MODULE

\
Acute and Chronic
Malnutrition in Children
For the Ethiopian Health Center Team

Tefera Belachew, M.D., M.Sc., DLSHTM; Challi Jira, B.Sc., P.H., M.P.H.;
Kebede Faris, B.Sc., M.Sc.; Girma Mekete B.Sc., M.Sc.;
Tsegaye Asres, B.Sc., M.Sc., DLSHTM; Bishaw Deboch, B.SC., M.Sc.

Jimma University

In collaboration with the Ethiopia Public Health Training Initiative, The Carter Center,
the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education

2005
 Funded under USAID Cooperative Agreement No. 663-A-00-00-0358-00.

Produced in collaboration with the Ethiopia Public Health Training Initiative, The Carter
Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education.

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Limited permission is granted free of charge to print or photocopy all pages of this
publication for educational, not-for-profit use by health care workers, students or
faculty. All copies must retain all author credits and copyright notices included in the
original document. Under no circumstances is it permissible to sell or distribute on a
commercial basis, or to claim authorship of, copies of material reproduced from this
publication.

2005 by Tefera Belachew, M.D., M.Sc., DLSHTM; Challi Jira, B.Sc., P.H.,
M.P.H.; Kebede Faris, B.Sc., M.Sc.; Girma Mekete B.Sc., M.Sc.; Tsegaye
Asres, B.Sc., M.Sc., DLSHTM; Bishaw Deboch, B.SC., M.Sc.

All rights reserved. Except as expressly provided above, no part of this publication may
be reproduced or transmitted in any form or by any means, electronic or mechanical,
including photocopying, recording, or by any information storage and retrieval system,
without written permission of the author or authors.

This material is intended for educational use only by practicing health care workers or
students and faculty in a health care field.
AKNOWLEDGEMENTS

The development of this module has gone through series of individual and group works, meetings,
discussions, writings and revisions. We would like to express our deep appreciation to The Carter
Center, Atlanta Georgia, for their financial support of the activities in the development of this
module all the way through. The contribution of Professor Dennis Carlson, a senior consultant of
the Carter center, Atlanta Georgia both in initiating the development of this module and reviewing
the manuscript is immense.

The input of many academicians at home and abroad has contributed a lot to the development of
this module. The following academicians deserve special appreciation for taking their invaluable
time in reviewing the module, namely: Dr. Charles Larson. Professor Donald Johnson, Professor
Nicholas Cunningham, Professor Joyce Murray, Professor Joe Wray, Professor Maurine Kelly, Dr.
Asfaw Desta, Dr. Gimaye Haile, Dr. Ameha Mekasha, Dr. Teshome Desta, Dr. Asnake Tesfahun,
Dr. Ashenafi Negash, Mr. Teklebirhan Tema, Mr. Esayas Alemayehu and Mr. Zewdineh
Salemariam.

We are indebted to the team of Gondar college of Medical Sciences, Addis Ababa University
faculty of Medicine, Southern University-Dilla college of Teachers Education and Health Sciences
and Alemaya University-faculty of Health Sciences for reviewing the module as a team.

Dr. Damtew Woldemariam, the president of Jimma University has contributed a lot in facilitating
the development of the module by allowing the team to work on the modules. We also like to
extend our thanks to the Faculty of Medical Sciences, Faculty of Public Health, Community Health
Programme, Health Officers Programme, School Of Nursing, School Of Medical Laboratory
Technology, and School of Environmental Health of Jimma University for allowing the team to
work on the module.

We are also grateful to Mr. Aklilu Mulugeta for logistic support during the process of development
of the module.

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 TABLE OF CONTENTS
Acknowledgement................................................................................................... i

Table of contents .................................................................................................... ii

UNIT 1.0 Introduction

1.1 Purpose and use of the module .................................................... 1

1.2 Directions for using the module .................................................... 2

UNIT 2.0 Core Module

2.1 Pre and post tests......................................................................... 3
2.2 Significance and brief description of the problem ......................... 17
2.3 Learning objectives....................................................................... 18
2.4 Case study: learning activities ...................................................... 19
2.5 Definition....................................................................................... 22
2.6 Epidemiology of acute and chronic malnutrition ........................... 22
2.7 Etiology and pathogenesis ........................................................... 24
2.8 Clinical features (signs and symptoms) ........................................ 29
2.9 Diagnosis ...................................................................................... 30
2.10 Case management ....................................................................... 32
2.11 Control and Prevention ................................................................. 49
2.12 Learning activities (case study) continued.................................... 54

UNIT 3.0 Satellite Modules

3.1. Health Officer................................................................................ 55
3.2. Public Health Nurses .................................................................... 62
3.3. Medical Laboratory Technician..................................................... 67
3.4. Sanitarians.................................................................................... 81
3.5. Primary health worker/ Community health worker ....................... 87
3.6. Take home message for care givers ............................................ 92

UNIT 4.0 Role and Task Analysis ...................................................................... 94

UNIT 5.0 Glossary and Abbreviation .................................................................. 101

UNIT 6.0 Bibliography ......................................................................................... 104

UNIT 7.0 Annexes and Answer Key .................................................................... 106

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 UNIT ONE

INTRODUCTION

1.1 Purpose of the Module

The lack of appropriate and relevant teaching material is one of the bottlenecks that hinder
training of effective, competent task oriented professionals who are well versed with the
knowledge, attitude and skill that would enable them to solve the problems of the
community. Preparation of such a teaching material is an important milestone in an effort
towards achieving these long-term goals.

Therefore, this module is prepared to facilitate the process of equipping trainees with
adequate knowledge, attitude and skill through interactive teaching mainly focused on acute
and chronic malnutrition.

The preparation of this module has considered the current guideline on the management of
severe acute malnutrition, guideline on infant and young child feeding, the essential nutrition
actions approach and guideline on micronutrient deficiency prevention and control of the
Federal Democratic Republic of Ethiopia Ministry of health.

This module can be used in the basic training of health center teams in the training
institutions and training of health center teams who are already in the service sectors, health
extension workers and care givers. However, it was not meant to replace standard text
Books or reference materials.

1
1.2 Direction for Using the Module

In order to make maximum use of the module the health center team should follow the
following directions:-

1.2.1 Check prerequisite knowledge required to use the module.

1.2.2 Do the pretest pertaining to the core module section 2.1.1.

1.2.3 Read the core module thoroughly.

1.2.4 After going through the core module try to answer the pretest questions.

1.2.5 Evaluate yourself by referring to the key given in section 7.1 and 7.2.

1.2.6 Read the case study and try to answer questions.

1.2.7 Use the listed references and suggested reading materials to substantiate and
supplement your understanding of the problem.

1.2.8 Look at the satellite module and the task analysis related to your field to
understand your role in the team in managing a case of severe acute
malnutrition.

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 UNIT TWO

CORE MODULES

2.1 Pre-and Post Test

2.1.1 Pre and Post Test for the Health Center Team

(From the Core Module)

Directions: Choose the letter of the choice with the right answer.

1. Which age groups of children are more predisposed to severe acute malnutrition
(kwashiorkor)?
a) Under one year
b) All under five
c) Children 2-3 years old
d) Children 4-5 years
e) None

2. What are the different risk factors involved for the development malnutrition in children?
a) Low socioeconomic conditions
b) Ignorance of parents about the importance of child nutrition
c) Infections like measles, Pertusis, diarrhea
d) Child abuse (Neglect)
e) All of the above

3. How common is childhood malnutrition?

a) Severe forms of malnutrition are frequent in the order of 5-10% in developing
countries
b) The prevalence of mild and moderate acute and chronic Malnutrition range
from 20-40%
c) Stunting is the more common form of malnutrition than wasting in most
developing countries including Ethiopia
d) Wasting follows seasonal shortage of food
e) All are correct

3
4. List the different forms of acute and chronic malnutrition?
a) .............................................................................................
b) .............................................................................................
c) .............................................................................................
d) .............................................................................................
e) .............................................................................................

5. Why is weaning time usually the period for the malnutrition to set in?
a) Ceasing or reduction of breast-feeding
b) Improper weaning practices like introduction of supplementary foods abruptly
c) Use of bottle-feeding with diluted and dirty formula predisposing the child to
infection
d) All
e) None

6. How do you differentiate kwashiorkor from Marasmus clinically? List at least four specific
manifestations for each.
Washiorkor
a)
b)
c)
d)
Marasmus
a) .....
b) ..
c) ...
d) .

7. What other diagnostic methods could you list?

a) .............................................................................................
b) .............................................................................................
c) .............................................................................................

8 What are the different phases of management of cases of severe acute malnutrition?
a) .............................................................................................
b) .............................................................................................

4
9. What is the danger of administration of high protein and energy in the first phase of the
management of a case of severe acute malnutrition?
.........................................................................................................

10. What are the basic causes malnutrition?

a) Drought
b) Social inequality
c) War
d) All of the above
e) None

11. Which of the following is a false statement?

a) Malnutrition is associated with diarrhea
b) Immunization can prevent malnutrition
c) Marasmus is one of the problems of our society
d) Malnutrition is non-preventable communicable disease
e) A and D

12. What sanitary measures should be taken to prevent malnutrition?

a) Provision of safe and adequate food
b) Sources of water should be protected
c) Personal and environmental hygiene should be maintained
d) All of the above
e) None of the above

13. In the clinical work up of severe acute malnutrition, what laboratory investigations can be
done in a routine laboratory setup?
a) Hemoglobin determination
b) Stained red blood cell morphology assessment
c) Serum albumin determination
d) Differential leukocyte count
e) All of the above

5
14. What is the importance of hemoglobin determination in the assessment of sere acute
malnutrition?
a) To diagnose anemia
b) To diagnose polycythemia
c) To assess the presence of abnormal red blood cell morphology
d) None of the above

15. What is the importance of studying stained red cell morphology in the assessment of
severe acute malnutrition?
a) To assess nutritional anemia
b) It enables the classification of anemia
c) To diagnose iron deficiency anemia
d) All of the above

16 What is the importance of serum albumin determination in the assessment of severe

acute energy malnutrition?
a) To diagnose hypo-albunemia
b) To assess protein malabsorbtion
c) To diagnose hyper-albuminemia
d) A and B

17. What is the importance of differential leukocyte count (particularly lymphocyte count) in
the assessment of severe acute malnutrition?
a) To diagnose the presence of infections
b) To determine the relative lymphocyte count as an indicator of viral infection in
protein energy malnutrition
c) To see the presence of atypical lymphocytes
d) All of the above

18. What pathogens contribute indirectly to the development of malnutrition?

a) Viruses
b) Bacteria
c) Parasites
d) All of the above

6
19. The basic objective of managing a child with severe acute malnutrition is the following
except one:
a) Treating superimposed infections
b) Correction of specific nutrient deficiencies
c) Managing complications
d) Provision of immunization (measles)

20. One of the advantages of providing small frequent feeds in the acute phase of dietary
management of severe acute malnutrition is:
a) It increases appetite; therefore, the child could strive to gain weight at earliest
time
b) It reduces the risk of infection
c) It minimizes the risk of vomiting, hypoglycemia and hypothermia
d) None of the above

21. The objective of the rehabilitation phase in dietary management of severe acute
malnutrition is:

a) To decrease the risk of vomiting, diarrhea and hypothermia

b) To increase and promote a rapid rate of catch up growth through administration

of high energy and protein

c) To avoid unnecessarily prolonged hospital stay so as to prevent cross infection

d) To promote the participation of mothers/care givers in the dietary management

process.

22 About 80% of the deaths related malnutrition is due to severe malnutrition (true/ False).

23 Outline infant and young child feeding strategies for the first 24 months to prevent
occurrence of malnutrition.

24 Admission criteria for admission of a case of acute severe malnutrition to therapeutic

feeding centers in the emergency areas includes for children 6-18 months include(circle
all that apply),
a. Bilateral edema
b. Weight for height < 70%
c. Loss of appetite
d. Mid upper arm circumference < 11 Cm in children > 75 cm length

7
25 Mention all the essential nutrition actions approach components

____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
________________________________________________________

26 List the contact points of target population (women, infants and young children) with the
health service that can be use to promote essential nutrition actions approach.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
__________________________________________________

2.1.2 Pre and Posttest for Specific Categories of the Health Center
Team (from the Satellite Module)

2.1.2.1 Health Officers

Directions: Choose the letter of the choice with the right answer.

1. One of the following is a nutritional problem of public health importance in developing

countries.
a) Stunting and wasting
b) Iron deficiency anemia (IDA)
c) Iodine deficiency diseases (IDD)
d) Vitamin A deficiency
e) Vitamin D deficiency

2. The commonest type of malnutrition in Ethiopian Community is

a) Over weight
b) Under weight
c) Wasting
d) Stunting
e) Kwashiorkor

3. Which of the following problems are indicators that a child with severe acute
malnutrition needs a very careful inpatient care?

8
 a) Age < 1 year plus severe sever acute malnutrition
b) Severe acute malnutrition plus dehydration
c) Severe acute malnutrition plus hypothermia
d) Severe acute malnutrition plus infection
e) Recurrence of the situation in the same child after discharge

4. Which of the following diseases have a very close relationship with malnutrition?

a) Tuberculosis

b) Measles

c) Diarrhea

d) Pertusis (whooping cough)

e) Common cold

Abebech brought 3years old male child called Temam to the pediatric OPD of Jimma
Hospital. She told you that the child has diarrhea on and off type, loss of appetite.
Besides she stated that the child is not interested in his surrounding and sits
miserably. On physical examination you found out that the child is apathetic,
hypotensive, has gray easily pluckable hair, edema, weighs 9kg. While he is
expected to weigh 14kg. Answer questions 5 to10 based on the above scenario.

5. What is the type of malnutrition the child is suffering from?

a) Marasmus

b) Kwashiorkor

c) Marasmic-kwashiorkor

d) Underweight

e) Stunting

6. How would you manage this child?

a) Admit him and correct fluid and electrolyte balances first
b) Start him with low protein 1 - 1.5g/kg/d and low energy 100kcal/kg/d in the
stabilization phase and later increase to 5gm of protein/kg/d and 180kcal/kg/d
in the rehabilitation phase
c) The treatment principles are different for the different types of severe acute
malnutrition (for marasmus and kwashiorkor)
d) High dose of vitamin A is required
e) Screen him for infection and treat accordingly

9
7 What will be your approach to the mother to prevent the recurrence of the situation?

a) Nutrition education on child feeding and meal planning

b) Counseling her on the importance of mixing different foods (cereals with

legumes) and other food staffs like oil or sugar to enrich the protein and
energy content of weaning food

c) Tell her the importance of gardening in her yard-garden if she has a land

d) Work with her how to improve the nutritional status of her child

e) Appoint her for follow-up (growth monitoring)

8 What other history would have been important to ask about this child?
a) About breast feeding
b) About weaning process and type of complementary food
c) Immunization history
d) About who is carrying for the child at home
e) Income of the family, marital status, educational status and family size

9 The main objectives of treating this child in the rehabilitation phase is

a) To promote catch up growth

b) To promote restoration of the wasted tissue
c) To prevent death because of the complications
d) To correct hypoglycemia
e) To prevent recovery syndrome

10 What will be the consequence if adequate catch up growth does not occur in this child
during this rehabilitation phase?

a) The child will remain stunted and tracks below the standard and ends up in a
small (short) adult
b) Both his physical growth and mental development will be hampered
c) He will have poor physical work output as an adult later in his life
d) There will be difficulty in giving birth if she is a female
e) He will definitely grow up to be as tall as his maximum genetic potential

10
11 Which of the following is correct?

a) The limiting factor for a catch-up growth of a child with protein energy
malnutrition is protein

b) Small frequent feeds are advisable for children with severe acute mal
nutrition because of the alteration of the GI-histology as due to the pathology
and due to the fact that they have small stomach

c) Administration of other micro-nutrients like zinc, magnesium and potassium in

the stabilization and rehabilitation phase is equally

Important

d) Basically all mothers free of HIV/AIDS be advised to exclusively breast feed

their young for the first 4-6 months and for a minimum of 2 years then after

e) Using cup and spoon is by far the most preferred method of child feeding as
compared to bottle feeding

12 The types of classification of malnutrition so far in clinical use is

a) Gomez classification

b) Waterlow classification

c) Welcome classification

d) id upper arm circumference

13 The type of classification that has a relative advantage for community survey of
malnutrition is

a) Gomez classification

b) Water low classification

c) Well comes classification

d) Not stated here

14 Other micronutrient deficiencies that co-exist with wasting and stunting include:

a) Vitamin A deficiency

b) Vitamin D deficiency

c) Riboflavin deficiency

d) Iron deficiency

11
15 If you find stunting and wasting in children of a given community, this condition
indicates that:

a) There is a long standing nutritional problem

b) Wasting indicates that there is still an acute nutritional problem

c) There might be other social and environmental factors hidden in community

d) All

16 What main dangers do you anticipate in the first phase management of severe acute
malnutrition?

a) Cardiac problem

b) Dehydration

c) Infection

d) Hypothermia

e) All

1.2.1.2 Pre and Posttest to Public Health Nurses

Direction: Respond to the following questions accordingly.

1. List the roles of the public health nurse in a team approach to nutrition care:
a) .............................................................................................
b) .............................................................................................
c) .............................................................................................

2. The following are the responsibilities of public health nurse in managing severe acute
malnutrition except:
a) Maintain the childs body temperature with in normal range
b) Keeping the intake and output accurately
c) Preventing bed sore and infection by keeping the skin clean and dry.
d) Avoid stimulation since this disturbs sleeping pattern of a child.

3. List at least 3 points to be told to the mother of a child with malnutrition?

a) .............................................................................................
b) .............................................................................................
c) .............................................................................................

12
4. Write seven rules, which can largely improve nutritional status in the community.
a) .............................................................................................
b) .............................................................................................
c) .............................................................................................
d) .............................................................................................
e) .............................................................................................
f) .............................................................................................
g) .............................................................................................

2.1.2.3 Pre and Post Test for Medical Laboratory Technicians

Direction: Circle on any of the following choices that you think are the best answer

1 What laboratory investigations can be carried out to determine severe acute

malnutrition?

a) Hemoglobin determination

b) Stained red blood cell morphology assessment

c) Serum albumin determination

d) Differential leukocyte count

e) All of the above

2 What are the sources for blood samples for hematological tests to assess nutritional
anemia?

a) Capillaries

b) Venous

c) Arteries

d) A and B

3. What are the morphologic classifications of anemia in stained thin blood film
examination in the assessment of severe acute malnutrition

a) Normocytic normochromic

b) Microcytic hypocromic

c) Macrocytic normocromic

d) All of the above

13
4. What is the normal differential range of lymphocytes in the age groups of 1-4 years?

a) 38-45%

b) 25-35%

c) 44-55%

d) 50-60%

5 What is the approximate albumin normal range in g/l?

a) 30-45

b) 25-35

c) 20

d) 30

6 By what percentage is the level of albumin lowered in infants and when individuals are
lying down?
a) 10%
b) 20%
c) 30%
d) 40%

1.2.1.4 Pre and Post Test on PEM for the Sanitarians

Direction: Circle on any of the following choices, which you think, is the best answer.

