3 - MANAGEMENT OF MODERATE ACUTE MALNUTRITIONS

3.1- Overview
This section covers the design elements and implementation strategies to manage the
Moderate Acute Malnutrition (MAM) at the health facility and community level.

In Yemen, management of MAM strategies are linked to national health programmes and
are incorporated into Mother and Child Health (MCH) programmes which form part of the
primary health-care infrastructure.

The main aim of managing moderately malnourished people is to meet the additional
nutritional needs of the malnourished individuals of a vulnerable group, and reduced
mortality and morbidity and prevent MAM from deterioration to severe malnutrition, or
prevent deterioration of nutritional status of those at-risk (e.g., infants, children, pregnant
and lactating women). This is basically done with supplementary feeding, nutrition
counseling, and treatment of common ailments at the health facility and community level.

Managing MAM includes encouraging pregnant and lactating women to attend antenatal
clinics and mothers to practice regular growth monitoring of children under five years. In
areas where HIV/AIDS and/or TB prevalence is high, nutritional support and care is essential
for people living with HIV/AIDS and/or TB and at a community level.

Who are the most nutritionally vulnerable in Yemen?

In Yemen, just like in any other emergency setting, the most nutritionally vulnerable groups
can be categorized according to the following:

1- Physiological vulnerability: this refers to

- Children under 5 years
- Pregnant and lactating women
- Special groups, chronically ill like people living with HIV/AIDS and/or with TB2-

2-Geographical vulnerability: Vulnerability is also disaggregated by geographical areas;

some regions are more insecure than others.

3- Internal displacement and refugee status (IDPs) hundreds of thousands have been
displaced mostly due to political crisis and have no access food.

The objectives of setting up an MAM intervention are to:

 reduce the risk of mortality, and morbidity associated with MAM;

 prevent moderately malnourished patients from becoming severely wasted;
 manage moderately malnourished patients discharged from therapeutic feeding
program and prevent deterioration in their condition;
 provide a nutritious supplement to those with increased nutritional requirements;
and
 increase awareness of mothers/care givers targeted on optimal child feeding
practices.

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 3.1.1 Types of MAM Interventions under Supplementary
Feeding Program (SFP) in Yemen
3.1.2. What is Supplementary Feeding?

Supplementary feeding is the provision of nutritious rations to targeted individuals that

supplement the energy and nutrients missing from the diet of those with higher nutritional
needs (such as children under 5years, pregnant women, lactating women with infants under
6 months), or those who are moderately malnourished. It normally provides a ration that is
additional to food provided through the food distribution (usually General Food Distribution
GFD). However, there may be situations where only supplementary feeding is required
(without GFD).

3.1.3 Types of SFPs

There are two main types of supplementary feeding programs:

 Blanket SFP preventive approach (BSFP): It targets all those in “at risk” groups
irrespective of nutritional status.
 Targeted SFPs treatment approach (TSFP): It targets moderately malnourished
individuals.

How do We Determine Case Load for SFP?

In order to determine the number of beneficiaries, the health or nutrition worker must have
the estimated population size of the target area. This information can be obtained from
district office or nearest health facility or local leaders. Use the estimated population size to
calculate the number of children under 5 years, pregnant and lactating mothers by use of
the following respective proportions:

• Proportion of children under five years is estimated as 18 percent of the total

population in the target area of Yemen.
• Proportion of children under two years is estimated as 6.2 percent of the total
population in the target area of Yemen.
• All pregnant women and lactating mothers until maximum 6 months after delivery is
estimated as 6 percent of total population in the target area of Yemen.

3.1.4 .1. Prevention Approach (Blanket SFP)

To Children from 6 to 24 months

SFPs provide prevention for children aged 6-24 months without acute malnutrition. Blanket
SFP may be implemented during an emergency for a defined time period when the
prevalence of acute malnutrition is high and general food rations are inadequate. BSFPs may
include all children under a certain age for example all children under 2 years as in Yemen,
because children under two years old are found to be most at risk among all those below 5
years old (SMART Surveys).

When to implement Blanket supplementary feeding program

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 Box 5: When to Implement BSFP?

Usually Blanket Supplementary program can be started when 15 percent or more of children are
malnourished or assessment results show GAM levels of 15 percent or more or 10 to 14
percent with aggravating factors and sufficient resources including food, personnel, and logistics
are available. In addition, when:

 General food distribution systems are not adequately in place and/or not covering the needs of
certain vulnerable groups
 There are problems in delivering/distributing the general ration
 There are large numbers of mild and moderately malnourished individuals and likely to become
severe due to aggravating factors
 There is anticipated increase in rates of malnutrition due to seasonally induced epidemics
 There are reported cases of micronutrient deficiency outbreaks, to provide micronutrient-rich food
to the target population.

