Training Module National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years Participant’s Manual

Revised on May 2020

Table of Contents

Foreword 4 Message 5 Acknowledgements 6 Symbols, Units, Acronyms 7 List of Tables 9 List of Figures 10 List of Annexes 11

Module 1: Understanding Philippine Integrated Management of 12 Acute MalnutritionAcute Malnutrition (PIMAM) (PIMAM) Session 1: Malnutrition 14 Session 2: Nutrition Plan and Framework 18 Session 3: Philippine Integrated Management of Acute Malnutrition (PIMAM) 20

Module 2: Identification of Moderate Acute Malnutrition (MAM) 23 Session 1: Measurement of Weight for Length/Height and Determination of 25 Z-score Session 2: Measurement and Interpretation of the Mid-Upper Arm 3435 CircumferenceCircumference (MUAC) (MUAC) Session 3 : Clinical Assessment of Bilateral Pitting Edema 36

Module 3: Management of Moderate Acute Malnutrition 38 SessionSession 1: Community outreach 40 Session 2: Assessment and Admission 46 Session 3: Interventions and Services 50 Session 4: Monitoring, Follow-up, and Referral 62 Session 5: Discharge 69 Session 6: Linkaging 71 Session 7: MAM in Emergencies 72

Module 4: Community Simulation 80

Annexes 89 Definition of Terms 128 Reference 131

Participant’s Manual 3

Foreword

The Department of Health’s Agenda for 2016-2022 supports the achievement of the Sustainable Development Goals for the next 15 years, particularly in addressing childhood malnutrition, which accounts for 45% mortality among the under-five children worldwide. One form of malnutrition is acute malnutrition. In the Philippines, based on the Food and Nutrition Research Institute 2015 computation, among those with acute malnutrition, over 73 percent or over 700,000 are having moderate acute malnutrition (or moderate wasting) while the rest are having the severe form.

Centered on the multi-dimensional development of a child, the DOH developed the Strategic Framework for Comprehensive Nutrition Implementation Plan for 2014-2025, the Administrative Order 2015-0055 National Guidelines for the Management of Acute Malnutrition and the jointly developed Philippine Plan of Action for Nutrition 2017-2022 together with the members of the National Nutrition Council Governing Board. These plans and policy have paved way to the creation of the Manuals of Operations for the Management of Moderate Acute Malnutrition (MAM) supported by the World Food Programme (WFP). Its objective is to build the capacity of the local implementers in addressing the nutritional needs of moderately wasted children and preventing them from becoming worse whose risk for mortality is even higher.

With these additional manuals available, the management of acute malnutrition is now complete with the augmentation of the nutrition specific and sensitive interventions in place.

The DOH is grateful for the support provided by the World Food Programme (WFP) and the members of the Community-based Management of Acute Malnutrition (CMAM) Technical Working Group in coming up with these manuals which prove and show that partnership is key to the achievement of any goals set in the 17 SDGs.

Here is for a better generation of healthy, well-developed and globally competitive Filipino children.

FRANCISCO T. DUQUE III, MD, MSC Secretary of Health

Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under 4 Five Years

Message

Good Nutrition is the foundation of life.

By providing means and platforms to address the health and nutritional needs of children in their growing years, we will guide them towards achieving their full potential and live a brighter future.

The World Food Programme (WFP) and the Department of Health (DOH) have joined efforts in responding to the challenges of the Sustainable Development Goals in the next 15 years, particularly in the area of malnutrition by finding better solutions to address some, if not all, of its causes.

The problem of acute malnutrition or wasting among children under-five years in the Philippines has been a long prevailing concern in the last two decades. As a result, roughly one million children are at an increased risk of early mortality and poor cognitive and physical development, particularly those living in underserved and vulnerable communities. This needs to be put to an end.

In July 2017, WFP and DOH have jointly launched the National Guidelines for the Management of Moderate Acute Malnutrition (MAM). This has led to the further development of manuals for the trainers, course coordinators and participants in order to enhance and strengthen their capacities in implementing the Integrated Management of Acute Malnutrition program in the country.

It is with our profound hope that with these manuals, we contribute to the establishment of a better health service delivery and a health system that addresses the nutritional needs of children resulting in better health outcomes for the population.

STEPHEN GLUNING Representative and Country Director WFP Philippine Country Office

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Acknowledgement

The DOH and WFP acknowledge the support of the members of the CMAM Technical Working Group who provided direction and technical advice in the development of the Manuals for the Management of Moderate Acute Malnutrition:

Dr. Maria Joyce Ducusin, Dr. Anthony Calibo, Dr. Wida Silva, and Ms. Luz Tagunicar (DOH Family Health Office); Ms Josephine Guiao (DOH-Health Facilities Development Bureau); Ms. Maria Lourdes A. Vega and Ms. Margarita Enriquez (National Nutrition Council); Ms. Janice Feliciano (DOH-Health Emergency Management Bureau); Ms. Helena Alcaraz (Food and Drug Adminstration); Dr. Juliet Sio-Aguilar, (Philippine Society for Pediatric Gastroenterology, Hepatology and Nutrition);Ms. Balbina Borneo (Mother & Child Nurses Association of the Philippines); Dr. Maria Asuncion Silvestre (Kalusugan ng Mag-Ina, Inc.); Dr. Esther Miranda (Plan International); Dr. Amado Parawan (Save the Children Philippines); Dr. Rene Gerard Galera, Dr. Rene Andrew Bucu, Mr. Alvin Manalansan (UNICEF); Dr. Jacqueline Kitong (WHO); Dr. Corazon VC. Barba and Dr. Martin Parreño (WFP) and Ms. Dana Kriselli Munoz (WFP Volunteer).

Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under 6 Five Years

Symbols, Units & Acronyms

< Less than > Greater than < Less than or equal to cm Centimeters mm millimeters ml milliliters

BHS Barangay Health Station BHW Barangay Health Worker BNS Barangay Nutrition Scholar BSFP Blanketed Supplementary Feeding Program

CHT Community Health Teams CMAM Community-Based Management of Acute Malnutrition CTC Community Therapeutic Care

DepEd Department of Education DHMT District Health Management Team DOH Department of Health DALY Disability-Adjusted Life Year DSWD Department of Social Welfare and Development

ENA Essential Nutrition Action ENN Emergency Nutrition Network EPI Expanded Program of Immunization

FBF Fortified Blended Food FDA Food and Drug Administration FDS Family Development Session FNRI Food and Nutrition Research Institute FANTA Food and Nutrition Technical Assistance

GAM Global Acute Malnutrition GFD General Food Distribution GIDA Geographically Isolated and Disadvantaged Area GNC Global Nutrition Cluster GP Garantisadong Pambata

HC Health Center

IEC Information, Education, and Communication IFE Infant Feeding during Emergency IYCF Infant and Young Child Feeding IMAM Integrated Management of Acute Malnutrition IMCI Integrated Management of Childhood Illness IPF In-Patient Facility ITC Inpatient Therapeutic Care IU International Units IUGR Intrauterine Growth Restriction

LNS Lipid-Based Nutrient Supplement LMCIs Low and Middle Income Countries

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MAM Moderate Acute Malnutrition MCH Maternal and Child Health MHO Municipal Health Officer MNAO Municipal Nutrition Action Officer MNP Micronutrient Powder MSWDO Municipal Social Welfare and Development Officer MUAC Mid-Upper Arm Circumference

NAOs Nutrition Action Officers NiE Nutrition in Emergency NNC National Nutrition Council NNS National Nutrition Survey

OPD Out-Patient Department OPT Operation Timbang OTC Outpatient Therapeutic Care

PPAN Philippine Plan of Action for Nutrition PHN Public Health Nurse PIMAM Philippine Integrated Management of Acute Malnutrition PTA Parent Teacher Association

RHM Rural Health Midwife RHU Rural Health Unit RUSF Ready-to-Use Supplementary Food

SAM Severe Acute Malnutrition SFC Supplementary Feeding Center SBFP School-based Feeding Program SFP Supplementary Feeding Program

TB Tuberculosis TSFP Targeted Supplementary Feeding Program

UNICEF United Nations Children’s Fund

WFL/H Weight-for-Length/Height WFP World Food Programme WHO World Health Organization

Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under 8 Five Years

List of Tables

Table 1 Criteria for classifying degree of acute malnutrition in young children 6 to 59 months

Table 2 WHO classification of the acute malnutrition severity

Table 3 MUAC Classification/ Interpretation

Table 4 Classification of Edema

Table 5 Case finding criteria

Table 6 Sample timeline for routine health services in a year

Table 7 Vitamin A Supplementation

Table 8 Mebendazole/Albendazole Treatment

Table 9 Micronutrient Powder Supplementation

Table 10 Iron/Folate Therapeutic Dose

Table 11 Summary of tracking and monitoring in the SFC

Table 12 Discharge criteria for MAM

Participant’s Manual 9

List of Figures

Figure 1 Framework for the determinants of child malnutrition Figure 2 Global distribution of deaths among infants and young children under five Figure 3 Nutrition interventions for mothers and children across the lifecycle Figure 4 PIMAM components Figure 5 Integrated Management of Acute Malnutrition Figure 6 Methods for Case Finding Figure 7 Referral decision for case finding Figure 8 Minimum standards in humanitarian response and acceptable levels of coverage for the management of MAM as indicated in the SPHERE handbook Figure 9 Types of feeding program Figure 10 Flowchart for Targeted Supplementary Feeding Program (TSFP), Outpatient Therapeutic Care, and Inpatient Therapeutic Care Figure 11 Measuring length with the patient in lying position Figure 12 Measuring height with the patient in standing position Figure 13 Techniques for MUAC screening Figure 14 MUAC tape Figure 15 Checking for edema on both feet Figure 16 Elements and Actions for Community Outreach and Mobilization Figure 17 Flowchart for TSFP, OTC, and ITC Figure 18 Procedure for admission Figure 19 IMCI immunization schedule Figure 20 IEC material for MNP Figure 21 MAM decision tool steps for emergencies Figure 22 Risk deterioration assessment Figure 23 Determining program type for management of MAM in emergency Figure 24 Procedure for monitoring Figure 25 Approach to manage failure to respond to treatment Figure 26 Linkaging MAM with other services

Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under 10 Five Years

List of Annexes

Annex 1 Child Feeding Assessments Annex 2 Feeding Counseling and Recommendations Annex 3 Computation of Locally Prepared Food (Comparable to RUSF) Annex 4 The Food Exchange Lists for Meal Planning Annex 5 Registration Book for MAM Children Annex 6 Supplementary Feeding Program Commodities/ RUSF Alternatives Annex 7 Individual Ration Cards Annex 8 MAM Child Card Annex 9 Monthly Center Tally Sheet Annex 10 Monthly MAM Treatment Report Annex 11 C-MAMI Assessment for Nutritional Vulnerability in Infants aged <6 months

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M O D U L E 1

3 Inpatient Cry e for Health SAM witl› System and complications (ZTC} Services

1. Commune Outreach and 3. Outpadent Care for SAM without Moblllz omplicatlons (OTC)

4. Piogi ailis and services for the management of MAM (TSC-P)

Module Description and Objectives

This module is divided into three sessions. Session 1 defines malnutrition, specifically, the moderate acute malnutrition (MAM) as a form of undernutrition. Session 2 describes the Philippine Plan of Action for Nutrition (PPAN) 2017-2022 and Session 3 discusses the Philippine Integrated Management of Acute Malnutrition (PIMAM), its four integral components and four guiding principles. The last session also deals with community outreach and mobilization.

At the end of the module, the participants will be able to: 1. Explain what malnutrition is and its related concepts, 2. Discuss the problem of moderate acute malnutrition (MAM) as one form of undernutrition, 3. Describe the Philippine Integrated Management of Acute Malnutrition (PIMAM), its four integral components and the four guiding principles.

Participant’s Manual 13 Session 1:

Malnutrition

Key Concepts

Malnutrition refers to deficiencies, excesses or imbalances in a person’s intake of energy and/or nutrients. The term malnutrition covers two (2) broad groups of conditions. One is undernutrition—which includes stunting (low height for age), wasting (low weight for height), underweight (low weight for age) and micronutrient deficiencies or insufficiencies (a lack of important vitamins and minerals). The other is overnutrition – which can be classified as either overweight or obesity. (WHO, 2016)

Wasting or also known as acute malnutrition is a form of undernutrition that generally results from recent rapid loss of weight or a failure to gain weight due to reduced food intake, inappropriate childcare practices and illnesses, or a combination of these. The degree of acute malnutrition is classified as either moderate or severe based on anthropometric and clinical measures. Children with severe wasting or severe acute malnutrition (SAM) can be described as manifesting bilateral pitting edema (kwashiorkor),severe thinness (marasmus), or both (marasmic-kwashiorkor), depending on the severity. Bilateral pitting edema is the swelling due to excessive retention of fluid in the body. Children, however, with moderate wasting or moderate acute malnutrition (MAM) are only thin and do not manifest bilateral pitting edema.

During emergencies, the focus is given to acute malnutrition cases because it is linked with increased risk of mortality. Acute malnutrition is often used to assess the severity of an emergency because it is caused by illness and/or sudden, severe scarcity of food and is strongly related to mortality (WFP, Hunger Glossary, 2016). It can also be seen as an early warning for future increases in chronic malnutrition. However, this can be reversed with appropriate treatment (DOH, 2015). The Mid-Upper Arm Circumference (MUAC) is used for rapid screening, especially during emergencies, and as an admission tool for potential cases. It is also more widely used at the community level because it is easier to use and is more portable.

Children with MAM have four times (4x) the risk of dying than well-nourished children under five. Although children with SAM have higher immediate risk of mortality at the individual level, which is nine times (9x) than normal, the number of deaths in children affected by MAM is much greater (10.2%), thus having a higher absolute mortality than SAM with only 4.4% (Black, et al., 2008). Children with MAM have increased vulnerability to infections as well as the risk of developing SAM, which is immediately life-threatening (Lancet Series, 2013).

Table 1. Criteria for classifying degree of acute malnutrition in young children 6 to 59 months Tool MAM SAM Mid Upper Arm S115mm (S11.5cm) to <115mm or Circumference (MUAC) <125mm (< 12.5cm) (< 11.5cm) Weight for Length/Height -3 Z-score to < - 2 Z-score <-3 Z-score (WFL/H) Bilateral Pitting Edema Absent (-) Absent (-)/Present (+) MAM is defined either by: a) low weight-for-length/height (WFL/H) between negative 3 (- 3) and less than negative 2 (<-2 Z-scores) of the standard deviation of the WHO child

14 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

growth standards, or b) with low Mid-Upper Arm Circumference (MUAC) of > 115mm and < 125mm (>11.5cm and <12.5cm), and WITHOUT bilateral pitting edema.

Burden of Acute Malnutrition

The sum of both MAM and SAM is called Global Acute Malnutrition (GAM), sometimes, it is referred to as the prevalence of wasting. In 2011, the GAM was reported to affect 8% (52 million)1 of children under-five years of age worldwide, which has dropped to 7.7% in 2016, but affecting the same approximate number of children. Of this number, 33 million have MAM and the rest have SAM. Acute malnutrition is a major underlying cause of death and illness which is relatively more prevalent in low-income to middle-income countries. Approximately 3.1 million (45%), see figure 2, of children die from undernutrition, becoming the single greatest threat to their survival. It affects roughly one in ten children under-five years of age in the least developed countries, with 70% of them reported to be living in Asia2.

Acute Malnutrition Statistics in the Philippines

• The 8th National Nutrition Survey (DOST, FNRI 2016)3, reported that the prevalence of GAM or the national prevalence of wasting in 2015 among Filipino infants and young children under five was at 7.1% (5.2% MAM and 1.9% SAM). Refer to Table 2 below for the classification. • Approximately, a million children aged 0-5 years are affected by acute malnutrition and more than 700,000 are suffering from moderate acute malnutrition. From these reports, it was concluded that malnutrition has remained a public health issue because there is either slow improvement due to uncured cases, and/or inadequate feeding and poor caring practices.

Table 2. WHO classification of the acute malnutrition severity4 Severity of the situation Prevalence of Wasting (GAM) Low < 5% Poor 5 – 9 % Serious 10 – 14 % Critical S15%

Determinants of Undernutrition

1UNICEF-WHO-the World Bank, Joint Child Malnutrition Estimates, http://www.who.int/nutgrowthdb/jme_unicef_who_wb.pdf; https://data.unicef.org/wp- content/uploads/2017/06/JME-2017_brochure_June-25.pdf 2Black, R E, et al. “Maternal and Child Undernutrition: Global and Regional Exposures and Health Consequences.” Lancet (London, England)., U.S. National Library of Medicine, 19 Jan. 2008, www.ncbi.nlm.nih.gov/pubmed/18207566. 3 Food and Nutrition Research Institute/Department of Science and Technology. Updating of the 8th National Nutrition Survey. 2016 4GUIDELINES for Rapid SMART surveys for Emergencies Version 1, September 2014

Participant’s Manual 15

Figure 1. Framework for the determinants of child undernutrition

Figure 1 shows that the causes of undernutrition are multi-sectoral, embracing food, health, and caring practices. They are also classified as immediate, underlying, and basic, whereby factors at one level influence other levels. Interventions that target the reduction of undernutrition can be directed at any of these levels. This framework is used at the national, regional, and local levels to help plan effective actions to improve nutrition. It serves as a guide in assessing and analyzing the causes of the nutrition problems and helps in identifying the most appropriate combination of interventions.

16 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

Figure 2. Global distribution of deaths among infants and young children under five

Nearly half (45%) of all deaths of under-five children can be attributed to undernutrition (Figure 2). The severity of undernutrition can be associated with increased risk of all- causes of mortality and increased risk of death from diarrhea, pneumonia, measles, and other infectious diseases (Black, et.al., 2013)2.

The vicious cycle of malnutrition significantly describes the relationship between undernutrition and illnesses. The cycle may begin with infection such as diarrhea or pneumonia that will progress in undernourishment of the child. Conversely, undernourishment increases the susceptibility of a child to extended illnesses and complications, which may lead ultimately to death.

Management of Moderate Acute Malnutrition

The management of acute malnutrition, which is the primary responsibility of the Department of Health and the Local Government Units, aims to rehabilitate and prevent the progression of MAM to SAM with proper dietary treatment using: • lipid –based Ready-to-Use Supplementary Food (RUSF) • locally available food sources with the sufficient amount of nutrients to meet the needs of a MAM child, • fortified blended cereals

The management of MAM is always complemented by other health services such as but not limited to immunization, deworming, treatment of illnesses, vitamin supplementation and oral health.

Management of MAM is important to prevent further deterioration to SAM. If there are no programs to address MAM in normal circumstances, especially during emergencies, the prevalence of SAM often increases, which puts additional strain to available health systems or programs that manage SAM.

Participant’s Manual 17 Session 2: Nutrition Plan and Framework

Key Concepts

The Philippine Plan of Action for Nutrition (PPAN) 2017-2022 is an integral part of the Philippine Development Plan 2017-2022. It is consistent with the Duterte Administration 10-point Economic Agenda, the Health Agenda of the Department of Health (DOH), the development pillars of malasakit (protective concern), pagbabago (change or transformation), and kaunlaran (development), and the vision of Ambisyon 2040. It factors in and considers country commitments to the global community as embodied in the 2030 Sustainable Development Goals, the 2025 Global Targets for Maternal, Infant and Young Child Nutrition, and the 2014 International Conference on Nutrition. It consists of 8 nutrition-specific, 11 nutrition-sensitive and 3 enabling programs with 46 projects, serving as a framework for actions that could be undertaken by member agencies. Nutrition sensitive programs such Agriculture and Food Security, Social Safety Nets, Early Child Development, Maternal Mental Health, Women’s Empowerment, Child Protection, Classroom Education, Water and Sanitation, and Health and Family Planning Services are necessary to complement the nutrition-specific interventions. Nutrition sensitive programmes and approaches, though not necessarily related to health, are shown as having potential effects in addressing the underlying determinants of malnutrition and incorporate specific nutrition goals and actions. It also shows how an enabling environment can be built to support interventions and programmes to enhance growth and development

One of the five major objectives of the PPAN is to reduce childhood acute malnutrition to less than 5% from the current prevalence of 7.1%. The other objectives include reduction of stunting, reduction of micronutrient deficiencies to levels below public health significance, having no increase in overweight among children, and reduction of overweight among adolescent and adults.

The Philippine Strategic Framework for Comprehensive Nutrition Implementation Plan 2014-2025

As early as 2014, the Department of Health laid down an integrated plan to address the needs of individuals across life cycle. This recognizes that the risk of undernutrition is present across all stages of the life cycle but most critical during infancy and early childhood because the effects accumulate through adulthood.

18 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

Figure 3. Nutrition interventions for mothers and children across the lifecycle

In disadvantaged sectors and low-income households, undernutrition begins in the womb during pregnancy often leading to low birth weight (LBW), newborns with birth weight below 2.5 kilograms. Specific interventions, both preventive and curative, are therefore emphasized per stage of the lifecycle.

