INTRODUCTION

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

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

Nearly 20 million children under five suffer from severe acute malnutrition Severe acute malnutrition is defined by a very low weight for height (below -3 z scores1 of the median WHO growth standards),by visible severe wasting,or by the presence of nutritional oedema. In children aged 6–59 months, an arm circumference less than 110 mm is also indicative of severe acute malnutrition. Globally, it is estimated that there are nearly 20 million children who are severely acutely malnourished. Most of them live in south Asia and in sub-Saharan Africa.

Severe acute malnutrition contributes to 1 million child deaths every year Using existing studies of case fatality rates in several countries, WHO has extrapolated mortality rates of children suffering from severe acute malnutrition. The mortality rates listed in the table at right reflect a 5–20 times higher risk of death compared to well-nourished children. Severe acutemalnutrition can be a direct cause of child death, or it can act as an indirect cause by dramatically increasing the case fatality rate in children sufferingfrom such common childhood illnesses as diarrhea and pneumonia. Current estimates suggest that about 1 million children die every year from severe acute malnutrition.

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

Severe acute malnutrition in children can be identified in the community before the onset of complicationsCommunity health workers or volunteers can easily identify the children affected by severe acute malnutrition using simple coloured plasticstrips that are designed to measure mid-upper arm circumference (MUAC). In children aged 6–59 months, a MUAC less than 110 mm indicates severeacute malnutrition, which requires urgent treatment.Community health workers can also be trained to recognize nutritional oedema of the feet, another sign of this condition. Once children are identifi ed as suffering from severe acute malnutrition, they need to be seen by a health worker who has the skills to fully assess them following the Integrated Management of Childhood Illness (IMCI) approach. The health worker should then determine whether they can be treated in the community with regular visits to the health centre, or whether referral to in-patient care is required. Early detection, coupled with decentralized treatment, makes it possible to start management of severe acute malnutrition before the onset of life threating complications.

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

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

Community-based management of severe acute malnutrition can have amajor public health impactWith modern treatment regimens and improved access to treatment, case-fatality rates can be as low as 5 per cent, both in the community and in health-care facilities. Community-based management of severe acute malnutrition was introduced in emergency situations. It resulted in a dramatic increase of the programme coverage and, consequently, of the number of children who were treated successfully – yielding a low case-fatality rate.

The same approach can be used in non-emergency situations with a high prevalence of severe acute malnutrition, preventing hundreds of thousands of child deaths when applied at scale.

Ready-to-use therapeutic foodsChildren with severe acute malnutrition need safe, palatable foods with a high energy content and adequate amounts of vitamins and minerals. RUTF are soft or crushable foods that can be consumed easily by children from the age of six months without adding water. RUTF have a similar nutrient composition to F100, which is the therapeutic diet used in hospital settings. But unlike F100, RUTF are not water-based, meaning that bacteria cannot grow in them. Therefore these foods can be used safely at home without refrigeration and even in areas where hygiene conditions are not optimal. When there are no medical complications, a malnourished child with appetite, if aged six months or more, can be given a standard dose of RUTF adjusted to their weight. Guided by appetite, children may consume the food at home, with minimal supervision, directly from a container, at any time of the day or night. Because RUTF do not contain water, children should also be offered safe drinking water to drink at will. The technology to produce RUTF is simple and can be transferred to any country with minimal industrial infrastructure. RUTF cost about US$3 per kilogram when locally produced. A child being treated for severe acute malnutrition will need 10–15 kg of RUTF, given over a period of six to eight weeks.

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

Ending severe acute malnutrition

Prevention first…Investing in prevention is critical. Preventive interventions can include: improving access to high-quality foods and to health care; improving nutrition and health knowledge and practices; effectively promoting exclusive breastfeeding for the first six months of a child’s life where appropriate; promoting improved complementary feeding practices for all children aged 6–24 months — with a focus on ensuring access to age-appropriate complementary foods (where possible using locally available foods); and improving water and sanitation systems and hygiene practices to protect children against communicable diseases.

