SAM Participant's Manual

Training Module on the National
Guidelines on the Management of

Severe Acute Malnutrition
for Children under Five Years
September
2016
Participant’s ManuaL
This draft was prepared by Kalusugan ng Mag-Ina, Inc. (KMI) for the Department of Health DPCB Family
Health Office, under UNICEF Contract 43202011
Training Module on the National
Guidelines on the Management of
for Children under Five Years
September
2016
©UNICEF Philippines/2014/JReyna
Participant's Manual
Table of Contents
Preface 8 Module 5: Outpatient Therapeutic Care (OTC) 83
Acknowledgment 9 Session 5.1: Admission 84
SYMBOLS, UNITS and ACRONYMS 10 Session 5.2: OTC Treatment 90
Module 1: Overview 12 Session 5.3: Weekly Monitoring 93

Session 1.1: Severe Acute Malnutrition in Session 5.4: Discharge 95
Children: The Silent Emergency 12
Session 1.2: The PIMAM Program Guidelines, Module 6: Inpatient Therapeutic Care (ITC) 127
Roles & Responsibilities 25
Session 6.1: Pathophysiology of Severe Acute
128
Module 2: Identification of SAM 30 Malnutrition
Session 6.2: Assessment and Admission 130
Session 2.1: Measuring Malnutrition 32
Session 6.3: Triaging of children with SAM into
Session 2.2: Measuring Length 32 emergency and non-emergency care 131
Session 2.3: Measuring Height 34 Session 6.4: Nutritional Management of SAM
Children 6-59 Months 134
Session 2.4: Determining the appropriate Z-score
Session 6.5: Carry Out the Nutritional
for WFH or WFL 36
Management of a SAM Infant <6
Session 2.5: Measuring the Mid Upper Arm Months of Age 142
Circumference (MUAC) 38
Session 6.5A: Encouraging/Supporting
Session 2.6: Identifying Bilateral Pitting Edema 40 Breastfeeding in a SAM Infant <6 Months 142
Session 6.5B: Full use of therapeutic milk to
Session 2.7: Conducting the Appetite Test 41
manage nutrition of the SAM infant < 6 months
Session 2.8: Hand Hygiene 43 when ALL efforts to sustain breastfeeding have
been exhausted 145
Module 3: Community Mobilization 53 Session 6.6: Orienting and Caring for the
Caregiver 146
Session 3.1: Community Assessment 54
Session 6.7: Individual Monitoring and Follow-up 146
Session 3.2: Community Sensitization and
Session 6.8: Monitoring and Referring the Child in
Developing Key Messages and
Transition (to RUTF or F100) 148
Materials 55
Session 6.9: Referral and Transition 149
Session 3.3: Training and Case-Finding 56
Session 6.10: Discharge 150
Session 3.4: Referral and Follow-up 59
Session 6.11: Identify, treat and Prevent
Module 4: Philippine Integrated Management Hypothermia 153
of Malnutrition (PIMAM) 63
Session 6.12: Identify, treat and Prevent
Session 4.1: Policy Guidelines on the Hypoglycemia 154
Management of Acute Malnutrition
Session 6.13: Identify, treat, monitor and prevent
for Children under 5 Years 65
dehydration and shock 155
Session 4.2: Managing a Philippine Integrated
Management of Acute Malnutrition Module 7: Communication and Counseling 178
(PIMAM) Program in your LGU 67
Session 7.1: Stages of Behavior Change 179
Session 4.3: Logistics & Supply Management 73
Module 8: Community Practicum on
Session 4.4: Program Monitoring & Reporting 76
Anthropometric Measurements and
Case Finding 186
Session 4.5: Bottleneck Analysis 78
Session 4.6: SAM in Emergencies 80
Participant's Manual 5
List of Tables
Table 1.1 Distinguishing MAM from SAM Table 6.1 Criteria for Admission to ITC
Table 1.2 Global Deaths in Children Younger Table 6.2 Medications for Uncomplicated Cases
than 5 years Attributed to Nutritional
Disorders Table 6.3 Medications for Complicated Cases
Table 2.1 Identification of Acute Malnutrition in Table 6.4 Amount and Preparation of F75 Milk
Children to be Given for Children aged 6-59
Table 2.2 Grading of Edema Months in Phase 1
Table 6.5 Indications for Use of an Appropriate
Table 3.1 Community-level Case-finding Criteria
Size NGT
Table 3.2 Criteria for Case Identification and Table 6.6 Amount of RUTF to Give per Feeding
Referral in the Community
Table 6.7 Amount of F100 to be Given to Children
Table 4.1 Minimum Performance Standards for
aged 6-59 Months in Transition Phase
the Management of SAM
Table 6.8 Amount of F100 Therapeutic Milk to be
Table 4.2 Tasks and Responsibilities at Different
Given in Phase 2
Levels
Table 6.9 Dilute F100 (or F75 for Cases with
Table 4.3 Estimation of Supplies Required for
Edema) for Infants aged <6 Months
SAM Treatment
Table 6.10 Amount of Dilute F100 (or F75 for
Table 4.4 Minimum Performance Standards for
Cases of Edema) to Give to Infants
the Management of SAM
aged < 6 Months who are not able to
Table 4.5 Roles and Responsibilities of Members Breastfeed (only after all options to
According to Function breastfeed are taken)
Table 5.1 Identification of Acute Malnutrition in Table 6.11 Surveillance of Patients in ITC
Children 6-59 Months of Age
Table 5.2 Identification of Acute Malnutrition in Table 6.12 Reasons for Deterioration in the
Children Less than 6 Months of Age Transition Phase
Table 5.3 Criteria for New Admission to Inpatient Table 6.13 Monitoring in Phase 2
or Outpatient Therapeutic Care
Table 6.14 Criteria for Discharge from Transition
(children 6-59 months)
Phase to OTC
Table 5.4 Criteria for New Admission to Inpatient
Table 6.15 Criteria for Discharge from Phase 2
or Outpatient Therapeutic Care (infants
<6 months) Table 7.1 Approach to Counseling in the Different
Table 5.6 Summary Table of Routine Treatment Stages of Behavior Change
on Admission in OTC Table 7.2 Sample Cases with Different
Table 5.7 Ready-to-use Therapeutic Food Counseling Styles
(RUTF) Ration
Table 5.8 Criteria for ITC Referral on Follow-up
Table 5.9 Discharge Criteria from OTC
Table 5.10 Outcome of OTC Treatment
6 Training Module on the National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
List of Figures
Figure 1.1 UNICEF Conceptual Framework on the Causes Of Undernutrition
Figure 1.2 Prevalence of wasting among 0-60 months from 1989-2015.
Figure 1.3 Prevalence of wasting among 0-60 months from 2008-2013.
Figure 1.4 Prevalence of stunting among 0-60 months from 1989-2015.
Figure 1.5 The First 1000 Days
Figure 1.6 Nutrition Targets
Figure 1.7 Interventions for Mothers and Children across the Lifecycle
Figure 1.8 PIMAM Components
Figure 2.1 How to Measure the Length (1)
Figure 2.5 How to Measure the Height (1)
Figure 2.6 How to Measure the Height (2)
Figure 2.7 MUAC Tape
Figure 2.8 Positioning the MUAC tape
Figure 2.9 How to Handrub
Figure 2.10 How to Handwash
Figure 3.1 Stages in Community Mobilization
Figure 3.2 MUAC Tape
Figure 3.3 RUTF supplies
Figure 4.1 PIMAM Coordination and Reporting Structure
Figure 4.2 Management Cycle for Medicines and Nutrition Supplies
Figure 4.3 What is the Bottleneck Analysis Approach for the Management of Severe Acute Malnutrition?
Figure 5.1 Decision flowchart for Outpatient or Inpatient Therapeutic Care for 6-59 months of age
Figure 5.2 RUTF Composition
Figure 6.1 Ten Steps in the Care of Severely Malnourished Children
Figure 6.2 How to Estimate the Amount of RUTF to Give
Figure 6.3 Referral Form (SAM)
Figure 6.4 Hydration in a Severely Malnourished Child
Figure 6.5 Algorithm for Monitoring Weight
Figure 6.6 Algorithm for Differential Diagnosis of Heart Failure and Pneumonia
Figure 7.1 The Stages of Behavior Change
Preface
T
he Philippines strives continuously to improve the overall health of children particularly the vulnerable
less than 5 year old group. Nutritional status bears a great impact on their health. According to the
National Nutrition Survey in 2015, 21.5% of Filipino children under the age of five are underweight;
7.1% are nutritionally wasted. These figures have changed little, even increased from 25 years ago when
the rate of underweight and wasting were 27.3% and 6.2%, respectively. It is a fact that nutritional wasting
is potentially deadly. Children with severe acute malnutrition (SAM) are nine to twelve times more likely to
die than those without it.
Globally, over the last decade, a health systems as well as multi-sector approach including nutritionally
sensitive and specific interventions has evolved to counter and treat nutritional conditions. This approach
has since been adopted by the Department of Health (DOH) via the Strategic Framework for Comprehensive
Nutrition Plan 2014-2025. In June 2015, with assistance from the UNICEF and stakeholders such as the
Community-Based Management of Acute Malnutrition (CMAM) Working Group, the Manual of Operations
(MOP) on the National Guidelines on the Management of Severe Acute Malnutrition for Children Under Five
Years was completed. This was followed by the issuance of Administrative Order 2015-0055 in December
2015 which laid out the policies and strategic framework enabling the implementation of the said MOP
guidelines.
To help translate the policy now into implementation and action, this corresponding training course on the
management of SAM has been designed, training manuals and job aids developed, using an outcomes-
based education (OBE) model. The current training course for both Providers and Facilitators is a product of
multiple technical consultations and two pilot training runs involving health workers from Regions IVA, V and
VIII. These measures were undertaken to enable a comprehensive yet practical and feasible technology
transfer to health care providers who work in either community, outpatient or in-hospital settings.
It is envisioned that through this training course, participants will have a common understanding of current
concepts of malnutrition, perform standardized data collection and reporting methods, and have an improved
appreciation of the importance of collecting vital information from and thereafter counselling the caregiver
and patient. One of the goals of this training course is to enhance our health care provider’s capacity in
identifying, managing and referring, if need be, a SAM patient to the appropriate health facility. Towards this
end, it is expected that all health providers – from doctors in regional and provincial hospitals to Barangay
Health Workers and Nutrition Scholars in the community – will be able to decide themselves the next
appropriate steps in the care of a child with SAM.
On behalf of the Family Health Office of the Disease Prevention and Control Bureau and the whole of the
DOH, this training workshop is offered to address the gaps in the resources and the capabilities of our LGUs
and their communities in managing children afflicted with SAM. Standardized trainings shall be continually
supported and conducted throughout the country through the use of this course to achieve our goal of Zero
SAM. It is also hoped that eventually, every trainee will be able to share the information taken from this
course onto their respective workplaces and communities.
Paulyn Jean B. Rosell-Ubial, MD, MPH, CESO II

Secretary of Health
Acknowledgments
T
he DOH acknowledges the dedication and sheer determination of the CMAM working group
composed of the following organizations/representatives: ACF (Action Against Hunger International/
Dr. Celna Tejare); Mother and Child Nurses Association of the Philippines (MCNAP/Balbina Borneo);
National Nutrition Council (NNC/ Margarita Enriquez); Philippine Society for Pediatric Gastroenterology,
Hepatology and Nutrition (PSPGHAN: Dr. Juliet Sio-Aguilar, Dr. Marilou Tan and Dr. Judy Lyn Vitug);
UNICEF Cotabato/Dr Sally Bataclan and Ms. Kristine Angeli Gimongala; World Vision/Ms Kathrine Yee;
and the DOH Regional Office XII (Ms. Tiffanee Matalam). Deepest gratitude also goes to the technical
experts and development partners who actively supported and contributed to the drafting of these
manuals: Mr. Khasmin Ismael of Health of Mindanao (HOM), Dr. Milton Amayun of International Care
Ministries (ICM), Ms. Josephine Guiao of the DOH Health Facility Development Bureau (HFDB), Dr.
Muhammad Amir, Medical Officer III of Cotabato City, Ms. Jocelyn Lumaad of the Barangay Nutrition
Scholars (BNS) of Davao City, Ms. Luz Tagunicar of DOH, Dr. Amado Parawan of Save the Children and
most especially to Dr. Anthony Calibo of the Family Health Office and the Regional DOH staff of Regions
IVA, V and VIII for their active participation during consultations, meetings and the training itself.
Sincere appreciation is also extended to UNICEF Health and Nutrition Consultants Dr. Rene Galera, Dr.
Andrew Bucu, and Mr. Alvin Manalansan, and Kalusugan ng Mag-Ina, (Health of Mother and Child) Inc.
(KMI) for their dedication and unwavering support throughout this work.
Mario S. Baquilod, MD
Disease Prevention and Control Bureau, DOH
Officer-in-Charge
Symbols, Units and Acronyms
< Less than F
> Greater than Therapeutic Milk containing

F75
75kcal/100mL
cm centimeters Therapeutic Milk containing
F100
ml milliliters 100kcal/100mL
FBF Fortified Blended Food
mm millimeters
FDA Food and Drug Administration
A
FNRI Food and Nutrition Research Institute
AO Administrative Order
Acquired Immune Deficiency G
AIDS
Syndrome GAM Global Acute Malnutrition
B
GMP Growth Monitoring and Promotion
BHS Barangay Health Station
GP Garantisadong Pambata
BHW Barangay Health Worker
GNC Global Nutrition Cluster
BLHD Bureau of Local Health Development
H
BNS Barangay Nutrition Scholar
HC Health Center
C Health Emergency Management
HEMB
CHO City Health Office Bureau
Community-based Management of HFDB Health Facility Development Bureau

CMAM
Acute Malnutrition Health Facilities and Services
HFSB
CNC City Nutrition Committee Regulatory Bureau
HIV Human Immunodeficiency Virus
CNO City Nutrition Officer(s)
Health Management Information
CWC Council for the Welfare of Children HMIS
System
D Health Promotion and
HPCS
Communication Service
DALY Disability Adjusted Life Years
HW Health Worker
DOH Department of Health
I
DOHRO DOH Regional Office
Information, Education and
IEC
DepEd Department of Education Communication
Department of Social Welfare and Integrated Management of Acute
DSWD IMAM
Development Malnutrition
Disease Prevention and Control Integrated Management of
DPCB IMCI
Bureau Childhood Illness
E ITC Inpatient Therapeutic Care
Early Childhood Care and IUGR Intra-uterine Growth Restriction

ECCD
Development
IYCF Infant and Young Child Feeding
EPI Expanded Program on Immunization
L PMB Program Management Bureau
LBW Low Birth Weight Prevention of Mother to Child

PMTCT
Transmission
LGU Local Government Unit
R
LMD Logistics and Management Division
RHU Rural Health Unit
LMICs Low and Middle Income Countries
RUTF Ready-to-Use Therapeutic Food
M
S
MAM Moderate Acute Malnutrition
SAM Severe Acute Malnutrition
MNAO Municipal Nutrition Action Officer
SC Stabilization Center
MNC Municipal Nutrition Committee Standard Deviations from the mean
SD
Maternal, Newborn, Child Health and (also known as Z-scores)
MNCHN
Nutrition SFP Supplementary Feeding Program
MNPs Micronutrient Powders Surveillance in Post Extreme
SPEED
MMD Materials Management Department Emergencies and Disasters
SPEED Technical Assistance and
MUAC Mid-Upper Arm Circumference START
Response Team
MW Midwife SUN Scaling up Nutrition
N T
NGO Non-Governmental Organization TB Tuberculosis
NIE Nutrition in Emergencies TCL Target Client List (for the sick child)
NINA Nutrition Initial Needs Assessments U
NNC National Nutrition Council UHC Universal Health Care
National Online Stock Inventory UNICEF United Nations Children’s Fund
NOSIRS
Reporting System
National Telecommunications W
NTC
Commission WASH Water, Sanitation, Hygiene
NTP National Tuberculosis Program
WFP World Food Program
O
WHO World Health Organization
OTC Outpatient Therapeutic Care
WFH Weight-for-Height
OPT Operation Timbang
WFL Weight-for-Length
P
WFZ Weight-for-Height Z-score
PGN Promote Good Nutrition
PHO Provincial Health Office(r)

Philippine Integrated Management of
PIMAM
Acute Malnutrition
Module 1
Overview
Target Learners
This module is intended for those in health facilities and local governments who are involved in
the care and management of children with severe acute malnutrition across all sectors.
Module Description and Objectives
An explanation of the different concepts behind malnutrition and undernutrition will be discussed.
This will be followed by an analysis of the Philippine burden of malnutrition and undernutrition
among children less than 5 years old.
The module then introduces the Philippine Integrated Management of Acute Malnutrition
(PIMAM), the principles that this strategy adheres to in order to ensure a comprehensive yet
feasible and acceptable way of delivering treatment for undernutrition through various levels
of care. The Department of Health’s (DOH) National Guidelines on the Management of Acute
Malnutrition for Children under 5 years will also be discussed.
______________________________________________________________
At the end of the module, you will be able to:
1. Explain what malnutrition is and its related concepts

2. Discuss the problem of childhood morbidity and deaths due to severe acute malnutrition
3. Describe the Philippine Integrated Management of Acute Malnutrition (PIMAM)
4. Explain the four guiding principles of PIMAM
5. Explain the four components of the integrated management of severe acute malnutrition
Session 1.1:
Severe Acute Malnutrition in Children: The Silent Emergency
Definition of Terms
Malnutrition
• Occurs when the body’s dietary or food intake is not in balance with its nutritional needs
failing to maintain healthy tissues and organ function
• Results to either undernutrition or overnutrition
1. Undernutrition
Defined as a lack of nutrients caused by
inadequate dietary intake and/or disease
Undernutrition includes: 1, 2
1.1. Acute Malnutrition
• The sudden weight loss or wasting and/or bilateral edema that results due to any or a
combination of the following: insufficient food intake, concurrent or repeated bouts of
infection, inappropriate childcare practices.2
• Wasting - characterized by rapid weight loss and in its severe form can lead to death
• Nutritional Edema - is characterized by bilateral pitting edema (affecting both sides of the
body) in the lower legs and feet which as it progresses becomes more generalized to the
arms, hands and face
• Low weight for height (WFH) and low weight for length
• Classified by severity of wasting into moderate acute malnutrition (MAM) and severe acute
malnutrition (SAM), which combined is also termed as Global Acute Malnutrition (GAM)
• GAM is the sum of the prevalence of SAM plus MAM at a population level.
Table 1.1 Distinguishing MAM from SAM
Moderate Acute Malnutrition Severe Acute Malnutrition
Weight-for-Height Z-score less than -2 Mid Upper Arm Circumference less than 11.5cm
but greater than -3 (or 115 mm)
OR OR
Mid Upper Arm Circumference greater than or Weight-for-Height Z-score less than -3
equal to 11.5 cm (or 115mm) but less than 12.5cm OR
(125mm) Bilateral pitting edema
(Note: MUAC applicable only for those over 6 months of age)
Children with SAM are at least 9-12 times more likely to die than children who are well nourished.
Their resistance to disease is reduced and their organ functions are impaired.
Related terms:
Protein Energy Malnutrition (PEM) (old terminology)
• Combined deficiencies in protein, calories (energy) and micronutrients with two main types:
1. Marasmus - derived from the Greek word marasmos, which means withering or wasting.
Marasmus involves inadequate intake of protein and calories and is characterized by
severe thinness.
2. Kwashiorkor - refers to inadequate protein intake but with reasonable caloric (energy)
intake. Edema is characteristic of kwashiorkor but is absent in marasmus.
3. Marasmus and kwashiorkor are one and the same as the wasting and nutritional
edema forms of Severe Acute Malnutrition (SAM), respectively.
Module 1
Marasmus Kwashiorkor
1.2. Chronic Malnutrition or Stunting
• Is a slow, cumulative process occurring over a long period of time and is caused by any or
a combination of the following: insufficient intake of some nutrients, repeated infections,
inappropriate child care—largely during the first 1000 days (from time of conception to the
child’s 2nd birthday).
• Manifests as being too short for one’s age; Low height for age (HFA), also inadequate weight for
age but they look well-proportioned
• Well-established risk marker of poor child development
• Stunting before the age of 2 years predicts poorer cognitive and educational outcomes in later
childhood and adolescence
• Mental and physical deficits are potentially irreversible beyond two years
1.3. Micronutrient Deficiency
• Over 40 nutrients are essential to health. If any one nutrient is deficient then the infant/child will
not be healthy and resist disease. Many are ignored and the deficiency is not recognized.
• Micronutrient deficiency is divided into 2 groups in terms of response to a deficiency (see Annex
1.1. Differences between Type I and Type II Micronutrient Deficiency)
1. Type I Micronutrient Deficiency/ Functional Nutrients
• Growth continues in early stages
• With specific clinical signs (e.g. anemia with iron deficiency, beri-beri with Vitamin
B1 (thiamine) deficiency, scurvy with Vitamin C deficiency, xerophthalmia with
Vitamin A deficiency)
2. Type 2 Micronutrient Deficiency/ Growth Nutrients
• Results in growth failure
• No specific clinical signs
Other types of undernutrition:
1.4. Fetal Growth Restriction and Low Birth Weight
• A condition in which fetal growth that is less than normal for the growth potential of a specific
infant;
• Most of these growth restricted fetuses will be born with birth weights less than 2.5 kg, i.e. low
birth weight. Some growth-restricted fetuses may be born at weights more than 2.5
• Poor maternal nutrition ranks high as a causative factor
• Compared to babies with normal weight, babies with fetal growth restriction are 15 times more
likely to die in the newborn period
1.5. Suboptimal breastfeeding
• This occurs when a mother breastfeeds less than what is recommended - i.e. she does not
breastfeed exclusively for 6 months and does not continue to breastfeed up to 2 years after
complementary solids are started.
• Globally, this causes about 800,000 childhood deaths each year
2. Overnutrition
Occurs when the body has more nutrients
than it needs typically due to excessive dietary
intake; overnutrition conditions include both
overweight and obesity
Key Concepts
Basic Principles
Every child has food, health and care needs that must be fulfilled to grow well. When these are
not met, children are at high risk of becoming undernourished. We MUST care about optimum
nutrition because of the strong links between malnutrition and death.
Malnutrition could either be OVERnutrition or UNDERnutrition.
Undernutrition
• Is a neglected condition and not given attention/treatment
• Is overlooked when there are co-existing medical problems
• Globally, causes 3.1 million deaths every year or 45% of all under 5 year old deaths.
Undernutrition kills.
Module 1
Table 1.2. Global Deaths in Children Younger than 5 years Attributed to Nutritional
Disorders (Black, RE et al. 2013. The Lancet Nutrition Series Part 1)
Proportion of total deaths
Attributable deaths
among under 5 year olds
Fetal growth restriction / LBW 817,000 11.8%
Suboptimal breastfeeding (0-23 months) 804,000 11.6%
Stunting (1-59 months) 1,179,000 17%
Underweight (1-59 months) 1,180,000 17%
Wasting (1-59 months) 800,000 11.5%
Severe wasting (1-59 months) 540,000 7.8%
Zinc deficiency (12-59 months) 116,000 1.7%
Vitamin A deficiency (6-59 months) 157,000 2.3%
Vitamin A deficiency (6-59 months) 157,000 2.3%
Joint effects of fetal growth restriction 19.4%
1,348,000
and suboptimum breastfeeding
Cumulative effects (ALL) 3,149,000 45.4%
i. There are basic (societal), underlying (community and household) and immediate (individual)
causes of undernutrition (Figure 1.1)
Figure 1.1. UNICEF Conceptual Framework on the Causes Of Undernutrition

(Modified by Black, et al., 2008, The Lancet)
Maternal and
Child Undernutrition,
Disability and Death
Inadequate
Immediate causes
Disease Individual level
dietary intake
Poor water and

Insufficient access Inadequate maternal and sanitation and lack
to food child care practices of health services
Underlying causes
Household and community level
Income
poverty
Basic causes
Lack of capital: financial, human,
physical, social and natural Societal level
Social, economic and political

context
The framework shows that causes of malnutrition are multi-sectoral, embracing food, health and
caring practices. They are also classified as immediate, underlying, and basic, whereby factors
at one level influence other levels. Interventions that target the reduction of undernutrition can be
directed at any of these levels.
The framework is used at national, district and local levels, to help plan effective actions to improve
nutrition. It serves as a guide in assessing and analyzing the causes of the nutrition problem and
helps in identifying the most appropriate mixture of actions.
For those who survive undernutrition, then impact can be
• A lifetime of ill-health due to structural in-utero changes and also, postnatally, low immunity
to disease
• Unrealized human potential because of cognitive impairments and low school performance
with poor economic activity as adults
• Intergenerational effects which further propagate cycles of hunger and poverty in already
impoverished countries
Malnutrition - childhood wasting in the Philippines
ii. In 26 years, the Philippine under 5-year old trend for wasting has not improved. It is increasing.
Figure 1.2. Prevalence of wasting among 0-60 months from 1989 -2015.
Source: FNRI DOST. 8th National Nutrition Survey. 2015.
The Philippines and wasting in childhood

FNRI DOST, National Nutrition Survey, 2015
% of Under 5 with Wasting

9
8 7.5 7.7 7.9

6.8 6.8 6.9
7 6.2 6.2 6 7.3
6
7.1
5 5.8
4
0
1989 1990 1993 1996 1998 2001 2003 2006 2008 2011 2013 2016
% of Under 5 with Wasting
Module 1
iii. There are 1.5 million Filipino children with wasting under five years of age, of whom around a
third (estimated 500,000) are severely wasted (National Nutrition Survey 2015)
Figure 1.3. Prevalence of wasting among 0-60 months from 2008-2013.

Among Filipino children, those 12 months old

and younger are most affected
0-5 months 6-11 months 12 months x 24 months x 36 months 48-60 months
16
14
12
WASTING
10
WITH
%
8
6
x x
x x
4 x x
2
0
2008 2011 2013
0-5 months 11.9 11.1 13.4
6-11 months 11.6 11.9 11.4
12 months 9.4 9.1 10.6
x 24 months 5.5 6.6 6.4
x 36 months 4.4 4.5 5.8
48-60 months 4.3 5.5 5.5
Prevalence of wasting among 0-60 months from 2008-2013 FNRI DOST, 8th National Nutrition Survey, 2013
iv. Children less than 1 year old are the most affected age group by wasting.
Figure 1.4. Prevalence of stunting among 0-60 months from 1989-2015.

Stunting among Filipino children 0-59 months

FNRI Updating Surveys as reported in FNRI (2015) and FNRI (2016)
Percent with stunting

50
45
44.7
40
39.8
35.9
35 33.1 33.6
33.4
30
25
11% decrease in 25 years

20
15
10
0
1989 1996 2001 2005 2011 2015
• Stunting decreased a little from 2011 to 2015 however it remains a significant societal and
individual level concern.
• Having suffered through poor nutrition during the time they were still in their mothers’ wombs to
after being born, many children end up stunted or short for age.
• Being Filipinos, short stature or height (“pagkabansot”) is typically accepted.
• However, there is a significant number of children who were made short because of undernutrition
even from the womb.
• These children’s lives would irreversibly be affected either with premature death or the prospect
of lifelong recurrent illness and/or cognitive problems.
• Stunting is really the silent emergency that we need to address as well.
However, there are simple yet powerful solutions that can make all the difference in the quality of life
and health for women and children that target Optimum Fetal and Child Nutrition and Development.
Optimum Fetal and Child Nutrition and Development
• Targeted objective for all children

• Directly affected by diet, behavior and health practices (immediate cause of undernutrition)
• Approached via two strategies:
1. Nutrition - sensitive interventions - actions addressing underlying determinants of

poor nutrition such as social welfare, agriculture, food security, etc.
2. Nutrition - specific interventions - addresses the immediate causes of undernutrition.
The actions target prevention and treatment of undernutrition particularly in the first 1,000
days from pregnancy up to the first two years of life. This includes maternal nutrition
and prevention of low birthweight, infant and child feeding, prevention and treatment of
micronutrient deficiencies, as well as prevention and treatment of severe acute malnutrition
which is the main topic of this training course
The first 1,000 days of a child’s life, from conception to the age of two, affect the overall health outcomes
later on in life. This is a critical window that demands the right nutrition. UNICEF with the DOH has
launched and intensified this campaign in the country which has now been called the first 1000 days.
Figure 1.5. The First 1000 Days

(ILO 2015. Healthy beginnings for a better society breastfeeding in the workplace is possible: A toolkit)
Pregnancy First six months 6 to 23 months

270 Days + 180 Days + 550 Days
= 1,000 Days
Module 1
This initial period of a child’s life dictates the brain development, immunity to disease, and physical
growth through the life-course.
It’s safe to say that optimum maternal health, nutrition and survival, the care that she gives to her child
plays heavily into the child’s growth and cognitive development. The potential for economic productivity
of individuals and societies are hinged on these first 1000 days. Maternal nutrition during pregnancy,
exclusive breastfeeding, appropriate complementary feeding with continuation of breastfeeding are
crucial.
Global Nutrition Report 2015: Actions and Accountability to Advance Nutrition and Sustainable
Development
• This is a call to make rapid advances in malnutrition reduction via scaled up concrete action
backed by financing to reduce all forms of malnutrition by 2025.
• The 6 World Health Assembly Nutrition Goals were reiterated as target for countries by the year
2025.
• The 6 targets are:
1. achieve a 40% reduction in the number of children under-5 who are stunted;
2. achieve a 50% reduction of anemia in women of reproductive age;
3. achieve a 30% reduction in low birth weight;
4. ensure that there is no increase in childhood overweight;
5. increase the rate of exclusive breastfeeding in the first 6 months up to at least 50%;
6. reduce and maintain childhood wasting to less than 5 %
Figure 1.6. Nutrition Targets
World Health Assembly

Global Nutrition Targets
40% REDUCTION IN THE

50% REDUCTION OF
NUMBER OF CHILDREN
1 UNDER WHO ARE 2 ANAEMIA IN WOMEN OF
REPRODUCTIVE AGE
STUNDED
NO INCREASE
30% REDUCTION IN
3 LOW BIRTH WEIGHT 4 ON CHILDHOOD
OVERWEIGHT
INCREASE THE
RATE OF EXCLUSIVE REDUCE AND MAINTAIN
5 BREASTFEEDING IN 6 CHILDHOOD WASTING
THE FIRST 6 MONTHS TO LESS THAN 5%
UP TO AT LEAST 50%
• The incentives to conquer malnutrition and improve nutrition are strong. Good nutrition provides
a vital foundation for human development, central to meeting our full potential. When nutritional
status improves, it leads to a host of positive outcomes for individuals and families.
Philippine Strategic Framework for Comprehensive Nutrition Implementation Plan 2014-2025
• The Philippines laid down an integrated plan for nutrition - sensitive and nutrition - specific
programs and outlined a multi-sector approach
• This recognizes that the risk of undernutrition is present across all stages of the life cycle
but most critical during infancy and early childhood because the effects accumulate through
adulthood. In disadvantaged sectors and low income households, undernutrition begins in the
womb during pregnancy, often leading to low birth weight (LBW). Specific interventions, both
preventive and curative, are therefore emphasized per stage of the lifecycle.
Figure 1.7. Interventions for Mothers and Children across the Lifecycle
PREVENTIVE/PROMOTIVE
Pre- Infancy and Maternal and

Pregnancy Delivery childhood morbidity
Conception Under 5 YO and mortality
Better cognitive
growth and
neurodevelopmental
outcomes
WRA pregnant
Adolescence women and post Infants and children
partum
• Mgt. of LBW
• Management of • Management of
infants (iron
anemic micronutrient Maternal anemic
drops) and work capacity and
CURATIVE
Management of Anemia, Preterm productivity
Malnutrition in WRA & Pregnant

infants SAM MAM Mgt. Economic
• Mgt. of development
neonatal
illnesses
Bold – Intervention modeled Italics – Other interventions reviewed
Delivery platforms: Community delivery platforms, integrated management of childhood illnesses, child health days, school-
based delivery platforms, fortification strategies, nutrition in emergencies
It includes the ten nutrition - specific interventions: with focus on the first 1000 days—1.
periconceptual folic acid supplementation, 2. maternal balanced energy protein supplementation,
3. maternal calcium supplementation, 4. multiple micronutrient supplementation in pregnancy,
5. promotion, protection and support of breastfeeding, 6. appropriate complementary feeding,
7. Vitamin A supplementation and 8. preventive zinc supplementation in children aged 6-59
months; also the 9. management of severe acute malnutrition (SAM), and 10. management
of moderate acute malnutrition (MAM).
Philippine Integrated Management of Acute Malnutrition (PIMAM)
• A component of the Strategic Framework for Comprehensive Nutrition Implementation Plan of

2014-2025 and focuses on the management of moderate and severe acute malnutrition
• Relies heavily on the community component, participation in the prevention and treatment of
malnutrition
• Rationale: Hospitals were primarily the facilities that managed severe malnutrition however,
1. Protocols are outdated and ineffective
2. Stigma of “malnutrition wards”
3. Overcrowding in the hospitals
4. High risk of cross-infection
5. High default rates - mothers wanted to go home to take care of other children
6. Renders a heavy workload of hospital staff
7. Malnutrition is a reality in both normal times and emergencies in which prevention and care
should start at the community/primary level
Module 1
• Principles of the Integrated Management of SAM:

1. Maximum Coverage and Access - bringing treatment into the local health facility and the
home
2. Timeliness – case finding and mobilization
3. Appropriate Care – availability of simple, effective outpatient care, and inpatient care as
necessary
4. Care when and where it is needed – part of routine health services and linked with other
interventions such as IYCF, deworming, micronutrients
PIMAM Components and the related components of the Integrated Management of SAM:
• Community Mobilization
1. Engagement with the community to promote a common understanding of acute malnutrition
and promote
2. the services offered
3. Identification of severely, acutely malnourished children at the community level on an on-
going basis to enable
4. widespread early detection and referral before the
5. patient’s condition deteriorates further.
6. Aims to increase coverage and maximize effectiveness of treatment.
Nutrition workers in the

community
Source: The Davao Integrated
Management of Acute Malnutrition
Initiative (IMAM) Facebook Page (https://
www.facebook.com/davaocity.imam/)
• Outpatient Therapeutic Care (OTC)

1. Management of non-complicated cases of SAM in outpatient care setting
2. Offered through the decentralized health structures–the Rural Health Units (RHU),
Barangay Health Centers (BHC), Barangay Health Stations (BHS) or within the Out-patient
Departments (OPD) of hospitals
• Inpatient Therapeutic Care (ITC)

1. Management of complicated cases of SAM according to WHO protocols on an inpatient
basis at facilities with appropriate capacity (hospitals)
• Management of Moderate Acute Malnutrition (MAM)

1. Targets cases of MAM with supplementary food, some basic medicines, monitoring and
nutritional education.
Figure 1.8 PIMAM Components
Inpatient Therapeautic
Care (ITC) for SAM
withcomplications
Health
System &
Services
Outpatient Therapeautic
Care (OTC) for SAM
without complications
Community Mobilisation
& Outreach
Programmes for
Management of
MAM
National Guidelines on the Management of Acute Malnutrition for Children

under 5 years (2015) / DOH AO 2015-0055
• Standardized protocol for prevention,

identification, management and referral
of children under five years old with acute
malnutrition
• Describes the roles and focus of the four

components of the integrated management of
SAM
• Emphasis on the need for linkages and referrals,

supply networks, indicators for monitoring, and
importance of PIMAM in emergency settings
Module 1
Content Summary
Undernutrition is a neglected condition that over the years has continued to affect an increasing
number of Filipino children under the age of 5 years. It is an underlying cause for nearly half of
all childhood deaths but is often unrecognized and untreated. Nutrition-sensitive and -specific
interventions and programs are needed to combat both the determinants and direct causes of
undernutrition. PIMAM represents a nutrition-specific program directed towards management of
malnutrition in children for both normal times and emergencies.
Annex
ANNEX 1.1
Differences between Type I and Type II Micronutrient Deficiency
TYPE I TYPE II
Micronutrient Deficiency
Functional Nutrients Growth Nutrients
Potassium
Fat-soluble vitamins
Phosphorus
Vitamin B complex
Protein
Vitamin C
Sodium
Iron
Sulfur
Examples Iodine
Zinc
Copper
Magnesium
Calcium
Nitrogen
Selenium
Essential amino acids
Manganese
Chloride
Growth Continuous in early stages Growth failure is 1st response
Specific clinical signs (+) (-)
(+) (-)
Body store Concentrated in particular Not concentrated in any
tissues particular tissue
Effect on metabolism Specific enzymes affected General effect on metabolism
Anorexia Not usually Common
Independent of other type of Dependent upon all the other
nutrients Type II nutrients
Tissue concentration Drops with deficiency Maintained with deficiency
Maintained with different May change (drop) with
metabolic states metabolic state
Ratio in foods Food sources variable Not very variable
Do not give specific biochemical
Biochemical abnormality Diagnosed by biochemical tests
abnormalities
Diagnosed by anthropometric
Anthropometric abnormality Appears late in deficiency
abnormality
Session 1.2:
PIMAM Guidelines, Roles and Responsibilities
Session Description and Objectives
The session discusses the Philippine Integrated Management of Acute Malnutrition (PIMAM)
as outlined in DOH AO 2015-0055 and reviews the roles and responsibilities that have been
assigned to national agencies and local governments.
Session Objectives
• Discuss the principles of the Philippine Integrated Management of Acute Malnutrition as

outlined in AO 2015-0055.
• Identify which are the roles and responsibilities of national and local agencies in
implementing the PIMAM program.
Key Concepts
Severe acute malnutrition (SAM) is a public health nutrition issue that needs to be urgently
addressed in development and emergency situations.
Acute malnutrition or “wasting” is the life-threatening form of malnutrition. If not properly treated
with evidence-based interventions, children with severe acute malnutrition are 12 times more
likely to die compared to normal children.
Emergencies and disasters put at-risk children with SAM. Nutrition situation worsens during
emergencies when the risk of developing wasting is high. Four Guiding Principles:
• Maximum Coverage and Access

• Timeliness
• Appropriate Care
• Care when and where it is needed
Philippine Integrated Management of Acute Malnutrition (PIMAM)

Four Linked Components
1. Community Mobilization
2. Outpatient Therapeutic Care (OTC)
3. Inpatient Therapeutic Care (ITC)
4. Management of Moderate Acute Malnutrition (MAM)
National Guidelines on the Management of Acute Malnutrition for Children under 5 years
(2015) / DOH AO 2015-0055
• Standardized protocol for prevention, identification, management and referral of children

under five years old with acute malnutrition
• Describes the roles and focus of the four components of the integrated management of
SAM
Module 1
• Emphasis on the need for linkages and referrals, supply networks, indicators for monitoring, and
importance of PIMAM in emergency settings
General Guidelines for PIMAM (DOH AO 2015-0055)
5. Mothers and caregivers of children under 5 years shall have access to information and
PIMAM health services including the prevention, diagnosis, management and referral of acute
malnutrition, especially during emergencies and disasters.
6. All public health and nutrition programs including but not limited to IMCI, EPI, IYCF, micronutrient
supplementation, and growth monitoring shall integrate PIMAM principles and strategies to
provide clear policy guidance for allocating and mobilizing needed resources to ensure the
continuity of and access to evidence-based and life-saving nutrition interventions.
7. PIMAM services in development and emergency settings shall be available and accessible at
all communities and health facilities. Intermediary LGUs, Regional Offices for Health, and DOH-
Central Office shall provide technical support and assume augmentation and surrogate roles in
times of disasters.
8. All Local Government Units, through their Local Health Offices, shall be responsible in enhancing
the capacities of their communities to identify, refer, and manage cases of acute malnutrition.
9. Competent PIMAM service providers shall be developed and established at all levels with the
capacities to deliver quality services both under routine health programs during emergencies.
10. All implementing agencies (LGUs, Hospitals, NGOs) shall establish and implement mechanisms,
tools, and systems for supplies management and monitoring and evaluation of service delivery
during routine health programs and emergencies.
11. All implementing agencies shall develop, implement, and sustain information management
systems and strategies to ensure that appropriate, timely and evidence-based information
are available at all times and levels. Systems shall be put in place for making the information
available and accessible in the case of disasters and emergencies.
12. Coordinating, advocacy, networking, and partnership mechanisms shall be established and/or
strengthened at all levels for effective and efficient PIMAM service delivery during routine health
programs and emergencies.
13. The components of PIMAM shall be Community Mobilization, Inpatient Therapeutic Care
(ITC), Outpatient Therapeutic Care (OTC) and Targeted Supplemental Feeding (TSFP). These
components shall sit within a multi-sectoral range of health and nutrition interventions and
services which focus on tackling the determinants of undernutrition in the “critical 1000 day
window”.
Roles and Responsibilities
1. National Government Agencies

b. Department of Health Central Office
c. Disease Prevention and Control Bureau (DPCB)
d. National Nutrition Council (NNC)
e. Health Emergency Management Bureau (HEMB)
f. Health Promotion and Communication Service (HPCS)
g. Epidemiology Bureau (EB)
h. Bureau of Local Health Systems and Development
i. Health Facility Development Bureau
j. Health Facilities and Services Regulatory Bureau shall identify specific PIMAM requirements
that will be incorporated in the checklist for routine licensing applications (new and renewal
of license) of health facilities and PhilHealth accreditation.
k. Knowledge Management Information Technology Service - provide technical assistance
to the NPMT in ensuring the functionality, maintenance, and integration of PIMAM into
existing health information management systems (iClinicsys, PHIE< FHSIS< PIDSR,
disease registries and others).
l. Pharmaceutical Division - expedite the registration of PIMAM commodities in the PNDF
and issuance of clearance for commodities, drugs and medicines as needed.
m. Food and Drug Administration
i. Provide technical assistance in the acceptance of international and local donations,
especially food and drugs.
ii. Facilitate the acceptance and clearance of food, drugs and supplies which are
necessary for PIMAM program implementation.
n. Health Human Resource Development Bureau
i. In coordination with other NPMT members, standardize the training of trainers
(PIMAM, active screening, Essential Nutrition Action, Breastfeeding community
initiative, mother-to-mother network group).
ii. Develop or conduct other related learning and educational development activities.
o. Bureau of International Health Cooperation
i. Facilitate the processing of international donations of commodities or grants
ii. Facilitate the acceptance of international donations of foods, drugs and supplies, and
administer such in accordance with the terms of the grant or donation.
p. Health Policy Development and Planning Bureau shall, in coordination with other NPMT
members, review and provide technical assistance in the development of the PIMAM
protocol.
2. DOH Regional Offices and National Nutrition Council Regional Offices - the DOH Regional
Directors shall directly oversee the implementation and adoption of these policies within their
Regions, create Regional PIMAM management teams, and provide feedback, suggestions,
and policy recommendations to the Secretary of Health.
The Regional PIMAM Management Teams, led by the Family Health Officer, shall be responsible
for the implementation and adoption of these guidelines in their respective regions.
The Regional Offices for Health, being the lead of the PIMAM Regional Management Team,
and Regional National Nutrition Councils, as co-lead, shall:
a. Formulate plans, procedures and protocols to implement this policy and guidelines.
b. Provide and implement a mechanism of coordination and collaboration with hospitals (both
government and private), LGUs, partners and other stakeholders, to ensure the timely and
effective service delivery.
c. Support monitoring and evaluation activities.
d. Provide technical assistance and logistics support to implementing agencies and regions.
Design, update, and conduct necessary training to enhance capabilities of PIMAM
implementers.
e. Conduct studies and facilitate technical resource development that will contribute to
improving service delivery.
f. Identify, develop and enhance capacity of the members of the health and nutrition sector.
g. Plan for and manage supplies efficiently and effectively.
h. Develop/improve and sustain a safe and efficient referral system of children with acute
malnutrition.
i. Through the respective Development Management Officers, ensure the supportive
supervision, monitoring and coordination of PIMAM implementation at the LGU level
including logistics coordination.
3. Local Government Units
4. Hospitals - The Medical Center Chiefs/Chief of Hospitals shall administer these regulations
and support all the policies and guidelines mentioned in this Order. He/she shall lead in the
dissemination of these guidelines, their integration of the same in the hospital and the creation
of Hospital PIMAM Management Teams. He/she shall ensure the availability of personnel
and funds to support all the needed training and response. He/she shall submit reports to the
respective Regional Office, LGU, DOH-CO.
Module 1
The Hospital PIMAM Management Team, led by the Chief of Clinics, shall directly oversee the
implementation of these guidelines in their respective hospitals. He/she shall report to the Chief
of Hospital/Medical Center Chief.
Hospitals shall:
a. Formulate plans, procedures and protocols to implement this policy and guidelines.
b. Implement all policies, and adhere to all standards, requirements and systems.
c. Provide and implement a mechanism of coordination and collaboration with hospitals (both
government and private), LGUs, partners and other stakeholders, to ensure the timely and
effective service delivery.
d. Support monitoring and evaluation activities.
5. PhilHealth - Develop strategies to ensure coverage for children requiring treatment of severe
acute malnutrition including, but not limited to: outpatient treatment with routine medicines
and therapeutic food provided in capacitated health facilities, in-patient treatment of severe
acute malnutrition with medical complications, reimbursement, point-of-care delivery in non-
PhilHealth accredited institutions/health service providers during emergencies and disasters.
6. Other Government Agencies
7. Academe and Professional Societies

a. Ensure that all curricula relevant to PIMAM are updated and implemented and that bodies
of evidence on PIMAM are generated and disseminated.
8. Non-Government Organizations
Content Summary
The PIMAM guidelines in AO 2015-0055 are based on the success of several municipalities and
cities with high burdens of severe acute malnutrition who have successfully treated and cured
children under five years. The DOH order provides the policies and framework to guide a multi-
sectoral approach. National agencies and local governments have been assigned roles and
responsibilities. The successful and quality delivery of services will meet the goal of improving
the survival of children with SAM under five years.
References
1. Philippines Department of Health. Administrative Order 2015-0055. National Guidelines

on the Management of Acute Malnutrition for Children under 5 years.
2. Philippines Department of Health. National Guidelines on the Management of Severe
Acute Malnutrition for Children under Five Years Manual of Operations. 2015.
3. Philippines Department of Health. Strategic Framework for Comprehensive Nutrition
Implementation Plan 2014-2025.
? Test Yourself
1. Undernutrition includes the following conditions:

a. suboptimum breastfeeding
b. stunting (chronic malnutrition)
c. wasting and nutritional edema (acute malnutrition)
d. All of the above
2. Acute Malnutrition is
e. sudden wasting and/or edema that is due to any or a combination of the following:
insufficient food intake, concurrent or repeated bouts of infection, inappropriate
childcare practices
f. inadequate weight relative to height compared to the WHO reference population
g. muscle wasting identified using Mid Upper Arm circumference (MUAC)
h. All of the above
3. True or False. Bilateral pitting edema is a sign of severe acute malnutrition
4. PIMAM guidelines aim to

a. increase the number of hospitals with malnutrition wards
b. utilize the LGU health setting only for case finding
c. integrate the management of malnutrition into routine basic health services at all levels
d. increase the number of feeding programs for malnutrition
5. What is not a component of integrated SAM management?

a. Outpatient therapeutic care for SAM without medical complications
b. A community mobilization phase
c. Management of MAM via supplementary feeding program
d. Inpatient therapeutic care for SAM without medical complications
References
1. Black RE et al. (2013). Maternal and child undernutrition and overweight in low-income
and middle-income countries. The Lancet Nutrition Series Part 1. Retrieved from www.
thelancet.com
2. Hay Jr. WW et al. (2001). Intrauterine Growth Restriction. NeoReviews. 2:6. Retrieved
from http://neoreviews.aappublications.org/
3. UNICEF (n.d.) Overview of CMAM. (PowerPoint Slides)
4. Sethuraman, Kavita et al. (2014). Managing Acute Malnutrition: A Review of the Evidence
and Country Experiences in South Asia and a Recommended Approach for Bangladesh.
Washington DC:FANTA
5. West KP. (n.d.) Protein Energy Malnutrition and Undernutrition. Causes, Consequences,
Interactions and Global Trends. (PowerPoint Slides) Retrieved from http://ocw.jhsph.edu/
courses/InternationalNutrition
6. International Food Policy Research Network. 2015. Global Nutrition Report: Actions and
Accountability to Advance Nutrition and Sustainable Development.
Answer key: 1.- d; 2.- d; 3. - True; 4.- c; 5.-d
Module 2
Identification of Severe Acute Malnutrition (SAM)
Target Learners
This module is intended for community and hospital healthcare providers directly involved in the
identification, triage and management of infants and children with malnutrition.
The module describes how to recognize a child with severe acute malnutrition (SAM) using
anthropometric measurements including mid-upper arm circumference (MUAC), weight, height/
length; by testing for edema as well for appetite. The determination of the appropriate Z-score
based on the child’s weight and height will also be explained.
______________________________________________________________
1. Identify children with SAM

2. Measure weight and height or length correctly
3. Determine the appropriate Z-based on weight or height
4. Measure the mid upper arm circumference correctly
5. Test for the presence or absence of edema
6. Perform the appetite test
Definition of Terms
Anthropometry
• The study and technique of human body measurement which are then used to monitor the
nutritional status of an individual or a population
Edema
• Occurs when an unusually large amount of fluid gathers in the child’s tissues. The tissues
become filled with the fluid and look swollen or puffed up
Height for age (HFA)

• A measure of linear growth. A child who is below minus two standard deviations (-2 SD)
from the median of the WHO reference population in terms of height-for-age is considered
short for his/her age, or stunted, a condition reflecting the cumulative effect of chronic
malnutrition. If the child is below minus three standard deviations (-3 SD) from the
reference median, then the child is considered to be severely stunted. A child between -2
SD and -3 SD is considered to be moderately stunted.
Mid Upper Arm Circumference (MUAC)
• Is a measure of muscle wasting and has been shown to have the highest correlation with
risk of mortality of any anthropometric indicator.
• This means that children with MUAC measurements lower than the cutoff values are in
danger of dying and need immediate care
Weight for height (WFH)

• Describes current nutritional status. A child who is below minus two standard deviations (-2
SD) from the reference median for weight-for-height is considered to be too thin for his/her
height, or wasted, a condition reflecting acute or recent nutritional deficit. As with stunting,
wasting is considered severe if the child is below minus three standard deviations (-3 SD)
below the reference mean. Severe wasting is closely linked to mortality risk.
Weight for age (WFA)

• A composite index of weight-for-height and height-for-age, and thus does not distinguish
between acute malnutrition (wasting) and chronic malnutrition (stunting). A child can be
underweight for his age because he is stunted, because he is wasted or both. Weight-for-
age was considered as a good overall indicator of a population’s nutritional health but is
programmatically not useful.
Key Concepts
Acute Malnutrition
• classified as moderate or severe, using weight for height (WFH) or length (WFL), MUAC
and presence or absence of edema
• MUAC is only measured and used to identify SAM in children more than 6 months
of age up to 5 years.
Table 2.1 Identification of Acute Malnutrition in Children
Normal MAM SAM
Edema None None Present

and/or
≥125 mm = greater than 115 mm to 124 mm <115 mm = less than
MUAC or equal to 125 mm 115 mm (11.5 cm)
(12.5 cm)
and/or
-2 and above <-2 to -3 = less than -2 <-3 = less than -3
WFH Z-score
to -3
Note:
1. 125 mm = 12.5 cm; 115mm = 11.5 cm
2. Edema is graded as follows: Grade 1 mild, both feet; Grade 2, moderate, both feet plus lower legs, hands, lower arms
intermediate between mild and severe; Grade 3, severe, generalized edema including both feet, legs, hands, arms and face
Module 2
Session 2.1:
Measuring weight
Measuring weight
• There are different weighing scales but the use of the 25 kg hanging spring scale graduated to
0.10 kg OR an electronic balance are recommended
• Do not forget to standardize the scales daily (Annex 2.1: Standardizing scales).
Steps in weighing the child:
1. Explain to the mother/caregiver what you are doing and why

2. Do not forget to adjust the scale to zero before each weighing.
3. When using the hanging weighing scale:
i. Use a plastic washbasin, malong, duyan, etc. attached and secured by four ropes to the
scale
ii. Ensure that the washbasin is clean and disinfected
iii. Ensure that the washbasin is close to the ground
4. Ask permission to remove the child's clothes including the diaper, but keep the child warm with
a blanket or cloth while carrying to the scale.
5. Put a cloth in the scale pan or basin so the child does not get cold.
6. Place the naked child gently in the weighing pan or basin.
7. Wait for the child to settle and the weight to stabilize.
8. Take the measurement at your eye level.
9. Measure weight to the nearest 100 grams or as precisely as possible.
10. Record immediately.
11. Wrap the child immediately to re-warm.
Session 2.2:
Measuring length
Measuring length
• Measure length for children less than 87 cm (or less than about 3 feet) or those too weak to
stand
• Measure with the child lying down. This requires at least two people to perform
• Ensure that the mother/caregiver is nearby to help soothe and comfort her/his child.
• Cover the measuring board with a thin cloth to avoid discomfort for the child and sticking to the
board
• If possible, remove shoes and clothing (lower garments only) of the infant/child so that the
length measurement will be most accurate; diapers make it difficult to hold the infant’s legs
together and straighten them.
»» If child is upset or cold, keep the clothes on, but ensure they do not get in the way of
measurement.
»» Always remove shoes and socks if worn
»» Remove any worn hair ornaments
»» After measuring, re-dress or cover the child quickly so that he does not get cold.
Steps in measuring length

2. Place the measuring board on the ground
3. Position the child lying along the middle of the board.
4. Both measurer and assistant kneel at both ends of the measuring board.
5. The assistant holds the sides of the child’s head with hands cupped over ears and positions the
head until it firmly touches the fixed headboard with the hair compressed.
Figure 2.1. How to Measure the Length (1)

(Illustration from WHO Training Course 2002)
6. Ensure that the child’s line of sight is perpendicular to the base of the board

(Illustration from DOH National Guidelines on Management of Acute Malnutrition 2015)
90˚
7. As the measurer, place your hands on the child’s legs, gently stretch the child’s legs and then
keep one hand on the thighs to prevent flexion.
8. While positioning the child’s legs, push the sliding footplate firmly against the bottom of the
child’s feet.

