable the newly trained facilitators consolidate their newly acquired skills and improve capacity in all the implementing inpatient facilities

6. All staff from PML childrens hospital need to be trained, particularly the nurses and doctors working in the malnutrition ward, the matron, sisters in charge from all the wards including staff working in the emergency and outpatient wards. . 7. Supplies of therapeutic feeds, combined Mineral and Vitamin Mix (CMV) and utensils for preparation of therapeutic feeds and ReSoMal including kitchen weighing scales should be procured, if not made available at the site of training and in all health facilities where the recently trained participants are working. . 8. PML hospital and other health facilities where inpatient care of SAM are admitted should implement the Ten Steps of case management of SAM. Priority should be given to transition from F-75 to RUTF and not F-100 as is currently being done. This will enable the hospital to fully implement CMAM since there is already a programme of OPC just behind he hospital (in case of PML) where patients are being successfully managed with RUTF with some form of supplementary feeding programme going on in this same centre

27

9. As the country sets about implementing CMAM within its health system, there is need to open up a lot of OPC sites as close to the community initially. Successful implementation of OPC alongside Community Outreach activities which will enable both acute moderate and severe uncomplicated cases of SAM to be identified and managed at community level. This will lead to reduction of complicated cases of SAM which require hospital care. Establishment of OPC should then follow implementation of community based care services. 10. Once several OPC sites have been set up with the catchment areas of the inpatient facilities, CMAM will be successfully implemented leading to significant reduction in case fatality rates due to SAM 11. There is need to adopt a multi-sectoral approach in management of SAM and foster linkages with other programmes like HIV/AIDS and Malaria programme which are well funded in order to improve care of SAM 12. The country should seriously consider treating children with SAM free of charge, particularly that, currently management of these children is supported by partners. Equally attainment of MDG4 is closed linked with early and improved care of SAM cases 13. There is need to partner with other stakeholders (WHO, UNICEF, FANTA, USAID etc) to ensure uninterrupted supply of therapeutic feeds (F-75, RUTF and to lesser extent F-100, which is not longer required in large stocks with use of RUTF), CMV, ReSoMal and essential drugs used in the case management of SAM in inpatient and outpatient facilities. 14. The effort being made to promote local production of RUTF in partnership with Nutriset France should be commended as this will result in a local source of supplies and reduce the costs since some of the major ingredients are available locally.

15. There is need to advocate for large scale implementation and support of the supplementary feeding programme in order to curb the large number of acute moderately malnourished programme waiting to become severely malnourished in order to access care

16. There is need to change the working conditions of kitchen staff in all inpatient facilities to ensure continuous provision of feeds day and night 17. There is urgent need to finalize the National Guidelines on CMAM since a number of health workers have been trained and will be in position to contribute to this process. Equally the additional information from the WHO case management modules should be included into the guidelines

28

18. There is need to revise the current WHO case management training materials in order to include proceedings of the 2004 and 2007 consultations including new evidence which has been made available including new adaptations in view of recent developments (new WHO growth standards and use of RUTF). The training materials should include CMAM guidelines and all the Reporting Forms required for appropriate programme monitoring and evaluation. In the current form the training modules are outdated and training with a lot of annexes causes confusion among participants

The updates received from WHO still have some omissions and certain areas require to be revised still. There is need to constitute a small group of experts to look at all the available materials with a view to produce one set of training materials which will include all the new information

29

ANNEX 1 SCHEDULE FOR FACILITATOR TRAINING

DAY 1 Tuesday 25th August, 2009 Activity 1. Opening session A. Introductions B. Administrative tasks C. Review of purpose of the course 2. Introduction to facilitator training A. Context of facilitator training B. Materials needed C. Objectives of facilitator training D. Teaching methods E. Schedule for facilitator training F. Introduction to Facilitator Guide Module: Introduction A. Review and Demonstration B. Facilitator Techniques: Working with a Co-Facilitator Module: Principles of Care A. Facilitator Techniques: Introducing a module B. Reading and work on module C. Facilitator Techniques: Leading a discussion D. Reading and work on module E. Facilitator Techniques: Adapting for nurses groups F. Facilitator Techniques: Individual feedback G. Reading and work on module, practice group discussion H. Facilitator Techniques: Oral drills I. Reading and short answer exercises J. Facilitator Techniques: Video activity K. Facilitator Techniques: Summarizing a module Module: Initial Management A. Reading and practice introducing module B. Facilitator techniques: Conducting a demonstration

Time 30 minutes

45 minutes

3.

15 minutes

4.

4 hours

5.

1.5 hours

6. Assignments for the next day: Read and doe exercises in Initial Management module Read corresponding facilitator guidelines Prepare for assigned activities

30

DAY 2 Wednesday, 26th August, 2009 Activity 1. Continuation of Module: Initial Management A. Practice of facilitator techniques B. Facilitator Techniques: Coordinating role plays 2. Module: Feeding A. Introduction and Exercise A, preparing F-75 and F-100. Introduce RUTF and discuss its composition B. Facilitator Techniques: While participants are working C. Reading/work through Exercise B; practice of facilitator techniques D. Reading/work through end of module; practice of facilitator Techniques

Time 3 hours

4 hours

3.

Assignments for the next day Read and do exercises in Daily Care Module Read and corresponding facilitator guidelines Prepare for assigned activities DAY 3 Thursday, 27th August, 2009 Activity

Time

Clinical practice session

1. Module: Daily Care A. Introduction of module, discussion of questions B. Practice of facilitator techniques

2 hours
1.5 hours

2.

