1 Nepal IMAM Guideline

NEPAL Integrated Management of
Acute Malnutrition (IMAM) Guideline

Draft 7: 8 February 2016
Page 1
Acknowledgements
This IMAM guideline has been developed with the support of UNICEF, Nepal. The development has
been facilitated, and the content authored by UNICEF and Valid International. The guideline has been
established with active inputs by national stakeholders in Nepal. In particular, sections related to
moderate acute malnutrition (MAM) have been provided by WFP. Special thanks goes to the Nutrition
Section, Child Health Division, Ministry of Health and Population, Government of Nepal for providing
guidance on the document’s scope and development Similarly, ACF and NYF have been provided their
constrictive feedback and support during development of this guideline.
Foreword
In 2008, inspired by the global progress made on community-based management of acute
malnutrition (CMAM) and the issuance of the WHO/UNICEF/WFP Standing Committee on Nutrition
(SCN) joint statement in 2007, UNICEF and the Ministry of Health and Population (MoHP) Nepal
conducted a feasibility study of the approach. The recommendations from the study led to a five
district pilot of CMAM in districts with high prevalence in a cross section of eco-geographical zones.
Implementation was conducted in collaboration with the national, regional and district health
authorities, working through the existing health structures and with the health staff (hospital and
health facilities’ staff and FCHVs) as well as the local NGOs and the community-based organisations
(e.g. women‘s groups).
The aim of the pilot was to test different implementation strategies, evaluate outcomes and generate
lessons learned for future expansion of the CMAM approach. Until this time, the treatment of acute
malnutrition in Nepal was carried out mainly on an inpatient basis in Nutrition Rehabilitation Homes
(NRHs) supported by the Nepal Youth Opportunity Foundation (NYOF). Assistance to families of
malnourished children focused mainly on household counselling on hygiene, feeding practices and
balanced diet, as well as on treatment with a mix of therapeutic milk (WHO recipe) and food. The NRH
approach required the child and his/her caretaker to stay in the NRH for a minimum of four weeks,
which posed difficulties for caretakers with other children as well as work responsibilities, and thus
led to a high default rate. In addition, the NRHs could not address malnutrition on a large scale due to
their limited number and low capacity at each unit. The outcomes of the CMAM pilot were evaluated
in 20111 and found to be very positive. The evaluation indicated that the CMAM approach offered:
- Ability to reach more children with services for the management of acute malnutrition;
- Effective treatment outcomes; and
- A service that could be sustained within the regular health service with existing human
resources and facilities.
As a result, the MoHP Nepal has incorporated community-based management of severe acute
malnutrition (SAM) into the National Health Sector Program II (NHSPII) that runs until 2017, and into
the Multi-sector Nutrition Plan (MSNP) 2013-172, which was developed in 2011 and approved by the
cabinet. Scale-up plans for community-based management of SAM are now under development and
piloting of effective interventions to address MAM have also been included in the MSNP. The CMAM
evaluation recommended that the approach improve links across the sectors and with malnutrition
prevention strategies and programmes as part of a comprehensive approach. At the same time, both
1
UNICEF 2011. Evaluation of Community Management of Acute Malnutrition (CMAM). Nepal country case
study. UNICEF Evaluations Office, July 2011.
2
Government of Nepal, National Planning Commission. Multi-Sector Nutrition Plan: For Accelerating the
Reduction of Maternal and Child Undernutrition in Nepal 2013-2017 (2023).
-
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the UNICEF CMAM pilot evaluation in 2011 and a joint review of the Mother and Child Health Care
(MCHC) programme conducted by the MoHP, the Ministry of Education (MoE), and WFP in 2011
highlighted gaps in the management of moderate acute malnutrition (MAM) and recommended the
development of national MAM guidelines. Thus, Integrated Management of Acute Malnutrition
(IMAM) in Nepal was born.
The Government of Nepal (GoN) has strengthened its efforts to fight hunger since 2009, conscious of
the role nutrition plays in national development outcomes. The Nutrition Assessment and Gap
Analysis (NAGA) represented a first step in this direction and led the GoN to develop the MSNP 2012
to sustain improvements in the nutrition field. The plan represents a robust framework for the
development of a healthy society with a competitive human capital, and it will contribute to break the
vicious circle of poverty in the future. The MoHP/GoN is also a member of the lead group of the Global
Scaling Up Nutrition (SUN) movement, with the MSNP representing the Government’s commitment
to that movement. A ‘Declaration of Commitment for an Accelerated Improvement in Maternal and
Child Nutrition’ was also signed in 2012 by the GoN, UN, development partners, civil society and the
private sector. Furthermore, a drafted Strategy for Infant and Young Child Feeding (2013-2017) calls
for accelerated reduction of under nutrition in women and children as a high priority for the Health
Nutrition and Population Sectoral Programme of Nepal. The scale-up of IMAM is one of the actions
identified in the strategy for achieving this goal.
The IMAM guideline has been developed to meet the objectives of the MSNP 2012 and to reflect
Nepal’s commitment to accelerated improvements in maternal and child nutrition and the drafted
strategy for Infant and Young Child Feeding. It incorporates the lessons from the CMAM pilot and
MCHC review and is intended to be used by health and nutrition care providers (doctors, nurses and
programme staff) working at all facility levels of health and nutrition service provision in Nepal, as well
as by policy makers, academic and NGO staff. The technical protocols are based on the WHO protocols
for inpatient management of SAM, standard CMAM protocols, WHO technical information on
supplementary foods for the management of MAM and UN and Global Nutrition Cluster guidelines for
the management of MAM. The guideline primarily covers the age group from 6-59 months (the most
common age group affected by acute malnutrition) and infants. It aims to reflect a shift to a more
integrated approach in which the services for SAM and MAM management sit clearly within and link
to the existing structures and services. Hence the shift to the term Integrated Management of Acute
malnutrition (IMAM).The guideline will be complemented by training materials that give more
explanation, exercises and examples of the management of acute malnutrition using the IMAM
approach.
The guideline is structured to give a basic introduction and principles of the IMAM approach. This is
followed by a general section on assessment and classification of acute malnutrition. The guideline is
then split into the major components of the IMAM approach: Community Mobilisation, Management
of SAM (Inpatient and Outpatient) and Management of MAM. Programme monitoring and
programme management are then covered jointly for all components and finally a section is included
for implementation in an emergency context.
Rolling out of the guideline and the protocols will be guided by the Multi Sector Nutrition Plan and
revised National Nutrition Policy and Strategy, and will prioritise districts for expansion according to
the WHO thresholds, considering the burden of acute malnutrition in those districts.
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Contents
List of Tables and Figures ................................................................................................................................. 7
List of Terms .................................................................................................................................................... 8
1 Introduction ............................................................................................................................................ 9
1.1 What is acute malnutrition?................................................................................................................ 10
1.2 Burden of acute malnutrition in Nepal ................................................................................................ 11
2 Objectives, principles and structure of IMAM ....................................................................................... 12

2.1 Objectives of IMAM ............................................................................................................................. 12
2.2 Principles of IMAM .............................................................................................................................. 12
2.3 Structure of IMAM............................................................................................................................... 13
2.4 Integrating IMAM into the existing services and structures ............................................................... 14
3 Community mobilisation/outreach ....................................................................................................... 15

3.1 Introduction to community mobilisation ............................................................................................. 15
3.2 Developing a district community mobilisation strategy ...................................................................... 15
3.2.1 STEP 1: District consultation meeting ............................................................................................. 16
3.2.2 STEP 2: Community assessment ..................................................................................................... 16
3.2.3 STEP 3: Conduct sensitisation and community dialogue ................................................................ 16
3.2.4 STEP 4: Developing messages and materials .................................................................................. 17
3.2.5 STEP 5: Community training ........................................................................................................... 18
3.3 Protocols for case-finding and referral ................................................................................................ 18
3.3.1 Active adaptive case-finding for SAM ............................................................................................. 19
3.3.2 Active case-finding for MAM .......................................................................................................... 20
3.4 Actions for non-acutely malnourished clients ..................................................................................... 21
3.5 Protocols for follow-up of clients with acute malnutrition .................................................................. 21
3.6 Set-up requirements ............................................................................................................................ 22
4 Assessment and classification of acute malnutrition ............................................................................. 22

4.1 Assessment of Children 6-59 months .................................................................................................. 22
4.1.1 Step 1. Determine age .................................................................................................................... 23
4.1.2 Step 2. Check for pitting oedema on both feet .............................................................................. 23
4.1.3 Step 3. Measure MUAC ................................................................................................................... 23
4.1.4 Step 4. Assessment of appetite and medical complications ........................................................... 23
4.2 Assessment of infants under 6 months ............................................................................................... 26
4.3 Summary classification of acute malnutrition..................................................................................... 29
5 Management of SAM ............................................................................................................................ 31

5.1 Pathophysiology of SAM ..................................................................................................................... 31
5.2 Outpatient Therapeutic Care ............................................................................................................... 31
5.2.1 Assessment of nutritional status and medical condition ................................................................ 31
5.2.2 Admission or referral based on programme criteria ...................................................................... 32
5.2.3 Medical Management ..................................................................................................................... 33
5.2.4 Nutrition Management ................................................................................................................... 34
5.2.5 Orientation and counselling for the mother/caretaker .................................................................. 35
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5.2.6 Individual monitoring and follow-up .............................................................................................. 35
5.2.7 Discharge from Outpatient care ..................................................................................................... 37
5.2.8 Operationalising links ..................................................................................................................... 38
5.2.9 Set-up requirements ....................................................................................................................... 39
5.3 Inpatient Therapeutic Care.................................................................................................................. 39
5.3.2 Admission or referral based on programme criteria. ..................................................................... 41
5.3.4 Nutrition Management ................................................................................................................... 41
5.3.5 Orientation and counselling for the care giver ............................................................................... 43
5.3.6 Individual monitoring and follow-up .............................................................................................. 43
5.3.7 Transition and discharge or continued rehabilitation in inpatient care ......................................... 43
5.3.8 Operationalising links ..................................................................................................................... 45
5.3.9 Set-up requirements ....................................................................................................................... 45
5.4 Management of SAM in infants <6 months old .................................................................................. 46
5.4.2 Admission or referral based on programme criteria ...................................................................... 46
5.4.4 Nutrition management ................................................................................................................... 46
5.4.5 Orientation and counselling for the mother/caretaker .................................................................. 48
5.4.6 Individual Monitoring ..................................................................................................................... 48
5.4.7 Discharge ........................................................................................................................................ 48
6 Management of MAM ........................................................................................................................... 49

6.1 Strategy for management of MAM ..................................................................................................... 49
6.2 Set-up requirement for Management of MAM ................................................................................... 50
6.3 Screening and referral to Management of MAM ................................................................................ 50
6.4 Admission criteria for Management of MAM ..................................................................................... 50
6.5 Assessment of MAM patient ............................................................................................................... 51
6.6 Nutritional management..................................................................................................................... 52
6.6.1 Protocol A: Using locally available foods and micronutrient supplements .................................... 52
6.6.2 Protocol B: Using Supplementary Food Ration ............................................................................... 53
6.6.3 Specialized Nutritious Foods for treating MAM ............................................................................. 54
6.7 Medical management ......................................................................................................................... 55
6.7.1 Vitamin A ........................................................................................................................................ 55
6.7.2 Mebendazole/Albendazole is given to all children aged 12-59 months on enrolment. ................. 55
6.7.3 Iron.................................................................................................................................................. 56
6.7.4 Vaccination ..................................................................................................................................... 56
6.7.5 Record all medications given in the registration book. .................................................................. 56
6.8 Monitoring and follow-up of MAM patient ......................................................................................... 56
6.9 Discharge............................................................................................................................................. 57
6.10 Operationalizing links .......................................................................................................................... 58
7 Management of acute malnutrition with HIV ........................................................................................ 58

7.1 Dietary management of acute malnutrition in HIV-Infected Children ................................................ 58
7.2 Medical management of acute malnutrition in HIV-infected children ................................................ 59
7.3 Discharge criteria and referral to HIV services .................................................................................... 59
8 IMAM programme monitoring and reporting ........................................................................................ 59
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8.1 Performance indicators ....................................................................................................................... 60
8.2 Minimum performance standards ...................................................................................................... 61
8.3 Monitoring formats and systems ........................................................................................................ 61
8.3.1 Community level ............................................................................................................................. 61
8.3.2 Facility level .................................................................................................................................... 62
8.3.3 Treatment Coverage Assessment ................................................................................................... 62
8.3.4 Supply monitoring........................................................................................................................... 63
8.4 Analysis and Feedback ........................................................................................................................ 63
9 Programme management ...................................................................................................................... 64

9.1 National level ...................................................................................................................................... 64
9.2 Regional level ...................................................................................................................................... 65
9.3 Sub-national level ................................................................................................................................ 65
9.4 Village development committees level ................................................................................................ 66
9.5 Municipal level .................................................................................................................................... 66
9.6 Programme planning .......................................................................................................................... 67
9.7 Human resources and roles ................................................................................................................. 67
9.7.1 Management of moderate acute malnutrition .............................................................................. 67
9.7.2 Outpatient Therapeutic care .......................................................................................................... 68
9.7.3 Inpatient Therapeutic care ............................................................................................................. 68
9.7.4 Staff training ................................................................................................................................... 68
9.8 Supply management ........................................................................................................................... 68
9.8.1 Supply requirements ....................................................................................................................... 68
9.8.2 Supply chain .................................................................................................................................... 71
9.9 Supervision and review........................................................................................................................ 72
10 Implementation in the emergency context............................................................................................ 73

10.1 Disaster Risk Reduction and Preparedness actions ............................................................................. 73
10.2 Agreeing thresholds for response ........................................................................................................ 74
10.3 Implications for programme management of acute malnutrition ...................................................... 76
10.4 MAM programming in emergencies ................................................................................................... 76
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List of Tables and Figures
Table 1. Diagnostic criteria for acute malnutrition in children aged 6-59 months............................... 11
Table 2. Criteria for admission to in- or out-patient care (children 6-59 months) with SAM: ............. 25
Table 3. Criteria for referral of children with MAM for medical treatment and SFP ........................... 26
Table 4. Criteria for admission to inpatient and outpatient care – Infants <6 months ........................ 28
Table 5. Summary admission criteria .................................................................................................... 29
Table 6. Summary admission and referral for SAM .............................................................................. 32
Table 7. Routine medicines for outpatient therapeutic care* (for detail see Annex 10) ..................... 33
Table 8. Criteria for referral to inpatient from outpatient treatment during follow-up ...................... 36
Table 9. Modified formula of Super Flour (Sarbottam Pitho) .............................................................. 53
Table 10. Modified formula for Poshilo Jaulo ....................................................................................... 53
Table 11. Discharge criteria for MAM treatment ................................................................................. 57
Table 12. Minimum performance standards for IMAM........................................................................ 61
Table 13. Calculation of RUTF requirements for OTC service ............................................................... 70
Table 14. Nutritional supply requirements calculated per number of SAM cases to treat .................. 70
Table 15. Nutritional supply requirements calculated per number of MAM cases to treat ................ 71
Table 16. Nepal thresholds and benchmarks for Nutrition in Emergencies (WHO 2000) .................... 75
Figure 1. UNICEF conceptual framework of malnutrition....................................................................... 9

Figure 2. The intergenerational cycle of growth failure ....................................................................... 10
Figure 3. Components of IMAM in Nepal ............................................................................................. 14
Figure 4. Stages in community mobilisation ......................................................................................... 16
Figure 5. Signs of visible wasting .......................................................................................................... 27
Figure 6. WHO steps for management of SAM ..................................................................................... 40
Figure 7. Simple tools for monitoring barriers to access ...................................................................... 63
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List of Terms
CHD/W Child Health Day/Week
CB-IMNCI Community-Based Integrated Management of Childhood Illness
CMAM Community-Based Management of Acute Malnutrition
ENN Emergency Nutrition Network
FBF Fortified Blended Food
GAM Global Acute Malnutrition
GMP Growth Monitoring and Promotion
GNC Global Nutrition Cluster
GoN Government of Nepal
HIV Human Immunodeficiency Virus
HMIS Health Management Information System
HP Health Post
IMAM Integrated Management of Acute Malnutrition
ITC Inpatient Therapeutic Care
IYCF Infant and Young Child Feeding
MAM Moderate Acute Malnutrition
MNPs Micronutrient Powders
MoE Ministry of Education
MoHP Ministry of Health and Population
MSNP Multi-sector Nutrition Plan
MUAC Mid Upper Arm Circumference
NDHS Nepal Demographic and Health Survey
NGO Non-Governmental Organisation
NRH Nutrition Rehabilitation Home
OTC Outpatient Therapeutic Care
PHC Primary Health Care
PICT Provider Individual Counselling and Testing
RUTF Ready-to-Use Therapeutic Food
SAM Severe Acute Malnutrition
SC Stabilisation Centre
SD Standard Deviations (or Z-Scores)
SFP Supplementary Feeding Programme
SHP Sub Health Post
SUN Scaling Up Nutrition
TSFP Targeted Supplemental Feeding Program
UNICEF United Nations Children’s Fund
WFP World Food Programme
WHO World Health Organisation
WHZ Weight for Height Z-scores
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1 Introduction
The consequences of malnutrition are serious and life-long, falling hardest on the very poor and on
women and children. Overall in developing countries, nearly one-third of children are underweight or
stunted (low height for age)3. Under nutrition interacts with repeated bouts of infectious disease;
causing an estimated 3.5 million preventable maternal and child deaths annually4, and its economic
costs in terms of lost national productivity and economic growth are huge. In all its forms, malnutrition
accounts for more than 50 per cent of child mortality in Nepal based on WHO estimates. Malnourished
children who do survive are more frequently ill and suffer the life-long consequences of impaired
physical and cognitive development. These consequences translate to poor human resource capital
and poor economic development.
The term malnutrition5 covers a range of short and long term conditions that result in physiological
impairment caused by lack of (or excess of) nutrients in the body. The term malnutrition can include:
i. Wasting and nutritional oedema (Acute Malnutrition) ii. Stunting (Chronic Malnutrition), iii.
Intrauterine growth restriction leading to low birth weight iv. Micronutrient deficiencies and v.
Overweight/obesity (Over nutrition). These conditions may be experienced over a scale of severity
and are usually classified into moderate and severe forms. They may occur in isolation within an
individual or in combination. The causes of under nutrition are multiple and context specific and are
summarised in the below conceptual framework (Figure 1).
Figure 1. UNICEF conceptual framework of malnutrition
Death, Malnutrition
& Inadequate
Development
Inadequate
Disease
Dietary Intake
Inadequate Insufficient
Inadequate Care
Access to Health Services &
for Children
Food Unhealthy
and Women
Environment
Inadequate Education
Resources and Control

Human, economic and
organizational resources
Political and Ideological Superstructure
Economic Structure
Potential
Resources
3
UNICEF/WHO/World Bank Joint Child Malnutrition Estimates: Levels and trends in child malnutrition. 2012.
4
RE. Black et al. Maternal and Child Undernutrition 1. Global and regional exposures and health consequences.
Lancet 2008 p5.
5
The term undernutrition is often used internationally to denote those conditions associated with lack of nutrients
and overnutrition for those conditions associated with a surplus. However, the term malnutrition is still used in a
majority of contexts to denote all forms of undernutrition and is therefore used throughout this guideline.
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Recent evidence clarifies that the period of greatest vulnerability to nutritional deficiencies begins
during pregnancy. During this period, nutritional deficiencies have a significant adverse impact on
child survival and growth. Chronic under nutrition in early childhood (up to age two) also results in
diminished cognitive and physical development, which puts children at a disadvantage for the rest of
their lives. For example, chronic under nutrition may lead individuals to perform poorly in school as
children, and as adults can lead to less productivity, less earnings and higher risk of disease versus
adults who were not undernourished as children. For girls especially, chronic under nutrition in early
life, either before birth or during early childhood, can later lead to their babies being born with low
birth weight, which can in turn lead to under nutrition as these babies grow older. Thus a vicious cycle
of under nutrition repeats itself, generation after generation. This is known as the intergenerational
cycle of growth failure (see Figure 2).6
Figure 2. The intergenerational cycle of growth failure
The longitudinal relationship between chronic and acute malnutrition has not been extensively
studied, but recent evidence indicates that wasting or poor weight gain may lead to higher risk of
stunting in children.7
Specifically for acute malnutrition, severely wasted children8 have been estimated to have a greater
than nine fold increased risk (relative risk of 9.4) of dying compared to a well-nourished child, and
moderately wasted children a threefold increased risk.9 In fact, the 2008 Maternal and Child Nutrition
Lancet series recognises severe wasting as one of the top three nutrition related causes of death in
children under five (Ibid).
This guideline specifically deals with the identification and management of acute malnutrition. It also
aims to place the management of acute malnutrition within the broader range of interventions and
approaches for addressing malnutrition in general.
1.1 What is acute malnutrition?
6
UNICEF. Tracking progress on child and maternal nutrition: a survival and development priority. 2009.
7
SA. Richard et al. Wasting is associated with stunting in early childhood. Journal of Nutrition. July 1 2012
p.1291-1296.
8
Assessed according to weight for height z scores using the WHO standards.
9
RE. Black et al. Maternal and Child Undernutrition 1. Global and regional exposures and health consequences.
Lancet 2008.
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Acute malnutrition (or wasting and/or oedema) occurs when an individual suffers from severe
nutritional restrictions, a recent bout of illness, inappropriate childcare practices or a combination of
these factors. The result is sudden weight loss or the development of bilateral pitting oedema, which
can be reversed with appropriate treatment. Acute malnutrition is diagnosed if a child has inadequate
weight relative to height compared to the WHO reference population and/or if muscle wasting is
present using Mid Upper Arm Circumference (MUAC) and/or bilateral pitting oedema. Acute
malnutrition may be classified as moderate or severe according to the degree of wasting in
comparison to specific cut-off points or reference standards. Bilateral pitting oedema is always
classified as severe (see Table 1).
Table 1. Diagnostic criteria for acute malnutrition in children aged 6-59 months10
Measure Cut-off
Severe Acute Malnutrition Weight-for-height* < -3SD
MUAC <115mm
Bilateral pitting oedema Grades 1, 2 or 3
Moderate Acute Malnutrition Weight-for-height <-2SD and ≥-3SD
MUAC <125mm and ≥115mm
* Based on WHO Standards (www.who.int/childgrowth/standards)
1.2 Burden of acute malnutrition in Nepal

