Stabilization Centre

Stabilization
Centre
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Field Card 1. Taking measurements

1. Taking a child’s weight

Children are weighed with a 25 kg hanging sprint scale, graduated to 0.100 kg. Do not forget to re-adjust the
scale to zero before each weighing.

A plastic wash basin should be supported by four ropes that attach (are knotted) underneath the basin. The basin
is close to the ground in case the child falls out and to make the child feel secure during weighing. If the basin
is soiled, first clean it with disinfectant. The basin is comfortable and familiar for the child, can be used for ill
children, and is easily cleaned. In the absence of a basin, weighing pants can be used although are sometimes
inappropriate for very sick children. When the pant is soiled, it can be cleaned and disinfected to reduce the risk
of passing an infection to the next patient.

When the child is steady in the basin or pant, record the measurement to the nearest 100 grams, recording with
the frame of the scale at eye level. The scales must be checked for accuracy by using a known weight on a
regular basis, i.e. weekly.

Taking a child’s weight

Instructions on Taking the Weight 1

2

• Before weighing the child, take all his/her

clothes off. If possible, provide privacy
for girls.
• Zero the weighing scale (i.e. make sure
the arrow is on 0 after placing the empty
basin or the weighing pants).
• Ensure that the weighing scale is at eye
level. 5

• Place the child in the basin or the

4
weighing pans.
• Make sure the child is not holding onto
anything.
• Read the child’s weight. The arrow must
be steady.
• Record the weight in kg to the nearest
100 g e.g. 6.6 kg.
• Do not hold the scale when reading the
weight.

Source: How to Weigh and Measure Children: Assisting the Nutritional Status of Young Children, United Nations, 1986
 Stabilization Centre

2. Using the electronic scale.

Controls and displays

Mother-and-baby key
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If several children are to be weighed consecutively, it is

important that it is always the same adult who performs
the measurement and that this person’s weight does not
change (e.g due to a piece of clothing being removed).

The mother-and-baby function remains switched on

until

• you press the mother-and-baby key again (total

weight is displayed).
• the scale swtiches off automatically.
 Stabilization Centre

3. Taking a Child’s Length or Height

3
Taking a child’s length 2

For children less than 87 cm the measuring board is

placed on the ground.
5
• You will need two people to take a good
measurement. If there is no assistant, the mother may 8
help by holding the head straight.
• The child is placed lying down along the middle of the
board.
9 7 4
• The assistant holds the sides of the child’s head and
positions the head until it firmly touches the fixed
headboard with the hair compressed.
• The measurer places her hands on the child’s legs,
1
gently stretches the child and then keeps one hand on
the thighs to prevent flexion.
• While positioning the child’s legs, the sliding foot-plate
is pushed firmly against the bottom of the child’s feet. 6
• To read the length measurement, the foot-plate must
be perpendicular to the axis of the board and vertical.
• The length is read to the nearest 0.1 cm.

Source: How to Weigh and Measure Children: Assisting the Nutritional Status of Young Children, United Nations, 1986

Taking a child’s height

Headpiece firmly on head

For children taller than 87 cm the measuring board is 15 Measurer on knees

3
fixed upright on level ground.

• The child stands, upright against the middle of the Hand on chin 9

measuring board. Shoulder level 10

• The child’s head, shoulders, buttocks, knees, and Child’s hands
11
and arms at side
heels are held against the board by the assistant.
Left hand on
• The measurer positions the head and the cursor. knees; knees 5
together against
• The height is read to the nearest 0.1 cm. board

• Measurement is recorded immediately.

2 Right hand on child’s

heels against back and
Assistant on knees less on board 12
8
Line of sight
13

16
1
Questionnaire and pencil on
clipboard on floor or ground

Source: How to Weigh and Measure Children: Assisting the Nutritional Status of Young Children, United Nations, 1986
 Stabilization Centre

4. Taking a Child’s Middle Upper Arm Circumference (MUAC)

MUAC is especially used for children six months old to five years old to measure thinness.

How to Measure MUAC

• Ask the mother to remove any clothing

covering the child’s left arm.
• Calculate the midpoint of the child’s
left upper arm: first locate the tip of the
child’s shoulder with your finger tips.
• Bend the child’s elbow to make the right
angle.
• Place the tape at zero, which is indicated
by two arrows, on the tip of the shoulder
and pull the tape straight down past the
tip of the elbow.
• Read the number at the tip of the elbow
to the nearest centimetre. Divide this
number by two to estimate the midpoint.
As an alternative, bend the tape up to the
middle length to estimate the midpoint.
• Mark the midpoint with a pen on the arm.
• Straighten the child’s arm and wrap the
tape around the arm at the midpoint.
Make sure the numbers are right side
up. Make sure the tape is flat around the
skin.
• Inspect the tension of the tape on the
child’s arm. Make sure the tape has the
proper tension and is not too tight or too
loose. Ensure that there is no bulging (the
tape sits well on the skin and cannot be
moved). Repeat any step as necessary.
• When the tape is in the correct position
on the arm with correct tension, read and
call out the measurement to the nearest
0.1cm.
Source: How to Weigh and Measure Children: Assisting the Nutritional Status of Young Children, United Nations, 1986
• Immediately record the measurement.

The colours in the MUAC tapes used in most centres in Somalia do not reflect current criteria to define
malnutrition. Until these are replaced, DO NOT FOLLOW THE COLOUR CODES.

Instead, just note the number of mm and follow the guidelines:

< 115 mm : Severe acute malnutrition
>=115 and < 125 mm : Moderate acute malnutrition
> 125 mm: No malnutrition
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5. Diagnosing Bilateral Oedema

• Oedema is the swelling of the body or one of its parts.

• Oedema is an indication of Kwashiorkor.
• Kwashiorkor oedema should be in both feet (bilateral). It is noticed when the bilateral oedema is pitting on
both feet after pressing for a few seconds. “Pitting” means that when you press on the top of the feet or the
leg the finger leaves a pit in the skin for some seconds.
• Any oedemas which appear only in one foot or leg are not Kwashiorkor. Oedema that is not pitting is not
Kwashiorkor either. However these patients still need to be seen by a medical person, in order to do a proper
diagnosis.

Steps of diagnosing oedema

• Oedema is evaluated first on the top of the feet.

• Press gently with your thumbs on each foot, while you count: 121, 122, 123 (approx 3 seconds).
• After removing the thumb, there is kwashiorkor oedema if a pit stays for some seconds.
• Do the same thing for the leg (above the knee) and for the back of the hands and the face (around the eyes).

Oedema is coded in the following way:

Oedema in both feet: +
Oedema in both feet plus legs: ++
Oedema in both feet, legs and hands or face: +++

@ Get picture for “bilateral” and for other parts of the body

Pitting oedema on dorsum of foot.

After applying pressure for a few seconds,
a pit remains after the finger is removed.
 Stabilization Centre

Field Card 2. Determining Weight-for-height (W/H)

Most children who are healthy have weight in a normal range. When children weight less than the normal, they
are malnourished. This can be measured and classified into Z-scores. Z-scores are used to see if the children are
moderately or severely malnourished and admit then in the different programmes.

Use the charts in the following two pages of this Field Card to understand how they work.

This is the process to follow for each patient:

1. Write down the weight, height and sex of the child.

2. Select the chart that corresponds to the child’s sex (there is one for boys and one for girls).
3. Select the column to use:
1. Length: If the child was measured lying down (less than 87 cm), use the chart in the left.
2. Height: If the child was measured standing (more than or equal to 87 cm), use the chart in the right.
4. Follow the column to the left of the chart you just selected. Scroll down through the numbers until you reach
a number higher than the height of the child. Select the height value that is closest to the height of the child:
1. Example: If the height of the child was 55.7, choose 55.5;
2. Example 2: If the height of the child was 55.8, choose 56.
5. Now you have selected the line that is going to be used to check the child’s weight.
6. Follow this line to the right (it is recommended to use a ruler, to be sure that you do not move to a different
line). When you reach a weight that is above the weight of the child, stop.
7. Check the colour of the column where you have stopped, or the heading of the column, to obtain the W/H
group of the patient.
8. Write the result.
9. Using the W/H, MUAC and oedema findings, decide if the child needs admission, and to which programme.

The groups of weight for height are:

< -3 -----------------> Severe acute malnutrition.

