NEPAL Integrated Management of Acute Malnutrition (cid:523)IMAM(cid:524) Guideline : (cid:884)(cid:882)(cid:883)7 Page 1 A(cid:272)k(cid:374)o(cid:449)ledge(cid:373)e(cid:374)ts This IMAM guideline has been developed with the support of UNICEF, Nepal. The development has been facilitated, and the content authored by UNICEF and Valid International. The guideline has been established with active inputs by national stakeholders in Nepal. In particular, sections related to moderate acute malnutrition (MAM) have been provided by WFP. Special thanks goes to the Nutrition Section, Child Health Division, Ministry of Health and Population, Government of Nepal for providing guida(cid:374)(cid:272)e o(cid:374) the do(cid:272)u(cid:373)e(cid:374)t(cid:859)s s(cid:272)ope a(cid:374)d de(cid:448)elop(cid:373)e(cid:374)t Similarly, ACF and NYF have been provided their constrictive feedback and support during development of this guideline. Fo(cid:396)e(cid:449)o(cid:396)d In 2008, inspired by the global progress made on community-based management of acute malnutrition (CMAM) and the issuance of the WHO/UNICEF/WFP Standing Committee on Nutrition (SCN) joint statement in 2007, UNICEF and the Ministry of Health and Population (MoHP) Nepal conducted a feasibility study of the approach. The recommendations from the study led to a five district pilot of CMAM in districts with high prevalence in a cross section of eco-geographical zones. Implementation was conducted in collaboration with the national, regional and district health authorities, working through the existing health structures and with the health staff (hospital and health fa(cid:272)ilities(cid:859) staff and FCHVs) as well as the local NGOs and the community-based organisations (cid:894)e.g. (cid:449)o(cid:373)e(cid:374)(cid:858)s g(cid:396)oups(cid:895). The aim of the pilot was to test different implementation strategies, evaluate outcomes and generate lessons learned for future expansion of the CMAM approach. Until this time, the treatment of acute malnutrition in Nepal was carried out mainly on an inpatient basis in Nutrition Rehabilitation Homes (NRHs) supported by the Nepal Youth Opportunity Foundation (NYOF). Assistance to families of malnourished children focused mainly on household counselling on hygiene, feeding practices and balanced diet, as well as on treatment with a mix of therapeutic milk (WHO recipe) and food. The NRH approach required the child and his/her caretaker to stay in the NRH for a minimum of four weeks, which posed difficulties for caretakers with other children as well as work responsibilities, and thus led to a high default rate. In addition, the NRHs could not address malnutrition on a large scale due to their limited number and low capacity at each unit. The outcomes of the CMAM pilot were evaluated in 20111 and found to be very positive. The evaluation indicated that the CMAM approach offered: - Ability to reach more children with services for the management of acute malnutrition; - Effective treatment outcomes; and - A service that could be sustained within the regular health service with existing human resources and facilities. As a result, the MoHP Nepal has incorporated community-based management of severe acute malnutrition (SAM) into the National Health Sector Program II (NHSPII) that runs until 2017, and into the Multi-sector Nutrition Plan (MSNP) 2013-172, which was developed in 2011 and approved by the cabinet. Scale-up plans for community-based management of SAM are now under development and piloting of effective interventions to address MAM have also been included in the MSNP. The CMAM evaluation recommended that the approach improve links across the sectors and with malnutrition prevention strategies and programmes as part of a comprehensive approach. At the same time, both 1 UNICEF 2011. Evaluation of Community Management of Acute Malnutrition (CMAM). Nepal country case study. UNICEF Evaluations Office, July 2011. 2 Government of Nepal, National Planning Commission. Multi-Sector Nutrition Plan: For Accelerating the Reduction of Maternal and Child Undernutrition in Nepal 2013-2017 (2023). - Page 2 the UNICEF CMAM pilot evaluation in 2011 and a joint review of the Mother and Child Health Care (MCHC) programme conducted by the MoHP, the Ministry of Education (MoE), and WFP in 2011 highlighted gaps in the management of moderate acute malnutrition (MAM) and recommended the development of national MAM guidelines. Thus, Integrated Management of Acute Malnutrition (IMAM) in Nepal was born. The Government of Nepal (GoN) has strengthened its efforts to fight hunger since 2009, conscious of the role nutrition plays in national development outcomes. The Nutrition Assessment and Gap Analysis (NAGA) represented a first step in this direction and led the GoN to develop the MSNP 2012 to sustain improvements in the nutrition field. The plan represents a robust framework for the development of a healthy society with a competitive human capital, and it will contribute to break the vicious circle of poverty in the future. The MoHP/GoN is also a member of the lead group of the Global Scaling Up Nutrition (SUN) movement, with the MSNP representing the Go(cid:448)e(cid:396)(cid:374)(cid:373)e(cid:374)t(cid:859)s commitment to that (cid:373)o(cid:448)e(cid:373)e(cid:374)t. A (cid:858)Declaration of Commitment for an Accelerated Improvement in Maternal and Child Nutrition(cid:859) (cid:449)as also sig(cid:374)ed i(cid:374) (cid:1006)(cid:1004)(cid:1005)(cid:1006) (cid:271)(cid:455) the GoN, UN, development partners, civil society and the private sector. Furthermore, a drafted Strategy for Infant and Young Child Feeding (2013-2017) calls for accelerated reduction of under nutrition in women and children as a high priority for the Health Nutrition and Population Sectoral Programme of Nepal. The scale-up of IMAM is one of the actions identified in the strategy for achieving this goal. The IMAM guideline has been developed to meet the objectives of the MSNP 2012 and to reflect Nepal(cid:859)s commitment to accelerated improvements in maternal and child nutrition and the drafted strategy for Infant and Young Child Feeding. It incorporates the lessons from the CMAM pilot and MCHC review and is intended to be used by health and nutrition care providers (doctors, nurses and programme staff) working at all facility levels of health and nutrition service provision in Nepal, as well as by policy makers, academic and NGO staff. The technical protocols are based on the WHO protocols for inpatient management of SAM, standard CMAM protocols, WHO technical information on supplementary foods for the management of MAM and UN and Global Nutrition Cluster guidelines for the management of MAM. The guideline primarily