(Illustration from WHO Training Course 2002)
Module 2
9. Read the measure, with the footplate at a 90o angle (perpendicular) to the axis of the board and
vertical.
10. The length is read to the nearest 0.1 centimeter or 1 millimeter.
a. The longer lines indicate centimeters and the shorter lines, millimeters.
The child's feet are against this

side of the movable footboard.
This child's length is 66.3cm.
60 61 62 63 64 65 66 68 69 70 71 72 73 74 75
©WHO Growth standard training
11. Record immediately.
Session 2.3:
Measuring height
Measuring height
• Measure height for those children who can stand or who are taller than 87 cm (about 3 feet)
• Ask at least one person to help you measure height
• Use a height board with a vertical backboard, a fixed base board, and a movable head board.
• Place on a level floor.
• Remove the child’s socks and shoes for accurate measurement.
• Remove any worn hair ornaments.
Steps in measuring height

2. Both measurer and assistant are on their knees.
3. Help the child stand with back of the head, shoulder blades, buttocks, calves and heels touching
the vertical board.
4. Hold the child’s knees and ankles to keep the legs straight and feet flat. Prevent children from
standing on their toes.
5. Position the head so that the child is looking straight ahead (line of sight is parallel to the base
of the board).
6. Place thumb and forefinger over the child’s chin to help keep the head in an upright position.
7. With the other hand, pull down the head board to rest firmly on top of the head and compress
hair.
Figure 2.5. How to Measure the Height (1)
97
96
94
The child's head
93
is against this side
of the movable
headboard. The
92
child's length is
94.2cm
91
©WHO Growth standard training
Figure 2.6. How to Measure the Height (2)
1. Questionnaire and pencil on clipboard

Headpiece firmly on head
15
on floor or ground
2. Assistant on knees
Hand on chin 9
3. Measurer of knees
Shoulders level
10
4. Hands cupped over ears; head
against base of board
11 Hands at side 5. Arms comfortably straight

Left hand on knees; knees
5
together against board Measurer on knee
3
Right hand on Shins; heels against 4
6. Line of sight perpendicular to base of
back and base of board board
7. Child flat on board

2
Assistant on knee
8. Hands in knees or shins; legs straight
12
8
1
Line of
9. Feet flat against footpiece
Questionnaire and pencil on clipboard sight
on floor or ground
13
10. Shoulders level
14 11. Hands at side

Body Flat against board
12, 13, 14. Body flat against board

7
Module 2
Session 2.4:
Determining the appropriate Z-score for WFH or WFL
What is a Z score?
It is a way of comparing a measurement, in this case a child’s weight-for-length or weight for height
compared to an “average”.
Steps in determining the Z-score:
1. Determine age**
a. Infant/ children from 0 - 23 months of age
i. Take weight and length measurements
b. Infant/ children 24 - 59 months of age
**For children older than 59 months of age refer to Annex 2.6. Identification of SAM for children/adolescents older than
59 months of age
2. Check the weight-for-height/length table and determine the Z-scores by referring to the following
tables:**1
a. The Child Growth Standards Table for boys and girls (24-60 months old and birth - 2 years)
are distinct and separate
b. The Child Growth Standards Table used includes height/length measurements expressed
in 0.5 cm increments
Annex 2.2 for WHO Child Growth Standards (birth to 2 years or 0 to 23 months) for boys
Annex 2.3 for WHO Child Growth Standards (birth to 2 years or 0 to 23 months) for girls
Annex 2.4 for WHO Child Growth Standards (24 months to 60 months) for boys
Annex 2.5 for WHO Child Growth Standards (24 months to 60 months) for girls
3. Round off the length or height measurement to the nearest 0.5 cm mark.
a. Measurements would have to be rounded off using 0.5cm intervals, e.g., 60.0 -- 60.5 -- 61.0
-- 61.5 -- 62.0 -- 62.5 -- 63.0 …
b. Round off measurements within 0.2 cm below or above of a number that represents or
marks the 0.5cm interval to the latter
c. Example:
79.8
79.9
80.0 80.0cm is used for 79.8, 79.9cm as well as for 80.1 and 80.2cm
80.1
80.2
80.3
80.4
80.5 80.5cm is used for 80.3, 80.4cm as well as for 80.6 and 80.7cm
80.6
80.7
80.8
80.9
81.0 81.0cm is used for 80.8, 80.9cm as well as 81.1 and 81.2cm
81.1
81.2
1
**For children older than 59 months of age refer to Annex 2.6. Identification of SAM for children/adolescents older than 59
months of age
4. Locate the infant/ child’s weight and determine under which classification it falls under
(severely wasted, wasted, normal, overweight or obese).**2
Exercise: A 25 month old boy with length of 66 cm and weight of 6.3 kg
1. Locate the measured height or length on the appropriate growth standards table for boys
2. Place a ruler or piece of card/paper under the length (or height, if appropriate) you located
on the table. See table below.
Weight (kg)
Height Severely Wasted Normal Overweight

Obese
(cm) Wasted From To From To From To
< -3SD -3SD < -2SD -2SD +2SD > +2SD +3SD > +3SD
65.0 5.8 5.9 6.2 6.3 8.8 8.9 9.6 9.7
65.5 5.9 6.0 6.3 6.4 8.9 9.0 9.8 9.9
66.0 6.0 6.1 6.4 6.5 9.1 9.2 9.9 10.0
66.5 6.0 6.1 6.5 6.6 9.2 9.3 10.1 10.2
67.0 6.1 6.2 6.6 6.7 9.4 9.5 10.2 10.3
67.5 6.2 6.3 6.7 6.8 9.5 9.6 10.4 10.5
3. Along this line, locate the child’s weight and determine under which classification it falls
under, that is, classify as severely wasted, wasted, normal, overweight or obese. See table
below.
Weight (kg)
Height Severely Wasted Normal Overweight

Obese
(cm) Wasted From To From To From To
< -3SD -3SD < -2SD -2SD +2SD > +2SD +3SD > +3SD
65.0 5.8 5.9 6.2 6.3 8.8 8.9 9.6 9.7
65.5 5.9 6.0 6.3 6.4 8.9 9.0 9.8 9.9
66.0 6.0 6.1 6.4 6.5 9.1 9.2 9.9 10.0
66.5 6.0 6.1 6.5 6.6 9.2 9.3 10.1 10.2
67.0 6.1 6.2 6.3 kg

6.6 between
6.7 6.19.4
and 6.49.5 10.2 10.3
67.5
So
6.2
the Z
6.3
score is
6.7
between
6.8
-3 and
9.5
< -2SD,
9.6
and
10.4 10.5
falls under the category of "wasted"
The boy with a length of 66cm and weight of 6.3 kg has a Z score between -3SD and less than -2SD
and is classified as wasted.
Remember!
Normal MAM SAM

WFH Z-score
to -3
WFH Z-score = Weight for Height Z-score

2
**For children older than 59 months of age refer to Annex 2.6. Identification of SAM for children/adolescents older than 59
months of age
Module 2
? Z-Score Exercises
Cases:
Weight for Length / Height Z score

1. Corey is a 54 month old girl who has a weight of 14.8 kg, length of 110.8 cm.
a. What is the WFH Z score?
b. What is the category of wasting?
c. What is the nutritional assessment?
2. Oscar is a 4 month old boy whose weight is 7 kg, length is 60.2 cm.
a. What is the WFL Z score?
3. Rene is a 28 month old boy who has a weight of 9.8 kg, length of 88.9 cm.
a. What is the WFL Z score?
Session 2.5:
Measuring the Mid Upper Arm Circumference (MUAC)
Measuring the Mid Upper Arm Circumference (MUAC)
• The MUAC is a simple measure of muscle wasting and has been shown to strongly predict
whether a child is at risk of dying
• You do not have to countercheck your classification using MUAC against WFH measurements
(because MUAC is a stand-alone or independent measure of SAM).
• If your facility is capable of doing Weight-for-Height Z-score (WHZ), this can also be used as
another independent measure for identifying children with SAM.
Steps in measuring height

2. Ask the mother to remove clothing that may cover the child’s left arm.
3. While behind the child, estimate the midpoint of the child’s left upper arm.
a. Place the MUAC tape at zero, which is indicated by two arrows, on the tip of the shoulder
(Arrow 4).
b. Pull the tape straight down past the tip of the elbow (Arrow 5).
c. Read the number at the tip of the elbow to the nearest centimeter.
d. Divide this number by two to estimate the midpoint.
e. Mark the midpoint with a pen on the arm (Arrow 6).
4. Straighten the child’s arm and wrap the tape around the arm at the midpoint.
a. Insert and pull the pointed end through the slit opening beside the window.
b. Make sure the numbers are right side up so that you can read them.
c. Make sure the tape is flat around the skin (Arrow 7).
d. Inspect the tension of the tape on the child’s arm.
e. Make sure the tape has the proper tension (Arrow 7) and is not too tight so that the skin is
compressed or too loose so that the tape does not contact the skin all the way around the
arm (Arrows 8 and 9).
5. Repeat any step as necessary.
6. When the tape is in the correct position on the arm with correct tension, read and call out the
measurement to the nearest 0.1 cm or 1 mm (Arrow 10).
7. Immediately record the measurement
Figure 2.7. MUAC tape
WINDOW SLIT
Opening Opening
Arm circumference "insertion" tape

0. cm 1. Locate tip of shoulder
2. Tip of shoulder
cm 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
0. cm
3. Tip of elbow
2 4
4. Place tape at tip of shoulder
1 6
5. Pull tape past tip of bent elbow

5
3
1. Locate tip of shoulder 2. Tip of shoulder 4. Place tape at tip of 6. Mark midpoint
6. Mark midpoint
3. Tip of elbow shoulder
5. Pull tape past tip of bent
elbow
7. Correct tape tension
8. Tape too tight
9. Tape to loose
7
10. Correct tape position for arm
7. Correct tape tension circumference
10
9 10
8. Tape too tight
9. Tape too loose 10. Correct tape position for arm circumference
Source: How to Weigh and Measure Children: Assessing the Nutritional Status of Young Children, United Nations, 1986.
Remember!
Normal MAM SAM

(12.5 cm)
Module 2
Session 2.6:
Identifying Bilateral Pitting Edema
Identifying Bilateral Pitting Edema
• Edema occurs when an unusually large amount of fluid gathers in the child’s tissues. The tissues
become filled with the fluid and look swollen or puffed up.
• Bilateral edema is the sign of kwashiorkor which is always a severe form of malnutrition. Children
with bilateral edema are directly identified to be acutely malnourished. These children are at
high risk of dying and need to be treated in a therapeutic feeding program urgently.
In order to determine the presence of edema:

Step 1. Normal thumb pressure is applied to both feet for at least three seconds.
»» If a shallow print persists on both feet, then the child has edema.
»» Only children with bilateral edema are recorded as having nutritional edema
You must formally test for edema with finger pressure. You cannot tell by just looking.
Source: National Guidelines on the Management of Severe Acute Malnutrition (SAM) for Children under Five Years
Step 2. Note the severity or grade of edema.
Table 2.2 Grading of Edema
EDEMA BILATERAL PITTING EDEMA
+1 Both feet
+2 Both feet, legs, and may include hands, lower arms
Both feet, legs, hands, lower arms, upper arms
+3
and face
Review!
Normal MAM SAM

and/or
(12.5 cm)
and/or
WFH Z-score
to -3
Session 2.7:
Conducting the Appetite Test
Conducting the Appetite Test
• A critical part of the assessment of the child

• Helps distinguishes whether the child needs a referral to OTC or ITC
• Loss of appetite is the best sign of severe metabolic malnutrition
• Appetite is tested using Ready to Use Therapeutic Food (RUTF)
Steps in the Appetite Test:
1. Do the test in a separate quiet area.

2. Explain to the caregiver the purpose of the appetite test and how it will be carried out.
3. The caregiver, should wash her/his and the child’s hands.
4. Ask the caregiver to sit comfortably with the child on their lap and either offer the RUTF from the
packet or put a small amount on her finger and give it to the child.
5. Give the caregiver clean water for the child to drink from a cup as s/he is taking the RUTF.
6. Ask the caregiver to gently offer the child the RUTF while encouraging the child throughout the
process. If the child refuses, then the caregiver should continue to quietly encourage the child
and take time over the test. The test usually takes a short time but if a child is distressed, it may
take longer. The child must not be forced to take the RUTF.
7. Observe if the child is able to consume the required amount (the test MUST be observed by a
health worker).
8. Record the result of the test (Pass or Fail) on the OTC or hospital chart.
Pass Fail
The child takes less than 3 - 4 mouthfuls of RUTF.

The child takes 3 - 4 mouthfuls or more of RUTF S/he is considered to lack sufficient appetite for
OTC and should be referred to the ITC.
9. When the health worker thinks the child does not like the taste of RUTF or the child is just
frightened or not cooperating, the child still has to be referred to ITC.
Module 2
Content Summary
Identification of SAM is an important skill for all who work in health, from the barangay to
the hospital level. The classification of malnutrition to moderate or severe is dependent on
anthropometric measurements and testing for edema.
It is important to accurately measure weight and height, determine the appropriate Z score,
alternatively to measure the MUAC. Testing appetite is critical to deciding whether a child needs
OTC or ITC treatment. Correct identification of SAM can save that child’s life.
? Test Yourself
1. You are assessing an infant less than 6 months of age, which of the following measurements
will you do to diagnose SAM?
a. MUAC
b. Edema
c. Head circumference
d. Weight for height
2. You have weighed a child and are about to write down the weight. What is the appropriate
way to record the weight?
a. 6,255 g or 6.255 kg
b. 6,200 g or 6.2 kg
c. Both of the above
d. None of the above
3. You have measured a child’s height to be 80.7 cm. You round it off correctly and write down
which of the following?
a. 81 cm
b. 80.5 cm
c. Both of the above
4. Steps in checking for nutritional pedal edema includes:

a. Observe for periorbital edema
b. Press heavily unto both feet for 3 seconds
c. Apply normal thumb pressure on one foot then the other
d. Apply normal thumb pressure on both feet for 3 seconds
5. You are doing an appetite test. Which of the following children with SAM can be treated with
OTC?
a. The child takes 3 mouthfuls of RUTF
b. The child takes 2 mouthfuls of RUTF
c. The child tastes the RUTF, but spits it out
d. The child is scared and refuses to open her/his mouth
Answer key: 1. – b; 2. – b; 3. – b; 4 – d; 5 - a
Annex
ANNEX 2.1
Standardizing scales
• Set the scale to zero.

• Weigh three objects of known weight (e.g., 5, 10, and 15 kg) and record the measured weights.
• Repeat the weighing of these objects and record the weights again.
• If there is a difference of 0.01 kg or more between duplicate weighings, or if a measured weight
differs by 0.01 kg or more from the known standard, check the scales and adjust or replace them
if necessary
Reference: WHO Training Course on the Management of Severe Malnutrition, 2002
Session 2.8:
Hand Hygiene
Why is this important?
• Thousands of people die every day around the world from infections acquired while receiving
health care.
• Hands are the main pathways of germ transmission during health care.
• Hand hygiene is therefore the most important measure to avoid the transmission of harmful
germs and prevent health care-associated infections.
• This brochure explains how and when to practice hand hygiene.
Who does this apply to?
• Any health-care worker, caregiver or person involved in direct or indirect patient care needs to
be concerned about hand hygiene and should be able to perform it correctly and at the right
time.
How is this activity done?

• Clean your hands by rubbing them with an alcohol-based formulation, as the preferred mean for
routine hygienic hand antisepsis if hands are not visibly soiled. It is faster, more effective, and
better tolerated by your hands than washing with soap and water.
• Wash your hands with soap and water when hands are visibly dirty or visibly soiled with blood
or other body fluids or after using the toilet.
• If exposure to potential spore-forming pathogens (microorganisms that cause disease) is
strongly suspected or proven, including outbreaks of Clostridium difficile, hand washing with
soap and water is the preferred means.
Module 2
Figure 2.9. How to Handrub

(from World Health Organization 2009. Hand Hygiene: Why, How and When)
RUB HANDS FOR HAND HYGIENE! WASH HANDS WHEN VISIBLY SOILED
Duration of the entire procedure: 20-30 seconds
1a 1b 2
Apply a palmful of the product in a cupped hand, covering all surfaces; Rub hands palm to palm;
3 4 5
Right palm over left dorsum with Palm to palm with fingers interlaced; Backs of fingers to opposing palms
interlaced fingers and vice versa; with fingers interlocked;
6 7 8
Rotational rubbing of left thumb Rotational rubbing, backwards and Once dry, your hands are safe.
clasped in right palm and vice versa; forward with clasped fingers of right
hand in left palm and vice versa;
Figure 2.10. How to Handwash
(from World Health Organization 2009. Hand Hygiene: Why, How and When)
WASH HANDS WHEN VISIBLY SOILED! OTHERWISE, USE HANDRUB

Duration of the entire procedure: 40-60 seconds
Module 2
ANNEX 2.2
WHO Child Growth Standards (birth to 2 years) for boys
CHILD GROWTH STANDARDS TABLE**

Weight (kg) for Length (cm) of Boys 0-23 Months
INSTRUCTIONS FOR USE

Upon taking the child's length, round off the actual reading to the nearest 0.5 cm. For instance, for a child 51.3 cm. in length, refer to row 51.5 cm., or if a child's length is
58.3 cm., refer to row 58.5 cm. Depending under which column the weight of the child falls, classify the child as severely wasted, wasted, normal, overweight or obese.
Weight (kg) Weight (kg)

Length Severely Wasted Normal Overweight Length Severely Wasted Normal Overweight
Obese Obese
(cm) Wasted From To From To From To (cm) Wasted From To From To From To
< -3SD -3SD < -2SD -2SD +2SD > +2SD +3SD > +3SD < -3SD -3SD < -2SD -2SD +2SD > +2SD +3SD > +3SD
45.0 1.8 1.9 1.9 2.0 3.0 3.1 3.3 3.4 78.0 7.8 7.9 8.5 8.6 12.0 12.1 13.1 13.2
45.5 1.8 1.9 2.0 2.1 3.1 3.2 3.4 3.5 78.5 7.9 8.0 8.6 8.7 12.1 12.1 13.2 13.3
46.0 1.9 2.0 2.1 2.2 3.1 3.2 3.5 3.6 79.0 8.0 8.1 8.6 8.7 12.2 12.3 13.3 13.4
46.5 2.0 2.1 2.2 2.3 3.2 3.3 3.6 3.7 79.5 8.1 8.2 8.7 8.8 12.3 12.4 13.4 13.5
47.0 2.0 2.1 2.2 2.3 3.3 3.4 3.7 3.8 80.0 8.1 8.2 8.8 8.9 12.4 12.5 13.6 13.7
47.5 2.1 2.2 2.3 2.4 3.4 3.5 3.8 3.9 80.5 8.2 8.3 8.9 9.0 12.5 12.6 13.7 13.8
48.0 2.2 2.3 2.4 2.5 3.6 3.7 3.9 4.0 81.0 8.3 8.4 9.0 9.1 12.6 12.7 13.8 13.9
48.5 2.2 2.3 2.5 2.6 3.7 3.8 4.0 4.1 81.5 8.4 8.5 9.0 9.1 12.7 12.8 13.9 14.0
49.0 2.3 2.4 2.5 2.6 3.8 3.9 4.2 4.3 82.0 8.4 8.5 9.1 9.2 12.8 12.9 14.0 14.1
49.5 2.4 2.5 2.6 2.7 3.9 4.0 4.3 4.4 82.5 8.5 8.6 9.2 9.3 13.0 13.1 14.2 14.3
50.0 2.5 2.6 2.7 2.8 4.0 4.1 4.4 4.5 83.0 8.6 8.7 9.3 9.4 13.1 13.2 14.3 14.4
50.5 2.6 2.7 2.8 2.9 4.1 4.2 4.5 4.6 83.5 8.7 8.8 9.4 9.5 13.2 13.3 14.4 14.5
51.0 2.6 2.7 2.9 3.0 4.2 4.3 4.7 4.8 84.0 8.8 8.9 9.5 9.6 13.3 13.4 14.6 14.7
51.5 2.7 2.8 3.0 3.1 4.4 4.5 4.8 4.9 84.5 8.9 9.0 9.6 9.7 13.5 13.6 14.7 14.8
52.0 2.8 2.9 3.1 3.2 4.5 4.6 5.0 5.1 85.0 9.0 9.1 9.7 9.8 13.6 13.7 14.9 15.0
52.5 2.9 3.0 3.2 3.3 4.6 4.7 5.1 5.2 85.5 9.1 9.2 9.8 9.9 13.7 13.8 15.0 15.1
53.0 3.0 3.1 3.3 3.4 4.8 4.9 5.3 5.4 86.0 9.2 9.3 9.9 10.0 13.9 14.0 15.2 15.3
53.5 3.1 3.2 3.4 3.5 4.9 5.0 5.4 5.5 86.5 9.3 9.4 10.0 10.1 14.0 14.1 15.3 15.4
54.0 3.2 3.3 3.5 3.6 5.1 5.2 5.6 5.7 87.0 9.4 9.5 10.1 10.2 14.2 14.3 15.5 15.6
54.5 3.3 3.4 3.6 3.7 5.3 5.4 5.8 5.9 87.5 9.5 9.6 10.3 10.4 14.3 14.4 15.6 15.7
55.0 3.5 3.6 3.7 3.8 5.4 5.5 6.0 6.1 88.0 9.6 9.7 10.4 10.5 14.5 14.6 15.8 15.9
55.5 3.6 3.7 3.9 4.0 5.6 5.7 6.1 6.2 88.5 9.7 9.8 10.5 10.6 14.6 14.7 15.9 16.0
56.0 3.7 3.8 4.0 4.1 5.8 5.9 6.3 6.4 89.0 9.8 9.9 10.6 10.7 14.7 14.8 16.1 16.2
56.5 3.8 3.9 4.1 4.2 5.9 6.0 6.5 6.6 89.5 9.9 10.0 10.7 10.8 14.9 15.0 16.2 16.3
57.0 3.9 4.0 4.2 4.3 6.1 6.2 6.7 6.8 90.0 10.0 10.1 10.8 10.9 15.0 15.1 16.4 16.5
57.5 4.0 4.1 4.4 4.5 6.3 6.4 6.9 7.0 90.5 10.1 10.2 10.9 11.0 15.1 15.2 16.5 16.6
58.0 4.2 4.3 4.5 4.6 6.4 6.5 7.1 7.2 91.0 10.2 10.3 11.0 11.1 15.3 15.4 16.7 16.8
58.5 4.3 4.4 4.6 4.7 6.6 6.7 7.2 7.3 91.5 10.3 10.4 11.1 11.2 15.4 15.5 16.8 16.9
59.0 4.4 4.5 4.7 4.8 6.8 6.9 7.4 7.5 92.0 10.4 10.5 11.2 11.3 15.6 15.7 17.0 17.1
59.5 4.5 4.6 4.9 5.0 7.0 7.1 7.6 7.7 92.5 10.5 10.6 11.3 11.4 15.7 15.8 17.1 17.2
60.0 4.6 4.7 5.0 5.1 7.1 7.2 7.8 7.9 93.0 10.6 10.7 11.4 11.5 15.8 15.9 17.3 17.4
60.5 4.7 4.8 5.1 5.2 7.3 7.4 8.0 8.1 93.5 10.6 10.7 11.5 11.6 16.0 16.1 17.4 17.5
61.0 4.8 4.9 5.2 5.3 7.4 7.5 8.1 8.2 94.0 10.7 10.8 11.6 11.7 16.1 16.2 17.6 17.7
61.5 4.9 5.0 5.3 5.4 7.6 7.7 8.3 8.4 94.5 10.8 10.9 11.7 11.8 16.3 16.4 17.7 17.8
62.0 5.0 5.1 5.5 5.6 7.7 7.8 8.5 8.6 95.0 10.9 11.0 11.8 11.9 16.4 16.5 17.9 18.0
62.5 5.1 5.2 5.6 5.7 7.9 8.0 8.6 8.7 95.5 11.0 11.1 11.9 12.0 16.5 16.6 18.0 18.1
63.0 5.2 5.3 5.7 5.8 8.0 8.2 8.8 8.9 96.0 11.1 11.2 12.0 12.1 16.7 16.8 18.2 18.3
63.5 5.3 5.4 5.8 5.9 8.2 8.3 8.9 9.0 96.5 11.2 11.3 12.1 12.2 16.8 16.9 18.4 18.5
64.0 5.4 5.5 5.9 6.0 8.3 8.4 9.1 9.2 97.0 11.3 11.3 12.2 12.3 17.0 17.1 18.5 18.6
64.5 5.5 5.6 6.0 6.1 8.5 8.6 9.3 9.4 97.5 11.4 11.5 12.3 12.4 17.1 17.2 18.7 18.8
65.0 5.6 5.7 6.1 6.2 8.6 8.7 9.4 9.5 98.0 11.5 11.6 12.4 12.5 17.3 17.4 18.9 19.0
65.5 5.7 5.8 6.2 6.3 8.7 8.8 9.6 9.7 98.5 11.6 11.7 12.5 12.6 17.5 17.6 19.1 19.2
66.0 5.8 5.9 6.3 6.4 8.9 9.0 9.7 9.8 99.0 11.7 11.8 12.6 12.7 17.6 17.7 19.2 19.3
66.5 5.9 6.0 6.4 6.5 9.0 9.1 9.9 10.0 99.5 11.8 11.9 12.7 12.8 17.8 17.9 19.4 19.5
67.0 6.0 6.1 6.5 6.6 9.2 9.3 10.0 10.1 100.0 11.9 12.0 12.8 12.9 18.0 18.1 19.6 19.7
67.5 6.1 6.2 6.6 6.7 9.3 9.4 10.2 10.3 100.5 12.0 12.1 12.9 13.0 18.1 18.2 19.8 19.9
68.0 6.2 6.3 6.7 6.8 9.4 9.5 10.3 10.4 101.0 12.1 12.2 13.1 13.2 18.3 18.4 20.0 20.1
68.5 6.3 6.4 6.8 6.9 9.6 9.7 10.5 10.6 101.5 12.2 12.3 13.2 13.3 18.5 18.6 20.2 20.3
69.0 6.4 6.5 6.9 7.0 9.7 9.8 10.6 10.7 102.0 12.3 12.4 13.3 13.4 18.7 18.8 20.4 20.5
69.5 6.5 6.6 7.0 7.1 9.8 9.9 10.8 10.9 102.5 12.4 12.5 13.4 13.5 18.8 18.9 20.6 20.7
70.0 6.5 6.6 7.1 7.2 10.0 10.1 10.9 11.0 103.0 12.5 12.6 13.5 13.6 19.0 19.1 20.8 20.9
70.5 6.6 6.7 7.2 7.3 10.1 10.2 11.1 11.2 103.5 12.6 12.7 13.6 13.7 19.2 19.3 21.0 21.1
71.0 6.7 6.8 7.3 7.4 10.2 10.3 11.2 11.3 104.0 12.7 12.8 13.8 13.9 19.4 19.5 21.2 21.3
71.5 6.8 6.9 7.4 7.5 10.4 10.5 11.3 11.4 104.5 12.8 12.9 13.9 14.0 19.6 19.7 21.5 21.6
72.0 6.9 7.0 7.5 7.6 10.5 10.6 11.5 11.6 105.0 12.9 13.0 14.0 14.1 19.8 19.9 21.7 21.8
72.5 7.0 7.1 7.5 7.6 10.6 10.7 11.6 11.7 105.5 13.1 13.2 14.1 14.2 20.0 20.1 21.9 22.0
73.0 7.1 7.2 7.6 7.7 10.8 10.9 11.8 11.9 106.0 13.2 13.3 14.3 14.4 20.2 20.3 22.1 22.2
73.5 7.1 7.2 7.7 7.8 10.9 11.0 11.9 12.0 106.5 13.3 13.4 14.4 14.5 20.4 20.5 22.4 22.5
74.0 7.2 7.3 7.8 7.9 11.0 11.1 12.1 12.2 107.0 13.4 13.5 14.5 14.6 20.6 20.7 22.6 22.7
74.5 7.3 7.4 7.9 8.0 11.2 11.3 12.2 12.3 107.5 13.5 13.6 14.6 14.7 20.8 20.9 22.8 22.9
75.0 7.4 7.5 8.0 8.1 11.3 11.4 12.3 12.4 108.0 13.6 13.7 14.8 14.9 21.0 21.1 23.1 23.2
75.5 7.5 7.6 8.1 8.2 11.4 11.5 12.5 12.6 108.5 13.7 13.8 14.9 15.0 21.2 21.3 23.3 23.4
76.0 7.5 7.6 8.2 8.3 11.5 11.6 12.6 12.7 109.0 13.9 14.0 15.0 15.1 21.4 21.5 23.6 23.7
76.5 7.6 7.7 8.2 8.3 11.6 11.7 12.7 12.8 109.5 14.0 14.1 15.2 15.3 21.7 21.8 23.8 23.9
77.0 7.7 7.8 8.3 8.4 11.7 11.8 12.8 12.9 110.0 14.1 14.2 15.3 15.4 21.9 22.0 24.1 24.2
77.5 7.8 7.9 8.4 8.5 11.9 12.0 13.0 13.1
1/ Based on the WHO Child Growth Standards, Methods and Development, 2006
2/ This table is also downloadable at url.www.nnc.gov.ph
ANNEX 2.3
WHO Child Growth Standards (birth to 2 years) for girls

Weight (kg) for Length (cm) of Girls 0-23 Months


Obese Obese
45.0 1.8 1.9 2.0 2.1 3.0 3.1 3.3 3.4 78.0 7.4 7.5 8.1 8.2 11.7 11.8 12.9 13.0
45.5 1.9 2.0 2.0 2.1 3.1 3.2 3.4 3.5 78.5 7.5 7.6 8.1 8.2 11.8 11.9 13.0 13.1
46.0 1.9 2.0 2.1 2.2 3.2 3.3 3.5 3.6 79.0 7.6 7.7 8.2 8.3 11.9 12.0 13.1 13.2
46.5 2.0 2.1 2.2 2.3 3.3 3.4 3.6 3.7 79.5 7.6 7.7 8.3 8.4 12.0 12.1 13.3 13.4
47.0 2.1 2.2 2.3 2.4 3.4 3.5 3.7 3.8 80.0 7.7 7.8 8.4 8.5 12.1 12.2 13.4 13.5
47.5 2.1 2.2 2.3 2.4 3.5 3.6 3.8 3.9 80.5 7.8 7.9 8.5 8.6 12.3 12.4 13.5 13.6
48.0 2.2 2.3 2.4 2.5 3.6 3.7 4.0 4.1 81.0 7.9 8.0 8.6 8.7 12.4 12.5 13.7 13.8
48.5 2.3 2.4 2.5 2.6 3.7 3.8 4.1 4.2 81.5 8.0 8.1 8.7 8.8 12.5 12.6 13.8 13.9
49.0 2.3 2.4 2.5 2.6 3.8 3.9 4.2 4.3 82.0 8.0 8.1 8.7 8.8 12.6 12.7 13.9 14.0
49.5 2.4 2.5 2.6 2.7 3.9 4.0 4.3 4.4 82.5 8.1 8.2 8.8 8.9 12.8 12.9 14.1 14.2
50.0 2.5 2.6 2.7 2.8 4.0 4.1 4.5 4.6 83.0 8.2 8.3 8.9 9.0 12.9 13.0 14.2 14.3
50.5 2.6 2.7 2.8 2.9 4.2 4.3 4.6 4.7 83.5 8.3 8.4 9.0 9.1 13.1 13.2 14.4 14.5
51.0 2.7 2.8 2.9 3.0 4.3 4.4 4.8 4.9 84.0 8.4 8.5 9.1 9.2 13.2 13.3 14.5 14.6
51.5 2.7 2.8 3.0 3.1 4.4 4.5 4.9 5.0 84.5 8.5 8.6 9.2 9.3 13.3 13.4 14.7 14.8
52.0 2.8 2.9 3.1 3.2 4.6 4.7 5.1 5.2 85.0 8.6 8.7 9.3 9.4 13.5 13.6 14.9 15.0
52.5 2.9 3.0 3.2 3.3 4.7 4.8 5.2 5.3 85.5 8.7 8.8 9.4 9.5 13.6 13.7 15.0 15.1
53.0 3.0 3.1 3.3 3.4 4.9 5.0 5.4 5.5 86.0 8.8 8.9 9.6 9.7 13.8 13.9 15.2 15.3
53.5 3.1 3.2 3.4 3.5 5.0 5.1 5.5 5.6 86.5 8.9 9.0 9.7 9.8 13.9 14.0 15.4 15.5
54.0 3.2 3.3 3.5 3.6 5.2 5.3 5.7 5.8 87.0 9.0 9.1 9.8 9.9 14.1 14.2 15.5 15.6
54.5 3.3 3.4 3.6 3.7 5.3 5.4 5.9 6.0 87.5 9.1 9.2 9.9 10.0 14.2 14.3 15.7 15.8
55.0 3.4 3.5 3.7 3.8 5.5 5.6 6.1 6.2 88.0 9.2 9.3 10.0 10.1 14.4 14.5 15.9 16.0
55.5 3.5 3.6 3.8 3.9 5.7 5.8 6.3 6.4 88.5 9.3 9.4 10.1 10.2 14.5 14.6 16.0 16.1
56.0 3.6 3.7 3.9 4.0 5.8 5.9 6.4 6.5 89.0 9.4 9.5 10.2 10.3 14.7 14.8 16.2 16.3
56.5 3.7 3.8 4.0 4.1 6.0 6.1 6.6 6.7 89.5 9.5 9.6 10.3 10.4 14.8 14.9 16.4 16.5
57.0 3.8 3.9 4.2 4.3 6.1 6.2 6.8 6.9 90.0 9.6 9.7 10.4 10.5 15.0 15.1 16.5 16.6
57.5 3.9 4.0 4.3 4.4 6.3 6.4 7.0 7.1 90.5 9.7 9.8 10.5 10.6 15.1 15.2 16.7 16.8
58.0 4.0 4.1 4.4 4.5 6.5 6.6 7.1 7.2 91.0 9.8 9.9 10.6 10.7 15.3 15.4 16.9 17.0
58.5 4.1 4.2 4.5 4.6 6.6 6.7 7.3 7.4 91.5 9.9 10.0 10.7 10.8 15.5 15.6 17.0 17.1
59.0 4.2 4.3 4.6 4.7 6.8 6.9 7.5 7.6 92.0 10.0 10.1 10.8 10.9 15.6 15.7 17.2 17.3
59.5 4.3 4.4 4.7 4.8 6.9 7.0 7.7 7.8 92.5 10.0 10.1 10.9 11.0 15.8 15.9 17.4 17.5
60.0 4.4 4.5 4.8 4.9 7.1 7.2 7.8 7.9 93.0 10.1 10.2 11.0 11.1 15.9 16.0 17.5 17.6
60.5 4.5 4.6 4.9 5.0 7.3 7.4 8.0 8.1 93.5 10.2 10.3 11.1 11.2 16.1 16.2 17.7 17.8
61.0 4.6 4.7 5.0 5.1 7.4 7.5 8.2 8.3 94.0 10.3 10.4 11.2 11.3 16.2 16.3 17.9 18.0
61.5 4.7 4.8 5.1 5.2 7.6 7.7 8.4 8.5 94.5 10.4 10.5 11.2 11.4 16.4 16.5 18.0 18.1
62.0 4.8 4.9 5.2 5.3 7.7 7.8 8.5 8.6 95.0 10.5 11.6 11.4 11.5 16.5 16.6 18.2 18.3
62.5 4.9 5.0 5.3 5.4 7.8 7.9 8.7 8.8 95.5 10.6 11.7 11.5 11.6 16.7 16.8 18.4 18.5
63.0 5.0 5.1 5.4 5.5 8.0 8.1 8.8 8.9 96.0 10.7 10.8 11.6 11.7 16.8 16.9 18.6 18.7
63.5 5.1 5.2 5.5 5.6 8.1 8.2 9.0 9.1 96.5 10.8 10.9 11.7 11.8 17.0 17.1 18.7 18.8
64.0 5.2 5.3 5.6 5.7 8.3 8.4 9.1 9.2 97.0 10.9 11.0 11.9 12.0 17.1 17.2 18.9 19.0
64.5 5.3 5.4 5.7 5.8 8.4 8.5 9.3 9.4 97.5 11.0 11.1 12.0 12.1 17.3 17.4 19.1 19.2
65.0 5.4 5.5 5.8 5.9 8.6 8.7 9.5 9.6 98.0 11.1 11.2 12.1 12.2 17.5 17.6 19.3 19.4
65.5 5.4 5.5 5.9 6.0 8.7 8.8 9.6 9.7 98.5 11.2 11.3 12.2 12.3 17.6 17.7 19.5 19.6
66.0 5.5 5.6 6.0 6.1 8.8 8.9 9.8 9.9 99.0 11.3 11.4 12.3 12.4 17.8 17.9 19.6 19.7
66.5 5.6 5.7 6.1 6.2 9.0 9.1 9.9 10.0 99.5 11.4 11.5 12.4 12.5 18.0 18.1 19.8 19.9
67.0 5.7 5.8 6.2 6.3 9.1 9.2 10.0 10.1 100.0 11.5 11.6 12.5 12.6 18.1 18.2 20.0 20.1
67.5 5.8 5.9 6.3 6.4 9.2 9.3 10.2 10.3 100.5 11.6 11.7 12.6 12.7 18.3 18.4 20.2 20.3
68.0 5.9 6.0 6.4 6.5 9.4 9.5 10.3 10.4 101.0 11.7 11.8 12.7 12.8 18.5 18.6 20.4 20.5
68.5 6.0 6.1 6.5 6.6 9.5 9.6 10.5 10.6 101.5 11.8 11.9 12.9 13.0 18.7 18.8 20.6 20.7
69.0 6.0 6.1 6.6 6.7 9.6 9.7 10.6 10.7 102.0 11.9 12.0 13.0 13.1 18.9 19.0 20.8 20.9
69.5 6.1 6.2 6.7 6.8 9.7 9.8 10.7 10.8 102.5 12.0 12.1 13.1 13.2 19.0 19.1 21.0 21.1
70.0 6.2 6.3 6.8 6.9 9.9 10.0 10.9 11.0 103.0 12.2 12.3 13.2 13.3 19.2 19.3 21.3 21.4
70.5 6.3 6.4 6.8 6.9 10.0 10.1 11.1 11.1 103.5 12.3 12.4 13.4 13.5 19.3 19.5 21.5 21.6
71.0 6.4 6.5 6.9 7.0 10.1 10.2 11.1 11.2 104.0 12.4 12.5 13.5 13.6 19.6 19.7 21.7 21.8
71.5 6.4 6.5 7.0 7.1 10.2 10.3 11.3 11.4 104.5 12.5 12.6 13.6 13.7 19.8 19.9 21.9 22.0
72.0 6.5 6.6 7.1 7.2 10.3 10.4 11.4 11.5 105.0 12.6 12.7 13.7 13.8 20.0 20.1 22.2 22.3
72.5 6.6 6.7 7.2 7.3 10.5 10.6 11.5 11.6 105.5 12.7 12.8 13.9 14.0 20.2 20.3 22.4 22.5
73.0 6.7 6.8 7.3 7.4 10.6 10.7 11.7 11.8 106.0 12.9 13.0 14.0 14.1 20.5 20.6 22.6 22.7
73.5 6.8 6.9 7.3 7.4 10.7 10.8 11.8 11.9 106.5 13.0 13.1 14.2 14.3 20.7 20.8 22.9 23.0
74.0 6.8 6.9 7.4 7.5 10.8 10.9 11.9 12.0 107.0 13.1 13.2 14.3 14.4 20.9 21.0 23.1 23.2
74.5 6.9 7.0 7.5 7.6 10.9 11.0 12.0 12.1 107.5 13.2 13.3 14.4 14.5 21.1 21.2 23.4 23.5
75.0 7.0 7.1 7.6 7.7 11.0 11.1 12.2 12.3 108.0 13.4 13.5 14.6 14.7 21.3 21.4 23.6 23.7
75.5 7.0 7.1 7.7 7.8 11.1 11.2 12.3 12.4 108.5 13.5 13.6 14.7 14.8 21.6 21.7 23.9 24.0
76.0 7.1 7.2 7.7 7.8 11.2 11.3 12.4 12.5 109.0 13.6 13.7 14.9 15.0 21.8 21.9 24.2 24.3
76.5 7.2 7.3 7.8 7.9 11.4 11.5 12.5 12.6 109.5 13.8 13.9 15.0 15.1 22.0 22.1 24.4 24.5
77.0 7.3 7.4 7.9 8.0 11.5 11.6 12.6 12.7 110.0 13.9 14.0 15.2 15.3 22.3 22.4 24.7 24.8
77.5 7.3 7.4 8.0 8.1 11.6 11.7 12.8 12.9
Module 2
ANNEX 2.4
WHO Child Growth Standards (24 months to 60 months) for boys

