REPUBLIC OF RWANDA MINISTRY OF HEALTH PROTOCOL FOR THE MANAGEMENT OF ACUTE MALNUTRITION FEBRUARY 2018 Protocol for the Management of Acute Malnutrition MINISTRY OF HEALTH Protocol for the Management of Acute Malnutrition 2 Protocol for the Management of Acute Malnutrition FEBRUARY 2018 Protocol for the Management of Acute Malnutrition 3 Protocol for the Management of Acute Malnutrition 4 CONTENTS Contents.........................................................................................................................................25 List of tables ..................................................................................................................................79 List of boxes ..................................................................................................................................810 List of figures .................................................................................................................................810 Acronyms and abbreviations ........................................................................................................911 Preface ........................................................................................................................................1113 Acknowledgements......................................................................................................................1214 1. Pathophysiology of severe acute malnutrition (SAM) .....................................................1416 2. Definition of Severe Acute Malnutrition ...........................................................................1819 3. Management in the Community.......................................................................................2121 3.1 Community engagement ................................................................................................2121 3.2 Community screening .....................................................................................................2222 3.3 Home visits ......................................................................................................................2323 4. Triage at the health facility ..............................................................................................2525 4.1 The appetite test..............................................................................................................2525 4.1.1 The observed appetite test .............................................................................................2525 4.1.2 Why to do the appetite test? ...........................................................................................2525 4.1.3 How to do the appetite test.............................................................................................2626 4.2 Medical history and examination.....................................................................................2727 4.2.1 Take the history ...............................................................................................................2827 4.2.2 Examine the child.............................................................................................................28 4.3 Decision from triage criteria on whether to treat as an in- or outpatient .........................2929 4.4 Classification of nutritional oedema..................................................................................3130 4.5 Transport of sick patients.................................................................................................3131 4.5.1 IPF ...................................................................................................................................3231 4.5.2 OTP .................................................................................................................................3231 4.5.3 District Hospital Nutrition Officer (focal point) and Emergency Department ..................3231 5. Outpatient management of SAM in children aged over 6 months ..................................3433 5.1 Tools for OTP ..................................................................................................................3433 5.2 Initial assessment............................................................................................................3534 5.3 Ensure decision-making for outpatient or inpatient care was appropriate during triage ...................................................................................................................3534 5.3.1 First priorities ..................................................................................................................3634 5.4 Medical management .....................................................................................................3635 5.4.1 Treatment to be given in the clinic ..................................................................................3635 5.5 Dietary treatment in outpatient care ...............................................................................3937 5.6 Monitoring and follow-up treatment as an outpatient .....................................................4239 5.7 Failure to respond to treatment as an outpatient.............................................................4542 5.8 End of outpatient care treatment ....................................................................................4744 5.8.1 Criteria for the end of treatment ......................................................................................4744 5.8.2 Procedures for the end of treatment ..............................................................................4845 6. Management of complications of severe acute malnutrition in children over 6 months of age ......................................................................................................5046 6.1 Emergency Triage Assessment and Treatment in hospital settings ...............................5046 6.1.1 Principles of ETAT+ .........................................................................................................5460 6.1.2 Shock ..............................................................................................................................5248 6.1.3 Dehydration but no shock ...............................................................................................5550 6.1.4 Hypernatræmic dehydration ..........................................................................................5953 6.1.5 Respiratory distress ........................................................................................................6561 6.1.6 Severe pneumonia .........................................................................................................6156 6.1.7 Congestive heart failure .................................................................................................6256 6.1.8 Anaemia ..........................................................................................................................6356 Protocol for the Management of Acute Malnutrition 5 6.1.9 Convulsions .....................................................................................................................6560 6.1.10 Hypoglycaemia ...............................................................................................................6606 6.1.11 Hypothermia ...................................................................................................................6761 6.1.12 Eye signs of vitamin A deficiency ....................................................................................6862 6.1.13 Candidiasis ......................................................................................................................6962 6.1.14 Parasitic infections ...........................................................................................................6963 6.1.15 Helminthiasis ...................................................................................................................7063 6.1.16 Persistent diarrhoea .........................................................................................................6470 6.1.17 Osmotic diarrhoea caused by carbohydrate intolerance (re-feeding diarrhoea) ...........7064 6.1.18 Cholera or very severe watery diarrhoea ........................................................................7164 6.1.19 Eye infections ..................................................................................................................7165 6.1.20 HIV ...................................................................................................................................7165 6.1.21 Tuberculosis ...................................................................................................................7265 6.1.22 Malaria .............................................................................................................................7266 6.1.23 Measles ..........................................................................................................................66.72 6.1.24 Meningitis .......................................................................................................................66.73 6.1.25 Otitis media ......................................................................................................................7367 6.1.26 Skin infections .................................................................................................................7367