Wasting (measured by low weight for height compared to the WHO reference population) has
remained nearly unchanged over the last decade in Nepal; 11 per cent in 200111, 13 per cent in 200612;
and 11 per cent in 201113. As per the WHO decision making criteria14, wasting prevalence is at a critical
level in Nepal, affecting an estimated 430,000 children under five years of age at any point in time. As
per the most recent data (NDHS 2011), 2.6 per cent or 91,000 under-five year old children in Nepal
are suffering from severe acute malnutrition (SAM). Most of these children are not likely to survive
unless they are identified and treated in a timely and effective manner. A further 8.3 per cent, or
290,000 under-five year old children in Nepal, are suffering from moderate acute malnutrition (MAM).
It is estimated that preventable deaths of Nepali children due to severe wasting are 1,500 each year
and deaths due to moderate wasting are more than double that number. This translates to 2 million
DALYs (estimates of death and disability due to current wasting, discounted at 3 per cent) and more
than USD 160 million lost per year of income due to child deaths and the impaired income-earning
potential of the survivors.15
At the regional level, the trend is increasing overall for prevalence of SAM and global acute
malnutrition (GAM) in the hill and mountain regions, while in the Terai region the prevalence has
fluctuated drastically and has reached 3.2 and 11.2 per cent, respectively, in 2011. The prevalence of
SAM was higher in the urban areas compared to rural areas in 2011, while the GAM was higher in the
rural areas. The prevalence of SAM and GAM is higher among boys than among girls and mother’s
10
Adapted from WHO Child growth standards and the identification of severe acute malnutrition in infants and
children: A joint statement by the World Health Organisation and the United Nations Children’s Fund. 2009 and
WHO, UNICEF, WFP and UNHCR Consultation on the Programmatic Aspects of the Management of Moderate
Acute Malnutrition in Children under five years of age. 24-26 February 2010, WHO, Geneva.
11
Nepal Demographic Health Survey 2001
12
13
14
WHO. The Management of Nutrition in Major Emergencies, Geneva, 2000.
15
Webb, P and K-J Kang. 2010. Wasting No Time. Tufts University, Boston. Mimeo.
Page 11
level of education and household wealth are inversely associated with GAM. Strikingly, the prevalence
of MAM almost doubles between the lowest and highest wealth quintiles (7.4 per cent of cases are in
the highest quintile and 13 per cent are in the lowest quintile), and between children born from
mothers with at least secondary education and mothers with no education (6 per cent versus 13 per
cent).
Acute malnutrition has multiple direct and indirect causes as noted in Figure 1. In the absence of in-
depth research on food security and child development in Nepal, the reasons for the continuing critical
levels and regional patterns of acute malnutrition are difficult to explain, particularly in view of the
positive progress on other MDG indicators such as poverty and mortality.
Notably, there are still geographic areas of food insecurity in the country. Access to a diverse and
nutrient-dense diet remains a challenge, infectious diseases are rampant and sanitation and hygiene
are unsatisfactory in most of the country. Cholera outbreaks occur during the rainy summer season
and intestinal parasites alone constitute one of the major public health problems in Nepal. In addition,
as noted in the recently drafted Nepal strategy for Infant and Young Child Feeding 2013-2017,existing
evidence has demonstrated that feeding and care practices of infants and young children, particularly
breastfeeding, complementary feeding, and care practices including hygiene and sanitation are not
optimal in Nepal’. Merely a third of infants are initiated to breastfeeding within one hour of birth
though 70 per cent are exclusively breastfed during the first six months. Only 65 per cent of children
receive appropriate complementary feeding at six months16.
2 Objectives, principles and structure of IMAM
2.1 Objectives of IMAM

The primary objectives of IMAM are:
 To reduce mortality and morbidity risks in children under five due to acute
malnutrition;
 To rehabilitate children with acute malnutrition to a state of health in which they are
able to sustain their nutritional status upon discharge as cured;
 To prevent the condition of children with acute malnutrition from deteriorating thus
requiring more intensive treatment;
 Contribute to the prevention of acute malnutrition in young children in the critical
1000 day window17; and
 Prevent micro-nutrient deficiency disorders among under five year old children
associated with acute malnutrition.
2.2 Principles of IMAM

IMAM is a strategy to address acute malnutrition. IMAM focuses on the integration of effective
management of acute malnutrition into the ongoing routine health services at all levels of the health
facilities whilst still striving for maximum coverage. It also aims to integrate the management of
acute malnutrition across the sectors to ensure that treatment is linked to support for continued
16
Nepal Demographic and Health Survey, 2011
17
Leading scientists, economists and health experts agree that improving nutrition during the critical 1,000 day
window (between a woman’s pregnancy and her child’s 2 nd birthday) can have a profound impact on a child’s
ability to grow, learn, and rise out of poverty and can shape a society’s long-term health, stability and prosperity.
It is one of the best investments we can make to achieve lasting progress in global health and development.
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rehabilitation of cases and to wider malnutrition prevention programmes and services focused on
the critical 1000 day window.
IMAM is based on the same principles as the initial CMAM programme. These are as follows:
- Maximum coverage and access – IMAM is designed to achieve the greatest possible
coverage by making services accessible and acceptable to the highest possible proportion of
a population in need.
- Timeliness – IMAM prioritises early case-finding and mobilisation so that most of the cases
of acute malnutrition can be treated before complications develop.
- Appropriate care – Provision of simple, effective outpatient care for those who can be
treated at home and clinical care for those who need inpatient treatment. Less intensive
care is provided for those suffering from MAM.
- Care for as long as it is needed - By improving access to treatment and integrating the
service into the existing structures and health system, IMAM ensures that children can stay
in the programme until they have been cured
2.3 Structure of IMAM

IMAM has four components: Community mobilisation, Inpatient Therapeutic Care (ITC), Outpatient
Therapeutic Care (OTC) and Management of MAM.
Community mobilisation involves identification of acutely malnourished children at the community

level on an on-going basis to enable widespread early detection and referral before the clients
condition deteriorates further (i.e. children with MAM becoming SAM and children with SAM
developing complicated SAM). It aims to increase coverage and maximise the effectiveness of
treatment. The community mobilization also provides an opportunity to counsel mothers/caretakers
of children under five years on IYCF practices, as well are prevent future cases of malnutrition through
behaviour change communication activities such as water and sanitation education and nutrition
promotion activities In Nepal, the primary vehicle for this component is the Female Community Health
Volunteer (FCHV).
Inpatient Therapeutic Care (ITC) involves management of complicated cases of SAM according to
WHO protocols on an inpatient basis at tertiary level facilities (hospitals) or specialised units (Nutrition
Rehabilitation Homes).
Outpatient Therapeutic Care (OTC) involves the management of non-complicated cases of SAM in
outpatient care using ready-to-use therapeutic foods (RUTF) provided on a weekly/fortnightly 18 basis,
simple routine medicines, and monitoring and orientation for the mothers/caretakers. Outpatient
care is offered through decentralized health structures (e.g. health posts or sub-health posts).
Management of Moderate Acute Malnutrition (MAM) may take two forms depending on the
household food security level of the district including in emergency context. It involves either a) the
provision of micronutrient powders (MNPs) ) where available or if the district is MNP program
district and nutrition counselling in areas where local food is available to provide a nutritious diet
for children, or b) targeted supplementary feeding with fortified blended food plus nutrition
counselling in areas where local foods are not available. In both cases, individual monitoring and
18
Outpatient care may, in some cases, is carried out fortnightly depending on the situation e.g. if
mothers/caretakers are defaulting because they are too busy or the site is far then they may be more likely to attend
a fortnightly session (National Medical Protocol, CMAM, March 2009).
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orientation to mothers/caretakers is provided, plus referral for any medical issues in line with CB-
IMNCI protocols.
These components sit within a wider range of health and nutrition interventions and services that
focus on the ‘critical 1000 day window’. In Nepal these currently include nutrition counselling for
IYCF support, WASH, ECD. IMAM may also be linked to local production of RUTF/RUSF/Fortified
Blended Food.
Figure 3. Components of IMAM in Nepal
RUTF/RUSF/Fortifi
ed Blended Food NRH
production Inpatient
Rehabilitation of HOSPITAL
SAM Inpatient
COMMUNITY LEVEL stabilisation of
Community sensitization, SAM
case finding and follow-up HEALTH FACILITY/
- FCHV
Outpatient management of SAM
- ECD facilitators etc.
Management of MAM
Links to other community - MNP + counselling (where nutritious diet available)
level services** - TSFP + counselling (where nutritious diet NOT
available)
Links to other health facility services*
* GMP, CB-IMNCI, IYCF counselling, PMTCT

** ECD, CBIMCI, MMPs, Child Cash Grant, WASH, IYCF counselling, PICT
2.4 Integrating IMAM into the existing services and structures

Integrated management of acute malnutrition is where management of acute malnutrition:
- Is one of the basic health services to which a child has access;
- Is embedded into a broader set of nutrition activities (IYCF, micronutrients etc.) focusing on
the 1000 day critical window.; and
- Is integrated within a multi-sectoral approach to tackle the determinants of undernutrition
focusing on the 1000 day critical window (including, WASH, ECD, social protection and local
governance mechanisms).
As noted above, where IMAM has been implemented in Nepal, it has been done as an integral part of
the health system. The services for treatment of SAM and MAM are rooted in CB-IMNCI assessment
Page 14
protocols and should be implemented, managed and monitored by existing health facility and district
health staff. The programme monitoring and supply chain for the service for SAM has been done
through the existing MoHP supply system with logistics support from UNICEF. Increasingly, focus can
now shift to the MoHP supply system including the involvement of the Regional Medical Stores
through which products pass to reach the district warehouses. The supply chain for MAM products
may also be added through support from WFP and other agencies. In some critical emergency periods,
there will likely still be a need to augment this with additional staff and external support (see chapter
9).
In addition, IMAM aims to link with broader activities at facility and community levels. This is achieved
in a number of ways:
- Through the addition of basic sensitisation on IMAM and identification of acute malnutrition
into the roles and training of existing facility and community-level workers from a range of
sectors (including WASH, ECD, Health, Education) and services (GMP, ECD centres, CB-IMNCI,
New-born care, WASH promotion, the child cash grant, Child Health Days/Weeks (CHD), EPI,
HIV/TB, child clubs, parent teacher associations)
- By ensuring that acutely malnourished clients are linked with all other services that may aid
in their rehabilitation (HIV/TB services, GMP, MNP distribution, IYCF counselling)
- By setting IMAM firmly within the IYCF package through integrating trainings and counselling
activities with the aim of bringing together treatment and prevention aspects of malnutrition
3 Community mobilisation/outreach
3.1 Introduction to community mobilisation

Community mobilisation/outreach is a core component of IMAM and is critical for maximising access
and coverage by removing the barriers to community accessing the service. It must be developed at
the planning stage in each district as there will likely be differences in the structures in place between
districts. The process of community engagement is also essential prior to commencing the service to
ensure it is set up in an appropriate and sustainable manner to avoid issues later on. If mother has
problem on access to the program the FCHV and mother group will discuss and if the problem being
not solved then the issue goes up to monthly meeting of health facilities level and discussed.
Community mobilisation should primarily aim to increase access and service uptake (coverage) of
IMAM services by tapping into community level resources and structures to make sure that as many
children as possible can be reached at the community level with timely MUAC assessments (see
Chapter 4).
The main objectives of community mobilisation for IMAM include:

- Engage and empower the community by increasing knowledge and understanding on acute
malnutrition and the services available;
- Ensure widespread early case-finding and referral of new SAM and MAM cases;
- Provide appropriate nutrition education and counselling focusing IYCF and care practices;
- Follow-up on particularly at risk and problem cases; and
- Engage communities for joint problem solving on barriers to service uptake.
3.2 Developing a district community mobilisation strategy

The community mobilisation strategy should be based upon, 1. Establishing dialogue with the
community about the IMAM services, 2. Generating a clear picture of local perceptions, terms and
understanding around acute malnutrition, 3.Mapping of community structures and means of
communication that can be used to raise awareness on acute malnutrition and the programme, and
Page 15
4. Mapping of all opportunities to access children at the community level for identification and follow-
up of cases. This is achieved via a number of steps:
Figure 4. Stages in community mobilisation
3.2.1 STEP 1: District consultation meeting

This meeting should bring together district officials with key community representatives to discuss the
objectives and principles of the IMAM services. This is a first advocacy step to highlight the need for
the programme from the service providers’ perspective and to hear the communities’ response. This
initial meeting could be done in parallel to the below community assessment step, which goes into
more depth in building understanding around malnutrition and acute malnutrition in particular, and
therefore can provide a basis for more meaningful discussion about the need for the service.
3.2.2 STEP 2: Community assessment

The community level assessment takes place through a series of interviews and focus group
discussions with key community informants. These may include community leaders, elders and other
influential people (teachers, ECD facilitators), mothers, fathers, caretakers and traditional healers. The
assessment is key in determining local understanding of acute malnutrition, in identifying available
resources and the factors that are likely to impact on both service delivery and demand for services.
It and can be conducted by district health teams, clinic staff and FCHVs. The assessment should
identify:
- Local terms for malnutrition, perceived causes and common local solutions
- The key community persons, leaders and other influential people and organisations to help
sensitise the communities on the components of the IMAM programme
- Existing structures and community based organisations/groups
- Social and cultural characteristics related to nutrition including identification of most
vulnerable groups
- Formal and informal channels of communication that are known to be effective
- Attitudes and health seeking behaviours
- IYCF practices, child care patterns and locally available services.
- Other existing nutrition and health interventions in the community including for child care
The information collected can be consolidated for use in the below steps (see Annex 1 for some tools
to facilitate this process).
3.2.3 STEP 3: Conduct sensitisation and community dialogue

The aim of good community sensitisation is to facilitate the engagement of the community in the
service provided. Engage the community and other partners with community-based programmes to:
Page 16
- Discuss the problem of acute malnutrition, causes and possible solutions (e.g. IYCF practices,
care practices, WASH practices, ECD and social protections etc.)
- Introduce and negotiate on the adoption of IMAM as an approach to the management of
acute malnutrition in their communities
- Agree on what needs to be done, the relevant groups, organisations and structures to be
involved in different aspects of IMAM, and discuss clear roles as well as responsibilities
- Once services for the management of acute malnutrition have started, continue the dialogue
to address concerns, maintain changes in behaviour and share success stories
Box 1. Community level agents for involvement in case finding in Nepal

 Female Community Health Volunteers
 Community health workers from local health facilities who are responsible for and
conduct primary health care outreach clinics
 Early Childhood Development Centre staff and Facilitators
 WASH volunteers
 Traditional healers
 Mothers’ Group Members
 Social Mobilisers
 Community Health Workers of CBOs/local NGOs/clubs
 Ward citizen forums
 Citizen awareness centres
 Women cooperatives/federations
 Teachers
Notes:
 Where FCHVs are active and are the primary community level workers acting in an area,
they can act as a focal point for all other community agents who are conducting case
finding, i.e. other agents can refer clients to the FCHV for checking of MUAC and
oedema measurements before they are referred to the health facility. ECD facilitators
will complement the roles of FCHVs in the particular communities in case findings,
referrals and case follow up and defaulter actions
 Assessments can be made once these groups are active in community sensitisation
regarding whether they include any agents who can reliably take MUAC measurements
themselves
3.2.4 STEP 4: Developing messages and materials

Based on the above, developing sensitisation messages for acute malnutrition and the IMAM service
for handbills or pamphlets, local radio as well as television is essential (See Annex 2 for additional
guidance on developing messages, posters, flipcharts/counselling cards and handbill). Local terms for
RUTF and fortified blended food used for the supplementary feeding should be used in all
communication materials.
Develop a sensitisation plan detailing who to target and how to sensitise, based on the information
gathered during the community capacity assessment. Review the plan with influential persons in the
community to check if it is culturally appropriate before disseminating.
Page 17
3.2.5 STEP 5: Community training
The District Health/Public Health Offices have a responsibility to ensure that the identified community
volunteers (including FCHVs, ECD facilitators and other groups identified – see Box 1) are trained on
how to engage with the community and disseminate messages effectively and on identification, and
referral of cases.
3.3 Protocols for case-finding and referral

Case-finding is important to ensure that clients with SAM and MAM are identified early before the
development of severe medical complications. In order for identification to be ‘early’, case-finding
must be carried out on a regular basis (either on-going or monthly) at all possible opportunities (see
Box 2) in order to ‘catch’ cases before they deteriorate. A combination of approaches is
recommended. Case finding may be implemented through existing points of contact within the health
system where simply adding MUAC to the assessment process ensures that the opportunity to identify
acute malnutrition is not missed (this may be called ‘passive’ case-finding). Where agents at the
community level, on an ongoing basis or during existing health/nutrition campaigns (vitamin A
supplementation, immunization) actively seek out cases of acute malnutrition, this is called ‘active’
case-finding.
Identified SAM and MAM clients are usually referred to the nearest health facility/appropriate acute
malnutrition service, though in some cases they may be referred directly to inpatient management
depending on the identification of medical complications.
The FCHVs, ECD facilitators and other identified community level agents should:
- Screen for acute malnutrition at various contact points (home visits, community meetings,
health facility outreach programmes, and at other opportunities identified during assessment
– see box below) using the Mid-Upper Arm Circumference (MUAC) and pitting oedema for all
client groups (see Chapter 4).
- Act as a focal point in their community where mothers/caretakers can come if they are
worried about their child losing weight or being sick so that they can be assessed for acute
malnutrition.
- Identify and refer acutely malnourished clients appropriately and provide IYCF counselling,
WASH/care practices, demonstration of locally available nutritious foods (food diversity and
minimum meal frequencies) etc.
In addition, FCHVs in particular will be able to act as focal points in their communities for the
assessment of severe acute malnutrition with medical conditions (using CB-IMNCI tools) to directly
identify those children requiring referral to inpatient care located in local hospitals or PHCCs.
Other community agents will refer all SAM cases, along with MAM cases, directly to the nearest health
facility where this assessment of medical conditions can take place.
Page 18
Box 2. Contact points for identification of cases at community level in Nepal
Passive case-finding
 During health facility visits by parents with their child
 At ECD centres by ECD facilitators
 During consultation visits by parents bringing child to the FCHVs’ house
 During PHC outreach clinics by community health workers with support of FCHVs or
other community volunteers
 During growth monitoring sessions by community health workers- MUAC can be taken
on any growth faltering children
 During community level ECD sessions organised by ECD facilitators
 During mothers’ group meetings by FCHVs if mothers bring their children
Active case-finding
 At child clubs jointly with child club members
 During community campaigns such as vitamin A and deworming campaigns,
immunization campaigns, or any other health campaigns targeting children under 5
years
 During special immunization days
 During house-to-house visits whenever these are carried out by FCHVs and other
community health workers
 during monthly mothers group meetings
For all cases when a client needs to be referred, the community agent should explain why referral is
necessary and let the mother/caretaker know what to expect when they attend the facility. They
should explain to the mother/caretaker where the nearest facility offering appropriate care is and
stress the urgency of taking the child as soon as possible. Wherever possible, the community agent
should fill in a standard referral slip that carries their name and the child’s name (see Annex 3). This
allows both the FCHV and health facility to track whether the referral has been successful.
3.3.1 Active adaptive case-finding for SAM

Identification of cases of SAM at the community level is aided by evidence that shows, if local terms
for thin, swollen and sick children are used to identify, through key informants, which children in a
village may be acutely malnourished, 100 per cent of SAM children in the village/communities can be
found without the need to go from house to house conducting screenings19.
This method (called active-adaptive case-finding) was developed for surveys but can also be used
outside the survey context whenever it is necessary to identify cases and will be particularly useful
during the initiation of services in a district and where FCHVs are not fully familiar with the patterns
of acute malnutrition in their area of operation. This method can greatly reduce the time taken at the
community level to identify cases and therefore allow more regular early identification. It has also
proven to perform better in identifying cases of SAM than either central location screenings or house
to house screening in most contexts (apart from some urban and camp contexts) (see Box 3).
19
Myatt, Mark et al. 2012. Semi-Quantitative Evaluation of Access and Coverage (SQUEAC)/Simplified Lot
Quality Assurance Sampling Evaluation of Access and Coverage (SLEAC) Technical Reference. Washington,
DC: FHI360/FANTA.
Page 19
Box 3. Active Adaptive Case-finding
Active Adaptive Case-finding is based on two principles:
1. The method is active: SAM cases are specifically targeted. Case finders do not go house-
to-house in the selected villages measuring all children aged between 6 – 59 months.
Instead, only houses with children with locally understood and accepted descriptions of
malnutrition and its signs are visited.
2. The method is adaptive: At the outset key informants help with case-finding in the
community but other sources of information found during the exercise and through
discussion with beneficiaries coming into the facility are used to improve the search for
cases.
Step 1. Use findings of community assessment to identify:

 The appropriate case-finding question – According to the terminology used by the
population to describe the signs of SAM
 The most useful key informants to assist with case-finding – Those who are likely to be
able to identify cases, who know about the health of children in the community or who
people consult when their child is sick
 Any context-specific factors affecting the case-finding process – Such as cultural norms,
daily and seasonal activity patterns, as well as the general structure of villages
Step 2. Using key informants, identify the households with SAM children
Step 3. Visit these households and check oedema and MUAC for children 6-59m
Step 4. Make any adjustments to definitions required based on whether cases were
correctly identified
Step 4. When children with SAM are identified, ask if the key informant or anyone in that
household knows where children who are similarly malnourished live
Step 5. Use this method exhaustively until only children already measured are identified
3.3.2 Active case-finding for MAM

For MAM children, active adaptive case finding is not found to be as effective since they do not always
appear sick. These children are also less likely to be brought to the health facility for medical care.
Therefore, it is extremely important to actively search for MAM children within the community. This
can be most effectively done through aactive screening for MAM at least twice a year, along with the
vitamin A mass supplementation program. This strategy will ensure coverage of at least 90 per cent
of children living in the catchment areas (NDHS, 2011). Additional coverage can be attained through
FCHVs visiting non-attending families the day after supplementation and taking the MUAC
measurements at the household level.
All sectors should be involved at the community level during the active case finding and the frequency
of these events should be determined by the DHO/DPHO.
Page 20
3.4 Actions for non-acutely malnourished clients
It is important that during any active screening activities by health staff and FCHVs, children measured
and found not to be acutely malnourished are referred for any complementary services where
appropriate (as would be done routinely anyway). This is particularly important as a number of these
children may need attention and these complementary actions will help prevent their condition from
deteriorating. Such actions include:
 Referral to the health facility for any medical problems identified according to CB-IMNCI
 Counselling on IYCF practices, care, WASH, ECD etc. where appropriate and available
 Referral for growth monitoring and counselling where appropriate and available
 Referral/orientation about livelihood/safety net/social protection programmes available,
including the cash grant programme, if they are eligible
 Provide vitamin A and deworming tablets to those children who did not receive the treatment
and supplementation in the past six months or during the last campaign
 Refer children older than nine months, who did not receive measles vaccination, to the health
facility or outreach clinic to obtain necessary immunisation
3.5 Protocols for follow-up of clients with acute malnutrition

Some clients with acute malnutrition require follow-up at home during their time in treatment, in
addition to the follow-up they receive at the health facility on their periodic visits (every week for
SAM20) and fortnightly follow up in case of geographical difficulty areas. These are cases who are at
increased risk of disease and death. They should be monitored to ensure sustained improvement in
their condition. Follow-up requires effective linkage between the community and health facilities and
therefore is best carried out by the FCHVs linking with the facility staff. Follow up should entail the
following:
- Identification of priority cases for follow-up by health facility staff (see Box 4) and
communication to FCHVs at health centre monthly meetings
- Home visits with these cases that focus on asking and understanding the constraints under
which the clients are operating
- Provision of any appropriate counselling (based on IYCF materials and training), or medical
referral if required based on CB-IMNCI check
- Recording of relevant information and give feedback to health providers during health centre
monthly meetings
- Linking clients to livelihood/safety net/social protection programmes available where
particular issues are identified and/or clients are eligible e.g. child cash grant etc.
20
Outpatient care in some cases may be carried out fortnightly if, for example, many mothers/caretakers are
defaulting because it is harvest time or if the health facility is serving a very large geographical area.
Page 21
Box 4. Priority cases for follow-up
Following up through home visits can be time consuming if done thoroughly, as a variety of
factors need to be discussed during the visit. However, it is not necessary to conduct home
follow-up visits with all SAM or MAM clients, especially those gaining weight in the
programme. Follow-up should focus on the following:
 Clients with medical complications who have refused to transfer to inpatient care
and are being treated on an outpatient basis
 Cases who are not responding in the programme (loss or static weight for two
weeks) and aspects of the home environment are suspected to be playing a role
rather than medical issues
 Repeated absentees from treatment
3.6 Set-up requirements

The major requirement for setting up effective community mobilisation is having someone responsible
for the community assessment and strategy development. This will ensure that these critical activities
do not get missed and that appropriate community agents and mechanisms for case-finding and
referral are set up in line with the above.
The only additional requirements are MUAC tapes, counselling cards (see training package) and the
simple report formats discussed in Chapter 8.3 and given in Annex 4.
4 Assessment and classification of acute malnutrition
4.1 Assessment of Children 6-59 months

Acutely malnourished children (aged 6 to 59 months) are identified by:
- Measuring the mid –upper arm circumference (MUAC)
- Checking for the presence of bilateral pitting oedema
- Taking weight and height of children
MUAC is a measure of muscle wasting and has been shown to have the highest correlation with risk
of mortality of any anthropometric indicator. It is also a simple and transparent measure and therefore
the most appropriate for use in decentralised and community based services.
For the majority of cases, this first assessment of MUAC and oedema will occur at the community level
(see Chapter 3). As noted above, however, in additional measurement should be completed at all
points where the client has contact with the service/health system. Identification, particularly within
larger health centres and within hospitals, needs to be at all points at which clients enter the system:
- In the community, through key community agents, by health and support staff during
campaigns and during outreach (as outlined in Chapter 3)
- At PHC/ORC, SHP, HP, PHC and Out-Patient Department (OPD) of Hospitals, HIV and or PICT
clinics
It is important that the taking of measurements is standardised (through training and supportive
supervision and monitoring). If cases referred from the community are rejected at the facility due to
faulty measurements (i.e. mothers/caretakers are told their child is eligible and then told they are not)
coverage can be adversely effected as they are unlikely to return even if their child does lose more
weight and are also likely to portray the service in a negative light to other community members.
Page 22
Where such cases arise, it is advisable to ensure that all available services are provided to the client
(see Section 3.4) and to ensure that the error is followed up with supportive supervision and
monitoring from a community worker (see Chapter 8.4).
* NOTE:
MUAC and bilateral pitting oedema are the preferred admission criteria. However, if there is already
capacity and equipment in place to assess additional cases of acute malnutrition on the basis of
weight-for-height measurements at facility level this can be done. In this case, the criteria of WHZ <-3
for SAM and ≥-3WHZ<-2 for MAM can be used as an additional admission criteria.
4.1.1 Step 1. Determine age

Age groups are best identified by using a local calendar of events to help determine the age if a birth
date is not known. Birth dates can also be identified with the help of a birth registration certificate or
Child health card. It is not recommended to use a height cut-off as proxy for six months of age; in a
stunted population many infants six months or older will have a height less than 65 centimetres (cm).
4.1.2 Step 2. Check for pitting oedema on both feet

Bilateral oedema is the sign of Kwashiorkor. Kwashiorkor is always a severe form of malnutrition.
While lesser degrees of oedema can be effectively treated in OTC care, children with generalised, third
degree oedema are at high risk of mortality and need to be urgently treated in a stabilisation centre
so it is important for grade of oedema to be identified correctly. Oedema caused by acute malnutrition
presents with special characteristics:
- It starts from both feet, extending upwards to the arms, face and entire body
- It is pitting (leaves an impression after pressure is applied)
See Annex 5 for how to check oedema.
4.1.3 Step 3. Measure MUAC

MUAC is measured only for children aged 6-59 months as identified above. The MUAC measurement
can be done using a simple calibrated tape with colours corresponding to severe (red), moderate
(yellow), and no (green) acute malnutrition. Single cut-offs are used for the diagnosis of acute
malnutrition for all children between 6-59 months of age. These are:
- <11.5cm for SAM and
- ≥11.5- <12.5cm for MAM
See Annex 5 for how to measure MUAC.
4.1.4 Step 4. Assessment of appetite and medical complications

Once acute malnutrition has been identified, a CB-IMNCI check (depending on the level of contact) is
required to identify any medical complications that would necessitate referral for inpatient
therapeutic care (for acute malnutrition with complications) or whether the child can be treated in
OTC or the MAM programme. Most commonly this will take place at the health facility as a result of
the CB-IMNCI check, however in some cases the FCHV may urgently refer to the nearest health facility
based on her CB-IMNCI check.
Page 23
At community level - CB-IMNCI
When FCHVs measure the MUAC and check for the oedema, they should also look for the danger signs
according to CB-IMNCI. There are between seven and nine main danger signs identifiable by the
FCHVs, following CB-IMNCI guidelines. These are dealt with in detail in FCHV training materials:
- The child has had convulsions / is unconsciousness /is apathetic, lethargic /not alert
- The child vomits everything
- The child has severe diarrhoea and/or dehydration
- The child has hypothermia
- The child has high fever
- The child has rapid breathing
- The child is not able to drink or breastfeed and/or does not eat (anorexia)
- The child has severe oedema (+++ Grade 3)
- The child has severe anaemia (severe palmar pallor)
On referral of these cases to the nearest health facility, the FCHV should explain the possibility that
the child will require inpatient care.
At facility level
Once MUAC and oedema have been assessed and the child identified with acute malnutrition, health
facility staff must assess the condition of child and presence of complications:
- Assess the appetite- Test with RUTF (See Box 5 and Annex 8), if the child initially refuses, move
the child and caretaker to a quiet area. The health worker must observe the child eating the
RUTF before the child can be admitted to the out-patient care centre.
- Take history- for Diarrhoea, Vomiting, Stools, Urine, Cough, Appetite, Breastfeeding, Swelling,
and Oedema. If needed, ask further questions about the duration of the symptoms, etc. to get
a clear picture of the problem.
- Carry out medical assessment - As per CB-IMNCI, paying special attention to the conditions
mentioned in Table 2.
- Take weight (and height*) measurement As a baseline for weight monitoring during follow-
up visits (see Annex 5)
*NOTE: In addition, where there is existing capacity at facility level to take weight and height
measurements, height may be taken and weight-for-height z score calculated as an additional (not
substitute) admission criteria to MUAC.
Assess based on the above whether the child requires referral to inpatient care (refer to).
Box 5. The importance of the appetite test?

Malnutrition changes the way infections and other diseases express themselves. Children
severely affected by the classical CB-IMNCI diseases who are also malnourished, frequently
show no signs of these diseases. However, the major complications lead to a loss of appetite.
Therefore, an important criterion to decide if a patient with SAM should be sent to in- or
outpatient management is the Appetite Test. SAM with a poor appetite means that the child
has a significant infection or a major metabolic abnormality such as liver dysfunction,
electrolyte imbalance, cell membrane damage or damaged biochemical pathways. These are
the patients at immediate risk of death, as a child with major complications and a poor
appetite will not consume RUTF at home and will continue to deteriorate or die.
For detail on how to conduct the test see Annex 8.
Page 24
Table 2. Criteria for admission to in- or out-patient care (children 6-59 months) with SAM:
Factor Inpatient care Outpatient care
Oedema Bilateral pitting oedema grade 3 (+++) Bilateral pitting oedema grade 1
) or 2 (+ and ++)
MUAC <11.5cm AND one of the below <11.5cm AND both of the below
or
WFH <-3 SD and one of the below <- 3 SD AND both of the below
Appetite Not able to eat the test dose of RUTF Demonstrates appetite by eating
the test dose of RUTF
Medical NO medical complications
complications
Vomiting and/or Intractable (empties contents of stomach)
diarrhoea
Temperature Fever > 101.3 °F (38.5°C) under arm pit;
(102.2°F/39°C rectal)
Hypothermia < 95 °F (35°C) under arm pit;
(96°F/35.5°C rectal)
Respiration rate ≥60 resp/min for infants under 2 months
≥50 resp/min from 2 to 12 months ≥ 40
resp/min from 1 to 5 years
≥ 30 resp/min for over 5 year olds
And any chest in-drawing (for children > 6
months)
Anaemia Very pale (severe palmer pallor), difficulty
breathing
Superficial Extensive skin infection (including Redness,
infection swelling, abscess/pus, or foul odour around
skin) requiring Intra-Muscular treatment
Extensive mouth ulcers
Ear pain with tender swelling behind the

ear
Urinary tract infection

Alertness Very weak, apathetic, unconscious
Fitting/convulsions
Hydration status Severe dehydration based primarily on
recent history of diarrhoea, vomiting,
fever, anuria (lack of discharge of urine),
thirst, sweating and clinical signs
Page 25
Jaundice History of dark yellow urine, yellowish
conjunctiva, lips and nails, yellow skin
Eye infection and Corneal clouding or other signs of Vitamin
other eye A deficiency (Xerophthalmia, bitot spots
problems and corneal ulceration or history of night
blindness)
Hypoglycaemia -Hypothermia
-Lethargy
-Limpness
-Loss of consciousness
-Sweating and pallor (These signs may not
occur in SAM children)
Table 3. Criteria for referral of children with MAM for medical treatment and SFP
Factor Medical treatment and SFP Supplementary Feeding or MNP
distribution with counselling
MUAC ≥11.5cm and <12.5cm AND one of ≥11.5cm and <12.5cm AND the
below below
(or WHZ <-2 and ≥-3 z-score AND one of (or WHZ <-2 and ≥-3 z-score AND
the below) the below)
Medical As table 2 NO medical complications

Complications
4.2 Assessment of infants under 6 months

Clinical signs in infants under 6 months should be assessed in the same way as above according to CB-
IMNCI procedures. In addition infants under 6 months may become malnourished if they have:
- never been breastfed
- been only partially breastfed, combined with inadequate, unsafe artificial feeds and/or with
inappropriate complementary feeds (e.g. watery, introduced too early)
- their mothers are dead or absent
- their mothers are malnourished, traumatised, ill, or unable to respond normally to their
infants’ needs
- they have some form of disability that affects their ability to suckle or swallow, and/or a
developmental problem affecting feeding.
- They have suffered from repeated infections or chronic illness
- were low birth weight babies as a result of prenatal malnutrition or preterm birth and have
failed to ‘catch up’
Their assessment needs to help identify these causes in order to provide the most appropriate
treatment. It is difficult to distinguish between malnourished infants who were low birth weight babies
who have failed to catch-up and those who have become malnourished after birth. However recent
International research21 indicates that Infants identified as wasted using WHO or NCHS growth norms
are not predominantly ex-low birth weight.
21
Management of Acute Malnutrition in Infants (MAMI) project. Summary report October 2009
Page 26
The above criteria illustrate the need not just to assess the infant but to also asses the mother to see
if they are ‘malnourished, traumatised, ill, or unable to respond normally to their infants’ needs’ and
to assess the infant feeding practices of the infant and mother.
At community level
Infants under 6 months with bilateral pitting oedema (tested as above) and/or visible wasting (see
below), or who are noted to be lethargic (according to CB-IMNCI) are not measured with MUAC but
referred to the nearest health facility where they are further investigated. There is currently no
appropriate MUAC criteria for the identification or SAM or MAM in infants though research is
underway in this area.
Figure 5. Signs of visible wasting
Signs of visible wasting (Figure 5) in the infant under 6 months can best be seen if the client has
removed some clothing in order for the community worker or heath provider to get a clear picture.
For identification of severe marasmus in children of less than 6 months of age, look for loss/reduction
of subcutaneous fat with loss of muscle bulk and sagging skin, loss of muscles around the shoulders,
arms, buttocks, ribs and legs, and check to see if the outline of the client’s ribs is seen easily. Examine
them from the side view to see if the fat of the buttocks is significantly reduced. In extreme cases you
will see folds of skin that make it seem like the child is wearing baggy pants.
FCHVs may also be able to conduct a rapid assessment of feeding practices (see Annex 24) in order to
determine whether there is immediate risk to the baby and therefore a need for immediate referral
for full assessment at the health facility or if the mother needs only community based supportive care.
In addition a health assessment of mother according to CB-IMNCI and anthropometric assessment

using MUAC can be done. A MUAC of <23.0 cm in the mother of an infant under 6 months would lead
to either inpatient or outpatient admission of the infant depending on their condition and registration
of the mother to also receive support through the MAM programme.
At facility level
At the nearest health facility criteria of visible wasting may also be used. However where there is the
possibility to do so, weight and height measurements can also be taken and the infant assessed for
Page 27
presence of severe wasting according to the WHO growth standards for WHZ. Note that paediatric
balance scales are required for the accurate recording of weight in infants to precision of 10g. It should
also be noted that the use of the WHO growth standards for the assessment of infants < 6 months of
age diagnoses a much larger group than previously used standards.
Full assessment should also be made of breastfeeding practice in accordance with national IYCF
guidelines (see annex 24). On the basis of these assessments care givers will receive IYCF counselling
at community level, IYCF counselling on an outpatient basis (along with any medical support required
and supplementary feeding for the mother if available), or the infant will be referred for inpatient
care. Currently there are no international guidelines for the nutritional treatment of infants <6 months
in outpatient care using RUTF. However research is underway in this area.
Table 4. Criteria for admission to inpatient and outpatient care – Infants <6 months
In-patient care Outpatient /Infant feeding IYCF counselling at community
support (medical treatment, level
IYCF counselling at facility,
supplementary feeding for
mother where available)
visible wasting and/or visible wasting and WHZ <-2 ≥ - Breastfeeding: status, frequency,
WHZ <-3 zscores 3 zscores night feeding
and/or oedema AND Basic breastfeeding difficulties
None of the complications identified during assessment:
AND requiring inpatient care - mother lacks confidence
One of the below - misconceptions, worries about
complications: breastfeeding
OR
- doubts about having adequate
Breastfeeding infants whose breast milk
Any of the medical mother is malnourished or ill - requests for breast milk
complications outlined substitutes to supplement
for children 6-59m
breastfeeding
(table 2) - interest in increasing breast
milk
Infant is lethargic and - poor attachment or ineffective
unable to suckle suckling
- discomfort or mild pain from
Recent weight nipples
loss/inability to gain
weight Feeding not age appropriate
(frequency, amount, texture,
Ineffective feeding variety, active feeding and hygiene)
(attachment,
positioning and
suckling) directly
observed Any medical
or social issue needing
more detailed
assessment or
intensive support
(e.g. disability,
depression of the
Page 28
mother/caretaker, or
other adverse social
circumstances)
Note: in inpatient care full nutritional support for the lactating mother should also be provided.
4.3 Summary classification of acute malnutrition

A summary of the classification of acute malnutrition based on the above steps is given in Table 5.
Table 5. Summary admission criteria

Inpatient management of SAM Outpatient management Management of MAM
WHO and CB-IMNCI protocols of SAM
Severe acute malnutrition with Severe acute malnutrition Moderate acute

complications without complications malnutrition
Children 6-59m Children 6-59m Children 6-59m

Nutritional oedema +++ MUAC<11.5 cm MUAC 11.5cm- <
Or WHZ<-3 ZScore 12.5cm
(<11.5cm with any grade of And /or Nutritional or WHZ <-2
oedema) oedema + and ++ MUAC>11.5cm where
facility capacity exists
OR
MUAC <11.5cm AND AND
Or WHZ<-3 ZScore Appetite No bilateral pitting
Clinically well oedema
with any of the following Alert Appetite
complications: Clinically well*
- Anorexia, no appetite Alert
- Increased respiration rate
High fever
- Severe dehydration
- Severe anaemia
- Not alert (very weak,
lethargic, unconscious,
convulsions)
- Hypothermia
- Intractable vomiting
- Severe diarrhoea Infants Lactating Women
- Hypoglycaemia
Infants <6 months who Infant enrolled in
meet criteria for outpatient inpatient care and
Infants support (see Table 4) MUAC <23.0cm
Infants <6 months who meet
criteria for inpatient admission Referral from ITC Referral from OTC
(see Table 4)
After stabilisation 2 months SFP regardless
of MUAC or W/H
Referral from OTC
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Due to deterioration or non-
response
*NOTE: Where the service encounters children with MAM with severe medical complications these
clients should be referred for the appropriate urgent medical care (as per Table 3) and where some
form of supplementary feeding is available and also be registered to receive it. Where possible, these
cases should be also given seven packets of RUTF to aid in their convalescence.
Page 30
5 Management of SAM
5.1 Pathophysiology of SAM

The pathophysiological responses to nutrient depletion place children with SAM at an increased risk
of life-threatening complications that lead to increased risk of death. Therefore, successful
management of SAM in children requires systematic medical treatment of underlying infections and
a dietary treatment or rehabilitation with specially formulated therapeutic foods, such as F75 and
F100 milk, or a ready-to-use therapeutic food (RUTF). Therapeutic foods have the correct balance of
nutrients and a high nutrient density and bioavailability. They are soft or crushable foods that are
easily consumed by children from the age of six months without adding water. The treatment aims to
restore the metabolism through correction of electrolyte balance, reverse metabolic abnormalities,
restore the organ functions and provide nutrients for catch-up of growth. It should be noted that,
according to the WHO statement on community-based management of SAM, since RUTF do not
contain water, children should also be offered safe drinking water to drink at will throughout the
treatment.
Due to the pathophysiological changes that accompany SAM, these children often do not present
typical clinical signs of infection that sick children without SAM have when they are ill, such as fever.
Consequently, children with SAM need to be provided with systematic medical treatment for
underlying infections. Treatment protocols for children with SAM for some medical complications,
such as dehydration or shock, differ from the classical treatment protocols for ill children without
SAM. Misdiagnosis of medical complications, inappropriate treatment and feeding of children with
SAM contributes to slow convalescence and increased risk of death, thus adherence to these
treatment guidelines in their entirety is critical.
5.2 Outpatient Therapeutic Care

Outpatient therapeutic care is aimed at providing treatment for children with SAM who have an
appetite and have no medical complications and can therefore be treated at home with simple routine
medicines and RUTF (see Annex 6). It achieves this objective through timely detection, referral and
early treatment before the onset of a complication. Effective community mobilisation, active case
finding, referral and follow-up are the cornerstones of successful outpatient therapeutic care (see
Chapter 3).
Outpatient therapeutic care should be delivered from as many health facilities as possible (with
sufficient capacity in place) and should be a component of routine service delivery. This ensures good
access and coverage so that as many acutely malnourished clients as possible can access treatment
within a day’s walk from their homes.
Children may be received directly into outpatient care when they come to the health facility, by
referral from a FCHV or other community agent, or by referral from inpatient care once their condition
has stabilised.
Non-complicated SAM cases should be treated in Nutrition Rehabilitation Homes which serve as OTC
Centres where community based facilities are not available.
5.2.1 Assessment of nutritional status and medical condition