Blanket supplementary feeding program is set so as to provide a food supplement to all

members of a particular group such as all children under 2 years old.

Other recommendations for implementing BSFP:

• Blanket feeding should be implemented in an area near TFC/SC/OTP or a referral
system for treatment of severe acute malnutrition exists.
• Blanket Feeding should be a program for a specific time period with delineated entry
and exit criteria usually not more than 4 months. An extension of Blanket Feeding
should be justified by a specific technical review of the situation.

Due to the high level of chronic malnutrition in Yemen, blanket supplementary feeding is
normally implemented year-round for a period of 18 months between the age of 6 and 24
months.

How do you Select Beneficiaries for BSFP?

Blanket supplementary feeding should be targeted at groups with the highest risk of being
acutely malnourished. In Yemen, this group is between 6 and 24 months of age. They are
also the critical groups to prevent chronic malnutrition. Additional beneficiaries can be
enrolled in program by use of clinical diagnosis such as:
• All adults showing signs of malnutrition,
• All the elderly,
• Disabled,
• Chronically ill.
How do We Determine Case Load for BSFP?

In order to determine the number of beneficiaries, the health or nutrition worker must have
the estimated population size of the target area. This information can be obtained from
district office or nearest health facility or local leaders. Use the estimated population size to
calculate the number of children under five years, pregnant and lactating mothers by use of
the following respective proportions:
• Proportion of children under five years is estimated as 18 percent of the total
population in the target area of Yemen.

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 • Proportion of children under two years is estimated as 6.2 percent of the total
population in the target area of Yemen.
• All pregnant women and lactating mothers until maximum 6 months after delivery is
estimated as 6 percent of total population in the target area of Yemen

When to Exit BSFP?

Blanket SFPs are closed when the GFD is adequate and prevalence of GAM is below 15
percent without aggravating factors. Duration depends on the scale and severity of the
disaster, as well as the effectiveness of the initial response.

3.1.5.2 Treatment Approach (Targeted SFPs)

TSFP provides food supplements to the general population of acutely moderately

malnourished.

 Provide treatment for children aged 6-59 months with MAM also includes children
discharged from OTP. In some cases children discharged from inpatient care (where
there is no OTP).Children are admitted according to specific entry criteria (see
admission criteria).
 Malnourished pregnant and lactating women (PLW).
 Acutely malnourished pregnant women from the first contact with the antenatal
services which is mostly in the second trimester.
 Acutely malnourished lactating women whose child is less than 6 months old.

BOX 6: When to Implement TSFP?

TSFP is implemented when malnutrition rates are 10-14 percent or 5-9 percent with aggravating
factors. Aggravating factors include; general food rations below the mean energy requirement,
crude mortality rate more than 1 per 10,000 per day, epidemic of measles or whooping cough and
high incidence of diarrheal diseases. Other additional reasons for implementing TSFP include:
 When resources for implementing blanket distribution are scarce.
 When there are discharges from Therapeutic Feeding Programs.
 When there are large numbers of mild and moderately malnourished individuals reported
 When large numbers of children are likely to become mild or moderately malnourished due to
aggravating factors.
 High prevalence of micronutrient deficiencies in the target area

How do We Select Beneficiaries for TSFP?

At the community level, use anthropometric measurements to identify and enroll eligible
persons into program. Steps to conduct anthropometric measurement are in Annex 4 and
cut-off points for admission are in Table 2 (page 10). The following groups of individuals can
be enrolled in TSFP:

 Malnourished children under five years and depending on availability of resources. All
children that fall between >=3 W/H-<-2 Z-scores are eligible for admission.
 All discharges from the therapeutic feeding programs (both in-patient and out-
patient care)
 Pregnant and lactating women that are malnourished (MUAC <23Cm)
 Any other individuals considered acutely malnourished as per age specific
anthropometric assessment.

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How do We Determine Case Load for a Targeted SFP?

Based on the findings of the most current nutritional assessment (CFSS, 2012), the number
of beneficiaries for a targeted SFP can be estimated as follows:

Total number of malnourished group = Population of vulnerable group X Prevalence

rate of MAM (where Vulnerable group are either children under five years or
pregnant and lactating women)

Prevalence rate of moderate malnutrition rate can be obtained by subtracting SAM rate from
the GAM rate.