1. Which of the following are risk factors for the development of malnutrition
a) Poverty
b) Infection
c) Lack of knowledge on food sanitation
d) All could be the possible risk factors

2. How is diarrhea associated with the malnutrition?

a) During infection there will be increased loss of nutrients due to diarrhea
b) Their causative agents are the same
c) Both are health problems to children under five years of age
d) None

3. Which of the following acute infection has a very close relationship with malnutrition?
a) Whooping cough
b) Leprosy
c) Malaria
d) All

14
4. What are the immediate causes of malnutrition?
a) Parasitic infection
b) Lack of knowledge about feeding and cleanliness
c) Lack of clean and unadulterated food
d) All of the above

5. The nutrition education to be given to the caregivers should focus on: -

a) The importance of hygienic preparation and storage of food
b) Feeding balanced diet (unadulterated diet) for children
c) Importance of breast feeding
d) All of the above

6 Which of the following is the most important requirement for a child to be healthy and
active?
a) Immunization
b) The child should be fed non-adulterated food
c) Keep the personal hygiene of the child
d) All of the above

7. Why is acute and chronic malnutrition is one of the major health problems for children of
the third world countries?
a) Poor sanitation coverage
b) No safe and adequate water supply
c) Shortage of safe and proper food
d) All of the above

8. What type of quick sanitary survey could be conducted to identify sanitary problem in a
community.
a) Health walk
b) Computer analysis
c) Observational hygiene analysis
d) a and c

Give Short answer for the following questions:

9. Describe the major symptoms of malnourished children in the community?

10. Explain some of the major interventions that should be conducted by you to prevent
acute and repeated infection?

11. Mention some points that we should focus on to make hygiene/health education
more successful?

15
2.1.2.5 Pretest for Health EXTENSION Workers (HEW)

1. The cause of malnutrition is

a) Germs
b) Evil eye
c) Lack of adequate child feeding practice
d) Tooth extraction
e) None of the above

2. One of the following is not a method of preventing malnutrition: -

a) Keeping personal hygiene and proper waste disposal
b) Bottle feeding
c) Immunization
d) Food hygiene
e) Exclusive breast-feeding up to 6 months and addition of supplemental food
and then after.

3. Which of the following is not a signal for malnutrition?

a) Loss of appetite
b) Stopping or ceasing of growth
c) Gray and lusterless hair
d) Happy smiling child
e) Swelling of the body

4. Which of the following is a risk factor for the occurrence of malnutrition?

a) Poor feeding both in quality and quantity
b) Neglect of children in the household by parents or care givers
c) Harmful traditional practices
d) Economic problems
e) All are correct

5. What would you have done to prevent to development of malnutrition if you were in
Jiren village?
a) .............................................................................................
b) .............................................................................................
c) .............................................................................................
d) .............................................................................................
e) .............................................................................................

16
2.2 Significance and Brief Description of the Problem

The term acute and chronic malnutrition includes a wide spectrum of malnutrition al
disorders primarily affecting children in developing countries (infants, pre-school). Its severe
acute clinical forms are: Marasmus, Kwashiorkor and Mixed feature called marasmic-
kwashiorkor.

In the community, stunting (chronic form) and wasting (acute) forms of malnutrition are
highly rampant in developing countries.

In rural Ethiopia, up to 1983, wasting was between 5-10%. By late 1983, it increased to 15-
20% in parts of Wollo, North Shoa and Hararge. In 1984, it further increased to 30% in Bale
and Sidamo. Child malnutrition in Bale, Kaffa, Gojam region that usually produce food
surpluses, was found to be higher than the national average. At present, within those
regions relatively unaffected by drought, it is estimated that about one third of rural children
are chronically malnourished and nearly one-half are underweight. However, according to
demographic and health survey (DHS) 2000, 51% of under five children are student while
11% and 47% are wasted and underweight, respectively.

The 1992 rural nutrition survey in Ethiopia revealed that stunting affected most of the
northern parts of Ethiopia, namely Gondar, Gojam, Wollo and Tigray and also Showa,
Sidamo and Illubabor located in the southern part of the central plateau. Tigray and Gondar,
in northern Ethiopia, were again most affected by wasting plus underweight and regions of
the western plateau and extreme south (Sidamo, North Omo, Borena) were also more
affected by wasting and underweight.

17
2.3. Learning Objectives
For effective management of a case of severe acute malnutrition (SAM) the students
at the end of the training will have the following knowledge, attitude and behavioral
outcomes: -
1. Define and identify the types of SAM

2. Enumerate the causes and factors contributing to SAM

3. Describe the magnitude and contribution of SAM to the overall child health problems
in the country and locally.

4. Identify and describe the clinical manifestations of SAM and its Complications.

5. Demonstrate the process of assessing a child with SAM

6. Identify the degree of SAM in a child

7. List the diagnostic methods and procedures for a case with SAM.

8. Describe the principles and methods of treating SAM

9. Select the appropriate treatment for a case of SAM

10. Describe methods of preparing dietary treatment for a case of SAM

11. Identify and manage or refer timely when needed, a case of sever SAM

12. Demonstrate the appropriate management of a case of SAM

13. Weigh children regularly and monitor their growth (growth Monitoring) and take action

14. Promote hygienic preparation and storage of weaning foods.

15. Identify methods and targets for health education in the prevention of SAM

16. Describe proper growth monitoring activities and their importance in the prevention of
SAM

17. Promote breast-feeding and proper weaning practice

18. Promote immunization of children

18
2.4 Case Study: Learning Activity Health Professionals in
Jiren a Rural Community
Almaz lives in a rural village of Jiren community. She has many children of which several
have died, but more are still alive. Her children were always weak, unhealthy, full of
parasites, and irritable. They were not playful like most kids in the neighborhood. Almaz is a
believer in God and therefore accepts every thing as natural.

August 19, 2000 was the first time when a health center team (a nurse, a sanitarian, a
laboratory technician and a health officer) from the Jimma health center came to their village
to do a health walk. Together with the village elders, the team walked all round the village
and observed the environmental sanitation conditions, housing condition, water supplies
sanitation facilities, and the health of children. In their preliminary assessment they
registered many things that needed to be corrected in order to improve the health condition
of the villagers. Some of the health and sanitation problems observed were:

1 Feces of adults and children in many places; some of the excreta contained ascaris
worms.
2 Wastes such as rubbish, and dung, etc were scattered all over the place.
3 No clean water supply in the village.
4 No single latrine in the whole village was seen.
5 The eyes of most children were unwashed, infested with flies and covered with
discharge.
6 Many children seen were not playful, & happy, but weak looking, with big bellies, thin,
and gray or cooper hair.
7 All the houses, except for a few scattered dwellings were thatched with a single room.
8 Almost all dwellings were used as barn & the houses were in general crowded.
9 Children were playing in highly commentated environment.

Having made all these observations and discussions with the elders, the health center team
(the health officer, the nurse, the laboratory technician and the sanitarian) reached a
consensus that, although almost all people in our country are leading the same life, this
village, in particular, seems even more deprived of all the necessary health promotion
mechanisms. The population is not that poor, but they have been isolated, uninformed and
unexposed to health care services and mostly illiterate.

The team discussed their observations and agreed to start an intervention program together
with the people. They agreed that the intervention programs should start from the basics and
build up later.

19
The most important ones were: -
Basic hygiene education.
Teach basic and proper child nutrition.
Protect the water source.
Give basic technical help for all to have access to latrines.

The next day, when the car which brought the health center staff arrived and parked under a
tree, children were running around to tell their mothers about the guests arrival. Ladies were
calling each other to come to the meeting. On the way, they were asking each other what
the meeting would really be about. They speculated about many things.

At the meeting place, children were crying, people were moving here and there, and the
team was unloading things such as kerosene stoves, some bottles containing oil, some flour
and chopping board from the car.

After everyone sat down and the supplies were unloaded, the health officer clapped his hand
for silence. All except some children were quiet. The nurse, the health officer and the lab
technician were dressed in white gowns; the sanitarian is dressed in neat Khaki trousers and
a local cap for the sun.

Once they were quite and relaxed, the health officer began to explain to them what they do
in the health centers and the team will be having in the village in the future.

The sanitarian then told them how disease is transmitted from one person to another. He
then pointed out the sanitation problems in the villages and explained that when children
play in those areas; they contaminate themselves and their families. He also discussed how
diseases are transmitted through water or flies. He told them these things in a simplified
way, showing them some posters, which he brought with him.

The health officer and the public health nurse reinforced what the sanitarian hve just said by
asking them simple questions such as, how many of youve children that pass ascaris worms
with their stools? Almost every mother raised her hand. Again they asked; how many of you
have children that have had diarrhea in the last four days including today? Again many
mothers raised their hands.

Then, they stopped asking and started to tell them about childrens health, cleanliness and
nutrition. They added that in order for children to grow, they have to be kept clean, fed
properly (nutritious food as often as five or more times a day), teach them good habit of

20
hand washing and always monitor their growth, mood, and illness especially from parasitic
disease as much as possible. Children should eat, and drink clean water or milk

If the children are not getting the necessary nutrients, such as body builders (proteins)
energy foods (carbohydrates and fats) and protective nutrients (vitamins and minerals)
they: -
Grow slowly
Be weak, unhappy, not playful
Look like an old person
Have elastic skin
Have no resistance to disease
Have frequent attack of diarrhea
Have slow mental development
Eventually may die

She started showing them pictures of a child with different kinds of nutritional deficiencies.
She pointed to the pictures of Marasmus, Kwashiorkor and Marasmic-kwashiorkor and
asked the mothers if they have seen a child such as the one in the picture before. One
mother pointed to her own child and asked whether it is the same? The nurse told her it was
the same. Getting a living example the nurse started to tell them about what had happened
and they can reverse the condition. She put on her apron and asked the mothers to make a
circle and observe so that they see how to prepare simple foods in their house in clear and
simple manner.

They told mothers how much and how frequently they need to feed their children with the
above nutrients and their locally available food sources. This shows that we do not have to
be necessarily very rich to have our children grow healthy and strong.

The food must be prepared fresh if possible or leftover food must be stored and covered in
clean utensils and in clean place. Leftover food must also be heated adequately before
giving it to a child.

21
2.5 Definition

Severe acute malnutrition (SAM) is a diagnosis that includes several overlapping

syndromes. The scientific basis for SAM was questioned in the early 20th century and
different terms were introduced to describe it and there were different views as to its
etiology. Controversies raged since 1930 and in 1935 cicely Williams introduced the
Ghanaian diagnosis Kwashiorkor (a disease of child disposed from breast by birth of the
next one).

The term kwashiorkor -remained constant in spite of the criticisms because it doesnt
describe the cause. Over the next 20 years around 50 different alternative names have
been given to the same syndrome.

In 1959, Jelliffe, proposed the term protein calorie malnutrition (PCM) to include all
syndromes relating to inadequate feeding. This has been largely replaced by protein-energy
malnutrition (PEM) or malnutrition. Recently, according to the free radical theory of Professor
Michael Golden on the cause of sever acute malnutrition; the syndrome is a multi-deficiency
state involving the deficiency of protein, energy and other micronutrients. Protein energy
malnutrition is therefore a misnomer and no more used in the nomenclature of this
syndrome. Therefore, there is a general consensus that the term severe acute malnutrition
(SAM) be used instead of protein energy malnutrition.

2.6 Epidemiology

Stunting and wasting are the major nutritional problems of the third world countries. Its
prevalence ranges from 20-40% in Africa and Southeast Asia. In Ethiopia, according to CSA
rural nutrition survey in 1992, the highest prevalence of stunting was recorded in South
Gondar (74.5%) and the lowest prevalence in South Omo (49.2). Whereas the highest
prevalence of wasting was recorded in Tigray (14.2%), and the lowest in Bale (4.4%).
Concerning the prevalence of underweight, the highest (59.9%) was recorded in Tigray and
the lowest in Bale (29.2%). Generally, the prevalence of moderate and severe forms of
stunting and underweight in Ethiopia showed an increasing trend over a decade according to
the report on rural nutrition survey in 1992 (see Figure 1). According to DHS the national
prevalence 51% of fewer than five children in Ethiopia are stunted and 11% and 47% are
wasted and underweight, respectively. In Ethiopia, 70% of children are sub-optimally
breastfed.

22
Sever acute malnutrition is mostly common in children under five years of age. Marasmus is
common in children less than 12 months of age and kwashiorkor is prevalent in children less
than 5 years, commonly in the age groups of 2-3 years.

Many studies show that malnutrition is associated with different factors like improper
weaning practice (early abrupt weaning with dilute and dirty formula), infections (diarrhea,
measles, tuberculosis, pertusis, etc.), harmful traditional practices (age bias in feeding, sex
bias in feeding, food prejudices- omission from family diet), and child neglect, sub-optima
breast-feeding and complementary feeding Practices. These factors do operate in the
Ethiopian context. In Ethiopia, there is a cyclic occurrence of malnutrition in most rural
agrarian communities following the turn of the seasons. The winter (rainy) season is
therefore called the hunger (lean) season and that of the summer (dry) season is the harvest
season. This seasonality of energy and protein intake is reflected in the variations in the
prevalence of PEM in those two seasons.

23
 70 64.2
60 47.6 1982
42.1
50 38.1
1992
40
Percent
30
20 11.6
8
10
0
Under weght Sunting Wasting
Tyepes of Malnutrition

Figure 1. Trend of protein Energy malnutrition in children 5-59 months

in Ethiopia over 10 years (1982-1992)
Source: CSA report on ruran nutrition surveycor module, 1992

2.7 Causes, Etiology and Pathogenesis

2.7.1 Causes
Causes of protein energy malnutrition are multi-factorial having a number of interwoven
factors operating simultaneously. The causes could be categorized as immediate, underlying
and basic.

The following diagram depicts the causes operating at different levels.

24
 Consequences
Functional Consequences: Mortality,
Morbidity, Lost Productivity, etc.

Manifestations
Nutritional Status

Immediate
Diet Health Causes

Household Environ. Health,

Food Security Care of Mother Underlying
Hygiene & Sanitation
and Child Causes

Human, Economic, and

Institutional Resources

Root
Political and Ideological Structure Causes

Potential Resources
Sourec : UNIUNICEF

At the level of the individual child one or more of the following factors may operate:-

Lack of knowledge -People do not understand the nutritional nature of their Childs
health problem

Poverty - lack of means to obtain and provide food to their child (as in the case of war)

Famine and vulnerability- destitution, being orphan (Example orphan vulnerable

children due to HIV/AIDS)

Infections - there is a reciprocal relationship between malnutrition and infection. During

infection, the requirement for nutrients increases, there will be increased loss of nutrients
due to diarrhea; genesis of fever and other acute phase reactants is at the expense of
nutrients.

25
 Emotional deprivation- In orphan children and in children whose parents are negligent in
giving care to their children, due to different reasons, children will lose appetite for feeding
and hence end up in state of malnutrition

Cultural factors- Different biases as to who should take the lions share of the family s
food (Example, age biasolder children are given more food than the smaller ones,

Sex biasmale children are more favored in getting nutritious food than female children
in some families, etc.)

Mal-distribution of foodstuffs - within the family, it occurs between the different ages
and sexes due to biases, food prejudices and taboos. It also occurs between the different
regions of a country because of inappropriate food and nutrition policy, poor marketing
and distribution system due to different reasons like embargo, country under-siege, etc.

2.7.2 Etiology of Severe acute malnutrition (SAM)

Acute malnutrition: is a multi- deficiency state and not just a deficiency of protein and energy.
Marasmus is a semi-starvation, which includes the deficiency of energy, protein and other
nutrients. There are several theories for kwashiorkor among which four are stated below: -
Low Protein Intake: -

Low protein intake, which leads to hypo-albuminemia, which in turn leads to edema.
However, different studies have shown that children can have low albumin without
edema, it was found difficult to produce edema in animals on protein deficient diet, and
edema may go and come unpredictability regardless of their protein intake.
Dys-adaptation

Edema is determined not only by diet but also by intrinsic differences among children
with regard to their protein requirement or hormonal response. Hence, kwashiorkor
develops in children that poorly adapted and Marasmus develops in children that are well
adapted to the states of lower nutrient intake.

Aflatoxins:- It was reported from a study in Sudan by Hendricks that children with
Aflatoxins developed edema compared to those with no aflatoxin intake.

Free Radical Damage

The outcome of malnutrition is determined by extrinsic factors (noxae) leading to free

radical formation and intrinsic factors (micronutrient deficiencies), which may impair
body's ability to scavenge free radical species. This results in membrane damage and
leakage of fluid from the calls. This theory accommodates all other theories.

26
2.7.3. Pathogenesis

Marasmus and Kwashiorkor in their extreme forms have basically different pathogenesis.
The initiation of the pathogenesis of both problems can be traced back to the time of
weaning. Kwashiorkor develops following the additional demand levied on the bodys already
marginalized nitrogen balance due to infection of a child that is on monotonous starchy
family diet. As a result of fragile nitrogen balance that the child has, negative nitrogen
balance sets in when the available nitrogen is used to produce antibodies or other acute
phase reactants in the face of infection, this will lead to kwashiorkor. On the other hand
Marasmus develops due to negative energy balance as a result of starvation therapy that
follows the bouts of diarrhea. The following diagram depicts the scenario.

27
 Urban Rural
Breast-
feeding

Early abrupt weaning Late gradual weaning

around 5 months around one year

Dilute Dirty formula

feed Monotonous starchy family diet

Repeated gastro intestinal

infections (Gastroenteritis) Acute infections like
Tuberculosis, pneumonia, etc.

Diarrhea
Negative nitrogen Balance

Decreased feeding of the child both in

frequency and quantity (Starvation therapy)
leading to Negative energy Balance

Nutritional Marasmus Marasmic -Kwashiorkor Kwashiorkor

Adapted From Maclarane

28
2.8 Clinical Features
The severest clinical forms acute malnutrition are Marasmus, kwashiorkor and features of
both called Marasmic- kwashiorkor. The following symptoms and signs clinically characterize
them-

Marasmus

Marasmic children have retarded growth with specific clinical manifestations including:-
Wasting of subcutaneous fat and muscles (flabby muscles), Wizened monkey (old man
face), Increased appetite, sunken eye balls, mood change

(always irritable) and mild skin and hair changes.

Figure 2. A child with marasmus manifesting with old mans face and bone and skin appearance

Kwashiorkor

Children with the kwashiorkor syndrome may have the following clinical manifestations; -
Growth failure, wasting of muscles and preservation of subcutaneous fat, edema (pitting
type), fatty liver (hepatomegaly), psychomotor retardation (difficulty of walking), moon face
due to hanging cheeks as a result of edema and preserved subcutaneous fat, loss of
appetite, lack of interest in the surrounding (apathy) and miserable, skins changes
(ulceration and depigmentation or hyper pigmentation), and hair changes (de-pigmentation,
straightening of hair and presence of different color bands of the hair indicating periods of
malnourishment and well nourishment (flag sign) Straightening of hair at the bottom and
curling on the top giving an impression of a forest (Forest sign) and easily pluckable hair.
Marasmic kwashiorkor can have the clinical features of both Marasmus and kwashiorkor.

29
In children with marasmus or kwashiorkor, there are usually deficiencies of micronutrients
like: - riboflavin, vitamin A, Iron and Vitamin D. Therefore, it is advisable to have high index
of suspicion and look for the signs and symptoms of deficiencies of these nutrients.

