Recommended Citation Ministry of Health (MOH). 2016. Guidelines for Community-Based Management of Acute Malnutrition. 2nd Edition. Lilongwe, Malawi: MOH. Contact Information Nutrition Unit of the Ministry of Health P.O. Box 30377 Lilongwe 3 Malawi Telephone: +265 (01) 789 400 Fax: +265 (01) 789 431 Foreword Despite past and on-going efforts, undernutrition remains a major contributing factor to child mortality worldwide. Globally, it is estimated that 3.1 million children die from malnutrition-related causes annually. The preliminary Malawi Demographic and Health Survey (DHS) 2015 reported a prevalence of acute malnutrition of 2.7 percent. Even though this is classified as normal according to the WHO classification of acute malnutrition, there are regional variations in Malawi. More recent nutrition surveys conducted in 2016 showed prominent disparities across the five livelihood zones of Malawi, with Lower Shire recording the highest Global Acute Malnutrition (GAM) prevalence of 6.6 percent which is classified as poor. The GAM prevalence in Shire Highlands was reported at 4.0 percent, Thyolo-Mulanje 3.4 percent, Lake Chirwa Phalombe Plain 3.1 percent, Rift Valley Escarpment 2.1 percent, Kasungu-Lilongwe 1.3 percent, and Central Karonga-Chitipa 1.1 percent. A substantial proportion of children under 5 years of age diagnosed with acute malnutrition develop severe acute malnutrition (SAM) with medical complications due to delayed case detection, and underlying infections, including HIV/AIDS and TB. The Ministry of Health, therefore, adopted the Community-based Management of Acute Malnutrition (CMAM) approach to ensure maximum coverage, timeliness, access, and provision of appropriate care to those in need. CMAM is part of the Government of Malawi Essential Health Care Package, whose aim is to deliver basic health services to the population, especially those living in the rural areas. The Ministry of Health developed the first edition of Malawi CMAM Guidelines in 2012 after the Community Therapeutic Care (CTC) Interim Guidelines of 2006. In 2013, the World Health Organisation (WHO) provided updates on the management of SAM in infants and children, which necessitated the Ministry to update its 2012 CMAM Guidelines. These guidelines have been updated considering global and local scientific evidence on the management of acute malnutrition, and contextual and policy issues within Malawi. The guidelines provide optimal guidance on delivery of the four components of CMAM, including Community Outreach, Supplementary Feeding for Moderate Acute Malnutrition (MAM), Outpatient Care for SAM without medical complications, and Inpatient Care for SAM with medical complications. The guidelines also provide guidance to service providers on comprehensive management of acute malnutrition in the context of HIV. The Ministry of Health is appealing to all service providers, academic institutions, development partners, and individuals involved in the management of acute malnutrition in the country to use these guidelines as first point of reference. The Ministry of Health sincerely acknowledges the financial, material, and technical support of different partners, individuals, and institutions in the review and finalization of these guidelines. The Ministry of Health remains the custodian of these guidelines and commits itself to continue providing necessary leadership and creating an enabling environment for a holistic management of malnutrition in Malawi. Dr. Charles Mwansambo CHIEF OF HEALTH SERVICES Malawi Guidelines for Community-Based Management of Acute Malnutrition, 2nd Edition i Acknowledgements The Ministry of Health (MOH) led a rigorous process of reviewing and updating the Guidelines for Community-based Management of Acute Malnutrition (CMAM), which involved several working sessions, stakeholder consultations and review of latest available evidence. The MOH worked closely with local and international nutritionists and paediatricians to inform the process. The review of these guidelines was done under the guidance of the Directorate of Clinical Services and Department of Nutrition HIV and AIDS (DNHA). In this regard, the MOH would like to acknowledge policy direction from Dr George Chithope Mwale, Director of Clinical Services–MOH, Mr Felix Pensulo Phiri, Director of Nutrition–DNHA, and Mrs Janet Guta, Deputy Director of Clinical Services -Nutrition. The MOH is also indebted to Mr Sylvester Kathumba, Principal Nutritionist in the Ministry, Dr Jaden Bendabenda, Deputy Project Manager at Food and Nutrition Technical Assistance III Project (FANTA), Alice Nkoroi, Country Project Manager at FANTA, Violet Orchardson at USAID, and Senior Lecturers and Professors at the University of Malawi, College of Medicine: Dr Ajib Phiri, Dr John Phuka, Professor Kenneth Maleta and Emeritus Professor Geert Tom Heikens for their leadership and technical guidance during the process of drafting, field testing, and production of these guidelines. The following experts contributed technically to the guidelines: Blessings Muwalo DNHA Frank Msiska MOH Urunji Mezuwa Banda MOH –Nkhotakhota District Health Office (DHO) Christopher Chirwa MOH –Rumphi DHO George Mtengowadula MOH - Ntcheu DHO George Mphasa MOH - Dowa DHO Isabel Potani MOH - Queen Elizabeth Central Hospital (QECH) Kondwani Mkandawire Medical Council of Malawi Thokozire Lipato Nurses and Midwives Council Dr Susan Kambale WHO Dr Sangita Jacobs UNICEF Kudakwashe Chimanya UNICEF Dr. Muhammad Shahid Hanif UNICEF Mabasa