Community-based Management of Acute Malnutrition (CMAM)

2012

Objective

• To learn and differentiate the approaches to treating moderate and severe acute malnutrition

• To understand the basic knowledge about CTC; components and principles

• To gain the basic knowledge and techniques of implementing standardized CTC programme

• To learn the importance, techniques and concerns about community mobilization

Overview of Malnutrition Causes and Types

Definition of Malnutrition

• Broadly defined as a pathological state resulting from a relative or absolute deficiency or excess of one or more essential Nutrients

(protein, carbohydrate, fat, minerals, vitamins)

Lack of Human, Economic, and Institutional Resources

Malnutrition

Illness Inadequate intake

Household Food insecurity

Lack of Resources

Ecological Conditions

Lack of care of Mother and Child

Poor Environ. Health,Hygiene & Sanitation

Poor Political and Ideological Structure BasicCauses

ImmediateCauses

UnderlyingCauses

Adapted from UNICEF

Conceptual Framework for Malnutrition

Types of Malnutrition

• Undernutrition: too little– Protein Energy Malnutriton (PEM)– Micronutrient deficiencies

• Overnutrition: too much– Obesity

1. Protein-energy malnutrition (PEM):

Best assessed by weight & height

Majority of PEM is ‘hard to see’

Kwashiokor & marasmus affect very few children, except in severe famine situations

2. Micronutrient malnutrition (vitamin A, iron, iodine, vitamin D)

– Best assessed by clinical and biochemical measurements

Most micronutrient deficiencies are ‘hard to see’

Indicators of Nutritional Status Indicators of Nutritional Status (most frequently used)(most frequently used)

Anthropometric (Determination of Age, sex,weight and

height), Mid upper Arm Circumference(MUAC)

Clinical (Kwashiokor and Marasmus, oedema, conjunctiva

pallor, thyroid, …)

Laboratory

Others (dietary, …)

Assessing PEM:Assessing PEM:Anthropometric IndicatorsAnthropometric Indicators

Birth weight

Weight for Age (WA)

Height for Age (HA)

Weight for Height (WH)

Mid- Upper Arm Circumference (esp. emergencies)

Body Mass Index (BMI) – adults (wt/ht2)

What is CTC?

• A community-based nutritional intervention

to address malnutrition during emergencies

and in development

TFC Vs CTCTFCTFC CTCCTC

Severely Severely malnourished malnourished childrenchildren

all managed all managed inpatient inpatient

Only those with Only those with medical medical complicationscomplications

RiskRisk Risk of cross-Risk of cross-infectioninfection

No riskNo risk

Opportunity costOpportunity cost Very high to Very high to families for they families for they stay with admitted stay with admitted childchild

Low opportunity Low opportunity cost for the child cost for the child stays at homestays at home

CoverageCoverage Only few could be Only few could be managedmanaged

Close to 100 Close to 100 percent for many percent for many could be managed could be managed in their homesin their homes

Four core principles are at the heart of CTC:

• High coverage and good access to services- many are managed at home- services are closer to the people (decentralized)- Community mobilization techniques are used to engage the affected population

• Timeliness- begin case-finding and treatment before the prevalence of malnutrition escalates & medical

complications occur

Four core principles are at the heart of CTC …contd

• Appropriate care,- simple, effective outpatient care for those

who can be treated at home and clinical care for those who need inpatient treatment

• Care as long as needed- programmes build on local capacity and

existing structures and systems, helping to equip communities to deal with future periods of vulnerability

The CTC model three key innovations:

• Ready-to-use therapeutic food (RUTF);

• A new classification of acute malnutrition;

And

• Screening and admission by Mid Upper Arm Circumference (MUAC).

