1. Management of Acute severe malnutrition Moderator Presenter Dr.Chetna Maliye Rohan R. Patil

2. Content & Acronyms  Content  Definition & principles behind community-based management of SAM  Key elements  Impact  Cost effectiveness  Acronyms  Community-based Therapeutic Care (CTC)  Community-based Management of Acute Malnutrition (CMAM)  Integrated Management of Acute Malnutrition (IMAM)

3. Problem statement  Globally nearly 20 million children suffer from severe acute malnutrition.  Severe acute malnutrition contributes to 1 million child deaths every year  Most of them live in south Asia and in sub-Saharan Africa.  India shares majority of toll.

4. Case Defination Severe acute malnutrition  Middle Upper Arm Circumference (MUAC) < 110mm in children between 6 – 59 months of age or Weight-for-height <70% of median or below -3SD of mean reference values ("wasted")  Bilateral pitting oedema of nutritional origin ("oedematous malnutrition")

5. Magnitude of problem(NFHS-3)

6. Magnitude of problem

7. CHILD MALNUTRITION IN INDIA AND CHINA

8. Children’s Nutritional Status Varies by State

9. Problem statement in Maharashtra

11. Why we need to worry ?  WHO Crisis Classification using rates of Global Acute Malnutrition (GAM) SeverityPrevalence of GAM Acceptable<5% Poor5-9% Serious10-14% critical>=15%

12. Latest UNICEF statistics on nutrition in India (Nov – 08) nutrition% % of infants with low birth weight, 1998-2005*30 % of children (1996-2005*) who are: exclusively breastfed (<6 months)37 % of children (1996-2005*) who are: breastfed with complementary food (6-9 months) 44 % of children (1996-2005*) who are: still breastfeeding (20-23 months)66 % of under-fives (1996-2005*) suffering from: underweight, moderate & severe 47 % of under-fives (1996-2005*) suffering from: underweight, severe18 % of under-fives (1996-2005*) suffering from: wasting, moderate & severe16 % of under-fives (1996-2005*) suffering from: stunting, moderate & severe 46 Vitamin A supplementation coverage rate (6-59 months), 200451 % of households consuming iodized salt, 1998-2005*57

13. Types of malnutrition  Acute malnutrition  Marasmus (wasting)  Kwashiorkor (oedematous)  Chronic malnutrition  Stunting  Growth faltering (underweight)  Composite of acute & chronic malnutrition  Specific nutrient deficiency  Anaemia, Iodine etc  Malnutrition secondary to disease  HIV / TB  Any illness

14. Framework of Malnutrition rr Malnutrition and death Inadequate dietary intake Disease Inadequate education Formal and nonformal institutions Political and ideological superstructure Economic structure Potential resources Inadequate access to food Inadequate care for mothers and children Insufficient health services and unhealthy environment Immediate causes Outcomes Underlying Causes Basic Causes

15. Differences between acute and chronic malnutrition  Aetiologies & presentation  Diagnostic indicators  Types of intervention  Different Therapeutic regimes

17. Aspects of SAM  Economic deprivation  Social exclusion  Re-occurring  Individual pathological changes

18. Principal - Maximise Impact SOCIO-ECONOMIC FOCUS Population level impact (coverage) Access to services Early presentation Compliance with treatment CLINICAL FOCUS Individual level impact (cure rates) Efficient diagnosis Effective clinical protocols Effective service delivery

19. Physiological imbalance: Acute malnutrition “reductive adaptations” homoeostasis. Nutritional insult Prone to stresses infection

20. r strategies Surveillance /Surveys Screening/Triage No wasting & no edema No Acute malnutrition No wasting & no edema No Acute malnutrition Moderate Wasting Treatment of moderate wasting Moderate Wasting Treatment of moderate wasting Severe wasting Treatment of severe wasting Severe wasting Treatment of severe wasting Monitoring Evaluation Surveillance /Survey

21. Surveys  Anthropometry : Age Sex Weight Height Bilateral edema MUAC  Retrospective Mortality

22. Screening:  At community level : Household  At hospital & Health Centre: -Curative: -OPD and Emergency ward -Preventive: -Immunization Campaign

23. Modes of treatment  24 hr care (In patient)  Day Care( Residential)  Day Care(Non residential)  Full Out Patient treatment(At home)  Mobile teams

24. Steps in the protocol  Admission  Phase I (acute phase-in patient)  Transition Phase  Phase II  Discharge  Follow up

25. Screening triage appetite test Direct admission to phase I Pass Appetite test Direct admission to phase I Pass Appetite test Phase I In patient treatment Phase I In patient treatment Phase II Out Patient Treatment Phase II Out Patient Treatment Direct admission to phase I Fail Appetite test Direct admission to phase I Fail Appetite test Phase II Transition phase Discharge to follow up Fails Appetite test Or modification Return of appetite and reduction of edema

