Government of Sudan Federal Ministry of Health Interim Manual Community-Based Management of Severe Acute Malnutrition Version 1.0 Table of Contents Table of Contents ................................................................................................................................... i Acknowledgements ............................................................................................................................... i Foreword ................................................................................................................................................ ii Acronyms and Abbreviations ............................................................................................................. iii 1. Introduction ....................................................................................................................................... 1 1.1 Acute Malnutrition as a Form of Undernutrition ............................................................................ 1 1.1.1 What is Undernutrition? ........................................................................................................... 1 1.1.2 What is Acute Malnutrition? ..................................................................................................... 2 1.1.3 Assessing Acute Malnutrition .................................................................................................. 2 1.1.4 Pathophysiology of SAM ......................................................................................................... 4 1.2 The Burden of Acute Malnutrition ................................................................................................. 5 1.2.1 Burden of Acute Malnutrition at the Global Level .................................................................... 5 1.2.2 Burden of Acute Malnutrition in Sudan .................................................................................... 5 1.3 Principles of the Community-Based Management of SAM .......................................................... 6 1.3.1 Community Outreach ............................................................................................................... 8 1.3.2 Outpatient Care for Children 6-59 Months .............................................................................. 8 1.3.3 Inpatient Care .......................................................................................................................... 8 1.3.4 Supplementary Feeding for Children 6-59 Months and Pregnant and Lactating Women (PLW) with MAM ........................................................................................................................ 9 1.4 The Management of SAM in the Context of Sudan ...................................................................... 9 1.4.1 Operational Practices on Community-Based Management of SAM ....................................... 9 1.4.2 Policy Framework for Community-Based Management of SAM ............................................. 9 1.4.3 National Strategy for Community-Based Management of SAM ............................................ 10 2. Community Outreach ...................................................................................................................... 12 2.1 Step One: Conduct a Community Assessment .......................................................................... 13 2.1.1 Objectives of the Community Assessment ............................................................................ 13 2.1.2 The Assessment Team .......................................................................................................... 13 2.1.3 At The State and Community Levels ..................................................................................... 14 2.1.4 Organisation of the Community Assessment ........................................................................ 15 2.1.5 Validating Information ............................................................................................................ 15 2.1.6 Reporting and Presenting the Information from the Community Assessment ...................... 16 2.2 Step Two: Formulate a Community Participation and Outreach Strategy .................................. 17 2.2.1 CMAM Community Focal Persons ........................................................................................ 17 2.2.2 Linking with Community Mechanisms ................................................................................... 17 2.2.3 Planning for Community Participation ................................................................................... 18 2.2.4 Developing Standardised Information Messages on CMAM ................................................. 18 2.2.5 Planning for Community Participation and Outreach Activities ............................................. 18 2.3 Step Three: Conducting Training on Community Participation and Outreach for CMAM .......... 21 2.3.1 The CMAM Support Team and Trainers ............................................................................... 21 2.3.2 Training at Various Levels ..................................................................................................... 21 2.3.3 Methods ................................................................................................................................. 22 2.4 Step Four: Implementing Community Participation and Outreach Activities .............................. 22 2.4.1 Community Participation and Outreach Activities and Responsible Persons ....................... 23 2.5 Step Five: Supervision and M&R on Community Participation and Outreach Activities ............ 23 2.5.1 Supportive Supervision of CMAM ......................................................................................... 23 2.5.2 M&R of CMAM Community Participation and Outreach Activities ........................................ 