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

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

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

It specifically aims in Assessment of the criteria for the enrollment of the child under this program. Determining the compliance of patients to regular visits. Assessment of impact of noncompliance on the children. Assessment of the criteria of improvements in the children. Determining the differences in the results of children among who has been

breastfed and who hasn't. Determining the socio-economic strata of the family of SAM patient. Determining the level of satisfaction of the mother with DIMAM program.

Program Description

A. Davao Integrated management of acute malnutrition (DIMAM)

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

1. Identify malnourished children under 5 years old2. Treat Acute Malnutrition3. Prevent and reduce malnutrition

C. Components of DIMAM1. Community mobilization2. Outpatient Therapeutic Program (OTP)3. In patient Therapeutic Program (ITP)4. Supplementary Feeding Program (SFP)

C1. Community mobilization: Build relationships and foster active participation of the community Identify and carry out active screening and carry out follow up

C2. Out patient Therapeutic Program (OTP): Management of SAM patients without complications Provide home based treatment and rehabilitation using RUTF Monitor children’s progress through regular outpatient clinics

C3. In patient Therapeutic Program (ITP) Management of SAM patients with complications Requires hospitalizations and close monitoring of the patient

D. Nutrition Rehabilitation and RUTF

Ready to Use Therapeutic Food (RUTF): It is a high energy, nutrient-dense food used for nutrition rehabilitation in

outpatient care in combination with systemic medical treatment It is ideal for outpatient care because it does not need to be cooked or mixed

with water It can be easily distributed and carried Easy to store RUTF is not for healthy children and should not be shared with other family

members as snacks Lipid based RUTF is most commonly used in outpatient care with a caloric

value of 520 to 550 kilocalories per 100g of product The number of sachets to be fed are calculated according to the table below

provided by the ACF:

BODY WEIGHT RANGE (kg)

RUTFSachets per day Sachets per week

3.0 – 3.4 1 ¼ 93.5 – 4.9 1 ½ 115.0 – 6.9 2 147.0 – 9.9 3 21

10.0 – 14.9 4 2815.0 – 19.9 5 3520.0 – 29.9 6 42

Lipid based RUTF is composed of:o 25% peanut buttero 26% milk powdero 27% sugaro 20% oilo 2% combined mineral and vitamin mix

For In patient care F75, F100 and ReSoMal are used

F-75:o Is used in the acute phaseo Is the "starter" formula used during initial management of

malnutrition, beginning as soon as possible and continuing for 2-7 days until the child is stabilized

o Severely malnourished children cannot tolerate normal amounts of protein and sodium or high amounts of fat. They may die if given too much protein or sodium. They also need glucose, so they must be given a diet that is low in protein and sodium and high in carbohydrate.

o F-75 has is specially mixed to meet the child's needs without overwhelming the body's systems in the initial stage of treatment. Use of F-75 prevents deaths.

o F-75 contains 75 kcal and 0.9 g protein per 100 ml.o Daily dose during acute phase: 100kcal/kg/day

As soon as the child is stabilized on F-75, F-100 is used as a "catch-up" formula to rebuild wasted tissues.

F-100:o Contains more calories and protein: 100 kcal and 2.9g protein per 100

mlo Its nutritional value is equal to RUTFo Is used as Therapeutic milk for infants less than 6 months oldo Daily dose during transition phase: 130 to 150kcal/kg/day

E. Criteria for admission

Who should be admitted to Outpatient care: Patient should have a positive for at least one of the three indicators (Z score,

MUAC, Edema) Children should be of age 6 – 59 months who have severe acute malnutrition

(SAM), an appetite (ability to eat RUTF, passing the appetite test) and no medical complications

Children whose mother/caregiver refuses inpatient care despite advice; the child will require follow up home visits and close monitoring while in outpatient care

Who should not be admitted to Outpatient care: Children with SAM and medical complications, including no appetite

(should be referred to Inpatient care) Children under 6 months who have bilateral edema or visible wasting and

whose mother has insufficient breast milk (Should be referred to Inpatient care)

Moderately malnourished children (Should be given multiple micronutrient powder (MMP) or multivitamin supplements)

Children who are sick but do not have SAM (referred to other appropriate health services)

