Integrated Management of

Acute Malnutrition(IMAM)
Mr Abdiasis Mohamed Gure( BSN &
MPH)
Lecturer at
1. Mogadishu University
2. Salaam University
3. Daha INTERnational University
4. Hilal University
5. KownAYn University
6. Capital University
7. Alimra -international University
 Common forms of
malnutrition in Somalia
• Malnutrition is a major public health
problem in many developing countries.
It is one of the main health problems
facing women and children in Et. The
country has the second highest rate of
malnutrition in Sub-Saharan Africa
(SSA).
 Somalia faces the four major forms of malnutrition:

1. acute and chronic malnutrition,

2. iron deficiency anaemia (IDA),
3. vitamin A deficiency (VAD),
4. and iodine deficiency disorder (IDD).
• The 2005 Demographic Health Survey
(DHS) has shown that about 47 % and 11%
of Somalia children under five years of
age were stunted and wasted respectively.
 OVERVIEW OF ACUTE
MALNUTRITION
• Acute malnutrition is a deadly disease. It arrives
as the consequence of insufficient or
inappropriate feeding and as a consequence of
disease. Without appropriate treatment, acute
malnutrition may result in the death of the child.
• Even the children that survive may remain
vulnerable to other episodes of malnutrition and
disease and present lower intellectual and
psycho-motor abilities, which will in turn reduce
their chances later in life.
 Acute malnutrition: types and
classification
• The term acute malnutrition makes reference
to two different medical entities with different
clinical and pathological characteristics:
Marasmus (or wasting) and Kwashiorkor.
• Each of them is the consequence of different
metabolic disturbances. Despite these
differences, the standard protocols to treat
them are similar, with small – but important –
differences.
MODERATE ACUTE MALNUTRITION
• Moderate acute malnutrition (MAM), also known as
wasting, is defined by a weight-for-height indicator between
-3 and  -2 z-scores (standard deviations) of the international
standard or by a mid-upper arm circumference (MUAC)
between 11 cm and 12.5 cm.
• SEVERE ACUTE MALNUTRITION
• Severe acute malnutrition (SAM) is the most dangerous form
of malnutrition. If left untreated, SAM can result in death.
 Marasmus

• It is a clinical syndrome and a form of

under nutrition characterized by failure to
gain weight due to inadequate caloric
intake.
 Clinical features in Marasmus
• Marked muscle wasting and loss of
subcutaneous fat.
• Monkey Faces
• Skin becomes loose and hangs in folds
• Abdomen protuberant due to hypotonic
muscles
• Temperature is usually sub-normal
• Child is alert
02/13/2022 Lecturer by : Dr Abdinor Ali Ahmed
• Thin face.
• Ribs and shoulders clearly visible
through the skin.
• Very loose skin that sometimes
hangs in folds in the upper arms,
thighs, and buttocks.
• Persistent dizziness.
• Sunken eyes.
• Diarrhea.
• Active, alert, or irritable behavior.
• Frequent dehydration.
02/13/2022
Lecturer by : Dr Abdinor Ali Ahmed
 Kwashiorkor
• It is a condition caused by severe protein
deficiency It is most often encountered in
developing countries in which the diet is
high in starch and low in proteins.
• It is common in young children weaned to a
diet consisting chiefly of starch.
 Clinical features of Kwashiorkor
• change in skin and hair color (to a rust color) and texture.
• fatigue.
• diarrhea.
• loss of muscle mass.
• failure to grow or gain weight.
• edema (swelling) of the ankles, feet, and belly.
• damaged immune system, which can lead to more frequent
and severe infections.
• irritability.
• Moon face
• Loss of appetite
• Dermatitis
 Grades of oedema
Grades of oedema Definition
Absent Absent
Grade + Mild: both feet/ankles
Grade ++ Moderate: both feet, plus lower
legs, hands and lower arms
Grade +++ Severe: generalized oedema
incl. both feet, legs, arms, face
Finger pressure test – you cannot tell just
by looking
02/13/2022 Lecturer by : Dr Abdinor Ali Ahmed
 CMAM components