25 2.5.3 Assessing Coverage .............................................................................................................. 26 3. Outpatient Care for Children 6-59 Months .................................................................................... 27 3.1 Screening of Children for SAM ................................................................................................... 27 3.2 Admission Criteria for Outpatient Care ....................................................................................... 27 3.3 Admission Procedure at the Health Facility ................................................................................ 28 3.3.1 Admission Categories ............................................................................................................ 31 3.4 Routine Medication ..................................................................................................................... 32 3.4.1 Children Admitted Directly into Outpatient Care.................................................................... 32 3.4.2 Children Referred from Inpatient Care .................................................................................. 34 3.5 Dietary Treatment ....................................................................................................................... 35 3.5.1 Provision of RUTF ................................................................................................................. 35 3.5.2 Feeding Procedure ................................................................................................................ 35 3.6 Individual Monitoring During Follow-Up Visits ............................................................................ 35 3.6.1 Anthropometry ....................................................................................................................... 35 3.6.2 Physical Examination ............................................................................................................ 36 3.7 Home Visits ................................................................................................................................. 36 3.8 Criteria to Refer Child from Outpatient Care to Inpatient Care or for Medical Investigation ...... 36 3.9 Discharge Criteria ....................................................................................................................... 37 3.10 Discharge Procedures .............................................................................................................. 37 3.11 Failure to Respond to Treatment in Outpatient Care ............................................................... 38 4. Inpatient Care for the Management of SAM with Medical Complications in Children 6-59 Months ........................................................................................................................................... 39 4.1 Admission Criteria ....................................................................................................................... 39 4.2 Admission Procedure.................................................................................................................. 40 4.3 Stabilization Phase ..................................................................................................................... 40 4.3.1 Medical Treatment ................................................................................................................. 41 4.3.2 Dietary Treatment .................................................................................................................. 41 4.3.3 Individual Monitoring .............................................................................................................. 44 4.3.4 Progression from the Stabilisation to Transition Phase ........................................................ 44 4.4 Transition Phase ......................................................................................................................... 44 4.4.1 Medical Treatment ................................................................................................................. 44 4.4.2 Dietary Treatment .................................................................................................................. 45 4.4.3 Individual Monitoring .............................................................................................................. 47 4.4.4 Progression from the Transition Phase to Outpatient Care .................................................. 47 4.5 Rehabilitation Phase ................................................................................................................... 48 4.5.1 Medical Treatment ................................................................................................................. 48 4.5.2 Dietary Treatment .................................................................................................................. 48 4.5.3 Individual Monitoring .............................................................................................................. 50 4.6 Criteria for Discharge from Inpatient Care After Full Recovery .................................................. 51 4.7 Discharge Procedures ................................................................................................................ 51 4.8 Failure to Respond to Treatment in Inpatient Care .................................................................... 51 4.8.1 Care for Children Failing to Respond to Treatment in Inpatient Care ................................... 52 4.8.2 Action Required When a Child Fails To Respond to Treatment in Inpatient Care ................ 53 5. Inpatient Care for the Management of SAM of Infants Under 6 Months .................................... 