Management of acute malnutrition and micronutrient deficiencies standard 2: Severe acute malnutrition
Severe acute malnutrition is addressed.
Key actions(to be read in conjunction with the guidance notes)
Establish from the outset clearly defined and agreed criteria for set-up or increased support to existing services and for scale-down or closure (see guidance note 1).
Include interventions with inpatient care, outpatient care, referral and population mobilisation components for the management of severe acute malnutrition (see guidance note 2).
Maximise access and coverage through involvement of the population from the outset (see guidance notes 1–3 and Core Standard 1).
Provide nutritional and medical care according to nationally and internationally recognised guidelines for the management of severe acute malnutrition (see guidance notes 4–8).
Ensure discharge criteria include both anthropometric and non-anthropometric indices (see guidance note 6).
Investigate and act on causes of default and non-response or an increase in deaths (see guidance notes 6–7).
Address IYCF with particular emphasis on protecting, supporting and promoting breastfeeding (see guidance notes 9–10).
Key indicators (to be read in conjunction with the guidance notes)
These indicators are primarily applicable to the 6–59 month age group, although others may be part of the programme.
More than 90 per cent of the target population is within less than one day’s return walk (including time for treatment) of the programme site.
Coverage is >50per cent in rural areas, >70per cent in urban areas and >90per cent in camp situations (see guidance note 3).
The proportion of discharges from therapeutic care who have died is <10per cent, recovered is >75per cent and defaulted is <15per cent (see guidance note 6).
- Programme design: Programmes should be designed to build on and support existing health system capacity wherever possible. The level of additional support required to ensure effective management of severe acute malnutrition should be determined based on existing capacity at health facility and community levels, the numbers and geographical spread of disaster-affected individuals and the security situation. From the start, programmes should consider exit strategies or plans for longer-term support beyond the emergency. Criteria for closure or transition of programmes should consider existing capacity and opportunities to integrate into existing systems.
- Programme components: Programmes addressing the management of severe acute malnutrition should comprise inpatient care for individuals with medical complications and all infants <6 months of age with acute malnutrition and decentralised outpatient care for children with no medical complications. Inpatient care may be through direct implementation or referral. Programmes should also be linked with other services addressing the immediate and underlying causes of undernutrition such as supplementary feeding, HIV and AIDS and TB networks, primary health services and food security programmes including food, cash or voucher transfers. Effective community mobilisation will help to achieve programme acceptance, accessibility and coverage. Outpatient programme sites should be close to the targeted population to reduce the risks and costs associated with travelling long distances with young children and the risk of people being displaced to them.
- Coverage: As with moderate acute malnutrition, coverage can be affected by the acceptability of the programme, location and accessibility of programme sites, general security situation, frequency of distributions, waiting time, service quality, extent of mobilisation, extent of home visiting and screening, and screening and admission criteria alignment. Methodologies to measure coverage vary in the level of reliability and type of information generated. The method used must be stated when reporting. Current guidance should be consulted when deciding which method is appropriate in the given context (see Management of acute malnutrition and micronutrient deficiencies standard 1, guidance note 2).
- Guidelines: Where national guidelines exist, they should be adhered to. In the absence of national guidelines or where they do not reach international standards, international guidelines should be adopted. Internationally accepted guidelines are found in the References and further reading section.
- Admission criteria should be consistent with national and international guidance (see Appendix 4: Measuring acute malnutrition, and References and further reading).Admission criteria for infants <6 months and groups whose anthropometric status is difficult to determine should include consideration of clinical and breastfeeding status. Individuals who are tested or suspected to be HIV-positive and those who have TB or are chronically ill should have equal access to care if they meet the criteria for admission. PLHIV who do not meet admission criteria often require nutritional support, but this is not best offered in the context of treatment for severe acute malnutrition in disasters. These individuals and their families should be supported through a range of services including community home-based care, TB treatment centres and prevention programmes aimed at mother-to-child transmission.
- Discharge criteria and recovery: Discharged individuals must be free from medical complications, have regained their appetite and have achieved and maintained appropriate weight gain without nutrition-related oedema (e.g. for two consecutive weighings). Breastfeeding status is especially important for infants under 6 months as well for children to 24 months. Non-breastfed infants will need close follow-up. Discharge criteria should be adhered to in order to avoid the risks associated with premature discharge. Guidelines define limits for the mean length of stay for treatment and are aimed at avoiding prolonged recovery periods. Mean length of stay will differ depending on the guidelines in use and so should be adjusted to national context and guidelines in use. Mean weight gain should be calculated separately for individuals with and without nutritional oedema. HIV, AIDS and TB may result in some malnourished individuals failing to respond to treatment. Options for longer-term treatment or care should be considered in conjunction with health services and other social and community support services (see Essential health services - sexual and reproductive health standard 2).
- Performance indicators for the management of severe acute malnutrition should combine inpatient and outpatient care outcomes without double counting (i.e. removing transfers between the two components). Where this is not possible, interpretation of outcome rates should be adjusted accordingly, for example, programmes should expect better indicators where implementing outpatient care alone and should strive for the indicators as outlined for combined care when implementing inpatient care alone.The population of discharged individuals for severe acute malnutrition is made up of those who have recovered, died, defaulted, or not recovered (see Management of acute malnutrition and micronutrient deficiencies standard 1, Guidance note 4). Individuals who are referred to other services (e.g. medical services) have not ended treatment. Where programmes report for outpatient treatment only, transfers to inpatient care must be reported when assessing performance. Factors such as HIV clinical complexity will affect mortality rates where a proportion of admissions are HIV positive. Though performance indicators have not been adjusted for these situations, their consideration is essential during interpretation. In addition to discharge indicators, new admissions, number of children in treatment and coverage rates should be assessed when monitoring performance. Causes of re-admission, deterioration of clinical status, defaulting and failure to respond should be investigated and documented on an ongoing basis. The definition of these should be adapted to guidelines in use.
- Health inputs: All programmes for the management of severe acute malnutrition should include systematic treatments according to national or international guidance and established referral for the management of underlying illness such as TB and HIV. In areas of high HIV prevalence, strategies to treat malnutrition should consider both interventions that seek to avoid HIV transmission and those that support maternal and child survival.Effective referral systems for TB and HIV testing and care are essential.
- Breastfeeding support: Infants who are admitted for inpatient care tend to be among the most unwell. Mothers need skilled breastfeeding support as part of nutritional rehabilitation and recovery, particularly for children <6 months. Sufficient time and resources should be provided for this – a designated area (breastfeeding corner) to target skilled support and enable peer support may help. Breastfeeding mothers of severely malnourished infants under 6months should receive a supplementary ration regardless of their nutritional status unless they meet the anthropometric criteria for severe acute malnutrition in which case they should also be admitted for treatment.
- Social and psychosocial support: Emotional and physical stimulation through play is important for children with severe acute malnutrition during the rehabilitation period. Caregivers of such children often require social and psychosocial support to bring their children for treatment. This may be achieved through mobilisation programmes which should emphasise stimulation and interaction as both treatment and prevention of future disability and cognitive impairment (see Protection Principle 4). All caregivers of severely malnourished children should be enabled to feed and care for their children during treatment through the provision of advice, demonstrations and health and nutrition information.