Chapter 4 Review of MAMI guidelines - ennonline.net · notes International guidelines: WHO...

48

Chapter 4 Review of MAMI guidelines

Management of Acute Malnutrition in Infants (MAMI) Project

49

Chapter 4 Review of MAMI guidelines

Chapter 4: Review of MAMI guidelines

This chapter reviews current guidelines on the management of acute malnutrition, both inpatient and community-based. The chapter looks at similarities and differences on how infants <6m are treated and identifies strengths, weaknesses and gaps in guidance materials.

4.1 Why population burden of disease mattersA review of current recommended approaches to managing acute malnutrition in infants <6m was carriedout to:

• Contextualise and help interpret quantitative feeding programme data (Chapter 5)• Contextualise and help interpret qualitative data from key informant interviews (Chapter 6)• Help set a baseline for future progress in the management of infants <6m malnutrition by:

- Understanding the range of current practices- Understanding the focus and emphasis of current guidelines- Identifying strengths of current guidelines- Identifying gaps in current guidelines

4.2 MethodsSAM and MAM guidelines and protocols (collectively referred to as guidelines from heron) were identified by purposive sampling of:

• Published guidelines available in print and on-line• Final and draft guidelines, obtained via MAMI steering group members and key informants.

Key themes and topics relevant to infants <6m were identified and tabulated. Internationally recognised AGREE (Appraisal of Guidelines for Research and Evaluation) criteria were used to appraise guideline quality130 (see Box 5). A formal AGREE scoring was not applied to each individual guideline, as this was beyond the scope of the MAMI Project. Instead an overview discussion highlights common issues.


50

4.2 Methods

Scope and Purpose

1. The overall objective(s) of the guideline should be specifically described.

2. The clinical question(s) covered by the guideline should be specifically described.

3. The patients to whom the guideline is meant to apply should be specifically described.

Stakeholder Involvement

4. The guideline development group should include individuals from all the relevant professional

groups.

5. The patients’ views and preferences should be sought.

6. The target users of the guideline should be clearly defined.

7. The guideline should be piloted among end users.

Rigour of Developement

8. Systematic methods should be used to search for evidence.

9. The criteria for selecting the evidence should be clearly described.

10. The methods used for formulating the recommendations should be clearly described.

11. Health benefits, side effects and risks should be considered.

12. There should be an explicit link between recommendations & supporting evidence.

13. The guideline should be externally reviewed by experts prior to publication.

14. A procedure for updating the guideline should be provided.

Clarity and Presentation

15. The recommendations should be specific and unambiguous.

16. Different options for diagnosis and/or treatment of the condition should be presented.

17. Key recommendations should be easily identifiable.

18. The guideline should be supported with tools for application.

Applicability

19. Potential organisational barriers in applying recommendations should be discussed.

20. Potential cost implications of applying the recommendations should be considered.

21. The guideline should presents key review criteria for monitoring and audit purposes

Editorial Independence

22. The guideline should be editorially independent from the funding body.

23. Conflicts of interest of guideline development members should be recorded.

Box 5: ‘AGREE’ CRITERIA (Appraisal of Guidelines for Research & Evaluation)

4.3 Guidelines overviewA total of 37 (14 international and 23 national) guidelines were identified for review. Table 5 presents an overview of the international organizations and countries represented. International guidelines were defined as generic guidelines, owned and written by one lead agency, UN or NGO, and intended for use in multiple settings. National guidelines were focused on one particular setting, often led by a Ministry of Health or other equivalent government body. The list presented is unlikely to be exhaustive. Other guidelines are known to be in development but were not available for this review.

Similarities between guidelinesThe many similarities between documents were striking. This partly reflects common ‘evolutionary origins’.The ‘common ancestor’ of almost all current guidelines is the 1999 WHO guideline on management of SAM.131This formalised the ‘phased’ (stabilisation and rehabilitation) treatment of acute malnutrition and included a description of the ’ten steps’ approach to care (see Figure 8 in chapter 2). Thus WHO (1999) is widely referenced and often directly summarised in subsequent documents. CMAM approaches represent another major step forward in the ‘evolution’ of treatment for SAM and many guidelines also draw on Valid(2006) as a key source.132

This ‘common origins’ finding has several implications. If two programmes use the same guidelines then it is, in theory, possible to compare programme outcomes and assess impact of context factors, such as


51

4.3 Guidelines overview

quality of implementation or patient profiles. Common terminologies and shared understandings also enable global sharing of ideas and staff exchange. A possible disadvantage of having guidelines that come as a ‘package’, is that individual elements become ‘standard’ and difficult to withhold, even if the underlying evidence for them is slim.

Differences between guidelinesThere are many minor inter-guideline variations. Mostly these are explanations of particular issues, rather than major differences in approach. This makes it difficult to disentangle whether guidelines themselves or other factors (e.g. severity of disease, availability of resources to implement the guidelines, willingness and ability of staff to implement the guidelines, background social circumstances impacting SAM/MAM) are responsible for good or bad patient outcomes. It is especially difficult to infer the effects of multiple minor variations.

IFE Module 2 stands out as different from the other guidelines reviewed here. Whilst created as a training tool, IFE Module 2 provides a ‘stop gap’ in MAMI guidance. Chapter 8 of Module 2 is specifically devoted to the management of SAM in infants <6m, the basis for which is the collation of SAM guidelines and experiences of NGOs, as well as expert authorship from relevant professionals and field teams. Consequently IFE Module 2 content on SAM largely reflects many of the NGO approaches and guidelines reviewed by the MAMI Project, with a strengthened breastfeeding component.

Evolutionary developments across the guidelines The main development since the WHO (1999) inpatient guidelines is that outpatient approaches to SAM treatment are now widely accepted for cases without medical complications. The majority of recent guidelines recognise outpatient-based models of care as complementary to inpatient care.

Also notable is that national SAM/MAM guidelines obtained for this report are very recent, mostly from the last two to three years, the oldest being Burundi in 2002. It is not known whether there were earlier guidelines pre-dating these. Whatever the case, there is evidently a clear trend towards both global rollout of SAM/MAM strategies and increasing national ownership of SAM/MAM guidelines.

Focus on infants <6m in current guidelinesThe majority of guidelines have a separate section focusing explicitly on infants <6m, which varies widely in length. A few, including WHO (1999), recognize infants <6m only indirectly as part of a broader age group, e.g. children <5 years. In the CTC Manual (Valid, 2006), one of the foundation reference materials for CMAM, infants <6m are only referred to in one small section.


52


Table 5: Overview of available acute malnutrition guidelines

Guideline type Authors / contributors

Region CountryorOrgan-ization

Guideline Date CMAMorInpatientonly

SAMorMAMfocus

language draftorfinal

MoH UNICEF WHO Interna-tional NGOorconsultant

Local NGO orconsul-tant

notes

International guidelines:

WHO Managementof severemalnutrition:a manual forphysicians &other seniorhealthworkers*

1999 Inpatientonly

SAM English,Spanish,French,Portuguese

FIN n/a n/a Y Y n/a available on WHO website http://www.who.int /nutrition/publications/ severemalnutrition/ 9241545119/en/index.html

WHO Guidelines forthe inpatienttreatment ofseverelymalnourishedchildren *

2003 Inpatientonly

SAM English,French,Spanish

FIN n/a n/a Y n/a n/a available on WHO website http://www.who.int/nutrition/publications/severemalnutrition/9241546093/en/index.html

WHO Manual forthe healthcare ofchildren inhumanitarianemergencies

2008 CMAM bothSAMandMAM

English FIN n/a n/a Y n/a n/a available on WHOwebsite:http://whqlibdoc.who.int/publications/2008/9789241596879_eng.pdf

WHO Pocket bookofHospital carefor children(Guidelinesfor themanagementof commonillnesses withlimitedresources)*

2005 Inpatientonly

SAM English,French,Portuguese,Russian

FIN n/a n/a Y Y n/a available on WHO webs http://www.who.int/child_adolescent_health/documents/9241546700/en/index.htmlNoted that this "updates & expands guidelines inWHO 2000 'Management of the child with a serious infection or severemalnutrition'"

WHO HandbookIMCIIntegratedManagementof ChildhoodIllness*

2005 n/a MAM(for SAMguidanceis torefer tohospital)

English,French

FIN n/a Y Y Y n/a available on WHO webhttp://www.who.int/child_adolescent_health/documents/9241546441/en/index.htmlThis is a book focused on all aspects of paediatric care at primary care level, of which assessment & treatment of malnutrition is just one chapter

ActionContre laFaim(ClaudinePrudhon)

Assessment &Treatment ofMalnutritionin EmergencySituations (Manual ofTherapeuticCare & Planningfor a NutritionalProgramme)

2002 Inpatientonly

bothSAMandMAM

English FIN n/a n/a n/a Y n/a Book covering multiple aspects of nutrition: treatment is just one section

MSF NutritionGuidelines(1st edition)

1995 inpatientonly

bothSAMandMAM

English FIN n/a n/a n/a Y n/a Book covering multipleaspects of nutrition: treatment is just one section

Inte

rnat

iona

l


53



Region Country orOrganization


SAMorMAMfocus


MoH UNICEF WHO Internat-ional NGOorconsultant

Local NGO orconsul-tant

notes


MSF NutritionGuidelines

May2006

CMAM bothSAMandMAM

English FIN n/a n/a n/a Y n/a Update of 1995guidelines, though available in electronic version rather as a book

MSF GuidelineInfants lessthan 6 monthsold (Benson)MSF - OCBA

Oct2007

n/a SAM English ? n/a n/a n/a Y n/a This is a chapter ocused on infants alone and is one of a wider set of guidelines relating to malnutrition

ValidInternational

Community-basedTherapeuticCare (CTC), Afield manual (first edition)

2006 CMAM bothSAMandMAM

English FIN n/a n/a n/a Y n/a book describing multiple aspects

UNHCR Handbook forEmergencies(thirdedition)

Feb2007

CMAM bothSAMandMAM

English FIN n/a n/a n/a Y n/a Available onlinehttp://www.unhcr.org/publ/PUBL/ 471db4c92.htmlNB Interesting to note that 3rd edition has significantly more IYCF detail than 2nd

UNHCR Themanagementof Nutritionin MajorEmergencies

2000 Inpatientonly

bothSAMandMAM

English FIN n/a n/a Y Y n/a book covering multiple aspects of nutrition

IFE CoreGroup

InfantFeeding inEmergenciesIFE module 2,version 1.1for healthand nutritionworkers inemergencysituations, fortraining,practice andreference

Dec2007

n/a SAM English FIN n/a n/a n/a Y n/a Training modulecovering externsivedetails of IYCF especiallyskilled breastfeedingsupport produced in UNand NGO collaborationwith expert collaboratorsand review. Includes achapter dedicated tomanagement of acutelymalnourished infants <6m (Chapter 8), supported by content in other chapters. Available on ENN website:http://www.ennonline.net/resources/view.aspx?resid=4

ICRC(InternationalCommittee ofthe Red Cross)

NutritionManual forHumanitarianAction

Aug2008

n/a English FIN n/a n/a n/a Y n/a Book covering multiple aspects of nutrition. Includes 1 chapter onTherapeutic Feeding and 1 on Supplementary Feeding Available onICRC website: http://www.icrc.org/web/eng/siteeng0.nsf/html/p0820

Table 5 cont’d

Inte

rnat

iona

l


54



Region Country orOrgan-ization


SAMorMAMfocus



Local NGO orconsult-ant

notes

National guidelines

Burundi ProtocoleNational deNutrition

Aug2002

Inpatientonly

French FIN Y Y Y Y Y

Ethiopia Protocol fortheManagementof SevereAcuteMalnutrition

Mar2007

CMAM SAMonly

English FIN Y Y Y no Y

Madagascar Depistage etprise encharge de lamalnutritionaigue

Sep2007

CMAM bothSAMandMAM

French FIN Y Y Y ? ?

Malawi Guidelines fortheManagementof SevereAcuteMalnutrition(book T3)

2007 Inpatientonly

SAM English FIN Y Y Y Y Y One of a set of guidelines on acutemalnutrition - othersfocus on CMAM.Separate MAM / CMAMguidelines available

Mozambique Manual deOrientacaoparaTratamentodaDesnutricaoAguda Grave

Jun2008

CMAM bothSAMandMAM

Portugese Dr Y Y ? Y Y recently replaced 2007protocol

Tanzania Managementof AcuteMalnutritionNationalGuidelines

2008 CMAM bothSAM(mainfocus)andMAM

English FIN Y Y Y Y Y includes checklist ofSAM management

Uganda IntegratedManagementof AcuteMalnutrition

Nov2006

inpatientonly

bothSAMandMAM

English Dr Y Y ? Y ? reference made toseparate guidelinesfocused on therapeuticfeeding centres

Zambia IntegratedManagementof AcuteMalnutrition


English Dr Y ? ? Y ? includes supervisionchecklist

Zimbabwe Guidelines fortheManagementof SevereAcuteMalnutritionthroughCommunity-basedTherapeuticCare (CTC)


English FIN Y Y n/s Y Y guidelines include: 1) supervision checklist2) indicators forassessing quality &appropriatenessReference also made tothe "Zimbabwetherapeutic feedingprotocol" which outlinesdetails of infant <6mcare

Table 5 cont’d

1. a)

East

ern

Afric

a


55





SAMorMAMfocus




notes

National guidelines

DRC ProtocolNational dePrise en Chargede laMalnutritionAigue

Oct2008

CMAM French FIN Y Y ? Y ? Acknowledgements page blank

Sudan(Southern)

Guidelines fortheManagementof Severe AcuteMalnutrition

Jul2008

CMAM SAM English Dr Y Y Y Y ? references WHO(1999), Valid (2006) & Golden & Grellety as sources

Sudan(North)

NationalIntegratedManual on theManagementof Severe AcuteMalnutritionin healthfacilities & atcommunitylevel

Jan2008

CMAM SAM English Dr Y Y Y Y n/s (for medical doctors and senior healthworkers)

Botswana Guidelines fortheManagementof Severe AcuteMalnutrition inChildren

Jun2007

CMAM SAM English Dr Y Y Y Y Y noted that developed in line with WHO reference manuals, 1999, 2003

BurkinaFaso

None yet - indraft

n/s CMAM bothSAMandMAM

French Dr ? ? ? ? ? only draft outline available

CoteD'Ivoire

ProtocoleNational dePrise en chargede lamalnutritionsevere

May2005

Inpatient only(CMAM typehometreatmentnoted inannex


Guinea ProtocoleNational dePrise en Chargede laMalnutritionAigue

May2008

CMAM SAMandMAM

French FIN Y Y ? ? ?

Mali ProtocoleNational de laprise en chargede lamalnutritionaigue

Dec2007

CMAM SAMandMAM

French Dr Y Y Y Y Y

Niger ProtocolNational dePrise en Chargede laMalnutritionAigue

Dec2006

CMAM bothSAMandMAM


Table 5 cont’d

1.b)

Mid

dle A

frica

1.d)

Sout

hern

Afric

a1.

e) W

este

rn A

frica


56





SAMorMAMfocus




notes

National guidelines

Senegal Protocole deprise en chargede lamalnutritionaigue

May2008

CMAM bothSAMandMAM


Afghanistan Community-basedManagement ofAcuteMalnutritionprogramme inAqcha andMardyanDistrict ofJawzjanProvinceNorthernAfghanistan(StabilizationCentreGuidelines)

June2008

CMAM SAM English Dr Y Y Y No Y compiled by Savethe Children UK

India Indian Academyof Paeditricsguidelines

2006 Inpatient only SAM English FIN Y Y Y No Y Published injournal 'IndianPaediatrics, (2007: 44: 443-61)

Pakistan Protocol for theinpatienttreatment ofseverelymalnourishedchildren in thePakistanearthquakeemergency

Dec2005

Inpatient only SAM English Dr Y Y Y Y Y based on WHO 1999protocol

Sri Lanka None yet - indraftManagement ofSevere AcuteUndernutrition:Manual forHealth Workersin Sri Lanka

n/s CMAM bothSAMandMAM

French Dr ? ? ? ? ? only draft outline available

Table 5 cont’d

*These WHO resources are the same guideline produced in different formats.


57

4.4 Guideline Comparisons


4.4.1 Case definitions of SAM & MAM (general)See Table 6 for an overview of case definitions. All guidelines reviewed use anthropometry as the main indicator for SAM/MAM. All also acknowledge oedematous malnutrition as an indicator of SAM.

Weight-for-height vs. weight-for-ageMost guidelines use weight-for-length criteria as recommended by WHO (1999). Cutoffs for SAM and MAMare also mostly consistent with WHO (1999). Exceptions are the 2008 WHO Manual on healthcare of children in emergencies and IMCI guidelines, which both use weight-for-age as the main indicator (although IMCI also uses visible severe wasting as an alternative). This difference must be addressed.

NCHS vs. WHO-GS (in context of z-score vs. %-of-median)NCHS growth references are still dominant in the guidelines reviewed. Only Sri Lanka and Mozambique explicitly use WHO-GS, though several other guidelines do footnote their availability alongside NCHS. It is only recently, in May 2009 that UNICEF and WHO released a joint statement formally recommending the new WHO-GS for identifying severe acute malnutrition133. It is likely therefore that their use will increase in the coming years. Some of the possible implications of this change for infants are discussed in Chapter 3.

MUACMUAC is increasingly used in SAM/MAM guidelines. It is an independent admission criterion noted alongside weight-for-height, and in a small number or guidelines (Valid 2006, Uganda 2006), it is the major case definition criterion. No guidelines recommend its use in infants <6m.