55 5.1 Breastfed Infants Under 6 Months With a (Potential) Lactating Mother (or Caregiver for Wet Nursing) ...................................................................................................................................... 55 5.1.1 Admission Criteria ................................................................................................................. 55 5.1.2 Routine Medicines and Supplements .................................................................................... 56 5.1.3 Dietary Treatment .................................................................................................................. 56 5.1.4 Individual Monitoring .............................................................................................................. 59 5.1.5 Supportive Care for Mothers ................................................................................................. 59 5.1.6 Discharge Criteria .................................................................................................................. 60 5.1.7 Follow-Up After Discharge ..................................................................................................... 60 5.2 Infants Under 6 Months Without the Prospect of Breastfeeding ................................................ 60 5.2.1 Admission Criteria ................................................................................................................. 60 5.2.2 Stabilisation Phase ................................................................................................................ 60 5.2.3 Transition Phase .................................................................................................................... 62 5.2.4 Rehabilitation Phase .............................................................................................................. 63 6. Inpatient Care for the Management of SAM in Older Age Groups ............................................. 65 6.1 Admission Criteria in Older Age Groups..................................................................................... 65 6.1.1 Children 5-9 Years ................................................................................................................. 65 6.1.2 Adolescents 10-18 Years ...................................................................................................... 66 6.1.3 Adults ..................................................................................................................................... 66 6.2 Stabilisation Phase for Adolescents and Adults ......................................................................... 66 6.3 Rehabilitation Phase for Adolescents and Adults ....................................................................... 67 6.4 Discharge Criteria for Adolescents and Adults ........................................................................... 67 6.5 Failure to Respond to Treatment in Adolescents and Adults ..................................................... 67 7. Monitoring and Reporting .............................................................................................................. 68 7.1 M&R Tools .................................................................................................................................. 68 7.1.1 Registration............................................................................................................................ 68 7.1.2 Individual Monitoring .............................................................................................................. 69 7.1.3 Service Monitoring ................................................................................................................. 70 7.2 Performance Indicators .............................................................................................................. 74 7.2.1 Indicators Measuring Output ................................................................................................. 74 7.2.2 Indicators Measuring Outcome.............................................................................................. 75 7.2.3 Additional Indicators Measuring Process .............................................................................. 75 7.3 Support and Supervision ............................................................................................................ 76 7.3.1 Quality of Individual Treatment .............................................................................................. 77 7.3.2 Organisation and Management of Services .......................................................................... 77 7.3.3 Quality of Services ................................................................................................................. 77 7.4 CMAM M&R System ................................................................................................................... 78 References ........................................................................................................................................... 80 ANNEXES List of Annexes... ................................................................................................................................... 82 Annex 1: Community Outreach Messages... ........................................................................................ 83 Annex 2: Admission and Discharge Criteria for CMAM in Children Under 5 ........................................ 87 Annex 3: Anthropometric Measurements .............................................................................................. 88 Annex 4: Anthropometry Look-Up Tables ............................................................................................. 96 Annex 5: Guidance Table to Identify Target Discharge Weight. ......................................................... 101 Annex 6: Routine Medicines Protocols ............................................................................................... 