INTRODUCTION

COMMUNITY BASED MANAGEMENT OF SEVERE ACUTE MALNUTRITION

Severe acute malnutrition remains a major killer of children under ve years of age.
Until recently, treatment has been restricted to facility-based approaches, greatly
limiting its coverage and impact. New evidence suggests, however, that large
numbers of children with severe acute malnutrition can be treated in their
communities without being admitted to a health facility or a therapeutic feeding
centre.

The community-based approach involves timely detection of severe acute
malnutrition in the community and provision of treatment for those without
medical complications with ready-to-use therapeutic foods or other nutrient-dense
foods at home. If properly combined with a facility-based approach for those
malnourished children with medical complications an implemented on a large scale,
community-based management of severe acute malnutrition could prevent the
deaths of hundreds of thousands of children.

Nearly 20 million children under ve suffer from severe acute malnutrition
Severe acute malnutrition is dened by a very low weight for height (below -3 z
scores1 of the median WHO growth standards),by visible severe wasting,or by the
presence of nutritional oedema. In children aged 659 months, an arm
circumference less than 110 mm is also indicative of severe acute malnutrition.
Globally, it is estimated that there are nearly 20 million children who are severely
acutely malnourished. Most of them live in south Asia and in sub-Saharan Africa.

Severe acute malnutrition contributes to 1 million child deaths every year
Using existing studies of case fatality rates in several countries, WHO has
extrapolated mortality rates of children suffering from severe acute malnutrition.
The mortality rates listed in the table at right reect a 520 times higher risk of
death compared to well-nourished children. Severe acute
malnutrition can be a direct cause of child death, or it can act as an indirect cause by
dramatically increasing the case fatality rate in children suffering
from such common childhood illnesses as diarrhea and pneumonia. Current
estimates suggest that about 1 million children die every year from severe acute
malnutrition.

The large burden of child mortality due to severe acute malnutrition remains largely
absent from the international health agenda, and few countries, even in high
prevalence areas, have specic national policies aimed at addressing it
comprehensively. With the addition of community based management to the
existing facility-based approach, much more can now be done to address
this important cause of child mortality.


Severe acute malnutrition in children can be identied in the community
before the onset of complications
Community health workers or volunteers can easily identify the children affected by
severe acute malnutrition using simple coloured plastic
strips that are designed to measure mid-upper arm circumference (MUAC). In
children aged 659 months, a MUAC less than 110 mm indicates severe
acute malnutrition, which requires urgent treatment.
Community health workers can also be trained to recognize nutritional oedema of
the feet, another sign of this condition. Once children are identi ed as suffering
from severe acute malnutrition, they need to be seen by a health worker who has
the skills to fully assess them following the Integrated Management of Childhood
Illness (IMCI) approach. The health worker should then determine whether they can
be treated in the community with regular visits to the health centre, or whether
referral to in-patient care is required. Early detection, coupled with decentralized
treatment, makes it possible to start management of severe acute malnutrition
before the onset of life threating complications.

Uncomplicated forms of severe acute malnutrition should be treated in the
community
In many poor countries, the majority of children who have severe acute
malnutrition are never brought to health facilities. In these cases, only
an approach with a strong community component can provide them with the
appropriate care.
Evidence shows that about 80 per cent of children with severe acute malnutrition
who have been identied through active case finding, or through sensitizing and
mobilizing communities to access decentralized services themselves, can be treated
at home.

The treatment is to feed children a ready-to-use therapeutic food (RUTF) until they
have gained adequate weight. In some settings it may be
possible to construct an appropriate therapeutic diet using locally available
nutrient-dense foods with added micronutrient supplements. However, this
approach requires very careful monitoring because nutrient adequacy is hard to
achieve. In addition to the provision of RUTF, children need to receive a short course
of basic oral medication to treat infections. Follow-up, including the provision of the
next supply of RUTF, should be done weekly or every two weeks by a skilled health
worker in a nearby clinic or in the community.

Community-based management of severe acute malnutrition can have a
major public health impact
With modern treatment regimens and improved access to treatment, case-fatality
rates can be as low as 5 per cent, both in the community and in health-care facilities.
Community-based management of severe acute malnutrition was introduced in
emergency situations. It resulted in a dramatic increase of the programme coverage
and, consequently, of the number of children who were treated successfully
yielding a low case-fatality rate.
The same approach can be used in non-emergency situations with a high prevalence
of severe acute malnutrition, preventing hundreds of thousands of child deaths
when applied at scale.