58


Table 6: Case definitions of SAM & MAM

Case Definitions of SAM & MAM

Country orOrganization

Guideline Date Growth'norm'(alternative,if noted)

Index (WH:weight forheight;WA:weight orage)

MainRecommendedindicator (+ alternative, ifnoted)

Indicatorpresentedin tables(if shown)

CasedefinitionSAM(in allguidelines,oedema=SAM)

MUAC-based casedefinitionof SAM

CasedefinitionMAM

MUAC-basedcasedefinitionof MAM

Notes

International guidelines

WHO Managementof severemalnutrition:a manual forphysicians &other seniorhealthworkers

1999 NCHS WH z-score(% of median)

WHZ(NCHS)boys & girls split sextables

<-3 WHZ (<70%WHM)

not used -3 ≤ WHZ <-2 (70 to79%WHM)

not used Lengthmeasured if child<85cm or <2years.Height if >85cmor >2years

WHO Guidelines forthe inpatienttreatment ofseverelymalnourishedchildren

2003 NCHS WH z-score(% of median)

WHZ(NCHS)boys & girlssplit sextables

<-3 WHZ (<70%WHM)

not used -3 ≤WHZ<-2 (70 to79%WHM)

not used Lengthmeasured if child<85cm & heightif >85cm

WHO Manual forthe healthcare ofchildren inhumanitarianemergencies

2008 n/s WA low weight-for-age

weight-for-age chartshow inannex, butlines arenotlabelled

~ MUAC<110mm(>6months)~ visibleseverewasting

<110mm(if child >6months old)

no visibleseverewasting,MUAC>110mmvery lowweight-for-age

n/s

WHO Pocket bookof Hospitalcare forchildren

2005 NCHS WH z-scoreOR% of median


<-3 WHZ OR<70% WHM

not used n/s n/s Lengthmeasured if child<85cm & heightif >85cm

WHO HandbookIMCIIntegratedManagementof ChildhoodIllness

2005 n/s WA Visible severewastingLow weight-for-age

weight-for-age chartshow inannex, butlines arenot labelled

Low weight-for-age

not used n/s n/s notes that onweighing childshould wear lightclothing

ActionContre laFaim(ClaudinePrudohn)

Assessment &Treatment ofMalnutritionin EmergencySituations

2002 NCHS WH (WA isdescribed)

% of median(z-score)

WHM(NCHS/WHO 1982)combinedsex WHZ(NCHS/WHO 1983)split sex

<70% WHM (<-3 Z-score

<110mm(noted ascontroversialif length<75cm)

WHM≥70%and<80% (WHZ ≥-3 and<-2)

≥110mmand<120mm

Lengthmeasured if <2years age, heightif >2year(85cm a proxy ifage unknown) Noted that WHMpredicts deathbetter than WHZ.Use WHZ onlywhen WHMrejects a high riskchild

MSF NutritionGuidelines(1st edition)

1995 NCHS WH % median (z-score)

WHM(NCHS/WHO 1982)combinedsex WHZ(NCHS/WHO 1983)split sex

<70% WHM (<-3 Z-score)

<110mm(if child >12months or>75cmlength)

WHM≥70%and<80% (WHZ ≥-3 and<-2)

<135mmreferredfor screen,but onlyenrolled iffulfilsWHM orWHZcriteria

Lengthmeasured if <2years age, heightif >2years(85cm a proxy ifage unknown)


59










CasedefinitionMAM


Notes


MSF NutritionGuidelines

May2006

NCHS WH % median(notes z-scoresused in somecountries

n/a <70%WHM (<-3 Z-score)

<110mm(if child >6months old)

WHM≥70%and<80% (WHZ ≥-3 and<-2)

n/s

MSF ProtocolInfants lessthan 6months old(Benson)MSF - OCBA

Oct2007

n/s WH % of median WHM(NCHS/WHO 1982)combinedsex WHZ(NCHS/WHO 1983)split sex

<70%WHM

n/a (focus ison infants<6m)

n/a n/a

ValidInternational

Community-basedTherapeuticCare (CTC), Afield manual(first edition)

2006 NCHS MUAC* UnadjustedMUAC %median or Z-score noted

no tablesshown

<70%WHM<-3WHZ

<110mm (if length>65cm)

WHM≥70% and<80%(WHZ ≥-3 and<-2)

110mm to<125mm

* MUACemphasised asprimarymeasure(WHnoted)

UNHCR Handbook forEmergencies(thirdedition)

Feb2007

NCHS* WH % of medianORz-score

no tablesshown

<70%WHM (or<-3 Z-score)

<110mm(if aged 6 to59months)

70% to79% WHM(-3 to -2WHZ)

110mm to<125mm

also mentionLBW babies (nodetails given) * recognisedWHO & statesthat UNHCR is inprocess ofassessing thenew standards

UNHCR Themanagementof Nutrition inMajorEmergencies

2000 NCHS WA z-score (% of median)


<-3 WHZ(<70%WHM)

<-3 ZMUAC-for-age /MUAC-for-height

≥-3 to <-2 WHZ (70 to79% WHM

≥-3 ZMUAC-f-age/MUAC-f-height to<-2z

notes that onweighing childshould wear lightclothing

IFE CoreGroup

InfantFeeding inEmergenciesIFE Module 2,version 1.1

Dec2007

NCHS WH % of median tables notshown

<70%WHM(NCHS)

n/a (focus ison infants<6m)

n/s n/s n/s

ICRC NutritionManual forHumanitarianAction

Aug2008

NCHS WH(describesotherindices,incl WA,MUAC)

z-score (describes otherindicators)

WHZ(NCHS)boys & girls split sextables(MUAC byage Z-scoretables alsogiven)

severaldescribed,including<-3 WHZ(NCHS) andMUAC-for-height <-3z (75%median)

<110mm(<125mmalso referredto as 'severe' inanthro-pometrychapter)

140 or135mm to125mm

Lengthmeasured if <2years age, heightif >2 yearsnotes thatanthropometryshould not bethe only basis ofadmission

National guidelines

Burundi ProtocoleNational deNutrition

Aug2002

NCHS WH % of median combinedsex, WHM(NCHS)

<70%WHM(NCHS)

<110mm(if length>65cm)

between70 to 79%WHM

<125mm height <65cmequated withage <6 monthsno referencegiven for tables

Table 6 cont’d


60










CasedefinitionMAM


Notes

National guidelines

Ethiopia Protocol for theManagementof Severe AcuteMalnutrition

Aug2002

NCHS WH % of median combinedsex, WHM(NCHS)

<70%WHM(NCHS)


between70 to 79%WHM

<125mm height <65cmequated withage <6 monthsno referencegiven for tables

Madagascar Depistage etprise en chargede lamalnutritionaigue

Sep2007

NCHS WH % of median WHM(NCHS)combinedsex

<70%WHM(NCHS)


70 to 79%WHM

n/s

Malawi Guidelines fortheManagementof Severe AcuteMalnutrition(book T3)

2007 NCHS WH % of median WHM(NCHS)combinedsex

<70%WHM(NCHS)

<110mm(ages 1 to 5years)

70 to 79% 110 to119mm

(NB printed as acard separate tothe book)

Mozambique Manual deOrientacaoparaTratamento daDesnutricaoAguda Grave

Jun2008

WHO-GS(2007protocolusedNCHS)

WH % of median * tablelabelled"% ofmedian(WHO-2004)joint sex

<70%WHM

<110mm 70 to 79%WHM

110 to125mm

* appears tohave calculatedweight cut-offsbased on WHO(2006) boysmedian tables Lengthmeasured if child<85cm & heightif >85cm

Tanzania Managementof AcuteMalnutritionNATIONALGuidelines

2008 NCHS WH % of medianOR z-score

WHZ(NCHS)boys &girls splitsex tables

<70%WHM OR<-3 WHZ

<110mm(6-59m or65 to110cm)

70-79%WHM or<-2SD

110-120mm

Lengthmeasured if child<85cm & heightif >85cm

Uganda IntegratedManagementof AcuteMalnutrition

Nov2006

n/s MUACemphasis-ed

UnadjustedMUAC %median or Z-score noted

no tablesshown

<70%WHM <-3WHZ

<110mm (if length>65cmand/or>6months)

WHM≥70% and<80%(WHZ ≥-3and <-2)

110mm to<125mm

Zambia IntegratedManagementof AcuteMalnutrition

2009 NCHS* WH % of median no tablesshown

<70%WHM OR<-3 WHZ

<110mm(6-59m)

WHM≥70%and <80% (WHZ ≥-3 and<-2)

≥110 and<125mm

*WHO GS notedas a footnote inthe introductionbut notthereafter**z-score notedonce inintroduction butnot thereafter)

Zimbabwe Guidelines fortheManagementof Severe AcuteMalnutritionthroughCommunity-basedTherapeuticCare (CTC)

2008 NCHS WH % of median WHZ(NCHS)boys &girls splitsex tables

<70%WHM

<110 70 to 80% 110 to125mm

Length if <85cmor <2 years,Height ≥85cm or>2years

Table 6 cont’d


61










CasedefinitionMAM


Notes

National guidelines

DRC ProtocolNational dePrise en Chargede laMalnutritionAigue

Oct2008


<70%WHM(NCHS)


70 to79.9%

110 to119mm

Sudan(Southern)

Guidelines fortheManagementof Severe AcuteMalnutrition

Jul2008


<70%WHM(NCHS)

<110mm(for height>65cm)

70 to79.9%

n/s Lengthmeasured if child<85cm & heightif >85cm*WHO GS notedas a footnote inthe introductionbut not thereafter** z-score notedonce inintroduction butnot thereafter

Sudan(North)

NationalIntegratedManual on theManagementof Severe AcuteMalnutritionin healthfacilities and atcommunitylevel

Jan2008

NCHS WH % of medianOR z-score

draft - notyetinserted

<70% <110mm(with length>65cm or>1year old)

≥-3 to <-2 WHZ or70 to 79%WHM

n/s Length if <85cmor <2 years,Height ≥85cm or>2years (tablesstate 85cm cutoff,text gives age OR85cm cutoff)

Botswana Guidelines fortheManagementof Severe AcuteMalnutrition inChildren

Jun2007

NCHS WH % of median annexesnotcomplete(draftguidelines)

<70%WHM(NCHS)

<110mm n/s n/s Length measuredif child <85cm &height if >85cmequates age<6months withheight <65cm*z-score notedonce inintroduction butnot thereafter

BurkinaFaso

Guidelines fortheManagementof Severe AcuteMalnutrition inChildren

Jun2007


<70%WHM(NCHS)

<110mm ≥70 to<80%WHM

110 to125mm

equates age<6months withheight <65cm

CoteD'Ivoire

ProtocoleNational dePrise en chargede lamalnutritionsevere

May2005


<70%WHM(NCHS)

<110mm n/s n/s Lengthmeasured if child<85cm & heightif >85cmequates age<6months withheight <65cm

Guinea ProtocoleNational dePrise en Chargede laMalnutritionAigue

May2008


<70%WHM(NCHS)

<110mm(if height>65cm)

≥70 to<80%WHM

110 to125mm

Lengthmeasured if child<85cm & heightif >85cm

Table 6 cont’d


62










CasedefinitionMAM


Notes

National guidelines

Mali ProtocoleNational de laprise en chargede lamalnutritionaigue

Dec2007


<70%WHM(NCHS)

<110mm(if height>65cm)

≥70 to<80%WHM

110 to119mm

Length <85cm,Height ≥85cmequates age<6months withheight <65cm

Niger ProtocolNational dePrise en Chargede laMalnutritionAigue

Dec2006


<70%WHM(NHCS)(WHZ<-3WHO isfootnotedas analternativecasedefinition)

<110mm(for height>65cm)

70% to<80%WHM

n/s Length if <85cmor <2 years,Height ≥85cm or>2years

Senegal Protocole deprise en chargede lamalnutritionaigue

May2008

NCHS WH % of medianOR z-score

WHM(NCHS)combinedsex

<70%WHMOR<-3 WHZ

<110mm(if aged 6 to59 months)

≥-3 to <-2 WHZ or70 to 79%WHM

110 to125mm

Length if <2years, Height if>2 years <65cmlength seen asproxy for<6months age

Afghanistan Community-basedManagement ofAcuteMalnutritionprogramme inAqcha andMardyanDistrict ofJawzjanProvinceNorthernAfghanistan

June2008

notspecifited

WH % median(z-score)

annexesnotcomplete(draftguidelines)

<70%WHM(or <-3WHZ)

<110mm n/s n/s Length measuredif child <85cm &height if >85cmif age unknown,<65cm length isproxy for<6months age

India Indian Academyof Paeditricsguidelines

2006 NCHS WH % median(z-score)

not shown <70%WHM(or <-3WHZ)

<110mm n/s n/s

Pakistan Protocol for theinpatienttreatment ofseverelymalnourishedchildren in thePakistanearthquakeemergency

Dec2005

NCHS WH % median(z-score)

not shown(footnotessuggestthat Z-score tableas in WHO1999guidelineslikely to beinserted)

<70%WHM(or <-3WHZ)

not stated n/s n/s Lengthmeasured if child<85cm & heightif >85cm

Sri Lanka Management ofSevere AcuteUndernutrition:Manual forHealth Workersin Sri Lanka

2007 WHO WH z-score WHZ(WHO)split sex

<-3Z WHZ(WHO)

no n/s n/s Lengthmeasured if child<2years &height if >2years

Table 6 cont’d


63


4.4.2 Infant <6m SAM and MAM case definitionsSee Table 7 for overview.

Infant <6m severe acute malnutrition (SAM)In all of the guidelines infants <6m with SAM are treated as inpatients. This includes CMAM guidelines where the management strategy is referral of malnourished infants <6m for inpatient care. Weight-for-length criteria are always the same as for older children, though sometimes this is implied rather than directly stated.

Infants >6m but <3 or 4kgThere is often a ‘secondary criterion’ of a child >6 months but <3 or 4 kg. Some guidelines recommend these should have the same initial treatment as an infant <6m.

Infants <6m and length <65cm Several guidelines implicitly or explicitly equate age <6 months and length <65cm, sometimes using length as a proxy for age. However confusion arises when these measures conflict, e.g. infant is known to be >6 months but length is <65cm. It is not clear which treatment protocol should be applied and if a MUAC measurement is valid if length is <65cms.

Length < 49cmSome guidelines make an allowance for where length <49cm and so W/H cannot be measured. For example, IFE Module 2 recommends “visibly severe thinness” where measurement of W/L is not possible, and mentions that some agencies use a criterion of <2.1kg irrespective of length. WHO-GS go down to 45cm as the minimum length in length-for-height tables. This represents almost -3 z length-for-age at birth: not being able to determine a weight-for-length should therefore be much less of an issue in the future.

Measurement of weight in infants <6mNone of the guidelines draws attention to particular considerations in the anthropometric assessment of infants <6m (see Section 9.3.2). Research has shown weighing scales used in emergencies to be largely unsuitable for weighing infants <6m.134

Assessment of ageSince birth is a recent event in an infant <6m, it is in theory easier to accurately assess age than for older children. None of the guidelines gives details of age assessment of how to best do this e.g. use of calendar to elicit exact age in months.

Infant <6m moderate acute malnutrition (MAM)I dentifying and treating infants <6m with MAM is not specifically dealt with in any of the guidelines except

one (Burkina Faso). Infant MAM is only recognized implicitly, by assuming that the same MAM weight-for-length criteria applicable to older children are applicable to infants. Management therefore requires inference from other sections of the guidelines, e.g. where lactating mothers with infants <6m are admitted to SFP. IFE Module 2 focuses on skilled breastfeeding support for moderately malnourished infants (implicitly including infants <6m).135 Burkina Faso stands out by explicitly stating that infants with MAM should be treated by their mothers receiving SFP rations and health and nutrition education.

Further assessment recommended for infants <6mSome guidelines recommend initial admission to an ‘assessment’ area where breastfeeding can be more closely observed. No current guideline differentiates complicated vs. uncomplicated infant <6m acute malnutrition.

Clinical admission criteria for infants <6mMany guidelines recommend clinical admission criteria, in addition to anthropometry. Common criteria include “an infant who is too weak or feeble to suckle” and “mother not producing enough milk”. Minor variations of emphasis and phrasing (e.g. ‘not enough milk’ with weight loss vs. ‘not enough milk’ alone) make it likely that there are significant inter-programme variations in terms of which infants <6m are admitted to care. It is also not clear whether carer reports or clinician assessments should carry the greaterweight. Inter-user variations in interpreting even the very same guidelines are very likely.


64


Table 7: Infant <6m SAM & MAM case definitions

Separateguideline forinfants <6m?

Case Definition (Infants) ~ for admission


Guideline Infant <6mSAM

Infant <6mMAM

Pages ofguidelinedevotedto infants / totalpages (excl.annexes)

% ofguidelinedevotedto infants

Who apartfrominfants<6mshouldfollowinfantguidelines

Anthropometriccriteria(except for MUAC,which is not used forinfant <6m, assumesame case definitionsof SAM, MAM unlessotherwise stated)

Clinical criteria Notes


WHO Management ofseveremalnutrition: amanual forphysicians &other seniorhealth workers 1999

not specificallymentioned.*

n/a n/a n/a n/a n/a Preface states thatprotocol refers to"malnourished childrenunder 5 years of age"

WHO Guidelines forthe inpatienttreatment ofseverelymalnourishedchildren, 2003

not specificallymentioned.

n/a n/a n/a n/a n/a

WHO Manual for thehealth care ofchildren inhumanitarianemergencies2008

not specificallymentioned

n/a n/a n/a n/a n/a ~ noted that patientsneeding inpatient careshould be treatedfollowing "current WHOguidelines"

WHO Pocket book ofHospital care forchildren 2006

yes n/s 1/24 4% no othergroupsnoted

same not specified separate chapter on"supportive care" givesdetails of breastfeedingissues, includingsupplementary suckling

WHO Handbook IMCIIntegratedManagement ofChildhoodIllness 2005

yes yes n/a no othergroupsnoted

n/a n Recommends thatinfants and children withsevere malnutrition arereferred urgently toohospital, and does notcover their specifictreatment

ActionContre laFaim(ClaudinePrudohn)

Assessment &Treatment ofMalnutrition inEmergencySituations, 2002

yes yes 5/58(of sectionontreatment)

9% <4kg same 1) Too weak tosuckle effectively; and/or 2) Mother notproducing enoughmilk

~ notes that infant <6mshould be nursed in aseparate area of the ward~ also suggests pressingon mothers breasts tocheck for presence ofmilk

MSF NutritionGuidelines (1stedition), 1995


same Not specificallystated

in "Infant feeding"section, infant notdefined to mean infant<6m alone

MSF NutritionGuidelines, 2006


WHM <70% 1) Weight loss orgrowth stagnation (1 to 2 weeks)2) Too weak tosuckle3) Insufficientbreastmilk4) Inappropriatealternative infantfeeding

whole chapter in thebook devoted to infant<6mrecognised LBW, preterminfantsnotes need formechanical scalesaccurate to 10g


65






Infant <6mMAM







MSF ProtocolInfants lessthan 6months old(Benson)MSF – OCBA2007

yes n/s (10/10) (100%) <3kg beingbreast-fed

WHM <70% 1) Infant tooweak or feebleto suckleeffectively(independent ofWHM)

one chapter from a widerset of guidelines notesneed for a 'breastfeedingcorner'notes no growthstandards for infants whoselength <49cm and that thenutrition unit is notappropraite for treatingpremature and LBW infants<49cm. These should bereferred to nursery forappropriate care

ValidInternational

Community-basedTherapeuticCare (CTC), Afield manual(first edition)2006

yes n/s 0.5/13pages oninpatientcare

4% no othergroupsnoted

WHM <70% visible wasting Guideline does not attemptto directly address infant<6m treatment, referringinstead to other guidelines,notably the 2001Operational Guidance onInfant & Young ChildFeeding in Emergencies,volume 1

UNHCR Handbook forEmergencies(third edition)2007

yes notdirectly

infant U6mmentionedin severalparagraphsmixed inmain text

no othergroupsnoted

same "visible severewasting inconjunction withdifficulties in BF"

- notes that infantsU6 SAMtreatment is based onpromotion of BF (ifpossible)- details not described

UNHCR Themanagementof Nutrition inMajorEmergencies2000

infant <6mmalnutritionrecognised, but notsplit into SAM &MAM

1/24 4% no othergroupsnoted

same not specificallystated

States that "formalnourished infants<6m, it is the mother whoshould be included, NOTthe infants (infants shouldbe exclusively breastfed)"

IFE CoreGroup


yes yes 17/114pagesfocus juston infantwith SAM(see notes)

(15%) >6monthsold but<65cm~ 4kg

WHM <70% failure to gainweight at homeor undermanagement ata breastfeedingcorner

One chapter (8) focusesexclusively on infant <6msevere malnutrition.Chapter 5 adrresses lowbirth weight infants,”visiblythin”/moderatelymalnourished infants andmalnourished mothers. Thewhole 223 page manualdirectly or indirectlyaddresses this age groupthrough guidance onskilled assessment andsupport for breastfeeding.

