Participant Manual Fbcsa Malnutrition

Participant Manual
for
Facility Based Care of
Severe Acute Malnutrition
Ministry of Health and Family Welfare

Government of India, 2013
Purpose of this Training Manual

This training manual is designed for doctors and nurses involved in management of children with severe
malnutrition in hospital settings. Severely malnourished children often die because health care providers
unknowingly use practices that are suitable for most children, but highly dangerous for severely malnourished
children. With appropriate case management in hospitals and follow-up care, the lives of many children can be
saved, and case fatality rates can be reduced.
In 2006, Indian Academy of Paediatrics undertook the task of developing guidelines for the management of
severely malnourished children based on adaptation from WHO guidelines. This training manual is based on the
revised consensus recommendations made by the IAP Task Force and the Training Course on Management of
Severe Malnutrition, WHO 2009 .
This Training Manual will be used as course material for training service providers in Facility Based Management
of Children with Severe Acute Malnutrition. A Facilitator Guide has been developed to assist the Master Trainers
in conducting the training course. The training course includes classroom sessions and clinical practice sessions
wherein the participants shall visit, observe and practice in real hospital setting.
After going through the course, participants will acquire the skills and knowledge specifically needed for
management of severely malnourished children in hospital settings. It is expected that after returning to their
hospitals (or Nutrition Rehabilitation Centres), participants will implement the case management practices
described in this training manual. Basic supplies and equipment required to implement these practices are
described in detail in the Operational Guide for Facility Based Management of SAM, 2011.
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Government of India
Ministry of Health & Family Welfare
Nirman Bhawan, New Delhi - 110 108
MESSAGE
The National Rural Health Mission is being implemented across the country and
undertaking massive efforts for the reduction of child mortality. Improvement of
nutrition status of children is critical to child survival, provides enhanced growth
opportunities and avenues for increased life expectancy. Under NRHM, nutritional
interventions are an integral component of child health programme and include
promotion of IYCF practices, micronutrient supplementation, and facility based
management of children with Severe Acute Malnutrition through Nutritional
Rehabilitation Centres.
Smt. Anuradha Gupta, IAS
Additional Secretary &

Mission Director NRHM
Children with Severe Acute Malnutrition (SAM) have nine times higher risk of
dying than well-nourished children. An effort has been made towards treatment
and recovery of such children under various Nutritional Rehabilitation Centres
established since 2006 in many States and to restore them to path of healthy
development. The National Family Health Survey -3 revealed that 6.4 percent
of all children under-five years of age are severely wasted. With appropriate
nutritional and clinical management, many of the deaths due to severe wasting
can be prevented.
Quality training of Staff of NRCs is crucial for management of Severely Malnourished
Children and their rehabilitation. The training manuals are designed with expert
inputs from UNICEF, WHO, other child health experts across the country. I am
sure it would enhance technical and management expertise for treatment of
Children with Severe Acute Malnutrition. I urge the States to use these modules
and undertake trainings as prescribed for realisation of the goal of Facility based
Rehabilitation of SAM children.
I compliment Child Health Division for bringing out the training Manual
Anuradha Gupta
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Government of India
Ministry of Health & Family Welfare
Nirman Bhawan, New Delhi - 110 108
MESSAGE
The nutritional status of the people is an internationally recognized as an
indicator of national development. Nutrition is both an input into and output
of indicator of the development process. A well-nourished, healthy workforce
is a pre-condition for successful economic and social development and as such
promoting nutritional status of the people is of utmost importance.
Dr. Rakesh Kumar, IAS

Joint Secretary (RCH)
Under National Rural Health Mission, Nutrition Rehabilitation Centres (NRCs)

have been set up at health facilities in many districts. Programme Managers
have expressed a need for comprehensive training modules in order to ensure
optimal operationalizing Nutrition Rehabilitation Centres. In response to this
need, Reproductive and Child Health Programme, Ministry of Health and Family
Welfare, Government of India in collaboration with United Nations Childrens
Fund (UNICEF) and the World Health Organization (WHO), in consultation with
domain experts and program managers have drafted these modules.
Children with Severe Acute Malnutrition (SAM) have nine times higher risk of
dying than well-nourished children. In India, the prevalence of SAM in children
remains high despite overall economic growth. Many Nutritional Rehabilitation
Centres are operational in the States at district and below district level facilities. A
validated training curriculum based on scientific evidence would help in building
technical expertise of health service providers and take this important initiative
forwards.
I am confident, these modules will be instrumental in developing a technically
sound workforce.
November 2012
New Delhi
Dr. Rakesh Kumar
Contributors
Writing Team Members:
1
Dr. S. Aneja, Kalawati Saran Childrens Hospital
Dr. Praveen Kumar, Kalawati Saran Childrens Hospital
Dr. Nidhi Chaudhary, WHO India
Dr. Dheeraj Shah, University College of Medical Sciences, New Delhi
Dr. Sriram Krishnamurthy, JIPMER, Puducherry
Reviewers for the Manual:

1
Dr. Ajay Khera, Deputy Commissioner Child Health & Immunisation, MoHFW, GoI
Dr. Sila Deb, Deputy Commissioner Child Health, MOHFW, GoI
Dr. Deepti Agarwal, Consultant Child Health, MOHFW, Goi
Dr. Shinjini Bhatnagar, AIIMS, New Delhi
Dr. H.P.S. Sachdev, Sitaram Bhartia Institute of Science & Research, New Delhi
Ms. Anuja Agrawala, AIIMS, New Delhi
Dr. Panna Choudhary, Past President, Indian Academy of Paediatrics
Dr. V.K. Anand, UNICEF India
Dr. Piyush Gupta, University College of Medical Sciences, New Delhi
10
Dr. T. Sundararaman, National Health Systems Resource Centre, New Delhi
11
Dr. Padam Khanna, National Health Systems Resource Centre, New Delhi
Abbreviations
AWW
Anganwadi worker
ARV
Anti retro viral
ART
Anti retroviral treatment
ASHA
Accredited Social Health Activist
IMNCI
Integrated Management of Newborn and Childhood Illnesses
Hb
Hemoglobin
HIV
Human Immunodeficiency Virus
HFA Height-for-age
IV Intravenous
IU
International Unit
mcg micrograms
MCP card
Mother and Child Protection Card
MUAC
Mid-Upper Arm Circumference
NACO
National AIDS Control Organisation
NRC
Nutrition Rehabilitation Centre
NFHS
National Family Health Survey
ORS
Oral Rehydration Solution
PR
Pulse rate
RR
Respiratory rate
SAM
SD
Standard Deviation
SST
Supplementary Suckling Technique
TB Tuberculosis
WFA Weight-for-age
WFH Weight-for-height
WFL
Weight -for- length
WHO
World Health Organization
CONTENTS
SECTION-1: INTRODUCTION
3
3
3
1.1
1.2
1.3
Understanding Malnutrition
Measuring Undernutrition
Types of Undernutrition
SECTION-2: PRINCIPLES OF CARE5

2.1
2.2
2.3
2.4
2.5
2.6
2.7
Recognize signs of severe malnutrition

Weigh and Measure the child
Mid-upper arm circumference (MUAC)
Identification of Children with Severe Acute Malnutrition
Criteria for hospitalization/in-patient care
Organization of care
Physiology of severe malnutrition
7
8
11
13
14
16
16
SECTION-3: INITIAL MANAGEMENT
19
21
24
26
27
28
29
36
36
38
38
3.1
3.2
3.3
3.4.
3.5.
3.6.
3.7
3.8
3.9
3.10
Identifying and managing the severely malnourished child with emergency signs
Assessment of severely malnourished child
Steps in management of the severely malnourished child
Step 1: Manage hypoglycaemia
Step 2: Manage hypothermia
Step 3: Manage dehydration and shock
Step-4: Correct Electrolyte Imbalance
Step-5: Treat Infection: Give antibiotics
Give emergency eye care for corneal ulceration
Step-6: Give Micronutrients
SECTION-4: INITIAL FEEDING
39
41
43
44
44
44
45
4.1
4.2
4.3
4.4
4.5
4.6
Prepare Starter diet

Feed the child with Starter diet
Feeding children who have diarrhoea and vomiting
Nasogastric (NG) feeding
Record intake and output on a 24-Hour Food Intake Chart
Adjust the childs feeding plan for the next day
SECTION-5: REHABILITATIVE PHASE
47
49
53
5.1
5.2
Step 8-Catch-up Growth

Daily Care
SECTION-6: INVOLVING MOTHERS IN CARE
59
61
62
63
6.1 Organize facility routine to encourage mothers involvement

6.2. Prepare for feeding the child at home
6.3 Step 9: Teach mothers the importance of stimulation and how to make and use toys
SECTION-7: PREPARE FOR DISCHARGE & FOLLOW-UP
65
67
67
68
7.1
7.2
7.3
Criteria for discharge

Teaching parents to care for the child and prevent recurring malnutrition
Treatment for Helminthiasis
7.4 Follow-up

7.5 Give general discharge instructions

7.6 If early discharge is unavoidable, make special arrangements for follow-up
68
68
68
SECTION-8: MANAGEMENT OF SAM IN INFANTS LESS THAN 6 MONTHS OF AGE
69

8.1 Initial assessment and treatment
8.2 Feeding

8.3 Relactation through Supplementary Suckling Technique (SST)
71
71
71
SECTION-9: MANAGEMENT OF SAM IN HIV EXPOSED/HIV INFECTED CHILDREN
73
SECTION-10: MONITORING AND PROBLEM SOLVING
77
79
81
83
84
84
10.1
10.2
10.3
10.4
10.5
Use a process to identify and solve problems

Monitor and solve problems with an individual patient
Monitoring patient outcomes
Monitoring patient care in the ward
Monitoring facility level outcomes
ANNEXURES
87
Annexure - 1 : WHO Growth Reference Charts

Annexure - 2 : Appetite Test
Annexure - 3 : Antibiotics Reference Card
Annexure - 4 : Daily Ward Feeding Chart
Annexure - 5 : 24 Hour Food Intake Chart
Annexure - 6 : Weight Chart
Annexure - 7 : Daily Care Chart
Annexure - 8 : Starter Diet Reference Chart
Annexure - 9 : Volume of Starter Diet for Children with Severe Oedema
Annexure - 10 : Catch up Diet Reference Chart
Annexure - 11 : Home Made Alternative Food Items
Annexure - 12 : Composition of Concentrated Electrolyte Mineral Solution
Annexure - 13 : Preparation of Rehydration Solution for Malnourished Children
Annexure - 14 : Management of Continuing Diarrhoea
Annexure - 15 : Severe Anaemia in Malnourished Children
Annexure - 16 : Examples of Simple Toys (Adapted from WHO Guideline)
Annexure - 17 : Examples of Language and Motor Activities with Children
Annexure - 18 : Sample Discharge Card
Annexure -19 : Checklist Proforma for Monitoring Food Preparation
Annexure -20 : Checklist for Monitoring Ward Procedures
Annexure -21 : Checklist for Monitoring Hygiene
Annexure - 22 : Equipment and Supplies
Annexure - 23 : Calculate Case Fatality Rate for The Ward
Annexure - 24 : Guidance Table to Identify Target Weight
Annexure - 25 : Feeding Recommendations for Children as per IMNCI
89
91
92
93
94
96
97
98
99
100
101
102
103
104
105
106
107
109
110
111
113
114
115
116
117
Charts
Chart 1 : Triage
Chart 2 : 10 Steps of Routine Care
Chart 3 : Management of Shock in Children with SAM
23
27
34
Figures
Figure 1 :
Figure 2 :
Figure 3 :
Figure 4 :
Figure 5 :
Figure 6 :
Figure 7 :
Figure 8 :
Figure 9 :
Figure 10 :
Figure 11 :
Figure 12 :
Figure 13 :
Child with Severe Wasting

Child with Severe Wasting (Baggy Pants Appearance)
Pedal Oedema
Measuring Length
Measuring Height
Measuring Childs Mid-Upper-Arm Circumference
Measuring MUAC with 3 Coloured Tape
Criteria for Facility-Based Care
Child with Oedema and Dermatosis
Vitamin a Deficiency Signs
Checking Skin Pinch
Checking Capillary Refill
Supplementary Sucking Technique
7
7
8
9
10
12
13
15
25
26
30
33
72
WHO Classification of Vitamin a Deficiency

Antibiotics for Severely Malnourished Children
Recipe for Starter Diets
Starter Lactose Free Diets
Recipe for Catch-Up Diet
Recipe for Low Lactose Catch-Up Diet
Amounts ff Catch Up Diet Diluted for Infants put on SST
Definition of Key Terms for Indicators
25
37
41
42
49
50
72
85
Tables
Table 1
Table 2
Table 3
Table 4
Table 5
Table 6
Table 7
Table 8
:
:
:
:
:
:
:
:
SECTION
INTRODUCTION
SECTION
INTRODUCTION
1.1 Understanding Malnutrition
Malnutrition is a general term. It most often refers
to undernutrition resulting from inadequate
consumption, poor absorption or excessive loss
of nutrients but the term also encompasses
overnutrition, resulting from excessive intake of
specific nutrients. An individual will experience
malnutrition if the appropriate amount or quality of
nutrients comprising a healthy diet is not consumed
for an extended period of time. In subsequent text,
the words malnutrition and undernutrition are used
interchangeably.
Malnutrition in children is widely prevalent in
developing countries including India. More than 33%
of deaths in 0-5 years are associated with malnutrition.
1.2 Measuring Undernutrition

In children, undernutrition is synonymous with
growth failure - undernourished children are shorter
and lighter than they should be for their age /height.
To get a measure of malnutrition in a population,
young children are weighed and/or their height is
measured and the results compared to those of a
reference population known to have grown well.
Measuring weight and height is the most common
way of assessing malnutrition in a given population.
Anthropometry is a widely used, inexpensive and
non-invasive measure of the general nutritional
status of an individual or a population group. The
three commonly used anthropometric indices are:
Weight-for-age (WFA)
Height/Length-for-age (HFA)
Weight-for-Height/Length (WFH).
1.3 Types of Undernutrition

The three indices - weight-for-age, height/lengthfor-age, weight-for-height/length are used to
identify three nutrition conditions: underweight,

stunting and wasting, respectively. Each of the three
nutrition indicators is expressed in standard deviation
units (Z-scores) from the median of the reference
population based on which undernutrition may be
further classified as moderate or severe.
Underweight
Underweight, based on weight-for-age, is a composite
measure of stunting and wasting and is recommended
as the indicator to assess changes in the magnitude of
malnutrition over time.
This condition can result from either chronic or acute
malnutrition, or both. Underweight is often used as a
basic indicator of the status of a populations health
as weight is easy to measure. Evidence has shown
that the mortality risk of children who are even mildly
underweight is increased, and severely underweight
children are at even greater risk.
An underweight child has a weight-for-age Z score
that is at least two standard deviations (-2SD) below
the median in the World Health Organization (WHO)
Child Growth Standards.
Stunting
Failure to achieve expected height/length as
compared to healthy, well-nourished children of the
same age is a sign of stunting. Stunting is an indicator
of linear growth retardation that results from failure
to receive adequate nutrition over a long period
or recurrent infections. It may be exacerbated by
recurrent and chronic illness. It is an indicator of past
growth failure. It is associated with a number of longterm factors including chronic insufficient nutrient
intake, frequent infection, sustained inappropriate
feeding practices and poverty. Stunting often
results in delayed mental development, poor school
performance and reduced intellectual capacity. This
Participant Manual - Facility Based Care of Severe Acute Malnutrition
in turn affects economic productivity at national level.

A stunted child has a height-for-age Z score that is
at least two standard deviations (-2 SD) below the
median for the WHO Child Growth Standards.
Wasting
Wasting represents a recent failure to receive
adequate nutrition and may be affected by recent
episodes of diarrhoea and other acute illnesses.
Wasting indicates current or acute malnutrition
resulting from failure to gain weight or actual weight
loss. Causes include inadequate food intake, incorrect
feeding practices, disease, and infection or, more
frequently, a combination of these factors. Wasting
in individual children and population groups can
change rapidly and shows marked seasonal patterns
associated with changes in food availability or disease
prevalence to which it is very sensitive.
A wasted child has a weight-for-height Z score that
is at least two standard deviations (-2SD) below the
median for the WHO Child Growth Standards.
Severe Acute Malnutrition (SAM)

Severe acute malnutrition is defined by very low
weight-for-height/length (Z- score below -3 SD of the
median WHO child growth standards), or a mid-upper
arm circumference < 115 mm, or by the presence of
nutritional oedema.
Severe Acute Malnutrition is both a medical and
social disorder. Lack of exclusive breast feeding, late
introduction of complementary feeds, feeding diluted
feeds containing less amount of nutrients, repeated
enteric and respiratory tract infections, ignorance,
and poverty are some of the factors responsible for
Severe Acute Malnutrition (SAM).
SAM significantly increases the risk of death in children
under five years of age. It can be a direct or indirect
cause of child death by increasing the case fatality
rate in children suffering from such common illnesses
as diarrhoea, acute respiratory infections, malaria and
measles. According to National Family Health Survey
3 (2005-06), 6.4% of children below 60 months of age
or nearly 8 .1 million were estimated as having severe
acute malnutrition.
Moderate Acute Malnutrition

A child with 70-80% of median weight-for- height
(Z score of <-3SD to <-2 SD), or a Mid Upper Arm
Circumference of 115-125 cms and no oedema is
classified as a case of Moderate Acute Malnutrition.
In addition the child should have appetite, be alert
and clinically well. Children with moderate acute
malnutrition can be managed in the Outpatients
setting where there is a provision for supplementary
feeding.
1.4 Case Fatality in children with

Children with severe acute malnutrition can be
categorized into complicated and uncomplicated
cases based on clinical criteria. Children with SAM
should be treated in as inpatients, preferably in
specialized units like the Nutrition Rehabilitation
Centres with skilled manpower and adequate resources
for nutrition rehabilitation. Median case fatality rate in
children with SAM is approximately 23.5%, which may
reach 50% in oedematous malnutrition. The high case
fatality has been attributed to various factors related
to the management and includes:
1. Inability to distinguish between acute and
rehabilitation phases
2. Excessive use of intravenous (IV) fluids
3. Fluid overload due to lack of monitoring during
rehydration
4. Use of diuretics (for oedema) and albumin
5.
Not keeping the child warm and euglycaemic

(normal blood glucose levels)
6. Low index of suspicion for infection

7. Early use of diets high in protein, sodium, energy
8. Failure to monitor food intake
9. Early treatment of anaemia with oral iron
The case fatality can be brought down to approximately
7-10% by standard case management protocol, which
the participants will learn in this course.
SECTION
PRINCIPLES
OF CARE
SECTION
PRINCIPLES OF CARE
Learning objectives
At the end of this section, the participant will be
able to:
Identify the signs of severe acute malnutrition
Determine a standard deviation score (SDscore) based on the childs weight and length/
height.
Describe how the physiology of severe acute
malnutrition affects care of the child
List the essential components of care for
children with SAM
Look at the front view of the child:

Is the outline of the childs ribs easily seen?
Does the skin of the upper arms look loose?
Does the skin of the thighs look loose?
Look at the posterior view of the child:
Are the ribs and shoulder bones easily seen?
Is there any wasting seen on buttock?
When wasting is extreme, there are folds of skin on
the buttocks and thighs. It looks as if the child is
wearing baggy pants (Figure-2). Because a wasted
child has lost fat and muscle, this child will weigh less
than other children of the same height and will have
a low weight-for-height.
2.1. Recognize signs of severe

2.1.2. Oedema
malnutrition
You may be familiar with the following signs that are
related to severe acute malnutrition.
2.1.1. Severe wasting

If the diet is deficient for a
short duration, the body
adapts its metabolism
to compensate for the
deficit to some extent. If
the food deficit persists
for a longer
duration then the fat
is utilized for energy &
body metabolism and
then muscle is depleted.
A child with severe
wasting has lost fat and
Figure 1: Child with Severe Wasting
muscle and appears like
skin and bones. Another term used for this condition
is marasmus. To look for severe wasting, remove the
childs clothes.
Oedema is swelling
from excess fluid in
the tissues. Oedema
is usually seen in the
feet and lower legs.
In severe cases it may
also be seen in the
upper limbs and face.
To check for oedema,
grasp the foot so that it
rests in your hand with
your thumb on top of
the foot. Press your
thumb gently for a few Figure 2: Child with Severe Wasting
seconds (approximately (Baggy Pants Appearance)
10 seconds). The child
has oedema if a pit (dent) remains in the foot when
you lift your thumb (Figure-3).
To be considered a sign of severe acute malnutrition,
oedema must appear in both feet. If the swelling is
only in one foot, it may just be a sore or infected foot.
The extent of oedema is commonly rated in the

following way:
+ + + severe: generalized oedema including feet, legs,

hands, arms and face
+ mild: both feet

+ + moderate: both feet, plus lower legs, hands, or
lower arms
Note: Oedema is a characteristic of kwashiorkor, which is a form of

severe acute malnutrition.
You must formally test for oedema with finger pressure

you cannot tell by just looking
Figure 3: Pedal Edema
2.2.
Weigh and Measure the
child
In addition to looking for visible signs of severe
malnutrition and pedal oedema, it is important to
weigh and measure the child to identify SAM children.
After weighing & measuring the childs weight-forheight should be compared to the reference standard.
2.2.1. Measure length/height

Depending on a childs age and ability to stand,
measure the childs length or height. A childs length
is measured lying down (recumbent) position. Height

is measured with child standing upright.
In general, standing height is about 0.7 cm less than
recumbent length. This difference was taken into
account in developing the WHO growth standards
used to make the charts in the Growth Record.
Therefore, it is important to adjust the measurements
if length is taken instead of height, and vice versa.
Allow the mother or care giver of the child to be
nearby to help soothe and comfort the child while
measuring length or height.
Measuring length and height

If a child is less than 2 years old (or less than 87 cm if the age is not available), measure recumbent length.
If the child is aged 2 years or older (or 87 cm or more if the age is not available) and able to stand, measure
standing height.
If a child less than 2 years old will not lie down for measurement of length, measure standing height
and add 0.7 cm to convert it to length. If a child aged 2 years or older cannot stand, measure recumbent
length and subtract 0.7 cm to convert it to height.
To measure length
Use a measuring board like infantometer with a
headboard and sliding foot piece. Lay the measuring
board flat, preferably on a stable, level table. Cover
the board with a thin cloth or soft paper to avoid
causing discomfort and the baby sticking to the
board. Measurement will be most accurate if the
child is naked; diapers make it difficult to hold the
infants legs together and straighten them. However,
if the child is upset or hypothermic, keep the clothes
on, but ensure that they do not get in the way of
measurement. Always remove shoes and socks. Undo
braids and remove hair ornaments if they interfere
with positioning the head. After measuring, clothe or
cover the child quickly so that he does not get cold.
Work with a partner. One person should stand or
kneel behind the headboard and:
Position the child lying on his back on the
measuring board, supporting the head and
placing it against the headboard. (Figure-4)
Position the crown of the head against the
headboard, compressing the hair.
Hold the head with two hands and tilt upwards
until the eyes look straight up, and the line of
sight is perpendicular to the measuring board.
Check that the child lies straight along the centre
line of the measuring board and does not change
position.
The other person should stand alongside the

measuring board and:
Support the childs trunk as the child is positioned
on the board.
Place one hand on the shins or knees and press
gently but firmly.
Straighten the knees as much as possible without
hurting the child (Figure 4).
With the other hand, place the foot piece firmly
against the feet. The soles of the feet should be
flat on the foot piece, toes pointing up. If the
child bends the toes and prevents the foot piece
touching the soles, scratch the soles slightly and
slide in the foot piece when the child straightens
the toes.
Measure length to the last completed 0.1 cm and
record immediately on the Case recording form.
2.2.2. To measure standing height