Weight (kg) for Length (cm) of Boys 24-60 Months


Obese Obese
65.0 5.8 5.9 6.2 6.3 8.8 8.9 9.6 9.7 93.0 10.7 10.8 11.5 11.6 16.0 16.1 17.5 17.6
65.5 5.9 6.0 6.3 6.4 8.9 9.0 9.8 9.9 93.5 10.8 10.9 11.6 11.7 16.2 16.3 17.6 17.7
66.0 6.0 6.1 6.4 6.5 9.1 9.2 9.9 10.0 94.0 10.9 11.0 11.7 11.8 16.3 16.4 17.8 17.9
66.5 6.0 6.1 6.5 6.6 9.2 9.3 10.1 10.2 94.5 11.0 11.1 11.8 11.9 16.5 16.6 17.9 18.0
67.0 6.1 6.2 6.6 6.7 9.4 9.5 10.2 10.3 95.0 11.0 11.1 11.9 12.0 16.6 16.7 18.1 18.2
67.5 6.2 6.3 6.7 6.8 9.5 9.6 10.4 10.5 95.5 11.1 11.2 12.0 12.1 16.7 16.8 18.3 18.4
68.0 6.3 6.4 6.8 6.9 9.6 9.7 10.5 10.6 96.0 11.2 11.3 12.1 12.2 16.9 17.0 18.4 18.5
68.5 6.4 6.5 6.9 7.0 9.8 9.9 10.7 10.8 96.5 11.3 11.4 12.2 12.3 17.0 17.1 18.6 18.7
69.0 6.5 6.6 7.0 7.1 9.9 10.0 10.8 10.9 97.0 11.4 11.5 12.3 12.4 17.2 17.3 18.8 18.9
69.5 6.6 6.7 7.1 7.2 10.0 10.1 11.0 11.1 97.5 11.5 11.6 12.4 12.5 17.4 17.5 18.9 19.0
70.0 6.7 6.8 7.2 7.3 10.2 10.3 11.1 11.2 98.0 11.6 11.7 12.5 12.6 17.5 17.6 19.1 19.2
70.5 6.8 6.9 7.3 7.4 10.3 10.4 11.3 11.4 98.5 11.7 11.8 12.7 12.8 17.7 17.8 19.3 19.4
71.0 6.8 6.9 7.4 7.5 10.4 10.5 11.4 11.5 99.0 11.8 11.9 12.8 12.9 17.9 18.0 19.5 19.6
71.5 6.9 7.0 7.5 7.6 10.6 10.7 11.6 11.7 99.5 11.9 12.0 12.9 13.0 18.0 18.1 19.7 19.8
72.0 7.0 7.1 7.6 7.7 10.7 10.8 11.7 11.8 100.0 12.0 12.1 13.0 13.1 18.2 18.3 19.9 20.0
72.5 7.1 7.2 7.7 7.8 10.8 10.9 11.8 11.9 100.5 12.1 12.2 13.1 13.2 18.4 18.5 20.1 20.2
73.0 7.2 7.3 7.8 7.9 11.0 11.1 12.0 12.1 101.0 12.2 12.3 13.2 13.3 18.5 18.6 20.3 20.4
73.5 7.3 7.4 7.8 7.9 11.1 11.2 12.1 12.2 101.5 12.3 12.4 13.3 13.4 18.7 18.8 20.5 20.6
74.0 7.3 7.4 7.9 8.0 11.2 11.3 12.2 12.3 102.0 12.4 12.5 13.5 13.6 18.9 19.0 20.7 20.8
74.5 7.4 7.5 8.0 8.1 11.3 11.4 12.4 12.5 102.5 12.5 12.6 13.6 13.7 19.1 19.2 20.9 21.0
75.0 7.5 7.6 8.1 8.2 11.4 11.5 12.5 12.6 103.0 12.7 12.8 13.7 13.8 19.3 19.4 21.1 21.2
75.5 7.6 7.7 8.2 8.3 11.6 11.7 12.6 12.7 103.5 12.8 12.9 13.8 13.9 19.5 19.6 21.3 21.4
76.0 7.6 7.7 8.3 8.4 11.7 11.8 12.8 12.9 104.0 12.9 13.0 13.9 14.0 19.7 19.8 21.6 21.7
76.5 7.7 7.8 8.4 8.5 11.8 11.9 12.9 13.0 104.5 13.0 13.1 14.1 14.2 19.9 20.0 21.8 21.9
77.0 7.8 7.9 8.4 8.5 11.9 12.0 13.0 13.1 105.0 13.1 13.2 14.2 14.3 20.1 20.2 22.0 22.1
77.5 7.9 8.0 8.5 8.6 12.0 12.1 13.1 13.2 105.5 13.2 13.3 14.3 14.4 20.3 20.4 22.2 22.3
78.0 7.9 8.0 8.6 8.7 12.1 12.2 13.3 13.4 106.0 13.3 13.4 14.4 14.5 20.5 20.6 22.5 22.6
78.5 8.0 8.1 8.7 8.8 12.2 12.3 13.4 13.5 106.5 13.4 13.5 14.6 14.7 20.7 20.8 22.7 22.8
79.0 8.1 8.2 8.7 8.8 12.3 12.4 13.5 13.6 107.0 13.6 13.7 14.7 14.8 20.9 21.0 23.9 23.0
79.5 8.2 8.3 8.8 8.9 12.4 12.5 13.6 13.7 107.5 13.7 13.8 14.8 14.9 21.1 21.2 23.2 23.3
80.0 8.2 8.3 8.9 9.0 12.6 12.7 13.7 13.8 108.0 13.8 13.9 15.0 15.1 21.3 21.4 23.4 23.5
80.5 8.3 8.4 9.0 9.1 12.7 12.8 13.8 13.9 108.5 13.9 14.0 15.1 15.2 21.5 21.6 23.7 23.8
81.0 8.4 8.5 9.1 9.2 12.8 12.9 14.0 14.1 109.0 14.0 14.1 15.2 15.3 21.8 21.9 23.9 24.0
81.5 8.5 8.6 9.2 9.3 12.9 13.0 14.1 14.2 109.5 14.2 14.3 15.4 15.5 22.0 22.1 24.2 24.3
82.0 8.6 8.7 9.2 9.3 13.0 13.1 14.2 14.3 110.0 14.3 14.4 15.5 15.6 22.2 22.3 24.4 24.5
82.5 8.6 8.7 9.3 9.4 13.1 13.2 14.4 14.5 110.5 14.4 4.5 15.7 15.8 22.4 22.5 24.7 24.8
83.0 8.7 8.8 9.4 9.5 13.3 13.4 14.5 14.6 111.0 14.5 14.6 15.8 15.9 22.7 22.8 25.0 25.1
83.5 8.8 8.9 9.5 9.6 13.4 13.5 14.6 14.7 111.5 14.7 14.8 15.9 16.0 22.9 23.0 25.2 25.3
84.0 8.9 9.0 9.6 9.7 13.5 13.6 14.8 14.9 112.0 14.8 14.9 16.1 16.2 23.1 23.2 25.5 25.6
84.5 9.0 9.1 9.8 9.9 13.7 13.8 14.9 15.0 112.5 14.9 15.0 16.2 16.3 23.4 23.5 25.8 25.9
85.0 9.1 9.2 9.9 10.0 13.8 13.9 15.1 15.2 113.0 15.1 15.2 16.4 16.5 23.6 23.7 26.0 26.1
85.5 9.2 9.3 10.0 10.1 13.9 14.0 15.2 15.3 113.5 15.2 15.3 16.5 16.6 23.9 24.0 26.3 26.4
86.0 9.3 9.4 10.1 10.2 14.1 14.2 15.4 15.5 114.0 15.3 15.4 16.7 16.8 24.1 24.2 26.6 26.7
86.5 9.4 9.5 10.2 10.3 14.2 14.3 15.5 15.6 114.5 15.5 15.6 16.8 16.9 24.4 24.5 26.9 27.0
87.0 9.5 9.6 10.3 10.4 14.4 14.5 15.7 15.8 115.0 15.6 15.7 17.0 17.1 24.6 24.7 27.2 27.3
87.5 9.6 9.7 10.4 10.5 14.5 14.6 15.8 15.9 115.5 15.7 15.8 17.1 17.2 24.9 25.0 27.5 27.6
88.0 9.7 9.8 10.5 10.6 14.7 14.8 16.0 16.1 116.0 15.9 16.0 17.3 17.4 25.1 25.2 27.8 27.9
88.5 9.8 9.9 10.6 10.7 14.8 14.9 16.1 16.2 116.5 16.0 16.1 17.4 17.5 25.4 25.5 28.0 28.1
89.0 9.9 10.0 10.7 10.8 14.9 15.0 16.3 16.4 117.0 16.1 16.2 17.6 17.7 25.6 25.7 28.3 28.4
89.5 9.0 10.1 10.8 10.9 15.1 15.2 16.4 16.5 117.5 16.3 16.4 17.8 17.9 25.9 26.0 28.6 28.7
90.0 10.1 10.2 10.9 11.0 15.2 15.3 16.6 16.7 118.0 16.4 16.5 17.9 18.0 26.1 26.2 28.9 29.0
90.5 10.2 10.3 11.0 11.1 15.3 15.4 16.7 16.8 118.5 16.6 16.7 18.1 18.2 26.4 26.5 29.2 29.3
91.0 10.3 10.4 11.1 11.2 15.5 15.6 16.9 17.0 119.0 16.7 16.8 18.2 18.3 26.6 26.7 29.5 29.6
91.5 10.4 10.5 11.2 11.3 15.6 15.7 17.0 17.1 119.5 16.8 16.9 18.4 18.5 26.9 27.0 29.8 29.9
92.0 10.5 10.6 11.3 11.4 15.8 15.9 17.2 17.3 120.0 17.0 17.1 18.5 18.6 27.2 27.3 30.1 30.2
92.5 10.6 10.7 11.4 11.5 15.9 16.0 17.3 17.4
ANNEX 2.5
WHO Child Growth Standards (24 months to 60 months) for girls

Weight (kg) for Length (cm) of Girls 24-60 Months


Obese Obese
65.0 5.5 5.6 6.0 6.1 8.7 8.8 9.7 9.8 93.0 10.3 10.4 11.2 11.3 16.1 16.2 17.8 17.9
65.5 5.6 5.7 6.1 6.2 8.9 9.0 9.8 9.9 93.5 10.4 10.5 11.3 11.4 16.3 16.4 17.9 18.0
66.0 5.7 5.8 6.2 6.3 9.0 9.1 10.0 10.1 94.0 10.5 10.6 11.4 11.5 16.4 16.5 18.1 18.2
66.5 5.7 5.8 6.3 6.4 9.1 9.2 10.1 10.2 94.5 10.6 10.7 11.5 11.6 16.6 16.7 18.3 18.4
67.0 5.8 5.9 6.3 6.4 9.3 9.4 10.2 10.3 95.0 10.7 10.8 11.6 11.7 16.7 16.8 18.5 18.6
67.5 5.9 6.0 6.4 6.5 9.4 9.5 10.4 10.5 95.5 10.7 10.8 11.7 11.8 16.9 17.0 18.6 18.7
68.0 6.0 6.1 6.5 6.6 9.5 9.6 10.5 10.6 96.0 10.8 10.9 11.8 11.9 17.0 17.1 18.8 18.9
68.5 6.1 6.2 6.6 6.7 9.7 9.8 10.7 10.8 96.5 10.9 11.0 11.9 12.0 17.2 17.3 19.0 19.1
69.0 6.2 6.3 6.7 6.8 9.8 9.9 10.8 10.9 97.0 11.0 11.1 12.0 12.1 17.4 17.5 19.2 19.3
69.5 6.2 6.3 6.8 6.9 9.9 10.0 10.9 11.0 97.5 11.1 11.2 12.1 12.2 17.5 17.6 19.3 19.4
70.0 6.3 6.4 6.9 7.0 10.0 10.1 11.1 11.2 98.0 11.2 11.3 12.2 12.3 17.7 17.8 19.5 19.6
70.5 6.4 6.5 7.0 7.1 10.1 10.2 11.2 11.3 98.5 11.3 11.4 12.3 12.4 17.9 18.0 19.7 19.8
71.0 6.5 6.6 7.0 7.1 10.3 10.4 11.3 11.4 99.0 11.4 11.5 12.4 12.5 18.0 18.1 19.9 20.0
71.5 6.6 6.7 7.1 7.2 10.4 10.5 11.5 11.6 99.5 11.5 11.6 12.6 12.7 18.2 18.3 20.1 20.2
72.0 6.6 6.7 7.2 7.3 10.5 10.6 11.6 11.7 100.0 11.6 11.7 12.7 12.8 18.4 18.5 20.3 20.4
72.5 6.7 6.8 7.3 7.4 10.6 10.7 11.7 11.8 100.5 11.8 11.9 12.8 12.9 18.6 18.7 20.5 20.6
73.0 6.8 6.9 7.4 7.5 10.7 10.8 11.8 11.9 101.0 11.9 12.0 12.9 13.0 18.7 18.8 20.7 20.8
73.5 6.9 7.0 7.5 7.6 10.8 10.9 12.0 12.1 101.5 12.0 12.1 13.0 13.1 18.9 19.0 20.9 21.0
74.0 6.9 7.0 7.5 7.6 11.0 11.1 12.1 12.2 102.0 12.1 12.2 13.2 13.3 19.1 19.2 21.1 21.2
74.5 7.0 7.1 7.6 7.7 11.1 11.2 12.2 12.3 102.5 12.2 12.3 13.3 13.4 19.3 19.4 21.4 21.5
75.0 7.1 7.2 7.7 7.8 11.2 11.3 12.3 12.4 103.0 12.3 12.4 13.4 13.5 19.5 19.6 21.6 21.7
75.5 7.1 7.2 7.8 7.9 11.3 11.4 12.5 12.6 103.5 12.4 12.5 13.5 13.6 19.7 19.8 21.8 21.9
76.0 7.2 7.3 7.9 8.0 11.4 11.5 12.6 12.7 104.0 12.5 12.6 13.7 14.8 19.9 20.0 22.0 22.1
76.5 7.3 7.4 7.9 8.0 11.5 11.6 12.7 12.8 104.5 12.7 12.8 13.8 14.9 20.1 20.2 22.3 22.4
77.0 7.4 7.5 8.0 8.1 11.6 12.7 12.8 12.9 105.0 12.8 12.9 13.9 14.0 20.3 20.4 22.5 22.6
77.5 7.4 7.5 8.1 8.2 11.7 12.8 12.9 13.0 105.5 12.9 13.0 14.1 14.2 20.5 20.6 22.7 22.8
78.0 7.5 7.6 8.2 8.3 11.8 12.9 13.1 13.2 106.0 13.0 13.1 14.2 14.3 20.8 20.9 23.0 23.1
78.5 7.6 7.7 8.3 8.4 12.0 12.1 13.2 13.3 106.5 13.2 13.3 14.4 14.5 21.0 21.1 23.2 23.3
79.0 7.7 7.8 8.3 8.4 12.1 12.2 13.3 13.4 107.0 13.3 13.4 14.5 14.6 21.2 21.3 23.5 23.6
79.5 7.7 7.8 8.4 8.5 12.2 12.3 13.4 13.5 107.5 13.4 13.5 14.6 14.7 21.4 21.5 23.7 23.8
80.0 7.8 7.9 8.5 8.6 12.3 12.4 13.6 13.7 108.0 13.6 13.7 14.8 15.9 21.7 21.8 24.0 24.1
80.5 7.9 8.0 8.6 8.7 12.4 12.5 13.7 13.8 108.5 13.7 13.8 14.9 15.0 21.9 22.0 24.3 24.4
81.0 8.0 8.1 8.7 8.8 12.6 12.7 13.9 14.0 109.0 13.8 13.9 15.1 15.2 22.1 22.2 24.5 24.6
81.5 8.1 8.2 8.8 8.9 12.7 13.8 14.0 14.1 109.5 14.0 14.1 15.3 15.4 22.4 22.5 24.8 24.9
82.0 8.2 8.3 8.9 9.0 12.8 13.9 14.1 14.2 110.0 14.1 14.2 15.4 15.5 22.6 22.7 25.1 25.2
82.5 8.3 8.4 9.0 9.1 13.0 13.1 14.3 14.4 110.5 14.3 14.4 15.6 15.7 22.9 23.0 25.4 25.5
83.0 8.4 8.5 9.1 9.2 13.1 13.2 14.5 14.6 111.0 14.4 14.5 15.7 15.8 23.1 23.2 25.7 25.8
83.5 8.4 8.5 9.2 9.3 13.3 13.4 14.6 14.7 111.5 14.6 14.7 15.9 16.0 23.4 23.5 26.0 26.1
84.0 8.5 8.6 9.3 9.4 13.4 13.5 14.8 14.9 112.0 14.7 14.8 16.1 16.2 23.6 23.7 26.2 26.3
84.5 8.6 8.7 9.4 9.5 13.5 13.6 14.9 15.0 112.5 14.9 15.0 16.2 16.3 23.9 24.0 26.5 26.6
85.0 8.7 8.8 9.5 9.6 13.7 13.8 15.1 15.2 113.0 15.0 15.1 16.4 16.5 24.2 24.3 26.8 26.9
85.5 8.8 8.9 9.6 9.7 13.8 14.9 15.3 15.4 113.5 15.2 15.3 16.6 16.7 24.4 24.5 27.1 27.2
86.0 8.9 9.0 9.7 9.8 14.0 14.1 15.4 15.5 114.0 15.3 15.4 16.7 16.8 24.7 24.8 27.4 27.5
86.5 9.0 9.1 9.8 9.9 14.2 14.3 15.6 15.7 114.5 15.5 15.6 16.9 17.0 25.0 25.1 27.8 27.9
87.0 9.1 9.2 9.9 10.0 14.3 14.4 15.8 15.9 115.0 15.6 15.7 17.1 17.2 25.2 25.3 28.1 28.2
87.5 9.2 9.3 10.0 10.1 14.5 14.6 15.9 16.0 115.5 15.8 15.9 17.2 17.3 25.5 25.6 28.4 28.5
88.0 9.3 9.4 10.1 10.2 14.6 14.7 16.1 16.2 116.0 15.9 16.0 17.4 17.5 25.8 25.9 28.7 28.8
88.5 9.4 9.5 10.2 10.3 14.8 14.9 16.3 16.4 116.5 16.1 16.2 17.6 17.7 26.1 26.2 29.0 29.1
89.0 9.5 9.6 10.3 10.4 14.9 15.0 16.4 16.5 117.0 16.2 16.3 17.7 17.8 26.3 26.4 29.3 29.4
89.5 9.6 9.7 10.4 10.5 15.1 15.2 16.6 16.7 117.5 16.4 16.5 17.9 18.0 26.6 26.7 29.6 29.7
90.0 9.7 9.8 10.5 10.6 15.2 15.3 16.8 16.9 118.0 16.5 16.6 18.1 18.2 26.9 27.0 29.9 30.0
90.5 9.8 9.9 10.6 10.7 15.4 15.5 16.9 17.0 118.5 16.7 16.8 18.3 18.4 27.2 27.3 30.3 30.4
91.0 9.9 10.0 10.8 10.9 15.5 15.6 17.1 17.2 119.0 16.8 16.9 18.4 18.5 27.4 27.5 30.6 30.7
91.5 10.0 10.1 10.9 10.0 15.7 15.8 17.3 17.4 119.5 17.0 17.1 18.6 18.7 27.7 27.8 30.9 31.0
92.0 10.1 10.2 11.0 11.1 15.8 15.9 17.4 17.5 120.0 17.2 17.3 18.8 18.9 28.0 28.1 31.2 31.3
92.5 10.2 10.3 11.1 11.2 16.0 16.1 17.6 17.7
Module 2
ANNEX 2.6
Identification of SAM for children/adolescents older than 59 months
Steps in the Appetite Test:
1. Take weight and height measurements

2. Compute for the body mass index or BMI (weight in kg multiplied by height in m2) and determine
the Z-scores by referring to the following charts:
Reference: Growth reference 5-19 years © WHO 2016 http://www.who.int/growthref/who2007_bmi_for_age/en/
BMI-for-age GIRLS
5 to 19 years (z-scores)
32 32
30 30
2
28 28
26 26
1
24 24
BMI (kg/m3)
22 22
0
20 20
18 18
-2
16 16
-3
14 14
12 12
Months 10 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9
10
Years 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Age (completed months and years)
2007 WHO Reference
3. Locate the child’s/adolescent’s BMI and determine under which classification it falls under
(severely thinness, thinness, normal, overweight or obesity).
Interpretation on cut-offs Cut-offs
Greater than +2SD (equivalent to BMI 30 kg/m2 at

Obesity
19 years)
Greater than +1SD (equivalent to BMI 25 kg/m2 at
Overweight
19 years)
Thinness Less than -2SD
Severe thinness Less than -3SD
Reference: Growth reference 5-19 years © WHO 2016 http://www.who.int/growthref/who2007_bmi_for_age/en/
List of Tables
Checklists
A. Determining the WFH or WFL Z score
Done Partially Not done

STEPS
(2 pts.) done (1 pt.) (0 pt)
1. Determine age
2. Determine sex
3. Get the correct WHO Growth Standards Table
4. Round off measured length or height to the nearest 0.5 cm
5. Locate the rounded off length or height in the WHO Growth
Standards Table
6. Located the weight of the patient in the Table along the same
line as the length/height
7. Determine the category of wasting, if any, of the child
8. Record the Z score
9. Interpreted the Z score
10. Recorded the diagnosis
B. Measuring the MUAC
Partially
Done Not done
STEPS done
(2 pts.) (0 pt)
(1 pt.)
1. Asked the mother to remove clothing that may cover the
child’s left arm
2. Calculated the midpoint of the child’s left upper arm.
3. Divided the number by two to estimate the midpoint.
4. Marked the midpoint with a pen on the arm
5. Straightened the child’s arm and wrapped the tape around
the arm at the midpoint. Made sure the numbers are right
side up. Made sure the tape is flat around the skin.
6. Inspected the tension of the tape on the child’s arm.
7. When the tape was in the correct position on the arm with
correct tension, read and called out the measurement to the
nearest 0.1cm
8. Immediately recorded the measurement
Total Score
Module 2
C. Checklist on Bilateral Edema Identification
Done Partially done Not done

STEPS
(2 pts.) (1 pt.) (0 pt)
1. Applied normal thumb pressure to both feet for at
least three seconds. Checks upper extremities.
2. Identified the presence or absence of edema
3. Recorded the presence or absence of edema
Total Score
References

2. WHO Training Course on the Management of Severe Malnutrition. 2002
3. Sethuraman, Kavita et al. 2014. Managing Acute Malnutrition: A Review of the Evidence
and Country Experiences in South Asia and a Recommended Approach for Bangladesh.
Washington, DC: FHI 360/ Food and Nutrition Technical Assistance III Project (FANTA).
Module 3
Community Mobilization
Target Learners
This Module is intended for Barangay Health Workers, Barangay Nutrition Scholars, City Nutrition
Officers, and other health workers or volunteers based in the community or local government
unit.
It is an optional module for training workshops in hospital settings where there are practicing
specialists.
This module discusses community mobilization as a vital part of any program for managing
SAM. It involves engagement with the community to promote a common understanding of acute
malnutrition. Available services to prevent and treat malnutrition are actively promoted. Key is the
timely detection, treatment and warranted referral of children with SAM prior to their worsening
or deterioration. Equally emphasized is the importance of ensuring continuity of treatment until
each child is cured. This aims to find every child with SAM and protect her/him from further
deterioration or death.
______________________________________________________________
1. Effectively describe community mobilization and its stages

2. Discuss the importance and process of engagement with the community prior to
commencing the service and during implementation
3. Describe the process of community sensitization for community awareness of acute
malnutrition, its effects, and available local treatment
4. Discuss case finding of acute malnutrition in the community
5. Refer patients for treatment and follow-up at-risk cases of severe acute malnutrition at
home when needed
Definition of Terms
Community Mobilization
• Community mobilization includes activities to sensitize the community to the program,
screening children in the community to find cases needing treatment and community-
based activities that support keeping the child in treatment until s/he is cured.
Community Sensitization
• Community sensitization aims to make the local community aware of SAM and understand
the condition, its possible treatment and effects
Module 3
Key Concepts
Figure 3.1. Stages in Community Mobilization
Links with other community initiatives
Developing Training
Community Case Recording
Community Message Community
Sensitization Finding Follow-up and
Assessment and Outreach
and Dialogue Referral Reporting
Materials Workers
Ongoing community sensitization

and mobilization
Planning Phase Implementation Phase
Session 3.1:
Community Assessment
A community assessment:
• Aims to understand the existing capacities in health, nutrition and community awareness of
malnutrition at local level
• Includes a series of interviews and focus group discussions conducted with key community
informants
• Important elements of a community assessment
»» Local perceptions of acute malnutrition and the terms used to describe it (e.g., “payat at
sakitin” or “niwang ug masakiton”), perceived causes and common treatments.
»» Community structures, focal persons and means of communication which can be used to
raise awareness
»» Attitudes toward illness and malnutrition and usual health-seeking behaviors
»» Ethnic, social and cultural characteristics related to feeding and nutrition of young children
»» Dialogue with the community about the SAM treatment services
»» Opportunities to access children at community level for identification and follow-up of SAM
cases
»» Child care practices and locally available services
»» Other existing nutrition and health interventions in the community for child care (e.g., OPT
and GP)
Session 3.2:
Community Sensitization and Developing Key Messages
and Materials
• Based on the community capacity assessment, a sensitization plan should be developed by the
City/Municipal Nutrition Committee (C/MNC) in collaboration with City/Municipal/LGU official,
local nutrition cluster, and key community representatives through local meetings
• The sensitization plan aims to inform all sectors of the community regarding the services for
treating SAM and this should be reviewed with influential persons in the community to check if
it is culturally appropriate before disseminating it.
• After the program has started, the community dialogue is continued in order to continue
maximizing the number of children with SAM who are able to access treatment.
• Key information to be included in a sensitization plan, and therefore in sensitization messages:
»» Information about the signs and symptoms of infants and children with SAM
»» Why treating children with SAM is important to the community
»» How children with SAM can be identified using MUAC, edema, or weight-for-height
»» Which age group is eligible for treatment
»» Information regarding where and when to access treatment for children with SAM
»» What to expect when a child with SAM is being treated (e.g. what is given and how long)
»» Whether SAM treatment is part of regular health services or an emergency response
»» Information that most children can be treated at home but some may still need hospital
treatment
»» What treatment can a child with SAM receive at home, including RUTF and medicines
»» Information that RUTF is Halal
• Based on the information gathered during the assessment and preparation for sensitization,
simple sensitization messages for acute malnutrition and the SAM treatment service are
developed.
• A short flyer translated into the local language/dialect, may be provided to reinforce messages
given at the community sensitization meeting or to distribute to communities unable to access
the orientation meeting.
IMPORTANT MESSAGE TO ALL CAREGIVERS AND FAMILIES WITH CHILDREN

AGES BETWEEN 6 MONTHS AND 5 YEARS
A new treatment is now available at Rural Health Units and Barangay Health Stations for the
treatment of children between six months and five years who are very thin, or who have swollen
feet. Children with these features suffer from a severe form of malnutrition. The families with such
children now do not have to stay in the hospital for a long time but can treat the child at home under
the supervision of the local health team.
To be eligible for this treatment, the child has the arm measured with a special tape (called a MUAC
tape) to see if he/she is thin. The feet are also checked to see if they have begun to swell. If the
arm is too thin or there is swelling of the feet, the child visits the closest RHU or BHS to their home.
Many types of person can do the measurement. The Barangay Nutrition Scholar or Barangay Health
Worker will check the measurement to ensure it is correct and will then initiate the treatment with
the assistance of the local midwife / nurse. The child will receive antibiotics and a special treatment
for severe malnutrition called RUTF. RUTF is a special "medicinal food", like a sweet peanut butter,
containing all of the nutrition the child needs to recover. The child may be required to visit the doctor
in some circumstances to be prescribed extra medicines.
The child will visit the RHU /BHS weekly or two weekly to assess recovery and to receive more
supplies of RUTF. The health team will determine how much RUTF the child should eat each day /
week. Full recovery takes approximately 6 to 8 weeks.
If you know a child who is very thin, or whose feet have started to swell, let his parents or guardians
and any pregnant or lactating caregivers know about this new treatment. They can inquire with the
Barangay Captain or Barangay Nutrition Committee for the name of the person trained in the arm
measurement, or they can go direct to the RHU or BHS.
All members of the community, with children who are eligible for treatment, may access this service;
no one is excluded.
Module 3
• The following items can be shown as Information, Education and Communication (IEC) materials
»» A MUAC tape should be shown to community members during the orientation meetings,
indicating the cut off point for treatment.
Figure 3.2. MUAC Tape
SAM - Less than 115mm/11.5cm (colored RED)

MAM - 115mm/11.5cm to 125mm/12.5cm (colored YELLOW)
Normal - Greater than or equal to 125mm/12.5cm (colored GREEN)*
• A packet of RUTF should be provided during meetings to show to community members.

»» Before and after treatment photographs of children who have successfully completed
treatment should be supplied.
Figure 3.3. RUTF supplies
Examples of types of RUTF used for treating SAM
Session 3.3:
Training and Case Finding
Training
• SAM treatment training activities related to community mobilization should be coordinated

through the Barangay/City/Municipal Nutrition Committees.
• The City/Municipal Health Officer (MHO) and the City/Municipal Nutrition Action Officer (MNAO),
as well as supervising midwives should ensure that the BNSs/BHWs and other volunteers are
trained in engaging with the community, disseminating sensitization messages effectively and
identifying and referring SAM cases.
• MUAC is used as an alternative measure of “thinness” to weight-for-height in children more than
6 months to five years.
»» It is a simple measure of muscle wasting and has been shown to have the highest
correlation with risk of mortality of any anthropometric indicator
»» It is the most appropriate for use in decentralized services but does not take the place of
routine growth monitoring.
»» The steps for taking the MUAC are indicated in Module 2: Identification of SAM
• Bilateral edema is a sign that a child is acutely malnourished and has a high risk of dying. This
child should be started on a therapeutic feeding program immediately. The technique to show
that edema is present is indicated in Module 2: Identification of SAM.
Case Finding
• The aim of case finding is to ensure that children are screened regularly so as to identify SAM
in its early stages, when it is most easily treated. Mothers and caregivers are asked about and
observed on their breastfeeding as part of the case-finding to integrate so-called ‘breastfeeding-
sensitive’ interventions.
• Where BNS/BHWs are active and serve as the primary community level workers acting in an
area, they can act as a focal point for all these other community workers who are conducting
case finding (i.e. these workers can refer children to the BNS/BHW for checking of MUAC and
edema measurements before they are referred to the health facility).
• 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, general structure of villages.
• Different types of case finding:
»» Active case finding - when the BHW/BNS/Midwife visits the community to find cases of
SAM; only households with children 6 - 59 months matching the locally understood and
accepted descriptions of malnutrition and its signs are visited
»» Passive case finding - when the child comes to the BHW/BNS/Midwife or health center for
some other purpose and is screened for SAM during that activity. This may be through use
of the IMCI tool. Passive case finding should be done systematically whenever possible so
that every child is screened at every visit.
»» Active adaptive case finding - instead of going house-to-house, the BHW/BNS may visit
every third or fourth house screening for SAM and ask if the parents know of other children
in the neighborhood who they suspect might have SAM
• Criteria for identification of cases:
»» Children aged 6-59 months and infants are the focus for the management of SAM. To
determine age, birth dates can be identified and confirmed with the help of a birth certificate,
child health card or ECCD Card. In some cases, age groups can be identified by using a
local calendar of events to help determine age if a birth date is not known.
»» In the Philippines, MUAC and assessment of edema are the priority tools for case finding
at community level.
Table 3.1. Community-level Case-finding Criteria
Moderate Acute Malnutrition Severe Acute Malnutrition
MUAC (equivalent to 115 mm) 11.5 cm

Edema Bilateral Pitting
Module 3
»» Identified SAM children are then further assessed by the BHW/BNS or other facility staff
for appetite and complications.
• Case finding for SAM treatment involves identifying children who are should be treated. Case
finding may be ‘passive’ or ‘active’. For the purposes of community mobilization, case finding is
done mainly in the community by the BNS/BHW or other local volunteer worker.
»» Community level workers for involvement in case finding in the Philippines
1. Local Nutrition Committee/Cluster
2. BNSs and BHWs
3. Midwives and other RHU staff
4. Barangay Council for the Protection of Children (BCPC) members
5. Municipal and Barangay Social Workers
6. Early Childhood Care and Development (ECCD) staff and Facilitators
7. WASH volunteers
8. Traditional healers and traditional birth attendants (“hilot”)
9. Caregivers’ Group Members and individual caregivers
10. Social Mobilizers
11. Community Health Workers of CBOs/local NGOs/clubs
12. Informal assemblies
13. Citizen Awareness Center
14. Women Cooperatives/Federations
15. Faith-based groups
16. Teachers
• Achieving Coverage:
»» Coverage assessments may involve specific active case finding activities in order to
assess whether the program is enabling access to treatment for all children with SAM in
the community.
»» Specific training will be given in this circumstance to the BHW/BNS and clinical staff
involved in the assessment.
»» Coverage refers to maximizing the number of children with acute malnutrition who can
receive treatment, thereby maximizing child survival.
number of children with SAM

who are being treated
COVERAGE = _______________________ x 100 (answer in percent)
total number of children with
SAM in the community
»» Many factors can influence coverage. Some of these factors can improve coverage
(boosters) while some can reduce it (barriers).Examples of boosters and barriers to
coverage in the Philippines
1. Boosters
a. Knowledge about acute malnutrition
b. Awareness that treatment is available
c. Awareness that treatment is available locally
d. Caregivers take children to the health center for treatment quickly when SAM is
identified
e. Good standard of treatment
f. Good community support for service
g. Good supplies of medicines and RUTF
2. Barriers
a. Lack of knowledge about malnutrition
b. Lack of awareness that treatment is available
c. Distance to treatment is too far
d. Caregivers’ workload
e. Caregivers take child to other places thus delaying treatment when SAM is
identified
f. Physical barriers (mountains, rivers, landslides)
g. Climate (heat, monsoon rains)
h. Poor standard of treatment
i. Service is not valued by the community
j. Shortages of medicines and RUTF
Session 3.4:
Referral and Follow-up
Referral:
• When a case of SAM is found, the child is then referred to the nearest treatment point. In many
cases, this may be the RHU but may also be the local Barangay Health Station.
Table 3.2. Criteria for Case Identification and Referral in the Community
Normal MAM SAM

and/or
(12.5 cm)
Referral
• The BNS/BHW and other identified community level personnel should:

»» Act as a focal point in their community whom caregivers can turn to if they are worried
about their child losing weight or being sick so that they can be assessed for SAM.
»» Screen for acute malnutrition in children during routine contact opportunities (e.g. home
visits, community meetings, BHS outreach programs, OPT, GP, Buntis Congresses,
etc) and at other opportunities identified during assessment (passive case finding). It is
important that this is done systematically for every child and not just for children who
appear to be underweight.
»» Screen for acute malnutrition through active or active adaptive case finding during coverage
assessments or other house-to-house health/nutrition-related activities (e.g. EPI).
»» Identify and refer SAM children to the nearest treatment location.
»» Provide counseling on IYCF, WASH, oral health, vaccination and other health care
practices for caregivers of children with SAM in collaboration with the midwife responsible
for supervising treatment.
• For cases of SAM identified by people other than the BNS/BHW or midwife at community level
(e.g. by the ECCD worker), these should be referred to the BNS/BHW or midwife for the next
level of assessment.
• For these cases:
»» Explain why referral is necessary and let the mother/caregiver know what to expect when
they reach the BHS.
»» Stress the urgency of bringing the child for consult as soon as possible. Offer to go with the
mother to the nearest BHS if needed.
Module 3
Follow-Up
• Some children with SAM require a follow-up at home during their time in treatment, in addition to
the follow-up they receive at the health facility during their periodic visits. These may be cases
who have been absent from treatment or are recovering slowly or who may be at increased risk
(e.g. following admission for inpatient treatment).
• An effective follow-up requires a good linkage between the community and health facilities and
therefore, is best carried out by the BNS/BHW linking with the midwife, public health nurse and
other facility staff. A well-supervised BNS/BHW should be able to:
»» Follow-up priority cases promptly identified by the C/MHO, PHN and midwife.
»» Conduct home visits which focus on assessing the home environment related to recovery
from SAM.
»» Counseling regarding the use of RUTF and other foods.
»» For children less than two years of age, assess and counsel on IYCF practices.
»» Find, then refer immediately any children with the following to the nearest health facility for
review by a clinician:
1. Eating less than 50% of the RUTF daily ration
2. General deterioration in health since the last health check
3. Untreated persistent vomiting or diarrhea
4. Refer directly to ITC if the child has:
a. Any IMCI danger sign
b. A lack of appetite for RUTF
»» Complete a record of the home visit (and a home visit checklist) and submit to the
responsible clinician (health officer or midwife). If it is only possible to give a verbal report
(e.g. by phone) the responsible clinician should document the report in the child’s treatment
record.
1. Children who are repeatedly absent or who have defaulted from treatment against the
advice of the health worker should be checked for edema and the MUAC measured.
2. A ‘defaulter form’ should be completed, which identifies the reason for defaulting.
3. If the child has defaulted but remains SAM, the caregiver should be urged to bring the
child to the health center immediately.
4. All defaulted cases should be counseled to return to treatment and counseled in
health, hygiene and nutrition practices as appropriate.
»» Home visit assessments also provide an opportunity to find out whether the child/caregiver
has been linked with other social protection or nutrition support programs or counseling.
The BNS/BHW should promote and facilitate linkages to other support programs where
these exist in the local area
»» There is no need to conduct home follow-up visits with all SAM children, especially those
gaining weight in the program. Follow-up should focus on the following:
1. Children with medical complications who have refused transfer to inpatient care and
are being treated on an outpatient basis
2. Children who are not responding in the program (losing weight or not gaining weight
for two weeks) and whose aspects of the home environment are suspected to be
playing a role rather than medical issues
3. Repeated absentees from treatment
4. Infants < 6 months old not gaining weight during a period of IYCF counselling
»» The BNS/BHW at each weekly visit should:
1. Measure MUAC, weight and check for edema; check if height/length was measured
on admission day (take the measurement if not done)
2. Check MUAC and WHZ (if appropriate) for discharge criteria
3. Take body temperature
4. Do the appetite test either routinely for all children or whenever there has been a poor
weight gain
5. Ask about the progress of the child, including IMCI danger signs (See Annex 3.1)
6. Examine the child
7. For infants < 6 months old, ask about breastfeeding practice, and any improvement
in milk production
8. Give routine treatment at the appropriate visits (if a visit is missed, give at the next
visit)
9. Complete the OTC chart
10. Make any necessary referrals
11. Recalculate the weekly RUTF ration according to current weight and provide the ration
»» During the home visit, the BNS/BHW should:
1. Discuss with the caregiver to help her/him understand the constraints that they are
operating under and offer suggestions/support
2. For infants < 6 months, ask for breastfeeding concerns and observe if attachment and
position techniques are effective
3. Do any appropriate counseling (based on IMCI/IYCF materials and training), or
medical referral if required based on CB-IMCI check
4. Link clients to livelihood/safety net/social protection programs available where
particular issues are identified and/or clients are eligible (e.g. child cash grant, etc.)
5. Whenever home visits are made, write all relevant information in the child’s treatment
record.
6. Give feedback to the midwife/other OTC worker where relevant. If the child stopped
attending treatment against advice, note down reasons for default. This may help
the program managers understand and identify solutions to make treatment more
accessible.
Content Summary
It is important to engage the community in the management of SAM, in order to have a clear,
common understanding of the condition, and to let people know that there are services available
for its treatment.
Part of community mobilization is training health workers and other volunteers in the community
to identify children with SAM through MUAC measurement and identifying the presence of
edema. To prevent SAM, it is also important to routinely ask about breastfeeding concerns and
to provide practical help among infants < 6 months during screening.
A health worker or a volunteer should also know how to refer a child once identified with SAM to
either inpatient care or outpatient care.
It is also important for a health worker or volunteer to know when a child with SAM should be
followed-up and monitored regarding his/her treatment and outcomes.
? Test Yourself
1. During a home visit, you note that a child has been lethargic and not been consuming the
RUTF. What should you do?
a. Give paracetamol
b. Send to ITC immediately
c. Feed more RUTF
d. Do watchful waiting
Module 3
2. Which of the following is an INCORRECT message regarding the sensitization on SAM?

a. Treatment is available in outpatient and inpatient settings
b. RUTF is Halal
c. SAM is not life threatening
d. Children 6-59 months are eligible for treatment
3. Which of the following is correct about active case finding?

a. The health worker goes from house to house to look for cases
b. The health worker goes to every 3rd to 4th house and asks parents about cases
c. The health worker in the health center detects cases among children brought in for
checkups
4. Which of the following is a barrier to coverage?

a. Poor standard of treatment
b. Adequate supply of medicines and RUTF
c. Well trained health workers in malnutrition
d. Families are aware that treatment is available
5. Which child DOES NOT need regular follow-up after treatment?

a. A child with medical complications when she/he was treated in the hospital
b. A child who still is losing weight or not gaining weight for two weeks
c. A child who is gaining weight
d. A child who is repeatedly absent from treatment
Answer key: 1. - b; 2. - c; 3 - a; 4 - a; 5 - c
Annex
ANNEX 3.1
Integrated Management of Childhood Illness (IMCI) Danger Signs
Check for General Danger Sign

• Not able to drink or breastfeed
• Vomits everything
• Convulsions
• Lethargic or unconscious
• Convulsing now
Source: Integrated Management of Childhood Illness (IMCI) Chart Booklet, UNICEF, 2014
Module 4
Philippine Integrated Management of
Target Learners
This module is intended for local government officials, health leaders, and hospital managers
who will organize and implement the LGU PIMAM program based on guidelines in DOH AO
2015-0055.
The module introduces learners to the organization and management of an integrated,

community-based, public health strategy which will address severe acute malnutrition in children
from 6 months to under 5 years.
______________________________________________________________
At the end of the session, you will be able to develop appropriate policies, plan, review standards
and protocols, manage and mobilize resources, supplies and linkages to maximize coverage
and access to community-based treatment of children with SAM.
Specifically, you will be able to
1. Review how to assess the SAM situation in your LGU

2. Discuss an LGU best practice – the Davao City IMAM
3. Discuss the roles and responsibilities of a local SAM program management team
4. Identify linkages and how your SDN can work for an effective SAM program.
5. Estimate the annual SAM supply of supplies and medicines
6. Develop a financing and linkage strategy for SAM
7. Cite the performance indicators for monitoring and evaluating SAM.
8. Practice using bottleneck analysis
9. Review SAM protocols for disasters and emergencies.
Key Concepts
The integrated management of SAM is a public health strategy to address the life threatening
and emergency treatment of severe acute malnutrition in children from 6 months to under 5
years.
The approach is based on four principles:
1. Maximum coverage and access. PIMAM is designed to achieve the greatest possible
coverage by making services accessible and acceptable to the most number of children
who are in need.
2. Timeliness. Priority is given to early case-finding and mobilization so cases of SAM can
be treated before complications happen which can lead to death.
Module 4
3. Appropriate care. The program ensures that simple, effective outpatient care is available
or clinical care in hospitals is assured.
4. Care when and where it is needed. PIMAM links children to continuous and appropriate
care.
The community integrated management of SAM has three components:
1. Community Mobilization which involves engagement with the community to get a

common understanding of acute malnutrition and the services that are offered. It involves
identification of severely acutely malnourished children on an on-going basis. Detection
is done early so referrals can be done before a child’s condition deteriorates.
2. Outpatient Therapeutic Care (OTC) involves the management of non-complicated
cases of SAM using ready-to use therapeutic foods (RUTF) provided weekly or bi-
weekly to mothers/caregivers. The outpatient care is offered through Rural Health Units,
Barangay Health Stations or outpatient departments of hospitals.
3. Inpatient Therapeutic Care (ITC) involves management of complicated cases of SAM
following DOH guidelines and WHO protocols.
PIMAM Elements
The implementation of SAM requires an enabling environment and efficient organization. The
success of the program will need
1. Local policies aligned with national policies and guidelines

2. Community assessment and research on the extent of the problem in the locality
3. Prioritization and support from major stakeholders
4. Funding for SAM treatment supplies, equipment and personnel
5. Training and re-training of community workers and hospital health professionals
6. Organization of SAM Program with clear roles and responsibilities
7. Linkages to other services
8. Sustained provision of treatment supplies and medicines
9. Implementation and close monitoring
10. Evaluation of SAM programs
Special skills will help ensure the successful implementation of SAM programs. These include
evidence-based action planning of health programs, advocacy, counseling, estimating caseload
and bottleneck analysis, among others.
? Test Yourself
1. What are the three components of a SAM Program?
2. What are at least five elements that lead to success in implementing an LGU SAM program?
3. What are the four principles that need to be followed in developing and implementing a SAM
program?
4. Why is it effective for the SAM program to be integrated and community-based?
Session 4.1:
Policy Guidelines on the Management of Acute Malnutrition for
Children under 5 Years
This session presents the national policy that guides the management of acute malnutrition
among children under-5 years. It serves as the basis for creating local government policies and
hospital clinical standards to treat children, from 6 months to under 5 year, with severe acute
malnutrition (SAM). The Davao City model is presented to gain insights into how the program
was successfully launched.
Session Objectives
At the end of the session, you will be able to:
• Discuss the guidelines in DOH Administrative Order 2015-0055.

• Discuss the Davao City SAM program and policies that were issued.
• Identify the ten elements of a successful PIMAM program.
Key Concepts
1. The Department of Health issued AO 2015-0055 realizing that “wasting ” or acute

malnutrition is a serious health emergency that affects more than 800,000 Filipino
children under five years old.
2. A multi-sectoral approach is needed to solve the problem. Since 2010, the Integrated
Management of Acute Malnutrition has been implemented in emergency and non-
emergency situations. In 2014, in Davao City, a city-wide implementation was started.
3. Evidence-based action planning will lead to the development of LGU policies to organize,
fund and implement a SAM program.
4. There are elements that are needed in a PIMAM program: community assessment,
advocacy, information & stakeholder mobilization, policy & protocols, PIMAM organization
with clear roles & responsibilities, funding & linkages, orientation & training, continuous
supply of medicines & supplies, implementation & monitoring & evaluation.
Content Summary
Responsibility for Managing Treatment of Children with SAM
The overall management of all drugs, supplies, therapeutic and supplementary commodities,
and diagnostic tools for PIMAM and the development and dissemination of corresponding
guidelines and protocols shall be the responsibility of DOH and the local government units. (AO
2015-0055).
The local government units shall ensure that policies and guidelines for SAM treatment supplies
management are implemented properly at their level. They shall also actively participate in the
monitoring and evaluation of the implementation of these policies and guidelines. (AO 2015-
0055).
Module 4
Table 4.1. Minimum Performance Standards for the Management of SAM
Recovery rate >75%

Death rate < 10%
Defaulter rate < 15%
Coverage > 50 – 70%*
*Treatment coverage for rural areas is greater than 50%, in urban centers greater than 70%
and in disaster resettlement areas should be greater than 90%.
The implementation of SAM requires a multi-sectoral and community-based approach. The

DOH Administrative Order 2015-0055 shows the different processes that need to be done.
Case Study: Davao City Experience in Implementing SAM
Beginning with an evidence-based action planning (EBaP) process in 2013 where a series of
consultation with stakeholders were undertaken, Davao City moved to strengthen their Nutrition
Program by launching an equity focused Integrated Management of Acute Malnutrition (IMAM)
initiative. The EBaP uses the bottleneck analysis (Tanahashi Model) as basis of analysis. This
process showed that acute malnutrition remains significant in the city and that the distribution
of malnutrition is unequal with certain districts bearing malnutrition rates that rank as ‘serious’
according to the WHO Crisis Classification scale. The IMAM initiative was supported by UNICEF
and ACF International and was integrated into the local health system.
As a result of the EBaP analysis, the City Health and Planning Office's Annual Operations Plan
(AOP) nutrition budget for 2014 increased from PhP 6.5 to PhP 11.5 million primarily focused
on implementing lifesaving IMAM services. This resulted to the screening of 83,441 children
(6–59 months) and the treatment of 236 children with SAM through 577 trained health workers
and 176 outpatient therapeutic care (OTC) sites from January to December 2014. Passage of
an Executive Order #26 in May 2014 adopting the program for integration into MNCH program
of Davao City.
Some of the facilitating factors towards this initiative include the use of an evidence-based
planning process, extensive advocacy amongst different stakeholders, policy support of local
decision-makers and partnership and coordination of the different stakeholders. At the same
time, there are factors which hindered this implementation such as lack of incentives for health
workers, the need for a more sustainable health financing and the need to strengthen the health
system as a whole. Addressing the roots of malnutrition concurrently with this program is also
imperative.
Case Study Discussion Guide Questions
1. Why did Davao City decide to make SAM a health priority?