ICRC NutritionManual forHumanitarianAction 2008

no(notesTFP oftenrestrictedto<5years)

no n/a n/a n/a n/a n/a no separate section for careof infant <6m. Does however have aparagraph on BF. Notes it asan "absolute priority, andevery effort should bemade to encourage orrestore it"

Table 7 cont’d


66






Infant <6mMAM






National guidelines:

Burundi ProtocoleNational deNutrition2002

yes n/s 5/33 15% <6m or<3kg beingBF

same 1) Mother doesnot have enoughmilk AND infantloosing weight2) Infant tooweak to suckleand loosingweight even ifmother does havemilk

Ethiopia Protocol fortheManagementof SevereAcuteMalnutrition2007


WHM <70% too weak orfeeble to suckleeffectively(any WH)

Protocol notes no growthstandards for infantswhose length <49cm andthat the nutrition unit isnot appropriate fortreating premature andLBW infants <49cm. Theseshould be referred tonursery and given infantformula.

Madagascar Depistage etprise encharge de lamalnutritionaigue 2007

yes n/s 3/52 6% <3.5kg WHM <70% 1) Too weak orfeeble to suckleeffectively or2) Mother doesnot have enoughmilk and infant isloosing weight

Malawi Guidelinesfor theManagementof SevereAcuteMalnutrition(book T3)2007

yes yes (ingroup'infants<6m withnutritionproblemsbut notSAM')

10/38 26% <3kg WHM <70% 1) Infant notgaining or loosingweight but notSAM or2) Motherreportsinsufficient BM or3) Weak or feebleand not sucklingwell but not SAM

Protocol notes no growthstandards for infantswhose length <49cm andthat the nutrition unit isnot appropriate fortreating premature andLBW infants <49cm -should be referred tonursery for appropriatecare

Mozambique Manual deOrientacaoparaTratamentodaDesnutricaoAguda Grave2008

yes n/s 8/91 9% <3kg WHM <70% 1) Too weak orfeeble to suckleeffectively or2) Not gainingweight at home

Tanzania Managementof AcuteMalnutritionNATIONALGuidelines2008

yes n/s 1/67 1% - same not stated Protocol has only 1paragraph which states "Ifthe mother isbreastfeeding, assist her tobreastfeed or expressbreastmilk. Give theprescribed amount of F75in addition to thebreastmilk"

Table 7 cont’d


67






Infant <6mMAM







Uganda IntegratedManagementof AcuteMalnutrition2006

yes n/s 1/53 2% 2% same not stated reference made toseparate guidelinesfocused on therapeuticfeeding centres referencealso make to link withIMCI guidelines

Zambia IntegratedManagementof AcuteMalnutrition2009

yes(but seenotes)

n/s 1/35 3% <3kg WHM <70% 1) Infant <6munable tobreastfeed

~ Though infant <6mSAM recognised briefly as"special cases", statedelsewhere that theseguidelines are targeted at6 to 59m children. Thusno separate section orchapter for infant <6m.~ Also referencesseparate "Nationalguidelines" for fulldetails of treatmentduring (inpatient)stabilisation

Zimbabwe Guidelines fortheManagementof Severe AcuteMalnutritionthroughCommunity-basedTherapeuticCare (CTC) 2008

yes(but seenotes)

n/s 1/56 2% n/s n/s not stated ~ reference made toseparate guidelinesfocused on therapeuticfeeding centres~ infants <6m nototherwise focused on inthis guideline in thechapter on "StabilisationCentre" care

DRC GuidelineNational dePrise en Chargede laMalnutritionAigue 2008

yes n/s 5/68 7% <3.5kg <70% WHM 1) Too weak orfeeble to suckleeffectively (anyWH) or2) Mother does nothave enough milkto feed her child or3) Not gaining (orloosing) weight athome

Sudan(Southern)

Guidelines fortheManagementof Severe AcuteMalnutrition2008

yes n/s 7/103 7% <3kg beingbreast-fed

<70% WHM 1) Too weak orfeeble to suckleeffectively (any WH)2) Not gaining (orloosing) weight athome

noted that RUTFinappropriate as "reflexof swallowing is not yetpresent"

Sudan(North)

NationalIntegratedManual on theManagementof Severe AcuteMalnutritionin healthfacilities and atcommunitylevel 2008

yes n/s 7/103 7% <3kgbeingbreast-fed

<70% WHM 1) Too weak orfeeble to suckleeffectively (anyWH)2) Not gainingweight at home

notes that infant <6mshould be ideally benursed in a separate areaof the ward

Table 7 cont’d


68






Infant <6mMAM







Botswana Guidelinesfor theManagementof SevereAcuteMalnutritionin Children2007


same 1) Too weak or feebleto suckle effectively(any WH) or2) Mother does nothave enough milk tofeed her child

Protocol notes no growthstandards for infantswhose length <49cmand that the nutritionunit is not appropriate fortreating premature andLBW infants <49cm.These should be referredto nursery and giveninfant formula.

Burkina Faso None yet - indraft

yes yes 5/57 9% <3kg ORlength<65cm (aproxy forage)

same 1) Mother does nothave enough milk andbaby loosing weight2)Infant too weak tosuckle and loosingweight even ifmother has milk

SFP recommended formothers of MAM infants<6m. General health andnutrition education alsorecommended

Cote D'Ivoire ProtocoleNational dePrise encharge de lamalnutritionsevere 2005

yes n/s 10/65 15% <3kg ORlength<65cm (aproxy forage)

<70% WHM (NCHS)(for non-breastfedinfant)

1) Mother does nothave enough milkand baby loosingweight (does notmatter what exactWHM is atassessment)2)Infant too weak tosuckle and loosingweight even ifmother has milk

Protocol notes no growthstandards for infantswhose length <49cmand that the nutritionunit is not appropriate fortreating premature andLBW infants <49cm.These should be referredto nursery and giveninfant formula

Guinea ProtocoleNational dePrise enCharge de laMalnutritionAigue 2008

yes n/s 8/98 8% <3kg <70% WHM (NCHS) 1) Mother does nothave enough milkand baby loosingweight (does notmatter what exactWHM is atassessment)2) Infant too weak tosuckle and loosingweight even ifmother has milk

Mali ProtocoleNational dela prise encharge de lamalnutritionaigue 2007

yes n/s 4/97 4% <3kg <70% WHM (NCHS) 1) Mother does nothave enough milk andbaby loosing weight2) Infant too weak tosuckle and loosingweight even ifmother has milk

noted that RUTFinappropriate as "reflexof swallowing is not yetpresent"

Niger Protocole deprise encharge de lamalnutritionaigue 2008

yes yes(motherreferred to SFP)

7/93 8% <3kg <70% WHM (NCHS) Main criterion is"failure of effectivebreastfeeding":1) Tooweak or feeble tosuckle effectively (nomatter what weight-for-height)2) Notgaining (or loosing)weight at home

notes that infant <6mshould be nursed in aseparate area of the ward

Table 7 cont’d


69






Infant <6mMAM







Senegal Protocole deprise en chargede lamalnutritionaigue 2008

yes n/s 3/45 7% notmentioned

<70% WHM (NCHS) 1) Too weak to suckleand loosing weighteven if mother hasmilk2) Loosing weightwith mother who hasinsufficient milk

Afghanistan Community-basedManagement ofAcuteMalnutritionprogramme inAqcha andMardyan Districtof JawzjanProvinceNorthernAfghanistan2008


same Main criterion is"failure of effectivebreastfeeding":1) Too weak or feebleto suckle effectively2) Not gaining weightat home

Protocol notes nogrowth standards for infants whoselength <49cm andthat the nutritionunit is notappropriate fortreating prematureand LBW infants<49cm. Theseshould be referred to nursery and given infant formula

Guinea ProtocoleNational de Priseen Charge de laMalnutritionAigue 2008

yes n/s 8/98 8% <3kg <70% WHM (NCHS) 1) Mother does nothave enough milk andbaby loosing weight(does not matterwhat exact WHM is atassessment)2) Infant too weak tosuckle and loosingweight even if motherhas milk

India Indian Academyof Paeditricsguidelines 2006

Notexplicitly.Introdoesmentionchildrenaged 0 to4 years

n/s 0/14 0% n/a n/a n/a No specific detailsof infant <6mtreatment noted inprotocol summary.

Pakistan Protocol for theinpatienttreatment ofseverelymalnourishedchildren in thePakistanearthquakeemergency 2005

notexlplicitly

n/s n/s n/s n/s n/s n/s

Sri Lanka Management ofSevere AcuteUndernutrition:Manual forHealth Workersin Sri Lanka2007

targetgroup forprotocolis 0 to 59months

n/s noseparatesection forinfant<6m

n/s notmentioned

same not specified Outpatient carenoted as only for 6to 59 month oldchildren

Table 7 cont’d


70


4.4.3 Key medical treatments for infants <6mSee Table 8 for overview.

Admission proceduresAdmission procedures for SAM and MAM include a basic medical history and clinical examination. Some guidelines annex a template ‘history/examination’ proforma, thereby standardizing admission practices. Few guidelines suggest significant extra or different admission procedures for infants <6m. Exceptions and possible models for future guidelines include:

• IFE Module 2 provides the most detail of various aspects of presentation, including recognizing low birth weight infants, infant feeding status (e.g. breastfed or not) and full assessment of breastfeeding (with dedicated sections and a standard checklist).

• MSF 2006 highlights “Additional history, including feedings other than EBF; presence and attitude of the mother, state of the infant, flow of mother’s milk and attachment and suckling.”

• Botswana’s national guidelines note the need to observe breastfeeding “position, attachment, suckling,breast conditions”

• Cote d’Ivoire suggests that suck can be assessed by inserting a finger into the infant’s mouth. Adequacy of current admission procedures will be reviewed in detail in Chapter 9.

Treatment guidelinesAll guidelines recognize a phased approach to care. Many go into significantly more detail on the WHO (1999) ‘ten steps’. There is, however, no specific focus on infants <6m with the exception of IFE Module 2.

Specific treatmentsWhere sections on infant <6m exist in guidelines, they commonly recommend vitamin A, folic acid, iron (usually mixed into the therapeutic milk, but only once the child has improved and is in recovery phase) at appropriate doses. For malaria, local guidelines are referred to. Antibiotics are universally recommended. The most common first line therapy is amoxicillin, with several minor variations in dose/ dose regimen. Second line therapy is often not directly covered in the infant section of the guideline. If noted, initial ampicillin (with switch after two days to oral amoxicillin) plus gentamycin is common.

Kangaroo careii for nursing young / small infants is noted in many guidelines, but often only as a treatment for hypothermia rather than as a default ‘ideal’ position for infants <6m. One exception is IFE Module 2, where Kangaroo care is recommended to “prevent or treat hypothermia” in severely malnourished infants, and also as the default treatment of low birth weight infants, supported by detailed content136.

HIVDetails of HIV-related issues are limited in most guidelines. Those written most recently seem to have greater detail, which probably reflects increased availability of antiretroviral treatments. Where HIV is mentioned, explicit links and references to local HIV-specific guidelines are not made. This is an area for future developers to address, to ensure closer links between services (see Section 9.9 for more HIV considerations).

ii Kangaroo care is a technique where the infant is held in continuous skin-to-skin contact with an adult, usually the mother. It facilitates temperature regulation, reduces infant stress, and helps establish and maintain breastfeeding.


71


Table 8: Key medical treatments recommended for infants <6m


Guideline Treatmentobjective

Admission Vitamin A

Folic acid 1st lineantibiotic

2nd lineantibiotic

Anti-malarial

Iron Other Kangaroocare


WHO Managementof severemalnutrition:a manual forphysicians &other seniorhealthworkers1999

n/a Clinicalassessment

50,000IU (onadmission)followedby smalldaily doses

5mg doseatadmission,then dailydose of1mg

cotrimoxazolex2 per dayfor 5 days

ampicillin (50mg/kg/6hrs im for 2 days)then amoxicillin 15mg/kg/8hrs orally for 5daysplus gentamycin7.5mg/kg daily for 7 days

Recommendsfollowingnationalguidelines

all get irononcompletionofstabilisationphase

notspecified

WHO Guidelines forthe inpatienttreatment ofseverelymalnourishedchildren,2003

n/a Clinicalassessment

50,000IU (onadmission)followedby smalldaily doses

50,000IU (onadmission)followedby smalldailydoses

If no complicationscotrimoxazolex2 per dayfor 5 daysif complications amp +gent as above

not specified 3mg/kd/day(onceimproved)

notspecified

WHO Manual forthe healthcare ofchildren inhumanitarianemergencies2008

n/a n/a 50,000IU (onadmission)

notroutinely

amoxicillin notspecified

according tonationalguideline

notroutinely

notspecified

WHO Pocket bookof Hospitalcare forchildren 2005

n/s Clinicalassessment

50,000IU (onadmission)then smalldaily dose

5mg onadmissionthen1mg/day

cotrimoxazolex2 per dayfor 5 days

as above not specified 3mg/kg/day (onceimproved)

alsonotes2mg/kg/day zinc and 0.3mg/kg/day copper

notspecified

WHO HandbookIMCIIntegratedManagementof ChildhoodIllness 2005

n/a n/a n/a n/a n/a n/s n/a n/a n/a n/a

ACF Assessment &Treatment ofMalnutritionin EmergencySituations 2002

Increasemothersmilk supplyuntil BMalonesufficientfor growth

clinicalexaminationmentionedbut nodetailsgiven

50,000IUon days1,2 and atdischarge

5mgsingledose atadmission

amoxicillin20mg/kgx3 per dayfor 10 days

notspecified

according tonationalprotocol

in F100dilute(onceimproved)

noted aspart ofhypo-thermiaprevention

MSF NutritionGuidelines(1st edition)1995

stated thatBF shouldbepromotedandcontinuedduring thewholetreatmentcourse

noadditionaldetailsspecified

notes thatvit Ashould notbe givendue topossibletoxicity

no specificdetailsgiven

no specificdetails given

notspecified

no specificdetails given

no specificdetailsgiven

notspecified


72




Admission Vitamin A


2nd lineantibiotic

Anti-malarial



MSF NutritionGuidelines2006

reducemortality &morbidity- dischargeon EBF

- additionalhistory:- feeds otherthan EBF;presence +attitude ofmother; - state ofinfant, - flow ofmother's milk, - attachment,suckling

50,000 IU(furtherdoses ifxeropth-almia)


notspecified

treat only ifinfant hasmalaria- need fornets topreventtransmis-sion alsonoted

daily or weeklysupplementationdescribed inmicronutrientschapter

yes- diagramincluded

MSF ProtocolInfants lessthan 6months old(Benson) MSF- OCBA 2007

To returninfants tofull EBF

no additionaldetailsspecified

50,000 IU(furtherdoses ifxeropth-almia)


amoxicillin35-50mg/kg x2 perday for 5days plusgentamicin

notspecified

notspecified

in F100dil(once improved)

yes- diagramincluded

Valid Community-basedTherapeuticCare (CTC), Afield manual(first edition)2006

n/a no additionaldetailsspecified

n/a n/a n/a n/a n/a n/a n/a n/a

UNHCR Handbook forEmergencies(third edition)2007

n/s n/s n/s n/s n/s n/s n/s n/s n/s n/s

UNHCR Themanagementof Nutritionin MajorEmergencies2000

treatmother notinfant

treat mothernot infant

n/a n/a n/a n/s n/a n/a n/a n/a

IFE CoreGroup


Detailsdescribed

50,000IU(admissiononly)

5mgsingledose

n/s n/s n/s ferroussulphate,in F100dilute(onceimproved)

Givesextensivedetails ofsupportivecare forbreast-feeding

Yes,including toprevent aswell astreathypother-mia

ICRC NutritionManual forHumanitarianAction 2008

n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a

National guidelines

Burundi ProtocoleNational deNutrition2002

n/s no additionaldetailsspecified

50,000 IU atadmission


amoxycillinfrom 2kg,20mg/kgx3 per day

notspecified

notspecified

ferrous sulphate, inF100dilute (onceimproved)

notspecified

Ethiopia Protocol fortheManagementof SevereAcuteMalnutrition2007




2.5mgsingledose

amoxycillinfrom 2kg,30mg/kgx2 per dayplusgentamycin

notspecifiednot clearwhethergentamycinis 1st or 2ndlinetreatment

nationalprotocol(coartemfrom 3months)

ferroussulphate,in F100dilute(onceimproved)

notspecified

Table 8 cont’d


73




Admission Vitamin A

Folicacid

1st lineantibiotic

2nd lineantibiotic

Anti-malarial


National guidelines

Madagascar Depistage etprise encharge de lamalnutritionaigue2007

To ensuremother canproduce milkof sufficientquantity andquality forinfant togrownormally


notspecified

notspecified

notspecified

notspecified

notspecified

notspecified

noted ingeneralsection onhypothermia

Malawi Guidelinesfor theManagementof SevereAcuteMalnutrition(book T3)2007

To stimulateBF untilsufficient toallow theinfant togrowproperly



5mgsingledose

amoxycillin15mg/kgx3 / day,phase 1 +4 daysextra)

ampicillinivandgentamycinim

notspecified

in F100dil(onceimproved)

noted astreatmentforhypothermiain generalsection

Mozambique Manual deOrientacaoparaTratamentodaDesnutricaoAguda Grave2008


notspecified

5mgsingledose

amoxycillin20mg/kgx3 per dayplusgentamycin

notspecified

notspecified


HIV-relatedtreatmentsnoted forexposedinfants

noted ingeneralsection onhypothermia

Tanzania Managementof AcuteMalnutritionNATIONALGuidelines2008

n/s not stated 50,000 IUd1 (+d2,d14 ifclinicalsignsdeficiency)

