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Nutrition Care Process NUTRITION CARE AND TREATMENT Nutrition Care Components Key Information Process Nutritional Medical, nutrition and social Information about current/recent illnesses and medications, past medical and Integrating Nutrition Interventions in Care and Treatment: The Screening and history surgical interventions and dietary intakes in last 1 month. Probe for recent roles of the Comprehensive Care Team Assessment unexplained weight loss (3 months), food insecurity2 and barriers to food intake such as illnesses of the digestive system and psychosocial factors, and food allergies. Anthropometric and Accurately measure the client’s weight in kg (use a regularly calibrated scale) and functional impairment height in cm. Mid upper circumference measurement is used for screening those at assessment risk in community settings and in assessment of maternal nutrition in pregnant women. Waist and hip measurements are also necessary in assessing changes in body shape and over nutrition. Muscle strength using the grip strength tester and level of functional impairment eg Clinical Staff Hand grip test, Karnofsky Performance status scale3 . (Doc tors, Laboratory assessment Laboratory based testing target s biochemical markers and haematology. Anaemia , nurses, etc) vitamins and minerals correlate with nutrition status and disease progression 4 Spouse / (deficiency, normal, overload). Social worker Partner Nutritional Protein energy malnutrition Severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) with 5 Diagnosis1 (Under nutrition/wasting) medical complications and or not able to feed orally, refer for inpatient care . Severe acute malnutrition and moderate acute malnutrition without medical complications. (Other forms include stunting and underweight in children5) Over nutrition Over weight and obese. Micronutrient deficiency Vitamin and mineral deficiency diseases and disorders e.g. nutritional anaemia, diseases & disorders goitre, rickets, pellagra, osteoporosis, beriberi and scurvy. Micronutrient overloads and Acute overloads leading to vitamin or mineral poisoning and chronic over toxicity accumulation of vitamins and minerals leading to overload disorders e.g. acute iron Physiotherapist/ overload in the liver, heart and immune cells. Family & Nutrition Counselling & education Counselling for change and motivation to respond to recommended treatment, and Occupational Intervention optimum dietary practices. Education on safe use of micronutrients and critical Therapist friends (see note on nutrition practices. Referral to organizations providing food aid (wrap around food) therapeutic and and livelihood security support. supplemental Oral therapeutic foods (RUTF) Severe acute and moderate acute under nutrition (wasted) patients who are not nutritional able to feed orally are admitted for inpatient management (as per Phase I protocol) formulations) Stable inpatients with Severe under nutrition (wasted) are managed with RUTF and continued as out patients. Stable outpatients with severe wasting are managed as outpatients following outpatient therapeutic program (OTP) and using food by prescription (FBP) protocol. Community Oral supplemental foods Used for stable patients with moderate and mild acute under nutrition in out patients and inpatients. health service Counsellor providers Single or multiple Therapeutic/pharmacological doses for replacement in severe deficiencies. micronutrients Supplemental doses for preventive and maintainance for those at risk. Resistance exercise/Physical Muscle function and muscle regeneration. activity Micronutrient overloads and Refer both acute and chronic overloads for clinical management (including Spiritual Nutrition toxicity withdrawal, gastric suction, use of activated charcoal sorbent and chelators among caregivers service others). providers Nutrition Patient focused plan Adherence, % Weight gain, rate of weight gain (eg kg/wk), BMI increases, MUAC Monitoring & increases over time. Evaluation Unexpected response eg no change or further loss in weight and MUAC, length/height. Changes in level of functional impairment. Treatment outcomes (recovery from malnutrition). The Comprehensive care team plays an important role in the management Linkages to improve food security and livelihood supporting organizations. of patients. This is through medical treatment, counselling for nutrition and

1 Dietary intake, physical functional status, psychosocial factors including stigma and social cultural factors along with illnesses healthcare, psychosocial support, adherence counselling, referral and link- (related diseases), presence of oedema and physiological status should be considered in the diagnostic statement. 2 Refers to household hunger score (HHS) criteria (See last page on HHS). ages to livelihood support. Family members also ensure that the patient is well 3Rating on the ability for self care: Level 1 – Requires special care and assistance (unable to care for self); Level 2 – Able to care for taken care of at home and follows all treatment instructions. some or most self care needs but unable carry out active work (requires assistance); and Level 3 – Able to carry normal activities with some signs and symptoms or without complaints. A hand grip test assesses muscle function by measuring grip strength and endurance. Measurements are expressed as a percentage of a standard for men and women: Men: 48.8±7.0 kg; women 34.4± 4.7 kg. 4 Inflammatory markers (C - reactive protein and alpha - 1 - acid glycoprotein) are required for correct interpretation of nutrition bio markers. 5 National Guidlines for Intergrated Management of Acute Malnutrition, 2009 and Kenya National Clinical Nutrition and Dietetics Reference Manual, 2010. 1 2

6 - 60 Months: Length 45 - 80 cm WEIGHT AND HEIGHT MEASUREMENT IN YOUNG CHILDREN

Height measurement in children • Ensure the height meter is accurate and the numbers are legible • The client should remove shoes and jackets/ sweaters • The client should stand straight and look straight ahead • The head, shoulders, hips, knees and heel must be in contact with the board or against the wall. • Take the reading from the front and record it immediately • For children who cannot stand, length measurements are taken as illustrated below

90°

1 National Guidelines for Integrated Management of Acute malnutrition, 2009. 3 4

6 - 60 Months: Length 81 - 120 cm

MEASURING THE MID-UPPER ARM CIRCUMFERENCE (MUAC) IN CHILDREN 1 - 5 YEARS OLD MUAC is a measure used for screening. There are different cut-off points to help classify malnutrition based on age of the child11

1 Ministry of Medical Services and Ministry of Public Health and Sanitation; National Guidelines for Integrated Management of Acute malnutrition IMAM), 2009 5 6

Notes ALGORITHM FOR MANAGEMENT OF SEVERE ACUTE MALNUTRITION

TREATMENT FLOW CHART FOR SEVERE ACUTE MALNUTRITION Other medical complications that necessitate hospitalization In addition to severe bilateral pitting oedema (+++), marasmic Measure anthropometry and check bilateral pitting oedema kwashiorkor and poor appetite, the following complications necessitate inpatient care:

Intractable vomiting -Evaluate nutritional status and health condition Convulsions -Check for medical complications -Perform appetite test Lethargy, not alert Unconsciousness Lower respiratory tract infection High fever If SAM without medical complication and passed If SAM with medical complication and/or Severe dehydration appetite test failed appetite test Severe anaemia Hypoglycaemia Hypothermia Medical complication developed, decreased Eye signs of vitamin A deficiency Admission to Admission to appetite, weight loss or stagnant weight, oedema Outpatient care Inpatient care Skin lesions increase or no decrease

The following complications require referral of patient for further medical evaluation:

Treatment Treatment No appetite (failed appetite test) IMCI danger signs Appetite returning (passed appetite test) Oedema decreasing, Increase in or newly developed bilateral pitting oedema Medical complication resolving Weight loss because of diarrhoea (re-feeding or other origin) Weight loss for three consecutive weeks Static weight (no weight gain) for five consecutive weeks Other signs of failure to respond to treatment

SAM Treatment completed (based on discharge criteria): Discharge to home or refer for supplementary feeding and other services that address underlying causes of malnutrition

7 Heigh 1 1 1 1 1 1 1 1 1 1 1 1 1 9 9 9 9 9 9 9 9 9 1 0 0 0 0 0 0 0 0 0 0 0 0 0 9 9 6 7 9 8 8 7 6 02 t(cm 2 4 3 5 4 3 1 1 5 3 0 2 0 ...... 9 1 5 4 5 7 2 8 9 ...... 4 7 9 5 3 2 6 2 1 6 8 8 4

Severe

- ) 3

S Weigh D

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

3 2 2 3 2 2 2 1 1 1 3 3 2 1 3 3 2 1 1 2 2 1 1 .37 .79 .08 .27 .99 .69 .29 .98 .67 .36 .58 .17 .49 .88 .48 .09 .39 .79 .48 .89 .20 .57 .27 t(k g ) Heigh 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 07 02 03 t(cm 9 8 6 5 3 1 1 0 9 7 4 0 9 7 5 4 2 3 8 6 ...... M 1 2 5 7 9 1 6 8 9 4 8 3 5 8 2 3 5 4 7 1 BOYS