Farawo UNICEF Elsie Mawala UNICEF Samuel Kirichu UNICEF Vitowe Harazi UNICEF/MOH Lucy Chirwa Oguguo UNICEF/MOH Taonga Msiska UNICEF/MOH Emma Chimzukira WFP Martin Ahimbisibwe WFP Keisha Nyirenda WFP Chawanagwa Jere FANTA/FHI 360 Phindile Lupafya FANTA/FHI 360 Clement Banda CHAI Samuel Mpatula Baylor, College of Medicine Patience Musiwa Baylor, College of Medicine Catherine Mkangama Save the Children International Moses Mtumbuka Save the Children International Packson Tsiku Action Against Hunger Cristina Diaz Action Against Hunger Eva Maria Castello Action Against Hunger Rosalie Bartels Malawi Liverpool Wellcome Trust Mphatso Chisala QECH Jessica Chikwana QECH Wilfred Gaven Malawi College of Health Sciences The Ministry of Health acknowledges the financial support received from different partners and donors throughout the review process and specifically USAID through FANTA/FHI 360 and UNICEF. Malawi Guidelines for Community-Based Management of Acute Malnutrition, 2nd Edition ii Malawi Guidelines for Community-Based Management of Acute Malnutrition, 2nd Edition iii Contents Introduction ........................................................................................................................................... 1 Purpose of the Guidelines ............................................................................................................... 1 Who Should Use the Guidelines ..................................................................................................... 1 How to Use the Guidelines ............................................................................................................. 2 What is New in These Guidelines ................................................................................................... 2 1 Overview of Malnutrition ............................................................................................................. 6 1.1 Causes of Malnutrition ............................................................................................................ 6 1.2 Nutrition Essentials ................................................................................................................. 7 1.3 Infant and Young Child Nutrition ........................................................................................... 9 1.4 Growth Monitoring and Promotion (GMP) ............................................................................ 9 1.5 Critical Nutrition Actions for People Living with HIV/AIDS ................................................ 9 1.6 CMAM Overview ................................................................................................................... 9 1.7 CMAM in the Context of HIV .............................................................................................. 10 1.8 Selection Criteria for CMAM and Triage ............................................................................. 11 1.9 Steps in the Identification of Acute Malnutrition ................................................................. 12 1.10 Interpreting Anthropometric Measurements ......................................................................... 13 Annex 1-1: Guiding Principles on Infant and Young Child Feeding............................................ 18 Annex 1-2: Breastfeeding Support Checklist ............................................................................... 23 Annex 1-3: Health Education Topics ............................................................................................ 26 Annex 1-4: How to Measure MUAC ............................................................................................ 27 Annex 1-5: How to Assess for Bilateral Pitting Oedema ............................................................. 28 Annex 1-6: How to Measure Weight ............................................................................................ 29 Annex 1-7: How to Measure Length/Height................................................................................. 31 Annex 1-8: How to Calculate Weight for Height ......................................................................... 33 Annex 1-9: Weight-for-Length Reference Tables, Birth to 2 Years of Age ................................. 34 Annex 1-10: Weight-for-Height Tables for Children from 2–5 Years of Age ............................. 36 Annex 1-11: Weight-for-Age (Girls Birth to 5 Years) ................................................................. 38 Annex 1-12: Weight-for-Age (Boys Birth to 5 Years) ................................................................. 39 2 Community Outreach ................................................................................................................. 40 2.1 Aims of Community Outreach .............................................................................................. 40 2.2 Roles of Service Providers in Community Outreach ............................................................ 40 2.3 Stages of Community Outreach ............................................................................................ 41 Annex 2-1: Community Volunteer Screening Form ..................................................................... 46 Annex 2-2: Community Volunteer Screening Report Form ......................................................... 47 Annex 2-3: Community Volunteer Referral Slip .......................................................................... 