MODULE 9

Management of Acute Malnutrition (MAM)

Name
Designation
Office/Agency
Target Learners
All healthcare providers of infants or children with MAM at
community levels:
1.Community – barangay health station, day care center, school
2.OTC facility – BHS, RHU Clinic, or CHO
3.OPD of an ITC facility

2
Module Description
Discusses what the health worker will do when a child with MAM
and mother/caregiver visit a community facility, an OTC facility or
OPD facility of an ITC facility

Session 1: Admission
Session 2: Treatment
Session 3: Monitoring & Follow-Up
Session 4: Discharge
Session 5: Linkaging

3
Learning Objectives

At the end of the module, the participants will be able to:

1.Discuss the criteria for admission of child with MAM to the Targeted
Supplementary Feeding Program (TFSP)
2.Discuss the management of MAM through the TSFP and Routine
Child Health Services
3.Discuss monitoring, follow-up, discharge, and linkaging of children
with MAM with other services.

4
Session 1
Admission

5
Decision
Flowchart
for TSFP, Refer to Targeted Supplementary

OTC or ITC Feeding Program (TSFP)

Recovery (link to other

services- acute malnutrition
prevention such as blanket
feeding)

6
Decision
Flowchart
for TSFP, Refer to Targeted Supplementary

OTC or ITC Feeding Program (TSFP)

Recovery (link to other

services- acute malnutrition
prevention such as blanket
feeding)

7
 Identify if the
Decision
child has MAM!
Flowchart
Identify if the Virgin
forhas
child TSFP,
MAM or Refer to Targeted Supplementary
and
OTC or ITC Relapse
SAM.
Feeding Program (TSFP)

cases of MAM
only

Recovery (link to other

services- acute malnutrition
prevention such as blanket
feeding)

8
 Decision
Identify if the
Flowchart
Identify
child if the
has MAM!
forhas
child TSFP,
MAM or Refer to Targeted Supplementary

OTC or ITC
SAM.
Feeding Program (TSFP)

Recovery (link to other

services- acute malnutrition
prevention such as blanket
feeding)

9
Decision
Flowchart
for TSFP, Refer to Targeted Supplementary

OTC or ITC Feeding Program (TSFP)

Recovery (link to other

services- acute malnutrition
prevention such as blanket
feeding)

10
Assessment and admission of MAM patients are
performed at designated MAM Centers or
Targeted Supplementary Feeding Centers:
• Barangay health stations
• Rural health unit clinics
• Health offices
• Any defined location in the community like school, barangay hall

11
Steps for MAM Admission
Do initial assessment

Identify Moderate Acute Malnutrition (MAM)

Refer Child with MAM to TSFP

12
 Do initial assessment
Steps for MAM Admission
Identify MAM
A. Do initial assessment
Explain to the caregiver Refer patient to TSFP

Assessment to determine if treatment needed, what to expect

B. Identify MAM (virgin and relapse cases only)
Confirm birth date and age
Take anthropometric measurements
6-59 mos. of age
MUAC, WFL/WFH Z-score, edema

Infants < 6 mos of age

WFL Z-score, edema
13
Classification of Acute Malnutrition for children over
6 to 59 months based on MUAC, WFH/WFL Z-score , Edema

Parameter Normal MAM SAM

MUAC ≥ 12.5 cm 11.5 to 12.4 cm < 11.5 cm

and and/or and/or
WFL or WFH -2 to +2 SD < -2 to -3 SD < -3 SD
Z-Score
and and and/or
Edema None None Present
14
Classification of Acute Malnutrition for Infants
less than 6 months based on WFL Z-score and Edema
Parameter Normal MAM SAM

WFL Z-Score -2 to +2 SD < -2 to -3 SD < -3 SD

and and and/or

Edema None None Present

NOTE: MUAC is NOT RECOMMENDED For children <Less than 6 months old as MUAC of these age
group is naturally small

15
Admission
1. Determine signs of medical complication
2. Check for all vaccination status
3. Assess the child’s feeding status
4. Explain to the mother/caretaker the reasons why the child
is to be admitted to the MAM management program and
how the treatment will be organized
5. Carefully explain the expected outcomes
6. Enter information of the child eligible for admission