< -2 -----------------> Moderate acute malnutrition.
0 -----------------> Normal

For interpretation,

< - 3 means that the patient’s W/H is below -3 Z-scores.

< - 2 means that the patient’s W/H is between -3 and - 2 Z-scores.
0 means that the patient’s W/H is between -2 and 0 Z-scores.
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Field Card 3. The appetite test

Once the child has been diagnosed as presenting SAM, you need to decide if the patient can be treated at the
OTP or if he/she needs to be transferred to the SC. This is done by looking for the presence of complications and
through the appetite test.

Why do we do the appetite test?

The appetite test is the most important step to decide if a child has complicated malnutrition and should go to
the SC. A poor appetite means that the child is ill and requires treatment in a SC or hospital.

A poor appetite means that the child has a significant infection or a major metabolic abnormality such as liver
dysfunction, electrolyte imbalance, and cell membrane damage or damaged biochemical pathways. These are
the patients at immediate risk of death. Often, the child with SAM does not present any other signs of these
complications.

Furthermore, a child with a poor appetite will not take the diet at home and will continue to deteriorate or die.
As the patient does not eat the special therapeutic food (RUTF) the family may take the surplus and become
habituated to sharing.

How to do the appetite test

1. The appetite test should be conducted in a separate quiet area.

2. Explain to the carer the purpose of the appetite test and how it will be carried out.
3. The carer should wash her hands and the child’s hands.
4. The carer should sit comfortably with the child on her lap and either offer the RUTF from the packet or put a
small amount on her finger and gives it to the child.
5. The carer should offer the child the RUTF gently, encouraging the child all the time. If the child refuses then
the carer should continue to quietly encourage the child and take time with the test. The test usually takes a
short time but may take up to one hour. The child must not be forced to take the RUTF.
6. The child needs to be offered plenty of safe water to drink from a cup as he/she is taking the RUTF.

The test can be done with a table spoon (if the size of the sachet is not practical). Take the amount of one spoon
and put it in a plate or cup, and let the child eat it with the fingers. When the child has completed one spoon,
add a second one – until he/she does not eat any more. Count the number of spoons to see the result of the test.

This is the minimum amount that malnourished patients should take to pass the appetite test. If the child does
not take at least the amount in the table, in sachets or in spoons, then he/she should be sent to the nearest SC.

RUTF (Plumpy’nut)
Body Weight (kg) Sachets Spoons
Less than 4kg 1/8th 1/3rd
4 - 6.9 1/4th 2/3rd
7 - 9.9 1/3rd 1
10 - 14.9 1/2th 1 1/2th
15 - 29 3/4th 2
Over 30kg 1 3

If you think that the child did not pass the test because he/she was frightened or didn’t like the product, try
repeating it in a calmer environment. This test can be done with other products other than Plumpy’nut, following
the amounts in spoons.
 Stabilization Centre

Field Card 4. Clinical presentation of SAM

These are the main clinical characteristics of Marasmus and Kwashiorkor, the two manifestations of SAM.

Marasmus Kwashiorkor

• Severe weight loss and wasting • Bilateral pitting oedema

• Ribs prominent • Loss of appetite
• Limbs emaciated • Brittle thinning hair
• Muscle wasting • Hair colour change
• May have good appetite • Apathetic and irritable
• With correct treatment, good prognosis • Face may seem swollen
• High risk of death
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Field Card 5. SAM History and examination

The usual signs and symptoms that are recorded on these patients are the following (see OTP card and SC card):

History: Ask the carer if the child presented any of the following in the last few days:

Diarrhoea (Yes, No) If yes, ask for more details

Stools per day (1-3, 4-5, >5) Diarrhoea is only when there are more than 3
watery stools/day
Vomiting (Yes, No) If yes, ask for more details
Cough (Yes, No) If yes, ask for more details. Consider
respiratory distress
Appetite (Good, Poor, None) Ask the mother. Do not report the appetite
test here!
If oedema, how long swollen (number of days) Longer duration of oedema implies severity
Breastfeeding (Yes, No) If the child is less than 1 year and not
breastfeed, ask why, and give counseling

Physical examination: Explore the patient for any of the following:

Respirations per minute (<30, 30-39, 40-49, Respiratory distress if: >60 (children
50-59, 60+) <2mths); >50 (2 – 12 mths); >40 (1-5 yrs);
>30 (over 5 yrs).
Chest retractions (Yes, No) This is always a sign of respiratory distress
Temperature (number in ºC) Remember, SAM children may not have fever
Conjunctiva/palms (Normal, Pale) If pale, consider anaemia. Check chapter 8 to
decide if it is real anaemia or hemodilution
Eyes (Normal, Sunken, If eyes sunken, consider dehydration.
Discharge) Check chapter 8. If discharge, treat for
conjunctivitis
Dehydration (None, Moderate, Always check Chapter 8 for diagnosis of
Severe) dehydration. Malnutrition and dehydration are
very similar and can be confused!
Ears (Normal, Discharge) If discharge, treat for otitis
Mouth (Normal, Sores, If sores or candida, treat as in FC 18
Candida)
Lymph nodes (None, Neck, Axilla, If lymph nodes are swollen consider local
Groin) infections
Disability (Yes, No) Consider what special help the child may
need.
Skin changes (None, Scabies, Peeling, Treat according to findings, check FC 18
Ulcers/Abscesses)
Hands/feet (Normal, Cold) If cold, consider dehydration and septic
shock. Check chapter 8.
 Stabilization Centre

Field Card 6. Pathophysiology of Severe Acute Malnutrition

This section has been specifically written for doctors attending patients with complicated SAM at the
Stabilisation Centre or in the Paediatric Ward of a Hospital. It is important to understand as the characteristics
of children with SAM are so different from other sick children.

Severe acute malnutrition can result in profound metabolic, physiological and anatomical changes. Virtually
all physiological processes are altered due to severe acute malnutrition. Every organ and system is involved in
reductive adaptation.

Reductive adaptation is the physiological response of the body to undernutrition i.e. systems slowing down to
survive on limited macro and micro-nutrient intake. The system reduces activity, to adapt to the lack of nutrients
and energy.

Reductive adaptation results in profound physiological and metabolic changes, some of which can be observed
by the clinician and others which are not. The initial reductions will not alter normal functioning of the body
BUT will affect its capacity to adapt to any other new situation (an infection, cold, or even to an IV infusion
or excessive oral liquids). For example, the circulatory system may still be working correctly, with no signs or
symptoms of presence of a problem... BUT it may not be able to adapt to a sudden increase of circulatory volume
(after an infusion or a transfusion, for example). Since the adaptive mechanisms to increased volume cannot
be mobilised, a simple infusion may result in cardiac overload and lethal pulmonary oedema. Similar situations
occur with: digestive system, and the amount of proteins and other nutrients that can be absorbed in one meal;
immune system, and its ability to respond to infection; the liver’s ability to detoxify; and the kidney’s ability to
excrete, etc.

In addition, some of the changes mentioned result in unusual signs and symptoms. For example, a child with
severe acute malnutrition may not be able to present fever in face of an infection. In fact, very often the infection
will present with hypothermia! You can see other examples in the following page.

These are the reasons why it is so important to follow standard protocols for the treatment of severe acute
malnutrition and its complications (like this one). The changes in metabolic and physiological responses in the
malnourished child are so important that therapeutic decisions which are lifesaving in a well nourished child can
be potentially deadly in a malnourished child.

The following page presents some of the main alterations in each of the body systems. Knowing them can help
understand the evolution and therapy of severe acute malnutrition and its complications.
 Stabilization Centre

Cardiovascular system Gastro-intestinal system

• Cardiac output and stroke volume are reduced. • Production of gastric acid is reduced.
• Infusion of saline may cause an increase in venous • Intestinal motility is reduced.
pressure. • Pancreas is atrophied and production of digestive
• Any increase in blood volume can easily produce enzymes is reduced.
acute heart failure. • Small intestinal mucosa is atrophied; secretion of
• Any decrease will further compromise tissue digestive enzymes is reduced.
perfusion. • Absorption of nutrients is reduced.
• Blood pressure is low.
• Renal perfusion and circulation time are reduced.
• Plasma volume is usually normal and red cell
volume is reduced.

Liver function Genitourinary system

• Synthesis of all proteins is reduced. • Glomerular filtration is reduced.

