assessment of severe acute malnutrition

143 Pages·2016·3.49 MB·English

by  Makson Omogbai

UNITY&FAITH,PEACE&PROGRESS
NATIONAL GUIDELINES

FOR INPATIENT MANAGEMENT OF SEVERE ACUTE MALNUTRITION
IN INFANTS AND YOUNG CHILDREN IN NIGERIA
FEDERAL MINISTRY OF HEALTH, NIGERIA FAMILY HEALTH DEPARTMENT, NUTRITION DIVISION FEBRUARY, 2016
UNITY&FAITH,PEACE&PROGRESS
NATIONAL GUIDELINES
FOR INPATIENT MANAGEMENT OF
SEVERE ACUTE MALNUTRITION IN INFANTS
AND YOUNG CHILDREN IN NIGERIA
FEDERAL�MINISTRY�OF�HEALTH,�NIGERIA�
FAMILY�HEALTH�DEPARTMENT,�NUTRITION�DIVISION
FEBRUARY,�2016
NATIONAL GUIDELINES FOR INPATIENT MANAGEMENT OF SEVERE ACUTE MALNUTRITION IN INFANTS AND YOUNG CHILDREN IN NIGERIA
Table of Contents
Acknowledgements vi
Foreword vii
List of Contributors viii
Acronyms and Abbreviations ix
CHAPTER 1: Background 1
1.1. Severe Acute Malnutrition (SAM) in Nigeria 2
1.2. Integrated Management of Acute Malnutrition (IMAM) approach 3
CHAPTER 2: Assessment of severe acute malnutrition 5
2.1. Definition of severe acute malnutrition 6
2.2. Inpatient admission criteria 6
2.3. Nutritional Assessment 7
2.3.1. Measuring MUAC 7
2.3.2. Checking bilateral oedema and Grading 8
2.3.3. Measuring Weight 8
2.3.4. Measuring Length/Height 9
2.3.5. Determining Weight- for-Height/length Z-Score 10
2.4. Initial clinical assessment 12
2.5. Medical complications in patients with SAM 12
2.6. Appetite test 13
2.6.1. How to do Appetite Test 13
2.6.2. Interpretation of Appetite Test 14
CHAPTER 3: Principles of Inpatient care 15
3.1. Phases of Inpatient Care for Children 6-59m 16
3.1.1. Stabilization Phase 16
3.1.1.1 Dehydration in marasmic patients 17
3.1.1.2 Shock 23
3.1.1.3 Septic (Toxic) shock 24
3.1.1.4 Absent bowel sounds, gastric dilatation and intestinal splash
with abdominal distension 26
3.1.1.5 Heart Failure 27
3.1.1.6 Correct electrolyte 29
3.1.1.7 Correct Severe Anaemia 30
3.1.1.8 Hypoglycemia 31
3.1.1.9 Hypothermia 33
3.1.1.10 Infection 34
3.1.1.11 Micronutrient deficiencies 35
3.1.1.12 Feeding including Breastfeeding 36
3.1.1.13 Addressing Associated Conditions 40

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NATIONAL GUIDELINES FOR INPATIENT MANAGEMENT OF SEVERE ACUTE MALNUTRITION IN INFANTS AND YOUNG CHILDREN IN NIGERIA
3.1.2. Transition Phase 46
3.1.2.1. Catch-up Growth Feeding 46
3.1.3 Rehabilitation Phase 52
3.2 Infants <6months with SAM 54
CHAPTER 4: Organization of Inpatient Facility (IPF) 63
4.1. Admission ward 64
4.2. Roles of Service providers 64
4.2.1. Doctors 64
4.2.2. Nurses 65
4.2.3. Dietitians and Nutritionists 65
4.2.4. Pharmacist 65
4.2.5. Records Officer 65
4.2.6. Medical Social WorkersCommunity Health Extension workers/
Community Health Officers 65
4.3. Records 66
4.3.1. Malnutrition record books 66
4.3.2. Admission and monitoring charts 66
4.4. Medicines 66
4.4.1. Routine first line 66
4.4.2. Alternative and supplementary medicines 66
4.5. Equipment and supplies 67
4.5.1. Anthropometric tools 67
4.5.2. Kitchen equipment and supplies 67
4.5.3. Therapeutic foods and other materials 67