2. What steps did the City Health Office do to make it a city-wide program?
3. What are the facilitating factors? What challenges need to be solved?
4. In your LGU, what are the facilitating and challenges you will encounter?
5. What are the five activities will you do to implement a SAM program?
Small Group Work
Write a draft policy for implementing a SAM program in your local government. Refer to the
sample policy of the Davao City Government.
References

4. Davao City Policy on Eliminating Severe Acute Malnutrition (EO 26, May 2014).
Session 4.2:
Managing a Philippine Integrated Management of Acute
Malnutrition (PIMAM) Program in your LGU
This session identifies the roles and responsibilities of the PIMAM program team. The
organization of the PIMAM follows a good community assessment and research and advocacy
among stakeholders of its urgency. It is the PIMAM program management team which manages
SAM treatment, gives advice and addresses concerns on implementation, roll-out and scale-up.
The units are dynamic and change depending on program needs.
Session Objectives
At the end of the session, you will be able to:
• Identify the general roles and responsibilities of the program management team in
community implementation of SAM or hospitals.
• List the agencies and organizations you need to link with in implementing SAM.
• Diagram the PIMAM coordinating and reporting structure for your local government.
Key Concepts
1. In the past, treatment of severe acute malnutrition was restricted to facility-based

approaches, greatly limiting its coverage and impact. Large numbers of children can now
be treated in their communities without being admitted to a health facility or a therapeutic
feeding center.
2. 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 severely acute malnourished children
with medical complications and implemented on a large scale, community-based
management of severe acute malnutrition could prevent the deaths of hundreds of
thousands of children.
Module 4
Content Summary
Organize a PIMAM Program Management Team in Your LGU
The general roles and functions of the program management team are
1. Policy standards and guideline development

2. Capacity building
3. Logistics management
4. Information and Knowledge Management
5. Monitoring and Evaluation
6. Coordination, Networking and Partnerships
7. Advocacy and Social Mobilization.
The structure below can be adopted by local governments in organizing their SAM response
structure. Refer to Table 4.5 for the enumerated roles and responsibilities.
Figure 4.1. PIMAM Coordination and Reporting Structure
National Nutrition National PIMAM Department of Health

Council Management Team DPCB
DOH Regional Director

Regional Nutrition Program Regional Nutrition DOH and
or Regional Nutritionist
Coordinator Committee Regional Hospital
Dietician
Provincial or District
Provincial Nutrition Provincial Nutrition Provincial Health
Hospitals
Action Officer Committee Officer
Private Hospitals/Clinics
City/Municipal Nutrition City/Municipal Nutrition City/Municipal Nutrition Municipal Hospitals

Action Officer Committee Officer Private Hospitals/Clinics
Supervising ITC Doctor/

Nurse Chief Nurse
Midwife
Barangay Barangay
Nutritionist/ Social
Nutrition Health Nurse
Dietician Worker
Scholar Worker
Set up Implementation Arrangements – OTC and ITC
There are two parts to the implementation arrangements for your PIMAM program. The goal of your
program is to make sure that you maximize coverage and ensure access by the caregivers/children to
the program services. First, be guided by (1) considerations of the patient: cost of access to services,
time of travel to get the care they need, seasons and how they may affect access to health facilities,
the geography of your LGU. Second, be guided by (2) a decentralized structure in choosing your OTC
and ITC.
The Outpatient Therapeutic Care for SAM without complications is centered in the rural health unit or
Barangay Health Station of an LGU. The health officer, midwife, or nurse will supervise the care from
these treatment centers every one to two weeks. The monitoring of recovery and delivery of RUTF to
patients need not be limited to physical OTC structures and can be done by BHWs and BNSs. RHUs
will need to have enough space for storage of supplies, adequate shelter and an area with privacy for
anthropometric measurements.
Specific roles at the OTC are:
Doctors/Medical Officer – shall see cases of SAM on admission and if there are medical problems if
the patient does not respond to care.
Midwife/Nurse – is primarily responsible for the monitoring recovery and should see SAM cases during
routine visits to the RHU/BHS for the delivery of other services. Children should be followed up once a
week at the start of treatment and then during recovery, every two weeks.
BHW/BNS – will assist the midwife/nurse in the delivery of care and may be requested to follow up on
the children at home in between visits to the BHS.
Your ITC facility for SAM should provide good access from the catchment areas where OTC services
are located. ITC will typically be at the District, Provincial, or Regional DOH hospitals. Ideal distance
should be less than 4 hours. This will minimize transport time for life-threatening complications that
require referral to ITC.
Make sure Your Service Delivery Network (SDN) works for SAM. Your existing SDN needs to be
used to treat children with SAM.
Integrate SAM in LGU Health Systems & Programs. SAM programs will be strengthened by other
health programs that ensure the health of the mother, the newborn and appropriate Infant and Young
Child Feeding. Nutrition-sensitive interventions should be addressed too. The policy brief cites:
“As Local Nutrition Committee Members… Engage with program officers and representatives from
health, social welfare, sanitation, education, agriculture, interior and local government, and others to
strengthen multi-sectoral coordination targeted at removing bottlenecks (such as limited budget/
funds for LGU nutrition programs or the mothers’ lack of awareness of available programs) in quality
nutrition and health service delivery at facility, community, and household levels.“ (UNICEF 1000
Days Policy Brief)
LGU Financing & Resource Mobilization. It is important to find all ways to generate funds for SAM
treatment. The 1991 LGU Code directs that LGUs are primarily responsible for the provision of basic
services for their communities. Each LGU must mobilize and establish financing for SAM. Evidence
- based plans are presented to local officials for the annual allocation of funds for SAM treatment
interventions. Strong advocacy can sustain allocations in regular and supplemental LGU budgets or in
the 20% development funds. Other financing schemes may also be needed to supplement resources
from the LGU.
Module 4
• National resources are an important resource. SAM is a shared responsibility between the DOH
and LGUs. LGUs can augment their resources and purchase the needed supplies (amoxicillin,
ORS, MNPs) using their own budget. Therapeutic food and milk, medicines and micronutrient
supplements can be accessed from DOH.
• PhilHealth benefit packages help finance needs for the management of SAM. The following
benefit packages can be utilized:
»» Outpatient Benefit Package
»» Inpatient Benefit Package
»» Malaria Outpatient Benefit Package
Capability or skills are needed to write project proposals to mobilize resources from the donor
community and other development partners.
Linkages. The child being treated for SAM has usually suffered some combination of nutritional deficit
and/or infection and often may come from the poorest families in the community. The treatment of SAM
provides a continuum of care. Children with SAM no longer need to go to the hospital for treatment.
Care during treatment may involve accessing other services. Some of these include wet nursing, cross
nursing, human milk banking services and EPI for completion of vaccinations.
Depending on services available in the LGU, the following should be considered:
• Ongoing IYCF/breastfeeding/nutrition counselling

• Referral to a mothers support group as well as baby clinics
• Referral to a dietary supplementation program
• Referral to multiple micronutrient supplementation or complementary feeding support
• Enrolment in a growth monitoring program – Operation Timbang Plus
• Referral to a food security program
• Referral to social welfare
• Ensure coverage by PhilHealth
? Test Yourself
1. What are the roles and responsibilities of a program management team? Check seven
below to correspond with the roles as stated in the Manual of Operation.
___ Writing a proposal and budget on SAM

___ Writing a hospital circular
___ Organizing a stakeholders meeting
___ Mothers’ Education
___ Counseling
___ Capacity building
___ Securing a storeroom for RUTF
___ Writing policy on storage of supplies
___ Documentation
___ Building a malnutrition ward in a hospital
___ Bottleneck Analysis
___ Liaison with DSWD and the Agriculture office
___ Speaking on Radio about SAM
Annex
Table 4.2. Tasks and Responsibilities at Different Levels
Institution/
Organization
• Provincial/City/Municipal Nutrition Council oversees all nutrition programs.
• Plans, implements, organizes, coordinates and controls the management of
City/Municipal
SAM program within the municipality.
Health Offices
• Overall organization of the program in the city/municipality: recruits and
(CHO/MHO)
recommends staff appointments, in-job training, supervision, monitoring and
through the Local
evaluation, management of the therapeutic products and routine drugs at OTC
Nutrition Councils
level and coordination and referrals with the inpatient facilities at city/municipality
level (normally the pediatric or medical ward within the municipal hospital).
• Plans, implements, organizes, coordinates and controls the management of
SAM program within the hospital and with nearby OTCs.
• Overall organization of the program in the hospital: recruits and recommends
Hospitals
staff appointments, in-job training, supervision, monitoring and evaluation,
management of the therapeutic products and routine drugs at ITC level and
coordination with the outpatient therapeutic facilities at city/municipality level.
Provide technical support and supportive supervision to the City/Municipal Health
Offices in the following:
• Based on national guidelines, formulates/improves and disseminates and

updates (as needed) the plans, policies, guidelines and protocols on the
management of SAM and ensure the implementation of their provisions at the
provincial level.
• Ensures the effective implementation of the mechanism, standards and
procedures for the supply and logistics management (planning, procurement,
storage, allocation, distribution and monitoring) of the program for the
management of SAM at the provincial level.
• Develops and conducts research and documentation strategies to provide
evidence-based information and identified best practices for the continuous
Provincial Health improvement of the program for the management of SAM.
Offices (PHO) • Develops capacities of health and nutrition human resources, infrastructure
or technology for the management of SAM. Identifies, orients and capacitates
provincial-level trainers and technical assistance providers for the management
of SAM.
• Supports the assessment, monitoring and evaluation of the implementation of
the management of SAM.
• Defines strategies and mechanisms necessary for the effective networking,
coordination and partnership building.
• When an emergency is declared or anticipated, links with existing emergency
coordination mechanisms.
• Ensures that information and appropriate interventions are immediately
coordinated with the regular program managers for sustainable implementation.
• Leads in advocacy, promotion and social mobilization as sustainable support
to the program for the management of SAM (targeting decision makers at local
level; social mobilization aimed at community level).
Module 4
Table 4.2. Tasks and Responsibilities at Different Levels
Institution/
Organization
• Formulates and disseminates and updates (as needed) the plans, policies,
guidelines and protocols on the integrated management of SAM and ensure
the implementation of their provisions at all levels of the health and nutrition
sectors.
• Develops capacities of health and nutrition human resources, infrastructure or
technology for the management of SAM. Identify orient and capacitate National
level trainers and technical assistance providers for the integrated management
of SAM.
• Develops the mechanism, standards and procedures for the supply and
logistics management (planning, procurement, storage, allocation, distribution
and monitoring) of the program for the management of SAM.
• Develops and conducts research and documentation strategies to provide
evidence-based information and identified best practices for the continuous
improvement of the program for the management of SAM.
• Leads in the assessment, monitoring and evaluation of the implementation of
the program for the management of SAM.
• Defines strategies and mechanisms necessary for the effective coordination
and partnership building.
Regional Offices
• Strengthens referral system in the management of SAM through a functional
for Health
service delivery network from outpatient therapeutic program (OTC) to inpatient
facility (ITC) and vice-versa and the referral and action on reports of adverse
reactions.
• Develops and ensure effective implementation of appropriate health financing
strategies to provide financial risk protection.
• Provides technical assistance to its counterparts at the regional and local
government units.
• Strengthens networking with the academe and professional organizations to
ensure SAM management integration in the curriculum particularly in medical
and allied health courses.
• When an emergency is declared or anticipated, links with existing emergency
coordination mechanisms.
• Ensures that information and appropriate interventions are immediately
coordinated with the regular program managers for sustainable implementation.
• Leads in advocacy, promotion and social mobilization as sustainable support
to the program for the management of SAM (targeting decision makers at local
level; social mobilization aimed at community level).
• When needed, provides support for the management of SAM through training,
NGOs/Private
coordination, IT support, advocacy, etc. and intensified implementation during
Organizations
emergencies and disasters.
References
1. International Food Policy Research Network. 2015. Global Nutrition Report: Actions and
Accountability to Advance Nutrition and Sustainable Development.
5. Joint Statement of WHO, UNICEF, World Food Program and the UN. Retrieved from
http://www.unicef.org/media/files/Community_Based__Management_of_Severe_Acute_
Malnutrition.pdf
Session 4.3:
Logistics & Supply Management
This module will discuss how to ensure that there is adequate and consistent supplies of
diagnostic equipment, medicines and RUTF by managing the logistics and supplies of SAM
programs.
Session Objectives
At the end of this session, the participants will be able to:
• Recognize the management cycle for medicines and nutrition supplies

• Discuss the relevant policies in procurement of supplies and equipment.
• Estimate annual supplies and medicines for SAM program using the caseload formula.
Key Concepts
1. The availability of RUTF at the point of service delivery is absolutely vital to the successful
treatment of children aged 6 to 59 months with SAM.
2. At the National level, the estimation of supplies and medicines required annually is made
from the most recent data of the National Nutrition Survey (NNS). However, actual data
from LGUs through their OPT and regular screenings can be used to provide more
accurate estimates of caseloads and thus supply requirements. Acute malnutrition has
seasonal fluctuations and calculations are treated as estimates and need to be reviewed
regularly.
3. Storage of drugs and nutrition supplies need to carefully managed to avoid spoilage and
under recommended storage conditions.
Module 4
Content Summary
Relevant Policies on LGU Logistics Management of SAM Supplies
1. The local government units shall ensure that policies and guidelines for SAM treatment
supplies management are implemented properly at their level.
2. DOH shall ensure that medicines and nutritional products are in accordance with national
guidelines.
3. Quantification and ordering shall be based on utilization rate, projects increase in cases,
and provision of buffer stocks. RUTF buffer stocks should be maintained at 20%.
4. Procurement shall follow the Government Procurement Reform Act or RA 9184.
5. Medicines and supplies shall be stored under appropriate conditions and accounted for
through proper recording.
6. Disposal of expired and damaged medicines and nutritional supplies shall follow the
government rules and regulations.
7. LGUs shall set aside funds for the emergency procurement of sufficient quantities
of drugs and nutrition supplies in times of impending shortage to ensure continuous
availability of SAM treatment.
Figure 4.2. Management Cycle for Medicines and Nutrition Supplies
Quality Quality
Product Selection
monitoring monitoring
Management Support Systems:
• Information system
Rational use,
• Organization and infrastructure Quantification
monitoring and
• Human resources and Procurement
evaluation
• Planning and budgeting
• Training and supervision
• Monitoring and evaluation
Inventory
Quality management, Quality
monitoring storage and monitoring
distribution to the
next level
Policy, legal and regulatory framework
Estimating SAM Supplies
The estimation of SAM supplies is done annually. Refer to Annex 54 in the Manual of Operations.
1. First, estimate the caseload using the formula:
Caseload = N x P x K x C
N = Size of population aged 6 to 59 months of age

P = estimated prevalence of SAM
K = correction factor to account for new (incident) cases over a period of 1 year
C =mean program coverage in 1 year (startup year = 50%)
2. Refer to the calculation method below. (Reference: Table 18. Estimation of supplies required
for SAM treatment, Manual of Operations)
Table 4.3. Estimation of Supplies Required for SAM Treatment
Globally Recommended Units for

Supply Calculations
Treatment per Child
Therapeutic spread, Outpatient and Inpatient Therapeutic SAM Caseload:
sachet 92g/CAR-120 Care Requirements Total Population x 12.15% x SAM
Prevalence x K x Coverage
1 carton/child
# of RUTF Cartons Needed = SAM
Caseload
F-75 therap. diet, sachet, Inpatient Therapeutic Care SAM Caseload45: x (Estimated or
102.5g/CAR-120 Requirement actual rate of complicated cases)
12 sachets/child; 120 sachets in one # F-75 Cartons Needed: (SAM

carton Caseload x 10%47 x 12)/120
F-100 therap. diet, Inpatient Therapeutic Care SAM Caseload45: x (Estimated or
sachet, 114g/CAR-90 Requirement actual rate of complicated cases)
4 sachets/child; 90 sachets in one # F-100 Cartons Needed: (SAM

carton Caseload x 10%45 x 12)/90
ReSoMal, 42g sachet for Inpatient Therapeutic Care SAM Caseload4545: x (Estimated or
1 liter/CAR-100 Requirement actual rate of complicated cases)
0.2 sachets/child # ReSoMal Cartons Needed: (SAM

Caseload x 10%45 x 0.2)/100
MUAC, Child 11.5 Red/ Outpatient and Inpatient Therapeutic # of MUAC Packs = 10 packs x
PAC-50 Care Requirements Number of RHUs/Hospital
10 packs per RHU/Hospital

Amoxici.pdr/oral sus Outpatient and Inpatient Therapeutic # of Amoxicillin bottles Needed: SAM
125mg/5mL/BOT-100mL Care Requirements45 Caseload x 1.5
1-2 bottles per SAM child

Mebendazole 500mg Outpatient and Inpatient Therapeutic # of Mebendazole/Albendazole
chewable tabs/PAC-100 Care Requirements Packs Needed: (SAM Caseload)/100
or
Albendazole 400mg 1 tablet/child
tabs/PAC-100
Module 4
Review Your Estimates Regularly
Acute malnutrition has seasonal fluctuations. Calculations are estimates. They need to be
reviewed regularly using survey or program data. If the severe wasting prevalence data in the
OPT are larger than the recent nutrition survey data, then the former should be used as the
prevalence or P in the calculation for SAM supplies.
Guidelines for Receiving of Medicines and RUTF
Assign a person in your unit to take charge of drug management. The LGU point person for drug
management shall perform the following:
1. Obtain the supply receipt forms accompanying the delivery.

2. Check for quantity of each item, check medicine labels, strength and dosage form,
damages and note expiry date.
3. Record discrepancies and send feedback to disbursing unit.
4. Sign the receipt form.
5. Keep a copy and file the Delivery Receipt form.
6. Encode data into the NOSIRS or supply data base/logbook.
Storage of Drugs and Nutrition Supplies
The storage of drugs should ensure quality of supplies. Refer to the Manual of Operations,
Chapter 8. The LGU is advised to:
1. Maintain a clean storehouse with restricted storage and access

2. Organize RUTF/medicine boxes so labels can be read, check expiry dates
3. Remove all expired or damaged items
4. Return excess medicines to provincial/city NTP coordinator for redistribution
5. Promote good air circulation in the storehouse
6. Keep medicine containers closed
7. Store RUTF boxes under recommended storage conditions
a. Maximum stack height = 2.4 m
b. Temp = less than 40oC
c. Cool shaded room
d. Never on the floor, use pallets
8. Maintain proper records
Session 4.4:
Program Monitoring & Reporting
The session outlines how program monitoring and reporting is a critical management component
since it ensures that the overall goal is being achieved of identifying, treating and curing SAM.
A well-designed monitoring and evaluation system will identify gaps, provide information for on-
going needs assessment, advocacy, planning, redesign and accountability.
Session Objectives
• Identify the three major components of program monitoring and evaluation

• Summarize SAM program indicators and standards.
• Review monitoring forms and reporting guidelines.
Key Concepts
1. Program effectiveness is measured by the combination of treatment quality and coverage.

2. A program monitoring system should include data capture, compilation, analysis and
feedback.
3. Program performance indicators are compared with standard cut-offs to monitor health
facility performance and take corrective action as needed.
Content Summary
Performance Indicators
The following program performance indicators are used to monitor SAM:
• Number of admissions – The total number of children admitted into the program during
the reporting month.
• Cure rate – The number of children successfully discharged cured, as a percentage of
all discharges during the reporting month.
• Death rate – The number of children who died during treatment, as a percentage of all
discharges during the reporting month.
• Default rate – The number of children who defaulted, as a percentage of all discharges
during the reporting month. Default is defined as absent for three consecutive visits in
OTC or three days in ITC.
• Non-cured rate – The number of children 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 months in the program as long as all possible investigations and follow-
up have been attempted.
• Human resource coverage – Number of health workers who have been trained on SAM
management as a percentage of all health workers in SAM implementation/target areas.
• Treatment coverage – The percentage of eligible patients (primarily children 6 to 59
months old with SAM) existing in the areas who are reached by the service.
• Geographical Access/Coverage – the number of health/facilities in an area which offer
management of SAM services as a percentage of all health facilities.
Minimum performance standards for the management of SAM
Program 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.
Targets have been developed for use in emergency and non-emergency settings. Each facility
and the program as a whole should achieve them.
Module 4
Table 4.4. Minimum Performance Standards for the Management of SAM
Recovery rate >75%

Death rate < 10%
Defaulter rate < 15%
Treatment coverage > 50 – 70%*
There are different performance standards for rural, urban and resettlement centers. Treatment
coverage for rural areas should be greater than 50%. In urban areas - greater than 70% and in
resettlement areas is greater than 90%.
Program process indicators and standards
Tracking these indicators will help to identify the causes of poor performance and therefore
areas to focus attention:
- Geographic access to treatment

- Sensitization activities
- Screening and referral
- Coordination meetings related to community mobilization for SAM treatment
- Facility
- Formal evaluation activities
Please refer to Manual of Operations, p 113 to 114.
Session 4.5:
Bottleneck Analysis
This module discusses how to conduct a bottleneck analysis in planning, monitoring and
evaluation.
Session Objectives
At the end of this session, you will be able to:
• Perform a bottleneck analysis on common problems in the implementation of SAM.
Key Concepts
1. Periodic evaluation of the CMAM program through bottleneck analysis (BNA) can help
identify obstacles to service delivery in order to address what stops or improves coverage
of services.
2. Seven indicators are measured across a specific time period: commodity availability,
human resources availability, geographic availability, community mobilization activities,
utilization of services, continuity of services and quality of services.
Content Summary
The bottleneck analysis (BNA) was adapted from the Tanahashi’s health service coverage
evaluation model. Tanahashi’s approach to assess health system bottlenecks focuses on the
actual use of these services by various sub-populations. It identifies what are blocks to good
system performance.
At its core it involves:
• identification of bottlenecks to service delivery, root causes and solutions

• activity planning for resolving bottlenecks and tracking corrective actions
• monitoring of bottlenecks to determine whether the actions are effective and to support
service providers to adjust action as needed.
Indicators for Bottleneck Analysis:
• Commodity which refers to the % of health facilities that did not have stock outs of RUTF
in the last 3 months.
• Human Resources which is the % of health workers who have been trained on CMAM
• Geographic Access is the % of health facilities offering CMAM treatment
• Outreach is the % of community health workers who have been trained on CMAM
• Utilization is the % of children from 6 months to 59 months with SAM admitted for
treatment
• Continuity is the % of children from 6 months to 59 months who did NOT default from
treatment
• Quality is % of children from 6 months to 59 months who were cured
Please refer to Annex 59 of the Manual of Operations, p.216 for detailed indicators, numerators and
denominators.
Steps in Implementation:
• Collect Data. Use the Indicators that are identified in Annex 59 of the Manual of
Operations. Calculate for each determinant: commodity, human resources, geographic
access, outreach, utilization, continuity and quality.
• Identify Bottlenecks. Plot the data in graphs to evaluate and compare trends.
Figure 4.3. What is the Bottleneck Analysis Approach for the

Management of Severe Acute Malnutrition?
Retrieved from: http://www.coverage-monitoring.org/wp-content/uploads/2015/12/BAA-12-08-2015.pdf
Module 4
• Analyze Causes of Bottlenecks. Once the main bottlenecks have been identified,
stakeholders find out why specific determinants are low. The key is to go beyond the
symptoms and identify the root causes. One approach is to use the “5 why approach” to
get to the heart of the issue. There may be many causes for one bottleneck.
• Find Solutions and Corrective Actions. Determine the solutions that address the
causes of the bottlenecks and prioritize the solutions.
Ask the following questions:

a. Is the proposed solution doable? Is it feasible?
b. How much is the solution? Is it cost effective?
c. Is the solution acceptable to all stakeholders?
d. Will the solution promote the continuity and resilience of the program?
• Create a Work Plan. Develop a work plan to implement the corrective actions. Monitor
progress and make adjustments as needed. See how the SAM program can be part of
the bigger nutrition and health programs in the local government or hospital.
References
1. Annex 59. Bottleneck Analysis. Manual of Operations, p.216 – 217

2. UNICEF Handout on Bottleneck Analysis. Retrieved from http://www.coverage-
monitoring.org/wp-content/uploads/2015/12/BAA-12-08-2015.pdf.
Session 4.6:
SAM in Emergencies
Target Learners
This session is intended for health, nutrition and social workers from government, non-
government organizations and private entities, including volunteers at all levels.
This session emphasizes the critical need to treat children with SAM, who are more vulnerable
during disasters and emergencies.
Session Objectives
At the end of the session you will be able to:
• Identify the role of the nutrition cluster in emergencies.

• Discuss the operational guidelines to IYCF - E
• List the steps in conducting an initial rapid assessments during emergencies or disasters.
Key Concepts
Children with SAM are even more vulnerable during disasters and need immediate and urgent
attention.
Content Summary
In an emergency, children with SAM are particularly vulnerable. SAM program managers will
need to shift gear and deal with a situation that has limited resources. Managers will need to
develop policies to cover the following areas:
• Responsibilities of the SAM Team & others during Emergencies

• Rapid and Comprehensive Nutrition Assessments
• Coordination & Information Management
• Areas where SAM is implemented
• Areas where SAM is not implemented
• Logistics during Emergencies
• Reporting during Emergencies
• Transition to Post Emergency
Roles and Responsibilities among Members of the Assessment Team
During emergency/disaster situation it is imperative that efforts are coordinated and responsive
to ensure smooth and quick implementation of nutrition services. The roles and responsibilities
of members according to function are listed below.
Table 4.5. Roles and Responsibilities of Members According to Function
Responsibility Center Roles and Responsibilities
Focal Point • Provide overall direction in conducting the Nutrition Initial Needs
Assessments (NINA) in consultation with members of the nutrition cluster.
• Direct the organization of the assessment teams and planning for the
conduct of NINA.
• Lead the review of the NINA Findings.
• Approve the NINA report for submission to the local DOH Office and for
integration in HEARS report and to upper cluster.
• Endorse recommended nutrition interventions based on the NINA findings.
Information and Data • Follow-up submission of accomplished NINA forms from the assessment
Manager teams.
• Encode and collate reports from local assessment teams in the NINA
reporting tool.
• Analyze and interpret information generated from NINA.
• Prepare the report not more than 48 hours after the conduct of NINA.
• Maintain the data repository for NINA.
Assessment Team • Plan the conduct of NINA.
• Conduct nutrition initial needs assessment in the assigned area.
• Submit accomplished NINA no longer than 24 hours to the Information and
Data Manager.
• Provide technical inputs and feedback on nutrition situation of affected
area to the nutrition cluster during meetings.
Module 4
It is recommended that an assessment team is composed of three or more members when

conducting the actual initial assessment in the evacuation center or barangay level. The team
will appoint a team leader to be assisted by the rest of the members. The team leader will be
responsible for ensuring that the NINA is conducted as prescribed in these guidelines.
The team will conduct key informant interview(s) among any or all of the following: camp
manager, barangay official and health worker to collect all necessary information.
[1] Villafuerte J, et al. (2015). Addressing Severe Acute Malnutrition: The Experience of Davao City,
Philippines. BMJ Open 2015.
[2] Community Management of Acute Malnutrition. A Joint Statement by World Health Organization, the
World Food Programme, the United Nations System Standing Committee on Nutrition and the United
Nations Children’s Fund.
Module 5
Outpatient Therapeutic Care (OTC)
Target Learners
This module is intended for all healthcare providers of infants or children with SAM in the
community and hospital levels.
Outpatient therapeutic care provides treatment for children with SAM who demonstrate adequate
appetite and have no medical complications. These children can be treated at home with simple
routine medicines and RUTF. Outpatient Therapeutic Care is delivered in the OPD of an Inpatient
Therapeutic Care (ITC) facility or an Outpatient Therapeutic Care (OTC) facility (Barangay
Health Station, Rural Health Unit Clinic, or City Health Office). This module, discusses in detail
the process the health worker, infant/child and parent/caretaker undergoes when they visit and
outpatient facility.
______________________________________________________________
1. Do initial assessment and intervention and identify acute malnutrition.

2. Classify the patient to OTC or ITC
3. Demonstrate how to refer patient to the nearest ITC for treatment in a timely manner.
4. Demonstrate how to record on OTC chart on admission to OTC.
5. Choose the appropriate medical management.
6. Choose the appropriate nutritional management treatment according to age.
7. Demonstrate how to orient the caregiver on treatment.
8. Demonstrate how to monitor the child weekly.
9. Identify OTC patients needing referral to ITC.
10. Demonstrate how to conduct an ITC referral if needed on follow-up.
11. Identify patients needing further clinical or social assessment and make appropriate
referral.
12. Identify patients needing follow-up at home.
13. Identify patients for discharge from the OTC.
14. Classify the outcome of treatment of discharged patients and record in the registration
book and chart.
15. Demonstrate discharge procedure.
Definition of Terms
Ready-to-Use Therapeutic Food (RUTF)

• An energy dense mineral/vitamin enriched food nutritionally equivalent to F100, which
is recommended by the WHO for the treatment of malnutrition and which has particular
technical and quality specifications for its composition and production (see Annex 5.1.
Ready-to-Use Therapeutic Food [RUTF]).
Module 5
Key Concepts
Figure 5.1. Decision flowchart for Outpatient or Inpatient Therapeutic Care

for 6-59 months of age
Introduce yourself
Do proper handwashing
Do history and clinical examination
Do anthropometrics, edema test
Advise on proper IYCF practices,
NO
vaccinations, give multivitamins,
Presence of SAM? NO Presence of MAM?
YES Refer to Supplementary Feeding

YES
Program (SFP)
Triage of emergency cases:

YES
Medical complications?
NO
Out-Patient Therapeutic Care (OTC): In-Patient Therapeutic Care (1TC):

passes appetite test, fails appetite test,
no medical complication, NO Failed appetite test? YES with medical complication,
no severe edema or with severe edema (+++) or
no marasmic-kwashiorkor marasmic-kwashiorkor
Fails appetite test, worsening edema or development of a

medical complication
Stabilization
Rehabilitation REFERRAL
Transition
Return of appetite, sufficient loss of edema and resolving
medical complications
Recovery (link to other services - OTC or Phase 2

including SFP if available)
Session 5.1:
Admission
i. Do initial assessment and intervention and identify acute malnutrition.
1. On arrival, give approximately 10% sugar-water solution immediately to obviously sick patients
and those that will clearly need inpatient or other medical treatment to prevent dehydration and low
blood sugar levels.
Prepare by mixing 10g or 1 tablespoon of

sugar in 100ml of water.
2. Explain to the caregiver that you will be assessing their child to determine whether they need
treatment and let them know what to expect.
3. Determine age.
• Birth dates can be identified and confirmed with the help of:
a. Birth certificate
b. Child health card
c. Early Childhood Care and Development (ECCD) card (see Annex 5.3: Early Childhood
Care and Development card)
d. Local calendar of events if a birth date is not known (see Annex 5.4: Example of local
event calendar for calculation of age)
• Do not use a height cut-off as proxy for 6 months of age; in a stunted population many infants
six months or older will have a height less than 65 centimeters (cm).
4. Take anthropometric measurements and examine child.3

• Infants less than 6 months of age
a. Take weight and length measurements.
b. Check the weight-for-length table and determine the z-scores (refer to Module 2 on
Identification of SAM)
3
For children older than 59 months of age refer to Module 2 Annex 2.6. Identification of SAM for children/adolescents older
than 59 months of age
c. Check for edema (refer to Module 2 on Identification of SAM), take the temperature and
count the number of breaths in a full minute.
• Infants/Children 6-59 months of age

a. Take MUAC and weight measurements (refer to Module 2 on Identification of SAM)
including for those children referred from the community or other facilities.
b. Check for edema (refer to Module 2 on Identification of SAM), take the temperature and
count the number of breaths in a full minute rate.
c. When able, also take height/length, and determine the Z-scores using the weight-for-
height table (refer to Module 2 on Identification of SAM).
• Identify if infant or child has SAM.4

a. Decide if the child has SAM or MAM based on the criteria below (see Table 5.1 and 5.2
below).
b. For these children, their details can be entered in the Target Client List (TCL) for sick
children/registration book/hospital admission chart depending on the level at which they
enter the service. If at Barangay level, the OTC chart admission column can be started
(see Annex 5.5: Registry Book Example).
c. The child’s Early Childhood Care and Development (ECCD) number, existing household
number or TCL number (whichever is in most common use) is noted on the OTC/ITC
charts. This will allow the child to be tracked if they require home visits or referral in the
future.temperature and count the number of breaths in a full minute rate.
4
For children older than 59 months of age refer to Module 2 Annex 2.6. Identification of SAM for children/adolescents
older than 59 months of age
Module 5
Table 5.1. Identification of Acute Malnutrition in Children 6-59 Months of Age
Normal MAM SAM

and/or
≥125 mm = greater than
<115 mm = less than
MUAC or equal to 125 mm 115 mm to 124 mm
115 mm (11.5 cm)
(12.5 cm)
and/or
<-2 to -3 = less than -2
WFH Z-score -2 and above <-3 = less than -3
to -3
Table 5.2. Identification of Acute Malnutrition in Children Less than 6 Months of Age
Normal MAM SAM

and/or
<-2 to -3 = less than -2
WFH Z-score -2 and above <-3 = less than -3
to -3
Do appetite test on SAM referrals age 6-59 months old. (Refer to Module 2 on Identification of SAM)
• Do medical assessment on SAM referrals. Ask the caregiver the following and record on OTC
chart:
a. Dietary History: what food and medicines the child eats/takes
b. Food and fluids taken in past few days
c. Usual diet before current episode of illness
d. Detailed breastfeeding history
e. Examine the child: check if s/he has severe medical complications using IMCI/CIMCI
criteria (see Annex 5.6: Philippines IMCI & CIMCI [existing formats] for IMCI/CIMCI
procedure). Remember that for malnourished children, clinical signs may still be absent.
f. Alertness
g. Convulsions
h. Temperature
i. Respiratory rate
j. Chest in-drawing
k. Visible anemia
l. Visible vomiting or diarrhea
m. Medical History: make a record of the medical assessment on the OTC or hospital chart
– Any complaints
– Appetite
– Recent sinking of eyes
– Duration and frequency of vomiting and diarrhea, appearance of vomit and stool
– Coughing
– Changes in skin and hair
– Time when urine was last passed
– Contact with measles and tuberculosis
– Any deaths of siblings
– Immunization history
• Do feeding assessment for infants less than 6 months with SAM.
a. Full assessment should be made of the caregiver’s breastfeeding practice following the
C-MAMI Tool (see Annex 5.16: C-MAMI [Community Management of uncomplicated
Acute Malnutrition in Infants less than 6 months of age] Assessment for Nutritional
Vulnerability (C-MAMI Tool Nov. 2015). Other useful materials include national IYCF/
IMCI guidelines and training package (see Annex 5.7: IYCF counseling at community and
facility level (IMCI) and Annex 5.8: Infant feeding assessment IMCI).
b. Breastfeeding must be supported closely and the mother helped in her confidence and if
necessary, her resumption of breastfeeding or re-lactation. ALL means to continue with
breastfeeding and/or breastmilk feeding must be exhausted before commercial formula is
resorted to.
• Refer non-SAM referrals

a. If the child has MAM, use IMCI protocols to provide counseling and medical care and
refer to Blanket or Targeted SFP if in place (see guidelines for management of MAM).
b. For infants younger than 6 months with MAM, continued assessment, Breastfeeding
support and counseling as outlined in the C-MAMI Tool should be provided (see Annex
5.16: C-MAMI [Community Management of uncomplicated Acute Malnutrition in Infants
less than 6 months of age] Assessment for Nutritional Vulnerability (C-MAMI Tool Nov.
2015). Also, IYCF counseling should be provided for caregivers and caregivers admitted
to Blanket or Targeted SFP if in place (see guidelines for management of MAM).
c. For children not meeting criteria, the opportunity should be used to provide any medical
treatment required and any nutritional counseling available at the facility (e.g. IMCI
feeding counselling see Annex 5.7: IYCF counselling at community and facility level
(IMCI), Annex 5.8: Infant feeding assessment IMCI and IYCF counseling cards)
5. Classify the infant/ child to to OTC or ITC

• If 6-59 months old
a. Admit to OTC if criteria are met (see Table 5.3)
b. Admit to ITC if criteria are met (see Table 5.3)
Module 5
Table 5.3. Criteria for New Admission to Inpatient or Outpatient Therapeutic Care
(children 6-59 months)
Factor Inpatient Therapeutic Care Outpatient Therapeutic Care
Bilateral pitting edema Grade 3 (+++)

Edema Bilateral pitting edema Grade 1 or 2 (+ and ++)
OR Marasmic Kwashiorkor*
MUAC < 115mm (11.5cm) OR MUAC < 115mm (11.5cm) OR

WFH or WFL < -3 Z-scores WFH or WFL < -3 Z-scores
Anthropometry
AND one of the below AND both of the below
Appetite Fails appetite test with RUTF Passes appetite test with RUTF
Medical Complications Any of the below NO medical complications
Vomiting Intractable (emptied contents of stomach)
Fever > 38.5˚C (101.3˚F) axillary

Fever > 39.0˚C (102.2˚F) rectal
Temperature
Hypothermia < 35˚C (95˚F) axillary
< 35.5˚C (90˚F) rectal
> 50 resp/min from 6 to 12 months

> 40 resp/min from 1 to 5 years
Respiration rate > 30 resp/min for over 5 year olds
And any chest in-drawing

(for children > 6 months)
Very pale (severe palmar pallor, roof of the mouth

Anemia (oropharynx), nailbeds, eye palpebrae), difficulty
breathing
Extensive skin infection requiring

Superficial infection
Intra-Muscular antibiotics
Very weak, apathetic, unconscious

Alertness
Fitting/convulsions
Recent history of diarrhea/vomiting with

Hydration status
appearance of sunken eyes.
*MUAC less than 115mm (11.5cm) or WFH or WFL < -3 Z-scores AND with any grade of edema
• If less than 6 months old

a. Admit to OTC if criteria are met (see Table 5.4 below)
b. Admit to ITC if criteria are met (see Table 5.4 below)
Table 5.4. Criteria for New Admission to Inpatient or Outpatient Therapeutic Care
(infants <6 months)
Outpatient Breastfeeding Support*
(C-MAMI Tool, Nov. 2015; IMCI medical
Factor Inpatient Care
treatment, supplementary feeding for
mother, where available)
Anthropometry Bilateral pitting edema; WFL < -2 Z-scores;
OR WFL < -3 Z-scores; AND none of the complications requiring
AND one of the below inpatient care
History Recent weight loss/ inability to gain weight
Medical Any of the medical complications outlined
for children 6-59 mos. old;
Any medical issue needing more detailed
reassessment or intensive support (e.g.
disability)
Feeding Ineffective feeding (attachment, positioning
practices and sucking) directly observed;
Infant is lethargic and unable to suckle;
No possibility of breastfeeding (e.g. death
of mother)
Condition of Depression of the mother/caregiver, or OR mother is malnourished or ill
mother other adverse social circumstances
* Note: Refer to Annex 5.16: C-MAMI (Community Management of uncomplicated Acute Malnutrition in Infants less
than 6 months of age) Assessment for Nutritional Vulnerability (C-MAMI Tool Nov. 2015).
6. Refer to the nearest ITC, if needed, in a timely manner.

• Explain that the child is very sick and needs to be treated immediately and can easily become
sicker.
• Fill out the appropriate two-way referral documentation with details of the assessments
conducted and any treatments administered (see Annex 5.10: OTC/ITC referral form).
• Communicate with the inpatient facility by telephone for advice and support for the management
of the patient.
a. Record the telephone call, advice given and the name of the doctor and inpatient facility
on the treatment card.
• Make arrangements for transportation in coordination with district or referral healthcare facilities.
a. Make the child as comfortable as possible and administer small amounts of 10% sugar
water to keep them hydrated before and during transportation.
b. Explain why public transport is not recommended.
c. Stabilize the child if health worker has ITC protocols and measures training before
transport is taken.
7. Record on OTC chart upon admission to OTC.

• Review and record any relevant information from the referral document (if available) onto the
OTC chart (see Table 5.5. Types of OTC Admission below)
Table 5.5. Types of OTC Admission
New Admissions New SAM cases identified during screening or self-referral
Relapse a. New episode of SAM

b. Admission after more than 2 months of absence
c. Admission after previously discharged as cured
Readmission Admission after absence of less than 2 months (Return Defaulter)
Admission of patients already a. Transfer from another OTC
under SAM treatment b. Transfer from ITC
c. Return from ITC, back to OTC (OTC-ITC-OTC)
• Continue with the same registration number on referral document.

• Conduct assessments as above to check information on referral document and identify any
additional issues which may have arisen during the transfer.
• Complete existing registration documentation and OTC chart.
Module 5
Session 5.2:
OTC Treatment
i. Choose the appropriate medical management for the infant/ child with SAM.
• ALL cases admitted to OTC should be treated according to the following routine treatment
schedule in order to treat probable and potential underlying illnesses (small bowel bacterial
overgrowth and minor infections at the least) that may not always show classical signs and
symptoms in severely acutely malnourished children (see Table 5.6: Summary table of routine
treatment on admission in OTC below).
Table 5.6. Summary Table of Routine Treatment on Admission in OTC*

(see Annex 5.11: Routine medicine doses in OTC for details and dosages and Annex 5.12:
Antibiotic alternatives for OTC)
Medication Dose Administration
Amoxicillin < 10kg: 250mg 1 dose at admission then 2 times a day for 5
> 10kg < 14kg: 500mg days at home
14 to 19kg: 750mg
Albendazole/Mebendazole < 12 months Do not give to < 12 months
12 to 23 months: 200mg Give 1 dose on the 2nd visit (unless received in
> 24 months: 400mg last month)
Measles vaccine 6 to 9 months Only during measles epidemic
> 9 months: standard Refer to immunization clinic or 1 vaccine on the
4th visit
Vitamin A** RUTF has sufficient daily Do not give outside regular campaigns
allowance
* For children referred from inpatient therapeutic care/stabilization, a check should be made for the treatments already received and
the above adapted accordingly.
** Vitamin A is no longer recommended as additional supplement for children with SAM in OTC as a sufficient daily allowance is
available in RUTF20. It is given only during emergencies or measles outbreaks (symptomatic cases should be referred to ITC).
• The child’s immunization status should be checked and the mother/caregiver referred to the
BHS for any vaccinations due (including for measles vaccination).
• Check for the date of the child’s last deworming and refer to BHS.
• Refer to the national guidelines for malaria treatment.
• Refer to the national guidelines for diagnosis and treatment of tuberculosis.
• Record any supplementation/ treatment given on the child’s ECCD chart if they have one.
• Other medical conditions/symptoms – eye infections, ear discharge, mouth ulcers, fungal
infections, minor skin infections and lesions – should be treated according to the IMCI guidelines.
• Additional medication should be prescribed conservatively.

a. Do not give iron and folic acid routinely.
- Where severe anemia is identified according to CB-IMCI guidelines, the severely
malnourished child should be referred to inpatient care.
- Where moderate anemia is identified, start treatment only after 14 days in the program
and not before, because a high dose may increase the risk of severe infections.
Treatment should be given according to IMCI protocol (one dose daily for 14 days).
b. Do not give zinc to patients taking RUTF.

c. Do not give medicines against vomiting (anti-emetics) in OTC.
d. Do not give cough suppressants.
e. Do not give paracetamol routinely, due to its toxicity in a malnourished child. For
management of fever, see Annex 5.13:
f. Fever and SAM.
g. Do not give aminophylline in OTC.
h. Do not give normal/high dosage metronidazole. The dosage should be reduced as
indicated in Annex 5.12: Antibiotic alternatives for OTC.
i. Avoid ivermectin in any edematous child.
ii. Choose the appropriate nutritional management for the child with SAM.
• Determine the amount of Ready-to-Use Therapeutic Food/ RUTF required by the child based
on their current weight, as indicated in the RUTF ration table (see Table 5.7: Ready-to-use
therapeutic food (RUTF) ration below). Fill up OTC treatment card (see Annex 5.14: OTC
Treatment Card)
a. The amount of RUTF a child should consume is determined by the need for an intake of
200kcal/kg/day.
b. The amount given to each patient is therefore calculated according to his/her current
weight and must be adjusted as weight increases during treatment.
Table 5.7. Ready-to-use Therapeutic Food (RUTF) Ration
Ready-to-use therapeutic food (RUTF)

Body Weight
Sachets per day Sachets per week*
3.0 - 3.4 1 1/4 sachet 8 sachets

3.5 - 4.9 1 1/2 10
5.0 - 6.9 2 15
7.0 - 9.9 3 20
10.0 - 14.9 4 30
15.0 - 19.9 5 35
20.0 - 29.9 6 40
* Values are rounded off.
• Do not give RUTF if:

a. The infant is less than 6 months old. The mother and caregiver should receive
breastfeeding counseling and supplementary food if it is available and their condition
monitored (see below for Management of Infants through Outpatient Breastfeeding
Support).
b. The child is suffering from known peanut allergy, refer to ITC for treatment with
therapeutic milk (F75/F100).
Module 5
iii. Orient the mother/ caregiver on the infant/ child’s treatment.
• Explain how much RUTF to give the child each day (refer to Table 5.7: RUTF ration).
• Discuss a number of simple key messages on the use of RUTF:

a. For breastfeeding infants older than 6 months of age, advise mother to continue
breastfeeding as before and give the RUTF after each feeding.
b. For older children, always give plenty of safe water with RUTF as it doesn’t contain any
itself. But do not mix RUTF with water.
c. The RUTF is all the food a child needs to recover. No other foods should be given until
the full daily ration (each day) has been finished.
d. Teach how to give RUTF ration (timing and amount) to mother/caregiver so that it won’t
be consumed immediately.
e. Alert health worker regarding appetite increase of the infant/child to evaluate if increase
in RUTF ration is needed.
f. May give fresh fruits and vegetables once ration is finished and infant/child request for it.
g. Encourage child to take small amounts of RUTF frequently during the day directly from
the packet.
h. RUTF is a medicinal food for thin and swollen children. It should never be shared with
other members of the family.
i. Attend the health center weekly for monitoring and to receive the next weekly RUTF
ration.
j. Return empty RUTF packets to the health center each week.
• Explain how to give medicines at home. Ask the mother/caregiver to repeat to you how she will
give the medication.
• Explain the importance of hygiene and sanitation. Wash the child’s hands and face with soap
and water before eating and after stooling or defecation.
• Explain that malnourished children need to be kept warm (ensure child wears enough clothes).
• Inform them of their local volunteer/ health worker and the support that they can offer for them.
• Inform mothers/ caregivers who refused transfer to inpatient care facilities that their local
volunteer/health worker (BHW and/or BNS) will be visiting them at home during the week.
• Inform mothers/ caregivers that if they are concerned about the child’s condition, they can bring
the child straight back to the health facility for medical review and advice (example, no appetite,
is vomiting, has diarrhea, is sick, or has increasing edema).
• Encourage the mothers/caregivers to ask questions. Give them sufficient time to ask any
questions on the management process.
• On subsequent visits, additional counseling may be provided while mothers/caregivers are

waiting for their consultation. This may focus on:
a. Particular IYCF topics (Breastfeeding and Complementary Feeding in particular) based
on the C-MAMI Tool (2015) and national IMCI guidelines (Annex 5.7: IYCF counseling at
community and facility level [IMCI]) and IYCF counseling cards particularly for mothers of
infants with SAM referred for outpatient care
b. Handwashing with soap and the importance of growth monitoring of the child especially
once discharged from OTC
• Management of Infants younger than 6 months through Outpatient Breastfeeding Support
a. Management of the infant younger than 6 months on an outpatient basis does NOT
include use of RUTF.
b. The mother should attend the local health center and receive individual counseling on
breastfeeding promotion using the C-MAMI Tool (2015) and appropriate IYCF counseling
cards (Annex 5.7: IYCF counseling at community and facility level [IMCI]) and in order to
improve effective breastfeeding).
c. If, after individual counseling, the mother does not report improved breast milk intake or
if the infant fails to gain weight, the child should be referred to inpatient care (see Module
6).
d. Relactation should be supported. Where possible, the support of a trained lactation
counselor needs to be engaged, as well as that of a human milk bank (wherever possible
and available) to ensure access to breast milk while the feeding problems are addressed.
Session 5.3:
Weekly Monitoring
i. The BNS/BHW should do the following at each weekly visit:
• Introduce yourself.
• Ask about the medical history of the child. Ask about the progress of the child, including IMCI
danger signs (See Annex 2.1).
• Examine the child, after proper handwashing

a. Check body temperature
b. Measure MUAC, weight and check for edema (refer to Module 2: Identification of SAM).
c. Check if height/length was measured on admission day (take the measurement if not
done).
d. Check MUAC and weight-for-height/length z-score (if appropriate) for discharge criteria.
• Do routine appetite test for all children especially when there has been poor weight gain (refer
to Module 2: Identification of SAM).
• For infants less than 6 months old, take a detailed feeding history, ask about breastfeeding
practice and any improvement in milk production.
• Give routine treatment at the appropriate visits (if a visit is missed, give at the next visit).
• Complete recording on the OTC chart (Annex 5.9: OTC chart).
• Make any necessary referrals (see below).
• Recalculate the weekly RUTF ration according to current weight and provide the ration.
• Arrange for home visit or further clinical/ social investigation where required.
Module 5
ii. Identify OTC patients needing ITC referral (see Table 5.8 below)
Table 5.8. Criteria for ITC Referral on Follow-up
Criteria
i. Increase or development of edema

ii. No appetite or unable to eat RUTF (less than 3-4 mouthfuls/ failed appetite test)
iii. Deterioration in medical condition to develop any of the IMCI danger signs
iv. Weight loss for 3 consecutive weighings
v. No change in weight for 5 consecutive weighings
vi. No improvement after 1 week and continued weight loss of infant
vii. Other general signs as identified by the health worker that warrants referral (as per IMCI)
Do the following steps if ITC referral on follow-up is needed.
• Write on the chart of the patient the reason for transfer.