Participant’s Manual 19

Session 3:

Philippine Integrated Management of Acute Malnutrition (PIMAM)

Key Concepts

The Philippine Integrated Management of Acute Malnutrition (PIMAM) is a component of the Strategic Framework for Comprehensive Nutrition Implementation Plan of 2014-2025 and focuses on the management of moderate and severe acute malnutrition. It relies heavily on the community component, participation in the prevention and treatment of acute malnutrition.

Rationale behind PIMAM: Hospitals were primarily the facilities that manage acute malnutrition, but due to various reasons such as; 1. Outdated and ineffective protocols, 2. Existence of stigma of “malnutrition wards”, 3. Overcrowded hospitals, 4. High risk of cross-infection, 5. High defaulting rates - mothers wanted to go home to take care of other children, 6. Heavy workload for hospital staff, and that 7. Malnutrition is a reality, during both normal times and emergencies, in which prevention and care should start at the community/primary level; community involvement was deemed important and necessary in the management of acute malnutrition.

The Four Guiding Principles of the Integrated Management of Acute Malnutrition

The integrated management of acute malnutrition focuses on the effective management of MAM into the on-going routine health and nutrition services at all levels while still striving for maximum coverage through maintaining a strong community component. This approach is based on four (4) principles (see Figure 4):

Maximum Coverage Timeliness

Integrated Management of Acute Malnutrition

Appropriate Medical and Nutrition Care as long as needed Rehabilitation

Figure 4. Integrated Management of Acute Malnutrition

20 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

1) Maximum coverage – to bring to treatment as many people as possible, with the most affordable and accessible services available; 2) Timeliness – to detect acute malnutrition early and start treatment before the onset of threatening conditions; 3) Appropriate medical and nutrition rehabilitation – to ensure efficiency of programs and services on nutrition, it is important to provide the proper treatment of cases by the proper providers; and, 4) Care as long as needed – to reduce barriers to access and ensure that children stay in the program until they recover.

Four Key Components of PIMAM

There are four (4) key components in the management of acute malnutrition in the Philippines (see Figure 5). However, this manual shall focus on the management of MAM, but taking into consideration that it is an integral part of PIMAM, which incorporates SAM and MAM. The internationally accepted recommendation to implement PIMAM is to link the management of MAM with the management of SAM whenever possible. Linkages at the health service at the community levels are essential in emergencies to take care of the increased numbers of acutely malnourished children.

Figure 5. The Four PIMAM Components

1. Community Outreach and Mobilization – entails promotion of community involvement in programs combating wasting through the processes of assessment,

Participant’s Manual 21 sensitization, case finding referral, and case follow-up. The description of this component will be detailed in module 3. 2. In-patient Therapeutic Care (ITC) for SAM WITH medical complication - involves management of complicated cases of SAM according to WHO protocols on an inpatient basis at facilities with appropriate capacity (hospitals). 3. Out-patient Therapeutic Care (OTC) for SAM WITHOUT medical complications – involves the management of non-complicated cases of SAM in outpatient care facilities such as the Rural Health Units (RHU), Barangay Health Centers (BHC), and Barangay Health Stations using ready-to-use therapeutic foods (RUTF). 4. Management of MAM through the targeted supplementary feeding program (TSFP) – handles supplementary feeding for children with MAM with the distribution of supplementary foods in the form of ready-to-use supplementary foods (RUSFs) which are lipid-based nutrient supplement, locally available food with the same nutrient contents as that of an RUSF or blended cereals. It also serves as follow-up venue for cured SAM-cases. Details will be discussed in module 3.

Community sensitization and mobilization, community screening and referral systems are made jointly between MAM and SAM programs. Where possible, training and other program aspects should be undertaken jointly. Referral mechanisms between acute malnutrition prevention and management of MAM and SAM activities are very important and should be established as part of the nutrition response.

Content Summary

• Malnutrition is a form of physiological impairment related to the body’s use of nutrients, and can be classified as either undernutrition or overnutrition. Undernutrition covers both “short-term” (acute) or “long-term” (chronic) conditions. • Acute malnutrition can be classified as either moderate or severe. Moderate Acute Malnutrition (MAM) or moderate wasting, is defined either by low weight-for- length/height between -3 and <-2 Z scores or a MUAC between S115mm and <125mm, AND without bilateral pitting edema. • The Philippine Integrated Management of Acute Malnutrition (PIMAM) is a component of the Strategic Framework for Comprehensive Nutrition Implementation Plan of 2014-2025 and focuses on the management of moderate and severe acute malnutrition. It relies heavily on the community component, participation in the prevention and treatment of malnutrition. • The PIMAM has four guiding principles: maximum coverage, timeliness, appropriate medical and nutrition rehabilitation, and care as long as needed. • The PIMAM is composed of four key components namely, community outreach and mobilization, ITC for SAM with medical complications, OTC for SAM without medical complications, and TSFP for MAM. For the management of MAM, the key components are: (1) community outreach and mobilization and (2) TSFP.

22 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

Participant’s Manual 23 Module Description and Objectives

This module has three sessions describing how to identify a child with Moderate Acute Malnutrition (MAM) using anthropometric measurements and clinical assessment. Session 1 focuses on the measurement of weight for length/height and the determination of the appropriate Z-score. Session 2 discusses the measurement and interpretation of the Mid- Upper Arm Circumference while Session 3 deals with the clinical assessment for the presence or absence of bilateral pitting edema.

At the end of the module, the participants will be able to:

1. Measure weight for length/height correctly; determine the appropriate Z-score and its interpretation 2. Measure and interpret the Mid-Upper Arm Circumference correctly 3. Assess for the presence or absence of bilateral pitting edema, and 4. Identify children with MAM

24 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

Session 1: Measurement of Weight for Length/Height and Determination of Z-score

Key Concepts

In children under five, one of the most common anthropometric indices to assess their growth is through their weight-for length/height. Low weight-for-length/height indicates wasting or thinness, which is associated to acute malnutrition and/or severe diseases. High weight-for-length/height indicates overweight or obesity.

Accuracy (closeness of a measured value to a standard or known value) and precision (closeness of two or more measurements to each other) is essential when taking a child’s weight and length/height to ensure proper identification of MAM. An incorrect measurement especially if it falls within the borderline between severe and moderate would deny the child the proper intervention that could result to further deterioration or even death.

Children may be weighed by using a 25-kilogram hanging sprint scale or an electronic balance graduated to 0.100 kg. It is important to have an accurate and precise measurement for the proper determination of the child’s nutritional status and for appropriate intervention.

How to take weight

1. Do not forget to re-adjust the scale to zero before each weighing. 2. Four ropes that go underneath the basin should attach a plastic washbasin or its equivalent. The basin needs to be close to the ground in case the child falls out, and to make the child feel secure during weighing. 3. If the basin is dirtied, then it should be cleaned with disinfectant. The basin is much more comfortable and familiar for the child; can be used for ill children and is easily cleaned. Weighing pants that are used during surveys should not be used - they are uncomfortable, difficult to use, inappropriate for sick children and Figure 6. Taking a child’s weight quickly are soiled thus, passing an infection to the next patient. Source: Action Against Hunger (L), UNICEF (R) 4. When the child is steady, read the measurement to the nearest 100 grams, with the frame of the scale at eye level. Each day, the scales must be checked by using a known weight.

Note: Ensure that the weighing scale is properly calibrated. Digital weighing scale, if available, is preferred. Ensure batteries are new

Participant’s Manual 25 How to take the length with the child lying down (children from zero to less than 24 months)

1. Questionnaire and pencil on clipboard on floor or ground 2. Assistant on knees 3. Measurer on knees 4. Hands cupped over ears; head against base of board 5. Arms comfortably straight 6. Line of sight perpendicular to base of board 7. Child flat on board 8. Hands on knees or shins; legs straight 9. Feet flat against foot piece

Note: For children aged below 24 months but can already stand, get the height and add 0.7 cm in order to get the length.

Figure 7. Measuring length with the child in lying position

26 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

How to take the height with the child standing up (children 24 months and above)

1. Questionnaire and pencil on clipboard on floor or ground 2. Assistant on knees 3. Measurer on knees 4. Hands cupped over ears; head against base of board 5. Arms comfortably straight 6. Line of sight perpendicular to base of board 7. Child flat on board 8. Hands on knees or shins; legs straight 9. Feet flat against foot piece 10. Shoulders level 11. Hands at side 12. -14. Body flat against board

Note: For children aged 24 months and above but still cannot stand, get the length and minus 0.7 cm in order to get the height.

Figure 8. Measuring height with the child in standing position

Note: Ensure that the length/heightboard is properly calibrated.

Participant’s Manual 27

How to determine the Z-score

The Z-score system expresses the anthropometric value as a number of standard deviations or Z-scores below or above the reference mean or median value. It’s a substantial recognition as the most appropriate descriptor of malnutrition. Z-score is also referred to standard deviation (sd).

Steps in determining the Z-score:

1. Determine the age a. Infant/children from 0-23 months of age i. Take weight and length measurements b. Infant/children 24-59 months of age 2. Check the weight-for-height/length table and determine the Z-scores by referring to the Child Growth Standards Table for Boys and Girls (0-23 months and 24-60 months). 3. Round off the length or height measurement to the nearest 0.5 cm mark. a. Measurements would have to be rounded off using 0.5 cm intervals, e.g. 60.0 - 60.5 - 61.0 - 61.5 - 62.0 - 62.5 - 63.0 … (as seen in the Child Growth Standard). b. Round off measurements within 0.2 cm below or above of a number that represents or marks the 0.5 cm interval to the latter.

Example:

EGN Height (Em} 78.0 78.5 7R.0 7R.5 80.0 80.5 81.0 81.5 82.0 82.5 8E.0 8E.5

4. Locate the infant/child’s weight and determine under which classification it falls under (severely wasted, moderately wasted, normal, overweight, or obese).

28 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

Example:

If a girl’s height is 87.1 cm, and the weight is 9.4 kg, what is the equivalent height that will be used according to the Child Growth Standard (CGS) Table? What is the child’s nutritional status classification?

87.1 cm

Round off the height of 87.1 cm to 87.0 cm. Then on the same row, find the range where the weight 9.4 kg would fall. This time it falls between 9.2 to 9.9 kg. The girl’s nutrition status classification is “Wasted”.

Participant’s Manual 29 WHO Child Growth Standards

30 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

Participant’s Manual 31

32 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

Participant’s Manual 33 Session 2: Measurement and Interpretation of the Mid-Upper Arm Circumference (MUAC)

Key Concepts

Mid-Upper Arm Circumference (MUAC)

MUAC is used as an alternative measure of “thinness” to weight-for-height. It is particularly used in children aged 6-59 months.

Figure 9. Techniques for MUAC screening

34 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

Step-By-Step Procedure in Taking the MUAC Measurements (refer to figure above)

Step 1. Locate the tip of the shoulder (1) of the left arm.

Step 2. From the tip of the shoulder (2), with the elbow bent, find the tip of the elbow (3). Step 3. Place the tape at the tip of the shoulder and extend it to the tip of the elbow (4 and 5). Step 4. Mark the midpoint between the two (6). Step 5. Then, slide the tape around the midpoint and take the reading. Step 6. Feed the end of the tape down through the first opening and up to the third opening. Read the measurement from the middle window where the arrows point inward. Read the number in the box that is completely visible in the middle window. Step 7. Use enough tension to hold the tape against the skin but not pull the skin (7). If the tape is too tight where the skin in pinched (8) or too loose where the tape isn’t touching the skin (9), the measurement will be inaccurate. Step 8. Immediately record the measurement.

Figure 10. MUAC tape

Note: Ensure that the distance from the arrow (0.0 cm, in the eyehole) to 6.0 cm is really is really 6.0 cm.

Table 3. MUAC Classification/ Interpretation Classification SAM MAM Normal MUAC <11.5 cm 11.5 to <12.5 cm >12.5 cm Color RED YELLOW GREEN

Participant’s Manual 35 Session 3: Clinical Assessment of Bilateral Pitting Edema

Key Concepts

Bilateral edema is the sign of Kwashiorkor. Children with bilateral pitting edema are directly identified to have severe acute malnutrition. These children are at high risk of mortality and in need of urgent treatment in a therapeutic feeding program (refer to SAM Guidelines).

In order to determine the presence of bilateral pitting edema: • Apply normal thumb pressure to both feet of the child for at least three seconds (equivalent to counting: one thousand one, one thousand two, one thousand three); • A shallow print persists on both feet if the child has edema.

Figure 11. Checking for edema on both feet

Table 4. Classification of Edema Severity of Edema Recording Mild Both feet + Moderate Both feet, plus lower legs, hands or lower ++ arms, intermediate between mild and severe Severe Generalized edema including both feet, +++ legs, hands, arms, and face

36 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

Content Summary

A child with Moderate Acute Malnutrition (MAM) can be identified through either their Weight-For-Length/Height Z-scores or Mid-Upper Arm Circumference (MUAC) interpretations, and the absence of bilateral pitting edema.

Proper methods in measuring the anthropometric measurements (weight, length/height, and Mid-Upper Arm Circumference), appropriate identification of Z-scores, and correct assessment for the presence or absence of bilateral pitting edema should be followed to determine accurately whether a child has moderate acute malnutrition.

Exercises

Classify the child as normal, MAM or SAM, based on the following conditions and check. Check the circle according to their classification.

CHILD NORMAL MAM SAM

John Mary

Anne

Juan

Jane

1. John, a 4-year old preschool child, was measured at the health center today. He weighed 13.7 kg, with the height of 104 cm. His MUAC measurement was 125 mm. He did not show any presence of bilateral pitting edema.

2. Mary turned 2 years old today. Upon assessment, her weight was 9.2 kg with a height of 71 cm. Her Mid-Upper Arm Circumference was 130 mm. She looked healthy with no signs of bilateral pitting edema.

3. You measured Anne to have a normal weight-for-height, with a Z-score between -2SD and +2SD. She had a Mid-Upper Arm Circumference of 12.3 cm. The child had no presence of bilateral pitting edema.

4. Juan had a Z-score between -3SD to <-2 SD, and a Mid-Upper Arm Circumference of 119 mm, bilateral pitting edema and came in for immunization.

5. Jane, 4-year old girl, was 110.5 cm tall, weighed 14.6 kg. Her MUAC measurement was 117 mm. There was no sign of bilateral pitting edema.

Participant’s Manual 37

Moderate Acute Malnutrition

Module Description and Objectives

This module contains seven sessions that introduce the organization and management of an integrated, community-based public health strategy addressing Moderate Acute Malnutrition (MAM) in infants from 0 to <6 months and children from 6–59 months of age.

Session 1 discusses about the concepts governing community outreach to increase access and coverage of the programs and services for the management of MAM. Procedures in the assessment of MAM in the community will be discussed in Session 2 while interventions and services in the management of MAM in the community will be discussed in Session 3. Session 4 focuses on the monitoring, follow-up, and referral protocol. Discharge and linkaging are discussed in Sessions 5 and 6, respectively. Session 7 deals with the management of MAM during emergencies.

At the end of the module, the participants will be able to:

1) Identify cases of MAM, 2) Determine the prevalence of MAM in the community, 3) Discuss and perform the various interventions in the Targeted Supplementary Feeding Program (TSFP) and Routine Child Health Services for the management of MAM for children aged 6-59 months and infants below 6 months 4) Discuss and demonstrate MAM monitoring, follow-up, referral, discharge, and linkaging procedures, and 5) Assess the coverage and performance of MAM program in your community using prescribed indicators. 6) Discuss the management of MAM during emergencies.

Participant’s Manual 39 Session 1: Community Outreach

Key Concepts

The first integral component of PIMAM involves community outreach, which includes mobilization and education of the community, case finding, and referral of cases to increase access and coverage of the programs or services for the management of MAM. A strong community outreach corresponds with the principles of timeliness, maximum coverage and providing services as long as the community needs it.

Community outreach workers should aim for early identification of MAM cases before they deteriorate to SAM or will have complications, do follow-up home visits for problematic cases, educate caregivers about acute malnutrition or wasting, promote services that are available in the community, a and encourage the community to help in case-finding and in referring cases to the services.

Key stakeholders, such as community health workers and members of the nutrition committees, should also identify and understand social, economic and cultural barriers in the community and be able to discuss these accordingly with involved organizations or government agencies in the implementation of MAM management, in order to carry out services smoothly. Not only is the community outreach important in identifying cases in the early stage, but it can also contribute to the prevention of acute malnutrition in general.

Advocacy and Community Mobilization

Prior to the implementation, it is necessary for the community to know about the program: understand the objectives, the methods that will be used to identify and treat the children, the nature of their involvement, the cost and other inputs to the program by the community, for how long the program has secured funding and how the program complements the other health and nutrition programs in the area. The information about the program must include its aims, methods, organization and the persons involved including their responsibilities and accountability.

Full acceptance of the program is not expected until it has already been implemented and the community sees its value. They should be highly involved to take ownership of the program once it is established and shown to be effective.

There should be a step-by-step approach with continuing dialogue, feedback and exchange between the program staff and the community leaders.

40 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

Social Preparation

In the community, communication activities (interpersonal and group communication, community dialogue) on nutrition should be a major part of the activities of the mother- to-mother support groups and other groups within the community itself. The parents and caretakers, whose children become undernourished, generally come from the poorest sections of society. Many have not attended school nor can read or write. They are often unaware of the nutritional needs of children, the importance of play and psychosocial stimulation in child development, the effects of poor hygiene and pollution, the measures to take when children become ill, and the signs and symptoms of developmental and the behavioral disorders in children (e.g. Anxiety Disorder, AD/HD, Autism Spectrum Disorder, mood disorders, eating disorders, or schizophrenia). Basic facts about breastfeeding and complementary feeding, sexually transmitted disease and HIV, reproductive health and the ill effects of some traditional practices are not known or are ignored.

Health messages therefore should be simplified and easily remembered. The local community leaders themselves can generate or modify the messages that usually emanate from the national level. Such community leaders include the local barangay officials, religious leaders, teachers, traditional healers, community volunteers and the health center staff. They themselves are more reliable in disseminating the messages. It is also more often effective to use informal methods of passing information about the program. The information is most effectively passed in places where people gather normally, namely at the market, where they collect water or wash clothes and gather to socialize. The use of women’s groups, schools (child-to-child or child-to-parent), basketball and sporting events, and other networks should be explored. An important group to involve is the group of religious leaders of the community and passing information at places of worship can be particularly powerful.

The target groups must include the decision-makers in households namely, fathers, mothers, grandparents and mothers-in-law.

Mobilization and Education

An important aspect of community outreach is the mobilization and education of the members of the community. This include activities to sensitize the community to the program, screening of children in the community to find cases needing treatment and community-based activities that support keeping the child in treatment until s/he is cured.

Through sensitization, education activities and strategies, and mobilization, the community becomes aware of what constitutes MAM:

• MAM signs and symptoms • how MAM affects their families • why it is important to address MAM • what available treatment and services for MAM are present in their area • who can be treated in these facilities • when, where and how to access services • the process of treatment

Mobilization and education can be attained by giving out messages and information, education and communication (IEC) materials to inform community leaders, major stakeholders, parents, and caregivers, by integrating it in the existing activities for nutrition and health, in meetings and gatherings in the community.

Participant’s Manual 41 Information can also be disseminated from children to parent through nutrition education that is integrated in the curriculum set by the Department of Education (Dep Ed). Parent- Teacher Association (PTA) is a way to educate the community, especially the parents of children under five. Nutrition sensitive programs such as the Cash Transfer Program’s Family Development Session (FDS) of the DSWD, where health and nutrition education are provided also help in addressing malnutrition by providing social protection to families in the community.

Elements of Community Mobilization

Figure 12. Elements and Actions for Community Outreach and Mobilization

Community assessment - identify barriers to service access; recognize how the community is organized, how acute malnutrition is viewed, how the services will likely be received, and how the community can best support outreach

Formulation of outreach strategy - case-finding and referral as necessary steps to ensure maximized service access and uptake or coverage

Development of messages and materials

42 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

- community education, health promotion and disease prevention communicating key messages that clarify the program: who can benefit, where to access, the process of treatment, schedules of consultation, etc.

Training and community mobilization - this element encourages community involvement and action, allowing the members a sense of ownership of the program, contributing to its sustainability

Case Finding and Referral

Case finding is also an essential aspect of community outreach to ensure regular screening and early detection of MAM cases among the children under five in the community.

Deciding on which method/s to use during the outreach, the implementers should look into these considerations: • Prevalence of MAM in the community • Level of community awareness • Accessibility of homes • Existing networks of outreach works • Time and resources available for training outreach workers • Envisioned timeframe for case-finding

Three Methods of Case-Finding

Case finding can be done through any of the Three Methods of Case Finding following methods: Active – screening of children house to 1. Active case finding, outreach workers or house or in a defined location community volunteers regularly screen and monitor children so that cases of malnutrition Active-Adaptive – screening using can be identified promptly and treated locally understood and accepted immediately. This leads to high coverage, descriptions of acute malnutrition to faster rehabilitation and lower mortality find cases in households rates. There are two types of active case finding. Passive – screening of children during health facility visit

House-to-house case finding happens when outreach workers periodically perform health checks (edema and MUAC or the WFL/H z-score5 whenever height boards and weighing scales are available and portable) in the homes of target community members (see Table 5). This can be necessary during start-up of the program to ensure that members in the outskirts of the community are not overlooked and that all families are aware of the program.