16
MAM Referral Form (Same with SAM Referral Form)
Referral/Transfer Form (MAM)- Copy of Receiving Facility (TSFP/OTC)
Referral/Transfer Form (MAM)- Copy of Receiving Facility (TSFP/OTC)

TSFP/OTC TSFP/OTC

17
Admission – Registry Book (page 1)

18
Admission – Registry Book (page 2)

19
Refer non-MAM/non-SAM patients
Non-MAM/non-SAM patients should have
access to:

1.IMCI for counseling and medical care

2. Blanket Supplementary Feeding Program

(BSFP), if in place

3. Advice/counseling on proper IYCF

practices - continued breastfeeding,
appropriate complementary feeding
20
Once the child has been screened, assessed and identified
as having Moderate Acute Malnutrition (MAM)

The next step is to refer the child to the TARGETED

SUPPLEMENTARY FEEDING PROGRAM (TSFP)
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Exercise
To Admit or Not to Admit to TSFP

22
Exercise

Infant/ Age Bilateral MUAC

WFH Z-score Admit to TSFP?
Child (mos.) Edema (cm)
Anna 50 No 10.2 Less than -3SD N
Buboy 45 Yes 11.1 Less than -3SD

Carmela 7 No 11.7 -3SD to less than -2SD

Daniel 12 No 9.5 -3SD to less than -2SD

Edel 18 No 12.0 -3SD to less than -2SD

23
Exercise

Infant/ Age Bilateral MUAC

WFH Z-score Admit to TSFP?
Child (mos.) Edema (cm)
Anna 50 No 10.2 Less than -3SD NO (SAM)

Buboy 45 Yes 11.1 Less than -3SD

Carmela 7 No 11.7 -3SD to less than -2SD

Daniel 12 No 9.5 -3SD to less than -2SD

Edel 18 No 12.0 -3SD to less than -2SD

24
Exercise

Infant/ Age Bilateral MUAC

WFH Z-score Admit to TSFP?
Child (mos.) Edema (cm)
Anna 50 No 10.2 Less than -3SD NO (SAM)N
Buboy 45 Yes 11.1 Less than -3SD NO (SAM)

Carmela 7 No 11.7 -3SD to less than -2SD

Daniel 12 No 9.5 -3SD to less than -2SD

Edel 18 No 12.0 -3SD to less than -2SD

25
Exercise

Infant/ Age Bilateral MUAC

WFH Z-score Admit to TSFP?
Child (mos.) Edema (cm)
Anna 50 No 10.2 Less than -3SD NO (SAM)

Buboy 45 Yes 11.1 Less than -3SD NO (SAM)

Carmela 7 No 11.7 -3SD to less than -2SD YES

Daniel 12 No 9.5 -3SD to less than -2SD

Edel 18 No 12.0 -3SD to less than -2SD

26
Exercise

Infant/ Age Bilateral MUAC

WFH Z-score Admit to TSFP?
Child (mos.) Edema (cm)
Anna 50 No 10.2 Less than -3SD NO (SAM)

Buboy 45 Yes 11.1 Less than -3SD NO (SAM)

Carmela 7 No 11.7 -3SD to less than -2SD YES

Daniel 12 No 9.5 -3SD to less than -2SD NO (SAM)

Edel 18 No 12.0 -3SD to less than -2SD

27
Exercise

Infant/ Age Bilateral MUAC

WFH Z-score Admit to TSFP?
Child (mos.) Edema (cm)
Anna 50 No 10.2 Less than -3SD NO (SAM)

Buboy 45 Yes 11.1 Less than -3SD NO (SAM)

Carmela 7 No 11.7 -3SD to less than -2SD YES

Daniel 12 No 9.5 -3SD to less than -2SD NO (SAM)

Edel 18 No 12.0 -3SD to less than -2SD YES

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Session 2
Treatment

29
Types of Feeding Feeding
Program Programs

General
Selective Feeding
Food
Program
Ration

Therapeutic Supplementary Feeding

Feeding Program Program (SFP)

Blanket Targeted
OTC ITC
SFP (BSFP) SFP (TSFP)

30
 Blanket vs Targeted Supplementary Feeding
Program

Blanket SFP
Targeted SFP
targets ALL CHILDREN
regardless of nutritional status targets MAM children only
(prevention of acute malnutrition)

