national guidelines on the integrated management of acute malnutrition

114 Pages·2010·3.52 MB·English

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MMAANNAAGGEEMMEENNTT OOFF AACCUUTTEE MMAALLNNUUTTRRIITTIIOONN
((IIMMAAMM))
SSwwaazziillaanndd NNaattiioonnaall NNuuttrriittiioonn CCoouunncciill
Acknowledgements
The Ministry of Health wishes to expressits appreciation to the Technical Working Group
composed of Danisile Vilakati, Thulani Maphosa, Arlerta Ndlela (SNNC), Eva Vicent, Karina
Lopez (ACF),Thandi Kunene (EGPAF), Dr Stephanie Marton,Dr Fiona Henderson(BAYLOR
CollegeofMedicine)andPercyChipepera(SINAN).
Special gratitude is extended to DrC.D Daudu, Dr Simon Zwane, Dr Kundunda, DrLuis
RodriguezPedro, Dr MariaEster Sanchez, Sr Khanyisile Nkhabindze, Ms Thandi Mndzebele
(MOH), DrPawelos(RFM),)DrHailuNicaSarero,SrJerrySimelane(GSH),SaraBernadini(WFP),Alison
End, Sam Meyer and Rebecca Egan (Clinton Foundation)for their technical support and
guidanceduringtheprocessofdevelopingtheguidelines.
Particular recognition is forwarded to the various government ministries MOH, MOAC,NGO’s
SNNC and partners that include UNICEF, WHO,WFP, SINAN,SNAP,ACF, Baylor College of
Medicine and World Vision for their remarkable participation and commitment in the
developmentofthisdocument.
Further thanks are directed to partners that include UNICEF, Clinton Foundation and the
Government ofSwazilandfortheirmajorcontributionstechnicallyandfinanciallythroughout the
process.
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FOREWORD
Globally and especially in the Sub Saharan region, malnutrition continues to affect many
populations, with adverse effects on health, mortality, and productivity.Malnutrition is a
potentiating factor in about half of the 10million deaths among children under 5 each year
worldwide,andimprovednutritionisconsidered essentialtotheachievement oftheMillennium
Development Goals. There isaclear relationshipbetween malnutrition and HIVthat cannot be
underestimatedwithmalnutritionprevalencelikelytobehighinareas whereHIVprevalenceis
alsohigh.
HIV and AIDS still remains high among pregnantwomen (42%, ANC Sentinel Surveillance,
2008) and 47% of child mortality related to HIV, (DHS, 2006-7). A majorityof Swazi children
(60%)admitted athealthfacilitiesduetosevere malnutritionhaveHIV asan underlyingcause
and clinicalmanagement of these children hasbeen difficultdue to thelackof comprehensive
guidelinesforPaediatricIntegratedManagementof acute Malnutrition.
Theseguidelineshavebeendevelopedthrough consultationswithhealthpersonnelat different
levels and health workers in the MOH facilities to provide a comprehensiveuser-friendly
guideline. The objective of the guideline is to help improve the quality of inpatient and out
patientcareofmalnutritionthusreducingunnecessarydeaths.
Ithereforeurgealldoctors,nurses,dieticians,nutritionistsandotherhealthworkersresponsible
forthe medicaland dietary management of severe and moderateacute malnutritiontoadhere
totheguidelinesastheydefinethenationalstandardsfortheservice.