Community case finding involves bringing children from different households together in a certain part of the neighborhood to perform health checks, for instance in the barangay hall. This may be done along with pre-existing health and nutrition outreach services such

5 This refers to the z-score or standard deviation using the WHO Child Growth Standard which for MAM is a score of negative 3 to less than negative 2 (-3 to < -2)

Participant’s Manual 43 as Operation Timbang (OPT) or immunization days.6 In addition, maternal and child health (MCH) services, or growth monitoring and promotion sessions.

Table 5. Case finding criteria Measure Normal Range MAM Range SAM Range MUAC >12.5 cm 11.5cm to <12.5cm <11.5cm WFL/H (Z- -2 to +2 -3 to < -2 <-3 Scores) Bilateral Pitting Absent Absent Absent/Present Edema

2. Active Adaptive case finding is a modified method of active case finding where a community health worker may visit selected households strategically to screen for MAM and to ask for other cases of MAM in the neighborhood, or visit other key informants in the community, such as teachers, barangay officials and religious leaders to identify children with MAM.

3. Passive case finding is the method used when health care workers systematically screen children during the conduct of existing health and nutrition services to find cases of MAM in the health facilities7 or its equivalent8. Assessment based on MUAC and/or WFL/H, or bilateral pitting edema, may take place during routine childcare visits and sick child consultations. In this method, the initiative lies with the members of the community, who themselves seek referral from appropriate health care providers in the community, or once the knowledge of programs and services is established.

Figure 13. Referral decisions for case finding

Identified MAM cases would then be automatically admitted (if the health facility is already identified as a MAM Center) or to be referred to facilities capable of MAM management, which will be discussed in more depth in the Module 3. In cases where children are identified or considered to have MAM by members of the community other than the outreach workers, volunteers or healthcare providers, these

6 Done annually during the 1st quarter of the year 7 This can be Rural Health Units, Barangay Health Stations or Centers, Hospitals including the Outpatient Department (OPD), clinics 8 In some far-flung communities, due to lack of infrastructure, barangay halls are designated as health facilities during monthly midwife visit

44 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

should be referred to and sent to the health facility for proper screening, as well as orientation for the caregivers if admissible, and eventually avail of the services.

Coverage

Coverage9 refers to individuals who are actually receiving treatment as against those who ideally need the treatment. Maximized coverage means the programs and services in combating MAM is reaching and treating as many MAM children as possible, reducing the prevalence of MAM in the community. It can be affected by the acceptance of the program in the community, the location and accessibility of the program sites, weather condition, frequency of distributions, waiting time, security situation, and service quality among other things.

To achieve this, an effective community outreach and mobilization should be achieved. The 2011 Sphere Handbook (The Sphere Project, 2011)10 on Minimum Standards in Humanitarian Response identifies the minimum acceptable levels of coverage for the management of MAM.

Sphere Standard Coverage Rural > 50% Urban > 70% Camp > 90% Figure 14. Minimum Standards in Humanitarian Response and acceptable levels

9 Total Number of MAM on treatment divided by Total Number of identified MAM cases 10 Sphere Project, Sphere Handbook: Humanitarian Charter and Minimum Standards in Disaster Response, 2011, 2011, available at: http://www.refworld.org/docid/4ed8ae592.html [accessed 10 October 2017]

Participant’s Manual 45 Session 2: Assessment and Admission

Key Concepts

Assessment in the management of MAM is performed in established MAM centers, such as barangay health stations, rural health units, health offices or any defined location in the community

Arrival and Classification of Nutritional Status

Figure 15. Flowchart for TSFP, OTC, and ITC

A child with MAM is enrolled in the Targeted Supplementary Feeding Program (TSFP) for nutritional rehabilitation and routine health care. If the child has a medical problem, s/he is referred to DOH Integrated Management of Childhood Illness (IMCI) protocol.

46 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

Admission

Figure 16. Procedures of Admission

Four Types of Admission • New Admission – newly admitted in accordance with the criteria for admission • Relapse – child with MAM returning after being discharged as cured o If a child who recovered from MAM or SAM is losing weight during follow-up or months after discharged and reaches the criteria for MAM, s/he is admitted to MAM program • Readmission – defaulter, after less than two (2) months of absence without reaching discharge criteria o Defaulter – when the patient has not returned for three (3) consecutive visits and a home visit, neighbor, village volunteer, or other reliable sources confirms that the patient is not dead

Participant’s Manual 47 • Referral – internal transfer from another TSFP site supported by documents

Procedures of Admission to the MAM program

STEP 1. Build rapport with the child and the caregiver so that assessment can proceed smoothly. Establish a functional worker-client relationship with the child, as well as with the mother or caregiver to encourage them to be active participants in the treatment process.

STEP 2. Determine the child’s age, whether or not she or he is within the age range of 6 months to 59 months. The attending health worker can confirm this with the help of birth certificates or existing records of the child in the clinic or health center (e.g. ECCD Card, health card). Where no records exist, the child’s age can be determined by referring to a local calendar of events.

STEP 3. Take the child’s anthropometric measurements Mid-Upper Arm Circumference of the left arm is a quick way of identifying acute malnutrition in children under five. It has a color-coded indicator of nutritional status. Weight-For-Length or Weight-For-Height (always using the same scale) is the assessment-adapted WFL/H chart. MAM is in the wasted category between -3 and <-2 standard deviation (SD) or Z-scores (see Module 2 for WHO CGS-based charts for boys and girls).

STEP 4. Examine whether the child has bilateral pitting edema. (Refer to National Guidelines on the Management of SAM) A child has edema when an indentation remains on the top side of each foot after pressing it gently but firmly for three seconds with the thumbs. If positive with the bilateral pitting edema test, the child should be admitted to the SAM treatment program, even though the child qualifies as MAM or normal in the MUAC and/or WFL/H measurements. Edema has three grades according to the level of the body affected: Mild (Grade 1): both feet up to the ankles (+) Moderate (Grade 2): both feet to the hips, including the dangling hands (++) Severe (Grade 3): whole body, plus the neck and face (+++)

STEP 5. Validate nutritional status. Check with the criteria for admission whether or not the child is eligible to be admitted for the MAM treatment program.

STEP 6. Determine if the patient has any sign of a medical problem; if the child has any complications according to the IMCI criteria (WHO, 2014), refer him/her to the nearest obviously ill to the health center. Prioritize them for special care. Take particular attention to children with cerebral palsy, heart problems, childhood TB, cleft palate, twins, children of teen mothers, and children under the care of relatives, who probably are at risk of acute malnutrition. Take note of this in the registration form. For management of co-morbidities, refer to higher facilities or to other programs that would help prevent malnutrition of these Cases

STEP 7. Systematically check for all vaccination status by updating on the EPI record, particularly for measles for children over 9 months. If the child has not been vaccinated, refer for vaccination to the nearest health center.

STEP 8. Assess the child’s feeding. (See Annex 1 for Feeding Assessment) Advise the mother/caregiver on proper feeding of the child. (See Annex 2 for Feeding Recommendations)

STEP 9. Explain to the mother/caretaker the reasons why the child is to be admitted to the MAM treatment program and how the treatment will be organized.

48 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

STEP 10.Carefully explain the expectations. Explain the manner of how the child should consume the supplement and visit the center (regular attendance, family sharing, MAM child to be fed separately from siblings, supplement not to be taken with ordinary meals, etc.). Explain as well that her/his child needs to gain weight with reference to length or height (WFL/H >-2 Z-score) every follow-up visit and/or they have to reach the ‘Green Color’ of MUAC (>12.5cm) before they can be discharged from the program. The treatment should be explained in detail to the parent, caregiver or beneficiary to ensure that the importance of adherence to treatment is understood.

STEP 11.Enter information of the child eligible for admission to the program in the registration book and assign a registration number if the child already has a Child Number as per ECCD Card, write it in the 2nd (registration number) column of the registration book.

STEP 12. Enter all the information for admission to the program in the ration card and give it to the caregiver. A good registration system allows both close monitoring and successful management of individuals, provides information for the compilation of appropriate indicators and statistics to monitor the functioning of the feeding program.

Referral to Other Services

Referrals in PIMAM services are fueled by strong community outreach resulting in active, active-adaptive, and passive (self-referrals) case-findings by community members. Admission criteria determine which component a child is admitted to initially.

Figure 17. Referral Scheme among CMAM Components

Types of referral in the MAM treatment program:

• Referral from community outreach (active case-finding or self-referral) • Referral to and from another MAM center, in case of migration

Participant’s Manual 49

Session 3: Interventions and Services

Key Concepts

Nutrition Intervention

The nutrition intervention for the management of MAM is through targeted supplementary feeding program (TSFP), while the blanket supplementary feeding program (BSFP) is the nutrition intervention for the prevention of MAM, provided with wet rations or dry rations.

Figure 18. Types of feeding programs

Targeted Supplementary Feeding Program (TSFP)

This is an intervention wherein a supplementary ration is provided to specific members of a vulnerable group whose requirements may not be met by the general ration (e.g. moderately acute malnourished children under five, or pregnant and lactating women).

The objectives of targeted supplementary feeding are: • To rehabilitate MAM cases; • To prevent cases of MAM from aggravating and developing to SAM; • To reduce of mortality and morbidity risks in children under five.

50 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

TSFP provides treatment for children with MAM. These children can be treated at home with locally available supplementary food fortified with micronutrient powders (see Annex 6 for RUSF alternatives) or RUSF and intensive nutrition counselling plus routine health care (consistent with IMCI guidelines, outpatient treatment of infections or referral to hospitals), in line with the National Supplementary Feeding Guidelines.

To be effective, TSFP should be implemented when there is sufficient food supply or an adequate general ration, while BSFP is often implemented when general food distribution (GFD) for the household has yet to be established or is inadequate for the level of food security in the population. The supplementary ration is meant to be an addition to, and not a substitute for the general ration.

Considerations in Establishing a TSFP

The main aim of a TSFP is to manage the moderately malnourished children in a population. It also plays a role in continued support for those who have been discharged from therapeutic feeding programs for the treatment of SAM. TSFP should be implemented when one or more of the following situations occur (WHO, 2000):

There are large numbers of malnourished children under 5: GAM rate of 10%-14%. There are large numbers of children predicted to be malnourished: GAM rate of 5%-9% plus the presence of aggravating factors

Aggravating factors can include: (Dent & Holland, 2011) ▪ Worsening of the nutritional status ▪ Food availability at household level less than the mean energy requirement of 2100 kcal/person/day ▪ GFD is below mean energy, protein and fat requirements ▪ Crude mortality rate more than 1/10,000 per day ▪ Epidemic of measles or whooping cough ▪ High prevalence of respiratory or diarrheal diseases

Location

If possible, TSFP should be situated at or near a local health facility to avoid duplication of services. If large numbers are anticipated for the targeted SFP, simple structures are often constructed a short distance away to avoid overwhelming the health facility and its usual beneficiary load.

Sites should be selected that are easily accessible and well distributed geographically to ensure that beneficiaries are within a few hour’s walk to and from the site including distribution time. Site should be selected with consideration of personal safety of caretakers and children, especially in insecure areas. Climatic context e.g. whether the area is likely to flood, if there is a river to cross, etc., may dictate site changes to ensure that the SFP is accessible.

Structure

The SFC will be managed in the health centers or barangay health stations. Note that the workload of the staff of the health structures is already burdensome with many programs to administer, including treatment of the severely malnourished. It is important to take note if the health staff have large numbers of children attending for supplementary feeding or MAM treatment (note there are normally about 10 MAM children for each SAM child), their facilities and staff become swamped so that all the essential health programs suffer.

Participant’s Manual 51 Distributions can be run by the SFC staff on a weekly or bi-weekly (every two weeks) basis. Weekly distributions have the benefit of more frequent follow up on health and nutrition status, while biweekly distributions entail less opportunity cost for caretakers. Monthly distributions are usually not possible as the premix given turns rancid after 2 weeks.

All equipment and supplies, including food commodities, can be kept and managed at the health centers if there is capacity, or transported by mobile teams in a strong equipment box. Alternatively, equipment and supplies could be stored in community stores where these exist. In addition, transport is needed for the small number of children who have to be referred.

Staffing

There is no need to have clinically trained staff (doctor or nurses). Midwives, BNSs and BHWs can run MAM treatment for two reasons: 1. the sick MAM child should be treated as a sick normal child following the IMCI protocol and guideline; and 2. the MAM child only needs to receive a regular periodical supplement of food, and counseling, to recover

Many times in emergencies, healthcare is lacking and SFPs are run by mobile services. It is important to assess the context and what is available when planning the organization and set up of SFPs and include additional medical staff to the SFP team and essential medical supplies if no health services are available. In addition, an overall supervisor is needed to manage the teams and ensure a functional network for referral.

MAM Treatment Supervisor ▪ Prerequisite: trained in the MAM treatment protocol ▪ Activities: o Manages the food and non-food items (stock control) o Prepares monthly reports o Manages human resources o Supervises MAM treatment o Organizes health and nutrition education/counseling

BNS, BHW or Community Volunteers ▪ Prerequisite: trained on the measurement techniques, admission and discharge criteria for the PIMAM program and the MAM treatment, and the procedures for patients who failed to respond to treatment ▪ Activities: o Does the anthropometric measurements (weight, length/height, MUAC) and edema check – there should be at least two staff members, particularly in measuring length of an infant or child o Checks for any medical problem, vaccinations, and refers child immediately to the nearest health center if medical problem is identified o Admits the child according to admission criteria o Explains to the mother/caregiver the management of MAM o Helps in the preparation, organizing and supervision of individual rations o Distributes the prepared ration to the child or caregiver o Gives health and nutrition education sessions o Registers the child, applies the criteria of admission discharge and failure to respond o Finds the defaulters and encourages them to come back

52 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

o Identifies defaulters and non-responders, reflects it in the record book and reports to the supervisor

The SFP requires at least one health center staff to perform medical assessment on children who are sick or those who need further evaluation and management of their condition. This staff could be either a doctor, staff nurse or midwife trained on IMCI.

If the number of MAM cases is low, the health center staff can do the screening, admission and follow-up of MAM cases. They may be assisted by the BHWs and BNSs who are trained to do anthropometric measurements and other tasks.

Tools and Materials

For measurements ▪ Scales, length board/height board, MUAC tape ▪ WFL/H charts ▪ CGS tables

For registration ▪ Posters for admission and discharge, failure to respond criteria ▪ Registration book (see Annex 5) ▪ Key Messages about the products (RUSF/porridge) in local languages ▪ Ration Card, ECCD cards (see Annex 7 and Annex 8) ▪ OPT forms for master-listing ▪ Monitoring tools (see Annex 9 and Annex 10)

For health-nutrition education ▪ Cooking materials ▪ Posters on education, health promotion and disease prevention with other materials

For ration preparation and distribution ▪ Supplemental ration supplies (with secure storage facilities) ▪ Salter scale (50kg), calibrated – same scale for admission and discharge ▪ Calculator ▪ Measuring cups/scoops ▪ Soap for washing utensils ▪ Buckets/basins

Routine medicines ▪ Vitamin A capsules ▪ Albendazole or Mebendazole tablets ▪ Micronutrient powder sachets ▪ Iron tablets ▪ Safe drinking water and drinking cups

Storage equipment ▪ Wooden palette for stacking

Participant’s Manual 53 Blanket Supplementary Feeding Program (BSFP)

This is an intervention wherein there is provision of supplementary ration to the general population of an identified vulnerable group (e.g. children under five in general, elderly persons, or women of childbearing age) for a defined period in order to impede the decline in nutritional status within this population. This is usually implemented during an emergency where there is lack of food supplies.

The objectives of blanket supplementary feeding are: • To prevent further deterioration in the nutritional status of at-risk groups in a population; and • To reduce prevalence of MAM in children under five, thereby reducing the mortality and morbidity risks.

Three Forms of Supplementary Food

Ready-to-Use Supplementary Food (RUSF)

Locally Prepared Foods Food

Supplementary Fortified Blended Cereals

Figure 19. Types of supplementary food

The three forms of supplementary food are RUSF, locally prepared foods with MNP and blended cereals, which are modified in their energy density, protein, fat and micronutrient composition to help meet the nutritional requirements of MAM children. One sachet or ration of supplementary food provides about 500 kcal. It is intended to supplement or add on to the usual home meals of under five children beyond the usual amounts of their home diets.

Supplementary foods are also different from food supplements, which refer to vitamin and mineral supplements in unit dose forms such as capsules, tablets, powders or solutions, where national jurisdictions regulate these products as food. Supplementary foods have been used to rehabilitate those who are moderately malnourished or to prevent the deterioration of nutritional status of those most at risk by meeting their additional needs, focusing particularly on children 6-59 months.

Examples of supplementary food includes RUSF which are lipid-based nutrient supplement ideal for the management of MAM; locally prepared foods which can be prepared and can be as good as commercial RUSF in meeting the nutrient needs when planned properly; and blended cereals which are fortified to meet the nutrient content needed for the management of MAM.

54 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

1. Ready-to-use Supplementary Food (RUSF) • Commercially produced food preparation made of peanuts*, sugar, milk, powder, vegetable oils, and vitamins and minerals, though they may be made with chickpeas, almonds or other commodities. • Specification o Comes in individual packages and used for the management of moderate acute malnutrition in infants and children 6-59 months o Provides 513-50 kcal per day, 12.6-15.4 grams of protein • It is fortified with 24 micronutrients and contains essential fatty acids and quality protein to ensure that the child’s nutritional needs are met. • It can be consumed directly from the package with no dilution, mixing or cooking necessary.

Products Ration Duration Energy & Nutrient Ratio Ready to use 1 Sachet/day Approx. 3 500 kcal Supplementary 92 g/day months (90 12.5 g Pro Food (e.g. days) 31g Fat Plumpy Sup) 42.7 g CHO*

*Carbohydrate is based on calculations from the energy, protein, and fat content of RUSF

* While G6PD is linked with broad beans (fava beans), there has been no report concerning G6PD and peanuts/groundnuts consumption on Medline (Briend, 2013). However, proceed with caution if a child enrolled in the program is known to have G6PD. Observe the tolerance of the child for RUSF throughout the course of the enrollment in the program.

2. Locally Prepared Foods

In the absence of RUSF, supplementary foods for 6-59 month children can be prepared from local food sources. Micronutrient Powder (MNP) should be added to the prepared food. When planned properly, the energy and macronutrient (protein, fat and carbohydrate) contents of the locally prepared food are comparable to the RUSF. For ease of computation, the Food Exchange list (Annex 4) can be used to calculate the energy and macronutrient content.

The steps in calculating the supplementary food, including sample calculation and sample menus are shown in Annex 3. The ND/nurse/midwife may modify the calculation depending upon the availability of local foods but making sure that the energy and macronutrient contents are close to that of RUSF.

• Locally prepared foods can be given in between the regular meals/feeding of breakfast, lunch and supper. o The food shall have an energy content of 500-550 kcal, protein of 9-15 grams and fat of 28-34 grams (the rest from carbohydrates: 30.5-70.5 g carbohydrates*), equivalent to a sachet of RUSF. o One sachet of MNP should be given every other day. MNP is distributed only to 6-23 month old children by DOH and the LGUs. Make sure that MNP is made available to 24-59 month old children with MAM. o The food should contain ALL essential nutrients in adequate amounts. The extra nutritional requirements will enable young children to have accelerated weight and height gain and full physiological recovery. o The nutrients should be biologically available to children with altered intestinal function that is associated with MAM.

Participant’s Manual 55 o Locally prepared foods can be stored at home up to 4 hours at a time at room temperature.

• In areas where infants and children can be gathered in a community, the BNS and the mothers can prepare the supplementary foods such as ginataang bilo-bilo, arroz caldo, squash congee, and fried rice in the community center. This may also be an opportunity for the BNS to conduct nutrition education, food safety, and WASH in the community. Cooking demonstrations of complementary/supplementary foods and gardening may also be done.

• The Barangay Nutrition Committee may also opt to identify local food vendors who can provide and/or prepare the complementary/supplementary food given that the local food vendors have the necessary business and sanitary permits, and health certification.

Products Ration Duration Energy & Nutrient Ratio Locally Prepared Can be given 1x or 3-6 months (90- 500-550 kcal Food 2x depending on the 180 days) 9-15gPro prepared food. 28-34gFat 30.5-70.5g CHO*

* Range of carbohydrate is based on calculations from the accepted range for energy, protein, and fat content of RUSF (WFP, Technical Specifications for Ready- to-Use Supplementary Food, 2016).