• Abnormal metabolites of amino acids are • Capacity of kidney to excrete excess acid or a
produced. water load is greatly reduced.
• Capacity of liver to take up, metabolize and excrete • Urinary phosphate output is low.
toxins is severely reduced. • Sodium excretion is reduced.
• Energy production from galactose and fructose is • Urinary tract infection is common.
much slower than normal.
• Gluconeogenesis is reduced, with high risk of
hypoglycemia during infection.
• Bile secretion is reduced.

Circulatory system Endocrine system

• Basic metabolic rate is reduced by about 30%. • Insulin levels are reduced and the child has glucose
• Energy expenditure due to activity is very low. intolerance.
• Both heat generation and heat loss are impaired. • Insulin growth factor 1 (IGF-1) levels are reduced.
• The child becomes hypothermic in a cold • Growth hormone levels are increased.
environment and hyperthermic in a hot • Cortisol levels are usually increased.
environment.

Immune system

• All aspects of immunity are diminished.

• Lymph glands, tonsils and thymus are atrophied
• Ig-A levels in secretions are reduced.
• Complement components are low.
• Phagocytes do not kill ingested bacteria efficiently.
• Tissue damage does not result in inflammation or migration of white cells to the affected area.
• Acute phase immune response is diminished and cell-mediated immunity is severely depressed.
• Typical signs of infection, such as an increased white cell count and fever, are frequently absent.
• Hypoglycaemia and hypothermia are signs of severe infection usually associated with septic shock.
 Stabilization Centre

Field Card 7. Admission criteria for children 6 to 59 months

This table summarizes the criteria for admission for SC, OTP and TSFP.

Admission criteria. Children 6 to 59months.

SC OTP TSFP

SAM with complications SAM no complications MAM

W/H (z-score) < -3 < -3 < -2

MUAC (mm) < 115 < 115 < 125
Bilateral oedema +++
No oedema, or Bilateral
Oedema Marasmus with any No oedema
oedema +, ++
oedema
Appetite NO APPETITE Pass appetite test N?A
New admissions

Uncontrollable vomiting
Fever > 39˚C
Hypothermia <35˚C
Lower respiratory tract
Complications infection No Complications No Complications
Severe anaemia
Extensive skin infection
Very weak, apathetic
Unconscious, convulsions

OTP Follow up: Chils

Transfer back from SC
Upgrades referred from OTP after
Other admissions

after recovery
recovery
Previously discharged as Previously discharged as
Relapse
cured but again SAM cured but again MAM
Return Return after defaulting Return after defaulting
Second twin Mother
Other Second twin
refuses SC

See FC-1 and FC-2 for calculation of W/H, MUAC and oedema.
See FC-3 for implementation of appetite test. See FC-8 for how to identify complicated SAM.

The criteria for admission of children less than 6 months and adults can be found in Chapter 8.
 Stabilization Centre

Field Card 8. Complicated and non-complicated malnutrition

A child with severe acute malnutrition will be treated in the OTP if he/she has good appetite and no
complications, but will be admitted to the SC if there are complications or appetite is poor.

It is important to be familiar with the complications of malnutrition in order to identify them and refer the
child when necessary. Ask your supervisor for advice if you are not sure that you can identify each of these
complications.

On admission:

Severe complication How to identify it

Oedema +++ Bilateral pitting oedema. See FC-1

Anorexia (lack of appetite) Perform appetite test

Intractable (uncontrolled) vomiting The child presents sudden vomiting, and he cannot
retain it (ex. He can't wait to do it outside)

Fever > 39 oC or hypothermia < 35 oC Use thermometer and measure for at least 1 minute.

Lower respiratory tract infection Always count respirations for at least 1 minute.
60 resp/min for under 2 months
50 resp/min for 2 – 12 months
40 resp/min for 1 – 5 years
OR any chest in-drawing.
Severe anaemia Check palms are very pale– compare with a healthy
child. If unclear, check conjunctiva or nail beds.

Extensive skin infection Examine the child without clothes for skin infection
or lesions and ask the mother for any other severe
infection.
Very weak, apathetic, unconscious, convulsions Observe child's attitude. Ask the mother about
convulsions (fitting – absences).

On children that are already under treatment:

Hydration status Recent history of diarrhoea or vomiting, and RECENT

appearance of clinical signs of dehydration reported
by the carer
Failure to gain weight Weight loss for 3 consecutive visits
Static weight for 5 consecutive visits

Increase or new oedema Increase of oedema, or new oedema in a child that

did not have it on admission.

This table is used for deciding who needs to be sent to SC, but as well to identify failure to respond to treatment.
It should be present in ALL consultations, and each item in the list should ALWAYS be checked.
 Stabilization Centre

Field Card 9. Admission criteria for other age groups

This table summarizes the criteria for admission for MAM (STFP) and SAM (OTP, and SC if severe complications).

To decide if the patient needs to be transferred to the SC, use the same criteria as for children (FC8).
ALL infants with SAM should be treated in the SC. These children cannot take RUTF (see Chapter 7).

Indicator SAM MAM Normal

Infants less than 6 months

Static weight or losing

W/H (W/L Z-scores) <-3 Gains weight at home
weight at home

Oedema Present Absent Absent

Clinical presentation To weak to suckle breast Poor feeding Normal feeding

Adolescents (10 – 18 years)

W/H (Z-scores) <-3 <-2 Above - 2

MUAC (mm) < 160 N/A N/A

Oedema Present Absent Absent

Adults (older than 18 years)

< 16 with weight loss in

BMI and clinical signs < 16 but no weight loss
the last 4 weeks

Oedema Present Absent Absent

Pregnant and lactating

women

< 210 with weight loss < 210 with no weight

MUAC (mm) No weight loss
in the last 4 weeks loss in the last 4 weeks
 Stabilization Centre

Field Card 16. Taking RUTF at home - messages for the carer.
When delivering these messages, replace the name RUTF for the local name of the product you use.

You should know these messages by heart.

Always check this Field Card to be sure that you didn’t forget anything.

• Breastfeeding is best – and first. For infants and young children, continue to put the child to the breast
regularly.
• RUTF should not be shared. It is a food and a medicine for the malnourished child only.
• Give small amounts and often. Sick children often do not like to eat. Give small regular meals of RUTF and
encourage the child to eat often (if possible 8 meals a day). RUTF can be left for later if not finished, and
be eaten during the course of the day.
• Give RUTF before other foods (except for breast-milk). RUTF is the only food the child needs in order to
recover. Other foods should only be offered after RUTF.
• Offer safe water. Always offer plenty of clean water to drink while he or she is eating the RUTF.
• Wash before eating. Use soap for children’s hands and face before feeding if possible.
• Keep food clean and covered.
• Give RUTF even if child is ill or has diarrhoea. When taking RUTF, the stools of the child may change.
This is normal. When a child has diarrhoea, never stop feeding. Give extra food and extra clean water and
breastmilk.
• Come to the OTP. Continue coming to the OTP even if the child has problems, or if he/she starts
participating in another programme.

Repeat the same messages at each visit, and ask the mother to repeat them as well, in order to check that she
has understood them. If the child is having problems gaining weight, you can use this list to ask the mother to
explain to you how she used the RUTF at home. Check one point at a time and don’t forget any of them.

In addition to these recommendations, it is important to train carers on how to feed their child with available local
foods. Each programme and centre should know what the availability of local foods is, and how they can be used
to improve the child’s diet – and transmit this information to the carers.
 Stabilization Centre

Field Card 17. Routine Medication for OTP and SC admissions

The next page presents a summary of the routine medication to be given to ALL children admitted directly into
OTP and to SC, even if they do not present clinical signs of infection. Children transferred from one centre to
another while undergoing treatment have already received their routine medications, and do not need to receive
them again.

Medications are given as a single-dose treatment so that the health worker can observe administration and avoid
problems with compliance. The one exception is the first-line antibiotic (Amoxycillin): the first dose should be
given in front of the health worker who explains to the carer how to continue treatment at home.