Box 7: Example of Determination Case Load for TSFP

Example:
A Comprehensive Food Security Survey (CFSS, 2012) conducted in Yemen indicated a coastal governorate
named Hodeida GAM level of 27.9% and a SAM of 8.6%. The estimated total population of the survey area
was 2,721,968. Based on the CFSS results, the estimated number of children to be enrolled in the program
is calculated as follows:

 Total population of the area = 2,721, 968

 Under 5 population (18% of total population) = 2,721,968 x 18/100 = 489,954
 Prevalence of moderate acute malnutrition = GAM- SAM =MAM level (27.9% - 8.6%)= 19.3%
 Number of moderately malnourished children in the area = 489,954 x 19.3/100 = 105,068
 50% of moderately malnourished children expected to be reached by SFP = 105,068 x 50/100 = 52,534

Note:
 According to Sphere standards, percentage coverage (in this case number expected to be reached by
program) can vary depending on the area, for rural community use 50% , urban 70% and refugee
camps 90%
 The location of the SFP should be determined based on security and socio-cultural considerations,
population density, water availability, and other public health considerations.

When to Exit TSFP?

Targeted SFP can be closed when the following criteria are satisfied:
• General food distribution is adequate (meeting planned nutritional requirements).
• Prevalence of acute malnutrition is below 10% without aggravating factors.
• Control measures for infectious diseases are effective.
• Deterioration in nutritional situations is not anticipated; i.e. seasonal deterioration.
• Low mortality rates.

New Approach on How to determine the appropriate programme type for MAM
prevention and treatment

The programme recommendation is based on the GAM prevalence (high, moderate, low)and
the sum risk score (high, moderate, low) as shown in Figure (2).

Four different interventions should be considered:

 Prevention and Treatment.
 Prevention alone.
 Treatment alone.
 No additional intervention than strengthening IYCF-E and monitoring the situation.

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To determine the most appropriate programme type/objective for MAM the decision tool
presents two different levels of factors to consider: a) historical information and b) risk of
deterioration. With this analysis, a programme recommendation can be obtained.

Figure 3: Programme Recommendation for Prevention and Management of MAM

Situation Analysis: The first considerations are pre-crisis vulnerability or historical

information. The current or historical prevalence of GAM in the affected population is a key
indicator of vulnerability. For the decision making process, GAM prevalence is considered
high when prevalence is above 15 percent, medium when between 8-15 percent and low
when it is < 8 percent. Trend analysis, including an understanding of seasonality of GAM in
the emergency affected population, is also critical in classifying the GAM prevalence. GAM
prevalence can also be corroborated by the number of children with MAM and SAM in
treatment if we have a clear understanding of the coverage and therefore met need. If data
is not available or data is not recent, older data and available screening data may be used to
make a judgment on GAM prevalence. When these are not available, the decision-making
process can start with information on risk of deterioration.

Risk of DeteriorationAssessment: Once the emergency has been characterized by

historical GAM prevalence the risk of deterioration should be evaluated and a sum score for
the emergency agreed upon. The four key factors that can predict a risk of deterioration of
the situation need to be considered are: (i) increased morbidity, (ii) decreased food
security, (iii) significant population displacement, and (iv) population density. Three
categories of expected/ predicted risk are defined as:
 Epidemic – high score (3);
 Increasing incidence/ high levels: moderate score (2);
 Stable incidence/low levels: low score (1)

3.2TYPES OF NUTRITION ASSISTANCE

Food supplements may be distributed as either take home rations (e.g., dry rations, ready to
use supplementary foods (RUTF) or on site feeding (wet rations). In Yemen and in nutrition
context, only dry ration and ready to use food are distributed.

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3.2.1.1 Take Home Ration
Take-home rations should be provided for both prevention and treatment unless there is a
clear rationale for on-site (wet) feeding (i.e., extreme security issues or lack of access to
cooking materials).While products may be selected appropriately for target groups and
programme objectives, in practice there may be issues related to production/availability and
pipeline for specialized nutrition products, particularly in large-scale emergencies. As a
result, secondary recommendations for products (e.g., ½ sachet of RUSF instead of a
medium quantity Lipid base nutrition supplement (LNS) or use of multiple products (e.g.,
using Super cereal Plus and RUSF for treatment may be necessary.