31
Blanket Supplementary Feeding Program
Provision of supplementary ration to the general population of an
identified vulnerable group (e.g. children under-5 years, elderly,
women of childbearing age) for a defined period

Objectives:
▪To prevent further deterioration in the nutritional status of at-risk
groups in a population
▪ To reduce prevalence of MAM in children under-5, thereby
reducing the mortality and morbidity risks

32
Targeted Supplementary Feeding Program (TSFP)
Supplementary ration is provided to specific members of a vulnerable
group (e.g. MAM children under five, pregnant and lactating women)
whose requirements may not be met by the general ration

Objectives:
• To rehabilitate children with MAM
• To prevent cases of MAM from aggravating and deteriorating to
SAM
• To reduce mortality and morbidity risks in children under five

33
Targeted Supplementary Feeding Program (TSFP)

▪ Can be done in the community, home, health center or in the

outpatient department of referral hospitals
▪ For TSFP to be effective, it should be implemented when there is
sufficient food supply or an adequate general ration
▪ The supplementary ration is meant to be an addition to, and
not a substitute for the general ration.

34
Admission (Registration Number)

Municipality/District/Health Center/ Program/Year-MAM Number

Province/ Municipality/ Program/ Year-MAM Number

Examples:
•Maguindanao/SouthUpi-RHU/TSFP/2018-0044
•Maguindanao/Buldon-BHS 1/TSFP/2018-0044

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SFP Individual Ration Card

36
Interventions for MAM

Targeted Supplementary
Feeding Program (TSFP)

Nutritional Routine Child

Intervention Health Services

37
Nutritional Intervention for MAM

Nutritional Intervention

RUSF Local Recipe + MNP Milled Form

38
 Three Types of Supplementary Food

Source: WFP

Ready to Use Supplementary Local Recipes/ Fortified Blended

Food (RUSF) Locally available food Food or cereals

39
Ready-to-use Supplementary Food (RUSF)
• WHO recommended energy-dense, On top of this
mineral and vitamin-enriched food
specifically designed either for MAM Regular meal
in children 6-59 months of age
• Eaten by the child in addition to •Breakfast
breast milk and other family foods for •Lunch
about 3 months •Dinner
• Standard for MAM •AM Snacks
•PM Snacks
• 1 sachet per day

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 Ready-to-use Supplementary Food (RUSF)
• 4 Brands are available in the market (1 generic)

✓ Chick-pea based ✓ Peanut based

Plumpy Sup (Nutriset)

Acha Mum (Ismail Industries Ltd)

RUSF
Eezee RUSF
(Generic, by USAID)
(GC Rieber Compact) 41
 Ready-to-use Supplementary Food (RUSF)

• Provides 513-550* kcal/100 grams per day

12.6 -15.4 grams protein
30 - 38.6 grams fat
42.7 grams carbohydrate

*Note: Plumpy Sup new formulation has 565 kcal

42
Salient differences between RUTF and RUSF
RUTF RUSF Remarks
Protein Content 50% from dairy (equivalent 33% from dairy (equivalent To support vertical growth
to 20% dried skimmed mikl to 10% dried skimmed milk
or whey protein) (less K, Ca, P) Higher dairy content
(more K, Ca, P) provides more K, Ca, P

Potassium 1100 mg/100 g RUTF 900 mg/100 g RUSF

(50% from KCl; 50% from
100% from KCl Potassium Citrate

Recipe One recipe (due to pre mix)Different recipes (due to

raw material-
chickpea/peanut, rice,
lentils and pre-mix

Source: WFP, UNICEF, USAID Harmonization of Lipid-based products (with MSF and Tufts University) 43
Locally Prepared Foods
Give On top of this
Local Food Regular meal
500-550 kcal
•Breakfast
PLUS •Lunch
•Dinner
1 sachet of MNP •AM Snacks
per day •PM Snacks

▪ MNP is distributed only to children 6-23 months old by DOH

and the LGUs. Make sure that MNP is made available to
children 24-59 months old with MAM.
44
Locally Prepared Foods
▪ Should contain ALL essential nutrients in
adequate amounts
▪ The nutrients should be biologically available to
children with altered intestinal function that is
associated with MAM
▪ Can be stored at home up to 4 hours at a time
at room temperature.
▪ Given once or twice daily for about 3-6 months
11 – 16 g protein
26 – 36 g fat
30.5 – 70.5 g carbohydrate