26. Criteria for admission  Children >= 6 months to 120 cm height:  W/H < 3 Z (WHO )  MUAC <110 mm for a child with length< 66 cm or  MUAC =66 cm or  Bilateral edema

27. Admission procedure  Triage  Do anthropometry  Do appetite test  Check IMNCI signs  Decide with mother  Register the patient  Fill out multi chart  Explain caretaker the procedure  Take essential history and examination in order to start treatment  Start routine treatment

28. Facility/hospital-based management of SAM  Treat/prevent hypoglycemia  Treat/prevent hypothermia  Treat/prevent dehydration  Correct electrolyte imbalance  Treat/prevent infection  Correct micronutrient deficiencies  Start cautious feeding with F-75  Achieve catch-up growth by feeding F-100 after appetite returns  Provide sensory stimulation and emotional support and  Prepare for follow-up after recovery

29. Elements for success of CTC  Maximise early presentation & access  Intensity of care appropriate to medical & nutritional needs  Maximise compliance & minimise resource requirements

30. Maximise early presentation & access  Severity at presentation directly related to lead time to presentation  Cases that present early easier to treat  Invest to develop understanding & participation amongst target population  Appropriate diagnosis

31. Appropriate diagnosis  Use MUAC to diagnose SAM  Weight for height to difficult to implement at scale  Weight for age or height for age inappropriate for diagnosis of SAM

32. Coloured MUAC tape No numbers Suitable for use by uneducated people Facilitates work of community-based case-finders

34. r rr Early presentation High cure rates Recognition and appreciation for program and people associated with it High motivation amongst volunteers & communities DEMAND FOR SERVICE

35. Decentralise to decrease barriers to access

36. Essential elements of CTC  Community mobilisation  Understanding  Early presentation  Compliance  Easy appropriate diagnosis  Decentralisation of care  Easy access  Low opportunity costs

37. Elements for success of CTC  Intensity of care appropriate to medical & nutritional needs Acute Malnutrition Severe Acute Malnutrition Moderate Acute Malnutrition Inpatient careOutpatient care % median weight for height (z scores)

38. 1. Bilateral pitting oedema grade 3* (severe oedema) OR 2. MUAC < 110mm AND bilateral pitting oedema grades 1 or 2 (marasmic kwashiorkor) OR 3. MUAC < 125mm OR bilateral pitting oedema grades 1 or 2 AND one of the following: Anorexia Lower Respiratory Tract Infection** Severe palmer pallor High fever Severe dehydration Not alert Inpatient Care IMCI/WHO Protocols With Complications Without Complications MUAC < 110 mm OR Bilateral pitting oedema grades 1 or 2* AND: Appetite Clinically well Alert Outpatient Care OTP Protocols Severe Acute Malnutrition

39. Outpatient protocols Treatment of SAM without complications  Extremely simple  Can be implemented by clinic workers after a one day training  Weekly visits to clinic  Nutrition, health and hygiene education  Including breast feeding support  200Kcal/Kg/day RUTF  Plus initial provision of:  Broad spectrum antibiotic (Amoxycillin / Cotrimoxazole)  Vitamin A  Folic acid  Deworming  Measles vaccination:  if required  Anti malarials

40. Essential elements of CTC  Outpatient care for majority of children with SAM  All those with SAM without complications  Use of appropriate rehabilitation diet  Proven efficacy in treatment of SAM compared to F100/RUTF gold standard  Contains all essential nutrients  Highly nutrient dense  Highly palatable  Safe to use and store at home  Easy for child to control intake

41. Elements for success of CTC  Appropriate admission to inpatient care  Only acute malnutrition with complications  Early discharge from inpatient facilities – as appetite returns  Reduces resource constraints  Decreases staff and bed demands  Decongests & improves quality of inpatient care  Decrease risk of acquired infection  Decreases costs to mothers and families  Increase compliance & decrease default  Effective patient tracking, referral and transport system

42. Treatment of SAM in mainstream primary health care  CTC/CMAM incorporated as a standard element in primary health care package  RUTF included on essential supplies lists  RUTF produced in India using appropriate local crops  Measures taken to link RUTF production with agriculture in vulnerable groups  Add MUAC & OTP protocols to Growth Promotion & IMCI  Harness existing programmes  Pre-service training of all levels of health care staff in developing countries  in-service training

43. CTC in wardha district Total CTC (8) Grade IGrade IIGrade IIIGrade IV Total Baseline 02233261118 Increased weight 0735010043

44. What can be done?  Adopting and promoting national policies and programs  Achieve high coverage of interventions  Provide training and support for community health workers  Providing the resources needed for management of SAM, and  Integrating the management of SAM with other health activities such as preventive nutrition initiatives.

45. Thank you