1.
I
n
t
e
g
r
a
t
e
dM
a
n
a
g
e
m
e
n
tof
A
c
u
t
eM
a
l
n
u
t
r
i
t
i
o
n(
I
M
A
M
)
tfilan Dhakal

2.
2

3.
3

4.
4

5.
I
M
A
M
inN
e
p
a
l
5
● 2008 – Community Based Management of Acute Malnutrition (CMAM) has
been implemented by MoHP with the help of UNICEF since 2008 in 5
districts (Achham, Bardiya, Jajarkot, Kanchanpur and Mugu).
● 2012 – IMAM- Scaled Up in 6 districts (Dhanusa, Jumla, Kapilvastu,
Okhaldhunga, Saptari and Sarlahi).
● 2015 – Emergency Response and Recovery – Earthquake affected 14
districts
● 2073/2074 – Scaled up in 10 MSNP districts (Kalikot, Humla, Dolpa,
Dadeldhura, Bajhang, Bajura, Baitadi, Panchthar, Doti, Parsa)

6.
O
b
j
e
c
t
i
v
e
sofI
M
A
M
6
The primary objectives of IMAM are:
a) To reduce mortality and morbidity risks in children under five due to acute malnutrition.
b) To rehabilitate children with acute malnutrition to a state of health in which they are able to sustain their
nutritional status upon discharge as cured.
c) To prevent the condition of children with acute malnutrition from deteriorating thus requiring more intensive
treatment.
d) Contribute to the prevention of acute malnutrition in young children in the critical 1000 day window.
e) Prevent micro-nutrient deficiency disorders among under five year old children associated with acute
malnutrition.

7.
7

8.
P
r
i
n
c
i
p
l
e
so
fI
M
A
M
8
a) Maximum coverage and assess: IMAM is designed to achieve the greatest possible coverage by making
services accessible and acceptable to the highest possible proportion of a population in need.
b) Timeliness: IMAM prioritises early case-finding and mobilisation so that most of the cases of acute
malnutrition can be treated before complications develop.
c) Appropriate medical care and rehabilitation: Provision of simple, effective outpatient care for those who
can be treated at home and clinical care for those who need inpatient treatment. Less intensive care is provided
for those suffering from MAM.
d) Care for as long as possible: By improving access to treatment and integrating the service into the existing
structures and health system, IMAM ensures that children can stay in the programme until they have been cured.

9.
S
t
r
u
c
t
u
r
e
/
C
o
m
p
o
n
e
n
to
fI
M
A
M
9
IMAM hasfour components:
★ Community mobilization
★ Inpatient Therapeutic Care (ITC)/SC
★ Outpatient Therapeutic Care (OTC)
★ Managementof Moderate AcuteMalnutrition (MAM)=TSFP

10.
S
t
r
u
c
t
u
r
e
/
C
o
m
p
o
n
e
n
to
fI
M
A
M
10
★ Community mobilization
➔ involvesidentification of acutelymalnourished children atthe community
levelon an on-going basisto enable widespread earlydetectionand
referral before the clientcondition deteriorates further.
➔ aimsto increasecoverageand maximisethe effectivenessof treatment.
➔ provides an opportunity to counselmothers/caretakers of children
under fiveyearson IY
CFpractices,aswellasprevent future casesof
malnutrition through behaviour changecommunication activities.

11.
S
t
r
u
c
t
u
r
e
/
C
o
m
p
o
n
e
n
to
fI
M
A
M
11
★ Inpatient Therapeutic Care (ITC): involves management of complicated cases
of SAM according to WHO protocols on an inpatient basis at tertiary level
facilities(hospitals) or specialisedunits (Nutrition Rehabilitation Homes).
★ Outpatient Therapeutic Care (OTC): involves the management of non-
complicated SAM cases in outpatient care using ready-to-use therapeutic
foods (RUTF) provided on a weekly/fortnightly basis, simple routine
medicines, and monitoring and orientation for the mothers/caretakers.
Outpatient care is offered through decentralized health structures (e.g.
health posts).

12.
S
t
r
u
c
t
u
r
e
/
C
o
m
p
o
n
e
n
to
fI
M
A
M
12
★ Management of Moderate Acute Malnutrition (MAM)=TSFP: may take
two forms depending on the household food security level of the district
including in emergencycontext.Itinvolves either
a)the provision of micronutrient powders (MNPs) ) where available or if the
district is MNP program district and nutrition counselling in areas where
localfood isavailable to provide anutritious diet for children, or
b)targeted supplementary feeding with fortified blended food plus
nutrition counselling in areas where local foods are not available. In both
cases, individual monitoring and orientation to mothers/caretakers is
provided, plus referral for any medical issues in line with CBIMNCI
protocols.