5mgsingledose

amoxycillin15mg/kgx3 per dayfor 5 days

ampicillin plusgentamycin7.5mg/kgdaily for 7days

notspecified

3mg/kg/day elementaliron once improved

noted as atreatmentforhypothermiain generalsection

Uganda IntegratedManagementof AcuteMalnutrition2006

n/s n/a n/a n/a n/a n/a n/a n/a n/a n/a

Zambia IntegratedManagementof AcuteMalnutrition2009


50,000IUatadmission

notspecified

notspecified

notspecified

notspecified

notspecified

notspecified

not specified

Zimbabwe Guidelinesfor theManagementof SevereAcuteMalnutritionthroughCommunity-basedTherapeuticCare (CTC)2008

n/s n/s 50,000IUatadmission

5mg atadmission

amoxycillin from 2kg,20mg/kg x3 per dayfor 7-10 days

not for<4kginfants

notspecified

notspecified

not specified

DRC ProtocolNational dePrise enCharge de laMalnutritionAigue 2008


50,000 IUatadmissiononly(not ifoedema)

notspecified


notspecified

notspecified

notspecified

Notes'healtheducationand socialcare' (forallchildren)

not specified

Table 8 cont’d


74




Admission Vitamin A


2nd lineantibiotic

Anti-malarial


National guidelines

Sudan(Southern)

Guidelinesfor theManagementof SevereAcuteMalnutrition2008

To improve orre-establishBF

no additionaldetailsspecified(thoughdisability,maternalillness,maternaltrauma notedas problemwhich canaffect infantfeeding)

50,000 IUatadmissiononly

2.5mgsingledose atadmission


notspecified

notspecified

ferrous sulphate, inF100dilute, onceimproved

notspecified

Sudan NationalIntegratedManual ontheManagementof SevereAcuteMalnutritionin healthfacilities andatcommunitylevel 2008

To returninfants to fullEBF





notspecified

notspecified

ferrous sulphate, inF100dilute, onceimproved

noted astreatmentforhypother-mia ingeneralsection

Botswana Guidelinesfor theManagementof SevereAcuteMalnutritionin Children2007

~ Treat SAM~ Restore tohealth~ Reducemortality~ Treatcomplications& associateddiseases~ Maintainor improvematernalmilkproduction

~ Observebreastfeeding(position,attachment,suckling,breastconditions)~ medicalconsultation(history,examination)


2.5mgsingledoseatadmission


notspecified

accordingto nationalguidelines

ferroussulphate6mgelementaliron/kg/day (onceimproved,growing)

Brieflymentions'healtheducationand socialcare' (for allchildren)

noted as atreatmentforhypother-mia ingeneralsection

Burkina Faso None yet - indraft

To increasethe qualityand quantityof BF




amoxycillin,from 2kg25mg/kgx3 per day

notspecified

notspecified

ferrous sulphate(once improved)

notspecified

Cote D'Ivoire ProtocoleNational dePrise encharge de lamalnutritionsevere2005

To re-establisheffective EBF(NOTnecessarily toregain 85%WHM)

Note~ Whetherpreterm ~ Birthweight~ Feeds(aside fromBM) ~ Strength ofinfant suck(by insertingfinger intomouth)

notspecified



notspecified

notreatmentif testsnegative7 daysartesunateif positive


Notes thatrisk ofhypother-mia &hypoglycae-mia high ==>infants to benursed closetogetherandmonitoredclosely

notspecified

Guinea ProtocoleNational dePrise enCharge de laMalnutritionAigue 2005

Tosupplementmaternal BFand get tothe pointwhere infantgrowing wellon BF alone




amoxycillin,from 2kg30mg/kgx2 per day+gentamycin

notspecified

notspecified


noted as atreatmentforhypother-mia ingeneralsection

Table 8 cont’d


75




Admission Vitamin A


2nd lineantibiotic

Anti-malarial


National guidelines

Mali ProtocoleNational de laprise encharge de lamalnutritionaigue 2007

n/s noadditionaldetailsspecified



amoxycillin, from 2kg20mg/kgx3 per day

notspecified


noted as atreatment forhypothermiain generalsection

Niger ProtocolNational dePrise enCharge de laMalnutritionAigue 2006





amoxycillin,from 2kg30mg/kgx2 per day

notspecified

notspecified


not specified

Senegal Protocole deprise encharge de lamalnutritionaigue 2008



not noted 2.5mgsingledose atadmission

amoxycillinfrom 2kg,20mg/kgx2 per dayfor 7 days

notspecified

notspecified

notspecified

not specified

Afghanistan Community-basedManagementof AcuteMalnutritionprogrammein Aqcha andMardyanDistrict ofJawzjanProvinceNorthernAfghanistan(StabilizationCentreGuidelines)2008




2.5mgsingledoseatadmission


addgentamycin(do not usechloram- phenicol)

accordingtonationalguidelines


noted insection onhypothermia,withimplicationthat isrecommendedfor all children

India IndianAcademy ofPaeditricsguidelines2006


Pakistan Protocol forthe inpatienttreatment ofseverelymalnourishedchildren inthe Pakistanearthquakeemergency2005


Sri Lanka Managementof SevereAcute Under-nutrition:Manual forHealthWorkers in SriLanka2007

n/s noadditionaldetailsspecified

"accordingtonationalprotocol"

notspecified

amoxycillin15mg/kgx3 per dayfor 5 days

gentamycin7.5mg/kgfor 7 daysplusampicillin ivfor 2 daysthen

notspecified

3mg/kg/day onceimproving/gainingweight

noted insection onhypothermiaas prevention/treatment

Table 8 cont’d


76


“Careful attention to infant feeding and support for good practice can save lives.Preserving breastfeeding, in particular, is important not just for the duration of anyemergency, but may have lifelong impacts on child health and on women’s futurefeeding decisions.

Every group of people has customs and traditions about feeding infants and youngchildren. It is important to understand these and work with them sensitively whilepromoting best practice.”

Operational Guidance on IFE, v2.1, 2007 &UNHCR Handbook for Emergencies, 3rd Edition

4.4.4 Nutritional treatments for infants <6m

See Table 9 for summary. Most guidelines divide infants into those who have the opportunity to breastfeed and those who do not. These will be dealt with in turn.

Treatment objective‘Restoration of effective exclusive breastfeeding’ (or similar phrasing implying the same) is a commonly stated treatment objective for infants <6m. This differs from the goal for older children, who aim for a nutritional ‘cure’ (commonly >80 or 85% weight-for-height / >-2 or -1 z-scores).

Breastfed infantsMost guidelines encourage the continuation of breastfeeding. However, details of breastfeeding support are rarely described. Exceptions are IFE Module 2 and the WHO pocket handbook of hospital care (2005). For infants <6m who can breastfeed, three hourly breastfeeding of ten to 20 minutes is generally recommended in guidelines. Some encourage more frequent feeds as demanded by the infant. Practical details of how to support and optimize breastfeeding are very limited. This makes prior specialist skills necessary to be able to implement and build on guidelines. Existing materials on breastfeeding support are rarely referenced.

All guidelines imply that infants <6m admitted to treatment would need at least short term supplemental feeds, with the exception of IFE Module 2 that gives the option of breastfeeding/expressed breastmilk alone where an infant is suckling and breastmilk supply is adequate. Diluted F100 was the most frequently recommended supplemental milk. Some guidelines mention F75 for infants with oedema. IFE Module 2 includes commercial infant formula as an option and advises against ‘home prepared’ F75 in thisage-group.

The supplementary suckling (SS) technique as a means of supplemental feeding is widely referenced and thoroughly described in guidelines, including with pictures and diagrams in many137. Using SS, weight gain criteria (20g per day cited by many guidelines) are used to signify that breastmilk production is improving. After a few days with good weight gain, the volume of supplemental milk is reduced. If weight gain continues, supplemental milk is stopped entirely and the infant is monitored to see whether he/she continues to gain weight on exclusive breastfeeding alone.

A minimum admission length is sometimes specified (e.g. nine to 11 days minimum, which includes two to three days each for phase one and two, plus five days for exclusive breastfeeding). Other guidelines urge a short as possible admission, depending on weight gain. All emphasise a need to ensure the infant is gaining adequate weight and is clinically well on exclusive breastfeeding alone, prior to discharge.

Non-breastfed infantsPossible reasons for not breastfeeding are not generally listed, with the exception of IFE Module 2. Thoughrare, none of the guidelines reviewed mention medical contra-indications to breastfeeding 138. The same supplemental milk recommended for breastfed infants is often recommended for this group: dilutedF100 or sometimes F75 for infants with oedema, fed by cup. Only a small number of guidelines explicitly warn of the hygiene risks of bottle/teat feeding.

The major difference for non-breastfed infants <6m arises in the rehabilitation phase of treatment. Here, volume of supplemental milk doubles to enable catch-up growth. Non-breastfed infants may also require transition to an appropriate breastmilk substitute, e.g. transition from diluted F100 to a commercial infant


77


formula. Rather than an ‘adequate weight gain’ discharge criterion, the non-breastfed infant is typically expected to reach the same anthropometric targets as older children prior to discharge (>80% or >85% weight-for-length).

Very few guidelines go into details about the challenges of long term use of infant formula, follow-up needs and resources required, and how to source supplies. Likewise, few note alternatives, such as wet nursing or modified animal milks. No guideline suggests that complementary foods or RUTF be started before six months.

Infant and young child feeding support in older age-groupThe lack of breastfeeding-specific guidance in current guidelines also has implications for older severely malnourished children, where breastmilk should continue to contribute significantly to their energy and nutrient intake. This compromises achievement of the Sphere indicator “as much attention is attached to breastfeeding and psychosocial support, hygiene and community outreach as to clinical care” (Correction of malnutrition standard 2: severe malnutrition).


78


Tab

le 9

: N

utr

itio

nal

tre

atm

ents

fo

r in

fan

ts <

6m

Coun

try o

rOr

gani

zatio

nGu

idel

ine

Divi

sion

into

'bre

ast-

fed'

and

'non

-BF'

Brea

st fe

edin

gBr

east

feed

ing

(det

ails)

Supp

lem

enta

lm

ilks

(BF i

nfan

t)

Supp

lem

enta

l m

ilk ro

ute

(BF i

nf.a

nt)

Supp

lem

enta

l m

ilk fe

edfre

quen

cy(B

F inf

ant)

Supp

lem

enta

l fe

ed

amou

nt(B

F inf

ant)

reha

b ph

ase

(BF i

nfan

t)du

ratio

nof

pha

ses

(BF i

nfan

t)

Disc

harg

e(B

F inf

ant)

No m

ater

nal

brea

stfe

edin

gav

aila

ble

Inte

rnat

ion

al g

uid

elin

es

WHO

Man

agem

ent o

fse

vere

mal

nutr

ition

,19

99

n/a

"sho

uld be

cont

inued

"No

ted i

n sec

tion

on pr

epar

ation

for d

ischa

rge

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

WHO

Guid

elin

es fo

r the

inpa

tient

trea

tmen

t of

seve

rely

mal

nour

ished

child

ren,

2003

n/a

"bre

astfe

ed as

ofte

nas

child

wan

ts"no

ted i

n sec

tion

on pr

epar

ation

for d

ischa

rge

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

WHO

Man

ual f

or th

ehe

alth

care

ofch

ildre

n in

hum

anita

rian

emer

genc

ies 2

008

n/a

not n

oted

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

WHO

Pock

et b

ook o

fHo

spita

l car

e for

child

ren

2005

no"if

child

is br

eastf

ed,

cont

inue w

ith th

is"se

para

tech

apte

r on

supp

ortiv

e car

eha

s det

ails o

nsu

ppor

ting B

F

In or

der o

fpr

efere

nce:

1)BM

alon

e 2)

Infan

tfo

rmula

3)

F100

dilut

e

not s

pecifi

ed(S

S des

cribe

din

differ

ent

chap

ter)

8 tim

es pe

r day

deta

ils no

tsp

ecifi

edde

tails

not s

pecifi

ed

not

spec

ified

not s

pecifi

edex

pres

sed

brea

stmilk

(ifav

ailab

le);

form

ula m

ilk or

infan

t for

mula

;m

odifie

dan

imal

milk

ACF

Asse

ssm

ent &

Trea

t-men

t of

Mal

nutr

ition

inEm

erge

ncy

Situ

atio

ns 20

02

>6m

onth

but <

4kg

infan

ts ar

ese

para

te

Ever

y 3 ho

urs

~ BF

for 1

0-20

mins

~ G

ive BM

S one

hour

afte

r BF

Dilut

ed F1

00su

pplem

enta

lsu

cklin

g(d

escri

bed)

8 tim

es pe

r day

130m

l/kg/

day

(=10

0kca

l/kg

/day

)

~ if

weigh

tinc

reasin

g for

15 da

ysth

en ha

lf am

ount

F100

dil ~

stop

SSaf

ter f

urth

er 3

days

mini

mum

stay w

ould

be 15

+ 3

+ 5

= 23

days

Once

gaini

ngwe

ight f

or 5

days

with

out

SS

Dilut

ed F1

00*

(pro

toco

l for

>6m

onth

but

<4k

g inf

ants)

MSF

Nutr

ition

Guid

elin

es (1

sted

ition

) 199

5

yes

"shou

ld be

prom

oted

and

cont

inued

durin

g the

whole

of tr

eatm

ent"

BMS A

FTER

each

sessi

on on

the b

reas

t

Reco

nstit

uted

enric

hed

form

ula m

ilk(re

cipie

given

)

small

spoo

n or

syrin

ge5-

6 tim

es pe

rda

y10

5kc

al/kg

/day

no sp

ecifi

c det

ails

not

spec

ified

not s

pecifi

edEn

riche

dfo

rmula

milk

(recip

e give

n)

MSF

Nutr

ition

Guid

elin

es20

06

yes

Ever

y 3 ho

urs

Ever

y 2 ho

urs f

or<

1.5kg

mor

e ofte

nif i

nfan

t wan

ts

~ BF

for 1

0-20

mins

~ G

ive BM

S one

hour

afte

r BF

SDTM

(ther

apeu

ticm

ilk)

supp

lemen

tary

suck

ling

8 tim

es pe

r day

100-

120

kcal/

kg/d

aysta

rt Tra

nsiti

on on

day 1

0 (m

ax d.

15).

Whe

n BM

outp

ut in

creas

es,

weigh

t incre

asing

,de

creas

e STD

M by

50%

. If st

ill ga

ining

weigh

t by 5

g/kg

/day

,sto

p SDT

M

phas

e 110

-15 d

ays

then

acco

rding

to pr

ogre

ss

Once

gaini

ngwe

ight f

or 5

days

with

out

SS

SDTM

(ther

apeu

ticm

ilk)


79


Coun

try o

rOr

gani

zatio

nGu

idel

ine

Divi

sion

into

'bre

ast-

fed'

and

'non

-BF'

Brea

stfe

edin

gBr

east

feed

ing

(det

ails)

Supp

lem

enta

lm

ilks

(BF i

nfan

t)

Supp

lem

enta

l m

ilk ro

ute

(BF i

nf.a

nt)

Supp

lem

enta

l m

ilk fe

edfre

quen

cy(B

F inf

ant)

Supp

lem

enta

l fe

ed am

ount

(BF i

nfan

t)

reha

b ph

ase

(BF i

nfan

t)du

ratio

n of

phas

es(B

F inf

ant)

Disc

harg

e(B

F inf

ant)

No m

ater

nal

brea

stfe

edin

gav

aila

ble

Inte

rnat

ion

al g

uid

elin

es

MSF

Prot

ocol

Infa

nts

less

than

6 m

onth

sol

d (B

enso

n) M

SF -

OCBA

2007

yes

Ever

y 3ho

urs

mor

eof

ten i

finf

ant

want

s

~ BF

for 1

0-20

mins

~ G

ive BM

S 30-

60m

ins af

ter B

F

F100

dil(F

75 if

oede

ma)

supp

lemen

tary

suck

ling

8 tim

es pe

r day

100-

120

kcal/

kg/d

ayde

creas

e to 5

0% of

main

tena

nce o

nce

baby

gaini

ng 20

g/da

ysto

p com

plete

ly on

cega

ining

>10

g/da

y

acco

rding

topr

ogre

ssfew

mor

e day

swi

thou

t SS

- can

also

goon

ce ch

ild BF

gree

dly if

mot

her w

ishes

F100

dilut

e OR F

75fo

r mar

asm

usf7

5 for

kwas

hiorko

r

Valid

Hand

book

for

Emer

genc

ies(t

hird

editi

on) 2

007

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

UNHC

RM

anua

l for

the

heal

th ca

re of

child

ren

inhu

man

itaria

nem

erge

ncie

s 200

8

reco

gnise

dbu

t not

descr

ibed i

nde

tail

yes

"trea

tmen

t sho

uldinc

lude s

uppo

rt fo

rBF

n/s

n/s

n/s

n/s

n/s

n/s

n/s

n/s

UNHC

RTh

e man

agem

ent

of N

utrit

ion

inM

ajor

Emer

genc

ies

2000

non B

Finf

ants

not

reco

gnise

d

discu

ssed

in an

nex

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

IFE C

ore

Grou

pIn

fant

Feed

ing

inEm

erge

ncie

s IFE

Mod

ule 2

, ver

sion

1.1 2

007

yes

yes

Exte

nsive

discu

ssion

of BF

issu

es. B

reas

tfee

ding o

r exp

resse

dbr

eastm

ilk gi

ven a

stre

atm

ent o

ption

.Su

pplem

enta

ryfee

ds m

ay be

indica

ted.