- o ) 2

dera S Weigh D 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

te 4 3 3 5 5 5 4 4 3 3 5 4 4 6 5 5 5 5 4 4 3 3 5 .03 .53 .29 .82 .59 .11 .74 .28 .90 .79 .48 .63 .52 .08 .71 .34 .22 .00 .39 .14 .66 .42 .94

t(k g ) Heigh 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 0 0 0 0 0 0 1 1 1 1 1 1 0 1 0 1 1 1 11 16 t(cm 6 5 2 9 8 8 7 6 5 4 4 3 1 1 0 9 3 7 5 2 0 ...... 7 1 4 6 7 2 7 2 7 7 2 3 9 5 6 1 8 2 6 9 1

- Mild ) 1 S Weigh D 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

9 8 8 8 8 7 7 7 6 6 6 6 5 7 6 5 8 7 7 7 6 6 8 .11 .81 .68 .39 .10 .81 .66 .25 .94 .78 .35 .05 .90 .53 .66 .75 .98 .97 .37 .09 .51 .20 .26 t(k g ) Year: 8 6: 6: 5: 5: AGE 6: 6: 6: 6: 5: 5: 6: 5: 5: 5: 6: 6: 6: 6: 6: 5: 5: 5: 5:

Month 1 10 10 1 9 7 3 1 9 3 5 7 5 1 8 6 4 2 0 8 6 4 2

Heigh 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 1 1 1 1 1 1 0 0 0 0 0 0 10 14 t(cm 3 2 1 0 9 8 7 6 5 4 4 3 2 1 0 9 8 7 6 5 4 ...... 6 7 8 9 1 2 2 3 3 9 5 1 2 3 5 6 6 7 8 8 8

- Mild ) 1 S Weigh D

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

8 7 6 5 8 7 7 7 7 7 6 6 6 6 6 5 5 5 5 8 7 6 5 .06 .22 .39 .56 .35 .94 .78 .65 .50 .10 .97 .82 .70 .27 .12 .97 .85 .41 .27 .22 .37 .54 .71 t(k g ) Heigh 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 t(cm 9 8 8 7 6 5 5 4 3 3 2 1 0 0 7 6 4 2 1 9 4 1 7 ...... M 5 6 2 8 1 7 3 5 6 2 7 9 5 1 4 6 9 3 4

GIRLS

- o ) 2 dera S Weigh D

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

te

4 4 4 4 3 3 2 2 5 5 4 4 4 4 4 3 3 3 3 3 3 3 2 .98 .76 .30 .08 .63 .40 .96 .73 .23 .09 .87 .65 .54 .43 .19 .98 .87 .74 .53 .29 .19 .06 .83

t(k g ) Heigh 1 1 1 1 1 1 1 1 1 1 9 9 9 9 9 9 9 9 9 9 1 9 9 0 0 0 0 0 0 0 0 0 0 8 6 9 9 8 7 7 6 5 5 0 7 9 t(cm 3 0 2 2 2 1 0 0 3 1 ...... 4 6 1 8 4 2 8 4 5 7 3

...... 2 9 9 5 1 7 5 2 6 3

Severe

- ) 3

S Weigh D

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

2 1 1 0 2 2 2 2 1 1 1 0 2 2 2 1 1 1 1 1 1 0 0 .46 .91 .37 .90 .65 .39 .29 .10 .82 .75 .19 .72 .56 .20 .01 .65 .56 .47 .28 .10 .01 .99 .81 t(k g )

5 - 17 yrs: Age 5:1 - 7:2 9 Height(cm) 114.2 112.1 106.3 114.9 112.8 111.4 110.7 109.2 108.5 107.8 115.6 113.5 115.2 113.1 111.7 109.6 107.4 105.9 113.8 110.3 108.1 114.5 112.4 108.9 106.6 111 110 107 Severe -3 SD Weight(kg) 16.30 15.71 15.00 14.48 13.90 15.90 15.20 14.08 16.84 16.63 16.10 15.39 14.79 14.29 16.72 16.19 15.99 15.47 15.28 15.09 14.90 14.37 14.19 13.79 16.52 15.79 14.59 13.98 Height(cm) 120.2 118.7 117.9 116.4 115.6 115.2 112.8 112.4 111.6 111.2 114.8 113.6 120.9 117.1 121.7 119.4 114.4 113.2 116.7 121.3 120.5 119.8 118.3 117.5 114 119 116 112 Moderate BOYS -2 SD Weight(kg) 17.77 19.73 19.50 18.88 18.63 18.50 18.24 18.11 18.02 17.90 17.65 17.53 17.15 17.03 16.80 16.68 16.44 16.20 17.28 16.91 16.56 19.99 19.10 19.86 18.98 19.38 19.60 18.75 Height(cm) 121.2 126.1 124.9 123.7 122.5 119.5 118.2 116.9 120.4 119.9 119.1 118.6 117.8 117.3 116.4 127.8 125.3 124.5 124.1 123.3 122.9 121.6 120.8 127.4 125.7 126.6 122 127 -1 SD Mild Weight(kg) 23.07 22.62 22.04 21.61 21.29 21.01 20.28 19.98 19.24 23.40 22.33 20.56 19.54 23.22 22.19 21.15 20.42 19.41 22.48 21.43 19.84 24.01 23.55 22.92 21.75 20.73 20.11 23.86 Year: Month 10 8: 10 7: 10 8: 11 7: 11 AGE 9: 2 9: 0 8: 6 8: 4 8: 0 7: 8 7: 6 7: 2 7: 0 8: 8 8: 5 8: 2 7: 7 7: 4 7: 1 9: 3 9: 1 8: 9 8: 7 8: 3 8: 1 7: 9 7: 5 7: 3 Height(cm) 126.9 125.9 123.1 121.2 120.3 119.4 118.5 117.6 115.8 127.8 127.3 126.4 125.4 124.5 123.5 122.6 122.1 121.7 120.8 119.8 118.9 117.1 116.7 116.2 115.3 124 125 118 -1 SD Mild Weight(kg) 23.50 23.35 22.83 22.64 22.34 22.17 21.99 21.52 21.34 21.03 20.71 20.58 20.41 20.24 20.10 19.66 19.49 19.36 19.20 19.07 18.64 18.48 23.68 23.01 21.81 21.17 19.79 18.90 Height(cm) 113.7 112.8 111.6 111.1 110.3 109.9 121.6 121.2 120.7 120.3 119.8 119.4 118.9 118.5 117.6 117.1 116.7 116.3 115.8 115.4 114.5 114.1 113.2 112.4 110.7 112 118 115 Moderate GIRLS -2 SD 16.91 16.40 16.29 15.94 15.80 15.34 19.52 19.39 19.23 18.96 18.80 18.68 18.52 18.25 18.10 17.98 17.83 17.70 17.45 17.30 17.18 17.06 16.79 16.55 16.17 16.06 15.69 15.45 Height(cm) 114.2 113.3 112.5 111.6 110.8 109.2 108.8 108.4 107.6 106.8 105.2 104.4 115.5 114.6 113.7 112.9 111.2 110.4 109.6 107.2 106.4 105.6 104.8 108 112 110 106 115 Severe -3 SD Weight(kg) 15.78 14.50 14.19 14.09 13.66 13.56 13.26 13.16 12.86 16.28 16.00 15.89 15.64 15.53 15.30 15.19 15.05 14.95 14.84 14.61 14.40 14.29 13.98 13.76 13.46 13.36 13.06 12.96

5 - 17 yrs: Age 7:3 - 9:11 11 Heigh 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 1 1 1 1 2 2 1 1 1 1 2 2 2 2 2 2 2 1 2 2 1 2 1 1 t(cm 4 2 1 0 9 8 7 6 5 4 7 6 6 5 5 4 3 3 2 1 0 8 2 1 9 9 0 8 ...... 1 5 8 4 7 3 6 9 7 9 3 6 3 9 3 5 7 3 9 1 7 7 2 4 3