Module: Monitoring and Problem Solving A. Introduction and work on the module B. Practice of facilitator techniques

3.5 hours

3. Module: Involving Mothers in Care A. Introduction of module B. Practice of facilitator techniques C. Facilitator Techniques: Review DAY 4 Friday, 28th August, 2009 Activity 1. Module: Overview of CMAM 2. Practical arrangements for the course 3. Closing Remarks to facilitators 4. Co-facilitators discuss plans for first day; set up classroom if possible

Time 2 hours

1 hour 1 hour

31

ANNEX 2
NAME Co-Course Director: Dr Thelma Brown Inpatient Instructor: Dr Matilda Agyemang Alice Nkoroi Clement Adams Akosua Kwakye

FACILITATOR LIST
DESIGNATION Paediatrician Medical Superintendent REGION Regional Hospital, Eastern Region Ga South District Hospital - Greater Accra Region Nutrition Department GHS, Head Quarters UNICEF ,Northern Region WHO, Accra PML ( Greater Accra) Saltpond Municipal Hospital Central Region Nutrition Department, GHS Head Quarters St. Joseph Hospital, Kirapa, Upper West Region Ridge Hospital, Greater Accra Region Nutiriton Department, GHS, Korle-Bu Teaching Hospital, Accra University Teaching Hospital, Lusaka Zambia TELEPHONE +233 243 827519 +233 277 159809

matildaagyemang@yahoo.c

CMAM & Emergency Nutrition Specialist FANTA-2 Health & Nutrition Officer Programme Officer, Nutrition Senior Medical Officer, Paediatrics Municipal Director of Health Co-ordinator Nutrition Rehabilitation Medical Assistant

+233 266 106542 +233 244 721294 +233 243 316706 +233 244 776574 +233 244 292684 +233 244 684216 +233 20 7021044

ankoroi@aed.org

cadams@unicef.org kwakyea@gh.afro.who.in eboabban@gmail.com kobbymed@yahoo.com mikeneeq@yahoo.co.uk

Dr Isaac Kobina Abban D Kwabena Sarpong Michael Ammon Neequaye Rev. Sister Patricia Zhage

Dr. Memuna Tanko Catherine Adu-Asare Prof Jennifer Welbeck Course Director: Dr. Beatrice Amadi

Senior Medical Officer Training Administrative assistant Paediatrician Paediatrician

+233 244 539960 +233 244 871133 +233 244 963625 +260 966 752739

mmabtanko@hotmail.com hiryna@yahoo.com Beatriceamadi@ymail.com

32

ANNEX 3 : LIST OF PARTICIPANTS NAME DESIGNATION DR ERNEST K ASIEDU DR AUDREY FRIMPONG BAAFI MONICA YELALIERE DORIS AMARTEY SAMUEL GBOGBO PRISCILLA TETE-DONKOR PEACE SODOKPO DR ERIC SIFAH SOFIE G. LASSEN MEDICAL OFFICER PAEDIATRICIAN NURSE PRATITIONER NURSE ASSISTANT PROGRAM MANAGER,IDD DIETITIAN NURSING OFFICER MEDICAL SUPERINTENDENT ASSOCIATE PROFESSIONAL OFFICER(CHILD &ADOL.HEALTH NURSING OFFICER MEDICAL OFFICER MEDICAL OFFICER MATERNAL AND CHILD HEALTH SPECIALIST SENIOR MEDICAL OFFICER MEDICAL OFFICER

REGION ASSIN FOSU,CENTRAL KORLE-BU TEACHING HOSP.ACCRA REGIONAL HOSP,UPPER WEST PML,ACCRA NUTRITION HEADQUARTERS,GHS PML, ACCRA PML,ACCRA PML HOSPITAL,ACCRA WHO

TELEPHO

+233 244 46 +233 20 813

+233 249 3 +233 265 10

+233 246 86

+233 244 62

+233 244 12

+233 20 817

+233 240 82

CHRISTIANA AKUFO DR GIFTY SUNKWA- MILLS DR JULIANA MITCHELL JULIANA PWAMANG DR PATRICK ATOBRAH DR ABDULAI A. FORGOR

INTITUTIONAL CARE DIVISION/GHS KASOA HEALTH CENTRE,CENTRAL KORLE-BU TEACHING HOSP.ACCRA USAID ZEBILLA HOSP. UPPER EAST NAV. MEMORIAL HOSP,UPPER EAST

+233 246 0

+233 20 630

+233 20 63

+233 244 58

+233 20 811

33

ANNEX 4 CASE MANAGEMENT TRAINING ON COMMUNITY MANAGEMENT OF SEVERE ACUTE MALNUTRITION (CMAM) - PML HOSPITAL, ACCRA 31st August 5th September, 2009 DATE ACTIVITY TIME Monday: 31st August, 2009 09.30 - 17.30hrs Registration Module: Introduction+ updates Module: Principles of Care + updates MUAC as measure of wasting Composition of RUTF(page 20) Video: Transformations Ward: Tour of the ward

5 hours

Tuesday: 1st September, 2009 08.30 17.30

Wednesday: 2nd September, 2009 08.30 17.30

Initial Management + updates Emergency Care Making ReSoMal Clinical signs, measuring MUAC Weighing children Module: Initial Management + updates(finish) Module: Feeding + updates. Introduce RUTF Reference Card Kitchen: Making F75/F100. Discuss RUTF Ward: Initial Management CCP Chart, including MUAC assessment. Feeding on F-75 Module: Feeding + updates (finish) Module: Daily Care+ updates Ward: Initial Management and Feeding transition From RUTF/when to give F-100

Module: Video: Kitchen: Ward:

7 hours

7 hours

Thursday: 3rd September, 2009 08.30 17.30

7 hours Friday: 4th September, 2009 08.30 17.30 Visit to Rehabilitation Centre (PML) Module: Daily Care + updates (finish) Module: Monitoring and Problem Solving + updates Ward: Monitoring patients on RUTF Use of CCP charts to monitor progress Criteria for Early Discharge Module: Video : Involving Mothers in Care + updates Teaching mothers about home feeding Malnutrition and mental development Presentations: Overview of CMAM, Implementing CMAM in Ghana. Monitoring Tools WAY FORWARD (GHS)

7 hours

Saturday: 5th September, 2009 08.30 16.30

CLOSING CEREMONY 17.00 NOTE: TEA BREAKS : 10.30 11.00 and 16.00 16.30 LUNCH BREAK: 13.00 - 14.00

6 hours

34

Annex 5 Schedule for Clinical, Kitchen and Video Sessions:

MONDAY Ward Group A 31st August 11.00 - 12.00 Tour of the ward TUESDAY 1 September 14.00 - 15.30 Clinical signs and Measuring MUAC &Weight
st

WEDNESDAY 2 September 11.00 - 12.30 Initial Management CCP Chart Feeding - F75
nd