Hon.BenedictXaba
MinisterofHealth
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Acknowledgements...................................................................................................................1
FOREWORD............................................................................................................................2
AcronymsandAbbreviations.....................................................................................................6
1 Background.......................................................................................................................7
1.1Purpose..........................................................................................................................7
1.2Rationale.........................................................................................................................7
1.3TargetandUsageoftheGuidelines:................................................................................7
2 FundamentalsoftheManagementofAcuteMalnutrition....................................................8
2.1 Definingmalnutrition.................................................................................................8
2.2 Diagnosingmalnutrition............................................................................................9
2.3 Structureoftheprogramformanagement ofacutemalnutrition..............................10
2.4 AdmissioncriteriaforITP,OTPandSFP................................................................11
3 CommunityMobilisation...................................................................................................12
3.1 CommunitySensitization........................................................................................12
3.2 Activecasefinding:screeningandreferra.l.............................................................12
3.3 Follow-upandtreatmentsupport............................................................................15
4 InpatientManagement ofMalnutrition..............................................................................16
4.1 Overview................................................................................................................16
4.2 ITPadmissioncriteria.............................................................................................17
4.3 Step1:Treat andpreventhypoglycaemia...............................................................18
4.4 Step2:Treat andpreventhypothermia...................................................................19
4.5 Step3:Treat andpreventdehydration....................................................................20
4.6 Step4:Correctelectrolyteimbalance.....................................................................24
4.7 Step5:Treat andpreventinfection.........................................................................25
4.8 Step6:Correct micronutrientdeficiencies...............................................................27
4.9 Step7:Startcautiousfeeding.................................................................................29
4.10 Step8:Achievecatch-upgrowth(Phase2)............................................................30
4.11 Step9:Providesensorystimulationandemotionalsuppor.t....................................32
4.12 Step10: Prepareforfollow-upafterrecovery..........................................................33
4.13 MonitoringandrecordingintheInpatientsites........................................................33
4.14 Dischargefromhospital..........................................................................................33
4.15 Failuretorespond..................................................................................................34
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5 SpecialProtocolforChildrenlessthan6Months.............................................................37
5.1 Admissioncriteria...................................................................................................37
5.2 Diet........................................................................................................................37
5.3 Routinemedicine....................................................................................................37
5.4 Treatmentforbreastfedchildren.............................................................................38
5.5 Treatmentforchildrenwithoutanyprospecttobreastfeed......................................39
5.6 Treatmentforchildrenthatarenotbreastfedonadmission.....................................40
6 OutpatientManagement ofMalnutrition...........................................................................42
6.1 Overview................................................................................................................42
6.2 Outpatientmanagementofsevereacutemalnutrition..............................................43
6.3 Outpatientmanagementofmoderateacutemalnutrition.........................................50
7 HIVandTBscreening.....................................................................................................54
7.1 HIVandmalnutrition...............................................................................................54
7.2 TBandmalnutrition................................................................................................56
8 NutritionEducation..........................................................................................................57
9 MonitoringandEvaluation...............................................................................................58
9.1 Recording...............................................................................................................58
9.2 Monitoringindividualtreatment...............................................................................58
9.3 Supervisionandcasereview..................................................................................60
9.4 Exchangeofinformation.........................................................................................60
9.5 Monitoringprogrammeeffectiveness......................................................................60
10 SuppliesandStorage..................................................................................................62
10.1 Organisingstoragefacilities....................................................................................62
10.2 Stockmanagement................................................................................................62
10.3 Keepingthefacilitysupplied...................................................................................62
11 Annexes......................................................................................................................63
11.1 Annex1:Howtomeasureweight...........................................................................63
11.2 Annex2:Howtomeasureheightorlength..............................................................65
11.3 Annex3:HowtomeasureMUAC...........................................................................67
11.4 Annex4:Howtoassessoedema............................................................................68
11.5 Annex5:WeightforLength/Heighttablesforchildren(49-130cmheight)...............69
11.6 Annex6:WeightforHeighttablesforadolescentboys(130.5to163.0cmheight.).71
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11.7 Annex7:WeightforHeighttablesforadolescentgirls(130.5to163.0cmheight.)..72
11.8 Annex8:Howtoconductahomevisit....................................................................73
11.9 Annex9:EquipmentneededinITPsites................................................................74
11.10 Annex10:CharacteristicsofReSoMalvslow-osmolarityORS................................75
11.11 Annex11: CharacteristicsofF75...........................................................................76
11.12 Annex12:PreparationofF75.................................................................................77
11.13 Annex13:AmountofF75togiveinPhase1..........................................................78
11.14 Annex14:CharacteristicsofF100..........................................................................80
11.15 Annex15:PreparationofF100milk........................................................................81
11.16 Annex16:F100togiveinTransitionPhase............................................................82
11.17 Annex17:F100togiveinPhase2.........................................................................83
11.18 Annex18:CharacteristicsofPlumpy’nut®..............................................................84
11.19 Annex19:Amountof Plumpy’nut®togiveinPhase2andOTP/SFP....................85
11.20 Annex20:HowtoprepareDilutedF100.................................................................86
11.21 Annex21:AmountofDilutedF100togiveforinfantsduring
Supplementary Suckling............................................................................................87
11.22 Annex22:SupplementarySucklingTechnique.......................................................88
11.23 Annex23:AmountsofF100diluted(orF75inoedematousinfants)togive
notbreastfedinPhase1................................................................................................