Severe

- ) 3

S Weigh D

2 2 1 1 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 2 1 1 1 1

0 0 9 8 7 7 0 0 9 9 9 8 8 8 8 8 7 7 7 6 0 8 7 0 9 9 8 7 ...... t(k 86 59 51 70 91 56 18 05 92 79 29 92 79 34 13 03 36 27 04 93 72 58 68 46 41 16 22 47 g

) Heigh 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 3 3 2 2 2 2 2 2 2 3 3 2 2 2 2 2 3 3 3 2 2 2 2 2 2 t(cm 4 3 2 2 1 9 6 5 4 3 3 2 0 0 8 7 6 6 5 2 1 0 9 8 7 8 5 2 ...... M 7 9 8 6 7 2 9 4 3 5 2 4 9 1 5 7 5 2 8 2 3 5 7 8 3 1

BOY

- o ) 2

de

S Weigh D r S a 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

te 1 2 5 4 4 3 3 2 2 1 1 1 1 1 0 0 0 4 4 3 3 2 2 1 0 0 4 3 .4 .3 .1 .6 .1 .3 .1 .5 .0 .9 .7 .3 .1 .0 .6 .5 .2 .8 .0 .8 .7 .8 .6 .8 .7 .3 .4 .2

t(k 1 8 4 3 6 7 2 3 8 8 0 0 7 3 4 1 4 2 1 7 2 1 7 4 4 8 8 3 g

) Heigh 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 3 3 3 3 3 3 2 3 3 3 3 3 3 3 3 3 3 3 3 3 2 2 2 3 3 3 3 2 t(cm 9 5 3 3 1 0 8 8 7 7 6 6 5 5 4 4 2 2 1 0 9 9 8 9 8 1 3 9 ...... 6 9 8 4 4 2 2 6 7 3 8 4 5 1 7 3 6 2 8 6 8 4 6 1 2

- Mild ) 1

S Weigh D 2 2 2 2 2 2 2 3 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

9 8 7 6 5 4 4 0 9 8 7 7 6 6 5 5 4 9 9 8 7 7 6 6 5 4 4 9 .03 .47 .03 .53 .73 .63 .16 .40 .60 .26 .91 .58 .87 .22 .57 .41 .94 .78 .20 .63 .74 .24 .37 .06 .09 .78 .31 .99 t(k g

) Year: 1 10: 10: 11: 11: 11: 10: 10: 9: 11: 11: 11: 11: 11: 10: 10: 10: 10: 10: 10: 10: 9: 10: AGE 2 9: 9: 9: 9: 9: 9:

Month 10 1 6 8 7 5 4 9 10 1 2 6 0 6 0 7 5 4 3 1 8 7 5 4 3 2 1 9

Heigh 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 4 4 3 3 3 3 3 3 3 3 3 3 2 4 3 3 3 3 3 3 3 2 2 2 4 3 3 3 t(cm 1 0 9 8 7 6 5 4 3 2 1 0 9 1 9 8 7 5 4 2 1 9 8 8 0 6 3 0 ...... 9 9 9 9 8 8 8 8 7 7 7 8 8 4 4 3 3 3 2 2 2 3 8 3 4 3 2 3

- Mild ) 1

S Weigh D 3 2 2 3 3 3 3 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

1 5 4 1 0 0 0 9 9 9 9 8 8 8 7 7 7 7 6 6 6 5 5 5 4 4 4 4 .61 .15 .41 .19 .97 .55 .34 .93 .71 .26 .05 .84 .45 .24 .85 .64 .26 .01 .81 .44 .24 .87 .67 .48 .96 .77 .22 .03 t(k g

) Heigh 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 3 3 3 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 2 2 2 2 2 2 2 2 2 2 t(cm 5 2 1 8 8 6 5 5 4 2 4 4 3 3 2 1 0 0 9 9 7 7 6 4 3 2 4 3 ...... M 2 7 2 7 2 8 8 4 4 1 7 2 7 2 2 7 7 2 7 2 8 3 3 9 5 6

GIRLS

- o ) 2 de

S Weigh D r a

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 2 2 1

te

5 5 5 5 4 4 4 3 3 3 2 2 2 2 2 1 1 1 1 0 0 0 0 0 9 4 3 9 .96 .58 .39 .03 .84 .65 .11 .75 .57 .39 .87 .69 .35 .21 .04 .71 .53 .36 .07 .90 .74 .60 .29 .12 .68 .29 .05 .99

t(k g

) Heigh 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 1 1 1 1 1 1 2 2 t(cm 5 4 2 1 1 9 8 6 5 8 7 7 6 5 4 3 3 2 0 0 9 8 7 7 6 9 7 6 ...... 1 1 2 7 3 4 5 8 9 4 9 4 5 5 6 6 2 7 8 4 9 1 7 2 3

Severe

- ) 3

S Weigh D

2 2 2 1 1 1 1 1 1 1 1 1 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1

1 0 0 9 8 8 7 7 7 7 6 6 1 0 0 0 9 9 9 9 8 8 8 7 7 7 6 6 ...... t(k 43 81 32 72 67 51 83 68 56 27 64 39 10 94 48 16 88 56 25 12 97 39 24 98 16 04 90 50 g

)

5 - 17 yrs: Age 10:0- 12:4 HEIGHT AND WEIGHT MEASUREMENT IN OLDER CHILDREN AND ADULTS

Height measurement Ensure the height meter is accurate and the numbers are legible The client should remove shoes and jackets/ sweaters The client should stand straig ht and look straight ahead The head, shoulders, hips, knees and heel must be in contact with the board or against the wall. If the health worker is shorter than the client, he/she should stand on an elevated surface in front of the client If the client has a high fixed hairstyle, the reading is taken from the highest point of the forehead Take the reading from the front and record it immediately

Weight measurement Ensure that the scale is functional and well calibrated Place the scale on a flat surface or hang the scale on a firm place All heavy clothing and shoes should be removed Children should be undressed fully and weighed in a warm room Ensure the machine reads zero before and after weighing Record all the measurements immediately Calibrate the machine with standard weights regulalry