3.2.2.2 Nutritional Product

A key component of MAM prevention and treatment is nutritional specialized products. There
are various types of nutrition support available as specialized products for management of
MAM. The following nutrition products items have been recommended for management of
acute malnutrition in Yemen (Table 3):

Table 3: Summary of Types of the Recommended Nutrition Products for Yemen

Nutrition Products Description

Recommended Nutrition products for MAM interventions
WSB (Wheat soya WSB is based on a cereal, usually wheat and soya blend. The blend is fortified
blended) with micronutrients. In an enhanced version milk has been added and phytate
removed thus suitable for children 6-59 months.
Beneficiaries require 6.600kg of WSB per person; this amount is intended to
last for one month (NB: Hygiene conditions must strictly be observed during
packaging and cooking).
Quantity per person per day.
If prepared as premix or other recipe for dry ration mix
220g of WSB + 30g oil + 20g sugar.
Supplementary The ready to use product designed specifically for the management of
Plumpy (generic moderate acute malnutrition. It is high energy density, has important logistical
name RUSF) used advantages, small risk of microbial contamination, does not require pre-mixing
for treatment of and can be used at home. Supplementary Plumpy is for children 6 to 59
moderate acute months.
malnutrition
Give the child one sachet of Supplementary Plumpy to eat every day.
Supplementary Plumpy should be eaten in addition to the food the child
normally eats at home.
Quantity per person per day
Give the child one sachet (92g) to eat every day in addition to breast milk and
other food the child eats at home. Ensure clean drinking water is available
when distributing Supplementary Plumpy.
Plumpy Doz This is high quality, fortified food that can be used as a supplementary food in
(generic name a blanket feeding. The nutritional composition is designed for prevention of
RUSF) used for acute malnutrition and has been shown to have a positive effect in preventing
prevention of acute malnutrition. It may be packed in jars or in pots. It may be used for a
acute malnutrition defined period of time in a blanket distribution to all children 6-24 months.
Quantity per person per: 46 g/per person/day or 3 table spoons/day
(1 pot /week)
Give the child 3 table spoons per day to eat every day in addition to breast milk
and other food the child eats at home.
Provide clean drinking water with the Plumpy Doz

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The ration is prescribed to supplement the diet at home and to provide sufficient energy and
nutrient density to allow for rehabilitation. The ration should provide 1000-1200
kcal/person/day with 10-12 percent energy from protein for pregnant and lactating women.
Rations in MAM programs usually consist of an imported produced blended food such as
WSB. Most blended foods are fortified with vitamins and minerals. They contain about 350-
400kcal/100g. Oil should also be included in the ration and should be fortified with Vitamin
A. Sugar can be added to blended food to increase palatability and energy. Milk powder
cannot be distributed alone. It must be mixed with a blended food before distribution.
Blended foods can be mixed with oil, sugar and/or powdered milk prior to distribution. This
is known as premix. The aim in using premix is to ensure that rations (particularly high value
commodities such as oil) do not end up being used for general household use or being sold
on the market. However, the process of pre-mixing can be time consuming. It also reduces
the shelf life of the ration. Once oil is mixed with blended food, it will last a maximum of two
weeks before going rancid. In Yemen, WSB, oil and sugar are distributed separately

Box 8: Nutrition Products Substitution

1. Ready to use supplementary food (RUSF) may be used in place of dry blended foods for the
treatment of MAM for children under 5. RUSF is highly energy and nutrient dense and does
not require cooking. It is also light in weight making it easy to transport and distribute.
2. Ready to use food for children is a concentrated nutrient dense paste which is used for the
treatment of severe acute malnutrition (Plumpy Nut). It may be used for a period of time to
children suffering from Moderate Acute Malnutrition if Plumpy Sup is not available or if there
is no MAM program.
3. Ready to use food for children (Plumpy Doz) is a concentrated nutrient dense paste which is
used for the prevention of acute malnutrition. It may be packed in cartons or in pots. It may
be used for a defined period of time in a blanket distribution to all children 6-24 months. In
case of Plumpy Doz is not available, Blended Food (WSB++) could be used instead of Plumpy
Doz.

3.2.3. 3. Nutrition Prescribed Rations for Special Cases

Special cases admitted into program such as people living with HIV/AIDS and TB patients
are managed using the respective disease’s treatment protocol. It is essential that the ration
is modified to match their special nutritional needs. While making modifications, the
following factors should be considered:

 Choose food items that meet the energy, protein, fat and micronutrient requirements
of the population.
 Consider the inclusion of micronutrient (vitamins and minerals) fortified blended food
and/or cereals.
For example, for:
 Adults: An increase of 10 percent in energy requirements is needed by asymptomatic
HIV-infected adults and 20-30 percent for symptomatic adults. Protein and fat sources
should contribute 10-12 percent and 17 percent respectively of the energy content of the
diet. WSB with sugar and oil-similar to PLW- can be considered possibly supplement with
plumpy Suplement in first weeks
 Children with weight decline or faltering need 50-100 percent more energy than HIV-
negative children of same age, sex. The additional energy can be achieved by
consuming sufficient amounts of balanced food, including one or more snacks in
between the meals in the course of the day.