13.
13

14.
14

15.
C
o
m
m
u
n
i
t
yM
o
b
i
l
i
z
a
t
i
o
n
/
O
u
t
r
e
a
c
h
15
Community mobilisation/outreach is a core component of IMAM and is critical for
maximising access and coverage by removing the barriers to community
accessing the service. It must be developed at the planning stage in each district as
there will likely be differences in the structures in place between districts. The process
of community engagement is also essential prior to commencing the service to ensure it
is set up in an appropriate and sustainable manner to avoid issues later on. If mother
has problem on access to the program the FCHV and mother group will discuss and if
the problem being not solved then the issue goes up to monthly meeting of health
facilities level and discussed. Community mobilisation should primarily aim to increase
access and service uptake (coverage) of IMAM services by tapping into community level
resourcesand structures to makesure that asmany children aspossible can be reached
atthe communitylevelwithtimely MUAC assessments.

16.
C
o
m
m
u
n
i
t
yMobilization:O
b
j
e
c
t
i
v
e
s
16
- Engageand empower the communitybyincreasing knowledge and understanding on acute
malnutrition and the servicesavailable;
- Ensure widespreadearlycase-findingand referral of newSAMand MAM cases;
- Provide appropriate nutrition educationand counselling focusing IYCFand carepractices;
- Follow-up on particularly atriskand problem cases;and
- Engagecommunitiesfor joint problem solvingon barriers to serviceuptake.

17.
C
o
m
m
u
n
i
t
yMobilization:S
t
a
g
e
s
17

18.
C
o
m
m
u
n
i
t
ya
g
e
n
t
si
n
v
o
l
v
e
dinc
a
s
ef
i
n
d
i
n
ginN
e
p
a
l
18

19.
A
c
t
i
v
ea
n
dP
a
s
s
i
v
ec
a
s
ef
i
n
d
i
n
g
19
Passive : casefinding through existingpoints of contactwithinhealthsystem
Active: agents at the community level, on an ongoing basis or during existing
health/nutrition campaigns (Vitamin A campaign, immunization) actively seek
out cases.

20.
20

21.
A
s
s
e
s
s
m
e
n
ta
n
dclassificationofa
c
u
t
em
a
l
n
u
t
r
i
t
i
o
n
21
1. Assessmentof children of 6-59 months
- Step1: Determine age
- Step2: Checkfor bilateral pitting oedema
- Step3: MeasureMUAC,Weight, height
- Step4: Assessmentof appetite and medical complications

22.
22

23.
A
p
p
e
t
i
t
et
e
s
t
23

24.
R
U
T
F
Ready-to-Use Therapeutic Food (RUTF) is an energy dense mineral/vitamin enriched food
nutritionally equivalent to F100, which is recommended by the WHO for the treatment of
malnutrition. 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, RUTFcan be safely
used for outpatient treatment of Severe Acute Malnutrition. As it is eaten uncooked it is an ideal
vehicleto deliver manymicronutrients that might otherwise be broken down by cooking.
Composition: Vegetable fat, peanut butter, skimmed milk powder, lactoserum, maltodextrin, sugar,
mineraland vitamincomplex.
1sachet= 92gramsof product =500 kcal.
24

25.
25

26.
A
s
s
e
s
s
m
e
n
tofm
e
d
i
c
a
lc
o
m
p
l
i
c
a
t
i
o
n
s
26
Asper CBIMNCI protocal
Examinethe symptoms mentioned in the table below

27.
27

28.
28

29.
A
s
s
e
s
s
m
e
n
tofi
n
f
a
n
t
su
n
d
e
r6m
o
n
t
h
s
Clinical signsin infants under 6months should be assessedin thesamewayasabove accordingto CBIMNCI
procedures.In addition infantsunder 6months maybecomemalnourished if theyhave:
29

30.
30

31.
31

32.
M
a
n
a
g
e
m
e
n
tofS
A
M
:O
u
t
p
a
t
i
e
n
tT
h
e
r
a
p
e
u
t
i
cC
a
r
e
Outpatient therapeutic care is aimed at providing treatment for children with SAM who have an appetite and
have no medical complications and can therefore be treated at home with simple routine medicines and
RUTF
.
Delivered through healthfacilities(healthpost,PHC, hospitals)
Steps involved in OTC
Step 1: Assessment of nutritional status and medical complication
First sugar water should be given to child to prevent hypoglycemia.
32