Use a stadiometer with a vertical back board, a
fixed base board, and a movable head board. The
stadiometer should be placed on a level floor. Remove
the childs socks and shoes for accurate measurement.
Also remove hair ornaments and undo braids if they
interfere with measurement.
Figure 4: Measuring Length
Work with a partner. One person should kneel or

crouch near the childs feet and:
Help the child stand with back of the head,
shoulder blades, buttocks, calves and heels
touching the vertical board. (Figure-5)
Hold the childs knees and ankles to keep the legs
straight and feet flat.
Prevent children from standing on their toes.
Young children may have difficulty standing to full
height. If necessary, gently push on the tummy to
help the child stand to full height.
The other person should bend to level of the childs
face and:
Position the head so that the child is looking
straight ahead (line of sight is parallel to the base
of the board).
Place thumb and forefinger over the childs chin

to help keep the head in an upright position.
With the other hand, pull down the head board to
rest firmly on top of the head and compress hair.
Measure the height to the last completed 0.1 cm
and record it immediately on the Case recording
sheet.
2.2.3. Weigh the child

Weigh the child as soon as possible after he arrives.
If the child is admitted, weigh the child once daily,
preferably at about the same time each day. The
weighing time should be about one hour before or
after a feed.
Head-piece firmly on head

Hand on chin
Shoulders level
Left hand on knees: Knees

together and legs straight
Hands at side
Right hand on shins: neels

against back and base of
board
Measurer on knee
Assistant on knees
Record form and pencil on clipboard on
floor or ground
Figure 5: Measuring Height
10
Line of sight
Body flat against board
It is recommended to weigh children using a scale

with the following features:
Solidly built and durable
Electronic (digital reading)
Measures to a precision of 0.01 kg (10g)
Allows tared weighing
Tared weighing means that the scale can be re-set
to zero (tared) with the person just weighed still on
it. Thus, a mother can stand on the scale, be weighed,
and the scale tared. While remaining on the scale, if
she is given her child to hold, the childs weight alone
appears on the scale.
Tared weighing has two advantages:
There is no need to subtract weights to determine
the childs weight alone (reducing the risk of error).
The child is likely to remain calm when held in
the mothers arms for weighing. If the SCALE for
tared weighing is not available, a beam scale or a
hanging scale (Salter type) may be used to weigh
the child :
Remove the childs clothes, but keep the child
warm with a blanket or cloth while carrying to the
scale.
Put a cloth in the scale pan to prevent chilling the
child.
Adjust the scale to zero with the cloth in the pan.
(If using a scale with a sling or pants, adjust the
scale to zero with that in place.)
Place the naked child gently in the pan (or in the
sling or pants).
Wait for the child to settle and the weight to
stabilize.
Measure weight to the nearest 0.01 kg (10 g) or as
precisely as possible & Record immediately.
Wrap the child immediately to re-warm.
Standardize scales
In case of other type of weighing scale standardize
scales daily or whenever they are moved:
Set the scale to zero.
Weigh three objects of known weight (e.g., 50
gms, 100 gms, 500 gms) and record the measured
weights.
Repeat the weighing of these objects and record
the weights again.
If there is a difference of 0.01 kg or more between
duplicate weighing, or if a measured weight differs
by 0.01 kg or more from the known standard,
check the scales and adjust or replace them if
necessary.
2.3.
Mid-upper arm circumference (MUAC)
Community based screening programmes for severe
malnutrition usually uses MUAC less than 11.5 cm
to identify severe wasting. MUAC is a quick and
simple way to determine whether or not a child is
malnourished using a simple coloured plastic strip.
MUAC is suitable to use on children from the age of 6
months up to the age of 59 months.
Arm circumference is measured on the upper left
arm. To locate the correct point for measurement, the
childs elbow is flexed to 90. A measuring tape is used
to find the midpoint between the end of the shoulder
(acromion) and the tip of the elbow (olecranon); this
midpoint should be marked (see Figure 6). The arm is
then allowed to hang freely, palm towards the thigh,
and the measuring tape is placed snugly around the
arm at the midpoint mark. The tape should not be
pulled too tight.
11
Figure 6: Measuring Childs Mid-Upper-Arm Circumference
12
If using a 3-colour tape:

(Figure 7)
A measurement in the green
zone means the child is
properly nourished;
A measurement in the yellow
zone means that the child has
moderate acute malnutrition;
A measurement in the red
zone means that the child has
severe acute malnutrition.
Repeat the measurement two
times to ensure an accurate
interpretation.
2.4.
Identification of children
with
severe
acute
malnutrition
Health professionals and healthcare providers
should assess nutrition status of all children and
detect children with SAM at every opportunity
provided by health contacts, be it for a medical
complaint or for health promotional measures

(e.g. growth monitoring or immunization). This
can be undertaken at every health facility (Primary
Health Centre and Sub-centre, health posts,
hospitals, day-care centres, etc.) and even in the
community at Anganwadi centres.
MUAC is a simple measure for the detection
of SAM. Screening of children with SAM in the
community can be done using MUAC tape.
Recommended criteria for identifying SAM in infants> 6 months of age

Any child who has following features are treated as severe acute malnutrition:
Weight-for-height less than -3 SD and/or
Visible severe wasting and/or
Mid arm circumference (MUAC) < 11.5 cm and/or
Oedema of both feet*
Recommended criteria for identifying SAM in infants <6 months of age

Any infant more than 49 cm** in length who has following features are treated as severe acute
malnutrition:
Weight-for-height less than -3 SD and/or
Visible severe wasting and/or
Oedema of both feet*
* Other causes of oedema e.g. nephrotic syndrome should be excluded.
** For children with length less than 49 cm in length, visible severe wasting can be used as criteria to identify SAM .
13
Standard Deviation
For identifying a child with severe acute malnutrition
standard deviation score (SD-score) based on childs
weight and length/height is determined.
An SD-score is a way of comparing a measurement, in
this case a childs weight-for-length, to an average.
The averages referred to in the manual are WHO
Growth Reference values for weight-for-height and
weight-for-length. A table is given in the end as
Annexure 1 that shows the SD-scores for children
of different weights and heights. SD-scores may be
loosely interpreted as follows:
-1 SD approximately corresponds to 90% of the
median weight-for-height.
The reason for considering a childs weight-for-height
rather than simply weight-for-age is that the latter is
affected by stunting. Stunting may cause low weightfor-age when a child is adequate weight-for-height.
Feeding can correct wasting but cannot easily correct

stunting.
To use the reference table

First find the childs length or height in the middle
of the table. If the length or height is between
those listed, rounds up or down: If the length/
height is 0.5 or more cm then take the next higher
value.
Look at the top of the column to see what the
childs SD-score is. The childs weight may be
between two SD-scores. If so, indicate that the
weight is between these scores by writing less
than (<). For example, if the score is between - 1
SD and -2 SD, write < -1 SD.
Examples of SD scores of weight for

height
A boy is 80 cm in length and weighs 8.5 kg. His score
is < -2 SD.
A girl is 76.5 cm in length and weighs 7.0 kg. Round
her length to 77 cm. Her score is < -3 SD.
EXERCISE-A
Refer to the table of SD-scores in Annexure I. Indicate the SD-score for each child listed below.
1. Sudha, girl, length 63 cm, weight 5.0 kg
SD: __________________
2. Ram, boy, height 101 cm, weight 11.8 kg
SD: __________________
3. Tanya, girl, length 69.8 cm, weight 6.4 kg
SD: __________________
4. Karan, boy, length 82 cm, weight 8.0 kg
SD: __________________
2.5. Criteria for hospitalization/

in-patient care
Decision for home or outpatient and inpatient care
depends on the facility available for management
of these children and the associated complications.
There is growing evidence that child with SAM
without complications does not require inpatient
treatment and can be effectively managed at the
community level. Children with complications may
14
be shifted to community based care programme after

stabilisation and if good support is available at the
community level.
Children with SAM and medical complications should
be admitted and managed in a health facility.
Appetite test can be conducted as described in
Annexure 2. Poor appetite is a reliable indicator for
severity of illness and thus need for hospitalization.
W/H < -3SD and / or

Visible severe wasting and / or
Bilateral pedal oedema and/ or
MUAC < 11.5 cm
If complications /poor appetite/ oedema

Facility-based management
Treatment comprises the first 7
steps of inpatient care (stabilizationphase) in a
health facility. When completed, child may be
transferred to community-based care.
No complication and good appetite and

no oedema
Community/Home-based
management
Step 8 to 10 of management
Figure 8: Criteria for Facility-Based Care
Children with following medical complications should be admitted in a Nutrition Rehabilitation centre
or a health facility
Presence of any of emergency signs
Oedema
Persistent vomiting
Very weak, apathetic
Fever (Axillary temperature > 38.5 degree Celsius )
Children with fast breathing / chest in drawing/ cyanosis
(Fast breathing is said to be present if number of breaths per minute is 60 or more in children up-to 2 months , 50 or more in children 2
months up-to 1 year and 40 or more in children 1 year up-to 5 years)
Extensive skin lesions, eye lesions, post-measles states

Diarrhoea with dehydration based on history and clinical signs
Severe anaemia
Hypothermia (Axillary temperature <35 degree centigrade)
Any other general sign which the clinician thinks warrants transfer to in-patient facility for assessment or
care
In addition to above criteria if the caregiver is unable to take care of the child at home, the child should be admitted.
15
Children with SAM should be admitted to special

wards (eg; Nutrition Rehabilitation Centres) or specific
area designated in the ward. These children have
an increased risk of mortality from hypoglycaemia,
hypothermia, fluid overload, and undetected
infections. For this reason they need to be treated
differently than children without SAM. The steps in
management of children with SAM will be dealt with
in the next session.
Note about low-birth-weight babies.

Low-birth-weight babies are not usually severely
wasted or oedematous and so are unlikely to meet
the criteria for severe malnutrition. Management of
low birth-weight babies is not taught in this
course.
EXERCISE-B
For the children whose details are given below write if he/she has SAM
Name
Age
Sex Weight
Length MUAC OEDEMA
(months)
(kg)
/ Height
(cm)
(cm)
Prince
12
M
9.8
73
13
No
Rani
15
F
7.1
75
12
No
Ritika
26
F
10.4
89
14
No
Dinesh
32
M
11.2
95
15
No
Iqbal
20
M
6.4
83
10.8
Yes
Nitin
6
M
5.8
66
9
No
Sakina
8
F
4.2
72
9.8
No
Sonu
12
M
6.6
73
10
No
Shyam
24
M
8.6
82
11.2
No
2.6. Organization of care

On admission, the child with severe malnutrition
should be kept in a warm area (25-30C). Washing
should be kept to a minimum, after which the child
should be dried immediately.
Facilities and sufficient staff should be available to
ensure correct preparation of appropriate feeds,
and to carry out regular feeding during the day and
night. Accurate weighing machines are needed, and
a record should be kept of the feeds given and the
childs weight so that progress can be monitored.
Several states have also started Nutritional
Rehabilitation
Centres/Malnutrition
Treatment
Centres for malnourished children to provide (i)
Medical Care to malnourished children (ii) Timely,
16
SD
Score
Does this child

have
SAM
No
adequate and appropriate feeding to these children

(iii) Training on preparation of low cost nutritious
diet from locally available stuffs (iv) Enhancement of
mothers skills on child care and feeding (v) Special
diets to severely malnourished children according to
their age and condition (vi) Monitoring health and
nutritional status of these children during the stay
at the nutrition rehabilitation centre and (vii) Followup of these children after discharge. Wherever these
centres are available, their services should be utilized.
2.7.
Physiology
of
malnutrition
severe
The child with severe malnutrition must be treated

differently as the body physiology becomes abnormal
due to reductive adaptation.
What is reductive adaptation?

The systems of the body begin to shut down with
severe malnutrition. The systems slow down and do
less in order to allow survival on limited calories. This
slowing down is known as reductive adaptation.
Reductive adaptation affects treatment of the child in
many ways. Some of the important implications are
as follows:
1. As the childs intake is insufficient, fat stores are
mobilized to provide energy. Later protein is
mobilized from muscle, skin and the intestine.
Energy is conserved mainly by reducing
physical activity and growth and reducing basal
metabolism.
2. The usual signs of infection may not be apparent
as the body does not use its limited energy to
respond in usual ways (such as inflammation or
fever), even though most children with severe
malnutrition have bacterial infections.
3. Due to reductive adaptation, children make less
haemoglobin than usual. Iron that is not used
for making haemoglobin is put into storage, and
therefore children have extra iron in the body
even though they may appear anaemic.
4. Normally body uses energy for maintaining

balance of potassium outside and sodium inside
the cells, which is critical for maintaining correct
distribution of water inside and around the cells
and in the blood. As the pumps maintaining this
balance become slower, potassium is lost from
the body while fluid may accumulate outside the
cells.
Children with Severe Acute Malnutrition are at
risk of death from:
Hypoglycaemia, as there is less supply of glucose
from the liver and muscle while at the same time,
the demand for glucose is high to fight infections;
Hypothermia, as Basal Metabolic Rate is reduced.
At the same time they are likely to lose more heat
than usual due to loss of insulating fat and a
higher surface area/kg body weight;
Fluid overload and cardiac failure due to changes
in the functioning of the kidneys and heart; and
Infections, as the bodys inflammatory and
immune responses slow down.
17
SECTION
INITIAL
MANAGEMENT
SECTION
INITIAL MANAGEMENT
Learning objectives
This section will describe:
Identifying and managing the severely
malnourished child with emergency signs
Identifying and managing the severely
malnourished child with complications:
Hypoglycaemia Hypothermia
Diarrhoea/Dehydratio Infections
Corneal ulceration/eye problems
Selecting appropriate antibiotics and
calculating dosages
Keeping a written record of initial findings
and treatments
3.1. Identifying and managing

the severely malnourished
child with emergency signs
The focus of initial management is to prevent death
while stabilizing the child. The first step is to check the
child for emergency signs and provide emergency
treatment as necessary.
Keep in mind the ABCD steps: Airway, Breathing,
Circulation, Coma, Convulsion, and Dehydration.
Make sure that the child is warm at all times.
Look: If active, talking, or crying, the child is

obviously breathing. If none of these, look again
to see whether the chest is moving.
Listen: Listen for any breath sounds. Are they
normal?
Feel: Can you feel the breath at the nose or mouth
of the child?
If the child is not breathing, you will need to manage
the airway and support the breathing artificially by
ventilating the child with a bag and mask.
3.1.1.
Does the Child Show Central
Cyanosis?
Cyanosis occurs when there is an abnormally low level
of oxygen in the blood. This sign may be absent in a
child who has severe anaemia. To assess for central
cyanosis, look at the mouth and tongue. A bluish or
purplish discoloration of the tongue and the inside of
the mouth indicates central cyanosis.
3.1.2.
Does the Child have Severe
Respiratory Distress?
Observe whether the child has significant discomfort
from not getting enough air into the lungs. Is there
difficulty in breathing while talking, feeding or
breastfeeding? Is the child breathing very fast,
have severe lower chest wall in-drawing, or using
the accessory muscles for breathing? Is there any
abnormal noises heard when breathing?
To assess whether or not the child is breathing, there

are three things you must do:
Signs of severe respiratory distress

Respiratory rate 70/min
Severe lower chest in-drawing
Use of accessory muscles of breathing
Unable to feed due to respiratory distress

Stridor* in a calm child

*Stridor is a harsh noise while breathing
21
3.1.3. Assess the circulation for signs

of shock
After the airway has been assessed, assess circulation:
Does the child have warm extremities?
If not, is the capillary refill time longer than 3
seconds?
Is the pulse weak and fast?
Details of assessment and management of children
with circulatory problem are given in step-3.
3.1.4. Assess the child for coma and

convulsion
C also represents Coma and Convulsion.
The following signs indicate impaired neurological
status: coma, lethargy, and convulsions. To assess the
childs neurological status you need to know:
Is the child in coma?
Is the child convulsing?
Is the Child in Coma?

A child who is awake is obviously conscious and you
can move to the next component of the assessment.
If the child is asleep, and there is any doubt, assess the
level of consciousness. Try to wake the child by talking
to him/her, e.g. call his/her name loudly. A child who
does not respond to this should be gently shaken.
A little shake to the arm or leg should be enough to
wake a sleeping child. Do not move the childs neck.
If this is unsuccessful, apply a firm squeeze to the
nail bed, enough to cause some pain. A child who
does not wake to voice or being shaken or to pain is
unconscious.
3.1.5. Assess the child for dehydration

After assessing ABC, assess for D i.e. dehydration if
there is history of diarrhoea.
Emergency Signs
Not breathing at all or gasping

Obstructed breathing
Central cyanosis
Severe respiratory distress
Shock : Cold hands and
Capillary refill >3 seconds and
Weak and fast pulse
Coma
Convulsions
Diarrhoea with severe dehydration: Any two signs:
Lethargy
Sunken eyes
Very slow skin pinch
22
Chart 1: TRIAGE
TREAT
Check for head/neck trauma before treating child
Do not move neck if cervical spine injury possible
Give appropriate treatment for +ve emergency signs
Call for help
Draw blood for Glucose, malaria smear, Hb
ASSESS FOR EMERGENCY SIGNS (In all Cases)
AIRWAY AND BREATHING

Not Breathing or Gasping or
Central cyanosis or
Severe respiratory distress
Manage airway
Provide basic life support (Not breathing/gasping)
Give oxygen
Make sure child is warm*
Any sign
positive
If the child has any bleeding, apply pressure to stop

the bleeding. Do not use a tourniquet.
Give oxygen
Insert IV and begin giving fluids rapidly
If not able to insert peripheral IV, insert an umbilical or
intraosseous line
CIRCULATION
Cold hands with:
If Positive
Capillary refill longer than 3 secs,
Check for
and
service acute
Weak and fast pulse
malnutrition
IF SEVERE ACUTE MALNUTRITION

(Age 2 months)
If lethargic or unconscious:
Insert IV line and give IV glucose and fluids If not lethargic
or unconscious:
Give glucose orally or by NG tube.
Proceed immediately to full assessment and treatment
Manage airway
Position the child
Check and correct hypoglycaemia
If convulsions continue give IV calcium in young
infants
If convulsions continue give anticonvulsants
COMA CONVULSING
Coma or
Convulsing (now)
If Coma for
Convulsing
SEVERE DEHYDRATION
WITH DIARRHOEA)
(ONLY
Diarrhoea plus any two of these:

Lethargy
Sunken eyes
Very slow skin pinch
Diarrhoea Plus Two

Signs Positve
Check for
service acute
malnutrition

Insert IV line and begin giving fluids rapidly following
PLAN C IF
SEVERE ACUTE MALNUTRITION (Age 2 Months)
Do not start IV immediately
Proceed immediately to full assessment and treatment.
*Check temperature; if baby is cold to touch, rewarm

IF THERE ARE NO EMERGENCY SIGNS LOOK FOR PRIORITY SIGNS:
These children need prompt assessment and treatment
Tiny baby (<2 months)

Bleeding
Pallor (severe)
Malnutrition: Visible
wasting
severe
Respiratory distress
Trauma or other urgent surgical
condition
Referral (urgent)
Oedema of both feet
Temperature <36.5C or > 38.5C

Restless, continuously irritable, or
lethargy
Poisoning
Burns (major)
NON-URGENT: Proceed with assessment and further treatment according to childs priority
Note: If a child has trauma or other surgical problems, get surgical help or follow surgical guidelines.
23
The above flowchart shows the process of triage of

sick children when they arrive at a facility.
The process of triage for children with SAM is similar;
however the management of shock and severe
dehydration is different for children with SAM.
Take a history concerning
Recent intake of food and fluids
Usual diet (before the current illness)
Breastfeeding
Duration and frequency of diarrhoea
and vomiting
Type of diarrhoea (watery/bloody)
Chronic cough
Loss of appetite
Family circumstances (to understand
the childs social background)
Contact with tuberculosis
Recent contact with measles
Known or suspected HIV infection.
Immunizations
3.2.
Assessment of severely
malnourished child
A good history and physical examination should be
recorded once the child is stabilized.
On examination, look for

Anthropometry- weight, height/ length, mid arm circumference
Oedema
Pulse, heart rate, respiratory rate
Signs of dehydration
Shock (cold hands, slow capillary refill, weak and rapid pulse)
Palmar pallor
Eye signs of vitamin A deficiency:
Dry conjunctiva or cornea,
Bitots spots
Corneal ulceration
Keratomalacia
Localizing signs of infection, including ear and throat infections,
skin infection or pneumonia
Fever (temperature 37.5 C or 99.5 F) or hypothermia
(axillary temperature <35.0 C or <95.0 F)
Mouth ulcers
Skin changes of kwashiorkor:
Hypo or hyperpigmentation
Desquamation
Ulceration (spreading over limbs, thighs, genitalia, groin,
and behind the ears)

Exudative lesions (resembling severe burns) often with
secondary infection (including Candida).
Note: Children with vitamin A deficiency are likely to be photophobic and will keep their eyes closed. It is important to examine the eyes very
gently to prevent corneal rupture.
3.2.1. Dermatosis
It is more common in children who have oedema
than in wasted children. A child with dermatosis may
have patches of skin that are abnormally light or dark
in colour, shedding of skin in scales or sheets, and
ulceration of the skin of the perineum, groin, limbs,
behind the ears and in the armpits. There may be
weeping lesions.
24
There may be a severe rash in the nappy area. Any

break in the skin can let dangerous bacteria get into
the body. When the skin is raw and weeping, this risk
is very high.
The extent of dermatosis can be described in the
following way:
+ mild: discoloration or a few rough patches of skin
+ + moderate: multiple patches on arms and/or legs
+ + + severe: flaking skin, raw skin, fissures (openings in

the skin) Figure 9 shows a child with severe dermatosis
(raw skin & fissures). Treatment of dermatosis will be

discussed in section on Daily Care.
Figure 9: Child with Odema and Dermatosis
3.2.2. Eye signs

Children with severe acute malnutrition may have
signs of eye infection and/or vitamin A deficiency.
WHO has classified Vitamin A deficiency in different
stages (Table-1).
While examining the eye look for:

Bitots spots are superficial foamy white spots on
the conjunctiva (white part of the eye).
Conjunctival & Corneal xerosis: (dryness of
conjunctiva and cornea).
Table 1. WHO Classification of Vitamin a Deficiency

XN
Night blindness
X1A
Conjunctival xerosis
X1B
Bitots Spot
X2
Corneal xerosis
X3A
Corneal ulceration, keratomalacia(<1/3 corneal surface)
X3B
Corneal ulceration, keratomalacia(>1/3 corneal surface)
XS
Corneal Scar
XF
Xeropthalmic fundus
25
Pus and inflammation (redness) - signs of eye

infection.
Corneal clouding - an opaque appearance of the
cornea.
Corneal ulceration is a break in the surface of the
cornea. It is a sign of severe vitamin A deficiency.
If not treated, the lens of the eye may push out
and cause blindness. Corneal ulceration is an
emergency and requires immediate treatment
with vitamin A and atropine (to relax the eye).
In the presence of corneal ulceration the child
has photophobia and resists opening of eyes.
One should be very gentle and careful during
examination of the eye to prevent the risk of
rupture and blindness. (Figure 10)
Treatment of all eye signs will be discussed in Initial
Management and in Daily Care.
3.2.3 Laboratory Tests

All children with SAM admitted as inpatients should
undergo the following basic investigations:
Haemoglobin or packed cell volume in children
with severe palmar pallor
Blood glucose
Serum electrolytes (sodium, potassium, and
calcium whenever possible)
Screening for infections:
Total and differential leukocyte count, blood
culture
Urine routine examination
Urine culture
Chest x-ray
Mantoux test
Screening for HIV after counselling
Any other specific test required based on
geographical location or clinical presentation e.g.
Celiac Disease , malaria etc.
3.3. Management of the severely

malnourished child
The following process is essential for successful
management of the severely malnourished child.
Figure 10: Vitamin a Deficiency Signs
26
Chart 2: 10 Stepsof Routine Care

MANAGEMENT STEPS
STABILISATION
Day 1-2
Day 3-7
REHABILITATION
Week 2-6
1 Treat/prevent hypoglycaemia
2. Treat/prevent hypothermia
3. Treat/prevent dehydration
4. Correct imbalance of electrolytes
5. Treat infections
6. Correct deficiencies of micronutrients
non iron
with iron
7. Start cautious feeding

8. Rebuild wasted tissues (catch-up growth)
9. Provide loving care and play
10. Prepare for follow-up
3.4. Step-1: Manage hypoglycemia

What is hypoglycaemia?
Hypoglycaemia is a low level of glucose in the blood.
In severely malnourished children, blood sugar level
less than <54 mg/dl is considered as hypoglycaemia.
The hypoglycaemic child is usually hypothermic (low
temperature) as well. Other signs of hypoglycaemia
include lethargy, limpness, and loss of consciousness.
Sweating and pallor may not occur in malnourished
children with hypoglycaemia.
Malnourished children may arrive at the hospital
hypoglycaemic if they have been vomiting, if they have
been too sick to eat, or if they have had a long journey
without food. Children may develop hypoglycaemia
in the hospital if they are kept waiting for admission,
or if they are not fed regularly. Hypoglycaemia and
hypothermia are also signs that the child has a serious
infection.
If hypoglycaemia is suspected, check blood glucose

level immediately. Use a glucometer if it is available. If
glucometer is not available and clinical symptoms are
suggestive, assume that the child has hypoglycaemia.
Treat hypoglycaemia
If blood glucose is low or hypoglycaemia is suspected,
immediately give the child a 50 ml bolus of 10%
glucose or 10% sucrose (1 rounded teaspoon of sugar
in 3 tablespoons of water). Glucose is preferable
because the body can use it more easily. If the child
can drink, give the 50 ml orally. If the child is alert but
not drinking, give the 50 ml by NG tube.
If the child is lethargic, unconscious, or convulsing,
give 5 ml/kg body weight of sterile 10% glucose by
IV, followed by 50 ml of 10% glucose or sucrose by
NG tube.* If the IV dose cannot be given immediately,
give the NG dose first.
27
* If the child will be given IV fluids for shock, there

is no need to follow the 10% IV glucose with an NG
bolus, as the child will continue to receive glucose in
the IV fluids.
Start feeding Starter diet half an hour after giving
glucose and give it every half-hour during the first
2 hours. For a hypoglycaemic child, the amount to
give every half-hour is of the 2-hourly amount.
The recipe for preparation of Starter diet is given in
following section.
As hypoglycemia and hypothermia coexist, make
sure to keep child warm (as described in step-2).
Administer antibiotics as hypoglycaemia may be a
feature of underlying infection (as described in step5).
Prevention
If the childs blood glucose is not low, begin feeding
the child with Starter diet right away. Feed the child
every 2 hours, throughout the day and night.
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
3.5 Step-2: Manage hypothermia

What is hypothermia?
Hypothermia is low body temperature. A severely
malnourished child is hypothermic if the
axillary temperature is below 35C or rectal
temperature is below 35.5C (95.9 F) .
Take temperature
If possible, use a low-reading thermometer (range
29C - 42C). If no low-reading thermometer is
available, use a normal thermometer. With a normal
thermometer, assume that the child has hypothermia
if the mercury does not move.
28
Steps for using

thermometer
an
axillary
Wipe thermometer and dry it.