Give safe drinking water to suspected cases and referrals waiting at the health facility for assessment
and prioritise assessment of any cases who look ill or lethargic. Sugar water can be given instead of
Page 31
water for any suspected cases of hypoglycaemia (low body temperature, lethargy, limpness, eye-lid
retraction, and loss of consciousness) if it is available. See Annex 7 for preparation and protocol for
use.
Assessment (see Chapter 4) aims to confirm any assessment already made at the community level:
- Determine age of the child (use local calendar if needed)
- Take MUAC and check for bilateral pitting oedema to confirm SAM
- Take weight (for weight monitoring during follow up visits)
- Conduct the appetite test (see Annex 8)
- Take medical history
- Assess medical condition of child and presence of complications
- Check vaccination status, last deworming and vitamin A supplementation
- Review and record any relevant information from referral document where there is one
5.2.2 Admission or referral based on programme criteria

If there are no complications present the child with SAM can be treated in Outpatient Therapeutic
Care Centres (see below). Details for the above assessments, plus relevant family information should
be entered on to the Outpatient Therapeutic Care (OTC) card (see Annex 9) and details entered into
the records of the health facility.
Table 6. Summary admission and referral for SAM

Admission to Outpatient Therapeutic Care Referral to Inpatient Therapeutic Care
MUAC <11.5cm or Nutritional oedema + or ++ Nutritional oedema +++
With Appetite
And with NO Medical Complications (see Table
2)
MUAC <11.5cm
With NO Appetite
And/or with Medical Complications (see Table
2)
Note: For infants, referral to inpatient care should be based on presence of the criteria outlined in
Table 4.
If complications are present (according to Table 2) explain to the mother/caretaker the child cannot
be treated in outpatient care at the (Sub) Health Post / PHC and needs in-patient care at least 3 to 7
days (some days), and refer to Inpatient Stabilisation, explaining to the mother/caretaker where to go
and what will happen there and fill in a referral form for them to take with them. The referral
document contains all the information about the child and their condition, any treatment given and
the reason for referral (see Annex 3 for standard form). If a mother/caretaker refuses to be referred
to inpatient care the child should be treated in Outpatient care but prioritised for follow-up at home
(particularly during the first few weeks of treatment) by the FCHV.
Transport for referral should be facilitated wherever possible (see Box 6).
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Box 6. Facilitation of emergency referral
It is important to ensure that referrals of complicated cases of SAM are able to make the
journey to the inpatient facility even if this is some distance away. These cases are at high risk of
death and therefore referral should be treated as an emergency. Health staff should discuss
with the mother/caretaker when and how they are going to travel to the inpatient facility. Funds
to support transfer may be available through emergency funds held by FCHVs or health facilities.
If needed provide vital medical treatment before referral such as 10 per cent sugar water in the
case of dehydration, diarrhoea hypoglycaemia or hypothermia. Do not give ORS to a child with
SAM.
Equally, children who have stabilised in the inpatient facility are nevertheless still at increased
risk of death and it is vital that they continue their rehabilitation in the OTC. Where possible
therefore transfer to OTC from stabilisation in inpatient care should also be similarly facilitated
wherever possible.
5.2.3 Medical Management
In order to treat probable and potential underlying illnesses that might cause only sub-clinical
symptoms in severely acutely malnourished children, ALL cases admitted to OTC should be treated
according to the following systematic treatment schedule.
Table 7. Routine medicines for Outpatient Therapeutic Care* (for detail see Annex 10)
Drug/Supplement When Age/Weight Prescription Dose
VITAMIN A** At Admission < 6 months*** 50,000 IU Single dose
(EXCEPT 6 – 12 months 100,000 IU (for children
children with > 12 months 200,000 IU with oedema
oedema) single dose on
Do not use with Oedema
discharge)
AMOXYCILLIN At Admission All SAM cases <10kg 125mg tds 3 times a day
>10kg 250mg tds for 7 days
CHLOROQUINE & At Admission All SAM cases See Annex 11 1 time a day for
PRIMAQUINE in malaria areas 3 days
(Terai) (on admission)
ALBENDAZOLE Second visit < 12 months DO NOT GIVE None

12 – 23 months 200 mg Single dose, on
≥ 24 months 400 mg second visit
MEASLES On week 4 6 – 8 months DO NOT GIVE Single dose;
VACCINATION until they when they
complete 9 reach 9 months
months of age old & after at
least 4 weeks in
OTC
≥ 9 months Standard Single dose
*For children referred from inpatient stabilisation a check should be made of the treatments already
received and the above adapted accordingly
** Vitamin A: Do not give if the child has already received Vitamin A in the last month. Do not give to
children with oedema until discharge from OTC, unless there are signs of Vitamin A deficiency
Page 33
*** Relevant for infants treated on outpatient basis (see Section 5.4.3)
IRON and FOLIC ACID: NOT to be given routinely. Where severe anaemia is identified according to CB-
IMNCI guidelines, the severely malnourished child should be referred to in-patient care. Where
moderate anaemia is identified treatment should begin after 14 days in the programme and not
before because a high-dose may increase the risk of severe infections. Treatment should be given
according to CB-IMNCI protocol (one dose daily for 14 days).
The child’s immunisation status should be checked and the mother/caretaker referred to the monthly
immunisation outreach clinic in his/her area.
Other medical conditions/symptoms – eye infections, ear discharge, mouth ulcers, minor skin
infections and lesions – should be treated according to the CB-IMNCI guidelines (see Annex 12).
It is important to record any supplementation/treatment given on the child’s medical card/growth

chart if they have one.
5.2.4 Nutrition Management

Nutritional rehabilitation in Outpatient Therapeutic Care is through the use of Ready-to-Use
Therapeutic Food (RUTF). RUTF is an energy dense mineral/vitamin enriched food nutritionally
equivalent to F100, which is recommended by the WHO for the treatment of severe acute malnutrition
(see Annex 6 for more information on RUTF). It is an oil-based paste usually made of peanuts, oil,
sugar and milk, with low water activity; thus it is microbiologically safe and can be kept for months in
simple packaging. Therefore, with proper hygiene instruction, RUTF can be safely used at home.
RUTF provides a complete diet for the severely acutely malnourished child with the exact balance of
micronutrients and electrolytes they require. The amount of RUTF a child should consume is
determined by the need for an intake of 200 kcal/ kg/ day.22 The amount given to each patient is
therefore calculated according to its current weight and must be adjusted as weight increases during
treatment. Annex 13 gives the amounts of RUTF to feed and take home rations.
If there is NRH in IMAM district, RUTF will be used for transition phase/appetite test otherwise
complicated SAM cases should be managed by F-100.
Box 7. RUTF and multiple micronutrient powders – DO NOT DOUBLE SUPPLEMENT

Note that children with SAM receiving treatment with RUTF should NOT receive any
supplementation with multi micronutrients (even if they are suffering from anaemia) as they
are already receiving appropriate micronutrient supplementation within the RUTF.
Mothers/caretakers therefore need to be told to discontinue micronutrient supplementation

if they are already registered for that service.
Cases of SAM with anaemia should be treated according to the protocols outlined in 5.2.3.
22
This is comparable to the WHO recommendation of 150 to 220 kcal/kg/day for nutritional rehabilitation in
phase 2 of the in-patient management of SAM
Page 34
5.2.5 Orientation and counselling for the mother/caretaker
On admission when giving the RUTF ration, the health worker should discuss a number of simple key
messages on the use of RUTF, continuation of breastfeeding, the need to feed plenty of drinking water,
and orientation on hygiene and sanitation with the mother/caretaker (see Box 8)
For all mothers/caretakers it is also important to make sure they are aware of their local FCHV and the
support that these women can offer for them.
In addition for refused transfers to inpatient care the mother/caretaker should be informed that their
local FCHV will be visiting them at home during the week.
On subsequent visits additional counselling may be provided while mothers/caretakers are waiting for
their consultation. This may focus on:
- Particular topics within the IYCF package (Breastfeeding and Complementary Feeding)
- ECD during breastfeeding, feeding and play
Box 8. Key messages for Mothers/Caretakers

o Explain how much RUTF to give the child each day (refer to RUTF ration table).
o If the mother is still breastfeeding, advise her to continue breastfeeding before giving
RUTF. If she is not breastfeeding, then always give plenty of safe water with RUTF as it
does not contain any itself.
o The RUTF is all the food a child needs to recover. No other foods should be given until
the full ration each day has been finished.
o Encourage the child to take small amounts of RUTF frequently during the day, eating
directly from the packet.
o Whenever possible, wash the child’s hands and face before eating and after defaecation.
o RUTF is a special food as medicine for thin and swollen children. It should never be
shared with other members of the family.
o If concerned about the child’s condition, tell the mother/caretaker to bring them straight
back to the health facility. For example, if the child is not eating, vomiting, having
diarrhoea, or is sick, or increasing oedema the child should be taken immediately directly
to the health facility for medical review and advice.
o Give medicines as advised by the health worker.
o Attend the health centre weekly for monitoring and to receive more RUTF supplies.
o properly dispose the empty sachet at the HH level by deep borrowing or burning
o Malnourished children need to be kept warm (ensure child wears plenty of clothes).
Note: Always ask the mother/caretaker to repeat back how s/he will feed the child and give any
medicines at home.
-
5.2.6 Individual monitoring and follow-up
Facility
Children’s progress is monitored on a weekly basis23 at the health facility ((S)HP/PHC) and recorded in
the register.
- Weight is measured and recorded to track progress
23
Outpatient care in some cases may be carried out fortnightly if for example a lot of mothers/caretakers are
defaulting because it is harvest time or if the health facility is serving a very large geographical area.
Page 35
- Degree of oedema (0 to +++) is assessed and recorded
- MUAC is taken and recorded to track progress
- Medical assessment is completed as per CB-IMNCI guidelines
- The mother/caretaker is asked about the progress of the child
- Appetite is discussed and RUTF appetite test performed at each follow-up
- The weekly ration is calculated according to current weight and provided
Any issues identified during the medical check and appetite test should be appropriately addressed
through treatment at the health facility (according to CB-IMNCI protocols) or referral to inpatient
therapeutic care according to the criteria set out in Table 8 below.
In addition, any child with the below should also be referred to inpatient therapeutic care if they are
not responding adequately to treatment in the OTC. This is defined by:
- No weight gain for five weeks
- Weight loss for three weeks
- Increased oedema or development of oedema (see summary in Table 8 below)
Table 8. Criteria for referral to inpatient from outpatient treatment during follow-up
Factor Criteria for inpatient referral
Oedema Increase of or development of oedema
Appetite No appetite or unable to eat
Medical complications As defined in Table 2 for admission to inpatient care
Weight changes Weight loss for 3 consecutive weighing

(2 consecutive weighing for 2 weekly follow-up)
Static weight for 5 consecutive weighing

(3 consecutive weighing for 2 weekly follow-up)
General Other general signs the health worker thinks warrants referral
(as per CB-IMNCI)
Note: For infants, referral to inpatient care during treatment should be based on the development of
any of the complications outlined in Table 4.
In some cases where children are not responding to treatment, chronic conditions may be suspected
and in this case children should be referred for further investigations in the hospital or appropriate
site. This can include:
- Referral for HIV counselling and testing
- Referral for TB testing counselling and testing (see Chapter 5.2.8)
All referrals should be accompanied by a referral document that contains all details of the child’s
condition, reason for transfer and any treatment received (see Annex 3 for standard form).
Page 36
Children with SAM can be transferred to outpatient care when their medical complications, including
oedema, are resolved. The criteria for transferring a child from inpatient to outpatient treatment
should follow the below guidelines:
- The child has a good appetite and RUTF test dose ok
- The child is clinically well and alert
- The decision to transfer a child from inpatient to outpatient care should be determined by
his/her clinical condition and not on the basis of specific anthropometric outcomes, such as a
specific mid-upper arm circumference or weight-for-height/length
- Decrease of oedema, and/ or minimum oedema present
- Min LOS (to ensure that stabilization and transition phases have been completed: 5 days
Community
Follow-up through home visit by the FCHV should be triggered for:
- Children with medical complications who have refused transfer to inpatient care and are being
treated on an outpatient basis
- Cases who are not responding in the programme (loss or static weight for two weeks) and
aspects of the home environment are suspected to be playing a role rather than medical issues
- Repeated absentees from treatment
See Chapter 3 for details on follow-up visits.
5.2.7 Discharge from Outpatient care

Discharge Cured Criteria
For children 6-59 months, admitted by MUAC (or by W/H)
- Minimum LOS of 6 weeks AND MUAC >11.5cm AND
- No oedema for two consecutive visits AND
- Weight gain for last two consecutive visits AND
- Clinically well and alert
Upon Discharge
- Children admitted with Oedema will get one dose of vitamin A (other outpatient children do
not get this discharge dose).
- If the child has completed nine months of age during his/her treatment in OTC, and did not
yet get a measles vaccination, the mother/caretaker should get confirm an appointment for
follow-up visit during EPI hours, or to visit the nearest EPI outreach clinic as soon as possible
to receive the vaccination.
- Children admitted at age six to eight months should schedule a follow-up appointment (during
EPI hours or outreach clinic) for the second measles vaccination after one month.
- All children will get a last ration of seven sachets of RUTF (for one week) to aid the transition
onto local and, in some cases, supplementary foods.
- The mother/caretaker should receive counselling on IYCF practices, care practices, hygiene,
feeding practices, food preparation for children etc. in line with standard IYCF counselling.
- The caretakers should be linked with the MAM programme (either supplementary feeding or
MNP distributions with counselling depending on which is available) and with any other
appropriate services ( e.g. further IYCF counselling) for which they are eligible and which
support the ongoing rehabilitation of the child (see below).
- Complete the patient record in the register with the discharge details.
Page 37
Discharge as non-cured
If a child does not reach the discharge criteria within three months and all referral and follow-up
options have been tried, they may be discharged as non-cured and linked with the MAM programme
where possible and to social support systems (see 5.2.8).
Discharge as defaulter
If a child is not seen for follow-up for three consecutive visits/consultations (or for two
visits/consultations if they are only being followed-up every two weeks) and it is not possible for
community level agents to locate them and encourage them back to the service, then that child should
be discharged as a defaulter.
5.2.8 Operationalising links

Where there are interventions in place targeting MAM children, those discharged from treatment for
SAM should be officially referred to these services as standard with the use of a referral slip.
Other interventions that are of benefit for referral of individual children with SAM and/or links with
the IMAM programme are:
- CB-GMP programmes- Which allow on-going monitoring of the child. During treatment in OTC
the child’s weight can be plotted on their growth chart. Upon discharge they should be
referred where GMP is in place for on-going monitoring.
- Specific IYCF counselling and support – This can be provided through trained HWs/FCHVs on
IYCF practices. It is important to emphasise these same IYCF messages and support for the
mothers/caretakers of acutely malnourished children.
- ECD centres – Stimulation is a key part of rehabilitation for malnutrition, therefore where ECD
centres are in place, children can be referred to them both during and after treatment for
SAM. Where ECD facilitators are working at the community level, children can also be linked
to them either via the health facility or FCHV.
- Health/WASH/Nutrition education- Linking to support for the prevention of malnutrition
throughout the critical 1000 day window is important. The major delivery mechanism for
counselling and support is the FCHV. It is important to emphasise during FCHV training the
importance of prevention counselling for mothers/caretakers of acutely malnourished
children.
- Micronutrient powder distribution (MNP)- Anaemia among children under two years of age
in Nepal is 72 per cent, and is 46 percent among under five year old children (NDHS 2011). In
response, the Nepal Ministry of Health has a new policy and plan for scaling up the promotion
and distribution of micronutrient supplementation for children aged 6 to 23 months, to
prevent anaemia and improve overall nutritional status. MNP distribution is also part of the
treatment for MAM in areas where sufficient local foods are available to provide for young
children. It is also part of the package of interventions for implementation during emergencies
for all children aged 6 to 59 months. In areas where micronutrients supplementation is already
in place, mothers/caretakers of children with SAM should be orientated on the importance of
MNPs for addressing anaemia and other micronutrient deficiencies and referred to receive
MNPs on discharge either within the Supplementary Feeding programme if in place or through
general distributions (NOT during treatment where sufficient supplementation is provided
through the RUTF).
- HIV counselling, testing and support –The proportion of children suffering from SAM who are
HIV positive is unknown in Nepal. However, the association between acute malnutrition and
HIV is known. As noted above, wherever possible, non or slow response of children in the
programme that creates suspicion of underlying chronic condition should lead to referral for
Page 38
counselling and testing. Equally, staff working on any facility or community outreach sites
where HIV/TB counselling and testing is being carried out (including PICT) should also be
trained in the identification of acute malnutrition and referral to IMAM.
- Child Cash grant – Where children are eligible for the child cash grant, the FCHV and other
community facilitators/volunteers can refer them to this programme. It is therefore important
that they are aware of the criteria. At the same time, efforts should be made within the cash
grant programme to sensitise mothers/caretakers about the IMAM programme.
- Ante and post-natal care services – It is important to use the contact with mothers through
ante-natal care to ensure that existing children are assessed for acute malnutrition. The
contact with mothers of children coming for SAM treatment is also an opportunity to ensure
that they are accessing ante-natal and reproductive health services as their health, nutritional
status and wellbeing are closely linked to that of both existing and future children.
- CB-IMNCI – As noted within the document, at various stages in the assessment and monitoring
of the child with SAM, CB-IMNCI protocols are adhered to. Therefore, to strengthen links,
trainings done on CB-IMNCI should include the module on identification and management of
SAM.
5.2.9 Set-up requirements

OTC Centers (OTCC) will operate either in PHCC or health posts or sub health posts in order to most
adequately reach the majority of the population with a service within a day’s walk. In IMAM program
district, if there is already NRH, the NRH will also provide both OTCC and ITC services. Where sub
health posts are included (based on identification of distance as a barrier to access), it is important
that minimum requirements are still met and that supply and supervision schedules include these
sites. In some cases in order to access the population the SAM treatment service may be taken out
with other services during outreach clinics. Sites selected for outreach clinics should also take account
of the following requirements. Minimum requirements before setting up capacity for management of
uncomplicated SAM are:
- Facility is manned by trained health staff able to conduct CB-IMNCI
- Running water (for consumption, hand washing and general hygiene)
- Gender sensitive latrines
- Shade under which children and their mothers/caretakers can wait for service
- Safe and adequate storage place for RUTF, medicines and equipment
- A separate area for measurements and consultations in order to protect privacy
Equipment requirements for setting up OTC Centres are outlined in Annex 14.
5.3 Inpatient Therapeutic Care

In the Nepal context, inpatient therapeutic care should most commonly take the form of stabilisation
care (or ‘phase’ of care according to WHO inpatient protocols) for cases of severe acute malnutrition
with medical complications. Once stabilised, these clients will be referred to outpatient care to
complete their treatment. In some cases e.g. in the NRH, the complete rehabilitation of children past
the stabilisation phase may occur where OTCC is not in place or accessible or for a minority of special
cases (infants <6 months, cases with high risk home environment, patient choice). Inpatient care is
carried out according to WHO protocols.
Inpatient stabilisation should be delivered from tertiary level facilities with capacity for 24 hour care
and where medical capacity is available for the treatment of complications. In some cases it may be
possible for the NRH linked to the hospital to provide this stabilisation care where there is not IMAM
program. Inpatient therapeutic care should be incorporated into the existing running of the facility
Page 39
though a specific section (bed space) and staff may be assigned. Children from districts where in-
patient care are unavailable should be taken to the nearest in-patient care facility in another district.
Children may be received directly into inpatient care via identification at the outpatient department
of the hospital, by referral from Outpatient care or by referral from the FCHV or other community
agents.
The general WHO principles for routine care should be kept in mind at all times. The last three have
been adapted for inpatient care to accommodate outpatient rehabilitation (see Figure 6).
Figure 6. WHO steps for management of SAM

Step 1. Treat/prevent hypoglycaemia
Step 2. Treat/prevent hypothermia
Step 3. Treat/prevent dehydration
Step 4. Correct electrolyte balance
Step 5. Treat/prevent infection
Step 6. Correct micronutrient deficiencies
Step 7. Start cautious feeding
Step 8. Transition to catch-up diet
Step 9. Provide sensory stimulation and emotional support
Step 10. Prepare for follow-up after stabilisation
Stabilisation Phase Rehabilitation Phase

Days 1 – 2 Days 3 – 7 Weeks 2 – 6
1. Treat/prevent hypoglycaemia
2. Treat/prevent hypothermia
3. Treat/prevent dehydration
4. Correct electrolyte balance
5. Treat/prevent Infection
No iron With iron
6. Correct micronutrient deficiency
7. Start cautious feeding
8. Catch-up growth
9. Sensory stimulation
10. Prepare for follow-up

This assessment may take place at the outpatient department (OPD) or through collaboration of the
OPD and the inpatient therapeutic unit depending on where staff trained in the particular
management of SAM are situated. Critical care of children with SAM differs from the standard
protocols and trained medical staff need to be involved to provide appropriate medical care for SAM
to reduce the risk of death. Assessment should include (see Chapter 4):
- Give water to suspected cases and referrals waiting for assessment.
- Any critically ill children should be triaged and prioritised for rapid assessment and immediate
treatment of any life threatening complications (see below.). At this stage, sugar water should
be made available to prevent hypoglycaemia (see Annex 7).
- Take MUAC and check for Bilateral pitting oedema to confirm SAM.
- Take weight (for weight monitoring during follow up visits) and height*.
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- Conduct Appetite test (see Annex 8).
- Assess history and medical condition of child and presence of complications.
*NOTE: In addition, where there is existing capacity at facility level to take weight and height
measurements, height may be taken and weight-for-height zscore calculated as an additional (not
substitute) admission criteria to MUAC.
5.3.2 Admission or referral based on programme criteria.