• Complete the referral form which should contain all details of the child’s condition, the summary
of the treatments given and the patient number (see Annex 5.10. OTC/ITC referral form).
• Give the referral form to the mother/caregiver to take with them to the ITC.
• Call the relevant ITC supervisor to inform them about the transfer.
a. They should facilitate direct admission to the ITC ward.
- The patient’s admission should not be processed through the emergency
department.
- This mechanism allowing for direct admission to the ward should be institutionalized
and practiced in the ITCs whenever a patient arrives with a
transfer form from an OTC.
b. When the patient returns to the OTC, similar contact should be made to avoid losing the
patient during the transfer.
• Take any steps to avoid transport trauma (see Annex 5.15: Appropriate referral of complicated
cases).
iii. Refer for further clinical or social investigation if the infant/child is not responding to
treatment (loss or static weight for two weeks) in the hospital or appropriate site. This
can include referral for:
• TB testing, counseling and treatment
• Screening and assessment of congenital abnormalities
• HIV counseling and testing
• Assessment of family functioning and capacity for care
iv. Refer for home visit if any of the following are present:
• Medical complications who have refused transfer to inpatient care and are being treated on an
outpatient basis
• Not responding to the program (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 absences from treatment
• Infants less than 6 months of age not gaining weight despite visits
Session 5.4:
Discharge
i. Identify patients for discharge from the OTC (see Table 5.9 below)
Table 5.9. Discharge Criteria from OTC
Patient Group Discharge Cured Criteria
Children 6-59 months Admitted on MUAC, MUAC > 125mm (12.5cm) for 2 consecutive visits
edema, or both MUAC and AND
WFH/WFL Z-scores No edema for 14 days
AND
Clinically well
Admitted on WFH/WFL WFH/WFL > -2 Z-scores for 2 consecutive visits
Z-scores only AND
No edema for 14 days
AND
Clinically well
Infants < 6 months Breastfeeding effectively
AND
has adequate weight gain (5g/kg/d)
AND
WFL > -2 Z-scores for 2 consecutive visits (where
capacity exists to measure)
OR
Reaches 6 months of age21
21
At this point MUAC should be taken to assess whether the infant qualities for enrollment in OTC as a child and to receive RUTF.
• Classify the infant/child’s outcome of treatment and record on the OTC chart and registration
book (see Table 5.10 below).
Table 5.10. Outcome of OTC Treatment
Outcome Description
Cured The patient has reached the criteria for discharge cured.
Dead The patient died during treatment in the OTC or in transit to the ITC.
Defaulter The patient has not returned for three consecutive visits and a home visit, neighbor,
village volunteer, or other reliable source confirms that the patient is not dead.
Discharged The patient does not reach the discharge criteria within four months and all referral and
as non-cured follow-up options have been tried (e.g. home visit conducted and household situation
assessed), they may be discharged as non-cured. In these cases, ensure that the child
is referred for assessment of possible medical complications if not yet done (e.g. TB)
and linked with the MAM program where possible and to social support systems.
Module 5
• Do the following steps for discharge.

a. Explain to the mother/caregiver that the child has recovered sufficiently to be discharged,
and congratulate them.
b. Refer for vaccination, if required:
- If the child has reached 9 months of age during treatment in OTC and has
not yet received vaccination against measles, the mother/caregiver should
follow up at the BHS or RHU to ensure their child receives the vaccination.
- Children admitted at age 6 to 8 months should get a follow-up appointment
for the second measles vaccination (booster) after one month.
c. All children will get a last ration for seven sachets of RUTF (one sachet each day for one
week) to aid the transition to local and in some cases, supplementary foods where a
dietary supplementation program is available.
d. The mother/caregiver should receive counseling on IYCF practices, care practices,
hygiene, feeding practices, food preparation for children, and so on, in line with standard
IYCF counseling. If enrolled in the 4Ps program, please ensure attendance in the Family
Development Sessions.
e. Link to dietary supplementation programs and/or other services available: All the patients
should be discharged to a dietary supplementation program for continued nutritional
rehabilitation where this is available.
f. Caregivers should be linked with any other appropriate services for which they are
eligible and which support the on-going rehabilitation of the child.
g. Fill in the patient record in the register with the discharge details.
Content Summary
OTC provides treatment at home for children with SAM with adequate appetite and no medical
complications. OTC admission of SAM patients involves the following:
• initial intervention of patients needing timely ITC referral;

• identification of acute malnutrition (through anthropometric measurements, edema test,
appetite test, medical assessment and feeding assessment);
• completing existing registration document and OTC chart using the same registration number
on referral document;
• giving routine with additional medications (if needed) and RUTF;
• proper orientation of the caregiver on the treatment;
• weekly monitoring to monitor the response to treatment or evaluating if needing ITC admission;
and
• Discharge the child if fully recovered.
? Test Yourself
1. Which of the following infants/ children will you admit to an OTC?
Age Bilateral MUAC

Appetite test WFH/WFL Z-score
(months) pitting edema (cm)
a. 50 pass none 10.2 Less than -3SD
b. 8 fail none 0.95 Less than or equal to -2SD
c. 12 fail none 0.95 Less than -3SD
d. 5 Not breastfeeding none - Less than -3SD
well
2. Which of the following advice is true regarding giving of RUTF?

a. You can give RUTF to an infant with SAM who is less than 6 months of age as long as
he/she has good appetite.
b. You can give RUTF to an infant with SAM who is older than 6 If the mother is still
breastfeeding, and advise her to give the RUTF after each feeding.
c. You can give RUTF to any infant with SAM as long as you mix RUTF with water before
giving it.
d. You can give other food even if the full ration of RUTF each day has not been finished.
3. Which of the following is a reason to refer immediately to an ITC facility on follow-up?

a. The child’s edema subsides.
b. The child’s weight decreases for 2 consecutive weighings.
c. The child’s weight does not increase for 5 consecutive weighings.
d. The child improves after 1 week and gains weight.
4. Which of the patients should be followed up at home?

a. Infants < 6 months of age gaining weight
b. Children repeatedly present for treatment
c. Loss or static weight loss for for one week (give 2 weeks)
d. Children with medical complications whose caregivers agreed to transfer to infant/child
to inpatient care
5. Which of the following infants/ children can be discharged from the OTC facility?
Age Bilateral MUAC

Appetite test WFH/WFL Z-score
(months) pitting edema (cm)
a. 5 Not breastfeeding none - Less than -3SD
effectively
b. 12 Clinically well present - Greater than or equal to -2SD
c. 6 Breastfeeding none 10.2 Greater than or equal to -2SD
effectively
d. 36 Clinically well none 12.5 Greater than -2SD but less
than -1
Answer key: 1.- a; 2.- b; 3.- c; 4.- c; 5.- d
Module 5
Annex
ANNEX 5.1.
Ready-to-Use Therapeutic Food (RUTF)
• An energy dense mineral/vitamin enriched food nutritionally equivalent to F100, which is

recommended by the WHO for the treatment of malnutrition and which has particular technical
and quality specifications for its composition and production.
• It is oil-based 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 for outpatient treatment
of Severe Acute Malnutrition.
• As it is eaten uncooked, it is an ideal vehicle to deliver many micronutrients that might otherwise
be broken down by cooking.
• Studies have shown that severely malnourished children given RUTF had a faster rate of
recovery than those given F100.
• While RUTF is a generic name, Plumpy’nut® is the trademark for the manufactured product from
the French company, Nutriset and Eeezee paste is the trademark name of the manufactured
product from India.
Figure 5.2. RUTF Composition

(from the National Guidelines on the Management of Severe Acute Malnutrition
for Children under Five Years Manual of Operations, p.146)
Minerals and Vitamins (CMV)
Peanut Butter
Milk Powder
Sugar
Oil
Composition:
Vegetable fat, peanut butter, skimmed milk powder, lactoserum, maltodextrin, sugar,
mineral and vitamin complex. Both GMO Free Certificate and Halal certificates may be
obtained from the manufacturer.
1 sachet = 92 grams of product = 500kcal.
Nutritional Value per 100g of product:
Energy: 545kcal
Proteins: 13.6g = 10% protidic calories
Lipids: 35.7g =59% lipidic calories
(Thus by deduction: 31% carbohydratic calories = 42.2g carbohydrates)
Vitamins: Minerals:
Vitamin A: 910 micrograms

Vitamin D: 16 micrograms
Calcium: 320mg
Vitamin E: 20mg
Phosphorus: 394mg
Vitamin C: 53mg
Potassium: 1111mg
Vitamin B1 0.6mg
Magnesium: 92mg
Vitamin B2: 1.8mg
Zinc: 14mg
Vitamin B6: 0.6mg
Copper: 1.78mg
Vitamin B12: 1.8 microgram
Iron: 11.53mg
Vitamin K: 21 microgram
Iodine: 110mg
Biotin: 65 microgram
Sodium: <290mg
Folic Acid: 210 microgram
Selenium: 30 microgram
Pantothenic Acid: 3.1mg
Niacin: 5.3mg
(from the National Guidelines on the Management of Severe Acute Malnutrition

for Children under Five Years Manual of Operations, p.147)
Shelf life:
24 months from manufacturing date (under well ventilated storage conditions with maximum 40°C
temperature; humidity has no impact)
Packaging and labeling:

Airtight sachet which includes an aluminum layer to protect against UV, light, and humidity.
Local Production of RUTF:

Since RUTF has to be imported, the costs are high. With this problem in mind, the development
of locally produced RUTF has been commenced in some countries, in order to try to ensure a
cheaper and more sustainable supply of the product. Any local product must adhere to international
specifications and be subject to national quality control testing and approvals.
ANNEX 5.2.
Example of Child Health Card
Education, counseling and referral information Immunization
Immunization protects your child against serious diseases.

Record special information given on Growth, Nutrition, Immunization and Illness
Follow and complete the immunization schedule below:
DATE OF VISIT Information

Date of
next visit
Vaccine Protects against How given Date given CHILD HEALTH CARD
BCG Tuberculosis Right Under Arm District: Child Registration No.:
At birth
Polio 0 Polio Mouth Drops Health Unit:
Polio 1 Polio Mouth Drops
Child's Name: Birth Weight (kg):
At 6 Weeks Diphtheria/Tetanus/Whooping Cough Left Upper Thigh
DPT/HebB/Hib1 /Hepatitis B/Haemophilus Influenzae Sex: Date of Birth: Birth Order:
type B _____/_____/________
Polio 2 Polio Mouth Drops 1. Mother's Name 2. Father's Name
DPT/HebB/Hib2 /Hepatitis B/Haemophilus Influenzae Occupation Occupation
type B
Where the Child lives:
Polio 3 Polio Mouth Drops
Sub County/Division:
DPT/HebB/Hib3 /Hepatitis B/Haemophilus Influenzae Parish:
type B
L.C.1
9 Months Measles Measles Left Upper Arm
Take your child for immunization even if the scheduled date is missed Tick reason for special care:
Vitamin A and De-worming Birth weight less than 2.5kg Brother or sisters undernourished
Age Vitamin A De-worming

Birth defect Mother dead
Date given Date given
Other handicaos or illness Father dead
Under 6 months
Fifth child or more 3 or more children in family dead
6 months
1 Year Birth less than 2yrs after last birth Multiple birth child
1 1/2 Years Severe jaundice Birth asphyxia

2 Years
2 1/2 Years
Any other reason for special attention
3 Years
3 1/2 Years
4 Years
4 1/2 Years
5 Years
Mother: Date Vitamin A Capsule Given Vitamin A should be given within two months of
Please carry this card every time you bring your child for care or attention
giving birth to this child.
______/_______/_________
Module 5
ANNEX 5.3.
Example of Early Childhood Care and Development (ECCD) Card
ANNEX 5.4.
Example of Local Event Calendar for Calculation of Age
January February March April May June July August
Rainy Season Dry Season
Land Preparation -
Land Preparation - Rice Land Preparation - Rice Planting - Rice
Corn (LPC)
Land Preparation
Planting - Rice Harvest - Corn
- Corn (LPC)
Hunger Gap Harvest - Rice Hunger Gap
ARI Skin Disease ARI
Department of Health. 2015. National Guidelines on the Management of Severe Acute Malnutrition for Children under
Five Years Manual of Operations, p.122.
ANNEX 5.5.
Registry Book Example
Exit to Facility Type of Exit
Date of
Transfer out Minimum
minimum
Date Wt. Ht. Edema MUAC weight Observation
WHZ Type weight
mm/dd/yy (kg) (cm) 0,1,2,3 (mm) (kg)
Code of the OTC/ mm/dd/yy
ITC
10
11
12
13
14
15
16
17
18
19
20

Module 5
Entry to Facility
Patient's Patient's Transfer
Name Name/ Address & form
Reg. # SAM No. Type of Sex DOB Age Date Wt. Ht. WH Edema MUAC
(surname, Caregiver's Phone No.
first name) name Entry F/M mm/dd/yy (months) mm/dd/yy (kg) (cm) Z 0, 1, 2, 3 (mm)
Code of the
OTC/ITC
10
11
12
13
14
15
16
17
18
19
20
Five Years Manual of Operations, p.199-200.
ANNEX 5.6.
Philippines IMCI & CIMCI
THEN CHECK FOR ACUTE MALNUTRITION
Edema of both feet PINK: • Give first dose appropriate antibiotic.

Check for Acute Malnutrition OR • Treat the child to prevent low blood sugar.
WFH/L less than -3 Z-scores COMPLICATED • Keep the child warm.
LOOK AND FEEL: OR SEVERE • Refer URGENTLY to hospital.
CLASSIFY MUAC less than 115mm (11.5cm) ACUTE
Look for signs of acute malnutrition NUTRITIONAL AND any of the following: Malnutrition
STATUS - Medical complication present
Look for edema of both feet or
Determine the WFH/L* ___ Z-score - Not able to finish RUTF
Measure MUAC** ___mm in a child 6 or
months or older. - Breastfeeding problem
If WFH/L less than -3 Z-scores or MUAC WFH/L less than -3 Z-scores YELLOW:• Give oral antibiotics for 5 days.
less than 115mm (11.5cm), then: OR • Continue breastfeeding.
MUAC less than 115mm UNCOMPLICATED • Give ready-to-use therapeutic food if
Check for any medical complication (11.5cm) SEVERE available for child aged 6 months or more.
present: AND ACUTE • Counsel the mother on how to feed the
- Any general danger sign Able to finish RUTF. Malnutrition child.
- Any sever classification • Assess for possible TB infection.
- Pneumonia with chest indrawing • Advice mother when to return immediately.
• Follow up in 5 days.
If no medical complications present:
- Child is 6 months or older, offer WFH/L between -3 and -2 YELLOW: • Assess the child's feeding and counsel the
RUTF*** to eat. Z-scores mother on the feeding recommendations.
Is the child: OR MODERATE • If feeding problem, follow up in 5 days.
Not able to finish RUTF portion? MUAC 115mm up to 125mm ACUTE • Assess for possible TB infection.
Able to finish RUTF portion? (11.5cm up to 12.5cm) Malnutrition • Advice mother when to return immediately.
- Child is less than 6 months, assess
WFH/L -2 Z-scores or more GREEN: • Assess the child's feeding and counsel the
breastfeeding:
OR mother on the feeding recommendations.
Does the child have a breastfeeding
MUAC 125mm or more NO • If feeding problem, follow up in 5 days.
problem?
(12.5cmor more) ACUTE • Assess for possible TB infection.
Malnutrition • Advice mother when to return immediately.
* WFH/L is Weight-for-Height or Weight-for-Length
determined by using the WHO growth standards chart.
** MUAC is Mid-Upper Arm Circumference measured using Department of Health. 2015. National Guidelines on the Management of Severe
MUAC tape in all children 6 months or older.
*** RUTF is Ready-to-Use Therapeutic Food for conducting Acute Malnutrition for Children under Five Years Manual of Operations, p.131
the appetite test and feeding children with secure acute
malnutrition.
sick child recording form
(child age 2 months up to 5 years)
Date: ____/____/____ BHW: _______________

Temperature: ______ Initial Visit Follow-Up
CHILD'S NAME: _________________________ _________________________ AGE: _______ _______

First Name Family Name Years Months
BOY GIRL
CAREGIVER'S NAME: ________________________ RELATIONSHIP: Mother/Father/Other: ___________
ADDRESS: ______________________________________________________________________________
CONTACT NO.: ____________________________
1. IDENTIFY PROBLEMS
ASK and LOOK Any DANGER SIGN? SICK but NO Danger Sign?
ASK: What are the child's problems? Encircle each
sign reported. If not reported, then ask to be sure.
Is there Cough? YES NO
Cough for 21 days or more Cough (less than 21 days)
If yes, for how long? ____ days
Is there Diarrhea (loose stools)? YES NO Diarrhea for 14 days or Diarrhea (less than 14
If yes, for how long? ____ days more days AND no blood in
Is there blood in stool? YES NO Blood in stool stool)
Is there Fever (reported or now)? YES NO
If yes, started ____ days ago.
Fever for 7 days or more
If yes, was there a visit/travel and stayed Fever less than 7 days
Any fever in a malaria area
overnight in a malaria area in the past
4 weeks? YES NO
Is there Convulsions? YES NO Convulsions
Is there Difficulty drinking or feeding? YES NO
Not able to drink or feed
If yes, Not able to drink or feed anything?
anything
YES NO
Is there Vomiting? YES NO
Vomits everything
If yes, Vomits everything? YES NO
Is there any other problem? YES NO
SEE 7 If any OTHER PROBLEMS, refer.
LOOK:
Is there Chest Indrawing? YES NO Chest Indrawing
If cough, count breathes in 1 minute? _______bpm
Fast breathing: YES NO
Fast breathing
Age 2 months up to 12 months: 50bpm or more
Age 12 months up to 5 years: 40 bpm or more
Very sleepy or
Is the child Very sleepy or unconscious? YES NO
unconscious
For child 6 months up to 5 years, MUAC strap colour:
Red MUAC Yellow MUAC
RED YELLOW GREEN
Is there swelling of both feet? YES NO Swelling both feet
If ANY Danger Sign, REFER If NO Danger Sign, treat at
2. DECIDE: REFER OR TREAT CHILD to health facility home and advise caregiver

Module 5
3. REFER OR TREAT CHILD If ANY Danger Sign, REFER If NO Danger Sign, treat at
(check treatments given and other actions) to health facility home and advise caregiver
If any danger sign, If no danger sign,

REFER URGENTLY to health facility TREAT at home and ADVISE on home care.
If Child Give ORS. Help caregiver give child ORS in front of

Assist referral to health facility: has you until child is no longer thirsty.
Diarrhea Give caregiver 2 ORS packets to take home. Advise
Explain why child needs to go to to give as much as child wants, but at least 1/2 cup OR
health facility solution after each loose stool.
Give zinc supplement. Give 1 dose daily for 10 days:
If the child has diarrhea and can - Age 2 months up to 6 months – 1/2 tablet OR
drink, begin giving ORS solution 1 and 1/2 bottle caps*
right away (2.5mL)
- Age 6 months up to 5 years – 1 tab OR 3 bottle caps*
For any sick child who can drink, (5mL)
advise to give fluids and continue
feeding. Help caregiver to give first dose now.
Advise to keep child warm. If child * Bottle cap of 60mL zinc syrup
is NOT hot with fever. For ALL Advise caregiver to give more fluids and continue
children feeding (kalamansi juice for cough).
Write a referral slip. treated Advise on when to return. Go to nearest health facility
at home, or, if not possible, return immediately if child
Arrange transportation, and help advise on - Cannot drink or feed
solve other difficulties in referral. home care - Becomes sicker
- Has blood in the stool
FOLLOW UP child on return at Give Paracetamol for temperature of 38.5˚C and
least once a week until child is above every 6 hours (until fever stops).
well.
SYRUP
AGE TABLET (500mg)
(120mg/5mL)
2 months up
1/4 5mL (1tsp)
to 3 years
3 years up to
1/2 10mL (2tsps)
5 years
Follow up child in 3 days.

For child with YELLOW on MUAC strap, refer to health
center for freeding advice.
Age Vaccine
Advise caregiver, if
4. CHECK Birth BCG Hep B1
VACCINES RECEIVED 6 weeks DPT1 OPV 1 Hep B2 WHEN is the next vaccine
(check vaccines completed, 10 weeks DPT2 OPV 2 to be given?
encircle vaccines missed) 14 weeks DPT3 OPV 3 Hep B3
WHERE?
9 months Measles
5. CHECK VITAMIN A STATUS: Given within the last 6 months? YES NO

(Give Vitamin A if child is 6 months old and is not given within the last 6 months)
6. CHECK DEWORMING STATUS: Given Mebendazole/Albendazole within the

last 6 months? YES NO
(Give Mebendazole/Albendazole if child is > 12 months old and has not been given deworming medicine within
the last 6 months.)
7. If any OTHER PROBLEM or condition you cannot manage, refer child to health facility,
write referral note, and follow up child on return.
Describe problem: _______________________________________________________________

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
8. When to return for FOLLOW UP (encircle):
Monday / Tuesday / Wednesday / Thursday / Friday / Weekend
9. Note on follow up:
Child is better–continue to treat at home. Day of next follow up: ________.

Child is not better–refer URGENTLY to health facility.
Child has danger sign–refer URGENTLY to health facility.

Module 5
ANNEX 5.7.
IYCF counselling at community and facility level (IMCI)
Card 6. Tamang Paghakab
»» Ang tamang paghakab ng bibig ng sanggol sa suso ng ina ay nakakatulong sa kapwa ina at sanggol.
Ang tamang paghakab ay nakatutulong sa maayos na pagsuso ng sanggol at sa patuloy na pagdaloy ng

gatas. Nakatutulong din ito para maiwasan ang mga sugat at bitak-bitak sa utong ng ina. Hindi dapat masakit
ang pagpapasuso.
»» Apat na palatandaan ng magandang paghakab:
1. Malawak ang bukas ng bibig ng sanggol.

2. Makikita ang higit na maitim na balat (areola ng suso) sa itaas ng bibig ng sanggol kaysa sa ibaba.
3. Ang ibabang labi ng sanggol ay naka-palabas.
4. Nakadikit ang baba ng sanggol sa suso ng ina.
»» Kung ang sanggol ay maayos na nakalapat sa suso ng ina at madali niyang makuha ang gatas, ito ay
senyales na maayos ang pagsuso. Ang ilang pang mga senyales ay:
1. Mabagal ngunit malalim, at minsan pahintu-hinto, na pagsuso ng sanggol. Maaring makita o marinig
siyang lumulunok pagkatapos ng isa o dalawang pagsuso.
2. Ang pagpapasuso ay kumportable at walang sakit para sa ina.
3. Pagkatapos ng pagsuso ay kumportable at walang sakit para sa ina.
x
4. Ang suso ay mas malambot pagkatapos ng pagpapasuso.
Feeding recommendations during sickness and health
Feeding recommendations FOR ALL CHILDREN during sickness and health, and including HIV EXPOSED children on ARV prophylexis
Newborn,
1 week up to 6 months 6 up to 9 months 9 up to 12 months 12 months up to 2 years 2 years and older
birth up to 1 week
• Immediately after birth, • Breastfeed as often as • Breastfeed as often as • Breastfeed as often as • Breastfeed as often as • Give a variety of foods
put your baby in skin to your child wants, look for your child wants. your child wants. your child wants. to your child, including
skin contact with you. signs of hunger, such as animal sourced foods and
beginning to fuss, sucking • Also give thick porridge • Also give a variety of • Also give a variety of Vitamin A-rich fruits and
• Allow your baby to fingers, or moving lips. or well-mashed foods. mashed foods or finely mashed foods or finely vegetables.
take the breast within Including animal-sourced chopped family food, chopped family food,
the first hour. Give your • Breastfeed day and night foods and Vitamin A-rich including animal-sourced including animal-sourced • Give at least 1 full cup
baby colostrum, the first whenever your baby fruits and vegetables. foods and Vitamin A-rich foods and Vitamin A-rich (1 cup = 250mL)
yellowish, thick milk. It wants, at least 8 times fruits and vegetables. fruits and vegetables.
protects the baby from in 24 hours. Frequent • Start by giving 2 to 3 • Give 3 to 4 meals each
many illnesses. feeding produces more tablespoons of food. • Give 1/2 cup to 3/4 cup at • Give 3/4 cup to one cup at day.
milk. Gradually increase to 1/2 each meal (1 cup = each meal (1 cup =
• Breastfeed day and night, cups (1 cup = 250mL) 250mL). 250mL). • Offer 1 to 2 snacks
as often as your baby • Do not give other foods or between meals.
wants, at least 8 times a fluids. Breastmilk is all • Give 2 to 3 meals each • Give 3 to 4 meals each • Give 3 to 4 meals each
day in 24 hours. Frequent your baby needs. day. day. day. • If your child refuses a new
feeding produces more food, offer "tastes"
milk. • Offer 1 or 2 snacks each • Offer 1 or 2 snacks • Offer 1 or 2 snacks several times. Show that
day between meals when between meals. The child between meals. you like the food. Be
• If your baby is small (low the child seems hungry. will eat if hungry. patient.
birth weight), fed at least • Continue to feed your
every 2 to 3 hours. Wake • For snacks, give small child slowly, patently, • Talk with your child during
the baby for feeding after chewable items that patiently. Encourage—but a meal, and keep eye
3 hours. If baby does not the child can hold. Let do not force—your child contact.
wake itself. your child try to eat the to eat.
snack, but provide/help if
• Do not give other foods needed.
or fluids. Breast milk is
what baby needs. This is
especially important for
infants of HIV-positive
mothers. Mixed feeding
increases the risk of
HIV mother-to-child
transmission compared to
exclusive breastfeeding.
A good daily diet should be adequate in quantity and include an energy-rich food (for example, thick cereal with added oil): meat, fish, eggs, or pulses; and fruits and vegetables.
107
Module 5
Recommendation FOR fedding and care for development
Birth up to 8 months 8 months up to 12 months up to 2 years and older

12 months 2 years
• Exclusively breast feed as • Breast feed as often as • Breast feed as often as • Give adequate amount
often as your child wants, your child wants. your child wants. of family foods at 3 meals
day and night, at least 8 a day.
times in 24 hours. • Add any of the following: • Give adequate amount of
Lugaw with oil, mashed family foods such as: • Give twice daily nutritious
• Do not give other foods vegetables or beans, rice, camote, potato, fish, food between meals such
or fluids. steamed tokwa, flaked chicken, meat, monggo, as: Boiled yellow camote,
fish, pulverized roasted steamed tokwa, pulverized boiled yellow corn,
dills, finely ground meat, roasted dills, milk and peanuts, boiled saba,
eggyolk, bite-sized eggs, dark green leafy banana, taho, fruits and
fruits. (3 times per day if and yellow vegetables fruit juices.
breastfeed, 5 times per (malunggay, squash),
day if not breastfeed) fruits (papaya, banana).
Add oil or margarine. 5
times a day.
• Feed the baby nutritious

snacks like fruits.
Birth up to 4 months 8 months up to 12 months up to 2 years and older

of age 12 months 2 years
• Play: Provide ways for

your child to see, hear,
feel and move. • Play: Give your child • Play: Give your child • Play: Help your child
clean, safe house hold things to stack up, and count, name and compare
things to handle, bang to put into container and things. Make simple toys
4 months to and drop. take out. for your child.
6 months
• Communicate: respond • Communicate: Respond • Communicate: Encourage
to your child's sound and to your child's sound and your child to talk and
interest. Tell your child interest. Tell your child answer your child's
the names of things and the names of things and questions. Teach your
people. people. child stories, song and
games.
• Play: Have large colorful

things for your child to Feeding Recommendation for a child who was PERSISTENT DIARRHEA
reach for, and new things
to see. • If still breastfeeding, give more frequent, longer breastfeeding, day and night.
• Communicate: Talk • If taking other milk such as milk supplements:

to your child and get a - Replace with increase breastfeeding
conversation going with - Replace half the milk with nutrient-rich, semi-solid food.
sounds or gestures.
• Do not use condensed or evaporated filled milk.
• For other food, follow feeding recommendations for the child's age.
Five Years Manual of Operations, pp. 128-130
ANNEX 5.8.
Infant Feeding Assessment IMCI
Then check for feeding problem or low weight for age/lenght
Use this table to assess feeding of all young infants except HIV-exposed young infants not breastfed. For
HIV-exposed non-breastfed young infants, see chart "THEN CHECK FOR FEEDING PROBLEM OR LOW
WEIGHT FOR AGE IN NON-BREASTFED INFANTS"
If an infant has no indications to refer urgently to hospital:
Check for Acute Malnutrition Not well attached YELLOW: • If not well attached or not
to breast sucking effectively, teach
CLASSIFY
ASK: OR FEEDING correct positioning and
FEEDING
Is the infant breastfed? If yes, how many Not sucking PROBLEM or attachment.
times in 24 hours? effectively LOW WEIGHT - If not able to attach
Does the infant usually receive any other OR well immediately, teach
foods or drinks? If yes, how often? Less than 8 the mother to express
If yes, what do use to feed the infant? breastfeeds in 24 breastmilk and feed by
hours a cup
LOOK AND FEEL: OR • If breastfeeding less than 8
Receives other times in 24 hours, advise
Look for signs of acute malnutrition foods or drinks to increase frequency of
OR feeding. Advise the mother to
Determine the weight for age Low weight for breastfeed as often and as
Look for ulcers or white patches in the age/lenght long as the infant wants, day
mouth (thrush). OR and night.
Thrush (ulcers or • If receiving other food and
ASSESS BREASTFEEDING: white patches in drinks, counsel the mother
mouth). about breastfeeding more,
Has the infant breastfed in the previous reducing other foods or drinks,
hour? If the infant has not fed in the and using a cup.
previous hour, ask the mother to put her • If not breastfeeding at all*
infant to the breast. Observe the breastfed - Refer for breastfeeding
for 4 minutes. counselling and possible
(If the infant was fed during the last hour, relactation.
ask the mother if she can wait and tell you - Advise about correctly
when the infant is willing to feed again.) preparing breast milk
substitutes and using a cup.
- Is the infant well-attached • Advise the mother how to fed
not well-attached and keep the low weight infant
good attachment was met home.
• Follow-up any feeding problem
To check attachment, look for: or thrush in 2 days.
- Chin touching breast • Follow-up low weight for age
- Mouth wide open in 14 days.
- Lower lip bummed outwards
- More areola visible above than below the
mouth Not low weight for GREEN: • Advise mother to give home
(All these signs should be present if the age/length and care for the young infant.
attachment is good) no other signs NO FEEDING • Praise the mother for feeding
of inadequate PROBLEM the infant well.
Is the infant sucking effectively (that is slow feeding.
deep sucks, sometimes pushing)?
not sucking effectively * Under not breastfeeding because the mother is HIV positive.
sucking effectively
Clear a blocked nose if it interferes with

breastfeeding.
Five Years Manual of Operations, p.140

Module 5
ANNEX 5.9.
Outpatient therapeutic care (OTC) chart
Admission Details: Outpatient Therapeutic Care (front)

Instructions:
Please fill up needed details and encircle appropriate text or values based on history taking and physical examination
Name Reg. No
Municipality Barangay
Age (months) Sex M F Date of Admission
Screened
Admission Readmission
by Walk-in From IC From SFP From other OC ITC Refusal
Status BNS/BHW
(Relapse)
Total Number # adults: # children: Distance to 4Ps Yes

Twin Yes No
in Household ___ ___ home (hrs) Beneficiary? No
Admission Anthropometry
MUAC (cm) wt (kg) ht (cm) WHZ score
Admission
Criteria (encircle Edema
MUAC
WHZ<-3 Others (specify)
<11.5cm
all applicable)
History
Able to drink or Does the Child Vomit Is child
IMCI Danger Has the child had convulsions?
breastfeed? Everything? lethargic/unconscious?
Signs Yes No Yes No
Yes No
Yes No
Diarrhoea Yes No Stools / Day 1-3 4-5 >5
Vomiting Yes No Frequency Passing Urine Yes No
Cough Yes No If edema, how long swollen?

Appetite at
Good Poor None Breastfeeding Yes No
home?
Other
Reported Congenital Other:
Medical Tuberculosis Malaria
Problems anomalies __________
Problems
Physical Examinations
Respiration
<30 30-39 40-49 50+ Edema None + ++ +++
Rate (#min)
Temperature Chest
Yes No
(˚C) Retractions
Eyes Normal Sunken Discharge Dehydration None Moderate Severe
Conjunctive Normal Pale Mouth None Sores Candida
Ears Normal Discharge Disability Yes No
Skin Changes None Scabies Peeling Ulcers / Abscesses Extremities Normal Cold
Appetite Test Pass Fail NOTE: If child failed appetite test, refer IMMEDIATELY to ITC
Routine Admission Medication
Admission:
Drug Date Dosage
Amoxycillin
2nd visit:
Mebendazole Measles
Other Medication
Drug Date Dosage Drug Date Dosage
follow up: outpatient therapeutic care (Back)
Name: Registration Number:
Week adm. 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Date
Anthropometry
Weight (kg)
Weight loss* (Y/N) * *
MUAC (cm)
Edema (+ ++ +++)
* WEIGHT CHANGES: MARASMICS: If below admission weight on week 3, refer to home visit. If no weight gain by week 3, refer to ITC.
History
Diarrhea
(4 days)
Vomiting
(4 days)
Fever
(4 days)
Cough
(4 days)
Physical Examination
Temperature (˚C)
Respiratory Rate (# / min)
Dehydrated Rate (Y/N)
Anemia (Y/N)
Skin Infection (Y/N)
Appetite Test (Pass/Fail)

Action Needed (Y/N)
(note below)
Other Medication
(see front of card)
RUTF (# sachets)
Name of Examiner
OUTCOME ***
*** A = absent D = defaulter (3 consecutive absences) T = transfer to Inpatient X = died C = discharged cured
RT = refused transfer HV = home visit NC = discharged non-cured
** Action Taken (include date)
Department of Health. 2015. National Guidelines on the Management of Severe Acute Malnutrition for Children under Five
Years Manual of Operations, pp. 148-149.

Module 5
ANNEX 5.10.
OTC/ITC Referral Form
Where there are existing two way referral formats in place these should be used and checked/amended
to ensure all the information on the following example is included. If no existing format is in place the form
below may be used/adapted for use.
Referral / Transfer From (SAM) - Copy for Receiving Facility (OTC/ITC)
Name: _________________________ Sex: ____ Date of Birth: _________________ Age: ______ months/years
Admission Information: MUAC: __________ Date of Referral: __________________
Name mother/caregiver (for child): ________________________________________
Registration Number (mother/caregiver): _____________________ Contact Number: ______________________
Municipality: ___________________ Barangay: _____________ House No.: ______
To be completed by referral focal point (ie. RHU staff-midwife/nurse/doctor)
Referred to Transfer to: OTC / ITC Date of referral / transfer: _______________________

Weight: _________ Height: _________ WH Z score (if used): ___________ Edema (circle): + ++ +++
Refer/Transfer from: ________________________________ (Name of Brgy/Health Center/OTC/Hospital)
Refer/Transfer to: __________________________________ (Name of Brgy/Health Center/OTC/Hospital)
Reason for transfer (circle): Anorexia (no appetite) Complications Edema No weight gain Other: ________
Referred/Transferred by (name of Health Worker): _________________ Contact Number: _________________
Received by (name of Health Worker): ________________________ Contact Number: _________________
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Cut along dotted lines - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Referral / Transfer From (SAM) - Copy for Referring Facility (OTC/ITC)

Five Years Manual of Operations, p.142
ANNEX 5.11.
Routine medicine doses in OTC
ROUTINE ANTIBIOTICS
Antibiotics should be given to every severely malnourished patient, even if they do not have signs of systemic
infection as the presence of infection may be masked due to immuno-suppression which limits response such
as fever.
»» Give on admission
»» Give 2 times a day for 5 - 7 days (10 days if needed)
»» The first dose should be given in front of the health worker and an explanation given to the mother
on how to continue this treatment at home.
The antibiotic regimen can be changed according to the resistance pattern of bacteria that arises from time to
time and amoxicillin replaced with another broad spectrum antibiotic.
First line Treatment: Amoxicillin2
Medication Route Dose Prescription
4 - 9.9kg 250mg On admission

Amoxicillin Oral 10 - 13.9kg 500mg Twice daily for 5 - 7
14 - 19kg 750mg days
Dosage of Cotrimoxazole prophylaxis for HIV positive children 6 - 59 months (additional)
40mg Trimethoprim
Cotrimoxazole
Oral 200mg Once daily
Suspension or tablet
Sulfamethoxazole
Malaria
»» Refer to the guidelines of the Philippine Malaria Control Program for asymptomatic malaria or
malaria prophylaxis (except that quinine tablets should not be used in the severely malnourished).
»» Refer symptomatic malarial cases for inpatient management.
»» Where complicated patients refuse admission to inpatients, treat with the regimen recommended for
inpatients.
»» Give insecticide impregnated bed nets in malaria endemic regions.
DEWORMING
»» This should be coordinated with the Garantisadong Pambata (GP) program

»» Give deworming for both those transferred from ITC to OTC and those admitted directly to OTC at
the 2nd outpatient visit. Worm medicine is only given to children than can walk.
Age <1 year 1 to 2 years > 2 years
Albendazole 400mg Not given 1/2 tablet Once daily

Mebendazole 500mg Not given 1/2 tablet 1 tablet
2 Amoxicillin is also effective in reducing the overgrowth of bacteria in the GI tract, commonly associated with severe acute malnutrition, and therefore
preferred over Cotrimoxazole which is standard first line antibiotic in Nepal.

Module 5
Measles
»» This should be coordinated with the Expanded Program of Immunization (EPI) program
»» Give measles vaccine to children over the age of 9 months and without a vaccination card during
their 4th visit; give a second dose to those that have been given measles vaccine as inpatients
when severely malnourished.
»» Do not give measles vaccine on admission to patients directly admitted to OTC, they are unlikely to
be incubating measles3 and will not be exposed to nosocomial infection.
Note: Measles vaccine on admission to OTC is thus omitted except in the presence of a measles epidemic,
because the antibody response is diminished or absent in the severely malnourished. The measles vaccine
is given at a time when there should be sufficient recovery for the vaccine to produce protective antibodies.
Vitamin A
»» Do not keep any child with clinical signs of vitamin A deficiency as an outpatient, the condition
of their eyes can deteriorate very rapidly and they should always be transferred for inpatient
management.
»» If an epidemic outbreak of measles is in progress, give vitamin A to all children.
»» During emergencies/disasters, give additional Vitamin A to 6 - 11 month old infants (100,000 IU)
and 12 - 59 month old children (200,000IU), unless they have received a similar dose in the past 4
weeks.
Medication Vitamin A IU orally
6 to 11 months One blue capsule (100,000IU 0 30,000ug)
12 months and more Two blue capsules or 1 red capsule (200,000IU 0 60,000ug)
Medicines for specific groups of sam children in otp
One dose of folic acid (5mg) can be given to children with clinical anemia. There is sufficient folic acid in the
RUTF to treat mild folate deficiency.4
Five Years Manual of Operations, p.143-144.
ANNEX 5.12.
Antibiotic alternatives for OTC
Where Amoxicillin resistance is common a short course of metronidazole should be given at a lower
dose than is normally prescribed - 10mg/kg/day (see Annex 19). Alternatively, Amoxicillin/Clavulanic
acid combination could be used (the level of resistance is lower than with amoxicillin alone at the
moment) – this recommendation should be reviewed periodically in light of the prevailing resistance
patterns in the population being treated.
Do not give chloramphenicol to babies of less than 2 months of age and with caution in infants less than
4kg or less than 6 months of age. Because of the danger of OTC staff giving chloramphenicol to these
categories of patient, it should not be used as routine treatment in OTC programs.
Years Manual of Operations, p.145.
ANNEX 5.13.
Fever and SAM
Antipyretics are much more likely to be toxic in the malnourished than in a normal child due to the
likelihood of reduced liver function.
Do not give aspirin to any child under the age of 12 years with fever. This may cause Reye's syndrome.
Other non-steroidal anti-inflammatory medicines (NSAIDS) should not be given in malnutrition due to
the risk of renal toxicity.
Paracetamol should not be given routinely to children with SAM. It is given as a stat dose with extreme
caution under the direction of a clinician only in ITC and OTC. It should never be dispensed as a take
home medicine in OTC. Paracetamol should be used with caution in children receiving phenobarbitone,
phenytoin or rifampicin.
If Paracetamol is prescribed as a stat dose, the oral route is recommended since the absorption of
rectal Paracetamol is highly variable.
For moderate fever up to 38.5°C rectal or 38.0°C underarm:

• Remove blankets, hat, and enough clothes to expose the back, chest and stomach. Remove
any sources of heat and keep away from windows exposing the child to direct sunlight. If in the
open, keep the patient in the shade in a well-ventilated area.
• Give frequent sips of cool water to drink.
• Check for malaria and examine for other sources of infection.
For fever of over 39°C rectal or 38.5°C underarm, where there is the possibility of hyperpyrexia
developing, in addition to the above, also:
• Place a damp/wet room-temperature cloth over the patient’s scalp, and chest area. Dampen
the cloth whenever it is dry. Use an electric fan or wave a fan over the child to increase the
cooling effect.
• Monitor the child’s temperature every 30 mins and stop aggressive cooling when the temperature
falls below 38.5°C (rectal) or 38.0°C (axilla).
• Give the patient frequent sips of cool water. Check with the physician regarding any limits to
fluid intake particularly where there are also IV fluids administered.
• If the temperature increases or does not reduce, the child should be undressed completely
and the damp/wet cloth can be extended to cover a larger area of the body. A physician should
reassess the status of the child and consider IV antibiotic therapy if not already started.
Years Manual of Operations, p.145.