45
Sample Recipes for Locally Prepared Food:

1. Sweet Ginataang Munggo (Source: WFP School Feeding Programme)

2. Pahiyas Brown Rice (Source: FNRI)
3. Munggo Sate (Source: WFP School Feeding Program)
4. Saucy Beans (Source: WFP School Feeding Program)
5. Mungbi with Chicken (Source: GTZ and FNRI)
6. Arroz Caldo with Egg (Source: MAM National Guidelines)

46
Sample Recipe 1:
Sweet Ginataang Munggo (Source: WFP School Feeding Programme)
Yield: 10 servings
Serving Size: 1 cup
Per Serving: 642 kcal, 17.1g protein, 28.4g Fat, 79.3g Carbohydrate

Ration for a child with MAM:

4/5 cup to 1 cup of sweet ginataang munggo mixed with 1 sachet
MNP
Ingredients for Sweet Ginataang Munggo Quantity Unit

Mung bean seed, green, dried (Munggo buto, berde, tuyo) 2 cup
Rice, well-milled (Bigas, maputi) washed 2 cup
Coconut cream (Niyog, gata) 4 cup
Sugar, white, refined (Asukal, puti) 2 cup
47
 Sample Recipe 2:
Pahiyas Brown Rice (Source: FNRI)
Yield: 5 ½ servings
Serving Size: 1 cup
Per Serving: 711 kcal, 17.5 g protein

Ration for a child with MAM:

Give ¾ cup of Pahiyas Brown Rice mixed with 1 sachet MNP
Ingredients for Pahiyas Brown Rice Quantity Unit
Cooking oil for frying 3 tbsp
Garlic, chopped 2 tbsp
Longganisa 6 pieces
Bell pepper, red, cubed 1/4 cup
Corn kernel, canned, drained 1/3 cup
Peas, frozen 1/4 cup
Brown rice, cooked 4 cups
Seasoning granules or powder (optional) 1/2 tbsp 48
 Sample Recipe 3:
Munggo Sate (Source: WFP School Feeding Program)
Yield: 25 servings
Serving Size: 1 piece (60 grams);
Per Serving of Munggo Sate: 298Cal, 12.9g protein, 19.6g Fat, 17.6g Carbohydrate
Ration for a child with MAM:
Give 2 pieces of munggo sate mixed with 1 sachet MNP
Ingredients for Munggo Sate Quantity Unit
Mung bean seed, green, dried (Munggo buto, berde, tuyo) 0.5 kg
Onion, spring (Sibuyas) 0.5 kg
Carrot 0.3 kg
Pepper, sweet/bell, long, red (Sili, sweet/bell, mahaba,) 4 tbsp
Onion, Bombay bulb (Sibuyas, Bombay ulo) 4 tbsp
Scad, big-eyed, smoked (Matang baka, tinapa) 2 cup
Egg, chicken, whole (Itlog, manok, buo) 8 piece
Salt, coarse (Asin, magaspang) 2 tbsp
Pepper, chili fruit (Sili, labuyo, bunga) 2 tbsp
Garlic bulb (Bawang Ulo) 4 tbsp
Oil, coconut (Mantika, niyog) 1 3/4 cup
49
Sample Recipe 4:
Saucy Beans (Source: WFP School Feeding Program)
Yield: 10 servings
Serving Size: 1 cup
Per Serving of saucy beans: 588 kcal, 16g protein, 24g Fat, 77g Carbohydrate

For a child with MAM:

Give 1 cup of saucy beans mixed with 1 sachet MNP
Ingredients for Saucy Beans Quantity Unit
Kidney/Snap bean seed, white, dried (Abitsuwelas buto, puti, tuyo) 2 Cup
Oil, corn (Langis, mais) 1 tbsp
Garlic bulb (Bawang Ulo), minced 1 tbsp
Onion, Bombay bulb (Sibuyas, Bombay ulo), chopped finely 4 tbsp
Soy sauce 2 tsp
Catsup, tomato ½ cup
Salt, coarse (Asin, magaspang) 1 tsp
Sugar, white, refined (Asukal, puti) 3 tbsp
Cornstarch 2 tbsp 50
 Sample Recipe 5:
Mungbi with Chicken (Source: GTZ and FNRI)
Yield: 15 servings
Serving Size: 1 cup
Per serving of Mungbi with chicken plus rice: 515 kcal, 16.3 g protein

