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Malnutrition

Page history last edited by asthak@... 7 months, 2 weeks ago

This page outlines the protocol for the malnutrition treatment program currently in place at Bayalpata Hospital. 

 

    1. Overview
    2. Summary of the CMAM Model
    3. Bayalpata Hospital-a CMAM Stabilization Center (SC)
      1. Admission Criteria for SC
      2. SC Admission Process
      3. Summary of Nutritional Treatment at Bayalpata-SC
      4. Discharge Criteria from SC
      5. SC Discharge Process
    4. Current Challenges and Limitations
    5. Resources

 

Overview

Community-based Management of Acute Malnutrition (CMAM) is a district wide pilot therapeutic feeding program designed in response to the crisis of severe acute malnutrition faced by some our youngest patients in Achham. Bayalpata Hospital joined the district wide pilot program in collaboration with District Health Office (DHO) Achham and UNICEF in December 2009. Currently, Bayalpata Hospital serves as one of only two Stabilization Centers (SC) for the entire district. The program adopts a community based therapeutic care (CTC) approach that aims to decentralize the treatment of acute malnutrition by involving RUTF (Ready to Use Therapeutic Food) that can be provided to caretakers for treatment at home. This program is intended to be a first step toward adopting a nation-wide strategy to tackle acute malnutrition via a community based approach while strengthening the available health system structures.

 

  

 

Summary of the CMAM Model

 

The core of the CMAM model can be summarized by the following three modes of care:  

  1. Community Outreach

    • Community assessments to develop an appropriate community outreach strategy, to develop tailor made counselling messages and materials and to better understand possible barriers to access to CMAM services.

    • Community sensitisation on importance of nutrition and causes and consequences of malnutrition as well as sensitisation for the available treatment provided through CMAM

    • Active case finding and referral through FCHVs conducting house-to-house visits or during consultations (individual case finding), through community case finding during mothers group meetings, outreach clinics or other community events or through passive case finding when the initiative comes from the care taker.

    • Follow up home visits for children discharged as cured, defaulting or presenting unsatisfactory weight gain and for moderate malnourished children to ensure nutrition counselling provided is put in practice resulting in nutrition rehabilitation of the child.

    • Nutrition counselling for care takers of moderately malnourished children, children discharged as cured, defaulters or children with insufficient weight gain during home visits, mothers group meetings or community events.

    • Service for this component of the program is provided by Nyaya Health CHWs and government employed FCHVs. 

  2. Outpatient Care is provided to children 6-59 months with severe acute malnutrition (SAM) and appetite but no medical complications through Outpatient therapeutic programmes (OTP) integrated into the routine services provided by the Ministry of Health and Population (i.e. at PHC, HP or SHP). The following services are provided through OTP services:

      • Medical assessment and anthropometric monitoring

      • Nutrition rehabilitation through home based care with ready-to-use therapeutic food (RUTF)

      • Systematic medical treatment

      • Service for this component of the program is provided at the Outpatient Department (OPD) at Bayalpata Hospital.  

  3. Inpatient Care is provided at Stabilization Centres (SC) integrated into MOHP health facilities (hospital or PHC) to children 6-59 months with SAM and medical complications and/or no appetite and to infants below 6 months of age with SAM. In addition children 6-59 months with MAM and having medical complications are also provided with inpatient care.

      • Medical treatment and nutrition rehabilitation is provided according to the guidelines of WHO and/or national protocols

      • Children 6-59 months move to outpatient care when the medical complication is resolved and appetite returns

      • Infants receive specialized treatment until full recovery

      • Service for this component of the program is provided at the Inpatient Department at Bayalpata Hospital.  

 

Bayalpata Hospital-a CMAM Stabilization Center (SC)

 

As one of only two inpatient hospitals in the entire district, the role of Bayalpata Hospital as a CMAM SC  is to provide the inpatient component of the care using standard WHO/IMCI protocol. The following provides a summary of the protocol currently in place on site. 

 

Admission Criteria for SC

 

  • Children aged 6 to 59 months with severe nutritional edema;
  • Children aged 6 to 59 months with MUAC <125mm and or nutritional edema or weight-for-height < -2 z-score and medical complications and/or no appetite; 
  • Children aged less than 6 months with a body weight less than 3kg and unable to suckle or lack of breast milk and/or identified with severe acute malnutrition (SAM). 

 

SC Admission Process

 

  1. All cases that are presented at a SC with a referral slip from an OTP health facility should be immediately referred to the nutrition ‘ward’ for appropriate assessment and treatment.

  2. Treat the most urgent cases presented at the SC first. Sugar water should be made available during transport and upon arrival to prevent hypoglycemia.

  3. Assess the child’s medical condition and initiate life-saving treatment as soon as possible, and follow routine WHO treatment protocols for SAM with medical complications.

  4. Record health and nutritional status information on the ‘Inpatient Care Treatment Card’.

  5. Provide an admission registration number. If the child was referred from an OTP, use this as the basis for its SC registration number. 

  6. Provide counselling to the mother/ caretaker on treatment, breastfeeding, nutrition, care practices and good hygiene practices.  

 

Summary of Nutritional Treatment at Bayalpata-SC

 

Children with SAM and medical complications:

Stabilisation F75 therapeutic milk

Transition from F75 to RUTF

Rehabilitation in OTP with RUTF

 

Children with MAM and medical complications:

If appetite: RUTF in SC

If no appetite: start F75, transition to RUTF in SC as soon as possible

 

Children < 6 months old:

Stabilisation F75

Transition from F75 to F100-diluted

Rehabilitation in SC with F100-diluted

 

Discharge Criteria from SC

 

  • Medical complications are resolving AND

  • Bilateral pitting oedema is decreasing AND

  • Child passes appetite test (the child eats more than &frac34; of the daily ration of RUTF) AND

  • Child is clinically well and alert

 

SC Discharge Process

 

For discharge from the SC, the following process for referral to OTP is used:

 

  1. If a child is ready for discharge from SC (and referral to OTP) assess the child’s clinical status, bilateral pitting oedema, MUAC, W/H and conduct an appetite test. The child is expected to eat at least &frac34; of its daily RUTF ration.

  2. Complete the referral slip.

  3. Inform the mother/caretaker where and on which day OTP services are offered closest to her home

  4. Provide an RUTF take-home ration that will last until the next OTP follow-up session. Where OTP services are offered daily the care taker should receive a one week ration allowing time to return home before attending the OTP for the first time.

  5. Discuss key messages about the use of RUTF and basic hygiene.

  6. Provide any remaining medications (single dose Vitamin A for children admitted with oedema plus other supplemental medications) and give clear instructions on how to use them. Ask the care taker to repeat the messages to ensure they are understood.

  7. Discharge from the SC can occur on any day. A child ready for discharge should not be retained in the SC if not really required.

  8. Inform the caretaker to go to the nearest health facility, if possible with OTP services, for medical assessment and follow-up treatment if the child’s condition deteriorates before the next OTP session.

  9. Where possible the OTP health facility staff should be informed about the discharge and referral so they can organise follow-up visit in case of non-presentation at the OTP HF.

  10. In case of MAM children discharged from the SC, follow step 1 and advise the care taker to contact the respective FCHV on their return to start nutrition counselling and monitoring of the child’s nutritional and medical status. 

 

Current Challenges and Limitations

 

Resources

 

 

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