Module 5
ANNEX 5.14.
OTC Treatment Card
OTP Ration and Home Instruction Card
Ration Card
OTP Registration Number / / /
OTP Site Address

Name Age
Target Weight
W/H RUTF
Done Weight (kg) Height (cm) MUAC (mm) Edema Others
score Received per day
ANNEX 5.15.
Appropriate referral of complicated cases
For very ill malnourished children brought to an outpatient facility for SAM and who need to be
“transferred” to inpatient care, it is critical to ensure that referral should take place quickly. However,
deterioration often occurs during transport and can lead to death soon after arrival, due to the length and
difficulty of the journey. This is known as “transport trauma.” A number of measures are recommended
to avoid this:
• Explain to the caregiver that the patient is critically ill and needs urgent transport to an inpatient
facility for more specialized care.
• Make the child as comfortable as possible and administer small amounts of 10% sugar water
to keep them hydrated before and during transportation.
• Contact the inpatient facility by telephone for advice and support for the management of the
patient. The telephone call, advice given and the name of the doctor and inpatient facility
contacted should be recorded on the treatment card.
• Where there is additional capacity (presence of the MHO) at the OTC and where training has
been carried out on ITC protocols and measures – in line with those protocols – further stabilize
the child before transport is taken.
• Public transport is not recommended.
Version 1.0, November, 2015
ANNEX 5.16.
C-MAMI Tool
Community management of uncomplicated acute malnutrition
in infants < 6 months of age (C-MAMI)
(C-MAMI Tool Nov. 2015).
Context of tool development
This tool provides a health worker with a format to assess, The exact location where a C-MAMI service takes place The C-MAMI tool has been developed by the ENN and
identify/classify and manage uncomplicated acute malnutrition is not specified as this will vary by context and will be the LSHTM, with expert input and in consultation with
in infants <6 months of age in the community (C-MAMI). determined by staff capacities. One scenario is that an programmers4. Please contact us with feedback, if you have
The aim of the C-MAMI Tool is to help put the latest WHO infant is assessed at clinic level and if enrolled in C-MAMI, opportunities to field test or are interested in collaborating to
technical guidance1 into practice. It was developed as a first management takes place at the clinic by capacitated staff. field test. A word version, to facilitate adaptation, is available
step to help fill a gap in programming guidance. The tool Another scenario is that enrolled infants are assessed at on request. Contact: Marie McGrath, ENN, email:
draws upon and seeks to complement existing national and clinic level and then referred to a different location/unit for marie@ennonline.net
international guidance and protocols. It is modeled on the management (e.g. where skilled breastfeeding support is
Integrated Management of Childhood Illness (IMCI) approach available in a local programme).
and resources2 in particular, e.g. in terms of identifying and
triaging at risk infants, colour coding the framework, and This tool has been developed as a 'working' document and as
layout of assessment and management tools. a first step to fill a programming gap in both emergency and
non-emergency contexts. The developers recognize the need
The tool refers to the management approach for an to map out capacity development and associated training
uncomplicated case of acute malnutrition as C-MAMI. needs for implementation of the tool. Another important area
Complicated cases are referred for inpatient case as per not yet elaborated within the tool is what C-MAMI-related
existing protocols; a great majority of countries already monitoring should take place within a programme; what
have detailed descriptions in their National Management of data would be valuable to inform programming and wider
Acute Malnutrition Guidelines on how to care for this group. learning, and how might this can be complied; and how
The tool refers to enrollment (to programme) — rather than this might gel with data collection in existing treatment and
admission — since the latter is often taken to mean admission health programming.
to inpatient care alone.
1
WHO. Guideline: Updates on the management of severe acute malnutrition http://www.who.int/elena/titles/sam_infants/en/. An update of this review is and external review by a MAMI technical interest group ('circle'): Zita Weise-
in infants and children. Geneva: World Health Organization; 2013. in final preparation for peer review publication. Prinzo, Maaike Arts, Angela Kangori, Diane Holland, Pascale Delchevalerie,
4
http://files.ennonline.net/attachments/2435/C-MAMI-Tool-Web-FINAL-Nov-2015.pdf
http://www.who.int/elena/titles/sam_infants/en/ This tool was developed in an ENN led collaboration funded by OFDA, Irish Aid, Nicki Connell, Dr. Yasir Arafat, Dr. Mothabbir Golan, Alison Donnelly, Christine
2
http://www.who.int/matenal_child_adolescent/topics/child/imci/en/ and Save the Children. Content was developed by the ENN (Marie McGrath), Fernandes, Sarah Butler, Caroline Wilkinson, Mark Manary, Martha
3
For a review of the MAMI content of national guidelines, see: Kerac M, Tehran I, ENN lead consultants (Mary Lung'aho, Maryanne Stone-Jimenez) and the Mwangowe, Cécile Bizouerne, Casie Tesfai, Saul Guerrero, Anne Walsh, Mike
Lelijveld N, Onyekpe I, Berkley J, Manary M. WHO; 2012. Inpatient treatment LSHTM (Marko Kerac) with expert input from ACF (Cécile Bizouerne, Paulina Golden, Yvonne Grellety, Britta Schumacher, Lynnda Keiss, Scott Ickes, Paulina
Infants less than 6 months of age) Assessment for Nutritional Vulnerability
C-MAMI (Community Management of uncomplicated Acute Malnutrition in
of severe acute malnutrition iin infants aged <6 months. Avosta, Elisabetta Dozio), independent experts (Himali De Silva, Maya Asir) Avosta, Elisabetta Dozio.
1
117
118
Module 5
Orientation to the C-MAMI Tool

Appropriate community management of uncomplicated acute malnutrition in infants <6 months (C-MAMI) is based on the severity on the infant's condition.
Assessment and classification of the infant's condition are necessary to identify appropriate management activities.
The assessment of C-MAMI is outlined in two sections:

Page
4 I C-MAMI Assessment for Nutritional Vulnerability in infants aged <6 months: Infant
7 II C-MAMI Assessment for Nutritional Vulnerability in infants aged <6 months: Mother
The following are the assessment steps required to determine appropriate management for both infant and mother.
Infant:
4 1. TRIAGE: Check for general clinical danger signs or signs of very severe disease (for infant only)
4 2. (A)nthropometric/Nutritional Assessment
5 3. (B)reastfeeding Assessment
6 3. (C)linical Assessment
Mother:
7 1. (A)nthropometric/Nutritional Assessment
8 2. (B)reastfeeding Assessment
8 3. (C)linical Assessment
8 3. (D)epression/Anxiety/Distress
Using the table framework below, determine if an infant meets the criteria for: Priority I is a category of infants for whom enrollment to C-MAMI is essential.
Ideally, priority 1 and 2 infants would be enrolled into a treatment programme.
Assess Colour However, this is context specific and may not always be possible due to limited
CLASSIFY ACT (MANAGE) resources, staff and programme capacity. In such cases of limited capacity, it is
Ask, Listen Identify, Analyze codes*
better to focus on infants in the higher risk 'pink' and 'yellow I' zones.
Inpatient referral and care Pink An infant is always managed in the 'highest' category care programme, i.e. if
there are any aspects of the assessment falling into the pink zone, then he/she
Priority 1 enrollment into C-MAMI should be referred for further assessment/inpatient care even if other parts of the
Yellow 1
outpatient-based care assessment are in 'yellow 2' or 'green' zones/
Priority 2 enrollment into C-MAMI As well as the infant, the mother is also assessed since her health and wellbeing
Yellow 2
outpatient-based care directly affects her infant; even if an infant is currently stable, he/she is at
immediate risk if the mother has problems and it is important to thus treat the
Reassurance and discharge with two as a dyad rather than as separate individuals. Whilst 'mother' is used to
Green
general advice only describe the primary caregiver, this may be substituted as necessary, e.g. where
an infant is being wet-nursed.
*Colour Codes are in line with IMCI colour classifications. The C-MAMI Tool has also sub-classified into Yellow 1 and Yellow
2 to aid prioritisation.
2
Training Module on the National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
C-MAMI Assessment for Nutritional Vulnerability in Infants aged <6 months:
Infant
Assess CLASSIFY ACT (MANAGE)
1. TRIAGE: Check for general clinical danger signs or signs of very severe disease (for infant only)
Ask, Listen Identify, Analyze • Any general danger sign Pink: • Actions as per IMCI, with URGENT referral to
• As per existing IMCI • Any IMCI danger • Any signs of severe or very severe disease VERY SEVERE inpatient care
assessment protocols signs • NB Be careful when assessing DEHYDRATION due to diarrhea: some DISEASE • Continue to anthropometric assessment once
signs (e.g. dry mouth,dry eyes, sunken eyes, decreased skin turgor) can any life-threatening problems have been addressed:
occur in severe wasting without dehydration. Focus more on history there may also be underling undernutrition
(vomiting/diarrhea/nor drinking/thirst); poor urine output (absent or very
dark/concentrated urine); recent weigfht loss; fast/weak oulse
2. (A)nthropometric/Nutritional Assessment
CHECK FOR ACUTE MALNUTRITION Severe Acute Malnutrition / HIGH Nutritional Risk Pink: • Actions as per IMCI, with URGENT referral to
LOOK AND FEEL: • WLZ <-3 COMPLICATED inpatient care
Look for signs of acute malnutrition OR SEVERE ACUTE • Continue to anthropometric assessment once
• Look for pitting oedema of both feet • Recent severe weight loss or prolonged (weeks-months) failure to gain MALNUTRITION any life-threatening problems have been
• Measure weight and length and determine weight weight addressed: there may also be underling
-for-length (WFL) z-score where calculable • Sharp drop across growth chart centile lines undernutrition
• Record Mid Upper Arm Circumference (MUAC) for all AND
infants (for on-going and future studies)5 Clinical complications:
• NOTE: clinical assessment for visible wasting is • Oedema of both feet6
not a reliable substitute for anthropometry and will • Any danger sign or sign of severe disease (as above)
result in cases being missed. It should only be done • Failure to respond to previous outpatient-based nutritional care
where length is <45cm and WFL z-score cannot be
calculated.
Severe Acute Malnutrition / MODERATE Nutritional Risk Yellow 1: • C-MAMI outpatient enrollment: Priority 1
ASK: • WLZ <-3 UNCOMPLICATED • Course of broad-spectrum oral anitbiotic, such as
• If growth monitoring card is available. OR SEVERE ACUTE amoxcicillin
If yes, note: • Moderate weight loss or recent (days-weeks) failure to gain weight MALNUTRITION • Detailed assessment of underlying cause(s) of
• Birth weight • Moderate drop across growth chart centile lines malnutrition + tailored action to address these
• Current growth centile • Plot & appraise growth chart for monitoring
AND
• Growth trend if previous data available progress
Clinically stable / none of above clinical complications
• Growth velocity and growth pattern (e.g. whether
tracking along or falling across centile lines)
If no, record:
• Weight for age (W/A)
Cont'd next page

5
There is growing evidence for use of MUAC in infants >2-<6 months. However, age and nutritional status classification cut-offs have not yet been established. For these reasons, MUAC
data are not intended for use in classification. However, we do strongly urge agencies to measure and collect MUAC data to contribute to strengthen future evidence in this area.
6
Nutritional oedema is rare in infants and therefore infants with oedema should always be admitted to investigate possible underlying medical cause.
4
119
120
Moderate Acute Malnutrition / SOME Nutritional Risk Yellow 2: If resources allow:

Module 5
• WL Z >= -3 tp <-2 UNCOMPLICATED • C-MAMI enrollment: Priority 2

AND MODERATE • Detailed assessment of underlying cause(s) of
No clinical complications ACUTE malnutrition + tailored action to address these
MALNUTRITION • Plot & appraise growth chart for monitoring progress
If programme capacity limited
• Detailed assessment of underlying cause(s) of
• General nutrition/feeding advice
• Plot growth chart to aid review
• Review in 1-2 weeks to check whether has got
better or worse (in which case enroll/step-up)
None of the above Green: • No C-MAMI enrollment

LOW • Praise, support, reassure
NUTRITIONAL • General advice / counseling on:
RISK • general IYCF / nutrition recommendations
• routine healthcare services e.g. vaccinations,
growth monitoring
• Advice to return if worsens or develops new
problems
3. (B)reastfeeding Assessment
Note: If mother is not breastfeeding, refer to Appendix 1: Non-breastfeeding Assessment, Counseling and Support Actions
Ask, Listen Identify, Analyze Meets ANY of the criteria below Pink: • URGENT referral to inpatient care
• Feeding history • Structural • Structural abnormalities (e.g. cleft lip/palate, or more complex conditions SEVERE FEEDING • Specialist referral for more detailed assessment
• Breastfed? How often? abnormalities through affecting the face, jaw and mouth) PROBLEMS and treatment of any structural problem
Any problems or physical examination • Abnormality of tone, posture and movement interfering with • Specialist referral for more detailed assessment
concern? (use clean/gloved breastfeeding and support for any disability
• Other feeds; Infant finger to feel inside • Unable to support head or trunk control • Feeding support tailored to addressing main
receives any water, mouth for hidden cleft • When held, infant's arms and legs fall to the sides underlying problem (e.g. aim for re-establishment
other liquids or milk? palate) • Infant's body stiff, hard to contain of move of effective exclusive breastfeeding wherever
When started? Infant • Muscular abnormalities • Excessive jaw opening or jaw clenching possible e.g. using supplementary suckling (page
receives any solid or • Breastfeeding based • Not willing/able to suckle at the breast 23)
semi-solid foods? on observation • Coughing and eye tearing (signs of unsafe swallowing) while
When started? breastfeeding
Cont'd next page
Feeding Assessment: Breastfeeding Meets ANY of the criteria below Yellow 1: • C-MAMI enrollment: Priority 1
• Use 1st Line Breastfeeding Assessment Tool • Not well attached to the breast MODERATE • Refer to 1st Line Breastfeeding Counseling and
OR FEEDING Support Actions (page 9)
• Not suckling affectively PROGRAM
OR
• Less than 8 breastfeeds in 24 hours
OR
• Receives other foods or drinks
Feeding Assessment: Breastfeeding Breastfed infant meets ANY of the criteria below Yellow 2: If resources allow:
• Use 2nd Line Breastfeeding Assessment Tool • Breastfeeding difficulties based on mother's breast conditions MILD / POSSIBLE • C-MAMI enrollment: Priority 2
• Non-severe respiratory difficulties interfering with breastfeeding e.g. FEEDING • Refer to 2nd Line Breastfeeding Counseling
nasal congestion PROBLEM and Support Actions (page 11)
• Plot and appraise growth chart for monitoring
progress
If programme capacity limited

• No enrollment for time being
• General nutrition/feeding advice
• Plot growth chart to aid review
• Review in 1-2 weeks to check whether has got
better or worse (in which case enroll/step-up)
• No signs of inadequate feeding Green: • No C-MAMI enrollment

• Not acutely malnourished NO FEEDING • Praise, support, reassure
• No additional issues for mother-infant dyad PROBLEM • General advice / counseling on:
• general IYCF / nutrition recommendations
• routine healthcare services e.g. vaccinations,
growth monitoring
• Advice to return if worsens or develops new
problems
4. (C)linical Assessment
Identify, Analyze • Risk of HIV or tested HIV positive • Investigate and treat as per national / local
• Possible underlying clinical problems • Risk of TB or tested TB positive guidelines
• Preterm or low birth weight
121
122
C-MAMI Assessment for Nutritional Vulnerability in Infants aged <6 months:
Module 5
Mother
1. (A)nthropometric/Nutritional Assessment
CHECK FOR SEVERE MALNUTRITION • Mother: Meets ANY of criteria below for severe malnutrition Pink: • REFER mother-infant DYAD to inpatient facility
Identify, Analise • MUAC: <180 mm (referral)7 SEVERE • Nutrition support for mother
Look for signs of severe malnutrition OR MATERNAL
• Measure MUAC (always) • BMI: <17 MALNUTRITION
• If equipment available and staff are
OR
trained:
• Pitting oedema of both feet
• Measure weight (in kg.), height
(in meters) • Mother: Meets ANY of criteria below for malnourished or ill Yellow 1: • Refer to Counseling and Support Action for
• calculate BMI (=weight/height2) • MUAC: <180 to <230 mm8 MODERATE Mother (page 21)
• Pitting oedema of both feet MATERNAL • Link between facility and community
OR
• BMI: <18.59 MALNUTRITION • Advice on:
• recommended nutrition practices
• recommended health services
• recommended care practices
• WASH practices
• Health education/information
• None of the above Green: • General nutrition advice and support, as

NO IMMEDIATE resources allow
NUTRITIONAL
CONCERN
Cont'd next page
7
Some agencies and MoH protocols use <185mm to define severe malnutrition.
8
Some agencies use a narrower <210mm cut off for moderate maternal malnutrition
9
http://apps.who.int/bmi/index.jsp?introPage=intro_3.html
Classification BMI (kg/m2)

Principal cut-off points Additional cut-off points 7
Underweight <18.50 <18.50
Severe thinness <16.00 <16.00
Moderate thinness 16.00 - 16.99 16.00 - 16.99
Mild thinness 17.00 - 18.49 17.00 - 18.49
Normal range 18.50 - 24.99 18.50 - 22.99
23.00 - 24.99
2. (B)reastfeeding Assessment
Ask, Listen Identify, Analyze Mother: Breastfeeding mother meets ANY of the indications for support below: Yellow 1: Breastfed infant: analysis & actions
• Feeding history • Breastfeeding • Re-lactating MOTHER-INFANT • Refer to 2nd Line Breastfeeding Counseling
based on • Discharged from Supplementary Feeding Programme DYAD ENROLLED and Support Actions (page 11)
observation & • Needs to express breastmilk and cup-feed IN C-MAMI • Refer to Counseling and Support Actions for
conservation • Breast conditions: engorgement; sore and cracked nipples; plugged ducts and mastitis; flat, Mother (page 21)
• Non- inverted, large pr long nipples; nipple pain; thrush
breastfeeding • Perception of not having enough breastmilk Non-breastfed infant: analysis & actions
based on • Other concerns: mother lacks confidence; concerns about her diet; working away from her • Refer to Appendix 1: Non-breastfeeding
observation & infant Assessment, Counseling and Support Actions
conservation (page 27)
Mother: Non-breastfeeding mother meets ANY of the indications for support below: • Refer to Counseling and Support Actions for
• Concerns about meeting the nutritional needs of her infant
• Working away from home
• Delegating infant feeding and care to another
3. (C)linical Assessment
• Clinical problems in mother • Anaemia Yellow 1: • Ensure mother is referred for or receiving
• Birth history of presenting infant • Tested HIV positive MOTHER-INFANT appropriate treatment for underlying condition
• Tested TB positive DYAD ENROLLED (e.g. antiretroviral drugs for HIV; iron
• Twin delivery (presenting infant/children) IN C-MAMI supplementation for anaemia)
• History of poor pregnancy outcomes (presenting infant low birth weight (LBW)) • Emphasize importance of adherence to ART for
• Adolescent mother (under 19 years) of presenting infant mother's health and to reduce HIV transmission
risk to infant
• Refer to 2nd Line Breastfeeding Counseling
and Support Actions (page 11)
4. (D)epression/Anxiety/Distress
Mother Pink: • REFERRAL to facility to conduct clinical
• Mother traumatized, in emotional crisis, rejecting infant SEVERE assessment: for example - WHO (Five) Well-
• Depressed (feels alone/no social support, unsatisfied, has little decision-making, has little MATERNAL Being Index (www.who-5.org)
power over life) DEPRESSION/ • REFERRAL to facility for community support
• Gender based violence ANXIETY/
• Marital conflict DISTRESS
Mother Yellow 1: • Refer to Family and Community Counseling

• Lack of care and social support MOTHER-INFANT and Support Actions for Mother (page 11)
DYAD ENROLLED • Support during pregnancy
IN C-MAMI • Group support
• Family support
• Partner support
• Community support
123
Module 5
List of Tables
A. Checklist on how to conduct an OTC admission

STEPS
done
1. On arrival, give approximately 10% sugar-water solution
immediately to obviously ill patients and those that will clearly
need inpatient or other medical treatment.
2. Explain to the caregiver that you will be assessing their child
to determine whether they need treatment and let them know
what to expect.
3. Determine age and confirm using available documents.
4. Take anthropometric measurements and examine child (test
for edema, body temperature and number of breaths in one
full minute)
5. Determine if the child has SAM or MAM based on the criteria
and enter details of infant/child in registration book.
6. Perform appetite test on SAM referrals.
7. Perform medical assessment on SAM referrals and record
on OTC chart.
8. Do feeding assessment for infants less than 6 months with
SAM.
9. Refer non-SAM referrals.
10. Classify the infant/child to OTC/ITC.
11. Refer to ITC if needed in a timely manner.
12. Record on OTC chart upon admission.
B. Checklist on how to orient the mother/caregiver on OTC treatment

STEPS
done
1. Explain how much RUTF to give the child each day. Fill-up
OTC treatment card. Ask mothers/ caregivers how to
repeat to you how she will give the medication.
2. Discuss a number of simple key messages on the
use of RUTF. Give at least 3 of the following:
a. If the mother is still breastfeeding, advise her to continue
breastfeeding as before and give the RUTF after each
feeding.
b. For older children, always give plenty of safe water with
RUTF as it doesn’t contain any itself. But do not mix RUTF
with water.
c. 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.
d. Encourage child to take small amounts of RUTF
frequently during the day directly from the packet.
e. RUTF is a medicinal food for thin and swollen children.
It should never be shared with other members of the family.
f. Attend the health center weekly for monitoring and to
receive the next weekly RUTF ration.
g. Return empty RUTF packets to the health center each
week.
3. Explain how to give medicines at home. Ask mothers/
caregivers how to repeat to you how she will give the
medication.
4. Explain the importance of hygiene and sanitation. Wash the
child’s hands and face with soap and water before eating
and after defecation.
5. Explain that malnourished children need to be kept warm
(ensure child wears plenty of clothes).
6. Inform them of their local volunteer/health worker and the
support that they can offer for them.
7. Inform mothers/ caregivers who refused transfer to
inpatient care facilities that their local volunteer/health
worker (BHW and/or BNS) will be visiting them at home
during the week.
8. Inform mothers/ caregivers that if they are concerned about
the child’s condition, they can bring the child straight back
to the health facility for medical review and advice (ex. no
appetite, is vomiting, has diarrhea, is sick, or has increasing
edema).
C. Checklist on how to monitor progress of the infant/child weekly

STEPS
done
1. Inquire about the medical history of the child. Ask about the
progress of the child, including IMCI danger signs.
2. Perform medical examination on the child.
a. Measure MUAC, weight and check for edema
b. Check if height/length was measured on admission day
(take the measurement if not done)
c. Check MUAC and weight-for-height/length Z-score (if
appropriate) for discharge criteria
d. Measure body temperature
3. Perform routine appetite test for all children especially when
there has been poor weight gain.
4. For infants < 6 months old, ask about breastfeeding
practice and any improvement in breastmilk production.
5. Give routine treatment at the appropriate visits (if a visit is
missed, give at the next visit).
6. Complete recording on the OTC chart.
7. Make any necessary referrals (ITC).
8. Recalculate the weekly RUTF ration according to current
weight and provide the ration.
9. Arrangement of home visit or further clinical/ social
investigation where required.

Module 5
D. Checklist on how to discharge infant/ child from OTC

STEPS
done
1. Explain to the mother/caregiver that the child has recovered
sufficiently for discharging, and congratulate them.
2. Refer for vaccination if required:
a. If the child has reached 9 months of age during
treatment in OTC and has not yet received vaccination
against measles, the mother/caregiver should follow up
at the BHS or RHU to ensure their child receives the
vaccination.
b. Children admitted at age 6 to 8 months should get a
follow-up appointment for the second measles vaccination
(booster) after one month.
3. All children will get a last ration for seven sachets of RUTF
(one sachet each day for one week) to aid the transition
onto local and in some cases, supplementary foods where
a dietary supplementation program is available.
4. The mother/caregiver should receive counseling on IYCF
practices, care practices, hygiene, feeding practices, food
preparation for children, and so on, in line with standard
IYCF counseling. If enrolled in the 4Ps program, please
ensure attendance in the Family Development Sessions.
5. Link to dietary supplementation program and/or other
services available: All the patients should be discharged to
the dietary supplementation program for continued
nutritional rehabilitation where this is available.
6. Caregivers should be linked with any other appropriate
services for which they are eligible and which support the
on-going rehabilitation of the child.
7. Recording on OTC chart: Fill in the patient record in the
register with the discharge details.
Reference:
Philippines Department of Health. National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years
Manual of Operations. 2015.
ENN, with support from USAID, OFDA, Irish Aid and Save the Children.
C-MAMI Tool. 2015. Available at: http://files.ennonline.net/attachments/2435/C-MAMI-Tool-Web-FINAL-Nov-2015.pdf
Module 6
Inpatient Therapeutic Care (ITC)
Target Learners
This module is intended for physicians, nurses and nutritionists/dieticians, medical social
workers, hospital administrators and other health providers working in the hospital who are
involved in the inpatient care of children with SAM with poor appetite and medical complications.
This module has two parts. The first part introduces the activities and steps that should be
followed in the inpatient care of a child with SAM (one treatment strategy for those 6-59 months
old and another for infants <6 months) with complications from admission until discharge.
The second part will discuss the management of the most common medical complications that
occur among children with SAM, namely: hypothermia, hypoglycemia, dehydration and shock.
______________________________________________________________
1. Explain why treatment of SAM children is different than those without SAM
2. Assess which patients should be admitted into ITC
3. Properly triage SAM patients as emergency and non-emergency cases
4. Identify, treat, monitor and prevent hypothermia, hypoglycemia and dehydration/shock
in children with SAM
5. Administer the appropriate medications for ITC
6. Administer the nutritional management of SAM children 6-59 months
7. Guide and administer the nutritional management of SAM infants <6 months
8. Orient the mother/caregiver in the care of her child with SAM
9. Explain how to monitor each child for signs of deterioration in each Phase
10. Explain how to assess a child’s readiness for discharge
Definition of Terms
F75
• is a low protein formulation (high protein at this stage increases the risk of death)
containing the right balance of macro and micronutrients to stabilize the child’s condition.
F75 provides 75kcal/100mL and allows micronutrient deficiencies to be corrected and the
abnormal pathophysiology of the child to be reversed. The F75 already contains all of
the micronutrients required for stabilization. There is no need for additional micronutrient
supplementation. F75 is also a low-lactose feed.
F100
• this milk provides 100kcal/100mL and is suitable for at least 6 months old infants and
above. Patients suffering from severe acute malnutrition that have an appetite and are
without major medical complications can commence with this treatment with the aim of
gaining weight (transition phase and phase 2).

Module 6
ReSoMal
• oral rehydration salts or ORS for severely malnourished children is used in inpatient
centers for the treatment of children with severe acute malnutrition.
Supplemental Suckling Technique (SST)

• is an effective method in re-establishing adequate breastfeeding. When done well, it can
stimulate breast milk output, hence it is important to put the child to the breast as often as
possible. As breastfeeding improves and the child gains weight, the amount of therapeutic
milk is gradually reduced and then discontinued. The infant is then discharged when
gaining weight on breast milk alone.
Key Concepts
Phases of Inpatient Therapeutic Care (ITC) – Nutritional Management of SAM

• Phase 1/Stabilization: Patients with an inadequate or poor appetite and/or an acute
major medical complication are initially admitted to Phase 1 for stabilization treatment.
During this phase, the therapeutic milk F75 is used to stabilize and reverse physiological
and metabolic abnormalities and correct electrolyte imbalances. Wasted children are not
expected to gain weight during this phase, and patients with edema start to lose weight in
this phase as the edema starts to resolve.
• Transition Phase: This phase marks the transition from stabilization to OTC where these
facilities exist (where OTC facilities are not available, the patient proceeds to Phase 2
instead). Clinically, the return of appetite and/or the improvement of clinical signs and
symptoms related to the medical complication indicate entry into this phase. In this phase,
the diet is changed or transitioned from F75 to RUTF (or to therapeutic milk F100 for
Phase 2 inpatient care). The amount of protein, energy and micronutrients is increased.
Wasted children now start to gain weight, while children with edema may continue to lose
weight until the edema is resolved.
• Phase 2: Where it is not possible to refer to OTC, children remain as inpatients until
cured of acute malnutrition. This phase continues treatment with F100 therapeutic milk or
RUTF, increasing the intake so as to promote rapid weight gain. The child remains under
treatment until the anthropometric criteria for discharge are reached.
Session 6.1:
Pathophysiology of Severe Acute Malnutrition
Severe acute malnutrition can result in profound metabolic, physiological and anatomical changes.
Virtually all physiological processes are altered due to severe acute malnutrition. Every organ and
systems are affected by the process called reductive adaptation.
Reductive adaptation is the physiological response of the body to undernutrition - the body’s organ
systems slow down to survive on limited macro (protein, carbohydrate and fats) and micronutrient
(vitamins, minerals and trace elements) intake. The system reduces activity to adapt to the lack of
nutrients and energy. This results in profound physiological and metabolic changes, some of which can
be observed by the doctor.
The initial reductions will not alter normal function of the body BUT will impact on its capacity to adapt
to any other new situation (an infection, cold, or even to an IV infusion or excessive oral liquids).
For example, the circulatory system may be still working correctly, with no signs or symptoms of
presence of a problem, but it may not be able to adapt to a sudden increase of circulatory volume (after
an infusion or a transfusion, for example). Since the adaptive mechanisms to increased volume cannot
be mobilized, a simple infusion may result in cardiac overload and lethal pulmonary edema.
Similar situations occur with: the digestive system, and the reduced amount of proteins and other
nutrients that can be absorbed in one meal; the immune system, and its diminished ability to respond
to infection; the liver, and its ability to detoxify, and the kidney, and its ability to excrete among others.
Children with malnutrition also do not show the usual signs and symptoms that a normal child
may show when they are sick.
Some of the changes mentioned above result in unusual signs and symptoms.
For example, a child with severe acute malnutrition with an infection may not be able to present with
fever, but will instead present with hypothermia or low temperature.
Usual life-saving actions may be dangerous in the malnourished child.

These are the reasons why it is so important to follow standard protocols for the treatment of severe
acute malnutrition and its complications. The changes in metabolic and physiological responses in the
malnourished child are so important that therapeutic decisions that are live-saving in a well-nourished
child can be potentially fatal in the malnourished child.
Knowing the following changes in each system can help understand the evolution and therapy of
severe acute malnutrition and its complications.
Cardiovascular system:
• Cardiac output and stroke volume are reduced.
• Infusion of saline may cause an increase in venous pressure.
• Any increase in blood volume can easily produce acute heart failure.
• Any decrease will further compromise tissue perfusion.
• Blood pressure is low.
• Renal perfusion and circulation time are reduced.
• Plasma volume is usually normal and red cell volume is reduced.
Gastro-intestinal system:
• Production of gastric acid is reduced.
• Intestinal motility is reduced.
• Pancreas is atrophied and production of digestive enzymes is reduced.
• Small intestinal mucosa is atrophied; secretion of digestive enzymes is reduced.
• Absorption of nutrients is reduced.
Liver function:
• Synthesis of all proteins is reduced.
• Abnormal metabolites of amino acids are produced.
• Capacity of liver to take up, metabolize and excrete toxins is severely reduced.
• Energy production from galactose and fructose is much slower than normal.
• Gluconeogenesis is reduced, with high risk of hypoglycemia during infection.
• Bile secretion is reduced.
Genitourinary system:
• Glomerular filtration is reduced.
• Capacity of kidney to excrete excess acid or water load is greatly reduced.
• Urinary phosphate output is low.

Module 6
• Sodium excretion is reduced.

• Urinary tract infection is common.
Immune system:
• All aspects of immunity are diminished.
• Lymph glands, tonsils and thymus are atrophied. Cell-mediated immunity is severely depressed.
• Ig-A levels in secretions are reduced.
• Complement components are low.
• Phagocytes do not kill ingested bacteria efficiently.
• Tissue damage does not result in inflammation or migration of white cells to the affected area.
• Acute phase immune response is diminished.
• Typical signs of infection, such as an increased white cell count and fever, are frequently
absent.
• Hypoglycemia and hypothermia are signs of severe infection usually associated with septic
shock
Endocrine system:
• Insulin levels are reduced and the child has glucose intolerance.
• Insulin growth factor 1 (IGF-1) levels are reduced.
• Growth hormone levels are increased.
• Cortisol levels are usually increased.
Circulatory system:
• Basic metabolic rate is reduced by about 30%.
• Energy expenditure due to activity is very low.
• Both heat generation and heat loss are impaired.
• The child becomes hypothermic in a cold environment and hyperthermic in a hot environment
Session 6.2:
Assessment and Admission
For inpatient care, initial steps of assessment should focus primarily on rapid identification of SAM with
complications and on initiation of treatment. In the inpatient facility, emergency treatment for any life-
threatening complications should be prioritized once SAM has been diagnosed. Once initial emergency
care has been provided to those cases needing it, further anthropometry and the appetite test can be
conducted.
Table 6.1. Criteria for Admission to ITC
Criteria for admission to ITC for children 6-59 Criteria for admission to ITC for children less
months of age (ANY OF THE FOLLOWING): than 6 months of age:
1. Presence of bilateral pitting edema Grade 3 1. Presence of bilateral pitting edema OR WFL
(+++) OR less than -3 z-score, AND
Marasmic Kwashiorkor (MUAC less than 2. ANY of the following conditions:
11.5cm) OR a. recent weight loss/inability to gain weight
WFH or WFL less than -3 Z-scores AND after 1 week in OTC
with failed appetite test OR any of the b. any of the medical complications outlined
following medical complications: for 6-59 months of age
a. Intractable vomiting c. any medical issue needing more detailed
b. Hyperthermia or hypothermia assessment or intensive support (e.g.
c. Tachypnea for age disability) or general signs as identified by
d. Anemia the health worker that warrants referral as
e. Superficial infection per IMCI
f. Altered alertness d. ineffective feeding (attachment, positioning
g. Convulsions and suckling) directly observed
h. Dehydration e. infant is lethargic and unable to suckle
i. Other general signs as identified by the f. no possibility of breastfeeding (e.g.
health worker that warrants referral as mother’s death)
per IMCI g. depression of the mother/caregiver or
other adverse social circumstances
Session 6.3:
Triaging of children with SAM into emergency and non-
emergency care
i. Provide EMERGENCY CARE as required for children with SAM:
• Assess the child’s airway, breathing, circulation and administer life-saving interventions
according to the PALS protocols
• Immediately treat life threatening complications, such as:
a. Hypoglycemia
b. Hypothermia
c. Dehydration/hypovolemic shock
d. Hypernatremic dehydration (see Annex 6.12. Treatment of hypernatremic dehydration)
e. Septic shock (see Annex 6.13. Treatment of septic shock)
f. Severe anemia (see Annex 6.14. Treatment of severe anemia)
g. Heart failure (see Annex 6.15. Treatment of heart failure)
h. Absent bowel sounds, gastric dilation and intestinal splash (see Annex 6.16. Treatment of
absent bowel sounds, gastric dilatation and intestinal splash with abdominal distention)
• Manage non-emergency cases (for new SAM patients):

a. Conduct IMCI medical check with medical history and the appetite test,
b. Take weight for calculation of medical and nutritional treatment and to set the baseline for
weight monitoring during treatment,
c. Refer to the OTC if without medical complications and good appetite is demonstrated,
and
d. Record all information on the patient record and ITC chart.

Module 6
For patients already being treated for SAM and transferred from another facility:
1. Review and record any relevant information from referral document where there is one,
continue with the same registration number,
2. Check information on referral document to check any new issues that may have arisen
during transfer, and
3. Record all information on the patient’s chart.
Based on the assessment, give the following medications:
Routine Medications in Phase 1/Stabilization
Give first line antibiotics according to age/ weight (if not already given). The type of antibiotic
given in Phase 1 primarily depends on whether the child presents to the inpatient unit with or
without identified medical complications.
Oral antibiotics should be given for uncomplicated cases and IM/IV antibiotics for children with
complications.
Table 6.2. Medications for Uncomplicated Cases

Amoxicillin* Oral / NGT 4 - 9.9kg = 250 mg On admission

10 - 13.9kg = 500 mg Twice daily for 5 - 7 days
14 - 19kg = 750 mg
If indicated, Metronidazole (10mg/kg/day) may be used to treat small bowel overgrowth of

bacteria not responding to amoxicillin. Note that the dosage of metronidazole is reduced for
children with SAM.
Table 6.3. Medications for Complicated Cases

Ampicillin* IM/IV 50mg/kg On admission 6 hourly for 2 days

Followed by Orally / NGT 4 - 9.9kg = 250mg Twice daily for 5 days
Amoxicillin 10 - 13.9kg = 500mg
14 - 19kg = 750 mg
* Where there is amoxicillin resistance give Cefotaxime (IM 50mg/kg once daily) for 2 days then give amoxicillin-clavulanic acid
combination for 5 days
AND
Gentamicin IM/IV 5mg/kg On admission once daily for 7

days
If the child does not improve within 48 hrs or deteriorates within 24 hrs, add:
Ceftriaxone* IM/IV 75 - 100mg/kg Once daily with Gentamicin
* Care must be taken in reconstituting or preparing and administering Ceftriaxone via the IM or IV route. Please refer to the product
data sheet for precautions. Cefotaxime (100mg/kg/day on 1st day followed by 50mg/kg/day on subsequent days) may be preferred
in septic shock.
Note: Chloramphenicol for children <1 year should be used with EXTREME caution. Risk for gray baby syndrome and death are
associated with its use.
Reminders:
• Vitamin A supplementation is not routinely indicated where commercially prepared F75/ F100
or RUTF are provided for treatment.
• In these preparations, vitamin A is already present in therapeutic amounts. Vitamin A
supplementation should be given on admission when other preparations are used (e.g.
preparations based on prescribed recipe but without CMV) as these do not have adequate
vitamin A content or for patients with symptoms of Vitamin A deficiency.
• Folic acid is present in adequate amounts in therapeutic milks and RUTF to treat mild anemia.
If moderate anemia is diagnosed then give a stat dose of 5mg on admission. There is no
requirement for daily doses.
• Deworming medicines or antihelminthics are absorbed through the gut and the active metabolite
generated in the liver. Early in treatment, poor absorption in the gut and poor liver function may
render the drug ineffective.
• Zinc is present in F75 and F100 therapeutic milks and in RUTF. Episodes of diarrhea should
be treated with antibiotics and ReSoMal (only if patient is admitted in ITC) if indicated by the
presence of dehydration. If commercially prepared F75/F100/RUTF is not available, then zinc
should be used in the management of diarrhea.
• Iron increases the risk of mortality in children with SAM through the increased risk of infection
and sepsis. Iron is given only in Phase 2, where it is added to the therapeutic milk (see Phase 2
care). Iron tablets do not need to be given to children receiving RUTF as iron is already present
in RUTF in adequate amounts.
When children with SAM are deemed for ITC, the following process serves as a guide and is essential
for the successful management of the child:
Figure 6.1. Ten Steps in the Care of Severely Malnourished Children

(from WHO 2003 Guidelines for the inpatient treatment of severely malnourished children)
MANAGEMENT STEPS Stabilization Rehabilitation
Day 1-2 Day 3-7 Week 2-6
1. Treat/prevent hypoglycemia
2. Treat/prevent hypothermia
3. Treat/prevent dehydration
4. Correct imbalance of electrolytes
5. Treat infections
6. Correct deficiencies of
micronutrients no iron with iron
7. Start cautious feeding
8. Rebuild wasted tissues (catch-up

growth)
9. Provide loving care and play
10. Prepare for follow-up

Module 6
Session 6.4:
Nutritional Management of SAM Children 6-59 Months
1A. Phase 1 or Stabilization (Days 1-7)

For new admissions to ITC, use F75 for Phase 1 nutritional management.
For admissions coming from OTC who are already demonstrating appetite, RUTF can be used and Phase 2 entered directly.
The diet used for children aged 6 - 59 months in stabilization is F75 therapeutic milk.
Steps in administering the F75:
Step 1 Calculate the quantity of F75 to be administered. The energy requirement of the child in
Phase 1 is 100kcal/kg/day. This translates to 130mL of F75 milk/kg/day. The F75 is therefore
given according to the weight of the child. Check manual calculations of milk requirement against
the tables for accuracy (See Table 6.4).
Step 2 Prepare F75

a. Boil water then cool and filter, if available
b. Mix one small packet of F75 (102.5g) with 500 ml water
c. Preparation of F75 should be made within 30 minutes of boiling the water
d. Do not use hot water stored in dispensers/thermos
Step 3 The milk should be given in divided feeds ideally every two to three hours in Phase 1
depending on the condition of the child (8 - 12 feeds per day)
a. Recognize that reducing the number of feeds will mean that the volume of each feed will
increase and the child may be unable to consume the larger volume.
b. Recalculate the volume of feeding if the frequency of feeds was not complied with (e.g.
during the night shift, staff shortage) to provide the child with the required amount of F75
milk.
Step 4 Pre-prepared feeds may be used overnight, but only where functional refrigeration units
are available for storage following preparation. The milk should be warmed before use by placing
the milk in a bowl of hand-hot water for 5 - 10 minutes. Milk should not be reheated by direct heat
or microwave. Unused refrigerated milk should be disposed of after 12 hours.
Step 5 If clinical assessment is delayed for any reason, give 10% sugar water (10g or 1
tablespoon of sugar in 100mL of water) if the child is able to take oral fluids in order to prevent
hypoglycemia.
When F75 is not available, there are alternative recipes or diluted F100 that can be prepared and
given in the same amounts as F75
Commercial milk formula is NOT a suitable substitute. Strongly advise against the use of these
products for the child with SAM.
Table 6.4. Amount and Preparation of F75 Milk to be Given
for Children aged 6-59 Months in Phase 1
Amount of milk per feed Amount of milk per feed
Weight of the child
8 feeds per day 6 feeds per day
2.0 - 2.1kg 40ml 50ml

2.2 - 2.4kg 45ml 60ml
2.5 - 2.7kg 50ml 65ml
2.8 - 2.9kg 55ml 70ml
3.0 - 3.4kg 60ml 75ml
3.5 - 3.9kg 65ml 80ml
4.0 - 4.4kg 70ml 85ml
4.5 - 4.9kg 80ml 95ml
5.0 - 5.4kg 90ml 110ml
5.5 - 5.9kg 100ml 120ml
6.0 - 6.9kg 110ml 140ml
7.0 - 7.9kg 125ml 160ml
8.0 - 8.9kg 140ml 180ml
9.0 - 9.9kg 155ml 190ml
10.0 - 10.9kg 170ml 200ml
11.0 - 11.9kg 190ml 230ml
12.0 - 12.9kg 205ml 250ml
13.0 - 13.9kg 230ml 275ml
14.0 - 14.9kg 250ml 290ml
15.0 - 19.9kg 260ml 300ml
Preparation of F75 milk:

• Mix one small packet (102.5g) with 500mL of water.
• Water should be boiled then cooled and preferably filtered.
• Therapeutic milk should then be made within 30mins of boiling the water. The use of hot
water from dispensers (while convenient) is not recommended as there is a risk of cross
infection and contamination if the dispensing nozzle is not meticulously cleaned between
every use.
Feeding:
• Feeding should be done orally by cup and saucer unless a particular need for nasogastric
tube (NGT) feeding is identified (Refer to Table 6.5)
• Breastfed children aged 6 - 59 months should always be offered breast milk before the
diet and the milk should always be given on demand.
• Children with SAM have weak muscles and swallow slowly. This makes them prone
to choking, with liquid or food particles entering their airways leading to aspiration
pneumonia. Appropriate feeding techniques are therefore important a suitable substitute.
Strongly advise against the use of these products for the child with SAM.

Module 6
Table 6.5. Indications for Use of an Appropriate Size NGT

Child is unable to consume at least 75% of the milk provided (refer to the ITC chart is designed to
monitor percentage of each feeding consumed)
Has pneumonia (fast breathing) and difficulty swallowing
Has painful sores of the mouth
Has cleft palate or other physical deformity
Shows disturbed level of consciousness
* The use of an NGT should not exceed three days and should only be used in Phase 1/Stabilization.
Appropriate feeding techniques:

• Set the child upright on the caregiver’s lap against his/her chest, with one arm behind his/
her back.
• Position the caregiver’s arm so that it encircles the child and hold a saucer under the
child’s chin
• Return any dribble that falls into the saucer to the cup.
• DO NOT force-feed an infant or child either by pinching his/her nose or pouring liquids
into his/her mouth (even with a spoon).
• Never give more therapeutic milk than what is prescribed for the child in Phase 1, even if
the child cries for more food. However, the child may continue to breastfeed on demand.
• Mealtimes should be sociable. The assistant should encourage the caregivers, talk to
them, correct any faulty feeding technique and observe how the child takes the milk.
• The meals for the caregivers should not be taken beside the patient. It is almost
impossible to stop the child demanding some of the caregiver’s meal. Sharing the
caregiver’s meal with the child can be dangerous for the child during Phase 1.
1B. Transition Phase
Transition Phase normally takes one to three days but may take longer. It signals a change in the
nutritional management of the child.
The amount of energy provided in Transition Phase is increased by 30% (to 130kcal/kg/day) and the
amount of protein is increased.
Transition Phase is entered once:

• Medical complications are resolving
• Appetite returns
• Edema is reducing
Transition may be divided into two distinct management approaches:

• Transition to outpatient care for SAM where it is available
• Transition to Phase 2 inpatient care where outpatient care for SAM is not available
Transition to RUTF in Preparation for Outpatient Care
The aim is to prepare the SAM child for nutritional rehabilitation in outpatient care (i.e. to eat
sufficient RUTF to gain weight and recover) while ensuring they get all the nutritional requirements
they currently need. This is done by gradually introducing and increasing the proportion of the daily
feeding provided by RUTF.
Procedure for transition to RUTF:

1. Encourage the mother to continue breastfeeding on demand.
2. Explain to the caregiver what RUTF is and how to administer it at each scheduled feeding
time (at least 5 times / day in Transition Phase).
3. Prepare F75 formula according to the prescription for the child’s weight.
4. Prepare a packet of RUTF and a glass of clean drinking water for the child.
»» The RUTF packet should be massaged thoroughly for 30 seconds before opening
which helps to mix the ingredients together. This should be done in front of the
caregiver to demonstrate the method.
»» If the RUTF is hard (due to cold temperatures or prolonged storage) first warm the
RUTF gently between your hands.
»» The caregiver should be instructed to wash their hands with soap and water
»» Before offering the F75, offer the RUTF to the child:
- If the child is capable of holding the packet, the child should feed itself directly from
the packet of RUTF with gentle encouragement from the mother
- If the child cannot eat directly from the packet, the mother may take a small amount
of RUTF on her clean finger and feed it to the child. The amount offered at each
mouthful should be approximately the size of an almond.
The table below gives a simple guide to the amount of RUTF that must be taken at each feed and
over 24 hours in Transition Phase.
Table 6.6. Amount of RUTF to Give per Feeding

Number of feeds/ Amount of RUTF in Amount to be eaten over
Weight of the Child
24 hours each feed 24 hours
<5kg 5-6 ¼ packet 1 ¼ to 1 ½ packets

≥5kg 6 ⅓ packet 1 ¾ to 2 packets
The picture on the left shows the

proper way of estimating portion sizes
of RUTF as ½, ⅓ and ¼. When the
child eats the RUTF, make sure that
his/her fingers are positioned to mark
the right amount s/he needs to eat.
»» It should be emphasized that the child must NEVER be force fed. It is vital to get a
true indication of appetite so that the child can be safely transitioned to outpatient
care.
»» After each mouthful, breast-feeding/- milk or a sip of water should be offered to the
child.
»» Under no circumstances should the RUTF be mixed with water / F75 or any other
liquid before the child eats it.
»» If the child fails to eat the required amount of RUTF at each feed, the child should
finish the feed by being offered the ration of F75 to drink in addition to any RUTF that

Module 6
has been eaten. The time taken to eat the RUTF and F75 (if necessary) should be no
more than 1 hour.
»» Record the amount of both F75 and RUTF consumed on the patient’s treatment
chart.
»» After each feed, the RUTF should be placed in a cool dry place, safe from insects
and re-used at the next scheduled feeding time.
»» The process of offering both RUTF and F75 continues until the child is able to take
the required amount (see Table 6.6
Transitioning to OTC
If transition is successful, F75 may be discontinued and the child is given only RUTF and breast
milk or water.
When at least 75% of this full amount is eaten in 24 hours and there are no other issues identified
during monitoring the child is judged to be ready to continue their rehabilitation at home with OTC.
The child may then be discharged from the ITC facility (e.g. hospital) and referred to the OTC
nearest to their home (or the referring OTC if previously enrolled).
Coordinate with and appropriately refer/endorse the child to the the OTC. This is critical to ensure
the continuity of care and prevention of relapses or defaulters. Fill up and provide information on
the referral form (Figure 6.3).
If the appetite of the child does not improve over 2 - 3 days (i.e. they are not eating the required
amount), reassess the child and change the treatment regimen:
1. If there is deterioration in clinical status, return the child to Phase 1
2. If the child is stable but appetite is not improving after 3 days in Transition Phase (the
required amount of each feed is not being taken) with RUTF, change the diet to F100 for
Transition Phase and continue treatment in inpatient care (transition to Phase 2). Transition
onto RUTF can be attempted again after a couple of days.
Transition to Phase 2 using F100
When there is no outpatient treatment available, the child must be treated and cured of SAM
entirely within the inpatient care setting.
For children remaining in inpatient care, the energy requirement of 130kcal/kg/day is given in the
form of F100 therapeutic milk.
F100 contains 100kcal/100mL of milk. This means that when the milk is changed from F75 to F100
in Transition Phase, the volume of milk the child has been receiving in Phase 1 remains the same;
only the type of milk changes.
The child should continue to be breastfed on demand. The amount of F100 milk to be given in
Transition Phase is indicated in the table below. As above, this transition onto a higher calorie diet
can take one to three days. The child should be monitored closely during this time.
When at least 90% of the prescribed F100 ration is being taken orally and no other issues are
identified during monitoring, the child is considered ready to continue their rehabilitation in Phase 2.
Figure 6.3. Referral Form (SAM)
Where there are existing two way referral formats in place these should be used and checked/amended
to ensure all the information on the following example is included. If no existing format is in place the form
below may be used/adapted for use.
Referral / Transfer From (SAM) - Copy for Receiving Facility (OTC/ITC)

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Cut along dotted lines - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Referral / Transfer From (SAM) - Copy for Referring Facility (OTC/ITC)


Module 6
Table 6.7. Amount of F100 to be Given to Children aged 6-59 Months

in Transition Phase
Weight of the child in kg 6 feeds per day 5 feeds per day
Less than 3.0 kg F100 full strength should not be used

3.0 - 3.4 kg 75 ml per feed 85 ml per feed
3.5 - 3.9 kg 80 95
4.0 - 4.4 kg 85 110
4.5 - 4.9kg 95 120
5.0 - 5.4kg 110 130
5.5 - 5.9kg 120 150
6.0 - 6.9kg 140 175
7.0 - 7.9kg 160 200
8.0 - 8.9kg 180 225
9.0 - 9.9kg 190 250
10 - 10.9kg 200 275
11 - 11.9kg 230 275
12 - 12.9kg 250 300
13 - 13.9kg 275 350
14 - 14.9kg 290 375
15 - 19.9kg 300 400
PHASE 2
Average duration: 2 - 3 weeks
Diet
In Phase 2, the energy and protein intake of the child is increased to 200kcal/kg/day, using F100
therapeutic milk. During Phase 2, iron is added to the therapeutic milk. The amount of iron to be added
is as follows:
• 200mg Ferrous Sulfate (1 tablet) in 2 liters therapeutic milk
• 100mg Ferrous Sulfate (1/2 tablet) in 1 liter therapeutic milk
• If smaller quantities of milk are being given, crush 100mg (1/2 iron tablet) and mix thoroughly
in 10mL of water (ensure the tablet is well crushed and leaves no sediment)
• Add 10mg Ferrous Sulfate (1mL of 10mL Iron solution) in each 100mL of therapeutic milk
Table 6.8. Amount of F100 Therapeutic Milk to be Given in Phase 2
Weight of the child in kg F100 (6 feeds per day) in mL F100 (5 feeds per day) in mL
Less than 3.0kg Do not use full strength F100; use diluted F100
3.0 to 3.4kg 110 130
3.5 - 3.9 kg 125 150
4.0 - 4.9kg 135 160
5.0 - 5.9kg 160 190
6.0 - 6.9kg 180 215
7.0 - 7.9kg 200 240
8.0 - 8.9kg 215 260
9.0 - 9.9kg 225 270
10.0 - 11.9kg 230 280
12.0 - 14.9kg 260 310
Responsive Feeding and Emotional Stimulation
In addition to nutritional management in Phase 2, as the child is continuing their treatment in an

institutional environment, it is important to also support play and emotional stimulation as an aid to
psychological recovery. This should be done by:
• Encouraging the caregiver to talk to the child with good eye contact during feeding
• Providing a brightly colored ward environment
• Providing toys suitable for children of various ages
Determine that the child is ready for discharge as cured from Phase 2 ITC when:
For those admitted based on MUAC, edema OR both MUAC and WFH Z-score
• MUAC > 12.5 cm for 2 consecutive visits AND
• No edema for 10 days AND
• Clinically well
For those admitted based on WFH Z-score only

• WFH or WFL > -2 Z-scores for two consecutive days AND
• No edema for 10 days AND
• Clinically well

Module 6
Session 6.5:
Carry Out the Nutritional Management of a SAM Infant
<6 Months of Age
Assessment and admission procedures should be the same as for older children with the addition of an
assessment of the breastfeeding practice.
This age group is also given the same general medical care as older children in general, though some
of the medical treatments are omitted
Infants younger than 6 months who are admitted as inpatients require nutrition protocols different from
older children. This is because these infants have an immature physiology and feeding them the wrong
diet may result in renal solute overload.
When an infant becomes malnourished, it is usually preferable to improve the breastfeeding practices
or to re-establish them if they have been discontinued. Inpatient staff should try to encourage and re-
establish breastfeeding where this is a possibility.
Where human milk banks are accessible, it should be considered as an interim source of breast milk
while re-lactation interventions are ongoing as described below.
Re-establishing effective breastfeeding requires skilled and patient counseling by trained providers
(e.g. lactation nurses, lactation counselors, peer support groups). It also requires adherence to and
compliance with the principles and rules in Philippine breastfeeding legislation (Executive Order 51).
For those infants who are being mixed-fed with formula, especially the young infants, assess if the
mothers are willing to go back to exclusive breastfeeding. Offer practical support for relactation as
needed.
In the hospital setting, compliance with the standards set by the Mother-Baby-Friendly Health Facility
Initiative (MBFHFI) particularly with respect to the use of commercial milk formulas, should be ensured
especially for MBFHFI-accredited facilities.
Session 6.5a. Encouraging/Supporting Breastfeeding in a SAM Infant

<6 Months (on demand or offer breastfeeding every three hours )
For these infants, there are no separate ‘phases’ of treatment.
As a first step, it is important to ASK the mother or caregiver what food or liquid the infant is fed with.
ASK if the infant is breastfed. Take a detailed breastfeeding history and establish breastfeeding
frequency. Ask if there have been any problems.
ASK the mother or caregiver about her thoughts and confidence in breastfeeding. PROBE gently for
any misconceptions about breastfeeding.
OBSERVE her breastfeed her infant. PAY ATTENTION to positioning and attachment or latch (See
Annex 6.4 & 6.5).
REASSURE the mother.
COUNSEL and SUPPORT her efforts in breastfeeding. When incorrect positioning or attachment is
observed, gently instruct her on how to correct these.
INFORM and educate her of the facts on breastfeeding.
STEPS to undertake:
1. Praise the mother for breastfeeding. Do proper handwashing. Inspect her breasts, especially
for mastitis (fever, redness, swelling and tenderness), sore nipples, etc. Observe at least one,
but ideally a few breastfeeding episodes. At the first observation (without helping the mother),
assess how she positions her infant and how the infant attaches (latches). Ideally, with a doll,
demonstrate/correct positioning and attachment and ask her to do the same for her infant. At
the start of ITC, the infant may not “demand” at the breast, and thus mother should breastfeed
every 1-3 hours, and not per demand. The mother may assist the infant by expressing breast
milk directly into the child’s mouth if the child is unable to empty the breast fully. As the infant’s
appetite improves, per demand feeding can be advised. Counsel the mother on feeding cues,
signs of satiety and voiding and stooling patterns.
If the baby is less than 6 weeks of age, give the mother vitamin supplementation.
2. Continue to counsel and support the mother. Praise her efforts. If space is available, infants
should be nursed at a separate space from the older malnourished children. This area may
be useful to bring breastfeeding mothers together for mutual support and counseling by staff.
3. ASSESS the infant for any other co-existing medical condition/s other than SAM. Treat
accordingly. Refer to Routine Medications for SAM.
• Do not neglect to assess the mother’s medical & nutritional status
4. IF the mother still has to improve her supply or re-establish breastfeeding, other means for
breastfeeding or breastmilk feeding must be sourced. Consider:
Wet nursing
• Cross nursing
• Donor human milk. Observe and educate on the proper storage of human milk (See Annex
6.6).
»» To feed breastmilk to the baby, FIRST use cup feeding. Continue with cup feeding
breast milk when the baby successfully feeds (See Annex 6.7).
»» A second alternative for feeding with breastmilk is the Supplemental Suckling
Technique (SST).
• If all efforts to source human breastmilk have been done and there is none, use diluted
F100 therapeutic milk. F75 therapeutic milk is used for the edematous infant.
5. Encourage for the infant to be maintained on skin to skin contact with the mother.
6. Have the mother allow the infant access to her breasts and latch as often as possible. The
more the baby suckles at the breast, the more her body would produce milk.
7. Teach the mother how to do manual expression of her own breastmilk to also feed to her infant.
The best time to do so would be before a breastfeed.
REMEMBER that when a baby then suckles, milk is not going to be all consumed and the
breasts depleted. It is the baby’s suckling that will stimulate and enable for more milk to be
produced.
8. MONITOR the baby’s overall physical and medical status. Note the infant’s urine output if
adequate. Normal urine output in infants is 1-2 ml/kg/hour.
9. MONITOR weight daily. Appropriate weight gain is 5gm/kg/day.
IF targeted weight gain is not being met, at least 30 minutes after a breastfeed, supplement
the non-edematous infant with diluted F100 therapeutic milk. F75 therapeutic milk is used for
the edematous infant.