For a child with MAM:

Give 1 cup of mungbi with chicken mixed with 1 sachet MNP and
½ cup cooked rice
Ingredients for Mungbi with Chicken Quantity Unit
Monggo, green 200 grams
Water 27 2/3 cups
Bihon noodles 250 grams
Cooking oil 3 tbsp
Garlic minced 5 cloves
Garlic strips 1 piece
Onion sliced (medium) 2 pieces
Chicken breast sliced 1 piece
Salt and sugar 3 and 2 tbsp
Malunggay leaves 16 stalks
Rice (cooked) ½ cup 51
 Sample Recipe 6:
Arroz Caldo with Egg (Source: MAM National Guidelines)
Yield: 1 serving
Serving Size: 1 cup
Per Serving of Arroz Caldo with Egg: 511 kcal, 12 g protein, 31 g fat

For a child with MAM (young children)

Give 1 cup of arroz caldo with egg mixed with 1 sachet MNP
Ingredients for Arroz Caldo with Egg Quantity Unit
Cooking oil 5 tbsp
Onion, medium, diced 1 Piece
Garlic, crushed 2 Cloves
Fresh ginger, 2 inch size, peeled, thinly sliced 1 Piece
Fish sauce 1 tbsp
Green onion, chopped 1 Piece
Lemon, sliced (optional) 1 Piece
Hard boiled chicken egg, medium, mashed 1 piece
52
Rice gruel 1 cup
FORTIFIED BLENDED FOOD (FBF)
• Not intended to be the only source of nutrients but
should complement the MAM child’s regular diet
• 130g/day containing 500 Cal
21 g protein On top of this
13 g fat
75 g carbohydrate
Regular meal
• Given for 3-6 months
•Breakfast
• 2 types of supplementary feeding with FBF
•Lunch
wet and dry supplementary feeding
•Dinner
•AM Snacks
•PM Snacks
53
Wet Supplementary Feeding (on-site rations)
▪ Food is prepared once or twice daily in SFC
▪ Consumed by the child in the SFC
▪ In emergency settings with limited access to
fuel and water
▪ Two meals are needed
▪ Can also be given while the child waits for
his/her dry ration.

54
Dry Supplementary Feeding (take-home rations)
▪ Ingredients are mixed in the SFC prior to
distribution
▪ Taken home to be prepared and consumed by the
child at home
▪ Distribution is every 1-2 weeks depending on the
resources, access to distribution sites, security,
and other conditions

55
Nutritional Intervention for MAM
∙ If RUSF is given, Vitamin A and MNP SHOULD NO longer be provided to the
child with MAM

∙ A child with MAM on locally available food with 1 sachet MNP, SHOULD NOT
receive any other MNPs. They SHOULD NOT be covered by the National
Policy on Micronutrient Supplementation for children 6-23 months. The child
shall receive Vit A

∙ It is recommended that the DOH develop a clear policy on the use of MNP on
children with MAM as a form of treatment. This SHOULD be different from the
existing National Policy on MNP among the 6-23 months.

56
Interventions for MAM

Targeted Supplementary
Feeding Program (TSFP)

Nutritional Routine Child

Intervention Health Services

57
Routine Child Health Services
Routine Child Health Services

Breastfeeding & Growth Treatment of Acute

Counseling Hand Hygiene
IYCF Monitoring & Chronic Illness

Supplementation Care Practices &

Oral Immunization Deworming Psychosocial
Health (Iron, Iodine) Services

58
Schedule of Routine Child Health Services

59
Therapeutic Interventions for MAM
For Infants <6 months with MAM:

•Use the C-MAMI Tool as discussed in Module 5 on Outpatient Therapeutic Care

for children with SAM

60
Session 3
Monitoring & Follow-Up

61
Procedures
for
Monitoring
• Follow-up is
done every 2
weeks

62
Criteria for failure to respond to treatment
Any weight loss Either no or trivial
Weight loss
within the 3 weight gain after 5
exceeding 5% of
consecutive weeks weeks in the
body weight at any
in the program or at program or at the
time
the 2nd visit 3rd visit

Failure to reach
Abandonment of
discharge criteria
the program
after 3 months in the
(defaulting)
program