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3.3Treatment OF MAM (Targeted SFP)

3.3.1Assessment and Diagnosis (criteria)

Criteria for admission are based upon precise cut-off points. The cut-off points used to
define moderate acute malnutrition should be in agreement with national relief or nutrition
policies and take into consideration capacity and resources for running the programme. MAM
cut-offs can be adapted in emergencies according to the needs and the available resources
(e.g., target the highest priority group, such as 6 to 24 months old children).There is
currently no internationally recognized consensus on the discharge criteria for SFP using the
new WHO Growth Standards (discharge criteria may change to percent of weight gain in line
with the management of SAM and transition to WHO Standards). In the interim, it is
recommended to continue using current guidelines, based on minimum length of stay and/or
using cut-offs in WHO standards more or less equivalent to that in NCHS reference.

CHWs and community volunteers will carry out active case finding and will identify and refer
acutely malnourished children to the health facility. Screening in the community is done
using the same criteria as admission criteria in a supplementary feeding program. The
referral criteria from the community will be MUAC <125mm for children under 5 years old.
Pregnant and lactating women should be referred from the community and admitted with
MUAC <230mm.

Table 4: Admission Criteria for MAM Program

Children 6-59 months* MUAC OR = 115mm< 125mm (Yellow)
W/H Z-score >-3 and < -2 Z score
No bilateral oedema And appetite
Clinically well, Alert

Pregnant (2nd trimester) and lactating MUAC < 230mm

women (whose child is less than 6 months
old)
Ill adult with chronic disease(TB,
HIV/AIDS)
Adults
BMI<18.5

Other reasons for SFP enrolment

Severely acutely malnourished child is transferred

Discharged from OTP
Readmission
Return after default
to SFP after completion of treatment in OTP
Children or pregnant or lactating women previously
discharged from SFP but meet SFP admission
criteria again.
Children or pregnant or lactating women who
return after default (absent more than one visit if
SFP is every month or more than 2 visits.

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3.3.2 Duration of the Program

 Treatment of MAM cases should take as long as required to meet the exit criteria. An
average period may take 2 or 3 months.
 Treatment for under 5 children with MAM should take minimum 45 days with the patient
receiving regular ration, systematic treatment and appropriate complementary support.
 For the non-responder, the program will continue till maximum 180 days as prescribed
by the physician,
 Pregnant women should be supported by the MAM program till delivery,
 Lactating women should be supported by the MAM program till her infant reaches 6
months
 Lactating women with under 6 months child can be supported even when she was not in
the program when pregnant.
 Lactating women still remain in the program if she did not reach the criteria of discharge
while her child is 6 months and above note
 For moderately malnourished children <6 months old, admit mother in supplementary
feeding,

3.3.3. Registration Enrolment and Admission Procedure

At the community level, the screener should select all vulnerable individuals; children,
pregnant and lactating mother, elderly (>60 years) and the individuals with social disorders.
This can be referred to the nearest SFP site or health facility for admission to BSFP or TSFP
depending on the selection criteria discussed in sections above.

After identifying the vulnerable persons at community level, those that are moderately
malnourished by taking their anthropometric measurements. Before taking anthropometric
measurement for children 6-59 months, check for bilateral oedema, if present do not take
MUAC, weight and height, instead refer to the nearest therapeutic feeding centre.

All infants <6 months should not be admitted in the program but their mothers are eligible
for admission if malnourished. Mother should be counseled to continue exclusive
breastfeeding. Use Table 5 to establish the appropriate measurement for each group of
people.

Table 5: Target Population and Type of Measurements

Target Group Type of Measurement
Children 6 to 59 1. Take Weight and length if child is less than 24months or less than 87cm,
months 2. Take height if child is 24months and above or more than 87cm
3. Take MUAC measurement for children 6 months and above using child MUAC
tape
Children Take weight for height and calculate Body Mass Index(BMI) (=W/H 2, height in
(6 to 19 years)* meters) for age
Pregnant and Take MUAC measurement using adult MUAC tape
lactating women
Adult 20 years Take Weight for height and calculate Body Mass Index (BMI) for adults (=W/H2,
and above height in meters)

After taking height and weight measurements, use the reference tables WHO growth
standard (Annex 4) to determine Z-scores and record.