Cases of SAM with medical complications requiring inpatient treatment (see Table 2) are registered
for treatment. The inpatient treatment register is filled in with details of the above assessments (see
Annex 15).
For cases of SAM presenting at the Outpatient department without medical complications identified
according to the criteria in Table 2 and with appetite it may be appropriate to refer to Outpatient
Therapeutic Care. A standard referral slip should be completed (see Annex 3) and the
mother/caretaker orientated to attend the nearest OTC site (ideally this will also be in the hospital).
Where cases of MAM with medical complications are encountered (see Table 3) urgent medical
treatment should be provided. These cases should not be referred to inpatient therapeutic care but
to the appropriate medical care required according to their complication as per the IMCI protocol.

Treat medical complications identified (see Annex 16 for details) including critical conditions (shock,
dehydration, hypothermia, heart failure). Note that for dehydration, ReSoMal and not ORS is used for
children with SAM. ReSoMal is specially formulated for these children for use in inpatient care only
(see Annex 19 for use and preparation of ReSoMal). If commercial ReSoMal is not available it can be
prepared (see Annex 22) or 10 per cent sugar water could be used for short term emergency
rehydration (see Annex 7).
Provide routine medicines for all admissions to inpatient care according to the protocols in Annex 17.
Note: The use of intravenous (IV) lines is strictly avoided except in case of shock or circulatory
collapse. Special care with intramuscular (IM) injections is required, as children with SAM have
reduced muscle mass and the risk of nerve damage is high.
5.3.4 Nutrition Management

Nutrition management for cases in inpatient care should be guided by age group and the appetite
test:
- Children 6-59m with SAM demonstrating appetite should be treated using RUTF calculated
according to Annex 13. This includes those children referred to stabilisation from outpatient care
who may already have appetite and be eating RUTF but not gaining weight for a number of
reasons.
- Children 6-59m with SAM with no appetite demonstrated should be treated using F75 (130ml
=100kcal). Quantity of feeds is calculated according to the weight of the child (see Annex 18). A
six-feed schedule (every four hour feeds) may be the most practical, but the option of an eight
feed schedule is also given. Where night feeds are problematic, five-to-six feeds should be given
during the daytime. Hypoglycaemia becomes a risk if the daytime intake is low.
- Infants less than 6 months old without oedema admitted according to the above criteria should
be treated with F100 diluted or SDTM and F75 in special cases, for example with oedema. (see
Chapter 5.4).
Page 41
Meal times should be sociable. The mother/caretakers should sit together in a semi-circle around an
assistant who talks to the mothers/caretakers, encourages them, corrects any faulty feeding
technique and observes how the child takes the milk or RUTF.
Care is needed to ensure that mothers’/caretakers’ meals are not taken beside the child. Sharing of
the meal with the child can be dangerous given their delicate pathophysiology.
Feeding with F75

F75 should be offered orally first. Feeding should be done by cup and saucer unless a particular need
for Naso Gastric Tube feeding is identified (see Box 9) because the child is unable to take sufficient
F75 by mouth. Breastfed children 6-59 months should always be offered breast-milk before the diet
and always on demand.
Box 9. Reasons for Using a NASOGASTRIC TUBE (NGT) to Feed the Child During Stabilisation
A NGT should be used if the child:
- Takes less than 80 per cent of the prescribed diet per 24-hours during stabilisation
- Has pneumonia (rapid respiration rate) and has difficulties swallowing
- Has painful lesions of the mouth
- Has cleft palate or other physical deformity
- Shows disturbed level of consciousness
The use of a NGT should not exceed three days and should only be used in the stabilisation
phase. The NGT should be placed only by trained staff, and checked before each utilization.
Aspiration pneumonia is very common in severely acutely malnourished children due to muscle
weakness and slow swallowing. Therefore, applying the correct feeding technique is important to
ensure the child has an adequate milk intake:
- The child should be on the mother’s/caretaker’s lap against her chest, with one arm behind
the caretaker’s back.
- The mother’s/caretaker’s arm encircles the child and holds a cup and saucer under the child’s
chin. The child should be sitting straight (vertical).
- The F75 is given by cup and any dribbles that fall into the saucer are returned to the cup.
- The child should never be force fed, have his/her nose pinched, or lie back and have the milk
poured into the mouth.
Feeding with RUTF

- Provide the RUTF to the mother/caretaker to feed the child. The mother/caretaker should be
encouraged to provide RUTF feeds at the same time as feeds were provided during the
stabilisation phase (five to eight feeds per day).
- Breastfed children should be offered breast milk on demand before being fed RUTF.
- Children should be offered as much water to drink as they will consume during and after they
have taken some of the RUTF.
- Although feeding with RUTF is more straight forward, it is still important to observe the
feeding to assess the proportion of the feed that they child has consumed and any appetite
issues.
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5.3.5 Orientation and counselling for the care giver
It is important to explain all medical and dietary protocols to the mother/caretaker of the child. The
key messages for RUTF are also appropriate for use in inpatient care (see Section 5.2.5 Box 8) with the
addition of an orientation on the use of F75 and F100:
- F75 is the only food that the child requires at this stage of their treatment. It is important that
they are not given other foods, except for breastfeeding, that can be harmful at this critical
stage.
Inpatient care gives additional opportunities, where possible, to conduct wider nutrition, health and
WASH orientation/education particularly for those cases who will complete their rehabilitation in
inpatient care (e.g. infants). The use of the existing IYCF package in particular is appropriate for use
with the mothers/caretakers of malnourished children.
Children with SAM have delayed mental and behavioural development. To address this, sensory
stimulation should be provided to the children throughout the period they are in inpatient care. As an
integral part of the treatment, it is essential that the staff understand the emotional needs of these
children and create a friendly supportive atmosphere. It is essential that the mother be with her child
in the hospital, and that she be encouraged to feed, hold, comfort and play with her child as much as
possible. Mothers/caretakers must never be chastised and the staff should never shout or become
angry.
Inexpensive and safe age appropriate toys should be available, made from cardboard boxes, plastic
bottles, tin cans, old clothes and blocks of wood and similar materials.
5.3.6 Individual monitoring and follow-up

Children’s progress is monitored on a daily basis during inpatient care and recorded on the patient
card as follows:
- Weight is taken at least every day
- Degree of oedema (0 to +++) is assessed at least each day
- Body temperature is measured at least twice per day
- Standard clinical signs (stool, vomiting, dehydration, cough, respiration, liver size etc.) are
noted at least each day
- MUAC is taken each week
- Record is taken if the patient is absent, vomits or refuses a feed, and whether the patient is
fed by naso-gastric tube or is given IV infusion or transfusion. This information is collected for
each feed, each day
- The mother/caretaker is consulted at least daily about the progress of the child
Any failure to respond to treatment must be quickly identified and acted upon. For detail on criteria
of failure to respond to treatment in inpatient care and appropriate actions, see Annex 20.
5.3.7 Transition and discharge or continued rehabilitation in inpatient care

Transition
As soon as the medical condition of the patient is stabilised, oedema is reducing and the complications
are resolving, the transition phase is started in preparation for transfer to OTC (or in a minority of
cases to rehabilitation in inpatient care). Transition is started by feeding the child a test dose of RUTF
at alternate feeds retaining the same feeding schedule. If the child refuses the RUTF, the
mother/caretaker is encouraged to try to get the child to start eating at every other milk feeding. In
the meantime, F100 is continued until appetite returns and RUTF can be given at every scheduled
Page 43
feed. Monitoring continues as for the stabilisation phase and if any of the following develops the client
should return to stabilisation.
Criteria for transfer from transition phase back to stabilisation:

- Weight gain of more than 10 g/kg bodyweight/day in association with an increase in
respiratory rate (indicative of excess fluid retention)
- Increasing or developing bilateral pitting oedema
- Rapid increase in liver size
- Any signs of fluid overload
- Tense abdominal distension
- Significant refeeding diarrhoea so that there is weight loss – note it is common for the children
to get some change in stool frequency when they change diet. This does not need to be
treated unless the children lose weight. Several loose stools without weight loss is not a
criterion to move back to the stabilisation phase.
- A complication that necessitates an IV infusion
- Medical complication
- A need for feeding by NGT
In a minority (<5 per cent) of inpatient cases where the child is unable to eat RUTF but needs to
progress to rehabilitation, F100 may be required. In this case F75 feeds are replaced with F100 during
transition (maintaining the same quantities as for stabilisation with F75) and progress monitored (see
Annex 21 for preparation and quantities of F100 for transition). For these children, progression onto
rehabilitation with RUTF will be dependent on them reaching the discharge criteria to OTC given
below. If these are not satisfied they may move into the inpatient rehabilitation phase (see below).
Discharge criteria to OTC

- Appetite returns – child eats >75 per cent of RUTF daily ration - To test and confirm the
complete recovery of appetite of a child, the child should be able to eat at least three quarters
of his/her RUTF ration for the day.
- No medical complications
- Oedema is resolving, and/ or minimum oedema present
- No objection/contraindications for rehabilitation at home
- Minimum length of stay is 5 days
Upon Discharge
- Children are referred to the OTC to continue their rehabilitation. Care should be taken to refer
them to the OTC closest to their home and where possible their transport should be facilitated
(see Box 6).
- Caretakers should get clear instructions and counselling why it is important to continue the
rehabilitation of the child.
- A referral slip specifying the treatment provided in SC should be given to facilitate admission
and proper follow-up at the outpatient health facility.
- Upon discharge from SC all children are given a single dose of Albendazole (see Annex 10 for
dosage, which is the same as for new admissions to OTC).
- A take-home one-week ration of RUTF to bridge the referral gap till admission in OTC is given.
- Provide the caretaker with key messages on use of RUTF and hygiene as specified in the OTC
protocol (see Section 5.2.5 Box 8).
Continued rehabilitation and then discharge in inpatient care

For a minority of other special cases rehabilitation may continue in inpatient care:
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- Where close medical supervision and treatment needs to continue
- Mother/caretaker refuses outpatient care
- The home environment means it is not possible for rehabilitation to continue at home
- Where no outpatient care is available
- Infants <6 months old (see section 5.4 for protocols)
For these special cases, the dietary management for children 6-59 months with appetite can be carried
out according to OTC protocols with the continued closer monitoring that is characteristic of inpatient
care. For a minority of cases (usually <5 per cent of inpatient cases), rehabilitation with F100 may be
required (See Annex 21 for preparation and quantities of F100 for rehabilitation).
Discharge should be according to the same discharge criteria given in the OTC chapter.
Upon discharge, these children aged 6-59 months should be referred to the programmes for the
management of MAM where these are in place. Otherwise they are sent directly home. As for children
discharged from OTC where possible they should be linked to other interventions and services for
which they are eligible (see Section 5.2.8).
Discharge as defaulter
If a child and mother/caretaker leaves the facility before the appropriate level of treatment has been
given and it is not possible for community level agents to locate them and encourage them back to
the service, then that child should be discharged as a defaulter.
5.3.8 Operationalising links

As for outpatient care there are a number of links that can be made to other services that can provide
continued rehabilitation for the child with SAM and link services focusing on treatment with
prevention throughout the critical 1000 days (see Section 5.2.8). In particular for inpatient care, it is
very important to link up with all the outpatient departments and other departments in the
hospital/facility to ensure that cases of SAM can be identified wherever they are present.
It is also important to link with any HIV/TB services offered within the hospital (see Chapter 5.2.8).
Where there is a Nutrition Rehabilitation Home linked to the hospital, roles for stabilisation of SAM
with medical complications, management of infants with SAM and for rehabilitation of special cases
must be agreed upon to ensure smooth implementation and referral between these facilities and
outpatient care.
5.3.9 Set-up requirements

Inpatient care can be established and integrated into the paediatric ward or as an attachment to an
existing hospital or health centre. In all cases, the following minimum requirements should be met
before treating complicated SAM:
- Trained clinical health staff able to manage medical complications 24 hours and 7 days per
week
- Clean running water (for preparing feeds, consumption, hand washing and general hygiene)
- Gender sensitive latrines and bathrooms
- Safe storage place for therapeutic foods, medicines and equipment
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- Sufficient bed space for the estimated needs (experience shows that, on average, around 15
per cent of all children with SAM will need stabilisation at inpatient care). Ideally children with
SAM with medical complications are kept in a separate ward, away from other ill children.
- Appropriate space/kitchen for preparation of feeds
- The facility is encouraged to be ‘baby friendly’ according to global BFHI criteria (see Annex
40) and early stimulation,
See Annex 23 for a list of supplies and equipment.
5.4 Management of SAM in infants <6 months old

As noted in Chapter 4 the assessment of infants needs to include assessment of both infant and care
giver and the breastfeeding practice (see Annex 24 for assessment protocols). Medical assessment of
the infant should be based on CB-IMNCI and follow the same format as for the child with SAM.
5.4.2 Admission or referral based on programme criteria

All infants <6months identified with SAM and in need of inpatient care according to the criteria in
table 4 should be treated in inpatient care. The type of management required however is dependent
on whether there is a possibility for breastfeeding (see below).
On admission a patient card should be filled in for the infant and the data from the above assessments
entered.
Where the breastfed infant does not satisfy criteria for inpatient care but on assessment breastfeeding
difficulties are identified (see section 4.2 table 4.) the mother/caretaker should be referred to receive
outpatient support at the facility for breastfeeding, plus any medical treatments required. Where the
mother/caretaker is malnourished herself (<23.0cm) she should also be referred to supplementary
feeding where this is in place, to support her to adequately breastfeed.

Routine antibiotic treatment should be provided for infants <6months with SAM admitted to inpatient
and outpatient care in the same way as for those >6months in an appropriately weight adjusted dose
(see Section 5.2.3).
Note: Do not use Chloramphenicol in young infants under 2 months, and use with caution in infants
2-6 months.
Folic Acid - Give 2.5 mg (tablet crushed) in a single dose.
See Annex 16 for detailed guidance on the management of additional medical complications in the
presence of SAM.
5.4.4 Nutrition management

Where there is a possibility of breastfeeding the infant
The main objective is to restore exclusive breastfeeding whether by the mother, a family member or
wet-nurse. Therefore supplement the child’s breastfeeding with therapeutic milk while stimulating
and supporting production of breast milk. This same principle applies in cases where the mother is
known to be HIV positive and is able and willing to breastfeed.
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- Breastfeed on demand or offer breastfeeding every three hours till mother feels that her
breast has been emptied by the child, without frequent switching. The infant should be
breastfed as frequently as possible.
- Between one half and one hour after a normal breastfeeding session, give maintenance
amounts of therapeutic milk.
- Provide F100-Diluted for infants with severe wasting at 130 ml/kg bodyweight/day,
distributed across eight feeds per day. F100-Diluted has a lower osmolality than F75 and thus
is better adapted to immature organ functions. Also, the dilution allows for providing more
water for the same energy with a better carbohydrate to lipid ratio.24 (see Annex 25 for
preparation and quantities)
- Provide F75 for infants with bilateral pitting oedema and change to F100-Diluted when the
oedema is resolved. (see Annex 25 for preparation and quantities)
Note: To prevent hypernatremia in hot climates, sips of water or 10 percent sugar-water solution (see
Annex 7) are given in addition to the milk diet until the thirst of the child is satisfied.
Give the maintenance amounts of F100-Diluted using the supplementary suckling technique and at
the same time give supportive care to the mother (see Annex 26).
- The infant should be weighed daily with a scale graduated to within 10 g (or 20 g).
- Monitoring should take place as for the older child (see section 5.3.6) and recorded on the
patient card
- If the volume of F100-Diluted being taken results in weight loss, either the maintenance
requirement is higher than calculated or there is significant malabsorption. If the infant loses
weight or has a static weight over three consecutive days but continues to be hungry and is
taking all the F100-Diluted, add 5 ml extra to each feed.
- If, after some days, the child does not finish all the supplemental feed, but continues to gain
weight, it means the intake from breast milk is increasing and the infant is taking adequate
quantities to meet his/her requirements.
- The quantity of F100-Diluted (or F75) is not increased as the child starts to gain weight.
Once the infant is gaining weight at 20 g per day (absolute weight gain)
- Gradually decrease the quantity of F100-Diluted by one-third of the maintenance intake so
that the infant gets more breast milk.
- If the weight gain of 10 g per day is maintained for two-to-three days (after gradual decrease
of F100-Diluted), stop F100-Diluted completely.
- If the weight gain is not maintained, increase the amount of F100-Diluted given to 75 percent
of the maintenance amount for two-to-three days, then reduce it again if weight gain is
maintained.
Infant with no possibility for breastfeeding

The aim of the treatment of infants under 6 months with SAM without the prospect of being breastfed
in Nepal is to receive F100-Diluted until they are old enough to take semisolid complementary food in
addition to adapted cow milk.
- Provide F100-Diluted for infants with severe wasting as F100-Diluted has a lower osmolality
than F75 and thus is better adapted to immature organ functions. Also, the dilution allows for
providing more water for the same energy with a better carbohydrate to lipid ratio (see Annex
25 for preparation and quantities)
Page 47
- Provide F75 for infants with bilateral pitting oedema and change to F100-Diluted when the
oedema is resolved. (see Annex 25 for preparation and quantities)
Note: To prevent hypernatremia in hot climates, sips of water or 10 percent sugar-water solution (see
Annex 7) are given in addition to the milk diet until the thirst of the child is satisfied.
Initial management – As for the breastfed child, give maintenance amounts of F100-Diluted at 130
ml/kg bodyweight/day (see Annex 25).
- Distribute the quantity of F100-diluted across eight feeds per day.
- Feed by cup and saucer or NGT by drip (using gravity not pumping).
- Only feed with NGT when the infant is not taking sufficient milk by mouth.
- The use of NGT should not exceed three days and should be used in the stabilisation phase
only
Transition - Move to transition when appetite returns and any oedema reduces to at least (++).
- The volume of the F100-Diluted feeds is increased by one-third in comparison to the
stabilisation phase (see Annex 27 for quantities)
Rehabilitation - Move to rehabilitation phase when infant is taking at least 90 percent of the F100-
Diluted prescribed for the transition phase, any oedema has gone, there are no additional medical
complications and there is a minimum stay of 2 days in transition
- The volume of the F100-Diluted feeds is increased to twice the volume that was given during
the stabilisation phase (see Annex 27 for quantities)
5.4.5 Orientation and counselling for the mother/caretaker

As for all inpatient care the medical and dietary procedures should all be fully explained to the
mother/caretaker of the infant.
The breastfed infant

Counselling for the mother/caretaker will focus on the importance of breastfeeding and breastfeeding
support (see Annex 24 and the National IYCF materials) as well as basic messages on hygiene.
The non-breastfed infant

Counselling for the caretaker will focus on hygiene and, towards the end of treatment, on appropriate
use of breast milk substitutes and complementary feeding (refer to what is in IYCF materials for non-
breastfed infants or Annex 25 or Annex 27)
5.4.6 Individual Monitoring

All infants should be weighed daily with a paediatric balance scale with precision to 10 g (or 20 g).
Monitoring of the infant should take place as for the older child (see section 5.3.6) throughout the
period of inpatient treatment and recorded on the patient card
In addition, monitoring of breastfeeding and troubleshooting of any issues should be included for the
breastfed infant (see Annex 24).
5.4.7 Discharge
The breastfed infant
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Once the infant is gaining weight at 20 g per day on breastfeeding alone
- Check that there is no oedema and the child is clinically well
- If the mother/caretaker is agreeable, it is advisable to keep the infant in the health facility for
an additional three-to-five days on breast milk alone to make sure that he/she continues to
gain weight and then discharged.
- If the mother/caretaker wishes to go home as soon as the infant is taking the breast milk with
increased demand, they should be discharged.
- When the child is gaining weight on breast milk alone, he/she should be discharged, no matter
what his/her current weight or weight-for-length.
- The lactating mother should continue to receive supplementation support under the MAM
programme until the infant is 6 months old.
The non-breastfed infant

Discharge takes place when the following conditions are met:
- Breast milk substitute for the child has been defined within the families possibilities and is
sustainable and child has moved onto the substitute and is still gaining weight
- No bilateral pitting oedema for two weeks
- Infant is clinically well and alert
- Mother/Caretaker has been adequately counselled on use of the breast milk substitute and
on complementary feeding (timing and foods) as per IYCF materials.
6 Management of MAM
This section provides practical guidelines for the identification and management of Moderate Acute
Malnutrition (MAM). The MAM children are at heightened risk of death in the medium and long term,
but, unlike the severely acutely malnourished, do not need immediate emergency treatment. While
the immediate risk of mortality is higher for a child with SAM than with MAM, but since the total
number of children affected by MAM is much greater, therefore absolute number of mortality is
higher for MAM than SAM. A Targeted Supplementary Feeding Center (TSFC) may include acutely
malnourished pregnant and lactating women, children discharged from OTC Centres and in some
cases children discharged from Inpatient Therapeutic Care center (where there is no OTC Centre).
The purpose of Management of MAM is to:

 Identify moderately acutely malnourished children aged 6-59 months and acutely malnourished
PLWs who have infant less than 6 months in the community.
 Prevent deterioration in the nutritional status and treat children aged 6-59 months with
moderate acute malnutrition.
 Prevent deterioration in the nutritional status and treat acutely malnourished pregnant and
lactating women who have children less than 6 months.
Management of MAM may provide treatment to:

 Children aged 6 to 59 months suffering from moderate acute malnutrition with appetite and
without medical complications.
 Pregnant women in the second and third trimester suffering from acute malnutrition.
 Lactating women suffering from acute malnutrition whose child is less than 6 months old.
6.1 Strategy for management of MAM