For Breastfeeding: • Continued breastfeeding for infants 6 to 24 months and beyond and giving of appropriate complementary foods is necessary in addition to the locally prepared food comparable with RUSF given to the child.

3. Fortified Blended Cereals The blended food is modified in its energy density, protein, fat or micronutrient composition to help meet the nutritional requirements of specific formulations.

This food is not intended to be the only source of nutrients but should complement the regular diet of the child. The blended cereals can be given to children as wet feeding or as dry take home rations where preparation can be done at home.

Products Ration Duration Energy & Nutrient Ratio Fortified Blended 130g/day 3-6 months 500 kcal Food (e.g. Ratio prop 500 (90-180 days) 21g PRO Supercereal Plus) kcal 13g Fat 75g Carb *Carbohydrate is based on calculations from the energy, protein, and fat content of blended cereals.

56 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

Types of Fortified Blended Cereal Feeding Wet Supplementary Feeding (on-site rations) ▪ Food is prepared once or twice daily in the kitchen of the supplementary feeding center (SFC) and is consumed by the child in the center for a duration of the treatment program. ▪ The child is then brought to the center daily to consume the supplementary food. ▪ Usually implemented in emergency settings when people have limited access to fuel and water, security conditions put people at risk while taking rations home, or for those who need additional food but cannot cook for themselves. ▪ Two meals are needed to provide the right amount of energy and protein given the small stomach size of children. ▪ Can also be given in the SFC while the participant waits for his/her dry ration.

Dry Supplementary Feeding (take-home rations) • The ingredients are mixed in the SFC prior to distribution; the mixture is taken home to be prepared and consumed by the child at home, or in temporary settlements for special circumstances such as emergencies. • The ration is a fortified blended food (FBF) with sugar and oil (pre-mixed or distributed separately), or may include high-energy biscuits, beans, lentils and wheat. • Distribution is every 1-2 weeks depending on the resources, access to distribution sites, security and other conditions. • One-week distribution is preferred for hygienic purposes, storing less food in the household. • Experience also shows that the ration is shared and consumed within a short time after distribution; biweekly distribution is preferred when the beneficiaries have a long way to travel to reach the SFC. • The distribution days are usually timed with market days, while there are MAM days or SFP days in some areas, and usually once a month distributions in GIDAs. • A take-home or dry ration is usually more than the amount required in order to compensate for family sharing. • Sharing of ration among family members will lessen the energy and nutrients that are intended for the child.

Management of Moderate Acute Malnutrition among Infants below 6 months in Community Management of Uncomplicated Acute Malnutrition (C-MAMI) Tool

The Emergency Nutrition Network (ENN) and the London School of Hygiene and Tropical Medicine (LSHTM) to fill in the gap in the programming guidance of non-emergency and emergency cases of malnutrition developed the community management of uncomplicated acute malnutrition (C-MAMI) tool. It is a short and practical tool to support community based management of uncomplicated cases of acute malnutrition in infants under six months of age. The tool was modelled after the Integrated Management of Childhood Illness (IMCI) framework (ENN, 2016). This tool is best used for moderate acute malnutrition cases in infants under 6 months. To determine the appropriate management, the following are the assessment steps required by the tool:

Infants 1. Triage: Check for general clinical danger sign or signs of very severe disease 2. (A)nthropometric/Nutritional Assessment 3. (B)reastfeeding Assessment 4. (C)linical Assessment

Mother

Participant’s Manual 57 1. (A)nthropometric/Nutritional Assessment 2. (B)reastfeeding Assessment 3. (C)linical Assessment 4. (D)epression/Anxiety/Distress

Ideally, Priority 1 and Priority 2 classification will be enrolled in the C-MAMI program, however, in the absence of resources, the program will focus on the infants with Priority 1 or infants with higher risks in ‘pink’ and yellow’ zone.

The management of moderate acute malnutrition in C-MAMI falls under Anthropometric/Nutritional Assessment of Infants. The Moderate acute malnutrition/SOME-nutritional risk classification is tagged as Yellow 2 or Priority 2 in C- MAMI. The two full assessment sections of the C-MAMI tool for both infants and mothers can be found in Annex 11. For more information about the C-MAMI tool, please refer to http://www.ennonline.net/c-mami. Routine Child Health Services

All children 6 to 59 months of age, whether registered or not to the SFP shall also receive their regular health services as scheduled (Table 6). These services are available in BHSs and RHUs.

If the SFC is far from the health facility, arrange for a mobile health team who can provide these services such as immunization, micronutrients, deworming as well as feeding and other health advice.

Table 6. Sample timeline for routine health services in a year Age Breastfeeding Oral Immunization MNP/Iron Other GP Package Health At Birth BF initiation, essential BCG and Hep B newborn care 1 month EBF Iron * GMP, Handwashing, hygiene 6 wks EBF OPV, DPT, Hep B, HiB 2 months EBF Iron * -do- 10 wks EBF OPV, DPT, Hep B, HiB 3 months EBF Iron * -do- 14 wks EBF OPV, IPV, DPT, Hep B, HiB 4th EBF -do- 5th EBF -do- 6th CF + Cont’d BF OH MNP Vit A, use of fortified foods, Counselling iodized salt, GMP, hand washing, hygiene 7th CF + Cont’d BF MNP use of fortified foods, iodized Counselling salt, (GMP), hand washing, hygiene 8th CF + Cont’d BF MNP -do- Counselling 9th CF + Cont’d BF MMR MNP -do- Counselling 10th CF + Cont’d BF MNP -do- Counselling 11th CF + Cont’d BF MNP -do- Counselling 12th CF + Cont’d BF OH MMR MNP Vit A, use of fortified foods, Counselling iodized salt, GMP, hand washing, hygiene, deworming EBF-Exclusive Breastfeeding, CF-Complementary Feeding, GMP- Growth Monitoring and Promotion, MNP- Multiple Micronutrient Powder, BCG- Bacillus Calmette-Guerin, OPV-Oral Polio Vaccine, IP- Inactivated Polio Vaccine, DPT- Diphtheria-Pertussis- Tetanus, HiB- Hemophilus Influenza B, MMR- Measles, Mumps, Rubella *for LBW and Pre-term

58 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

1. Check breastfeeding and feeding of the child. o If there are any breastfeeding or feeding problems, a trained health worker should be able to provide advice on feeding. (See Annex 2 for Feeding Recommendations)

2. Oral or dental health problems may affect feeding o Advise the mother or caregiver to bring the child to a dentist for check-up every 6 months.

3. Immunization o The Expanded Program on Immunization (EPI) is committed to its goal of universal access to all relevant vaccines for all at risk, including newborns, infants and under five children, in order to control vaccine-preventable disease and achieve better public health. Diseases targeted by EPI are complications of tuberculosis (e.g. TB meningitis, TB of the spine and miliary tuberculosis), Hepatitis B, diphtheria, pertussis (whooping cough), tetanus, pneumonia, meningitis and ear infection caused by Haemophilus influenzae type b, poliomyelitis, measles, mumps and rubella.

o All children between nine months and fifteen years of age (refer to DOH guidelines) should be immunized with necessary vaccines. The vaccination status of the child should be checked on admission and where no record exists, referral should be made to a health facility (or health care provider) where immunization services can be availed or provided. Where no facilities are available for referral, the vaccination should be provided within the program at the SFC.

Figure 20. IMCI Immunization Schedule

4. Vitamin A Supplementation

Table 7. Vitamin A Supplementation Age Group Vitamin A IU Oral Price/Unit11 Intake 6-11 months 100,000 IU P 1.44 12-59 months 200,000 IU P 1.44

11Source: DOH (2013). The Philippine Drug Price Reference Index (Second ed.). Manila: Department of Health.

Participant’s Manual 59 o On admission, check on the health card and/or ask the mother if the child has received Vitamin A in the last six months. o Administer Vitamin A as follows, if it has not already been taken in the past 2 months and it is not anticipated that it will be given in other programs within the next 2 months. o Vitamin A is routinely given 2x (every 6 months) through the Garantisadong Pambata every April and October (now the program is called GP everyday) o Children on RUSF SHALL NOT be given Vitamin A as RUSF already has sufficient micronutrients. There is a possibility of over-dosage if both Vit A and RUSF are given together.

5. Mebendazole 500 mg or Albendazole 400 mg

o Upon admission, check the health card and/or ask the caregiver (mother) of the child if s/he has taken Mebendazole in the last six (6) months. o If not, give Mebendazole to the child (12 months or older) on the second visit, with six 6-month intervals. Deworming is routinely given through the Garantisadong Pambata every April and October

Table 8. Mebendazole/Albendazole Treatment Age Group Mebendazole Price/Unit1 Albendazole Price/Unit11 500 mg (as of 2013) 400 mg (as of 2013) tablet tablet <12 months N/A - N/A - 12-23 months One (1) tablet P 1.97 200mg single P 0.84 x ½ as single dose dose/ 6 months 24 months and above One (1) tablet P 1.97 400mg single P 0.84 as single dose dose/ 6 months

6. Micronutrient Powder Supplement (MNP)

MNP Supplementation is a regular program of the Department of Health (DM 2011- 0303) for children aged 6-23 months, but it SHALL NOT BE GIVEN to MAM children on RUSF as RUSF is already sufficient on micronutrients. However, in the absence of RUSF, MAM children who are only given food with energy (500 kcal) and protein (13 grams) equivalent to RUSF shall receive MNP, one sachet everyday.

MNP is given is an easy-to-use mixture of vitamins and minerals designed for improved nutrition in children, providing essential nutrients by adding it to a child’s home-cooked food just before consumption. The benefits of MNP include proper growth, improved immune system, increase in appetite and prevention of micronutrient deficiencies in a child.

Table 9. Micronutrient Powder Supplementation Age MNP Price/Unit11 6-11 months 60 sachets to consume P 1.32 ($0.028) for a 1g within 6 months sachet 12-23 months 60 sachets within 6 months; 120 sachets in a year

60 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

▪ While MNP is provided to children 6-23 months, it can also be given as daily supplement to infants and young children up to 59 months of age for a minimum duration of 2 months, especially is there’s more than enough supply (HFTAG, 2016). ▪ Use this at 6 months of age during the introduction of complementary feeding. ▪ Mix MNP with complementary food, preferably soft or semi-solid, before feeding. ▪ Do not add MNP to food before or while cooking.

Figure 21. IEC material for MNP

o Methods of Distribution ▪ BHW/BNS provides orientation to beneficiaries regarding the use of MNP ▪ Mothers/Caregivers will be given one-month supply (10 sachets) of MNP ▪ Mothers/Caregivers will visit the health center every month for monthly supply of MNP

7. Iron (therapeutic dose for children with iron-deficiency anemia) o Iron: give one (1) daily dose for three (3) months

Table 10. Iron/Folate Therapeutic Dose Age or Weight Ferrous Price/dose1 Iron Syrups Price/Unit11 Sulfate 200 (as of 2013) (30mg/5ml) or (as of 2013) mg (60mg Iron Drops elemental iron) (15mg/0.6ml) 2-4 months Syrup: 1.0 mL P 10.65 for 60 (4 to <6kg) (<1/4 tsp) mL syrup or P 4-12 mos. Syrup: 1.25 mL 12.93 for 15 (6 to <10kg) (<1/4 tsp) mL drops 12mos.-3yrs. ½ tablet P 0.85 x ½ Syrup: 2.0 mL (10 to 14kg) (<1/2 tsp) 3-5 yrs. ½ tablet Syrup: 2.5 mL (14 to 19kg) (<1/2 tsp) Drops: 0.6 mL

Participant’s Manual 61 Session 4: Monitoring, Follow-Up and Referral

Key Concepts

Monitoring is assessing the progress of program implementation. This is done on a regular basis and more frequent than doing evaluation. Evaluation is not just assessing the degree to which the program objectives are being met but also to understand what factors affect access and uptake of the services.

The purpose of evaluation is to initiate action or modify actions to ensure the greatest number of individuals able to benefit from the program. This relies on information gathered through individual assessment. SFP performance and effectiveness can be assessed using a range of standard indicators.

The management of MAM requires appropriate monitoring of interventions and of the overall situation. This is important to ensure quality control of the program, that conditions are not deteriorating (to affect incidence and case load coverage), and evaluations should be scheduled to assess program effectiveness and impact in line with best practice standards.

Indicators to be monitored for all SFPs include coverage, recovery/cure, death, defaulting, and non-response rates. Monitoring and Evaluation (M&E) tools include individual record cards, ration cards, referral slips, tally sheets, monthly statistical reports, and commodity distribution records.

Tracking and Monitoring of MAM Cases

Upon admission, ensure that there is a record in the register of the following: - The target WFL/H and/or MUAC for discharge, include this also in the ration card and logbook; - The WFL/H and/or MUAC, which would trigger transfer to OTC for SAM - Consider the following procedures for monitoring and recording data for the management of MAM. - Make sure to reiterate that the child and caregiver should regularly visit the SFC for monitoring and distribution of supplementary ration.

Table 10. SFP Sphere Standards TSFP Indicators Acceptable Alarming Cure Rate >70% <50% Death Rate <3% >10% Defaulter Rate <15% >30% Non-Recovered Rate <10% Average Length of Stay (in the <8 weeks >12 weeks program) Average Daily Weight Gain S3g/kg/day Coverage 50% (rural) 70% (urban) 90% (camp)

62 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

Figure 22. Procedures for monitoring

STEP 1.Take the child’s MUAC measurement at each visit and compare with the discharge criteria to determine whether the child is already eligible for discharge or not, and/or take the WFL/H measurement once a month or if height board is readily available at the site.

STEP 2. Take weight measurements of the child at each visit and compare with the target weight recorded at the time of admission and with the minimum weight and/or MUAC for transfer to SAM treatment. Refer to OTC or ITC if qualified SAM case.

STEP 3. Diagnose whether the child meets any of the criteria for Failure to Respond to Treatment if in case there is no improvement with the child.

STEP 4. Check whether the MAM child meets the SAM criteria (WFL/H <-3 Z-score and/or MUAC <11.5cm, or presence of bilateral pitting edema) and if the child has SAM, immediately refer the child to the OTC or ITC (if with medical complications).

STEP 5. Ask the mother or caregiver if the child has an illness, and if yes, refer to the health center for medical check-up and treatment or IMCI assessment.

STEP 6. Record results in the appropriate TSFP Registration Book.

STEP 7. Provide routine treatment at the appropriate visits.

STEP 8. Follow-up on the child’s feeding practices, i.e. complementary feeding with continued breastfeeding.

STEP 9. Explain to the caregiver the change in the child’s nutritional status, if any.

STEP 10.Give and record ration at each visit on the Ration Card of the child.

Participant’s Manual 63

Table 11. Summary of Tracking and Monitoring in the SFC Activities in the SFC/SFP Frequency MUAC is taken Every 2 weeks Weight is taken using the same scale Every 2 weeks Height and length are measured At admission, monthly and if child substitution is suspected WFL/H can be calculated as required Day of admission and discharge (Golden & Grellety, 2011)

Failure to Respond to Treatment

Upon admission of MAM cases, calculate the discharge weight and/or MUAC and the weight and/or MUAC at which a criterion for SAM is reached. This should be recorded to identify children who are not responding to treatment accordingly. They should not stay in the standard program; the cause of failure to respond should be investigated, managed and actions be taken urgently.

When child shows failure to respond to treatment, consider the following:

1. Criteria for failure to respond 2. Reasons for failure to respond 3. Step-by-step approach to address the problem 4. Management of cases that failed to respond to treatment

Criteria for failure to respond to treatment

• Any weight loss within the consecutive 3 weeks in the program or at the 2nd visit • Either no or trivial weight gain after 5 weeks in the program or at the 3rd visit • Weight loss exceeding 5% of body weight at any time (the same scale must be used) • Failure to reach discharge criteria after 3 months in the program • Abandonment of the program (defaulting) Reasons for failure to respond

• Problems with the application of the protocol • Nutritional deficiencies that are not being corrected by SFP-supplied diet • Home/social circumstances of the patient • An underlying medical (e.g. Tuberculosis) or physical condition/illness (e.g. congenital defects) • Other causes

Step-by-step approach to address failure to respond

To address failure to respond to treatment, Golden and Grellety have developed an approach to manage such cases (Figure 23). This is performed by the trained individuals on the management of MAM (BNSs, BHWs, community volunteers) when it is evident that the child’s condition is not improving or reaching the expected results after months of treatment.

64 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

7. Idiopathic Non-Response

Figure 23. Approach to manage failure to respond to treatment a. Protocol Problems When a significant number (10% and above) of children in treatment fail to respond to treatment, proper application of protocol and the training of field level staff should be reviewed, if possible by external evaluation. Implementation issues should be corrected.

If the failure to respond to treatment is because the caregiver is not given due respect (e.g. staff is rude), this must be investigated by the supervisor/manager of the SFC and addressed accordingly. If it is suspected that rations being given come up short for the nutritional need of the child or that there is diversion of food, unannounced post-distribution monitoring should be implemented by the trained individuals (BNS, BHW, Community Volunteer) by reweighing the food of recipients exiting the SFC or visiting a random selection of cases at home and examining or weighing the food they have recently received. b. Uncorrected Nutritional Deficiencies The old diets used for supplementary feeding of MAM children (Corn Soya Blend (CSB), UNIMIX, FAMIX etc.) are neither designed to promote rapid catch-up weight gain nor to return children to physiological normality, even if taken exclusively; the nutrient density does not compensate for the very low levels of some essential nutrients in the remainder of the diet. They often have low concentrations of several essential nutrients (e.g. potassium, magnesium, available phosphorus or zinc, etc.). The availability of these nutrients is very low from some of the diets and

Participant’s Manual 65 there are high concentrations of anti-nutrients. Such unbalanced supplements can even aggravate the malnutrition. Further, some contain very high concentrations of iron, which destroys other essential nutrients, such as vitamin C, during food preparation.

Particularly, when cereal-based FBFs are used, the next step is to test whether the child has an uncorrected nutritional deficiency. This is done by changing the ration given to a nutrient dense diet with few anti-nutrients, usually by giving RUSF. It is important to emphasize that the recovery of the child is slower than expected and that the diet should be given exclusively to the child and not to be shared, and that it should be taken at least one hour before, or two hours after family meals and not mixed with the family food taken by the child.

c. Social Problems Where RUSF is being used and the correct instructions as to its use have been given (and the caretaker confirms that they have been followed), or locally available food sources have been properly provided to the child, the most likely cause of failure are social problems within the household. These could be: • skepticism of family decision-makers with the treatment • excessive sharing of ration within family members or selling of ration • sibling rivalry • parental psychopathology or mental health issues • child abuse • child rejection (paternity issues) • caregiver fatigue • abject poverty where the whole family is malnourished and use of the child’s state • to access food and services for the family (a full ration of food MUST be given to the • whole family) • discrimination against the family because of ethnicity

These are the more common causes, but there are many other causes of social disruption that lead to malnutrition in a young child that lead to that child failing to respond to treatment. To address these, a home visit is made if possible to evaluate home circumstances.

If the cause is not determined or a home visit is difficult to arrange, then the child is admitted in a facility – e.g. day care center, as linked with the social services of the LGU, and fed under careful supervision for about 3 days.

If the child gains weight well with directly observed feeding, yet fails to gain weight at home, then there is a major biopsychosocial problem. The health worker and the municipal social welfare and development officer (MSWDO) with an in-depth interview then investigate this with the parents who have seen the child gain under supervised feeding and possibly a further home visit.

d. Underlying Medical Conditions If the child does not respond to supervised feeding, then there may probably be an underlying medical problem. A careful history taking and thorough physical examination by a health professional should be performed and a search for common underlying conditions be made; in particular, tuberculosis, malaria, HIV, cerebral palsy, schistosomiasis, infections, cirrhosis, inborn errors of metabolism, Down’s syndrome, post-meningitis neurological damage, etc.

66 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

e. Other Conditions If the child is not improving and there is no recognized underlying condition, then the child should be referred to appropriate higher level health care facility with pediatric subspecialty services and diagnostic facilities.

Management of Treatment Failure

After doing the step-by-step process above in identifying the cause of failure to respond, the next step is to respond to the identified cause.

In addition to the main supplementary diet, or another blended fortified diet, a different supplementary diet shall be given, such as RUSF, which is a higher quality ready-to-eat supplementary product, fortified with all the nutrients.

Steps on managing treatment failures: 1. Improve nutritional intake 2. Check response to treatment 3. Investigate for social problems 4. Investigate underlying pathology

The following steps are taken one at a time in sequence without omitting any step:

Step 1: Improve the child's nutritional intake.

Give the child local recipes plus MNP or 2 sachets RUSF equivalent to 1000 kcal/day for 15 days.

If the child still fails to respond, you will not have effectively excluded an undiagnosed/untreated nutritional deficiency as the cause of the failure. It MUST be the best diet available for recovery of a malnourished child. Using RUSF can also address certain issues, such as incapability of the caregiver to provide supplementary food that needs preparation due to social factors.