CHAPTER 5: Failure to respond to treatment 68
5.1. High Mortality 69
5.2. Low weight gain during rehabilitation phase 70
5.3. Re-feeding syndrome 72
CHAPTER 6: Transfer to Outpatient Therapeutic Program (OTP) 74
6.1. Transfer criteria for rehabilitation in OTP 75
6.2. Two way referral system 75
6.3. Follow-up at OTP 76
6.4. Discharge criteria 76
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NATIONAL GUIDELINES FOR INPATIENT MANAGEMENT OF SEVERE ACUTE MALNUTRITION IN INFANTS AND YOUNG CHILDREN IN NIGERIA
CHAPTER 7: Monitoring quality of care 77
7.1. Definition of terms 78
7.2. Performance indicators 81
7.3. Mortality audit 82
7.4. IPF Monthly reporting 82
7.5. Categories for report writing 83
7.6. IPF Supervision by relevant agents 84
List of Tables
Table 1 Admission Criteria for inpatient care 6
Table 2 MUAC reading interpretation 7
Table 3 Grading of oedema 8
Table 4 Interpretation of weight for height Z-scores 11
Table 5 Medical Complications for admission into inpatient care 12
Table 6 Interpretation of Appetite test 14
Table 7 Vitamin A doses by age 36
Table 8 Amounts of F75 to give during Stabilization Phase 38
Table 9 Look up table for RUTF in Transition Phase per 24h 48
Table 10 Look up table for F-100 in Transition Phase per 24h 48
Table 11 Admission criteria for infants < 6 months 54
Table 12 Criteria for Failure-to-respond for In-Patients 69
Table 13 Case fatality rates 69
Table 14 Categorization of weight changes 70
Table 15 Admission and exit criteria 81
Table 16 SPHERE Indicators 82