• Community Mobilization

• Supplementary Feeding Programmes

• Outpatient Therapeutic feeding Programmes

• Stabilization Center
 Management Protocols
• Objectives and Target group

• Admission Criteria

• Products (Food)

• Medical Treatments

• Follow ups
How CMAM Components fit together
 Supplementary
Feeding
Programmes
(SFP)

Management of Moderate Acute Malnutrition (MAM)

 Supplementary Feeding Programmes (SFP)
• Objectives:
– The main objective of Supplementary Feeding Programmes/Centres (SFPs)
is to treat Moderate Acute Malnutrition (MAM) and prevent individuals
with MAM from becoming severely malnourished (SAM).
• SFPs are usually separated into two types:
– Blanket Supplementary Feeding Programmes (BSFP): is addressed to all
members of a particular group, like children below 5 years or pregnant or
lactating women, irrespective to their nutritional status (Except SAM): this
is mainly short time period; 3-6 months...The only admission criteria for
BSFP is the age grouping.
– Targeted Supplementary Feeding Programmes (TSFP): is addressed only to
those that present MAM. These can be children below 5 years, pregnant
and lactating women, etc. Targeted feeding is offered as well to children
discharged from OTP or SC, after recovering from SAM. This project can be
implemented longer time period....
Admission and Discharge Criteria of TSFP
 Other Discharge Criteria
Other conditions for discharge:

1. Died: died while admitted in program

2. Defaulted: Absent from program for 3 consecutive visits

3. Transfer: Condition of the patient deteriorated and

transferred to hospital or transferred to another SFP site

4. Non-response – Not attained cured discharge criteria

within 16 weeks ( 4 months) of program implementation
Systematic Medicine for Moderate Malnutrition in SFP
 Surveillance / Follow up of patients in SFP
Patients may attend the SFP every week, every other week, or monthly

• Follow up at the Targeted SFP: • Follow up at the Blanket SFP:

At each visit: • No individual monitoring is required in
• Measurement of oedema. Blanket SFPs.
• Measurement of weight. • A general report on geographic
• Measurement of MUAC. location, date of distribution, number
of beneficiaries and ration composition
• Medical checks and treatment if necessary.
is required for logistical purposes and
• Give routine medicines if necessary. evaluation.
• Distribute food items. • All beneficiaries should remain in the
• Update ration card and SFP card. programme for the duration of the
• Give health education. blanket feeding operation (often
 Monthly: around 4 months).
• Measure height/length.
• Recalculate W/H.
When necessary:
• Refer to medical facility for health problems
that cannot be treated at the SFP.
 Failure to respond to treatment in SFP
The reasons for failure to respond can be
Criteria for failure to respond to treatment
classified as:

• Failure to reach discharge criteria after

• Problems with the application of the
4 months in the program
protocol (when many children are not
• No weight gain after 6 weeks in the recovering)
program • Nutritional deficiencies that are not being
• Weight loss over 4 weeks in the corrected by the diet supplied in the SFP
program • Home/ Social circumstances of the
• Weight loss exceeding 5% of body patient (ex. Sharing or selling of the food)
weight at any time. • An underlying physical condition/ illness
(to be examined by an experienced nurse)
• other causes.
Transfer to OTP/SC:
All children that meet the criteria of Severe Acute Malnutrition should be
transferred to the OTP or SC depending on their condition. Additionally, those that
present a failure to respond to treatment that cannot be corrected in the SFP (after
having checked through the list above and tried all options) should also be
transferred for further investigation.
 Basic Staffing in TSFP

Health /
Nutrition
Coordinator

Nutrition
Supervisor /
Officer

Storekeeper /
Nurse (1) Screeners (2) Registration (1)
Distributor (1)
 Outpatient
Therapeutic
Programme (OTP)