Vitamin A
Give ONLY to wasted patients. DO NOT give on admission to patients with oedema.
Check if the child has already received Vitamin A during a vaccination campaign or a health day in the last three
months. In this case, do not give Vitamin A again, to avoid overdose.
Vitamin A deficiency in Somalia is very prevalent. The amounts of Vitamin. A in RUTF are enough to manage
mild deficiencies, but not to treat a child with important Vitamin A deficiency.
Vitamin A can be given as well at the 4th week of treatment, including those that have been transferred from
Inpatient care and those that did not receive it on admission because they had oedema.

Antibiotic
Most severely malnourished children have several infections, but they cannot be diagnosed due to diminished
inflammatory response (which hides the signs of infection). Treat all children admitted to the OTP.
First line choice is Amoxycillin for 7 days, as it is effective against small bowel overgrowth, usually associated
with malnutrition. See below for dosages based on child’s weight.
If a child is receiving Cotrimoxazole prophylaxis due to a chronic disease, this should continue at the same dose
throughout the duration of treatment. You still need to give the Amoxycillin to these children.

Malaria treatment
First line treatment in Somalia is with Artesonate (3 day) and Sulphadoxine Pyrimethamine(1 day). See the table
below for dosages based in child’s weight. Malaria treatment is give treatment if a rapid diagnostic check and/or
microscopy is positive or the child has clinical signs (particularly if fever persists after completing antibiotics),

Measles vaccination
Standard treatment includes measles vaccination to all children admitted to OTP. Measles vaccination is not
usually done in Somalia, due to lack of cold chain in many centres, except in the presence of a measles epidemic.
As soon as your centre is equipped with a cold chain, start vaccinating all children admitted to OTP.

De-worming
Albendazole is the only routine medicine that is given only on the second visit of the child and only for children
above 1 year. In case of doubt on age, give only to children who can walk. In some programmes, Albendazole
can be replaced with Mebendazole (but check dosages: they are different).

Iron and Folic Acid

Not to be given routinely, since there is enough in RUTF. Where anaemia is identified, treatment should begin
after 14 days of care and NEVER before, following standard guidelines. For severe anaemia, refer to inpatient
care.

Other nutrients
RUTF already contains all the other nutrients required to treat the malnourished child. Additional potassium,
magnesium or zinc should not be given – even if they present diarrhoea! -, as far as the child takes the RUTF, as
an additional micronutrients may cause excesses.
 Stabilization Centre

ROUTINE MEDICINES FOR SAM IN OTP and SC

Systematic Medicine for Severe Malnutrition in OTP

Name of Product When Age / Weight Prescription Dose

6 months to 100 000 IU

< 1 year
≥ 1 year 200 000 IU Single dose on
VITAMIN A* AT ADMISSION
admission
DO NOT GIVE TO CHILDREN WITH
OEDEMA
3 times a day for 7
AMOXYCILLIN AT ADMISSION All beneficiaries See protocol
days
MEASLES Single dose on
AT ADMISSION From 9 months (standard)
VACCINATION admission

< 1 year DO NOT GIVE NONE

ALBENDAZOLE SECOND VISIT 12 - 23 months 200 mg (1/2 tablet) Single dose on

≥ 2 years 400 mg (1 tablet) second visit

* VITAMIN A: do not give if child has already received within last 3 months

AMOXYCILLIN DOSAGES

Dosage of Amoxicillin

Weight range Amoxycillin (50 – 100 mg/kg/d)

Dosage – twice per day

Kg in mg capsules

<5kg 125 mg * 2 ½ cap.*2

5 – 10 250 mg * 2 1 cap * 2

10 – 20 500 mg * 2 2 cap * 2

20 - 35 750 mg * 2 3 cap * 2

> 35 1000 mg * 2 4 cap * 2

*2 implies that the dosage needs to be taken twice per day

Malaria Treatment

Patients with severe acute malnutrition may have an asymptomatic malaria infection. With the new recommenda-
tion from WHO that all suspected cases of malaria be confirmed parasitological (using either microspy or with a
malaria rapid diagnostic test - RDTs) before administration of antimalarials, the procedure for these children is
now the same irrespective of whether they live in an endemic or non-endemic malarial zone.
 Stabilization Centre

Endemic malarial zone and Non-endemic malarial zone

All children admitted for SAM should be systematically tested for malaria using either microscopy or RDTs ir-
respective of the presence or not of symptoms and /or signs of malaria and all positive cases treated with an an-
timalarial, regardless of clinical signs. If the patient tests negative (especially with RDT) but remains persistently
symptomatic for malaria, give full treatment for malaria. This is especially true if fever persists once the patient
has started antibiotics.

Treatment dosages are based on weight. Follow the dosages below.

ARTESUNATE & SULPHADOXINE/PYRIMETHAMINE

• Give Artesunate (50mg) & Sulphadoxine/Pyrimethamine (500mg/25mg) as a combination on Day 1

• Continue with Artesunate (50mg) on Day 2 and 3 as per the schedule below:

Dose

Artesunate SP
Weight of child in kg
Day1, Day2, Day3 Day 1 tablets

<5 ¼ ¼

5.0 – 7 ½ ½

7.1 – 12 1 ½

12.1 – 20 2 ¾

20.1 – 30 2 1

30.1 – 40 3 1½

40.1 – 50 4 2

50.1 – 60 4 2½

> 60 5 3
 Stabilization Centre

Field Card 24. SC - Promotion between phases

The patient must meet the following criteria to transfer from Phase 1 to Transition Phase and from Transition to
OTP or Phase 2:

Criteria From Ph1 to Transition Phase From Transition Phase to OTP/Ph2

Appetite and intake Appetite improved. Appetite is good.

Child taking all quantity of milk Child is taking at least 75 % of
prescribed RUTF or all F100 prescribed
Oedema (if present) Reduced to moderate++ Reduced to low +
Absent, if patient stays in Ph2
Medical complications Treatment has commenced and All medical complications must be
patient is recovering resolved, treatment completed
IV fluids and NG feeding They are not needed any more IV
or NG feeding

All patients are sent to OTP to complete treatment. If the patient is from an area with no OTP services, or if he/
she presents a chronic complication (ex. tuberculosis, clef palate) he/she may stay in Phase 2 at the hospital.

Criteria of return to Phase 1

Some patients develop complications when promoted from one phase to the next, usually related to fluid reten-
tion or development of new complications. This can happen in Transition phase and during the first week of
Phase 2. These patients need to re-start the treatment in Phase 1.

Criteria From Transition Phase or Ph2 to Ph1

Appetite and intake Patient presents anorexia or cannot complete meals

Oedema (if present) Increase of oedema
Child without oedema that develops it during treatment
Medical complications Child develops any of the medical complications in FC-8, and in
particular:
reduced consciousness (ex. hypoglycaemia), hypothermia, hyperthermia,
acute vomiting, as well as dehydration or septic shock
Fluid overload Signs of rapid increase in liver size
Development of tense abdominal distension
Weight gain is too fast >10g/kg/d (fluid retention)
Any signs of heart failure: increased respiratory rate, crepitants, ...
Other signs of fluid overload: increased venous pressure, new oedema...
Other complications Re-feeding diarrhoea WITH weight loss (if child gains weight, continue
treatment).
IV fluids and NG feeding Any condition that needs IV or NG tube

Some of the conditions that result in return to Phase 1 need specific treatment. See chapter 8 “treatment of
complications” for advice. It is common for some change in stool frequency when there is a change in diet. This
does not need to be treated unless the child loses weight. Several loose stools without weight loss are not a
criterion to move back to Phase 1.
 Stabilization Centre

Field Card 25. Quantity of milk and RUTF in SC

Quantity of Therapeutic milk and RUTF to give in each phase of treatment, according to child’s weight.