Module 6
The amount of therapeutic milk the child receives should be decreased during treatment as the
intake of breast milk improves while maintaining good progress in weight gain.
The aim of treatment is to stimulate breastfeeding and to supplement the child’s diet with
Diluted F100 therapeutic milk until breast milk supply is improved and sufficient.
• Provide F100-Diluted at 130mL/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.
• Provide F75 for infants with bilateral pitting edema and change to F100-Diluted when the
edema is resolved
Table 6.9. Dilute F100 (or F75 for Cases with Edema) for Infants aged <6 Months
Weight of the child in kg Amount of Diluted F100 8 feeds per day
Equal or less than 1.2 kg 25ml

1.3 - 1.5kg 30ml
1.6 - 1.7kg 35ml
1.8 - 2.1kg 40ml
2.2 - 2.4kg 45ml
2.5 - 2.7kg 50ml
2.8 - 2.9kg 55ml
3.0 - 3.4kg 60ml
3.5 - 3.9kg 65ml
4.0 - 4.4kg 70ml
To prepare the Diluted F100:
Add 1 small packet of F100 to 670mL of water instead of using 500mL as usual.
If only small quantities are needed and F100 has already been prepared for use in Phase 2, take
100mL of F100 and add 35mL of water. This will produce 135mL of diluted F100.
Once the infant is gaining weight at 20g per day (absolute weight gain):
1. Gradually decrease the quantity of F100-Diluted by one-third of the maintenance intake so
that the infant gets more breast milk.
2. If the weight gain of 10g per day is maintained for two to three days (after gradual decrease
of F100-Diluted), stop F100-Diluted completely.
3. If the weight gain is not maintained, increase the amount of F100-Diluted given to 75%
of the maintenance amount for two to three days, then reduce it again if weight gain is
maintained.
Session 6.5b. Full use of therapeutic milk to manage nutrition of the SAM
infant < 6 months when ALL efforts to sustain breastfeeding have been
exhausted
For children in whom all breastfeeding or breastmilk feeding options have been done, the infant must
be treated using therapeutic milk.
There are three distinct phases of treatment, as for older children using modified criteria for each
phase. The amount of therapeutic milk the child receives increases in each phase. The major
difference for infants is the use of Diluted F100 during all three phases unless the infant is admitted
with edema in which case F75 is used until the edema has resolved.
Procedure:
Step 1 Prepare and administer diluted F100 according to the infant’s weight.
Table 6.10. Amount of Dilute F100 (or F75 for Cases of Edema)
to Give to Infants aged < 6 Months who are not able to Breastfeed (only after all
options to breastfeed are taken)
Phase 1 Transition Phase Phase 2
Weight of the Infant
8 feeds per day (mL) 8 feeds per day (mL) 6 feeds per day (mL)
Equal or less than 1.5kg 30 40 60

1.6 -1.8kg 30 45 70
1.9 - 2.1kg 40 55 80
2.2 - 2.4kg 45 60 90
2.5 - 2.7kg 50 65 100
2.8 - 2.9kg 55 75 110
3.0 - 3.4kg 60 80 120
3.5 - 3.9kg 65 85 130
4.0 - 4.4kg 70 95 140
Step 2 The criteria for children to pass from Phase 1 to Transition Phase and from Transition
Phase to Phase 2 are mostly the same as for older children aged 6 to 59 months old. However,
if the infant is admitted with edema, all of the edema must have resolved before progressing to
Phase 2.
An infant < 6 months is ready for the transition phase when:

a. medical complications are resolving
b. appetite returns
c. edema is reducing
Step 3 If a child younger than 6 months is on discharge, then the child must continue on formula
milk until the age of 6 months, when complementary feeding is introduced. This is the only
situation when this is acceptable.
Step 4 The caregiver must also be advised on the introduction of age-appropriate complementary
feeding when the child reaches 6 months of age and is referred to ongoing IYCF counseling.

Module 6
Session 6.6:
Orienting and Caring for the Caregiver
The admission of a child into inpatient care is always a worrying time for the caregiver. Care should be
taken to ensure that all the procedures and treatments their child will receive are explained properly
and the next stage of the child’s treatment is also explained. The opportunity should also be taken to
ensure they receive proper nutrition counseling and care that facilitates their support for their child.
Whenever possible, care will be given so as to promote (or restore) age-appropriate breastfeeding
practices, including breastfeeding overnight (particularly important in facilities not providing feeds
during night-time).
In addition, some specific actions should be taken to care for the caregiver themselves in order to
facilitate their support for the child:
Procedure:
Step 1 Assessment of the physical and mental health status of the caregiver with the provision of
relevant treatment and ongoing support.
Step 2 Other ward routines for mealtimes, washing clothes and attending to hygiene needs must
be discussed as soon as possible after admission.
Step 3 Counsel the mother on maternal nutrition, self-care and birth spacing
Step 4 Counsel the mother on good IYCF practices, including exclusive breastfeeding
for children younger than 6 months, continued breastfeeding until the child is at least 2 years of
age and age-appropriate complementary feeding (including meal frequency and food diversity).
Step 5 The mother should receive multiple micronutrient tablets daily during admission if the
breastfeeding child is younger than 2 years of age.
Session 6.7:
Individual Monitoring and Follow-up
MONITORING THE CHILD IN PHASE 1
The minimum standards for monitoring in Phase 1 are outlined below. The recording of monitoring
data should be clearly assigned to staff and is needed to manage the child with SAM who in Phase
1/Stabilization is extremely vulnerable and at high risk of dying. The ITC chart in Annex 6.3 should
be used in combination with existing patient records to ensure appropriate monitoring of feeds and
nutritional status. The importance of the accuracy of the data should be emphasized.
The back of the ITC chart has four different panels. The first refers to the anthropometric measurements
monitoring.
Inpatient Details (Back)
DATE
Height (cm)
Anthropometrics
Weight (kg)
WH (Z score)
MUAC (mm)
Edema 0,+,++,+++
0.8
Second, the weight chart plot.

0.6
0.4
0.2
__Kg
0.8
0.6
0.4
Weight Graph
0.2
__Kg
0.8
0.6
0.4
0.2
__Kg
0.8
0.6
0.4
0.2
Third, the Nutritional or Feeding Plan;

__Kg
Phase
Product
Feeding
(F75, F100, RUTF)

# Meals/day
Quantity/meal (mL)
Oral, NGT
Meal Time
1
and fourth, the feeding monitoring.

Meal Time
1
3
Feeding Monitoring
x x x x x x
Amount Taken: 100% 3/4 1/2 1/4
x x x x

Module 6
In monitoring the feeding, estimate the proportion of the feed taken by the child and appropriately
indicate following the correct way of marking it as immediately shown in the boxes above.
Where a child has a complication or is undergoing fluid rehydration, the monitoring needs to be much
closer and should be indicated by the clinical staff on an individual patient basis. This is discussed
further in the Session on Medical Complications.
Table 6.11. Surveillance of Patients in ITC

After every feeding session Record any breastfeeding taken before the therapeutic milk
of therapeutic milk, the Record the amount of therapeutic feed taken carefully on the therapeutic
medical staff should: surveillance sheet
For infants younger than 6 months: note the amount of therapeutic milk
given
Every 12 hours Measure and record the child’s temperature, pulse rate and respirations
Everyday Indicate the prescription for therapeutic milk, measure and record the
weight , measure and record the level of edema, record symptoms
such as cough, indicate if the child has an NGT, for infants < 6 months:
assess breastfeeding practice
On a weekly basis Measure the MUAC
Session 6.8:
Monitoring and Referring the Child in Transition
(to RUTF or F100)
Surveillance
The child should be observed closely for any signs of deterioration during the Transition Phase:
Continue to monitor as above for Phase 1. In addition, after every feed:

• Record the amount of RUTF or F100 taken
• Record the amount of F75 taken
• Record the frequency of breastfeeding
It is not unusual for children to pass several very soft stools during the recovery process of the intestinal
tract. Unless there are signs of Re-feeding Syndrome, acute watery diarrhea, or osmotic diarrhea there
is no need for the child to pass back into Phase 1. There is also no need to treat the diarrhea unless the
child loses weight. The child should continue RUTF (or F100 if transitioning to Phase 2 inpatient care)
and be observed closely. The diarrhea should NOT be treated with Zinc.
Session 6.9:
Referral and Transition
Refer to Phase 1 care with F75 if:

• There is deterioration in clinical status of the child
• This should be accompanied by a thorough assessment/reassessment of the child’s treatment
Table 6.12. Reasons for Deterioration in the Transition Phase

»» Re-feeding syndrome - is a complex metabolic reaction that occurs when the energy or nutrient
load on the body causes a rapid shift of electrolytes and fluid between intracellular and extracellular
compartments in the body. The condition may occur when malnourished patients (and those who
have been fasting for more than one week) develop any of the following shortly after rapid and
large amounts of food are ingested: acute weakness or “floppiness”, lethargy, delirium, neurological
symptoms, acidosis, muscle necrosis, liver and pancreatic failure, cardiac failure, sudden
unexpected death. The syndrome is due to rapid consumption of key nutrients for metabolism
particularly if the diet is unbalanced. Frequently, there is a great reduction in plasma phosphorus,
potassium, and magnesium.
»» Re-activation syndrome - occurs when a previously undiagnosed infection becomes apparent.

This may occur as a result of the recovery of the immune and/or inflammatory system rather than
the development of a newly acquired infection. Treatment for disease conditions which become
apparent is according to national protocol except where modified by other protocols in these
guidelines.
»» Osmotic diarrhea resulting from a change in diet (less common with low osmolarity feeds)
»» Aspiration of food through improper feeding technique (children with SAM have weak muscles
and swallow slowly. This makes them prone to choking, with liquid or food particles entering their
airways and developing aspiration pneumonia).
»» Nosocomial infection
»» Inappropriate prescription / use of medications
Switch from RUTF to F100 for Transition if the child is:
Stable but appetite is not improving after three days in Transition (the required amount of each feed
is not being taken). In this case, switch to F100 and transition the child to Phase 2. Transition onto
RUTF can be attempted again after a couple of days.
In addition be vigilant for any of the following signs that the child is not coping with the transition:
1. Rapid increase in the size of the liver (one of the signs of overhydration; other signs to look
out for: increasing respiratory and pulse rates, increasing edema and puffy eyelids, visible
neck veins. If these signs occur, stop fluids immediately and reassess after one hour)
2. Any sign of fluid overload
3. Tense abdominal distension
4. Any significant re-feeding diarrhea involving weight loss
5. Any complication arising which necessitates intravenous fluids
6. Edema not reducing, any increasing edema or edema developing when it was previously
absent

Module 6
Monitoring the Child in Phase 2
Surveillance
During treatment in Phase 2, the child should continue to be monitored until recovery. Observations
should be recorded systematically on the Therapeutic Surveillance Sheet.
Refer back to Phase 1 care with F75 or transition if:

1. There is deterioration in the nutritional status of the child.
2. This should be accompanied by a thorough assessment/reassessment of the child’s
treatment
Transfer due to not reaching discharge criteria after 40 days:
In this case, if all further investigations possible at the inpatient facility have been tried, the child
should be transferred to a higher level facility/service for further investigation and treatment.
Table 6.13. Monitoring in Phase 2

Daily Observations • Record RUTF or F100 intake after each feed
• Measure weight
• Assess edema
• Count the number of breaths in a full minute
• Measure heart rate
• Measure temperature
• Assess clinical status (vomiting, diarrhea, dehydration, cough)
• Assess nutritional status against discharge criteria
Weekly observations Measure MUAC
Two-weekly observations Measure height/length
Session 6.10:
Discharge
Table 6.14. Criteria for Discharge from Transition Phase to OTC

Child aged 6 to 59 months Medical complications resolved (or chronic conditions controlled)
AND
edema subsiding (must have reduced to at least +2)
AND
appetite for RUTF (must be able to eat at least 75% of outpatient ration)
* There is no anthropometric criterion for discharge when transitioning from ITC to OTC because nutritional rehabilitation is continued
and completed in OTC.
Discharge Procedure:
Before the child is discharged from the inpatient care unit to a health facility offering outpatient care
for SAM which is accessible to them, the following should be accomplished:
Step 1 Explain to the caregiver that the child has recovered sufficiently enough to be discharged
and congratulate them.
Step 2 An adequate supply of RUTF must be given to last until the next possible appointment in
outpatient care.
Step 3 The caregiver must understand (and repeat) the key messages for giving RUTF. The
caregiver must understand (and repeat) the medications to be given after discharge (these are
any courses of medicines that the child needs to complete after discharge).
Step 4 Call the relevant RHU/BHS clinical staff to notify them of the child’s transfer to outpatient
care. RHU/BHS clinical staff should advise the BHW/BNS of the child’s return.
Step 5 Complete an appropriate referral form and give it to the caregiver. This should be
presented to the staff of the outpatient health facility at the next appointment.
Step 6 Record the following on the referral slip:

a. Hospital registration/treatment number
b. MUAC (measurement)
c. Weight (measurement)
d. Height (measurement)
e. Weight for Height Z score (where capacity exists)
f. Grade of edema
g. Ration of RUTF given (number of packets on discharge)
h. Medications received and medicines to be continued after discharge
i. Clinical condition on discharge
Step 7 Record the child as a “discharge to outpatient care” in the tally sheet/monthly report.
Step 8 Record the ration of RUTF given in the stock register.
Step 9 Complete other relevant clinical records and registers.
From Phase 2 Inpatient Care
Discharge cured criteria from Phase 2:
Patients who are completing their full treatment in ITC due to the absence of OTC should be
discharged when they reach the discharge cured criteria shown in the table below. Apart from
taking account of the difference in frequency of contact, the criteria are the same as those for
discharge from OTC.

Module 6
Table 6.15. Criteria for Discharge from Phase 2
Category Discharge Criteria
Child aged 6 to Admitted on MUAC ≥ 12.5cm (equivalent to 125mm) for 2 consecutive visits
59 months MUAC, edema, or AND
both MUAC and No edema for 10 days
WFH Z-score AND
Clinically well
Admitted on WFH WFH or WFL ≥ -2 Z-scores for two consecutive days
Z-score only AND
No edema for 10 days
AND
Clinically well
Infants less than 6 months Child is gaining weight more than 5g/kg/day on breast milk for 3
consecutive days**
AND
edema is absent
AND
Clinically well & childhood immunizations have been checked
** All therapeutic milk must have been stopped. The weight gain must be entirely due to breast milk.
Before the child is discharged from the inpatient care unit the following should be done:
Discharge Procedure:
Step 1 Explain to the caregiver that their child has recovered sufficiently to be discharged and
congratulate them.
Step 2 The caregiver must understand (and repeat) the medications which must be given after
discharge.
Step 3 Complete other relevant clinical records and registers.
Step 4 For infants:

a. Refer the infant to ongoing counseling and monitoring as an outpatient at the RHU/BHS.
The child may be discharged from care completely when the weight for length is greater
than -2 Z scores (child’s length is greater than 45cm).
b. Check that the caregiver understands the importance of continued breastfeeding and
timely introduction of appropriate complementary feeding. In cases where infant formula
will be used at home, ensure the caregiver is informed about proper preparation, use and
attendant risks.
Step 5 Complete a referral slip and advise the caregiver to attend the nearest local health facility:
a. Record the child’s registration number on all documentation
b. Record the MUAC and WFH/WFL (measurement on discharge)
c. Record any continuing medications
d. Advise attendance at a growth monitoring program
e. Advise attendance at the local health facility for further nutrition counseling
Management of Medical Complications in SAM.
Although community based treatment of severe acute malnutrition is now focused on the strategy
towards the reduction of malnutrition, there are still children who require in-facility treatment. ITC for
SAM is two pronged. There is nutritional management that was just previously discussed and there
is medical management of complications. The identified three most common complications will be
discussed here: hypothermia, hypoglycemia and dehydration/shock.
Review. What are the criteria or indications for a child with SAM to be admitted into ITC?
It is typical that these SAM children earn the admission to hospital due to reasons not related to
malnutrition.
Your role as a health worker is to first IDENTIFY SAM. (Review Module 2)
Though a pediatric patient may come in with acute medical complications, it is still standard practice
to do anthropometry and this information is fundamental in enabling the further steps in treatment of
SAM.
Remember that typical formulaic estimations of weight do not apply to children with SAM. It is
critically important to still carry out actual measurements.
Session 6.11:
Identify, treat and prevent hypothermia.
Hypothermia is common among SAM children and typically co-exists with hypoglycemia. Together,
these two conditions signal a serious infection.
Identify Hypothermia:
• By taking the infant or child’s temperature.
• When you read an axillary temperature of < 35 °C or rectal temperature of <35.5 °C.
• Check for hypothermia whenever hypoglycemia is detected.
Treat and Prevent Hypothermia:

• By re-warming a cold infant or child using the following –
a. Putting the infant/child on the mother’s bare chest (skin to skin) and cover them (e.g.
Kangaroo Mother Care)
b. Covering the child (including head) with a warmed blanket, if able
c. Promptly do diaper / nappy changes
d. Prevent draughts / keep child away from open windows
e. Avoid exposure, prolonged medical examinations
f. Increasing the room temperature with a heater or lamp placed nearby
g. DO NOT use hot water bottles for rewarming for risk of burning already fragile skin.
• Feed the infant or child

• Give antibiotics. Review routine medications for SAM children with complications.
Monitor. Take the child’s rectal temperature every 2 h until it rises to > 36.5 °C.
PREVENTION
• Keep the child covered and away from draughts of air
• The room temperature should be maintained at not less than 27°C if possible
• Avoid regular bathing, keep child dry, change wet diapers, clothes and bedding
• Avoid exposure (e.g. bathing, prolonged medical examinations)
• Let child sleep with mother/caregiver at night for warmth
• Feed regularly, give feeds throughout the day and night during Phase 1, if possible, especially
for the first 24 - 48 hours.

Module 6
Session 6.12:
Identify, treat and prevent hypoglycemia
Identify hypoglycemia:
• When there is a low level of blood glucose < 3 mmol/L (or < 54 mg/dl)
• Check for other signs of hypoglycemia:
a. lethargy, limpness, and loss of consciousness
b. convulsions
c. Sweating and pallor MAY NOT occur
Be alert for the likelihood of hypoglycemia when there is vomiting, long intervals without food (more
than 3 hours), waiting for admission, irregular feeding.
Treat and prevent hypoglycemia:

• All severely malnourished children are at risk of hypoglycemia and, immediately on admission,
should be given a feed or 10% glucose or sucrose (see below).
• If there is no capability to check blood glucose but the infant or child has symptoms,
presumptively treat for hypoglycemia.
• In deciding the treatment for hypoglycemia, first check the infant or child’s level of consciousness.
If conscious:
• Give 50 ml of 10% glucose or 10% sucrose solution (one rounded teaspoon of sugar in three
tablespoons of water) orally or by nasogastric tube, followed by the first feed as soon as
possible.
• Start feeding as soon as possible, within 2 to 3 hours.
a. Continue breastfeeding in infants less than 6 months old or feed breastmilk by cup,
spoon, dropper or needle-less syringe. (Refer to Session on Nutritional Management of
the Child less than 6 months old)
b. For those over 6 months to 60 months old, feed with F75 every 30 min. for two hours
(giving one quarter of the two-hourly feed each time).
c. Continue the feeding through day and night. Consider indications for NG tube placement.
Recommended feeding schedule:
Days Frequency Vol/kg/feed Vol/kg/d
1-2 2 - hourly 11ml 130ml

3-5 3 - hourly 16ml 130ml
6 - 7+ 4 - hourly 22ml 130ml
Example: If a SAM child with weight of 6 kg is to start feeding, calculate F75 as follows:
(6 kg * 11 ml) = 66 ml
66 ml / 4 feeds = 16.5 ml = give 16.5 ml every 30 minutes for two hours
• Start the appropriate antibiotic.
• Keep the infant/child warm.
If the child is lethargic, unconscious or convulsing:

• Give 10% Glucose
a. IV (5mL/kg body weight) AND
b. 50mL by NGT to prevent rebound hypoglycemia; may also use sucrose solution
*Defer NGT dose if child will receive IVF for shock as the child will receive glucose via IVF
• For the child > 6 months to 59 months: Give F75 every 30 minutes for first two hours (giving ¼
of the total recommended two hours’ feed)
a. Feed frequently every 3 hours including waking the child during the night
b. If unable to feed and monitor the child overnight, give the full volume of the daily feeding
in fewer rations (5 or 6 times daily)
Decrease number of rations = increase the volume of therapeutic milk
• Measures to keep the infant/child warm. Encourage skin to skin contact with the mother/
caregiver especially for the infants.
• Start the appropriate antibiotic.

* Give per rectal diazepam (0.5mg/kg body weight) for convulsion even after giving IV glucose
Monitor
• If the initial blood glucose was low, repeat the measurement (when available) after 30 min
• If blood glucose falls to < 3 mmol/litre (< 54 mg/dl), repeat the 10% glucose or oral sucrose
solution
• If the rectal temperature falls to < 35.5 °C, or if the level of consciousness deteriorates, repeat
the blood glucose measurement and treat accordingly
PREVENTION OF HYPOGLYCEMIA
• Frequent feeding is important.
• If possible, feeds during Phase 1/Stabilization should be given every 3 hours including waking
the child during the night.
• If staff and facilities are not available to properly feed and monitor the child overnight, the full
volume of daily feed should be given in fewer feeds (5 or 6 times daily).
• The likelihood of hypoglycemia is reduced if the child is given the proper amount of feed during
the day.
• NB: If the number of feeds is reduced for whatever reason, the volume of milk given at each
feed must be increased accordingly.
Session 6.13:
Identify, treat, monitor and prevent dehydration and shock
Misdiagnosis and mistreatment for dehydration is the commonest cause of death in children with SAM.
• Regardless of hydration status, signs of dehydration are present in SAM, particularly those with
severe wasting. Typically, they have non-elastic skin and sunken eyes
KEY is to take a detailed medical history

• Determine recent fluid loss from acute diarrhea or vomiting – sudden onset or past few days
• Elicit how well / frequent the child has voided, particularly the last 6 hours; ask about urine color
Physical examination
• Level of consciousness
• Skin pinch test – unreliable especially in marasmus which typically is (+) for this test
• Sunken eyes – confirm that this finding only occurred lately, elicit history for fluid loss; marasmic
children can have sunken eyes due to loss of fat behind eyeball
• Absent are the usually visible and full superficial veins on the head, neck, and limbs
• Palpate liver. Mark the liver edge.
• Check extremities if cold, clammy (hands and feet)

Module 6
Vital signs check: Heart rate, temperature, blood pressure, weight
Assume hypovolemic shock when the following signs are also present:
Decreased level of consciousness so that the patient is semi-conscious or cannot be roused PLUS
any of the following:
• Cold extremities
• Slow capillary refill in the nail beds (longer than 3 seconds) OR
• Fast or weak / absent radial / femoral pulse
a. Children 2 to 12 months - pulse rate greater than 160/ min
b. Children 1 to 5 years - pulse rate greater than 140 / min
About SAM children with edema (Kwashiorkor):

Children with bilateral edema cannot be dehydrated
• Patients with bilateral edema are overhydrated
• They have increased total body water, increased sodium levels
• But they are frequently hypovolemic as fluid is lacking in the intravascular compartment
QUICK review of pathology in nutritional edema:
Low
Decreased
Due to low Low oncotic circulating
intravascular
protein pressure blood
fluid
volume
Low blood volume can coexist with edema.

• Do not use the IV route for rehydration except in cases of shock and then do so with care,
infusing slowly to avoid flooding the circulation and overloading the heart
IF the IV route is used, maintain IV access (heplock, NOT KVO) only for
• Do not use the IV route for rehydration except in cases of shock and then do so with care, - IV
antibiotics in Phase 1/Transition
• Children with decreased consciousness
• Those with contraindication for oral or NGT feeds
• Remove once without indication
• Re-site frequently (q 5 days) if with continuing need for access
Remember!
• Children with SAM usually have reduced cardiac contractility and renal function.
• Rehydration therapy should be cautious than for the normally nourished
• SAM children fail to compensate for increased intravascular volumes (as what happens in
typical IV fluid resuscitation) heart failure
• The treatment of a child with nutritional edema is the same with septic shock and different from
what is done for a child with wasting.
Treat dehydration/shock:
The standard oral rehydration salts solution (90 mmol sodium/l) contains too much sodium and too
little potassium for severely malnourished children. Instead give special Rehydration Solution for
Malnutrition (ReSoMal).
IF the child is conscious:

• ReSoMal 5 ml/kg every 30 min. for two hours, orally or by nasogastric, then 5-10 ml/kg/h for
next 4-10 hours: the exact amount to be given should be determined by how much the child
wants, and stool loss and vomiting.
• Replace the ReSoMal doses at 4, 6, 8 and 10 hours with F-75 (i.e. alternated feeds) if
rehydration is continuing at these times, then
• If rehydration is still required at 10 h, give F75 as per the recommended feeding schedule
posted in this module
For the child with nutritional edema - If (+) watery diarrhea and (+) clinical deterioration:
• Replace fluid loss with 30ml ReSoMal per episode of watery stool.
If the child is not conscious or has a decreased level of sensorium

Give IV fluids, choice of:
• Ringer’s lactate solution with 5%dextrose or half-strength Darrow’s solution with 5% dextrose
• If neither is available, GIVE 0.45% saline with 5% dextrose
Figure 6.4. Hydration in a Severely Malnourished Child
Decreased consciousness and/or

Conscious SAM with sever dehydration
Hypovolemic shock
ReSoMal Intravenous Solution

10mL/kg - first 2 hours 15mL/kg - first 1 hour
5 - 10mL/kg - Next 10 hours
REASSESS
IF CONSCIOUS: Insert nasogastric IF IMPROVING:

tube and start ReSoMal 15mL/kg - second hour
(10mL/kg/hr)
REASSESS
IF NOT IMPROVING:
DIAGNOSE
SEPTIC SHOCK
The therapeutic window for rehydration therapy is narrower for a child with SAM than for a normally
nourished child due to the abnormal pathophysiology.
The reduced function of the cardiac, renal and abnormal cardiovascular system results in abnormal
responses to an increase in fluid load. It is much easier to quickly overhydrate the child resulting in
heart failure and death, as the increased fluid volume in the cardiovascular system cannot be excreted
normally.
A child with SAM in heart failure may not respond well to diuretic medications. *Avoiding overhydration
and heart failure is easier and far preferable to treating them.
* For the child with nutritional edema needing IV hydration, treat according to the guidelines on the management of septic shock
(See Annex 6.13).
During treatment, rapid respiration and pulse rates should slow down and the child should begin to pass urine.

Module 6
Monitor progress of rehydration:

Observe every 30 minutes for two hours, then hourly for the next 6-12 hours, assessing and recording:
• Weigh the patient (and calculate the target weight gain)
a. The target is to regain no more than 5% of baseline weight
• Heart/Pulse rate, temperature, respiration rate

• Heart sounds (over-hydration may result in a gallop rhythm)
• Observe for signs of respiratory distress (chest indrawing, nasal flaring)
• Observe for vomiting or diarrhea (estimate volumes and correlate with weight loss)
• Reassess the costal margin of the liver
• Reassess the absence or presence of jugular venous distension
• Monitor for presence or absence of urine output and, if present, urine color
Return of tears, moist mouth, eyes and fontanelle appearing less sunken, and improved skin turgor, are
also signs that rehydration is proceeding.
Succeeding steps in hydration will be based upon monitoring of weight:
Figure 6.5. Algorithm for Monitoring Weight
Monitor Weight*
Every 30-60 mins
Weight Gain Weight Stable Weight Loss
Clinically No clinical Increase ReSoMal Increase ReSoMal

improved improvement by 5mL/kg/hr by 10mL/kg/hr
STOP ALL Reassess every 60 mins until target Reassess every 60 mins until target
REHYDRATION weight is reached weight is reached
Continue to FLUIDS
target weight Give F75 and
and start F75 reassess.
Diagnose septic
shock.
Continuing rapid breathing and pulse during rehydration suggest coexisting infection or overhydration.
Signs of excess fluid (overhydration) are increasing respiratory rate and pulse rate, increasing edema
and puffy eyelids. If these signs occur, stop fluids immediately and reassess after one hour.
Monitoring the clinical status during the rehydration of the marasmic child
During rehydration therapy, breastfeeding should not be interrupted; the child should be breastfed on
demand. Successful rehydration results in an improvement of the clinical status of the child with an
improvement in the level of consciousness, and normal heart/pulse rate and blood pressure.
NB: Rehydration therapy should be stopped immediately if any of the following occur:
• Target weight for rehydration is achieved (start F75)
• There is development of edema (start F75)
• Jugular venous distension is observed
• Jugular veins become engorged when abdomen is pressed
• An increase in the costal margin of the liver of 1cm or more
• Tenderness of the liver on palpation
• An increase in respiratory rate of 5 breaths per minute or more
• Increase in pulse/heart rate of 25 beats/min or more
• Development of grunting expiratory sounds/labored breathing/increased respiratory effort
• Development of pulmonary rales or crepitations on auscultation
• Development of a triple rhythm (gallop) in the heart sounds or brachial pulse
Content Summary
This module provides an orientation of inpatient care for the management of severe acute
malnutrition (SAM) with medical complications and emphasized important issues. The module
outlines who should be admitted to inpatient care with its corresponding reasons. It also covers
admission and discharge processes and criteria as well as the basic principles of medical
treatment and nutrition rehabilitation. Emphasis is placed on ensuring a smooth referral process
between outpatient care and inpatient care, in both directions.
Additionally, in the management of medical complications among children with SAM, it was
emphasized that SAM may not manifest the true severity of their illness. Hypothermia and
hypoglycemia mark a serious infection. SAM children with medical complications are treated
with antibiotics. Dehydration is best treated with ReSoMal. IV fluids for rehydration should be
administered with caution. The management of dehydration/shock between the severely wasted
and those with nutritional edema is different.
Early re-establishment of oral feeding is desired among SAM children with medical complications.
This module is intended to be used alongside the National Guidelines on the Management of
Severe Acute Malnutrition for children under 5 years. For certain areas, inpatient care sites
provide the management of SAM until the child is fully recovered.
? Test Yourself
Exercise set 1:
For each child listed below, use your F75 Reference Tables to determine the amount of F75 to
give per feed.
The starting weight and edema classification is given for each child, as well as the current
frequency of feeds for the child.
Child 1: 6.8 kg, no edema, 3-hourly feeds, give ______ ml F75 per feed.
Child 2: 8.5 kg, mild (+) edema, 4-hourly feeds, give ______ ml F75 per feed.
Child 3: 5.2 kg, severe (+++) edema, 3-hourly feeds, give ______ ml F75 per feed.
Child 4: 7.0 kg, severe (+++) edema, (+) hypoglycemia, 3 feeds, give ______ ml F75 per
feed and _____.
Child 5: 10.6 kg, moderate (++) edema, 4-hourly feeds, give ______ ml F75 per feed
Answer key: Child 1: 110ml, Child 2: 180ml, Child 3: 90ml, Child 4: 125ml and for the hypoglycemia (child is conscious),
give: 50mL bolus of 10% glucose or sucrose solution (1 rounded teaspoon of sugar in 3.5 tablespoons water) orally or
by nasogastric (NG) tube, feed F75 every 30 minutes for first two hours (giving 1⁄4 of the total recommended two hours’
feed), keep the child warm, and start antibiotics, Child 5: 200ml

Module 6
Exercise set 2:
Case 1. Ana is 24 months old with weight 4.8 kg length 65 cm. Her WFL Z score is < -3SD.
MUAC is 10cm. She had no edema. Other physical findings were unremarkable.
1. What is her nutritional assessment? ____________________________

She failed her appetite test and was referred for ITC at your hospital where pediatric staff
had undergone the new training for management of severe acute malnutrition.
When she was admitted to the ward on Day 1. (Refer to your Participant Manual, p. 113, for
Table on Prescribed Amounts of F75 milk for Phase 1)
2. You want to prescribe 6 feeds per day and would give ___________ ml per feed.
Ana was a reluctant eater, but she finished most of her feeds and continued 4-hourly feeds
(6 feeds per day) on Day 2.
On Day 2, Ana was still reluctant to eat. At two feeds, she took less than 75% of the amount
offered, but then she took more at the next feeds.
3. Does Ana need an NGT for feeding? Mark X on the blank. ______ Yes ______ No
On Day 3, Ana’s appetite increased. She finished the ration of F75 milk each feeding and
would ask for more.
4. What are the criteria that signal the readiness to transition?

a. medical complications are resolving
b. appetite returns
c. edema is reducing
d. all of the above
You decided that Ana is ready for transition. The RHU in her vicinity has also just trained
for OTC.
5. What should Ana be given as feeding for Day 4? ________________________________

_____
6. What is the right amount of feeding to be given? Her weight in now 5.1 kg.
____________________________________________________________________
7. What would you instruct for Ana’s mother to do?

____________________________________________________________________
8. By Day 6-7, what would you consider to decide that Ana is ready to be discharged to OTC?
a. At least 75% of full RUTF amount is eaten in 24 hours
b. No other issues identified during monitoring
c. a and b
Case 2a. Marcia is a 38 months old girl with

weight 8.6 kg, height is 85.5 cm. Her WFH Z
score is < -3 SD. MUAC is 10.9 cm. She had
bilateral edema with poor appetite.
1. Write down the grade of her edema.

_________________________
2. Your diagnosis: ______________________

On day 1, you plan to start her nutritional
management.
3. What Phase of Nutritional management is this? ____________ Write this down in the ITC
chart.
4. What is the therapeutic milk you will give? _______________Write this down in the ITC
chart.
5. You want to give feeding every 4 hours. What volume of milk will you give each feed?
____________________. Write this down in the chart.
On Day 1, her oral feeding intake is reflected in the chart below.
6. What proportion of her recommended feed is she taking per feeding? ___________________
7. What will you do to help increase her intake of the recommended volume of meal?
_______________________
Meal Time
1
4:00 am
2 x
8:00 am x
3 x
Feeding Monitoring
12:00 pm x
4 x
4:00 pm x
5
8:00 pm
6
x x x x x x
Amount Taken: 100% 3/4 1/2 1/4
x x x x
By Day 2, you looked at her feeding monitoring and asked Marcia’s mother how Marcia is and
has her eating changed since yesterday. Below is her chart. She mentioned that as of 4pm,
Marcia asked to eat by mouth. Her chart is below. You decided to observe how much she would
eat on her own.
Meal Time
1 x x
4:00 am x x
2 x x x
8:00 am x x x
3 x x x
Feeding Monitoring
12:00 pm x x x
4 x x x
4:00 pm x x x
5 x x x x
8:00 pm x x x x
6 x x
12:00 am
7
x x x x x x
Amount Taken: 100% 3/4 1/2 1/4
x x x x

Module 6
You saw her again on Day 3 and looked at Marcia’s feeding chart.
Meal Time
1 x x x x
4:00 am x x x
2 x x x x x
8:00 am x x x x
3 x x x x x
Feeding Monitoring
12:00 pm x x x x x
4 x x x x x
4:00 pm x x x x x
5 x x x x
8:00 pm x x x x
6 x x x
12:00 am x x x
x x x x x x
Amount Taken: 100% 3/4 1/2 1/4
x x x x
8. What would you decide to do? ________________________________________________

ON further physical examination, you also tested that her edema is reducing.
9. Is Marcia ready to transition? __________________ If yes or no, why? ____________
TRANSITION
Case 2b. There is no OTC near where Marcia lives. You plan to transition her to 1.
1. What type of therapeutic feeding will you give Marcia? _____________________________
2. How much calories will this give her per kg body weight? ___________________________
3. How much volume would you give her at each meal if you plan to give her 6 meals/day?
She is now 8.8kg ______________________________.
On Day 5, her mother tells you that Marcia eats all the therapeutic milk on her own and
seems to want for more.
4. You decide that she is ready for what phase in nutritional management?
___________________________
5. To what calorie intake per kg body weight will she now be increased?
___________________________
6. How much volume of feed will you give per meal for 5 feeds per day? She is now 9 kg.
___________________________
DISCHARGE
7. What criteria will help you decide when she is ready for discharge? Encircle the letter of the
correct answer.
a. MUAC > 12.5 cm for 2 consecutive visits AND
b. No edema for 10 days AND
c. Clinically well
d. All of the above
Exercise set 3:
Case 1.
Enelra is a 16 month old girl who was brought in by her aunt due to malaise -- “matamlay.” Her
aunt also reported that Enelra ate last about 5 hours prior to their trip to the ER.
They had first gone to a private clinic but told to consult in the hospital because Enelra has very
thin arms and legs. Her feet also looked swollen.
Anthropometry: Weight 8.3 kg, Length – 84.2 cm, MUAC 11.3 cm

She was asleep but easily roused and kept awake.
Her Temp 35.5 C (axillary)
1. At this point, decide if Enelra should be managed in ITC (Yes or no). Why?
2. What two things need to be immediately done for her?
You tested her blood glucose and the result was 48 mg/dl.
3. Does Enelra have hypoglycemia?
4. What should be given for her hypoglycemia? How?
5. What feeding should Enelra be started on? How should it be given to her?
6. Should she be given antibiotics? Which?
Case 2.
Pau is a 28 month-old girl. Her mother said that Pau is on a Therapeutic supplementary feeding
program. However, Pau has had loose stools since early this morning, but she is alert and can
drink. Her mother also reported that Pau’s urine is very yellow.
Her weight is 8.0 kg. Her height is 82.2. MUAC 11.4 cm
On exam, she is alert and drinks. Her temperature is 36.2 oC axillary. Her skin is dry. She has
no pallor, her extremities are warm. There is no edema.
HR 145, RR 36
Her blood glucose is 52 mg/dl.
1. What are the three treatments that Pau needs to be given?
2. Discuss what you would give for her hypoglycemia.
3. Discuss how you would rehydrate her.

Module 6
4. When do you start feeding with F75? How much?
Case 3.
Andro is a 35 month old boy, weight of 13.6 kg, height 108.2 cm.
He has had loose stools since yesterday morning. He refuses to eat but was drinking some “am”.
He has been very sleepy.
His mother is unsure if he has had urine output as well.
On arrival at your hospital, his temperature read 35C. You assume that he is hypoglycemic.
He is lethargic. His palms, gums, lips, and inner eyelids appear normal in color (not pale).
On further exam, he has cold clammy palms and soles. The capillary refill time is > 3 seconds.
1. What are the key four treatments that Andro needs to be given?
2. How will you administer glucose? What kind and how much?
3. What route of rehydration?
4. If IV, what type of fluid?
5. How much and what rate of administration?
Andro is given IV fluids starting at 9:45 am. His respiratory rate at that time is 60 breaths
per minute, and his pulse rate is 130. Andro is monitored every 10 minutes over the next
hour, and both his respiratory and pulse rates slow down during this time. At 10:45 am, his
respiratory rate is 40 and his pulse rate is 105.
6. What should be done for the next hour?
After 2 hours of IV fluids, Andro is alert enough to drink, although he still appears unwell.
His blood glucose has been tested and is now up to 70 mg/dl. He is weighed again, and his
new weight is 14.1 kg.
7. What should Andro be given in alternate hours over the next period of up to 10 hours?
8. How much F-75 should be given at each feed?
Annex
Annex 6.1.
Composition of F75 and F100
Constituents Amount per 100 mL

F-75 F-100
Energy 75 calories 100 calories
Protein 0.9 gm 2.9 gm
Lactose 1.3 gm 4.2 gm
Potassium 3.6 mmol 5.9 mmol
Sodium 0.6 mmol 1.9 mmol
Magnesium 0.43 mmol 0.73 mmol
Zinc 2.0 mg 2.3 mg
Copper 0.25 mg 0.25 mg
Percentage of energy from:
Protein 5% 12%
Fat 32% 53%
Osmolarity 333 mOsmol/1 419 mOsmol/1
From: WHO 2011, Facility Based Care of Severe Acute Malnutrition
Annex 6.2.
Alternate F75 Recipes
Cereal CMV red

Type of milk Milk (g) Sugar (g) Oil (g) Water (ml)
powder (g) scoop
Dry skim milk 50 140 54 70 1

Add
Dry whole milk 70 140 40 70 1 lukewarm
Fresh cow milk 560 130 40 70 1 water up to
2000ml
Fresh goat milk 560 130 40 80 1
* Cereal powder is cooked for about 10 minutes before the other ingredients are added
To prepare F75:
Add the milk, sugar, pre-boiled cereal powder and oil to one liter (L) water and mix. Boil for 5 to 7
minutes. Allow to cool, add the combined mineral and vitamin mix (CMV) and mix again. Make up the
volume to 2,000 milliliters (mL) with cooled boiled water.
Note: Other local recipes for the preparation of F75 have been developed but require the addition of micronutrient supplementation to
the child in place of the CMV in the above.