4 basic elements

• Social mobilisation

• Supplementary feeding (SFP)

– Depending on context

• Outpatient Therapeutic Care (OTP)

• Stabilisation Centres (SC)

– Equivalent to WHO phase 1 Therapeutic Care

The Evolution of CTC program

The Evolution of CTC program…contd

CTC screening, admission and discharge criteria

CTC components

• Community mobilization• Supplementary program (SFP)• Out-patient Therapeutic Program (OTP)• Stabilization Centre (SC)

Components of the CTC program and how they fit together

Admission and Discharge criteria for Pregnant and Lactating women

4 basic elements

• Social mobilisation

• Supplementary feeding (SFP)

– Depending on context

• Outpatient Therapeutic Care (OTP)

• Stabilisation Centres (SC)

– Equivalent to WHO phase 1 Therapeutic Care

Screening and Admission

Screening and admission

• Effective identification gives access to largest number of children to the program

• Three anthropometric measurements are used to screen and identify malnourished cases: – MUAC

– Edema

– Weight for height

MUAC • Is simple to use allows community health workers

and volunteers to identify and refer children • It is simple and cheap • Improves efficiency of program sites • It is also prone to mistakes unless carefully

measured • It is a better indicator of mortality risk associated

with malnutrition than WHM• MUAC < 11CM and/or edema – refer to OTP • MUAC > 11 cm and less than 12cm - refer to SFP

Weight for height

• Is used to measure an acute malnutrition in the community

• Percentage median FHM < 70% - severe acute malnutrition

• Percentage median FHM 70% - 80% - moderate acute malnutrition

• Percent median is calculated with = actual weight/median weight X 100

Community Mobilization and Outreach

Why Community Mobilization?

• To increase coverage• To understand the community’s view and

understanding on causes and solution of malnutrition

• Increased knowledge and awareness, care seeking practices and compliance

• To involve and engage the community in identifying and referring malnourished children

• To ensure sustainability

Elements of Community Mobilization

• There are two phases of community mobilization – Planning phase

– Implementation phase

Stages of Community MobilizationStages of Community MobilizationAssessing community

capacity

Key CommunityFigures

Formal and Informal

Channels of Communication

Health Attitudes& Health Seeking

Behaviour

Community Groups &

Organisations

CommunitySensitisation

DevelopSensitisation

Messages

SensitisationPlan (Activities)

CaseFinding

ActiveCase-

Finding

CommunitySelf-

Referral

FollowUp

OutreachWorkers

Volunteers

Outreach Workers & Volunteers

OngoingSensitization

PeriodicMeetings

Planning Phase

• Assessing community capacity – Identifying key community figures – Community groups and organization – Formal and informal channels communication – Path to treatment of severe malnutrition – Motivating factor

Implementation phase

• Community sensitization using sensitization message

• Active case finding and promoting self referral

• Follow up: HEWs and CHPs

• Ongoing sensitization

How?

• Using existing health volunteers – Disseminate sensitization message – Active case detection (MUAC and edema

assessment) and referral – Follow up children in the program and defaulters,

absentees – Monitoring and reporting

• Using key community figures • Combination of both

Follow up

• Children who are losing weight and whose medical conditions are deteriorating

• Children who are not responding to treatment

• Children whose carers have refused to

admission to SC

Medicines used in OTP

Medicines In OTP program

• In OTP program medicines used are broadly classified in to two

• There are:1. Routines medicines for severe Malnutrition 2. Supplemental medicines for severe malnutrition

Routine Medicines

Amoxicillin

• Is given routinely to treat underling infections which can be masked by immune suppression

• Is effective in reducing the overgrowth of bacteria in the GI tract (an occult source of septicaemia in malnourished cases)

• Absorption is passive which does not require active transport mechanism which is impaired in this cases

Anti-malarial therapy

• National protocol should guide the anti-malarial to be used

• Recommendation; Para check and then give drugs (Coartam; artemether-lumefantrine)

• Do not give fansider with in 7 days of folic acid

Folic acid

• As folic acid is present in RUTF, priority is given to treating the life-threatening malaria.

• Treatment is given only if there is sign of anaemia

Mebendazole

• Mebendazole is best absorbed after reconditioning of the GI tract with amoxicillin.

• Mebendazole is actively absorbed from the intestine and is more effective when the GI tract is free of other infections, and is therefore given on the second visit.