Transition
Phase 1 Transition Phase Phase 2
Phase
F75 F100 F100
Plumpy’nut
Class of 8 feeds per 6 feeds per 8 feeds per 6 feeds per 6 feeds per 6 feeds per
Weight (kg) day day day day day day

sachets per
ml per feed ml per feed ml per feed
day

2 - 2.1 40 50

2.2 - 2.4 45 60
F100 diluted F100 diluted F100 diluted F100 diluted
2.5 - 2.4 50 65

2.8 - 2.9 55 70

3.0 - 3.4 60 75 60 75 1¼ 110

3.5 - 3.9 65 80 65 80 120

4.0 - 4.4 70 85 70 85 1½
150
4.5 - 4.9 80 95 80 95

5.0 - 5.4 90 110 90 110

180
5.5 - 5.9 100 120 100 120 2

6.0 - 6.9 110 140 110 140 210

7.0 - 7.9 125 160 125 160 240

8.0 - 8.9 140 180 140 180 3 270

9.0 - 9.9 155 190 155 190 300

10 - 10.9 170 200 170 200

350
11 - 11.9 190 230 190 230

12 - 12.9 205 250 205 250 4

450
13 - 13.9 230 275 230 275

14 - 14.9 250 290 250 290

15 - 19.9 260 300 260 300 5 550

20 - 24.9 290 320 290 320 650

6
25 - 29.9 300 350 300 350 750

30 - 39.9 320 370 320 370 7 850

40 -60 350 400 350 400 8 1000

 Stabilization Centre

Field Card 26. Preparation of F75 and F100

Prepare enough milk for the next three hours, not longer, to assure that it will not spoil.

If five or less children are being treated for severe acute malnutrition, smaller quantities of milk are necessary.
In this case, prepare small amounts by using the red scoop that comes with the package.

1. Decide on the amount of milk to prepare, by adding how much each child needs for the meal.
2. Boil the water.
3. Let the water cool down.
4. Add the milk powder WHILE THE WATER IS STILL WARM following this table:

Product Water quantities Product quantities

F75

Large packet of F75 (410 g) 2 litres of water 2.4 litres of F75

1 scoop (4.1 g) 20 ml of water 24 ml of F75

F100

Packet of F100 (456 g) 2 litres of water 2.4 litres of F100

1 scoop (4.1 g) 18 ml of water 22 ml of F100

• Mix
• Distribute to each child according to the amount needed for that meal.
 Stabilization Centre

Field Card 27. Feeding Technique

Never force-feed a malnourished child and also ensure that the mothers do not force-feed their children. This can
distress the child and can lead to aspiration pneumonia. Teach the mother how to sit the child in her lap, with an
arm behind the child’s back and the child sitting straight (vertical), and how to offer the cup with the other hand.

All feeds should be controlled by a feeding assistant. The mother or carer must be actively involved in the
feeding and the daily care of the child. They should be informed and sensitized to the importance of not
introducing other foods until the child is stabilised. Feeding is carried out with a cup (never from a bottle or with
a spoon). Feeding assistants should alert carers to the signs of acute danger so that they can call a nurse when
necessary (see section on complications).

The following information lessens the risk of aspiration pneumonia.

The child sits straight up (vertical) on the mother’s lap, leaning against her chest with one arm behind her back.
The mother’s arm encircles the child. She holds a saucer under the child’s chin.

• The milk feed is given by cup. Any dribbles that fall into the saucer are returned to the cup.
• The child is never force fed, never has his/her nose pinched, and never lies back and has the milk poured into
the mouth.
• Meal times are best to be social. The mothers can sit together in a semi-circle around an assistant who
encourages the mothers, talks to them, corrects any faulty feeding technique, and observes how the children
are taking the milk.
• Carers do not take their meals beside the patient. The child is likely to demand some of the mother’s meal and
this sharing is not recommended as the child’s appetite will reduce and then the milk will be refused.

Naso-gastric Feeding

Naso-Gastric (NG) tube feeding is required only when a patient is not taking a sufficient diet orally, which is
less than 75% of the prescribed diet per day . NG tube feeding is required when one or more of the following
is true:
• The patient takes less than 75% of the prescribed diet per 24 hours in Phase 1
• The patient presents with pneumonia with a rapid respiration rate
• The patient has painful lesions of the mouth
• The patient has a cleft palate or other physical deformity
• The patient is experiencing disturbances of consciousness

IMPORTANT: Each day, try patiently to give the patient F75 by mouth before using the NG tube. NG tube
feeding should not exceed three days, and is only used in Phase 1.
 Stabilization Centre

Field Card 28. Routine Medicines in SC (to be used with FC 17 and FC 29)
See FC 17 for a complete explanation of Routine medicines given to children on admission to OTP or SC. This
page only reflects what is different in SC.

Phase 1.

Vitamin A: As in OTP.
Measles vaccination: As in OTP.
Malaria treatment: As in OTP.
Folic acid: As in OTP.
Other Nutrients: As in OTP.

Systemic antibiotics: See next page.

Transition Phase:

Routine antibiotic therapy should be continued for four days after Phase 1 or until the patient is transferred to
OTP or Phase 2. This is to ensure that any infection is treated. Patients arriving to OTP after the SC do not need
to be given antibiotics again. Their transfer slip should clearly indicate what systematic treatment they received
at the SC.

Phase 2.

Iron

For inpatients receiving entire treatment of acute malnutrition in the inpatient health facility: Add iron to the F100
in Phase 2. RUTF already contains the necessary iron.

Iron is added to the F100 diet:

Crush an iron tablet and add to 4mls of water and mix well (Iron Solution).
• For one sachet of F100 (makes 2.4 litres of F100), add one (1) crushed tablet of ferrous sulphate (200mg) in
the 4mls of water (Iron Solution).
• For half a sachet of milk (1200ml of F100), add 2mls of the iron solution.
• For 600ml of F100, add 1ml of the iron solution.

If severe anaemia is identified, see “Treatment of Medical Complications”.

De-worming

De-worming is necessary for malnourished children being treated as inpatients, but should be delayed until they
are recovering in Phase 2 or discharged to OTP.

Use Albendazole as in OTP, with the same dosages (see FC 17).

 Stabilization Centre

Field Card 29. Systematic Antibiotics in SC

All severe acute malnourished children receive antibiotic treatment upon admission, regardless of if they have
clinical signs and symptoms of systemic infection or not. Nearly all these children have infections even if they are
not symptomatic.

Small bowel bacterial over-growth occurs in all SAM children. Enteric bacteria are frequently the source of
systemic infection by translocation across the bowel wall. This can also cause mal-absorption of nutrients and
failure to eliminate the substances excreted in the bile, fatty liver, intestinal damage, and can cause chronic
diarrhoea. The antibiotic administered for routine treatment must be active against small bowel bacterial
overgrowth.

Children with Kwashiorkor have free iron in their blood: this can lead to bacteria that are not normally invasive,
such as Staphylococcus epidermidis, and “exotic bacteria” to cause systemic infection or septicaemia.

Antibiotic Regime

First line antibiotic treatment:

Oral Amoxycillin. (If not available, doctor to decide appropriate alternative). See FC 17.

Second line antibiotic treatment:

• Add Chloramphenicol (FC 18) (do not stop Amoxycillin) OR
• Add Gentamycin 5 mg/kg IM daily (do not stop Amoxycillin) OR
• Switch to Amoxycillin/clavulinic acid (Augmentin®).

In inpatient settings where severe infection is common, this may sometimes be considered as the first line
antibiotic combination.

Third line antibiotic treatment:

Third line treatment is at the discretion of the medical doctor and is dependent on each patient’s medical
condition or complication. Frequently, a systemic anti-fungal (fluconazole) is added for patients who have signs
of severe sepsis or systemic candidiasis.

Important note: Co-trimoxazole is not active against small bowel bacterial overgrowth and is not adequate for the
severely malnourished child. If Co-trimoxazole is administered as a prophylaxis against pneumocystis pneumonia
in HIV-positive patients, the above recommended antibiotics should be administered in addition.

Duration of Antibiotic Treatment:

Antibiotics are administered every day of Phase 1 plus an additional four days or until transfer to OTP or Phase 2.
Whenever possible, antibiotics should be given orally or by NG tube. No CANULA PLEASE.

IV antibiotics should not be used with intravenous infusion because of the danger of fluid overload. Venous
access point are often colonised by resistant organisms and may give rise to bacteraemia or even systemic fungal
infection. Infusions containing antibiotics should not be used because of the danger of inducing heart failure.
Indwelling cannula should rarely be used. Additionally, never give intravenous infusions of quinine to a severely
malnourished patient in the first two weeks of treatment. Impregnated bed nets should always be used in malaria
endemic regions.
 Stabilization Centre

Field Card 30. Patient Follow Up in SC

See Chapter 12 for examples of patients’ cards.

Use the patient card as a guide for the information that needs to be collected and as a guide for your consultation
and decision making. All fields in the chart have a purpose and should be filled by the nurses or the doctor
visiting the patient.

Phase 1 and Transition phase:

Obtain the following information and record it in the chart...