Shake thermometer down to below 35C.
Place thermometer under armpit. (The bulb of the
thermometer should be in the apex of the axilla
parallel to the body, holding the arm close to the
body).
Keep in place for 3 minutes.
Record the temperature.
Actively re-warm the hypothermic

child
If the temperature is below 35 degree centigrade,
use one of the following re-warming techniques:
Have the mother hold the child with skin to skin
contact when possible (kangaroo technique), and
cover both of them. Keep the childs head covered.
Provide heat with an overhead warmer, an
incandescent lamp or radiant heater. Do not
point the heater directly at the child and avoid
contact with hot water bottles, so as to prevent
burns. Indirect warming with warm pads could be
attempted.
Monitor temperature every 30 minutes during
rewarming if a radiant warmer is used. Stop rewarming when the childs temperature becomes
normal.

Do NOT use hot water bottles due to danger of

burning fragile skin
If the rectal temperature <32C, child has severe

hypothermia and should be treated as follows:
Give warm humidified oxygen.
Give 5 mL/kg of 10% dextrose IV immediately or
50 mL of 10% dextrose by nasogastric route (if
intravenous access is difficult).
Start intravenous antibiotics.
Rewarm: Provide heat using radiation
(overhead warmer), or conduction (skin contact)
or convection (heat convector). Avoid rapid
rewarming as this may lead to dysequilibrium.
Give warm feeds immediately, if clinical condition
allows the child to take orally, else administer
the feeds through a naso/orogastric tube.
Start maintenance IV fluids (prewarmed), if

there is feed intolerance or contraindication for
nasogastric feeding.
Rehydrate using warm fluids immediately, when
there is a history of diarrhoea or there is evidence
of dehydration.
General measures
hypothermia
to
prevent
The following measures are important for all severely

malnourished children:
Feed immediately
Cover the child, including his head.
Move the child away from windows, secure
windows tightly to prevent draughts.

Maintain room temperature of 25 - 30 degree
Centugrade (77 - 86 degree F).
Keep the child covered especially at night.
Warm your hands before touching the child.
Avoid leaving the child uncovered while being
examined, weighed, etc.
Promptly change wet clothes or bedding.
Dry the child thoroughly after sponging or
bathing.
Do not give cold intravenous fluids.
If it is not possible to warm the room, let the child

sleep snuggled up to the mother, and cover them
with a blanket.
EXERCISE-C
1. Hari is 36 months old and weighs 7.4 kg. He has blood sugar of 42 mg/dl. What immediate treatment Hari
should be given?
_________________________________________________________________________________________
_________________________________________________________________________________________
2. 14 months Sunder has been brought to hospital with lethargy and unconsciousness.

He weighs 5.6 kg and his length is 72 cms. His mid arm circumference is 11.6 cm and there is no pedal
oedema. His blood sugar is 46 mg/dl.
2.1 Do you think Sunder has SAM?

_________________________________________________________________________________________
2.2 Is Sunder hypoglycemic?
_________________________________________________________________________________________
2.3 What immediate treatment will you give to Sunder?
_________________________________________________________________________________________
3.6 Step-3: Manage dehydration

It is difficult to determine dehydration status in a
severely malnourished child, as the usual signs of
dehydration (such as lethargy, sunken eyes) may be

present in these children all of the time, whether or
not they are dehydrated.
29
3.6.1. Assessment of Dehydration in

children without SAM is based
on following signs which are
quite reliable and easily elicited.
the skin for one second and then release. If the skin
stays folded for a brief time after you release it, the
skin pinch goes back slowly. If the skin pinch takes
more than 2 seconds to return back then it is classified
as very slow.
Signs of Dehydration
Lethargy: A lethargic child is not awake and alert
when s/he should be. S/he is drowsy and does not
show interest in what is happening around him.
Restless, irritable: The child is restless and irritable
all the time, or whenever s/he is touched or
handled.
Sunken eyes: Look for sunken eyes. Ask the mother
if the childs eyes appear depressed as compared
to eyes before onset of diarrhoea.
Thirsty: See if the child reaches out for the cup
when you offer fluids and when it is taken away,
the child wants more.
Skin pinch goes back slowly: Using your thumb and
first finger, pinch the skin on the childs abdomen
halfway between the umbilicus and the side of the
abdomen. Place your hand so that the fold of skin will
be in a line (up and down) the childs body. Firmly pick
up all the layers of skin and tissue under them. Pinch
Figure 11: Checking Skin Pinch
Assessment and classification of dehydration:

In any two of the following signs are present
Lethargic or unconscious
Sunken eyes
Not able to drink or drinking poorly
Skin pinch goes back very slowly.
In any two of the following signs are present:
Restless, irritable
Sunken eyes
Drinks eagerly, thirsty Skin
pinch goes back slowly.
3.6.2
Diagnosis of dehydration in
severely malnourished children
In children with SAM all the classical signs of
dehydration are unreliable. Thus:
n children who are severely wasted skin normally
30
The child has SEVERE DEHYDRATION
The child has SOME DEHYDRATION
lies in folds and is inelastic so that the skin pinch

test is usually positive without there being any
dehydration.
In children who are severely wasted, eyes are
normally sunken without there being any
dehydration.
Therefore, the main diagnosis comes from the

HISTORY rather than from the examination.
3.6.3 Treatment of dehydration in the

children with SAM without shock
There needs to be:

A definite history of significant recent fluid loss usually diarrhoea which is clearly like water (not
just soft or mucus) and frequent with a sudden
onset within the past few hours or days.
There should also be a HISTORY of a recent
CHANGE in the childs appearance.
If the eyes are sunken then the mother must say
that the eyes have changed to become sunken
since the diarrhoea started.
If the child has had watery diarrhoea or vomiting,

assume dehydration and give ORS. WHO recommends
use of Rehydration Solution for Malnourished Children,
which is not available commercially. Use either WHOlow Osmolarity ORS with potassium supplements (15
ml. of potassium chloride syrup added to one litre
ORS) as mentioned in step-4 or Rehydration Solution
for Malnourished Children prepared from WHO-low
Osmolarity ORS (Annexure-13).
Calculate amount of ORS to give
Give ORS as follows, in amounts based on the childs weight:

How often to give ORS
Every 30 minutes for the first 2 hours
Alternate hours for up to 10 hours
Amount to give
5 ml/kg body weight
5 - 10 ml/kg*
* The amount offered in this range should be based on the childs willingness to drink and the amount of ongoing losses in the stool. Starter (diet
is given in alternate hours during this period until the child is rehydrated.
BEFORE starting any rehydration treatment:

WEIGH the child (The weight should be taken on
admission).
MARK the edge of the liver and the costal margin
on the skin.
RECORD the respiration rate.
In addition the following should be recorded:
Pulse rate.
The capillary refill time .
the childs thirst helps to regulate the amount given

and avoids water overload.
Monitor the child who is taking ORS

Monitor the childs progress every half hour for the
first two hours; then monitor hourly, i.e., every time
the child takes Starter diet or ORS.
If the mother is able to give the ORS, she should be

taught to give it slowly. A naso/orogastric (NG) tube
should be used for giving ORS at the same rate in
weak or exhausted children, and in those who vomit,
have fast breathing, or painful mouth sores.
Signs to check
Respiratory rate- Count for a full minute.
Pulse rate- Count for 30 seconds and multiply by
2.
Urine frequency - Ask: Has the child urinated since
last checked?
Stool or vomit frequency - Ask: Has the child had a
stool or vomited since last checked?
Signs of hydration - Is the child less lethargic or
irritable? Are the eyes less sunken? Does skin
pinch go back faster?
IV fluids should not be used to treat dehydration

(except in case of shock). When fluids are given orally,
Note these signs on the case record form; also record the amount of
ORS given.
The malnourished child is managed preferably by:

Clinical signs of improvement and,
Clinical signs of over-hydration.
31
Signs of improving hydration status

Fewer or less pronounced signs of dehydration, for
example
Less thirsty
Skin pinch not as slow
Less lethargic
Note: Although these changes indicate that rehydration is proceeding,
many severely malnourished children will not show these changes
even when fully rehydrated.
Signs of over hydration

Stop ORS if any of the following signs appear:
Increased respiratory rate and pulse. (Both must
increase to consider it a problem -increase of Pulse
by 15 & RR by 5).
Jugular veins engorged.
Puffiness of eye.
Stop ORS as soon as possible as the child has 3 or
more of the following signs of improved hydration
status:
Child no longer thirsty
Less lethargic
Slowing of respiratory and pulse rates from
previous high rate
Skin pinch less slow
Tears
After rehydration, offer ORS after each

loose stool
When the child has 3 or more signs of improving
hydration (see above), stop giving ORS routinely in
alternate hours. However, watery diarrhoea may

continue after the child is rehydrated. If diarrhoea
continues, give ORS after each loose stool to replace
stool losses and prevent dehydration:
For children less than 2 years, give approximately
50 ml after each loose stool.
For children 2 years and older, give 100 ml after
each loose stool.
Breast feeding is continued with increased frequency
if the child is breastfed.
If there is weight gain and deterioration of the
childs condition with the re-hydration therapy, or no
improvement in the mood and look of the child or
reversal of the clinical signs:
Then the diagnosis of dehydration was probably
wrong.
Change to Starter diet or alternate Starter diet
and ORS.
Resolution of the signs of dehydration:
Stop all re-hydration treatment and start the child
on Starter diet.
During re-hydration breastfeeding should not
be interrupted. Begin to give Starter diet as soon
as possible, orally or by naso-gastric tube. ORS and
Starter diet can be given in alternate hours if there
is still some dehydration and continuing diarrhoea.
Introduction of Starter diet is usually achieved within
2-3 hours of starting re-hydration. The management
of persistent and continuing diarrhoea is given in
Annexure 14.
EXERCISE-D
Fill in the blanks in the following case studies:
1. Rajiv has watery diarrhoea and is severely malnourished. He weighs 6.0 kilograms. He should be given
_________ ml ORS every ______ minutes for ______ hours. Then he should be given __________ ml ORS in
__________ hours for up to _______ hours. In the alternate hours during this same period, _______ should
be given.
2. Yamuna arrived at the hospital in shock and received IV fluids for two hours. She has improved and can
now be switched to ORS. Yamuna weighs 8.0 kilograms. For up to _____ hours, she should be given ORS and
Starter diet in alternate hours. The amount of ORS to offer is ___________ ml per hour.
32
3. After the first two hours of ORS, a child is offered 5-10 ml/kg of ORS in alternate hours. What are the two
factors that affect how much to offer in this range?
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
3.6.3
Manage a severely acute
malnourished child with shock
Shock is a dangerous condition with severe weakness,
lethargy, or unconsciousness, cold extremities, and
fast, weak pulse. The severely acute malnourished
child is considered to have shock if he/she:
Has cold hands with
Slow capillary refill (longer than 3 seconds), AND
Weak and fast pulse
For a child 12 months to 5 years of age, a fast pulse is

140 beats or more per minute.
To check capillary refill:

Press the nail of the thumb or big toe for 3 seconds
to produce blanching of the nail bed.
Count the seconds from release until return of
the pink color. If it takes longer than 3 seconds,
capillary refill is slow.
For a child 2 months up to 12 months of age, a fast

pulse is 160 beats or more per minute.
A. Applying pressure to the

nall bed for 3 seconds
B. Check the time to the
return
of the pink
colour after releasing
the pressure
Figure 12: Checking Capillary Refill
The common causes of shock in children with SAM are diarrhoea with severe dehydration and septic shock.
33
Chart 3 : Management of Shock in Children with SAM

Give this treatment only if the child has signs of shock and is lethargic or has lost consciousness
Weigh the child. Estimate the weight if child cannot be weighed or weight not known
Give oxygen
Make sure child is warm
Insert an IV line and draw blood for emergency laboratory investigations
Give IV 10% Glucose (5 ml/kg)
Give IV fluid 15 ml/kg over 1 hour of either Ringers lactate in 5% Dextrose or half-normal
saline with 5% glucose or Ringers lactate
Measure the pulse and breathing rate at the start and every 5-10 minutes
Signs of improvement
(PR and RR fall)
Repeat same fluid IV 15

ml/ kg over 1 hour more;
then
Switch to oral or
nasogastric rehydration
with ORS, 10 ml/kg/hr up
to 10 hours
Initiate feeding with
starter formula
34
If the child fails to

improve after the first
15 ml/kg IV
If the child deteriorates

during the IV
rehydration
(RR increases by 5/min
or
PR by 15 beats/min).
Stop
the infusion and reassess
Assume
The child has septic shock
Give maintenance IV fluid (4 ml/kg/hr)

Review antibiotic treatment
Start dopamine
Initiate re-feeding as soon as possible
Treatment of Shock
The management of shock in child with severe acute
malnutrition is given in Chart 3. Broad spectrum
antibiotic should be administered immediately to all
SAM with septic shock (Table-2). Packed RBCs 10ml/
kg should be given over 4-6 hours if Hb is less than 4
gm/dl or active bleeding. If there is no improvement
with fluid bolus start dopamine at 10g/kg/min. If
there is no improvement in next 24-48 hours upgrade
antibiotics.
How to give Dopamine (By infusion pump)
Amount of dopamine (mcg) to be added = weight
in kg x 6
To convert this dose into amount to ml of
dopamine divide by 40 (1 ml of dopamine = 40
mg of dopamine)
Add this amount of dopamine (ml) to make 10 ml

of total fluid.
0.1 ml/hour of this fluid gives 1 mcg/kg/minute.
To give 10 mcg/kg/minute, give infusion at the
rate of 1 ml/hr
Example : Giving 10 mcg/kg/min for a 5 kg child
Amount of dopamine to be added = 5 x 6 = 30
mcg
Convert this dose into amount to ml of dopamine
= 30/40 = 0.75 ml
Add 0.75 ml to 9.25 ml of fluid to make 10 ml of
total fluid
Administering 1 ml/hr of this fluid by infusion
pump gives 10 mcg/kg/min of dopamine.
EXERCISE-E
In this exercise you are provided clinical information for two children. You are required to answer questions
about the appropriate treatment in each case. Use your training manual for reference.
Case 1 - Tina: Tina is an 18-month-old girl who was referred from a health centre. Her arms and shoulders appear
very thin. She has moderate oedema (both feet and lower legs). She does not have diarrhoea or vomiting, and her
eyes are clear. Her temperature is 34.5 degree centigrade and blood sugar estimation showed 50 mg/dl. Her weight
is 6.5 kg and length is 81 cms.
1(a)
What is Tinas weight-for-height SD-score?
_________________________________________________________________________________________
1(b)
Should Tina be admitted to the severe malnutrition ward? Why or why not?
_________________________________________________________________________________________
1(c)
Is Tina hypothermic?
_________________________________________________________________________________________
1(d)
Is Tina hypoglycaemic?
_________________________________________________________________________________________
1(e) Tina is alert and does not have cold hands. Her capillary refill is less than 3 seconds. According to the

definition given in this section, is Tina in shock?
_________________________________________________________________________________________
1(f ) What two immediate steps should be taken based on the above findings?
_________________________________________________________________________________________
_________________________________________________________________________________________
Case 2 - Kalpana is a 3-year-old girl and weighs 6 kg. She is very pale when she is brought to the hospital, but she
35
is alert and can drink. She is not having any breathing difficulty. She has no diarrhoea, no vomiting, and no eye
problems. Her Capillary refill time is less than 3 seconds. Her blood sugar is 46 mg/dl.
2(a) What should Kalpana be given immediately?
_________________________________________________________________________________________

How should it be given?
_________________________________________________________________________________________
2 (b) When should Kalpana begin taking Starter diet?
_________________________________________________________________________________________
2(c) How often and how much should she be fed?
_________________________________________________________________________________________
_________________________________________________________________________________________
3.7. Step-4: Correct Electrolyte

Imbalance
malnutrition. As a result, the usual signs of infection,

such as fever, are often absent, and infections remain
hidden.
Give supplemental potassium at 3-4 meq/kg/

day for at least 2 weeks. Potassium can be given
as syrup potassium chloride; the most common
preparation available has 20meq/15ml. It should
be diluted with water.
On day 1, give 50% magnesium sulphate IM
once (0.3 mL/kg) up to a maximum of 2 ml.
Thereafter, give extra magnesium (0.4 - 0.6 mmol/
kg/daily) orally. If oral commercial preparation is
not available you can give injection magnesium
sulphate (50% which has 2 mmol/ml) 0.2-0.3 ml/
kg orally as magnesium supplements mixed with
feeds. Give magnesium supplements for 2 weeks.
Give food without added salt to avoid sodium
overload.
The important principle is that all severely

malnourished children should be given appropriate
antibiotics as part of the initial treatment
3.8. Step-5: Treat Infection: Give

antibiotics
Select antibiotics
regimen (Table-2)
prescribe
Selection of antibiotics depends on the presence or

absence of complications.
If the child appears to have no complications give
Oral amoxicillin 15mg/kg 8-hourly for 5 days
If child has complications (septic shock,
hypoglycaemia, hypothermia, skin infections
or dermatosis (+++ with raw skin/fissures,
respiratory or urinary tract infections, or lethargic/
sick appearance) select antibiotic as shown in the
table below:
The body defence system (immune function) does

not work properly in children with severe acute
36
and
Table 2: Antibiotics for Severely Malnourished Children

All admitted cases with any Inj. Ampicillin 50 mg/kg/dose 6 hrly and Inj. Gentamicin
complications other than shock, 7.5 mg/kg once a day for 7 days
meningitis or dysentery
Add Inj. Cloxacillin 100 mg/kg day 6 hrly if staphylococcal infection
is suspected
Revise therapy based on sensitivity report
For septic shock or worsening/no Give third generation cephalosporins like Inj.
improvement in initial hours
Cefotaxime 150 mg/kg/day in 3 divided doses or Ceftriaxone 100
mg/kg/day in 2 divided doses along with Inj Gentamicin 7.5 mg/kg
in single dose. Do not give second dose until child is passing urine.)
Meningitis
IV Cefotaxime 50mg/kg/dose 6hrly or Inj Ceftriaxone 50 mg/kg 12
hrly plus Inj. Amikacin 15 mg/kg/day divided in 8 hrly doses.
Dysentery
Give Ciprofloxacin 15mg/kg in two divided doses per day for 3 days. If
child is sick or has already received ciprofloxacin, give Inj. Ceftriaxone
100 mg/kg once a day or divided in 2 doses for 5 days
Duration of antibiotic therapy depends on the
diagnosis. The following guideline can be followed in
general:
Suspicion of clinical sepsis: at least 7 days
Urinary tract infection: 7-10 days
Culture positive sepsis: 10-14 days
Meningitis: at least 14-21 days
Deep seated infections like arthritis and osteomyelitis:
at least 4 weeks.
If clinical condition does not improve after 5 days of
antibiotics treatment, reassess the child (check for
sites of infection and potentially resistant organisms)
and take appropriate measures. If there is partial

improvement after 5 days, complete a full 10-day
course.
If the child is HIV infected or exposed, cotrimoxazole
prophylaxis (5 mg/kg/day of trimethoprim) should
continue. If Pneumocystis Carinii pneumonia (PCP)
is suspected, it should be treated with appropriate
dosages of cotrimoxazole.
Treat associated conditions like malaria,
tuberculosis, amoebiasis or HIV as per the national
guidelines.
EXERCISE-F
Case - Anu
Anu weighs 6 kg and her length is 82 cm. She does not have any airway problem, doesnt have convulsion.
Capillary refill time is less than 3 seconds. She is lethargic. Her blood sugar is 40mg/dl, axillary temperature is
34.8 degree centigrade and she has mild dermatosis.
a.
What antibiotics should Anu be given now?
_________________________________________________________________________________________
b.
By what possible routes may antibiotics be given?
_________________________________________________________________________________________
c.
Given Anus body weight, determine the dose of each antibiotic.
_________________________________________________________________________________________
37
3.9.
Give emergency eye care
for corneal ulceration
3.10.
STEP 6:
utrients
Give oral vitamin A in a single dose to all children with

SAM unless there is evidence that child has received
vitamin A dose in last 1 month.
Other micronutrients should be given daily for at least

2 weeks:
Multivitamin supplement (should contain vitamin
A, C, D, E and B12 and not just vitamin B-complex):
Twice Recommended Daily Allowance.
Folic acid: 5 mg on day 1, then 1 mg/day.
Elemental Zinc: 2 mg/kg/day.
Copper: 0.3 mg/kg/day (if separate preparation
not available use commercial preparation
containing copper).
Iron: Start daily iron supplementation after two
days of the child being on Catch up diet. Give
elemental iron in the dose of 3 mg/kg/day in two
divided doses, preferably between meals. (Do not
give iron in stabilization phase.)
Vitamin A Oral Dose according to childs age

Age
< 6 months
6-12 months or if weight <8Kg
>12 months
Vit. A dose
50 000 IU
100 000 IU
200 000 IU
Give same dose on Days 1, 2 and 14 if there is

clinical evidence of vitamin A deficiency. Children
more than twelve months but having weight
less than 8 kg should be given 100,000 IU orally
irrespective of age. Oral treatment with vitamin A
is preferred, except for initial treatment of children
with severe anorexia, oedematous malnutrition,
or septic shock. For oral administration, an oilbased formulation is preferred. For IM treatment,
only water-based formulations and half of oral
dose should be used.
In case there is corneal ulceration, instill one drop
atropine (1%) into the affected eye(s) to relax
the eye and prevent the lens from pushing out.
Give antibiotic eye ointment. Bandaging may be
needed but can wait. If the child falls asleep with
his eyes open; close them gently to protect them.
Continuing treatment of corneal ulceration is
described in Daily Care.