Two basic strategies have been identified for management of MAM children and PLWs.
Page 49
- Protocol A will promote locally available foods, dietary diversity practices and enhanced health
counselling along with the provision of multiple micronutrient supplements for all MAM children
living in food secure areas and may be of choice for developmental context.
- Protocol B will promote dietary diversity and enhanced health counselling together with provision
of supplementary food for all MAM children living in highly food insecure areas and in emergency
response and recovery context.
Pregnant and Lactating women with children under 6 months of age may also be included as
targeted group under both protocols if resource allows.
Child Health division, nutrition section will decide in close coordination with Nutrition Cluster
members and concerned districts in the selection of food secured & unsecured VDCs and the target
beneficiaries. For this, CHD, nutrition section will take into consideration the recommendations and
reports by HLNFSSC (High Level Nutrition and Food Security Steering Committee) and Nepal Food
Security Monitoring Systems (NEKSAP), and will define which protocol should be assigned to the
different areas of the country.
In addition to protocols A and B, the Community Based Integrated Management of Newborn and
Childhood Illness (CB-IMNCI) protocols and criteria should always be followed when children are found
sick.
6.2 Set-up requirement for Management of MAM

- Facility is manned by trained health staff able to conduct CB-IMNCI
- Running water (for consumption, hand washing and general hygiene)
- Clean drinking water
- Gender sensitive latrines
- Shade under which children and their mothers/caretakers can wait for services
- Safe and adequate storage place for Supplementary food, medicines and equipment
- MUAC tapes
- Registration forms
- Guidelines
- Referral slips
- Weight/height table for children
- Weighting scale with at least 100 gr precision
- Child friendly environment (if possible)
6.3 Screening and referral to Management of MAM

Active case finding of acutely malnourished children and PLWs should take place at community level.
Community health workers and community volunteers will carry out active case finding and will
identify and refer acutely malnourished children and PLWs to the health facility. Moreover, MAM
Children and PLWs may also be screened and referred from the Health Facilities, Nutrition
Rehabilitation Homes and OTCs. The referral criteria for children 6-59m will be MUAC <125mm (<12.5
cm) and pregnant and lactating women with MUAC <230mm (<23 cm).
6.4 Admission criteria for Management of MAM

If no severe medical complications are present and the below criteria are satisfied the child can be
admitted into the service for MAM management. See chapter 3.4 for actions for children who are
assessed and found not to be acutely malnourished. If severe acute malnutrition is identified (see
Table 2) then referral to the nearest appropriate inpatient or outpatient therapeutic service should be
carried out.
Page 50
Category Criteria
MUAC = > 115mm (11.5 cm) and < 125mm (12.5 cm)
Children 6-59 months (Yellow)
AND without nutritional oedema
Pregnant (2nd or 3rd trimester) and
lactating women (whose child is less MUAC < 230mm (23 cm)
than 6 months old)
Other reasons for TSFC enrolment
Severely acutely malnourished child is transferred to
Discharged from OTCC
TSFC after completion of treatment in OTCC
Children or pregnant/lactating women previously
Readmission discharged from TSFC but meet TSFC admission criteria
again
Children or pregnant/lactating women who return after
default (absent more than one visit if follow up is every
Return after default
month or more than 2 visits if follow up is every two
weeks)
6.5 Assessment of MAM patient

At the facility, the following should be implemented by all the trained staff for assessment of a child
suffering from MAM:
- Determine age of the child.
- Take MUAC and check for Bilateral pitting oedema to confirm MAM
- Take Weight (for weight monitoring during follow up visits)
- Where capacity exists take height measurement for WHZ score
- Assess medical condition of child and presence of complications
- Check immunization status, last deworming and vitamin A supplementation
- Review and record all relevant information from referral document where there is one
At the facility, the following should be implemented by all the trained staff for assessment of a
Pregnant or Lactating Woman suffering from MAM:
- Determine age of the PLW.
- Take MUAC to confirm MAM
- Take Weight (for weight monitoring during follow up visits)
- Review and record all relevant information from referral document where there is one
The management will then be carried out according to the protocol being implemented with
combination of following components.
- Provision of multiple micronutrient powder
- Provision of Supplementary food
- Provision of routine medicines
- Counselling sessions on IYCF
- Counselling sessions on home-made nutritious meals
- Counselling sessions on maternal nutrition
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6.6 Nutritional management
Patients with moderate acute malnutrition need higher nutrient intake than non-malnourished
children but less than those suffering from SAM. Standard requirements for a child with MAM are
given in Annex 28. Supplementary foods designed for MAM treatment are provided to the MAM
children or PLWs on top of family meals. Locally available food should complement the daily intake of
fortified blended food. MAM children and PLWs must eat more frequently and more often than the
other family members. It is important to continue the practice of feeding the children at least three
to five times a day (depending on the age group) during the supplementation and even after the
children have fully cured from MAM.
The treatment of moderate acute malnutrition among children under five requires the following:
 Exclusive breastfeeding for the first six months of life
 Breastfeeding in combination with complementary food until 24 months of age (at least)
 Consumption of nutritious food
 Clean and Hygienic environment
 Access to health services (immunization, vitamin A supplementation)
 Provision of supplementary food depending on selected protocol for the area
 Nationally recommended IYCF practices.
6.6.1 Protocol A: Using locally available foods and micronutrient supplements

The dietary management of moderate acute malnutrition should focus on the optimal use of locally
available nutrient-dense foods to enhance the nutritional status of moderately acutely malnourished
children and protect them from becoming severely acutely malnourished. A diet largely based on plant
sources with few animal proteins do not meet these requirements and need to be improved by
different interventions. Multiple micronutrient supplementation represents one of the possible
strategies to fortify food. Similarly, key messages of IYCF should be delivered to both MAM and SAM
children’s mothers and caretakers.
Locally available foods

Caretakers should be educated on how to provide an adequate and nutritious diet for their children.
An example of such a diet is provided in Annex 29 and it should be continued even after recovery. On
top of this diet, locally available foods should be used to prepare one additional nutritious and high
energy-dense meal a day that will provide the extra nutrient requirements for MAM children
(specifically 25 kcal/kg body weight/day).
This guideline recommends the preparation of Sarbottam Pitho/Poshilo Pitho, a locally-developed

“super flour” to provide the extra nutrient requirements for MAM children. Sarbottam Pitho should
be regarded as an additional meal to complete and integrate the daily diet: 220g of Sarbottam Pitho
should be provided daily to a MAM child25.
The basic formula of Sarbottam Pitho has been modified in order to include animal proteins (see Table
9)
25
Vaidya. 1979. Mid Term Health Review 2035: Research and Evaluation of Health and Health Services Mid
Fifth Plan Period (2031-2036). His Majesty's Government, Ministry of Health, Kathmandu, June 1979.
Page 52
Table 9. Modified formula of Super Flour (Sarbottam Pitho)
Option n. 1: Option n. 2:
220g per child per Sarbottam Pitho Sarbottam Pitho
day
50g/2 mutthi Soy bean Soy bean
25g/1 mutthi Maize flour Wheat flour
25g/1 mutthi Wheat flour Rice
100g/tea glass Cow milk/ liver Cow milk/liver
10g/½ mutthi Sugar Sugar
10g/½ mutthi Ghee or vegetable oil Ghee or vegetable oil
Source: Food composition calendar of DFTQC (Department of Food Technology and Quality Control)
It is a common practice to add green leafy vegetables to Poshilo Jaulo, could be adopted by
mothers/caretakers to integrate the daily diet of MAM children in order to provide the extra nutrient
requirements for MAM children (see Table 10).
Table 10. Modified formula for Poshilo Jaulo

Option n. 3
75g per child per day Poshilo Jaulo
25g/ 1 mutthi Rice
15g/ small mutthi Dal/Meat/Fish/Liver
10g/ ½mutthi Clarified Butter
25g/ 1 mutthi Pumpkin leaves
A list of complementary recipes is provided in Annex 30 that could be used by health providers and
volunteers during the counseling session to increase available options for mothers/caretakers and
facilitate the provision of additional nutritious, locally available meals.
The preparation and intake of high-energy density meals such as Sarbottam Pitho should also be
encouraged to PLWs in order to meet the women’s daily nutrient requirements.
Multi Micronutrient Supplements

Locally available foods will be complemented by a distribution of micronutrient powders (MNPs)
through health facilities. Mothers/caretakers will be orientated to use the powders to fortify foods at
home, after preparation and just before consumption. Micronutrient powders contain iron, zinc,
iodine, copper, selenium, vitamins A, B1, B2, B3, B6, B12, C, D, E, and folic acid. The recommended
dosage for MNPs is 1 sachet every 2 days, or ½ a sachet per day (15 per month) MNPs should be added
to solid or semi-solid foods that are ready for consumption: one dose should be added in the individual
plate of the child. In areas where the multi-micronutrient supplementation is already in place,
caretakers should be advised not to provide a daily double dose of MNPs.
Lactating women of malnourished infants under 6 months will also receive micronutrient powders
together with enhanced counseling on the use of MNPs to fortify their daily diet.
6.6.2 Protocol B: Using Supplementary Food Ration
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Protocol B aims to tackle the needs of those districts where local food availability and access is not
sufficient to provide a balanced diet within the households or in emergencies in response and recovery
context.
6.6.3 Specialized Nutritious Foods for treating MAM

There are a number of specialized products available in the market for the treatment of MAM;
Fortified Blended Foods (FBF) and Lipid-based Nutrient Supplement (LNS). The use of Super Cereal
Plus is recommended as best option in the case of Nepal for treating the MAM children.
1.6.3.1 Fortified Blended Foods (FBF)
Super Cereal Plus is a mixture of Corn, Wheat, Rice, Soya, Milk Powder, Sugar, Oil, and Vitamins and
minerals, regarded as one of the best Fortified Blended Foods (FBF). A wide range of fortified food for
the treatment of MAM through Super Cereal Plus will be used in Nepal (see Annex 31). The nutritional
value for 200-250g of the fortified food of Corn, wheat, rice, soya, milk powder, sugar, oil, and vitamins
and minerals known as Super Cereal Plus is provided in Annex 32. The Super Cereal Plus provides all
the micronutrients needed to meet the recommended micronutrient intake for MAM children.
Ingredients: Super Cereal Plus is a mixture of Corn, Wheat, Rice, Soya, Milk Powder, Sugar, Oil, and
Vitamins and minerals.
Ration: Take home rations provide 200-250g of dry matter per day per child. The daily ration contains
787 kcal, 33g protein (17%), 20g fat (23%), essential fatty acids and all the required micronutrients.
Take home rations will be provided for a minimum period of 60 days. After discharge from the
programme, counseling sessions will be provided during two follow-up visits by FCHVs, where they
will focus on educating the mothers and caregivers on how to prevent further bouts of malnutrition.
Family sharing is taken into account for the calculation of this ration of 200-250g of Super Cereal Plus.
200g of the Super Cereal Plus per beneficiary also includes provision for intra-household sharing. Given
the provision of 100g of the Super Cereal Plus as daily ration size per beneficiary, there will be no
provision of intra house-hold sharing, which should be made very clear to the beneficiaries through
IYCF/MIYCN counseling.
Pregnant and lactating women of severely acutely malnourished infants less than six months will
receive their own ration of 200g of dry matter of fortified blended food per day in order to improve
the nutritional status, if resources allow.
1.6.3.2 Lipid-based Nutrient Supplement (LNS)
Besides highly recommending the use of Super Cereal Plus as the best option in the case of Nepal in
treating of MAM children, there are a number of choices for using the specialized nutritious foods as
Lipid-based Nutrient Supplement (LNS), Large Quantity (92-100g) such as Plumpy Sup (Peanut-based),
eeZee RUSF (Peanut based), Acha Mum (Chickpea-based) etc. which can be effectively used as Ready-
to-Use Supplementary Food (RUSF) for treating MAM children aged 6-59 months and malnourished
pregnant and lactating women with less than 6 months infants. The Lipid-based nutrient supplements
can be eaten directly from the sachet without prior cooking, mixing or dilution. Each nutrient
supplement has the same nutritional value to control and monitor dietary intake.
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Ingredients: 92g of each sachet Plumpy‘Sup contains Peanuts, Sugar, whey, vegetables oil, milk, soy
protein, cocoa, vitamins and minerals with 500 kcal, 13g protein (10%) and 31g fat (55%).92g of each
sachet eeZeeRUSF contains Peanut, sugar, milk, solids, vegetable oil, vitamins and minerals with 500
kcal, 13g protein (11%) and 31g fat(56%). Similarly, 100g of each Acha Mum sachet contains chickpeas,
vegetable oil, milk powder, sugar, vitamins, minerals and soya lecithin with 520 kcal, 13g protein (10%)
and 29g fat (50%) It does not contain any ingredient of animal origin, except for those derived from
milk.
Ration: Each admitted individual will be provided 1 sachet of RUSF per day for a period of 60 to 90
days as supplementary food. However, all caregivers, mothers and children will be encouraged to
utilize nutritious food available at household level. The RUSF will be provided as a fortnightly ration
with a special provision for one month in case of geographical difficulty for each individual. Each
beneficiary is required to come for a follow-up visit at the end of each fortnight to the Targeted
Supplementary Feeding Center (TSFC).
Basic background diet
Fortified blended foods and RUSF designed for MAM treatment are provided to the MAM children or
PLWs on top of family meals. Locally available food should complement the daily intake of fortified
blended food. As specified under the counseling section, in order to meet the increased nutrient
requirements, MAM children and PLWs must eat more frequently and more often than the other
family members. It is important to continue the practice of feeding the children at least three to five
times a day (depending on the age group) during the supplementation and even after the children
have fully cured from MAM.
Counseling on the use of Supplementary food

Counseling will be used to educate the caretaker on how to safely handle, store and cook the fortified
blended foods. Simple counseling cards for preparation and storage are provided in Annexes 33 and
34. Fortified blended foods must be stored in dry, ventilated and hygienic conditions. Instructions for
the preparation should be carefully followed. Specific instructions on how to cook and consume
should be consulted based on the specific product used (see Annex 35).
6.7 Medical management

The child with MAM should be treated medically like any child according to CB-IMNCI protocols.
The opportunity should be taken to ensure they are fully immunised and have received any additional
supplements (vitamin A), iron and anti-helminths that are included in the national protocols for all
children.
6.7.1 Vitamin A
 Vitamin A should be given to all children on enrolment (unless they have received
vitamin A in the last one month or are going to receive it within the following month).
 Children referred from OTCC, or other health facility where Vitamin A has already
been given should not be given vitamin A.
 Children showing clinical signs of vitamin A deficiency should be referred to the
nearest health facility for treatment according to National guidelines.
 Vitamin A is NOT given to pregnant women. Lactating women receive Vitamin A post-
partum (6 weeks after delivery) only.
6.7.2 Mebendazole/Albendazole is given to all children aged 12-59 months on enrolment.
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If the child is ≥ 1 years and has not had Albendazole in the previous 6 months, give one dose
of Albendazole 200 mg till 2 years then 400 mg after 2 years for possible hookworm or
whipworm
6.7.3 Iron
 Iron is given to children on admission if there are signs of anaemia. If there is severe
anaemia, refer to inpatient care.
o Give (home) treatment with iron (daily dose of iron/folate tablet or iron syrup) for
14 days.
o Ask the parent to return with the child after 2 weeks. Treatment should be given
for 3 months, where possible. It takes 2–4 weeks to correct the anaemia and 1–3
months after the hemoglobin reverts to normal to build up iron stores.
o Advise the mother about good feeding practices
 Iron folate acid tablet is given to all pregnant and lactating women on admission.
6.7.4 Vaccination
 Ensure the vaccination status of the child is satisfactory.
 Measles vaccine is given to all unvaccinated children above 6 months of age in case of
emergency.
6.7.5 Record all medications given in the registration book.
6.8 Monitoring and follow-up of MAM patient

Progress in the treatment of MAM should be monitored by the health workers at the health facility
on every follow-up. During the first visit, MAM children and mothers/caretakers will receive an
appointment for the follow-up visit, specifying time and venue, usually every follow-up. The
information will be recorded on the registration card but also on the registration books (see Annex
36).
During the follow-up visits at the health centre, health workers and volunteers should:
- Check oedema
- Check weight, height and MUAC
- Ask mother/caretaker about the progress of the treatment and feeding history
- Decide on appropriate counselling and/or action
Any children developing oedema or whose MUAC falls below 115 mm (11.5cm) should be referred to
either outpatient or inpatient therapeutic care depending on the presence of medical complications
and appetite (see Table 2).
In addition, health workers and community volunteers will need to investigate failure to respond to
treatment for all the children who:
 Did not gain weight after 60 days in the programme
 Lost weight during four consecutive weeks in the programme
 Lost weight exceeding 5 per cent of the body weight at any time
 Failed to reach the discharge criteria after four months in the programme
Possible reasons for failure to respond to the treatment include:
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 Problems with the application of the protocol
 An underlying physical condition/illness, such as HIV/AIDS, TB. If a child does not respond to
treatment it can be suspected they have HIV and/or TB and should be tested for both
 Economic and social circumstances of the mothers/caretakers
 Excessive sharing of the ration
 Nutritional deficiencies that are not being corrected by the diet supplied/feed
 Other causes
Health workers and community volunteers should assess the failure to respond to treatment and
address potential issues by following these steps:
- Review the patient’s register
- Confirm adherence to protocol
- Conduct full nutrition assessment
- Refer in the case of medical complications or SAM
- Request home visit to assess situation (see Section 3.5)
6.9 Discharge
The discharge criteria should meet MUAC threshold for discharge. Children are discharged from the
programme only after a minimum of two months of treatment in the programme according to the
following conditions.26
Table 11. Discharge criteria for MAM treatment
Category Discharge Criteria
MUAC>125mm (12.5 cm)

Children 6-59 months
And Minimum 2 months stay in the programme
MUAC>230mm (23 cm)
Pregnant and lactating women And Minimum of 2 months stay in programme
Or When infant reaches 6 months
Other reasons for TSFC Discharge
Absent for next visits if TSFC is monthly or 2
Defaulted
consecutive visits if TSFC is every 2 weeks
Died Died during time registered in TSFC
Patient has not reached discharge criteria within 4
Non-response
months
Upon Discharge
- If the child has completed nine months of age during his/her treatment in the MAM
programme, and did not yet get a measles vaccination the caretaker should schedule a firm
appointment for follow-up visit during EPI hours, or to visit the nearest EPI outreach clinic as
soon as possible to receive the vaccination.
- The caretaker should receive counselling on care practices, hygiene, feeding practices, food
preparation for children etc. in line with national IYCF guideline. The caretakers should be
26
Discharge criteria will be reviewed and assessed periodically by the Child Health division, nutrition section
according to the situation and resource availability.
Page 57
linked with any appropriate services (e.g. ongoing Multi Micronutrient supplements
distributions, further IYCF counselling) for which they are eligible and which support the on-
going rehabilitation of the child (see below).
- Fill in the patient card with the discharge details
6.10 Operationalizing links

Where there are interventions in place targeting SAM children there should be a close link between
the services to ensure that children discharged from the OTCC enter the MAM service center (TSFC)
and that any children deteriorating during treatment for MAM can be referred to the SAM service if
they attain the admission criteria.
Other interventions that are of benefit for referral of individual children with MAM and/or links with
the IMAM programme are the same as for SAM (see Section 5.2.8).
7 Management of acute malnutrition with HIV
Children with chronic illnesses, especially children living with HIV/AIDS often present higher
energy requirements. They are more likely to become malnourished as they show less appetite
and/or do not absorb enough nutrients. In Nepal, 4,621 children (under 18) are infected with
HIV/AIDS (National Centre for AIDS and STD control). Children with acute malnutrition who are HIV
infected should be managed with the same therapeutic feeding and supplementary feeding
approaches as children with acute malnutrition who are not HIV infected. However, HIV-infected
children need more time to recover from malnutrition; rates of weight gain are lower. In addition to
this, HIV-infected children often present more associated infections due to changes in their immune
system. It is important that nutrition support is given as early as possible in the onset of acute
malnutrition in order to give these individuals the best chance of recovery, therefore linking with
interventions for management of MAM is critical (see Chapter 6.).
Provider-Initiated Counselling and Testing (PICT) for HIV in children with acute malnutrition and their
parents is advised in areas with high HIV prevalence (>1 per cent ) wherever possible. HIV positive
individuals are at higher risk of acute malnutrition and take longer to recover when they become
acutely malnourished.
7.1 Dietary management of acute malnutrition in HIV-Infected Children

Protocols for the admission and management of SAM in children that are HIV infected both in inpatient
and outpatient care are the same as those for that are non HIV-infected. HIV infected children with
SAM with medical complications should be referred to inpatient care whereas those without medical
complications can be managed as outpatients if they still have a good appetite, are clinically well and
alert. Nutrition treatment with RUTF uses rations based on the weight of the child. Quantities are the
same as for non-infected children.
The protocols for the admission and management of children suffering from MAM will be similar to
those non HIV-infected and should, wherever possible, include nutrition support via supplementary
feeding with appropriate fortified blended foods.
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HIV-infected children identified with either SAM or MAM should be referred to available HIV support
services in line with the Nepal National Guidelines on HIV and nutrition.27
HIV-infected children are likely to have HIV-infected parents; additional support needs to be available
as the parent will suffer recurrent illness. During these illnesses the parent might not be able to care
for the malnourished child. Community mobilisation and support, as well as local NGOs, can be
invaluable in these circumstances. Similarly, MAM children living in child-headed households after
parents have died from HIV/AIDS need extra attention.
After discharge, health workers and FCHVs should make sure that HIV-positive and TB children are
referred and/or continue accessing HIV/AIDS treatment services. Children failing to be cured after 60
days in the program will need to be tested for HIV/TB if their HIV/TB status is unknown. If HIV/TB
status is known then case-by-case basis action should be explored and opportunity for inpatient care
should be evaluated with the child’s HIV/TB treatment provider.
7.2 Medical management of acute malnutrition in HIV-infected children