Step 2: On the 2nd visit, check the child's response to treatment.

If s/he now responds to treatment, this means that it was a nutritional problem and/or issue at home.

If it is solely nutritional problem, continue the treatment, with double quantity of local recipes plus MNP or two sachets of RUSF plus the SFC ration, for another month. If in addition there is social issue (with preparation of food), address this with encouraging the family to cooperate, or giving counselling with the assistance of social worker or SFC manager.

If s/he still does not respond to treatment, this means that the dominant problem is not a nutritional problem and that there is a need to investigate if it is mainly a social problem (proceed to next step).

Step 3: Investigate the home social circumstances; conduct home visit.

It is very important to realize that many or most social problems will hardly be identified during one home visit (e.g. discrimination against the child, neglect, caregiver illness, sibling rivalry, etc.). This is because parents’ and children’s behaviors change during a visit by an outsider.

Participant’s Manual 67 During the home visit, if a problem identified can be alleviated or solved, deal with the problem and leave the child at home until further visits and follow-up.

Example: sibling rivalry could be addressed by providing counseling to the family and helping them understand the importance of providing proper nutrition to the child with MAM with the cooperation of the family.

During the home visit, if a problem identified cannot be alleviated or solved at home, take any necessary step to address the problem, such as: • Admission of the child to a facility; • Putting more resources into the home (e.g. food source, livelihood); • Arrangement for a different caregiver (e.g. relative, foster care, institution); or, • Getting treatment for the caregiver (e.g. psychiatric, HIV, etc.)

It is important to get the professional assistance of social service providers (social workers) or health care providers. Example: with abject poverty, referring the family to the social services for initial response to lack of food or tapping sources of extra income for the family through links with available jobs, livelihood programs, etc.

During the home visit, if no problem is identified to account for the failure to respond to treatment, then it is still likely that there is a social problem that has not been identified during the home visit.

Admit the child for a trial feeding for 3 days under supervision. This can be in a daycare center or with “wet feeding” where the child is taken to a health center daily to receive food under supervision. Many of these facilities do not have full medical diagnostic capability – but they certainly can supervise feeding and care, and ensure that the child gets the food that is prescribed.

Step 4: Investigate underlying pathology.

If the child is still not responding to treatment, then s/he needs to be sent to a health facility (hospital) where there are clinicians/pediatricians or other physicians that would have expertise or training in evaluating the underlying medical condition.

If this facility does not find the cause, then the child should be referred to a national center/training and teaching hospitals for full investigation of unusual causes.

If the cause of the malnutrition has not been found, the child should then perhaps be entered into a registry, have specimens stored and be seen whenever there is a pediatrician, family medicine specialist or physician trained in the management of severe acute malnutrition and in other diseases.

If the final referral center does not find any cause for the failure of the child, then the child is labelled as idiopathic failure-to-respond and discharged from the program after four months of treatment.

68 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

Session 5: Discharge

Key Concepts

Discharge Categories

There are four categories of discharge considered when the treatment of the child is terminated and it is important to take note of this in the Registration Book and Ration Card.

Table 12. Discharge Criteria for MAM Category Discharge Criteria Cured MAM child • Admitted by WFL/H: S -2 Z-score for 2 consecutive (6-59 months) visits; AND/OR • Admitted by MUAC: S 12.5 cm for 2 consecutive visits • Clinically well • No bilateral pitting edema Defaulted • Absence for 3 consecutive visits Non-response • 4 months without reaching cured criteria • Failure to respond to treatment Died • Death of child

a. Cured (recovered, nutritionally recovered or discharged successfully)

Recovered children under the MAM program reaching the criteria for discharge:

✓ If the child was admitted to the program through MUAC measurement, s/he should reach a MUAC of 12.5cm (125mm) for two consecutive visits to be discharged as cured. When to discharge as cured For two consecutive weeks: ✓ If the child was admitted through - WFL/H S-2 Z-score WFL/H measurement, s/he should AND/OR reach a WFL/H of -2 Z-score for 2 - MUAC S12.5 cm (125mm) consecutive visits to be discharged as cured.

✓ If the child has no bilateral pitting edema.

b. Defaulter This is a beneficiary who is absent for 3 consecutive sessions (every 2 weeks). Ideally, home visit is arranged to determine reason for defaulting, as well as to encourage readmission to the program.

c. Death This is discontinuity of treatment and discharge when a child who is registered in the program or within 24 hours of transfer to another health facility died from any cause.

Participant’s Manual 69 d. Non-responder/Non-cured A beneficiary who has not reached discharge criteria after 4 months despite all investigations and transfer options is discharged from the program as non-responder or non-cured, and is referred for further investigation to professional health care providers.

Procedures of Discharge

Consider the following procedures when discharging a child in the MAM treatment program: a. As soon as the child reaches the criteria for discharge (WFL/H S-2 Z-score and/or MUAC S12.5cm) for two consecutive weeks, s/he can be discharged from the program.

• If cured, inform the caregiver that the child has successfully recovered from MAM and Procedures of Discharge congratulate them, encouraging • Inform caregiver the reason for them to maintain this status. discharge • If in cases of defaulting, encourage • Record anthropometric measurements the family to return to treatment • Check immunization &IYCF and address the reason for • Link to other services defaulting. If not convinced, • Follow up for 3 months inform them of the discharge status. 1. In case of death, express sympathy to the family. 2. In case of non-response amidst all efforts, explain to the caregiver the reason why the child is discharged from the program, and decide what to do next for the child, whether to refer to the hospital or other health professionals. b. Record the discharge date, WFL/H, MUAC measurements and the Type of Discharge in the Registration Book and in the Ration Card. Make sure that all necessary information is recorded. c. Check that immunizations are updated, counselling regarding IYCF and care practices are given and caregiver informed that the treatment is over. d. Link the caregiver or family of the child to continuing health, nutrition and social services available in the community that the child is eligible for and which supports improvement of nutritional status. e. Prepare a follow-up scheme of three months after the discharge.

70 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

Session 6: Linkaging

Key Concepts

As the PIMAM components are interlinked with each other, so is the management of MAM closely linked with existing health, nutrition, early child development, WASH and social services were possible within the community. It is encouraged that SFP sites are within a maximum of few hours’ accessibility for the beneficiaries, ideally in existing health facilities (RHU/barangay health center, BHS, day care center/child development center, government hospital) in case of immunization or treatment of illness. It is also ideal to have the MAM and SAM services to be within the same vicinity for referrals or transfers between the two modalities. This is in order for the child to continue or maintain health after recovery and prevent relapse.

Strategies for the management of MAM merge with public health interventions that promote optimal child development. These strategies include the promotion of age- appropriate breastfeeding and complementary feeding practices (IYCF), access to appropriate health care for the prevention and treatment of disease, and improved water, sanitation and hygiene practices (WASH). In addition, it is also essential to address food insecurity because it a major source of malnutrition, thus the linkages with food security and livelihood programs accessible in the community.

In summary, linkages could be formed with the following and considered by the health and nutrition workers in the community, as well as hospital staff. • SAM treatment • Health and nutrition programs through the Municipal/City Health Offices, District or • Provincial Hospitals: IYCF, Operation Timbang Plus, EPI, MNP Supplementation • IMCI • Mother support groups and activities in line with nutrition • Social welfare programs through the DSWD: Conditional Cash Transfer (4Ps), Sustainable Livelihood Program, KALAHI-CIDSS, Self-Employment Assistance- Kaunlaran (SEA-K) • Food security, agriculture and livelihood programs by LGUs, NGOs or private sectors • WASH promotion • PhilHealth enrolment and coverage

Figure 24. Linkaging MAM with other services

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Session 7: MAM in Emergencies

In general, the management of MAM in emergencies is the same as the protocol in normal conditions. However, due to special considerations being followed during emergencies, the guidelines below should be observed.

The conceptual framework shown in Figure 1 illustrates the causation of malnutrition including primary and underlying causes. In emergencies, essential services and support structures are often greatly disrupted, increasing the malnutrition risk to the population. Once malnourished, an individual’s ability to manage infection is compromised exacerbating the effects of potentially fatal diseases such as malaria, measles, diarrheal disease, pneumonia, HIV and AIDS. MAM needs to be addressed in the emergency context both to support a child’s right to sufficient food, growth and well-being and to prevent more serious illness and death.

Nutritional Situation Assessment for Emergencies

In order to determine if and how a feeding program should be implemented, it is necessary that an assessment is carried out to give information on the current nutritional situation and the presence of aggravating factors (absence or lack of general food ration, presence of epidemics or diseases, crude mortality rate) that can exacerbate nutritional insecurity. Minimum information needed to consider an SFP are:

▪ Pre-crisis prevalence rates of MAM, food insecurity, disease, access to health services and micronutrient deficiencies ▪ Likely scenarios of change in the nutritional status of children under five based on a food security assessment ▪ Understanding the seasonal dynamics and projecting forward regarding health and social support available during the emergency ▪ Social support networks and psychological stress on caretakers ▪ Trends of disease and malnutrition (past and projected) ▪ Likelihood of food sharing ▪ Variation in prevalence rates within a given geographical area and the implications these would have on type of intervention and coverage ▪ Capacity to implement programs

SFP is ideally implemented when nutrition/anthropometric surveys have been conducted and where the underlying causes of malnutrition are simultaneously being addressed. An SFP should be implemented alongside an adequate general emergency food ration to be effective (Global Nutrition Cluster, 2008). It is important to determine which primary type of SFP will be best suited for a given situation. TSFP mainly aim to support MAM cases when there is an alarming rate of GAM among children or prevalence of GAM with presence of aggravating factors. BSFP, on the other hand, aim to prevent widespread malnutrition and to reduce excess mortality among at-risk group by distributing supplementary food to the entire population.

72 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

Decision Making for Emergencies

The MAM Decision Tool for Emergencies (GNC, 2014) was developed by the MAM Task Force of the Global Nutrition Cluster to serve as a tool and guidance for the prevention of acute malnutrition and treatment of MAM in emergencies. The primary objective of MAM programming is to prevent mortality and morbidity, reduce the incidence of SAM and acute malnutrition that often occurs in emergency.

While this tool is intended as interim operational guidelines to address MAM in emergencies, the SC plans to use this guide to test whether this will also be applicable for non-emergency settings.

Different types of information and data are required in making decisions during emergencies: ▪ prevalence of GAM in the affected area ▪ information on the nature and severity of the crisis ▪ baseline health data in the areas affected and expectations of the crisis impact on illness ▪ food security situation and expectations of crisis impact on food security ▪ estimates of displacement and population density

Figure 25. MAM Decision Tool Steps for Emergencies

The Decision Tool has devised a process of determining the appropriate intervention to implement for the management of MAM in emergencies.

STEP 1. Determine the appropriate type of program for the current situation. Choose from (a) prevention and treatment of MAM, (b) prevention only, (c) treatment only or (d) no additional intervention than strengthening IYCF and monitoring the situation. This can be determined by performing a situational analysis, risk deterioration assessment, and coming up with a program recommendation.

Participant’s Manual 73

Figure 26. Risk deterioration assessment

Figure 27. Determining program type for management of MAM in emergency

STEP 2. Identify the modality and operation of response in managing MAM during emergencies.

Supplementary Feeding Program. BSFP is usually the modality used for preventing or treating MAM in situations where there is high prevalence of MAM, chronic malnutrition, or food insecurity even before the emergency. TSFP is ideally the choice for treatment of MAM through the direct provision of nutritious food supplements and routine medical treatment.

74 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

Cash/Voucher Program are considered standard programming options in emergency food security or livelihoods programs for increasing household assets and flexibility in adapting to shocks. For emergencies, this can be considered where the food and nutrient availability is good, markets have not been interrupted and caring practices can be sufficiently maintained or improved.

SBCC/IYCF Support is important in any emergency response. In some circumstances where SBCC (Social and Behavior Change Communication)/IYCF support alone is the appropriate response – for instance, when markets are functioning, age-appropriate food is available and households have sufficient income to purchase the nutrients and nutrient density required by infants and young children.

STEP 3. Establish program operation details.

Select target group for the intervention. The standard target groups are malnourished children 6-59 months of age, malnourished pregnant and lactating women 6 months postpartum (PLW) and malnourished people living with chronic illness (e.g., HIV, TB).

Select the right specialized nutritious food. Selecting specialized food for management of MAM is linked with the contexts of emergency and food security, and the risk group to be targeted. Three main factors to consider are: (1) objective of the intervention and target group, (2) household’s ability to cook, and (3) cultural practices and food preferences.

Estimate the duration, timing and cessation of the intervention. Duration may vary with range from 1 to 4 months after onset of emergency. Scale-down of programs in managing MAM is generally considered when GAM rates fall below 5% and no aggravating factors exist. Phase out can be considered when there is very low number of cases of MAM.

Determine the delivery mechanism. There are a number of factors to consider in planning the delivery of MAM treatment programs, such as access to the population, scale of the emergency (e.g. total area affected, etc.), implementation capacity and population density. Decision should come up with the number of delivery or treatment sites, frequency of delivery of services or commodities, and manner of distribution. It is important to keep in mind that sites for management of MAM require large areas for waiting, measuring, monitoring and providing the food supplement and it does not require health care staff for implementation. As much as possible management of MAM should not drain the existing health system.

STEP 4. Review and revise. The decisions made with this tool may require adaptation after certain time intervals, be it because the emergency has expanded, new risk factors have emerged, the time horizon needs to be extended, new nutrition interventions are included in the nutrition response, etc.

Considerations in Establishing MAM Program in Emergencies

During emergencies and disasters, implementers should consider the following in setting up PIMAM Program:

▪ Where PIMAM is implemented, a support for BNS/BHW in screening for cases of SAM in the community is needed, aiming to augment rather than replace current services; volunteers or assistants may provide ancillary help at the BHS/RHU. o Provision of mobile teams for communities unable to access health care and/or the establishment of temporary sites in camps where health centers and/or health staff are affected by disaster. o Provision of additional resources such as medicines and RUSF; buffer stocks

Participant’s Manual 75 from regular program may be used to ensure that children who need it are provided the service immediately. o Implementation of IYCF in emergency services. o Temporary medical sites if hospital services become inaccessible. o If TSFP is available, ensure proper screening and referral of children with MAM.

▪ Where no treatment service is currently implemented, the implementation will likely require the assistance of neighboring local government units or local or international NGOs with previous experience on PIMAM. Coordination of programming for the treatment of MAM shall be done through the relevant local authorities and the Nutrition Cluster. o The focus is on achieving high treatment coverage and early admission to treatment before complications can develop. As such, community mobilization and SFP shall be prioritized. o Before implementation, the emergency program must have a well-defined and sustainable ‘transition strategy’.

Program Linkages in Emergencies

Preventing and addressing undernutrition requires multi-sectoral action and there are other program linkages for MAM in emergencies including interventions to manage SAM, strengthen IYCF, address health, water, sanitation and hygiene and address food insecurity. Illness, food insecurity and suboptimal feeding practices influence the effectiveness of SAM and MAM interventions, therefore, any emergency nutrition response should be coordinated with these other programs when appropriate and advocate for them when necessary.

Basic linkages for managing MAM in emergencies include: ▪ Management of SAM ▪ Infant and Young Child Feeding (IYCF) ▪ Water, Sanitation and Health (WASH) ▪ Food Security and Livelihood Program

Content Summary

This module focuses on the organization and management of moderate acute malnutrition (MAM) in children 6-59 months of age and infants below 6 months of age. The first step is community outreach, which involves the mobilization and education of the community, case finding, and referral of cases to increase access and coverage of the programs and services for the management of MAM. This is followed by the assessment through their anthropometric assessments (WFL/WFH and MUAC) as well as clinical signs such as the presence or absence of bilateral pitting edema.

Once MAM cases are identified, interventions and services are delivered to the children. Targeted Supplementary Feeding Program (TSFP) is a type of intervention wherein a supplementary ration is provided to specific members of a vulnerable group whose requirements may not be met by the general ration. On the other hand, a Blanket Supplementary Feeding Program (BSFP) is a type of nutrition intervention wherein there is provision of supplementary ration to the general population or an identified vulnerable group for a defined period in order to impede the decline in nutritional status within the population. There are three types of supplementary food: (1) Ready-to-use Supplementary Food (RUSF), (2) Locally Prepared Foods, and (3) Fortified Blended Cereals.

76 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

Routine health services are also given to the children 6-59 months and below 6 months, whether registered or not in the supplementary feeding program. The services include breastfeeding and feeding of the child, dental health, immunization, vitamin supplementation, and other health interventions.

During and after these interventions, monitoring, follow-up, and referrals are conducted. The management of MAM requires appropriate monitoring of interventions and of the overall situation. This is important to ensure quality control of the program, that conditions are not deteriorating (to affect incidence and caseload coverage), and evaluations should be scheduled to assess program effectiveness and impact in line with best practice standards.

A child can be discharged under the following categories: cured, defaulter, death, and non- responder. These children are classified under these categories in accordance with the discharge criteria.

As the PIMAM components are interlinked with each other, so is the management of MAM closely linked with existing health, nutrition, early child development, WASH and social services were possible within the community. Strategies for the management of MAM merge with public health interventions that promote optimal child development. These strategies include the promotion of age-appropriate breastfeeding and complementary feeding practices (IYCF), access to appropriate health care for the prevention and treatment of disease, and improved water, sanitation and hygiene practices (WASH).

The risk of malnutrition to the population increases in the occurrence of emergencies. In order to support a child’s right to sufficient food, growth and well-being, and to prevent more serious illness and death, MAM needs to be addressed in the context of emergency.

Participant’s Manual 77 Exercises

Multiple Choice: Encircle the best answer. 1. Which of the following statements is true about MAM program evaluation?

Statement 1: Evaluation relies on information gathered through individual assessment.

Statement 2: Evaluation is done on a regular basis and more frequent than program monitoring.

a. Statement 1 only b. Statement 2 only c. Both are correct d. None of the above

2. The following is/are important in determining program for the management of MAM during emergencies: a. GAM level only b. Risk assessment level only c. Mortality levels only d. a and b e. a and c

3. A child with MAM can be discharged as cured if the following condition(s) is satisfied for two consecutive weeks: f. WFL/H S-2 Z-score g. MUAC S125mm (12.5cm) h. a and/or b i. Neither a or b

4. Which of the following statement is/are TRUE in the absence of the standard Ready- to-Use-Supplementary Food (RUSF). a. Any food of any serving portion/s mixed with MNP can be used to manage MAM b. The food shall have an energy content of 400 kcal, protein of 9-15 grams and fat of 28-34 grams (the rest from carbohydrates: 30.5-70.5 g carbohydrates*), equivalent to a sachet of RUSF. c. the recommended diet should be given exclusively to the child admitted to the MAM program and should not be shared. d. all of the above

5. Which of the following statement is/are FALSE.

a. Children with Moderate Acute Malnutrition are also having micronutrient deficiency, thus, aside from RUSF MNP shall also be provided. b. Fortified Blended Food are always recommended during emergency response c. MNP has 10 micronutrients during to support rehabilitation of MAM child d. It is recommended that a MAM child should be cured first for MAM before other health interventions are given

78 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

TRUE OR FALSE

1. Active case finding results to higher coverage, faster rehabilitation, and lower mortality rates.

2. A child with WFL/H Z-score of -3 to <-2 with bilateral pitting edema should be admitted to the MAM treatment program.

3. Blended food/cereals are intended to be the only source of nutrients for the treatment of children with MAM.

4. Once malnourished, an individual’s ability to manage infection is compromised.

5. Sharing of ration among family members lessens the energy and nutrients for the treatment of children with MAM.

Answer key:

Multiple Choice: 1) a, 2) c, 3) c, 4) d, 5)

True or False: 1) True, 2) False, 3) False, 4) True, 5) True

Participant’s Manual 79

*f7771 177 If 7t(?t/ if f71If!l”1t1t”J71

Module Description and Objectives

This module is designed to allow the learners to apply their newly acquired skills in identifying children with Moderate Acute Malnutrition (MAM), communicating and educating mothers and/or caregivers, providing the appropriate intervention and childcare services needed to rehabilitate the child through table top-exercise or hands-on experiences with children and their mothers/caregivers in the community – simulating an actual community-based management of MAM.

At the end of the module, through table-top simulation or actual visit in the community, the participants will be able to: 1. Apply the skills in identifying and assessing children with MAM through return demonstration; 2. Apply the skills in communicating and educating mothers/caregivers about the treatment for MAM through role playing or actual performance; 3. Apply the skills in determining the appropriate intervention and childcare services to be provided to children identified with MAM through simulation or actual demonstration; and 4. Apply the skills in implementing post treatment care in terms of follow-up, referral, monitoring and discharge through role play

Guidelines and Reminder (adapted from SAM Guidelines)

The purpose of the table-top exercise or community simulation is to have a hands-on experience in applying the skills taught in getting the weight and length/height, utilizing the CGS tables, measuring the MUAC, assessing for the presence or absence of bilateral pitting edema, communication and education of the parents and caregivers, and implementation of appropriate intervention and services including post treatment procedures.