F75 o

rF1

00 di

lute o

rIn

fant f

orm

ula

supp

lemen

tary

suck

ling

at le

ast 8

x /da

yvo

lume p

er kg

varie

sac

cord

ing to

weigh

t(ta

bles g

iven)

if inf

ant g

aining

weigh

t for

2-3d

ays,

atlea

st 20

g/ da

y the

nre

duce

SS by

1/3 a

ndfee

d for

furth

er 2-

3da

ys. C

ontin

ue to

redu

ce vo

lumes

ifinf

ant g

aining

weig

ht.

if gain

ingwe

ight,

each

redu

ction

ofBM

S volu

me

by 1/

3 oc

curs

ever

y2-

3 day

s

Once

gaini

ngwe

ight f

or 5

days

on BF

alone

F75 (

prefe

rred

optio

n)F1

00dil

or fo

rmula

also O

K

ICRC

Nutr

ition

Man

ual

for H

uman

itaria

nAc

tion

2008

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

Nat

ion

al g

uid

elin

es

Buru

ndi

Prot

ocol

e Nat

iona

lde

Nut

ritio

n 20

02ye

sEv

ery 3

hour

s~

BF fo

r 20 m

ins~

Give

BMS o

neho

ur af

ter B

F

F100

dilut

esu

pplem

enta

lsu

cklin

g(d

escri

bed)

8 tim

es pe

r day

130m

l/kg/

day

(=10

0kca

l/kg/

day)

decre

ase t

o 50%

ofm

ainte

nanc

e onc

eba

by ga

ining

20g/

day

not s

pecifi

edOn

ce ga

ining

weigh

t for

5da

ys w

ithou

t SS

F100

dilut

e OR F

75fo

r mar

asm

usf7

5 for

kwas

hiorko

r

Ethi

opia

Prot

ocol

for t

heM

anag

emen

t of

Seve

re A

cute

Mal

nutr

ition

2007

yes

Ever

y 3ho

urs

~ BF

for a

t lea

st 20

mins

~ BF

mor

e ofte

n if

infan

t wan

ts~

Give

BMS 3

0 to

60m

in af

ter B

F

F100

dilut

eor

com

mer

cial

form

ula(F

75 fo

r infan

tswi

th oe

dem

a)

supp

lemen

tal

suck

ling

(des

cribe

d)

8 tim

es pe

r day

130m

l/kg/

day

(=10

0kca

l/kg

/day

)

decre

ase t

o 50%

ofm

ainte

nanc

e onc

eba

by ga

ining

20g/

day,

stop c

omple

tely

once

gaini

ng>

10g/

day

"as s

hort

aspo

ssible

"On

ce ga

ining

weigh

t on B

Malo

ne

F100

dilut

e(F

75 fo

r infan

tswi

th oe

dem

a)

Table 9 cont’d


80


Coun

try o

rOr

gani

zatio

nGu

idel

ine

Divi

sion

into

'bre

ast-

fed'

and

'non

-BF'

Brea

stfe

edin

gBr

east

feed

ing

(det

ails)

Supp

lem

enta

lm

ilks

(BF i

nfan

t)

Supp

lem

enta

l m

ilk ro

ute

(BF i

nf.a

nt)

Supp

lem

enta

l m

ilk fe

edfre

quen

cy(B

F inf

ant)

Supp

lem

enta

l fe

ed am

ount

(BF i

nfan

t)

reha

b ph

ase

(BF i

nfan

t)du

ratio

n of

phas

es(B

F inf

ant)

Disc

harg

e(B

F inf

ant)

No m

ater

nal

brea

stfe

edin

gav

aila

ble

Inte

rnat

ion

al g

uid

elin

es

Mad

agas

car

Depi

stag

e et p

rise

en ch

arge

de l

am

alnu

triti

on ai

gue

2007

Reco

gnise

d but

not d

etail

edEv

ery 3

hour

s~

BF fo

r 20 m

ins~

Give

BMS o

neho

ur af

ter B

F

F100

dilut

esu

pplem

enta

rysu

cklin

g(d

escri

bed)

8 tim

es pe

r day

130m

l/kg/

day

(=10

0kca

l/kg/

day)

decre

ase t

o 50%

ofm

ainte

nanc

e onc

eba

by ga

ining

20g/

day

stop c

omple

tely

once

gaini

ng >

10g/

day

not s

pecifi

edOn

cega

ining

weigh

t for

5da

yswi

thou

t SS

Relac

tatio

n of

othe

r fem

ale ca

rer

(e.g

aunt

)re

com

men

ded)

Mal

awi

Guid

elin

es fo

r the

Man

agem

ent o

fSe

vere

Acu

teM

alnu

triti

on(b

ook T

3) 20

07

yes

Ever

y 3ho

urs

~ BF

for 2

0 mins

~ BF

mor

e ofte

n if

infan

t wan

ts~

Give

BMS o

neho

ur af

ter B

F

F100

dilut

esu

pplem

enta

rysu

cklin

g(d

escri

bed)

9 tim

es pe

r day

130m

l/kg/

day

(=10

0kca

l/kg/

day)

decre

ase F

100 d

ilute

by 1/

3 the

main

tena

nce o

nce

baby

gaini

ng20

g/da

y, de

creas

e by

a fur

ther

1/3 i

f stil

lga

ining

weig

ht af

ter

2-3 d

ays,

stop

F100

dilut

e if s

till

gaini

ng w

eight

~ "a

s sho

rtas

possi

ble"

~ 2-

3 day

sfo

r eac

hre

ducti

on of

1/3

F100

dilut

em

ainte

nanc

e

Once

gaini

ngwe

ight f

or 5

days

with

out S

S

F75

Moz

ambi

que

Man

ual d

eOr

ient

acao

par

aTr

atam

ento

da

Desn

utric

ao A

guda

Grav

e 200

8

yes

Ever

y 3ho

urs

~ BF

for 2

0 mins

~ BF

mor

e ofte

n if

infan

t wan

ts~

Give

supp

lemen

tal fe

edon

e hou

r afte

r BF

F100

dilut

e(F

75 fo

r infan

tswi

th oe

dem

a)

supp

lemen

tary

suck

ling

(des

cribe

d)

8 tim

es pe

r day

130m

l/kg/

day

(=10

0kca

l/kg/

day)

decre

ase t

o 50%

ofm

ainte

nanc

e onc

eba

by ga

ining

20g/

day

stop c

omple

tely

once

gaini

ng >

10g/

day

not s

pecifi

edOn

cega

ining

weigh

t for

5da

yswi

thou

t SS

F100

dilut

e(F

75 fo

r infan

tswi

th oe

dem

a)

Tanz

ania

Man

agem

ent o

fAc

ute M

alnu

triti

onNA

TION

ALGu

idel

ines

2008

no Relac

tatio

n of

othe

r fem

aleca

rer (

e.g au

nt)

reco

mm

ende

d)

"assi

st to

brea

stfee

dor

expr

ess

brea

stmilk

"

Give

pres

cribe

dam

ount

of F-

75 in

addit

ionto

brea

stmilk

not s

pecifi

ed8 t

imes

per d

ayas

per F

75pr

otoc

olEn

cour

age m

othe

rs to

BF. G

ive ad

dition

aldil

uted

F-10

0. As

BMpr

oduc

tion i

ncre

ases

,gr

adua

lly re

duce

amou

nt di

luted

F100

not s

pecifi

edas

for o

lder

child

ren,

>85

%W

HMor

>-1

WHZ

or M

UAC

>12

5mm

not s

epar

ately

deta

iled

Ugan

daIn

tegr

ated

Man

agem

ent o

fAc

ute M

alnu

triti

on20

06

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

Zam

bia

Inte

grat

edM

anag

emen

t of

Acut

e Mal

nutr

ition

2009

not s

pecifi

edno

tsp

ecifi

edno

t spe

cified

Infan

t for

mula

OR F1

00 di

lute

(F75

dilut

e for

infan

ts wi

thoe

dem

a)

not s

pecifi

ed8 t

imes

per d

ayno

t spe

cified

not s

pecifi

edno

t spe

cified

not

spec

ified

not s

pecifi

ed

Zim

babw

eGu

idel

ines

for t

heM

anag

emen

t of

Seve

re A

cute

Mal

nutr

ition

thro

ugh

CTC 2

008

not s

pecifi

edno

tsp

ecifi

edno

t spe

cified

not s

pecifi

edno

t spe

cified

not s

pecifi

edno

t spe

cified

not s

pecifi

edno

t spe

cified

not

spec

ified

not s

pecifi

ed

Table 9 cont’d


81


Coun

try o

rOr

gani

zatio

nGu

idel

ine

Divi

sion

into

'bre

ast-

fed'

and

'non

-BF'

Brea

stfe

edin

gBr

east

feed

ing

(det

ails)

Supp

lem

enta

lm

ilks

(BF i

nfan

t)

Supp

lem

enta

l m

ilk ro

ute

(BF i

nf.a

nt)

Supp

lem

enta

l m

ilk fe

edfre

quen

cy(B

F inf

ant)

Supp

lem

enta

l fe

ed am

ount

(BF i

nfan

t)

reha

b ph

ase

(BF i

nfan

t)du

ratio

n of

phas

es(B

F inf

ant)

Disc

harg

e(B

F inf

ant)

No m

ater

nal

brea

stfe

edin

gav

aila

ble

Inte

rnat

ion

al g

uid

elin

es

DRC

Prot

ocol

Nat

iona

lde

Pris

e en

Char

gede

la M

alnu

triti

onAi

gue 2

008

yes

Ever

y 3ho

urs

~ BF

for 2

0 mins

~ BF

mor

e ofte

nif i

nfan

t wan

ts~

Give

supp

lemen

tal

feed o

ne ho

uraf

ter B

F

F100

dilut

e(F

75 fo

r infan

tswi

th oe

dem

a)

supp

lemen

tary

suck

ling

(des

cribe

d)

8 tim

es pe

r day

130m

l/kg/

day

(=10

0kca

l/kg

/day

)

decre

ase t

o 50%

of m

ainte

nanc

eon

ce ba

byga

ining

20g/

day.

stop c

omple

tely

once

gaini

ng>

10g/

day

not s

pecifi

edOn

ce ga

ining

weig

ht on

EBF a

lone

F100

dilut

e(F

75 fo

r infan

tswi

th oe

dem

a)

Suda

n(S

outh

ern)

Guid

elin

es fo

r the

Man

agem

ent o

fSe

vere

Acu

teM

alnu

triti

on 20

08

yes

Ever

y 3ho

urs

~ BF

for 2

0 mins

~ BF

mor

e ofte

nif i

nfan

t wan

ts~

Give

supp

lemen

tal

feed o

ne ho

uraf

ter B

F

F100

dilut

esu

pplem

enta

rysu

cklin

g(d

escri

bed)

8 tim

es pe

r day

130m

l/kg/

day

(=10

0kca

l/kg/

day)

decre

ase t

o 50%

of m

ainte

nanc

eon

ce ba

byga

ining

20g/

day

stop c

omple

tely

once

gaini

ng>

10g/

day

not s

pecifi

edOn

ce ga

ining

weig

ht on

EBF a

lone

F100

dilut

e(F

75 fo

r infan

tswi

th oe

dem

a)

Suda

n(N

orth

)Na

tiona

lIn

tegr

ated

Man

ual

on th

eM

anag

emen

t of

Seve

re A

cute

Mal

nutr

ition

in h

ealth

facil

ities

and

at co

mm

unity

leve

l 200

8

yes

Ever

y 3ho

urs

~ BF

for 2

0 mins

~ BF

mor

e ofte

nif i

nfan

t wan

ts~

Give

supp

lemen

tal

feed 3

0-60

mins

afte

r BF

F100

dilut

e(F

75 fo

r infan

tswi

th oe

dem

a)

supp

lemen

tary

suck

ling

(des

cribe

d)

8 tim

es pe

r day

130m

l/kg/

day

(=10

0kca

l/kg/

day)

decre

ase t

o 50%

of m

ainte

nanc

eon

ce ba

byga

ining

20g/

day

stop c

omple

tely

once

gaini

ng>

10g/

day

as sh

ort a

spo

ssible

Once

gaini

ng w

eight

onEB

F alon

eF1

00 di

lute

(F75

for in

fants

with

oede

ma)

Bots

wan

aGu

idel

ines

for t

heM

anag

emen

t of

Seve

re A

cute

Mal

nutr

ition

inCh

ildre

n 20

07

yes

as of

ten

as possi

ble /

frequ

ently

"Edu

cate

and

dem

onstr

ate

prop

er BF

tech

nique

"

F100

dilut

esu

pplem

enta

rysu

cklin

g8 t

imes

per d

ay14

0ml/k

g/da

y70

ml/k

g/da

y10

-15 d

ays

intial

phas

e2 d

ays r

ehab

phas

eM

inim

um 4

days

final

phas

e

Whe

n gain

ing w

eight

(5 to

10g/

kg/d

ay) o

n EBF

alon

efo

r 5 co

nsec

utive

days

afte

rSS

stop

ped

NB so

me d

iscre

panc

y in

differ

ent s

ectio

ns of

guide

line a

s to l

engt

hs of

stay r

ecom

men

ded

F100

dilut

e(F

75 fo

r infan

tswi

th oe

dem

a)

Burk

ina F

aso

None

yet -

in d

raft

noEv

ery 3

hour

s~

BF fo

r 20 m

ins~

Give

supp

lemen

tal

feed o

ne ho

uraf

ter B

F

dilut

ed F1

00su

pplem

enta

lsu

cklin

g(d

escri

bed)

8 tim

es pe

r day

130m

l/kg/

day

(=10

0kca

l/kg/

day)

decre

ase t

o 50%

of m

ainte

nanc

eon

ce ba

byga

ining

20g/

day

Not

spec

ified

Once

gaini

ng w

eight

for 5

days

with

out S

Sno

t spe

cified

Cote

D'Iv

oire

Prot

ocol

e Nat

iona

lde

Pris

e en

Char

gede

la M

alnu

triti

onAi

gue 2

005

yes

Ever

y 3ho

urs

~ BF

for 2

0 mins

~ BF

mor

e ofte

nif i

nfan

t wan

ts~

Give

BMS 3

0-60

mins

afte

r BF

F100

dilut

esu

pplem

enta

lsu

cklin

g(d

escri

bed)

8 tim

es pe

r day

130m

l/kg/

day

(=10

0kca

l/kg/

day)

decre

ase t

o 50%

of m

ainte

nanc

eon

ce ba

byga

ining

20g/

day

"as s

hort

aspo

ssible

"On

ce ga

ining

weig

ht on

EBF a

lone

F100

dilut

e(F

75 fo

r infan

tswi

th oe

dem

a)

Table 9 cont’d


82

4.4 Guideline ComparisonsCo

untr

y or

Orga

niza

tion

Guid

elin

eDi

visio

nin

to'b

reas

t-fe

d' an

d'n

on-B

F'

Brea

st fe

edin

gBr

east

feed

ing

(det

ails)

Supp

lem

enta

lm

ilks

(BF i

nfan

t)

Supp

lem

enta

l m

ilk ro

ute

(BF i

nf.a

nt)

Supp

lem

enta

l m

ilk fe

edfre

quen

cy(B

F inf

ant)

Supp

lem

enta

l fe

ed am

ount

(BF i

nfan

t)

reha

b ph

ase

(BF i

nfan

t)du

ratio

n of

phas

es(B

F inf

ant)

Disc

harg

e(B

F inf

ant)

No m

ater

nal

brea

stfe

edin

gav

aila

ble

Nat

ion

al g

uid

elin

es

Guin

eaPr

otoc

ole N

atio

nal d

e Pris

een

Char

ge d

e la M

alnu

triti

onAi

gue 2

005

yes

Ever

y 3 ho

urs

~ BF

for 2

0 mins

~ BF

mor

e ofte

nif i

nfan

t wan

ts~

Give

BMS 3

0-60

mins

afte

r BF

F100

dilut

esu

pplem

enta

lsu

cklin

g(d

escri

bed)

8 tim

es pe

r day

130m

l/kg/

day

(=10

0kca

l/kg

/day

)

decre

ase t

o 50%

of

main

tena

nce

once

baby

gaini

ng20

g/da

y

"as s

hort

aspo

ssible

"On

cega

ining

weigh

t on

EBF a

lone

F100

dilut

e(F

75 fo

r infan

tswi

th oe

dem

a)

Mal

iPr

otoc

ole N

atio

nal d

e la

prise

en ch

arge

de l

am

alnu

triti

on ai

gue 2

007

yes

Ever

y 3 ho

urs

~ BF

for 2

0 mins

~ G

ive BM

S60

mins

afte

r BF

F100

dilut

esu

pplem

enta

lsu

cklin

g(d

escri

bed)

8 tim

es pe

r day

130m

l/kg/

day

(=10

0kca

l/kg/

day)

decre

ase t

o 50%

of

main

tena

nce

once

baby

gaini

ng20

g/da

y, sto

pco

mple

tely

once

gaini

ng >

10g/

day

not

spec

ified

Once

gaini

ngwe

ight f

or 5

days

with

out S

S

F100

dilut

e

Nige

r Pr

otoc

ol N

atio

nal d

e Pris

een

Char

ge d

e la M

alnu

triti

onAi

gue 2

006

yes

~ no

n-BF

prot

ocol

descr

ibes

findin

g wet

-nu

rse if

possi

ble

Ever

y 3 ho

urs

~ BF

for 2

0 mins

~ BF

mor

e ofte

nif i

nfan

t wan

ts~

Give

supp

lemen

tal

feed 6

0mins

afte

r BF

F100

dilut

esu

pplem

enta

lsu

cklin

g(d

escri

bed)

8 tim

es pe

r day

130m

l/kg/

day

(=10

0kca

l/kg/

day)

decre

ase t

o 50%

of

main

tena

nce

once

baby

gaini

ng20

g/da

y, sto

pco

mple

tely

once

gaini

ng >

10g/

day

not

spec

ified

Once

gaini

ngwe

ight f

or a

few da

yswi

thou

t SS

F100

dilut

e(F

75 fo

r infan

tswi

th oe

dem

a)

Sene

gal

Prot

ocol

e de p

rise e

n ch

arge

de la

mal

nutr

ition

aigu

e200

8

noEv

ery 3

hour

s~

BF fo

r 20

mins

~ G

ivesu

pplem

enta

lfee

d 60m

insaf

ter B

F

F100

dilut

esu

pplem

enta

lsu

cklin

g(d

escri

bed)