Ready-to-use therapeutic foods
Children with severe acute malnutrition need safe, palatable foods with a high
energy content and adequate amounts of vitamins and minerals. RUTF are soft or
crushable foods that can be consumed easily by children from the age of six months
without adding water. RUTF have a similar nutrient composition to F100, which is
the therapeutic diet used in hospital settings. But unlike F100, RUTF are not water-
based, meaning that bacteria cannot grow in them. Therefore these foods can be
used safely at home without refrigeration and even in areas where hygiene
conditions are not optimal. When there are no medical complications, a
malnourished child with appetite, if aged six months or more, can be given a
standard dose of RUTF adjusted to their weight. Guided by appetite, children may
consume the food at home, with minimal supervision, directly from a container, at
any time of the day or night. Because RUTF do not contain water, children should
also be offered safe drinking water to drink at will. The technology to produce RUTF
is simple and can be transferred to any country with minimal industrial
infrastructure. RUTF cost about US$3 per kilogram when locally produced. A child
being treated for severe acute malnutrition will need 1015 kg of RUTF, given over a
period of six to eight weeks.

Community-based management of severe acute malnutrition in the context of
high HIV prevalence
The majority of HIV-positive children suffering from severe acute malnutrition will
benet from community-based treatment with RUTF. However, experience shows
that rates of weight gain and recovery are lower among these children than among
those who are HIV-negative, and their case fatality rate is higher. The lower weight
gain is probably related to a higher incidence of infections in children who are HIV-
positive.
Given the overlap in presentation of severe acute malnutrition and HIV infection and
AIDS in children, especially in poor areas, strong links between community-based
management of severe acute malnutrition and AIDS programmes are essential.
Voluntary counselling and testing should be available for children with severe acute
malnutrition and for their mothers. If diagnosed as HIV-positive, they should qualify
for cotrimoxazole prophylaxis to prevent the risk of contracting Pneumocystis
pneumonia and other infections, and for
antiretroviral therapy when indicated. At the same time, children who are known to
be HIV-positive and who develop severe acute malnutrition should
have access to therapeutic feeding to improve their nutritional status.





Ending severe acute malnutrition

Prevention rst
Investing in prevention is critical. Preventive interventions can include: improving
access to high-quality foods and to health care; improving nutrition and health
knowledge and practices; effectively promoting exclusive breastfeeding for the rst
six months of a childs life where appropriate; promoting improved complementary
feeding practices for all children aged 624 months with a focus on ensuring
access to age-appropriate complementary foods (where possible using locally
available foods); and improving water and sanitation systems and hygiene practices
to protect children against communicable diseases.

but treatment is urgently needed for those who are malnourished
Severe acute malnutrition occurs mainly in families that have limited access to
nutritious food and are living in unhygienic conditions, which increase the risk of
repeated infections. Thus, preventive programmes have an immense job to do in the
context of poverty, and in the meantime children
who already are suffering from severe acute malnutrition need treatment.
In May 2002, the Fifty-Fifth World Health Assembly endorsed the Global Strategy for
Infant and Young Child Feeding, which recommends actively
searching for malnourished infants and young children so they can be identied and
treated. The development of the community-based approach
for the management of severe acute malnutrition should provide a new impetus for
putting this recommendation into practice. It is urgent,
therefore, that this approach, along with preventive action, be added to the list of
cost-effective interventions to reduce child mortality.


PHILIPPINES DAVAO
Severe Acute Malnutrition (SAM) is a silent emergency health condition that afflicts
the children of Davao City. From 2013 data alone, some 2,014 kids aged one to four
years have been found out to be suffering from SAM. It increases their chance to
have worse bouts of pneumonia and diarrhea. Furthermore, if not adequately
addressed, these children with SAM may even suffer irreversible negative effects on
their physical and brain development.
Fortunately, the Davao City Government, through the City Health Office in
partnership with UNICEF, has embarked on the SAM Initiative to help care for the
children with severe acute malnutrition. A pilot program has ran in three barangays
and is steadily improving the health of nine children with SAM through daily doses
of ready-to-use therapeutic food (RUTF) under the care of trained local health staff.






OBJECTIVES:
This study is to assess the involvement and improvement of SAM patient of
Barangay 5A enrolled in DIMAM program.