THURSDAY 3 September 14.00 - 15.30 Initial Management and Feeding: F-75 to RUTF Use of F-100
rd

FR
th

4 Se 14.00 - 1

Kitchen

**16.30 - 17.15 **Preparation of ReSoMal

15.00 - 16.00 Preparation of F75, F100 Show RUTF

Daily Ca Assessm Outpatie Treatme Card/Cr Early Di ****08.3

****VIS OUTPA CENTR

Video

**14.00 - 14.30 **Transformations

**11.00 - 11.30 **Emergency Care 11.00 - 12.30 Clinical Signs and Measuring MUAC &Weight

Ward Group B

12.00 - 13.00 Tour of the ward

14.00 - 15.30 Initial Management CCP Chart Feeding F-75

15.30 17.00 Initial Management and Feeding: F-75 to RUTF Use of F-100

15.00 - 1

Daily Ca Assessm OPC Ca for Earl

Kitchen

14.30 - 15.15 Preparation of ReSoMal

10.00 - 11.00 Preparation of F75, F100 show RUTF

****09.3

****VIS OUTPA CENTR

Video

**14.00 - 14.30 **Transformations

**11.00 11.30 **Emergency Care

**** FRIDAY 4TH SEPTEMBER: indicated in the schedule

ECAH GROUP VISIT THE REHABILITATION CENTRE at the times

35

PROTOCOL

INPATIENT MANAGEMENT OF SEVERE ACUTE MALNUTRITION

36

DEFINITION OF SEVERE ACUTE MALNUTRITION:

SEVERE WASTING - Weight-for-length/height <-3 SD MUAC <115mm AND/OR OEDEMA OF BOTH FEET

Bilateral pitting oedema +++ or Marasmic kwashiorkor: any grade of bilateral pitting oedema with severe Wasting (MUAC <115mm or wt/ht <-3 z-score) or Bilateral pitting oedema + or ++ or MUAC <115mm with any of the following medical complications: a. Anorexia, no appetite b. Intractable vomiting c. Convulsions d. Lethargy or not alert e. Unconscious f. Lower respiratory tract infections g. High fever (>39 C) h. Severe dehydration i. Severe anaemia j. Hypoglycaemia k. Hypothermia (<35C) or Referred from outpatient care according to action protocol Referred from general paediatric ward Other, e.g. infant 6months and <4kg

ADMISSION CRITERIA

37

PRINCIPLES OF CARE
The child with Severe Acute Malnutrition (SAM) MUST be treated differently because his physiology is seriously abnormal due to reductive adaptation. The systems of the body begin to shut down with SAM. The systems slow down and do less in order to allow survival on limited calories. This slowing down is known as reductive adaptation. As the child is treated, the bodys systems must gradually learn to function fully again. Rapid changes (such as rapid feeding or fluids) would overwhelm the systems, so feeding must be slowly and cautiously increased (see Appendix 3 : Physiological basis for treatment of severe malnutrition) How does Reductive Adaptation affect care of the child? Presume and treat infection Do not give iron early in treatment Provide potassium and restrict sodium Things NOT to do: Do not give diuretics to treat oedema Do not give iron during initial feeding phase. Add iron only after the child has been on F100 for 2days (usually week 2). Do not give high protein formula Do not give IV fluids routinely

Ensure that personnel in the Emergency Treatment Area of the hospital know these important things NOT to do, as well as what to do!

PROCESS FOR SUCCESSFUL MANAGEMENT OF THE SEVERELY MALNOURISHED CHILD

Treat/Prevent hypothermia and hypoglycaemia by feeding, keeping warm and treating infection

38

 Treat/prevent Dehydration using Rehydration Solution for Malnutrition (ReSoMal) Correct electrolyte imbalance (by giving feeds and ReSoMal prepared with CMV) Presume and treat infection with antibiotics Correct micronutrient deficiencies (by giving feeds prepared with CMV and folic acid as needed) Start Cautious feeding with F-75 TO STABILIZE the child (usually 2 7 days) Rebuild wasted tissues through higher protein/calorie feeds READY-TO USE-THERAPEUTIC FOOD (RUTF) and plan for early discharge once taking RUTF well (finishes >75% of days ration) Provide stimulation, play and loving care Prepare parents to continue proper feeding and stimulation after early discharge to Outpatient Therapeutic Programme (OTP)

Note:

If patient refuses to eat RUTF, but is finishing F75 CONSIDER giving F100 for 1-2 days, then try giving RUTF again. Once able to consume >75% of RUTF and has no complications, DISCHARGE to OTP

ON ADMISSION: Assess/Treat SHOCK, if present Assess/Treat hypoglycaemia

39

 Examine eyes (bitots spots, inflammation/pus, corneal clouding, corneal ulceration) Check for diarrhea and managed accordingly **(Use CCP initial management chart) MANAGEMENTOF HYPOGLYCAEMIA
If blood glucose <3mmol/l and alert, give 50ml bolus of 10% glucose or sucrose (oral or via NG) If blood glucose <3mmol/l and lethargic, unconscious or convulsing, give STERILE 10% glucose IV: 5ml/kg body weight Then give 50ml bolus NG

*Note time when glucose is given and route of administration

If unable to determine blood glucose, consider all new admissions as being hypoglycaemic and give 10% glucose as above MANAGEMENT OF SHOCK
Signs of Shock: Lethargic/unconscious Cold hand Slow Capillary refill (>3 seconds) Weak/fast pulse If signs of shock present: Give Oxygen Give IV Glucose 5ml/kg body weight Give IV Fluids: 15ml /kg body weight Monitor respiratory and pulse rates every 10 minutes for first hour If respiratory and pulse rates slower after 1 hour, repeat same IV amount for 2nd hour then alternate ReSoMal and F-75 for up to 10 hours as in right part of diarrhea box If no improvement on IV fluids, transfuse whole fresh blood (10ml/kg

Watery diarrhea? Blood in stool? Vomiting?

