Copyright May 2011, Ministry of Health and Child Welfare, Harare, Zimbabwe

Transcription

1 MANAGEMENT OF ACUTE MALNUTRITION IN ZIMBABWE A QUICK REFERENCE GUIDE MINISTRY OF HEALTH AND CHILD WELFARE VERSION I (MAY 2011) Copyright May 2011, Ministry of Health and Child Welfare, Harare, Zimbabwe Copies of this guide can be obtained from the National Nutrition Department, Ministry of Health and Child Welfare, in Harare, Zimbabwe. Please visit our website: 1 P a g e

2 ACKNOWLEDGEMENTS We are grateful to all those involved in the management of acute malnutrition in Zimbabwe. A special thank you is extended to those involved in the development of the draft National CMAM Guidelines the source material from which this quick reference guide has been developed. The following people and organizations were critical in the development of this guide: CMAM Task Force Members K. Nyadzayo, MoHCW National Nutrition Department V. Makanganise, MoHCW National Nutrition Department R. Danda, MoHCW, Parirenyetwa Group of Hospitals T. Stillman, Cluster Coordinator, UNICEF P. Mudzongo, Program Officer, UNICEF T. Ndumiyana, Program Officer, World Food Program 2 P a g e

3 ORGANIZATION OF THE QUICK REFERENCE GUIDE Section 1: Introduction to the Quick Reference Guide Page 4 Section 2: Classification of Acute Malnutrition Page 6 Section 3: Feeding Formulas for Malnourished Individuals Page 7 Section 4: Admission and Exit Criteria Page 9 A. Inpatient Therapeutic Care (Stabilization) Page 13 B. Outpatient Therapeutic Care Page 17 C. Supplementary Feeding Page 22 Section 5: Look up Tables A. Children 6-59 Months of Age Page 25 B. Children and Adolescents 6 to 18 Years of Age Page 29 C. Adult BMI Page 33 D. 15% Weight Gain Reference Table Page 35 3 P a g e

4 Introduction SECTION 1 INTRODUCTION TO THE QUICK REFERENCE GUIDE Purpose This booklet provides practical guidance for the administration of therapeutic foods to patients with acute malnutrition through hospitals and health centres in Zimbabwe. It seeks to promote the best available therapy to reduce the risk of death, shorten hospitalization, and facilitate full recovery of acutely malnourished individuals. The booklet is aimed at health personnel working at all levels of the health delivery system, including Doctors, Nurses, Nutritionists, Dieticians and Auxiliaries. The booklet is designed as a quick reference guide it is NOT a comprehensive treatment guideline. The quick reference guide should be used together with other available guidelines for the management of acute malnutrition and other illnesses. The booklet does not contain information regarding the clinical management of nutrition related complications treatment that is essential to the recovery of malnourished individuals. Background Malnutrition remains one of the most common causes of morbidity and mortality among children throughout the world. According to global estimates, 35% of all child mortality is attributable to maternal and child under nutrition 1 applying these estimates to Zimbabwe, malnutrition may contribute to nearly 12,000 child deaths each year. Acute malnutrition, defined by a low weight for height (children), low body mass index (adolescents and adults), presence of bi-lateral pitting oedema, or low mid-upper arm circumference, is the most immediate form of malnutrition. The risk of death in children with severe acute malnutrition (SAM) is 10 times greater than the risk of death in their well nourished counterparts, and the risk of death in children with moderate acute malnutrition (MAM) is more than 2 times greater than in their wellnourished counterparts. 2 The risk of dying increases with the severity of the condition. HIV and malnutrition are inter-related: HIV progressively weakens the immune system and impairs nutritional status through the reduced intake, 1 Black et al., 2006, Lancet 2 Collins et al., 2006, Lancet 4 P a g e

5 Introduction mal-absorption of nutrients, and increased metabolic requirements, while malnutrition exacerbates the effects of HIV by increasing susceptibility to AIDS related illness 3. Reports from routine program monitoring suggest that up to 70% of children admitted for treatment of SAM in Zimbabwe are HIV infected. Furthermore, it is estimated that 18 percent of chronically ill patients in Zimbabwe suffer from accompanying acute malnutrition (defined as BMI <18.5). Low BMI is a powerful and independent predictor of mortality after the start of ART 4, and significant weight loss in HIV positive individuals is associated with increased risk of opportunistic infection, complications, and early mortality 5. Acute malnutrition requires life-saving medical attention. Consistent with the 2007 joint UN statement on the "Community Based Management of Acute Malnutrition (CMAM)," the government of Zimbabwe has adopted CMAM as its primary strategy for managing acute malnutrition. CMAM aims to treat uncomplicated SAM on an outpatient basis using ready to use therapeutic foods and clinical protocols, to treat complicated SAM in inpatient facilities using F-75 and F-100 therapeutic milks and clinical protocols, and to treat MAM through provision of fortified supplementary foods and clinical protocols. Malnutrition results from socio-economic and other problems such as poor water and sanitation, sub-optimal care practices, poor access to nutritious food, low education and repeated infections, which may also be HIV, related. Successful management of malnutrition requires that both medical and social problems be recognized and corrected. 3 Kotlerr DP, 1994, Wasting syndrome: nutritional support in HIV Infection, AIDS 4 Koethe et al., 2009, Macronutrient Supplementation for Malnourished HIV infected Adults: A Review of the Evidence in Resource Adequate and Resource Constrained Settings, Clinical Infectious Diseases 2009; 49: Friis H, 2006, Micronutrient Intervention and HIV infection: A Review of Current Evidence, Tropical Medicine and International Health 5 P a g e