47 Annex 2-4: Home Visit Checklist ................................................................................................. 49 3 Supplementary Feeding Programmes (SFP) ............................................................................ 50 3.1 Aim of SFP ........................................................................................................................... 50 3.2 Roles and Responsibilities of SFP Service Providers ........................................................... 50 Malawi Guidelines for Community-Based Management of Acute Malnutrition, 2nd Edition iv 3.3 Admission Criteria ................................................................................................................ 51 3.4 Admission Procedure ............................................................................................................ 52 3.5 Medical Treatment in SFP .................................................................................................... 53 3.6 Nutrition Treatment in SFP ................................................................................................... 54 3.7 Monitoring during SFP Follow-Up Visits ............................................................................ 56 3.8 Health, Nutrition, and Hygiene Messages in the SFP ........................................................... 58 3.9 Discharge Criteria ................................................................................................................. 58 3.10 Discharge Procedure ............................................................................................................. 59 3.11 Competencies and Standards for the SFP ............................................................................. 60 Annex 3-1: SFP Monitoring Card—Child .................................................................................... 61 Annex 3-2: SFP Monitoring Card—Pregnant/Lactating Woman (up to 6 months postpartum) .. 63 Annex 3-3: SFP Register—Children ............................................................................................ 64 Annex 3-4: SFP Register—Pregnant/Lactating Woman (up to 6 months postpartum) ................ 66 4 Outpatient Therapeutic Programme (OTP) ............................................................................. 68 4.1 Aim of the OTP ..................................................................................................................... 68 4.2 Roles and Responsibilities of OTP Staff ............................................................................... 68 4.3 Admission Criteria ................................................................................................................ 69 4.4 Admission Procedure ............................................................................................................ 70 4.5 Medical Treatment in the OTP .............................................................................................. 72 4.6 Nutritional Treatment in the OTP ......................................................................................... 74 4.7 Monitoring During OTP Follow-Up Visits ........................................................................... 75 4.8 Health, Nutrition, and Hygiene Messages in the OTP .......................................................... 79 4.9 Discharge Criteria ................................................................................................................. 79 4.10 Discharge Procedure ............................................................................................................. 79 4.11 Competencies and Standards for Outpatient Care ................................................................ 80 Annex 4-1: OTP Monitoring Card ................................................................................................ 82 Annex 4-2: OTP Register ............................................................................................................. 84 Annex 4-3: Referral Form OTP and NRU .................................................................................... 86 Annex 4-4: Key CMAM Messages ............................................................................................... 87 5 Nutrition Rehabilitation Unit (NRU) ........................................................................................ 88 5.1 Aim of the Inpatient Care...................................................................................................... 88 5.2 Roles and Responsibilities of Staff Working in Inpatient Care ............................................ 88 5.3 Inpatient Care for the Management of SAM with Medical Complications for Children 6 Months to 15 Years ....................................................................................................................... 89 5.3.1 Admission Criteria for Children 6 Months to 15 Years ....................................................... 89 5.3.2 Admission Procedure ........................................................................................................... 90 5.3.3 Inpatient Care and Treatment ............................................................................................... 93 5.3.4 Discharge Procedure from Inpatient Care (NRU) to the OTP ........................................... 107 5.3.5 Failure to Respond to Treatment ........................................................................................ 