It specifically aims in
Assessment of the criteria for the enrollment of the child under this program.
Determining the compliance of patients to regular visits.
Assessment of impact of noncompliance on the children.
Assessment of the criteria of improvements in the children.
Determining the differences in the results of children among who has been
breastfed and who hasn't.
Determining the socio-economic strata of the family of SAM patient.
Determining the level of satisfaction of the mother with DIMAM program.
































Program Description
A. Davao Integrated management of acute malnutrition (DIMAM)
Davao Integrated management of acute malnutrition (DIMAM) is a Pilot program
initiated by the Davao City Government through the City Health Office in
partnership with UNICEF implemented to treat severely acute malnourished (SAM)
children between the age group of 6- 59 months. Last year in 2013, 2,014 children
aged one year to four years were found to be suffering from SAM within Davao city.
SAM is an emergency health condition that needs to be treated and prevented on
time before children suffer from irreversible negative effects on their physical and
overall development.
Through this program children aged 6-59 months are screened using the triage
approach. The Triage approach comprises of three indicators the Mid arm
circumference (MUAC), Z score (height/length for weight) and presence or absence
of bilateral edema. Children positive with either one of the three indicators are
enrolled in the program. Children are screened through Active Screening which is
done simultaneously with operation Timbang and other activities for under 5
children or they can be screened through Passive screening which is done during
routine under 5 OPD consultations.
If the Child is severely malnourished and has additional medical complications then
the child is enrolled in the In Patient program where in hospitalization is required
on the other hand, a child who is severely malnourished but without any medical
complications is enrolled in the Out Patient Program. Before enrolling a child in the
Out-patient program, an Appetite test is performed which the child needs to pass so
that he/she can be given Ready-to-use therapeutic food (RUTF).The care giver of the
SAM patients are given weekly supply of RUTF and are monitored ever week at the
Barangay Health center by the Barangay nutrition scholars. Weight and MUAC is
monitored on a weekly basis whereas the height is monitored every monthly.
B. Objectives of the Program
1. Identify malnourished children under 5 years old
2. Treat Acute Malnutrition
3. Prevent and reduce malnutrition

C. Components of DIMAM
1. Community mobilization
2. Outpatient Therapeutic Program (OTP)
3. In patient Therapeutic Program (ITP)
4. Supplementary Feeding Program (SFP)
C1. Community mobilization:
Build relationships and foster active participation of the community
Identify and carry out active screening and carry out follow up
C2. Out patient Therapeutic Program (OTP):
Management of SAM patients without complications
Provide home based treatment and rehabilitation using RUTF
Monitor childrens progress through regular outpatient clinics
C3. In patient Therapeutic Program (ITP)
Management of SAM patients with complications
Requires hospitalizations and close monitoring of the patient

D. Nutrition Rehabilitation and RUTF
Ready to Use Therapeutic Food (RUTF):
It is a high energy, nutrient-dense food used for nutrition rehabilitation in
outpatient care in combination with systemic medical treatment
It is ideal for outpatient care because it does not need to be cooked or mixed
with water
It can be easily distributed and carried
Easy to store
RUTF is not for healthy children and should not be shared with other family
members as snacks
Lipid based RUTF is most commonly used in outpatient care with a caloric
value of 520 to 550 kilocalories per 100g of product
The number of sachets to be fed are calculated according to the table below
provided by the ACF:
BODY WEIGHT RANGE
(kg)
RUTF
Sachets per day Sachets per week
3.0 3.4 1 9
3.5 4.9 1 11
5.0 6.9 2 14
7.0 9.9 3 21
10.0 14.9 4 28
15.0 19.9 5 35
20.0 29.9 6 42