• Albendazole should be given as alternative if Mebendazole is not available

Vitamin A• Should only be given if Vitamin A is not given with in

the last 30 days,• Should not be given to children with oedema related

to Malnutrition• RUTF contains enough Vitamin A (0.91mg/100gm) to

satisfy daily requirements• Recommended that Vitamin A not be given in areas

where there is active national campaign exists except in cases of measles, EOS

Measles vaccination

• Evidence shows that an early two-dose strategy from the age of 6 months is very effective.

• All children (except those in shock) should be given the vaccination on entry to the programme and this should be repeated when the child is over 9 months of age.

• This should be coordinated with the EPI programme where applicable

Supplemental Medicines for SAM • Chloraphenicol • Metronidazole• TTC eye ointment • Nystatin • Paracetamol • Benzyl benzoat• Whitefield • Genitian Violet • Quinine • Resomal

RUTF, BP 100 and F75

RUTF

• RUTF – refers Ready-to-Use-Therapeutic-Food • RUTF – is energy dense mineral /vitamin enriched

food specifically designed to treat severe acute malnutrition

• Is is equivalent to formulation F100 • Is is usually oil based and contains little available

water • Oil based RUTF can be made using low production

method

RUTF – OTP Ration Average 200kcal/kg/day

It comes in 92 gm packet and each contains 500kcal Weight of Child Weight of Child (in Kg) (in Kg)

Ration Per week Ration Per week Ration per day Ration per day

3.0 – 3.43.0 – 3.4 99 1 ¼1 ¼

3.5 – 4.93.5 – 4.9 1111 1 ½1 ½

5.0 – 6.9 5.0 – 6.9 1515 22

7.0 – 9.9 7.0 – 9.9 2020 33

10.0 – 14.910.0 – 14.9 3030 44

15.0 – 19.915.0 – 19.9 3535 55

20.0 – 29.920.0 – 29.9 4242 66

30.0 – 30.9 30.0 – 30.9 5050 77

40.0 – 60.0 40.0 – 60.0 5656 88

BP 100 • Is non-oil based therapeutic food • Is a solid food based on the F100 formula with

some iron added • It can be eaten as a biscuit or porridge mixed

with water • The porridge is recommended for children

under two years • CTC program recommends BP 100 use in

combination with Oil based RUTF to ensure younger children are treated with RUTF that does not require mixing

BP 100 Weight of Child Weight of Child (in Kg) (in Kg)

Ration Per week Ration Per week Ration per day Ration per day

3.0 – 3.43.0 – 3.4 1414 22

3.5 – 4.93.5 – 4.9 17 ½17 ½ 2 ½ 2 ½

5.0 – 6.9 5.0 – 6.9 2828 44

7.0 – 9.9 7.0 – 9.9 3535 55

10.0 – 14.910.0 – 14.9 4949 77

15.0 – 19.915.0 – 19.9 6363 99

20.0 – 29.920.0 – 29.9 7070 1010

30.0 – 30.9 30.0 – 30.9 8484 1212

40.0 – 60.0 40.0 – 60.0 9898 1414

F75/F100• Both are therapeutic milk • Is an initial therapeutic diet for children with major

complications and poor appetite • F100 is given for infants less than 6 months • F75 given to older children in Stabilization Center and

children less than 6 months with edema • Supplemental Suckling (SS) technique is used for infants less

than 6 month to stimulate sufficient breast milk for the growth of the child

• Breast milk should not be substituted with F100/F75 for children less than 6 months

Appetite Test

• Children affected by classic IMCI diseases, who are malnourished, frequently show no sign of these diseases,

• Major complications leads to loss of appetite, • Reduction in appetite is the only sign for metabolic

malnutrition • Is the most critical sign to decided to the child to go

to inpatient or out patient management

Appetite Test • A poor appetite indicates

– Severe infection – Major metabolic abnormality: liver dysfunction,

electrolyte imbalance, damage to biochemical path way,

• Poor appetite is a sign for high mortality and indicates immediate care

• Appetite test needs to be conducted carefully