Cotrimoxazole should be given to children when HIV is suspected, and indefinitely where Antiretroviral
Therapy (ART) is not yet available. This antibiotic is added to other systematic antibiotics given at the
start of treatment for SAM in the non-HIV infected child, and does not replace them.
Diagnosis of tuberculosis in HIV-infected children should always be considered. The signs are the same
as for those in children without HIV infection. HIV-infected children should also be assessed for other
opportunistic infections such as thrush or cryptosporidiosis and considered for ART when available.
Children with acute malnutrition who are HIV infected and who qualify for lifelong ART should be
started on antiretroviral drug treatment as soon as possible. For children with SAM this should be after
stabilisation of metabolic complications and sepsis. This would be indicated by return of appetite and
resolution of severe oedema. HIV-infected children with severe acute malnutrition should be given
the same antiretroviral drug treatment regimens, in the same doses, as children with HIV who do not
have severe acute malnutrition. HIV-infected children with severe acute malnutrition who are started
on antiretroviral drug treatment should be monitored closely (inpatient and outpatient) in the first six
to eight weeks following initiation of antiretroviral therapy, to identify early metabolic complications
and opportunistic infections
7.3 Discharge criteria and referral to HIV services

Children should be treated until nutrition recovery is achieved and be discharged according to the
same criteria as for non HIV-infected children. HIV-infected children will likely present with more
associated infections, and therefore rates of weight gain and recovery may be lower than in non HIV-
infected children. Those not receiving nutrition supports prior to the treatment for SAM or
intervention for the management of MAM, should be referred to the available services or community
support groups where appropriate as outlined in the Nepal National Guidelines on HIV and nutrition.
8 IMAM programme monitoring and reporting

In order to ensure that the Integrated Management of Acute Malnutrition (IMAM) interventions are
achieving their objectives of identifying, treating, and curing acute malnutrition, activities and
27
Section 6.5 Nutritional care and support of HIV-infected children. In National Guidelines on HIV and Nutrition.
P57. Government of Nepal April 2011.
Page 59
outcomes must be monitored. A well designed monitoring and reporting system can identify gaps in
implementation of respective components, provide information for on-going needs assessment,
advocacy, planning, redesigning and accountability.
Monitoring an IMAM programme is comprised of two major components:

- Assessment of effectiveness of treatment (i.e. proportion of clients treated effectively)
- Assessment of programme coverage (i.e. proportion of the target group being reached with
treatment) and appropriateness of the programme for communities
Even for a service that is achieving good clinical outcomes (high cure rates and low death rates), impact
is diminished if it only achieves low levels of coverage. The combination of treatment effectiveness
and coverage will determine the impact/or programme outcome hence:
Treatment effectiveness + coverage = programme outcome
The monitoring system in place to assess these components must include data capture, compilation,
analysis and feedback if it is to function effectively. It has integrated into current health management
information systems (HMIS) and report comes through the system.
8.1 Performance indicators

The following programme performance indicators collected on a monthly basis help in monitoring
whether the IMAM programme is achieving its objectives or not. They can be applied both to
management of SAM and MAM:
Recovery rate: The number of clients successfully discharged recovered, as a percentage of all
discharges during the reporting month28
Death rate: The number of clients who died during treatment, as a percentage of all discharges during
the reporting month
Default rate: The number of clients who defaulted, as a percentage of all discharges during the
reporting month. Default is defined as absent for three consecutive visits.
Non-cured rate: The number of clients discharged as non-cured, as a percentage of all discharges
during the reporting month. Non-cured is defined as not reaching discharge criteria after four or three
months in the programme.
Referral rate: The number of clients referred to therapeutic care from MAM management* (i.e. whose
condition has deteriorated to SAM), as a percentage of all discharges during the reporting period
Average length of stay: The total number of days a client remains in a programme, until cured and
discharged divided by the total number of cured patients
Treatment Coverage: The percentage of eligible clients (primarily children 6-59m with SAM) existing
in the area who are reached by the service29
28
In case of MAM, the term “cure rate” is used.
29
Note that due to the lack of clear measures of SAM in infants at community level they are not usually included
in standard coverage assessment. Coverage can be assessed for MAM but modifications are required to the
standard methodologies to do this.
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Geographical Coverage: The percentage of health facilities in an area that offers IMAM services. This
is a useful measure of the availability of the service.
Figures for Inpatient and Outpatient therapeutic care should be combined in order to appropriately
assess the performance of the service for SAM as a whole. However, particular indicators may be
useful to look at separately to assess particular aspects of treatment, such as length of stay in inpatient
care. Management of MAM should always be reported on separately.
*Note: Children referred between inpatient and outpatient components of management of SAM are
not recorded as discharges as they remain within the therapeutic service though they are recorded as
exits from a particular facility.
(see Annex 37 for calculations)
8.2 Minimum performance standards

Programme performance indicators are compared with standard cut-offs in order to monitor health
facility performance and take corrective action as needed. They are also used to assess the
performance of the service as a whole (i.e. at district level or at regional/national level) using compiled
figures from all facilities.
The targets indicated in Table 12 were developed for use in emergency settings, but are currently
accepted for use in non-emergency settings as well. Each facility and the programme as a whole should
achieve them.
Table 12. Minimum performance standards for IMAM

Management of SAM Management of MAM
30
Recovery rate > 75% > 75%
Death rate < 10% < 3%
Defaulter rate < 15% < 15%
Coverage > 50-70% > 50-70%
8.3 Monitoring formats and systems

Monitoring and data collection is performed through meetings, registration and reporting from
community and health facility levels and through specific assessments conducted at district level of
coverage. Collation can be performed at the district level and at health facilities. Computers are not
required for compilation but they can make the process easier.
8.3.1 Community level

On-going monitoring of community sensitisation and mobilisation efforts is required. This mainly
involves constant dialogue, in which the communities periodically voice their views and suggest
alternative courses of action. This entails regular meetings (monthly and/or quarterly) with key
community representatives, health staff from the nearest health facility, beneficiaries and other
partners to discuss different aspects of the programme, such as:
- Reviewing the selection and motivation of community agents conducting case-finding
- The community’s perspective of the programme which may include identifying new barriers
to access
30
In case of MAM, the term “cure rate” is used.
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- Joint solutions to problems limiting the impact of the programme. This promotes community
ownership of programme development and implementation.
Reporting on case finding is kept simple. As house to house screening or mass mobilisation and
screening is not going to be the most common method of case finding, it is not possible to draw
conclusions on prevalence or trend in acute malnutrition based on information on cases/numbers
screened. Therefore, reporting focuses just on the number of cases of SAM and MAM identified and
referred or counselled (where no additional treatment for MAM is available) and who enter
treatment. This is achieved using simple tally sheets in the exiting reporting format of the FCHVs (see
Annex 4).
In addition, FCHVs have simple formats to record the information of any follow-up home visits they
conduct in order to report back to the health facility. One of the key responsibilities of the VHT
members is to maintain records of the community members screened and referred, the health
education sessions conducted, as well as the analysis and submission to health facilities.
8.3.2 Facility level

Monthly reporting formats for the recording of admissions and exits according to a number of
categories should be filled at each facility implementing IMAM.
These formats can be completed using a simple tally sheet and the patient cards or from the register
book where this is in use. Compilation should occur at district level compiling results for all health
facilities implementing IMAM.
See Annex 38 for reporting formats.
8.3.3 Treatment Coverage Assessment

Along with all assessment of coverage is the identification of major barriers to coverage. These two
aspects can be best assessed fully through the periodic use of the direct coverage assessment methods
outlined in Annex 37.
It is important to note that barriers to coverage, though more likely to operate when the service is
getting up and running, can also develop at any time. Therefore, in addition to periodic assessment,
data already collected can be tallied and used at the health facility and district level on an on-going
basis to give an indication of whether any major barriers to coverage are operating. This can be done
through simple tallies and can be supported during supervision visits. Information can trigger further
investigation either by assessment or by community focus group discussion and includes:
Trends in admissions plotted against the seasonal calendar – This information from the monthly
reports can be plotted for the year so that any unusual patterns can be identified. An unusual
unseasonal drop in admissions may indeed be due to a drop in prevalence of SAM but it is also likely
to be due to the occurrence of a particular barrier to coverage.
Spread of MUAC on admission - A high proportion of admissions based on very low MUAC (<11.0cm)
is an indication of later presentation of cases (i.e. the service is not managing to catch cases of SAM
early in the progression of the disease) and therefore poor coverage (see Figure 6). Proportion of
referrals to inpatient care is also an indicator of late presentation (see below).
Distance that clients are travelling to access services – Where a large number of clients are travelling
for a full day to access services (especially where these are the clients arriving with very low MUACs)
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it is an indication that distance is a major barrier to coverage. Where most clients are travelling very
short distances it is an indication that the service is not reaching very far and the reasons for this need
to be investigated.
Default rate plotted against the seasonal calendar– High default is usually caused by particular
barriers to access. Also the same barriers creating default are likely to prevent new cases from
accessing treatment. Therefore, any high levels or unusual patterns should be investigated.
Figure 7. Simple tools for monitoring barriers to access
8.3.4 Supply monitoring

Simple monitoring of the monthly consumption of nutrition products should be carried out as part of
the stock control system (for standard formats see Annex 39). The reporting of consumption alongside
monthly reports of admissions is also very useful for programme management (see below).
8.4 Analysis and Feedback

Analysis based on the above information should focus on:
Treatment coverage and barriers to access – To identify any potential actions/modifications that need
to be made to the service e.g. further decentralisation, increase in number of days dedicated to the
service due to long waiting times
Numbers and trends in admissions – To identify seasonal patterns for resource planning, to identify
anomalies in these trends that require further investigation, to track the effects of mobilisation and
scale-up efforts and potentially (in programmes with good coverage) to identify deterioration in the
nutrition situation. This information will also be used to decide on when additional support is required.
Recovery, default, death and non-recovered as a proportion of exits as measures of programme
quality. These indicators can identify issues with adherence to treatment protocols, management of
the service (waiting times, approach to clients etc.), sharing of RUTF, insufficient community
mobilisation and poor coverage.
Numbers of clients transferred to inpatient care (as a proportion of admissions) – Can indicate issues
with adherence to treatment protocols, difficulties with referral mechanisms and/or coverage issues
(poor coverage = a lot of late presentation = large number of referrals).
RUTF and Therapeutic milks use (depending on other systems in place) – To aid with supply planning
and also to trigger investigation if quantities used differ greatly from the average that would be
expected given the numbers of children receiving treatment.
Numbers and trends in the proportion of ‘other’ admissions (mainly other age groups) – An indication
of the need for further programme support in identification and treatment of those groups. Increases
may also indicate deterioration in the nutrition situation.
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Numbers and locations of referrals - This allows the tracking of the activity of community agents,
identification of areas where additional services may be justified and to identify areas where there
may be gaps in coverage (low numbers of referrals may reflect low levels of SAM or poor identification
of cases).
At district, regional and national levels, reports and their interpretation should be shared with
stakeholders and fed back to facilities and to community agents through supervision visits and
meetings. The information should form the basis for focusing supervision, support and resources in
particular areas such as deciding on on-going training focus for staff, triggering further investigation
visits and potentially further coverage investigation.
9 Programme management
9.1 National level

The management of acute malnutrition is part of the national Multi-sector Nutrition Plan (MSNP) 2012
and the organisational structure for IMAM is modelled according to the MSNP specifications as well
as the Ministry of Health structures. An effective organisation of the IMAM programme is critical to
its success and ultimate impact and adequate resources and trained personnel are needed for efficient
service coverage.
A national Nutrition and Food Security Steering Committee (HLNFSSC) is already functioning under the
provision of the MSNP. The Committee is housed within the National Planning Commission (NPC) and
it provides overall leadership, resources allocation, coordination, monitoring and evaluation. It is
chaired by the Honorary Vice Chairperson of the National Planning Commission and it is composed of
different Secretaries and four nutrition experts. The Committee is assisted by a Secretariat responsible
for managing the information system, communication and advocacy activities and funding
mechanisms. The HLNFSSC is responsible for ensuring the implementation of the IMAM guidelines
after their approval at a national level.
Specifically the Committee will:

 Be responsible for policy direction and guidance
 Assess and review programme implementation on a monthly basis
 Coordinate the implementation of the IMAM guidelines with other sector policies and
programmes on food and nutrition and health
 Establish and activate District Nutrition and Food Security Steering Committees in each district
 Assign roles and responsibility for the implementation of IMAM guidelines among District
Nutrition and Food Security Steering Committees and District Health Offices
 Allocate financial resources to the District Nutrition and Food Security Steering Committees
 Determine which areas are food insecure and are entitled to received fortified blended food
Specifically the National Ministry of Health and Population will:

 Formulate/revise national policy and guideline of IMAM programme
 Formulate annual plans, implement and monitor/review the programme
 Allocate financial resources to the District Health/Public Health Offices for the
implementation of the IMAM guidelines in line with MSNP
 Assign roles and responsibilities of D/PHOs and relevant health/nutrition workers for the
implementation of the IMAM programme
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 Build capacity of human resources of D/PHOs and health facilities for programme
implementation and monitoring/review
 Manage human resources for IMAM implementation
 Scale up IMAM programme to address the issues of acute malnutrition as per WHO defined
GAM threshold
 Organise regular review and advocacy meetings at national and sub-national levels
9.2 Regional level

Regional Nutrition and Food Security Coordination Committees will be activated by the HLNFSSC in
order to provide oversight and coordinate the management of IMAM in all the programme regions.
They will also monitor and supervise the implementation of the IMAM activities at the regional level.
They will provide support and coordination to main regional stakeholders. The Regional Nutrition and
Food Security Coordination Committees will be composed of key regional bodies and will be chaired
by the Regional Administrator.
9.3 Sub-national level

The District Development Committees (DDCs), responsible for the overall planning, implementation
and monitoring of the MSNP at the district level, will incorporate the IMAM guidelines in the periodic
and annual planning through a multi-sector approach. The DDCs will look after the District Nutrition
and Food Security Steering Committees and will ensure implementation and periodic monitoring in
line with the national monitoring system. They will also coordinate the implementation of the IMAM
programme with other sectors and partners.
The District Nutrition and Food Security Steering Committee will be activated by the HLNFSSC in order
to steer, provide oversight and coordinate the management of MAM in all programme districts. The
District Nutrition and Food Security Steering Committees will be chaired by the DDC’s chief and co-
chaired by the District Health Officers (DHOs) or the Public Health Officers (PHOs). District Health
Office will be overall responsible to implement IMAM in district and district HLNFSSC will play advisory
role.
The District Nutrition and Food Security Steering Committees will be responsible for the:
 Analysis, review and endorsement of the IMAM programme in the district
 Multi-sector coordination in the district
 Establishment of effective cooperation among stakeholders
 Incorporation of IMAM indicators in the District Periodic Annual Plans
 Identification of vulnerable areas and population
 Assessment and review of programme implementation on a monthly basis
 Integration of data collection and reporting into the existing regular mechanisms for
reporting)
The District Level Nutrition Focal Person will be responsible to manage and to supervise the
implementation of the IMAM programme at the District Level. He/she will report to the District Health
Officers (DHOs) or to the Public Health Officers (PHOs), the key technical and administrative officers
who provide technical leadership for the management of acute moderate malnutrition programmes.
The District Level Nutrition Focal Person will be responsible for the:
 Overall management of the IMAM programme
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 Technical and administrative support during the implementation
 Sector coordination
 Training and supportive supervision
The District Health Office will:

 Design the district plan, set the appropriate targets and implement the programme
 Monitor and review of IMAM programme periodically
 Generate enough funds for the IMAM programme operation in coordination with MoHP and
local governance units (DDCs/VDCs)
 Identify district IMAM focal points to manage IMAM programme
 Collect, verify and compile IMAM data and incorporate it in the HMIS for periodic reporting
 Identify the most vulnerable/hard to reach areas and population for equity focus
 Complete regular screening for acute malnutrition through the national vitamin A
programme, including in hard to reach areas
 Manage supply chain of RUTF and other IMAM supplies through LMIS
9.4 Village development committees level

Village Development Committee (VDC) will incorporate the MAM guidelines into their periodic and
annual plans and monitoring mechanisms through a multi-sector approach. VDC Food and Nutrition
Steering Committees will be established in each VDC under the guidance of the District Nutrition and
Food Security Steering Committee.
The VDC Food and Nutrition Steering Committees:
 Integrate IMAM programmes in the VDC level annual plan in line with the multi-sector plan
adopted by the District
 Coordinate multi-sector and regular communication with different sectors in the VDC
 Review the progress of the implementation of IMAM guidelines
 Identify the most vulnerable areas and/or population in the VDC
The VDC Level Focal Person will be responsible for:

 Technical and administrative support
 Sector coordination
 Monitoring and reporting integrated into the existing reporting system
 Training and supportive supervision to Female Community Health Volunteers (FCHVs), Early
Childhood Care and Development (ECED) facilitators and volunteers in collaboration with the
other sectors, and with the support of trained health workers
 Organization of monthly meetings with community leaders and representatives from other
sectors
 Identification of vulnerable wards in need of additional targeted support
 Outreach activities and referral
9.5 Municipal level

Nutrition and Food Security Steering Committees will be activated at the municipal level. They will be
chaired by the Mayor and co-chaired by the District Health Officer or the District Public Health Officer.
They will be responsible for:
 Analyzing, reviewing and endorsing the IMAM programme in the municipality
 Reviewing progress in the implementation of the IMAM programme
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 Facilitating multi-sector coordination
At the ward level, FCHVs will be responsible for:
 Implementing activities related to IMAM within the ward
 Active and passive case finding
 Following up of MAM cases
 Home visits or defaulters
 Collection of data and reporting at the ward level (including the ECEDs centres)
 Supporting ECEDs facilitators and other volunteers
The role of FCHVs in the community is pivotal, and therefore the VDC Focal Person should
acknowledge their work and take into account their feedback in the planning process.
9.6 Programme planning

It is important that the essential steps of community assessment and development of the community
mobilisation strategy are conducted as part of the planning stage to ensure appropriate service.
In all cases, all support systems (supply, referrals, supervision etc.) must be carefully planned and in
place before starting case management activities. This prevents staff and the population from getting
discouraged by breaks in supply, monitoring and supervision leading to poor quality, which will have
a negative impact on the uptake of the services
Training should also be followed immediately by set-up of the service to ensure that new knowledge
is quickly put into practice and therefore retained.
Feedback loops to on-going programme adaptation (particularly for increased decentralisation) are
essential and need to be included in planning. The number of patients attending an outpatient care
service may vary from 10 – 20 per session to several hundreds. When too many children are attending
services on the same day a decision should be taken as to whether it would be more appropriate to
open new facilities or increase the number of service days for existing facilities.
9.7 Human resources and roles
9.7.1 Management of moderate acute malnutrition
Training for health facility staff and human resources management will differ according to the protocol
being implemented for the treatment of MAM. In food insecure districts, the focus will be on fortified
blended distribution and preparation, whereas in food secure districts, attention will be paid to MNP
supplementation, and Sarbottham Pitho (Poshilo Pitho) and Poshilo Jaulo preparation.
For both protocols, a trained nurse or other qualified clinical health worker (or several, depending on
workload) will be responsible for carrying out the admission and follow-on consultations. A trained
assistant or volunteer could assist the trained nurse and/or the qualified clinical health worker with
measurements and provision of fortified blended food, MNPs and counselling (depending on the
districts where the management of MAM is being implemented).
In coordination with the District Public Health officers (D/PHOs) and the health facility staff, storage
facilities will be established and proper storage will be ensured for both MNPs and fortified blended
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food. Training on products storage, distribution and preparation (both MNPs and fortified blended
food) will be provided to the health facility staff for smooth implementation of the programme.
9.7.2 Outpatient Therapeutic care

A trained nurse or other qualified clinical health worker (or several, depending on workload) is
sufficient to carry out the admission and follow-on consultations. Health workers must be well trained
and thus able to identify danger signs applying standard protocols (CB-IMNCI) and take decisions on
when and whether referral for inpatient care is necessary during admission and follow-up.
Health facility staff may need to be reorganised, and their job descriptions amended to fulfil the new
routines. To help with conducting measurements, and distributing RUTF and key messages,
community health workers or other trained assistants may be used to support the health workers.
9.7.3 Inpatient Therapeutic care

Clinical care staff: Includes nurses and/or physicians who have received specific training on the
management of SAM with medical complications. Danger signs and treatment protocols of medical
complications in children with a good nutrition status are not the same as for children with SAM. A
clinician should be available at night.
Feeding assistants: Nutrition or health assistants are in charge of monitoring the child, preparation
and/or supervision of the preparation of the feeds, supervising the meals, interacting with the
mothers, monitoring clinical warning signs and filling in most of the information on the patient's card.
A ratio of 1 staff per 10 patients is considered appropriate. They may also be in charge of emotional
and physical stimulation activities and breastfeeding support. Feeding assistants should cover all feeds
including where night feeds are scheduled.
Support staff: Cleaners and kitchen staff play a key role in maintaining a tidy environment and
preparing therapeutic milks and food for mothers/caretakers.
9.7.4 Staff training

Training is an essential part of the setup and the roll out of IMAM activities for managers and
supervisors as well as for health workers and should be based on these national guidelines. Formal
training and informal (on-the job training and supervision) trainings must be balanced to ensure
sufficient practical experience, as this is known to be the most vital aspect for effective learning.
Cascade types of training materials and job aids are available such as; manual for CMAM TOT, health
workers training and training of FCHVs. They should be used by trainers experienced in the
implementation of IMAM to ensure that appropriate training is delivered. However, the training
manuals and materials will be revised periodically as per the changed context and situation.
As noted above, it is important that training is followed immediately by set-up of the service to ensure
that new knowledge is quickly put into practice and therefore retained.
Community level agents will need to be trained using standard materials and mechanisms set up to
link them to the health facilities. Similarly, refresher training will be organized once in a year.
9.8 Supply management
9.8.1 Supply requirements