All severely malnourished children need vitamin A

on Day 1, and many need additional eye care, but
treatment can wait until later in the day. Treatment
of various eye signs is described in Daily Care.
38
Give
micron-
Annexure 12 provides a recipe for a combined

electrolyte/mineral solution. Adding 20 ml of this
solution to 1 litre of feed or ORS will supply the zinc
and copper needed, as well as electrolytes (potassium
and magnesium). If a combined electrolyte/mineral
solution is available, vitamin A, multivitamin
supplement, folic acid and iron need to be given
separately. The management of severe anaemia in
children with SAM is as given in Annexure 15.
If a Combined Mineral Vitamin (CMV) mix for severe
acute malnutrition is available commercially then
CMV mix can replace the electrolyte mineral solution,
multivitamin and folic acid supplements mentioned
in steps 4 and 6. However vitamin A and folic acid
supplements on day 1, and iron daily after weight
gain has started will be needed.
SECTION
INITIAL FEEDING
SECTION
INITIAL FEEDING
up diet contains more calories and protein: 100 kcal
and 2.9 g protein per 100 ml.
Learning Objectives
This section of the module will describe the
following:
Preparing Starter diet
Planning feeding for a 24-hour period
Measuring and giving feeds to children
Recording intake and output
Planning feeding for a ward
This section of the module will focus on preparing

the feeds, planning feeding, and giving the feeds
according to plan.
4.1. Prepare Starter diet

Prepare Starter diet as described below. The choice
of recipe depends on the availability of ingredients,
particularly the type of milk available, and the
availability of cooking facilities.
The guideline in this section applies to children

aged 6-59 months. For infants aged <6 months
follow specific guideline given in Section 8.
The principle behind the recipes is to provide the

energy and protein needed for stabilization and
catch-up.
Feeding is a critical part of managing severe

malnutrition; however feeding must be started
cautiously, in frequent, small amounts. Feeding should
begin as soon as possible with Starter diet, the starter
formula is used until the child is stabilized. Starter diet
is specially made to meet the childs needs without
overwhelming the bodys systems at this early stage
of treatment. Starter diet contains 75 kcal and 0.9 g
protein per 100 ml. It is low in protein and sodium and
high in carbohydrate, which is more easily handled by
the child and provides much-needed glucose.
Tips for correct preparation (all recipes)

Use a digital dietary scale so that you are able to
measure accurately. Choose a suitable container
for weighing the ingredients. Weigh the empty
container first, and account for this when weighing
the ingredients.
For measuring oil, choose a small container to
reduce the surface to which the oil can stick. Let
the oil drain out well when transferring it to the
blender or jug. Then rinse the container with
a little boiled water and add the rinsing to the
blender or jug.
When the child is stabilized (usually after 2 -7 days),

Catch-up diet is used to rebuild wasted tissues. Catch-
Table 3: Recipe for Starter Diets*

Contents (per 1000 ml)
Fresh Cows milk or equivalent milk
(e.g. toned dairy milk) (ml)
Sugar (g)
Cereal flour:
Powdered puffed rice (g)
Vegetable oil (ml)
Starter diet
Starter diet (Cereal based)
300
100
300
70
-20
35
20
41
Water: make up to (ml)***

Energy (kcal/100 mL)
Protein (g/100 mL)
Lactose (g/100 mL)
1000
75
0.9
1.2
1000
75
1.1
1.2
* Adapted from IAP Guidelines 2006.

*** Important note about adding water: Add just the amount of water needed to make 1000 ml of Starter diet. Do not simply add 1000 ml of
water, as this will make the preparation too dilute. A mark for 1000 ml should be made on the mixing container, so that water can be added to
the other ingredients up to this mark.
Be sure that the scale is set at zero before weighing.

Wash hands before measuring ingredients.
If using scoops for measurement, level ingredients
with a knife to ensure consistent measurement. Be
aware that equal weights of puffed rice powder
and sugar do not occupy the same volume; puffed
rice powder is a bigger volume. Therefore, one
must either weigh these ingredients or know the

corresponding volume for each.
The cereal based low lactose (low osmolarity) diets
are recommended as starter diets for children
with persistent diarrhoea. Children with persistent
diarrhoea, who continue to have diarrhoea on the low
lactose diets, should be given lactose free diets.
Table 4: Recipe for Starter Lactose free Diets

Contents per 1000 ml
Eggs White* (g)
Glucose (g)
Cereal Flour: Powdered puffed rice** (g)
Vegetable oil (g)
Water to make(ml)
Energy (kcal /100ml)
Protein (g/100ml)
Lactose (g/100ml)
Amount
50
35
70
40
1000
75
1
-
* Egg white may be replaced by 30 gm of chicken. Whole egg could be used and the vegetable oil may be adjusted accordingly.
** Other proteins that can be used are ground nut, soy or locally used pulses: however, they can increase the viscosity of the diet and require
cooking.
How to prepare the feed?

Wash hands before preparing feeds. Use clean
utensils and measures.
Diets without cereal do not need cooking. If
powdered puffed rice is used as a cereal, it also
does not need cooking, as it is pre-cooked. Take
an appropriate sized container. Add the desired
amount of sugar and oil to powdered puffed rice
and mix. Add the milk and water to prepare the
feed.
Mix oil well so that it does not separate out. Oil
is a vital source of energy; if oil floats to the top
of the mixture, there is a risk that some children
42
will get too much and others too little. If possible,

use an electric blender to thoroughly mix the oil.
Otherwise, use a strong rotary whisk or balloon
whisk. Use a long handled whisk so that your
hands do not dip into the formula while whisking.
Egg cereal diets: Whip the egg white well. Add
puffed rice powder to the whipped egg, glucose,
and oil and mix well. Add boiling water to the
mixture and mix rapidly to avoid clumping.
Chicken cereal diets: Cook the chicken and puree it
after removing the bones. Add puffed rice powder
and add boiling water to the required amount of
chicken puree. Add oil and sugar and mix rapidly
to avoid clumping.
4.2. Feed the child with Starter

diet
(i) Determine frequency of feeds
On the first day, feed the child a small amount of Starter
diet every 2 hours (12 feeds in 24 hours, including
through the night). If the child is hypoglycaemic, give
of the 2-hourly amount every half-hour for the first
2 hours or until the childs blood glucose is at least 54
mg/dl.
Night feeds are extremely important. Many children
die from hypoglycemia due to missed feeds at night.
Children must be awakened for these feeds. After the
first day, increase the volume per feed gradually so
that the childs system is not overwhelmed. The child
will gradually be able to take larger, less frequent
feeds (every 3 hours or every 4 hours).
(ii) Determine amount of Starter diet needed

per feed
Given the childs starting weight and the frequency
of feeding, use the reference table to look up the
amount needed per feed.
On the Starter diet Reference Card, the required daily
amount has been divided by the number of feeds to
show the amount needed per feed.
If the child has severe (+++) oedema, his weight will

not be a true weight; the childs weight may be 30%
higher due to excess fluid. To compensate, the child
with severe oedema should be given only 100 ml/kg/
day of Starter diet.
Tips for using the Starter diet

Reference Card
Note that childrens weights listed on the Starter
(diet Reference Card are all in even digits (2.0 kg,
2.2 kg, 2.4 kg, etc.). If a childs weight is between
these (for example, if the
weight is 2.1 kg or 2.3 kg), use the amount of
Starter diet given for the next lower weight.
While the child is on Starter diet, keep using the
admission weight to determine feeding amounts
even if the childs weight changes. (The weight is
not expected to increase on Starter diet).
If the child starts with severe oedema, continue
using the Starter diet table for severe oedema for
the entire time that the child is on Starter diet.
Also continue using the childs starting weight to
determine the amount of Starter diet, even when
the oedema (and weight) decreases. The volume
per feed on the chart is already based on the
childs estimated true weight.
Example of monitoring sheet- Daily care

Days in Hospital
1
Date
4/6
Daily weight(kg)
4.4
Weight gain(gm/kg) Calculate daily after
starting Catch-up diet
Grade of oedema (0/+/++/+++)
+
Diarrhoea/ Vomiting
D
0/D/V
Feed Plan [Starter
Starter
diet/Catch-up
diet]
diet
# feeds/daily
12
Total volume taken
570
Antibiotics
A/G
2
5/6
4.2
3
6/6
4.0
+
D
0
0
Starter Starter
diet
8
560
A/G
diet
6
560
A/G
43
(iii) Record the childs 24 hour feeding plan

Each childs feeding plan should be recorded on
a 24-Hour Food Intake Chart. A blank copy of a 24Hour Food Intake Chart is provided in Annexure- 5 of
this module. At the top of the 24-Hour Food Intake
Chart, record the date, the type of feed to be given,
the number of feeds per day, amount to give per feed,
and the total to give for the day. The details of each
feed will be recorded on this form throughout the day
(iv) Feed the child Starter diet orally, or by NG

tube if necessary
Oral feeding
It is best to feed the child with a cup (and spoon, if
needed). Encourage the child to finish the feed. It
may be necessary to feed a very weak child with a
nasogatric tube. Do not use a feeding bottle. Children
with SAM have weak muscles and swallow slowly. This
makes them prone to develop aspiration pneumonia.
It takes skill to feed a very weak child, so nursing staff
should do this task at first if possible. Mothers may
help with feeding after the child becomes stronger
and more willing to eat. Never leave the child alone
to feed. Feeding the child in mothers lap when child
is sitting straight is better. Catch dribbles by holding
a saucer under the cup. The saucer will allow feeding
more quickly without worrying about spilling. At the
end of the feed, give the child the amount caught in
the saucer. The child should never be force fed, have
his/her nose pinched or lie back and have the milk
poured into the mouth. The meals for the caregivers
should not be taken beside the patient. It is almost
impossible to stop the child demanding some of the
caregivers meal.
2 years should be given 50 ml of ORS after each loose

stool, while older children should be given 100 ml.
The amount given in this range should be based on
the childs willingness to drink and the amount of
ongoing losses in the stool. If the child vomits during
or after a feed, estimate the amount vomited and
offer that amount of feed again. If the child keeps
vomiting, offer half the amount of feed twice as often.
For example, if the child is supposed to take 40 ml of
Starter diet every 2 hours, offer half that amount (20
ml) every hour until vomiting stops.
4.4. Nasogastric (NG) Orogastric

feeding
It may be necessary to use a nasogastric (NG) tube if
the child is very weak, has mouth ulcers that prevent
drinking, or if the child cannot take enough Starter
diet by mouth. The minimum acceptable amount for
the child to take is 80% of the amount offered. At each
feed, offer the Starter diet orally first. Use an NG tube
if the child does not take 80% of the feed (i.e., leaves
more than 20%) for 2 or 3 consecutive feeds.
NG feeding should be done by experienced staff.
The NG tube should be checked every time before
administrative feed. Change the tube if blocked. Do
not plunge Starter diet through the NG tube; let it
drip in, or use gentle pressure.
Abdominal distension can occur with oral or NG
feeding, but it is more likely with NG feeding.
Remove the NG tube when the child takes:
80% of the days amount orally; or
Two consecutive feeds fully by mouth.
Encourage breastfeeding on demand between

formula feeds. Ensure that the child still gets the
required feeds of Starter (diet even if breastfeeding.
Exception: If a child takes two consecutive feeds fully

by mouth during the night, wait until morning to
remove the NG tube, just in case it is needed again in
the night.
4.3. Feeding children who have

diarrhoea and vomiting
4.5. R
ecord intake and output on
a 24-Hour Food Intake Chart
If the child has continuing watery diarrhoea after he

has been rehydrated, offer ORS between feeds to
replace losses from stools. As a guide, children under
Amount of offered feeds and feed taken should

be recorded on 24 hour food intake chart. See
instructions for filling the chart in Annexure 5.
44
EXAMPLE OF COMPLETED 24 HOURS FOOD INTAKE CHART

Name: ABCD Hospital, ID Number: A 406, Admission wt (kg): 3.2 kg, Todays wt (kg): 3.2 kg
Date: 4/06/07
Type of Feed: Starter diet
Give: 12
Feeds of 35 ml
Time
a. Amount
offered (ml)
8:00
10:00
12:00
14:00
16:00
18:00
20:00
22:00
24:00
2:00
4:00
6:00
Total
35
35
35
35
35
35
35
35
35
35
35
35
b. Amount
left in cup
(ml)
0
15
15
25
35
35
30
25
20
10
5
5
c. Amount
taken
orally (a-b)
35
20
20
10
0
0
5
10
15
25
30
30
200
d. Amount
taken by NG, if
needed (ml)
35
35
30
25
20
10
155
e. Estimated
amount
vomited (ml)
f. Watery
diarrhoea (if
present, yes)
10
10
Total volume taken over 24 hours = amount taken orally (c) + amount taken by NG (d) - total amount vomited (e) = 345 ml
4.6. Adjust the childs feeding

plan for the next day
The total amount of Starter diet given per day is based
on the admission weight and does not change (if the
child is rehydrated on the first day, use the rehydrated
weight) for further calculation. As the child stabilizes,
the child can take more at each feed, and feeds can be
less frequent.
Criteria for increasing volume/decreasing frequency
of feeds:
If vomiting, lots of diarrhoea, or poor appetite,
continue 2-hourly feeds.
If little or no vomiting, modest diarrhoea (for

example, less than 5 watery stools per day), and
finishing most feeds, change to 3-hourly feeds.
After a day on 3-hourly feeds: If no vomiting, less
diarrhoea, and finishing most feeds, changes to
4-hourly feeds.
Compare the total amount of Starter diet taken for the
day to the 80% column on the Starter diet Reference
Card (Annexure 8) to confirm that the child has taken
enough. If not, NG feeding may be needed. Continue
to offer each feed orally first; then use an NG tube to
complete the feed if the child does not take at least
80% orally.
45
SECTION
REHABILITATIVE
PHASE
SECTION
REHABILITATIVE PHASE
All children with SAM and medical complications
or poor appetite after stabilization and children
without complications and good appetite will need
rehabilitative care. Rehabilitative phase consists of
feeding with Catch-up, daily care and involving
mothers in care.
This section of the module will describe the following:

Preparing and shifting to Catch - up diets:
Adjusting to Catch-up diet during transition.
Feeding freely on Catch-up diet.
Daily care of children with SAM during
rehabilitation.
Structured play therapy.
Involving mothers in care.
wasted tissues. Catch-up diet contains more calories

and protein: 100 kcal and 2.9 g protein per 100 ml.
5.1. Catch-up Growth (Step-8)

5.1.1. Feed the child in transition
It may take up to 7 days, or even longer, for the child to
stabilize on Starter diet. When the child has stabilized,
one can begin to offer Catch-up diet, the higher
calorie, higher protein catch-up feed intended to
rebuild wasted tissues. Eventually the child will be
offered Catch-up diet freely. However, it is extremely
important to make the transition to free feeding on
Catch-up diet gradually and monitor carefully. If
transition is too rapid, heart failure may occur.
Few recipes for Catch-up diets are given in table 5 & 6.
When the child is stabilized (usually after 2-7 days),

catch-up formula or Catch-up diet is used to rebuild
Table 5: Recipe for Catch-Up Diet

Contents (Per 1000 ml)
Cows milk/toned dairy milk (ml)
Sugar (g)
Vegetable oil (g)
Puffed rice (g)
Water to make (ml)
Protein (g/100 mL)
Lactose (g/100 mL)
Catch-up diet
900
75
20
-1000
100
2.9
4.2
Catch-up diet
750
25
20
70
1000
100
2.9
3
49
Table 6: Recipe for Low Lactose Catch-Up Diet

Contents (Per 1000 ml)
Milk (cows milk or toned dairy milk (ml)
Egg white* (g)
Vegetable oil (g)
Cereal Flour: Powdered Puffed rice (g)
Protein (g/100 mL)
Lactose (g/100 mL)
Egg based
250
120
40
120
100
2.9
1
* Egg white may be replaced by 72g of chicken.
(i) Recognize readiness for transition

Look for the following signs of readiness, usually after
2 7 days:
Return of appetite (easily finishes 4-hourly feeds
of Starter diet).
Reduced oedema or minimal oedema.
The child may also smile at this stage.
(ii) Begin giving Catch-up diet slowly and

gradually
Transition takes 3 days, during which Catch-up diet
should be given according to the following schedule:
First 48 hours (2 days): Give Catch-up diet every 4
hours in the same amount as you last gave Starter
diet. Do not increase this amount for 2 days.
Then, on the 3rd day: Increase each feed by 10 ml
as long as the child is finishing feeds. If the child does
not finish a feed, offer the same amount at the next
feed; then if feed finished, increase by 10 ml. Continue
increasing the amount until some food is left after
most feeds (usually when amount reaches about 30
ml/kg per feed).
If the child is breastfeeding, encourage the mother to
breastfeed between feeds of Catch-up diet.
5.1.2. Feed freely with Catch-up diet

Transition usually takes 3 days. After transition, the
child is in the rehabilitation phase and can feed
freely on Catch-up diet to an upper limit of 220 kcal/
kg/day. (This is equal to 220 ml/ kg/day.) Most children
will consume at least 150 kcal/kg/day; any amount
50
less than this indicates that the child is not being fed
freely or is unwell.
The Catch-up diet Reference Card (Annexure 10)
shows that the 150 - 220 kcal/kg/day range of intake
is suitable for children of different weights up to 10
kg.
For children with persistent diarrhoea, who do not
tolerate low lactose diets (Table-6), lactose free diet
can be started.
To calculate the acceptable range yourself (for
example, if the child weighs more than 10 kg),
multiply the childs weight by 150 ml (minimum) and
220 ml (maximum); then divide each result by 6 (for 6
feeds per day).
An easier method may be to add together the feed
volumes for an appropriate combination of childrens
weights from the card. For example, if a child weighs
13.2 kg, add the volumes shown for a 10.0 kg child
plus a 3.2 kg child.
Examples
Meena weighs 6.2 kg. According to the Catch-up diet
Reference Card, her feeds of Catchup diet may be in
the range of 155 -230 ml.
Leena weighs 4.5 kg. Using the range for the next
lower weight, 4.4 kg, Leenas feeds may be in the
range of 110 - 160 ml.
The child should remain in hospital or the Nutrition
Rehabilitation Centre for the first part of the
rehabilitation phase. When all the criteria in the box
below are fulfilled (usually 10-14 days after admission)
the child may be transferred for rehabilitative care eg;

to the community care programme where these have
been initiated.
Criteria for transfer to a rehabilitation care
Eating well
Responds to stimuli, interest in surroundings
Minimal or No oedema No nasogastric tube, IV
infusions stopped
Gaining Weight >5 gm/kg per day for 3 successive
days.
5.1.3. Feeding children 7-24 months

During rehabilitation, Catch up diet should be
given every 4 hours, night and day. Transition to the
rehabilitation phase involves increasing the amount
of diet given at each feed by 10 ml (e.g. if the first is 60
ml, the second should be 70 ml, the third 80 ml, and
so on) until the child refuses to finish the feed.
When a feed is not finished, the same amount should
be offered at the next feed. If that feed is finished,
the amount offered for the following feed should
be increased by 10 ml. Continue this process until
some food is left after most feeds. The amount being
offered should then be dispensed for the child at each
feed on subsequent days. The amounts of each feed
offered and taken should be recorded on the feeding
chart and any food not taken should be discarded;
never reuse it for the next feed. During rehabilitation
most children take between 150 and 220 kcal/kg per
day. If intake is below 130 kcal/kg per day, the child
fails to respond.
5.1.4. Feeding children over 24 months

Children over 24 months can also be successfully
treated with increasing quantities of Catch up diet; it
is not essential to use a different diet. However, it is
appropriate to introduce solid food in older children,
especially for those who want a mixed diet.
For children with persistent diarrhoea, who do not
tolerate low lactose diets (Table 6), lactose free diet
can be started. Semi-solid and solid foods should be
added as soon as possible to prepare the child for
home based foods at discharge. They should have
comparable energy and protein concentrations once
the catch-up diets are well tolerated. Khichri, dalia,
banana, curd-rice and other culturally acceptable and

locally available diets can also be offered liberally.
To avoid the effects of food substances which reduce
the absorption of minerals Catch up diet should be
given between feeds of the mixed diet. For example,
if the mixed diet is given three times daily. Catch up
diet should also be given three times daily, making six
feeds a day. Water intake is not usually a problem in
children over 2 years because they can ask for it when
they are thirsty.
At the beginning of rehabilitation, the children should
be fed every 4 hours, day and night (six feeds per 24
hours). When they are growing well and are no longer
at risk of developing hypothermia or hypoglycaemia,
one of the night-time feeds can be omitted making
five feeds per 24 hours. This allows the child longer
undisturbed sleep and makes it much easier to
manage the child as a day-patient. It is also less taxing
for those caring for the child.
5.1.5:
Record intake / output;

determine if intake is acceptable
Record each feed on the 24-Hour Food Intake Chart.
To determine if daily intake is acceptable, compare
the volume taken to the range given on the table
on the Catch-up diet Reference Card. If the child is
not taking the minimum amount, there may be a
problem such as an infection, or the child may need
more encouragement to eat. In general, if the child is
gaining weight rapidly, he is doing well. If the child
has diarrhoea but is still gaining weight, there is no
need for concern, and no change is needed in the diet.
By week 3 or 4, if the child is doing well, there is no
need to continue using the 24-Hour Food Intake
Chart. If the child is gaining weight rapidly, you may
assume that he is doing well. Monitoring for danger
signs is no longer needed.
5.1.6. Adjust feeding plan as necessary

During rehabilitation, the child is expected to gain
weight rapidly, and the amount of Catch-up diet
given should be increased as the child gains. To plan
feeds for the next day:
Use the childs current weight to determine the
appropriate range of Catch-up diet each day.
Choose a starting amount within the range. Base
the starting amount on the amount taken in feeds
51
during the previous day. If the child finished most

feeds, offer a bit more. If he did not finish most
feeds, offer the same amount as the day before.
Do not exceed the maximum in the range for the
childs current weight. If the amount of Catch-up
diet offered may be increased during the day, write
a note to this effect on the 24-Hour Food Intake
Chart. For example, Increase by 10 ml until some
left - not to exceed 175 ml. If the child is starting
the day with the maximum amount allowed, write
on the chart, Do not increase.
5.1.7. Plan feeding for the ward