108 5.3.6 Treatment of Associated Conditions .................................................................................. 111 5.3.7 Management of SAM Children with Disability ................................................................. 113 Malawi Guidelines for Community-Based Management of Acute Malnutrition, 2nd Edition v 5.4 Inpatient Care for the Management of SAM with Medical Complications for Infants 0–6 Months ........................................................................................................................................ 115 5.4.1 Breastfed Infants ................................................................................................................ 115 5.4.2 Infants 0–6 Months without the Prospect of Breastfeeding ............................................... 119 Annex 5-1: Emergency Treatment for Children with SAM ....................................................... 124 Annex 5-2: Inpatient Care Treatment Chart ............................................................................... 126 Annex 5-3: Therapeutic Milk – New Sachet/Carton .................................................................. 132 Annex 5-4: Stabilisation Phase Look-Up Tables for F-75 for Children With Severe Wasting (Marasmus) ................................................................................................................................. 133 Annex 5-5: Stabilisation Phase Look-Up Tables for F-75 for Children With Severe Bilateral Pitting Oedema (Kwashiorkor) (+++) ......................................................................................... 134 Annex 5-6: Reference Table for Quantity of F-100 to Give to an Individual Child per Feed .... 135 Annex 5-7: Reference Table for Maintenance Amounts of F-100-Diluted to Give to an Individual Infant per Feed ........................................................................................................... 136 Annex 5-8: Reference Table for Amounts of F-100-Diluted (Marasmus) or F-75 (Kwashiorkor) to Give to Non-breastfed Infants in the Stabilisation Phase ............................... 136 Annex 5-9: Reference Table for Amounts of F-100-Diluted to Give to Non-breastfed Infants 0–6 Months or Older Infants Weighing Less Than 3.0 kg in the Transition Phase .................... 137 Annex 5-10: Reference Table for Amounts of F-100-Diluted to Give to Non-breastfed Infants 0–6 Months or Older Infants Weighing Less Than 3.0 kg in the Rehabilitation Phase .. 137 Annex 5-11: Preparation of F-75 ................................................................................................ 138 Annex 5-12: Preparation of F-100 .............................................................................................. 138 Annex 5-13: Preparation of F-100-Diluted ................................................................................. 139 Annex 5-14: Alternative Recipes for F-75, F-100, and ReSoMal Using Combined Mineral and Vitamin Mix (CMV) ............................................................................................................ 140 Annex 5-15: Therapeutic Milk Specifications ............................................................................ 141 Annex 5-16: Mean Nutritional Value of RUTF .......................................................................... 142 Annex 5-17: Infection Prevention Protocols in NRU ................................................................. 143 Annex 5-18: Nasogastric Feeding ............................................................................................... 144 6 Monitoring, Reporting, and Quality Improvement ............................................................... 146 6.1 Aim of Monitoring, Reporting, and Quality Improvement ................................................. 146 6.2 Monitoring individual Treatment ........................................................................................ 146 6.3 Reporting............................................................................................................................. 147 6.4 Monitoring Programme Performance ................................................................................. 148 6.5 Programme Outcome Indicators ......................................................................................... 150 6.6 Quality Improvement .......................................................................................................... 151 6.7 Death Audits ....................................................................................................................... 155 6.8 Mentorship and Supportive Supervision ............................................................................. 156 6.9 Exchange of Information with the Community .................................................................. 156 Annex 6-1: Summary of Admission and Discharge Criteria ...................................................... 157 Annex 6-2: Store Room Stock Management Card...................................................................... 160 Annex 6-3: Monthly Report Stock Sheet .................................................................................... 161 Annex 6-4: SFP Monthly Report ................................................................................................ 162 Annex 6-5: OTP Monthly Report ............................................................................................... 