102 Annex 7: Supplemental Medicine Protocols. ...................................................................................... 103 Annex 8: Drug Dosages of SAM Treatment for Children Under 5 ...................................................... 104 Annex 9: Appetite Test.. ...................................................................................................................... 110 Annex 10: Dietary Treatment .............................................................................................................. 111 Annex 11: Ranking Alternate Recipes for F75, F100 and ReSoMal Using CMV ............................... 114 Annex 12: Use of Home-Modified Cow Milk for Replacement Feeding in Case of No Access to Infant Formula.. ................................................................................................................................... 115 Annex 13: RUTF Specification ............................................................................................................ 116 Annex 14: Action Protocol in Outpatient Care .................................................................................... 119 Annex 15: Key Messages upon Admission in Outpatient ................................................................... 120 Annex 16: Health and Nutrition Education Messages ........................................................................ 121 Annex 17: Emotional and Physical Stimulation................................................................................... 124 Annex 18: Failure to Respond to Treatment in Inpatient Care. .......................................................... 126 Annex 19: Community Assessment Questionnaire and Tools ............................................................ 129 Annex 20: Referral Slip Community Screening... ............................................................................... 132 Annex 21: Community Outreach Reports ........................................................................................... 133 Annex 22: Checklist Home Visits ........................................................................................................ 135 Annex 23: Inpatient Care Treatment Card .......................................................................................... 136 Annex 24: Outpatient Care Treatment Card. ...................................................................................... 142 Annex 25: Referral Form Inpatient Care/Outpatient Care .................................................................. 144 Annex 26: Site Tally Sheet. ................................................................................................................. 145 Annex 27: Monthly Statistical Site Report ........................................................................................... 148 Annex 28: Monthly Statistical Locality or State Report.. ..................................................................... 149 Annex 29: CMAM Narrative Reporting Template................................................................................ 150 Annex 30: Checklists for Supervision ................................................................................................. 151 Annex 31: Set-Up of Inpatient Care and Outpatient Care.. ................................................................ 157 Annex 32: Checklist of Materials Needed for Inpatient Care .............................................................. 159 Annex 33: Checklist of Materials Needed for Outpatient Care ........................................................... 163 Annex 34: Forecasting Nutrition Product Needs ................................................................................. 165 Annex 35: Staff Needs, and Roles and Responsibilities ..................................................................... 167 Annex 36: List of Job Aids and Monitoring and Reporting Tools ........................................................ 174 Appendix: Clinical Management of SAM with Medical Complications in Inpatient Care .................... 176 LIST OF TABLES Table 1. Independent Indicators and Clinical Sign of Acute Malnutrition with Cutoff for SAM and MAM for Children 6-59 Months ......................................................................................................................... 3 Table 2. Case Definitions of Medical Complications with SAM .............................................................. 3 Table 3. Admission and Discharge Criteria to CMAM for Children Under 5 Based on Anthropometric and Clinical Status .................................................................................................................................. 7 Table 4. Community Participation and Outreach Activities and Responsible Persons......................... 23 Table 5. Indicators and MOV for CMAM Community Participation and Outreach ................................ 26 Table 6. Admission Criteria for the Community-Based Management of SAM for Children Under 5 .... 28 Table 7. First Line Antibiotic Treatment: Amoxicillin, 3 Times a Day for 7 Days (50-100 mg/kg/day) .. 33 Table 8. Malaria Treatment based on the First Line Antimalarial: Artesunate [AS 50 mg Tablet] and Sulfadoxine Pyrimethamine [S 500 mg P 25 mg Tablet] ...................................................................... 33 Table 9. Antihelminthic Drug Dosage, Single Dose .............................................................................. 34 Table 10. Look-Up Table for Amounts of 92 g Packets of RUTF Containing 500 kcal to Give to a Child per Day or Week Based on a Dosage of 200 kcal/kg bodyweight/day ................................................. 35 Table 11. Criteria for Defining Failure to Respond to Treatment in Outpatient Care............................ 38 Table 12. Stabilisation Phase Look-Up Tables for Volume of F75 for Persons with Severe Wasting .. 