MANAGEMENT OF DIARRHOEA
Yes Yes Yes No No No

slowly over 3 hours)

40

 If diarrhea, circle signs present: skin pinch goes back slowly

Restless/irritable Lethargic Thirsty Sunken eyes Dry mouth/tongue No tears

If diarrhea and/or vomiting, give ReSoMal, every 30 minutes for first 2 hours, monitor and give:
5ml/kg body weight ReSoMal every 30 mins for 2 hrs Note and write down time of starting ReSoMal Monitor respiratory rate, pulse rate, if passed urine or not, number of stools, number of vomits, hydrations signs and amount of ReSoMal given every 30 minutes for 2 hours STOP ReSoMal if: increase in pulse and respiratory rates, jugular veins

engorged, increasing oedema e.g. puffy eyelids

AFTER 2 HOURS:

(re-weigh patient and use this new weight to calculate amount of

ReSoMal and F-75 to give patient)

For the next 10 hours, give ReSoMal and F-75 in alternate hours. Monitor every hour. Amount of ReSoMal to offer: )
5 10 ml/kg body weight ReSoMal and alternate with F-75 Note and write down the time ReSoMal and F-75 is given Monitor respiratory rate, pulse rate, if passed urine or not, number of stools, number of vomits, hydration signs and amount of ReSoMal and F-75 given every hour STOP ReSoMal if: increase in pulse and respiratory rates, jugular veins

engorged, increasing oedema e.g. puffy eyelids

MANAGE SEVERE ANAEMIA:

If haemoglobin <4g/dl or PCV <12%, transfuse 10ml/kg whole fresh blood or 5.7ml/kg packed cells slowly over 3 hours

41

 Record amount of blood to be transfused, time transfusion started and ended Monitor temperature, pulse and respiratory rates during transfusion

CHECK EYES FOR SIGNS OF VITAMIN A DEFICIENCY AND INFECTION

Check eyes for: bitots spots pus/inflammation corneal clouding Corneal ulceration If ulceration, give Vitamin A and Atropine immediately. Record on daily care page Oral doses of Vitamin A: <6 months 50,000IU 6 12 months 100,000IU >12 months 200,000IU Do not give Vitamin A to children with oedema. Give Vitamin A after

oedema resolves

FEEDING:

Begin feeding with F-75 as soon as possible. If child is rehydrated, reweigh child before determining amount to feed. New weight______ Amount for 3 hourly feedings: _____ml F-75 Record time of first feed If hypoglycaemic, feed of this amount (recorded above) every 30 minutes for first hours. Continue until blood glucose reaches 3 mmol.l

Record all feeds on 24-hour Food Intake Chart!

INVESTIGATIONS TO BE DONE ON ADMISSION:

Malaria slide Full Blood Count

42

Blood culture Urea and electrolytes including creatinine Urinalysis/urine culture Lumbar puncture if indicated Stool examination (for persistent diarrhea only) Gastric lavage if indicated CXR Counsel and Test for HIV Other investigation as indicated

MEDICAL MANAGEMENT OF SEVERE ACUTE MALNUTRITION with complications 1st line antibiotics:
Benzyl penicillin 50,000 units/kg IV/IM every 6 hours for 5 days Gentamicin 7.5mg/kg IV/IM once daily for 7 days Cotrimoxazole prophylaxis for patients who are HIV positive (use dose schedule as provided in ART Clinic) 2nd line antibiotics: Cefotaxime (or any other cephalosporin) - follow sensitivity pattern Treat Malaria as per National Guidelines Amodiaquine/artesunate (dosage age-dependant)

Vitamin A 1 dose <6mo - 50 000IU 6-12mo 100 000IU >12mo 200 000 IU Do not give Vitamin A to children with oedema. Give dose after

43

Oedema clears. Do not give Vitamin A to children who recently received dose (during the past 4 weeks)

Give 3 doses of Vitamin A (therapeutic doses) to all children with Eyes signs of Vitamin A deficiency. Give therapeutic doses to such Children even when they have oedema to prevent blindness
Vitamin A therapeutic dosing: Days 1, 2 and Day 14 Mebendazole 500mg stat (give to children > 2 years) Folic Acid 5mg OD Ferrous Sulphate in REHABILITATION PHASE (2 days after starting F100)

NUTRITIONAL INPATIENT MANAGEMENT OF SEVERE MALNUTRITION:

1. Start 3 hrly feeds with F-75 orally or via NG tube if patient unable to take orally. CHECK F-75 Reference Card for correct amount of 3 hrly feed

44

using admission weight (or new weight if patient received ReSoMal for 1st 2 hrs) . FEED DAY AND NIGHT! i. Remember to use the right side of F75 reference card according to presence of oedema (+++) or (0, +, ++) ii. Record feeds offered and amount taken on 24-hr Feed Intake Chart 2. Every day CHECK and RECOGNISE readiness for Transition: i. Return of appetite (easily finishes 3 hrly feeds of F75) ii. Reduced oedema or minimal oedema iii. Child may also smile at this stage 3. If patient is ready for TRANSITION start RUTF (Use Chart to look up number of packets child should have per day. CONTINUE giving F75, but change to 4hrly feed (Look amount on the F-75 Reference Card, use admission weight for amount to be given 4 hrly)

4.

Offer RUTF (plumpy nut) - Explain key messages about RUTF How to give RUTF to the child

5. Ensure patient is being given RUTF as per instructions: i. Eating RUTF from the packet ii. Being given clean and safe water to drink as patient eats RUTF iii. RUTF being given in small regular feeds (if possible x8/day) and patient finishes prescribed pkts/day (>75% of days ration eaten) 6. Ensure mother does not: i. Mix RUTF with water ii. Mix RUTF into porridge iii. Put RUTF on bread iv. Give share RUTF with other children/adults for whom it has not been prescribed