F. Steps for Admission Children are checked for bilateral pitting edema, MUAC is taken, weight

and length or height is measured Press both legs/feet at the same time using both thumbs for three

seconds, then release and check

Edema Bilateral Pitting edema+1 Both lower extremity+2 Both lower and upper extremity+3 Both lower and upper extremity and

the face

If a child meets the admission criteria for severe acute malnutrition (SAM), the health care provider takes a medical history and conducts a physical examination

All information is recorded on the child’s outpatient care treatment card. Each child has a unique registration number noted on the outpatient care treatment card

The appetite is tested; RUTF is given to the mother/caregiver to give to the child for an observed appetite test. The child’s appetite is graded by the health care provider

Based on the appetite test the health care provider determines whether the child should be admitted to inpatient care or outpatient

The child will receive a ration of RUTF for one week and is told to come back the next week for a weekly checkup and for more ration for the following week

The mother/caregiver is also informed on the proper ways of feeding a child with RUTF

During the first week of feeding the child is given amoxicillin and if needed anti-helminths if needed

G. Appetite Test to determine whether child should be given RUTF It is important for a child to have an appetite before he or she can be

admitted for the outpatient care If a child has no appetite he/she will not be able to eat RUTF at home and

therefore needs referral to the in patient service. An appetite test is given to children ages 6 months and above to

determine whether the child can eat RUTF. The test shows whether the child has a good appetite and can accept the RUTF’s taste and consistency and can swallow.

If a child has a poor appetite then it is considered that he/she has severe disturbance of metabolism

How to perform an Appetite test Wash hands before conducting the test The assistant conducting the test should be cheerful and relaxed Allow child to play with an RUTF packet and become familiar with the

environment Sit comfortably with the child on a lap and offer the RUTF to the child (should

take only 15 mins) Child should not be forced to take the RUTF Offer plenty of water to drink from a cup during the test

Body weight/kgPaste in sachets

Poor Moderate Good<4 <1/8 1/8 -- 1/4 >1/44-6.9 <1/4 1/4 -- 1/3 >1/37-9.9 <1/3 1/3 -- 1/2 >1/210-14.9 <1/2 1/2 -- 3/4 >3/415-29 <3/4 3/4 -- 1 >1Over 30 <1 >1

H. Discharge criteria Patients who reach the target weight for 3 weeks may be discharged

only if he/she:o Has no new medical complicationso Did not develop edemao Has a good appetiteo Clinically well and alerto Has been given adequate counselling and advice prior to

discharge

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

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

Weight for Age:

Length/Height for Age:

Total Population

= 1515

Normal = 1348

Underweight = 131

Severely Underweight

= 14

Overweight = 2

Total Population

= 1515

Normal = 1309

Stunted = 181

Severely Stunted =

21

Tall for age = 4

Weight for Length/Height:

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

Total Population

1515

Normal = 1459

Underweight = 36

Severely Underweight

= 3

Overweight = 17

Pie Chart 1: Visit Compliance

38%

63%

Visit ComplianceYes No

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

Pie Chart 2: Reasons for Non-Compliance

20%

40%

40%

Reasons for Non-ComplianceMisunderstanding (Mother unable to understand the visit schedule) Illness Parents busy

As per the mother, reasons for non compliance were: 1) Misunderstanding; 20% of the non-compliant mother was unable to

understand that she was supposed to visit Barangay health center weekly. Thus after getting the RUTF for a week she failed to return back.

2) Illness; 40% of non-compliant mother reported that their baby were sick to be brought to the health office.

3) Busy; 40% of the non-compliant parents complained of being busy looking for job.

Pie chart 3: Criteria for Admission

13%

88%

Criteria for AdmissionZ-score, MUAC with edema Z-score, MUAC without edema

Out of the total number of respondents, 87.5% were admitted because they fell under the criteria of Z-score (weight

for length/height) and MUAC; but had no bilateral edema 12.5% was admitted under all 3 criteria (Z-score, MUAC and bilateral

edema).

Pie chart 4: Improvement

100%

Improvement

All the patients showed improvement in their weight, height, skin and motor function. According to the mothers, patient had visible improvement in their motor functions like activeness, good strong cry, running, speaking and playing.

