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  1. 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
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  5. 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. 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.
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  8. 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. 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. 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. 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. 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.
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  15. 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. 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. 17. C o m m u n i t yMobilization:S t a g e s 17
  18. 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. 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.
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  21. 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
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  23. 23. A p p e t i t et e s t 23
  24. 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
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  26. 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
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  29. 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
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  32. 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
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  36. 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. 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. 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. 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. 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. 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
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  43. 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. 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. 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. 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. 47. F75: 0.9g protein/100ml 47
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  50. 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. 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
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  53. 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. 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. 55. D i s c h a r g e The breastfed infant 55
  56. 56. M a n a g e m e n tofM A M 56
  57. 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. 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. 59. A s s e s s m e n to fM A M For Child FOR PLW 59
  60. 60. N utr itio na lM a n a g e m e n t 60
  61. 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. 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. 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. 64. M o n i t o r i n ga n df o l l o wu p 64
  65. 65. D i s c h a rg e 65
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