Each day (in the morning):

• Weight. Plot weight on the chart.
• Oedema (0, +, ++, +++).
• Body temperature (twice a day).
• Key clinical sings (stools, vomiting, dehydration, cough, respiration, etc.)
• Record patient’s feeds and fluid intake: record if the patient takes each feed, or if the patient refuses, vomits
or is absent during the meal.

Once a week: measure MUAC.

On admission and after 21 days (if the child is still in the centre): measure length / height.

Phase 2:

Patient surveillance in Phase 2 is less intensive and less frequent than during Phase 1 and Transition Phase.
However, it is important to routinely monitor progress.

Each day (in the morning):

• Body temperature (twice a day).
• Key clinical sings (stools, vomiting, dehydration, cough, respiration, etc.)
• Record patient’s feeds and fluid intake: record if the patient takes each feed, or if the patient refuses, vomits
or is absent during the meal.

Every other day:

• Weight. Plot weight on the chart.
• Oedema (0, +, ++, +++).

Once a week: measure MUAC.

Every month: measure length / height.

IMPORTANT
During Phase 1, you should not expect any increase in weight. The amount of energy given is not enough to
promote weight gain. If the child gains weight during this phase, suspect fluid retention and be careful with
further treatment and fluid overload. It is more frequent to observe weight loss, due to elimination of fluid
retained inside the cells.

During Transition Phase some weight gain is expected (around 6 g/kg/d), if there is no malabsorption and if the
patient is not loosing oedema. Once the patient is in Phase 2, expect rapid weight gain (up to 20 g/kg/d).
 Stabilization Centre

Field Card 31. Infants - Criteria for admission and discharge

Admission criteria for children less than six months (or less than 3 kg):

Age Admission Criteria

If there is a possibility of breast Too weak to suckle effectively (independently of weight-for-length), or

feeding not gaining weight at home, or
weight-for-length < -3 Z-scores, or
presence of bilateral oedema.

Age Admission Criteria

If there is NO possibility of breast Presence of bilateral oedema, or

feeding W/L (weight-for-length)< -3 Z-score (WHO)

Discharge Criteria for children less than six months (or less than 3 kg):

Age Admission Criteria

If the child is breast feeding • Child is gaining weight on breast-milk alone after the Supplementary
Suckling technique has been stopped, and
• There is no medical problem, and
• The mother has been adequately supplemented with vitamins and
minerals.
(there are no anthropometric criteria for discharge)

Age Admission Criteria

If the child is not breast feeding • The mother has been adequately supplemented with vitamins and
minerals, and
• When they reach -1 Z-Score, and
• An appropriate breast-milk substitute for the child is defined
considering the family’s possibilities and is sustainable, and
• Child is used to milk substitute, gaining weight and carer education
on preparing and dispensing the milk substitute is done.
 Stabilization Centre

Field Card 32. F100 diluted – preparation and distribution

Preparation of F100 Diluted

Dilute F100 (one packet) into 2.7l litres of water (instead of 2 litres) to make F100 Diluted.

To make small quantities of F100 Diluted:

1. Use 100ml of F100 already prepared and add 35ml of water, then you will get 135ml of F100 diluted. Discard
any excess waste. Don’t make smaller quantities.
2. If you need more than 135ml, use 200ml of F100 and add 70ml of water, to make 270ml of F100 diluted and
discard any excess waste.

If F100 Diluted is not readily available, the infant can be fed with the same quantities of commercial infant
formula, diluted according to the instructions on the tin. However, infant formula is not designed to promote
rapid catch up growth. Unmodified powdered whole milk should not be used.

Quantity of F100 Diluted and Timing of Feeds

It is important to feed these children often as they are small and will only take small quantities. The quantity of
F100 diluted to give to a malnourished infant is calculated depending on the body weight. As opposed to the
older children, the quantity is NOT increased as the infant starts to gain weight.

1. Breast feed every three hours for at least 20 minutes (more if the child cries or demands more)
2. Between 30 minutes and one hour after a normal breast feed, give maintenance amounts of F100-diluted
using the SS technique.
3. F100-diluted is given at 130 ml/kg/day, distributed in 8 meals.
4. If the child has oedema, use F75 instead of diluted F100.

Quantity of F100 Diluted to give to infants with a prospect of being breastfed, per Kg of body weight:

ml of F100 diluted per feed

Class of Weight (kg) (8 feeds/day)
Diluted F100
<=1.2 25 ml per feed

1.3 - 1.5 30

1.6 – 1.7 35

1.8 – 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

Children less than six months with oedema are started on F75 and not on F100 diluted. When the oedema has
resolved and the child suckles strongly, he/she is changed to F100 diluted or infant formula.
 Stabilization Centre

Field Card 33. Supplementary Suckling Technique

The supplementation is given using a tube the same size as n°8 NG tube. Cut the tip of the NG tube back
beyond the side ports on the tube, if these ports exist

• F100 Diluted or formula milk is put in a cup. The mother holds it.
• The end of the tube is put in 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. This way the infant will both get milk from the cup and at the same time
stimulate the breast and the mother’s milk production. Sometimes at the beginning the mothers find it better
to attach the tube to the breast with a piece of tape.
• When the infant suckles 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. It is like taking a drink through a straw.
• At first an assistant needs to help the mother by holding the cup and the tube in place. She encourages the
mother confidently. Later the mother nearly always manages to hold the cup and tube without assistance.
• At first, the cup should be placed at about 5 to 10cm below the level of the nipple so the milk does not flow
too quickly and distress the infant, and so the weak infant does not have to suckle excessively to take the
milk. As the infant becomes stronger the cup should be lowered progressively to about 30cm below the
breast.
• The mother holds the tube at the breast with one hand and uses the other for holding the cup.

Notes

• It may take one or two days for the infant to get used of the tube and the taste of the mixture of milks (F100
diluted and breastmilk), but it is important to persevere.
• By far the best person to show the mother the technique is another mother who is using the technique
successfully. Once one mother is using the SS technique successfully the other mothers find it quite easy to
copy her.
• The mother should be relaxed. Excessive or officious instructions about the correct positioning or attachment
positions often inhibit the mother and make her think the technique is much more difficult than it is. Any way
in which the mother is comfortable and finds that the technique works is satisfactory.
• If the formula diet is changed then the infant normally takes a few days to become used to the new taste. It is
preferable to continue with the same supplementary diet throughout the treatment.

Cleaning the tube

After feeding is completed the tube is flushed through with clean water using a syringe. It is then spun (twirled)
rapidly to remove the water in the lumen of the tube by centrifugal force. If convenient, the tube is then left
exposed to direct sunlight. For optimal hygiene replace tubes often.
 Stabilization Centre

Regulating Quantity of F100 Diluted

The child’s progress is monitored by his/her daily weight:

• If the child loses weight over three consecutive days yet seems hungry and is taking all the F100 Diluted, add
5mls to each feed.
• In general the supplementation is not increased during the stay in the centre. If the child grows regularly 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 milk, but continues to gain weight, it means
that the breast milk is increasing and that the child has enough.
• Weigh the child daily with a scale graduated to within 10g or 20g. When a baby is gaining weight at 20g per
day (whatever his weight):
• Decrease the quantity of F100 Diluted to one half of the maintenance intake.
• If the weight gain is maintained (10g per day whatever his weight) then stop supplemental suckling
completely.
• If the weight gain is not maintained then increase the amount given to 75% of the maintenance
amount for two to three days and then reduce it again if weight gain is maintained.
• If the mother is agreeable, it is advisable to keep the infant in the centre for a further few days on breast milk
alone to make sure that the infant continues to gain weight. If the mother wishes to go home as soon as the
child is taking the breast milk greedily then they should be discharged.
• When it is certain that the child is gaining weight on breast milk alone he should be discharged, no matter
what his current weight or weight-for-length.

Care for the Mother

Since the aims of the treatment are to increase breast milk and for the mothers learn from each other, and be-
cause the treatment is different from older patients, the infants should be together in a specific room that can be
monitored and kept quiet.

• Check mother’s MUAC and the presence of oedema.