1913 BOYS GIRLS

-3 SD -2 SD -1 SD -1 SD -2 SD -3 SD 5 - 17 yrs: Severe Moderate Mild AGE Mild Moderate Severe Age 12:5- 14:10 Height(cm) Weight(kg) Height(cm) Weight(kg) Height(cm) Weight(kg) Year: Month Height(cm) Weight(kg) Height(cm) Weight(kg) Height(cm) Weight(kg) 126.1 21.15 133.1 25.33 140 30.58 11: 8 142.4 31.84 135.7 26.15 128.9 21.60 126.5 21.28 133.5 25.49 140.5 30.99 11: 9 142.9 32.26 136.1 26.49 129.3 21.73 126.9 21.42 134 25.86 141 31.21 11: 10 143.4 32.49 136.6 26.68 129.8 22.07 127.4 21.75 134.4 26.01 141.5 31.43 11: 11 143.9 32.92 137.1 26.88 130.3 22.24 127.8 21.89 134.9 26.39 142 31.86 12: 0 144.4 33.36 137.6 27.26 130.7 22.55 128.3 22.06 135.4 26.58 142.5 32.08 12: 1 144.9 33.59 138 27.42 131.2 22.72 128.7 22.36 135.9 26.78 143 32.51 12: 2 145.3 33.99 138.5 27.81 131.6 22.86 129.2 22.54 136.4 27.16 143.6 32.79 12: 3 145.8 34.22 138.9 27.98 132 23.17 129.7 22.71 136.9 27.36 144.1 33.22 12: 4 146.2 34.63 139.3 28.33 132.5 23.35 130.2 23.05 137.4 27.56 144.6 33.45 12: 5 146.7 34.86 139.8 28.53 132.9 23.49 130.7 23.23 137.9 27.95 145.2 33.94 12: 6 147.1 35.27 140.2 28.89 133.3 23.81 131.2 23.41 138.5 28.20 145.7 34.18 12: 7 147.5 35.46 140.6 29.06 133.7 23.95 131.7 23.76 139 28.60 146.3 34.67 12: 8 147.9 35.87 141 29.42 134.1 24.28 132.2 23.94 139.5 28.80 146.9 34.96 12: 9 148.3 36.07 141.4 29.59 134.5 24.42 132.7 24.12 140.1 29.05 147.5 35.46 12: 10 148.7 36.48 141.8 29.76 134.8 24.53 133.2 24.48 140.6 29.45 148 35.70 12: 11 149.1 36.90 142.1 30.09 135.2 24.86 133.8 24.71 141.2 29.71 148.6 36.21 13: 0 149.4 37.05 142.5 30.26 135.6 25.01 134.3 24.89 141.7 30.12 149.2 36.51 13: 1 149.8 37.47 142.8 30.59 135.9 25.12 134.8 25.26 142.3 30.37 149.8 37.03 13: 2 150.1 37.63 143.2 30.76 136.2 25.41 135.4 25.48 142.9 30.83 150.4 37.32 13: 3 150.4 38.00 143.5 31.09 136.5 25.53 135.9 25.86 143.4 31.05 151 37.85 13: 4 150.8 38.20 143.8 31.22 136.9 25.86 136.4 26.05 144 31.52 151.5 38.10 13: 5 151.1 38.58 144.1 31.56 137.2 25.98 137 26.28 144.5 31.74 152.1 38.63 13: 6 151.3 38.69 144.4 31.69 137.4 26.05 137.5 26.66 145.1 32.00 152.7 38.94 13: 7 151.6 39.07 144.7 31.83 137.7 26.36 138 26.85 145.7 32.48 153.3 39.48 13: 8 151.9 39.23 144.9 32.12 138 26.47 138.6 27.09 146.2 32.70 153.8 39.74 13: 9 152.1 39.56 145.2 32.26 138.2 26.55 139.1 27.48 146.7 33.14 154.4 40.29 13: 10 152.4 39.72 145.4 32.56 138.5 26.86 139.6 27.67 147.3 33.41 154.9 40.79 13: 11 152.6 40.05 145.7 32.69 138.7 26.93 14 15 150.4 149.9 149.3 148.7 148.1 147.4 146.7 145.9 145.1 144.3 143.4 142.5 141.6 140.6 150.1 149.6 148.4 147.7 147.1 146.3 145.5 144.7 143.9 142.1 141.1 140.1 149 143 Severe - 3 S Weigh D

31.29 33.66 33.17 32.90 32.37 31.85 31.12 30.95 30.57 30.40 29.82 29.44 28.87 28.27 34.38 33.93 33.30 33.03 32.50 32.02 31.68 30.23 29.65 29.08 28.47 28.07 34.25 33.79

t(k g ) Heigh 158.1 157.6 157.1 156.5 155.9 155.2 153.7 153.4 152.9 152.5 152.1 151.7 151.2 150.8 150.3 149.3 148.8 147.8 154.5 149.8 148.3 157.9 157.4 156.8 156.2 155.5 154.9 154.1 t(cm M BOYS - o ) 2

dera S Weigh D 36.78 36.36 36.12 35.70 35.47 35.23 34.77 34.54 34.09 33.86 41.49 40.98 40.72 40.17 39.62 39.02 38.87 38.43 38.23 38.03 37.65 37.41 36.98 41.39 40.88 40.32 39.77 39.41

te

t(k g ) Heigh 165.9 165.4 164.9 164.3 163.7 163.3 162.7 162.3 161.9 161.5 161.2 160.7 160.3 159.9 159.5 158.5 158.1 157.6 157.1 156.5 155.5 165.6 165.1 164.6 159 156 163 164 t(cm - Mild ) 1 S Weigh D 49.31 48.68 48.00 45.73 44.97 44.27 41.88 41.11 49.61 49.49 48.86 48.24 47.38 46.66 46.17 45.45 44.74 43.46 43.24 42.72 42.45 41.61 50.64 50.06 47.56 46.89 43.99 50.18

t(k g ) Year: 16 15: 10 14: 10 15: 11 14: 11 16: 2 16: 1 16: 0 15: 8 15: 6 15: 5 15: 4 15: 3 15: 2 15: 0 14: 8 14: 7 14: 6 14: 4 14: 2 14: 0 16: 3 15: 9 15: 7 15: 1 14: 9 14: 5 14: 3 14: 1 AGE

Month Heigh 155.9 155.8 155.7 155.6 155.4 155.3 155.1 154.9 154.7 154.4 154.1 153.8 153.5 153.1 155.8 155.7 155.6 155.5 155.4 155.2 154.8 154.5 154.3 153.6 153.3 152.8 155 154 t(cm - Mild ) 1 S Weigh D 44.23 44.18 44.18 44.12 43.88 43.82 43.82 43.52 43.47 43.47 43.17 43.12 43.06 42.76 42.71 42.65 42.36 42.25 41.96 41.90 41.79 41.50 41.40 41.05 41.00 40.66 40.55 40.16

t(k g ) Heigh 149.1 149.1 148.9 148.9 148.8 148.7 148.7 148.6 148.5 148.4 148.2 148.1 147.9 147.8 147.7 147.4 146.9 146.5 146.3 146.1 145.9 148.3 147.5 147.2 147.1 146.7 149 148 t(cm M GIRLS - o ) 2 dera S Weigh D

36.01 36.01 35.97 35.92 35.92 35.65 35.60 35.60 35.55 35.28 35.24 35.19 35.14 34.87 34.83 34.78 34.51 34.47 34.37 34.11 34.02 33.97 33.66 33.57 33.48 33.18 33.09 32.78

te

t(k g ) Heigh 142.3 142.2 142.1 141.9 141.7 141.5 141.3 141.2 140.8 140.6 140.5 140.1 139.8 139.4 142.3 142.2 141.9 141.8 141.6 141.4 140.9 140.3 139.6 139.2 142 141 140 139 t(cm Severe - ) 3

S Weigh D

28.71 29.56 29.56 29.52 29.52 29.48 29.44 29.20 29.20 29.16 29.11 29.07 29.03 28.79 28.75 28.63 28.39 28.35 28.27 28.23 27.95 27.87 27.83 27.56 27.48 27.40 27.32 27.05

t(k g )

5 - 17 yrs: Age 14:11 - 17:3 17 Step Instructions S Heigh tep 150.9 153.6 153.2 152.7 152.4 152.1 151.7 151.3 153.5 153.4 153.3 153.1 152.8 152.5 152.2 151.9 151.5 151.1 150.6 C M Go Fin

153 sid 1: 2: o easure t(cm nfirm tot d Measurement R e,

t Severe

ead - h if ) 3 h e

S t e BM

h a t

t Weigh th h h g e D at

e e c e

37.04 36.71 36.61 36.52 36.14 36.00 35.63 35.44 35.02 34.84 36.99 36.66 35.67 36.57 36.19 36.05 35.53 35.12 34.93 34.47

h c

of

t ch I h ild h ild fo e t(k t art h

a r is e ’s g g

a ) c e a g hei h

e o g ild

Heigh f i 5

rl, g t

h h – o 160.8 160.4 159.9 159.7 159.6 158.6 158.4 161.1 160.9 160.5 160.3 160.2 159.4 159.2 158.8 160.9 160.6 t e 160 161 159

read n

1

i

c t(cm 7 n the h

M y “cm ild

BOYS r t - h s c o ) 2

h e in dera re S ” and

art, cells Weigh fe “year D re 44.90 44.53 44.21 44.10 44.05 44.00 43.68 43.63 43.52 43.21 43.10 43.05 42.69 42.58 42.01 41.90 44.58 44.53 42.47 42.11

a

te n nce wei o d

t(k n s”

p

t

c g l h g and ace h h ) e a t

ri rt i Heigh n “m y g a

o h “ n 168.6 168.5 168.5 168.4 168.3 168.2 168.1 167.9 167.8 167.7 167.5 167.4 167.2 167.1 166.9 166.7 166.5 166.3 166.1 ur t k onths” d ide