Based on the comparison of the first and last visits of the patient, the improvement in weight, height and mid-upper arm circumference are as follows:

Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 80

1

2

3

4

5

6

7

8

9

10

Improvement in Weight (kg)

Wei

ght

in k

g

Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 80

10

20

30

40

50

60

70

80

90

Improvement in Height (cm)

Hei

ght

in c

m

Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 80

2

4

6

8

10

12

14

16

Improvement in Mid-upper Arm circum-ference (mm)

Mid

-up

per

Arm

Cir

cum

fere

nce

(m

m)

Patient 1: Including the last visit, patient 1 had 13 visits in total. He is compliant with his visits and has shown gradual improvement in his weight, height and MUAC. Patient 2: Patient has been enrolled for 11 weeks. However, patient missed 3 visits. As per the mother, they had been too busy to bring the child to the health center. Patient had shown quiet a good improvement in weight and height, but the MUAC remains to be the same as that of his initial visit. Patient 3: Patient was supposed to visit 10 times but he missed 3 visits since his parents were busy looking for job. But still, patient showed significant improvement in his weight, height and MUAC. Patient 4: Including the last visit, patient was supposed to have 8 visits. However, he missed 2 visits because he was sick. So his total visits are 6. He showed improvement in his weight, height and MUAC.Patient 5: This is Patient’s third week of enrollment and she is compliant with her visits. She has been improving in her weight and height. But her latest MUAC decreased than that of her initial visit. Patient 6: Patient has been enrolled for 4 weeks but has missed 2 visits. There was misunderstanding of communication. But still patient showed significant improvement in her weight, height and MUAC. Patient 7: Patient is compliant with her visits and is on her 11th week of enrollment. She had shown good improvement in her weight, height and MUAC.

Patient 8: Including the last visit, patient had 5 visits. However, he is already on his 11th week of enrollment. Still, he showed a good improvement in his weight, height and MUAC.

Pie chart 5: Satisfaction

25%

13%

13%

50%

Mothers Satisfaction to the Program

Since my child seems healthy and has gained weight, I find this program nice

I am satisfied with the program

I would like to continue with the program

I am totally satisfied with the program, a 100% satisfaction

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

Pie chart 6: Exclusively Breastfed

50%

13%

13%

13%13%

Exclusive Breastfed6 months 1 year 9 months5 months Not breast fed since birth

Out of 8 patients, 4 of them were exclusively breastfed till the age of 6 months, 1 till the age of 1 year, 1 for 9 months, 1 for 5 months and 1 was not breastfed since birth (mother was unable to lactate). However, the level and rapidity of improvement between the exclusively breastfed and non-breastfed can not be determined because of the variation in the date of their enrollment and their compliance.

ConclusionThe patients who has been enrolled for DIMAM from Barangay 5A come from a low social economic strata. Large family having a single person to rely on for all the expenses is the major factor leading to financial instability. The main priority for spending are house rent and foods for the whole family. Between this, allocation for the child’s nutrition and medicine are not prioritized. Thus, leading to acute malnourishment in the children. However, the active involvement of DIMAM program on these SAM patients showed to be beneficial to the children aged 0-59 months. The benefits include:

1) Classification of children as normal, underweight, severely underweight, overweight, stunted, severely stunted and tall.

2) Measures taken to treat severely acute malnourished children. 3) Regular monitoring of the SAM patient i.e. their height, weight, mid arm

circumference and bilateral pitting edema.4) Proper guidance and counseling to the mother regarding the health condition

of child and the measures to be undertaken.

Based on our study, most of the patient were classified under the criteria of Z-score and MUAC, and just a few had bilateral pitting edema together with Z-score and MUAC. Children taking the allocated quantity of RUTF has shown improvement in their weight, height, mid-arm circumference and motor skills regardless of children being exclusively breastfed or not. Thus leading to the full satisfaction of the mother. However, the scheduled visits that the children has been missing has stood to be somewhat hampering the target weight, height and MUAC for the patient.

Recommendation As per instruction, mothers should be able to report on the Barangay health

office for receiving RUTF and for regular measurements. Since, on our studies few children who were unable to make scheduled visits failed to improve in the continuum process. But later when the visits were regular, patient progressed.

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

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

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

Appendix

Name:Age:Sex:Address:Informant:

Q) Do you go to the center weekly?

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

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

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

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

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

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