covers the age group from 6-59 months (the most common age group affected by acute malnutrition) and infants. It aims to reflect a shift to a more integrated approach in which the services for SAM and MAM management sit clearly within and link to the existing structures and services. Hence the shift to the term Integrated Management of Acute malnutrition (IMAM).The guideline will be complemented by training materials that give more explanation, exercises and examples of the management of acute malnutrition using the IMAM approach. The guideline is structured to give a basic introduction and principles of the IMAM approach. This is followed by a general section on assessment and classification of acute malnutrition. The guideline is then split into the major components of the IMAM approach: Community Mobilisation, Management of SAM (Inpatient and Outpatient) and Management of MAM. Programme monitoring and programme management are then covered jointly for all components and finally a section is included for implementation in an emergency context. Rolling out of the guideline and the protocols will be guided by the Multi Sector Nutrition Plan and revised National Nutrition Policy and Strategy, and will prioritise districts for expansion according to the WHO thresholds, considering the burden of acute malnutrition in those districts. Page 3 Co(cid:374)te(cid:374)ts List of Tables and Figures ................................................................................................................................. 7 List of Terms .................................................................................................................................................... 8 1 Introduction ............................................................................................................................................ 9 1.1 What is acute malnutrition?................................................................................................................ 10 1.2 Burden of acute malnutrition in Nepal ................................................................................................ 11 2 Objectives, principles and structure of IMAM ....................................................................................... 12 2.1 Objectives of IMAM ............................................................................................................................. 12 2.2 Principles of IMAM .............................................................................................................................. 12 2.3 Structure of IMAM ............................................................................................................................... 13 2.4 Integrating IMAM into the existing services and structures ............................................................... 14 3 Community mobilisation/outreach ....................................................................................................... 15 3.1 Introduction to community mobilisation ............................................................................................. 15 3.2 Developing a district community mobilisation strategy ...................................................................... 15 3.2.1 STEP 1: District consultation meeting ............................................................................................. 16 3.2.2 STEP 2: Community assessment ..................................................................................................... 16 3.2.3 STEP 3: Conduct sensitisation and community dialogue ................................................................ 16 3.2.4 STEP 4: Developing messages and materials .................................................................................. 17 3.2.5 STEP 5: Community training ........................................................................................................... 18 3.3 Protocols for case-finding and referral ................................................................................................ 18 3.3.1 Active adaptive case-finding for SAM ............................................................................................. 19 3.3.2 Active case-finding for MAM .......................................................................................................... 20 3.4 Actions for non-acutely malnourished clients ..................................................................................... 21 3.5 Protocols for follow-up of clients with acute malnutrition .................................................................. 21 3.6 Set-up requirements ............................................................................................................................ 22 4 Assessment and classification of acute malnutrition ............................................................................. 22 4.1 Assessment of Children 6-59 months .................................................................................................. 22 4.1.1 Step 1. Determine age .................................................................................................................... 23 4.1.2 Step 2. Check for pitting oedema on both feet .............................................................................. 23 4.1.3 Step 3. Measure MUAC ................................................................................................................... 23 4.1.4 Step 4. Assessment of appetite and medical complications ........................................................... 23 4.2 Assessment of infants under 6 months ............................................................................................... 26 4.3 Summary classification of acute malnutrition ..................................................................................... 29 5 Management of SAM ............................................................................................................................ 31 5.1 Pathophysiology of SAM ..................................................................................................................... 31 5.2 Outpatient Therapeutic Care ............................................................................................................... 31 5.2.1 Assessment of nutritional status and medical condition ................................................................ 31 5.2.2 Admission or referral based on programme criteria ...................................................................... 32 5.2.3 Medical Management ..................................................................................................................... 