43 Table 13. Stabilisation Phase Look-Up Tables for Volume of F75 for Persons with Bilateral Pitting Oedema................................................................................................................................................. 43 Table 14. Look-Up Table for Amounts of 92 g Packets of RUTF Containing 500 kcal to Give to a Child per Day Based on a Dosage of 150 kcal/kg bodyweight/day ............................................................... 46 Table 15. Transition Phase Look-Up Table for Quantity of F100 to Give to an Individual Child per Feed for Those Not Taking the RUTF (150 kcal/kg bodyweight/day) ................................................... 46 Table 16. Look-Up Table for Amounts of 92 g Packets of RUTF Containing 500 kcal to Give to a Child per Day Based on a Dosage of +/- 200 kcal/kg bodyweight/day .......................................................... 49 Table 17. Inpatient Rehabilitation Phase Look-Up Table for Quantity of F100 to Give to an Individual Child per Feed if No RUTF is Taken, Based on +/- 200 kcal/kg bodyweight/day ................................. 49 Table 18. Criteria for Defining Failure to Respond to Treatment in Inpatient Care .............................. 52 Table 19. Look-up Table for Maintenance Amounts of F100-Diluted (Severe Wasting) or F75 (Bilateral Pitting Oedema Until the Oedema is Resolved) to Give to an Individual Infant per Feed .................... 57 Table 20. Possible Difficulties Encountered by Mothers of Infants with SAM ...................................... 60 Table 21. Look-Up Table for Amounts of F100-Diluted (Severe Wasting) or F75 (Bilateral Pitting Oedema) to Give to Non-Breastfed Infants in the Stabilization Phase ................................................. 61 Table 22. Look-Up Table for Amounts of F100-Diluted to Give to Non-Breastfed Infants Under 6 Months or Less Than 4 kg in the Transition Phase .............................................................................. 62 Table 23. Look-Up Table for Amounts of F100-Diluted to Give to Non-Breastfed Infants Under 6 Months or Less Than 4 kg in the Rehabilitation Phase ........................................................................ 63 Table 24. Dietary Requirements in Stabilisation Phase of Adolescents and Adults ............................. 67 Table 25. Entry and Exit Categories for Individual and Service Monitoring of CMAM for Children 6-59 Months ................................................................................................................................................... 74 Table 26. Cutoffs for CMAM Outcome Indicators as Per Sphere Minimum Standards ........................ 78 LIST OF FIGURES Figure 1. Admission and Treatment Flow-Chart, Children 6-59 Months with SAM .............................. 32 Figure 2. Overview Treatment of Children with SAM: WHO 10-Steps According to the WHO 1999 Protocol for the Management of SAM ................................................................................................... 41 Figure 3. Supplementary Suckling Technique ...................................................................................... 58 LIST OF BOXES Box 1. Community Outreach for CMAM Terminology ........................................................................... 12 Box 2. Community Health Initiatives ..................................................................................................... 13 Box 3. Women’s Participation ............................................................................................................... 15 Box 4. Summary of Community Assessment Tools .............................................................................. 16 Box 5. Use of Traditional Practitioners for Case-Finding and Referral ................................................. 19 Box 6. Appetite Test .............................................................................................................................. 29 Box 7. Admission and Initial Treatment Procedures ............................................................................. 31 Box 8. Examples of Frequent Causes of Failure to Respond to Treatment in Outpatient Care ........... 38 Box 9. Admission Criteria for Inpatient Care for Children 6-59 Months ................................................ 39 Box 10. Summary of Reasons for the Use of NGT to Feed the Child during Stabilisation ................... 42 Box 11. Examples of Frequent Causes of Failure to Respond to Treatment in Inpatient Care ............ 54 Box 12. Discharge Criteria from the Inpatient Rehabilitation Phase for Non-Breastfed Infants ........... 63 Box 13. Admission Criteria for the Management of SAM in Older Age Groups in Inpatient Care ........ 65 Box 14. Overview of CMAM M&R Tools ............................................................................................... 79 Acknowledgements The Federal Ministry of Health of the Republic of Sudan would like to acknowledge the contribution of many individuals and organizations towards the development of the national guidelines of Community-Based Management of Severe Acute Malnutrition (CMAM). The Nutrition National Advisory Committee and CMAM Technical Working Group actively involved in the CMAM task force for the development of the national guidelines of CMAM are comprised of members of the following institutions and departments: distinguished pediatricians, Ahfad University for Women, the National Nutrition Program and the Integrated Management of Childhood Illnesses Program of the Directorate of Maternal and Child Health of the Federal Ministry of Health, the United Nations Children’s Fund, The World Health Organisation, and the World Food Programme. Special thanks are due to Dr. ElTayeb Ahmed, Dr. Amani Abdelmoniem, Selwa Sorkatti, Salma Awad Albalula, Dr. Hanan Mukhtar, Dr. Rania Sharawi, Dr. Farah Mohammed, Prof. Mabyou Mustafa, Dr. Elamin Osman, Dr. Ali Arabi, Prof. Osama Awad Salih, Eman Hassan Mahmoud, Dr. Ezzaldin Rahma, Susan Lilicrap, Dr. Wigdan Madani, Diane Holland, Dr .Tarig Mekkawi, Dr. Amal Abdallah, Vivienne Forsythe and Hedwig Deconinck, who contributed their expert knowledge and experience in finalising this document. On behalf of the Ministry, I wish to congratulate UNICEF/Sudan and the task force members for a job well done. I look forward to their continued support in the dissemination and development of state- level plans for the implementation of CMAM based on these national guidelines. Materials from the following sources are gratefully acknowledged: • Sudan FMOH. February 2009. Management of Acute Severe Malnutrition. Sudan Manual. • FANTA, Concern Worldwide, UNICEF and Valid International. 