Lipid based RUTF is composed of:
o 25% peanut butter
o 26% milk powder
o 27% sugar
o 20% oil
o 2% combined mineral and vitamin mix
For In patient care F75, F100 and ReSoMal are used
F-75:
o Is used in the acute phase
o Is the "starter" formula used during initial management of
malnutrition, beginning as soon as possible and continuing for 2-7
days until the child is stabilized
o Severely malnourished children cannot tolerate normal amounts of
protein and sodium or high amounts of fat. They may die if given too
much protein or sodium. They also need glucose, so they must be
given a diet that is low in protein and sodium and high in
carbohydrate.
o F-75 has is specially mixed to meet the child's needs without
overwhelming the body's systems in the initial stage of treatment. Use
of F-75 prevents deaths.
o F-75 contains 75 kcal and 0.9 g protein per 100 ml.
o Daily dose during acute phase: 100kcal/kg/day
As soon as the child is stabilized on F-75, F-100 is used as a "catch-up"
formula to rebuild wasted tissues.
F-100:
o Contains more calories and protein: 100 kcal and 2.9g protein per 100
ml
o Its nutritional value is equal to RUTF
o Is used as Therapeutic milk for infants less than 6 months old
o Daily dose during transition phase: 130 to 150kcal/kg/day
E. Criteria for admission
Who should be admitted to Outpatient care:
Patient should have a positive for at least one of the three indicators (Z score,
MUAC, Edema)
Children should be of age 6 59 months who have severe acute malnutrition
(SAM), an appetite (ability to eat RUTF, passing the appetite test) and no
medical complications
Children whose mother/caregiver refuses inpatient care despite advice; the
child will require follow up home visits and close monitoring while in
outpatient care
Who should not be admitted to Outpatient care:
Children with SAM and medical complications, including no appetite
(should be referred to Inpatient care)
Children under 6 months who have bilateral edema or visible wasting and
whose mother has insufficient breast milk (Should be referred to
Inpatient care)
Moderately malnourished children (Should be given multiple
micronutrient powder (MMP) or multivitamin supplements)
Children who are sick but do not have SAM (referred to other appropriate
health services)




F. Steps for Admission
Children are checked for bilateral pitting edema, MUAC is taken, weight
and length or height is measured
Press both legs/feet at the same time using both thumbs for three
seconds, then release and check
Edema Bilateral Pitting edema
+1 Both lower extremity
+2 Both lower and upper extremity
+3 Both lower and upper extremity and
the face


If a child meets the admission criteria for severe acute malnutrition
(SAM), the health care provider takes a medical history and conducts a
physical examination
All information is recorded on the childs outpatient care treatment card.
Each child has a unique registration number noted on the outpatient care
treatment card
The appetite is tested; RUTF is given to the mother/caregiver to give to
the child for an observed appetite test. The childs appetite is graded by
the health care provider
Based on the appetite test the health care provider determines whether
the child should be admitted to inpatient care or outpatient
The child will receive a ration of RUTF for one week and is told to come
back the next week for a weekly checkup and for more ration for the
following week
The mother/caregiver is also informed on the proper ways of feeding a
child with RUTF
During the first week of feeding the child is given amoxicillin and if
needed anti-helminths if needed


G. Appetite Test to determine whether child should be given RUTF
It is important for a child to have an appetite before he or she can be
admitted for the outpatient care
If a child has no appetite he/she will not be able to eat RUTF at home and
therefore needs referral to the in patient service.
An appetite test is given to children ages 6 months and above to
determine whether the child can eat RUTF. The test shows whether the
child has a good appetite and can accept the RUTFs taste and consistency
and can swallow.
If a child has a poor appetite then it is considered that he/she has severe
disturbance of metabolism

How to perform an Appetite test
Wash hands before conducting the test
The assistant conducting the test should be cheerful and relaxed
Allow child to play with an RUTF packet and become familiar with the
environment
Sit comfortably with the child on a lap and offer the RUTF to the child (should
take only 15 mins)
Child should not be forced to take the RUTF
Offer plenty of water to drink from a cup during the test


Body weight/kg
Paste in sachets
Poor Moderate Good
<4 <1/8 1/8 -- 1/4 >1/4
4-6.9 <1/4 1/4 -- 1/3 >1/3
7-9.9 <1/3 1/3 -- 1/2 >1/2
10-14.9 <1/2 1/2 -- 3/4 >3/4
15-29 <3/4 3/4 -- 1 >1
Over 30 <1 >1



H. Discharge criteria
Patients who reach the target weight for 3 weeks may be discharged
only if he/she:
o Has no new medical complications
o Did not develop edema
o Has a good appetite
o Clinically well and alert
o Has been given adequate counselling and advice prior to
discharge









Methodology
Study Design
This study was conducted through an Interview and Questionnaire Technique. A
set of questions were made and each patients mother/caregiver were
interviewed at the health center
Study Population
The respondents consisted of 8 patients from Barangay 5A.
Study Locale
The survey was conducted at the Barangay 5A health center, Bankerohan. The
respondents were contacted by their Barangay Nutrition Scholars (BNS).
Data collection
The study aimed to determine the impact of the program on SAM patients and
how it has made a difference in the health status of the severely malnourished
children belonging to the poorest socioeconomic class. The survey forms with
open-ended questions focused on how the patients were diagnosed to with SAM
and how they improved after being admitted in the OTP program.
Data Interpretation
The answers given by the respondents were collected and presented as pie
charts.



