33 5.2.4 Nutrition Management ................................................................................................................... 34 5.2.5 Orientation and counselling for the mother/caretaker .................................................................. 35 Page 4 5.2.6 Individual monitoring and follow-up .............................................................................................. 35 5.2.7 Discharge from Outpatient care ..................................................................................................... 37 5.2.8 Operationalising links ..................................................................................................................... 38 5.2.9 Set-up requirements ....................................................................................................................... 39 5.3 Inpatient Therapeutic Care .................................................................................................................. 39 5.3.1 Assessment of nutritional status and medical condition ................................................................ 40 5.3.2 Admission or referral based on programme criteria. ..................................................................... 41 5.3.3 Medical Management ..................................................................................................................... 41 5.3.4 Nutrition Management ................................................................................................................... 41 5.3.5 Orientation and counselling for the care giver ............................................................................... 43 5.3.6 Individual monitoring and follow-up .............................................................................................. 43 5.3.7 Transition and discharge or continued rehabilitation in inpatient care ......................................... 43 5.3.8 Operationalising links ..................................................................................................................... 45 5.3.9 Set-up requirements ....................................................................................................................... 45 5.4 Management of SAM in infants <6 months old .................................................................................. 46 5.4.1 Assessment of nutritional status and medical condition ................................................................ 46 5.4.2 Admission or referral based on programme criteria ...................................................................... 46 5.4.3 Medical Management ..................................................................................................................... 46 5.4.4 Nutrition management ................................................................................................................... 46 5.4.5 Orientation and counselling for the mother/caretaker .................................................................. 48 5.4.6 Individual Monitoring ..................................................................................................................... 48 5.4.7 Discharge ........................................................................................................................................ 48 6 Management of MAM ........................................................................................................................... 49 6.1 Strategy for management of MAM ..................................................................................................... 49 6.2 Set-up requirement for Management of MAM ................................................................................... 50 6.3 Screening and referral to Management of MAM ................................................................................ 50 6.4 Admission criteria for Management of MAM ..................................................................................... 50 6.5 Assessment of MAM patient ............................................................................................................... 51 6.6 Nutritional management..................................................................................................................... 52 6.6.1 Protocol A: Using locally available foods and micronutrient supplements .................................... 52 6.6.2 Protocol B: Using Supplementary Food Ration ............................................................................... 53 6.6.3 Specialized Nutritious Foods for treating MAM ............................................................................. 54 6.7 Medical management ......................................................................................................................... 55 6.7.1 Vitamin A ........................................................................................................................................ 55 6.7.2 Mebendazole/Albendazole is given to all children aged 12-59 months on enrolment. ................. 55 6.7.3 Iron .................................................................................................................................................. 56 6.7.4 Vaccination ..................................................................................................................................... 56 6.7.5 Record all medications given in the registration book. .................................................................. 56 6.8 Monitoring and follow-up of MAM patient ......................................................................................... 56 6.9 Discharge ............................................................................................................................................. 57 6.10 Operationalizing links .......................................................................................................................... 58 7 Management of acute malnutrition with HIV ........................................................................................ 58 7.1 Dietary management of acute malnutrition in HIV-Infected Children ................................................ 58 7.2 Medical management of acute malnutrition in HIV-infected children ................................................ 59 7.3 Discharge criteria and referral to HIV services .................................................................................... 59 8 IMAM programme monitoring and reporting ........................................................................................ 59 Page 5 8.1 Performance indicators ....................................................................................................................... 