The following are a few reminders and guidelines for the community visit:

Participant orientation before the community visit • Bring the necessary materials: pen, paper, checklists, felt tip marker or other marking materials, MUAC tape and CGS tables. • Find a partner within your respective group. • With your partner, find another pair within your big group whom you will take turns with in demonstrating the skills and observing/evaluating. • Review the provided checklists thoroughly. • Ask any questions for any points for clarification.

Before going to the health center • Make sure that you and your fellow participants are well accounted for through a buddy system or a count off. Make sure that no one will be left behind. • For trainers, ensure that necessary arrangements have been made with the focal point/ contact person at the health center and the objectives and details of the visit have been discussed clearly.

While inside the health center • Perform hand hygiene.

Participant’s Manual 81 • Familiarize oneself with the tools and the area together with your partner and counterpart pair. Make sure that the tools are calibrated, and properly assembled. Strategize on how to go about the tasks. • Hand your checklists to the pair who will observe/evaluate you and your partner. • Introduce yourselves to the mother/caregiver and child • Explain the purpose of this exercise, as if this is already done in the actual field setting. • Ask for consent, and ensure privacy and confidentiality. • Enumerate that you and your partner will be doing the following: o Measuring the MUAC o Identifying the presence of edema o Measuring the height/length and weight • Build rapport as you ask questions about the following: o Child’s name and mother’s/caregiver’s name o Age o Family – Does the have any siblings? Who takes care of the child? Are the parents working? o Birth history - Were there any problems at birth or during the pregnancy? Any illnesses? o Nutritional status - At present, what does the child eat? Who prepares the food? For an older child, does the parent allow the child to have money to buy from the sari-sari store? o Health status - Is the child frequently ill? Any noticeable delay in physical growth or development? o Brief nutritional history - Was the child breastfed? When did the child start eating solid foods? • Together with your partner, perform the necessary skills thoroughly. Clearly enumerate the step-by-step procedure to the mother/caregiver. Remember the correct way of doing the following: o MUAC measurement o Identifying the presence of edema o Getting length/height o Getting the weight • Remain orderly while waiting for your turn in using the height/length board or Salter scale. • In using the Salter scale, you should weigh the child without clothing or diapers as much as possible. In cases that the child (especially older children) refuses or shows sign of being uncomfortable without clothing, you may just opt to remove heavy pieces of clothing (ex. maong/denim shorts), and keep the underwear. • If using the trousers attached in the Salter scale, always disinfect and/or use a covering after every use for hygiene. • Write down or record your measurements/results. • Utilize the Z-score charts and interpret. • Consolidate your findings with your partner. • Provide the overall results and feedback to the mother/caregiver. • Praise the mother/caregiver for any positive health and nutritional behaviors (Example:“Mabuti po at pinapa-breastfeed ninyo ang anak ninyo”). Encourage them to continue theirbehavior. • Educate the mother/caregiver on areas in which he/she can improve on (Example: Relactation, vaccination, hand hygiene, etc.) • Summarize/wrap up with the mother/caregiver on what has transpired during the encounter. • Thank the mother/caregiver and the child for their time and cooperation. • If done, you may switch with your counterpart pair. • After your counterpart pair is done with demonstrating the skills, you may compare your findings to check for variations or discrepancies.

82 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

Before leaving the health center • Do another headcount to account for every participant. Make sure that no one gets left behind. • Thank the focal point/contact person for facilitating the arrangements and for allowing the practicum in their facility.

Step 1: Assessment (Refer to Module 3 Sessions 2: Case Finding and Referral) Determine the child’s age 1. Take WFL/H or MUAC of the child 2. Check for the presence of edema

Step 2: Admission (Refer to Module 3 Session 2: Admission) Case 1: Infants aged 0 to <6 months identified with MAM (Follow the complete procedure on Annex 11 for CMAMI Guidelines) 1. Based on Anthropometric/Nutritional Assessment a. If growth monitoring card is available, take note of the following: i. Birth weight ii. Current growth centile iii. Growth trend, if previous data is available iv. Growth velocity and growth pattern (e.g. whether tracking along or falling across centile lines)

b. If growth monitoring card is NOT available, record weight for age (W/A).

2. Based on Breastfeeding Assessment a. With breastfeeding difficulties based on mother’s condition.

b. With non-severe respiratory difficulties interfering with breastfeeding (e.g. nasal congestion)

Case 2: Children aged 6-59 months identified with MAM 1. Determine signs of medical complication 2. Check for all vaccination status 3. Assess the child’s feeding status 4. Explain to the mother/caretaker the reasons why the child is to be admitted to the MAM management program and how the treatment will be organized 5. Carefully explain the expected outcomes 6. Enter information of the child eligible for admission Case 3:Children identified with SAM 1. Refer to SAM Guidelines

Participant’s Manual 83 Step 3: Intervention and Services Case 1: Infants aged 0 to <6 months identified with MAM (Follow the complete procedure on Annex 11: CMAMI Guidelines) If resources allow, implement CMAMI Priority 2. ✓ Detailed assessment of underlying cause(s) of malnutrition and tailored action to address these ✓ Plot and appraise growth chart for monitoring progress

If program capacity is limited, ✓ No enrolment for the time being ✓ General nutrition/feeding advice ✓ Plot growth char to aid review ✓ Review in 1-2 weeks to check whether has got better or worse

Case 2: Children aged 6-59 months identified with MAM (Refer to Module 3 Session 3: Intervention and Services)

Supplementary Considerations for Ration Duration Food Implementation Ready-to-Use 1 sachet per Approx. 3 It can be consumed Supplementary day months directly from the package Food (RUSF) (90 days) with no dilution, mixing, or cooking necessary. In the absence of RUSF Locally Prepared Can be given 3-6 months Micronutrient Powder Food fortified with 1x or 2x (90-180 days) (MNP) should be added to MNP depending on the prepared food. the prepared food It can be given in between regular meals.

The food shall have an energy content equivalent to a sachet of RUSF.

In areas where infants and children can be gathered in a community, the BNS and the mothers can prepare the supplementary foods such as ginataang bilo-bilo, arroz caldo, squash congee, and fried rice. Fortified Blended 130g/day 3-6 months This food is not Food Ratio (90-180 days) intended to be the only proportion of source of nutrients but 500 kcal should complement the regular diet of the child.

Blended cereals can be given to children as wet feeding or as dry take home rations, where preparation can be done at home.

84 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

Points to remember! 1. This case assumes that TSFP is the mode of intervention implemented in the community. 2. Emphasize that supplementary ration is meant to be an addition to three full meals and two snacks, and NOT A SUBSTITUTE. 3. Emphasize that sharing of ration among family members will lessen the energy and nutrients that are intended for the child.

Step 4: Childcare Case 1: Infants aged 0 to <6 months identified with MAM Refer to 2nd Line Breastfeeding Counselling and Support Actions

Case 2: Children aged 6-59 months identified with MAM Routine Child Health Services 1. Check breastfeeding and feeding of the child. 2. Determine oral or dental health problems that may affect feeding. 3. Check if child has received immunization (e.g. measles and DPT) and supplementation (i.e. Vitamin A, Iron, MNP, etc.).

Step 5: Post Treatment a. Monitoring (Refer to Module 3 Session 4: Monitoring, Follow-up, and Referral) 1. Take the child’s MUAC measurement at each visit and compare with the discharge criteria to determine whether the child is already eligible for discharge or not, and/or take the WFL/H measurement once a month or if height board is readily available at the site. 2. Take weight measurements of the child at each visit and compare with the target weight recorded at the time of admission and with the minimum weight and/or MUAC for transfer to SAM treatment. Refer to OTC or ITC if qualified SAM case. 3. Diagnose whether the child meets any of the criteria for Failure to Respond to Treatment if in case there is no improvement with the child. 4. Check whether the MAM child meets the SAM criteria (WFL/H <-3 Z-score and/or MUAC <11.5cm, or presence of bilateral pitting edema) and if the child has SAM, immediately refer the child to the OTC or ITC (if with medical complications). 5. Check whether the MAM child meets the SAM criteria (WFL/H <-3 Z-score and/or MUAC <11.5cm, or presence of bilateral pitting edema) and if the child has SAM, immediately refer the child to the OTC or ITC (if with medical complications). 6. Check whether the MAM child meets the SAM criteria (WFL/H <-3 Z-score and/or MUAC <11.5cm, or presence of bilateral pitting edema) and if the child has SAM, immediately refer the child to the OTC or ITC (if with medical complications). 7. Provide routine treatment at the appropriate visits. 8. Follow-up on the child’s feeding practices, i.e. complementary feeding with continued breastfeeding. 9. Explain to the caregiver the change in the child’s nutritional status, if any. 10. Give and record ration at each visit on the Ration Card of the child.

Case 1: Failure to respond to treatment When child shows failure to respond to treatment, consider the following:

a. Criteria for failure to respond to treatment • Any weight loss within the 3 consecutive weeks in the program or at the 2nd visit

Participant’s Manual 85 • Either no or trivial weight gain after 5 weeks in the program or at the 3rd visit • Weight loss exceeding 5% of body weight at any time (the same scale must be used) • Failure to reach discharge criteria after 3 months in the program • Abandonment of the program (defaulting)

b. Reasons for failure to respond • Problems with the application of the protocol • Nutritional deficiencies that are not being corrected by SFP-supplied diet • Home/social circumstances of the patient • An underlying physical condition/illness • Other causes

c. Step-by-step approach to address failure to respond (Refer to Figure 23)

d. Management of cases that failed to respond to treatment 1. Improve the child's nutritional intake. Give the child local recipes plus MNP or RUSF (2 bags) with 1000 kcal/day for 15 days.

2. Check the child’s response to treatment on the second visit. Case 1: Responds to treatment This means that it was a nutritional problem and/or issue at home.

If it is solely nutritional problem, continue the treatment, with double quantity of local recipes plus MNP or two sachets of RUSF plus the SFC ration, for another month.

If in addition there is social issue (with preparation of food), address this with encouraging the family to cooperate, or giving counselling with the assistance of social worker or SFC manager.

Case 2: Does not respond to treatment This means that the dominant problem is not a nutritional problem and that there is a need to investigate if it is mainly a social problem (proceed to next step).

3. Conduct home visit to investigate home social circumstances. Case 1: Problem identified can be alleviated or solved Deal with the problem and leave the child at home until further visits and follow-up.

Case 2: Problem identified cannot be alleviated or solved at home Take any necessary step to address the problem, such as: ✓ Admission of the child to a facility; ✓ Putting more resources into the home (e.g. food source, livelihood); ✓ Arrangement for a different caregiver (e.g. relative, foster care, institution); or, ✓ Getting treatment for the caregiver (e.g. psychiatric, HIV, etc.)

Note: It is important to get the professional assistance of social service providers (social workers) or health care providers.

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Case 3: No problem is identified to account for the failure to respond to treatment It is still likely that there is a social problem that has not been identified during the home visit.

WHAT TO DO: Admit the child for a trial feeding for 3 days under supervision. This can be in a daycare center or with “wet feeding” where the child is taken to a health center daily to receive food under supervision.

4. Investigate underlying pathology. Case 1: Child still not responding to treatment Child needs to be sent to a health facility (hospital) where there are clinicians/pediatricians or other physicians that would have expertise or training in evaluating the underlying medical condition.

If this facility does not find the cause, then the child should be referred to a national center/training and teaching hospitals for full investigation of unusual causes.

Case 2: Cause of malnutrition has not been found The child should then perhaps be entered into a registry, have specimens stored and be seen whenever there is a pediatrician, family medicine specialist or physician trained in the management of severe acute malnutrition and in other diseases.

Case 3: Final referral center does not find any cause for the failure of child The child is labelled as idiopathic failure-to-respond and discharged from the program after four months of treatment. b. Discharge (Refer to Module 3 Session 5: Discharge) 1. As soon as the child reaches the criteria for discharge (WFL/H S-2 Z-score and/or MUAC S125 mm) for two consecutive weeks, s/he can be discharged from the program.

Case 1: Defaulter Encourage the family to return to treatment and address the reason for defaulting. If not convinced, inform them of the discharge status.

Case 2: Death Express sympathy to the family.

Case 3: Non-Responder Explain to the caregiver the reason why the child is discharged from the program, and decide what to do next for the child, whether to refer to the hospital or other health professionals.

2. Record the discharge date, WFL/H, MUAC measurements and the Type of Discharge in the Registration Book and in the Ration Card. Make sure that all necessary information is recorded.

3. Check that immunizations are updated, counselling regarding IYCF and care practices are given and caregiver informed that the treatment is over. c. Linkaging (Refer to Module 4 Session 6: Linkaging)

Participant’s Manual 87 Link the caregiver or family of the child to continuing health, nutrition and social services available in the community that the child is eligible for and which supports improvement of nutritional status.

d. Follow-Up Prepare a follow-up scheme of three months after the discharge.

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Annexes

Participant’s Manual 89 Annex 1. Child Feeding Assessments

Assess feeding if child is less than 2 years old has MODERATE ACUTE MALNUTRITION, ANAEMIA, CONFIRMED HIV INFECTION, or is HIV EXPOSED.

Ask questions about the child’s usual feeding and feeding during this illness.

Compare the mother’s answers to the Feeding Recommendations for the child’s age.

ASK – How are you feeding your child? If the child is receiving any breast milk, ASK: ▪ How many times during the day? ▪ Do you also breastfeed during the night? Does the child take any other food or fluids? ▪ What food or fluids? ▪ How many times per day? ▪ What do you use to feed the child?

If MODERATE ACUTE MALNUTRITION or if a child with CONFIRMED HIV INFECTION fails to gain weight or loses weight between monthly measurements, ASK: ▪ How large are servings? ▪ Does the child receive his own serving? ▪ Who feeds the child and how? ▪ What foods are available at home?

During this illness, has the child’s feeding changed? ▪ If yes, how?

Source: DOH, WHO, UNICEF (2015). Integrated Management of Childhood illnesses, Manila. Department of Health.

90 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

Annex 2. Feeding Counseling and Recommendations

Participant’s Manual 91 Annex 3. Computation of Locally Prepared Food (Comparable to RUSF)

Using the Food Exchange List in Meal Planning (DOST-FNRI, Food Exchange List For Meal Planning, 2012), below is the instruction on how to compute for the energy and nutrient content of the locally prepared foods to make it comparable to RUSF.

Table 1. Composition of Food Exchanges List Food Measure CHO PRO Fat ENERGY (g) (g) (g) (kcal) (kj) I.A. Veg. A 1 cup raw - - - - - I.A. Veg. A ½ cup, cooked - - - - - I.B Veg. B 2 cups raw 3 1 - 16 67 II. Fruit 1 cup cooked 3 1 - 16 67 III. Milk Or 10 - - 40 167 IV whole ½ cup, raw 12 8 10 170 711 V Low fat ½ cup cooked 12 8 5 125 523 VI. Skimmed Varies 12 8 tr 80 335 VII. Rice Varies 23 2 - 100 418 Meat 4 tablespoons - 8 1 41 172 Low fat Varies - 8 6 86 360 Med. Fat Varies - 8 10 122 510 High Fat Varies - - 5 45 188 Fat Varies 5 - - 20 84 Sugar Varies 1 teaspoon 1 teaspoon

The steps in calculating the energy and nutrient content of the locally-prepared foods are as follows:

1. Allow 1 exchange of meat of any variety to accommodate the protein content of carbohydrate-rich foods 2. To determine how many fat exchanges are allowed. a. Add the fat furnished the food groups already listed. b. Subtract this sum from the prescribed fat. c. Divide the difference by 5 (g Fat per exchange) 3. To determine the prescribed grams for carbohydrate. a. Add the kcal furnished by the foods already listed. b. Subtract this sum from the prescribed energy (kcal) c. Divide the difference by 4 (1 g of Carbohydrate contains four kcal). d. To determine the no. of rice exchanges. • List all the foods furnishing carbohydrates with the exception of rice, i.e., vegetables, fruit, milk and sugar. • Add CHO from vegetables, fruit and sugar. • Subtract this sum from the prescribes CHO • Divide the difference by 23 (g CHO furnished by one rice exchange). The nearest whole quotient is the number of rice exchange allowed. Four sample calculations are presented below to illustrate the different food items that can be chosen in the preparation of locally prepared foods.

The food items, menus and measurements of food can be altered depending upon the availability and cultural acceptability of the foods. It is important to check that the total calorie and macronutrients (protein, fat, and carbohydrates) are within the recommended range.

92 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

In addition, MNP should be given as prescribed to meet micronutrient adequacy.

SAMPLE COMPUTATION 1: Locally prepared food (comparable to RUSF)

Diet prescription: 500-550 kcal; 12.5 g Protein; 31 g Fat

Food No. of CHO (g) PRO (g) Fat (g) Energy (kcal) Exchanges Meat (medium Fat) 1 - 8 6 86

26 (prescribed Fat) -6 (partial sum of Fat) 20 ÷ 5 = 4 no. of exchanges of Fat

Fat 5 - - 25 225 510 (prescribed energy in kcal) -266 (partial sum of energy from protein and fat) 244 kcal from carbohydrate

244 ÷ 4 = 61 g (prescribed Carbohydrate)

61 ÷ 23 = 3 no. of exchanges of rice

Rice 2 46 4 - 200 TOTAL 46 12 31 511 MENU 1: Arroz Caldo with Egg Main ingredients: Rice gruel, egg, oil

Ingredients:

• 1 egg • 5 tsp oil • 1 cup of rice gruel • Optional: Spring Onions

Participant’s Manual 93

SAMPLE COMPUTATION 2: Locally prepared food (comparable to RUSF)

Diet prescription: 500-550 kcal; 12.5 g Protein; 31 g Fat

Food No. of CHO (g) PRO (g) Fat (g) Energy (kcal) Exchanges Meat (medium Fat) 1 - 8 6 86

26 (prescribed Fat) -6 (partial sum of Fat) 20 ÷ 5 = 4 no. of exchanges of Fat

Fat 5 - - 25 225 510 (prescribed energy in kcal) -266 (partial sum of energy from protein and fat) 244 kcal from carbohydrate

244 ÷ 4 = 61 g (prescribed Carbohydrate)

Vegetable B 2 6 2 - 32 61 (prescribed CHO) -9 (partial sum of CHO) 52 g of carbohydrate 52÷23 = 2 no. of exchanges of Rice Rice 2 46 4 - 200 TOTAL 52 14 31 543 MENU 2: Squash Congee Main ingredients: Squash, rice gruel, egg, oil

Ingredients: • 1 egg • 1 cup squash (boiled) • 5 tsp oil • 1 cup rice gruel

94 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

SAMPLE COMPUTATION 3: Locally prepared food (comparable to RUSF)

Diet prescription: 500-550 kcal; 12.5 g Protein; 31 g Fat

Food No. of CHO (g) PRO (g) Fat (g) Energy (kcal) Exchanges Meat (medium Fat) 1 - 8 6 86

26 (prescribed Fat) -6 (partial sum of Fat) 20 ÷ 5 = 4 no. of exchanges of Fat

Fat 5 - - 25 225 560 (prescribed energy in kcal) -266 (partial sum of energy from protein and fat) 294 kcal from carbohydrate

244 ÷ 4 = 74 g (prescribed Carbohydrate)

Vegetable A 2 3 1 - 16 Vegetable B 1 3 1 - 16 74 (prescribed CHO) -6 (partial sum of CHO) 68 g of carbohydrate 68÷23 = 3 no. of exchanges of Rice Rice 2 46 4 - 200 TOTAL 52 14 31 543 MENU 3: Fried Rice Main ingredients: Rice, egg, chayote, carrots, oil

Ingredients: • 1 egg • 5 tsp oil • 1 cup chayote • ½ cup carrots • 1 cup rice

Participant’s Manual 95 Annex 4. The Food Exchange Lists for Meal Planning (DOST-FNRI Publication No. 57-Nd 8(3) For easiness in the selection of food items in the planning and preparation of the recipe of the locally prepared foods, selected items in the Food Exchange List are shown below.