33.
33

34.
34

35.
35

36.
S
t
e
p2:A
d
m
i
s
s
i
o
no
rre
fe
rra
lb
a
s
e
do
ncriteria
36

37.
S
t
e
p3:M
e
d
i
c
a
lM
a
n
a
g
e
m
e
n
t
/
R
o
u
t
i
n
em
e
d
i
c
i
n
e
37

38.
S
t
e
p4:N
u
t
r
i
t
i
o
nM
a
n
a
g
e
m
e
n
t
❖ Nutritional rehabilitationisthrough theuseof Ready-to-Use TherapeuticFood (RUTF).
❖ RUTFprovides acompletedietfor the SAMchildwiththeexactbalanceof micronutrientsand
electrolytesthey require.
❖ Theamount of RUTFachildshould consumeisdetermined by the need for an intakeof 200kcal/ kg/
day.
❖ Theamount given to eachpatientistherefore calculatedaccordingto itscurrentweightand mustbe
adjusted asweightincreasesduring treatment.
38

39.
S
t
e
p5:O
r
i
e
n
t
a
t
i
o
na
n
dc
o
u
n
s
e
l
i
n
gf
o
rt
h
em
o
t
h
e
r
s
/
c
a
r
e
t
a
k
e
r
s
39

40.
S
t
e
p6:M
o
n
i
t
o
r
i
n
ga
n
df
o
l
l
o
wu
p
40
★ Follow up - weekly or fortnightly
★ Things to do:
➢ Weight is measured and recorded to track progress
➢ Degree of oedema (0 to +++) is assessed and recorded
➢ MUAC is taken and recorded to track progress
➢ Medical assessment is completed as per CB-IMNCI guidelines
➢ The mother/caretaker is asked about the progress of the child
➢ Appetite is discussed and RUTF appetite test performed at each follow-up
➢ The weekly ration is calculated according to current weight and provided

41.
S
t
e
p7:D
i
s
c
h
a
r
g
ef
r
o
mo
u
t
p
a
t
i
e
n
t
41

42.
42

43.
M
a
n
a
g
e
m
e
n
to
fS
A
M
:I
n
p
a
t
i
e
n
tT
h
e
r
a
p
e
u
t
i
cc
a
r
e
Inpatient stabilisation should be delivered from tertiary level facilities with capacity for 24 hour care and where
medicalcapacityisavailablefor the treatment of complications.In somecasesitmaybe possible for the NRHlinked to
the hospital to provide thisstabilisationcarewherethere isnot IMAM program.
WHO stepsfor managementof SAM
43

44.
S
t
e
p
si
n
v
o
l
v
e
dinI
T
C
44
Step1: Assessmentof nutritional statusand medical complications
Step2: Admission or referral basedon criteria
Step3: Medical management
➢ Treatidentified medicalcomplicationsincluding criticalconditionslike
shock,dehydration, hypothermia, heart failure
➢ For dehydration, ReSoMaland not ORSisusedfor SAM cases.
Step4: Nutrition Management
Step5: Individual Monitoring and follow up
Step6: Transitionand discharge

45.
S
t
e
p4:N
u
t
r
i
t
i
o
nM
a
n
a
g
e
m
e
n
t
45

46.
Initial treatment (stabilisation and transition): management of acute medical conditions
for approximately 3-7 days. It consists of medical and nutritional treatment according to WHO
recommended protocol, namely:Inpatient intensive care/medical treatment to control
infection, dehydration and electrolyte imbalance,thereby reducingthe mortalityrisk.
Nutritional treatment which consists of very frequent feeds with F-75 therapeutic milk (10-12
feeds per day) to prevent death from hypoglycaemia and hypothermia. This phase should not
be extended beyond one week because of the limited energy content of the diet. With the
adoption of outpatient care the transition phase includes examining the possibility of
transferring eligiblechildren to outpatient/community-based careusing RUTF
.
Rehabilitation: to achieve very high intakes and rapid weight gain of >10 g gain/kg/day using
the recommended milk-based F-100 which contains 100 kcal and 2.9g protein/100 ml. (WHO
1999). The “Rehabilitation Phase” can now take place on inpatient or outpatient basis
depending on the outcome of the transitionphase.
46