8 tim

es pe

r day

130m

l/kg/

day

(=10

0kca

l/kg/

day)

decre

ase t

o 50%

of

main

tena

nce

once

baby

gaini

ng20

g/da

y, sto

pco

mple

tely

once

gaini

ng >

10g/

day

as sh

ort a

spo

ssible

tom

inim

iseris

k of

noso

com

ialinf

ectio

n

Once

gaini

ngwe

ight f

or 5

days

with

out S

S

not d

etail

ed

Afgh

anist

anCo

mm

unity

-bas

edM

anag

emen

t of A

cute

Mal

nutri

tion p

rogr

amm

e in

Aqch

a and

Mar

dyan

Dist

rict

of Ja

wzja

n Pro

vince

Nor

ther

nAf

ghan

istan

(Sta

biliz

atio

nCe

ntre

Gui

delin

es) 2

008

noEv

ery 3

hour

s~

for a

t lea

st20

mins

~ m

ore o

ften i

fch

ild w

ants

F100

dilut

e(F

75 fo

r infan

tswi

th oe

dem

a)

Supp

lemen

tary

suck

ling

8 x pe

r day

(0.5

to 1

hraf

ter B

F)

130m

l/kd/

day

(100

kcal/

kg/

day)

(am

ount

NO

T inc

reas

ed

as in

fant g

ains

weigh

t)

decre

ase t

o 50%

of m

ainte

nanc

eon

ce ba

by ga

ining

20g/

day

if weig

htga

inm

ainta

ined,

then

stop

SS

Whe

nga

ining

weigh

t on

EBF a

lone

(no m

atte

rwh

at we

ight

or W

FL)

F100

dilut

e(F

75 fo

r infan

tswi

th oe

dem

a)

Indi

aIn

dian

Aca

dem

y of

Paed

iatr

ics g

uide

lines

onho

spita

l bas

ed m

anag

emen

tof

Seve

rely

Mal

nour

ished

Child

ren

2006

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

Paki

stan

Prot

ocol

for t

he in

patie

nttr

eat-m

ent o

f sev

erel

ym

alno

urish

ed ch

ildre

n in

the P

akist

an ea

rthq

uake

emer

genc

y 200

5

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

Sri L

anka

Man

agem

ent o

f Sev

ere

Acut

e Und

ernu

triti

on:

Man

ual f

or H

ealth

Wor

kers

in Sr

i Lan

ka 20

07

nono

ted t

hat "

BFsh

ould

beco

ntinu

ed fo

rall

infan

ts &

youn

g chil

dren

"

no ot

her d

etail

sno

t spe

cified

.By

impli

catio

n,inf

ant U

6 will

be tr

eate

d with

F75

n/a

n/a

n/a

n/a

n/a

n/a

n/a

Table 9 cont’d


83


4.4.5 Maternal care, preparation for discharge & follow-upSee Table 10 for overview.

Maternal dietMany guidelines recommend that lactating mothers receive increased food rations to give a total intake of2500kcal/day, and increased fluid intake to >2 litres/day. Vitamin A for the mother is recommended by many guidelines as a single large dose if the infant is <2 months old. Mothers of older infants may be pregnant so either it is withheld or a course of low dose Vitamin A is given. A small number of guidelines mention that general maternal micronutrient stores should be replenished though a high quality diet during breastfeeding.

Psychosocial carePlay therapy and psychosocial support of the malnourished child is one of WHO’s essential ten treatment steps. It is still recognized in many guidelines, often in dedicated sections, but none focus specifically on infants <6m.

The impact of severe infant malnutrition on feeding-associated interactions and feeding cues between a mother and her infant <6m, e.g. reduced demands for breastfeeding, and how to manage these are not generally addressed. IFE Module 2 does include content on this in the section concerned with breastfeeding support in malnourished infants but not specifically in the SAM chapter.

Specific psychosocial care for the mother/carergiver of either infants <6m or children, including assessment and treatment, is not included in the guidelines apart from general statements about ‘being supportive’, explaining treatments and avoiding blame for the infant’s malnutrition. The exception is IFE Module 2 that gives a more practical description of assessment and care for mothers. Given the relevance of psychosocial aspects of care to MAMI, Chapter 8 of this report undertakes a detailed review.

Follow-up care and supplementary feedingFollow-up on discharge from a TFP (inpatient or community-based) is almost universally recommended. SFP referral (if available) on discharge is almost universal and, by implication, this includes infants <6m where the mother benefits from supplementary food rations.

Promoting optimal infant and young child feedingTaking advantage of a captive ‘in-programme’ audience to work towards prevention of future malnutrition has obvious potential. Many guidelines highlight ‘health and nutrition education’ as part of the discharge package, but few are specific on what topics should be covered. Very few guidelines take advantage of thelarge body of IYCF literature available.

Feeding programmes for pregnant & lactating mothersSFP target groups frequently include pregnant women (in last trimester of pregnancy) and lactating women who are malnourished. However it is often not clear in guidelines whether the mothers of malnourished infants <6m should be admitted to SFPs, independent of the nutritional status of themother.


84


Tab

le 1

0: M

ater

nal

car

e, p

rep

arat

ion

fo

r d

isch

arg

e an

d f

ollo

w-u

p

Coun

try o

rOr

gani

zatio

nGu

idel

ine

Mat

erna

l die

tM

ater

nal

(care

give

r) ps

ycho

-so

cial i

ssue

s

Othe

rPr

epar

atio

n fo

r disc

harg

e(g

ener

al)

HIV

note

dFo

llow

–up

visit

sEx

tra h

ome

food

ratio

n?De

tails

of an

y IY

CFgu

idan

ceFe

eds

for

preg

nant

&lac

tatin

g wo

men

Inte

rnat

ion

al G

uid

elin

es

WHO

Man

agem

ent o

fse

vere

mal

nutr

ition

: am

anua

l for

phys

ician

s & ot

her

seni

or h

ealth

work

ers 1

999

not s

pecifi

edno

t spe

cified

not

spec

ified

Ensu

re ch

ild fu

lly im

mun

ized

Ensu

re m

othe

r or c

arer

:~

able

to fe

ed ch

ildap

prop

riate

ly~

able

to m

ake a

ppro

priat

eto

ys &

play

with

child

~

know

s how

to gi

ve ho

me

treat

men

t & re

cogn

ise si

gns

to se

ek m

edica

l assi

stanc

e

Yes:

~ ‘sh

ould

not b

e don

ero

utine

ly’; ~

‘HIV

stat

usha

s no r

ole in

man

agem

ent’;

~

‘resu

lt sh

ould

beco

nfide

ntial

, not

reve

aled t

o sta

ff

Yes

1 wee

k, 2 w

eeks

, 1m

onth

, 3m

onth

s & 6

mon

ths a

fter

disch

arge

not n

oted

none

not d

escri

bed

WHO

Guid

elin

es fo

r the

inpa

tient

trea

tmen

t of

seve

rely

mal

nour

ished

child

ren,

2003

not s

pecifi

edno

t spe

cified

Show

pare

nt/ca

rer t

o:~

feed

freq

uent

ly wi

then

ergy

and n

utrie

nt de

nse

food

s~

give

stru

cture

d play

ther

apy

Yes:

"reco

very

may

take

longe

r & tr

eatm

ent

failur

e is m

ore

com

mon

’~

‘trea

tmen

t sam

e as

for H

IV ne

g. ch

ild’

Yes

"regu

lar fo

llow-

up ch

ecks

"ad

vised

not n

oted

None

not d

escri

bed

WHO

M

anua

l for

the

heal

th ca

re of

child

ren

inhu

man

itaria

nem

erge

ncie

s 200

8

not s

pecifi

edm

enta

l hea

lth an

dps

ycho

socia

l sup

port

discu

ssed i

n sep

arat

ech

apte

r

not s

pecifi

edot

her c

hapt

er or

man

ual is

devo

ted t

oHI

V

not s

pecifi

edno

t spe

cified

Note

d, bu

t rea

der

refer

red e

lsewh

ere

for d

etail

s

not d

escri

bed

WHO

Pock

et b

ook o

fHo

spita

l car

e for

child

ren

2005

not s

pecifi

edim

porta

nce o

fps

ycho

logica

l facto

rsno

ted

Show

pare

nt/ca

rer t

o:~

feed

freq

uent

ly wi

then

ergy

and n

utrie

nt de

nse

food

s~

give

stru

cture

d play

ther

apy

Yes

Sepa

rate

chap

ter o

fbo

ok de

tails

HIV

issu

es

yes

1 wee

k, 2 w

eeks

, 1m

onth

, the

nm

onth

ly fo

r6m

onth

s

not n

oted

brea

stfee

ding a

ndyo

ung c

hild f

eedin

gde

scribe

d~

WHO

IYCF

docu

men

t not

refer

ence

d

not d

escri

bed

WHO

Hand

book

IMCI

Inte

grat

edM

anag

emen

t of

Child

hood

Illn

ess

2005

n/a

n/a

n/a

n/a

n/a

n/a

n/a

deta

iled s

ectio

n on

infan

t fee

ding

not d

escri

bed

ACF

Asse

ssm

ent &

Trea

tmen

t of

Mal

nutr

ition

inEm

erge

ncy

Situ

atio

ns 2

002

~ D

rink ≥

2l w

ater

per d

ay~

Eat ~

2600

kcal/

day

~ Su

pplem

ent w

ithvit

amins

& m

inera

ls(e

nsur

e typ

e 1nu

trien

t sto

res

adeq

uate

)

To su

ppor

t BF:

1) Li

sten t

o any

prob

lems

2) As

sess

BF3)

Help

durin

g BF

If gain

ing w

t 15d

ays:

-->ha

lve m

ilk --

>sto

p BM

S aftr

3da

ys --

->ke

ep fo

r 5 m

ore

days

to en

sure

prog

ress

main

taine

d

Yes n

otes

that

:~

field

treat

men

ts ar

ege

nera

lly in

adeq

uate

~ re

-feed

ing tr

eatm

ent

is sa

me

yes,

to~

weig

h inf

ant,

~ pr

ovide

supp

lemen

tary

food

to m

othe

r

week

ly(1

500k

cal/d

ay)

1st m

onth

;fo

rtnigh

t(7

00kc

al/da

y)2n

d mon

th;

mon

thly

(350

kcal/

day)

3-6m

onth

s

ch2.2

: Bre

ast m

ilk,

The p

racti

ce of

BF;

BMS;

Asse

ssing

feedin

g pra

ctice

s

Refer

ral t

o SFP

(but

evide

nce o

feff

ectiv

enes

sdis

cusse

d)


85


untr

y or

Orga

niza

tion

Guid

elin

eM

ater

nal d

iet

Mat

erna

l(ca

regi

ver)

psyc

ho-so

cial

issue

s

Othe

rPr

epar

atio

n fo

r disc

harg

e(g

ener

al)

HIV

note

dFo

llow

–up

visit

sEx

tra h

ome

food

ratio

n?De

tails

of an

yIY

CF g

uida

nce

Feed

s fo

rpr

egna

nt &

lact

atin

gwo

men

Inte

rnat

ion

al G

uid

elin

es

MSF

Nutr

ition

Guid

elin

es (1

sted

ition

) 199

5

~ m

entio

ns ne

ed fo

r ext

ra0.5

to 1

litre

fluids

/day

~ el

igible

for S

FP if

one i

sav

ailab

le

Stat

es "s

tress

isim

porta

nt fa

ctor

redu

cing t

hequ

antit

y of b

reas

tm

ilk;

Prot

ocol

note

s:~

need

for

psyc

hoso

cial

stim

ulatio

n

yes

~ no

ted th

at th

isdo

es no

t alte

rth

e trea

tmen

tstr

ategy

not

spec

ified

infan

ts ar

eeli

gbile

for

SFP a

fter T

FPca

re

None

SFP

(in pa

rticu

lar ca

ses

of fo

od in

secu

rity)

MSF

Nutr

ition

Guid

elin

es20

06

~ D

rink ≥

2l w

ater

per d

ay~

Eat 2

500k

cal/d

ayno

tes

psyc

holog

ical

supp

ort a

nden

cour

agem

ent t

om

othe

rs; al

so th

ene

ed fo

r priv

acy

and r

est

~ sti

mula

teem

otion

al an

dph

ysica

lde

velop

men

t~

prep

are pa

tient

for no

tmal

feedin

g prac

tices

1) Se

ction

onHI

V/AI

Ds,

focu

ses o

nnu

tritio

n;2)

Descr

ibed i

ninf

ant f

eedin

g &HI

V sec

tion

part

of in

fant

chap

ter d

escri

bes

supp

ort f

or BF

+alt

erna

tives

to BF

SFP o

r TFP

orsu

ppor

tive f

eedin

g(a

ccord

ing to

situa

tion)

MSF

Pr

otoc

ol In

fant

sle

ss th

an 6

mon

ths o

ld(B

enso

n) M

SF -

OCBA

2007

~ D

rink ≥

2l w

ater

per d

ay;

~ Ea

t 250

0kca

l per

day

~ Su

pplem

ent w

ith vi

tam

ins+

mine

rals

(ens

ure t

ype 1

nutri

ent s

tore

s ade

quat

e)~

Vit A

: 200

,000 I

U (si

ngle

dose

) if in

fant <

2mon

ths;

else 2

5,000

(wee

kly)

~ ne

ed to

enga

gem

othe

r with

treat

men

tpr

ogra

mm

ede

scribe

d~

need

to re

assu

re&

supp

ort

descr

ibed

Need

to nu

rse in

fants

in qu

iet,

sepa

rate

room

note

d no

t spe

cified

inth

is ch

apte

rno

t disc

usse

d in

this

chap

ter

not

spec

ified

inth

isch

apte

r

not s

pecifi

edin

this

chap

ter

not s

pecifi

ed in

this

chap

ter

not d

escri

bed

Valid

Inte

rnat

iona

lCo

mm

unity

-ba

sed

Ther

apeu

tic

Care

(CTC

), A

field

man

ual (

first

editi

on) 2

006

note

s nee

d for

nutri

tiona

lca

re of

mot

hers

(det

ails n

otsp

ecifi

ed)

note

s nee

d for

psyc

holog

ical c

are

of m

othe

rs (d

etail

sno

t spe

cified

)

n/a

yes

secti

on in

"futu

rede

velop

men

ts"ch

apte

rdis

cusse

s HIV

not

spec

ified

SFP i

fav

ailab

leIYC

F not

ed, b

utre

ader

refer

red

elsew

here

for

deta

ils

SFP i

f:~

MUA

C <21

0mm

& pr

egna

nt (3

rdtri

mes

ter)

~ M

UAC <

210m

m&

infan

t <6m

UNHC

RHa

ndbo

ok fo

rEm

erge

ncie

s(th

ird ed

ition

)20

07

n/s

n/s

n/s

yesd

etail

s abo

utHI

V and

nutri

tion

descr

ibed

n/s

SFP f

or al

ldis

char

ged

SAM

patie

nts

Has d

etail

edou

tlinin

g IYC

Fiss

ues,

includ

ingus

e of m

ilk pr

oduc

ts

targ

eted

SFP i

fM

UAC<

22cm

;bla

nket

SFP

othe

rwise

UNHC

RTh

em

anag

emen

t of

Nutr

ition

inM

ajor

Emer

genc

ies

2000

Addit

ional

supp

lemen

tary

ratio

n (no

t spe

cified

)su

gges

ted

Tnot

es th

atm

othe

rs/ca

rers

may

need

help

and

enco

urag

emen

t

Notes

: "W

hen a

mot

her is

seve

rely

maln

oursi

hed o

r suff

ering

from

seve

re inf

ectio

n or o

verw

ork,

she

may

prod

uce i

nade

quate

brea

stmilk

,lea

ding t

o maln

utrit

ion of

infan

t.Br

eastm

ilk pr

oduc

tion m

ay al

so be

affec

ted by

psyc

hoso

cial fa

ctors

n/a

yes

~ di

scusse

d in

deta

il in a

nnex

,inc

luding

issu

esof

BF &

HIV

n/a

SFP i

fav

ailab

leGu

iding

Princ

iples

for f

eedin

g inf

ants

and y

oung

child

ren

durin

g em

erge

ncies

refer

ence

d

SFP

deta

ils de

pend

onth

e situ

ation

IFE C

ore

Grou

pIn

fant

Feed

ing

inEm

erge

ncie

s IFE

Mod

ule 2

,ve

rsio

n 1.

120

07

~ D

rink e

xtra

1l w

ater

per

day

~ Ea

t ~ 25

00kc

al/da

y

Sepa

rate

chap

ter is

on "m

othe

rtra

umat

ised,

inem

otion

al cri

sis or

rejec

ting i

nfan

t"

seve

ral ch

apter

s foc

us on

care

form

othe

rW

hen B

F well

(if

BF)

Mot

her t

raine

dto

give

BMS

corre

ctly (

non-

BFinf

ants)

note

d in o

ther

chap

ters,

but

not i

n sec

tion o

nm

alnou

rishe

dinf

ant

at le

ast

week

ly fo

ra m

inium

umof

3 m

onth

SFP i

fav

ailab

leM

any c

hapt

ers o

fm

anua

l focu

s on

good

IYCF

prac

tices

refer

ence

to ot

her

guide

lines

give

n

Table 10 cont’d


86


untr

y or

Orga

niza

tion

Guid

elin

eM

ater

nal d

iet

Mat

erna

l(ca

regi

ver)

psyc

ho-

socia

l iss

ues

Othe

rPr

epar

atio

n fo

r disc

harg

e(g

ener

al)

HIV

note

dFo

llow

–up

visit

sEx

tra h

ome

food

ratio

n?De

tails

of an

y IY

CFgu

idan

ceFe

eds

for p

regn

ant

& la

ctat

ing

wom

en

Inte

rnat

ion

al G

uid

elin

es

ICRC

Nutr

ition

Man

ual

for H

uman

itaria

nAc

tion

2008

Secti

on on

psyc

holog

ical

supp

ort f

ocus

es on

child

rath

er th

anca

rer

~ im

mun

izatio

ns up

to da

teye

sCh

apte

r is de

vote

dto

feed

ing in

fants

and s

mall

child

ren

acco

rding

tonu

tritio

nal s

tate

Nat

ion

al G

uid

elin

es

Buru

ndi

Prot

ocol

eNa

tiona

l de

Nutr

ition

2002

~ D

rink ≥

2l w

ater

per d

ay~

Eat ~

2500

kcal/

day

~ Su

pplem

ent w

ith vi

tam

ins &

mine

rals

(ens

ure t

ype 1

nutri

ent s

tore

s ade

quat

e)~

Vit A

: 200

,000 I

U (si

ngle

dose

) if in

fant <

2mon

ths;

25,00

0 (we

ekly

if >2m

onth

s)

~ ne

ed to

enga

gem

othe

r with

treat

men

tpr

ogra

mm

ede

scribe

d~

need

to re

assu

re &

supp

ort m

othe

rde

scribe

d

impo

rtanc

e of

good

war

den

viron

men

tde

scribe

d

~ ha

s had

healt

hed

ucat

ion~

imm

uniza

tions

upto

date

noat

leas

t 3m

onth

sfo

llow-

upat

healt

hce

ntre

leve

l

Has m

essa

ges o

n:EB

F; co

ntinu

ed BF

until

2 ye

ars a

ge;

appr

opria

teco

mple

men

tary

food

s; ke

y chil

dcar

epr

actic

es

SF fo

r:pr

egna

nt w

oman

in3r

d trim

este

r if M

UAC

<21

0mm

; also

wom

en w

ith in

fant

<6m

if M

UAC

<21

0mm

Ethi

opia

Prot

ocol

for t

heM

anag

emen

t of

Seve

re A

cute

Mal

nutr

ition

2007

~ D

rink ≥

2l w

ater

per d

ay~

Eat ~

2500

kcal/

day

~ Su

pplem

ent w

ith vi

tam

ins &

mine

rals

(ens

ure t

ype 1

nutri

ent s

tore

s ade

quat

e)~

Vit A

: 200

,000 I

U (si

ngle

dose

) if in

fant <

2mon

ths

~ Ex

plain

aim of

treat

men

t/wha

t is

expe

cted;

reas

sure

SS w

orks

; be

atte

ntive

to m

othe

r&

intro

duce

her t

oot

her m

othe

rs

no sp

ecifi

c det

ails

yes.