168 si g” i t(cm de nde a . n n

- Mild C tify d ) x 1 i

s hoo S reco finge bet Weigh D the se 54.51 54.16 53.75 53.34 52.75 52.28 50.76 54.10 53.69 53.22 52.87 52.40 51.81 51.29 51.16 54.58 54.23 53.28 52.21 51.69

w r

d r col een t

h o o t(k e cellt n n u

t g a 5 m h ) p is -17 n i

e marked row. Year: h ce a yrs 18 17: 10 16: 10 17: 11 16: 11 t 17: 8 17: 7 17: 6 17: 5 17: 4 17: 3 17: 2 17: 0 16: 9 16: 8 16: 6 16: 5 16: 4 17: 9 17: 1 16: 7 AGE

o i

f . s If Month

pape neare t AGE h e

r c . st h

Heigh ild

a t t o 156.4 156.4 156.4 156.3 156.3 156.2 156.2 156.1 156.1 155.9 156.4 156.3 156.3 156.2 156.2 156.1 155.9

the 156 156 156

i t s h t(cm e act b cent o y - Mild ) 1

ua read S r e Weigh l D

of he

45.50 45.25 45.25 45.25 45.19 45.19 45.19 45.19 45.14 44.89 44.89 44.89 44.84 44.84 44.84 44.53 44.53 44.53 44.48 44.48

t

h the i g e h t(k

cells o t c

y h g ) ou art. Heigh ha n

t ve 149.8 149.8 149.8 149.7 149.7 149.7 149.6 149.6 149.6 149.5 149.5 149.5 149.4 149.4 149.4 149.3 149.3 149.2 149.2 149.2 h e

m t(cm left M easure GIRLS - o ) 2 dera S Weigh D d . 36.80 36.75 36.75 36.75 36.65 36.65 36.28 36.06 36.80 36.80 36.70 36.70 36.70 36.65 36.38 36.38 36.38 36.33 36.28 36.33

te

t(k g ) Heigh 143.2 143.1 142.9 142.9 142.8 142.7 142.5 142.4 143.2 143.1 143.1 142.9 142.8 142.7 142.6 142.6 142.5 142.4 143 143 t(cm Severe - ) 3

S Weigh D 30.14 30.14 30.10 30.10 30.10 30.06 30.06 30.02 30.02 30.02 29.98 29.93 29.89 29.89 29.85 29.61 29.98 29.93 29.85 29.61

t(k g )

5 - 17 yrs: Age 17:4 - 17:11 / Notes 19 Step 3: Identification Identify the cell with weight that is equal to or just less than the actual recorded weight along the age row. Identify the cell with height that is equal to or just less than the actual recorded height. Step 4: Classification Classify and report the child’s nutrition status as mildly undernourished if -1SD, moderately undernourished if -2SD or severely undernourished if -3SD by reading the BMI for Age Z score in the top row (Diagnostic rows) of the column where the actual height and weight falls. Note that if the height or weight fall in a different nutrition status category, then record and manage for the worse off nutrition status. Note that only children with a BMI for age less than – 2 SD and – 3SD are eligible for Food By Prescription or FBP. (For eligibility criteria of OVC, please refer to FBP protocol) Example (use the figure shown below) Joan’s date of birth is 30 August, 2000. Therefore, she is 8 years 7 months. Her height and weight are measured and found to be 115 cm and 17 kg respectively. Using the BMI for age 5 – 17 yrs reference chart, her BMI for age is obtained as follows; Reading from the AGE column of the chart, find the age 8 years 7 months and place your left index finger at this point. Since, Joan is a girl, move and read the right section of the chart. Establish that Joan’s height of 115cm is less than 118cm but greater than 112cm, shown on the chart. Similarly, her weight is less than 18.1 kg but greater than 15.05 kg. From the diagnostic rows, classify and report Joan as moderately undernourished because her height and weight correspond to a BMI for age Z score of -2 SD in the top of the row. Notes Notes

1. Read 3. Classify

BOYS GIRLS Diagnostic -3 SD -2 SD -1 SD -1 SD -2 SD -3 SD AGE rows Moderate Severe Moderate Mild Year: Mild Severe Height Weight month Height Weight Height Weight Height Weight Height (cm) Weight (kg) Height (cm) Weight (kg) Measurements (cm) (kg) (cm) (kg) (cm) (kg) (cm) (kg) 112.1 15.71 117.9 18.63 123.7 22.19 8: 75 123.1 21.52 117.1 17.83 111.2 14.84

2. Identify

20 a

b 22 - 24.9 18.6 - 21.9

c c

c c

a b c 21 22

Adult: Height 140 - 174cm MEASURING THE MID-UPPER ARM CIRCUMFERENCE (MUAC) IN ADULTS MUAC is used to assess nutrition status of the pregnant women and post partum mothers past 6 weeks. It is also used for assessing nutrition status of bed ridden patients.

23 19 24

Adult: Height 175 - 210cm 1925 26

Notes ORAL NUTRITIONAL THERAPIES FOR STABLE PATIENTS Oral Nutritional Therapies

Therapeutic food formulations Supplementation prescription They are energy and nutrient dense food formulations designed for treatment of severe The aim is to provide about 50% of energy, over 70% of whole protein and essential fatty acids 1 malnutrition (weight loss and wasting). Therapeutic formulations deliver energy and along with about 1 RDA of key micronutrients. The supplementation protocol is designed with nutrients as well as pharmacological levels of vitamins and minerals to meet daily the intention of drawing the remaining energy and nutrient requirements from consumption requirements and support nutritional reconstitution (rehabilitation phase). Commonly of home foods to raise the caloric intake by 2 - 2.5 times. This should facilitate transition to ® available formulations include, lipid based peanut-milk powder paste (Plumpy nut , home food upon recovery from malnutrition. Imunut®, Insta RUTF) and cereal-milk powder & plant protein based solid bars (BP-100®) among others. Typical energy values are 500 kcal/92g sachet (550 kcal/100g) for the paste In rehabilitation of moderately undernourished children a fixed dose prescription of 435 presentation and 300 kcal/57 g bar (526 kcal/100g) in the bar presentation. kcal/day or 100 g FBF/day for 6-23 months old and 870 kcal/day or 200g FBF/day for 2 to 9 years old children are recommended. A fixed dose prescription of 1350 kcal day or 300 g Supplemental food formulations FBF/day is recommended for rehabilitation of moderately undernourished children above 10 These foods are designed to facilitate faster recovery of moderate and mild malnutrition. years and all adults. Nutrient deficits of the prescribed therapeutic or supplemental Supplemental food formulations are nutrient dense fortified blended foods (FBF) or nutritional products should be met using home diets. composites of staple foods. They contain recommended daily allowances for selected vitamins and minerals (RDAs) levels and may be used concurrently with RUTF in treatment 1 of severe malnutrition. Brands available in the market include Nutrimix®, Foundation Plus®, - The total daily energy requirement (kcal/day) consists of resting (basal) energy expenditure (BEE) ® ® ® to maintain life, energy of activity (type of work – sedentary, light, moderate or heavy) and energy First Food , Advantage , and Plumpy soy among others. Typical energy values are 410-550 expended in digestion, transportation and processing of food (diet-induced). The BEE is kcal/100g. Guidelines for FBF are provided by Kenya Bureau of Standards Composite Flour dependent on age, size (weight and height), gender and environment. Clinical estimation of BEE is Specification; KS 1808:2010 based on Harris and Benedict equations. These equations are based on age (A) in years, height (H) in cm and adjusted weight (W) in kg. BEE (males) = (13.8 x W) + (5.0 x H) – (6.8 x A) + 66.5 (kcal/d) Rationale for prescription of therapeutic and supplemental formulations BEE (females) = (9.6 x W) + (1.8 x H) – (4.7 x A) + 655.0 (kcal/d) A set of adjustment factors that account for different clinical status are used to estimate TEE values from BEE. For example, the following factors are used to estimate TEE; during total bed rest BEE x Therapeutic prescription 1.2; patient with multiple fractures BEE x 1.2 to 1.4; HIV positive/AIDS patients BEE x 1. 5 to 1.8 and The aim is to provide close to 100% of recommended energy, proteins and lipids. The a maximum of 2 in patients with major burns. pharmacological levels of micronutrients are intended to facilitate recovery and storage 2 requirements of severely malnourished patients. Treatment should transition from – Assumes that patients have successfully completed the Phase 1 stabilization and the transition phase. In case of new stable patients particularly those with SAM, who have eaten little or nothing therapeutic intervention to supplemental intervention after the patient nutrition status during the previous 5 days or more, gentle re-awakening of the metabolic functions and ensuring improves to moderate/mild malnutrition status. nutrition-electrolyte balance is necessary. Sudden loading with therapeutic foods could precipitate life threatening fluid electrolyte imbalance also known as re-feeding syndrome. Patients aged