47.
F75: 0.9g protein/100ml
47

48.
48

49.
49

50.
S
t
e
p5:I
n
d
i
v
i
d
u
a
lm
o
n
i
t
o
r
i
n
ga
n
df
o
l
l
o
wu
p
50

51.
S
t
e
p6:T
r
a
n
s
i
t
i
o
na
n
dD
i
s
c
h
a
r
g
e
Transition
As soon as the medical condition of the patient is stabilised, oedema is reducing and the
complications are resolving, the transition phase is started in preparation for transfer to OTC (or in a
minority of casesto rehabilitationin inpatient care).
Transition is started by feeding the child a test dose of RUTF at alternate feeds retaining the same
feeding schedule.
If the child refuses the RUTF
,the mother/caretaker is encouraged to try to get the child to start
eatingateveryother milk feeding.
In the meantime,F100iscontinued until appetitereturns and RUTFcanbe givenateveryscheduled
feed.
Monitoring continuesasfor the stabilisation phaseand if anyof the following developsthe client
should return to stabilisation.
51

52.
52

53.
M
a
n
a
g
e
m
e
n
tofS
A
M
ini
n
f
a
n
t
s<
6
m
o
n
t
h
s
Where there is a possibility of breastfeeding the infant
The main objective is to restore exclusive breastfeeding whether by the mother, a family member or wet-nurse.
Therefore supplement the child’s breastfeeding with therapeutic milk while stimulating and supporting production of
breast milk. This same principle applies in caseswhere the mother is known to be HIV positive and is able and willing
to breastfeed.
53

54.
Infant with no possibility for breastfeeding
54
The aim of the treatment of infants under 6 months with SAM without the prospect of being
breastfed in Nepal is to receive F100-Diluted until they are old enough to take semisolid
complementaryfood in addition to adapted cowmilk.
-Provide F100-Diluted for infants with severe wasting as F100-Diluted has a lower osmolality
than F75 and thus is better adapted to immature organ functions. Also, the dilution allows for
providing more waterfor the sameenergy withabetter carbohydrate to lipid ratio
-Provide F75 for infants with bilateral pitting oedema and change to F100-Diluted when the
oedemaisresolved.

55.
D
i
s
c
h
a
r
g
e
The breastfed infant
55

56.
M
a
n
a
g
e
m
e
n
tofM
A
M
56

57.
S
t
r
a
t
e
g
i
e
so
fM
A
M
m
a
n
a
g
e
m
e
n
t
57

58.
A
d
m
i
s
s
i
o
ncriteriaf
o
rm
a
n
a
g
e
m
e
n
to
fM
A
M
58

59.
A
s
s
e
s
s
m
e
n
to
fM
A
M
For Child
FOR PLW
59

60.
N
utr
itio
na
lM
a
n
a
g
e
m
e
n
t
60

61.
P
r
o
t
o
c
o
lA
:U
s
i
n
glocallya
v
a
i
l
a
b
l
ef
o
o
d
sa
n
dm
i
c
r
o
n
u
t
r
i
e
n
t
ss
u
p
p
l
e
m
e
n
t
s
61
The dietary management of moderate acute malnutrition should focus on the optimal use of locally
available nutrient-dense foods to enhancethe nutritional statusof moderately acutelymalnourished children
and protect them from becoming severely acutely malnourished. A diet largely based on plant sources with
few animal proteins do not meet these requirements and need to be improved by different interventions.
Multiple micronutrient supplementation represents one of the possible strategies to fortify food. Similarly,
keymessagesof IY
CFshould be delivered to both MAM and SAMchildren’s mothers and caretakers.
Sarbottampitho, Poshilo Jaulo

62.
P
r
o
t
o
c
o
lB
:U
s
i
n
gS
u
p
p
l
e
m
e
n
t
a
r
yF
o
o
dR
a
t
i
o
n
- Fortified Blended Foods(FBF).Eg.Super Cereals Plus
- Lipid-based Nutrient Supplement (LNS).Eg. RUSF
62

63.
M
e
d
i
c
a
lM
a
n
a
g
e
m
e
n
t
Mebendazole/Albendazole is given to all children aged 12-59 months on enrolment.
If the child is ≥ 1 years and has not had Albendazole in the previous 6 months, give one dose of Albendazole 200
mgtill 2yearsthen 400mgafter 2yearsfor possiblehookworm or whipworm
63

64.
M
o
n
i
t
o
r
i
n
ga
n
df
o
l
l
o
wu
p
64

65.
D
i
s
c
h
a
rg
e
65

66.
66