Table 1. Vegetable Group A Exchange Equivalents (FEL page 22) Vegetable Group A (1 Exchange = 1 cup raw or 1/2 cup cooked) Acelgas (Chinese Cabbage) Katuray leaves (1) Alagaw leaves (1) Lettuce (2) Alugbati leaves (2) Malunggay leaves Ampalaya leaves (2) Malunggay pods Ampalya fruit Mushroom, fresh Baguio beans (abitsuelas) Mustard leaves (2) Balbalulang (seaweed) (1) Okra Bamboo shoot (labong) Onion bulb Banana heart (puso na saging) Papaya green Bataw pods (1) Patola Cabbage Pepper fruit Camote leaves (2) Peppper leaves (2) Cauliflower Petsay (2) Celery Pokpoklo (seaweed) Chayote fruit (2) Radish Chayote leaves Saluyot (1) (2) Cucumber Sigarilyas pods Eggplant Squash flowers (2) Gabi leaves (1) (2) Squash leaves (1) Garlic leaves (1) String beans leaves (sitaw, dahon) (2) Kangkong (2) Sweet pea pods (sitsaro) Katuray flowers (1) Tomato (2) Upo 1 These vegetables are rich sources of fiber 2 These vegetables are rich sources of pro vitamin A

Table 2. Vegetable Group B Exchange Equivalents (FEL page 23) Vegetable Group B (1 Exchange = ½ cup raw or ½ cup cooked) Carrot Coconut shoot (ubod) Cowpea pods (paayap bunga) Kamansi Lima bean, pods (patani, bunga) Mungbean sprout (toge) Pigeon pea pods (kadyos, bunga) Squash fruit String beans pod (sitaw bunga)

Table 3. Fruit Exchange Equivalents (FEL page 25-28) Fruits 1 Exchange Equivalents Apple 1/2 of 8 cm diameter or 1 (6cm diameter) Atis (3) 1 (5 cm diameter) Balimbing (1) 1-1/2 of 9 x 5 cm Banana: Lakatan 1 (9 x 3 cm) Banana: Latundan 1 (9 x 3 cm) Banana: Saba 1 (10 x 4 cm) Cashew 1 (7 x 6-1/2 cm)

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Chico 1 (4 cm diameter) Dalanghita 2 (6 diameter each) Datiles 1 cup Duhat 20 (2cm diameter each) Durian 1 segment of 6-1/2 x 4-1/2 cm Grapes 10 (2 cm diameter each) / 4 (3 cm diameter Guava each) Guyabano 2 (4 cm diameter each) Jackfruit ripe 1 slice (8 x 6 x 2 cm) or 1/2 cup Kamachile 3 segments (6 cm diameter each) Lansones 7 pods Mabolo 7 (4 x 2 cm each) Makopa 2/3 of 6 cm diameter) Mango: Green 3 (4 cm diameter each) Mango: Medium ripe 1 slice (11 x 6 cm) Mango: Ripe 1 slice (11 x 6 cm) Mango Indian 1 slice (12 x 7 cm) or 1/2 cup cubed Mangosteen 1 (6 cm diameter) Marang 3 (6 cm diameter each Melon 1/2 of 12 x 10 cm Papaya ripe 1 slice (12 x 10 x 3 cm) or 1-1/3 cup Pineapple 1 (6 cm diameter) Rambutan 1slice (10 x 6 x 2 cm) or 1/2 cup Santol 8 (3 cm diameter each) Singkamas tuber 1 (7 cm diameter) Siniguelas 1/2 of 9 cm diameter or 1 cup Star apple 5 (3 cm diameter each) Strawberry 1/2 of 6 cm diameter Suha 1-1/4 cups Tamarind 3 segments (8 x 4 x3 cm each) Tiesa 2 of 6 segments each Watermelon 1/4 of 10 cm diameter 1 slice (12 x 6 x 3 cm) or 1 cup

Table 4. Low Fat Meat and FishExchange Equivalents (FEL page 38-41) Low Fat Meat and Fish Exchanges 1 Exchange Equivalents 1. Lean Meat a. Beef: Shank (bias), lean 1 slice, matchbox size (5x3-1/2x1-1/2 cm) meat (laman), Round (pierna corta at pierna larga) b. Carabeef 1 slice, matchbox size (5x3-1/2x1-1/2 cm) Shank (bias), round (hita), meat (laman:bahagya, katamtaman at walang- taba), shoulder (paypay), round (pierna corta at pierna larga), rump (tapadera) c. Lean Pork Tendeloin, well trimmed

d. Chicken: leg (hita) or meat (laman) or breast meat (pitso) 1 slice, matchbox size (6-1/2 x 3 x 1-1/2 cm) 1 small leg (13-1/2cm long x 3cm diameter) 2. Variety Meats / internal organs: 1 slice, matchbox size (5 x 3-1/2 x 1-1/2cm)

Participant’s Manual 97 Blood (dugo)- pork, beef, chicken ¼ breast – 6 cm long Heart (puso)- pork, beef, carabeef Liver (atay)-pork, beef, carabeef, ¾ cup chicken Small intestine (bitukang maliit)- pork, beef, carabeef Spleen(lapay)- pork, beef, carabeef Tripe (goto)-beef

3. Fish: Large Variety (e.g. bakoko, bangus, dalag, labahita, lapu-lapu, etc.)

Medium variety: Hasa-hasa, dalagang bukid Galunggong Hito 1 slice (7x3x2 cm)

Small variety: Sapsap Tilapya Tamban Dilis 1 (18x4-1/2 cm) 4. Other Seafoods: 1 (14x3-1/2 cm) Alamang, tagunton ½ of 22 x 5cm Aligue: Alimango Alimasag Alimango/alimasag, laman Talangka 2 (10x5 cm each) Shrimps: Puti 2 (12x5cm each) Sugpo 2 (12-1/2x3 cm each) Suwahe ¼ cup Squid (pusit) Shells: halaan Kuhol 1-1/4 tablespoons Susong Pilipit 1 tablespoon Paros 3 tablespoons ¼ cup or ½ piece medium 5. Beans: 75 pieces A.P. Pigeon pea seeds, dried 5 (12 cm each) (kudyos, buto, tuyo) 2 (13 cm each) 5 (12 cm each) 3 (7x3 cm each) 1/3 cups shelled or 3 cups with shell 1/3 cup shelled or 2 cups with shell 1/3 cup shelled or 2 cups with shells 1 cup shelled or 2-2/3 cups with shel

1/3 cup

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Table 5. Medium Fat Meat and Fish Exchange Equivalents (FEL page 42-43) Medium Fat Meat and Fish Exchanges 1 Exchange Equivalents 1.Medium Fat Meat 1 slice, matchbox size (5 x 3 – ½ x 1-1/2 cm) Beef: Flank (kabilugan), Brisket (punta y pecho), plate (tadyang), Chuck (paypay) 1 slice (4 cm diameter x 2 cm thick) Pork: Leg (pata) 3/4 cup 2.Variety Meats / internal organs: Brain (utak) –pork, beef, carabeef 1 slice (15 x 7 x 2 cm) 3. Fish: Karpa

4. Egg: 1 pc Chicken 9 pcs Quail’s egg 1 pc Salted duck’s egg

5. Chicken 1 medium or 2 small Wings (pakpak) 2 heads Head (ulo) 1/2 cup 6. Beans: Soybean (utaw) 1/2 cup Soybean cheese, soft (tofu) 1 (6 x 6 x 2 cm) Soybean cheese, hard (tokwa)

Table 6. High Fat Meat and Fish Exchange Equivalents (FEL page 4)

High Fat Meat and Fish Exchanges 1 Exchange Equivalents 1. Pork Ham (pigue) 1 slice (3cm cube)

2. Variety Meats / internal organs: Tongue (dila) – beef 1 slice, matchbox size (3 cm cube)

3. Egg: Duck’s egg 1 piece Balut 1 piece Penoy 1 piece

4. Nuts Peanuts, roasted 1/3 cup

Table 7. Fat Exchange Equivalents(FEL page 45-46) Fat 1 Exchange Equivalents Saturated Fats: Butter 1 tsp Coconut, grated 2 tbsps Coconut, cream 1 tbsp Coconut oil 1 tsp Latik 2 tsps Margarine 1 tsp Mayonaise 1 tsp Sandwhich spread 1 tbsp

Participant’s Manual 99 Polyunsaturated Fats: Oil (corn, marine, soybean) 1 tsp

Monounsaturated Fats: Avocado 1/2 of 12 x 7 cm Peanut Butter 2 tsps Pili nut 5 pcs Peanut oil 1 tsp Shortening 1 tsp

Table 8. Rice Exchange Equivalents (FEL page 31-35) Rice Exchanges 1 Exchange Equivalents A. Rice and rice products 1. Rice cooked ½ cup, packed 2. Rice gruel (lugaw) ** thin consistency 4-1/2 cups ***medium consistency 3 cups ****thick consistency 1-1/2 cups

3. Rice Products Native kakanin: 3(9x3-1/2x2 cm each) Ampaw: Pinipig 1 (9x3-1/2x2 cm) Rice 1 slice (1/2 of 15 cm diameter, 2 cm thick) Bibingka: Galapong 1 slice (6x3x3cm) Malagkit 1 slice (10x5x1 cm) Biko ½ of 15x3x2 cm Cassava cake 2(11x2-1/2x1-1/2 cm each) Espasol 1 (4x6x2cm) Kalamay: Latik 1 slice (7x3x1-1/2 cm) Ube 1 (6 cm diameter x 2-1/2 cm) Kutsinta 4 (7-1/2x4x0.3 cm each) Palitaw, walang niyog 2(11x2x1 cm each) Puto: Bumbong 3 (4x3cm each) Pula 1 slice (9-1/2x3x3-1/2cm) or 1-1/2 round of 5 Puti cm diameter x 3 cm thick Seko, bilog 3(3-1/2 cm diameter1-1/2 cm thick each) Seko, haba,May niyoga 5(5 cm longx2 cm diameter each) Sapin-sapin 1 slice (5x3x4 cm) Suman: Ibos 1 (8x4x2 cm) Kamoteng kahoy ½ of 15x3x2cm Lihiyaa 1 (8x4x2 cm) Marwekosa 2(9x3x2cm each) Tamales 2(7x6 cm each) Tikoy 1 slice (10x3x1-1/2 cm) Tupig ½ of 14x3x1 cm

B. Rice Equivalents 1. Bread Pan amerikano 2(9x8x1cm each) Pan de bonetea 1(6 cm diameter basex7 cm thick) Pan de leche 1(3x8x8cm) Pan de limon 1(6x5x4 cm) Pan de monay 1(10x9x4cm) Pan de sal 3(5x5cm each) Rolls (hotdog/hamburger) 1 (11x4x3cm) Whole wheat bread a 2(11-1/2 x 8-1/2x1 cm each)

100 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

2. Bakery Products Cookies: Galyetas de patatas 10(4x4x1/2 cm diameter each) Pasensiya 22(3 cm diameter each) Masapudrida 1(7x1cm) Marie 22(4-1/2 cm diameter x0.3 cm thick each) Lady fingers 5(9x4 cm each)

Others Apas 6(1-1/2x12 cm each) Mamon tostado 3(8x3x3 cm each)

Hopia 1-1/2 of 3x2-1/2x2-1/2 cm diced or ½ of 7 cm diameterx1-1/2cm thick round Ensaymada 1(8-1/2 cm diameter x 2 cm thick)

3. Corn and Corn products Binatoga ½ cup Corn, boiled 1(12x4cm) Maha, mais 1 slice (5x4x2cm)

4. Noodles, cooked: Bihon, macaroni, a 1 cup Sotanghon, spaghetti

5. Rootcrops Sweet potato ½ of 11 cm long x 4-/2 cm diameter or ½ cup Cassavaa 1 (5cm longx4-1/2 cm diameter each) or 1 cup 2(6cm long x 4 cm diameter each) or 1 cup

Gabi 2-1/2 of 7 cm long x 4 cm diameter each or 1-

Potato 1/3 cup

Ubia 1(8-1/2 cm long x 4-1/2 cm diameter) or 1-1/3 Cup

6. Others Sago cooked ½ cup cooked ** ½ cup cooked rice + 5 cups of water *** ½ cup of cooked rice + 3 cups of water *** ½ cup cooked rice + 2 cups water aThese foods are good sources of fiber

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102 Annex 5. Registration forBook MAM

Seri Reg First Last Addre Type of Sex Date Age Admissi Five YearsFive Training Module theon National Guidelines on the Management of Moderate Acute Malnutrition for Children under al . Name Name s s Admission (F/M) of (mont on No. No and (New, Birth h) Date Weigh Length/ WFL/ Dischar MUA Discharg Ratio (mm/dd/y t H H ge C e n . Phon Relapse, (mm/d e Re- d/ yy) y) (kg) eight (z- Target (mm) Target Nam admission (cm) scor (WFL/ MUAC e , e) H (mm) (kg/g Referra z- ) l) score) 1 2 3 4

5 Children 6 7 8

9 10 11 12 13 14 15 16 17 18 19 20

Vitamin A A lbendazo l Others Visit 1 Visit 2 Visit 3 Visit 4 Visit 5 Visit 6 Serial No. Rat ion Rat ion Rat ion Rat ion Rat ion Rat ion Dat e Dat e Dat e Dat e Dat e Dat e Dat e Dat e Dat e Dosage Dosage Dosage Wt . (kg/ g) MUAC (mm) Name/total Wt . (kg/ g) MUAC (mm) Name/total Wt . (kg/ g) MUAC (mm) Name/total Wt . (kg/ g) MUAC (mm) Name/ t ot al Wt . (kg/ g) MUAC (mm) Name/ t ot al Wt . (kg/ g) MUAC (mm) Name/ t ot al (mm/ dd/ yy) (mm/ dd/ yy) (mm/ dd/ yy) (mm/ dd) (mm/ dd) (mm/ dd) (mm/ dd) (mm/ dd) (mm/ dd) (kg.g) (kg.g) (kg.g) (kg.g) (kg.g) (kg.g)

1

2

3

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5

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8

9

10

Visit 7 Visit 8 Visit 9 Visit 10 Discharge

Type of Discharge (Cure. Serial No. Rat ion Rat ion Rat ion Rat ion Rat ion Dat e Dat e Dat e Dat e Dat e Dead, Def ault er, Non- Wt . (kg/ g) MUAC (mm) Name/total Wt . (kg/ g) MUAC (mm) Name/total Wt . (kg/ g) MUAC (mm) Name/total Wt . (kg/ g) MUAC (mm) Name/total Wt . (kg/ g) MUAC (mm) Name/total (mm/ dd) (mm/ dd) (mm/ dd) (mm/ dd) (mm/ dd) responder, Ref erred t o (kg.g) (kg.g) (kg.g) (kg.g) (kg.g) ot her SFC/ ITC/ OTC) Observation

1

2

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Annex 6. Supplementary Feeding Program Commodities

Ready-to-Use (RUSF) and Milled Form Supplementary Food

Product purpose?

• RUSF is a lipid-based nutrient supplement used to treat MAM in children. It is fortified with micronutrients and contains essential fatty acids and quality protein to ensure a child’s nutritional needs are met.

Product type?

• RUSF is generally made of peanuts, sugar, milk powder, vegetable oils, and vitamins and minerals, though it may be made with chickpeas, almond or other commodities. It is a fortified, energy-dense, lipid-based supplementary food that comes in individual packages. It is consumed directly from the package with no dilution, mixing or cooking necessary.

When and where is it used?

• RUSF is at the beginning of intervention for the treatment of MAM and is mostly used in emergency operations before. It is used in addition to breastfeeding and complementary feeding for infant and supplementary feeding for young children (6-59 months) who are at high risk of developing malnutrition due to severe food insecurity.

How is it used?

• There are three brands currently available: Plumpy Sup (Nutriset), eeZeeRUSF (Compact) and Acha Mum (WFP Pakistan) that come in one-day sachets for approximately 3 months. It can be eaten directly from its container and is designed to be eaten in small quantities, as a supplement to the regular diet.

Specifications per 100g of RUSF (according to Codex Alimentarius)

• Energy: 513 – 550Kcal • Protein: 12.6 g – 15.4 g • Fat: 30.3 g – 38.6 g

104 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

Table 1. LNS-MAM micronutrient rate

Table 2. Limit of Microorganisms in LNS-MAM4

Source: WFP Technical Specification for LNS-MAM, Specification reference: LNS category. Version V1.1Date of Issue: 20 August 2012

Participant’s Manual 105 Table 3. Specialized Nutritious Foods for treating MAM

Objective Treatment of MAM Ready-to-Use Supplementary Generic Term Fortified Blended Food (FBF) Food (RUSF) High quantity* Products* Plumpy’Sup, EezeeRUSF, Acha Mum (Supercereal/oil/sugar)

Target Group 6-59 months 6-59 months Others: PLW, HIV+ adults Others: PLW, HIV+ adults Energy & 500 kcal 787kcal nutrient/ ration 12.5 g protein 33 g protein or dose 31 g fat 20 g fat Daily Sachet = 92g 200 g (250 kg/bag) ration/child 250 g (provision for sharing)

Shelf life 24 months SC: 12 months Ration or dose One sachet/day 200g/day 92g/day (75kcal/kg/day) Approximate 3 months (90 days) 3-6 months (90-180 days) duration of Intervention Cost/dose/day $ 0.29 = ® 13.63 SC: $ 0.11 – $ 0.16 = ® 5.17 – ® 7.52 *Quantity is referring to kcals in most cases (GNC MAM Task Force, 2014)

Micronutrient Powder Vita Mix and is the brand name of MNP distributed by the DOH as per Department Order 2011-0303 for children 6–23 months of age. A total of 60-sachet of MNP is supplied per child for a duration of 6 months, for a total of 120 sachets in a year. Every other day, it is mixed with locally prepared food before feeding the child.

Composition:

Vitamin A (Retinol) – 400 g RE Vitamin C – 30.0 mg Vitamin B12 -0.9 g Folic Acid – 150.0g Vitamin D – 5.0 g Vitamin E – 5.0 mg Vitamin B1 – 0.5 mg Vitamin B2 – 0.5 mg Niacin – 6.0 mg Iron – 10.0 mg Zinc – 4.1 mg Copper – 0.56 mg Selenium – 17.0 Iodine – 90.0 g Pyridoxine (B6) – 0.5 mg

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Annex 7. Individual Ration Cards

SFP RATION CARD SFP Registration / / Name of Child Number Caregiver's Age (months) Name Distribution Site Sex (M/F) Date of Address Admission

Relapse Referred Readmission New After from after Admission Admission being other defaulting Category cured SFP site

ADMISSION DISCHARGE DISCHARGE DATA DATA STATUS Weight (kg) Weight (kg) 1. Cured Length/Height Length/Height 2. Died (cm) (cm) 3. Defaulted WFL/H (Z- WFL/H (Z- 4. Non- score) score) recovered MUAC (mm) MUAC (mm) 5. Referred to Length of stay other (days) SFP/ITC/OTC

Drugs Given Once Date Remarks Vitamin A Deworming Measles Vaccination EPI Update

Date Weight Length/Height MUAC WFL/H Remarks

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108 Annex MAM8. Child Card

Five YearsFive Training Module theon National Guidelines on the Management of Moderate Acute

Target Weight (W): MAM W: Target MUAC: Discharge Date (mm/dd/yy)

Admission Date Visit ate (mm/dd/y Weight (kg.g) MUAC (mm) Ration Observation (mm/dd/yy) Tick the right answer:

Admission Type Admission

SFC Name 2 Cured

Location 3

Referred from 4 Dead

5 cause

First Name 6 IPF Other

Last Name 7 Defaulter

Address 8 cause

9

SFC Registration No. 10 Non-responder

11 cause

Date of Birth Transfer/Referred Age (in months) to another

Sex (M/F) SFC/ITC/OTC cause

Date Dosage Remarks Malnutrition for Children under Vitamin A Albendazole Other

Annex 9. Monthly Center Tally Sheet

CATEGORY 6-59 months TOTAL

Total at end last month (A)

New Admissions (B) (WFL/H -3 and <-2 Z-scores or MUAC >= 115mm and <125mm)

Other criteria (C) Relapse, Readmission, Referral

Total New Admission (D)

Re-admissions (E )

Total Admission (F) = D + E

Discharged in this Period Targets as Percent of Exits For 6-59 months

Cured (G) Recovered > 75% G/K * 100 =

Deaths (H) Deaths < 3% H/K * 100 =

Defaulters (I) Defaulters <15% I/K* 100 =

Non-responder (J) Non-responders J/K* 100 =

Referred to other SFC or ITC/OTC (K)

Total Exits (L) = G + H + I + J + K

New Total at month end (M) = (A + F) - L

Participant’s Manual 109

110 MAM Annex Report 10. Monthly Treatment

Five YearsFive Training Module theon National Guidelines on the SFP - MONTHLY STATISTICS REPORT - MANAGEMENT OF MODERATE ACUTE MALNUTRITION

SFP CODE IMPLEMENTING PARTNER

NAME OF THE FACILITY REPORT PREPARED BY:

TYPE OF FACILITY REPORT PERIOD from (dd/mm/yy) to National MOH Logo here REGION (dd/mm/yy)

DISTRICT DATE OF SUBMISSIONS

OPENING DATE

NEW ADMISSION Discharge (WFL/H -3 to <-2 Z- Relapse (after READMISSION (after REFERRAL (from other RERRAL TO T otal Exits Total Admissions Total Beginning score or MUAC being cured) default of <2 months) SFC) NON- OTHER SFC or (Discharge Total End of Age Group of the Month >=115mm & <125mm) CURED DEAD DEFAULTER RESPONDER ITC/OTC and Referral) Month

Management of Moderate Acute Malnutrition for Children under 6-59 months Total

% % % % % Error of admission specific type & month

Products Begin Month IN OUT Losses End Month Annex 11. C-MAMI Assessment for Nutritional Vulnerability in Infants

aged <6 months.