Management of uncomplicated Severe Acute Malnutrition (SAM); -

Outpatient Care.
Development of PlumpyNut–a
Ready to Use Therapeutic Food
(RUTF) equivalent to
F-100
Uncomplicated Complicated
 Outpatient Therapeutic Programmes (OTP)
• Objectives:
– OTP is a programme that treats patients with severe acute malnutrition (SAM) with present
of good appetite and no medical complications

• Fixed or Mobile teams:

– The OTP should ideally be organised as part of MCH activities in a Health Centre. However in some
areas with low access to health facilities, it is implemented independently. In both cases, the team
of the OTP may be fixed (they always work in the same centre) or mobile.

• Weekly or Bi-weekly visits:

– In most centres the child is seen weekly, while in others they are seen every other week. Weekly
centres have the advantage that the child's follow up is better (which is particularly important for
complicated cases that are treated in OTP instead of in the SC),

• OTP centres do not operate in isolation but with relationships:

– Community mobilization
– TSFP
– SC
 Why, Advantages and disadvantages of OTP?

• Before a Decade, All SAM cases used to be treated as inpatient

(therapeutic Feeding Center = TFC),

• The invention of the Ready to use therapeutic Food (RUTF) and the severe
cross infection complications in the TFC patients lead the idea of treating
SAM without complication as outpatient (OTP) while the rest cases, their
medical complications can be stabilized in the same TFC but now called
Stabilization Center (SC).
 Advantages and Disadvantage of OTP
Advantages of OTP: Disadvantages of OTP:

• High coverage (high number can • Not compliance or Potential of

be treated in short time), sharing of food and medications

• Caregivers can give care to other • Poor attendance or Absenteeism

children and family (security and distances),
Age Group, Admission and Discharge Criteria for OTP
Category Indicator Admission Criteria Discharge Criteria - Cured
WfH Z Score <-3 >-3
MUAC (CM) <11.5 cm >11.5 cm
No oedema for 2
Children 6 - 59 months

Oedema None or Oedema +, ++

consecutive visits
Appetite Passed Appetite good appetite
Medical status No medical Complications no medical complications
Transfer back from SC after
Other Indicators

died
recovery
previously discharged as
defaulter
cured but again SAM
return after defaulting non-cured after 3 months
Duration of stay Weekly visit for 12 weeks = maximum 3 months
If Seen medical complication (Danger signs) refer to SC
 How to do appetite test
A poor appetite means that the child is ill and requires treatment in a SC or hospital. He will not
take the diet at home and will continue to deteriorate or die.
Appetite is considered sufficient when the child eats willingly around ¾ of the sachet

How to do the appetite test

1. The appetite test should be conducted in a separate quiet area.
2. The carer should wash her hands and the child’s hands.
3. The carer should offer the child the RUTF gently, encouraging the
child all the time.
The child must not be forced to take the RUTF.
4. The child needs to be offered plenty of safe water to drink from a
cup as he/she is taking the RUTF.
If you think that the child did not pass the test because he/she was
frightened or did not like the product, try repeating it in a calmer
environment.
 Nutritional Product for the treatment of OTP

• For the moment, RUTF (Plumpynut) is the only prescribed food for SAM
children in the OTP,

• RUTF (500 Kcal = 92g) is an energy-dense, mineral/vitamin-enriched

product that is equivalent to F100 with added iron. It contains the
required energy and micronutrients to meet the nutritional needs of the
severely malnourished child. RUTF is an oil-based, ready-to-use product
that has a low risk of contamination.