List of Figures
Figure 1 Care model for severe acute malnutrition 4
Figure 2 Bilateral pitting pedal oedema 8
Figure 3 Measuring the length of the child less than 87cm 9
Figure 4 Measuring the height of the child greater than 87cm 10
Figure 5 Determination of Weight for height Z –Scores using unisex table 11
Figure 6 Treatment of dehydration in marasmic children 20
Figure 7 Monitoring rehydration in Marasmic children 20
Figure 8 Algorithm of respiratory distress 29
Figure 9 Managing Anaemia 31
Figure 10 Feeding F-75 by mouth 39
Figure 11 Breastfeeding Infant 53
Figure 12 Supplementary suckling technique 57
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NATIONAL GUIDELINES FOR INPATIENT MANAGEMENT OF SEVERE ACUTE MALNUTRITION IN INFANTS AND YOUNG CHILDREN IN NIGERIA
Annexes 85
Annex 1 Anthropometric measurement techniques 86
Annex 2 Weight for length/Height Unisex Table 94
Annex 3 Recipes for F-75,F-100 and ReSoMal 98
Annex 4 Critical Care Pathway Chart 100
Annex 5 Weight loss and weight gain by 5% chart 101
Annex 6 Drug reference tables 102
Annex 7 RUTF specification 108
Annex 8 Daily Ward Feed chart 112
Annex 9 F-75 feed volumes for children 113
Annex 10 Multi- chart for monitoring progress 114
Annex 11 Inserting a Nasogastric tube RUTF ration chart 118
Annex 12 Simple toys for emotional and psychological stimulation 120
Annex 13 RUTF/F-100 ration chart 121
Annex 14 Supplementary Sucking technique milk volumes 123
Annex 15 IPF Record book 125
Annex 16 F-100 Dilute look- up table 126
Annex 17 Transfer form 127
Annex 18 IPF Monthly reporting form 128
Annex 19 IPF Supervisory checklist 129
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NATIONAL GUIDELINES FOR INPATIENT MANAGEMENT OF SEVERE ACUTE MALNUTRITION IN INFANTS AND YOUNG CHILDREN IN NIGERIA
ACKNOWLEDGEMENT
The Federal Ministry of Health is indebted to several Stakeholders for their concerted efforts in the
development of this guideline. The process included series of consultative meetings and workshops
in collaboration with relevant stakeholders in Nutrition on the review of various materials and
experiences in the management of acute malnutrition in Nigeria and global research findings.
The technical and financial contributions of UN Agencies, Development partners, Multi-lateral and
Bi-lateral agencies, representatives from the Core Technical Committee on Maternal, Newborn and
Child Health (MNCH), National Primary Health Care Development Agency (NPHCDA), State
Ministries of Health and State Primary Health Care Development Boards is highly commendable.
The Academia and Professional bodies including Dietitians Association of Nigeria, Nutrition
Society of Nigeria, Paediatric Association of Nigeria, Paediatric Nurses Association of Nigeria and
Consultants whose contributions in reviewing this document are also appreciated.
Finally, the facilitation of the Federal Ministry of Health; Department of Family Health, Nutrition
Division under the leadership of Dr. Chris Osa Isokpunwu is acknowledged gratefully.
Dr. Wapada I. Balami, mni
Head, Family Health Department
February, 2016
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NATIONAL GUIDELINES FOR INPATIENT MANAGEMENT OF SEVERE ACUTE MALNUTRITION IN INFANTS AND YOUNG CHILDREN IN NIGERIA
FOREWORD
Management of acute malnutrition has been primordial due to the nutritional effects on the socio-
economic development of any nation. The 21st century eight-millennium development goals and
the current seventeen Sustainable Development Goals (SDGs) emphasized at various International
and National Summits have direct or indirect link to nutrition. Though poor knowledge of basic
nutrition education and poverty are major challenges to optimal nutritional practices, yet, inherent
behavioural factors are consistently the basic cause of poor health seeking and promotion practices
in Nigeria.
Nigeria has developed National Guidelines and Training Manuals for Community Management of
Acute Malnutrition with emphasis on management at Primary Health facilities called Outpatient
Therapeutic Programme (OTP) sites. According to WHO (2013), the use of Inpatient guidelines on
Management of Severe Acute Malnutrition has contributed immensely to the reduction of case
fatality load in secondary and tertiary facilities. The use of both National Guidelines for Inpatient
