Management of Moderate Acute Malnutrition

Supplementary Feeding Programme (SFP)

PRESENTER: Mr.Abdikadir Shekh Hussein

TELL:0613080842/0613080843/0615961264
EMAIL:nationaltcc01@gmail.com
 Objectives

To Learn SFP Protocols

To learn how to manage moderately

malnourished patients
To treat moderate acute malnutrition
(MAM) and prevent individuals with
MAM from becoming severely
malnourished
What is Moderate Acute Malnutrition
o A person is considered as moderately acutely malnourished if he/she
falls under the following anthropometric criteria:

o Weight-for-height < -2 z-scores (WHO GS)

o MUAC < 12.5 cm for children below 5 years old
o MUAC < 21 cm for Pregnant and breastfeeding
women
o MUAC < 23.3cm for PLWHA
o BMI between 16 and 16.9 for adults
o BMI < 18.5 for adults (PLWHA
* In this guideline, only children 6-59 months are
considered
SFPs

Types of SFPs
Blanket SFP – addressed to all members of a
particular group

Targeted SFPs – addressed to those that

presents MAM
Both types of SFPs are related to other
services, namely community mobilization
and OTP/SC
Diagnosis
Diagnosis procedures

Anthropometric measurements
 Screen children 6-59 months, Pregnant and Lactating mothers,
presenting with clinical wasting for malnutrition;

◦ Measure weight

◦ Measure height

◦ Measure MUAC

◦ Check oedema ( if present refer for therapeutic care)

◦ Check Medical conditions

Calculate and determine nutritional status
o Calculate
◦ Weight-for-height for children<5yrs
◦ BMI for adults**

o Determine nutritional status

◦ Use cut-off points to determine the level of
moderate acute malnutrition (at risk or
moderate)

o Record
◦ Record measurements on patient card
 Conduct causal assessment of MAM

Health status
Food consumption and care
 Assess patient's practices
general health:
 For children, check Breastfeeding practices (note:
immunization status exclusive for <6months)
and Vit A Food consumption and frequency
supplementation Child care practices
 For PLW, check
micronutrient
deficiencies and
iron/folate
supplementation
status
Choice of treatment
o If the patient is moderately malnourished, refer for nutrition
and medical treatment as well as nutrition counseling

o If the patient is at risk of malnutrition, refer for nutrition

counseling

o If there is inadequate food at household level: refer

individual to available food-based program

o If the individual is sick, requires immunization,

micronutrient supplementation or suffers from
micronutrient deficiencies, refer to the relevant health
services
ROUTINE MEDICATION
Systematic Medicine for Moderate Malnutrition in SFP
Name of Product When Age / Weight Prescription Dose

6 months to <1 100 000 IU

year
Single dose on
VITAMIN A* AT ADMISSION ≥ 1 year 200 000 IU admission
DO NOT GIVE TO CHILDREN WITH
OEDEMA

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

< 1 year DO NOT GIVE NONE

200 mg (1/2
ALBENDAZOLE AT ADMISSION 12 - 23 months tablet) Single dose on
second visit
≥ 2 years 400 mg (1 tablet)

6 – 24 months 12.5mg Iron

24 – 59 months 20-30 mg Daily for one
IRON FOLATE ** AT ADMISSION month
6 – 11 years 30-60 mg
adults 60 mg

* VITAMIN A: do not give if child has already received within last 3 months

** IRON: DO NOT give in malaria endemic areas. In this areas give only to children with anaemia.
Treatment for Pregnant and Lactating Women

Name of When Physiological Prescription Dose

Product status
Vitamin A* Within first 6 Post partum 200000IU Single dose on
weeks after admission
delivery if not
lactating
Within first 8 Lactating 200000IU Single dose
weeks
Mebendazole NOT Second trimester 400mg Single dose
Recommended Albendazole
during pregnancy
and lactation (BNF)

500mg Single dose

mebendazole
Iron/ Folic On admission During 60mg+400µg folic Daily dose
acid pregnancy and acid
lactation

* Vitamin A can be obtained from UNICEF and should be

included in any list of essential drugs.
Nutritional support
 Supplementary food should provide the beneficiary with;

 1000 – 1200kcal per day;

 35 to 45g protein per day
 fat supplies 30% of the required energy per day

 A typical food ration should comprise of a cereal, pulses, oil and

sometimes sugar

 Take home ration should be premixed before distribution

 SFP: Treatment Notes
•Ensure the SFP card is completed (the mother /
caretaker takes the card home and brings it back
next visit).
•Clear advice needs to be given to mothers
caretakers on how to prepare the ration.
•Where appropriate a cooking demonstration
can be conducted for new cases.
•Ensure the mother/caretaker understand that
the ration is intended for the malnourished
individual and is not to be shared.
•Explain how to store the ration safely.
Nutritional counselling
◦ All patients should receive nutrition
counseling

◦ Counseling should include:

 Getting information about the cause of malnutrition,
and how to avoid a relapse
 Food preparation (demonstration) and conservation
 Special care for the malnourished child
 Best family care practices
 Health and Nutrition Education
All the pregnant women will be motivated for:
 Taking good diet which is available during pregnancy and Lactation.