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 1. Those children that fall between ≥-3 and <-2 Z-score should be referred to the
registration section. Those that are >-2 Z-score should have their caregivers
counseled on proper nutrition and health practices and allowed to go back home.

2. Children 6-59 months with MUAC showing between 115-125mm should be referred
to registration section for admission.

3. Pregnant and lactating mothers with MUAC <23cm should be referred to registration
section for admission.
Elderly with BMI <18.5 should be referred to registration section for admission
Other Reasons for MAM Enrolment

 Discharged from OTP Severely acutely malnourished child is transferred to SFP after
Completion of treatment in OTP
 Readmission: children who have been discharged from SFP and then meet the
criteria for enrolment again are counted as new enrolees.
 Return after default: children who return after defaulting (absent more than one visit
if SFP is every month or two visits if SFP is every two weeks)

Integrated Management of Acute Malnutrition for SAM and MAM:

It is essential to have good coordination between in- and out-patient care and between SAM
and MAM programs with community workers to make sure children do not miss the
program. Community workers are informed when a child is transferred from OTP to inpatient
care or to MAM program when a child is absent/defaulted in OTP or MAM program so that
they can follow up with the child and mother/caretaker at home and investigate the reasons.

Table 6: Admission Procedure in Case of MAM

Age Group Admission criteria

W/H - W/L ≥-3 and <-2 Z score (WHO2006 standards
CHILDREN 6 to 59 MONTHS
unisex table, Annex 4) or MUAC≥115 mm and <125mm
NO ANTHROPOMETRIC CRITERIA
ALL SAM CURED CHILDREN
FOLLOW UP FOR 3 MONTHS

Table 7: Discharge Procedure in Case of MAM

Age Group Discharge criteria

W/H – W/L ≥-1.5 Z score (WHO2006 standards unisex table)
CHILDREN 6 to 59 MONTHS
and MUAC≥125mm
FOLLOW UP FOR 3 MONTHS
And W/H – W/L ≥-1.5 Z score (WHO2006 standards unisex
ALL SAM CURED CHILDREN
table) and
MUAC≥125mm

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 1. Register pregnant or lactating women and/or child 6-59 m0nths in their registration
books and give ration cards (Annex 30).
2. Administer systematic treatment: de-worming, Iron and vitamin A supplementation.
3. Distribute the food ration which should last for two weeks or one month depending
on the distribution plan and indicate amount on ration card.
4. Distribute non-food items such as mosquito nets, soap, blankets tents, buckets.
5. Give beneficiary or caretaker routine nutritional counseling.
6. Counsel caregiver and explain the meaning of additional food ration, what it is meant
for and/or the separate supplementary ration meant for moderate malnutrition child
only.
7. Give the next follow up appointment date.

Figure 4: Summary of the Steps in the Management of MAM

3.3.4 Routine Medicine

Vitamin A

Children 6-59 Months

 Routine supplementation should be given on admission except where Vitamin A has

been given in the past 3 months or health campaigns have ensured good coverage.
 Children referred from outpatient care, inpatient care or other health facility where
Vitamin A has already been given should not be given Vitamin A.
 Children showing clinical signs of Vitamin A deficiency should be referred for
treatment at inpatient facility center.

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 Table 8: Vitamin A for Children 6-59 Months
Vitamin A At admission 6 months to 11 months 100000IU Single dose on admission
12 to 59 months 200000IU Single dose on admission
Antihelminths
To ensure adequate weight gain, all children 12-59 months must be routinely treated (every six months)
for worm infections with mebendazole or albendazole .On admission check on the health card and/or ask
the mother if the child has received Albendazole in the last six months. If not administer Albendazole to
all children over 11 months.

Table 9: Routine Medicine for MAM Antihelminths

<11 months Do not give
12-23 months 200mgs 1/2 tab on admission
Albendazole* At admission
>23 months 400mg 1tab on admission

Iron and Folic Acid

Children 6-59 months: Children with anemia should be treated according to WHO and Integrated
Management of Childhood Illness (IMCI) guidelines; this should include malaria testing and treatment in
endemic areas (in malaria endemic areas, prevention should be an important part of the
intervention).Children with severe anaemia should be referred to in patient facility center (TFC)for
treatment Administer Iron/Folic Acid fortnightly, as shown in Table 10.