• RUTF is prescribed according to the weight (Kg) of the patient and the
caregiver is usually given a message of health and how to use the product,
 Dosage prescribed for RUTF in the OTP
(500 Kcal = 92g) ,average 200kcal/kg/day

Weight of Child Packet Per day Packet Per Week

(kg)
3.5-3.9 1.5 11
4.0-5.4 2 14
5.5-6.9 2.5 18
7.0-8.4 3 21
8.5-9.4 3.5 25
9.5-10.4 4 28
10.5-11.9 4.5 32
>_12 5 35
 Key Messages for OTP with RUTF
 Breastfeeding is best – and first. For infants and young children, continue to put the child to
the breast regularly.
 RUTF should not be shared. It is a food and a medicine for the malnourished child only)

 Give small regular meals of RUTF. Sick children often do not like to eat. Encourage the child
to eat often (if possible 8 meals a day).
 Give RUTF before other foods (except for breastmilk). RUTF is the only food the child needs
in order to recover.
 Offer safe water. Always offer plenty of clean water to drink while he or she is eating the
RUTF.
 Wash hands and face with soap before eating and after going to the toilet.
Keep food clean and covered.
 Give RUTF even if child is ill or has diarrhoea. Give extra food and extra clean water and
breastmilk if the child has diarrhoea. Seek medical treatment if large amounts of watery
diarrhoea.
 Sick children get cold quickly. Always keep the child covered and warm.
 Recommend use of an insecticide-treated to protect the child while sleeping at night in
malarial areas.
 Outpatient Care:
Routine Medication

• Amoxycillin
• Anti-Malarials
• Vitamin A
• Anti-helminths
• Measles
vaccination

41
 Systematic Treatment
Systematic Medicine for Severe Malnutrition in OTP
Name of Product When Age / Weight Prescription Dose

6 months to 100 000 IU

< 1 year

VITAMIN A* AT ADMISSION ≥ 1 year 200 000 IU Single dose

on admission
DO NOT GIVE TO CHILDREN
WITH OEDEMA

AMOXICILLIN AT ADMISSION All beneficiaries See protocol 3 times a day

for 7 days

MEASLES VACCINATION AT ADMISSION From 9 months (standard) Single dose

on admission

< 1 year DO NOT NONE

GIVE

ALBENDAZOLE SECOND VISIT 12 - 23 months 200 mg (1/2

tablet) Single dose
on second
400 mg (1 visit
≥ 2 years tablet)

* VITAMIN A: do not give if child has already received within last 3 months
 Follow up Visits
Procedure Rationale
Weight and MUAC Review progress with carer to ensure weight gain; investigate causes if not
Oedema check Check for oedema to ensure that it is resolving and to make sure it has not
developed. Consider transfer to inpatient care if oedema develops or persists

Complete OTP card This card is designed to help nutrition site workers carry out essential assessments
and follow up (see ANNEX B)

Complete carer’s Given to help ensure continuity of care if the carer has to move area (see ANNEX C)
/ration card

Clinical assessment, Carry out every visit to evaluate if child requires inpatient care or can continue in
history, appetite test OTP; refer to inpatient if there is a deterioration

Complete medicines Check systematic treatment table and vaccination calendar and complete as
required: prescribe additional medicines to treat specific conditions if necessary

Provide RUTF Ensure the child still has appetite and provide RUTF (Plumpynut) ration
Education Repeat key messages on RUTF and other health/nutrition messages
Community follow up Link with community health workers if not already done so
 Failure to Respond

Assessment of failure to respond to treatment – examples.

Indications of failure to respond require
further investigation or transfer to SC and Both social and clinical causes should be considered.
Social Clinical
include:

– Failure to gain any weight or  Poor hygiene  Conditions

weight loss after 3 consecutive  Poor feeding practices resistant to
weeks of treatment  Sharing of RUTF treatment
 Undiagnosed
– No improvement in clinical Causes
condition pathology
– Increase of oedema and/or no
resolution of oedema by 3 weeks
– Child has not reached discharge
criteria by week 16 = Community Clinician:
nonresponder Worker/volunteer: home  Seek causal
visit pathology
– Note – do not wait until week 16 to
take action. Investigate and deal  Investigate cause  Treat possible
with immediately.  Reinforce health causes
Actions education
 Feedback to clinician
Stabilization Center
(SC)