60 8.2 Minimum performance standards ...................................................................................................... 61 8.3 Monitoring formats and systems ........................................................................................................ 61 8.3.1 Community level ............................................................................................................................. 61 8.3.2 Facility level .................................................................................................................................... 62 8.3.3 Treatment Coverage Assessment ................................................................................................... 62 8.3.4 Supply monitoring........................................................................................................................... 63 8.4 Analysis and Feedback ........................................................................................................................ 63 9 Programme management ...................................................................................................................... 64 9.1 National level ...................................................................................................................................... 64 9.2 Regional level ...................................................................................................................................... 65 9.3 Sub-national level ................................................................................................................................ 65 9.4 Village development committees level ................................................................................................ 66 9.5 Municipal level .................................................................................................................................... 66 9.6 Programme planning .......................................................................................................................... 67 9.7 Human resources and roles ................................................................................................................. 67 9.7.1 Management of moderate acute malnutrition .............................................................................. 67 9.7.2 Outpatient Therapeutic care .......................................................................................................... 68 9.7.3 Inpatient Therapeutic care ............................................................................................................. 68 9.7.4 Staff training ................................................................................................................................... 68 9.8 Supply management ........................................................................................................................... 68 9.8.1 Supply requirements ....................................................................................................................... 68 9.8.2 Supply chain .................................................................................................................................... 71 9.9 Supervision and review ........................................................................................................................ 72 10 Implementation in the emergency context............................................................................................ 73 10.1 Disaster Risk Reduction and Preparedness actions ............................................................................. 73 10.2 Agreeing thresholds for response ........................................................................................................ 74 10.3 Implications for programme management of acute malnutrition ...................................................... 76 10.4 MAM programming in emergencies ................................................................................................... 76 Page 6 List of Tables and Figures Table 1. Diagnostic criteria for acute malnutrition in children aged 6-59 months ............................... 11 Table 2. Criteria for admission to in- or out-patient care (children 6-59 months) with SAM: ............. 25 Table 3. Criteria for referral of children with MAM for medical treatment and SFP ........................... 26 Table 4. Criteria for admission to inpatient and outpatient care – Infants <6 months ........................ 28 Table 5. Summary admission criteria .................................................................................................... 29 Table 6. Summary admission and referral for SAM .............................................................................. 32 Table 7. Routine medicines for outpatient therapeutic care* (for detail see Annex 10) ..................... 33 Table 8. Criteria for referral to inpatient from outpatient treatment during follow-up ...................... 36 Table 9. Modified formula of Super Flour (Sarbottam Pitho) .............................................................. 53 Table 10. Modified formula for Poshilo Jaulo ....................................................................................... 53 Table 11. Discharge criteria for MAM treatment ................................................................................. 57 Table 12. Minimum performance standards for IMAM........................................................................ 61 Table 13. Calculation of RUTF requirements for OTC service ............................................................... 70 Table 14. Nutritional supply requirements calculated per number of SAM cases to treat .................. 70 Table 15. Nutritional supply requirements calculated per number of MAM cases to treat ................ 71 Table 16. Nepal thresholds and benchmarks for Nutrition in Emergencies (WHO 2000) .................... 75 Figure 1. UNICEF conceptual framework of malnutrition....................................................................... 9 Figure 2. The intergenerational cycle of growth failure ....................................................................... 10 Figure 3. Components of IMAM in Nepal ............................................................................................. 14 Figure 4. Stages in community mobilisation ......................................................................................... 16 Figure 5. Signs of visible wasting .......................................................................................................... 