Until this point, this section has focused on planning
feeding for the individual child. It is also important to
plan feeding for the ward as a whole, so that the staff
knows how much food to prepare, how much food to
put in cups at each feed, etc. (Annexure 4).
(i) Determine a schedule for feeding and related

activities in the ward
The ward schedule should include times for the
following activities:
Preparing feeds (as often as necessary to ensure
freshness).
Reviewing patient charts and planning feeding
for the day.
Feeding according to 2-hourly, 3-hourly, and
4-hourly plans.
Weighing
Bathing
Shift changes.
Once these activities are scheduled, you will see where
time for organized play and educational activities
will most conveniently fit in. In general, monitoring
activities (such as measuring temperature and pulse
and respirations) will take place every four hours on an
individual basis, before a child feeds. There is no need
to include these activities on the written schedule for
the ward. Individual treatments and drugs will also be
given on an individual basis.
Time for preparing feeds

Based on storage capabilities, the lengths of time
feed will stay fresh, and availability of kitchen staff,
decide whether feeds should be prepared every 12
52
hours or every 24 hours. 12 hours is most common. If

refrigeration is poor or if there are very many children, it
may be necessary to make feeds more frequently, even
for every feed. If well-refrigerated, feeds will stay fresh
for 24 hours. Food must be discarded after 24 hours.
Time for review and planning

Select a time of day to review each childs past 24Hour Food Intake Chart; plan feeding for each child
(if this has not already been done during physician
rounds); and compile feeding plans for each child
onto a feeding chart for the entire ward.
Feeding times
Select a time of day that each feeding day (24 hours)
will start. This is usually in the morning after totals
have been done from the previous day, and a Daily
Ward Feed Chart has been prepared for the new day.
The time selected should be after staff have arrived
and had time to prepare the food.
Plan times for 2-hourly, 3-hourly and 4-hourly feeds.
At almost every hour, some children will have feeds.
Ensure that no feeds occur at times of shift changes.
For example, if shift changes are on the hour, plan for
feeds to occur on the half-hour. Keep in mind that a
few children, for example, those with hypoglycemia
or continued vomiting, may be on a special halfhourly or hourly feeding schedule. Those children will
need special attention to ensure the more frequent
feeds are provided outside the normal schedule.
Weighing and bathing

Daily weighing will need to occur at about the same
time each day, preferably one hour before or after a
feed. Since the children are undressed for weighing,
this is also a good time for bathing. Generally children
on 2-hourly feeding schedules are new to the ward
and are likely to be too ill to be bathed. Children
on 3-hourly and 4-hourly schedules may be bathed
when they are weighed if this is convenient.
Shift changes
Shift changes may already be fixed for your hospital,
and you may need to work around them in planning
your schedule. Often there are three shifts per day, with
the night shift being the longest. Keep in mind that no
feeding should be scheduled during a shift change. It
is best for shifts to overlap slightly so that instructions

may be communicated from one shift to the next.
5.2. Daily Care

Attentive and consistent daily care will make the
difference in a severely acute malnourished childs
recovery. The routine of daily care in a severe
malnutrition ward includes such tasks as feeding,
weighing, giving antibiotics, and monitoring and
recording each childs progress. Throughout a very
busy day, and also through the night, the staff must
be patient and caring with both the children and their
parents.
Feeding tasks were described in the Feeding section.
Weighing and measuring tasks were described in
Principles of Care. This section will describe other
aspects of daily care. You will practice tasks related to
daily care during ward visits (Annexure 7).
This section and related clinical sessions will describe:
Sensory stimulation and play therapy.
Handling a severely acute malnourished child
appropriately.
Caring for the skin of a severely
acute
malnourished child.
Giving prescribed antibiotics and other
medications and supplements.
Caring for the eyes.
Monitoring pulse, respirations, and temperature
and watching for danger signs.
Completing and interpreting the Daily Care page.
Preparing and maintaining a weight chart.
5.2.1. Step-9: Sensory stimulation

Severe acute malnutrition affects mental and
behavioural development, which can be reversed by
appropriate treatment including sensory stimulation
and emotional support.
During rehabilitation provide:
Tender loving care (smiling, laughing, patting,
touching, talking, etc.).
A cheerful stimulating environment.
Structured play therapy for 15-30 minutes a day.
The play sessions should make use of toys made
of locally available discarded materials (see

annexure 16).
Physical activity as soon as child is well.
Maternal involvement as much as possible (e.g.,
comforting, feeding, play) so that the special care
is continued at home.
Structured play activities

Children with SAM reduce their activities, dont play or
cry, doesnt complain or show normal emotions. Due
to lack of interaction and play children with SAM have
delayed mental and behavioural development. Play
therapy is intended to develop language and motor
skills aided by simple, inexpensive toys. It should take
place in loving, relaxed, and stimulating environment.
In addition to informal group play, the aim should be
to play with each child individually, for 15-30 minutes
each day. Each play session should include language
and motor activities, and activities with toys.
Various activities have been described in detail in
Annexure 17.
5.2.2. Handle the child gently

Severely malnourished children must be handled
very gently, especially at the beginning of their care.
The severely malnourished childs body is fragile
and bruises easily. The child needs all his energy to
recover, so he must stay calm and not become upset.
It is important to speak quietly and handle children
as little as possible at first. Hold and touch children
with loving care when feeding, bathing, weighing,
and caring for them.
Nurses can set a good example by:
Removing the childs clothes gently.
Bathing the child gently.
Talking softly to the child while giving treatments.
Holding the child close while feeding.
Encouraging a mother who is helping to provide
care.
Comforting a child after a painful procedure.
As the child recovers, stimulation of the child should
increase. Play, physical activities, and mental and
emotional stimulation become very important to
the childs complete recovery. There will be more
information on these activities in Involving Mothers.
53
5.2.3. Care for skin and bathe the child
some cases both types of eye drops may be needed.
Bathe children daily unless they are very sick. If a child

is very sick, wait until the child is recovering to bathe
him.
If the child has:
If the child does not have skin problems, or has only

mild or moderate dermatosis, use regular soap for
bathing.
2. Pus or inflammation- Give chloramphenicol or

tetracycline (1%) eye drops.
If the child has severe (+++) dermatosis, bathe for 10

-15 min/day in 1% potassium permanganate solution.
To make a 1% solution, dissolve a crystal in enough
water so that the colour is slightly
purple and still transparent. Sponge the solution onto
affected areas while the child is sitting in a basin.
This dries the lesions, helps to prevent loss of serum
and inhibits infection. Initial on the Daily Care page
of the Case record when the bath is done circle 1%
permanganate if it is used. If the child has severe
dermatosis but is too sick to be bathed, dab 1%
potassium permanganate solution on the bad spots,
and dress oozing areas with gauze to keep them clean.
If potassium permanganate solution is not available,
affected areas may be dabbed with gentian violet.
Apply barrier cream to raw areas. Useful ointments
are zinc and castor oil ointment, petroleum jelly, or
paraffin gauze dressing. These help to relieve pain and
prevent infection. Use a different tube of ointment for
each child to avoid spreading infection.
If the diaper area becomes colonised with candida, use
nystatin ointment or cream after bathing. (Candidiasis
is also treated with oral fluconazole)
Leave off diapers (nappies) so the affected area can
dry. Be sure to dry the child well after a bath and wrap
the child warmly.
5.2.4. Give vitamin A

As mentioned in earlier section, give Vitamin A on Day
14 (besides Day 1 and 2).
5.2.5. Care for the eyes

Chloramphenicol or tetracycline eye drops are given
for eye infection or possible eye infection. Atropine eye
drops are used to relax the eye when there is corneal
involvement (i.e., corneal clouding or ulceration). In
54
1. Bitots spots only (no other eye signs). No eye

drops needed.
3. Corneal clouding or Corneal ulceration, Give

both:
Chloramphenicol or tetracycline (1%) eye
drops and
Atropine (1%) eye drops.
Instill drops into the affected eye(s):
Chloramphenicol or tetracycline (1%): 1 drop, 4
times daily.
Atropine (1%): 1 drop, 3 times daily.
If both types of drops are needed, they may be given
at the same time for convenience. For example, give
tetracycline 4 times daily, and at 3 of those times also
give atropine. Continue drops for at least 7 days and
until all eye signs are gone. Use special care and be
gentle in examining the eyes and instilling eye drops.
To avoid spreading infection, use a separate dropper
and bottle for each child. Also be sure to wash hands
before and after treating each child.
The affected eye(s) should also be bandaged for 3-5
days until inflammation and irritation subside. Use
eye pads soaked in 0.9% saline solution, held in place
with gauze bandages. The damp pads and bandages
will cool the soreness, prevent the childs scratching
his eyes, and promote healing. Change pads and
bandages whenever drops are given.
To bandage the eyes:
Wash hands.
Soak eye pads with 0.9% saline solution.
Place a pad over each affected eye.
Wrap a gauze bandage over the pads and around
the head (not too tight, just tightly enough to
hold in place).
Some severely malnourished children sleep with their
eyes open. Nurses should gently close the childs eyes
while sleeping to prevent abrasion.
EXERCISE-G
In this exercise you will decide the treatment for children with various eye signs. For each child, determine
how many doses of vitamin A are needed and what kind of eye drops are needed.
1. Rani has corneal clouding. She has not had a dose of vitamin A in the last month.
On what days should this child receive vitamin A? What eye drops should be given, if any?
_________________________________________________________________________________________
2. Arun has a Bitots spot and inflammation. He has not had a dose of vitamin A in the last month.
On what days should this child receive vitamin A? What eye drops should be given, if any?
_________________________________________________________________________ ________________
5.2.6. Recognize danger signs
Check vital signs

The following increases in pulse and respiratory rate
should be confirmed in order to determine if there is
problem:
If pulse increases by 15 or more beats per minute,
recheck and confirm in 30 minutes.*
If respiratory rate increases by 5 or more breaths
per minute, recheck and confirm in 30 minutes.*
* If on IV fluids, confirm in 10 minutes and watch

closely.
If the above increases in pulse AND respiratory rates

are BOTH confirmed, they are a danger sign. Together,
these increases suggest an infection, or heart failure
from over hydration due to feeding or rehydrating too
fast. Stop feeds and ORS, and do complete evaluation.
Summary of Danger Signs Related to Pulse, Respiration, and Temperature

Danger Signs:
Suggests:
Pulse
and Confirmed increase in pulse rate of 15 or more Infection or Heart failure (possibly
Respirations beats per minute , along with confirmed increase from over hydration due to feeding or
in respiratory rate of 5 or more breaths per rehydrating too fast)
minute
Pneumonia
Respirations Fast breathing:
only
50 breaths / minute or more in child
2 months up to 12 months old
40 breaths / minute or more in child
12 months up to 5 years
Temperature Axillary temperature
Infection
> 38 degree centigrade or <36 degree centigrade Hypothermia (possibly due to infection, or
child being uncovered)
Other danger signs

In addition to watching for increasing pulse or
respirations and changes in temperature, watch for
danger signs such as:
Anorexia (loss of appetite)
Change in mental state (e.g. becomes lethargic)
Jaundice (yellowish skin or eyes)

Cyanosis (tongue/lips turning blue from lack of
oxygen)
Difficult breathing
Difficulty feeding or waking (drowsy)
Abdominal distension
55
Recent onset oedema

Large weight changes
Increased vomiting
Petechiae (bruising)
Watch carefully any child with an infection such

as pneumonia or sepsis, ear infection, or UTI. Keep
children with infections near the nurses station
so that they can be easily watched. If a child has
diarrhoea or a rash, keep the child separate from the
other children, if possible. Take special care with hand
washing after handling these children.
5.2.7. Provide continuing care at night

Many deaths in severely malnourished children occur
at night because a feed is omitted or the child becomes
uncovered and cold. It is extremely important that
enough staff are assigned to work at night, and that
they are properly trained.
Night nursing staff must:
Keep each child covered to prevent hypothermia.
Feed each child according to schedule during the
night (at first this will be every 2 hours). This will

involve gently waking the child to feed.
Take 4-hourly measurements of pulse, respirations,
and temperature.
Watch carefully for danger signs and call a
physician if necessary.
The following questions relate to the example of
the Monitoring Record on the opposite page. The
child monitored is 2 years old.
Weigh the child daily and maintain

weight chart
How to weigh the child was described in Principles of
Care. Remember to weigh the child at about the same
time each day, about one hour before or after a feed.
After weighing the child each day, record the childs
weight on the Daily Care chart. Then plot the childs
weight on the Weight Chart (Annexure 6). The Weight
Chart will visually show the childs progress towards
discharge weight, any loss of weight due to oedema,
or failure to improve.
EXERCISE-H
In this exercise you will prepare a weight chart for Dinesh, a boy admitted with oedema of both feet (+).
Dineshs weight on admission is 10.1 kg. His height is 87 cm. Enter this information in the blanks beside the
Weight Chart on the opposite page.
1. Plot Dineshs admission weight (10.1 kg) on the chart above Day 1. Then plot the weights given below for
Days 2-14. Connect the points.
Day
Weight
Day
Weight
Day 2
10.05 kg
Day 9
Free-feeding on Catch-up diet - 9.4 kg
Day 3
9.8 kg
Day 10
9.6 kg
Day 4
9.6 kg
Day 11
9.7 kg
Day 5
9.4 kg
Day 12
9.65 kg
Day 6
Transition to Catch-up diet - 9.2 kg Day 13
9.8 kg
Day 7
Transition - 9.2 kg
Day 14
9.9 kg
Day 8
Transition - 9.3 kg
56
Weight Chart
Name of the Child ______________
Weight on admission____________ Weight on discharge____________
0
.5
.5
.5
0
0
10
11
12
13
14
15
16
Day
57
2. Summarize Dineshs weight changes on the blank weight chart (on the next page).
_________________________________________________________________________ __________________
_______________________________________________________ ____________________________________
3. Is Dineshs slight weight loss on Day 12 a reason for concern? Why or why not? What are some possible causes
of the weight loss?
_________________________________________________________________________ __________________
_______________________________________________________ ____________________________________
When you have finished this exercise, please discuss your answers with a facilitator.
58
SECTION
INVOLVING
MOTHERS IN
CARE
SECTION
INVOLVING MOTHERS IN CARE

It is essential for the mother (or caregiver) to be with
her severely malnourished child in the hospital. For
the following reasons, she must be encouraged to
feed, hold, comfort, and play with her child as much
as possible:
Emotional and physical stimulation are crucial
for the childs recovery and can reduce the risk of
developmental and emotional problems.
The childs mother can provide more continuous
stimulation and loving attention than busy staff.
When mothers are involved in care at the hospital,
they learn how to continue care for their children
at home.
Mothers can make a valuable contribution and
reduce the workload of staff by helping with
activities such as bathing and feeding children.
Learning Objectives
This section will describe and allow you to discuss
and observe:
Ways to encourage involvement of mothers in
hospital care; and
Ways to prepare mothers to continue good
care at home, including proper feeding of the
child and stimulation using play.
On the ward or in role plays, this section will allow you

to practice:
Teaching a mother to bathe or feed a child; and
Giving complete discharge instructions.
6.1. Organize facility routine

to encourage mothers
involvement
There are many ways to encourage mothers
involvement in hospital care. Mothers can be taught
to:
Prepare food;
Feed children;
Bathe and change children; and
Play with children, supervise play sessions, and
make toys.
The staff must be friendly and treat mothers as
partners in the care of the children. A mother should
never be scolded or blamed for her childs problems
or made to feel unwelcome. Teaching, counselling
and befriending the mother are essential to longterm treatment of the child.
Mothers should have a place to sit and sleep on the
ward. They also need washing facilities and a toilet,
and a way to obtain food for themselves. Some
mothers may need medical attention themselves
if they are sick or anaemic. The staff should also
make other family members feel welcome. All family
members are important to the health and wellbeing of the child. When possible, fathers should be
involved in discussions of the childs treatment and
how it should be continued at home. Fathers must be
kept informed and encouraged to support mothers
efforts in care of the children.
61
Involve mothers in comforting,

feeding, and bathing children
Staff should informally teach each individual mother
certain skills. First, they may need to show the mother
how to hold her child gently and quietly, with loving
care. Immediately after any unpleasant procedure,
staff should encourage the mother to hold and
comfort her child.
Teach groups of mothers about

feeding and care
There are many topics that can efficiently be presented
to groups of mothers and other interested family
members. Group teaching sessions may be held on
topics such as nutrition and feeding, hygiene, making
ORS to treat diarrhoea, family planning, etc. Staff
members with good communication skills should be
assigned to teach these group sessions. There may be
several staff members who can take turns presenting
different topics. The selected staff must know the
important information to cover on a topic and be able
to:
Communicate clearly in a way that mothers
understand.
Prepare and use suitable visual aids such as
posters, real foods, etc. demonstrate skills when
necessary (e.g., cooking procedures, hand
washing, making ORS).
Lead a discussion in which mothers can ask
questions and contribute ideas.
The sessions should not be limited to lecture,
but should include demonstrations and practice
whenever possible. Encourage questions from the
mothers so that the session is interactive.
6.2 Prepare for feeding the child

at home
After the child recovers and is discharged from facility,
the child should be fed at home according to advice.
Once child reaches -1SD of WFH, they should be fed
according to IMNCI feeding guideline. For a child age
2 years or older, this means giving the child 3 meals
each day, plus giving nutritious food between meals
twice daily.
62
Before returning home, the child must become

accustomed to eating family meals. While the child is
on the ward, gradually reduce and eventually stop the
feeds of Catch-up diet, while adding or increasing the
mixed diet of home foods, until the child is eating as
he or she will eat at home.
Appropriate mixed diets are the same as those
recommended for a healthy child. They should
provide enough calories, vitamins, and minerals to
support continued growth. Home foods should be
consistent with the guidelines below:
The mother should continue breastfeeding as
often as the child wants.
If the child is no longer breastfeeding, animal milk
is an important source of energy, protein, minerals
and vitamins.
Solid foods should include a well-cooked
staple cereal. To enrich the energy content, add
vegetable oil (5-10 ml for each 100 g serving/half
katori of approximately 200 ml size) or ghee, or
groundnut paste. The cereal should be soft and
mashed; for infants use a thick pap.
Give a variety of well-cooked vegetables, including
orange and dark-green leafy ones. If possible,
include seasonal fruit e.g., banana, mango, cheeku
in the diet as well.
Pulses and beans are also good sources of protein.
If possible, include meat, fish, or eggs in the diet.
Give extra food between meals (healthy snacks).
Give an adequate serving size (large enough that
the child leaves some) of healthy snacks that are
high in energy and nutrients include:
Bread or chapatti with butter or groundnut
paste (peanut butter).
Yoghurt, milk, puddings made with milk.
Ripe banana, papaya, mango, other fruits.
Cooked potatoes.
To prepare the mother to continue appropriate
feeding at home:
Discuss with the mother (and other family
members, if possible) the childs previous diet and
the foods that are available at home.
Discuss practical ways to address specific
problems in the childs past diet. Be sure to involve
the mother as a partner in deciding what to feed
the child, so that the decisions will be practical.

Explain how to use or adapt available foods for
preparing a healthy diet.
Summarize what to feed the child, how much
to give at each meal, and how many meals and
snacks to give. Write it down or give the mother
a prepared card with feeding instructions. Use
pictures for mothers who cannot read.
Remind the mother to sit with the child and
encourage the child to eat.
Before discharge, when the child is adjusting to
home foods under hospital supervision, have the
mother practise preparing recommended foods
and feeding them to her child.
Review instructions before discharge and ask
the mother checking questions to be sure she
understands what to do, for example:
What will you feed your child? Where will you
get the ingredients to prepare foods at home
as you have done it here?
How many meals and snacks will you feed
your child each day?
How much will you feed your child at each
meal or snack?
6.3
Step 9-Teach mothers the
importance of stimulation
and how to make and
use toys
Severely malnourished children have delayed
mental and behavioural development. As the child
recovers, he or she needs increasing emotional and
physical stimulation through play. Play programmes
that begin during rehabilitation and continue after
discharge can greatly reduce the risk of permanent
mental retardation and emotional problems.
The hospital can provide stimulation through the
environment, by decorating in bright colours,
hanging colourful moving toys over cots, and having
toys available. Mothers should be taught to play with
their children using simple, homemade toys. It is
important to play with each child individually at least
15-30 minutes per day, in addition to informal group
play.
63
SECTION
PREPARE FOR
DISCHARGE &
FOLLOW-UP
SECTION
PREPARE FOR DISCHARGE &

FOLLOW-UP
7.1. Criteria for Discharge
The criteria for discharge are outlined below.
However, flexible approach is necessary depending
upon the local and individual circumstances. The key
problem with prolonged hospitalization is high risk of
nosocomial infections and mothers unwillingness to
stay for long period.
In places where there is a functional program on

community-based management of SAM, discharge
may be given early after the child has recovered from
the stabilization phase and has started to gain weight.
Criteria for discharge from inpatient care

Child
Achieved weight gain of 15% (See Annex 20 for target weight at 15%
weight gain) and has satisfactory weight gain for 3 consecutive days (>5
gm/kg/day)
Oedema has resolved
Child eating an adequate amount of nutritious food that the mother can
prepare at home
All infections and other medical complications have been treated
Child is provided with micronutrients
Immunization is updated
Mother/caregiver
Knows how to prepare appropriate foods and to feed the child
Knows how to make appropriate toys and play with the child
Knows how to give home treatment for diarrhoea, fever and acute
respiratoryinfections, and how to recognise the signs that/he must seek
medical assistance
Follow-up plan is completed
In places where there is a functional program on
community-based management of SAM, discharge
may be given early after the child has recovered from
the stabilization phase and has started to gain weight.
All children with SAM should be followed by the
health workers at home or at community centres till
s/he reaches weight for-height of -1 SD.
7.2.
Teaching parents to care
for the child and prevent
recurring malnutrition
Parents should be educated about:

Correct breastfeeding and feeding practices
(frequent feeding with energy and nutrient dense
foods)
Taking the child to the health facility for vitamin
A supplementation (children aged 9-59 months)
for the next dose as advised on discharge and for
subsequent 6 monthly doses
Taking the child to the health facility for
vaccination as per the schedule in Mother and
Child Protection card/Immunisation card
Giving structured play therapy to the child.
67
Give general
7.3. Treatment for Helminthiasis 7.5.
instructions
Treatment for helminthic infections should be given
to all children with SAM before discharge. Give a
single dose of any of the following antihelminthics
orally:
200 mg albendazole for children aged 12-23
months, 400 mg albendazole for childrenaged 24
months or more or
100 mg mebendazole twice daily for 3 days for
children aged 24 months or more.
7.4. Follow-up
Before discharge, make a plan with the parent for
a follow-up visit at 1 week after discharge. Regular
check-ups should also be made at 2 weeks in first
month and then monthly thereafter until WHZ
reaches -1 SD or above. If a problem is found,
visits should be more frequent until it is resolved.
At each follow-up visit, the child should be
examined, weighed, measured and the results
recorded. The mother should be asked about the
childs recent health, feeding practices and play
activities. Training of the mother should focus on
areas that need to be strengthened, especially
feeding practices, and mental and physical
stimulation of the child.
68
discharge
In addition to feeding instructions, mothers will need

to be taught:
How to continue any needed medications,
vitamins, folic acid (for 2-weeks), and iron (for 2-3
months) at home.
when to bring the child back for immediate care:
Not able to drink or breastfeed. Stops feeding.
Develops fever.
Has fast or difficult breathing. Has a convulsion.
Has diarrhoea for more than a day, or blood
in stool.
7.6.
If early discharge is
unavoidable, make special
arrangements for followup
If a child must be discharged before the discharge
criteria are met it is critical to make arrangements for
follow-up of the child (for example, special visits by a
health worker to the childs home, or outpatient care
at a health facility or nutritional rehabilitation centre).
Mothers will need special training to prepare feeds
and give iron, folic acid, and multivitamins at home.
SECTION
MANAGEMENT
OF SAM
IN INFANTS LESS
THAN 6 MONTHS
OF AGE
SECTION
MANAGEMENT OF SAM IN INFANTS

LESS THAN 6 MONTHS OF AGE
8.1.
Initial assessment
treatment
and
Any infant more than 49 cm* in length who has

following features is treated as severe acute
malnutrition:
Weight-for-height less than - 3 SD; and /or
Visible severe wasting; and/or
Oedema of both feet.
* For children with length less than 49 cm, visible severe wasting can
be used as criteria for identification and admission.
Initial steps of management i.e., hypoglycemia,

hypothermia, dehydration, infection, septic shock are
same as described for older children.
8.2. Feeding
Feeding severely acute malnourished young infants
is labor intensive and requires a different approach
from those needed for older children. There is lack of
data about the ideal feeding choice for non breastfed
children. Most of the experts recommend following
feeding options:
Feed the infant with appropriate milk feeds
for initial recovery and metabolic stabilization.
Wherever possible breastfeeding or expressed
milk is preferred in place of Starter diet. If the
production of breast milk is insufficient initially,
combine expressed breast milk and non cereal
starter therapeutic diet initially. For non breastfed
babies, give Starter diet feed prepared without
cereals.
Provide support to re-establish breastfeeding as
soon as possible. A mother may need support
and help to express breast milk if the infant is too
weak to suckle. Keep mother and infant together,
to help the mother care for and respond to the
baby, to provide skin-to-skin contact (Kangaroo

care) to warm the baby.
Give supplementary milk feeds if breast milk is
not enough or if breastfeeding is not possible
or mother is HIV +ve and opted for replacement
feeds.
Give good diet and micronutrients supplements
to the mother.
In the rehabilitation phase, provide support to the
mother to give frequent feeds and try to establish
exclusive breast feeding. In artificially fed without
any prospects of breastfeeds, the infant should be
given diluted Catch-up diet. [Catch-up diet diluted
by one third extra water to make volume 135 ml in
place of 100 ml]. On discharge the non-breastfed
infants should be given locally available animal
milk with cup and spoon. The infant formulas are
very expensive and should only be advised if the
parents can afford this.
Discharge the infant from the facility when
gaining weight for 5 days on breastfeeding alone
and has no medical complications.
8.3. Relactation through

Supplementary Suckling
Technique (SST)
Supplementary Suckling Technique (SST) is a
technique which can be used as a strategy to initiate
relactation in mothers who have developed lactation
failure.
How SST works

The infant suckles and stimulates the breast at the
same time drawing the supplement (expressed
mothers milk or therapeutic formula) through the
tube, and is thereby nourished and satisfied. SST
71
stimulates prolactin reflex to secrete more milk.