Management of complicated Severe Acute Malnutrition –

Inpatient Care
 Stabilization Center
• Objectives:
• To stabilize the metabolic malfunction and medical
complication of children with SAM cases,

• Set up of the center:

– See the basic organo-gram for the stabilization center

– It should be opened where 24 hr care is suitable (Hospital –

Pediatric Wards are the best choice)
• Pediatric Wards
• Kitchen (Clean)
• Lightings
• Enough Supplies
 Basic Staffing (Organo-gram) at the stabilization Centers

Hospital Administrator /
Nutrition Coordinator

Qualified Nurses
(general caring, Medical Doctor
education, drug (Treatment of
administration, Medical
reporting etc) complications)

Nurse Assistants Others

(feeding, phase (Storekeeper,
monitoring etc) Cleaners etc)

Note: qualified Nurses, Nurse Assistants and others are mandatory to be working in each shifts
(Day and Night Shifts)….Doctors can be working according to their availability.
 Admission and Discharge Criteria of the SC
Admission Criteria for SC
Children 6-59 months Admission Criteria for children <6 months:
SAM with complications
• Children from 0-6 months with:
W/H (Z-score) <-3
MUAC (mm) < 115 – Clinical Manifestation of
Bilateral oedema +++ Malnutrition
Oedema Marasmus with any oedema – Not able to feed (breastfeed)
Appetite NO APPETITE – Have medical complications
Uncontrollable vomiting
Fever > 39 ºC
Hypothermia < 35 ºC
Lower respiratory tract infection
Complications Discharge Criteria for all:
Severe anaemia
Extensive skin infection • No medical complication
Very weak, apathetic • No Oedema
unconscious, convulsions • Good appetite
Child referred from OTP due to
complications or lack of weight • Feeding well (Breastfeeding)
Other
gain
Choice of the carer
Phases of nutritional treatment and medication in the
stabilization center

• Management of Stabilization Center has 3 phases: (Average total duration

= 2 weeks):

– Stabilization Phase (Phase 1) …(1st -7th day of Treatment)

– Transition Phase…. (8th-9th Day of the treatment)

– Rehabilitation phase (Phase 2)…. (10th-14th day of the treatment)

 Monitoring and Promotion between phases to Discharge

Phase 2 - Discharge
CRITERIA Phase 1 - Transiftion Phase Transition Phase - Phase 2 Criteria (to OTP)

Appetite improved. Appetite is good. Appetite is Very Good

Appetite and intake

Child taking all quantity of Child is takingr all the F100 Child is taking at least or
F75 milk prescribed prescribed more than 75% of
Plumpynut

Oedema (if present) Reduced to moderate++ Reduced to low + Absent Oedema

Treatment Completed & All medications and

Treatment has commenced
Medical complications and patient is recovering most of complications medical complications
resolved resolved

They are not needed any

IV fluids and NG feeding No Need No need
more IV or NG feeding
 Stabilization Phase (Phase 1)
• Objectives with Phase 1:
– Restore metabolic functions
– Stabilise patients with complications
– Prevent and/or treat associated conditions and complications and,
– Intensively monitor patients

• Start diet with F75 Therapeutic Milk and Sugared water (10% sugar)(see
details next slides)
• Might be fed with Nasogastric (NG) Tube,
 F75 therapeutic Milk (Phase 1)

• Feeding should begin as soon as possible, at admission, with a starter diet

of F75.

• F75 is designed to meet the child's needs without overwhelming the

body’s metabolism at this early stage of treatment.

• F75 formula promotes rapid recovery of normal metabolic function and

nutrition-electrolyte balance.

• F75 is not designed to promote weight gain, as this would be dangerous

for the child at this stage of treatment.