• Explain to the mother what the aim of treatment is and what is expected of her.
• Do not make the mother feel guilty for the state of her child or blame her for giving other foods. Discourage
self-criticism for the lack of milk.
• Strongly reassure the mother that the technique works and that she will produce enough milk to make her
baby better.
• Be attentive to her and introduce her to the other mothers in the centre.
• She should drink at least two (2) litres of fluids per day.
• She must eat enough - about 2500kcal/day (one porridge in the morning, one or two family meals, one
porridge in the afternoon).
• The mother who is admitted in the centre with her child receives Vitamin A (200,000 IU): If the child is below
1 month old (there should be no risk of pregnancy)
• Micronutrient supplementation must also be given to the mother. The quality of the milk depends upon the
mother’s nutritional status. It is critical that the mother receives meals while the child is an inpatient. The
breast feeding mother’s diet is important for the recovery of the infant from malnutrition.
• The length of stay in the inpatient facility should be as short as possible.
 Stabilization Centre

Field Card 34. Infants Less Than Six Months without Prospect of Being Breastfed
There are special circumstances where a child less than six months cannot be exclusive breastfed (these include
abandonment, a child being orphaned, medical conditions or when a mother who is HIV positive meets the
criteria for, and chooses, exclusive replacement feeding).

When there is no prospect of being given breast milk, then severely malnourished infants less than six month
old are treated according to the standard protocols of management of severe acute malnutrition in Phase 1,
Transition and Phase 2. However, the following dietary modifications explained here must be applied.

Nutrition Support: Diet and Frequency

Follow the same phases as for older children (see FC 24 for criteria to move from one phase to the next).
Use ONLY F100 diluted for children without oedema. Give F75 for children with oedema (at the same amounts)
and switch to F100 dilute once oedema resolves.

Phase 2
Phase 1 Transition Phase
F100

Diluted F100 or F75 (kwash) Dilute F100 Diluted F100

8 feeds per day 8 feeds per day 6 feeds per day

Class of
Weight (kg)
ml per feed ml per feed ml per feed

Below 1.5 30 45 60
1.6 - 1.8 35 53 70
1.9 – 2.1 40 60 80
2.2 - 2.4 45 68 90
2.5 - 2.7 50 75 100
2.8 – 2.9 55 85 110
3.0 - 3.4 60 90 120
3.5 – 3.9 65 98 130
4.0 – 4.4 140

Routine Medication

Routine medicine is the same as for infants under six months who are breastfed.

Surveillance

Surveillance is the same as for phase 1, inpatient care. See FC 30.

Follow – up after discharge

Follow-up for these children is very important and needs to be organized between the carer and the health
staff. With the absence of breastmilk, other milks need to be included in the diet to prevent relapse. Nutrition
counselling for the mother or caregiver is essential. If the child has been exposed to HIV, refer to appropriate
clinics for diagnosis and treatment.
 Stabilization Centre

Field Card 35. Treatment of Dehydration for the Marasmic Patient

When possible and feasible, re-hydrate the patient orally with ReSoMal. Intravenous infusions are dangerous and
NOT recommended unless there is: 1) severe shock with 2) loss of consciousness from 3) confirmed dehydration.

The management of dehydration is based on the accurate measurement of a patient’s weight which is the best
measurement of fluid balance. The patient should be weighed without any items of clothing on (naked).

Before starting any re-hydration treatment:

1. Weigh the child;

2. Take and record the child’s pulse;
3. Record the child’s respiration rate and;
4. Mark the edge of the liver and the costal margin on the skin with an indelible marker pen (skilled staff only).
5. If the staff is qualified to do so, record the patient’s heart sounds (presence or absence of gallop rhythm).

The marasmic malnourished dehydrated child is managed entirely by:

• Weight changes
• Clinical signs of improvement such as alertness
• Clinical signs of over-hydration (engorged veins, rapid pulse, respiratory distress)

Step 1: Determine 5% of patient’s body weight

For the severely malnourished dehydrated child, a maximum of 5% of the child’s body weight is replaced in
the form of fluids during the rehydration process. To determine 5% of body weight, equate: body weight in
grams/100 x 5.
Therefore, 5% body weight of a 4kg child equals: 4000g/100 x 5 = 200gm which then equates to 200ml of
re-hydration fluid.
It is estimated that a severely dehydrated marasmic child will lose a maximum of 5% of body weight so it is
important to only replace this amount otherwise there is a danger of over-hydration.

Step 2: Administer re-hydration fluid

The fluid must be given slowly over time to prevent complications such as overload or heart failure.
• Give ReSoMal orally or by NG tube
• Give: 5ml/kg every 30 minutes for first two (2) hours
• Give 5-10mls hourly until weight gain has been achieved

Case Study
For a 4kg child, over the first two hours give the following orally or by NG tube:
• 5ml/kg ReSoMal every 30 minutes for two hours = 20ml x four (there are four 30 minute intervals in two
hours) = 80ml. (This is 2% of a 4kg child’s body weight).
• Over the next few hours give 5 to 10ml/kg/hour ReSoMal until weight gain is achieved and the patient shows
improvement. Therefore for a 4kg child, give 20 to 40ml per hour after the initial two hours.

It is important to re-assess frequently to make sure that the patient does not become over-hydrated. Fluid
balance is measured at frequent intervals by weighing the child.
 Stabilization Centre

Step 3: Complete the re-hydration

Give re-hydration fluid until the weight deficit (measured or estimated) is corrected (maximum of 5% body
weight). Stop as soon as the child is re-hydrated, having reached the target re-hydrated weight. As the child
gains weight during re-hydration, definite clinical improvement should be obvious. The signs of dehydration
should disappear. If there is no improvement with weight gain, the initial diagnosis of dehydration was wrong and
re-hydration therapy must be stopped, and the child should be reassessed for another medial diagnosis.

Treatment of dehydration- assessment

ONLY rehydrate until the weight

deficit (measured or estimated) is
correct and then STOP – Do not give
extra fluid to prevent “recurrence”

CONSCIOUS UNCONSCIOUS

ReSoMal IV Fluid

• 5 ml/30 min first 2 hours Darow’s solution or

• 5 to 10 ml/kg/hour, 12 hours ½ saline & 5% glucose or
Ringer lactate & 5% dextrose at
15 ml/kg the first hour & reasses

• If improving, 15 ml/kg 2nd hour

• If conscious, NasoGastric tube:
Resomal
• If not improving ==> Septic Shock

Step 4: After rehydration

After rehydration, usually no further treatment is given. However, for severe acutely malnourished children from
6 to 24 months, 30ml of ReSoMal can be given for each incidence of a watery stool. The standard instructions
to give 50-100ml for each stool should not be applied. It may cause fluid overload which is dangerous.

Treatment of dehydration- monitoring

Monitor weight

Gain Stable Loss

Clinically Clinically not

improved improved

Continue • STOP ALL • Increase Resomal • Increase Resomal

re-hydration fluid by 5 ml/kg/hour by 10 ml/kg/hour
• Give F75 • Reassess every • Reassess every
Target weight
• Re-diagnose & hour hour
assess
F75
 Stabilization Centre

Two hours after commencing re-hydration therapy, make a major medical reassessment.

• Check all vital signs such as body temperature, pulse and respiration rate.
• Check heart sounds.
• Check for clinical signs of respiratory distress.
• Check level of consciousness and weight gain.
• Check for vomiting and/or diarrhoea.

If there is:

• Continued weight loss: Increase ReSoMal by 10ml/kg/hour and re-assess the patient in one hour.
• No weight gain: Increase ReSoMal by 5ml/kg/hour and re-assess the patient in one hour.
• Weight gain and...
...deterioration of the child’s condition with the re-hydration therapy:
• The diagnosis of dehydration was definitely wrong. (Even senior clinicians make mistakes in the
diagnosis of dehydration in malnutrition.)
• Stop the ReSoMal and start the child on F75 diet.
...no improvement in the mood and look of the child, or no reversal of the clinical signs:
• The diagnosis of dehydration was probably wrong.
• Change to F75.
...clinical improvement, but signs of dehydration:
• Continue with treatment until the appropriate weight gain is achieved.
• Continue with ReSoMal alone. Or F75 and ReSoMal can be alternated.
...resolution of the signs of dehydration:
• Stop re-hydration treatment and start the child on F75 diet.

During re-hydration, breast-feeding should not be interrupted.