Deta

ilsinc

lude:

1)Ne

ed fo

rte

sting

; 2)

TB co

-infec

tion

3)AR

V & st

art o

fAR

V

~ m

onth

lyfo

llow-

upun

til ag

ed 6

mon

ths

Mot

her in

SFP ~

mon

thly

until

6mon

ths a

ge

Anne

x 12 g

ives 9

key B

F mes

sage

s; An

nex 1

3 give

s 7ke

y mes

sage

s on

nutri

tion &

grow

th

not d

escri

bed

Mad

agas

car

Depi

stag

e et p

rise

en ch

arge

de l

am

alnu

triti

onai

gue 2

007

not s

pecifi

edno

t spe

cified

~ H

ealth

& nu

tritio

ned

ucat

ionno

spec

ific

infan

tfo

llow-

upno

t not

ed

Refer

ral t

o SFP

reco

mm

ende

dfo

r all

disch

arge

d SAM

patie

nts

briefl

y not

ed in

a lis

tof

healt

h and

nutri

tion e

duca

tion

topic

s

SFP f

or:

~ pr

egna

nt (3

rdtri

mes

ter)

& lac

tatin

gwo

men

with

MUA

C<

210m

m

Mal

awi

Guid

elin

es fo

r the

Man

agem

ent o

fSe

vere

Acu

teM

alnu

triti

on(b

ook T

3)20

07

~ D

rink a

t lea

st 2l

wate

r per

day

~ Ea

t ~ 25

00kc

al/da

y~

If inf

ant <

2 mon

ths,

mot

her

shou

ld ha

ve Vi

t A 20

0,000

IU

need

to re

assu

rem

othe

r not

edIf E

BF no

tpo

ssible

,alt

erna

tives

liste

d inc

lude:

- mod

ified

cow

or go

at m

ilk- i

nfan

t for

mula

~ ne

ed fo

r lov

ing ca

re,pla

y and

stim

ulatio

nno

ted

~ If

EBF n

ot po

ssible

,alt

erna

tives

liste

dinc

lude:

mod

ified

cow

or go

atm

ilk, in

fant f

orm

ula

note

d in l

ist of

caus

es of

failu

reto

resp

ond t

otre

atm

ent

refer

ral fo

rgr

owth

mon

itorin

gno

ted

Refer

ral t

o SFP

reco

mm

ende

dfo

r all

disch

arge

d SAM

patie

nts

none

SFP f

or:

~ pr

egna

nt &

lacta

ting w

omen

, up

to 6

mon

ths a

fter

birth

, with

MUA

C<

210m

m

Moz

ambi

que

Man

ual d

eOr

ient

acao

par

aTr

atam

ento

da

Desn

utric

aoAg

uda G

rave

2008

~ D

rink a

t lea

st 2l

wate

r per

day

~ Ea

t ~ 25

00kc

al/da

y~

If inf

ant <

2 mon

ths,

mot

her

shou

ld ha

ve Vi

t A 20

0,000

IU; if

<2m

onth

s, th

en25

,000IU

/wee

k~

Nee

d to r

eplen

ish ty

pe I

micr

onut

rient

stor

es no

ted

need

to re

assu

rem

othe

r and

expla

intre

atm

ents

note

d

~ H

as de

taile

d cha

pter

on ps

ycho

-socia

lsti

mula

tion &

care

yes

Who

le ch

apte

rde

vote

d to H

IViss

ues

for 3

mon

ths

afte

rdis

char

ge

Refer

ral t

o SFP

reco

mm

ende

dfo

r all

disch

arge

d SAM

patie

nts

has d

etail

ed se

ction

in an

nexe

s out

lining

IYCF i

ssues

SFP r

eferra

l for:

~ pr

egna

nt &

lacta

ting w

omen

with

MUA

C <22

0mm

Table 10 cont’d


87


Coun

try o

rOr

gani

zatio

nGu

idel

ine

Mat

erna

l die

tM

ater

nal

(care

give

r)ps

ycho

-socia

liss

ues

Othe

rPr

epar

atio

n fo

r disc

harg

e(g

ener

al)

HIV

note

dFo

llow

–up

visit

sEx

tra h

ome

food

ratio

n?De

tails

of an

y IY

CFgu

idan

ceFe

eds

for p

regn

ant &

lact

atin

g wo

men

Nat

ion

al G

uid

elin

es

Tanz

ania

Man

agem

ent

of A

cute

Mal

nutr

ition

NATI

ONAL

Guid

elin

es20

08

not s

pecifi

edno

t spe

cified

not s

pecifi

edPr

otoc

ol de

scribe

s:~

Ensu

reim

mun

izatio

nsdo

ne~

Play

ther

apy &

sens

ory s

timula

tion

men

tione

d in

histo

ry; H

IVscr

eenin

g is

"nec

essa

rylab

orat

ory

inves

tigat

ion"

ever

y 2 m

onth

s for

6 m

onth

s (co

ntinu

e/co

mple

te an

ym

edica

tions

;co

ntinu

e BF i

f ch

ild BF

)

not s

pecifi

edNo

neno

t des

cribe

d

Ugan

daIn

tegr

ated

Man

agem

ent

of A

cute

Mal

nutr

ition

2006

not s

pecifi

edno

t spe

cified

Prot

ocol

focus

es on

RUTF

-relat

edm

essa

ges f

or ol

der

child

ren

yes, W

hole

chap

ter d

evot

edto

HIV

issu

es,

with

sepa

rate

guide

lines

for

HIV+

patie

nts.

(NB f

ocus

ed at

>6m

onth

olds

)

not s

pecifi

edRe

ferra

l to S

FPre

com

men

ded

for a

lldis

char

ged

SAM

patie

nts

Need

to lin

k with

othe

r nat

ional

child

healt

h and

nutri

tion

prog

ram

mes

note

d

SFP r

eferra

l

Zam

bia

Inte

grat

edM

anag

emen

tof

Acu

teM

alnu

triti

on20

09

not s

pecifi

edno

t spe

cified

Prot

ocol

note

s:~ba

sic he

alth

educ

ation

mes

sage

s

yes

not s

pecifi

edRe

ferra

l to S

FPre

com

men

ded

for a

lldis

char

ged

SAM

patie

nts

None

SFP

for:

~ All

preg

nant

(3rd

trim

ester

)& la

ctatin

gwo

men

(with

infan

t<6

m &

child

ren on

PMTC

T com

ing fro

m fo

odins

ecur

e hou

seho

lds~

MUAC

<22

5mm

Zim

babw

eGu

idel

ines

for t

heM

anag

emen

tof

Seve

reAc

ute

Mal

nutr

ition

thro

ugh

CTC

2008

not s

pecifi

edno

t spe

cified

~ H

ealth

&nu

tritio

n edu

catio

n~

Link

s with

instit

ution

s,or

ganiz

ation

s &su

ppor

t gro

ups

(e.g.

socia

l welf

are,

hom

e bas

ed ca

re)

yes

deta

ils gi

ven

n/s

not s

pecifi

edNo

neSP

F for

P&L w

ithM

UAC<

185m

m;

OTP f

or M

UAC <

185m

m

DRC

Prot

ocol

Natio

nal d

ePr

ise en

Char

ge d

e la

Mal

nutr

ition

Aigu

e 200

8

~ Ea

t ~25

00kc

al/da

y~

Vit A

: 200

,000 I

U(si

ngle

dose

) if

infan

t <2m

onth

s

need

to re

assu

rean

d sup

port

mot

her s

tate

d

Prot

ocol

descr

ibes:

~ H

ealth

and

nutri

tion e

duca

tion

~ Pl

ay th

erap

y &ps

ycho

socia

lsu

ppor

t

noSp

ecifi

c inf

ant

follo

w-up

not

deta

iled

Refer

ral t

o SFP

reco

mm

ende

dfo

r all

disch

arge

dSA

M pa

tient

s.

briefl

y not

ed in

a lis

t of

healt

h and

nutri

tion

educ

ation

topic

s, als

ono

tes th

at fee

ding

bottl

es an

d arti

ficial

teats

shou

ld be

bann

ed

SFP f

or:

~ m

othe

rs of

infan

tswi

th M

AM~

lacta

ting w

omen

with

MUA

C <21

0mm

Suda

n(S

outh

ern)

Guid

elin

esfo

r the

Man

agem

ent

of Se

vere

Acut

eM

alnu

triti

on20

08

~ D

rink ≥

2l w

ater

per d

ay~

Eat ~

2500

kcal/

day

~ Su

pplem

ent w

ithm

icron

utrie

nts

~ Vi

t A 20

0,000

IU if

infan

t <2 m

onth

s

para

grap

h on

supp

ortiv

e car

efo

r mot

hers

men

tions

men

tal

and e

mot

ional

supp

ort f

ortra

uma /

depr

essio

n

Prot

ocol

descr

ibes:

~ H

ealth

and

nutri

tion e

duca

tion

~ Pl

ay th

erap

y &ps

ycho

socia

lsu

ppor

t~

Imm

uniza

tions

up-to

-dat

e

yes

deta

ils gi

ven

yes

"At r

egula

r inte

rvals

follo

wing

disch

arg

Refer

ral t

o SFP

reco

mm

ende

dfo

r all

disch

arge

dSA

M pa

tient

s.

IYCF n

oted

, but

read

erre

ferre

d else

wher

e for

deta

ils

not d

escri

bed

Table 10 cont’d


88


untr

y or

Orga

niza

tion

Guid

elin

eM

ater

nal d

iet

Mat

erna

l (ca

regi

ver)

psyc

ho-

socia

l iss

ues

Othe

rPr

epar

atio

n fo

r disc

harg

e(g

ener

al)

HIV

note

dFo

llow

–up

visit

sEx

tra h

ome

food

ratio

n?De

tails

of an

y IY

CFgu

idan

ceFe

eds

for p

regn

ant &

lact

atin

g wo

men

Nat

ion

al G

uid

elin

es

Suda

n(N

orth

)Na

tiona

lIn

tegr

ated

Man

ual o

n th

eM

anag

emen

t of

Seve

re A

cute

Mal

nutr

ition

in h

ealth

facil

ities

and

at co

mm

unity

leve

l 200

8

~ D

rink ≥

2l w

ater

per

day

~ Ea

t ~ 25

00kc

al/da

y~

Supp

lemen

t with

micr

onut

rient

s~

Vit A

200,0

00IU

ifinf

ant <

2 mon

ths,

2500

0IU w

eekly

othe

rwise

need

to re

assu

re an

d sup

port

mot

her s

tate

d~

ensu

re ch

ild is

fully

re-in

tegr

ated

in fam

ily &

com

mun

ity~

fully

imm

unize

d~

healt

h and

nutri

tion e

duca

tion

note

d in

list o

fm

ultipl

eca

uses

oftre

atm

ent

failur

e

~af

ter 1

wee

k, 2

week

s, 1 m

onth

, 3m

onth

s and

6mon

ths

Refer

ral t

o SFP

reco

mm

ende

d for

all di

schar

ged

SAM

patie

nts.

(SFP

for m

othe

r inca

se of

infan

t<

6m)

None

not d

escri

bed

Bots

wan

aGu

idel

ines

for t

heM

anag

emen

t of

Seve

re A

cute

Mal

nutr

ition

inCh

ildre

n 20

07

~ D

rink ≥

2l w

ater

per

day

~ Ea

t ~ 25

00kc

al/da

y~

Supp

lemen

t with

vitam

ins &

mine

rals

(ens

ure t

ype 1

nutri

ent

store

s ade

quat

e)

need

to re

assu

re an

d sup

port

mot

her (

e.g. 'b

e atte

ntive

')em

phas

ised

Mot

her s

hould

rece

ive m

edica

ltre

atm

ent i

f nee

ded

~ co

unse

lling a

ndhe

ath ed

ucati

onco

mple

ted~

imm

uniza

tion

up-to

-date

~ arr

ange

men

tsm

ade f

or fo

llow-

up

note

d in

list o

f 6ca

uses

ofpo

orwe

ight

gain

~ w

eekly

for 1

mon

th~

fortn

ightly

next

mon

th~

mon

thly

for n

ext 2

mon

ths

~ as

need

edth

erea

fter

no no

ted

Says

"fee

d fre

quen

tlywi

th en

ergy

and

nutri

ent d

ense

food

s"Fe

eding

bottl

es an

dar

tificia

l tea

ts sh

ould

be ba

nned

not d

escri

bed

Burk

ina

Faso

None

yet -

in d

raft

~ D

rink ≥

2l w

ater

per

day

~ Ea

t ~ 25

00kc

al/da

y~

Supp

lemen

t with

vitam

ins &

mine

rals

(ens

ure t

ype 1

nutri

ent

store

s ade

quat

e)~

Vit A

200,0

00IU

;Iro

n&fo

late

(60m

g+40

0mcg

) for

3m

onth

s afte

r adm

ission

~ ne

ed to

enga

ge m

othe

r with

treat

men

t pro

gram

me d

escri

bed

~ ne

ed to

reas

sure

& su

ppor

tm

othe

r des

cribe

d~

impo

rtanc

e of g

ood

envir

onm

ent d

escri

bed

~ ne

ed to

enga

ge m

othe

r with

treat

men

t pro

gram

me d

escri

bed

~ ne

ed to

reas

sure

& su

ppor

tm

othe

r des

cribe

d~

impo

rtanc

e of g

ood

envir

onm

ent d

escri

bed

Prot

ocol

men

tions

:~

Child

care

prac

tices

~ Pa

rent

ingca

pacit

y~

Play

ther

apy

nofo

llow

up no

ted b

utno

t det

ailed

Refer

ral t

o SFP

reco

mm

ende

d for

all di

schar

ged

SAM

patie

nts.

None

SFP i

f MUA

C <21

0mm

or if

her in

fant <

6mha

s MAM

Cote

D'Iv

oire

Prot

ocol

eNa

tiona

l de P

rise

en ch

arge

de l

am

alnu

triti

onse

vere

2005

~ D

rink a

t lea

st 2l

wate

r per

day

~ Ra

t ~ 25

00kc

al/da

y~

Mot

her s

hould

bead

equa

tely

supp

lemen

ted w

ithvit

amins

& m

inera

ls(ty

pe 1

nutri

ent s

tore

sad

equa

te) -

Vit A

200,0

00IU

2 pag

es of

prot

ocol

devo

ted t

ops

ycho

socia

l car

e & su

ppor

t~

coun

sellin

g and

heat

h edu

catio

nco

mple

ted (

good

child

care

prac

tices

are d

escri

bed i

nde

tail)

~ im

mun

izatio

nup

-to-d

ate

~ ar

rang

emen

tsm

ade f

or fo

llow-

up

yes

follo

w up

for a

t lea

st3 m

onth

s pos

t-dis

char

ge

~ M

othe

r sho

uldha

vesu

pplem

enta

ryfee

ds to

main

tain

quan

tity a

ndqu

ality

of m

ilksu

pply

None

not d

escri

bed

Guin

eaPr

otoc

ole

Natio

nal d

e Pris

een

Char

ge d

e la

Mal

nutr

ition

Aigu

e 200

5

~ Ea

t ~ 25

00kc

al/da

y~

Vit A

: 200

,000 I

U(si

ngle

dose

) if in

fant

<2m

onth

s

need

to re

assu

re an

d sup

port

mot

her s

tate

dPr

otoc

ol de

scribe

s:~

Hea

lth an

dnu

tritio

n edu

catio

n~

Play

ther

apy &

psyc

hoso

cial

supp

ort

noSp

ecifi

c inf

ant f

ollow

-up

not d

etail

edRe

ferra

l to S

FPre

com

men

ded f

orall

disch

arge

dSA

M pa

tient

s.

briefl

y not

ed in

a lis

t of

healt

h and

nutri

tion

educ

ation

topic

s, als

ono

tes th

at fee

ding

bottl

es an

d arti

ficial

teats

shou

ld be

bann

ed

SFP f

or:

~ m

othe

rs of

infan

tswi

th M

AM~

lacta

ting w

omen

with

MUA

C <21

0mm

Table 10 cont’d


89


untr

y or

Orga

niza

tion

Guid

elin

eM

ater

nal d

iet

Mat

erna

l(ca

regi

ver)

psyc

ho-so

cial

issue

s

Othe

rPr

epar

atio

n fo

r disc

harg

e(g

ener

al)

HIV

note

dFo

llow

–up

visit

sEx

tra h

ome

food

ratio

n?De

tails

of an

yIY

CF g

uida

nce

Feed

s fo

rpr

egna

nt &

lact

atin

gwo

men

Nat

ion

al G

uid

elin

es

Mal

iPr

otoc

ole N

atio

nal d

e la p

rise

en ch

arge

de l

a mal

nutr

ition

aigu

e 200

7

~ Dr

ink ≥

2l w

ater p

er da

y~

Eat ~

2500

kcal/

day

~ Su

pplem

ent w

ithvit

amins

& m

ineral

s~

Vit A

200,0

00IU

if inf

ant

<6 w

eeks

has p

arag

raph

on ps

ycho

socia

len

viron

men

t

Prot

ocol

men

tions

:~

play

ther

apy

~ he

alth a

nd nu

tritio

ned

ucat

ion

yes

~ A

chap

ter is

devo

ted t

o HIV

&re

lated

issu

es

as fo

r olde

r chil

dren

:for

3 m

onth

s~

week

ly for

1m

onth

~ for

tnigh

tlyth

ereaft

er

Refer

ral t

o SFP

reco

mm

ende

d for

all di

schar

ged

SAM

patie

nts.

note

d with

in lis

t of

healt

h and

educ

ation

topic

s for

com

mun

ity he

alth

worke

rs to

cove

r

SFP i

f MUA

C<

210m

m

Nige

r Pr

otoc

ol N

atio

nal d

e Pris

e en

Char

ge d

e la M

alnu

triti

onAi

gue 2

006

~ Dr

ink ≥

2l w

ater p

er da

y;~

Eat ~

2500

kcal/

day

~ Su

pplem

ent w

ith vi

tamins

& m

ineral

s (en

sure

type 1

nutri

ent s

tores

adeq

uate)

~ Vit

A 20

0,000

IU if

infan

t<2

mon

ths o

ld; Ir

on &

folat

e(6

0mg+

400m

cg) fo

r 3m

onth

s afte

r adm

ission

~ ne

ed to

enga

ge m

othe

rwi

th tr

eatm

ent

prog

ram

me

descr

ibed

~ ne

ed to

re

assu

re &

su

ppor

t mot

her

descr

ibed

Prot

ocol

men

tions

:~

play t

herap

y~

healt

h and

nutri

tion

educ

ation

yes

~ D

etail

s of H

IV an

dre

lated

issu

esdis

cusse

d

need

for r

egula

rfo

llow-

upem

phas

ised

Refer

ral t

o SFP

reco

mm

ende

d for

all di

schar

ged

SAM

patie

nts.