• Note: Rapid weight gain during phase 1 should be considered a sign of

danger (probably fluid accumulation), and rapid action should be taken.
 F75 therapeutic Milk (Phase 1)
• F75 feeding in stabilisation

– For children with low WFH or low MUAC: give 130ml of F75 (100 Kcal) per kg
bodyweight per day

– For children with oedema (+++): give 100ml per kg bodyweight per day until
oedema is clearly reducing and is (++)

• All feeds should be given with cups or through NG Tube and should be controlled
by a feeding assistant. The mother or carer must be actively involved in the feeding
and the daily care of the child.
Box 11: Use of Naso-Gastric tube (NGT) with the Milk Feeding
NGT should ONLY be used when:

         Child takes less than 75% of the prescribed F75 diet per 24-hours during stabilization

         Child has pneumonia (rapid respiration rate) and has difficulties swallowing

         Child has painful lesions of the mouth

         Child has cleft palate or other physical deformity

         Child shows disturbances of conscience

Try to give F75 by mouth every time before using the NGT. The use of NGT should not last more than
3 days, and should only be used in the stabilisation phase (phase1).
 Transition Phase
• Inpatient transition phase
– During the transition phase, the child receives an increased amount of energy to allow
catch-up growth.

• Feeding in transition phase

– The transition between F75 and catch up diets (RUTF or F100) and from milk diet to solid
therapeutic foods, should be progressive, but happens for most children within one or
two days. Energy intake is increased gradually until the target minimum intake is reached
(150 – 220 kcal/kg/day). The frequency of the feeds remains the same as in stabilisation
phase.

– RUTF and F100 have a similar nutrition composition per 100 kcal, with the exception of
iron which is present in RUTF but not in F100. As a rule, preference is given to RUTF over
F100 during the transition if the child accepts it. RUTF is offered first at every feed and is
complemented with F100 or continued F75 feeds where needed
 Rehabilitation Phase (Phase 2)
• Only children admitted that exceptionally need to complete
the full treatment in inpatient care should go through this
phase.

• Children are fed preferably with RUTF and with F100 if RUTF is
not available. Normal meals should be gradually introduced in
addition to the therapeutic food products.
 ROUTINE MEDICINES in SC
• Phase 1.
• Vitamin A: As in OTP.
• Measles vaccination: As in OTP.
• Malaria treatment: As in OTP.
• Folic acid: As in OTP.
• Other Nutrients: As in OTP.
 
• Transition Phase:
• Routine antibiotic therapy should be continued for four days after Phase 1 or until the patient is
transferred to OTP or Phase 2. This is to ensure that any infection is treated. Patients arriving to OTP after
the SC do not need to be given antibiotics again. Their transfer slip should clearly indicate what systematic
treatment they received at the SC.

• Phase 2:
• Iron:
• For inpatients receiving entire treatment of acute malnutrition in the inpatient health facility: Add iron to
the F100 in Phase 2. RUTF already contains the necessary iron.

• De-worming:
• De-worming is necessary for malnourished children being treated as inpatients, but should be delayed
until they are recovering in Phase 2 or discharged to OTP.
 Systematic Anti-biotics in SC
• All severe acute malnourished children receive antibiotic treatment upon admission, regardless of if
they have clinical signs and symptoms of systemic infection or not.

• Antibiotic Regime
– First line antibiotic treatment:
• Oral Amoxycillin. (If not available, doctor to decide appropriate alternative).
– Second line antibiotic treatment:
• Add Chloramphenicol (FC 18) (do not stop Amoxycillin) OR
• Add Gentamycin 5 mg/kg IM daily (do not stop Amoxycillin) OR
• Switch to Amoxycillin/clavulinic acid (Augmentin®).

• Duration of Antibiotic Treatment:

– Antibiotics are administered every day of Phase 1 plus an additional four days or until transfer to
OTP or Phase 2.

• Remeber:
– IV antibiotics should not be used with intravenous infusion because of the danger of fluid overload.
– Indwelling cannula should rarely be used because Venous access point are often colonised by
resistant organisms and may give rise to bacteraemia
– Impregnated bed nets should always be used in malaria endemic regions.
 THANK YOU
FOR
YOUR ATTENTION
END