Figure 3: Child with kwashiorkor manifesting with edematous swollen legs and apathy

2.9 Diagnosis
The diagnosis of severe acute malnutrition rests mainly on meticulous clinical examination
for the symptoms and signs of the syndrome plus anthropometric assessments using
different methods. Additionally one may need laboratory investigation for the assessment of
complications and other health problems associated with malnutrition. Nutritional
epidemiologic considerations also contribute to the diagnosis of malnutrition. Nutritional
survey and nutritional surveillance can be used to detect the early warning signs of
increased acute malnutrition (wasting) timely and design preventive and emergency
intervention measures. In addition community diagnosis of the level of chronic malnutrition
(Stunting) can be determined using nutritional surveys in order to avail information for food
security planning.

30
The clinical symptoms and signs are presented in section 2.8. The anthropometric
assessments can be done using the following methods:

I. Gomez classification (weight-for-age)

Percentage (%) Level of malnutrition

Of NCHS Reference

90-109 Normal

75-89 Mild (Grade I)

60-74 Moderate (Grade II)

< 60 Severe (Grade III)

The disadvantages of this classification are: - The cut off point 90% may be too high as
many well-nourished children are below this value, edema is ignored and yet it contributes to
weight and age is difficult to know in developing countries (agrarian society).

II. Well-come classification (weight-for-age)

Percentage (%) Level of malnutrition

NCHS Reference Edema No edema
60-79% Kwashiorkor Under-weight
< 60% Marasmic- kwashiorkor Marasmus
Shortcoming of this method is that it does not differentiate acute from chronic malnutrition.

III. Waterlow-classification (Height-for age and weight-for height)

Index % of NCHS reference Level of Malnutrition
90-94% Mild
Height Stunting
85-89% Moderate (Chronic
For
Age < 85% Severe malnutrition)

Mild
80-89%
Moderate Wasting
Weight
70-79% (Acute
for
<70% Severe Malnutrition)
Height

31
Laboratory Diagnosis
Laboratory investigation for severe acute malnutrition is to determine the level of serum
protein, hemoglobin and co-infections due to pathologic organisms that can be viral,
bacterial or parasitic origin. Besides determination of micronutrient deficiencies can also be
done.

2.10. Case Management

Management of a case of SAM focuses on the correction of specific nutrient deficiencies
(dietary management), treatment of complications and supper imposed infections. The
treatment approach is classified into two phases (Phase 1, transition phase and Phase 2).

I. Phase 1

The management is categorized in to two major parts. Part I- for patients older than 6
months and Part II-for patients below 6 months.

A. Management for patients older than 6 months

Admission criteria
For patients 6-18 months
o W/H < 70%
o Presence of bilateral edema
o MUAC < 110 mm in children of more than 75 cm length
For patients greater than 18 months old
o BMI < 16 kg/m2
o Presence of bilateral edema unless there is a clear cut other cause
The main focus of Phase 1 is treatment of infection and other complications like dehydration,
hypoglycemia, hypothermia and other electrolyte imbalances. Transition phase and phase 2
focuses on the restoration of the lost tissue and promotion of catch up growth.

MANAGEMENT OF COMPLICATIONS
Children are most at risk of dyeing during the phase 1. Dehydration, infection and severe
anemia are the main dangers. In severe acute malnutrition, cardiac and renal functions are
impaired and in particular malnourished children have a reduced capacity to excrete excess
water and a marked inability to excrete Sodium. The amount of fluid given and the Sodium
load must be carefully controlled to avoid cardiac failure. The rehydration solution used in
malnutrition (ReSoMal) a different composition than the normal glucose based ORS

32
Table1. Management of complications of complications severe acute alnutrition
Complications Treatment
Hypoglycemia - 5-10 ml/kg of sugar water for or F75 (F100) diet by
(Manifested by Eyelid mouth for conscious patients.
retraction during sleep) - Unconscious patients be given sugar water by NGT
they should also be given a single injection of 5
ml/kg of sterile 10% glucose solution)
- A malnourished child with hypoglycemia should be
treated with 2nd done anti biotic.
Hypothermia rectal - Use kangaroo care technique for patients. With a
0 0
(T < 35-5 C or axillaries T0 care taker
= < 350C) - Put a hat on child & wrap the mother & child together
- Give hot drinks to the wither so her shin gets wormer
- Monitor body temperature during re-warming
- Keep the room warm epically at might (between 28-
320C) maximum-minimum thermometer be on the
wall to monitor temperature in phase 1
- Treat hypoglycemia & give 2nd use antibiotic
Dehydration & septic shock - Take care of over load of fluid & solutes
(difficult to diagnose) - Use dehydration solution for malnourished
(ReSoMal)
- Total 50-100 ml/kg = over 12 hrs 5 ml/kg Q 30 mm
for the 1st 2 hrs.

Dietary management
A cautious approach is required; aiming at administration of about 100kcal/kg/day and 1-
1.15g of protein/kg/day. F75 (130 ml=100kcal) should be given for patients in all age except
for the less than 6 months old infant without edema.

PREPARATION:

Add 1 packet of F75 to 2 litters of water. This gives 2.4 liters of F75. Small frequent feeds (as
much as 8 times in 24 hours for the first two days and gradually tapering the number of
feeds to be 6 in 24 hours after a week) are ideal as they reduce the risks of diarrhea,
vomiting, hypoglycemia and hypothermia. If feeding 8 times is not possible give five to six
times using appropriate reference feed table. Breast fed children should be offered breast
milk before the diet and always on demand.

33
If prepackaged F75 is not available it can be prepared locally using one of the following
recipes

Table 2. Preparation of F75 from locally available foods for Phase 1

Type of Milk (g) Eggs (g) Sugar (g) Oil (g) Cereal Water (ml)

milk Powder (g)

DSM 25 0 70 27 35 Up to 1000

DWM 35 0 70 20 35 Up to 1000

Fresh 280 0 65 20 35 Up to 1000

milk

Fresh 280 0 65 20 40 Up to 1000

milk

Whole egg 0 80 70 20 40 Up to 1000

Egg yolk 0 50 70 15 40 Up to 1000

Nasogastric tube feeding is used when a patient will not take sufficient diet by mouth as
defined by intake less than 75% of the prescribed diet (for children about 75/kcal/kg/day).
The reasons for using for NGT are:

Taking less than 75% of prescribed diet per 24 hours in phase 1

Pneumonia with a rapid respiratory rate

Painful lesions of the mouth

Cleft palate or other physical deformity

Disturbances of consciousness

34
Table 3. Phase 1 Amounts of F75 to give during phase I
Class of weight 8 feeds per day ml 6 feeds per day 5 feeds per day
(kg) for each feed
2.0 to 2.1 kg 40 ml per feed 50 ml per feed 75 ml per feed
2.2 2.4 45 60 70
2.5 2.7 50 65 75
2.8 2.9 55 70 80
3.0 3.4 60 75 85
3.5 3.9 65 80 95
4.0 4.4 70 85 110
4.5 4.9 80 95 120
5.0 5.4 90 110 130
5.5 -5.9 100 120 150
6 6.9 110 140 175
7 7.9 125 160 200
8 8.9 140 180 225
9 9.9 155 190 250
10 -10.9 170 200 275
11 11.9 190 230 275
12 12.9 205 250 300
13 13.9 230 275 350
14 14.9 250 290 375
15 19.9 260 300 400
20 24.9 290 320 450
25 29.9 300 350 450
30 39.9 320 370 500
40 60 350 400 500

Do NOT give iron early before infection is controlled. High dose vitamin A should be given
even if there are no eye signs of deficiency.
On this regimen, edema will disappear and the general condition will improve. High energy
or high protein diets should not be introduced too early or too rapidly. Such action may
precipitate the recovery syndrome' which can prove fatal. Return of a good appetite is a
sign that a child is ready to progress to the next phase.

2. Transition Phase
The major criteria to move from phase 1 to transition phase are both return of appetite and
the beginning of loss of appetite. Children with gross edema (+++) should wait in phase 1 at
least until their edema has reduced to moderate (++) or moderate (+) edema. These children
are particularly vulnerable. The only change that is made in this phase as compared to
phase 1 is changing the diet that is given from F75 to F100.

35
Table 4. Transition Phase: amounts of F100 to give
Class of weight 8 feeds per day 6 feeds per day 5 feeds per day
(Kg) Ml for each feed
Less than 3 kg F100 full strength should not be given -Only F100
diluted should be given (see p.18)
3.0to 3.4 kg 60 ml per feed 75ml per feed 85 ml per feed
3.5-3.9 65 80 95
4.0-4.4 70 85 110
4.5-4.9 80 95 120
5.0-5.4 90 110 130
5.5-5.9 100 120 150
6 - 6.9 110 140 175
7 - 7.9 125 160 200
8 - 8.9 140 180 225
9 - 9.9 155 190 250
10-10.9 170 200 275
11-11.9 190 230 275
12-12.9 205 250 300
13-13.9 230 275 350
14-14.9 250 290 375
15-19.9 260 300 400
20-24.9 290 320 450
25-29.9 300 350 450
30-39.9 320 370 500
40-60 350 400 500

3. Phase 2

The aim of this phase is to restore wasted tissues and promote a rapid rate of catch-up
growth through administration of high energy and protein. A vigorous approach is required.
In this phase there is no danger of recovery syndrome.

The synthesis of new tissue requires protein and other nutrients. Synthesis also requires a
considerable amount of energy. The aim is to provide all necessary nutrients so that none
limits the rate of recovery. Normal rate of growth of children is such that they gain a weight
of 1gram/kg/day by taking 105 kcal/kg/d and 0.78gram of protein /kg/d. To increase this rate
of growth by 20 times the normal, the energy and protein intakes need to be increased to

36
200kcal/kg/day and 5kcal/kg/day, respectively. The following table summarizes the different
treatment s and criteria for transition from one phase to the other.

Different phases of dietary management of children with severe acute malnutrition (adults >
6m)

Table 5. Management of the different phases

Phase Criteria for moving to the next Management
phase or the previous phase
Phase 1 Child with gross edema (+++) - No iron
should wait in phase 1atleast - F75 = 100 kcal/kg/day
until their edema is reduced (++) - A single dose of Vitamin A-
The following are criteria to move 100,00 (for 6-12months) and
to transition phase: 200,00IU (for > 12 months)
- Return of appetites - Treat hypothermia, hypoglycemia
- Beginning of loss of and dehydration (1 above)
edema - Need to gain a weight of
5g/kg/day
- Antibiotics
Transition - Diet is changed from 75-F100
or mid - Good appetite - The number of feeds, their timing
edema (+) - Marasmic patient should and volume of diet given remains
spend at lest 2 days exactly the same as phase 1
- Kwashiorkor patient
should remain in TP until
they lose edema
Phase 2 - F100 (100 ml= 100 kcal) is used
- Five feeds of F100 or one
porridge may be given
- For pts > 8kg (around 24 month 5
feeds on F100 should be given
to children < 8 kg
- If children should get F100 before
F100.

37
What to give: The choice of ingredients will very with local circumstances. There are many
advantages in using milk as the basic ingredient, since milk can be modified very effectively
and easily, by adding sugar and vegetable oil, to produce a high-energy formula.

Table 6. Preparation of F100 from locally available foods for transition phase and
Phase 2
Type of milk Milk (g) Eggs (g) Sugar (g) Oil (g) Water (ml)
DSM 80 0 50 60 Up to 1000
DWM 110 0 50 30 Up t0 1000
Fresh cow milk 900 0 50 25 Up to 1000
Fresh goat milk 900 0 50 30 Up t0 1000
Whole eggs 0 220 90 35 Up to 1000
Egg yolks 0 170 90 10 Up t0 1000

Considerable flexibility exists in the ingredients that can be used, provided the target
requirements are met. Where milk is a not available, high-fat legume, nuts and oilseeds
(such as groundnuts, Soya, sesame seeds) provide both energy and protein in a relatively
compact form.

How much to give:

The greater the intake of energy and protein intakes the faster the growth. Hence one
should give the high-energy and protein formula of at least 180 ml/kg/day (6 feeds at 30
ml/kg/feed). This amount will provide 180 kcal/kg/day and 5-gram protein/kg/day.

38
Table 7. Phase 2 amount of F100 to give

Class of weight Ml per feed Ml per feed

(Kg) 6 feeds per 24 h 5 feeds per 24 h
Less than 3 kg Full strength F 100 is NOT used at this weight
3.0to 3.4 kg 100 ml per feed 75ml per feed
3.5-3.9 120 150
4.0-4.9 150 180
5.0-5.9 180 200
6.0-6.9 210 250
7.0-7.9 240 300
8.0-8.9 270 330
9.0-9.9 300 360
10.0 -11.9 350 420
12.0 -14.9 450 520
15.5 -19.9 550 650
20.0 -24.9 650 780
25.0 -29.9 750 900
30.0 -39.9 850 1000
40-60 1000 1200

Assessing Progress/ Surveillance:

Patients should be weighed at least 3 times week, preferably daily, and the weights
plotted. Height should be measured at least every 3 weeks and mid upper arm
circumference should be taken each week. Body temperature and observation of clinical
signs like vomiting, diarrhea should be checked each morning. Failure to maintain rapid
catch-up may signal an undiagnosed infection and/or inadequate intake. Keeping a record
of the child's food intake helps to elucidate the cause of poor weight gain (Use the multi-
chart).

Usual causes of failure to respond

Primary
Failure to regain appetite day 4
Failure to start to lose edema Day 4
Edema still present day 10

39
 Failure to regain weight more than 5 g/kg/d

Secondary
Failure to gain wt more than 5g/kg/d for 3 successive days = during phase 2

Usual causes of failure to respond

Problems with the treatment facility

o Poor environment for malnourished children

o Insufficient or poorly trained staff

o Inaccurate weighing machines

o Food prepared or given incorrectly

Problems with individual children

o Insufficient food given

o Food taken by siblings or care taker

o Vitamin or mineral deficiency

o Malabsorption

o Rumination

o Infection, especially:

Diarrhea, pneumonia, tuberculosis, urinary tract infection, otitis media,

malaria, HIV/AIDS, schistosomiasis/Lishmaniasis, hepatistis/cirrhosis
and other underlying diseases

Every child, which fails to respond, should be investigated for the common causes as follows
and must be treated:

1. Examine the child carefully (Vital signs To, PR, RR,)

2. Laboratory investigation (Urine analysis, stool exam, culture etc) as indicated

Almost all malnourished children have diarrhea, but it is rarely due to lactose intolerance.
Chronic diarrhea may result from gut parasites (e.g. Giardia) or bacterial overgrowth of the
small bowel. The introduction of the high-energy formula may cause mild diarrhea initially,
but this is not a cause for concern unless stool frequency exceeds 8 per 24 hours.

40
Discharge
1. Anthropometric Criteria
WL (W/H) > 85% for & consecutive weights & or no edema for 10 days
MNAC > 12.5 cm
In case of emergency situation where there is adequate supplementary feeding
program
W/L > 80% (Length < 85 cm) or
W/H = 80% (Length = 85 cm) for 2 consecutive
No edema for 10 days
MUAC > 12 cm
2. Counseling & health education
3. Immunization is up to date

Follow up after discharge

The child should be enrolled in a supplementary feeding program and given nutritional
support for another 4 months. For the first 2 months they attend every 2 weeks and then
once per month for further two months if the progress is satisfactory

B. MANAGEMENT FOR INFANTS BELOW 6 MONTHS (OR LESS THAN 3 KG)

1. MANAGEMENT FOR INFANTS BELOW 6 MONTHS (OR LESS THAN 3 KG) WITH A
FEMALE CARE TKATER
Admission criteria
Infant too week or feeble to suck effectively
Infant not gaining weight at home
If the infant is anthropocentrically malnourished: Weight for length < 70% or presence
of bilateral edema

Phase 1 transition phase- phase2

The aim is to stimulate breastfeeding and t supplement the child until breast milk is sufficient
to allow the child to grow properly. Breast milk is stimulated by the supplemental suckling
(SS) technique; it is important to put the child on breast as often as possible.
Breastfeed every 2-3 hours (8-12 times in 24 hours) on demand or on cues day and
night with proper positioning and attachment
About one hour after a normal breastfeed give maintenance amounts of F100 diluted
using the supplementary suckling technique

41
 F100 diluted: 130ml/kg/day (100Kcal/kg/day) divided in to 8 meals. Young infants
should be nursed in a separate space from the older malnourished children. This can
be a breast feeding corner.

Preparation of F100 diluted

Diluted F100 one packet in to 2.7 liter of water instead of 2 liters to make F100
diluted
Make small quantities of F100 Diluted
Use 100ml of F100 already prepared and add 35 ml of water, the you will get 135 ml
of F100 diluted
Discard any excess waste
If you need more than 135 ml, use 200 ml of F100 and add 70 ml of water, to make
270 ml of F100 diluted and discard any excess waste

Table 8. Amounts of F100 diluted to give for infants not breast-fed in phase 1
Class of weight Ml of F100 per feed in phase 1
(kg) (8 feeds/day) Children < 6
> = 1.2 kg 25 ml per feed months, with
edema, should
1.3 to 1.5 kg 30 ml per food be on F75 and
not on F100
1.6 -1.7 35 Diluted
1.8- 2.1 40
2.2 2.7 45
2.5 2.7 50
2.8 2.9 55
3.0 3.4 60
3.5 3.9 65
4.0 4.4 70

Note: F100 undiluted is never used for small infants (less than 3 Kg).

Assessing progress/ Surveillance

The progress of the child is monitored by the daily weight
If the child looses weight over 3 consecutive days, yet seems to be hungry and is
taking all his F100, add 5 ml to each feed

42
 The supplementation is not increased during the stay in the center. If the child is
growing with the same quantity of milk, it means the quantity of breast milk is
increasing
If after some days, the child does not finish all the supplemental food, but continues
to gain weight, it means that the breast milk is increasing and the child has enough.
When the baby is gaining weight at 20 g/day
o Decrease the F100 diluted to half of the maintenance intake
o If weight gain is maintained (10 g/day) then stop supplement suckling
completely.
o If weight gain is not maintained then increase the amount given to 75% of the
maintenance amount for 2 to3 days and then reduce it again if weight gain is
maintained.
Keep the child in the NRC for further 5 days on the breast milk alone to make sure
that he/she continues to gain weigh
The child should be discharged when it is certain that he/she is gaining weight no
matter the current weight for height.
Box 1. Supplementary Suckling Technique
Supplementation is given using a tube the same size as n08 NGT
F100 diluted is put in a cup. The mother holds it.
The end of the tube is put in to the cup.
The tip of the tube is put on the breast at the nipple and the infant is offered the
breast in the normal way so that the infant attaches properly.
When the infant sucks on the breast, with the tube in his mouth, the milk from the cup
is sucked up through the tube and taken by the infant.
At first, the cup should be placed at about 5 to 10 cm below the level of the breast so
the milk does not flow too quickly and distress the infant. As the infant becomes
stronger, the cup should be lowered progressively to about 30 cm below the breast.
Mother holds the tube at the breast with one hand and uses the other for holding the
cup. It may take a day or two to acquaint the infant to this
The best person to show the mother about SS technique is another mothers who was
successful doing it

43
Routine Medicine:
Vitamin A: 50,000 IU at admission only
Folic acid 2.5 mg (1 tablet) in one single dose
Iron (ferrous sulphate): when the child sucks well and starts to and start to grow (after
infection is controlled)
Amoxycillin 20mg/kg 3 times a day plus gentamycin (not chloramphenicol)

Care for the mother

Assess her nutritional status (BMI)
Counsel her about the aim of the treatment and what is expected of her
She should drink at least 2 litters of F100 per day
She must eat enough about 2500Kcal/day
Give her vitamin A 200, 000 IU if her baby is less than 2 months
Shorten her stays in the NRU as far as possible
Iron supplementation should be given to the mother and she should use iodized salt
in her diet

Discharge criteria
Discharge the infant when
It is clear that he/she is gaining weight on breast milk alone
There is no medical problem
The mother has been adequately supplemented with vitamins and minerals
N.B. there is no anthropometric criteria for discharge of a fully breast-fed infant who is
gaining weight.