163 Malawi Guidelines for Community-Based Management of Acute Malnutrition, 2nd Edition vi Annex 6-6: NRU Monthly Report .............................................................................................. 164 Annex 6-7: Essential CMAM Equipment for SFP and OTP ...................................................... 165 Annex 6-8: Essential CMAM Equipment for NRU .................................................................... 166 Annex 6-9: Division of Responsibilities in SFP ......................................................................... 168 Annex 6-10: Division of Responsibilities in OTP ...................................................................... 169 Annex 6-11: Division of Responsibilities in NRU ..................................................................... 170 Annex 6-12: Outreach / HSA Supervision Checklist .................................................................. 171 Annex 6-13: Supervision Checklist for Outpatient Therapeutic Programme (OTP) and Supplementary Feeding Programme (SFP) ................................................................................ 172 Annex 6-14: Supervision Checklist for Inpatient Care ............................................................... 175 Annex 6-15: Death Audit Form for Inpatient Care ..................................................................... 175 References .......................................................................................................................................... 185 LIST OF TABLES Table 1. Summary of New Updated Guidance ....................................................................................... 2 Table 2. Assessing and Identifying Malnutrition .................................................................................. 13 Table 3. Interpreting Growth Problems: Wasting, Underweight, and Stunting .................................... 14 Table 4. MUAC Cut-offs ...................................................................................................................... 14 Table 5. Summary of CMAM Admission Criteria .............................................................................. 16 Table 6: SFP Admission Criteria .......................................................................................................... 51 Table 7. SFP Admission Entry Categories ............................................................................................ 53 Table 8. Vitamin A Supplementation ................................................................................................... 54 Table 9. Anti-helminth .......................................................................................................................... 54 Table 10. Iron and Folic Acid Supplementation ................................................................................... 54 Table 11. Super Cereal Plus (CSB++) Ration Size per Child ............................................................... 54 Table 12. Likuni Phala / SuperCereal (CSB+) and Vegetable Oil Ration Size per child 5-15 years, and Pregnant/Lactating Woman ......................................................................................... 55 Table 13. SFP Discharge Criteria ......................................................................................................... 58 Table 14. SFP Exit Categories .............................................................................................................. 59 Table 15. Competency Standards for SFP ............................................................................................ 60 Table 16. OTP Admission Criteria ....................................................................................................... 69 Table 17. RUTF Appetite Test Results ................................................................................................. 70 Table 18. OTP Admission Entry Categories ......................................................................................... 72 Table 19. OTP Admission Entry Categories Amoxicillin Dosage*...................................................... 73 Table 20. Lumefantrine Artemether (LA) Dosages .............................................................................. 73 Table 21. Albendazole or Mebendazole Dosages ................................................................................. 73 Table 22. Reference Table for Amounts of RUTF to Give Children per Day or Week, based on 92 g Packets Containing 500 kcal .......................................................................................... 74 Table 23: Frequency of Assessment in Follow Up ............................................................................... 76 Table 24: Criteria for Failure to Respond to Treatment ........................................................................ 77 Table 25. OTP Action Protocol............................................................................................................. 78 Table 26. OTP Discharge Criteria......................................................................................................... 79 Table 27. OTP Exit Categories ............................................................................................................. 80 Table 28. Competency Standards in OTP ............................................................................................. 81 Malawi Guidelines for Community-Based Management of Acute Malnutrition, 2nd Edition vii