DAILY CARE, MONITORING AND INVOLVING MOTHERS

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1. Monitor patients progress every day by recording and reviewing information recorded on the CCP Charts ( Drug Chart; Temperature with RR and PR recording; Weight Chart; Feed Intake Chart): Ask mother/caretaker about patients any new symptoms every day as you do the ward round (diarrhea, vomiting, cough, fever, sores in the mouth etc) Ask if patient is finishing feeds (check patients cup to confirm that all milk feed is finished and if on RUTFcheck how much RUTF is still remaining) It is important to observe how patient is taking milk orally and if on RUTF, observe feeding on same Check Temperature Chart and note if hypothermia, hyperthermia present. Check Respiratory and Pulse Rate as recorded Check Drug Chart to ensure that all prescribed medications are being given correctly. Check how long patient has been on particular medication and made decision if needs to continue Check 24-Food Intake (Feed) Chart to see if prescribed feed is entered correctly and patient is receiving feed. Check intake and ensure patient is being given feeds correctly Check Weight Chart and assess response of patient as follows: i. If patient is on F-75, no weight gain is expected. If gaining weight (>0.2kg), reassess patient, diagnosis of severe acute malnutrition may be wrong ii. If weight gain while on RUTF praise and encourage mother/caretaker to continue feeding iii. If weight is static or weight loss on RUTF, try to investigate cause and intervene (evaluate patients condition symptoms, temperature and check intake of feeds). Counsel mother/caretaker about your findings and actions required to remedy the problem iv. Children on F100 are expected to gain weight every day. If no weight gain or weight loss, check if patient is taking feeds well; evaluate patient for continuing infection and/or new infection and act accordingly 2. If patients medical condition is under control and patient is finishing days ration of RUTF, counsel mother about childs condition and prepare for early discharge to OPC to continue care

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CRITERIA FOR DISCHARGE TO OPC (Outpatient Care)

Appetite returned (passed appetite test) and Medical complication resolving and Bilateral pitting oedema decreasing ( + or ++) and Clinically well and alert (marasmic kwashiorkor admission: bilateral pitting Oedema resolved)

PRACTICAL IMPLICATIONS IN DISCHARGES FROM INPATIENT CARE: Children with SAM who are discharged from inpatient care are referred to
the nearest outpatient centre (OPC). Please check the list of OPCs nearest to your hospital including the clinic day If there is no OPC site, continue outpatient treatment in the OPD by staff trained in Outpatient care of children with SAM Complete the Inpatient to Outpatient Treatment Card (Yellow card) with details of patients status on discharge. Fill out the patients status on discharge in the first column on the reverse side of this card (Follow-up: Outpatient Care). The mother should be given this card to take to the OPC site on first attendance. Communicate with OPC site where the child is being referred (phone call or radio communication) Give details of the discharged patients for possible follow-up at home if the patient does not turn up Children discharged from inpatient care are considered a priority for followup home visits during the first week in outpatient care, according to action protocol On discharge, the mother is given sufficient RUTF to last until the next OPC follow-up session. Key messages about the use of RUTF and basic hygiene are discussed again with the mother

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Key messages should include: i How to feed RUTF to the child ii When and how to give medicines to the child (if any given on discharge ) iii When to go to OPC for continued care iv The child should be taken to the health facility immediately if his/her condition deteriorates (develops fever, fast breathing, unable to feed, has diarrhea and vomiting)

INPATIENT CARE FOR THE MANAGEMENT OF SAM IN INFANTS UNDER SIX MONTHS OF AGE

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Treatment for infants with SAM under 6 months of age, or with a weight below four kg, should be done within the context of infant and young child feeding recommendations1. 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 severe malnutrition 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 their infants needs Disability that affects the infants 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, provide temporary or longer term appropriate therapeutic feeding as well as provision of nutritional, psychological and medical care for their caregivers. Ideally these infants should be admitted into a separate section, away from where the other older severely malnourished sick children are admitted. Infants less than 6 months with malnutrition should always be treated in inpatient care. RUTF is not suitable for infants less than 6 months as the reflex of swallowing is not yet present. In this section guidance is provided on treatment of two categories of children less than 6 months as outlined below: 1. Breastfed infants: infants less than 6 months with lactating female caregiver 2. Non-breastfed infants: infants less than 6 months without prospect of being breastfed Infants over 6 months of age with a bodyweight below 4 kg will fall in these categories as well.

As outlined in WHO and UNICEF 2003 and IFE Core Group 2007.

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1. Breastfed Infants less than 6 months who have lactating mother or caregiver for wet nursing Admission Criteria Breastfed infants less than six months or less than 4 kg, if the infant has: Presence of bilateral pitting oedema Visible wasting Also: Too weak to suckle effectively (independently of weight-for-length), or 1.1. Routine Medicines and Supplements 1. Antibiotics: No antibiotic treatment is provided unless there are signs of infection. Amoxicillin (for infants weighing minimum 2 kg): 30 mg/kg 2 times a day (60 mg/kg/day) in association with Gentamycin. Do not use Chloramphenicol in young infants. 2. Vitamin A: 50,000 IU single dose at admission only. 3. Folic acid: 2.5 mg (1 tab) in a single dose. 4. Ferrous sulphate: As soon as the child suckles well and starts to grow, use F100, which has been enriched with ferrous sulphate, diluted with 1/3 water (F100Diluted). (See Feed Preparation in Section 5.1.2) It is easier and safer to use F100-Diluted than to calculate and add ferrous sulphate to very small amounts of feed. 1.2. Dietary Treatment The objective is to supplement the childs breastfeeding with therapeutic milk while stimulating production of breastmilk. The infant should be breast fed as frequently as possible. Breastfeed every three hours for at least 20 minutes (more if the child cries or demands more) Between one and a half hours 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.

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Quantities of F100-Diluted F100-Diluted is given at 130 ml/kg/day, distributed across eight feedings per day Use the look-up tables 1 below for maintenance amounts of F100-Diluted to give to infants during feeding using the Supplementary Suckling technique (see Feeding Technique, figure 1 below). The quantity of F100-Diluted is not increased as the child starts to gain weight. Table 1: Look-up Table for amounts of F100-Diluted to give to an individual infant per feed Bodyweight (kg) F100-Diluted per feed if 8 feeds per day 1.2 Kg 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 weight. If the infant loses weight over 3 consecutive days but continues to be hungry and is taking all his F100-Diluted, add 5 ml extra to each feed2. Generally supplementation is not increased during the stay in the 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 that the intake from breast milk is increasing and that 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).
2

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 mal-absorption.