Follow up
The mother must be included in the supplementary feeding program (SFC) and receive
food to improve the quantity and quality of breast milk.

2. MANAGEMENT FOR INFANTS BELOW 6 MONTHS (OR LESS THAN 3 KG) WITHOUT
ANY PROSPECT OF BEING BREASTFED

Criteria for admission: Weight for length < 70% or presence of bilateral edema
NB. There are no standards for infants below 49 Cm and the increments to judge nutritional
status requires precise scales that are not generally available. The NRU is not appropriate

44
for treating premature low birth weight non-breast fed infants below 49 cm in length. These
infants should be referred to a nursery and given infant formula.

Phase 1- Transition Phase- Phase 2

When there is no prospect of being given breast milk then severely malnourished < 6
months infants should be treated according to the standard protocol with the following
modifications
Table 9. Phases of treatment for < 6 months non-breastfed
Phase Dietary management
Phase 1 Wasted marasmic infants < 6months can be given F100
diluted in phase 1
Edematous infants < 6 months should always be given
F75 during Phase 1(see table 10)
Transition During transition phase, only F100 diluted should be used
Phase with the same volume as phase 1. These small infants
should not be treated with full strength F1oo.
Phase 2 During Phase 2, twice the volume of F100 diluted that has
been given during phase 1 should be offered to infants (See
table 11)

Table 10. Amounts of F100 diluted to give for infants not breast-fed in Phase 1
Class of weight Ml of F100 per feed in phase 2
(kg) (8feeds/day)
Diluted F100
= 1.5 kg 30 ml per feed
1.6 to 1.8 kg 35 ml
1.9 2.1 40
2.2 2.4 45
2.5 2.7 50
2.8 2.9 55
3.0 3.4 60
3.5 3.9 65
4. 0 4.4 70

45
Table 11. Amount of F100 diluted to give for infants not breast-fed in Phase 2

Class of weight Ml of F100 per feed in phase 2

(kg) (6 to 8 feeds/day)
Diluted F100
= 1.5 kg 60 ml
1.6 to 1.8 kg 70 ml
1.9 2.1 80
2.2 2.4 90
2.5 2.7 100
2.8 2.9 110
3.0 3.4 120
3.5 3.9 130
4. 0 4.4 140

Criteria fro Discharge

When they reach 85% weight for length they can be switched to infant formula

Follow-up
Follow-up for these children is very important and need to be organized.

Role of the Family Diet:

Transfer to a family-type of diet is important in rehabilitation. Introducing a family-type diet at
an early stage of treatment is unlikely to permit catch-up growth because the traditional diet
usually does not provide enough energy and protein. There are two options:

1. Feed a high-energy formula until the child reaches his normal weight-for-height and then
transfer to a family-type diet as experienced in Jamaica.

2. Make an early transition to a modified family diet having a high energy and protein
concentration to support catch-up growth as evidenced in Bangladesh. Local
circumstances will influence which option is chosen. In the first option weight deficits
should be corrected in 4-6 weeks even in the most severe cases. The second option
provides an opportunity for catch-up growth and for demonstrating improved feeding
practices. This has been successful in India and Bangladesh for the home management
of malnutrition.

46
Where to Rehabilitate

1. In Hospital:

In many hospitals, treatment of severe acute malnutrition is unsatisfactory due to cross

infection and frequent relapses. Moreover, it is expensive and does not give a chance for
parental education:

Therefore, not all children with severe acute malnutrition should not be admitted to hospitals
merely for the purpose of feeding. Admission of children to a hospital be targeted to those
children with severe acute malnutrition plus other admission criteria (see Satellite module
for health officers section 2.10).

2. Home treatment programs alternative to conventional approach

As experienced in Bangladesh, even severe cases have been successfully rehabilitated at

home. But, this was successful only after one week of medical care to treat infections
and other complications. This method was also proved to be the most cost-effective, and
parents prefer the method, even though no food supplements were provided.
Treatment of children with SAM at home may be successful depending on the presence of
the following:
Reasonable home circumstance
A Willing caretaker
Regular home visits from a monitor
Close cooperation with NRU
Appropriately selected children may pass directly to phase 2
For phase & the child is fed a special dry diet ready to use therapeutic food
(RUTF) that is nutritional equivalent to f100 but can safely be given to the mother
at home (plumpy nut)

47
Table 12. Home management of a case of SAM
Phase Criteria for progress to the next Management
phase
Phase I Takes place NRU - Treatment of complication
(Management in - Need liquid milk - Dehydration is treated using
rehabilitation unit) - Are not alert (appear ill) ReSoMal
- Have complication - No iron
- Such as severe skin lesions - F75 = 100 kcal/kg/day
diarrhea, pneumonia, - A single dose of Vitamin A- 100,00
malaria or septic shock (for 6-12months) and 200,00IU (for >
- Have sever (Probable) 12 months)
moderate edema - Treat hypothermia, hypoglycemia and
- Are young infants dehydration (1 above)
- Do not have a willing care - Need to gain a weight of 5g/kg/day
taker - Antibiotics
- Do not have reasonable
home circum stances
- Patients who defaulted NRU
Phase 2 Alert children with good appetite - After ensuring that the patient is taking
(Home management) - A willing caretaker RUTF (plumpy) nut well, the care
- No complication taker is given sufficient packets of
- No grade ++ or +++ RUTF to provide approximately
edema 200kcal/kg/day for one week
- A family ration is given at the same
time from the SFC to ensure that the
therapeutic diet is given to the
malnourished patient
- In addition patients who are directly
admitted to home treatment are give
- A 1 week supply of amoxycilline
(3x/day)
- Single dose of vitamin A
- Single dose of folic acid
- Worm treatment( the doses are
the same as those used in the
conventional treatment)
NRU: Nutrition rehabilitation Unit

48
2. Day-care Nutrition Rehabilitation Centers (DCNRCs):-

Typically, these centers provide treatment for uncomplicated cases of acute malnutrition.
According to Bengoa's original concept, children receive 3 meals for 6 days of each week,
for 3-5 months, i.e. a period sufficiently long to enable parents to understand 'why' and 'how'
to improve infants' feeding practices. The primary long-term objective of DCNRCs is to
prevent malnutrition. In practice, this is often unpopular because of the time required by the
mothers/ caregivers to take the child to the center. In the Ethiopian context, day-care
nutritional rehabilitation centers that are attached to the health centers are organized in such
a way that children with severe acute malnutrition are brought to the center every 1-2 weeks
where the mothers/ care givers are provided nutrition education regarding how to prepare
nutritious food from locally available food stuffs and children are given supplementary
feedings.

3. Residential Nutrition Rehabilitation centers (RNRCs): -

These are usually convalescent centers for children treated initially in hospitals. Mothers
may accompany their children, e.g., in Kampala, where an intensive education programme
was provided. In Ethiopia, this approach is used in some areas under the NGOs. The
primary objective of this approach is preventative rather than curative, but again they may
be incompatible with the mother's other responsibilities.

2.11 Prevention of Acute and Chronic Malnutrition (Options for Intervention)

Many children attending outpatient clinics are malnourished. Prevalence of mild forms of
malnutrition like stunting and wasting is 40-50% while those severe cases is 5-10% in most
of the developing countries. If these cases of mild and moderate malnutrition are
recognized early enough by routine weight and height measurements (growth monitoring in
under five clinics) and relevant action taken, then severe malnutrition can often be
prevented easily.

It is not sufficient to treat only severe cases of malnutrition coming to the health institution,
as those coming to the health institution are the tips of an iceberg. Therefore, further
approaches at the grass root community level are required. The following are some of the
nutritional intervention approaches to be considered in the community.

49
2.11.1 Dietary Diversification and Nutrition Education

This approach focuses on educating mothers/care givers on the importance of having a

balanced diet through diversification of food. It also aims at the production foodstuffs at the
backyard garden and intensification of horticultural activities. The nutrition education should
focus on:
Cultural malpractice and beliefs in child feeding and weaning process, weaning foods,
exposure of children to sun light, time of weaning and food prejudices
Intra household mal-distribution of food (age and sex bias)

Fig.4: Mother breast-feeding her child

Effects of emotional deprivation and neglect on nutritional status of children and

proper child treatment practices
Importance of breast feeding
Hygiene (personal hygiene, food hygiene, environmental hygiene)
Importance of immunization
Importance of growing fruits and vegetables in the backyard garden and
consumption by the household members regardless of their age and sex.

Importance taking their children to health institutions for growth monitoring

Monitoring of the growth of children is very important for the following reasons:
Steady growth is the best indicator of childs health.

50
 Weight gain is the most sensitive measure of growth.
Serial measurement of weight is simple, universally applicable tool for assessing
growth.
Weight gain monitoring is the best method for early detection of health problems
whether from malnutrition or infection.

2.11.2 Dietary Modification:-

This approach focuses on modifying the energy, protein and micronutrient content of the
weaning foods. In order to reduce dilution of the energy and protein contents of the weaning
foods and their level of contamination, we need to educate mothers and demonstrate to
them the benefits of sprouting (germination) and fermentation. Fermentation renders the
food less contaminated probably because of acid formation as result. Using sprouted
(germinated) flour otherwise known as power flour or amylase rich flour (ARF) makes the
weaning food more liquid but less dilute. This is an attempt to reduce the problem of bulky
low -energy density weaning foods, which arise from the water holding capacity of cereals,
which makes them swell and become viscous upon cooking. This means that large volume
is required to satisfy their energy needs.

The upper limit of dry matter in a gruel made up of ordinary flour is 20 % (0.7-0.8 kcal/gram),
because beyond this level, the gruel would be too thick to stir. When germinated flour is
used or added to an already made thick gruel (up to even 30% solid concentration), the
meal becomes liquefied almost instantly. A meal prepared in this way with 25 to 30% dry
matter would have an energy density above 1 kcal/gram. This is an energy density
recommended for the weaning food on the basis that breast milk has an energy density of
0.7 Kcal/gram.

On top of this, supplementation of micronutrient like vitamin A and iron to children below five
years of age and fortification of salt with iodine could also be considered based on the local
needs.

2.11.3. Economic Approach:

This approach aims at improving the incomes of the target community as a solution to their
nutritional problems. It is considered usually in areas where there are many poor people and
if their purchasing power is low as in the case of urban slums and people displaced because
of war and other natural calamities. There are different methods in this approach: -

Food for work- This involves offering of some work for the poor people and paying them
off in terms of food. It is good in that it offsets seasonality in the dietary intake, but it is
donor dependent.

51
 Food subsidy- This involves subsidizing of either producers or consumers of food by
the government. Structural adjustment policies interfere with the materialization of this
approach.
Income generating projects- This method operates in some regions of Ethiopia and
involves development of income generating projects in the community to make them
generate fund for buying food. It includes organizing the community and using their
potentials in the running of the project. The projects could be weaving, pottery, Bee
keeping, etc. This approach needs a good feasibility study on how the income generated
is used, the sustainability of the programme, etc.
The above approaches could be used either simultaneously where it applies or
independently. This should be determined by doing a thorough Strength, weakness,
opportunities and constraints (SWOC) analysis.

Surveillance

Targets for surveillance:- Infants & child growth monitoring and promotion(GMP) activities
need to carried out in an integrated manner with other PHC services. Missed opportunities
for GM should be fully utilized in such a way that children coming to the health institutions for
other purposes are covered in the growth monitoring (GM) activities. Besides, every child
should be regularly monitored for growth performance (growth take up) every month. Triple
A cycle (assessment, analysis and action) be employed in effecting GM activities.

Assessment includes regular measurement of weight &heights of < 5 children and

comparing their growth with the standard growth curve.
Analysis of the direction of growth performances of children and discussion of the
possible causes and solutions with the mother/care taker
Action involves counseling on optimal infant and young child feeding practices as
nutritional intervention to curb the problems (working out the feasible solution with the
mother/care taker. We use the principle of change model of behavior change
communication (BCC)(see the BCC module for details).

The action may include rehabilitation of severely malnourished children and following them
up and micronutrient supplementation, Nutrition education on importance of backyard
gardening & horticultural activity, dietary diversification, breast feeding and proper child
feeding practices. All interventions will focus on the seven essential nutrition actions for
better result. The seven components of essential nutrition actions approach include:
1. Exclusive breast feeding for the first 6 months
2. Optimal complementary feeding after six months with continuation of breastfeeding
up to two years or beyond

52
 3. Appropriate sick child feeding
4. Maternal nutrition during pregnancy and lactation
5. Prevention of vitamin A deficiency
6. Prevention of Iodine deficiency disorders
7. Prevention of Iron deficiency anemia

These seven essential actions could be addressed during the six critical contacts of infants,
mothers and young children with the health service units, which include:

1. Pregnancy during antenatal care contact

2. Delivery
3. Postal natal care and family planning
4. Immunization
5. Growth monitoring and promotion & well baby clinic visit
6. Sick child visit

However essential nutrition action approach contacts can further be extended beyond the
regular contacts of women and children with the health service units. It could be delivered
integrated with: school health programs, national immunization days, EPI + programs, IMCI
and other child survival programs and reproductive health services. The same essential
action should be considered during emergency situations.

Preparation Nutritious Food from Locally Available Food Staffs

Balanced diet can be prepared by mixing different locally available foodstuffs. For
Example the requirements for protein, energy and other micronutrients of children by
preparing a diversified diet as following: -
1. Quadri mix---staple+ animal protein + plant protein + leafy vegetable
2. Triple Mix---Staple +animal protein + plant protein or leafy vegetables
3. Double mix--- staple + animal protein or plant protein or leafy vegetable

Parents / caregivers need to be instructed how to modify the protein, energy and other
nutrient contents of the locally available foodstuffs used in complementary feeding of
children after 6 months (See Dietary modifications, in part 2.11.2).

Nutritional Surveys

Community based nutritional surveys including anthropocentric measurements and dietary

consumption surveys need to be carried out among under five children in order to early
detect the occurrence of nutritional problems in the community. Nutrition surveillance

53
activities should carefully monitor the occurrence of acute malnutrition and trends of the
chronic one to avail information for proper planning.

2.12 Learning Activities (Case Study) Continued

Based on the story of health workers in Jiren community, different points of discussion have
been incorporated in the respective satellite modules. Therefore, the students are advised to
refer to the questions in satellite modules for each professional category and discuss them
in the class under the coordination of their facilitator.

54
 UNIT THREE

SATELLITE MODULES

3.1 SATELLITE MODULE FOR HEALTH OFFICERS

3.1.1 INTRODUCTION

3.1.1.1. Purpose and Use of the Module

The ultimate purpose of this training module is to produce Competent Health Officers who
can effectively manage and provide care for cases of severe acute malnutrition both in
clinical and community settings.

3.1.1.2 Direction for Using the Satellite Module

This satellite module can be used in the basic training of Health Center team particularly
health officers who are either already in the service or in the training programs. In order to
make maximum use of the satellite module, the health officer should follow the following
directions
Evaluate your self by doing the pre-test pertinent to your category under section
2.1.2.1 before going through the satellite module and evaluate your self by referring
to the answer keys given in the unit 7 section 7.1.1
Check or read the core module very thoroughly
Read the case study and try to answer questions pertinent to it
Use listed references and suggested reading materials to supplement your
understanding of the problem.
For total and comprehensive understanding of the causes, etiology, pathogenesis,
Epidemiology and prevention of acute and chronic malnutrition, the health officer
students are advised to refer to the core module.
After going through this module evaluate yourself by doing post-test and comparing
your score with the key given in unit 7 section 7.2.1

55
3.1.2. SATELLITE MODULE FOR HEALTH OFFICER
3.1.2.1. Pre and Post Test for the Satellite Module of Health Officers
See the pre- and post-tests for the health officers in the core module under unit 2, section
2.1.2.1

3.1.2.2 Significance and Brief Description of the Problem

See the part under unit 2 section 2.2 in the core module

3.1.2.3 Learning Objectives

For effective management a case of acute and chronic malnutrition (ACM), the health officer
student will be able to do the following at the end of the training
1. Demonstrate the process of assessing a child with ACM
2. Identify and describe the clinical manifestations/complications in a child with ACM
3. List the diagnostic methods and procedures for a case with ACM
4. Describe the principles and methods of treatment of ACM
5. List the indications for admission of a case of ACM for inpatient management
6. Identify and manage or refer timely when needed, a case of ACM
7. Demonstrate the appropriate management of case of ACM
8. Describe proper follow up of a case of ACM

Case Study: Learning Activity

Read the story of health professionals in Jiren again in the core module very thoroughly so
that you will be able to answer questions pertaining to it in section 2.12 of this module.

3.1.2.5 Definition
Refer to the core module unit 2 sections 2.5
3.1.2.6 Epidemiology
Refer to the core module unit 2 sections 2.6

3.1.2.7 Causes, Etiology and Pathogenesis

Refer to unit 2 section 2.7 of the core module

56
3.1.2.8 Clinical features (Symptoms and Signs)
The clinical features of SAM depend of its type. The severest clinical types include:
Marasmus, kwashiorkor and features of both called marasmic- kwashiorkor. The following
clinical symptoms and signs characterize them:

Kwashiorkor
Growth failure Marasmus
Wasting of muscles and preservation of Growth retardation
subcutaneous fat
Wasting of subcutaneous fat and
Edema (pitting type)
muscles (flabby muscles)
Fatty liver (hepatomegaly)
Weight is more effected than Height
Psychomotor retardation (difficulty of walking)
Wizened monkey (old man face)
Moon face due to hanging cheeks as a result
of edema and preserved subcutaneous fat. Sunken eye balls
Anorexia Increased appetite
Apathetic, miserable and have poor interest in Mood change (always irritable)
the surrounding
Mild skin and hair changes
Skin changes
Desquamation, De-pigmentation, Hypo-
pigmentation, Flaky paint dermatosis
especially on pressure areas, Hyper Chronic
pigmentation (mosaic or cracked skin)
especially on the head Insult to the brain
Hair changes development leading to Low
De-pigmentation, straightening of hair and school performance and
presence of different color bands of the hair
indicating periods of malnourishment and well impaired IQ (Severe stunting is
nourishment (flag sign) associated with reduction in IQ
Persistent lanugo hair, Long eye lashes, Gray by 5-10 points.
and easily pluckable hair
Straightening of hair at the bottom and curling Stunting and ending up in
on the top giving an impression of a forest short adult
(Forest sign)
With low fitness for physical
Acute and chronic complications of malnutrition activity and this s perpetuated
Acute through intergenerational cycle of
Electrolyte imbalance malnutrition
Diarrhea, dehydration and shock
Hypoglycemia
Hypothermia
Sepsis

57
3.1.2.9 Diagnosis of Acute and Chronic malnutrition
The clinical work up of cases of PEM mainly focuses on four factors, which do contribute to
accurate diagnosis and management. These are:-
1. Detailed history--pertinent to child feeding practices, weaning conditions, staple diet
and other relevant history on the socio-cultural, environmental and other predisposing
factors
2. Meticulous physical examination--of all systems of the body
3. Anthropometric assessment--Measurement of weight and height of children and
comparing it with the standard according to Gomez and Welcome classifications)
4. Epidemiological considerations--information regarding the age, sex, birth weight,
height, season, existence of epidemics, drought and other natural and man made
calamities will have to be assessed critically.
5. Laboratory findings--determination of albumin level or pre-albumins like retinal binding
proteins, etc. in the plasma may give some clues, but the diagnosis can be done without
laboratory investigations. Laboratory investigations for the diagnosis of concurrent
infections, micronutrient deficiencies like anemia are important to consider.