Data Collection and Interpretation
In pursuit of the assessment of the Impact Of DIMAM (Davao Integrated
Management of Acute Malnutrition) on Out Patient Therapeutic Program of SAM
Patient in Barangay 5 A, 8 patients were interviewed.


Weight for Age:







Length/Height for Age:





Total
Population
= 1515
Normal =
1348
Underweight
= 131
Severely
Underweight
= 14
Overweight =
2
Total
Population
= 1515
Normal =
1309
Stunted =
181
Severely
Stunted =
21
Tall for
age = 4
Weight for Length/Height:




Based on Barangay records, there are 1515 children under age group of 0-59
months, out of which 779 are boys and 734 are girls. Among this, 1348 children
were found to be normal under the criteria of weight for age. However, 131 were
classified to be underweight, 14 were classified to be severely underweight and 2 as
overweight. Under the criteria of length/height for age, 1309 children were
classified to be normal, 181 were classified to be stunted, 21 to be severely stunted
and 4 of them to be tall for age. Under the criteria of weight for length/height, 1459
children were found to be normal, 36 to be underweight, 3 to be severely
underweight and 17 to be overweight.
In the program, 9 children who fell under the criteria of SAM were enrolled from
Barangay 5A. However, in our study we had only 8 respondents since one of the
patient migrated to the other Barangay.
















Total
Population
1515
Normal =
1459
Underweight
= 36
Severely
Underweight
= 3
Overweight =
17
Pie Chart 1: Visit Compliance

63% of respondents were compliant with regular visits. However, 37% were unable
to report in the Barangay health center as required.

Pie Chart 2: Reasons for Non-Compliance


As per the mother, reasons for non compliance were:
1) Misunderstanding; 20% of the non-compliant mother was unable to
understand that she was supposed to visit Barangay health center weekly.
Thus after getting the RUTF for a week she failed to return back.
2) Illness; 40% of non-compliant mother reported that their baby were sick to
be brought to the health office.
37%
63%
Visit Compliance
Yes No
20%
40%
40%
Reasons for Non-Compliance
Misunderstanding (Mother unable to understand the visit schedule)
Illness
3) Busy; 40% of the non-compliant parents complained of being busy looking
for job.

Pie chart 3: Criteria for Admission

Out of the total number of respondents,
87.5% were admitted because they fell under the criteria of Z-score (weight
for length/height) and MUAC; but had no bilateral edema
12.5% was admitted under all 3 criteria (Z-score, MUAC and bilateral
edema).

Pie chart 4: Improvement

All the patients showed improvement in their weight, height, skin and motor
function. According to the mothers, patient had visible improvement in their
motor functions like activeness, good strong cry, running, speaking and
playing.
12%
88%
Criteria for Admission
Z-score, MUAC with edema Z-score, MUAC without edema
100%
Improvement
Based on the comparison of the first and last visits of the patient, the
improvement in weight, height and mid-upper arm circumference are as
follows:





Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 8
First Visit 6 5.3 8 6.5 7.1 7.3 6.2 8
Last Visit 6.8 5.9 9.5 7.2 7.3 8.4 7 9
0
1
2
3
4
5
6
7
8
9
10
W
e
i
g
h
t

i
n

k
g

Improvement in Weight (kg)
Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 8
First Visit 67 65 75 72 73.1 75.5 69.2 81
Last Visit 69.2 67 79 72.1 74.2 78 73 83.3
0
10
20
30
40
50
60
70
80
90
H
e
i
g
h
t

i
n

c
m

Improvement in Height (cm)