MAMI Assessment for Nutritional Vulnerability in Infants aged <6 months (Infant) Vulnerability <6 months Nutritional for aged Assessment MAMI in Infants

- I. I. C

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MAMI Assessment for Nutritional Vulnerability in Infants aged <6 months (Infant) Vulnerability <6 months Nutritional for aged Assessment MAMI in Infants

- I. I. C

112 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

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Assessment for Nutritional Vulnerability in Infants aged <6 months (Mother) <6 aged Vulnerability Nutritional months for in Infants Assessment

MAMI MAMI

- II. II. C

114 Training Module on the National Guidelines on the Management of Moderate Acute Malnutrition for Children under Five Years

II. C-MAMI Assessment for Nutritional Vulnerability in Infants aged <6 months (Mother)

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116 2nd Line Breastfeeding Counselling and Support Actions

Symptoms/Signs of Good Image Practice: Counselling and Support Actions Good Practice Five YearsFive Training Module theon National Guidelines on the Management of Moderate Acute Malnutrition for Children under Yes or No 2.1 Breastmilk expression, cup feeding and storage of breastmilk

Obse e b eas feeding: f infa t not able ttach Ask the mother mmedi e y, demonstr Wash her hands thoroughly reastmilk xp ession, cup ake herself f rtab feeding and s rage of Hold a wide necked clean tainer under her nipple and a eola. reastmilk timu e breast with lig s ing or ge tle c rcular motion around whole b s

re opposi e each other ( t least 4 cm f om the tip of the nipple).

epe t the a tion: press b he t a , pr d ho d get nd r e N : ot h r

A rn e be een breasts 5 or 6 time f t least 20 o 30 min ee video: http://globalhealthmedia.org/portfolio-items/expressing-and-storing-breastmilk/?portfolioID =10861

Cup eeding A eadiness for cup feeding: est the cup against the infant's lip , with milk ouching infant's op lip ait and ch for inf nt p ns f no p ns , t y at ne feed f no p nse f er 2-3 trial , then efer facili y whe nf nt an be 'supp ed' o suckl

Ask the mother or car r ut a cloth on the infa t's fr o pr t his clothes as some milk can spil Hold the infa t uprig t or semi-uprig t on the la t a meas red amou t of milk in the cup or pour only amoun o be used t one feeding i o the cu Hold the cup resting on the l er lip and tip the cup so th t the milk ouches the infan s upper li Wait for the infa o d aw in or suc e in the milk A w the infan o take the milk himse f DO NOT pour the milk in o the infant's mouth C er should pause and let infa r st f r y f e Ca i r d pay a tion nf n , ook nf y sa be ponsi nf u f r f notr se y milk the infa t does not d nk for another feedin

Storage of breastmilk Ask the mother to: Use a clean and covered glass or plastic container. Store only enough for one feeding in each container. Each container should be labelled with date and time. Store breastmilk in the coolest possible place; breastmilk can be left at room temperature (<26”C, in the shade) for 6to 8 hours. Store in refrigerator at back of lowest shelf for 5 days (if milk remains consistently cold). Store frozen for 2 weeks. Use oldest milk first. To warm the milk, put the container of milk in a bowl of warm water; don’t heat on the stove. Use a cup to feed the infant expressed breastmilk.

How is 6reortfeezfrnggo7ng7 Occurs on both breasts Keep mother and infant together after birth. Swelling A. Breast Engorgement Put infant skin-to-skin with mother. Hard Improve attachment. Tenderness Reposition infant. Warmth Slight redness Breastfeed more frequently on demand (as often and as long as infant wants) day and night: 8 to 12 Pain times per 24 hours. Skin shiny, tight and nipple Gently stroke breasts to help stimulate milk flow. Manual s Participant’ flattened and diGcult to Press around areola to reduce swelling, to help infant to attach. attach Offer both breasts. Can often occur on 3rd to Express milk to relieve pressure until infant can suckle. Sth day after birth (when milk production increases Apply cold compresses to breasts to reduce swelling. dramatically and suckling Apply warm compresses to help the milk flow before breastfeeding or expressing. not established) Note: on the first day or two infant may only feed 2 to 3 times. See video:

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Observe nipple appearance Flat, inverted, large or long nipples are managed using the same techniques: nipples Listen to the mother’s concerns. Inverted Nipple Give extra help with attachment; make certain that as the mother is putting the infant on her breast she: • gently touches the infant’s lips to encourage him/her to open widely and take a big mouthful of breast aims the infant’s lower lip well below her nipple, so that the nipple goes to the top of the infant‘s mouth and the infant’s chin touches her breast (see additional information under’Good Attachment’) for long nipples, place infant in a semi-sitting position to breastfeed Encourage mother to give the infant plenty of skin-to-skin contact near the breast, with frequent opportunities to find his or her own way of taking the breast into his/her mouth (mother should not force infant to take the breast, or force infant’s mouth open). Encourage mother to try different breastfeeding positions (e.g., lying down, holding infant in underarm position, or lying or leaning forward so that her breast falls towards the infant’s mouth. Teach mother to express her milk at least 8 times a day and to feed the expressed milk to the infant with a cup (see’Breastmilk Expression, Cup Feeding, and storage of breastmilk’). Avoid bottles and pacifiers which encourage the infant to suck with his/her mouth partly closed and lips pushed forward. Keep on trying. Most babies want to suckle and they will find out how to open their mouths wide enough to take the nipple eventually. It may take a week or two. For an inverted nipple: If it is possible to get a 20 ml plastic syringe, it can be used to pull out an inverted nipples in the following way: Cut off the adaptor end, and put the plunger in backwards. Put the smooth (uncut) end of the syringe over the nipple, and draw out the plunger. This will stretch out the nipple.

Manual s Participant’ Do this for half a minute to make the nipple stand out just before each breastfeed.

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Real“Not enough” breastmilk Look for bonding or rejection. production Look for illness or physical abnormality in the mother or infant. • Infant is still passing meconium, Explain to mother that she and infant will be seen daily until infant begins gaining weight, and it may on Day4(after birth) • Less than 6“wets”or urine/day take 3-7 days for the infant to gain weight. • For infants after day 4 up to 6 Explore possible reasons that mother may be producing smaller amounts of breastmilk (poor weeks: at least6 wets and 3 attachment, breastfeeding pattern, mother‘s mental condition, infant or mother ill). to4 stools/day • After 6 weeks of age some Build mother‘s confidence — reassure her that she can produce enough milk. breastfed babies have fewer Explain what the diGculty may be — growth spurts (around 3 weeks, 6 weeks, 3 months) or cluster feeds. stools which is not a cause for Explain:’The more an infant suckles and removes milk from the breast, the more milk the mother concern if they are gaining produces’; (many caregivers, and even health professionals think instead that breastmiIk“suppIy"comes weight • Infant is not taking good deep first; explain also that breast size does not matter to milk production). suckles followed by a visible or Assess and improve attachment and breastfeeding pattern: audible swallow • Infant not satisfied after Feed infant frequently (8-12 times per day), on demand, day and night. breastfeeding Let infant come off the first breast by him/herself before mother offers the 2nd breast. • Infant cries often Ask mother to compress the breast while infant is suckling to improve the flow of milk. • Very frequent and long breastfeeds Stop any supplements: infant should receive no other foods or fluid. • Infant refuses to breastfeed Avoid separation, and keep mother and infant skin-to-skin as much as possible. • Infant has hard, dry, or green Ensure mother gets enough to eat and drink. stools Average weight gain should be 10-16 g/kg/day, with smaller babies gaining weight more rapidly. • Infant has infrequent small stools If no improvement in weight gain after 7 days, refer mother and infant for supplementary suckling. • Infant is not gaining weight: See video: trend line on growth chart for atcpn’s Participant’ infant less than 6 months is flat or slopes downward - less than 500 gm/month

Mother thinks she has“not Listen to mother‘s concerns and why she thinks she does not have enough milk.

Manual enough” breastmilk Check infant’s weight and urine and stool output (if poor weight gain, refer). production Apply same counselling/actions as for real”not enough” breastmilk (above). • Mother thinks she does not

have enough milk • (Infant restless or unsatisfied) 121 First decide if the infant is getting enough breastmilk or not (weight, urine and stool output)

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Low weight for height For ALL breastfeeding mothers with low weight infants: Low weight for age If not well attached or not suckling effectively, demonstrate and assist mother to correctly position and attach infant (specify cross-arm/cross-cradle hold), and identify signs of effective suckling. Low weight infants fatigue easily and may fall asleep/shut down after few minutes; try again after a break.

If not able to attach well immediately, demonstrate breastmilk expression and feeding by a cup. If attached but not suckling, hand-express drops of milk into infant’s mouth to stimulate suckling. If breastfeeding less than 8 times in 24 hours, counsel to increase frequency of breastfeeding.

Counsel the mother to breastfeed as often and as long as the infant wants, day and night. Cross-arm/cross-cradle Counsel mother to wait until the infant releases one breast before switching to the other breast. Counsel mother on establishing exclusive breastfeeding:

• If infant is receiving other foods or drinks, counsel the mother about breastfeeding more, reducing

other foods or drinks, and using a cup rather than a bottle if infant has been bottle fed, Help mother to increase her breastmilk supply; see”Not enough” breastmilk. Mother may need to spend more time feeding, perhaps at times with a cup using only expressed

breastmilk. Mother may need to share some of her other household duties with others for a month or two. For the mother who has breastfed in the past and is interested in re-establishing breastfeeding: see

Under-arm Relactation. Counsel mother on how to keep the low weight infant warm at home; demonstrate KMC to mother Refer to Keeping the Low Weight Infant Warm at Home. Show mother how to provide stimulation and play to make her infant more alert. Weigh each infant weekly until weight gain is established (at least 125 g/week, 500 g/month) and

Manual s Participant’ appetite improves. Give mother frequent reassurance, praise and help, to build her confidence.

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B. Mother lacks confidence to Mother thinks she may be Listen to mother‘s concerns. breastfeed unable to breastfeed the Assess mother for any problem she thinks she may have; if appropriate, help mother address the issue. infant Encourage her to enjoy skin-to-skin contact and to play with her infant face-to-face. Build her confidence: Recognize and praise what she is doing right — including signs of milk flow. Give relevant information in an encouraging way and correct misconceptions. Provide mother with hands-on help to attach infant to breast and get breastfeeding established. Help her to breastfeed near trusted companions, which helps relaxation.

C. Mother expresses concerns Mother thinks her diet affects Listen to mother‘s concerns about her diet and her ability to breastfeed. about her diet her ability to produce enough Remind mother that breastmilk production is not affected by her diet: good quality breastmilk No one special food or diet is required to provide adequate quantity or quality of breastmilk. And no foods are forbidden (but mother should limit alcohol and avoid smoking). Encourage mother to eat more food to maintain her own health: Eat two extra small meals or’snacks’each day. ° Continue eating a variety of foods. In some communities, certain drinks are said to heIp‘make milk‘; these drinks usually have a relaxing effect on the mother and can be taken (but are not necessary).

D. Mother expresses concerns Listen to mother‘s concerns. about working or being away Explain to mother: if she must be separated from her infant, she can express her breastmilk and leave it from her infant and her ability her ability to feed her infant to be fed to her infant while she is absent. to breastfeed her inland exclusively on breastmilk Help mother to express her breastmilk and store it safely to feed the infant while she is away (see’Breast milk expression, cup feeding and storage of breastmilk‘). atcpn’s Participant’ Show mother how to store and safely feed expressed breastmilk from a cup. Breastmilk can be stored at room temperature (<26°C, in the shade) for 6 to 8 hours. Mother needs to carefully explain to caregiver how to store and safely feed expressed breastmilk from a cup. Caregiver should pay attention to infant, look into infant‘s eyes and be responsive to infant’s cues for

feeding.

Manual Mother should allow infant to feed frequently at night and whenever she is at home. Mother who is able to keep her infant with her at the work site or go home to feed the infant should be encouraged to do so and to feed her infant frequently.

125 Reassure mother that any amount of breastmilk will contribute to the infant‘s health and development, even if she cannot practice exclusive breastfeeding.

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Kangaroo Mother Care Low weight for height Keep the young infant in the same bed with the mother. Low weight for age Keep the room warm (at least 25°C) with home heating device and make sure there is no draught of cold air. Close windows at night. Avoid bathing the low weight infant. When washing or bathing, do it in a very warm room with warm water, dry immediately and thoroughly after bathing and clothe the young infant immediately. Change clothes (e.g. nappies) whenever they are wet. Provide skin to skin contact as much as possible, day and night. For skin to skin contact, demonstrate Kangaroo Mother Care: • Dress the infant in a warm shirt open at the front, a nappy, hat and socks. • Place the infant in skin to skin contact on the mother’s chest between her breasts. Keep the infant's head turned to one side. • Cover the infant with mother's clothes (and an additional warm blanket in cold weather). When not in skin to skin contact, keep the young infant clothed or covered as much as possible at all times. Dress the young infant with extra clothing including hat and socks, loosely wrap the young infant in a soft dry cloth and cover with a blanket. Check frequently if the hands and feet are warm. If cold, re-warm the infant using skin to skin contact. Breastfeed the infant frequently (or give expressed breastmilk by cup). Give a hot drink to the adult providing Kangaroo Mother Care for relaxation and production of more body heat.

Manual s Participant’

Definition of Terms

Acute Malnutrition • a form of undernutrition that generally results from recent rapid loss of weight or a failure to gain weight due to illness, reduce food intake, inappropriate childcare practices or combinations of these.

Anthropometry • study and technique of human body measurement, which are used to monitor the nutritional status of an individual or a population

Blanket Supplementary Feeding Program (BSFP) • an intervention wherein there is provision of supplementary ration to the general population of an identified vulnerable group (e.g. children under five in general, elderly persons, or women of childbearing age) for a defined period in order to impede the decline in nutritional status within this population • usually implemented during an emergency where there is lack of food supplies • Objectives: o To prevent further deterioration in the nutritional status of at-risk groups in a population; and o To reduce prevalence of MAM in children under five, thereby reducing the mortality and morbidity risks.

Community assessment • aims to understand the existing capacities in health, nutrition, and community awareness of malnutrition at local level • includes a series of interviews and focus group discussions conducted with key community informants

Community mobilization • includes activities to sensitize the community to the program, screening children in the community to find cases needing treatment, and community-based activities that support keeping the child in treatment until s/he is cured

Community sensitization • aims to make the local community aware of MAM and understand the condition, its possible treatment and effects

Cure Recovery Rate • number of children 6 to 59-month old with MAM who have recovered and are discharged as cured in proportion with that of the total number of discharged MAM cases

Default Rate • proportion of children 6 to 59-month old with MAM who are recorded as defaulters out of the total number of discharged MAM cases. Defaulters are admitted MAM cases who are absent for three (3) consecutive sessions, thus discharged

Death Rate • proportion of children 6 to 59-month old with MAM who died while in treatment out of the total number of discharged MAM cases

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Edema

• occurs when an unusually large amount of fluid gathers in the child’s tissues, which then become filled with the fluid and look swollen or puffed up

Malnutrition • a form of physiological impairment related to the body’s use of nutrients • results to undernutrition or overnutrition

Mid Upper Arm Circumference (MUAC)

• a measure of muscle wasting and has been shown to have the highest correlation with risk of mortality of any anthropometric indicator • children with MUAC measurements lower than the cut-off values are in danger of dying and need immediate care

Moderate Acute Malnutrition (MAM) • also called Moderate Wasting • classification of acute malnutrition defined by low weight-for-length/height (WFL/H) between negative 3 (-3) and less than negative 2 (< -2 Z-scores) of the standard deviation of the WHO child growth standards, just below the normal range, and without edema • also identified by low Mid-Upper Arm Circumference (MUAC) measurement of S115mm and <125mm (S 11.5cm and <12.5cm)

Non-Responder Rate • proportion of children 6 to 59-month old with MAM who are considered non- responders out of total discharged MAM cases o Non-responders are those who have been referred for medical investigation and are not reaching the discharge criteria after 4 months of treatment. o A child without recovery or relapse; a child who does not fulfill any criteria for recovery or deterioration

Targeted Supplementary Feeding Program (TSFP) • an intervention wherein a supplementary ration is provided to specific members of a vulnerable group whose requirements may not be met by the general ration (e.g. moderately acute malnourished children under five, or pregnant and lactating women) • Objectives: o To rehabilitate MAM cases; o To prevent cases of MAM from aggravating and developing to SAM; and o To reduce of mortality and morbidity risks in children under five.

Weight-for-Length/Height (WFL/H)

• shows how a child’s weight compares to the weight of a child of the same length/height and sex in the World Health Organization (WHO) standards • describes current nutritional status • A child who is below minus two standard deviations (-2 SD) from the reference median for weight-for-length/height is considered to be too thin for his/her length/height or is wasted.

Participant’s Manual 129

Figure 10. Flowchart for Targeted Supplementary Feeding Program (TSFP), Outpatient Therapeutic Care, and Inpatient Therapeutic Care

Table 3. MUAC Classification/Interpretation Classification SAM MAM Normal MUAC <11.5 cm 11.5 to <12.5 cm >12.5 cm Color RED YELLOW GREEN

Undernutrition • defined as a lack of nutrients caused by inadequate dietary intake and/or disease • There are different types of undernutrition such as micronutrient deficiency, underweight, stunting (chronic malnutrition), and wasting (acute malnutrition).

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References

Annan, R. A., Webb, P., & Brown, R. (2014, September). Management of Moderate Acute Malnutrition: Current Knowledge and Practice. Retrieved April 5, 2016, from www.cmamforum.org Bhutta, Z. A., Das, J. K., Rizvi, A., Gaffey, M. F., Walker, N., Horton, S. Black, R. E. (2013). Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? The Lancet, 382(9890), 452-477. Black, R. E., Allen, L. H., Bhutta, Z. A., Caulfield, L. E., de Onis, M., Ezzati, M., Rivera, J. (2008). Maternal and child undernutrition: global and regional exposures and health consequences. The Lancet, 371(9608), 243-260. Black, R. E., Walker, S. P., Victoria, C. G., Bhutta, Z. A., Christian, P., de Onis, M., Uauy, R. (2013). Maternal and child undernutrition and overweight in low-income and middle-income countries. The Lancet, 382(9890), 427-451. Dent, N., & Holland, D. (2011). Module 12: Management of moderate acute malnutrition. The Harmonized Training Package: Resource Material for Training on Nutrition in Emergencies, Version 2. Nutrition Works, Emergency Nutrition Network, Global Nutrition Cluster. DepEd. (2014). Implementation of the Department of Education (DepEd) and Department of Social Welfare and Development (DSWD) Funded School-Based Feeding Program (SBFP) for School Year (SY) 2014-2015. DepEd Order No. 37. s. 2014. Manila. DG ECHO. (2013). DG ECHO Thematic Policy Document No. 4 Nutrition: Addressing Nutrition in Emergencies. European Commission. DOH. (2014). DOH Strategic Framework for Comprehensive Nutrition Implementation Plan 2014-2025. Manila: Department of Health. DOH. (2015, December). National Guidelines on the Management of Acute Malnutrition for children under 5. Administrative Order No. 2015-0055. Manila. DOH, WHO, UNICEF. (2015). Integrated Management of Childhood Illnesses. Manila: Department of Health-World Health Organization. DOH-HEMS. (2011). Surveillance in Post Extreme Emergencies and Disasters (SPEED) Operations Manual for Managers. Health Emergency Management Staff, Department of Health. Manila: DOH. DOST-FNRI. (2015). Philippine Nutrition Facts and Figures 2013: 8th NNS Anthropometric Survey. Food and Nutrition Research Institute, Department of Science and Technology. Taguig City: DOST-FNRI. DOST-FNRI. (2016). 2016 National Nutrition Summit. Manila: Food and Nutrition Research Institute. fantaproject.org. (2008). Training guide for community-based management of acute malnutrition (CMAM): Guide for Trainers. Washington DC: Food and Nutrition Technical Assistance (FANTA) Project. Global Nutrition Cluster. (2008). A toolkit for addressing nutrition in emergency situations. New York: IASC Global Nutrition Cluster, UNICEF. GNC. (2014). Moderate Acute Malnutrition: A Decision Tool for Emergencies. Global Nutrition Cluster. GNC MAM Task Force. (2014). Moderate Acute Malnutrition: A decision tool for emergencies. Global Nutrition Cluster. Golden, M., & Grellety, Y. (2008, October). Failure to respond to treatment in supplementary feeding programmes (Field Exchange 34). Retrieved from Field Exchange: http://www.ennonline.net/fex/34/failure Golden, M., & Grellety, Y. (2011). Protocol: Integrated Management of Moderate Acute Malnutrition. Golden, M., & Grellety, Y. (2012). Protocol: Integrated Management of Acute Malnutrition. HFTAG. (2016, April 26). Frequently Asked Questions. Retrieved from Home Fortification Technical Advisory Group (HFTAG): http://www.hftag.org/faq-page/

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