None

SFP f

orpr

egna

nt an

dlac

tatin

gwo

men

(with

infan

t <6m

) if

MUA

C <21

0mm

Sene

gal

Prot

ocol

e de p

rise e

n ch

arge

de la

mal

nutr

ition

aigu

e20

08

~ D

rink ≥

2l w

ater

per d

ay~

Eat ~

2500

kcal/

day

~ ne

ed to

enga

ge m

othe

rwi

th tr

eatm

ent

prog

ram

me

descr

ibed

Prot

ocol

men

tions

:~ pl

ayth

erapy

~ nu

tritio

nal

advic

e to m

othe

r~en

sure

mot

her c

anrec

ognis

e 'da

nger

signs

'of

clinic

al de

terior

ation

yes

not s

pecifi

edre

ferra

l to S

FP (i

fav

ailab

le)re

com

men

ded f

orall

disch

arge

dSA

M pa

tient

s

None

SFP f

orpr

egna

nt an

dlac

tatin

gwo

men

(with

infan

t <6m

) if

MUA

C <21

0mm

Afgh

anist

anCo

mm

unity

-bas

edM

anag

emen

t of A

cute

Mal

nutr

ition

pro

gram

me i

nAq

cha a

nd M

ardy

an D

istric

tof

Jaw

zjan

Prov

ince

Nor

ther

nAf

ghan

istan

(Sta

biliz

atio

nCe

ntre

Gui

delin

es) 2

008

Mot

her s

hould

bead

equa

tely

supp

lemen

ted

with

vita

mins

& m

inera

ls(ty

pe 1

nutri

ent s

tore

sad

equa

te)

not s

pecifi

edno

t spe

cified

nom

onth

ly un

til ag

ed6 m

onth

sNo

neno

t des

cribe

d

Indi

aIn

dian

Aca

dem

y of P

aedi

trics

guid

elin

es on

hos

pita

l bas

edm

anag

emen

t of S

ever

ely

Mal

nour

ished

Child

ren

2006

not s

pecifi

edno

t spe

cified

Prot

ocol

descr

ibes:

~ H

ealth

and n

utrit

ioned

ucat

ion~

Play

ther

apy &

psyc

hoso

cial s

uppo

rt

noSp

ecifi

c inf

ant

follo

w-up

not

deta

iled

not s

pecifi

edbr

iefly n

oted

in a

list

of he

alth a

ndnu

tritio

n edu

catio

nto

pics,

also n

otes

that

feedin

g bot

tles

and a

rtific

ial te

atssh

ould

be ba

nned

not d

escri

bed

Paki

stan

Prot

ocol

for t

he in

patie

nttr

eatm

ent o

f sev

erel

ym

alno

urish

ed ch

ildre

n in

the

Paki

stan

eart

hqua

keem

erge

ncy 2

005

not s

pecifi

edno

t spe

cified

Prot

ocol

men

tions

:~

com

pletin

gim

mun

izatio

ns~

sens

itizin

g car

ers t

oho

me c

are

~ pl

ay th

erap

y

yes:

~ no

ted th

at "re

cove

rym

ay ta

ke lo

nger

and

treatm

ent f

ailur

e is

mor

e com

mon

~ tre

atmen

t sho

uld be

sam

e as f

or H

IV

yes

~ w

eekly

for 1

mon

th~

fortn

ightly

for 2

mon

ths

~ m

onth

ly fo

r 3m

onth

s

not s

pecifi

edNo

neno

t des

cribe

d

Sri L

anka

Man

agem

ent o

f Sev

ere A

cute

Unde

rnut

ritio

n: M

anua

l for

Heal

th W

orke

rs in

Sri L

anka

2007

not s

pecifi

edno

t spe

cified

anne

x has

secti

on on

play t

hera

pyno

refer

ral fo

r foll

ow-

up no

ted

guide

to fa

mily

food

s for

child

ren

aged

1 to

5 ye

ars

given

in an

nex

None

not d

escri

bed

Table 10 cont’d


90

4.5 An ‘AGREE’ appraisal of current guidelines

4.5 An ‘AGREE’ appraisal of current guidelinesUsing the ‘AGREE’ appraisal framework (boxed), these are the common issues identified in this review:

a) Scope and purpose of guidelines in addressing infant <6m malnutrition

Guideline objectives to address child malnutrition are generally well stated. Titles alone are often enough to determine whether all types of acute malnutrition or only SAM is the focus.

Guidelines are generally much poorer at explicitly stating the needs of infants <6m. Infant <6m MAM is almost universally neglected (except by Burkina Faso guideline and IFE Module 2). In some guidelines infants <6m are only indirectly addressed, including in the WHO 1999 and 2003 guidelines. Some guidelines usefully state the objective of infant treatment (e.g. “to restore exclusive breastfeeding”). As infant <6m management is different from that of older infants and children it seems sensible that future guidelines deal with it specifically.

b) Stakeholder involvement

1. The overall objective(s) of the guideline should be specifically described.

2. The clinical question(s) covered by the guideline should be specifically described.

3. The patients to whom the guideline is meant to apply should be specifically described.

It is not possible to say which professional groups had inputs into guideline writing without detailedprobing with guideline sources. Many current guidelines have minimal detail of how to clinically assessinfants <6m and focus heavily on supplemental feeds as the core treatment option. This possibly reflectspredominantly nutrition-focused writing groups. Other professionals that may be relevant in the writingof future guidelines on infants <6m include dieticians, paediatricians, obstetricians, nurses, midwives,speech & language therapists, HIV specialists, lactation specialists, psychologists and community healthworkers.

4. The guideline development group should include individuals from all the relevant

professional groups.

IYCF is a family affair and a severely malnourished infant <6m needs involvement of not just the mother orprimary caregiver, but the father, family and community to support treatment. It is clearly difficult forinternational guidelines to include users, however, this should certainly be a feature of national guidelines.Some CMAM guidelines note the importance of ‘community engagement’ as an essential element ofSAM/MAM management. This should be encouraged and made universal. Even basic understanding oflocal context factors influencing malnutrition may make big differences to acceptance and acceptability oftreatments.

5. The patients’ views and preferences should be sought.

Target users are often not clear in guidelines reviewed. Many guidelines, for example, combine details ofclinical management with details of programme management, which can confuse content. Future authorsshould consider and ideally research the pros and cons of a ‘comprehensive’ vs. ‘targeted’ approach. Forexample, small, clinically focused ‘case management’ pocket size handbooks are often liked by front lineclinical staff. Managers, meanwhile, might appreciate a large file with step-by-step instructions abouttroubleshooting programme databases.

6. The target users of the guideline should be clearly defined.


91

4.5 An ‘AGREE’ appraisal of current guidelines

8. Systematic methods should be used to search for evidence.

9. The criteria for selecting the evidence should be clearly described.

10. The methods used for formulating the recommendations should be clearly described.

11. Health benefits, side effects and risks should be considered.

12. There should be an explicit link between recommendations & supporting evidence.

13. The guideline should be externally reviewed by experts prior to publication.

Guidelines reviewed are ‘end-products’. Separate documents outlining the guideline development processand articulating the underlying evidence base behind individual recommendations were not available. A2004 WHO consultation to ‘Review the literature on Severe Malnutrition’139 is probably reflective of mostcurrent approaches to malnutrition guideline development. Expert consultations and critical reviews areused to identify, interpret and translate available research into policy. Guidelines for the development ofguidelines (e.g. GRADE140 and SIGN141) could be used in future.

In considering “health benefits, side effects and risks”, it is important to consider the implications oftherapeutic treatment of infants <6m amongst the wider infant population. For example, are there risksthat ‘supplemental’ feeding’ of malnourished breastfed infants <6m will carry mixed messages to thecaregiver and community regarding causes of malnutrition and benefits of exclusive breastfeeding? And,if so, how should these risks be managed? None of the guidelines reviewed address these broader issuesof ‘spillover’ and population impact. Locating strategies to treat SAM and MAM in infants <6m within abroader infant and young child feeding framework (see Chapter 2) can help to identify wider risks andinform risk management.

No guideline noted its ‘expiry date’. This probably reflects the short term and uncertain nature of fundingin international nutrition. However, for optimal future impact, regular guideline updates are needed andprocesses for this should be clearly stated.

d) Clarity & presentation

14. A procedure for updating the guideline should be provided.

15. The recommendations should be specific and unambiguous.

16. Different options for diagnosis and/or treatment of the condition should be presented.

17. Key recommendations should be easily identifiable.

There were considerable variations in how easy guidelines were to follow and how much detail theycontained. Varying formats made guideline comparisons difficult, with some recommendations often hardto find. Management of infants <6m was sometimes explicitly stated, (e.g. antibiotic choice), other timesnot, e.g. diagnosis of fluid overload. This issue needs to be addressed in future guidelines by statingexplicitly when and how infants <6m should be treated differently throughout and when treatment is thesame.

There is a clear ‘evolution’ of guidelines, which suggests a process of testing and refining. However, resultsof piloting and testing are not clearly stated in any of the guidelines reviewed. This would be helpful forusers and could be housed in a, probably web-based, repository of guidelines and evaluations for othersto learn from.

c) Rigour of Development

7. The guideline should be piloted among end users.


92

4.6 Summary findings and recommendations

A key strength of WHO 1999 and its wide acceptance and use is that it was accompanied by a trainingprogramme to aid implementation. Limited information was available as to whether reviewed guidelineswere actively promoted to target audiences and if tools were given to aid rollout.

Chapter 8 of IFE Module 2 is actually a training resource that has become a guidance material, due to thegap in formal guidance. An evaluation of IFE Module 2 amongst users (2006) found that content on SAM<6m was typically used as reference material for programmes more than a training content142.

e) Applicability

19. Potential organisational barriers in applying recommendations should be discussed.20. Potential cost implications of applying the recommendations should be considered.

These were not directly addressed in the majority of guidelines reviewed. This is most probably becauseall guidelines identified were primarily targeted at front-line field staff rather than policy-makers decidingon whether or not they wanted to implement the programme in the first place.

21. The guideline should presents key review criteria for monitoring and audit purposes

18. The guideline should be supported with tools for application.

A few recent guidelines (e.g. Tanzania, Zambia, Zimbabwe) include a ‘checklist’ to help programmemanagers to ensure that all factors relevant to high quality care were being considered. There is someevidence that ‘checklist’ strategies can have a positive impact on patient outcomes143, so this might beuseful for other guidelines to replicate in future. Ideally research should be done to develop an evidence-based checklist for infant <6m malnutrition, as well as for child malnutrition.

f) Editorial Independence

22. The guideline should be editorially independent from the funding body.23. Conflicts of interest of guideline development members should be recorded.

Organizations like WHO and UNICEF often play dual roles as both funders of guideline development andtechnical experts advising on guideline details. UNICEF also contributes funds and resources to inpatientprogrammes in some settings. Any risk of conflicts of interest can be minimized by having independentindividuals on the guideline writing team. This is currently the case for many national guidelines, whichhave a variety of authors involved. It would be good practice for future guidelines to name all contributingindividuals and organizations.

Future guidelines would be improved by aiming towards AGREE standards at the time of writing. This willrequire more person-time resources for writing / guideline development but may have positive impacts interms of individual outcomes.

4.6 Summary findings and recommendationsSummary findingsA total of 37 guidelines (14 international and 23 national) were identified for review. Most share a commonorigin in the WHO 1999 guideline and describe the ’ten steps’ approach to care.

Community-based management of Acute Malnutrition (CMAM) is rapidly being recognised as the ‘norm’ for the management of acute malnutrition for children aged 6 to59m. The Valid International field manual (2006) is a key reference.


93

4.6 Summary findings and recommendations

MUAC is frequently used in the guidelines as an independent admission criterion, though in no guidelines is it recommended for use in infants <6m.

There is wide variation in how current guidelines address acute malnutrition in infants <6m and some onlyimplicitly recognise the problem.

There is inconsistency in age, weight and length cut-offs used to identify infants <6m for admission and their subsequent treatment.

All guidelines recommend inpatient care for SAM in infants <6m and focus on nutritional treatments with the aim of restoring exclusive breastfeeding. Very few guidelines give details of the MAM in infants <6m.

Few guidelines include details of IYCF/breastfeeding support. MSF guidelines 2006, ACF Assessment and Treatment of Malnutrition, 2002 and IFE Module 2 are important exceptions.

Summary recommendationsFuture guidelines and guideline updates should build on and expand MAMI guidance, both SAM and MAM, and should give more details on IYCF/ breastfeeding support.

The following three guidelines could be considered a good reference/ template for future MAMI guidelines: MSF guidelines 2006, ACF Assessment and Treatment of Malnutrition, 2002 and IFE Module 2

Strategies with potential to improve outcomes of infant <6m SAM include implementation of routine kangaroo care144 for inpatient ‘complicated’ cases of SAM.

MAMI strategies should be located within a framework of safe and appropriate IYCF; synergies in programming between <6m and 6 to 24m age groups must be better reflected in the guidelines.

In the context of international rollout of CMAM programmes, it is noteworthy that MAMI is predominantly inpatient-focused. Options for outpatient based care in infants <6m should be considered in future guidelines.

Greater clarity is needed on anthropometric criteria, measurement cut-offs and age assessment for SAM & MAM infants <6m.

More resources should be devoted to future guideline development. Tools such as GRADE and AGREE should be used to better enhance the quality of future guidelines. An open access online ‘guideline library’might facilitate development of future documents.

130 http://www.gradeworkinggroup.org/131 WHO (1999) Management of severe malnutrition: a manual for physicians and other senior health workers. World Health Organisation.

Geneva: World Health Organisation. 132 Valid International (2006) Community-based Therapeutic Care (CTC). A Field Manual. Oxford: Valid International. 133 WHO & UNICEF (2009) WHO child growth standards and the identification of severe acute malnutrition in infants and children. A joint

statement by the World Health Organization and the United Nations Children's Fund. May 2009.134 Angood, C. (2006) Weighing scales for young infants: a survey of relief workers. Field Exchange. 2006(29):11-2.135 IFE Core Group (2007) Chapter 5. Section 5.3 Babies who are visibly thin or underweight. IFE Module 2. Oxford: Emergency Nutrition

Network. 136 IFE Core Group (2007) Chapter 5. IFE Module 2. Oxford: Emergency Nutrition Network.137 SS involves an initial attempt at normal BF. 30 to 60 minutes later the infant tries suckling again. But the breast this time has a small

nasogastric tube taped near to the nipple. The idea is that the process of suckling helps stimulate progressively increasing breastmilk production. Acknowledging that this takes time - but that infantU6m nutritional needs are urgent - BMS provides maintenance nutrients at 100kcal/kg/day.

138 WHO (2009) Acceptable medical reasons for use of breast-milk substitutes. WHO/NMH/NDH/09.01. Available via http://www.who.int/nutrition/publications/infantfeeding/WHO_NMH_NHD_09.01_eng.pdf

139 WHO. (2004) Severe malnutrition: Report of a consultation to review current literature. Geneva, Switzerland, 06 - 07 September, 2004.140 Jaeschke, R., Guyatt, G.H., Dellinger, P., Schunemann, H., Levy, M.M., Kunz, R., et al. (2008) Use of GRADE grid to reach decisions on

clinical practice guidelines when consensus is elusive. BMJ. 2008;337:a744.141 SIGN. Scottish Intercollegiate Guidelines Network. Available from: http://www.sign.ac.uk/.142 IFE Core Group (2007) Chapter 5. IFE Module 2. Oxford: Emergency Nutrition Network.143 Haynes, A.B., Weiser, T.G., Berry, W.R., Lipsitz, S.R., Breizat, A-H.S., Dellinger, E.P., et al. (2009) A Surgical Safety Checklist to Reduce

Morbidity and Mortality in a Global Population. N Engl J Med. 2009 January 29, 2009;360(5):491-9.144 Kangaroo care consists of skin-to skin contact between mother and infant. Key features are continuous and prolonged skin-to-skin contact

between the mother and baby, accomplished by the baby being firmly attached to the mother chest both day and night, allowing frequentand exclusive breastfeeding (or breastmilk substitute if required).

Endnotes

Chapter 4 Review of MAMI guidelines - ennonline.net · notes International guidelines: WHO...

Documents

Transcript of Chapter 4 Review of MAMI guidelines - ennonline.net · notes International guidelines: WHO...