2 above 10 years should be initiated on 100 mg Thiamine (vitamin B1) and complete multiple Treatment of stable severe malnutrition in children below 10 years is based on a fixed dose micronutrient formulation immediately before feeding and continue daily for the first 10 days. For prescription 170-220 kcal/kg/day3. The feed should be gradually increased to the fixed dose patients aged below 10 years, 50 mg Thiamine and multiple micronutrient formulation should be level to permit physiological stabilization. considered after consulting the doctor. Phosphate, potassium and magnesium supplements may be provided if plasma levels are low and the therapeutic nutritional formulation does not provide adequate amounts. Treatment of stable severe malnutrition2 in children above 10 years and adults a fixed dose prescription of approximately 40 kcal/kg/day is recommended until the patients is 3 - Management of severe malnutrition: a manual for physicians and other senior health workers. physiologically stable and recovery is evident. Thereafter, the energy intake is gradually World Health Organization, Geneva, Switzerland, 1999. 4 escalated to 85 kcal/kg/day until patient is cured and transitioned to maintenance diet. 4 - Collins S, Myatt M, and Golden B. Dietary treatment of severe malnutrition in adults Am. J. Clin. Nutr. 1998;68:193–9.

27 C V O C V 2 C V O 6 C V O C 1 5 O 4 h h h h 0 – u u u u r r r – – lie r pha pha pha

i i i i l l l l pha

- 2 n n n n l l l l 9 59

d d d d 3 1

e e e e

y r r r r 5 n m ra ra ra ra e e e e n n n m e

n y t n n n n e e e a o b b b b e

e o d d d r : : : : c n d

l l l l a n s

e e e e

a t

a a a r t

a h s h nd nd nd t nd

s e s

gor

y

unde M unde S unde M unde S unde M unde S unde M unde S D e e e e o o o o v v v v d d d d e e e e i a e e e e r r r r r r r r r r r r e e e e r r r r n n n n n n n n g a a a a

u u u u u u u u n t t t t e e e e t t t t t t t t r r r r r r r r o

i i i i i i i i t t t t t t t t s i i i i i i i i o o o o o o o o i s n n n n n n n n

- - - O ------

r

M A M W W A M W M B A M B M B A M B M W UAC M M M M ppe ppe ppe ppe UAC H F UAC H UAC UAC UAC UAC UAC H H I I I I Z Z Z

f f f f

t t t t

< o o o o < < < i i i i t t t t b

r r r r

- < < b < b < b e e e e - - -

e 2 A A A A 2

3 3 e e e t t t t 1 1 1 1 t P . . e e e e . . 0 t t t w g g g g 0 1 1 4 3 0 0 w w w s s s s r

e e e e

. . . .

Z e Z t t t t 5 5 5 5 Z Z i

een een een

e < < < <

m    

c c c sco c sco n

sco sco m m m - - - - m

2 2

a 3 3 1

. .

1 1 1 r . . 1 0 0 r r r r 0 0 e 4 3 1 e .

e e y

5 Z Z

. . .

Z Z

5 5 5

O - O E

sco sco

– – – sco sco 12 r r lig

1 1 1

r r 4 8 3 r r c e e . . . e e m 5 5 5

i O

b

c c c O O r m m m ility

r r

c r ite ------

r L B V L B V L B V L B V i i i i i a i i i i i i i i n n n n l l l l s s s s 1 a a a a k k k k i i i i

t t t t b b b b e e e e e e e e S l l l l r r r r d d d d e e e e a a a a e

O O O O l l l l w w w w

c p p p p V V V V a a a a o i i i i s s s s tt tt tt tt C C C C nda t t t t i i i i i i i i

n n n n n n n n g g g g g g g g

e e e e r d d d d y e e e e 28

m m m m

a a a a

- - - - / / / / + + + +

------e ( N e ( s N e p e p N e p Y e R Y e p e R O S O S T O S N O S 2 O S O T O S I O T I Founda Fo n n a g ...... 7 e e e e upp upp upp upp upp upp o o h h h U U g g g g g g g n n n n n n n n u u u u c f f 6

r r r r ung ung e e e W ...... h a a e e e e e e e e t t t t unda T T g

d d d d r r r r W ra ra ra W W w W W W

n n e m b b b b b b b b i i i i F F, a a a a a l l l l l l t t t t t t t a p p p

a a a a a a o o o o o o o o e e e e e e t s i i i i y y y y

i

s a a o o o o t e i c c

m m m m m m t t t t t t e e e e tt tt tt tt tt tt tt tt

e e p nd nd e e e e e e r h h n n n n i i i i p

t t u u u r . . . . l l l l l l l l 2

r r r r r r i i e e e e e e e I

e e e e G e e e e e e e e e

ild ild G t t t o o 21

G G G 1 c c c c r n n n n n n n i i i G G G . . . . r

n n o o o o c c c p p p p p p p p

y y u u

2 1 bag(3kg)permonth 2 1 bag(3kg)permonth w t t t t t t – u u u d t

uns uns uns uns

a a a a a a o o u u u

e e e e e e e e a

f f f a –

n n P P a a a e b b a 3 k r r ood r r r r ood r r ood l l l l l l ung ung a r a a

r u u

r r r l l

28 y 5 a a r d f f f f f f d

r r r m m m m m m m m u u d d d t t ood ood ood ood ood ood

g g d d d v ® e e e e ® o s s s r r ® ® ® s s o o o o o o o o ® ® ® a lin lin lin lin i i ® ® s : : f e

e

t t c c

n n n n n n n n a c

( 37g 37g ( i i

R g n ) ) h h 6 6 h o o

c t t t t t t t t

g g g g e e e e e e

h h h h h h h h

h i i U ild ild n n e t 276 k k . . g g g g g g

e e

e t i /

T g g o o o o o o o o

s / c c kg o . . t 300g 300g 200g 200g 1 1 kg

f f f f f f f f o o ) ) s F 2 1bag (4.5kg)permonth n n p 00g 00g g

n

uns uns p p s s s s s s s s

p u u e m i b b a a a a a a a a e

e e b e r t t a p f f f f f f f f o 2

r r r r r s m m m m m m o w e e e e e e e e g i i dy

e e a m m d w t t

p s

1 w w w w w w w w k s s s s lin lin s s i i y

c o o e

k ( o o

p p F F F F s w a a a a a a a a 9 r k

n n n n w a B B

B B

g g e e t t t t t t t t

d

k t t a e e e e e e e e c e c c

r r

F F F F e h h a h r r r r r r r r o o

g i

g d d

i g

y

( ( ( ( e g s s s s s s s s ) uns uns F F F F a a h e

t o o o o o o o o h p o s y y i i i i t 2 l l l l l l l l r r r r f t

e / u u u u u u u u

p s s s s / p F F

e e r p R t t t t t t t t t t t t e B B lin lin e

i i i i i i i i m e U Food Food Food Food r o o o o o o o o r F F r n n n n n n n n w o T d

g g d

n a F k

( ( ( ( ( ( ( ( a S S S S S S S S t y

y h i ®

®

W W W W W W W W ® ® e

o

o

) ) f 21 ) )

S S S S S S S S f

) ) ) ) ) ) ) )

------F B p 1 p - p sco G p p S p E G S N B E G S N B E E N W E G E N W

. 1 x x x x x x r r r r r r c w w P M M 0 r r r r o o o o H H ogr ogr ogr ogr ogr ogr o . i i i i i i a a a a