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When an infant is gaining weight at 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 baby gets more breast milk. If the weight gain is maintained (10 g per day regardless of current weight) then stop supplementary suckling completely. If the weight gain is not maintained then increase the amount given to 75% of the maintenance amount for 2 to 3 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 further few days on breastmilk alone to make sure that s/he continues to gain weight. If the caregiver wishes to go home as soon as the infant is taking the breast milk with increased demand, then they should be discharged. When it is certain that the child is gaining weight on breast milk alone he or she should be discharged, no matter what his current weight or weight-for-length. Feed Preparation

For a large number of children

Add a packet of F100 to 2.7 litres of water, instead of 2 litres to make F100Diluted Add 35 ml of water to 100 ml of F100 already prepared, and that will give 135 ml of F100-Diluted. Discard any excess milk after use. Do not make smaller quantities. 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 and discard any excess milk after use. If F100 is not readily available these infants can be fed with the same quantities of commercial infant formula diluted according to the instructions on the tin. If there is a range of milk formulas to choose from, use a formula designed for premature infants. However, infant formula is not designed to promote rapid catch up growth. Unmodified powdered whole milk should not be used.

For a small number of children

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.
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 Build the mothers 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 maintenance amounts of F100-Diluted. ONLY feed with a naso-gastric tube (NGT) when the infant is not taking sufficient milk by mouth. The use of NGT should not exceed 3 days and should be used in the stabilization 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 at the same time 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 a NGT (size n8) is put in the cup, and the tip of the tube 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 it can lowered to up to 30 cm.

Figure 1:

Supplementary Suckling Technique

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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. 1.3. Individual monitoring The following parameters should be monitored daily and entered on the individual treatment card (multi-chart): Weight Degree of oedema (0 to +++) Body temperature (twice per day) Standard clinical signs: stool, vomiting, dehydration, cough, respiration and liver size Any other record: e.g., absent, vomits or refuses a feed, and whether the patient is fed by naso-gastric tube or is given IV infusion or transfusion. 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-to-one counselling, and mother-to-mother support. Traumatized and depressed women may have difficulty responding to their infants and require mental and emotional support which should also support an increase in breastfeeding. It is important to assess nutritional status of the mother (MUAC and oedema). Explanation should be provided to the mother on the different steps of

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treatment that their child will go through and efforts should be made to strengthen the mothers confidence and discourage self criticism for perceived inability to provide adequate breast milk. Alert the mother on the risk of having 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 mothers food or micronutrient supplement. Therefore it is important that the mothers nutrient and energy needs are met. The mother should consume at least 2,500 kcal/day. It is suggested that the health facility should 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 less than two months. Dehydration may interfere with breast milk production. It is therefore important to ensure that the mother drinks at least two litres of water per day. 1.5. Discharge Criteria
Discharge Criteria Breastfed infant less than six months or less than four kg on admission: Successful re-lactation with effective suckling = Minimum 20g 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.

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 Supplementary Feeding Programme (SFP) and receive high quality food with the right balance of nutrients in order to improve the quantity and quality of breast milk. It is also important to monitor the infants progress, support breastfeeding and the introduction of complementary food at the appropriate age of 6 months.

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2. Infants less than 6 months WITHOUT prospect of breastfeeding Admission Criteria Non-breastfed infants less than six months or less than 4 kg: Presence of bilateral pitting oedema. Visible wasting 2.1. Stabilization phase

Routine Medicines and Supplements 1. Antibiotics: Amoxicillin (for infants weighing minimum 2 kg): 30 mg/kg 2 times a day (60 mg/day) in association with Gentamycin. Do not use Chloramphenicol in young infants. 2. Vitamin A: 50,000 IU single dose at admission only. 3. Folic acid: 2.5 mg (one tab) in a single dose. 4. Ferrous sulphate: As soon as the child suckles well and starts to grow, use the F100, which has been enriched with ferrous sulphate, diluted ferrous this with 1/3 water. It is easier and safer to use F100-Diluted than to calculate and add sulphate to very small feed.

Inpatient care is not appropriate for treating premature and low-birth-weight non-breast-fed infants below 6 months. These infants should be referred to the nursery and given infant formula.
3

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Dietary Treatment Wasted infants (marasmus) less than 6 months should be given F100-Diluted in the stabilization phase. Never provide F100 full-strength. Infants with oedema (kwashiorkor) < 6 months should always be given F75 in the stabilization phase.

Quantities of F100-Diluted or F75 to give

Use look-up table 2 below for amounts of F100-Diluted or F75 to give for nonbreastfed infants in the stabilization phase. Table 2: Look-up table for amounts of F100-Diluted (Marasmus) or F75 (kwashiorkor) to give to non-breastfed infants in the stabilization phase Bodyweight (kg) F100-Diluted or F75 per feed in stabilization phase 8 feeds per day no breastfeeding 1.5 Kg 30 ml per feed 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

For a large number of children

Add a packet of F100 to 2.7 litres of water, instead of 2 litres for F100-Diluted,

For a small number of children

Add 35 ml of water to 100 ml of F100 already prepared, for 135 ml of F100Diluted. Discard any excess milk after use. Do not make smaller quantities. 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 and discard any excess milk after use.

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Feeding Procedure Feed by cup and saucer or NGT by drip (using gravity not pumping) ONLY feed with NGT when the infant is not taking sufficient milk by mouth. The use of NGT should not exceed 3 days and should be used in the stabilization phase ONLY Feeding Technique Apply the correct feeding technique, it is important to ensure the infant has adequate intake. Individual monitoring The following parameters should be monitored daily and entered on the individual treatment card (multi-chart): Weight Degree of oedema (0 to +++) Body temperature (twice per day) Standard clinical signs: stool, vomiting, dehydration, cough, respiration and liver size Any other record: e.g., absent, vomits or refuses a feed, and whether the patient is fed by NGT or is given IV infusion or transfusion.

Criteria to progress from the stabilization phase to the transition phase

The criteria to progress from the stabilization phase to the transition phase are both: Return of appetite, and 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 stabilization phase until their oedema has reduced to moderate (++). These children are particularly vulnerable.