27 Figure 6. WHO steps for management of SAM ..................................................................................... 40 Figure 7. Simple tools for monitoring barriers to access ...................................................................... 63 Page 7 List of Terms CHD/W Child Health Day/Week CB-IMNCI Community-Based Integrated Management of Childhood Illness CMAM Community-Based Management of Acute Malnutrition ENN Emergency Nutrition Network FBF Fortified Blended Food GAM Global Acute Malnutrition GMP Growth Monitoring and Promotion GNC Global Nutrition Cluster GoN Government of Nepal HIV Human Immunodeficiency Virus HMIS Health Management Information System HP Health Post IMAM Integrated Management of Acute Malnutrition ITC Inpatient Therapeutic Care IYCF Infant and Young Child Feeding MAM Moderate Acute Malnutrition MNPs Micronutrient Powders MoE Ministry of Education MoHP Ministry of Health and Population MSNP Multi-sector Nutrition Plan MUAC Mid Upper Arm Circumference NDHS Nepal Demographic and Health Survey NGO Non-Governmental Organisation NRH Nutrition Rehabilitation Home OTC Outpatient Therapeutic Care PHC Primary Health Care PICT Provider Individual Counselling and Testing RUTF Ready-to-Use Therapeutic Food SAM Severe Acute Malnutrition SC Stabilisation Centre SD Standard Deviations (or Z-Scores) SFP Supplementary Feeding Programme SHP Sub Health Post SUN Scaling Up Nutrition TSFP Targeted Supplemental Feeding Program UNICEF U(cid:374)ited Natio(cid:374)s Child(cid:396)e(cid:374)(cid:859)s Fu(cid:374)d WFP World Food Programme WHO World Health Organisation WHZ Weight for Height Z-scores Page 8 1 Introduction The consequences of malnutrition are serious and life-long, falling hardest on the very poor and on women and children. Overall in developing countries, nearly one-third of children are underweight or stunted (low height for age)3. Under nutrition interacts with repeated bouts of infectious disease; causing an estimated 3.5 million preventable maternal and child deaths annually4, and its economic costs in terms of lost national productivity and economic growth are huge. In all its forms, malnutrition accounts for more than 50 per cent of child mortality in Nepal based on WHO estimates. Malnourished children who do survive are more frequently ill and suffer the life-long consequences of impaired physical and cognitive development. These consequences translate to poor human resource capital and poor economic development. The term malnutrition5 covers a range of short and long term conditions that result in physiological impairment caused by lack of (or excess of) nutrients in the body. The term malnutrition can include: i. Wasting and nutritional oedema (Acute Malnutrition) ii. Stunting (Chronic Malnutrition), iii. Intrauterine growth restriction leading to low birth weight iv. Micronutrient deficiencies and v. Overweight/obesity (Over nutrition). These conditions may be experienced over a scale of severity and are usually classified into moderate and severe forms. They may occur in isolation within an individual or in combination. The causes of under nutrition are multiple and context specific and are summarised in the below conceptual framework (Figure 1). Figure 1. UNICEF conceptual framework of malnutrition Death, Malnutrition & Inadequate Development Inadequate Disease Dietary Intake Insufficient Inadequate Inadequate Care Health Services & Access to for Children Unhealthy Food and Women Environment Inadequate Education Resources and Control Human, economic and organizational resources Political and Ideological Superstructure Economic Structure Potential Resources 3 UNICEF/WHO/World Bank Joint Child Malnutrition Estimates: Levels and trends in child malnutrition. 2012. 4 RE. Black et al. Maternal and Child Undernutrition 1. Global and regional exposures and health consequences. Lancet 2008 p5. 5 The term undernutrition is often used internationally to denote those conditions associated with lack of nutrients and overnutrition for those conditions associated with a surplus. However, the term malnutrition is still used in a majority of contexts to denote all forms of undernutrition and is therefore used throughout this guideline. Page 9 Recent evidence clarifies that the period of greatest vulnerability to nutritional deficiencies begins during pregnancy. During this period, nutritional deficiencies have a significant adverse impact on child survival and growth. Chronic under nutrition in early childhood (up to age two) also results in diminished cognitive and physical development, which puts children at a disadvantage for the rest of their lives. For example, chronic under nutrition may lead individuals to perform poorly in school as children, and as adults can lead to less productivity, less earnings and higher risk of disease versus adults who were not undernourished as children. For girls especially, chronic under nutrition in early life, either before birth or during early childhood, can later lead to their babies being born with low birth weight, which can in turn lead to under nutrition as these babies grow older. Thus a vicious cycle of under nutrition repeats itself, generation after generation. This is known as the intergenerational cycle of growth failure (see Figure 2).6 Figure 2. The intergenerational cycle of growth failure The longitudinal relationship between chronic and acute malnutrition has not been extensively studied, but recent evidence indicates that wasting or poor weight gain may lead to higher risk of stunting in children.7 Specifically for acute malnutrition, severely wasted children8 have been estimated to have a greater than nine fold increased risk (relative risk of 9.4) of dying compared to a well-nourished child, and moderately wasted children a threefold increased risk.9 In fact, the 2008 Maternal and Child Nutrition Lancet series recognises severe wasting as one of the top three nutrition related causes of death in children under five (Ibid). This guideline specifically deals with the identification and management of acute malnutrition. It also aims to place the management of acute malnutrition within the broader range of interventions and approaches for addressing malnutrition in general. 1.1 What is a(cid:272)ute (cid:373)al(cid:374)ut(cid:396)itio(cid:374)? 6 UNICEF. Tracking progress on child and maternal nutrition: a survival and development priority. 2009. 7 SA. Richard et al. Wasting is associated with stunting in early childhood. Journal of Nutrition. July 1 2012 p.1291-1296. 8 Assessed according to weight for height z scores using the WHO standards. 9 RE. Black et al. Maternal and Child Undernutrition 1. Global and regional exposures and health consequences. Lancet 2008. Page 10