2008. Training Guide for Community-Based Management of Acute Malnutrition (CMAM). Washington, DC: FANTA at FHI 360. http://fantaproject.org/cmam/training.shtml • Golden, M.H. and Y. Grellety. 2006. “Guidelines for the management of the severely malnourished.” Draft. • Valid International. 2006. Community-based Therapeutic Care. A Field Manual. 1st edition. Oxford, UK: Valid International. http://www.fantaproject.org/ctc/manual2006.shtml • WHO. 2003. Guidelines for the inpatient treatment of severely malnourished children. Geneva: WHO. http://www.who.int/nutrition/publications/severemalnutrition/9241546093/en/index.html • WHO. 1999. Management of severe malnutrition: a manual for physicians and other senior health workers. Geneva: WHO. http://www.who.int/nutrition/publications/severemalnutrition/9241545119/en/ • Prof. Michael Golden and Dr. Yvonne Grellety kindly permitted us to copy their original material on the clinical management of severe acute malnutrition with medical complications in inpatient care. This material is reproduced on the understanding that it can be taken and used by National Governments of developing countries and their teaching institutions without payment of any fees or the need to obtain further permission, provided that the material is not edited, abstracted or altered. Those from developed countries and those who wish to abstract or edit the material should seek permission from the copyright holders. i Foreword Nutrition is a priority for Sudan. Nutrition issues are the focus of Millennium Development Goals (MDGs) four (to reduce child mortality) and five (to improve maternal health), and constitute a considerable factor in the MDGs’ achievement. Nutrition is by its nature a cross-cutting issue with many sectors involved in improving health, infant and young child feeding and care, and food security. These sectors are therefore involved in planning and implementing services and programmes that have an impact on nutrition. Nutrition is the subject of interest for many actors and donors who respond to frequent nutrition crises in the country. These crises compelled the development of the community-based management of acute malnutrition (CMAM) manual, which place more emphasis on protocols to treat acute malnutrition at the community level. Community-based treatment protocols will result in more effective and efficient health services delivery and in the overall reduction of severe acute malnutrition (SAM) among children in Sudan. I commend this document to all stakeholders in the health sectors in particular and the Sudanese public and nutritional health community in general. ---Signature--- Name and Title Place and Date ii Acronyms and Abbreviations AIDS Acquired immune deficiency syndrome ACT Artemisinin-based combination therapy ART Antiretroviral therapy AWG Average daily weight gain BCC Behaviour change communication BMI Body mass index C-IMCI Community-Integrated Management of Childhood Illness CBI Community-Based Initiative CBO Community-based organisation CCP Critical care pathway CFCI Child Friendly Community-Based Initiative cm Centimetre(s) CMAM Community-Based Management of Acute Malnutrition CMI Community Malaria Initiative CMV Combined mineral and vitamin mix dl Decilitre(s) ENP Essential Nutrition Package EPI Expanded programme of immunisations F75 Formula 75 therapeutic milk F100 Formula 100 therapeutic milk FBF Fortified-blended food FGD Focus group discussion FMOH Federal Ministry of Health g Gram(s) GAM Global acute malnutrition GM Growth monitoring Hb Haemoglobin HFA Height-for-age HIV Human immunodeficiency virus HMIS Health Management Information System IDP Internally displaced person IM Intramuscular IMCI Integrated Management of Childhood Illnesses IU International unit IV Intravenous IYCF Infant and young child feeding kcal Kilocalorie(s) kg Kilogram(s) KII Key information interview L Litre(s) LOS Length of stay M&R Monitoring and reporting MAM Moderate acute malnutrition MDG Millennium Development Goal mg Milligram(s) ml Millilitre(s) mm Millimetre(s) mmol Millimole(s) MOH Ministry of Health MOV Means of verification MUAC Mid-upper arm circumference NAC National advisory committee NCHS National Centre for Health Statistics NGO Nongovernmental organisation NGT Nasogastric tube NIS Nutrition Information System NNP Sudanese National Nutrition Policy iii ORS Oral rehydration solution PLHIV People living with HIV PLW Pregnant and lactating women ReSoMal Rehydration Solution for Malnutrition RUTF Ready-to-use therapeutic food SABA Sudanese Association for Breastfeeding Action SAM Severe acute malnutrition SD Standard deviation(s) SFP Supplementary feeding programme SMOH State Ministry of Health SS Supplementary suckling SWOT Strengths, weaknesses, opportunities and threats TB Tuberculosis TFC Therapeutic feeding centre TWG Technical Working Group UN United Nations UN/SCN United Nations Standing Committee on Nutrition UNICEF United Nations Children’s Fund US United States RDA Recommended Daily Allowance WFA Weight-for-age WFH Weight-for-height WFL Weight-for-length WFP World Food Programme WHO World Health Organisation µg Microgram(s) iv