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5.2.2. Transition Phase Routine Medicines and Supplements Routine antibiotic therapy should be continued for four more days after the stabilization phase or until the child is transferred to the rehabilitation phase. Dietary Treatment Use the standard protocol for older children in 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 to the stabilization phase. Refer to Table 3 below for the amounts of F100-Diluted to give to nonbreastfed infants in the transition phase

Table 3: Look-up table for amounts of F100-Diluted to give to non-breastfed infants < 6 months or < 4 kg in the transition phase Bodyweight (kg) F100-Diluted per feed in transition phase if 8 feeds/day no breastfeeding 1.5 Kg 45 ml per feed 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

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Individual monitoring Continue surveillance as outlined in the stabilization 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: A good appetite. This means taking at least 90% of the F100-Diluted prescribed for the transition phase and Complete loss of oedema for oedematous patients (kwashiorkor) Minimum stay of two days in the transition phase for wasted patients No other medical problem 2.3. Rehabilitation Phase Dietary Treatment Use the standard protocol for older children in rehabilitation phase with the following modifications: Only F100-Diluted should be used. During the rehabilitation phase, infants receive twice the volume per feed of F100-Diluted than was given during the stabilization phase. Refer to table 4 below for amounts of F100-Diluted to give to non-breastfed infants in the rehabilitation phase Table 4: Look-up table for amounts of F100-Diluted to give to non-breastfed infants < 6 months or < 4 kg in the rehabilitation phase Bodyweight (kg) F100-Diluted per feed in rehabilitation phase if 6 to 8 feeds/day no breastfeeding 1.5 Kg 60 ml per feed 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

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Individual monitoring Continue with rehabilitation phase surveillance as outlined in the standard protocol for older children. Discharge criteria from inpatient rehabilitation phase for non-breastfed infants Discharge Criteria Infants less than six months or less than four kg with no prospect of being breastfed: 15% weight gain No oedema for two weeks Clinically well and alert, no medical problem Other recommendations: At discharge, the infant can be switched to infant formula 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 introduction of complementary food at the appropriate age of six months.

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APPENDIX 1 : THERAPEUTIC FEEDS THERAPEUTIC FEEDS (composition and recipes)

Feeding
Stabilisation phase Target is: 100 kcal/kg/day 1g protein/kg/day Give F75 (75 kcal and 0.9g protein/100ml) Rehabilitation phase (catch-up growth) (catchTarget is: 150-220 kcal/kg/day 1504-6 g protein/kg/day Give F100 (100 kcal and 2.9g protein/100ml) or RUTF (ready-to-use therapeutic food) (ready- toor modified family foods

F-75 is the starter formula to use during initial management, beginning as soon as possible and continuing for 2-7 days until the child is well stabilized. F-75 contains more carbohydrate and less protein and sodium - it specially made to meet the childs needs without overwhelming the bodys systems in the initial stage of treatment. F-75 contains 75 kcal and 0.9 g protein per 100 ml F-100 is the catch-up formula to rebuild wasted tissues. F-100 contains more calories and protein: 100kcal and 2.9g protein per 100ml

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F-75 RECIPE
Dried skimmed milk 25g Sugar 200g Vegetable oil 60g CMV 1 scoop Water to make 2000ml Osmolarity 415mOsmol/l In case of osmotic diarrhoea, replace 60g of sugar diarrhoea, with 70gm of cereal (maize meal) makes cereal based F-75 (300mOsmol/l) F-

(CMV combined mineral and vitamin mix)

Alternative recipes for F-75: Dried Whole milk 35 g Sugar 100 g Vegetable oil 20 g Combined Mineral/Vitamin mix level red scoop WATER TO MAKE 1000 ml

Fresh cows milk or Full cream (whole) long life milk 300 ml Sugar 100 g Vegetable oil 20 g Combined Mineral/Vitamin mix level red scoop WATER TO MAKE 1000 ml Osmolarity for above formulations: 415 mOsm/l

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Cooking recipes for F-75 (low-osmolarity F-75): All ingredients as above, but reduce amount of sugar to 70 g and add 35 g cereal flour (rice, corn, whole wheat flour etc) Mix the flour, milk or milk powder, sugar, oil in jug Slowly add cooled, boiled water up to 1000 ml Transfer to cooking pot and whist mixture vigorously Boil gently for 4 minutes, stirring continuously Some water will evaporate while cooking. Transfer the mixture into the measuring jug after cooking and add enough boiled water to make 1000 ml. whisk again ADD Combined Mineral/Vitamin mix (not to be added before cooking) Osmolarity: 300 mOsmol/l

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F-100 RECIPE
Dried skimmed milk 160g Sugar 100g Vegetable oil 120g CMV 1 scoop Water to make 2000ml Osmolarity 419mOsmol/l

Alternative recipes for F-100: Dried Whole Milk Sugar Vegetable Oil Combined Mineral/Vitamin mix WATER TO MAKE Fresh whole cows milk or Full cream (whole) long life milk Sugar Vegetable oil Combined Mineral/Vitamin mix WATER TO MAKE 110 g 50 g 30 g level scoop 1000 ml 880 ml 75 g 20 g level scoop 1000 ml

TIPS: Adding water Add just the amount of water needed to make 1000 ml formula and NOT TO ADD 1000 ml of water This amount will vary from recipe to recipe, depending on the other ingredients It is easier to make aliquots of 2 litres in order to add 1 level scoop of combined mineral/vitamin mix (CMV) since level scoop may be difficult to measure accurately

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Local production of
Ready to Use Therapeutic Food

(RUTF)

Groundnuts Milk powder Oil Sugar Vitamins / minerals

READY-TO-USE-THERAPEUTIC FOOD (RUTF) 1. RUTF is a high-energy, nutrient-dense food used for nutrition rehabilitation in inpatient and outpatient care in combination with systemic medical treatment. It should not be used alone to treat severe acute malnutrition (SAM) 2. Some characteristic of RUTF: Similar in composition to F-100 (except RUTF contains iron and is about 5 times more energy-nutrient dense) Soft lipid-based paste Ideal for outpatient care because it does not need to be cooked or mixed with water, which prevents growth of bacteria Easy to distribute and carry Easy to store (in a clean dry place) and can be kept for some time even when opened Available locally through either imports or local production 3. Lipid-based RUTF is most commonly used in outpatient care. It has a caloric value of 545kcal/100g of product. Plumpy nutR Contains 500kcal/92g satchet, the ration given is 200 kcal/kg/day.