Begin to give F75 as soon as possible after re-hydration has been completed. The F75 can be given orally or by
NG tube. ReSoMal and F75 can be alternated each hour in the case of a patient with mild dehydration and con-
tinuing diarrhoea. The introduction of F75 is usually achieved within two to three hours after starting the
re-hydration process when the patient should be improving. The re-commencement of F75 will also help to pre-
vent development of hypoglycaemia

Monitoring Re-hydration

Re-hydration (oral or intravenous) therapy must immediately stop if any of the following are observed:

• The target weight for re-hydration is achieved (start F75).

• Visible veins are full (start F75).
• The development of oedema (indicates over-hydration: start F75).
• The development of prominent neck veins.
• The neck veins engorge when the abdomen (liver) is pressed.
• An increase in the liver size by more than one centimetre.
• The development of tenderness over the liver.
• An increase in the respiration rate by 5 breaths per minute or more.
• The development of a “grunting” respiration (this is a noise on expiration not inspiration). This sign indicates
that the child has fluid overload, an over-expanded circulation, and is going into heart failure.
• The development of râles or crepitations in the lungs.
• The development of a triple rhythm.
 Stabilization Centre

Dehydration in the OTP

At the OTP, only well trained nurses will be able to differentiate true dehydration from marasmus. Those not
trained, should not recommend SAM children for transfer just because they appear dehydrated. A full history
and assessment should take place first.

If dehydration is confirmed and the child is conscious, start treating as in these guidelines: NEVER use ORS!
If ReSoMal is not available, use normal safe drinking water (water is less dangerous for the malnourished child
than ORS). The treatment may last for several hours, but it may work. Transfer the child as soon as possible.

If the child is unconscious, then transfer as an emergency. Mobilise local resources (transport, etc.) to get to
the SC as fast as possible. Unfortunately, OTPs cannot be equipped with the material for the treatment of
re-hydration, due to the complexities of its treatment and the risks of complications of treatment that can only
be addressed at the Hospital.

Diagnosis of Shock from Dehydration for the Marasmic Patient

The marasmic patient is going into shock when:

• There is definite dehydration determined by the patient’s history and the medical examination, AND
• There is a weak or absent radial or femoral pulse, AND
• The patient has cool or cold hands and feet (check with back of hand gently for five seconds).

The patient is going into severe shock when, in addition to the above signs, there is a decrease in the level of
consciousness, the patient is semi-conscious or cannot be roused. The treatment of cardiogenic shock or liver
failure is not the same as shock due to dehydration. With cardiogenic shock or liver failure, fluid given is severely
restricted or it can cause serious deterioration and the treatment itself could lead to death.

Treatment of Shock from Dehydration for the Marasmic Patient

If the patient is definitely dehydrated (a history of fluid loss, a change in the appearance of the eyes), and shows
all of the following three bullets, then the patient should be treated with intravenous fluids:
• Semi-conscious or unconscious and
• Rapid weak pulse and
• Cold hands and feet
The amount of IV fluid given is half or less of the amount used for nourished, dehydrated children.

Use one of the following solutions:

• Half strength Darrow’s solution
• Ringer-Lactate with 5% dextrose
• Half strength saline with 5% dextrose

Re-hydration needs to be done slowly and monitored closely to prevent over-hydration. Administer 15 ml/kg IV
over the first hour and reassess the child.
• If there is continued weight loss, or the weight is stable, repeat the 15ml/kg IV over the next hour. Continue
until there is weight gain with the infusion. (15mg/kg is 1.5% of body weight, so the expected weight gain
after two (2) hours is up to 3% of body weight.)
• If the child has gained weight but there is no improvement, assume that the child has toxic, septic or
cardiogenic shock or liver failure. Stop re-hydration treatment. Look and assess for other causes of loss of
consciousness.

As soon as the child regains consciousness, or the pulse rate drops to a normal level, then stop the intravenous
fluids and treat the child orally or by NG tube with 10ml/kg/hour of ReSoMal. Continue with the protocol above
for re-hydration of the child orally, using weight change as the main indicator of progress.
 Stabilization Centre

Note: Other Causes of Shock

Apart from the shock related to dehydration, there are four other causes of shock in the severe acutely
malnourished child.

1) Toxic shock
2) Septic shock
3) Liver failure
4) Cardiogenic shock.

Toxic shock may be caused by traditional medicines, self-treatment with other medication such as aspirin,
paracetamol, or metronidazole, etc.

Septic shock is a specific type of toxic shock where the damage is caused by overwhelming sepsis.
This is frequently associated with liver failure.

Diagnosis of Dehydration for the Kwashiorkor Patient

Patients with bi-lateral oedema are over-hydrated and have increased total body water and increased sodium
levels. Oedematous patients thus cannot be dehydrated, although they are frequently hypovolaemic.

The hypovolaemia (relatively low circulating blood volume) is due to a dilatation of the blood vessels with a low
cardiac output. The treatment of hypovolaemia in kwashiorkor is the same as the treatment for septic shock (see
below). If a child with kwashiorkor has watery diarrhoea, and the child is deteriorating clinically, then the fluid
lost can be replaced on the basis of 30ml of ReSoMal per watery stool.
 Stabilization Centre

Field Card 36. Active Screening of Acute Malnutrition

Active screening is a tool to rapidly estimate the general health and nutritional status of a child. It is part of the
community mobilisation activities.

The objectives of active screening are:

• to identify all children in the community that have malnutrition, and
• to diagnose malnutrition before the child develop complications.

Good active screening should therefore lead to better coverage and to less children needing inpatient care at SC,
which should translate in turn into better recovery rates and programme statistics.

This is particularly important in Somalia, where there are many OTPs that do not have the possibility to transfer
children with complicated SAM to a SC. When a child presents complicated SAM and cannot be treated
accordingly, his/her chances of survival are much lower.

Identify children to be screened (case finding):

Use the techniques presented in Chapter 9 (Community involvement) to organise activities.

There are many ways of organising case-finding. In general, it consists of sending volunteers/outreach workers to
their communities in order to visit families door to door, or to gather all children in a central place (door to door is
usually preferred to ensure that no child is missed) for screening.

Children identified as malnourished may be referred directly to the programme with a referral slip (SFP, OTP or
SC), or be told to present themselves at the next distribution. The outreach workers and the communities should
have a good understanding of the target groups for the different programmes, in order to reduce in appropriate
referrals and rejections at the distribution site.

Screening method at the community:

• Measure child’s MUAC

• Assess presence of bilateral oedema.
• Clinical status (wasting and weakness, particularly in children below 6 months)

Use criteria of admission as the threshold to decide if the child needs transferring.
W/H will be assessed at the centre, but the child may be admitted to the centre because of W/H, MUAC or
bilateral oedema.

Follow up of activity:

Volunteers and/or outreach workers should meet regularly with programme staff (from the SFP or OTP) and
provide a report of their activities (places visited, number of children screened, number of children referred, etc.).
They should report as well, on their activities to sensitize community leaders, local organisations, etc.

This meeting can be used to help evaluate outreach activities, and make plans of areas to visit in the following
weeks.
 Stabilization Centre

Field Card 39. Discharge Procedures

It is important to complete the discharge procedures, both for patients that have completed the treatment as
cured and for those that are discharged as non-respondents or transferred to a different centre.

• Give feedback to the parent/caregiver on the patient’s final outcome. Make sure that the carer understands
why the child is being discharged.

• Refer the patient to the appropriate centre (from SC to OTP and from OTP to SFP). Ensure the parent/caregiver
understands the importance of continuing treatment at the other centre, and knows when and where they
need to attend it.

• In OTP, give a final ration of seven (7) packets as a weaning off ration.

• Fill in date and reason of discharge on the register.

• Store the patient’s card with the other exits, for future reference (monthly reports or supervision).

• Advise parent/caregiver to return to the centre if child becomes sick or is losing weight again.

If the child was cured: Congratulate the carer. Some carers will receive the discharge as bad news, because they
appreciated receiving the food distributions. Explain that the child is cured and needs to return to eating normal
food – or continue treatment in the other centre. Let them know that they are not being “expelled” from the
programme for a bad reason, and that they are very welcome to come back if the child needs it.

If the child was non-response: Do not be judgemental with the carer. Explain that the child was not evolving
correctly, and that the centre has made the necessary medical and social investigations but could not find a
reason for the lack of weight gain. Encourage them to come back if the state of the child deteriorates again, or to
go to an Inpatient centre.