3.1.2.10 Case Management

Management of a case of a of severe acute malnutrition focuses on the correction of specific

nutrient deficiencies (dietary management), treatment of complications and superimposed
infections. The treatment approach is classified into two phasesThe acute stabilization
phase in which the main focus is treatment of infection and other complications like
dehydration, hypoglycemia, hypothermia and other electrolyte imbalances. The stabilization
phase focuses on the restoration of the lost tissue and promotion of catch up growth.

58
The ten steps in the management of a child with severe acute malnutrition developed by
Ashworth and Feachem are depicted in the following table.

Steps of Management Duration over which the interventions be started and continued
Day 1-2 Day 2-7+ Week 2-6
1.Hypoglycemia -------------
2. Hypothermia ----------->
3. Dehydration ----------->
4. Electrolytes ------------------- ---------------------------------------------------------->
5. Infection ----------------------------->
6. Micronutrients. ------------------- --- no iron-------------------with iron---------------->
7. Initiate feeding -------------------------------------->
8. Catch-up growth ------------------------------->
9. Sensory stimulation ---------------------------------------------------------->
10.Prepare for -------------------------------->
follow-up

The treatment procedures are the same for Marasmus and kwashiorkor.

Dietary Management

1. Acute Phase

Children are most at risk of dying during the acute phase. Dehydration, infection and severe
anemia are the main dangers. In SAM, cardiac and renal functions are impaired and in
particular malnourished children have a reduced capacity to excrete excess water and a
marked inability to excrete Sodium. The amount of fluid given and the Sodium load must
be, carefully controlled to avoid cardiac failure. A cautious approach is required, aiming at
about 100kcal/kg/d and 1.15g of protein/kg/d.

Schedule for Oral Feeding in the First Week

Day Number of Volume Energy Protein

Feeds/per day Per feed (Ml/Kg) Kcal/kg/day Gram/kg/Day
1-2 12 11
3-5 8 16 100 1.0
6-7 6 22

59
Small frequent feeds are ideal as they reduce the risks of diarrhea, vomiting, hypoglycemia
and hypothermia. Refer to the core module section 2.10 for the to give additional Potassium
4mmol/kg/d, Magnesium 2mmol/kg/d, and Zinc 2mg preparation of the maintenance
formula. It is important /kg/d), Copper 0.2mg/kg/d and a multivitamin preparation and folic
acid.

2. Phase 2
Refer to the core module section 2.10
Inpatient Management of PEM: -
In many hospitals and health centers, treatment of SAM as inpatient is unsatisfactory and
relapses are frequent. Attention needs to be given to: -
a) Reducing mortality through: rehydration, treatment of infection, and small frequent
feeds.
b) Reducing length of stay: through administration of high-energy feeds in the rehabilitation
phase.
d) Reducing relapses through: parental education, follow up, improvement of family
resources.
e) Not all children with severe acute malnutrition are admitted to hospitals merely for the
purpose of feeding. Admission of children to a hospital is targeted to those children with
SAM plus other conditions stipulated below. A child with severe acute malnutrition
(weight for height < 60%) and the following conditions should be admitted to a hospital
or health center for inpatient management. For details, see 7.3

3.1.2.11 Prevention of Protein Energy Malnutrition (Options for

Intervention)
Parental education on child feeding practice, importance of bringing their under five children
to the nearby health institutions every month in the first 1 year, every 2 months in the
second year 3 month then after for growth monitoring and follow up, the importance of
immunization and personal, food and environmental hygiene are critically important in
averting the occurrence and recurrence of protein energy mal nutrition. For further details
refer to the core module unit 2, section 2.11.

3.1.2.12 Learning Activities (Case Study) Continued

Refer to story of health professionals in the core module and discuss on the following
questions in the class. The instructor can assist you.
1. What pertinent history do you ask parents of children in the Jiren community?

60
 2. What pertinent physical signs would you look for?
3. What laboratory investigations would you order in order?
4. What other assessments do you carry out in order to determine the type of
malnutrition? What is your diagnosis from the story?
5. What other causes do you consider for the differential diagnosis?
6. What complications do you expect from malnutrition of such kind?
7. What are the risk factors for the development of malnutrition?
8. How would you manage the problem of Almaz?
9. What are the preventive measures for malnutrition?

3.1.2.13 Post Test

See the pre and posttest in the core module pertaining to health officers unit 2 section
2.1.2.1

3.1.2.14 Role and Task Analysis

Refer to unit 4 of the core module for the tasks expected of you.

3.1.2.15 Glossary and Abbreviations

Refer to unit 5 of the core module
3.1.2.16 References
Refer to unit 6 of the core module

3.1.2.17 Annexes
Refer to unit 7 of the core module for answer keys and other materials

61
3.2 SATELLITE MODULE FOR PUBLIC HEALTH NURSES
3.2.1. INTRODUCTION

3.2.1.1. Purpose and Use of the Module

The purpose of this satellite module is to equip students (trainees) with knowledge and skills
required to identify and manage effectively cases of severe acute malnutrition. The public
health nurses can use this satellite module in their pre-service or in-service training
programs.

3.2.1.2 Direction for Using the Satellite Module

For a better understanding of this module, the public health nurses are advised to follow the
following directions.
Do the pretest pertinent to your field in unit 2 section 2.1.2.2 of the core module
Read or refer the core module thoroughly
Read the story of health workers in Jiren community and try to address the question
relevant to you.
Evaluate yourself by doing posttests and comparing your score by referring to the key
given unit 7 section 7.2.2.

3.2.2. SATALLITE MODULES FOR PUBLIC HEALTH NURSES

3.2.2.1 Pre and Posttest

See the core module unit 2, section 2.1.

3.2.2.2 Significance and Brief Description of the Problem

See the core module unit 2, section 2.2

3.2.2.3 Learning Objectives

The main objectives of this satellite module is to equip the students or trainees with the
appropriate knowledge, and skills required to effectively identify and manage cases as well
as prevent and control acute and chronic malnutrition.

62
3.2.2.4 Case Study: Learning Activities
Read the story of health workers in Jiren community so that you will be able discusses
questions in section 2.12 of this module.

3.2.2.5 Definition
Refer to the core module unit 2, section 2.5

3.2.2.6 Epidemiology
Refer to the core module unit 2, section 2.6
3.2.2.7 Etiology and Pathogenesis
Refer to the core module unit 2, section 2.7

3.2.2.8 Clinical Features (Symptoms and Signs)

Refer to the core module unit 2, section 2.8

3.2.2.9 Diagnosis
Refer to the core module unit 2, section 2.9

3.2.2.10 Case Management

The nurse in the nutrition support team plays a central role in client care, management and
client relationship. As a team member, the public health nurse also coordinates client care
when discharged home on special support, teaches them how to follow their feeding
programs and provide them all the supplies and equipment needed. The nurse makes
arrangements for follow up care if necessary and is usually available to answer questions of
clients receiving home nutrition support.

3.2.2.10.1 Role of a Nurse in Helping the Sick Child to Eat

Sick children often require special care. Therefore, those who care for children must be
sensitive to their needs and feelings.
1) Notice the childs body posture. The body language will tell a childs feeling of pain or
discomfort.
2) Touch the child often and lovingly. Your touch communicates more than your words.
3) As adults, let the child choose what to eats as much as possible
4) Notice whether the child eats the food. Putting a tray of food in front of a child is not
enough.

63
5) Stay with the child during the meal or make sure a loved person is there. The child
will eat and assimilate food better if a caring person soothes anxiety and loneliness
away.
6) Encourage the child to eat the most nutritious foods first before they become too full
to complete the meal.
7) Let the child eat with other children if possible. They will enjoy meal times more,
accept more food and eat for longer periods.

3.2.2.10.2 Responsibilities of Public Health Nurse in Managing severe acute

malnutrition (SAM)

The nursing management of PEM consists of providing nutrition rich in the essential
nutrients to correct the dietary insufficiency and to promote normal growth and development.
The digestive capacity of malnourished child is poor. As a result oral feedings are given in
small frequent amounts, limited in proteins and carbohydrates especially fats that are hard to
digest.
In addition, the nurse is responsible for:
1. Maintaining the childs body temperature within a normal range.
2. Providing periods of rest and appropriate activity.
3. Providing stimulation
4. Recording intake, out put and daily weight
5. Turning position in bed frequently.
6. Preventing bedsore and infection by keeping the skin clean and dry.
7. Providing appropriate treatment of bedsore and oral trash if any.
8. Administering iron and folic acid to correct the accompanying anemia.
9. Diluting liquid iron preparations and giving through a straw to prevent staining of
tooth enamel

3.2.2.10.3. The PHN is Responsible for Advising the Mother to:

Provide sufficient iron containing foods such as liver, read meat, fish and legumes.
Prevent non-compliance with iron therapy by reminding that stools will change in
color when taking iron preparations.
Provide the child the type and amount of food recommended for his age as often as
recommended even if the child does not eat much.
Offer the childs favorite foods, if possible to encourage eating.
Avoid bottle-feeding if used and replace by cup and spoon-feeding.

64
 Return for follow up visit after 30 days or earlier if there is feeding problem.

3.2.2.11 Prevention and Interventions

The public health nurses should advise the mothers/care givers of malnourished children to
come for regular check up (growth monitoring) and vaccination to prevent the occurrence
and recurrence of mal nutrition. They should be advised about proper child feeding
practices. During the follow up visit, if the recommended changes in childs feeding are
helping, encourage the mother to continue accordingly, but if the child is continuing to loss
weight and no change in feeding seems likely, discuss with the other team members mainly
the health officers for further management.

3.2.2.11.1 Education to Improve Nutrition

This involves teaching all sections of the community, especially fathers and mothers, to
make the best use of the foods available (including breast-feeding), to make use of available
primary health care services, and to grow local foods in their own gardens.

3.2.2.11.2 Practical Nursing for Improving Nutrition

There are seven rules, which, if kept, can largely improve nutritional status in the community.
1) Identify the local sources of foodstuffs
2) Recognize the causes of improper feeding in the community
3) Explain the effects of improper feeding on different age groups.
4) Teach nutritional values of local foodstuffs.
5) Demonstrate how to cook balanced meals using locally available foodstuffs
6) Teach food hygiene in the home
7) Evaluate what the community members have learnt about improved nutrition

3.2.2.11.3 Practical Nursing for Infant Feeding

There are five rules that can largely prevent malnutrition in educating mothers or other
caregivers in-group or individually
1. Breast-feed at least until 1-2 years
2. Start thick porridge, paste or gruel at 4 months and continued breast-feeding
3. Use all available animal food sources
4. Use vegetable (cereals & legumes) mixture.
5. Give children four good meals a day

65
3.2.2.12 Learning Activities (Case Study) Continued

Refer to the story of health workers in Jiren community in the core module and discuss on
the following questions in the classroom. The instructor will help you.
1) What types of major health problems did the health center team identify in that
particular community?
2) What fundamental intervention programmes need to be planned by the health
workers in general?
3) Who should be involved in identifying and prioritizing the health problems for better
intervention and good outcome?
4) What is expected from the health workers to do in similar circumstances?
5) What hygienic behaviors and practices would bring changes and improve the health
of the community?
6) What type of worm is common to all children in the community?
7) What basic things were thought by the nurse in-order to help children to grow
healthier and to prevent parasitic diseases as much as possible?
8) What will happen to children if they do not get the necessary nutrients?
9) What could be the role of public health nurse in promotion of health and prevention of
diseases in the community?

66
3.3 SATELLITE MODULE FOR MEDICAL LABORATORY
TECHNICIANS

3.3.1. INTRODUCTION
3.3.1.1 Purpose of the Module
This module helps laboratory technicians to participate in the team management of protein
energy malnutrition, with a particular emphasis on the laboratory investigations of
malnutrition, associated infections and other complications.

3.3.1.2. Direction for Using the Satellite Module

Therefore, for a better understanding of this module the laboratory technicians are advised
to follow the following directions.
Do the pretest in your profession in unit 2, section 2.1.2.3 of the core module
Read the core module thoroughly
Use listed references and suggested reading materials to substantiate your
understanding of the problem
Evaluate yourself by doing the post test and referring to the keys given in unit 7
section 7.1.2.3

3.3.2.1. Pretest
Refer to the pre and post test in the core module unit 2 section 2.1.2.3

3.3.2.2. Significance and Brief Description of the Problem

See the core module unit 2 section 2.2.

3.3.2.3. Learning Objectives

After completion of this module students will able to:
Describe how to collect, handle and label blood specimens
Describe routine concept of laboratory diagnosis of malnutrition
Describe and demonstrate the laboratory procedures for hemoglobin determination
using Sahli-Hellige method
Describe and demonstrate how to prepare and stain thin blood film for red blood cell
morphology

67
 Demonstrate how to assess stained thin blood films including elements of the
blood films other than red cell morphology (e.g. haemoparasites)
Classify anemia based on red blood cell morphology and measured
hemoglobin

3.3.2.4. Learning Activities: Case Study

Read the story of health professionals in Jiren the core module very thoroughly so that you
will be able to answer questions pertaining to it in section 2.12 of this module.

3.3.2.5. Definition
Refer to the core module unit 2 sections 2.5.

3.3.2.6 Epidemiology
Refer to the core module unit 2 sections 2.6.

3.3.2.7 Cause, Etiology and Pathogenesis

Refer to the core module unit 2 sections 2.7.

3.3.2.8 Clinical Features

Refer to the core module unit 2 sections 2.8.

3.3.2.9 Diagnosis

3.3.2.9.1 Blood Collection

The proper collection and reliable processing of blood specimens is a vital part of the
laboratory diagnostic process in hemoglobin determination. This helps to assess the
morphology of red blood cells in thin blood film and to know the level and type of anemia in
relation to severe acute malnutrition. Unless an appropriately designed procedure is
observed and strictly followed, reliability cannot be ensured on subsequent laboratory results
even if the test itself is performed carefully.

3.3.2.9.2 Biohazard Safety

All material of human origin should be regarded as capable of transmitting infection.

Specimens from patients suffering from, or at risk of, hepatitis or human immunodeficiency
virus (HIV) infection require particular care. When collecting blood sample, the operator

68
should wear disposable rubber gloves. The operator is also strongly advised to cover any
cuts, abrasions or skin breaks on the hand with adhesive tape and wear gloves. Care must
be taken when handling especially, syringes and needles as needle-stick injuries are the
most commonly encountered accidents. Do not recap used needles by hand. Should a
needle-stick injury occur, immediately remove gloves and vigorously squeeze the wound
while flushing the bleeding with running tap water and then thoroughly scrub the wound with
cotton balls soaked in 0.1% hypochlorite solution.

Used disposable syringes and needles and other sharp items such as lancets must be
placed in puncture-resistant container for subsequent decontamination or disposal. Blood
sources for hematological tests are:
Capillary/peripheral blood
Venous blood

3.3.2.9.3 Blood Collection

3.3.2.9.3.1 Capillary/Peripheral Blood or Micro Blood Samples

This is frequently used when only small quantities of blood are inquired, e.g., for Hemoglobin
quantitation, and for blood smear preparation. It can be collected from palmar surface of the
tip of the ring or middle finger or free margin of the ear lobe in adults and plantar surface of
the big toe or the heel in infants and small children.
Notes: -
Edematous, congested and cyanotic sites should not be punctured.
Cold sites should not be punctured as samples collected from cold sites give falsely
high results of hemoglobin and cell counts. Site should be massaged until it is warm
and pink.

Materials:

- Gauze pads or cotton,

- 70% alcohol,
- Sterile disposable lancet

Technique:

Rub the site vigorously with a gauze pad or cotton moistened with 70% alcohol to remove
dirt and epithelial debris and to increase blood circulation in the area. If the heel is to be
punctured, it should first be warmed by immersion in warm water or applying a hot towel

69
compress. Otherwise values significantly higher than those in venous blood may be
obtained.

After the skin has dried, make a puncture 2-3mm deep with a sterile lancet. A rapid and firm
puncture should be made with control of the depth. A deep puncture is no more painful than
a superficial one and makes repeated punctures unnecessary. The first drop of blood, which
contains tissue juices, should be wiped away. The site should not be squeeze or pressed to
get blood since this dilutes it with fluid from the tissues. Rather, a freely flowing blood should
be taken or a moderate pressure some distance above the puncture site is allowable.

Stop the blood flow by applying slight pressure with a gauze pad or cotton at the site.

3.3.2.9.3.2 Venous Blood Collection

It is used when larger quantity of blood is required. E.g. serum albumin. It can be collected
from forearm, wrist or ankle. In infants and children, veni-puncture presents special problems
because of the small size of the veins and difficulty controlling the patient. Puncture of the
external jugular vein in the neck region and the femoral vein in the inguinal area is the
procedure of choice for obtaining blood.

Materials:

- Sterile syringe and needle,

- Tourniquet,
- Gauze pads or cotton,
- 70% alcohol,
- Test tubes without anticoagulant.

Technique:

1. Assemble the necessary materials and equipment. Remove the syringe from its
protective wrapper and the needle from the cap and assemble them allowing the cap
to remain covering the needle until use. Attach the needle so that the bevel faces in
the direction as the graduation mark on the syringe. Check to make sure the needle is
sharp, the syringe moves smoothly and there is no air left in the barrel. The gauge and
the length of the needle used depend on the size and depth of the vein to be
punctured. The gauge number varies inversely with the diameter of the needle. A 20 or
21 gauge needle should be used in children and infants whose veins are not well
developed.
2. Identify the patient and allow him/her to sit comfortably preferably in an armchair
stretching his/her arm.

