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Training Module Participant's Manual 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 Participant’s Manual 5 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 Participant’s Manual 7 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
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