The Suckling Technique (Figure-13)
The supplementation is given via an No-8
nasogastric tube.
The tip is cut back beyond the side ports
approximately 1cm and the cap at the end of the
tube is removed.
Catch up diet diluted is put in a cup. The mother
holds the cup with one hand initially 5-10 cms
above the breast.
The end of the tube is put in a cup.
The tip of the tube is put on the breast at the
nipple and the infant is offered the breast.
Health staff can hold the cup/katori and support

the mother.
It may take one or two days for the infant to get
used of the tube but it is important to continue.
When the infant sucks on the breast with the tube
in is mouth, the milk from the cup is sucked up
through the tube and taken by the infant.
The cup/katori is placed at least 10 cm below the
level of the breast so the milk does not flow too
quickly and distress the infant.
Figure 13: Supplementary Sucking Technique.
Table 7: Amounts of Catch-Up Diet Diluted for Infants put on SST

Class of Weight
(kg)
>=1.2
1.3-1.5
1.6-1.7
1.8- 2.1
2.2- 2.4
2.5- 2.7
2.8- 2.9
3.0- 3.4
3.5- 3.9
4.0- 4.4
72
Total ml of F
-100 diluted
200
240
280
320
360
400
440
480
520
560
Quantity of Catch up diet diluted Quantity of Catch up diet per feed in ml

per feed in ml (8 feeds/day)
(6 feeds/day)
25
33
30
40
35
47
40
53
45
60
50
67
55
73
60
80
65
87
70
93
SECTION
MANAGEMENT
OF SAM
IN HIV EXPOSED/HIV
INFECTED CHILDREN
SECTION
MANAGEMENT OF SAM IN HIV

EXPOSED/HIV INFECTED CHILDREN
SAM may occur in children who are HIV exposed/HIV
infected children. The basic principles and steps of
management of SAM in these children are similar. The
drugs that are used for TB and HIV are quite toxic to
the liver and pancreas. These organs are particularly
affected by SAM. If treatment with anti-TB drugs or
ARVs is started in the severely malnourished patient
they are likely to develop very severe side effects
from the drugs. Such side effects lead to withdrawal
of many of the patients from the ARV treatment
programs. Neither TB nor HIV is an emergency. All
antiviral drugs have significant side effects, and
their toxicity and pharmacokinetics have not been
assessed in the severely malnourished child. They
particularly affect mitochondrial function, which is
already compromised in the severely malnourished
child; the degree of dysfunction is related to mortality
and any further mitochondrial insult is likely to
have serious effects. Furthermore, there is excessive
mortality of patients shortly after commencing
ART, that appears to be related to nutritional status;
initiation of ART and other long-term treatment of
illnesses that are not immediately lethal should be
delayed until the metabolism of the major organs has
improved through nutritional therapy.
There are also major interactions between ARV
drugs and some of the drugs that may be used
in severe malnutrition. For example rifampicin
should be avoided at the same time as some of the
ARVs. These interactions are likely to be even more
serious in the malnourished patient who already

has a compromised hepatic function. This is another
reason why the treatment of HIV with ARVs should
be delayed until the drugs used in malnutrition have
been administered. The treatment of malnutrition
should be started at a minimum two weeks before
the introduction of anti-retroviral drugs to diminish
the risk of serious side effects from the anti-retroviral
drugs. Preferably anti-retroviral treatment should be
delayed until the recovery phase is well established.
Children with HIV should be given cotrimoxazole
prophylaxis against pneumocystis pneumonia.
This is inadequate antibiotic cover for the severely
malnourished patient; amoxicillin should be given in
addition to prophylactic doses of cotrimoxazole.
Once the patients SAM is being treated satisfactorily
and s/he have had adequate amounts of the essential
nutrients to resist the toxic effects of the drug
treatment HIV and TB treatment should be started
and should follow the national guidelines.
Continue cotrimoxazole prophylaxis as per NACO
guidelines. For severe pneumonia in HIV infected
children give adequate anti-staphylococcal and
gram-negative antibiotic coverage (e.g, ampicillin
and gentamicin). For pneumonia with severe hypoxia,
consider Pneumocystis pneumonia. Add highdose cotrimoxazole (trimethoprim 5 mg/kg/dose,
sulfamethoxazole 25 mg/kg/dose) 6-hrly for 3 weeks.
75
10
SECTION
MONITORING
AND PROBLEM
SOLVING
10
SECTION
MONITORING AND PROBLEM SOLVING

Many types of problems may occur in a hospital or
Nutrition rehabilitation Centre. There may be problems
with an individual patients progress or care, such as
failure to gain weight or treat an infection. There may
also be problems that affect the entire ward, such as
problems with staff performance, food preparation,
or ward procedures or equipment. All these problems
require attention to prevent patient deaths.
This section teaches a process for identifying and
solving problems that may occur on the ward. The
process includes:
Identifying problems through monitoring.
Investigating causes of problems.
Determining solutions.
Implementing solutions.
This process can be used in solving problems with
individual patients or problems that may affect the
entire ward.
Learning Objectives
This section will describe the following skills:
Identifying problems by monitoring:
Investigating causes of problems.
Determining solutions appropriate for causes.
Conducting a problem-solving session with a
group.
Childs appetite has not returned.

Child has failed to gain weight for several days
while taking Catch-up diet.
Mother wants to take her child home before the
child has reached the discharge weight.
Child seems to have an unrecognized infection.
By monitoring overall weight gain on the ward,
patient outcomes, and the case-fatality rate, you may
identify problems such as the following:
20% of children the ward have poor weight gain.
75% of mothers leave with their children before
they reach the desired discharge weight.
The case-fatality rate in the ward was 15% during
the months of June through August.
By monitoring case management practices, food
preparation, ward procedures, and hygiene, you
may identify additional problems, which may in fact
be causes of poor weight gain or adverse outcomes.
For example, you may identify problems such as the
following:
Feeds are not being prepared as per the
instructions.
Children are not fed every 2 hours through the
night.
Staff do not consistently wash their hands with
soap.
10.1. Use a process to identify

and solve problems
To describe the problem, state when, where, and with

whom the problem is occurring. Also try to determine
when the problem began. Knowing the details will
help you find the cause, or causes, of the problem.
10.1.1 Identify problems
10.1.2 Investigate causes of problems
By monitoring individual patient progress, weight

gain and care, you may identify problems such as the
following:
It is critical to find the cause(s) of a problem before

trying to solve it. Different causes require different
solutions. Investigation of causes may involve doing
79
laboratory tests for a patient, observing and asking

questions of staff, reviewing patient records, and/or
monitoring food preparation and ward procedures.
c. Not create another problem.
10.1.3 Determine solutions
Problem: Weight gain in a severe malnutrition ward

is not as good as it was several months ago. Instead of
good weight gain for most children on Catch-up (diet
(that is, 10 g/kg/ day or more), the typical weight gain
is now less than 10 g/kg/day.
Solutions will depend on the causes of the problems.

For example, if staff do not know how to do a new
procedure, a solution may be training. On the other
hand, if the cause is a lack of equipment or supplies, a
different solution is needed. Solutions should:
a. Remove the cause of the problem (or reduce its
effects);
b. Be feasible (affordable, practical, realistic); and
Example of problem solving process
The senior nurse decides to investigate by monitoring

ward procedures and food preparation. Following are
some possible causes that she might find, along with
an appropriate solution for each.
Possible Cause: Possible Solution:

Possible Cause
The type of milk available for making feeds has
changed, and the recipes have not been adjusted
appropriately.
Staff adds too much water when making Catch-up
diet. They add 1000 ml. instead of just enough water
to make 1000 ml of formula.
Measuring scoops have been lost, and staffs are
estimating amounts of ingredients for feeds.
Children are not being fed 2 hourly through the
night. There are more children on the ward, and staff
numbers have not increased. Nurses cannot spend as
much time feeding each child.
It is important to recognise that buying new scoops
will not solve the problem if the cause is really lack of
an appropriate recipe. By investigating the cause of a
problem, one can avoid wasting money and time on
the wrong solutions.
Implement solutions
Implementing a solution may be relatively simple
(such as speaking with an individual staff member,
or changing a childs feeding plan) or quite complex
(such as changing staff assignments throughout the
ward). Good communication with staff is important
whenever any change is made.
To promote good communication when solving
problems:
80
Possible Solution
Adjust the feed recipes appropriately to use the milk
that is available. Post the new recipes and teach them
to staff.
Explain the recipe to staff. Be sure that 1000 ml is
clearly marked on mixing containers. Demonstrate
how to add water up to the mark.
Obtain new scoops
Invest time in teaching mothers to feed and care for
the children and involve them
Hold regular staff meetings, during which positive

feedback is given and any problems, causes, and
solutions are discussed.
Provide staff with job descriptions which list their
assigned tasks.
Provide clear instructions whenever any change is
made.
Provide job-aids such as checklists or posted
instructions for any complex tasks.
Follow up to determine if a solution is implemented
as intended. Then continue monitoring to determine
whether the problem is solved. Give feedback to staff
that includes praise for work done well, along with
any instructions for improvement.
10.2.
Monitor
and
Solve
Problems
with
an
Individual Patient
10.2.1:
Monitor individual
progress and care
patient
Nursing staff should monitor certain signs (such

as pulse rate, respiratory rate, and temperature)
repeatedly during the day, especially during initial
treatment. If there are danger signs (such as increasing
pulse and respiratory rate, or a sudden drop in
temperature), the staff should immediately respond.
Doctor/s should do a ward round at least once every
day. During rounds, a doctor should:
Observe the child and question the mother and
nurse:
Is the child more alert? smiling? sitting up?
able to play?
Has the child lost oedema?
Is there less diarrhoea?
Has dermatosis improved?
How is the childs appetite?
Review the childs weight chart.
Is the child gaining weight according to the
weight chart?
If there is a loss, is it due to decreasing oedema?
Review the Case record and food intake chart:
Is the child getting the recommended feeds?
Is prescribed care (such as antibiotics, folic
acid, iron) being given?
Are
there any danger signs recorded on the

Case record: increased pulse rate, respiratory
rate, or temperature?
Daily, after a child is taking Catch-up diet, a clinician

should calculate the childs weight gain in grams per
kilogram body weight (g/kg/day) and judge whether
weight gain is sufficient:
Good weight gain: 10 g/kg/day or more.
Moderate weight gain: 5 up to10 g/kg/day. Poor
weight gain: Less than 5 g/kg/day.
To calculate daily weight gain:
Subtract the childs weight yesterday (W1) from
the childs weight today (W2).
Note: Do this even if the child has lost weight. If the child has lost
weight, the result will be negative. Express the difference as grams
(kg 1000). This is the total amount of weight gained during the day.
W2 - W1 = ____ kg- ____ kg 1000 = ____ grams

gained
Divide the grams gained (from step a) by the
childs weight yesterday. The result is the weight
gain in g/kg/day.

Weight gain in grams W1 = ____ g/kg/day
If the child has lost weight during the past day, the
weight gain for that day will be negative.
Note: This calculation is not useful until the child is on Catch-up

diet, as the child is not expected to gain weight on Starter diet. In
fact, weight may be lost on Starter diet due to decreasing oedema.
Remember that this calculation will be most useful if the child is
weighed at about the same time each day.
81
EXERCISE - I
Example
Kalim began taking Catch-up diet on Day 4 in the severe malnutrition ward. By Day 6 he began to gain
weight. On Day 6, Kalim weighed 7.32 kg. On Day 7, he weighed 7.4 kg. His weight gain in g/kg/day can be
calculated as follows:
a. 7.4 kg - 7.32 kg = 0.08 kg 1000 = 80 grams gained
b. 80 grams 7.32 = 10.9 g/kg/day
A gain of 10.9 g/kg/day is considered a good weight gain.
Calculate the daily weight gain for the children described below. Assume that the weights were taken at
about the same time each day.
1. Manish weighed 7.25 kg on Day 10. He weighed 7.30 kg on Day 11. What was his weight gain in g/kg/day?

2. Kavita weighed 6.22 kg on Day 8. She weighed 6.25 kg on Day 9. What was her weight gain in g/kg/day?

3. Gaurav weighed 7.6 kg on Day 9. He weighed 7.5 kg on Day 10. What was his weight gain in g/kg/day?

10.2.2 Identify the child who is failing to respond

A child is failing to respond if he or she does not improve initially; or gains weight but then levels off or
deteriorates. Some criteria for failure to respond are listed below as a guide:
Criteria
Failure to regain appetite Failure to start to lose oedema Oedema still present Failure to gain at least 5 g/kg/day for 3 successive days
after feeding freely on Catch-up diet.
10.2.3 Determine cause (s) of failure

to respond
The causes of a childs failure to respond may be related
to procedures, staff, equipment, or the environment
throughout the ward, or they may be related only
to the individual child. If many children are failing to
respond, look for causes that affect the entire ward,
82
Approximate time after admission

Day 4
Day 4
Day 10
such as incorrect feeding practices or poor hygiene.
If your investigation is focused on one child, consider
such possible causes as the following:
Insufficient food given:
Has the feeding plan been adjusted as the
child gains weight? Is the correct feed being
given?
Is the correct amount offered at the required
times? Is the child being fed adequately at
night?
Is the child being held and encouraged to eat?

Are
leftovers recorded so the childs recorded

intake is accurate?
Vitamin or mineral deficiency
Is mineral mix added to the childs food each
day?
Is an appropriate multivitamin given?
Unrecognized infection - Infections most
commonly overlooked include pneumonia,
urinary tract infection, ear infection, and
tuberculosis.
Others include malaria, fungal infection and HIV
infection.
Serious underlying disease (such as congenital
abnormalities, immunological diseases).
Is insufficient attention given to the child?
Is the mother present to assist in feeding and care
of the child?
Rumination - The child regurgitates food from the
stomach to the mouth, then vomits part of it and
swallows the rest. This usually happens when the
child is not observed.
Is the child eating well but failing to gain
weight?
Does the child smell of vomit or have vomitstained clothes or bedding? Does the child
seem unusually alert and suspicious?
Does the child make stereotyped chewing
movements?
Remember that there may be multiple causes of

failure to respond. For example, a child may have an
infection plus a vitamin deficiency. Try to find all of
the causes.
10.2.4.
Identify
and
implement
solutions for the individual
child
In some cases, the cause of a problem may require a
specific medical solution. If the child has an infection, a
clinician will need to prescribe appropriate treatment.
If the child is ruminating, it is best to have experienced
staff members give special attention to the child.
They need to show disapproval whenever the child
begins to ruminate, without frightening the child, and
encourage less harmful behaviours.
Example of a problem with root causes:- may draw a

diagram
Problem: A child becomes hypoglycaemic during her
first night on the ward. One cause: She was not fed at
2:00 and 4:00 a.m.
Root cause: The childs mother was too tired to wake
up and feed her.
Root cause: There is not enough night staff, so
mothers are expected to feed the children at night.
Root cause: There is no quiet time or place for
mothers to rest during the day.
Solutions: To solve this problem, it will be necessary
to address all of the causes. Possible solutions include
getting more night staff or finding a time and place
for mothers to rest during the day. Night staff could
also be asked to wake up the mothers and supervise
night feeds, or help those mothers whose children
require 2-hourly feeds.
10.3 Monitoring
outcomes
patient
Record each patients outcome on

the Case record sheets
The last page of the Case record sheets has a space for
recording patient outcomes. Record the outcome for
the patient whether it is successful or not. Also record
any relevant comments, such as circumstances and
causes of adverse outcomes.
Successful outcome:
Clinically well
Achieved Target Weight
MUAC>11.5 cms
Adverse outcomes:
Death
Early exit or early discharge (and circumstances in
which child left early)
Referral (and circumstances in which referral had
to be made)
83
Review patient records for common

factors in adverse outcomes
10.4.2
Monitor case
practices
Periodically and whenever there is a death. Note

common factors that would suggest areas where case
management practices or ward procedures may need
to be carefully examined and improved. For example,
note whether recent deaths have occurred within the
first 2 days after admission or later. Deaths that occur
within the first 2 days are often due to hypoglycaemia,
over hydration, unrecognized or mismanaged septic
shock, or other serious infection. Deaths that occur
after 2 days are often due to heart failure; check to
see if deaths are occurring during transition to Catchup diet. An increase in deaths occurring during the
night or early morning, or on weekends, suggests that
care of children at these times should be monitored
and improved. For example, if there are many early
morning deaths, it is possible that children are not
being adequately covered and fed during the night.
Deaths during initial case management are often

the result of well-intentioned but incorrect practice.
Monitor to ensure that all clinicians are following the
case management practices
If many mothers are choosing to take their children

home after only a few days, look for common reasons.
Are the mothers unable to leave other children at
home? Is the ward uncomfortable for them? Are
the staff unfriendly? Early departures also suggest a
need to monitor and improve ward conditions and
procedures.
There are some problems that require individual

solutions and should be handled privately. For
example, if you find that a particular staff member is
doing a procedure incorrectly or dangerously, correct
that person privately.
Review of patient records for adverse outcomes can

provide a basis for staff to discuss and solve problems.
10.4. Monitoring patient care in

the ward
10.4.1
Monitor
practices
procedures
and
Periodically, or to investigate causes of problems, you

may need to monitor case management practices:
Food preparation;
Ward procedures; and/or
Hygiene.
Suggestions for monitoring are provided in this
section. Monitoring Checklists for use during ward
visits are provided in Annexure 19, 20 and 21. Any
NO answer to a question on the checklist indicates
a problem that needs to be corrected.
84
management
described in the manual, particularly during initial

treatment. Ensure that emergency room personnel
are also following appropriate practices for severely
malnourished children.
10.4.3 Monitor food preparation

Problems such as poor weight gain on the ward
may be due to problems with food preparation.
Periodically, or whenever you suspect that there is a
problem, carefully observe preparation of feeds.
10. 4. 4 Solve problems
On the other hand, some problems may be solved

by working with staff members as a group to discuss
the causes and possible solutions. Some examples of
problems that could be reviewed as a group might
include:
A diarrhoea outbreak in the ward;
An increasing case fatality rate; or
Procedural problems involving all or many of the
staff.
Staff may have useful information to contribute on the
causes of problems and creative ideas for solutions.
They are also more likely to work together towards
implementing a solution if they are involved in the
decision making process.
10.5.
Monitoring facility level
outcomes
It is suggested that the following gender and age
disaggregated indicators be used for monitoring
the quality of service being provided by the health
facility/Nutrition Rehabilitation Centre.
Indicators to be monitored at NRC
Admissions
Gender disaggregated
Referred by AWW/ASHA/ Self/
Paediatric ward or emergency
Average length of stay
Bed Occupancy rate
Average weight gain
Rate of referral to higher facility
Recovery rate
Case fatality rate
Defaulter rate
Relapse rate
Non- respondents
Death rate following discharge from
NRC while still in program
Average length of stay in the program
(till target weight is achieved)
The table below defines the key terms for indicators:
Table 8: Definition of Key Terms for Indicators

Definition of key terms
Admission Indicators:
New admission: an admitted patient who has never been in the facility before Re-admission: a defaulter who
has come back to the facility within 2 months.
Relapse: a patient who has been discharged as cured from the facility within the last 2 months but is again
eligible for admission. A large number of relapses are often a sign of food insecurity.
85
Exit Indicators:
Exit indicators provide information about the proportion of patients completing the treatment successfully or
not successfully (recovered, defaulter, death). They are calculated as a percentage of the total number of exits
(discharges) during the reporting month
Recovery (or cured) rate: Number of beneficiaries that have reached discharge criteria within the reporting
period divided by the total exits.
Defaulter rate: Number of beneficiaries that defaulted during the reporting period divided by the total exits.
A person is considered as a defaulter when he/she has not attended the NRC for 3 consecutive days.
Medical Transfer rate: The beneficiary is categorised as a transfer when s/he is transferred to another health
facility, regardless of the level of the health facility s/he is referred to.
Non-respondent: This exit category includes those beneficiaries who fail to respond to the treatment e.g. the
patient remains for a long period of time under the target weight. If after investigation there are no specific
reasons for failure or actions that can be taken to improve the treatment, the patient should be referred to an
appropriate higher level facility. When the number of cases in this category is high it may indicate underlying
problems related to the patients (e.g. chronic disease) that need to be addressed
Acceptable levels of care

Performance of facilities/Nutrition Rehabilitation Centres may be assessed based on the criteria described below.
Recovery rate
Death rate
Defaulter rate
Weight gain
Length of stay
Acceptable
>75%
<10%
<15%
>8 g/kg/day
<4 wks
Alarming
50%
>15%
>25%
<8 g/kg/day
>6 wks
All excess mortality should be investigated. Lessons learned could save a number of lives; analysis of reports can
point out to the need for training of the staff and help change the entrenched practices. The overall functioning
of the NRCs can be monitored against the sphere standards. The calculation of Case fatality rate for the ward is
explained in Annexure 23.
For further information regarding monitoring formats, reporting mechanisms and programme management
at district and state level, refer to the Operational Guidelines on Facility Based Management of Children with
Severe Acute Malnutrition published by the Ministry of Health and Family Welfare (2011).
86
ANNEXURES
ANNEXURE - 1: WHO Growth Reference Charts