70
3. Prepare the arm by swabbing the ante-cubital fossa with a gauze pad or cotton
moistened with 70% alcohol. Allow it to dry in the air or use a dry pad or cotton. The
area should not be touched once cleaned.
4. Apply a tourniquet at a point about 6-8cm above the bend of the elbow making a loop
in such a way that a gentle tug on the protruding end will release it. It should be just
tight enough to reduce venous blood flow in the area and enlarge the veins and make
them prominent and palpable. The patient should also be instructed to grasp and open
his/her fist to aid in the build up of pressure in the area of the puncture. Alternatively,
gently tapping the antecubital fossa or applying a warm towel compress can visualize
the veins.
5. Grasp the back of the patients arm at the elbow and anchor the selected vein by
drawing the skin slightly taut over the vein.
6. Using the assembled syringe and needle, enter the skin first and then the vein. To
insert the needle properly into the vein, the index finger is placed along side the hub of
the needle with the bevel facing up. The needle should be pointing in the same
direction as the vein. The point of the needle is then advanced 0.5-1.0cm into the
subcutaneous tissue (at an angle of 450) and is pushed forward at a lesser angle to
pierce the vein wall. If the needle is properly in the vein, blood will begin to enter the
syringe spontaneously. If not, the piston is gently withdrawn at a rate equal to the flow
of blood. The tourniquet should be released the moment blood starts entering the
syringe/vacuum tube since some hemo-concentration will develop after one minute of
venous stasis.
7. Apply a ball of cotton to the puncture site and gently withdraw the needle. Instruct the
patient to press on the cotton.
8. With the syringe and needle system, first cover the needle with its cap, remove it from
the nozzle of the syringe and gently expel the blood into a tube without anticoagulant
and Stopper the tube. Label the tubes with patients name, hospital number and other
information required by the hospital.
9. Rei-nspect the veni-puncture site to ascertain that the bleeding has stopped. Do not let
the patient go until the bleeding stops

3.3.2.9.4. Estimation of hemoglobin by the Acid Hematin Method of Sahli-

Hellige

Principle: -
Hemoglobin in a sample of blood is converted to a brown colored acid hematin by treatment
with 0.1 N HCl and after allowing the diluted sample to stand for 5 minute to ensure

71
complete conversion to acid hematin it is diluted with distilled water until its color match as
with the color of an artificial standard (tinted glass).

Materials:-

Sahli Hemoglobinometer

1 Sahli pipettes that measures 20l (0.02ml)

2. Stirring glass rod
3. Absorbent cotton
4. 0.1N HCl
5. Dropping pipette

Technique:

Fill the graduated Sahli tube to the 20 mark of the red graduation/or 39% mark of the yellow grad
with 0.1 N HCl using the dropper provided. Take a well-mixed venous blood or capillary blood
from a freely flowing skin puncture to the 20 mark of the Sahli pipette. Wipe the outside of the
pipette with a piece of cotton. Check that the blood is still on the mark. Blow the blood from the
pipette into the tube of acid sol. Rinse the pipette by drawing in and blowing out the acid sol. 3
times. Avoid the formation of bubbles. The mixture of blood and acid gives a brownish, color.
Allow standing for 5 minutes. Place the graduated tube in the hemoglobinometer. Stand facing
a window. Compare the color of the tube containing diluted blood with the color of the standard
glasses. If the color of the sample is darker than that of the standard glasses, continue to dilute
by adding 0.1NHCl or distilled water drop by drop. Stir with the glass rod with adding each drop.
Remove the rod and compare the colors of the sample and standard stop when the colors
match. Note the mark reached. Depending on the type of hemoglobinometer, this gives the
hemoglobin concetration either in g/dl or as a percentage of normal. To convert the percentage
to g/l, multiply by 1.46.

Normal Range of Hemoglobin at Different age Groups Emoglobin in Mg/DL

Children at birth 13.6-19.6

Children at 1 year 11.3-13.0
Children, 10-12 years 11.5-14.8
Women 11.5-16.5
Men 13.0-18.0

72
3.3.2.9.5 Preparation, Staining and Examination of Peripheral Blood Film

3.3.2.9.5.1 Preparation of Thin Blood Film

Examination of the blood film is an important part of the hematological evaluation and the
validity or reliability of the information obtained from blood film evaluation, the differential
leukocyte count in particular depends heavily on well-made and well-stained films.

If not made from skin puncture, films should be prepared within 1 hour of blood collection
into EDTA. Adequate mixing is necessary prior to film preparation if the blood has been
standing for any appreciable period of time.

A thin blood films can be prepared on glass slides or cover glasses. The latter
has the single most important advantage of more even distribution of leucocytes.

Preparation of blood films on glass slides has the following advantages:

Slides are not easily broken
Slides are easier to label
When large numbers of films are to be dealt with, slides will be found much easier to
handle.

Technique: The Two-Slide or Wedge Method

A small drop of blood is placed in the centerline of a slide about 1-2cm from one end.
Another slide, the spreading slide placed in front of the drop of blood at an angle of 300 to
the slide and then is moved back to make contact with the drop. The drop will spread out
quickly along the line of contact of the spreader with the slide. Once the blood has spread
completely, the spreader is moved forward smoothly and with a moderate speed. The drop
should be of such size that the film is 3-4cm in length (approx. 3/4th of the length of the
slide). It is essential that the slide used as a spreader have a smooth edge and should be
narrower in breadth than the slide on which the film is prepared so that the edges of the film
can be readily examined. It can be prepared in the laboratory by breaking off 2mm from both
corners so that its breadth is 4mm less than the total slide breadth. If the edges of the
spreader are rough, films with ragged tails will result and gross qualitative irregularity in the
distribution of cells will be the rule. The bigger leucocytes (neutrophils and monocytes) will
accumulate in the margins and tail while lymphocytes will predominate in the body of the
film. The ideal thickness of the film is such that there is some overlap of the red cells through
out much of the films length and separation and lack of distortion towards the tail of the film.

73
Thickness and length of the film are affected by speed of spreading and the angle at which
the spreader slide is held. The faster the film is spread the thicker and shorter it will be. The
bigger the angle of spreading the thicker will be the film. Once the slide is dry, the name of
the patient and date or a reference number is written on the head of the film using a lead
pencil or graphite. If these are not available, writing can be done by scratching with the edge
of a slide. A paper label should be affixed to the slide after staining.

3.3.2.9.5.2. Staining of Thin Blood film with Romanowsky Dyes

Modern Romanowsky stains are common (e.g., Wrights) containing an acidic component
(eosin B) and a basic component (ethylene blue).

Wrights Stain

It is purchased as a solution ready to use or as a powder 1gm of which is carefully dissolved

in 600ml of methyl alcohol and then filtered before use.

Staining Method
1. Place the air-dried smear film side up on a staining rack (two parallel glasses rods kept
5cm apart).
2. Cover the smear with undiluted stain and leave for 1 minute. The methyl alcohol fixes
the smear. When it is planned to use an aqueous or diluted stain, the air dried smear
must first be fixed by flooding for 3-5 minutes with absolute methanol. if films are left
unfixed for a day or more, it will be found that the background of dried plasma stains
pale blue and this is impossible to remove Without spoiling the staining of the blood
cells.
3. Dilute with distilled water (approximately equal volume) until a metallic scum appears.
Mix by blowing. Allow this diluted stain to act for 3-5 minutes.
4. Without disturbing the slide, flood with distilled water and wash until the thinner parts of
the film are pinkish red.
5. Place the slide on end to dry.

Appearance of cells and cell components in Romanowsky-

Stained blood films

Films stained with Wrights stain are pinkish in color when viewed with the naked eye.
Microscopically,
Red cells - pink with a central pale area
Nuclei of leukocytes - blue to purple
Cytoplasmic neutrophilic granules - tan
Eosinophilic granules - red orange each distinctly discernible

74
 Basophilic granules - dark blue
Cytoplasm of monocytes - faint blue gray
Platelets - violet granules
Malaria parasites - sky blue cytoplasm and red purple chromatin

3.3.2.9.5.3 Examination of Stained Thin Blood Films

Examination of stained thin blood film helps for Morphologic classification of anemia and is
considered to be the most appropriate and practical way for the correct appraisal of red cell
morphology.

1. Normocytic Normochromic Anemia

There is normal sized RBC with normal hemoglobinization. Mean cell volume (MCV), Mean
cell hemoglobin (MCH) and Mean cell hemoglobin concentration (MCHC) are normal. This is
caused by increased red cell loss, blood loss, blood loss anemia, and hemolytic anemia

2. Microcytic Hypochromic Anemia

These are small, incompletely hemoglobinized red cells. MCV, MCH and MCHC are
decreased. It is caused by iron deficiency anemia

3. Macrocytic Normochromic Anemia

There are large red cells with MCV, MCH increased. It is caused by folic acid and/or vitamin
B12 deficiency.

3.3.2.9.6. The Differential Leukocyte Count

It is the enumeration of the relative proportions (percentages) of the various types of white
cells as seen on stained films of peripheral blood. The count is usually performed by visual
examination of blood films, which are prepared on slides by the wedge technique. For a
reliable differential count the film must not be too thin and the tail of the film should be
smooth. To achieve this the film should be made using a smooth glass spreader. This should
result in a film in which there is some overlap of the red cells diminishing to separation near
the tail and in which the white cells on the body of the film are not too badly shrunken. If the
film is too thin or if a rough-edged spreader is used, 50% of the white cells accumulate at the
edges and in the tail and gross qualitative irregularity in distribution will be the rule. The
polymorphonuclear leucocytes and monocytes predominate at the edges while much of
smaller lymphocytes are found in the middle.

75
3.3.2.9.6.1 Methods of Counting

Various systems of performing the differential count have been advocated. The problem is to
overcome the differences in distribution of the various classes of white cells, which are
probably always present to a small extent even in well-made films.
The lateral strip (crenellation) pattern of differential counting is the most routinely used
pattern and in this method the field of view is moved from side to side across the width of the
slide in the counting area just behind the featheredge where the cells are separated from
one another and are free from artifacts. Multiple manual registers or electronic counters are
used for the count.

N.B: The following elements of the blood film must be observed while performing the
differential count.

Erythrocytes: size, shape, degree of hemoglobinization presence of inclusion bodies

The presence of atypical lymphocytes
Haemoparasites: malaria, borrelia, babesia, microfilariae, trypanosoma, etc.

3.3.2.9.6.2. Reporting the Differential Leukocyte Count

The differential leukocyte count could be expressed as the percentage of each type of cell or
it could be related to the total leukocyte count and the results reported in absolute numbers.

3.3.2.9.6.3 Normal Differential Ranges:

1-4 years 10 years Adults

Neutrophils 36-48% 45-55% 55-65%
Eosinophils 2-5% 2-5% 2-4%
Basophils 0-1% 0-1% 0-1%
Lymphocytes 44-54% 38-45% 25-35%
Monocytes 3-6% 3-6% 3-6%

3.3.2.9.6.4 Interpretation: -

The relative lymphocyte count is increased above 8.0 x 109/l in children in viral causes of
infections in protein energy malnutrition (e.g., measles), in chronic infections (e.g.,
Tuberculosis, malaria).

76
3.3.2.9.7 Measurement of Serum or Plasma Albumin
Serum or plasma albumin levels are mainly measured to investigate liver diseases, protein
energy malnutrition, and disorders of water balance, nephrotic syndrome, and protein-losing
gastrointestinal diseases.

Method

The bromocresol (BCG) binding method is recommended as a manual colorimetric

technique for measuring serum or plasma albumin.

Principle of the BCG Albumin Method

Bromocresol green is an indicator, which is yellow between pH 3.5-4.2. When it binds to

albumin the color of the indicator changes form yellow to blue-green. The absorbance of the
color produced is measured in a colorimeter using an orange filter or in a spectrophotometer
at 632 nm wavelengths. Turbidity in the solutions is avoided by the addition of Brij-35.

Albumin + BCG PH4.2 -- Albumin-BCG complex Reagent

1. Bromocresol green (BCG), when stored at 2-80 C the BCG reagent is stable for several
months. It should be allowed to warm to room temperature (20-280C) before use.
2. Albumin standard, 30 g/l

Technique:

Specimen: The method requires 20l (0.02 ml) of patients serum or plasma.
The blood must be collected with the minimum of venous stasis and haemolysis should be
avoided.
1. Take four or more tubes (depending on the number of tests) and label as follows.
B - Reagent blank
S - Standard, 30 g/l
1.2 etc. - Patients Tests
2. Pipette 4 ml of BCG reagent (Warmed to room temperature) into each tube.
3. Add to each tube as follows;
Tube
B 20l (0.02 ml) distilled water
S 20l standard, 30 g/l
1, 2, etc 20l patients serum or plasma

Note: If a patients sample appears turbid, prepare a serum blank by mixing 20 of patients
Serum or plasma in 4 ml of succinate buffer

77
4. Mix well but avoid frothing of the solutions. If air bubbles are present the absorbance
readings will be incorrect.
5. Read immediately the absorbance of the solution in a colorimeter using an orange filter
(e.g. Ilford No. 607) or in a spectrophotometer set at 632 nm. Zero the instrument with
the reagent blank solution in tube B.

Note: - If using a serum blank, read its absorbance after zeroing the instrument with distilled
water. Subtract this reading from the reading of the patients BCG sample (Read
against the reagent blank solution).
6. Calculate the concentration of albumin in the patients samples by:
-Using the following formula: -

AT
Albumin g/l = AS = x 30
Where: - AT= Absorbance of test(s)
As = Absorbance of 30 g/l standard

7. Report the patients results in g/l

Approximate albumin Normal range is 30-45 g/l

To convert from g/l to g%, divide by 10.
To convert form g% to g/1, multiply by 10.

Note:- Albumin levels are lower in infants and when individuals are lying down (by 10%)
Interpretation of Serum or Plasma Albumin Results Increase
Increases:

Serum or plasma albumin levels are rarely raised, except artefactually by prolonged venous
stasis.
Decreases:

Many of the causes of low total protein levels are the result of hypoalbuminaemia, especially
the nephrotic syndrome. The pathogenesis and management of nephrotic syndrome have
been described in the paper of Chosen. Several parasitic infections cause a reduction in the
synthesis of albumin.

78
 Summary of Albumin Method

1. Pipette into tubes as follows:

Blank Standard Test 1,2, etc
Bromocresol green (BCG) 4ml 4ml 4ml
reagent
Distilled water 20l - -
Standard, 30g/l - 20l -
Patients serum or plasma - - 20l

1. Mix well but avoid frothing

2. Read absorbance immediately
Colorimeter: Orange filter. E.g. Ilford No.607
Spectrophotometer: 632
Zero instrument with blank solution in tube B
3. Calculate the results as follows:
Albumin g/l = Absorbance of test X 30
Absorbance of 30g/l standard
4. Report patients result in g/l

3.3.2.10 Case Management

Refer to the core module unit 2 sections 2.10.

3.3.2.11 Prevention and Intervention

Refer to the core module unit 2 sections 2.11.

3.3.2.12. Learning Activities (Case Study) Continued

Refer to story of health professionals in the core module and discuss on the following
questions in the class. The instructor can assist you.
How is blood specimen collected, stained and examined for blood morphology
examination?
What could be the etiology of protein energy malnutrition?
What laboratory investigations could be done at the health station or health center
level?
What materials are required to carry out the investigations?
What should be reported in the laboratory request form in the determination of
hematological tests for the assessment of protein energy malnutrition?

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3.3.2.13. Roles and Task Analysis
Refer to the core module unit 4.

3.3.2.14. Glossary and abbreviations

Refer to the core module unit 5.

3.3.2.15. Bibliography
Refer to the core module unit 6.

3.3.2.16. Annexes
Refer to the core module unit 7.

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3.4 SATELLITE MODULE FOR SANITARIAN

3.4.1.INTRODUCTION
The role of the sanitarian in the prevention of mannutritin is mostly on awareness creation,
environmental sanitation improvement and behavior change in nutritional improvement and
hygiene practices.

3.4.1.1. Purpose and use of the Module

The main purpose of this module is equip sanitarians with adequate knowledge and skill for
the prevention and management of cases of malnutrition together with the other team
members.

3.4.1.2. Directions for using the Module

For a better understanding of this module, the sanitarians are advised to follow the following
directions.
Do the pretest pertinent to your field in unit 2 section 2.1.2.4 of the core module. The
sanitarians should also read the core module thoroughly at first and when referred
in this module.
The sanitarians could be successful in using this module if he works with other team
members and inter-sectoraly with other development workers (agriculture extension
agents, health extension workers, development workers, home economists etc.)
Since malnutrition and diarrhea are directly associated the sanitarians should use the
module on diarrhea (core, satellite) in conjunction with this module.
Read the story of health workers in Jiren community and try to address the question
relevant to you.
Evaluate yourself by doing posttests and comparing your score by referring to the
key given unit 7 section 7.1.2.4.

3.4.2.1. Pretest and Post Test:

Please refer to section 2.1.2.1 in the core module

3.4.2.2. Significance and Brief Description of the Problem:

Please refer to section 2.2 in the core module.

3.4.2.3. Learning Objectives

The objective of this module is to equip the sanitarian with the appropriate knowledge,
attitude and skills required to effectively prevent acute and chronic malnutrition conduct

81
health and nutrition education to targets for sustainable behavioral change. Therefore, at the
end of this module, the sanitarians will be able to: -
1) Describe the prevention methods protein energy malnutrition
2) Identify appropriate methods and the primary targets for nutrition and
health education program in the prevention of malnutrition
3) Describe why personal hygiene, nutrition education and environmental
sanitation practice prevents those risk factors which are associated with
malnutrition
4) Describe the whole mechanism of different factors that are associated
with the problem of malnutrition

3.4.2.4 Learning Activities: Case Study

Read the story of health workers in Jiren community so that you will be able to discuss
question in section 2.12 of this module.

3.4.2.5 Definition
Please refer to the core module unit 2 sections 2.5
3.4.2.6 Epidemiology:
Please refer to the core module unit 2 sections 2.6

3.4.2.7 Etiology and pathogenesis

Please refer to the core module unit 2 sections 2.7

3.4.2.8 Prevention and Intervention

There are five important areas for the sanitarian to concentrate on in order to prevent
malnutrition. These are:

1. Prevent Infection

Many studies have shown that chronic and acute malnutrition is associated with acute
infection (Tuberculosis, Pneumonia, measles, pertusis etc) as well as repeated infection
(diarrhea, helmenthiasis). Almost all malnourished children have diarrhea. Therefore, to
prevent this problem the following are major interventions that has to be conducted by the
sanitarian together with other team members and the community.

Proper disposal of human feces. Please refer to the module on diarrhoeal

diseases for the sanitarian, section 2.8. No 1.

82
 Water protection at the source and use at home, please refer to the module on
diarrhoeal disease for the sanitarian, section 2.8 no.2
Food hygiene, please refer to the module on diarrhoeal disease section 2.8
Domestic and environmental sanitation, please refer to the module on diarrhoeal
disease for the sanitarian section 2.8 No. 5

2. Nutrition Education

Nutrition education should be given to the target group (mothers and caregivers) on the
importance of:
1) Feeding balanced diet through the use of locally available food resources
2) Proper and hygienic preparation and storage of food.
3) Proper preparing and feeding of unadulterated and uncontaminated fresh food

3. Health's and Hygiene Education

It has to be understood that one of the problems for the spread of malnutrition in children is
lack of knowledge or information on simple preventive measures such as proper food
preparation, storage and cleanliness. Hygiene or health education program should therefore
be planned to help community members understand the importance of hygienic practices in
weaning food preparation, in the prevention of diarrhoeal and helminthic infections and
general health promotion. To be successful in hygiene /health education program we should
focus on the following facts.
Health/Hygiene education should be targeted
Health/Hygiene education should be simple (short and to the point facts has to be
given to the targets)
Health/ hygiene education program should be Convincing (target should be able to
get the point and demonstrate it)
Health/ Hygiene education program should be programmed to be given at
appropriate time, place, and condition.