Module 6
Annex 6.3.
Inpatient Treatment Record
Inpatient Details (Front)
Inpatient Facility: ____________________________________________________
Referred from: OTC ________________ Others ____________ Self-Referral
Name: ________________________________________ Age & Sex: _________ Registration Number: ____/____/____/____
Barangay & Municipality: __________________________________________ Mobile Phone No.: ______________________
Name of Caretaker: _____________________ Relation to Patient: Mother Father Grandmother Others ______
Contact No.: ___________________________
ADMISSION DISCHARGE
Date ___/___/___ Time_______ Date ___/___/___ Time_______
Admission Type Admission Criteria Successfully Treated Follow-up ___________

New Admission SAM with medical complication Died Cause ______________
Readmission _________ Defaulter/HAMA Cause ______________
Relapse Edema+++ Marasmic Kwashiorkor Non-cure Cause ______________
Transfer from OTC <6 months old Poor or No Appetite
Inpatient Details (Back)

DATE
Height (cm)
Anthropometrics
Weight (kg)
WH (Z score)
MUAC (mm)
Edema 0,+,++,+++
0.8
0.6
0.4
0.2
__Kg
0.8
0.6
0.4
Weight Graph
0.2
__Kg
0.8
0.6
0.4
0.2
__Kg
0.8
0.6
0.4
0.2
__Kg
Phase
Product
Feeding
(F75, F100, RUTF)

# Meals/day
Quantity/meal (mL)
Oral, NGT
Meal Time
1
3
Feeding Monitoring
x x x x x x
Amount Taken: 100% 3/4 1/2 1/4
x x x x
Annex 6.4.
The Correct Positioning in Breastfeeding
• Newborn's neck is not flexed or

twisted
• Newborn is facing the brest
• Newborn is close to mother's body
• Newborn's whole body is supported
Unang Yakap 2011. (Powerpoint Presentation)
Annex 6.5.
The Correct Attachment / Latch
• Signs of good attachment

1. Mouth open wide
2. Baby's chin touching breast
3. Lower lip turned outwards
4. Less areola visible underneath the
chin than above the nipple
Unang Yakap 2011. (Powerpoint Presentation)

Module 6
Annex 6.6.
Breastmilk Storage Guidelines
Storage Duration
Location Comments
Temperature Term Preterm
Countertop, table Room 6 hours 4 hours Containers should be covered and

temperature kept as cool as possible; covering the
container with a cool towel may keep
milk cooler.
Insulated cooler 15˚C 24 hours 12 hours Keep frozen gel packs in contact with
bag milk containers at all times, limit opening
cooler bag.
Refrigerator 4˚C 48 hours 24 hours Store milk in the back of the main body
of the refrigerator.
Domestic -15˚C 2 weeks 2 weeks Store milk toward the back of the freezer,
refrigerator (1- where temperature is most constant. Milk
door) stored for longer durations in the ranges
Domestic -18˚C 2 months 2 months listed is safe, but some of the lipids in
refrigerator (2- the milk undergo degradation resulting in
door) lower quality.
Milk Bank
Freezers
Unpasteurized -20˚C 3 months 3 months
Pasteurized 12 months 6 months
DOH 2011. The Philippine Human Milk Banking Guidelines
Annex 6.7.
Cupfeeding
• Wash hands
• Prepare cup, no more than 30 ml capacity, do not fill to brim
• Support alert and awake infant in upright, sitting position, secure arms
• Tilt the rim of the cup towards the lower lip
• Milk must be at the rim
• Do not pour milk into mouth
• Maintain position until baby laps up milk using the tongue and feeds/swallows
• Remove cup when baby stops feeding
• Return cup when with signs of readiness to feed
• Rinse cup in hot soapy water when finished
• Maintain position until baby laps up milk using the tongue and feeds/swallows
• Remove cup when baby stops feeding
• Return cup when with signs of readiness to fee
• Rinse cup in hot soapy water when finished
Annex 6.8.
Supplementary Suckling Technique
The Supplementary Suckling Technique is a technique used in therapeutic feeding centers to feed
children less than 6 months or children more than six months, but with a weight < 3 kg.
The goal is to provide children with a feeding supplement, if necessary, while stimulating the breast milk
production at the same time.
Department of Health. 2015. National Guidelines on the Management of Severe

Acute Malnutrition for Children under Five Years Manual of Operations, p.175
Explain to the mother what you propose to do. If she is not motivated, explain more, let her speak to
other mothers who have used this technique or ask her if you can show her once to let her see
Wash your hands and ask the mother to wash her hands
Tape a feeding tube n°8, the tip cut off, with the tip next to the nipple of the mother
Put the right quantity of breastmilk or F-100 Diluted in a cup, and place the other end of the NGT (open)
in the cup.
First an assistant holds the cup about 10 cm lower than the breast, and the child is offered the breast.
When the child suckles, the milk is sucked from the cup. When the mother is used to the technique,
she can hold the cup herself
It may take the child 1 or 2 days to adjust to feeding by the tub. Sometimes the child notices the
difference between the taste of the breast milk and the F-100 and rejects the tub feeding initially but it
is important to persevere
After use, the tube is cleaned with clean water & a syringe, then spun to dry.

Module 6
Annex 6.9.
Identifying Hypoglycemia
MEASURING BLOOD GLUCOSE LEVEL
If possible, testing for blood glucose level should be done using glucose paper test strips. When the
end of the paper strip is covered with a blood sample, the strip changes color to indicate the blood
glucose level. Check the expiry date of the strips; if the date is expired, the readings may not be correct.
Different testing kits may have different instructions. In general, instructions are as follows:
• Touch the paper to the blood sample
• Wait for an appropriate number of seconds
• Wash the blood off the strip with running water
• Compare the test paper to the color scale provided with the strips.
In many cases the color scale for the paper strips may not clearly show the level. For example, it may
say that a certain color corresponds to 2 - 4mmol/L. If a range is given, assume that the child’s blood
glucose is the lower reading (2mmol/L in this case).
Annex 6.10.
Identifying Hypothermia
Hypothermia is a condition with low body temperature (axillary temperature is below 35°C). A rectal
temperature of < 35.5°C is a more reliable indicator of hypothermia. If available, a low reading rectal
thermometer should be used. Check for hypoglycemia whenever hypothermia is detected.
Using a rectal thermometer

• Shake the thermometer down to below 35°C.
• Position the child on his side or back with legs lifted.
• Insert thermometer in rectum so that the bulb goes in about ½ inch.
• Keep in place for 1 minute and take the reading.
Using an axillary thermometer

• Shake the thermometer down to below 35°C.
• Place thermometer under armpit.
• Keep in place for 3 minutes.
• If below 35°C take rectal temperature for more accurate reading.
Annex 6.11.
Oral Rehydration Solutions in the Treatment of Dehydration/ Hypovolemic Shock
ORAL REHYDRATION SOLUTIONS

1. Rehydration Solution for Malnutrition (ReSoMal) should be used as the standard therapy for
SAM children admitted in ITC diagnosed with dehydration
2. Low Osmolarity Oral Rehydration Solution (LO-ORS) may be used for the treatment of children
with SAM but only for those who have a positive diagnosis of Acute Watery Diarrhea (AWD)
or Cholera
Note: Standard (full strength) Oral Rehydration Solution (ORS) does not have a suitable formulation for the treatment of
dehydration in children with SAM.
Where ReSoMal is not available, a modified, half-strength solution of LO-ORS may be used with added potassium and glucose.
Resomal Formulation:
ReSoMal (ORS for severely malnourished children), 42g sachet to be diluted in 1 liter of purified/boiled
and cooled water.
Technical Specifications:
Contents per sachet of 42 grams:
• Sucrose: 25g
• Glucose Anhydrous: 10g
• Sodium Chloride: 1.75g
• Trisodium Citrate, dihydrate: 45g
• Potassium Chloride: 2.54g
• Tripotassium Citrate: 0.65g
• Magnesium Chloride Anhydrous: 0.61g
• Zinc Acetate: 0.0656g
• Copper Sulphate Anhydrous: 0.0112g
• Osmolarity: 300mmol/L
All the ingredients must comply with one of the pharmacopeias:

BP, Ph.Eur, Ph.Int, USP.
INTRAVENOUS REHYDRATION SOLUTIONS
1. Ringers Lactate Solution with 5% Dextrose

2. 0.45% Saline with 5% Dextrose
Annex 6.12.
Treatment of Hypernatremic Dehydration
Hypernatremic dehydration (serum sodium concentration greater than 145 mEq/L) is common in areas
with very dry atmosphere particularly if the ambient temperature is also high.
It is most likely to occur in patients that have been transported over long distances to the ITC/OTC under
the sun, without stopping to rest or having something to drink. It is important that those arriving at clinics,
OTC, etc. are given water/sugar-water to drink and not kept waiting under the heat. Hypernatremia can
also occur when the feeds are too concentrated (for example if the mother has been making up infant
formula incorrectly).
Hypernatremia is difficult to treat safely, but is easy to prevent. Malnourished patients, particularly those
in dry and hot environments, should be given continuous access to sufficient plain water.
The conventional treatment of hypernatremia is to give normal saline slowly, either orally or intravenously.
However, this treatment is NOT used in SAM because sodium intake in the severely malnourished child
should be restricted.
DIAGNOSIS
The first sign to appear is a change in the texture of the skin;
• The skin develops a doughy consistency
• The eyes can be somewhat sunken.
• The abdomen frequently becomes flat and may become progressively scaphoid or wrinkled.
• Fever may develop.
• The patient may become drowsy and progress to unconscious state.
• Convulsions may follow.

Module 6
If treatment for hypernatremia is not instituted, this may lead to death. The convulsions are not
responsive to the usual anticonvulsants (phenobarbitone, diazepam). Failure to control convulsions
with anticonvulsants may be the first indication of the underlying diagnosis.
The diagnosis can be confirmed by an elevated serum sodium concentration of more than 150mmol/L.
TREATMENT
For incipient hypernatremic dehydration, i.e., an alert patient with only skin changes:
• Breastfeed the child or give breast milk. This can be supplemented with up to 10mL/kg/hr of
10% sugar-water in sips over several hours until thirst is satisfied. At this early stage, treatment
is relatively safe.
• Give small amounts of water and have the patient drink slowly over several hours to correct
the dehydration.
For developed hypernatremic dehydration, treatment should be given over 24 - 48hrs
IF POSSIBLE, measure serum sodium:

• Aim to reduce the serum sodium concentration by about 12mmol/24hrs. Rapid correction of
hypernatremia runs the risk for death from cerebral edema.
IF IT IS NOT POSSIBLE to measure the serum sodium:

• Take at least 48 - 72hrs to correct hypernatremic dehydration.
Progress is assessed by serial weight measurements of the patient:

1. First, put the patient in a relatively humid, thermoneutral (28º to 32ºC) environment – this is the
most important step.
2. Second, Weigh the patient on an accurate balance and record the weight.
The objective of treatment is to place the patient in a positive water balance of about 60mL/kg/day over
the course of treatment (assessed by weight gain), which is equivalent to 2.5mL/kg/hr of plain water.
This amount should not be exceeded and is continued until the child is awake and alert.
For the child who is conscious, fluid replacement is given orally. If the child is semiconscious or
unconscious and there is no ongoing diarrhea:
• Insert an NGT and start 2.5mL/kg/hr of 10% sugar-water or breast milk. Do not give F75 at this
stage. Never give F100 or infant formula. Expressed breast milk is the best “rehydrating” fluid
available. (Note that 5% dextrose and 10% sucrose solutions are both isotonic).
• Reweigh the patient every 2 hours.
If the weight is static or there is continuing weight loss, check the ambient temperature and correct
as necessary to prevent further evaporative water losses. Then, increase the amount of sugar-water
intake to compensate for additional fluid loss from heat (calculated at 2.5mL/kg/hr PLUS the amount of
fluid to replace the additional losses).
If the weight is increasing, continue treatment until the child is awake and alert.
If there is accompanying diarrhea:

• Give 0.18% normal saline in 5% dextrose orally or by NGT
If the child is unconscious,

• Give the same volumes of fluid (5% dextrose if there is no diarrhea and 0.18% saline in 5%
dextrose if there is diarrhea) by intravenous infusion.
• Ideally, there should be an intravenous infusion pump. If not, at the very least, use a pediatric
soluset in order to ensure that that the rate of administration of fluid is not exceeded during
treatment.
When the child is awake and alert and the skin quality returns to normal (or the serum sodium is
normal), start feeding with F75.
Annex 6.13.
Treatment of Septic Shock
Septic shock is caused by decreased tissue perfusion and oxygen delivery as a result of infection and
sepsis. It can cause multiple organ failure and death. Children, immunocompromised individuals and
the elderly are most susceptible as their immune systems cannot cope with infection as well as healthy
adults do. The mortality rate from septic shock can be high.
Septic shock presents with some of the signs of dehydration, hypovolemic shock or cardiogenic shock.
The differential diagnosis is often very difficult. If a child diagnosed with hypovolemic shock is not
responding to treatment then septic shock should be diagnosed (see Annex 21). A child with cardiogenic
shock may be hypovolemic or hypervolemic.
Septic shock may present as cold septic shock characterized by low cardiac output and high peripheral
vascular resistance or warm septic shock characterized with low peripheral vascular resistance and
variable cardiac output. Central venous pressure is typically low. If a high central venous pressure,
crackles or other signs of fluid overload are present then the child should be treated for heart failure
(Annex 25).
If septic shock develops after admission, treatment must be carefully reviewed to determine if the
treatment is the cause of the clinical deterioration. Any drugs considered not essential for immediate
treatment should be stopped.
DIAGNOSIS OF SEPTIC SHOCK

Septic shock is diagnosed when:
• Tachycardia with weak or absent radial pulses (femoral pulses may also be weak)
• Cold extremities (capillary refill time more than 3 seconds)
• Reduced level of consciousness
• Absent signs of heart failure
• Possible signs of infection (may be masked in children with malnutrition)
NB: The differential diagnosis of hypovolemic shock and septic shock is often very difficult in children
with SAM. If a concomitant illness such as viral infection, malaria or other severe condition is present,
septic shock should be assumed. Septic shock is often seen in immunocompromised individuals or
hospital acquired infections.
TREATMENT OF SEPTIC SHOCK
Patients diagnosed with septic shock should immediately be given treatment:

• Give oxygen via face mask or nasal cannula
• Give broad spectrum, first line / second line antibiotic
• Conscious patients should be started on F75 (or sugar water) orally / NGT (Phase 1 protocols)
• Treat/prevent hypoglycemia in unconscious patients
• Treat /prevent hypothermia
• Keep physical disturbance of the child to the minimum required to deliver emergency care
If there is a decreased level of consciousness which is diagnosed to be due to poor cerebral perfusion:
• Whole blood transfusion 10mL/kg over at least 3 hours
OR
• Intravenous rehydration solutions at 10mL/kg/hr

Module 6
NB: Administration of intravenous fluids when septic shock is diagnosed must be done with extreme
caution so as not to induce fluid overload. The patient should be monitored every 10 minutes for
signs of clinical changes. Blood transfusion should be given within 24 hours of admission. During
blood transfusion, oral feeding must be discontinued. When the child regains consciousness and blood
transfusion is no longer required the child may be started on F75. As soon as clinical signs have
improved all intravenous fluids must be stopped.
Annex 6.14.
Treatment of Severe Anemia
When possible, the hemoglobin should be measured on admission in any child that presents with
clinical signs of anemia.
• If the hemoglobin is above 4g/100mL or the packed cell volume is above 12%
OR
• If the patient has started treatment with F75 for more than 48 hours (preferably 24 hours) and
less than 14 days
• If the hemoglobin concentration is less than 4g/100mL

OR
• The packed - cell volume is less than 12% in the first 24 hours after admission
• The patient has very severe anemia that should be treated.
1. Give 10mL per kg body weight of packed red cells or whole blood slowly over 3 hours.
2. Fast the patient during, and for at least 3 hours after, a blood transfusion.
3. Do not transfuse a patient between 48h after the start of treatment with F75 and 14 days
later.
4. Do not give iron during the acute-phase of treatment
If the facilities and expertise exist (neonatal units) it is preferable to give an exchange transfusion to
severely malnourished patients with severe anemia. If a transfusion is necessary during the danger
period of 48 hrs to 14 days after starting dietary treatment or if there is heart failure with very severe
anemia then the patient cannot be given a straight transfusion and needs an exchange transfusion.
If the expertise does not exist locally, then transfer the patient to a center where there are the facilities
and skill to do an exchange transfusion (neonatal unit). Heart failure due to anemia is clinically different
from normal heart failure; when the failure is due to anemia alone there is ‘high output’ failure with a
hyperdynamic circulation, easily felt pulse and heartbeat and warm peripheries.
Anemia or a falling hemoglobin, and respiratory distress is a sign of fluid overload and an expanding
plasma volume; the heart failure is not being caused by the anemia per se; the anemia is ‘dilutional’ and
the heart failure is caused by the fluid overload.
Extreme caution should be used in the interpretation of a low hemoglobin level and it should not be
measured subsequently in most circumstances. This is to avoid an inexperienced clinician transfusing
the patient during the danger period of electrolyte disequilibrium (day 2 to 14) in response to a low
reading. Do not give a straight transfusion of blood or even packed cells to these patients.
Annex 6.15.
Treatment of Heart Failure
SIGNS AND SYMPTOMS
Heart failure should be considered when there is:

• Physical deterioration in the presence of weight gain
• An increase in respiration rate with weight gain
• An acute increase of more than 5 breaths per minute (particularly during rehydration treatment)
• Greater than 50 breaths/minute in infants or more than 40 breaths/minute in children 1 - 5 years
• A sudden increase in liver size (thus, it is important to mark the liver edge on the skin before
starting any infusion)
• Tenderness developing over the liver
• Respiration with a “grunting” sound during each expiration
• Breath sounds indicate crepitations or rales
• Prominent neck and other superficial veins
• Engorgement of the neck veins when the liver is pressed
• Enlargement of the heart (may be very difficult to assess in clinical practice)
• Appearance of gallop or triple rhythm in the heart rate / pulse
• An acute fall in hemoglobin concentration or hematocrit (measures quite accurately the degree
of expansion of the intravascular volume)
As heart failure progresses, there is either (1) marked respiratory distress with rapid pulse rate, cold
hands and feet, edema, and cyanosis or (2) sudden, unexpected death. This is cardiogenic shock, and
it usually occurs in the child with SAM after treatment has started.
The underlying cause is excessive intake of sodium from the diet, rehydration fluids, or from drugs.
Even if sodium intake is restricted, heart failure can still occur due to the residual sodium in the diet
or the amount of sodium coming out of the cells as the cells recover. Excess sodium given during the
initial treatment of dehydration can give rise to heart failure several days later when the sodium inside
the cells (i.e., intracellular sodium) enters the vascular space. There is usually weight gain.
DIFFERENTIAL DIAGNOSIS
Heart failure and pneumonia are clinically similar and very difficult to distinguish.
• If there is increased respiratory rate AND weight gain, heart failure should be the first
consideration.
• If there is increased respiratory rate with a loss of weight, pneumonia is more likely the
diagnosis. Pneumonia should never be considered if there has been a gain in weight just
before the onset of respiratory distress.
• If there is no change in weight (fluid balance), differentiation should be made using other signs
of heart failure.
Children with edema can go into heart failure even without a gain in weight. This occurs when the
expanded circulation due to edema fluid is mobilized from the tissues into the vascular space.
TREATMENT
As edema fluid is mobilized (as in kwashiorkor) and sodium is moving out of the cells (in both kwashiorkor
and marasmus), plasma volume expands but the volume of red cells remains constant. There is thus
a FALL IN HEMOGLOBIN concentration. This DILUTIONAL anemia happens to some extent in nearly
all children as they recover. A substantial fall in hemoglobin, a sign of an expanding circulation is also
indicative of impending or actual volume overload with heart failure. Heart failure here is not caused by
anemia per se but by the expanding blood volume resulting in heart failure. Children with respiratory
distress and anemia should never be transfused.

Module 6
Figure 6.6 Algorithm for Differential Diagnosis of Heart Failure and Pneumonia
RESPIRATORY DISTRESS
Examine daily weights
Weight Increase Weight Stable Weight Decrease
FLUID OVERLOAD PNEUMONIA

HEART FAILURE (ASPIRATION)
When heart failure is diagnosed:

• Stop all intakes of oral or IV fluids. No fluid or food should be given until the heart failure has
improved even if this takes 24 - 48 hours. Small amounts of sugar-water can be given orally to
prevent hypoglycemia.
• Review drug regimen and reduce dose or stop those which are given as the sodium salt (see
Annex 28).
• Give furosemide (1mg/kg/dose). This is generally not very effective and diuretic treatment
should not be relied upon in the malnourished patient to manage heart failure.
• Optional: Digoxin can be given as a single dose (5 micrograms/kg). A loading dose is not given.
Use the pediatric preparation whenever possible.
Annex 6.16.
Treatment of Absent Bowel Sounds, Gastric Dilation and Intestinal Splash with
Abdominal Distension
Functional ileus with bacterial overgrowth can present with findings similar to intestinal obstruction.
Gram-negative bacterial translocation is usually observed across the intestine in septicemia. Gastric
emptying is delayed and there may be no intestinal peristalsis. Fluid can subsequently accumulate
in the intestinal lumen. These are very grave signs. This state is often accompanied by severe liver
dysfunction and resembles the “gray baby syndrome” associated with chloramphenicol toxicity. When
the condition develops after admission, all drugs are potentially hepatotoxic and must be discontinued.
Apart from drug toxicity, it is possible that some patients develop this syndrome from super-infection by
organisms resistant to antibiotics or from herbal medicines given by traditional healers. Since there is
no gastric emptying, nothing can be absorbed orally.
Warn the mother that the prognosis is not good
The following measures should be taken:

• Give antibiotics intravenously as outlined for developed septic shock.
• STOP all other drugs that may cause toxicity (including antiretrovirals).
• Give an IM injection of magnesium sulfate (4mL of 25% solution) and repeat twice daily until
stool is passed and gastric residuals are reduced.
• Insert an NGT and aspirate the contents of the stomach, then irrigate the stomach with isotonic
clear fluid (plain normal saline solution). Infuse 50mL of the solution into the stomach and then
gently aspirate all the fluid back again. Repeat this until the gastric fluid becomes clear.
• Instill 5mL/kg of sugar-water solution (10% sucrose solution) into the stomach and leave it
there for one hour. Aspirate the stomach contents. If the volume retrieved is less than the
amount that was introduced, return the aspirate to the stomach and give additional sugar-water
solution to make a total volume of 5mL/kg.
• Because gastric and esophageal candidiasis is common, instill oral nystatin suspension or
fluconazole through the nasogastric tube.
• Always keep the patient warm.
• Give intravenous glucose since these children are often unconscious, semiconscious or
delirious (see section on hypoglycemia).
• Do not insert an intravenous drip at this stage, but monitor the patient carefully for 6 hours
without giving any other treatment. Use the critical care form.
• Monitor closely to see if there is any improvement in the following:
1. Intestinal function when abdominal distension has decreased; visible peristalsis are noted
through the abdominal wall; bowel sounds have returned to normal; and gastric aspirates
have reduced in volume.
2. General condition of the child.
If there is intestinal improvement:

• Start giving small amounts of F75 by NGT (half the quantities given in Table 6.4). Aspirate the
stomach before each feed.
• If the volume of gastric residuals is more than 50% of amount instilled, decrease the amount
of F75.
• If the amount of aspirate is small, the volume to be fed can be gradually increased.
If there is no improvement after 6 hours:

• Consider putting up an IV drip. It is very important that the fluid given contains adequate amounts
of potassium. Intravenous Potassium Chloride should be added to all solutions that do not
contain potassium at a final concentration of 20mmol/L. Use 0.18% saline in 5% dextrose (D5
0.18% saline) if it is available; otherwise use Ringer’s lactate in 5% dextrose or 0.45% saline in
5% dextrose. The drip should be run VERY SLOWLY – the amount of fluid to be given should
be NO MORE THAN 2 to 4mL/kg/hr. A pediatric soluset or infusion pump should be used.
• When the gastric aspirates decrease so that one half of the fluid given into the stomach is
absorbed, discontinue IV treatment and maintain on oral treatment alone.
References
1. Ashworth A (2001). Treatment of Severe Malnutrition. Journal of Pediatric Gastroenterology

and Nutrition 32:516–518.
2. Ashworth A, et al. (2003). Guidelines for the inpatient treatment of severely malnourished
children. Geneva: WHO.
3. Kalusugan ng Mag-ina, Inc. (updated 2015). Breastfeeding. [Powerpoint slides] In The
Essential Intrapartum and Newborn Care Quality Assurance Course.
5. World Health Organization (2011) Facility Based Care of Severe Acute Malnutrition.
6. World Health Organization. (2013) Pocketbook of Hospital Care for Children. Geneva:WHO

Module 7
Communication and Counseling
Target Learners
This Module is intended for all healthcare providers of infants/children with SAM in both the
community and hospital levels.
Counseling is an essential skill for the health worker in the comprehensive care of the child with
severe acute malnutrition (SAM). It is important for the health worker to be able to identify the
situation on hand and choose the appropriate approach to the mother or caregiver. Needless to
say, communication skills should be well-developed first before the health worker can move on
to counseling.
______________________________________________________________
1. Distinguish the stage of behavior change the mother and/or caregiver is/are in regarding
the care of the child with severe acute malnutrition (SAM)
1.1. Unaware: Never heard of the behavior or does not know about its benefits
1.2. Thinking about it: Has heard about it but is not doing it
1.3. Trying: Is trying out the behavior
1.4. Maintaining: Is continuing to do the behavior
2. Perform the different skills necessary for counseling to be successful
2.1. Establishing rapport
2.2. Active listening
2.3. Asking the right questions
2.4. Giving advice
2.5. Ensuring understanding
2.6. Helping the mother formulate the plan and/or solution
2.7. Breaking the bad news
3. Demonstrate the steps in counseling the mother and/or caregiver in different situations
involving the child with SAM.
3.1. Identification of a child with SAM
3.2. Decision-making for appropriate management
3.2.1. Outpatient therapeutic care (OTC)
3.2.2. Inpatient therapeutic care (ITC)
3.3. Identification of a child with SAM needing immediate emergency care
3.4. Follow-up at the home of the child with SAM
4. Demonstrate the steps in counseling the mother and/or caregiver whose child did not
meet admission criteria.
Definition of Terms
Counseling
• As it is used here refers to giving advice and support to the mother/caregiver and other
people to help them deal with problems and make important decisions regarding nutritional
conditions of children less than five years old (under-5). It does not refer to counseling
as professional guidance of the individual by utilizing psychological methods especially
in collecting case history data, using various techniques of the personal interview, and
testing interests and aptitudes.
Key Concepts
1. The mother/caregiver is a vital part of the recognition, monitoring and treatment of a child
with SAM.
2. The healthcare worker should be able to be well-equipped in counseling in order to
ensure that the messages are delivered across and the procedures are properly done.
Session 7.1:
Stages of Behavior Change
A person goes through different stages before a change in behavior can occur. Knowing the the stage
where the counselee is at is important in order to apply the appropriate approach. Figure 7.1 shows the
different stages of counseling as:
• Unaware: Never heard of the behavior or does not know about its benefits
• Thinking about it: Has heard about it but is not doing it
• Trying: Is trying out the behavior
• Maintaining: Is continuing to do the behavior
The fifth step in the ladder should be advocacy in which the counselee does not only continue to
practice the behavior but also encourages others to do the same.
Figure 7.1. The Stages of Behavior Change
Maintaining
Is continuing to
do the behaviour
Trying
Is trying out the
behaviour
Thinking about it
Has heard about it
but is not doing it
Unaware
Never heard of the
behaviour or doesn't
know about its benefits
(From Caring for the Newborn at Home: A Training Course for Community Health Workers Community
Health Worker Manual. WHO. 2012)

Module 7
The counselor should be able to identify correctly in which the stage of behavior change the mother and/
or caregiver is/are in in order to determine the succeeding steps to follow. Table 7.1 below illustrates
how the stage of behavior change affects the next step/s of the counselor.
Table 7.1. Approach to Counseling in the Different Stages of Behavior Change

Stage of Behavior
Situation Situation
Change
Ana is the mother of Annie, identified Unaware Explain what is SAM to Ana.
to have SAM in a routine community Explain the benefits of identifying SAM.
visit by the health worker
Juana is the mother of Juanito, just Thinking about it Encourage Juana to go to the OTC to
identified to have SAM and is now learn more about how her child can be
being told that she has to bring her treated.
daughter to the OTC. She is aware
of SAM from talking to her neighbor, Identify the reasons or problems why she
Ana, whose child Annie was is hesitant to go to the OTC and discuss
identified to have SAM the week these with her.
before.
Teresa is the mother of Teresita, a Trying it Encourage the Teresa to continue the
child identified to have SAM and visits to OTC until her child becomes
brought to OTC for the first time well. Praise her for her persistence and
and is being counseled to come for effort. Identify and solve any problems
succeeding visits that might prevent her from continuing
bringing Teresita to OTC.
Liza is the mother of Lizzie, who was Maintaining it Praise the Liza for continuing to care for
identified to have SAM and brought Lizzie.
to OTC but has to be brought to ITC
after 2 weeks because she was not Explain to her why there is a need to
responding adequately. carry on the management further. Identify
and solve any problems that might
prevent her from continuing care.
Counseling is only a part of the communication skills which should be well-developed in health workers.
Anyone tasked with counseling the mother and/or caregiver, or even the rest of the members of the
family and community, should be able to be competent in: (1) Establishing rapport; (2) Asking the right
questions and active listening; (3) Giving advice; (4) Ensuring understanding; (5) Helping the mother
formulate a plan and/or solution; and (5) Breaking the bad news.
1. Skills For Establishing Rapport: Greeting And Building Good Relations

• Be friendly and respectful
• Speak in a gentle voice
• Talk to the mother, caregiver and the whole family, if necessary
• Explain the reason for talking to her, e.g. why you are doing a home visit
2. Skills For Asking And Listening
Ask open-ended questions to find out about the child’s and the family’s situation.
• A closed-ended question is answerable by a yes or a no. These answers have little
information.
• An open-ended question can elicit more information, These questions are asked when
more information is needed and so are preferred in counseling. Examples are: “ How do
you…”, “Please describe…”, “What are the…”, “Why do you…”, “Please tell me about…”
Show that you are listening.
• Use “body language” that show your interest in her/their answers:
a. Sit opposite the person you are listening to.
b. Lean slightly towards the person to demonstrate interest in what she/they is/are
saying.
c. Maintain eye contact as appropriate to the situation.
d. Look relaxed and open, show you are at ease with them; arms should not be crossed
e. Do not rush or act as if you are in a hurry
f. Use gestures, such as nodding and smiling, or saying ”mmm” or “ah”
g. Touch the mother/caregiver, as appropriate to the situation
• Show that you are listening by reflecting back what the mother says so that she will continue
to talk. For example, when the mother says, “I am worried because my child is not getting
any better.” You can reflect what she is feeling with “So you are worried because your child
is not getting any better?”
• Empathize with how the person is feeling. Empathizing builds trust. It shows that you
understand what the other person is feeling by putting yourself in their place and thinking of
how they feel in that situation. If a mother says “I am exhausted with breastfeeding all day,”
a response showing empathy would be: “You are feeling exhausted from breastfeeding all
day, that must be very difficult for you.”
• Avoid words that sound judgmental. Use with caution such judging words such as: right,
wrong, well, badly, good, enough, properly. For example:
• Do not say: "Do you breastfeed your baby enough?"
Instead say: "How is your baby breastfeeding?" This is an open-ended question with no
judging words.
3. Skills for Giving Relevant Information
Accept or acknowledge what the woman thinks or feels.

When a mother says something that you do not agree with because of your knowledge
about facts or good practices or a mother feels disproportionately upset about something,
it is important not to disagree head-on with the mother or family member. However, it is
also important not to agree with a mistaken idea. Instead, accept what the mother thinks
or feels. Accepting means responding in a neutral way, and not agreeing or disagreeing.
For example, if the mother says, “I am very troubled because my baby is not breastfeeding
at all.” You may reflect back, “ So you are troubled that your baby is not breastfeeding at
all?” But you should not say: "Don't worry -- your baby is doing very well" or " Yes, this could
be very dangerous. Why did you not inform me earlier?”
Give a little, relevant information at a time based on the present situation and in what stage the
mother and/or caregiver is/are are in adopting a new behavior.
Tell a story
Tell a story to give information without seeming like you are giving instructions. Many of
the counseling cards that you will use will ask you to tell a story. By telling a story of how
a family was successful in nursing a child with SAM back to health, you can describe the
behaviors that you want the families to adopt and the corresponding benefits they will
achieve.
Make suggestions instead of commands

An example of a command is, “Do not share Lizzie’s RUTF to your other children.” Instead,
a suggestion could be phrased, “What about trying to cook something delicious for your
other children so that we can give the right amount of RUTF to Lizzie and she can get
better faster?”

Module 7
Give information in short sentences and use simple language

Use short sentences because they are usually easier to follow and understand. Do not
use technical words if not commonly used, but local words such as “mahina ang dugo” for
anemia.
4. Skills for Checking Understanding
Use open-ended questions to check understanding.

Have the mother or family members repeat what needs to be done in her/their own words.
This gives you feedback – what they understand you have said and what they remember. This
is very important to ensure that they have understood what needs to be done. If necessary,
repeat your advice in a different way.
Praise when appropriate.

Praise the mother and family if they are doing something well or if they have understood
correctly. Praising the mother/family for this will strengthen her/their confidence to maintain
the beneficial behavior and to adopt other beneficial behaviors. Be sure that praise is
genuine. You can always find something to praise. Praise can be given throughout the
counseling process when appropriate.
For example:
Mother: “I sent my husband to find you because the baby doesn’t seem well.”
HW: “It was very good that you called me so quickly because you were concerned about
the baby.”
5. Skills for Helping the Mother Formulate the Solution to the Problem
Discuss what the mother, caregiver and the family plan to do.
This is perhaps the most important part of the counseling process. Encourage the mother/
family to tell you what they plan to do about the behaviors you have talked about. (Do not
assume they will do what you have said.) Encourage them to tell you if they have any concerns
or problems. Praise the family for doing so.
Together, try to solve any problems the mother, the caregiver or the family have in adopting
a behavior. Only if they tell you their concerns or problems and discuss what they feel can be
done, can you arrive at a solution that will be relevant for them.
6. Breaking the Bad News
Sometimes it is necessary to give a mother or her family bad news. The baby may also be ill
aside from SAM and may need transfer to an ITC or they may need to be referred to another
hospital or the baby may have died. Or maybe there is a problem with the mother.
If information we have to give can have negative consequences for a mother or her family, be
aware that the way it is communicated can help them accept what has happened.
Depending upon what the bad news is and if a mother is alone, arrange for a relative or friend
to come and be with her.
How you give the news is also important

• Use nonverbal skills:
a. Be kind and gentle in your actions.
b. If the mother is sitting down, sit down with her
c. Touch her appropriately.
d. Do not leave the mother alone.
e. Allow the mother to react in her own way
f. Let the mother or father and other members of the family be with the baby.
• Use verbal skills:

a. Give a simple and clear explanation of what is wrong. Avoid technical terms.
b. Make sure the mother understands what you are telling her by using ‘open’ questions
to encourage her to repeat what you have told her.
c. Give her time to ask questions.
d. Speak softly.
e. Respect her cultural beliefs and customs.
f. Ask if there is anyone near the hospital/clinic who can be with her.
g. Express regret.
Teaching-Learning Activities:
1. Interactive Lecture
2. Role Play
• Role Play for Establishing Rapport: Greeting the family and building good relations
Role Play
ROLE PLAY SCENARIO:

Greet the family and build good relations
CASE 1: Health Worker Ria is actively looking for SAM cases by going house-to-house visits.
Ana is the mother of Annie.
ROLE PLAY Script:

HW Ria: Tao po. May tao po ba? Magandang umaga po.
Nanay Ana: Magandang umaga naman. Bakit po kayo nagpunta dito?
HW Ria: Ako po si Ria. Health worker po ako na naglilibot sa inyong kumonidad upang
tingnan kung ang mga bata ay nasa wastong timbang at pangangatawan (Sa
mahinahon na boses). Mga mga anak po ba kayo? (Ngumiti at tumingin kay
Ana).
Nanay Ana: Meron po akong isang anak na apat na taong gulang. Annie ang kanyang
pangalan. Okay naman po siya kaya lang sabi ng titser payat daw siya.
HW Ria: Kaya po nandito ako ngayon. Gusto ko po sanang tulungan kayong malaman
kung wasto sa timbang at paglaki si Annie. May panahon ho ba kayo ngayon?
Nanay Ana: Sige po. Mas mabuti po na nandito na kayo sa bahay. Pinapapunta po kami sa
Center pero wala pa po kaming pamasahe sa ngayon.
HW Ria: Tamang-tama po pala ang pagpunta ko. Pwede na po bang makita si Annie?

Module 7
2.2. Role play or discuss the following cases:
Table 7.2 Sample Cases with Different Counseling Styles
Situation Key Messages Counseling Approach
Ana is the mother of • Annie was identified to have • Establish rapport

Annie, identified to SAM based on MUAC less than • Explain what SAM is to Ana.
have SAM in a routine 11.5 cm and bilateral pitting • Explain the benefits of identifying
community visit by the edema SAM.
health worker. She • Acute nutrient depletion • Explain the findings on Annie and the
has not heard of SAM places a child with SAM at need to bring her to the facility for
at all. increased risk of life-threatening further assessment
complications that lead to • Check for understanding
increased risk of death • Help the mother see that the solution
• Further assessment is needed is allowing her daughter to be
in a health facility to determine properly assessed and treated at the
the proper treatment health facility
Juana is the mother of In addition to the above key • Establish rapport
Juanita, just identified messages: • Encourage Juana to go to the OTC
to have SAM and is • Some procedures done in the to learn more about how her child
now being told that community will be repeated can be treated.
she has to bring her upon arrival at the health facility • Encourage her to ask questions
son to the OTC. She like taking of anthropometric • Identify the reasons or problems why
is aware of SAM measurements, appetite test she is hesitant to go to the OTC and
from talking to her • It is important to go to the OTC discuss these with her.
neighbor, Ana, whose for the initial assessment and
child Annie was plan for treatment.
identified to have SAM
the week before.
Teresa is the mother • Some medicines are routinely • Explain the procedures to be done in
of Teresita, a child given to children with SAM to the OTC
identified to have SAM treat probable and potential • Encourage Teresa to continue the
and brought to OTC underlying illnesses that do not visits to OTC until her child becomes
for the first time and always show the classical signs well.
is being counseled to and symptoms • Stress the importance of taking care
come for succeeding • Nutritional management of herself and keeping herself clean
visits. includes use of RUTF, and hygienic.
continuation of breastfeeding • Ensure that she knows proper
and drinking plenty of water. handwashing prior to food
• It is important to attend the preparation.
service regularly for monitoring • Praise her for her persistence and
and additional supply of RUTF effort.
• Mother/caregiver should follow • Identify and solve any problems that
good hygiene and sanitation might prevent her from continuing
especially handwashing as they bringing Teresita to OTC
prepare the food.
Situation Key Messages Counseling Approach
Liza is the mother • Inpatient care is indicated • Praise Liza for continuing to care for
of Lizzie, who was when a child fails the appetite Lizzie.
identified to have test with RUFT or there are • Explain to her why there is a need to
SAM and brought to medical complications needing carry on the management further.
OTC but has to be additional care • Identify and solve any problems that
brought to ITC after 2 • Admission to ITC is urgent might prevent her from continuing
weeks because she because patient may deteriorate care.
was not responding • It is best to admit in an ITC • If the mother/caregiver refuses
adequately. because the personnel are well- referral to ITC, give the advantages
trained in the management of of admission to ITC. If she still
SAM. refuses, accept the final decision and
just note on the OTC card.
Paula is the mother • Paulette will be admitted to a • Explain to Paula that Paulette is a
of Paulette who supplementary feeding program. child with MAM but she is at risk for
was screened in the • She may deteriorate from MAM developing SAM
community but who to SAM • Emphasize to Paula the need to
did not meet the closely monitor Paulette for signs of
admission criteria deterioration
As a counselor on SAM, prepare your own counseling cards. Get 10 pieces of white oslo papers.
Cut them half crosswise. Choose at least 10 key messages which you think are important. Draw
or paste a picture/pictures to show your message. Put your intended dialogue and important
notes on the other side. Laminate them to preserve your precious counseling cards.
For starters, IYCF Counseling Manual has a resource of counseling cards on the following
topics:
18 counselling cards on
• Antenatal
• Delivery in Facility
• Grandmother Offering Food to Breastfeeding Daughter/Daughter-in-law
• How to Attach Baby to the Breast
• Breastfeeding Positions
• Breastfeed on Demand, Both Day and Night
• During the First 6 Months, Your Baby Needs ONLY Your Breastmilk
• How to Hand Express Breastmilk and Cup Feed
• Optimal Child Spacing
• Complementary Feeding Starting at 6 Months
• Complementary Feeding from 6–8 Months
• Hygiene: Wash Your Hands with Soap and Water
• Breastfeed

Module 8
Community Practicum on Anthropometric
Measurements and Case Finding
Target Learners
This Module is intended for BNS’s, BHW’s or ECCD workers working at the community level.
This Module is designed to allow the learners to apply their newly acquired skills in communicating
with mothers/caregivers, measuring weight, height/length and MUAC, determining and
interpretation of Z-scores, checking for edema and, if needed, performing an appetite test
through hands-on experiences with children and their mothers/caregivers in a RHU or daycare
center.
______________________________________________________________
1. Apply the skills in proper handwashing

2. Apply the skills in measuring the MUAC.
3. Apply the skills in getting the height or length, and weight
4. Apply the skills in determining the Z-score and its interpretation
5. Apply the skills in checking for presence or absence of edema
6. If needed, apply the skills in performing the appetite test
7. Apply the skills in communicating and educating mothers/caregivers
Guidelines and Reminder
The purpose of the practicum is to have a hands-on experience in applying the skills taught
in measuring the MUAC, getting the length/height and weight and utilizing the Z-score charts,
as well as communication and education of the caregivers. If needed, an appetite test will be
performed. The following are a few reminders and guidelines for the community visit:
Participant orientation before the community visit

• Bring the necessary materials: pen, paper, checklists, felt tip marker or other marking
materials, MUAC tape and z-score charts
• Find a partner within your respective group
• With your partner, find another pair within your big group whom you will take turns with in
demonstrating the skills and observing/evaluating.
• Review the provided checklists thoroughly.
• Ask any questions for any points for clarification.
Before going to the health center

• Make sure that you and your fellow participants are well accounted for through a buddy
system or a count off. Make sure that no one will get left behind.
• For trainors, ensure that necessary arrangements have been made with the focal point/
contact person at the health center and the objectives and details of the visit have been
discussed clearly.
While inside the health center

• Perform hand hygiene
• Familiarize oneself with the tools and the area together with your partner and counterpart
pair. Make sure that the tools are calibrated, and properly assembled. Strategize on how
to go about the tasks.
• Hand your checklists to the pair who will observe/evaluate you and your partner
• Introduce yourselves to the mother/caregiver and child
• Explain the purpose of this exercise, as if this is already done in the actual field setting.
Ask for consent, and ensure privacy and confidentiality.
• Enumerate that you and your partner will be doing the following:
a. Measuring the MUAC
b. Identifying the presence of edema
c. Measuring the height/length and weight
• Build rapport as you ask questions about the following:

a. Child’s name and mother’s/caregiver’s name
b. Age
c. Family – Does the have any siblings? Who takes care of the child? Are the parents
working?
d. Birth history - Were there any problems at birth or during the pregnancy? Any
illnesses?
e. Nutritional status - At present, what does the child eat? Who prepares the food? For
an older child, does the parent allow the child to have money to buy from the sari-
sari store?
f. Health status - Is the child frequently ill? Any noticeable delay in physical growth or
development?
g. Brief nutritional history - Was the child breastfed? When did the child start eating
solid foods?
• Together with your partner, perform the necessary skills thoroughly. Clearly enumerate
the step-by-step procedure to the mother/caregiver. Remember the correct way of doing
the following:
a. MUAC measurement
b. Identifying the presence of edema
c. Getting length/height
d. Getting the weight
• Remain orderly while waiting for your turn in using the height/length board, or Salter scale
• In using the Salter scale, you should weigh the child without clothing or diapers as much
as possible. In cases that the child (especially older children) refuses or shows sign of
being uncomfortable without clothing, you may just opt to remove heavy pieces of clothing
(ex. maong/denim shorts), and keep the underwear.
• If using the trousers attached in the Salter scale, always disinfect and/or use a covering
after every use for hygiene.
• Write down or record your measurements/results
• Utilize the Z-score charts and interpret
• Consolidate your findings with your partner
• Provide the overall results and feedback to the mother/caregiver
• Praise the mother/caregiver for any positive health and nutritional behaviors (Example:
“Mabuti po at pinapa-breastfeed ninyo ang anak ninyo”). Encourage them to continue their
behavior.
• Educate the mother/caregiver on areas in which he/she can improve on (Example:
Relactation, vaccination, hand hygiene, etc.)

Module 8
• Summarize/wrap up with the mother/caregiver on what has transpired during the encounter.
• Thank the mother/caregiver and the child for their time and cooperation.
• If done, you may switch with your counterpart pair.
• After your counterpart pair is done with demonstrating the skills, you may compare your
findings to check for variations or discrepancies
•
Before leaving the health center:
• Do another headcount to account for every participant. Make sure that no one gets left
behind.
• Thank the focal point/contact person for facilitating the arrangements and for allowing the
practicum in their facility.

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Training Module on the National

Guidelines on the Management of

Acknowledgment 9 Session 5.1: Admission 84

SYMBOLS, UNITS and ACRONYMS 10 Session 5.2: OTC Treatment 90

Module 1: Overview 12 Session 5.3: Weekly Monitoring 93

Session 4.6: SAM in Emergencies 80

Table 5.9 Discharge Criteria from OTC

Table 5.10 Outcome of OTC Treatment

Figure 1.1 UNICEF Conceptual Framework on the Causes Of Undernutrition

Figure 1.2 Prevalence of wasting among 0-60 months from 1989-2015.

Figure 1.3 Prevalence of wasting among 0-60 months from 2008-2013.

Figure 1.4 Prevalence of stunting among 0-60 months from 1989-2015.

Figure 1.5 The First 1000 Days

Figure 1.6 Nutrition Targets

Figure 1.8 PIMAM Components

Figure 2.1 How to Measure the Length (1)

Figure 2.2 How to Measure the Length (2)

Figure 2.3 How to Measure the Length (3)

Figure 2.4 How to Measure the Length (4)

Figure 2.5 How to Measure the Height (1)

Figure 2.6 How to Measure the Height (2)

Figure 2.7 MUAC Tape

Figure 2.8 Positioning the MUAC tape

Figure 2.9 How to Handrub

Figure 2.10 How to Handwash

Figure 3.1 Stages in Community Mobilization

Figure 3.2 MUAC Tape

Figure 3.3 RUTF supplies

Figure 4.1 PIMAM Coordination and Reporting Structure

Figure 4.2 Management Cycle for Medicines and Nutrition Supplies

Figure 5.2 RUTF Composition

Figure 6.1 Ten Steps in the Care of Severely Malnourished Children

Figure 6.2 How to Estimate the Amount of RUTF to Give

Figure 6.3 Referral Form (SAM)

Figure 6.4 Hydration in a Severely Malnourished Child

Figure 6.5 Algorithm for Monitoring Weight

Figure 7.1 The Stages of Behavior Change

Paulyn Jean B. Rosell-Ubial, MD, MPH, CESO II

< Less than F

> Greater than Therapeutic Milk containing

Community-based Management of HFDB Health Facility Development Bureau

E ITC Inpatient Therapeutic Care

Early Childhood Care and IUGR Intra-uterine Growth Restriction

LBW Low Birth Weight Prevention of Mother to Child

PHO Provincial Health Office(r)

Module Description and Objectives

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

1. Explain what malnutrition is and its related concepts

1.1. Acute Malnutrition

Table 1.1 Distinguishing MAM from SAM

Moderate Acute Malnutrition Severe Acute Malnutrition

1.2. Chronic Malnutrition or Stunting

1.3. Micronutrient Deficiency

1.4. Fetal Growth Restriction and Low Birth Weight

1.5. Suboptimal breastfeeding

Malnutrition could either be OVERnutrition or UNDERnutrition.

Figure 1.1. UNICEF Conceptual Framework on the Causes Of Undernutrition

Poor water and

Social, economic and political

For those who survive undernutrition, then impact can be

Malnutrition - childhood wasting in the Philippines

The Philippines and wasting in childhood

% of Under 5 with Wasting

8 7.5 7.7 7.9

SAM Participant's Manual

SAM Participant's Manual