and Community Management of Acute Malnutrition would “strengthen the effective and safe
nutrition actions to counteract the public health effects of malnutrition”.
The National Guidelines for Inpatient Management of Severe Acute Malnutrition at Inpatient
facilities seek to provide practical guide to health and nutrition workers who design, implement,
monitor and evaluate acute management programmes in Secondary and Tertiary health facilities.
The adaptation of this guideline is from the 2013 WHO Updates on the management of Acute
malnutrition in infants and children and the 2012 Generic Protocol for Integrated Management of
Acute Malnutrition (WHO, 2013; Golden et al., 2012). It would be useful to all health
practitioners and planners/managers in Public and Private Institutions as it takes cognizance of the
local realities and circumstances of Nigeria.
I recommend that this relevant information for management of complicated acute malnutrition will
be useful to all health workers in various Referral Health institutions across the Federation.
Professor Isaac F. Adewole FAS, FSPSP, DSc (Hons)
Honourable Minister of Health
February, 2016
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NATIONAL GUIDELINES FOR INPATIENT MANAGEMENT OF SEVERE ACUTE MALNUTRITION IN INFANTS AND YOUNG CHILDREN IN NIGERIA
LIST OF CONTRIBUTORS
Federal Ministry of Health
Dr. Wapada I. Balami, mni
Dr. Chris Osa Isokpunwu
Mrs. R. E. Gabriel
Mr. J. E. Uruakpa
Thompson K.C.
Mr. E. A. Peter
Ms. F. R. Kia
Mrs. B.N. Ali
Mrs. F.U.Oyibo
Pharm Gbenga. S. Joseph
Mrs. O.E. Oladapo
National Primary Health Care Development Agency
Mrs. Chinwe Ezeife
Dr. Ogechi Akalonu
Lagos State Ministry of Health
Dr. Abimbola Ajayi
Mrs. Oluwatoyin Adams
Aishatu Yahya Muhammad, Kano State Primary Health Care Management Board
Mrs. Endaline Ezeri, Women and Children Welfare Clinic, Sokoto
Prof. E. O. Ojefeitimi, Academia
Professional Bodies
Sani S. Hassan, Nutrition Society of Nigeria
Tamra Runsewe-Abiodun, Paediatric Association of Nigeria
Lawal R. Olubunmi, Paediatric Nurses Association of Nigeria
Partners
Dr. Andrew L. Mbewe, WHO
Dr. B.D. Omotola, UNICEF
Christine Kaligirwa
Oluniyi Oyedokun
Dr. Tamanna Ferdous, ACF
Dr. Adaeze Oramalu, SCI
Dr. Friday Ilop Joseph
Consultants
Dr. Chika Ndiokwelu
Dr. Halima Abdu
Administrative staff
Mrs. Theresa Danjuma
Mr. Umar Abdul
Mrs. Glory Owunna
Mrs. Theresa Oyi
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NATIONAL GUIDELINES FOR INPATIENT MANAGEMENT OF SEVERE ACUTE MALNUTRITION IN INFANTS AND YOUNG CHILDREN IN NIGERIA
ACRONYMS AND ABBREVIATIONS
ACF Action La Contre Faim (Action against Hunger)
ACT Artemisinin Combination Therapy
AIDS Acquired immunodeficiency syndrome
ART Antiretroviral therapy
BCG Bacille Calmette-Guérin
CSF Cerebrospinal fluid
DHS Demographic and Health Survey
F-75 Therapeutic milk used in acute phase of SAM Inpatient treatment
F-100 Therapeutic milk used in Transition/Recovery phases of SAM treatment
GAM Global Acute Malnutrition
GMP Growth Monitoring and Promotion
Hb Haemoglobin
HIV Human immunodeficiency virus
IFE Infant Feeding in Emergency (documents on feeding infants less than 6
months
IM Intramuscular (injection), intramuscularly
IMAM Integrated Management of Acute Malnutrition
IMCI Integrated Management of Childhood Illness
IPF In-Patient Facility
IU International Units
IV Intravenous (injection), intravenously
IYCF Infant and Young Child Feeding
Kg Kilogramme
LoS Length of Stay
MAM Moderate Acute Malnutrition
MUAC Mid Upper Arm Circumference
ORS Oral rehydration salt(s)
OTP Outpatient Therapeutic Programme
PENTA Pentavalent vaccine that has replaced Diphtheria, pertussis, tetanus (DPT)
ReSoMal Rehydration solution for malnutrition
RUTF Ready-to-Use Therapeutic Food (has same nutritional composition as F100
with added iron and clinically tested in efficacy trials to ensure their
therapeutic equivalence to F100
SAM Severe Acute Malnutrition
SC Stabilization Centre
SD Standard Deviation
SFP Supplementary Feeding Programme
SNO State Nutrition Officer
TB Tuberculosis
UNICEF United Nations Children Fund
WFH Weight-for-Height (Z scores)
WFP World Food Programme
WHO World Health Organization
W/H &W/L Weight-for-Height & Weight-for-Length
Z score Standard Deviations score
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