Patient 1: Including the last visit, patient 1 had 13 visits in total. He is compliant
with his visits and has shown gradual improvement in his weight, height and MUAC.
Patient 2: Patient has been enrolled for 11 weeks. However, patient missed 3 visits.
As per the mother, they had been too busy to bring the child to the health center.
Patient had shown quiet a good improvement in weight and height, but the MUAC
remains to be the same as that of his initial visit.
Patient 3: Patient was supposed to visit 10 times but he missed 3 visits since his
parents were busy looking for job. But still, patient showed significant improvement
in his weight, height and MUAC.
Patient 4: Including the last visit, patient was supposed to have 8 visits. However,
he missed 2 visits because he was sick. So his total visits are 6. He showed
improvement in his weight, height and MUAC.
Patient 5: This is Patients third week of enrollment and she is compliant with her
visits. She has been improving in her weight and height. But her latest MUAC
decreased than that of her initial visit.
Patient 6: Patient has been enrolled for 4 weeks but has missed 2 visits. There was
misunderstanding of communication. But still patient showed significant
improvement in her weight, height and MUAC.
Patient 7: Patient is compliant with her visits and is on her 11
th
week of
enrollment. She had shown good improvement in her weight, height and MUAC.
Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 8
First Visit 11.4 11.3 12.3 11.8 14.5 12.1 12 12.4
Last Visit 11.5 11.3 14 12 13.5 13.6 12.5 13
0
2
4
6
8
10
12
14
16
M
i
d
-
u
p
p
e
r

A
r
m

C
i
r
c
u
m
f
e
r
e
n
c
e

(
m
m
)


Improvement in Mid-upper Arm
circumference (mm)
Patient 8: Including the last visit, patient had 5 visits. However, he is already on his
11
th
week of enrollment. Still, he showed a good improvement in his weight, height
and MUAC.

Pie chart 5: Satisfaction

Though the mothers had different view about the program, they were all satisfied.


Pie chart 6: Exclusively Breastfed

Out of 8 patients, 4 of them were exclusively breastfed till the age of 6 months, 1 till
the age of 1 year, 1 for 9 months, 1 for 5 months and 1 was not breastfed since birth
(mother was unable to lactate). However, the level and rapidity of improvement
between the exclusively breastfed and non-breastfed can not be determined
because of the variation in the date of their enrollment and their compliance.
25%
12%
13%
50%
Mothers Satisfaction to the Program
Since my child seems healthy
and has gained weight, I find
this program nice
I am satisfied with the
program
I would like to continue with
the program
I am totally satisfied with the
program, a 100% satisfaction
50%
12%
12%
13%
13%
Exclusive Breastfed
6 months 1 year 9 months 5 months Not breast fed since birth
Conclusion
The patients who has been enrolled for DIMAM from Barangay 5A come from a low
social economic strata. Large family having a single person to rely on for all the
expenses is the major factor leading to financial instability. The main priority for
spending are house rent and foods for the whole family. Between this, allocation for
the childs nutrition and medicine are not prioritized. Thus, leading to acute
malnourishment in the children.
However, the active involvement of DIMAM program on these SAM patients showed
to be beneficial to the children aged 0-59 months. The benefits include:
1) Classification of children as normal, underweight, severely underweight,
overweight, stunted, severely stunted and tall.
2) Measures taken to treat severely acute malnourished children.
3) Regular monitoring of the SAM patient i.e. their height, weight, mid arm
circumference and bilateral pitting edema.
4) Proper guidance and counseling to the mother regarding the health condition
of child and the measures to be undertaken.
Based on our study, most of the patient were classified under the criteria of Z-score
and MUAC, and just a few had bilateral pitting edema together with Z-score and
MUAC. Children taking the allocated quantity of RUTF has shown improvement in
their weight, height, mid-arm circumference and motor skills regardless of children
being exclusively breastfed or not. Thus leading to the full satisfaction of the mother.
However, the scheduled visits that the children has been missing has stood to be
somewhat hampering the target weight, height and MUAC for the patient.

Recommendation
As per instruction, mothers should be able to report on the Barangay health
office for receiving RUTF and for regular measurements. Since, on our studies
few children who were unable to make scheduled visits failed to improve in
the continuum process. But later when the visits were regular, patient
progressed.

Barangay health workers should inform about the program in detail to the
mothers. They also should make mother understand what the program is
about and its impact on their children. If the mothers wont be able to learn
about the program, they wont be actively involved.

The amount of RUTF allocated for the children should be taken by them
within the given time. Barangay officers should be clear to the mothers about
the amount, frequency and timing and also mothers should be responsible.

As advised, additional food should be strictly not given except for breast
milk.

Appendix
Name:
Age:
Sex:
Address:
Informant:

Q) Do you go to the center weekly?

Q) If no. Why? What is your reason?

Q) What criteria lead to the admission of the child in this program?
Z-score
MUAC
Bilateral pitting edeme

Q) How has your child improved? (In what parameters)

Q) Is your child exclusively breastfed? If yes, for how long? If no, why?

Q) How is your Socio-economic status? What is your priority of things to buy?

Q) What is your opinion about this program? Are you satisfied?