Table 10: Routine Medicine for MAM Iron

6 to 24 months (with 12.5mg Daily dose for one month
low birth weight ) iron/50µg folic
Iron /folate At admission 24 to 59months acid
20-30mg Daily dose for one month
6 to 11 years 30-60mg Daily dose for one month
Adolescents and adults 60mg Daily dose for one month

MALRIA Treatment
Systematically screen all children for malaria in endemic areas on admission regardless of their body
temperature, if diagnostic tests are available. If in clinical doubt or symptoms, repeat the malaria test in
the weeks following the initial test.

If no diagnostic test is available but malaria symptoms are diagnosed, treat the child.
Treat malaria according to the national treatment protocol ( see Annex 11 )

Immunization
(EPI) update, should be provided through referral to clinic services and administered according to
national guidelines.
Note:
International guidelines on Integrated Management of Childhood Illnesses (IMCI) recommend that during
emergencies measles vaccine should be given to children starting from 6 months because their immunity
is likely to be compromised as a result of inappropriate dietary intake and/or increased levels of
infections.

It is also important to check each child’s immunization card for measles vaccination status and give
measles vaccine if the child has not been vaccinated for measles. If child has no card or proof of
vaccination against measles, assume that the child has not been vaccinated.

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Pregnant and Lactating Women
 Pregnant women should NOT be given Vitamin A.
 Vitamin A is given at postpartum, within six weeks after delivery only.

Table 11: Systematic Treatment for Pregnant and Lactating Mothers

Name of Product When Physiological Prescription Dose

status
Vitamin A Within first 8 weeks Lactating 200000IU Single dose on
admission
Note: Avoid high dose of vitamin A (200000IU) to pregnant women because it can cause risk of
birth defects

Albendazole** At admission Second 400mg Single dose

trimester

Note: In Malaria endemic areas and transmission of infection is high give curative anti-malaria
on admission, all women should be advised on prevention measures and clinical cases of Malaria
treated promptly according to the national guidelines.
** Or other antihelminth according to national guideline: e.g. Mebendazole: Not recommended
during the first trimester of the pregnancy and lactation; At 2nd trimester give 500mg
mebendazole (single dose) or 100mg mebendazole twice daily for 3 days. [Studies have shown
that slightly higher rates of foetal abnormalities have been seen in mothers taking Mebendazole
during early pregnancy (Roundworm, clinical knowledge summaries, 2007)].

3.3.5 Nutrition Counseling and Health Education

3.3.6 .1 Nutrition Counseling

The patient or caregiver must receive adequate information about the cause of their
malnutrition, and how to avoid a relapse. Some patients may require both nutrition
counseling and food rations. Ensure that they receive both. After counseling, ask caregiver
or adult patient to explain what they will do at home. This is to make sure they understand
the new practices. It is also important to inform the community worker about the counseling
messages for follow-up purposes.

 Give key messages.

 Advise mothers/caretakers clearly on how to prepare the ration.
 Explain how to store the ration safely.
 Give, where possible, preparation and cooking demonstrations at the SFP site or in
the community.
 Ensure the mother/caretaker understands that the ration is intended for the
malnourished individual and is not to be shared.
 Make sure the mother/caretaker knows when to return to the SFP.

3.3.7.2 Health and Nutrition Education for MAM Cases

 Provide clear information on how to use the nutrition product in a hygienic manner and
how and when it should be consumed. Provide practical preparation and cooking
demonstrations at the SFP site/in the community. The gathering of large numbers of
mothers and caretakers is a good opportunity for health education.

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 Simple messages can be developed for use in the SFP and in the community that
attempt to address some of the underlying reasons for the child or mother becoming
malnourished in the first place. In some contexts, these messages may already exist and
can be adapted (for infant and young child feeding breastfeeding and complementary
feeding messages). Every attempt should be made to use the same or similar messages
that are given out in other existing programmes.

 It is essential that messages are reinforced by practice. These messages should focus
on: basic hygiene such as hand-washing,(ten steps) the importance of frequent and
active feeding and what local foods to give young children; identifying malnutrition;
management of diarrhea and fever and recognizing serious signs.

3.3.8 Nutrition Products Distribution

Specialized nutritional products are recommended to MAM patients in Yemen. The

recommended amounts of each commodity are shown (in Table3) For those taking home
dry ration based on blended foods such as WSB, conduct a cooking demonstration for new
patients and caregivers. Explain how to make and serve the porridge and adapt it to the
local recipes.

Remind patients and caregivers that the nutrition product is only for the patient.
Explain to them how long the nutrition product should last (usually for two weeks if it is for
children, or one month depending on the quantity if it is for PLW).