Weight-for-Length Reference Card (below 87 cm)
-4 SD
1.7
1.8
2.0
2.1
2.2
2.4
2.5
2.7
2.9
3.1
3.3
3.5
3.7
3.9
4.1
4.3
4.5
4.7
4.9
5.1
5.3
5.5
5.6
5.8
6.0
6.1
6.3
6.4
6.6
6.7
6.9
7.0
7.2
7.3
7.4
7.6
7.7
7.9
8.0
8.2
8.4
8.6
Boys` weight (kg)

-3 SD
-2 SD
-1 SD
1.9
2.0
2.2
2.0
2.2
2.4
2.1
2.3
2.5
2.3
2.5
2.7
2.4
2.6
2.9
2.6
2.8
3.0
2.7
3.0
3.2
2.9
3.2
3.5
3.1
3.4
3.7
3.3
3.6
3.9
3.6
3.8
4.2
3.8
4.1
4.4
4.0
4.3
4.7
4.3
4.6
5.0
4.5
4.8
5.3
4.7
5.1
5.5
4.9
5.3
5.8
5.1
5.6
6.0
5.3
5.8
6.2
5.5
6.0
6.5
5.7
6.2
6.7
5.9
6.4
6.9
6.1
6.6
7.1
6.3
6.8
7.3
6.5
7.0
7.6
6.6
7.2
7.8
6.8
7.4
8.0
7.0
7.6
8.2
7.2
7.7
8.4
7.3
7.9
8.6
7.5
8.1
8.8
7.6
8.3
8.9
7.8
8.4
9.1
7.9
8.6
9.3
8.1
8.7
9.5
8.2
8.9
9.6
8.4
9.1
9.8
8.5
9.2
10.0
8.7
9.4
10.2
8.9
9.6
10.4
9.1
9.8
10.6
9.3
10.0
10.8
Mdian
2.4
2.6
2.8
2.9
3.1
3.3
3.5
3.8
4.0
4.3
4.5
4.8
5.1
5.4
5.7
6.0
6.3
6.5
6.8
7.0
7.3
7.5
7.7
8.0
8.2
8.4
8.6
8.9
9.1
9.3
9.5
9.7
9.9
10.1
10.3
10.4
10.6
10.8
11.0
11.3
11.5
11.7
Length
(cm)
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
Mdian
2.5
2.6
2.8
3.0
3.2
3.4
3.6
3.8
4.0
4.3
4.5
4.8
5.1
5.4
5.6
5.9
6.1
6.4
6.6
6.9
7.1
7.3
7.5
7.7
8.0
8.2
8.4
8.6
8.8
9.0
9.1
9.3
9.5
9.7
9.9
10.1
10.3
10.5
10.7
11.0
11.2
11.5
Girls` weight (kg)

-1 SD
-2 SD
-3 SD
2.3
2.1
1.9
2.4
2.2
2.0
2.6
2.4
2.2
2.7
2.5
2.3
2.9
2.6
2.4
3.1
2.8
2.6
3.3
3.0
2.8
3.5
3.2
2.9
3.7
3.4
3.1
3.9
3.6
3.3
4.2
3.8
3.5
4.4
4.0
3.7
4.6
4.3
3.9
4.9
4.5
4.1
5.1
4.7
4.3
5.4
4.9
4.5
5.6
5.1
4.7
5.8
5.3
4.9
6.0
5.5
5.1
6.3
5.7
5.3
6.5
5.9
5.5
6.7
6.1
5.6
6.9
6.3
5.8
7.1
6.5
6.0
7.3
6.7
6.1
7.5
6.9
6.3
7.7
7.0
6.5
7.8
7.2
6.6
8.0
7.4
6.8
8.2
7.5
6.9
8.4
7.7
7.1
8.5
7.8
7.2
8.7
8.0
7.4
8.9
8.2
7.5
9.1
8.3
7.7
9.2
8.5
7.8
9.4
8.7
8.0
9.6
8.8
8.1
9.8
9.0
8.3
10.1
9.2
8.5
10.3
9.4
8.7
10.5
9.7
8.9
-4 SD
1.7
1.9
2.0
2.1
2.2
2.4
2.5
2.7
2.8
3.0
3.2
3.4
3.6
3.8
3.9
4.1
4.3
4.5
4.7
4.8
5.0
5.1
5.3
5.5
5.6
5.8
5.9
6.0
6.2
6.3
6.5
6.6
6.7
6.9
7.0
7.1
7.3
7.5
7.6
7.8
8.0
8.1
89
Weight-for-Height Reference Card (87 cm and above)

-4 SD
8.9
9.1
9.3
9.4
9.6
9.8
9.9
10.1
10.3
10.4
10.6
10.8
11.0
11.2
11.3
11.5
11.7
11.9
12.1
12.3
12.5
12.7
12.9
13.2
13.4
13.6
13.8
14.1
14.3
14.6
14.8
15.0
15.3
15.5
90
Boys` weight (kg)

-3 SD
-2 SD
-1 SD
9.6
10.4
11.2
9.8
10.6
11.5
10.0
10.8
11.7
10.2
11.0
11.9
10.4
11.2
12.1
10.6
11.4
12.3
10.8
11.6
12.6
11.0
11.8
12.8
11.1
12.0
13.0
11.3
12.2
13.2
11.5
12.4
13.4
11.7
12.6
13.7
11.9
12.9
13.9
12.1
13.1
14.2
12.3
13.3
14.4
12.5
13.6
14.7
12.8
13.8
14.9
13.0
14.0
15.2
13.2
14.3
15.5
13.4
14.5
15.8
13.7
14.8
16.1
13.9
15.1
16.4
14.1
15.3
16.7
14.4
15.6
17.0
14.6
15.9
17.3
14.9
16.2
17.6
15.2
16.5
18.0
15.4
16.8
18.3
15.7
17.1
18.6
16.0
17.4
19.0
16.2
17.7
19.3
16.5
18.0
19.7
16.8
18.3
20.0
17.1
18.6
20.4
Mdian
12.2
12.4
12.6
12.9
13.1
13.4
13.6
13.8
14.1
14.3
14.6
14.8
15.1
15.4
15.6
15.9
16.2
16.5
16.8
17.2
17.5
17.8
18.2
18.5
18.9
19.2
19.6
20.0
20.4
20.8
21.2
21.6
22.0
22.4
Length
(cm)
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
Mdian
11.9
12.1
12.4
12.6
12.9
13.1
13.4
13.6
13.9
14.1
14.4
14.7
14.9
15.2
15.5
15.8
16.1
16.4
16.8
17.1
17.5
17.8
18.2
18.6
19.0
19.4
19.8
20.2
20.7
21.1
21.5
22.0
22.4
22.8
Girls` weight (kg)

-1 SD
-2 SD
-3 SD
10.9
10.0
9.2
11.1
10.2
9.4
11.4
10.4
9.6
11.6
10.6
9.8
11.8
10.9
10.0
12.0
11.1
10.2
12.3
11.3
10.4
12.5
11.5
10.6
12.7
11.7
10.8
12.9
11.9
10.9
13.2
12.1
11.1
13.4
12.3
11.3
13.7
12.5
11.5
13.9
12.8
11.7
14.2
13.0
12.0
14.5
13.3
12.2
14.7
13.5
12.4
15.0
13.8
12.6
15.3
14.0
12.9
15.6
14.3
13.1
15.9
14.6
13.4
16.3
14.9
13.7
16.6
15.2
13.9
17.0
15.5
14.2
17.3
15.8
14.5
17.7
16.2
14.8
18.0
16.5
15.1
18.4
16.8
15.4
18.8
17.2
15.7
19.2
17.5
16.0
19.6
17.8
16.3
19.9
18.2
16.6
20.3
18.5
16.9
20.7
18.9
17.3
-4 SD
8.4
8.6
8.8
9.0
9.1
9.3
9.5
9.7
9.8
10.0
10.2
10.4
10.5
10.7
10.9
11.1
11.3
11.5
11.8
12.0
12.2
12.4
12.7
12.9
13.2
13.5
13.7
14.0
14.3
14.5
14.8
15.1
15.4
15.6
Annexure - 2: Appetite Test

The appetite test has been standardised using Ready to use Therapeutic Food (RUTF). As RUTF is currently not
available, a method for testing appetite using local therapeutic food and based on experience from Madhya
Pradesh is presented below:
Appetite test feed

Based on the nutritional needs, the suggested method of testing of appetite is as follows:
For children 712 months: Offer 30-35 ml/kg of Catch-up diet. If the child takes more than 25 ml/kg
then the child should be considered to have good appetite.
For children >12 months: Feed locally prepared with the following food items may be offered.
a. Roasted ground nuts 1000 gm
b. Milk powder 1200 gm
c. Sugar 1120 gm
d. Coconut oil 600 gm
How to prepare
Take roasted ground nuts and grind them in mixer

Grind sugar separately or with roasted ground nut
Mix ground nut, sugar, milk powder and coconut oil
Store them in air tight container
Prepare only for one week to ensure the quality of feed
Store in refrigerator
How to do appetite test?
Do the test in a separate quiet area.

Explain to the mother/caregiver how the test will be done.
The mother/caregiver should wash her hands.
The mother sits comfortably with the child on her lap and offers therapeutic food.
The child should not have taken any food for the last 2 hrs.
The test usually takes a short time but may take up to one hour.
The child must not be forced to take the food offered.
When the child has finished, the amount taken is judged or measured.
Amount of local therapeutic feed that a child with SAM should take to PASS the appetite test.
Body weight (kg)
Less than 4 kg
4-7 kg
7-10 kg
Weight in grams
15 g or more
25 g or more
33 g ore more
91
Annexure - 3: Antibiotics Reference Card

STATUS
ANTIBIOTICS
All admitted cases without any complications or Inj. Ampicillin 50 mg/kg/dose 6 hourly and Inj.
complications other than shock, meningitis or Gentamicin 7.5 mg/kg once a day for 7 days.
dysentery
A
dd Inj. Cloxacillin 100 mg/kg day 6 hourly
ifstaphylococcal infection is suspected.
Revise therapy based on sensitivity report.
For septic shock or worsening/ no improvement in Give third generation cephalosporins like Inj.
initial hours
Cefotaxime 150 mg/kg/day in 3 divided doses
or Ceftriaxone 100 mg/kg/day in 2 divided doses
along with Inj. Gentamicin 7.5 mg/kg in single
dose.

Meningitis
Dysentery
92
(If child is not passing urine, gentamicin may

accumulate in the body and cause deafness. Do
not give second dose until child is passing urine.)
IV Cefotaxime 50mg/kg/dose 6hrly or Inj.
Ceftriaxone 50 mg/kg 12 hourly plus Inj. Amikacin
15 mg/kg/day divided in 8hrly doses.
Give Ciprofloxacin 15mg/kg in two divided doses
per day for 3 days. If child is sick or has already
received ciprofloxacin, give Inj. Ceftriaxone 100
mg/kg once a day or divided in 2 doses for 5 days.
Annexure - 4: Daily Ward Feeding Chart

Date:__________________ Ward: _______________________
Name of Child
Number
feeds (ml)
Starter diet
Amount/
feed (ml)
Starter diet (total ml) needed for 24 hours

Amount needed for __ hours*
Amount to prepare (round up to whole litre)
Total (ml)
Catch-up diet
Number
Amount/
Total (ml)
feeds
feed
Catch-up diet (total ml)

needed for 24 hours
Amount needed for _
hours*
Amount to prepare (round
up to whole litre)
* Divide daily amount by the number of times food is prepared each day. For example, if feeds are prepared every
12 hours, divide daily amount by 2.
93
Annexure - 5: 24 Hour Food Intake Chart

Name: _________ Hospital ID Number: ______ Admission weight (kg): _____ Todays weight (kg): _________
Date: __________ Type of Feed: _____________ Give: ____________________ Feeds of ________________ ml
Time
a. Amount
offered (ml)
b. Amount
left in cup
(ml)
Column Total
c. Amount
taken orally
(a-b)
d. Amount e. Estimated
f. Watery
taken by NG,
amount
diarrhoea (if
if needed
vomited (ml) present, yes)
(ml)
c.
d.
Total yes:
Total volume taken over 24 hours = amount taken orally (c) + amount taken by NG (d) - total
amount vomited (e) = _______ ml
Instructions for completing chart

In the spaces above the chart, record the childs name, hospital ID number, admission weight and todays weight.
On the top row of the chart, record the date, the type of feed to be given, the number of feeds per day, and the
amount to give at each feed.
At each feed:
In the left column, record the time that the feed is given. Then record in each column as follows:
a. Record the amount of feed offered.
b. After offering the feed orally, measure and record the amount left in cup.
c. Subtract the amount left from the amount offered to determine the amount taken orally by the child.
d. If necessary, give the rest of the feed by NG tube and record this amount.
e. Estimate and record any amount vomited (and not replaced by more feed).
f. Ask whether the child had watery diarrhoea (any loose stool) since last feed. If so, record yes.
94
At the end of 24 hours:
Total the amount of feed taken orally (column c).

Total the amount of feed taken by NG tube, if any (column d).
Total the estimated amount lost through vomit (column e).
Add the totals taken orally and by NG tube. Then subtract any loss from vomiting. The result is the total
volume taken over 24 hours. Record this at the bottom of the 24-Hour Food Intake Chart and on the Daily
Care page.
95
Annexure - 6: Weight Chart

Name of the Child ______________Weight on admission____________ Weight on discharge_______________
0
.5
.5
.5
0
0
Day
96
10
11
12
13
14
15
16
Annexure - 7: Daily Care Chart

Name__________________________ Hospitals ID Number_______________ Date of admission_____________
Days in hospital
Date
Daily weight (kg)
Weight gain (g/kg)
Week 1
1 2 3
Week 2
7 8 9
Week 3
10 11 12 13 14 15 16 17 18 19 20
Calculate
daily after
one Catchup diet.
Oedema 0 + ++ +++
Diarrhoea/vomit
0/D/V FEED PLAN:
Type
feed No. of feeds daily
Total volume taken
(ml)
Antibiotics
(Name and dose)
List prescribed antibiotics in left column. Allow one row for each daily dose. Draw a box around days/times
that each drug should be given. Initial when given.
Folic acid
Vitamin A
Multivitamin syrup
Iron
Potassium
Magnesium
97
Annexure 8: Starter Diet Reference Card

Weight of child
(kg)
2.0
2.2
2.4
2.6
2.8
3.0
3.2
3.4
3.6
3.8
4.0
4.2
4.4
4.6
4.8
5.0
5.2
5.4
5.6
5.8
6.0
6.2
6.4
6.6
6.8
7.0
7.2
7.4
7.6
7.8
8.0
8.2
8.4
8.6
8.8
9.0
9.2
9.4
9.6
9.8
10.0
Volume of Starter diet per feed (ml)a

Every 3 hoursc
Every 4 hours (6
Every 2 hoursb (12
feeds)
(8 feeds)
feeds)
20
30
45
25
35
50
25
40
55
30
45
55
30
45
60
35
50
65
35
55
70
35
55
75
40
60
80
40
60
85
45
65
90
45
70
90
50
70
95
50
75
100
55
80
105
55
80
110
55
85
115
60
90
120
60
90
125
65
95
130
65
100
130
70
100
135
70
105
140
75
110
145
75
110
150
75
115
155
80
120
160
80
120
160
85
125
165
85
130
170
90
130
175
90
135
180
90
140
185
95
140
190
95
145
195
100
145
200
100
150
200
105
155
205
105
155
210
110
160
215
110
160
220
Daily total (130

(ml/kg)
80% of daily
totala (minimum)
260
286
312
338
364
390
416
442
468
494
520
546
572
598
624
650
676
702
728
754
780
806
832
858
884
910
936
962
988
1014
1040
1066
1092
1118
1144
1170
1196
1222
1248
1274
1300
210
230
250
265
290
310
335
355
375
395
415
435
460
480
500
520
540
560
580
605
625
645
665
685
705
730
750
770
790
810
830
855
875
895
915
935
960
980
1000
1020
1040
Volumes in these columns are rounded to the nearest 5 ml.

Feed 2-hourly for at least the first day. Then, when little or no vomiting, modest diarrhoea (<5 watery stools per day), and finishing most feeds,
change to 3-hourly feeds.
c
After a day on 3-hourly feeds. If no vomiting, less diarrhoea, and finishing most feeds, change to 4-houly feeds.
a
98
Annexure 9: Starter Diet Reference Card for Children with Severe

Oedema
Volume of Starter diet for children with severe (+++) oedema
Weight with
+++ oedema (kg)
3.0
3.2
3.4
3.6
3.8
4.0
4.2
4.4
4.6
4.8
5.0
5.2
5.4
5.6
5.8
6.0
6.2
6.4
6.6
6.8
7.0
7.2
7.4
7.6
7.8
8.0
8.2
8.4
8.6
8.8
9.0
9.2
9.4
9.6
9.8
10.0
10.2
10.4
10.6
10.8
11.0
11.2
11.4
11.6
11.8
12.0
Volume of Starter diet per feed (ml)a

Every 3 hoursc
Every 4 hours (6
Every 2 hoursb (12
feeds)
(8 feeds)
feeds)
25
40
50
25
40
55
30
45
60
30
45
60
30
50
65
35
50
65
35
55
70
35
55
75
40
60
75
40
60
80
40
65
85
45
65
85
45
70
90
45
70
95
50
75
95
50
75
100
50
80
105
55
80
105
55
85
110
55
85
115
60
90
115
60
90
120
60
95
125
65
95
125
65
100
130
65
100
135
70
105
135
70
105
140
70
110
145
75
110
145
75
115
150
75
115
155
80
120
155
80
120
160
80
125
165
85
125
165
85
130
170
85
130
175
90
135
175
90
135
180
90
140
185
95
140
185
95
145
190
95
145
195
100
150
195
100
150
200
Daily total (130

(ml/kg)
80% of daily
totala (minimum)
300
320
340
360
380
400
420
440
460
480
500
520
540
560
580
600
620
640
660
680
700
720
740
760
780
800
820
840
860
880
900
920
940
960
980
1000
1020
1040
1060
1080
1100
1120
1140
1160
1180
1200
240
255
270
290
305
320
335
350
370
385
400
415
430
450
465
480
495
510
530
545
560
575
590
610
625
640
655
670
690
705
720
735
750
770
785
800
815
830
850
865
880
895
910
930
945
960
Volumes in these columns are rounded to the nearest 5 ml.

Feed 2-hourly for at least the first day. Then, when little or no vomiting, modest diarrhoea (<5 watery stools per day), and finishing most feeds,
change to 3-hourly feeds.
c
After a day on 3-hourly feeds. If no vomiting, less diarrhoea, and finishing most feeds, change to 4-houly feeds.
a
99
Annexure 10: Catch-up Diet (Free Feeding) Reference Chart

Weight of child
(kg)
2.0
2.2
2.4
2.6
2.8
3.0
3.2
3.4
3.6
3.8
4.0
4.2
4.4
4.6
4.8
5.0
5.2
5.4
5.6
5.8
6.0
6.2
6.4
6.6
6.8
7.0
7.2
7.4
7.6
7.8
8.0
8.2
8.4
8.6
8.8
9.0
9.2
9.4
9.6
9.8
10.0
Range of volumes per 4-hourly feed of

Catch up diet (6 feeds daily)
Minimum (ml)
Maximum (ml)a
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145
150
155
160
165
170
175
180
185
190
195
200
205
210
215
220
225
230
235
240
245
250
75
80
90
95
105
110
115
125
130
140
145
155
160
170
175
185
190
200
205
215
220
230
235
240
250
255
265
270
280
285
295
300
310
315
325
330
335
345
350
360
365
Range of daily volumes of Catch up

diet
Minimum (150 ml/ Maximum (220 ml/
kg/day)
kg/day)
300
440
330
484
360
528
390
572
420
616
450
660
480
704
510
748
540
792
570
836
600
880
630
924
660
968
690
1012
720
1056
750
1100
780
1144
810
1188
840
1232
870
1276
900
1320
930
1364
960
1408
990
1452
1020
1496
1050
1540
1080
1588
1110
1628
1140
1672
1170
1716
1200
1760
1230
1804
1260
1848
1290
1892
1320
1936
1350
1980
1380
2024
1410
2068
1440
2112
1470
2156
1500
2200
Volumes per feed are rounded to the nearest 5 ml.

If the childs weight is between the weights given on the Catch up diet Reference Card, use the range
for the nearest lower weight.
100
Annexure - 11: Homemade Alternative Food Items

Example of homemade culturally acceptable alternatives to Catch-up diet.
1. Khichri
Ingredients
Rice
Lentils (dal)
Edible Oil
Potato
Pumpkin
Leafy Vegetable
Onion (2 medium size)
Spices (ginger, turmeric, coriander powder)
Water
Total Calories/kg
Total Protein/kg
Amount for 1 Kg Khichri

120 gms
60 gms
70 ml
100 gms
100 gms
80 gms
50 gms
According to taste
1000 ml
1,442 kcal
29.6 gms
2. Halwa
Ingredients
Wheat flour (atta)
Lentils (dal) / Besan / Moong dal powder
Oil
Jaggery / Gur / Sugar
Water to make a thick paste
Total Calories/kg
Total Calories/100 gm
Total Protein/kg
Total Protein /100 gm
Amount for 1 Kg Khichri

200 gms
100 ml
100 ml
125 gms
600 ml
2404 kcal
240 kcal
50.5 gms
5.05 gm
101
Annexure - 12: Composition of Concentrated Electrolyte Mineral

Solution
Weigh the following ingredients and make up to 2500 ml. Add 20 ml of electrolyte/mineral solution to 1000 ml
of milk feed.
Potassium Chloride: KCl

Tripotassium Citrate: C6H5K3O7.H2O
Magnesium Chloride: MgCl2.6H2O
Zinc Acetate: Zn(CH3COO)2.2H20
Copper Sulphate: CuSO4.5H2O
Water: make up to 2500 ml
Quantity (g)
224
81
76
8.2
1.4
Molar content of 20 ml
24 mmol
2 mmol
3 mmol
300 mol
300 mol
Note: Add selenium if available (sodium selenate 0.028 g, NaSeO410H20) and iodine (potassium iodide 0.012 g, KI) per 2500 ml.
Preparation: Dissolve the ingredients in cooled boiled water. Store the solution in sterilised bottles in the fridge
to retard deterioration. Discard if it turns cloudy. Make fresh each month.
If the preparation of this electrolyte/mineral solution is not possible and if premixed sachets (see Step 4) are not
available, give K, Mg and Zn separately:
Potassium
Make a 10% stock solution of potassium chloride (100 g KCl in 1 litre of water):
For oral rehydration solution, use 40 ml of stock KCl solution instead of 33 ml electrolyte/mineral solution.
For milk feeds, add 22.5 ml of stock KCl solution instead of 20 ml of the electrolyte/ mineral solution.
If KCl is not available, give syrup K (4 mmol/kg/day).
Magnesium
Give 50% magnesium sulphate intramuscularly once (0.3 ml/kg up to a maximum of 2ml).
Zinc
Make a 1.5% solution of zinc acetate (15 g zinc acetate in 1 litre of water). Give the 1.5% zinc acetate solution
orally, 1 ml/kg/day.
102
Annexure - 13:
Preparation of Rehydration
Malnourished Children
Solution
for
Composition of Rehydration Solution

Component
Glucose
Sodium
Potassium
Chloride
Citrate
Magnesium
Zinc
Copper
Osmolarity
Concentration (mmol/l)
125
45
40
70
7
3
0.3
0.045
300
Oral Rehydration Solution

The recipe using the new ORS formulation* for preparing Rehydration Solution for malnourished children is
given below:
Ingredient
Water (boiled and cooled)
WHO-ORS (new formulation)
Sugar
Electrolyte-mineral solution
Amount
1700 ml
One 1000 ml-packet
40 g
35 ml (composition given in Annexure12.)
* 2.6 g sodium chloride, 2.9 g trisodium citrate dihydrate, 1.5 g potassium chloride and 13.5 g glucose.
103
Annexure - 14: Management of Continuing Diarrhoea

Persistent diarrhoea: Diarrhoea is common in severe malnutrition but with cautious refeeding, it should
subside during the first week. In the rehabilitation phase, the poorly formed loose stools are not a cause
for concern, provided the childs weight gain is satisfactory. If the child has persistent diarrhoea, screen for
non-intestinal infections and treat appropriately. Diarrhoea due to lactose intolerance is suspected if child
is having large volume, loose stools with perianal excoriation. If loose stool is persisting manage with low
lactose diet as described in section persistent diarrhoea. Continue breast feeding and try to give feeds with
low lactose initially and subsequently change to lactose free options if diarrhoea persists. Details of different
type of low lactose and lactose free diets are given in step-7. Suspect and treat associated infections and
underlying conditions like UTI, Pneumonia, Fungal infections HIV etc.
Osmotic diarrhoea- may be suspected if diarrhoea worsens substantially in young children with diarrhoea
who are given Starter diet prepared with milk powder, which has slightly higher osmolarity. In these cases
low osmolar cereal based Starter diet may help and then Catch-up diet may be introduced gradually.
Giardiasis & Amoebiasis: Examine stool by microscopy. Treat with metronidazole if positive (7.5 mg/kg
8-hrly for 7 days).
104
Annexure - 15: Severe Anaemia in Malnourished Children

A blood transfusion is required if:
Hb is less than 4g/dl or packed cell volume is less than 12 g/dl; or
If there is respiratory distress and Hb is between 4 and 6 g/dl.
If haemoglobin is less than 40 g/l, (or packed cell volume is less than 12%), give a packed cell/blood
transfusion.
1. Stop all oral intake and IV fluids during the transfusion.
2. Look for signs of congestive heart failure such as fast breathing, respiratory distress, rapid pulse, engorgement
of the jugular vein, cold hands and feet, cyanosis of the fingertips and under the tongue.
3. Give 10 ml/kg of packed cells or whole fresh blood. If there are signs of congestive heart failure, be ready to
give packed cells (5-7 ml/kg) instead of whole blood.
4. Give Furosemide (1 mg/kg, given by IV) after starting BT.
5. If there are no signs of congestive heart failure, transfuse whole fresh blood at 10 ml/kg slowly over 3 hours.
If there are signs of heart failure, give 5-7 ml/kg packed cells over
3 hours instead of whole blood.
6. Look for transfusion reactions.
105
Annexure - 16:
Examples of Simple Toys (Adapted from WHO
Guideline)
Ring on a string (from 6 months)
Thread cotton reels and other small objects (e.g, cut from the
neck of plastic bottles) on to a String. Tie the string in a ring.
Leaving a long piece of string hanging.
Rattle (from 12 months)

Cut long strips of plastic from coloured plastic bottles. Place them
in a small transparent plastic bottle and glue the top on firmly.
Drum (from 12 months) Any tin with a tightly fitting lid.