63
Reasons for failure to respond to treatment

1. Problems with the application of the protocol

2. Nutritional deficiencies that are not being corrected by SFP-supplied diet
3. Home/social circumstances of the patient
4. An underlying medical (e.g. Tuberculosis) or physical condition/illness
(e.g. congenital defects)
5. Other causes

64
Step-by-step Approach to Address Failure to
Respond to Treatment
1 2 3 4
Check for problems with
Make a diagnosis of Check for problems in Change the diet to check
environment/ social
failure to respond to the proper application for uncorrected
problems; If possible
treatment for the protocol nutritional deficiencies
perform home visit

5 6 7
Admit for full clinical Refer to a center with
assessment to search for diagnostic facilities and senior Idiopathic Cause (Unknown)*
underlying undiagnosed pediatric personnel for further Non-response
pathology case management

(Golden & Grellety,652008)

Management of Non-Responder/Treatment Failure

Step 2
Step 3
Step 1 On the next visit, Step 4
Investigate the
Double the child's check the child's
home social Investigate
nutritional intake response to
circumstances; underlying
for 15 days. treatment.
conduct home pathology.
Continue for
visit.
another month.

66
MONTHLY STATISTICS REPORT

67
Session 4
Discharge

68
Criteria for Discharge (6-59 months)
Category Discharge Criteria
Cured
∙ Reached WFL/H: ≥ -2 Z-score for 2 consecutive visits;
AND/OR
∙ Reached MUAC: ≥ 12.5 cm for 2 consecutive visits
∙ Clinically well
∙ No bilateral pitting edema
Defaulter ∙ Absence for 3 consecutive visits (every 2 weeks visit)
Non-Responder/
Non-Cured ∙ 4 months without reaching cured criteria
∙ Failure to respond to treatment
Died ∙ Death of child from any cause

69
Criteria for Discharge (<6 months)
Category Discharge Criteria
Cured ∙ Admitted by WFL Z-score ≥ -2 SD for 2 consecutive visits
∙ Clinically well
∙ No bilateral pitting edema

Defaulter ∙ Absence for 3 consecutive visits (every 2 weeks visit)

Non-Responder/ ∙ 4 months without reaching cured criteria
Non-Cured ∙ Failure to respond to treatment

Died ∙ Death of child from any cause

70
Pre-requisite before Discharge
∙ At any follow-up period, if the child reaches a WFL/H z-score of -2 or above or a MUAC of
12.5 cm and above WITHOUT Bilateral pitting edema:

1) The child must maintain these criteria for 2 consecutive visits (1 visit = 2 weeks)
2) During this time, the child must be continuously provided with 14 sachets of RUSF
for another week.
3) While the maximum duration for treatment is 3 months for RUSF and 3-6
months for the locally food with 1 sachet MNP per day, the child may not finish
this long if he/she already reaches the discharge criteria for 2 consecutive
visits

71
Procedures for Discharge

72
Go Back to the Registry Book (page 2)

73
Session 5
Linkaging

74
Linkaging MAM with Other Services

75
 Summary
▪ A MUAC of 11.5 to 12.4 cm and/or a Z-score of <-2 to -3SD and the absence of
bilateral pitting edema qualify a 0 to 59 months old child to be admitted to the
TSFP (only virgin and relapse cases of MAM)
▪ TSFP includes both treatment with supplementary food (RUSF or locally
available food with MNP or fortified blended cereals) AND regular child health
services like Breastfeeding and IYCF, counseling, deworming, vitamin
supplementation, etc.
▪ In the absence of RUSF, the child can be given locally available food plus MNP.
The energy and calorie of the local food shall be comparable to RUSF.

76
 Summary
▪ The child with MAM is treated for maximum of 3 months (RUSF) or 6 months
(local food + MNP) and followed-up every 2 weeks.
▪ If child reaches the discharge criteria, this should be maintained for 2 consecutive visits.
▪ Linkaging with other programs should be part of TSFP.
▪ The child is discharged when the MUAC and Z-score become normal (CURED)
and under the following other categories: defaulter, death, and non-responder.
▪ Once discharged cured, the child is followed up at home for the next 3 months to
ensure that he/she is doing well.

77
Closing Remarks
Name
Designation
Office/Agency
Thank you.