3.3.9 SURVEILLANCE

 Take the MUAC measurement at each visit and compare with the discharge criteria.
 Take weight measurements of children at each site and on discharge and compare with
the target weight recorded at the time of admission and to the minimum weight for
transfer to SAM treatment.
 Diagnose whether the child meets any of the criteria of failure to respond to treatment
 Check whether the child meets the minimum weight and has now met the SAM
criteria(W/H <-3 ZScore) immediately transfer them to the OTP.
 For the SAM follow up childern check whether the child meets the minimum weight to
enter the criteria for MAM (W/H<-2 and >- 3Z the child should then be reclassified as a
new MAM case.
 Treat any infection such as skin infection or eye infection.
 Refer the patient to the nearest hospital if medical complications developed. .
 Give routine treatment at the appropriate visits
 Explain the change in the nutritional status to the caregiver.
 Give and record ration at each visit on the ration card of the caregivers
 Inform of the next visit

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 Table 12: Summary of the Surveillance in SFP

3.3.10 Home Visits

Program outreach health workers /community volunteers should take up the responsibility of
following up program beneficiaries that are recorded as absent or defaulted. A patient that
misses an appointment is considered an absentee and must be followed by the outreach
worker and reasons for lack of visit established. This patient should be encouraged to return
to program. A patient is reported to be an absentee if he/she fails to attend a follow-up visit
once and said to be a defaulter if absent for more than 3 consecutive visits for bi-weekly
distribution and 2 consecutive visits for monthly distribution.

3.4 Failure to Respond to Treatment

It is essential to strictly apply the failure to respond criteria: children must not languish in
the SFP for weeks or months without being identified and the cause of failure investigated
and managed. For this reason, on admission, not only the discharge weight should be
calculated but also the weight at which criterion for SAM is reached and actions needs to be
taken urgently.

3.4.1 Criteria for Failure to Respond to Treatment

These are maximum time limits for labelling the patient as failure to respond to treatment, in
most circumstances, action should be taken before these limits are reached.

1. Either no or trivial weight gain after 5 weeks in the program or at the 3rd visit.
2. Any weight loss by the 3rd week in the program or at the 2nd visit.
3. Weight loss exceeding 5
percent of body weight at any time (the same scale must be used).
4. Failure to reach discharge criteria after 3 months in the program.
5. Abandonment of the program (defaulting).

3.4.2 Reasons for Failure to Respond

1. Problems with the application of the protocol: this should be addressed first.
2. Nutritional deficiencies that are not being corrected by the diet supplied in the SFP.
3. Home/ Social circumstances of the patient.
4. An underlying physical condition/illness.
5. Other causes.

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3.4.3 How to Manage Failure to Treatment

To test whether any of these are the cause first an appetite test can be conducted. If the
child is eating well or is hungry and yet fails to gain weight at home then a major social
problem is confirmed. This is then investigated with an in-depth interview with the
head/main decision maker in the household (father, mother-in-law) and a home visit is
performed. If the child does not take the test meal and appears not to have an appetite, this
may be because of shyness, unfamiliarity with or dislike of the RUSF/RUTF, then one
strategy is to admit the child to day-care and feed the child under direct supervision for a
day or so.

3.4.4 Discharge Beneficiary from Program

There are several ways of discharging a beneficiary from a program, these are;

 Cured: Fully recovered or does not show any signs of malnutrition according to the
discharge criteria shown in Table 2. If the beneficiary has not recovered, an
immediate investigation should be done to determine causes of delay in responding
to treatment. The causes of these delays could range from irregular food
distributions, medical problems to social related problems.

 Died: Died after admission in program.

 Defaulted: Absent from program for 3 consecutive visits for bi-weekly distribution
and absent from 2 consecutive visits for monthly distribution.
 Transfer: Condition of the patient deteriorated and transferred to hospital (SC/OTP)
or transferred to another SFP site.
 Non-response: If beneficiary has not attained cured criteria for discharge after 3
months, conduct investigation and continue treatment for another one month,
discharge as non-respondent if does not recover by the 4th month.

Table 13: Discharge Criteria of MAM

Exit criteria for SFP

Criteria
Category

Cured - Children 6-59 MUAC>125mm

months* AND Minimum 2 months stay in the programme

Cured - Pregnant and MUAC>230mm

lactating women AND Minimum of 2 months stay in programme
Or When infant reaches 6 months

Defaulted Absent for 2 consecutive visits if SFP is monthly or 3

consecutive visits if SFP is every 2 weeks

Died Died during time registered in SFP

Non-response Child has not reached discharge criteria within 4 months

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