Mirror (from 18 months) A tin lid with no sharp edges.
In-and-out toy (from 9 months)

Any plastic or cardboard container and small
objects (not small enough to be swallowed).
Posting bottle (from 12 months)

A large transparent plastic with a small neck and small long objects
that fit through the neck (not small enough to be swallowed).
Blocks (from 9 months)

Small blocks of wood. Smooth the surfaces
with sandpaper and paint in bright colours,
if possible.
Push-along toy (from 12 months)

Make a hole in the centre of the base and lid of a
cylindrical-shaped tin. Thread a piece of wire (about 60
cm long) through each hole and tie the ends inside the
tin. Put some metal bottle tops inside the tin and close
the lid.
Pull-along toy (from 12 months)

As above, except that string is used instead of wire.
Doll (from 12 months)
Cut out two doll shapes from a piece of cloth and sew the edges
together, leaving a small opening. Turn the doll inside-out and
stuff with scraps of materials. Stitch up the opening and sew or
draw a face on the doll.
Stacking bottle tops (from 12 months)

Cut at least three identical round plastic bottles in half
and stack them.
Nesting toys (from 9 months)

Cut off the bottom of two bottles of identical shape, but
different size. The smaller bottle should be placed inside
the large bottle.
Book (from 18 months)

Cut out three rectangular-shaped piece of the same size
from a cardboard box. Glue or draw a picture on both sides
of each piece. Make two holes down one side of each piece
and thread string through to make a book.
Puzzle (form 18 months)
Draw a figure (e.g, a doll) in a crayon
on a square-or rectangular-shaped piece
of cardboard. Cut the figure in half or
quarters.
106
Annexure 17: Examples of Language and Motor Activities with

Children
Language activities
At each play session:
Teach local songs and games using the finger and toes.
Encourage the child to laugh.
Describe what s(he) is doing , and repeat what s(he) says.
Teach action words with activities e.g. bang bang as s(he) beats a drum, bye bye as s(he) waves etc.
Teach words at every opportunity.
Motor activities
Encourage the child to perform the next motor milestones. For example:
Bounce the child up and down and hold him/her under the arms so that the feet support the child weight.
Prop the child up , roll toys out of reach, encourage the child to crawl after them.
Hold hand and help the child to walk.
When starting to walk alone, give a push-along and later pullalong toy.
Activities with toys

Simple toys can easily be made from readily available materials. These toys can be used for a variety of different
motor activities:
Ring on a string
Swing the ring within the reach and encourage the child to go for it.
Suspend ring over the crib and encourage the child to knock it and make it swing.
Let child explore the ring, then place it a little distance from the child with the string stretched towards him/
her and within reach.
Teach the child to retrieve the ring by pulling on the string. Sit the child on the lap, then holding the string,
lower the ring towards the ground. Teach child to get the ring by pulling up on the string vertically. Also
teach child to dangle the ring.
Rattle and drum
Let the child explore rattle. Show him/her how to shake it saying shake shake.
Encourage the child to shake the rattle by saying shake but without demonstrating.
Teach child to beat drum with a rattle saying bang-bang.
Roll drum out of reach and let child crawl after it , saying fetch-it.
Get child to say bang-bang as s(he) beats drum.
In and Out toys with blocks
Let the child explore blocks and container. Put blocks into container and shake it then teach child to take
them out, one at a time , saying out and give me.
107
Teach the child to take out blocks by turning container upside down.
Teach the child to take out blocks by turning containers upside down.
Teach the child to hold the blocks in hand and bang them together.
Let the child put blocks in and out of containers saying in and out.
Cover blocks with container saying where are they, they are under the cover. Let the child find them. Then
hide them under two and then three covers.
Turn the containers upside down and teach the child to put blocks on top of the container.
Teach the child to stack blocks; first stack two then gradually increase the number. Knock them down saying
up up then down. Make a game of it.
Line up blocks horizontally: first line up two then more; teach the child to push them along making train or
noises.
Teach to sort blocks by colour, first two then more, and teach high and low building make up games.
Posting bottle
Put an object in the bottle, shake it and teach the child to turn the bottle upside down and to take the object
out saying can you get it? Then teach the child to put the object in and take it out. Later try with several
objects.
Stacking bottle tops
Let the child play with two bottle tops then teach the child to stack them saying - I am going to put one on
top of the other. Later, increase the number of tops. Older children can sort tops by colour.
Books
Sit the child on your lap. Teach the child to turn the pages of the book and to point to the pictures. Then
teach the child to point the pictures that you name. Talk about the pictures. Show the child picture of the
simple familiar objects, people and animals.
Dolls
Encourage the child to hold and cuddle the doll. Sing songs whilst rocking the child.
Teach the child to identify his/her own body parts and those of the doll when you name them. Teach older
children to name their own body parts.
Put the doll in a box as a bed and give sheets , teach the words bed and sleep and describe the games you
play.
108
109
Date
Record of Visit
Dose
DTP1
OPV1
BCG
OPV0
OPV2
DTP2
Measles
OPV3
DTP3
Vitamin A - Bring Child for a Dose Every Six Months

Immunization GIven
Next Immunization
Trick or record date given:
Date
Does (s) needed
Vitamin A - Bring Child for a Dose Every Six Months

Next Planned Follow-Up
Date
Place
% wt-for ht
Fast or difficult breathing
Swelling in feel, hands,
Record of Visit
Hight/length
Weight
Convulsion (fits)
Fever (feels hot)
Date
day or blood stool
breastfeed
Not able to drink or breastfeed

Next Planned Follow-Up
Date
Place
Diarrhoea more than 1
Not able to drink or
Danger Signs - Bring Child for Immediate Care if:
Annexure - 18: Sample Discharge Card
Weight (kg)
Ht/length (cm)
% weight for height
Other :
Give ___________________________________ iron twick daily for 1 month.
Give 1 tablet to folic acid once daily ofr __________________ days.
Give _________________ drops______________ (multivitamin preparation) with food once daily.
Medications and SUpplements
How much and how often ?
What to feed? (Include recipe if needed)
Discharge
Admission
Date
Address: _________________________________________________________________________
Chaild Name:____________________________________ M F Date of Birth:___________________
For Child Recovering from Severe Malnutrution Hospital Name
DISCHARGE CARD
Annexure - 19: Checklist Proforma for Monitoring Food Preparation

Observe
Are ingredients for the recipes available?
Is the correct recipe used for the ingredients that are
available?
Are ingredients stored appropriately and discarded at
appropriate times?
Are containers and utensils kept clean?
Does kitchen staff (or those preparing feeds) wash hands
with soap before preparing food?
Are the recipes for Starter diet and Catch up diet followed
exactly? (If changes are made due to lack of ingredients,
are these changes appropriate?)
Are measurements made exactly with proper measuring
utensils (e.g., correct scoops)?
Are ingredients thoroughly mixed (and cooked, if
necessary)?
Is the appropriate amount of oil mixed in (i.e., not left
stuck in the measuring container)?
Is correct amount of water added to make up a litre of
formula? (Staff should not add a litre of water, but just
enough to make a litre of formula.)
Is food served at an appropriate temperature? Is the food
consistently mixed when served (i.e., oil is mixed in, not
separated)?
Are correct amounts put in the dish for each child?
Is leftover prepared food discarded promptly?
110
Yes
No
Comments
Annexure - 20: Checklist for Monitoring Ward Procedures

Observe
A. Feeding
Are correct feeds served in correct amounts?
Are feeds given at the prescribed times, even on nights
and weekends?
Are children held and encouraged to eat (never left alone
to feed)?
Are children fed with a cup (never a bottle)?
Is food intake (and any vomiting/diarrhoea) recorded
correctly after each feed?
Are leftovers recorded accurately?
Are amounts of Starter diet kept the same throughout the
initial phase, even if weight is lost?
After transition, are amounts of Catch-up diet given freely
and increased as the child gains weight?
B. Warming
Is the room kept between 25 - 30 C (to the extent
possible)?
Are blankets provided and children kept covered at night?
Are safe measures used for re-warming children? Are
temperatures taken and recorded correctly?
C. Weighing
Are scales functioning correctly? Are scales standardized
weekly?
Are children weighed at about the same time each day?
Are they weighed about one hour before a feed (to the
extent possible)?
Do staff adjust the scale to zero before weighing? Are
children consistently weighed without clothes?
Do staff correctly read weight to the nearest division of
the scale?
Do staff immediately record weights on the childs case
sheets?
Are weights correctly plotted on the Weight Chart?
D. Giving antibiotics, medications, supplements
Are antibiotics given as prescribed (correct dose at correct
time)?
When antibiotics are given, do staff immediately make a
notation on the daily care charts?
Is folic acid given daily and recorded?
Is vitamin A given according to schedule?
Yes
No
Comments
111
Is a multivitamin given daily and recorded?

After children are on Catch-up diet for 2 days, is the correct.
Dose of iron given twice daily and recorded?
E. Ward environment
Are surroundings welcoming and cheerful?
Are mothers offered a place to sit and sleep?
Are mothers taught/ encouraged to be involved in care?
Are staffs consistently courteous?
As children recover, are they stimulated and encouraged
to move and play?
112
Annexure - 21: Checklist for Monitoring Hygiene

Observe
Hand washing
Are there working hand washing facilities in the ward?
Does staff consistently wash hands thoroughly with soap?
Are their nails clean?
Do they wash hands before handling food? Do they wash
hands between each patient?
Mothers cleanliness
Do mothers have a place to bathe, and do they use it?
Do mothers wash hands with soap after using the toilet or
changing diapers?
Do mothers wash hands before feeding children?
Bedding and laundry
Is bedding changed every day or when soiled/ wet?
Are diapers, soiled towels and rags, etc. stored in bag, then
washed or disposed off properly?
Is there a place for mothers to do laundry? Is laundry done
in hot water?
General maintenance
Are floors swept?
Is trash disposed off properly?
Is the ward kept as free as possible of insects and rodents?
Food storage
Are ingredients and food kept covered and stored at the
proper temperature?
Are leftovers discarded?
Dishwashing
Are dishes washed after each meal?
Are they washed in hot water with soap?
Toys
Are toys washable? Are toys washed regularly, and after
each child uses them?
Yes
No
Comments
113
Annexure - 22: Equipment and Supplies

Ward Equipment/Supplies
Glucometer
Thermometers
(preferably low-reading)
Weighing scales Infantometer
Stadiometer (to measure standing
height)
Haemoglobinometer
IV cannulas IV Sets
Bottles or bags
Paediatric nasogastric tubes Safe,
homemade toys
Clock
Calculator
Pharmacy Equipment/Supplies
ORS
Electrolytes
and
minerals:
Potassium chloride
Magnesium chloride/Sulfate Zinc
acetate/sulfate
Iron syrup (e.g., ferrous fumarate)
Multivitamin without iron Folic
acid
Vitamin A syrup Glucose (or
sucrose) IV Fluids
Ringers lactate solution with 5%
glucose*
0.45% (half-normal) saline with 5%
glucose*
0.9% saline (for soaking eye pads)
Drugs
Amoxicillin
/Ampicillin/
Benzylpenicillin
Chloramphenicol Cotrimoxazole
Ceftriaxone
Gentamicin Metronidazole
Tetracycline or chloramphenicol
eye drops
Atropine eye drops
Kitchen Equipment/Supplies
Dietary scales able to weigh to 5 g
Electric blender or manual whisks
Large containers and spoons for
mixing/cooking feed for the ward
Feeding cups, saucers, spoons
Measuring cylinders (or
suitable utensils for measuring
ingredients and leftovers)
Jugs
(1-litre
and
2-litre)
Refrigeration
Supply for making Starter diet and
Catch-up diet: Dried skimmed
milk, whole
dried milk, fresh whole milk, Sugar
Puffed rice flour Vegetable oil
Clean water supply
Foods similar to those used
in homes (for teaching/use in
transition to home foods)
In addition, Nutrition Rehabilitation Centres require kitchen equipment. Also equipment and supplies will vary depending on the level of care.
Refer to Operational Guidelines on Facility based Management of Children with Severe Acute Malnutrition for further information.
114
Annexure - 23: Calculate Case Fatality Rate for the Ward

In a big ward (for example, with 100 admissions per month), calculate the case-fatality rate once each month if
possible. Also calculate the case-fatality rate monthly in any ward where the current rate is poor or unacceptable.
This will allow improvements to be seen rapidly.
In a small ward (for example, 10 cases per month), or in a ward where the case-fatality rate is moderate or better,
the case fatality rate may be calculated less often (e.g., every 3 months).
To calculate the case-fatality rate:
Determine the number of patients admitted to the severe malnutrition ward in the past month(s).
Determine the number of those patients who died. (Wait to count deaths until the outcomes for the patients
are known. For example, wait until mid-November to count deaths among patients admitted in October.)
Divide the number of deaths by the number of patients and express the result as a percentage.
For the purposes of this training course, a case-fatality rate of:
>20% is unacceptable
11-20% is poor
5-10% is moderate
<5% is acceptable
Carefully review the circumstances of deaths and identify and solve related problems in order to reduce the
case-fatality rate.
The objective of a severe malnutrition ward should be to achieve a case-fatality rate of less than 5%.
115
Annexure - 24: Guidance Table to Identify Target Weight

Weight on admission*
4.1
4.3
4.5
4.7
4.9
5.1
5.3
5.5
5.7
5.9
6.1
6.3
6.5
6.7
6.9
7.1
7.3
7.5
7.7
7.9
8.1
8.3
8.5
8.7
8.9
9.1
9.3
9.5
9.7
9.9
10.1
10.3
10.5
Target weight: 15%

weight gain
4.7
4.9
5.2
5.4
5.6
5.9
6.1
6.3
6.6
6.8
7.0
7.2
7.5
7.7
7.9
8.2
8.4
8.6
8.9
9.1
9.3
9.5
9.8
10.0
10.2
10.5
10.7
10.9
11.2
11.4
11.6
11.8
12.1
Weight on admission*
* Or weight, free of oedema.
116
10.7
10.9
11.1
11.3
11.5
11.7
11.9
12.1
12.3
12.5
12.7
12.9
13.1
13.3
13.5
13.7
13.9
14.1
14.3
14.5
14.7
14.9
15.1
15.3
15.5
15.7
15.9
16.1
16.3
16.5
16.7
16.9
17.1
Target weight: 15%

weight gain
12.3
12.5
12.8
13.0
13.2
13.5
13.7
13.9
14.1
14.4
14.6
14.8
15.1
15.3
15.5
15.8
16.0
16.2
16.4
16.7
16.9
17.1
17.4
17.6
17.8
18.1
18.3
18.5
18.7
19.0
19.2
19.4
19.7
Annexure - 25:
Feeding Recommendations for Children as per
IMNCI
Up to 6 months
Breast feed as often
as the child wants,
day and night, at
least 8 times in 24
hours.
Do not give any
other foods or
fluids not even
water
Guidelines
6 to 12 months
12 months - 2 years
2 years and older
Breast feed as often as
Breast feed as often as Give family foods at
the child wants.
the child wants
3 meals each day.
Give at least one katori Offer food from the Also twice daily,
serving* at a time:
family pot
give nutritious food
Give
at
least
1
between
meals,
Mashed roti/
rice/
katori
serving*
at
a
time
such
as:
banana
/
bread / biscuit
of:
biscuit
/
cheeku/
mixed in sweetened
mango/papaya as
undiluted milk
Mashed roti/ rice/
snacks
OR
bread mixed in thick
dal with added
Mashed roti/ rice/
ghee/ oil or khichri
bread mixed in thick
with added oil/
dal with added
ghee. Add cooked
ghee/ oil or khichri
vegetables also
with added oil/
in the servings
ghee. Add cooked
OR
vegetables also
in the servings
Mashed roti/ rice/
OR
bread/ biscuit
mixed in sweetened
Sevian/dalia/ halwa
undiluted milk
/ kheer prepared
OR
in milk or any
cereal porridge
Sevian/dalia/ halwa/
cooked in milk
kheer prepared
OR
in milk or any
cereal porridge
Mashed boiled/ fried
cooked in milk
potatoes
OR
Also give nutritious food
between meals, such
Mashed boiled/ fried
as: banana / biscuit /
potatoes
cheeko/ mango/ papaya Also give nutritious food
as snacks
between meals, such
as: banana / biscuit /
cheeku/ mango/ papaya
*3 times per day if breast feed; 5
as snacks
times per day if not breast
* 5 times per day
Remembers:
Remembers:
C o n t i n u e Keep the child in
lap and feed with
breastfeeding if the
own hands
child is sick.

Wash you own
childs hands with
and water every
before feeding
Remembers:
Remembers:
Ensure that the
that
your Ensure
child finishes the
the
child finishes the
your
serving
serving

Teach your child
and W a s h y o u r c h i l d s
wash his hands
hands with soap and
soap
with soap and
water every time before
time
water every time
feeding
117

Participant Manual Fbcsa Malnutrition

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Participant Manual Fbcsa Malnutrition

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Participant Manual

Ministry of Health and Family Welfare

Purpose of this Training Manual

Additional Secretary &

Dr. Rakesh Kumar, IAS

Under National Rural Health Mission, Nutrition Rehabilitation Centres (NRCs)

Dr. Rakesh Kumar

Dr. S. Aneja, Kalawati Saran Childrens Hospital

Dr. Praveen Kumar, Kalawati Saran Childrens Hospital

Dr. Nidhi Chaudhary, WHO India

Dr. Dheeraj Shah, University College of Medical Sciences, New Delhi

Dr. Sriram Krishnamurthy, JIPMER, Puducherry

Reviewers for the Manual:

Dr. Sila Deb, Deputy Commissioner Child Health, MOHFW, GoI

Dr. Deepti Agarwal, Consultant Child Health, MOHFW, Goi

Dr. Shinjini Bhatnagar, AIIMS, New Delhi

Ms. Anuja Agrawala, AIIMS, New Delhi

Dr. Panna Choudhary, Past President, Indian Academy of Paediatrics

Dr. V.K. Anand, UNICEF India

Dr. Piyush Gupta, University College of Medical Sciences, New Delhi

Dr. T. Sundararaman, National Health Systems Resource Centre, New Delhi

Anti retro viral

Anti retroviral treatment

Accredited Social Health Activist

Integrated Management of Newborn and Childhood Illnesses

Human Immunodeficiency Virus

Mother and Child Protection Card

Mid-Upper Arm Circumference

National AIDS Control Organisation

Nutrition Rehabilitation Centre

National Family Health Survey

Oral Rehydration Solution

Severe Acute Malnutrition

Supplementary Suckling Technique

Weight -for- length

World Health Organization

SECTION-2: PRINCIPLES OF CARE5

Recognize signs of severe malnutrition

SECTION-3: INITIAL MANAGEMENT 

SECTION-4: INITIAL FEEDING 

Prepare Starter diet 

SECTION-5: REHABILITATIVE PHASE 

Step 8-Catch-up Growth 

SECTION-6: INVOLVING MOTHERS IN CARE 

6.1 Organize facility routine to encourage mothers involvement

SECTION-7: PREPARE FOR DISCHARGE & FOLLOW-UP 

Criteria for discharge 

SECTION-8: MANAGEMENT OF SAM IN INFANTS LESS THAN 6 MONTHS OF AGE 

SECTION-9: MANAGEMENT OF SAM IN HIV EXPOSED/HIV INFECTED CHILDREN 

SECTION-10: MONITORING AND PROBLEM SOLVING 

Use a process to identify and solve problems 

Annexure - 1 : WHO Growth Reference Charts 

Child with Severe Wasting 

WHO Classification of Vitamin a Deficiency 

1.2 Measuring Undernutrition

1.3 Types of Undernutrition

identify three nutrition conditions: underweight,

Participant Manual - Facility Based Care of Severe Acute Malnutrition

in turn affects economic productivity at national level.

Severe Acute Malnutrition (SAM)

SECTION-2: PRINCIPLES OF CARE5

Recognize signs of severe malnutrition

SECTION-3: INITIAL MANAGEMENT

SECTION-4: INITIAL FEEDING

Prepare Starter diet

SECTION-5: REHABILITATIVE PHASE

Step 8-Catch-up Growth

SECTION-6: INVOLVING MOTHERS IN CARE

6.1 Organize facility routine to encourage mothers involvement

SECTION-7: PREPARE FOR DISCHARGE & FOLLOW-UP

Criteria for discharge

SECTION-8: MANAGEMENT OF SAM IN INFANTS LESS THAN 6 MONTHS OF AGE

SECTION-9: MANAGEMENT OF SAM IN HIV EXPOSED/HIV INFECTED CHILDREN

SECTION-10: MONITORING AND PROBLEM SOLVING

Use a process to identify and solve problems

Annexure - 1 : WHO Growth Reference Charts

Child with Severe Wasting

WHO Classification of Vitamin a Deficiency

1.4 Case Fatality in children with

2.1. Recognize signs of severe

2.5. Criteria for hospitalization/

3.1. Identifying and managing