In addition, preparation for health/hygiene education should start from the behavior analysis.
Behavior is culture bound and hence each culture will have to be analyzed critically so that
proper strategy could be formulated to change or modify existing behavior.

83
3.4.3.1. Behavioral Analysis:
This means understanding what the current or existing behaviors of people in the
communities are with regard to:
Type of food prepared for children
The care or practices of food hygiene during preparation and storage
Having latrine or latrine use
Water hygiene

3.4.3.2. Select Target Behavior

There are many ideal or feasible behaviors that health professionals wants to see people
practicing, but, it may not be practical to achieve all. It is therefore necessary to select target
behaviors from among many ideal ones to act upon.
What target behavior do you want to change?
For example in the case of malnutrition prevention the ideal behaviors among many
which the sanitarian may have to concentrate will be focused on the prevention of
diarrhea and helminthic infection.

3.4.3.3. Are their Approximation that you want to build on?

Building on local knowledge and practices is much better and short cut than to introduce new
behaviors or practices. For example,
i People wash hands with soap after eating but not before eating
ii Other people wash hands before eating but not after latrine use

3.4.3.4. Types of Communication

In the arts of communication, messages are transmitted in many different ways. Examples
are:
Interpersonal Communication
Person To Person Or What Is Called Interpersonal Communication
Group Communication
Mass Communication

3.4.3.5. Channels of Communication

Channels are tools and means by which message is communicated to the intended
audience. The hygiene educator should prepare not only the messages but also the
channels so that messages will be effectively delivered and understood by the target

84
audiences. Channels are different for each method of communication. For example for
mass communication we may have to use radio, TV or newspaper, but for person-to-person
communication we should use posters, or flip charts. Some of the channels used for
hygiene education are: Radio
Posters Newspaper
Tape recorders Drama
Flip charts Songs
TV Folk tales etc

3.4.3.4 Selecting Targets for Hygiene Education

Selecting targets for health/hygiene education is the other important thing that has to be
considered when organizing health/hygiene education. Targets are selected by asking the
following questions.
To who is this message appropriate?
When and where should it be given?
Past effort in disease prevention taught us that nutritional problems associated factors such
as diarrhea and helminthic are transmitted because of sanitary defects and practices in the
living environment. Unsanitary conditions and practices are performed in the house by those
who are actively engaged in cleaning work, food preparation, water vending, child feeding
etc. These members of the household (Mothers, caretakers) are the primary targets?

Usually the right time and place for addressing is to conduct hygiene using a person-to-
person approach and at times when the primary targets are actively engaged in child feeding
or any households chores. This way, examples could be used from the actual performance
of the primary audiences or the targets.
The right person for this task is a person that could speak the language, share the culture
and is trained in hygiene education methods and principles.

1. Importance of Immunization
Since immunized children will have better immunity to disease or infection the sanitarian
should work together with the rest of the team in the promotion of immunization.
2. Promote Backyard Farming
The sanitarians should promote Backyard farming for two important purposes.
Waste matters such as garbage and refuse which are health hazards if left in the
open could be used for compost that can be used to condition the soil of the
household garden. Motivated households that are using compost will therefore
eliminate the waste and boost his harvest.

85
 Secondly, because of the backyard farming practice the household will get enough
green vegetables, carrots and other carbohydrate sources.
The fact that the backyard is used for vegetable garden the chance is that it will be
kept clean.
3. Learning Activities (Case Study) Continued
Read the story of health workers in Jiren community and answer the following questions.
1. Why is malnutrition more prevalent in Jiren village?
(Check your response with the following key answers)
a) Because there is no clean water
b) No sanitary latrine
c) Children and adults are infested with parasites
d) Because the communities are not aware of the problem
2. What are some of the methods where quick sanitary survey could be conducted to
identify sanitary defects in a community (Check your response with the following key
answers)
a) Do health walk with elders in the community
b) Observation of people or children's hygiene condition
c) Observation of hygiene practices at home level
d) Observation of children playing habits and environment
3. What are the necessary things required for a child to grow healthy and strong? (Check
your response with the following key answers)
a) The child should be kept clean
b) The child should be fed at least five times a day
c) The child should be taught about cleanliness of especially the hand as early
as possible.
d) Monitoring the child on his mood, illness, growth etc.
e) Immunization
4. What are some of the symptoms you can see on a malnourished child? (Check your
response with the following key answers.)

a) Weak looking, unhappy and not playful

b) Look like an old person
c) Have elastic skin
d) Have no quick mental response

86
3.5 SATELLITE MODULE FOR Health Extension
WORKERS (HEW)
3.5.1.1 Purpose and Use of the Module
Materialization of the Community based management of malnutrition is made possible
through training of PHWs/CHWs that are well equipped with the basic knowledge attitude
and skill of diagnosing, treating, timely referring, preventing and controlling malnutrition.
Therefore, this satellite module will be utilized in the training or refreshment of PHWs/CHWs
by the health center team, NGOS and other like organizations.

3.5.1.2. Direction

Administer the pretest before starting the actual training

Read the core module thoroughly before using this satellite module for the training of
PHWs / CHWS
Read the story of health workers in Jiren community to pose practical questions to
the PHWs/CHWs
If possible interpret it into the main local language
Use more participatory and simple methods of training for this group.
Administer the post-test at the end of the training and compare their results by
referring to the keys given n unit 7, section 7.5.

3.5.2 SATELLITE MODULE FOR HEALTH EXTENSION WORKERS

(HEW)

3.5.2.1 Pre and Post-test

See the pre and post test for primary health workers Health extension workers in the core
module section 2.1.2.5

3.5.2.2 Significance and Brief Descriptions of the Problem

The user of this module for training health extension workers (HEW) is highly advised to
refer to the core module sections 2.2.

87
3.5.2.3. Learning Objectives
At the end of completing these modules the Health extension workers (HEW) will be
able to:
Define and identify types of malnutrition.
Identify symptoms and signs of malnutrition.
Demonstrate preparation of high energy and protein foods to the mothers and care
givers.
Refer children with severe malnutrition (weight for age < 60% of the standard) to the to the
next health institution.
Give health education on the preventive methods of malnutrition and importance of child
nutrition for proper growth and development.

Advice mothers/care givers on the importance of exclusive feeding during the first 4-
6 months and supplementary feeding with breast milk there after.
Educate mothers/care givers/or other members of the family about the importance of
horticulture and backyard gardening, immunization, importance of continued feeding
during diarrhea.

3.5.2.4 Learning Activities (Case Study)

Read the story of health workers in Jiren community for the class or make them read it
thoroughly so that they will be able discuss the questions related to the story in unit 2,
section 2.12

3.5.2.5 Definition
Severe acute malnutrition is the manifestation of deficient intake of dietary energy, protein
and other nutrients mainly in children under five years of age.

3.5.2.6 Epidemiology
It affects toddlers and infants in developing countries. The SAM affects 5-10% and mild to
moderate forms account affects 20-40 % of children in Africa and Southeast Asia. In
Ethiopia, the chronic forms of malnutrition (stunting) is a common problem, it affects about
51% of children under five years of age. Acute form of malnutrition (wasting) affects about
11% of Ethiopian children < years.

3.5.2.7 Causes
Different factors contribute to the occurrence of malnutrition. These include: Lack of
knowledge about child feeding and child handling, infection, cultural malpractices, poverty,

88
manmade and natural calamities, social unrest (war), poor food production, uncontrolled
population growth and poor marketing, storage and distribution systems.

3.5.2.8 Clinical Features

Children with malnutrition are shorter and lighter than their healthy counterparts of the same
age and sex. Children with kwashiorkor have swelling of the body and graying of hair
regardless of the nutritional deficiency they are suffering. They are not interested in their
surrounding and have poor appetite. Whereas, marasmic children are so skinny and have
old man appearance. They are always irritable, cry frequently, have good appetite and no
marked change on their hair. (See figures 2 & 3 )
Refer to core module, unit 2, and section 2.8

3.5.2.9. Diagnosis
In diagnosing the severe acute malnutrition and identifying the clinical forms, proper history,
physical examination and anthropometric assessments are essential.
History- the following information needs to be asked by the HEW in order to identify
malnutrition in children and specific risk factors pertaining to the index child.
- Dietary history
- Weaning practices
- Food taboos
- History of diarrhea or other infection
- History of immunization
- Birth interval in the family
- Child care practices

Physical Examination

- Vital signs Pulse rate, Respiratory rate, Weight and height

- Irritability
- Graying of hair and easy pluckability
- Skin changes
- Edema (swelling of the body)
- Emaciation and old mans appearance, loss of muscle and subcutaneous fat

3.5.2.10 Case Management

Upon regular growth monitoring and promotion activities care givers of those children
with lower nutritional status should be educated to improve their child feeding practices by
preparing high energy and high protein diet from locally available foodstuffs. Children in the

89
state of severe malnutrition and those who fail to improve in their nutritional status in the
subsequent measurements (follow up) be referred to the next health institution for better
management. For further details refer to the core module unit 2, section 2.10.

3.5.2.11 Prevention & Intervention

Give nutrition education to mothers or care givers on: -
Proper child feeding practices like:
Exclusive breast feeding during the first 6 months
Optimal complementary feeding at six months with continuation of breast feeding for
the first 24 months or more
Avoidance of bottle feeding and use of cup instead
Using iodized salt for preparation of complementary and consumption of the same
by the family
Importance of increasing the frequency breast feeding and giving other
complementary foods and fluid during sickness continued feeding during diarrheal
attack
Introduction of complementary foods of children gradually and step by step with liquid
through semi-solid diet to solid diet
Example,
Soft porridge, mashed foodat 6 months
Finger foods a 8 months
Family Food ---at 12 months
Avoidance of unhygienic practices that contribute to the development of PEM (Food and
water hygiene, personal hygiene, environment hygiene & proper waste and excreta
disposal)
Importance of immunization on prevention of PEM
Report to next level health facility (health center team) in the face of unusually
increased number of cases of PEM in your village.
Measure the weights and heights of under five children in your village regularly every
month in the first 1years, and every two months in the second year and 3 months
afterwards (Growth monitoring) and refer those who have weight for height < 60%
to the next health institution.

90
3.5.2.12 Learning Activities (Case Study)

Continued:

Read story of health workers in Jiren community to the class (make them read) and discuss
the following questions.
1) What should parents of children in the Jiren community do to prevent malnutrition?
2) If parents of these children come to see you first what do you do to address their
problem?
3) What other factors contribute to development of malnutrition?
4) What do you think are the preventive measures of malnutrition?

UNIT:4 ROLE AND TASK ANALYSIS

See unit four of the core module for the expected role and tasks of PHW/CHW

UNIT: 5 GLOSSARY AND ABBREVIATIONS

See unit five of the core module
UNIT: 6 BIBLIOGRAPHY
Se unit six of the core module
UNIT: 7 ANNEXES
See unit seven of the core module

91
3.6 TAKE HOME MESSAGE FOR THE MOTHER /
CAREGIVER

Severe acute (Malnutrition): is a general poor state of health of children that arises
from poor (improper) child feeding practices such as early abrupt weaning, bottle
feeding, poor food hygiene, avoidance of breast feeding and poor nutritional quality of
the weaning foods. The mothers or caregivers should be instructed to do the following
for prevention of malnutrition: -

Optimal breast-feeding
Exclusive breast-feeding during the first 6 months with
Complementary feeding after 6 months and continue breast feeding up to 2
years or beyond
Switching the baby from one breast to the other after completely emptying the
first one
Proper positioning and attachment
Breast-feed frequently on demand / on cue day and night 8-12 times.
Avoidance of bottle feeding and use of cup and spoon instead
Weaning of children gradually and step by step with liquid diet through semi-solid
diet to solid diet.
Understand the importance of continued feeding during diarrheal attack
Get your child weighed in the nearby health institution/health post (PHCU) at least
every month in the first one year, every two months in the second year and
every 3 months thereafter for proper growth monitoring
Understand the importance of small frequent feeds for young children
Hygiene, environment hygiene & proper waste and excreta disposal)
Avoid unhygienic practices contributing to development of (food and water
personal hygiene)
Understand the importance of immunization on prevention of malnutrition
Visit the primary health care unit (PHCU) when your child gets sick or fails to grow
as expected.

92
 Figure 9. Proper child feeding practices (breast-feeding and using spoon than bottles

Breast-feeding

Spoon feeding

Figure 10. Sources of vitamins and minerals for good health

93
 UNIT FOUR
TASK AND ROLE ANALYSIS
Table 4.1 Knowledge Objective And Essential Tasks Of The Health Center Team (Health Officer, Public Health Nurse, Medical Laboratory
Technician and Sanitarians)

Learning objective HO PHN EH MLT Activity

(expected out Come)

Define and describe Define and describe Define and describe Define and describe Define & describe Define &
types of acute & chronic types of ACM. types of ACM types of ACM. types of ACM Characterize
malnutrition(ACM) types of ACM
List causes and risk List different causes List different causes List different causes of List different List the different
Knowledge

factor of ACM of and their of ACM & their ACM their association causes of ACM causes of ACM
association with the association with the with the different risk
different risk factors. factors. & associated risk
different risk factors factors.
Describe the Magnitude Pin point the Pin point prevalence Pin point prevalence Pinpoint the * Explain the burden
and contribution of prevalence of of malnutrition on & of malnutrition and its prevalence of malnutrition of malnutrition
malnutrition and its morbidity & mortality
ACM to over all childhood its contribution to contribution to and its condition to
contribution to in children
mortality & Morbidity mortality and Morbidity morbidity and mortality in
health problems locally & mortality & morbidity in children locally & * Describe the
in children locally children locally and
nationally in children locally and nationally. commonest Causes
nationally
nationally and nationally. of PEM

94
Table 4.2. Knowledge Objective and Essential Tasks of The Health Center Team (Health Officer, Public Health Nurse,
Medical Laboratory Technician and Sanitarians)

Learning Objective HO PHN EH MLT Activities

(Expected Outcome)

Describe the assessment SAM Enumerate the clinical Describe the complication Describe the Perform SOAP
and its investigation & their manifestation of
Manifestations and different methods (Subjective objective, Assessment plan)
malnutrition.
Complications of malnutrition of laboratory of patients and. Investigate causes of
investigation malnutrition; record and report the result.
Knowledge

for malnutrition
Describe the principle & treatment Explain how to treat Describe how to List the different methods of treatment of
methods of malnutrition.
malnutrition and their administer the malnutrition
principle under laying it treatment and ---- ---- Describe what advice should be given to
the caregiver.
advising the mother
or care givers.
Describe the pathogenesis of -Elaborate the mechanism or Indicate the different steps
protein energy malnutrition. development of different types of --- --- --- existing in the development of different
SAM
types of malnutrition
Elaborate methods of preparing Elaborate methods of Preparing Elaborate Methods of Describe the different ingredients in the
dietary treatment for the case of dietary treatment for the case of preparing dietary therapy malnutrition
SAM SAM ---- ------
Dietary treatment of SAM

95
Table 4.3. Attitude Objective and Essential Tasks of The Health Center Team (Health Officer, Public Health Nurse,
Medical Laboratory Technician and Sanitarians)
Learning Objective HO PHN EH MLY Activities
(Expected out come)
-Believe in the -Instruct HEW (community -Instruct HEW -Instruct HEW Advise HEW, mothers and
importance of breast health workers) mothers (Community health -Instruct HEW (community (Community health care givers for the utility of
feeding and weaning and care gives in reducing Workers) mothers, & health workers) mothers workers Mothers & feeding high energy and
practices in reducing mortality due to protein care gives in reducing and care givers in reducing caregivers. In protein diet in facilitating
mortality due to energy malnutrition mortality due to protein mortality due to protein Reducing mortality recovery from malnutrition.
protein energy energy malnutrition energy malnutrition due to malnutrition
malnutrition.
-Believe in promoting -Advocate continued feeding of -Advocate continued Advocate continued -Advocate -Educate mothers care
proper Feeding of a child required less feeding of a feeding of a child continued feeding giver and community
infants (children) with malnutrition. Child regardless of m regardless of malnutrition. of a child health agent, about the
case of protein energy Malnutrition. regardless of importance of proper
Attitude

malnutrition malnutrition feeding of a child with

malnutrition
-Believe in utilization -Advice mothers care giver, -Advice mothers care -Advice mothers, care gives -Advice mothers -Teach about the
of health service to and CHW to promote utilization givers and HEW to and HEW to and care givers importance of taking
facilitate the treatment of promote promote utilization of and HEW to children to health service
of malnutrition in health services for cases of Utilization of health health services for promote utilization setting for management of
children. malnutrition services for cases of protein energy malnutrition of health services malnutrition
malnutrition. in children for protein
energy malnutrition
in children
-Up hold the idea that -Educate mothers, care givers -Educate mothers or -Educate care givers and -Educate care gives -Educate the mothers, care
protein malnutrition is and CHW that malnutrition is care givers and HEW that protein and HEW that givers and HEWs that
caused by deficiency caused by deficiency of - HEW that malnutrition is caused by is malnutrition is malnutrition is caused by is
of nutrients nutrients malnutrition is caused caused by deficiency of caused by is caused by deficiency of
by deficiency of nutrients caused by nutrients
nutrient deficiency of
nutrients

96
Table. 4.4 Practice Objective And Essential Tasks of the Health Center Team (Health Officer, Public Health Nurse, Medical Laboratory
Technician and Sanitarians)
Learning Objective HO PHN EH MLY Activities
(Expected out come)
-Demonstrate the process of -Take appropriate history and -Assess vital signs and ----- ------ -Ask relevant symptoms
assessing a perform proper determine existence or - Look, at relevant signs and
child with malnutrition and physical examination. note decide the degree of
identify its complications. of malnutrition and malnutrition
Complications like - Determine if lab
infection, etc Investigation is needed.
-Demonstrate how to do -Carry out laboratory investigation ----- -------- -Carry out - Make a laboratory
laboratory tests malnutrition laboratory investigation
malnutrition investigation protein on malnutrition
energy malnutrition
-Demonstrate the preparation of -Demonstrate and explain the -Demonstrate and -Demonstrate the -Show materials and
formula for the preparation of high energy and explain the Preparation importance of clean ingredients to be used
Practice

treatment of malnutrition to the protein foods and their of their proper use in the water and utensils in in the preparation and
---
caregivers. administration in the treatment of treatment of the preparation of utilization of feeding
malnutrition malnutrition food in feeding a formula in the treatment of
child with alnutrition malnutrition.
-Identify a case of protein -Demonstrate the management -Demonstrate -Identify the case and its
energy malnutrition principle, identify the complication appropriate feeding and complication
demonstrate its appropriate and manage accordingly rehydration and Mange the case by
management. drug administration and ------ ------ selecting appropriate
also provide proper treatment plan Refer PRN
nursing care to the
clients.
Demonstrate proper Display Effective communication Display effective Display effective Identity practical ways of
communication to the skills with mothers care givers and communication skills communication skills educating mothers
mother or care givers for health CHW in treatment prevention and with mothers care givers with mothers, care care givers or CHW on
education control of malnutrition and community health givers and community treatment prevention and
------
pertinent to malnutrition workers on health workers on control of malnutrition
treatment prevention prevention and control
and management of of malnutrition
malnutrition

97
 Table 4.5. Knowledge Objective and Essential Tasks of Health Extension Workers (HEW)

Learning Objective Community Health Workers Care Giver Workers Activity

(Expected out come)
-Describe the principle and - Describe how to prepare dietary - Describe how to prepare food - Explain methods of preparation of
treatment methods of malnutrition feeding formula and its administration in for treating the child with feeding formula in the treatment of
treatment of malnutrition malnutrition based on family malnutrition to the care workers CHW
diet home
- Explain what type of food to give and
how much to give in the treatment of
Knowledge

case with malnutrition

-List the major information, -Describe methods of giving health education - Explain major points the care - List main methods used to communicate
methods & targets for health on malnutrition and identify target groups & giver/ mother need to tell to information on malnutrition
areas of focus (mothers /care givers the family members regarding for the different targets (HEW )
education in malnutrition patients,)
treatment and prevention of Enumerate main points that the care giver
malnutrition needs to instruct the family and the
parent/care givers
-List causes and risk factors for - List the different causes of malnutrition and - Explain the cause of Explain the relationship between the risk
malnutrition their association with risk factors. malnutrition in general and factors and development of malnutrition
what risk behaviors are (HEW)
associated to it. Describe that malnutrition is caused by
improper feeding
Infection, diarrhea etc.