0

t t t t t t itc itc r

Z r o o o o I I dua dua dua dua

e

Z Z e e c c c c c c

Z e e e e

f f sco

x lie lie lie lie lie lie h h e e e e e e

d d d d o o

= = sco ss ss ss s s s

i e e e e r r

t t s s s t t t t o o t n n n n n n

o o m m m m e e e e r

A A r r

t t t t t t

e

c

r

F F w w w w a a a a g g > >

f f f f f f e r B B r r r r r r

e e

h h h h o o o o -

i o o o o o o -

F F

t = = e e e e n n n n 1 m m m m m m 1

e n n n n

p p .

o o . 0 2 2 2 2 r

0 :

r r r r W B B

F F F F F F

W e e Z i c c c c

Z B B B B B B > > M M a o o o o scr scr

H

sco H P P P P P P n n n n 3 - sco - I I

Z

s s s s 3

i i Z & & & & & & & 3 f f e e e e p p .

r . o o 0 =

c c c c r

0 t t = e m m m m m m

r r u u u u e

i i

Z o

A o o

Z

o A A t t t t r o o o o o o

n n i i i i r

sco

v v v v c sco n n n n n n ge ge >

s s > e e e e t

i i i i i i

-

o o t t t t t t

i

r o o o o o o v v v v = = - 1 r n n o e

r r r r r r

e i i i i 1 . o o

l l s s s s 0 n

y y . its its its its r r

0 Z

s

> > Z

-

Summary Protocol: OVC

Special Precautions In pregnant women the number of sachets and the period of treatment with RUTF should be carefully monitored to avoid high loading with vitamin A. In patients with diabetes, caution is required and careful adjustment of the treatment protocol is required because RUTF contains large amounts of sugar.

/bar The risk of micronutrient overload with iron, zinc and selenium along with fat soluble vitamin A and D could significantly increase if large amounts of RUTF are consumed over a prolonged period. Administration of mega dose vitamin A in management of SAM in children and initiation of RUTF treatment should be carefully evaluated to avoid Vitamin A overload. Risk of hyperlipidemia is increased patients who are adequately nourished and or from prolonged use of RUTF.

Contraindications Adverse Reactions to Foods Food intolerance, sensitivity and allergies are commonly associated with peanuts (ground nuts), tree nuts (macadamia, walnuts etc), fish, shellfish, milk (casein), cheese, soybeans, eggs (albumin), meat and meat products and fruits. Past history of signs and symptoms following ingestion of these foods may indicate intolerance or allergy.

1 Source: World Health Organization/World Food Programme/United Nations System Standing Committee on Nutrition/The United Nations Children’s Fund, 2007 2 Source: Manufacturer - Compact AS, Norway 29 ( P P a C V O C A 1 nd o r h u r s e d lie t s pha

i l g 6 t u n l

d a n

P lts m e b r n a a ra e n ove n o r : t n

e t b n t 18

u d :

c w t l 1 m e

h

a a 5+ y

o s nd t

e m ) w e

a y o gor e r e s m n a

r e s y n

l R unde M unde S g P unde M unde S unde M unde S o a D oor e e e a s o o o i v v v p s n d d d e e e i

i a

d e e r r e r r r r r r r w e e e r r r n n n n n n

g w a a

a

. e u u u u u u

n t t t ; i e e e e t t t t t t g r r r r r r o i / / / h g

M i i i i i i M M t t t t t t s t h i i i i i i

o o o o o o i ild t ild ild s

n n n n n n

; ;

- B o A ------A ------f

M nd/ nd/ N

> o I

M H H ( k M H A M M H A M c O O s O H O A M B H O O B 0 L M

Low n O O m t c g . M M ppe ppe a ppe I I I I r VC r VC VC VC I I o 7 lie

UAC UAC UAC UAC UAC UAC / UAC V V V V

V V i r r g

w

m

n I I

kg/ e

n

t + + + + + + s 1 < o w t t t e ges B M M B t v v

6 i i

i n v v 2 v v s n 1 m t t t M M e e e

b b < b < <

e e e t

UAC UAC e e e e t 6 t

o

h i o

i

1 ta o

g e e e I I 1 t t 1 t 1 o r P kg/

6 e e e n t t t

h

9 9 6 ti n f f < w w w 3

s s s r t t

o o -

a

t t t h on c c c

i

18. c m een een een r r

18.

g m m m l m    b <

r

i a A A r i

a 2 n e

t 1

a i 5

l

5 e a t

g g

n O 4

p O

n w

1

we r kg/ e e 1 1 . c r i o i 5 o 6 r

r m e 9 9 a d y < <

f

r

e c –

i

m – – m

w

gh - - < m n E

w 2

18.

3 2 2

a 2 e 1 . lig

1 i

. 0 t 3 3 l i . t

0 4

3 O

5 g h ga

&

Z c c .

Z

h 5

m m r c W

i

i

sco t

m l – b sco

n

o

l H

) w

18. o ility

r s O r

e s e 5

c r ite - - O - - - - - O - - - - -

F B F B I I a a M

M c c r ilu ilu V V B B B B B V o o i I I a n n i M i M i i i i

l l l s s < s r r < t t a a 1 a e e i i i r r 20

I I

t t t b b b <

o o

e e e t t < < 20 S l l l l l o o r r r e e e

kg/ a a a 2 2

& & e

g g l l w w l w 0 0 kg/

c a a

p p p o o m kg/ kg/ a a a i i o r r n n i i i s s s tt tt tt m

2 nda t t t

A A

w w i i i i i

i m m 2 n n n n n n R R

e e

g g g g g g 2 2 T T

i i

g g e e e r

. h h

d d d y t t e e e 30

m m m d d

e e a a a - s s

p p - - - / / / i i + + + t t

e e

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S S

e e e b b b b b b i i i i r r r r l l l l l l t t t t t ) ) n n p p p n n n n o o o o a a a a o o e e e e e e s s s i i e e e e o o

m m m m m m t t e e t t e tt tt tt tt tt tt a a a a . . p p p e e e e g g

n n t t t t t t u u u l l l l P A l l l l l l r r r r

i i i i e e i i e e e e e . . e e I e e e e e e

t t t n n n n o o o o o o

G o c c r r r N n n n n W W n n n i i G G i G

n n n n n n u u u u c c o o c p p p p s p p w w t t t t w t t u t C t

uns uns a a a a a a t t t t u u

u

e e e e e e a a f f f

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a a a i i i i

r l l l l l l

e e r f f f f f f a t t t t

r r c

r m m m m m m u u u u u u d rG rG i i i i ood ood ood ood ood ood d d d o v t e e o o o o s s s s s s ® a o o o o o o uns ® ® ® lin lin ® ® ® ® ® ®

n n n n e l e e e

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t t t t t t a a

g g e e e e e e o

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uns e e e e d d e e

d d d d i 76g lin o o o o o o

o ...... 300g 300g 3 3 3 3 ® ®

f f f f f f 2 1 bag(4.5kg) 2 1 bag(4.5kg) 2 1 bag(4.5kg)p i i i i 00g 00g 00g 00g

n n n n n

g s s s s s s

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a g

p

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c , e e e f f f f

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g

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r y y y n n n n s s s s s s ) ) ) a a a a a a e

o o o o o o

a g g g g p p p o o o p p y y y y y y f 2 l l l l l l l

f f f e e o e e e u u u u

u u e

c c c c

F F F F F

F

& r r r r r o o o o r l R R R t t t t t t B B B B B B l i i i i i i m m m u u u u o m m