Calculating targets
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Supply requirements are best estimated by calculating the target number of admissions to a service
unit, or district. Where the service is already in place previous admissions reports and supply orders
can be used for this though there should be some adjustment (estimate) made for:
- Per cent reporting, i.e. if only 75 per cent of facilities with IMAM services submit reports giving
a total admissions of 362 children, a very rough estimate for 100 per cent of facilities would
be (362/75) x 100
- Adding an estimated number of cases for any predictable surges in coverage and therefore
admissions due to mobilization events, or further decentralization of services. The numbers
to add on could be based on previous experiences of similar surges.
- Any predicted increases in prevalence compared to the previous year (e.g. where early
warning indicators predict higher than usual seasonal increases)
For districts newly implementing IMAM, a very rough estimation of target admissions for a year period
for the purposes of planning can be obtained by using the equation in Box 10 below:
Box 10: Calculation of targets for newly initiated IMAM services
SAM
Target = Population 6-59m in geographical area x [Prevalence SAM + (Prevalence SAM x 1.6)]
x treatment coverage (%)
Where
- Population 6-59 in the geographical target area = total population in the geographical
target area (n) x estimated proportion of children 6-59m in the population (%)
- Prevalence SAM = prevalence of SAM from the latest survey in the area
- 1.6 is an (estimated) correction factor for calculating incidence of SAM from prevalence
allowing an estimation of numbers over a full year period.
- Treatment coverage = an estimate of the projected treatment coverage that will be
attained in the first year (note this may be below the minimum performance standards in
the first year.
MAM
Target = Population 6-59m in geographical area x [Prevalence MAM + (Prevalence MAM x
1.6)] x treatment coverage (%)
Where
- Population 6-59 in the geographical target area = total population in the geographical
target area (n) x estimated proportion of children 6-59m in the population (%)
- Prevalence MAM = prevalence of MAM from the latest survey in the area
- 1.6 is an (estimated) correction factor for calculating incidence of MAM from prevalence
allowing an estimation of numbers over a full year period.
- Treatment coverage = an estimate of the projected treatment coverage that will be
attained in the first year (note this may be below the minimum performance standards in
the first year.
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These targets should be used with the information below to identify supply needs. Particularly when
the service is new it is important to adjust supply forecasts after the first few months of
implementation to reflect the caseload being experienced.
Due to the difficulties in identification at community level for children < six months of age, these
numbers are best factored into planning once a service is up and running where numbers can be
calculated based on previous admissions. Another way of obtaining a rough estimate would be to use
the admissions figures from a neighbouring district already implementing IMAM and with similar
population size.
Outpatient Therapeutic Care supplies

Each child in outpatient care consumes approximately twenty packets of RUTF a week, which
corresponds to 13 kg per seven week treatment. Note that the total requirement of RUTF depends on
the treatment’s duration and the child’s weight at the beginning of treatment; however, average
monthly consumption in an individual site can be calculated as follows:
Table 13. Calculation of RUTF requirements for OTC service

Number of OTC beneficiaries A A
Monthly consumption per child (@20 packets B 80
/child/week)
Monthly packet consumption for a site C AxB
Monthly carton consumption for a site D C/150
Monthly net weight (MT) (@13.8kg/carton) E D x 13.8/1000
Monthly gross weight (MT) (@14.9kg/carton) F D x 14.9/1000
Inpatient Therapeutic Care supplies

Assuming an average duration of treatment of ten days, two kg (five packets) of F75 per child can be
used for planning.
Usually less than five per cent of children admitted for complicated malnutrition will not be able to
eat RUTF during rehabilitation phase and will require F100. For these children, a planning figure of 12
kg of F100 per child for the whole rehabilitation phase can be used. This is equivalent to six kg per
month of dry F75 for each paediatric bed dedicated for the management of complicated forms of
severe acute malnutrition.
RUTF is needed for a few days for every child in the transition phase, and for all children in inpatient
care (any phase) with appetite.
Table 14. Nutritional supply requirements calculated per number of SAM cases to treat
Therapeutic Required for % of SAM Duration Quantity Quantity/100
Food children of per SAM cases in
using treatment treatment kg (PxQx100)
product (P) in kg
(Q)
F75 Inpatient 10% 5-7 days 2 20
stabilisation
F100 Inpatient 1% 4 weeks 12 12
rehabilitation
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RUTF Outpatient 90% 8 weeks 15 1350
and inpatient
rehabilitation
ReSoMaL Inpatient care 5% 0.084 0.5
CMV Inpatient care dependent
on use
Moderate Acute Malnutrition supplies

Assuming an estimated duration of treatment of 90 days, a total of Supercereal Plus or We have 6 to
23 months old children, who will receive 180 Sachets of MNP in total, with 60 Sachets each for
children 6 to 11 months, 12 to 17 months, 18 to 23 months and above can be used for planning
Table 15. Nutritional supply requirements calculated per number of MAM cases to treat
Supplementa Required for % of MAM Duration Quantity per Quantity per
ry product children of treatment + MAM cases
using the treatment protection*** (PxQx100)**
product ** (Q) *
(P)*
Supercereal Protocol B - 90 days 18 + 3 = 21kg -
Plus
MNPs Protocol A - 180 days 180+15= 195 -
packets
*To be determined by GoN after analysis of district needs
** Minimum duration of treatment is 90 days; maximum is 120 days
***An amount of ration added to accommodate sharing
**** To be determined by GoN after analysis of district needs
9.8.2 Supply chain

An uninterrupted supply of supplementary (Fortified Blended Food and MNPs) and therapeutic
products (F75 and RUTF) is essential for the service to function effectively. Due to the decentralised
nature of outpatient therapeutic and supplementary care and the fact that products (RUTF and
Fortified Blended Food) are heavy, bulky, and high value products, supply chain is particularly
challenging. A number of measures are required to support effective supply chain:
- Forecasting of needs – see 9.8.1 above
- Definition of minimum stock levels at facility and district levels – it is vital that each facility
and district is supported to define their minimum stock levels to ensure orders are made in a
timely fashion.
- Stock control – stocks must be closely and accurately monitored as influx of admissions can
quickly deplete stores (See Annex 39 for standard formats)
- Appropriate storage conditions – are also critical to minimise any stock losses that could affect
the supply chain (see Box 11)
- On the basis of forecasting and minimum stock level the concerned district health office will
send demand form and letter to Child Health Division. With reference demand form CHD
recommends for supplies to LMD and LDM again requests to supply to central ware house
Pathlaiya. After that Central Ware house proceed to dispatch as demand.
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Box 11. Storage of Nutritional products
Nutrition products also have limited shelf life. Their shelf life is determined mostly by the stability
of the vitamins and minerals contained in the finished product. Shelf life of RUTF and therapeutic
milk is 24 months and it is indicated on the label as Best Before Date.
Best Before Date indicates the time until which the manufacturer guarantees the product’s
compliance with product specifications. Use of products after Best Before Date is not
recommended. It is not possible to extend product shelf life based on analytical testing of product
samples.
Appropriate storage conditions – The product shelf life can be affected by the storage conditions.
High humidity and high temperatures accelerate the degradation processes of vitamins.
Therefore, it is important to comply with instructions provided by the manufacturers when storing
nutritional products. The following should be considered:
 Products should be stored in clean, dry and cool warehouses away from direct sunlight
 Temperature and humidity in the warehouse should be regularly checked and recorded
 Products should be stored in a way that ensures the circulation of air is not prevented and
regular stock turnover can be assured
9.9 Supervision and review

Supportive supervision should become a routine internal process happening on-site. For example,
there should be a supervisor in charge of the daily supervision of the activities in each health facility.
The day-to-day attention to quality should be implemented through on-site supervision.
Supportive supervision is designed to improve the quality of care offered in line with the standards
outlined in Chapter 7 by:
- Identifying weaknesses in the performance of activities, taking immediate action and apply
shared corrective solutions
- Strengthening the technical capacity of health workers and motivating staff through
encouragement of good practices
In addition, IMAM supervision visits should be carried out by the DHO/DPHO/Regional/Centre team
supported as applicable by agencies’ staff and local partners. Supervision should be carried out at least
once a month for each particular facility. Supervision for IMAM activities, when integrated, should be
done at the same time as the visits for other programmes and by the same personnel.
Supervisors should:
1 Review submitted reports to identify any issues prior to their visit
2 Assess, during their visit through structured observation and discussion with the person in-charge
and health workers:
- Organisation of the activities
- Structural condition and hygiene of the health facility
- Storage of products and equipment
- Reference documents and job aids
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- Application of criteria and treatment protocols and procedures (anthropometric
measurements, medical examination, appetite test, referral, medical treatment, and
provision of RUTF, MNPs and Fortified Blended Food) and correct where applicable
- Individual counselling, health and nutrition education
- Links to community components and prevention activities
- Completeness of individual patient monitoring and recording
- Completeness of programme documentation (forms and filing)
- Stock control procedures
- Treatment performance at facility and actions taken to address issues
- Compilation of available information to monitor coverage and actions taken to address issues
(see Section 8.4)
3 Review the following documents to inform the above:
- Individual patient cards (to check admission and discharge criteria and completeness of
patient monitoring)
- Registration book if being used
- Data collection sheets at the facility level (tally sheets and monthly reports)
- Stock cards
During the visit, gaps and discrepancies should be identified in consultation with the health workers
and, as much as possible, with FCHVs. Immediate feedback should be given to the health workers and
joint discussion carried out on possible solutions to the problems identified. Supervisions are also
essential for improving staff capacities through the organisation of formal or informal refresher
training and mentoring (on-the-job training) during the visits, particularly in less accessible areas
where staff movement is difficult.
10 Implementation in the emergency context
It is clear from national and regional data31 that the nutrition situation of acute malnutrition for much
of the population is vulnerable to shocks and that a number of pre-existing factors are likely to
contribute to its deterioration in the event of a crisis:
- Only one in two households in Nepal (49 per cent) is food secure and has access to food year
round;
- 14 per cent of children under age five had diarrhea in the two weeks before the last NDHS
survey;
- 36 per cent of households still use a bush or open field for open defecation and 40 per cent of
rural households have no access to toilet facilities;
- The majority of households (82 per cent) do not treat drinking water; and
- ARIs are a leading cause of childhood morbidity and mortality.
The likelihood of increased incidence of illness and decreased food security will have a deleterious
impact on GAM especially in light of the baseline information highlighted above (NDHS, 2011).
10.1 Disaster Risk Reduction and Preparedness actions

The increased decentralization of services for the management of SAM to health facility levels as part
of national scale-up is in line with Disaster Risk Reduction (DRR) guidance. Scale-up provides additional
treatment capacity, catching children with SAM earlier in the progression of the disease and treating
them closer to home. This helps to reduce both the vulnerability of children to additional shocks and
31
Nepal has a ‘serious’ national prevalence of GAM (10.9%) according to the WHO classification, but in certain
areas GAM has already reached the rate classified as ‘critical’ (Central Hill, 15% and Western Terai, 15.2%).
Page 73
the vulnerability of families caring for those children. These families are able to continue with their
livelihood and coping strategies while their children receive treatment, thus protecting community
resilience. Specific actions to enhance preparedness and DRR are outlined below in Box 12.
Box 12. Preparedness and DRR actions for management of SAM
 Establish integrated guidelines for management of acute malnutrition

 Assess coverage of existing services for management of severe acute malnutrition (SAM)
and establish a contingency supply and distribution plan
 Map community capacities and existing communication channels to identify the most
effective ones for passing nutrition information
 Ensure that on-going Situation Analysis takes account of trends in SAM admissions
(admission numbers and whether any particular groups in addition to children 6-59m are
being identified with regularity)
 Ensure emergency preparedness is included in national management of SAM scale-up plans
and UNICEF national work plans
 Capacity Development for management of SAM
 Ensure contingency plans are in place for supplies and staffing needs in the event of an
emergency
10.2 Agreeing thresholds for response

Nationally, Nepal has agreed thresholds to guide response based on prevalence of GAM and
aggravating factors and in line with WHO guidance (see Table 16).
In addition to address the issues associated with periodic emergencies coming on top of on-going
needs for services for the management of acute malnutrition, local level thresholds for SAM can be
agreed. These correspond to the numbers of children with SAM that each health facility (or district)
can manage with existing non-emergency levels of support.
The use of the thresholds model adds the critical component of defining the capacity gap that needs
to be built and of identifying support partners and support modalities for emergency response as part
of preparedness ahead of an emergency response.
Contingency agreements can then be reached with district/sub-national and national health teams on
the type and intensity of additional support required (in the areas of supply and logistics, HR,
supervision and monitoring, data collection and analysis) and who will supply it should those
thresholds be exceeded.
Thus emergencies for the management of SAM based on the capacity of the system to manage the
caseload rather than on SAM prevalence. It therefore serves to sharpen programme focus on disaster
risk reduction and local capacity development as explicit strategies for the long term to contribute to
communities’ and the health systems own resilience in the face of multiple shocks.
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Table 16. Nepal thresholds and benchmarks for Nutrition in Emergencies (WHO 200032)
Severity Prevalence Action required Status of Nepal
of Global
Acute
malnutrition
(GAM)
Acceptable <5% - No districts fall into this category
Poor 5–9% - No need for - Approx. 30 districts fall in this
population category
interventions - Even in the poor nutrition situation,
- Attention to attention should be given to the
malnourished acutely malnourished children
individuals through through community and existing
regular community health services
services
Serious 10 – 14 % or - No general rations, - Most of the districts (more than 40)
5-9% with but fall in this category
aggravating - Supplementary - Nepal national figures (11% GAM
factors* feeding targeted to and 2.6% SAM) fall in this category.
individuals identified In the majority of the districts, two
Emergency/disast as malnourished in or more defined aggravating factors
er Threshold of vulnerable groups exist
malnutrition
- Therapeutic feeding
for severely acutely
malnourished
individuals
Critical > = 15 % or -General rations - Few districts especially mid and far
10-14% with (unless situation is western hills and mountainous, few
aggravating limited to vulnerable districts of central and western
factors* groups); plus Terai and central hills falls in the
- Supplementary serious situation
feeding for all
members of
vulnerable groups
- Therapeutic feeding
for severely acutely
malnourished
individuals
* The aggravating factors include: general food ration below the mean energy requirement,
epidemic of measles of whooping cough (pertussis), high incidence of respiratory or diarrheal
diseases, epidemic of HIV and AIDS, prevalence of malaria, natural disasters such as floods,
earthquakes, droughts, heavy snow/hail falling and destroying agriculture products and massive
casualty, climate change and destroying humankinds or foods or livelihood, high prevalence of
pre-existing malnutrition, such as stunting etc.; complex humanitarian situation such as armed
conflict, household food insecurity, crude mortality rate greater than 1/10,000/day; under-five
crude mortality rate greater than 2/10,000/day etc.
32
Management of nutrition in major emergencies. WHO 2000. p40 & p75
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10.3 Implications for programme management of acute malnutrition
The protocols and practice for the management of severe acute malnutrition do not change when
there is an emergency. However, a number of factors may affect both programme management for
SAM and MAM programming and there may need to be a shift in focus of the protocols employed for
the management of MAM:
Increases in the numbers of children being identified with acute malnutrition and additional age
groups may become affected by acute malnutrition. Therefore keeping up to date information on the
admissions to the current service to complement any emergency assessments is critical.
Increased staffing needs as a result of the above may require staff to be moved from elsewhere, or
additional capacity may be required from external sources.
Increased supply needs as a result of the above may require additional supply and logistics systems
to be put in place and emergency stocks of medicines, equipment and therapeutic products mobilised.
Influx of new cases from areas where there has been no treatment in place may lead to a larger
proportion of cases requiring inpatient care and therefore facilities may require extra bed space and
staff capacity.
Supplementary feeding is more likely in the emergency context that there will be a deterioration in
the food security situation and therefore an escalation of efforts to provide supplementary feeding
either for all children under five years of age (blanket approaches) or targeted to those with MAM.
This offers more opportunity for referral of discharges from OTC to supplementary feeding in order to
continue their rehabilitation and for the identification of cases of SAM, which may present to SFP sites.
Therefore, links and referral mechanisms will need to be strengthened.
General food distributions and/or cash transfers to support household food security will require links
to ensure that families of acutely malnourished children are included in distributions.
Coordination during emergency situations there are likely to be more agency actors getting involved
in support for IMAM, and therefore coordination through the district health administration and
national MoHP needs to be emphasised. The use of standard guidelines, protocols and monitoring will
need to be reinforced by the ministry of health. This will ensure that short term emergency
approaches do not hinder long term progress for IMAM by undermining government ownership,
creating parallel services or by putting in place inappropriately resource intensive solutions to
implementation issues (such as monetary incentives for community level workers and complicated
reporting systems).
Preparedness actions including the agreement of potential support modalities can help to avoid issues
being created by the above (see Section 10.2).
10.4 MAM programming in emergencies

During the onset of an emergency household food security is often compromised and it is therefore
difficult to manage MAM cases without the provision of supplementary foods.
The GNC MAM decision-making tool for emergencies33 should be consulted in order to define the
nature of the MAM response. Decisions should be based on the following information:
- Prevalence of GAM in the affected area
- Information on the nature and severity of the crisis
- Baseline and health assessment data in the areas affected and expectations of the crisis
impact on illness
- Food security situation and expectations of crisis impact on food security
- Estimates of displacement and population density
33
Global Nutrition Task Force. 2012. Moderate Acute Malnutrition: A decision tool for emergencies.
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The decision tool guides the evaluation of appropriate response which, depending on the findings may
include both the prevention and the treatment of MAM.
10.2.1 Blanket Supplementary Feeding (BSF) for prevention of MAM

BSF could be provided to:
- All the children between 6 to 23 months or 6 to 59 months depending on the assessment
findings from the decision making tree
- All the pregnant and lactating women of infants under six months
- All the HIV-infected children 6 to 59 months in the affected area
BSF should be started as early as possible after the onset of the crisis. It will create an opportunity for
community participation in the integrated management of MAM and SAM, as well as for fundamental
health interventions such as deworming, vitamin A supplementation and immunizations.
A daily ration size of 200g of a novel fortified blended food containing wheat or corn, dehulled soya
beans, refined soya bean oil, dried skim milk powder, sugar and a wide range of vitamins and minerals
will be provided to the beneficiaries of the BSF program. The timeframe of the intervention should be
assessed and evaluated on an ad-hoc basis, but it is recommended to plan the intervention for a period
of three to six months.
10.2.2 Targeted Supplementary Feeding (TSF) for treatment of MAM
Page 77
The target groups and protocols for TSF are detailed in the main MAM section above under protocol
B; however, the programme is likely to be implemented more widely in the country and to include
pregnant as well as lactating women as a target group in the emergency context.
Page 78

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NEPAL Integrated Management of

Acute Malnutrition (IMAM) Guideline

List of Terms .................................................................................................................................................... 8

2 Objectives, principles and structure of IMAM ....................................................................................... 12

3 Community mobilisation/outreach ....................................................................................................... 15

4 Assessment and classification of acute malnutrition ............................................................................. 22

5 Management of SAM ............................................................................................................................ 31

6 Management of MAM ........................................................................................................................... 49

7 Management of acute malnutrition with HIV ........................................................................................ 58

8 IMAM programme monitoring and reporting ........................................................................................ 59

9 Programme management ...................................................................................................................... 64

10 Implementation in the emergency context............................................................................................ 73

Figure 1. UNICEF conceptual framework of malnutrition....................................................................... 9

Figure 1. UNICEF conceptual framework of malnutrition

Resources and Control

Political and Ideological Superstructure

Figure 2. The intergenerational cycle of growth failure

1.1 What is acute malnutrition?

1.2 Burden of acute malnutrition in Nepal

2 Objectives, principles and structure of IMAM

2.1 Objectives of IMAM

2.2 Principles of IMAM

2.3 Structure of IMAM

Community mobilisation involves identification of acutely malnourished children at the community

Figure 3. Components of IMAM in Nepal

Links to other health facility services*

* GMP, CB-IMNCI, IYCF counselling, PMTCT

2.4 Integrating IMAM into the existing services and structures

3.1 Introduction to community mobilisation

The main objectives of community mobilisation for IMAM include:

3.2 Developing a district community mobilisation strategy

Figure 4. Stages in community mobilisation

3.2.1 STEP 1: District consultation meeting

3.2.2 STEP 2: Community assessment

3.2.3 STEP 3: Conduct sensitisation and community dialogue

Box 1. Community level agents for involvement in case finding in Nepal

3.2.4 STEP 4: Developing messages and materials

3.3 Protocols for case-finding and referral

3.3.1 Active adaptive case-finding for SAM

Step 1. Use findings of community assessment to identify:

3.3.2 Active case-finding for MAM

3.5 Protocols for follow-up of clients with acute malnutrition

3.6 Set-up requirements

4 Assessment and classification of acute malnutrition

4.1 Assessment of Children 6-59 months

4.1.1 Step 1. Determine age

4.1.2 Step 2. Check for pitting oedema on both feet

See Annex 5 for how to check oedema.

4.1.3 Step 3. Measure MUAC

See Annex 5 for how to measure MUAC.

4.1.4 Step 4. Assessment of appetite and medical complications

Box 5. The importance of the appetite test?

Extensive mouth ulcers

Ear pain with tender swelling behind the

Urinary tract infection

Medical As table 2 NO medical complications

4.2 Assessment of infants under 6 months

Figure 5. Signs of visible wasting

In addition a health assessment of mother according to CB-IMNCI and anthropometric assessment

4.3 Summary classification of acute malnutrition