98
Table 4.6 Attitude Objectives and Essential Tasks of Community Health Extension Workers (HEW)
Learning Objective CHW Care giver Activity
(Expected out come)
-Promote utilization of health service -Advice care givers to - Advice friends and families to - Educate care givers the importance of taking
facilities for the treatment of bring a child with visit health worker the health children with protein energy malnutrition to
malnutrition malnutrition to the service Units in case of protein health service institution
health service units to energy malnutrition -Encourage visits health service unit the case of
Consult health worker malnutrition
-Advocate the importance of exclusive - Instruct mothers or - Advise family friends and -Advocate / Promote breast feeding practices in
Attitude

breast care givers the neighbors to continue breast prevention of malnutrition (CHW)
Feeding in the first 6 months and importance of feeding in a child with Encourage breast feeding practices of, family, in
continued - Breast-feeding in malnutrition the prevention of
Feeding then after in reducing reducing morbidity and
mortality and morbidity due to mortality from
malnutrition malnutrition.
-Promote continued feeding of children -Advocate and - Feed the child with diarrhea - Emphasize on importance of feeding
with diarrhea encourage proper properly and encourage friends of a child with diarrhea (CHW)
feeding of children peers to do so. -Feed the child with diarrhea and advise
with diarrhea by Friends or relatives to do so.
mothers or caregivers.

99
Table 4.7. Practice Objective and Essential Tasks of Health Extension Workers (HEW)

Learning Objective (Expected out come) CHW Care giver Activities

Demonstrate preparation of feeding Demonstrate preparation of Demonstrate Show materials and

formula for the treatment of malnutrition feeding formulas their properly how and ingredients to be used in the
administration to the case of what to prepare preparation of Feeding
and its proper use.
malnutrition for caretakers. and administer to a formulas
child With
Malnutrition.

Identify a case of malnutrition and demonstrate Identify complications of Identify signs of Identify sings and symptoms
Practice

its appropriate management malnutrition and its degrees and symptoms of of malnutrition and administer
advise the caregiver to feed the malnutrition and its proper feeding practices (see
patient properly. complications and the core module).
decide whether
there is a need for
admission or
referral

Demonstrate proper communication to Display Effective Communication Identify ways of educating

mothers skill with ------- Mothers/ care gives about
or Mothers or care givers on malnutrition

care givers pertaining to malnutrition. Treatment and prevention of

malnutrition

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 UNIT FIVE

GLOSSARY & ABBREVIATIONS

Antioxidant:- Micronutrients like vitamins A, C, E, & minerals, selenium which detoxify
(scavenge) free radical species formed in the body and protect body cells from oxidative
damage.

Anthropometric Assessment:- Measurement of different body dimensions and

proportions at different nutritional states and interpretation of the result by comparing to the
standard to determine whether a person is malnourished or well nourished.

Catch Up Growth:- Rapid increase in weight and height of children after a period of
nutritional deprivation in response to corrective dietary intervention.

Day Care Nutrition Rehabilitation Centers (DCNRC): Feeding and nutrition

demonstration centers attached to health units where mothers/care givers bring their
malnourished children and get them fed and see how to prepare balanced diet from locally
available foodstuffs.

Dehydration: - Excessive loss of fluid and electrolyte from the body that impairs cellular
function if not corrected timely.

Emotional Deprivation: - State of mood change in a child that occurs following neglect of
child (poor care given to the child by the mother or care giver).

Exclusive Breast-feeding: - Breast-feeding of infants with no additional (supplementary)

food administration.

Flag Sign: -Different color bands (gray versus black) on a long curly hair of malnourished
child as a mark of seasonal variation in the nutritional status (Black = period of good
nutrition, Gray = period of nutritional deprivation).

Forest Sign: - Appearance of body hair of a malnourished child in which the hair is straight
and lusterless at the bottom and curled at the top giving an impression of a forest.

Free Radicals: - Highly-active reduced species produced in the body as a result of normal
body chemical reactions and these result in oxidative death of cells of the body. E.g. Super
oxide, Hydroxyl radical

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Gomez Classification: - A classification of malnourished children by comparing their
weight with the weight of reference child of the same age.

Hypoglycemia: - Reduction of fasting blood glucose level below 50 gm/dl in older infants
and children.

Hypothermia: - Reduction of the Core body temperature less than 350C as measured
rectally.

Kwashiorkor: - A form of severe protein energy malnutrition characterized by wasting of

muscles, edema, gray easily pluckable hair, apathy and dermatotic skin changes and weight
for age between 60-79% of the NCHS reference pursuant of nutritional deprivation.

Marasmus: - A form of severe protein energy malnutrition in which there is severe loss of
weight due to wasting of both muscles & subcutaneous(weight for age < 60% of the NCHS
reference), irritability, growth retardation, increased appetite and minimal hair changes
following restriction energy intake.

Negative Energy Balance: - A situation in which energy intake is less than energy
expenditure resulting in mobilization of body fat & muscle protein for energy production.

Negative Nitrogen Balance: - A state of affairs in which nitrogen intake is less than
nitrogen excretion secondary to a diet poor in protein content.

PEM: - Protein Energy Malnutrition

Recovery Syndrome: - Fluid over load, congestive heart failure and death due
administration of high protein and high calorie to a malnourished child during the acute
(stabilization) phase of the management of protein energy malnutrition.

Residential Nutrition Rehabilitation Centers (RNRCS): - These are usually

convalescent centers for children treated initially in hospitals where mothers may
accompany their children. Nutrition education and demonstrations of food preparation and
child feeding will be done to prevent the recurrence of the situation in the family.

Sensory Stimulation: - Stimulation of malnourished children using different toys, stories

etc in order to reverse the mood changes that followed the state of malnutrition in order to
revive their appetite and facilitate the process of cure.

Starvation Therapy: - A harmful traditional practice in which mothers/ care givers deprive
their child with diarrhea of food & fluid intake due to the wrong belief that giving food and
fluid may increase the volume & attack of diarrhea.

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Stunting: - A state of chronic malnutrition characterized by normal weight for height
(>80%) & low height for age (<80%) according to Waterlow classification

Wasting: - Is a state of acute malnutrition characterized by normal height for age (>80%) &
low (< 80%) weight for height according to water low classification.

Water Low Classification: - Classification of malnourished children that uses two

indices: weight for height and height for age for detection of acute and chronic states of
malnutrition in the community.

Weaning: - Administration of food (solid or liquid including formula or cows milk) in addition
to breast milk or without breast milk.

Welcome Classification: - Classification of malnourished children based on their weight,

age & presence of edema. This classification is used to distinguish the clinical form of PEM.

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 UNIT SIX

BIBILIOGRAPHY
Ashworth, A et al. Ten steps to recovery (report), Child health dialogue, second and third
quarter, 1996.

Brown. L.V, et al. Evaluation of the impact of weaning food messages on infant feeding
practices and child growth in rural Bangladesh. Am.J.Clin.Nutr. 1992. 56: 994-1003.

Cohen, R., et al, Effects of Age of introduction of complimentary foods on infant breast
milk intake, total energy intake, and growth: a randomized intervention study in

Central Statistics Authority. The transitional government of Ethiopia. Report on the

national Rural Nutrition Survey, Core module, March, 1992.

Dewey, K.G., et al, Growth Pattern of breast fed infants in affluent (United States) and poor
(Peru) communities, implications for timing of complimentary feeding, A.M.J.Clin.Nutr. 1992;
56: 1012-1018.

Ethiopian Public Health Association, Food and Nutrition Strategy and Policy issue,

Honduras. The lancet, 1994; 344: 288-293.

Husaini, M.A., et al., Developmental effect of short term supplementary feeding

in nutritionally at risk Indonesian infants. Am.J.Clin.Nutr, 1991: 54: 799-804

Latham, M.C., Human nutrition in the Developing World, Rome: F.A.O; 1997.

Latham, M.C., Human nutrition in tropical Africa. Second edition, F.A.O, Rome; 1979

Lofti, M., Weaning foods-new uses of traditional methods. SCN news No.6 Addis Ababa,
Nov. 1997

Lorri,W, and Svanberg, U., Lower Prevalence of diarrhea in Young Children fed lactic Acid
fermented cereal gruels, food and nutrition bulletin, 1994: 15 (1): 57-63

Mahan LK, Stump SE. Kruses food, Nutrition and diet therapy, 9th ed., USA: Saunders,
1996.

MOH. Guideline for the management of severe acute malnutrition for Ethiopia. MOH, May ,
2004

MOH. Infant and young child feeding strategy for Ethiopia, MOH, 2004.

104
MOH. Guideline for control and prevention of macronutrient deficiency in Ethiopia. MOH,
2004.

Rahway, M.I., Protein Energy Malnutrition (PEM), Merck manual, 16th. Edition 1992.

Tshikuka, J.G., et al. The relationship of childhood protein energy, malnutrition and parasite
infections in an urban African setting. Trop. Med. Int. Health. 1997; 2 (4): 374- 382

Walker, A., The contribution of Weaning Foods to Protein-Energy malnutrition. Nutrition

research reviews, 1990; 3: 25-47.

Walker, S.P., et al, Nutritional supplementation, psychosocial stimulation, and growth of

stunted children: the Jamaican study. Am. J.Clin.Nutr. 1991, 54: 642-648.

Waterlow, J.C. et al, Protein Energy malnutrition, Edmund bury press, London, 1992.

Weaver, L.T., Feeding the weanling in the developing world: problem and solution.
International journal of food sciences and nutrition, 1994; 45: 127-134.

MOH, Ethiopia. Guideline for the management of Severe acute malnutrition. MOH, Ethiopia,
May 2004.

MOH, Ethiopia. Ifant and yong child feeding strategy . MOH, Ethiopia, May 2004

MOH, Ethiopia. National Guideline for control and Porevention of Micronutrient deficiency.
MOH, Ethiopia, May 2004

WHO, BASICS, UNICEF. Nutrition essentials: a guideline for health managers, WHO, 1999.

105
 UNIT SEVEN
ANNEXES
7.1 Answer Keys

7.1.1 Keys for the Core Module (all categories)

Q.No.1. C

Q.No.2. E

Q.No.3. E

Q.No.4. A Marasmus
a. Kwashiorkor
b. Marasmic kwashiorkor
c. Underweight
d. Stunting and wasting

Q.No.5. D

Q.No.6. Kwashiorkor
a. Pitting edema
b. Gray and easily pluckable hair
c. Miserable and apathetic
d. Loss of muscle & preservation of subcutaneous fat

Marasmus
A. Loss of both subcutaneous fat and muscle (skin and bone
appearance)
B. Irritability and moodiness
C. Wizened monkey faces (old man appearance)
D. Absence of edema

Q.No.7.
a. Anthropometric assessment
b. Biochemical or laboratory, assessment
c. Epidemiological (dietary assessment)
Q.No.8. a. Acute (stabilization) phase
b. Rehabilitation phase

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Q.No.9. Because it causes fluid overload and death from heart failure (a
condition called recovery syndrome)

Q.No.10. D

Q.No.11. D

Q.No.12. D

Q.No.13. E

Q.No.14. A

Q.No.15. D

Q.No.16. D

Q.No.17. D

Q.No.18. D

Q.No.19. D

Q.No.20. C

Q.No.21. B

Q.No.22. False

Q.No.23. Exclusive breast feeding for the first 6 months and optimal complementary
feeding after 6 months with the continuation of breast feeding up to 24
months or beyond

Q.No.24. A, B, C, D

Q.No.25. 1. Eclusive breast-feeding for the first 6 months

2. Optimal complementary feeding at 6 months with the Continuation of
breast-feeding at 6 months
3. Sick child feeding (during illness and for 2 weeks after illness)
4. Maternal nutrition
5. Control and prevention of vitamin A deficiency (VAD)
6. Control and prevention of vitamin Iron deficiency (IDA)
7. Control and prevention of vitamin Iodine deficiency disorders (IDD)

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7.1.2. KEYS FOR SATELLITE MODULES (SPECIFIC
PROFESSIONAL CATEGORIES)

7.1.2.1. HEALTH OFFICERS

Q.No. 1. A to E

Q.No. 2. B to E

Q.No. 3. A to D

Q.No. 4. A to D

Q.No. 5. C

Q.No. 6. A, B, D and E

Q.No. 7. A to E

Q.No. 8 A to E

Q.No. 9. A and B

Q.No. 10. A, B, C and D

Q.No. 11. B, C, D and E

Q.No. 12. A and B

Q.No. 13. B

Q.No. 14. A to D

Q.No. 15. D

Q.No. 16. D

7.1.2.2. PUBLIC HEALTH NURSE

Q.NO. 1 A. Coordinate client care when discharged home

B. Teach them how to follow the feeding program.
C. Provide the necessary supplies and equipment

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Q.NO. 2 . D
Q.NO. 3 A. Provide iron rich foods, after the first 7days
B. Prevent non compliance by giving appropriate and
adequate information
C. Offer the child favorite food.
D. Avoid bottle feeding
E. Return to clinic after a month or so.

Q. NO. 4. A. Identify the local sources of foods stuffs.

B. Recognize the cause of improper feeding in a given
community.
C. Provide information regarding the effect of improper
feeding.
D. Teach nutritional values of local foodstuffs.
E. Support the information with appropriate demonstrations.
F. Teach the food hygiene at home.
G. Evaluate the feeding programme.
7.1.2.3. MEDICAL LABORATORY TECHNOLOGY
Q.No. 1. E
Q.No. 2. D
Q.No. 3. D
Q.No. 4. C
Q.No. 5. A
Q.No. 6. A

7.1.2.4. SANITARIANS
Q.No. 1. A
Q.No. 2. A
Q.No. 3. B
Q.No. 4. D
Q.No. 5. D
Q.No. 6. D
Q.No. 7. D
Q.No. 8. D

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7.1.2.4. PRIMARY HEALTH WORKER (PHW)/COMMUNITY HEALTH WORKER (CHW)

Q.No.1. C
Q.No.2. A, B, C, D
Q.No.3. A, B, C, D, E
Q.No.4. E

Q.No.5. Education of parents of children on:-

A. Proper child feeding practices like exclusive breast feeding for the first
4-6 months, gradual weaning, using cup and spoon than bottle,
continue feeding during diarrhea,
B. Personal, environmental and food hygiene
C. Importance of taking their children to the health institutions for Growth
monitoring
D. Importance of getting their children immunized
E. Stimulation and proper treatment of children

7.2. * Rehydration solution for the malnourished (ReSoMal)

Ingredient Amount
Standard WHO-ORS One 1-litre packet
CMV 1 red scoop (6 gr.)
(Mineral & Vitamin mix)
Sucrose (sugar) 50 g
Water 200 ml

For small quantities of ReSomal- F75 F100 package

Product One red scoop water to add

ReSoMal 5.9g 140 ml
F75 4.1g 20 ml
F100 (powder) 4.1g 18 ml

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7.3. Admission and discharge criteria for severely malnourished
patients
Class of Age Admission criteria Discharge criteria
< 6 months old - The infant is too weak or feeble to suckle - It is clear than he/she is gaining
effectively (any weight-for-length). weight on breast milk alone for 5
- Or the mother does not have enough milk consecutive days after the
to feed her child. supplemented sucking technique
- And the infant is not gaining weight at has been used.
home, malnourished (weight-for length < - And there is no medical problem
70%) - And the mother has been
adequately supplemented with
vitamins and minerals, so that she
has accumulated body stores of he
type 1 nutrients
6 months to 18 - Weight/Length < 70% (for length< 85 cm) - W/H> 85% for 2 consecutive
years old and weights
Weight/Height < 70% (for - And to edema for 10 days
height>=85 cm), - And MUAC> 12 cm
- Or presence of bilateral edema
- Or MUAC < 100 mm (only for children of
more than 75 cm height)
> 18 year old - BMI < 16 - W/H > 85% for 2 consecutive
- Or presence of bilateral edema unless there weights
is a clear cut other cause - And no edema for 10 days
And MUAC > 12 cm

Criteria fro moving from phase to phase in a therapeutic feeding center

From phase 1 to transition From transition to phase 2

- the return of appetite - A good appetite
and the beginning of loss of edema for - And a minimum of 2 days in transition
kwashiorkor patients Phase for marasmic patients
- And the complete loss of edema for
kwashiorkor patients

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7.4. THE AUTHORS
TEFERA BELACHEW (MD, MSc, DLSHTM), Associate professor and head Student
Research Programme (SRP) of Jimma University. Obtained degree doctor of medicine (MD)
from the former Jimma Institute of Health Sciences and Masters Science (MSC) in human
nutrition from University of London, London School of Hygiene and Tropical Medicine, UK.

CHALLI JIRA (BSc, MPH, CHMPP), Associate professor in the Community Health
Programme of Jimma University. Head, Health Planning and Health Services Management
Department In the Community Health Program and head, External Relations Office Of
Jimma University. He obtained his BSc in public health from the former Gondar college of
Public Health and his MPH from Royal Tropical Institute, Amsterdam, the Netherlands.

KEBEDE FARIS Associate professor. He obtained his diploma in Sanitary Science from the
former Gondar College of Public Health and his BSc and MSc in Environmental Health from
University of Tennessee State University, USA. Currently working in Addis Ababa Bureau of
beautification agency.

GIRMA MEKETE (BSc, MSc) Lecturer in the school of Medical Laboratory Technology,
Jimma University. He obtained his BSc in Biology From Addis Ababa University. Master of
science from A university in South Africa.

TSEGAYE ASRE (BSc,MSc), Lecturer in the School of Nursing of the school, Jimma
University. He obtained his BSc in nursing from the former Jimma Institute of Health
Sciences and His MSc from University of London, London school of Hygiene and tropical
Medicine, UK.

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