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o

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n n n n n n F F F

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t

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h i d

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n

s

t o o g I I I t t

n

dua

0 e t o I

o

2 c c e e c e t

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3 lie lie x lie o

c h f e e e 5 =

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t e

w n u

s c ss ss ss

e

o o o

w i e e B kg/ c F > o g m t ;

t t h h 2 i t t n n r n r r

= u e o m m

e h B r

g a O F i

e

2

e e i t t t

v

> > >

t c

h

g i o

F > F w 0 i n n a a i m R p n e

f f f g r 2 2 16 kg/ v r

B

h t r r

r

: : 2 p kg/

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0 0

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r t s e n n

t

m m m n

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m

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1 n o kg/ p

g o m i t a 2 2 scr 9 n r n

h a r b o B F F F

i

i e i c c t 2 n

c

i m m n s p B B B a h f

m M m n a o o scr m i

e o t ft O p = t s P P P n n 2 2

3 h r 2 2 i = r

I

t e

o

a &

v

s s o R

s

O

i & & & i & & r 2 > o e e p n nd e o

r

o

c

c r r 6 d

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s n t c 18. > m m W O m

u

> u r i

o

B

A s o w

o o s 1 t t B UAC R n

o o o e n M n t

i o i n 5 . k t v v c e M s n n n 3 i

s n h

l

g M e s ady kg/ e e I 2

t y i i i

a l

o h c t t t I

i

=

y

o o o v v n UAC u

n o t >

= r r r

i i

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s

> = n

Summary Protocol: Adults

APPETITE TEST AND FREQUENTLY ASKED QUESTIONS ON ORAL NUTRITION THERAPIES

Appetite Test Dietetic Counselling Session – Frequently Asked Questions1 1. Are Oral Nutritional Supplemental and Therapeutic formulations food or Points to Consider When Conducting an Appetite Test for children drugs? • Conduct the appetite test in a quiet, separate area. 2. Who is supposed to use them? • Provide an explanation to the caregiver regarding the purpose of the appetite 3. How often should I use them along the day? test and outline the procedures involved. 4. What should I do when I do not manage to finish because of nausea, • Observe the child eating the RUTF and determine if the child passes or fails vomiting, loss of appetite or diarrhoea? the appetite test. 5. Can the therapeutic food formulations be mixed with other foods? • Advise the caregiver to: 6. What should I avoid to drink or eat together with RUTF? o Wash hands and or spoon used for giving the RUTF 7. What are the consequences if I share my ration of RUTF with other persons? o Sit with the child in his/her lap and gently offer the RUTF 8. Is it good for somebody who is not HIV positive to use RUTF? o Encourage the child to eat the RUTF without force-feeding 9. Is it good for somebody who is not thin to use RUTF? o Offer plenty of clean water to drink from a cup while child is eating the 10. When should I stop using RUTF? RUTF 11. Will I become thin again when I stop eating RUTF?

Appetite Test Results Pass Appetite Test Fail Appetite Test The child eats at least one third of a packet of The child does not eat one third of a packet of RUTF (92 g). RUTF (92 g).

Notes: 1. Many children will eat the RUTF enthusiastically straight away, while others might initially refuse it. These children need to sit quietly with their caregivers in a secluded place and be given time to become accustomed to it. 1 Dibari et al; A qualitative investigation of adherence to nutritional therapy in malnourished adult 2. For adults, if an appetite test must be conducted, the food given should be in the AIDS patients in Kenya. Public Health Nutrition 10. 101; 1-8, 2011. form that the patient will eventually use at home. It is essential that this test is used to establish swallowing capacity of a combined preparation of RUTF and

FBF. Health workers should conduct demonstrations on food preparations for all

new patients. 3. Short term pharmacological interventions with an antiemetic and an apppetite stimulant should be considered for patients with severe nausea/vomiting and anorexia.

31 32

Notes Critical Practices in Nutrition Assessment, Counselling and Support (NACS) Determining Household Food Security: Application of the Household Hunger Score1 (HHS) Critical Nutrition Practice1 Key message and Actions A: 1. Periodic nutrition assessment is Anthropometric measurements of height and weight (to assess % weight B: QUESTION C: RESPONSE OPTIONS D: CODE NO critical for effective maintenance changes, Body Mass Index (BMI) or Z score) and MUAC provide useful In the past four weeks, was there and management of malnutrition information on nutrition and health status of patient. Changes in body shape ever no food to eat of any kind in 0 = No (skip to Question 2) 1. and waist to hip ratio may be observed to detect fat distribution disorders. your household because of lack of 1 = Yes ….|___| 2. Adequate intake of a balanced diet Dietary assessment of the adequacy of food consumptions from different resources to get food? to meet increased energy and food groups and their access (food security), and barriers to food intake that 1 = Rarely (once or twice in the past four weeks) nutrient requirement is essential are disease related is required. This informs in selection of appropriate diet 1.a How often did this happen? 2 = Sometimes (three to ten times in the past four weeks) for effective maintenance of and meal plans that include nutrient dense foods. In case s of clinical 3 = Often (more than ten times in the past four weeks) ….|___| optimal nutrition status and nutritional deficiency disorders/diseases, prescription of supplemental or In the past four weeks, did you or management of malnutrition therapeutic food or micronutrients is indicated. any household member go to sleep 0 = No (skip to Question 3) 2. 3. Regular drinking of adequate safe Water intake must be sufficient to meet essential functions including at night hungry because there was 1 = Yes ….|___| and clean water is critical for digestion, absorption, transport and metabolism of nutrients. Drinking not enough food? optimum nutrition and health plenty of water can reduce side effects from medications, and also help with status. dry mouth and constipation. Patients must remain adequately hydrated at 1 = Rarely (once or twice in the past four weeks) 2.a How often did this happen? 2 = Sometimes (three to ten times in the past four weeks) all times and use safe water to take drugs. The water must be boiled or 3 = Often (more than ten times in the past four weeks) ….|___| treated. 4. Maintaining good personal Frequent hand washing with clean water and soap, and making it a must In the past four weeks, did you or any household member go a whole hygiene, food safety and after using the toilet, before handling food and before eating is vital. 0 = No (questionnaire is finished) 3. day and night without eating 1 = Yes environmental cleanliness is key Washing fruits and vegetables with safe clean water is also vital in anything because there was not ….|___| to effective prevention of prevention of opportunistic infections and malnutrition consequences. enough food? opportunistic infections. 1 = Rarely (once or twice in the past four weeks) 5. Food and drugs interactions are Side effects of drugs may impact on nutrition status of a client by altering 3.a How often did this happen? 2 = Sometimes (three to ten times in the past four weeks) important in effective patient intake, absorption and metabolism. Medications can affect taste; 3 = Often (more than ten times in the past four weeks) ….|___| management. precipitate nausea, vomiting, loss of appetite, diarrhoea and constipation. Dietary interventions can reduce the severity of drugs related side effects. Oral drugs may also require specific dietary practices to enhance their Creating a Household Hunger Score for a household efficacy. Step1. The response for each question (column C) is recorded under column D 6. Positive living behaviours improve Lifestyles that increase the risk of infection with other strains of HIV and or (Code). ‘Never’ should always be coded as 0. ‘Rarely’ or ‘Sometimes’ should be the coping mechanism of the infecting others must be discouraged. Clients must be encouraged to use coded as 1. ‘Often’ should be coded as 2. clients. condoms when having sex or abstain altogether, to stop alcohol consumption and smoking. These risk factors exacerbate disease Step 2. The responses given by a household in column D for the three questions are progression and reverse all treatment gains. Clients should be given good added to obtain the household’s aggregated HHS score. psycho social support to be able to seek help from family and friends and or referred to peer support groups. . 7. Adequate physical activity is key to Regular physical activity enhances muscle tone, prevents muscle wasting, Interpretation maintenance muscle tone and stimulates regeneration, increases appetite and improves sleep patterns Based on the HHS score, each household is categorized as follows: regeneration following wasting. Encourage patients to engage in daily physical activity for at least 30 minutes. HHS SCORE CATEGORY 8. Good health seeking behaviour Timely and effective management of opportunistic infections helps in 0 1 Little to no household hunger facilitate prompt access to slowing down progression of the disease and malnutrition Effective 2 3 Moderate household hunger treatment and support management of opportunistic infections and appropriate nutritional 4 6 Severe household hunger interventions are vital in slowing down the progression of disease. . Encourage patients to seek help anytime they develop signs and symptoms of an opportunistic infection. The minimum score possible is 0. This would be the HHS score for a household that responded “NO/never” to all three questions. The maximum score possible is 6. This would be the HHS score for a household that responded “YES/often” to all three questions. Households in this category merit food aid and livelihood support.

1 Provide patient with reinforcing IEC material such as “Eat Well Stay Healthy” and “Nutrition in Management 1 Deitchler, Megan, Terri Ballard, Anne Swindale and Jennifer Coates. Validation of a Measure of Household of HIV/AIDS” Hunger for Cross-Cultural Use. Washington, DC: Food and Nutrition Technical Assistance II Project (FANTA-2), AED, 2010 33