 Antenatal Checkups as per schedule.

 vaccination (TT as per schedule)

 Iron/Folic acid during pregnancy and after delivery

 Delivery under Trained Birth Attendant

 Complete Immunization of child according to schedule with special

emphasis on Measles immunization.
 Infant feeding and Hygiene

All the lactating women will be motivated for:

• Early breast feeding (with one hour after delivery)

• Exclusive breast feeding for first six months of lactation.
• Complementary feeding at 6 months of age.
• Continue breast feeding for at least 2 years
• Continue feeding even child is ill
• Increase food soon after illness of child.
• Complete immunization before 1st birth day especially measles
• Hand washing with soap before and after feeding child and after use
of toilet
Key messages for supplementary feeding

o Remind patients and caregivers that the ration is only for the
patient.

o Explain how long the ration should last

o Carefully explain to the patient or caregiver what is expected

for the next visit and its importance.

o Conduct a cooking demonstration for those taking blended

foods
Surveillance/follow-up of patients in SFP

 Make an appointment with the patient for

follow-up, or encourage the caregiver to come
to the next nutrition counseling and food ration
allocation sessions

 Explain the expected progress from the child

and likewise the adult patient.

 Explain to the patient or caregiver that a CHW

is likely to visit his/her home for follow-up.
Introduce the CWH if she/he is present.
 Follow-up at the targeted SFP

At each vist: Monthly:

 At each visit: •Measure height/length.
 Measurement of oedema. •Recalculate W/H.
 Measurement of weight. When necessary:
 Measurement of MUAC. Refer to medical facility for
 Medical checks and treatment if health problems that
cannot be treated at the
necessary.
 Give routine medicines if
SFP
necessary.
 Assess evolution of the patient:
organise home visit or refer if no
evolution.
 Distribute food items.
 Update ration card and SFP card.
 Give health education.
Follow-up at the blanket SFP
No individual monitoring is required in
Blanket SFPs. There is no registration of
beneficiaries.
A general report on geographic location,
date of distribution, number of beneficiaries
and ration composition is required for
logistical purposes and evaluation.
All beneficiaries should remain in the
programme for the duration of the blanket
feeding operation (often around 4 months).
Discharge criteria for SFP

Cured
 W/H > -2 Z-score, and
 MUAC > 12.5 mm, and
 For 2 consecutive visits
 Default
 Absent for 3 consecutive visits
 Death
 Died during time registered in SFP
 Non-cured
 Has not reached target weight within 4 months
 Transfer to OTP/SC
 Condition has deteriorated and requires transfer to OTP or SC

Discharge criteria SFP
• Pregnant and lactating mothers attain a MUAC
that is above >21cm
Failure to respond to treatment in sfp

A child that does not gain weight or develops

complications is defined as a failure to respond
to treatment. A special procedure should be
implemented to identify these children and
provide appropriate action (improvement of
treatment follow up or transfer). This should be
always done before the child reaches the 4
months of treatment and is discharged as “non-
cured”.
Criteria for failure to respond
Failure to reach discharge criteria after 4
months in the program
No weight gain after 6 weeks in the
program
Weight loss over 4 weeks in the program
Weight loss exceeding 5% of body weight
at any time
Reasons for failure to respond

Problems with the application of the protocol

(when many children are not recovering)
Nutritional deficiencies that are not being
corrected by the diet supplied in the SFP
Home/ Social circumstances of the patient
(ex. Sharing or selling of the food)
An underlying physical condition/ illness (to
be examined by an experienced nurse)
other causes
Treatment Effectiveness Indicators

 Average weight gain >3 g/kg bodyweight/day

 Cure Rate (proportion of exits recovered) > 75 %
(SPHERE)
 Default rate (proportion of exits defaulted) < 15 %
(SPHERE)
 Mortality Rate (proportion of exits who have died) < 3
% (SPHERE)
Setting up program
1. Collection of information
2. Procure equipment and documentation
3. Recruit and allocate staff
4. Determine expected patient load
5. Supplies procurement and distribution
6. monitoring and evaluation
Collection of information
o Population by catchment health facility

o Staffing positions

o Storage space

o Transportation and road conditions

o Supply chain for immunization

o Documentation of all intervention processes

Procure Equipment and Documentation
 The anthropometric equipment required include:
◦ height boards
◦ weighing scales
◦ MUAC tapes, both child and adult
◦ clinic cards, ration cards, and register books
 Nutrition education and training materials:
◦ counseling cards;
◦ monthly report sheets;
◦ Request forms
Staffs allocation
 Ideally a nutritionist/nurse to manage the program, give
nutrition counseling, and organize refresher courses as
protocols and guidelines are revised

 A nurse to assess patients for common ailments and give

health-related counselling

 A store keeper to manage supplies (for non-integrated)

 A cook (for wet feeding program)

 Community Health Workers (CHW) to assist nutritionist

and conduct follow-up
Calculate Expected Patient Load
The expected number of moderately
acute malnourished patients per health
facility can be calculated by using the
nutritional data recorded at each
health facility
Supplies Procurement and Distribution
An accurate estimate of supplies is essential to
avoid supply shortages or over-supply that
result in wastage