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4. Lipid-based RUTF is composed of : 25% peanut butter 26% milk powder 27% sugar 20% oil 2% combined mineral and vitamin mix (CMV)

APPENDIX 2: MANAGEMENT OF DIARRHOEA ReSoMal FOR MANAGEMENT DIARRHOEA:

Manage diarrhoea with ReSoMal

Water (boiled and cooled) 2litres WHO-ORS 1 satchet Sugar 50g CMV 1 scoop Contains: 37.5mmol Na, 40mmol K and 3mmol Mg/litre

Notes: Use Low Osmolarity (75mmol Na+) ORS which is usually diluted in 1 litre of water

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APPENDIX 3 Physiological basis for treatment of severe malnutrition

Affected organ and system Cardiovascular system Effects
Cardiac output and stroke volume are reduced Infusion of saline may cause an increase in venous pressure Any increase in blood volume can easily produce acute failure: any decrease will further compromise tissue perfusion Blood pressure is low Renal perfusion and circulation time are reduced |Plasma volume is usually normal and red cell volume is reduced Synthesis of all proteins is reduced Abnormal metabolites of amino acids are produced

Treatment
If the child appears dehydrated, give ReSoMal or F-75 diet (see protocol above). Do not give fluids intravenouslu unless in shock

Restrict blood transfusion to 10ml/kg and give a diuretic

Liver

Do not give the child large meals Ensure that the amount of protein given does not exceed the metabolic capacity of the liver, but is sufficient to support synthesis of proteins (12g/kg/day) Reduce the dosage of drugs that depend on hepatic disposal or are hepatoxic

Capacity of liver to take up, metabolize and excrete toxins is severely reduced Energy production from substrates such as galactose and fructose is much slower than normal

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Liver

Gluconeogenesis is reduced, which increases the risk of hypoglycaemia during infection Bile secretion is reduced

Ensure that sufficient carbohydrate is given to avoid the need for gluconeognesis

Genito-urinary system

Glomerular filtration is reduced Capacity of kidneys to excrete excess acid or a water load is greatly reduced Urinary phosphate output is low Sodium excretion is reduced Urinary tract infection is common

Do not give iron supplements, which may be dangerous because transferring levels are reduced Prevent further tissue breakdown by treating any infections and providing adequate energy (80100Kcal/kg/day) Do not give the child more protein than is required to maintain tissues Ensure that high-quality proteins are given, with balanced amino acids Avoid nutrients that give acid load, such as magnesium chloride Restrict dietary sodium (1mmol/kg/day) during initial phase of treatment

Gastrointestinal system

Ensure that water intake is sufficient but not excess Production of gastric acid is Give the child small, frequent feeds reduced Intestinal motility is reduced Pancreas is atrophied and production of digestive enzymes is reduced If absorption is poor, increase the frequency and reduce the size of each feed If there is malabsorption of fat, treatment with pancreatic enzymes may be

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Gastrointestinal system

Small intestinal mucosa is atrophied; secretion of digestive enzymes is reduced Absorption of nutrients is reduced when large amounts of food are eaten All aspects of immunity are diminished Lymph glands, tonsils and the thymus are atrophied Cell-mediated (T-cell) immunity is severely depressed IgA levels in secretions are reduced Complement are low Phagocytes do not kill ingested bacteria efficiently Tissue damage does not result in inflammation or migration of white cells to the affected area Acute phase immune response is diminished Typical signs of infection, such as an increased white cell count and fever, are frequently absent Hypoglycaemia and hypothermia are both signs of severe infection and are usually associated with septic shock

useful

Immune system

Treat all children with broad-spectrum antimicrobials (see protocol above) Because of the risk of transmission of infection, ensure that newly admitted children are kept apart from children who are recovering from infection

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Endocrine system

Insulin levels are reduced and the child has glucose intolerance Insulin growth fact 1 (IGF1) levels are reduced, although growth hormone levels are increased Cortisol levels are usually increased Basic metabolic rate is reduced by about 30% Energy expenditure due to activity is very low

Give the child small, frequent feeds Do not give steroids

Circulatory system

Both heat generation and heat loss are impaired; the child becomes hypothermic in a cold environment and hyperthermic in a hot environment

Keep the child warm to prevent hypothermia; dry the child quickly and properly after washing and cover with clothes and blankets, ensure that windows are kept closed at night and keep the temperature of the living environment at 25-30 oC If the child has fever, cool the child by sponging with tepid (not cold) water (never alcohol rubs)

Cellular function
Sodium pump activity is reduced and cell membranes are more permeable than normal, which leads to an increase in intracellular sodium and a decrease in intracellular potassium and magnesium Give large doses of potassium and magnesium to all children (Potassium 4 mmol/kg body wt.; Magnesium 0.6mmol/kg/day)

Restrict sodium intake (1mmol/kg /day)

Protein synthesis is reduced

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Skin, muscles and glands

The skin and subcutaneous fat are atrophied, which leads to loose folds of skin Many signs of dehydration are not unreliable; eyes may be sunken because of loss of subcutaneous fat in the orbit Many glands, including the seat, tear and salivary glands, are atrophied; the child has dryness of the mouth and eyes and sweat production is reduced Respiratory muscles are easily fatigued; the child is lacking in energy

Rehydrate the child with ReSoMal or F-75 diet (refer to protocol above)

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REFERENCES: 1. WHO. Management of severe malnutrition: a manual for physicians and other senior health workers. Geneva: WHO 1999 2. Ann Ashworth, Ann Burgess et al. Caring for Severely Malnourished Children. Macmillan Publishers/AED 2003 3. Ann Ashworth, Sultana Khanum et al. Guidelines for the inpatient treatment of severely malnourished children. Geneva: WHO 2003 4. Collins S, Dent N, Binns P et al., Management of severe acute malnutrition in children. www.thelancet.com 2006 5. Community Based Management of Acute Malnutrition, Module 5: Inpatient Care for the Management of SAM with Medical Complications in the context of CMAM. FANTA

Prepared by: DR BEATRICE AMADI DR THELMA BROWN DR MATILDA AGYEMANG

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