11.24 Annex24:AmountsofDilutedF100togiveforinfantsnotbreastfedinPhase.2.....90
11.25 Annex25:InformationtogivetocaregiversonadmissiontoOTP...........................91
11.26 Annex26:PerformingtheAppetiteTest..................................................................92
11.27 Annex27:RoutineMedicinesinOTP/SFP............................................................93
11.28 Annex28:CharacteristicsofCornSoyaBlend(CSB).............................................94
11.29 Annex29:Howtocalculatemeanweightgain........................................................95
11.30 Annex30:Multichart...............................................................................................96
11.31 Annex31:OTPcard...............................................................................................97
11.32 Annex32:OTPPatientCard..................................................................................99
11.33 Annex33:Supervisioncheck-lists........................................................................101
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Acronyms and Abbreviations
AIDS AcquiredImmunodeficiencySyndrome
CSB CornSoyaBlend
DHS DemographicHealthSurvey
HFA HeightforAge
HIV HumanImmunodeficiencyVirus
IMAM IntegratedManagement ofAcuteMalnutrition
IMCI IntegratedManagement ofChildhoodIllnesses
ITP InpatientTherapeuticProgram
MDGs MillenniumDevelopmentGoals
MOH MinistryofHealth
MUAC MiddleUpperArmCircumference
NCHS NationalCentreofHealthStatistics
NCP NeighbourhoodCarePoint
OPD OutpatientDepartment
OTP OutpatientTherapeuticProgram
PHU PublicHealthUnit
RHM RuralHealthMotivator
RTHC RoadtoHealthCard
RUTF ReadytoUseTherapeuticFood
SD StandardDeviation
SFP SupplementaryFeedingProgram
SNNC SwazilandNationalNutritionCouncil
WFA WeightforAge
WFH WeightforHeight
WHO WorldHealthOrganization
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1 Background
ChildmortalityinSwazilandisontheincrease,accordingtotheSwazilandDemographicHealth
Survey (DHS) 2006-2007. Swaziland is one of the countries with the highest HIV/AIDS
prevalence in the region. Acute malnutrition coupled with HIV/AIDS is a major contributor to
childmortalityinSwaziland.AccordingtotheDHS2006-7,oneineverythreechildrenunderthe
age of 5 years is stunted; 5% of children are underweight while 3% are wasted. This level of
malnutritioncompounded bythehighprevalenceof HIV/AIDS hasnegativeimpactson survival,
growth and development and ultimately will compromise the attainment of the Millennium
DevelopmentGoals(MDGs)forSwaziland.
While children with malnutrition in the country are managed in hospital-based Inpatient
Therapeutic feeding Programs (ITPs) and in Outpatient Therapeutic feedingPrograms (OTP)
using the WHO guidelines, their management hasnot been well defined and standardized to
Swaziland’scontext.In response,theMinistryof Health(MOH)throughthe Swaziland National
Nutrition Council (SNNC) has developed national guidelines for management of severe and
moderate acute malnutrition.These guidelines have been developed in collaboration with
partnersbasedonthe WHOguidelinesandexperiencewithinandoutsidethecountry.
TheMOHrecognizesthattimelyandeffectivemanagement ofacutemalnutritioninSwaziland’s
context of high HIV/AIDS prevalence saves lives and reduces the burden on our healthcare
resources. TheMOHtherefore urgesalltherapeuticfeedingsites’staff andotherimplementing
partnerstofollowandadhere totheseguidelinesandallaccompanyingmaterials.
The MOH wishes sincerely to acknowledge the dedication and contributions of all those who
have tirelessly worked towards the successful completion of these guidelines through their
technicalinput,materialandfinancialassistancefortheproductionoftheseguidelines.
1.1Purpose:Thepurposeoftheseguidelinesistoprovideastandardized,nationalmodel
forintegratedmanagement ofsevereandmoderateacutemalnutritioninchildren. The
individualcomponentsof thisapproachcanbeimplementedatalllevelsofhealthcareinorder
totargetthelargestnumberofmalnourishedchildrenpossible.Individualprovidersmayneedto
applytheseguidelineswhileadaptingthemtotheirindividualclient’s situationsandlocal
resourceconcerns.
1.2 Rationale: Children that have fallen behind in their nutritional status need acute
assistance to regain a healthy and balanced nutritional status. In order to decrease child
mortalityfrommalnutritionandtofulfill themandateoftheSwazilandGovernmentanditsefforts
to achieve the MDGs, these guidelines provide a rational and standardized approach to
management for all malnourished childrenin Swazilandacross all levels of health care, from
communityleveltooutpatientcareandhospitals.
1.3 Target and Usage of theGuidelines: Theguidelinesgiveusefulandpractical
informationforthosethatcareforchildrenatalllevelsof healthcareinSwaziland.Thisincludes
physiciansandnursesathospitalsandhealthcentres,PublicHealthUnit(PHU)staff,clinicstaff
aswellascommunityworkersandRural HealthMotivators(RHMs).
Everyefforthasbeenmade tomaketherecommendationsoutlinedareconsistentwithother
national guidelines atthe time ofpublication.Theseguidelines should always be implemented
in considerationof recommendations from other national guidelinesincludingPaediatric HIV
andAIDSManagementandInfantandYoungChildFeedingGuidelinesamongothers.
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