6 Classification of Acute Malnutrition SECTION 2 CLASSIFICATION OF ACUTE MALNUTRITION Acute malnutrition can be classified as either moderate or severe using several different indices. The table below represents Zimbabwe specific cutoffs for classifying acute malnutrition, by Age and Index. Age Group Children Less than 6 Months Children 6 to 59 Months Children and Adolescents (6 to 18 Years ) Adults (Above 18 Years) Pregnant or Lactating Women (Any Age) Classification Measurement Severe Acute Moderate Acute Index Malnutrition Malnutrition Classify severe if presence of any of the following: Bilateral pitting oedema Weight for Length <-3 SD (WHO) Infant too weak or feeble to suckle effectively Mother reports breastfeeding failure AND infant is not gaining weight at home Weight for Height (W/H) <-3 SD (WHO) <-2 & -3 SD (WHO) Mid-upper Arm Circumference (MUAC) <115 mm <125 & 115 mm Bilateral Pitting Oedema Yes No Body Mass Index (BMI) <-3 SD (WHO) OR for Age visible wasting <-2 & -3 SD (WHO) Bilateral pitting oedema Yes No Body Mass Index (BMI) <16 kg/m 2 <18.5 & 16 kg/m 2 Bilateral pitting oedema Yes No Mid-upper Arm Circumference (MUAC) <190 mm <230mm & 190mm Bilateral pitting oedema Yes No Section 5 of this reference guide contains look up tables to assist in the classification of individual patients. There are separate look up tables for boys and girls (Weight for height), adolescents (BMI for age), and adults (BMI) it is critical that providers use the appropriate age/sex specific table in classifying patients. For adolescents, you must calculate BMI prior to referring to the BMI for Age Table. Calculation of BMI for Adolescents and Adults Measured Weight (kg) Height (x) Height (m) 6 P a g e

7 Feeding Formulas SECTION 3 FEEDING FORMULAS FOR MALNOURISHED INDIVIDUALS What is F-75? F-75, Formula 75, is used during the first phase in the management of of complicated severe acute malnutrition. F-75 is administered until the patient has fully stabilized, which typically takes between 2 and 7 days. Severely malnourished patients with complications have difficulty tolerating protein, sodium, or high amounts of fat introduction of these nutrients in incorrect proportions may lead to death. F-75 is specially formulated to meet the malnourished patient s needs without overwhelming the body's systems during the initial stage of treatment. F-75 contains 75 kcal and 0.9 g protein per 100 ml. F-75 should never be administered on an outpatient basis. What is F-100? F-100, Formula 100, is introduced after the patient is stabilized and is intended to rebuild wasted tissues as quickly as possible during the rapid recovery phase. Like F-75, F-100 is specially formulated to provide the the appropriate mix of nutrients as the patient recovers. F-100 contains more calories and protein than F-75: 100 kcal and 2.9g protein per 100 ml. F-100 should never be administered on an outpatient basis. What is RUTF? RUTF, Ready to Use Therapeutic Food, is made of powdered ingredients embedded in a lipid rich paste, resulting in an energy dense food that resists microbial contamination. RUTF is a mixture of milk powder, vegetable oil, sugar, peanut butter, powdered vitamins and minerals. As the name implies, RUTF does not require preparation prior to consumption. RUTF has the same basic formulation as F-100, and is used to support rapid recovery of uncomplicated severely malnourished patients. While RUTF must be consumed with water, no other foods are necessary for the rehabilitation of the malnourished child. RUTF can be safely stored at ambient temperatures for up to 24. RUTF can be administered on an outpatient basis. 7 P a g e

8 Feeding Formulas What is CSB Plus? CSB Plus is a dried blended food consisting of heat treated maize, soya beans, sugar, vitamins, and minerals. The product is typically prepared in the home as a porridge or gruel using boiled water. The most common preparation uses 1 part of CSB Plus to 5 parts water. CSB Plus is prescribed to recently recovered severely malnourished patients and to patients over the age of 2 years with moderate acute malnutrition. CSB Plus should be provided as a take-home ration. What is CSB Plus Plus? CSB Plus Plus is a dried blended food prepared from heat treated maize and de-hulled soya beans, sugar, dried skim milk, refined soya bean oil, vitamins and minerals. The product is typically prepared in the home as a porridge or gruel using boiled water. CSB Plus Plus is prescribed for children between 6 and 24 months of age. The product is to be used as a complement to breastfeeding in the home - the product should NOT be used as a breast-milk substitute. 8 P a g e

9 ACTION DIAGNOSIS SECTION 4 ADMISSION CRITERIA FOR MANAGEMENT OF ACUTE MALNUTRITION INFANTS (LESS THAN 6 MONTHS OF AGE) Bilateral pitting oedema any grade OR Weight for Length <-3 SD (WHO) OR Infant too weak or feeble to suckle effectively OR Mother reports breastfeeding failure AND infant is not gaining weight at home Admit to Stabilization care Give dilute F-100 (DF-100) Manage according IMNCI protocols Provide health and nutrition counseling and continued follow up 9 P a g e Admission Criteria

10 ACTION DIAGNOSIS Admission Criteria CHILDREN (6 TO 59 MONTHS OF AGE) WITH COMPLICATIONS WITHOUT COMPLICATIONS Bilateral Pitting Oedema (any grade) Bilateral Pitting Oedema (grade one or two) Weight for height OR OR <-2SD & 3 SD (WHO) Weight for height <-2 SD (WHO) Weight for Height < -3SD (WHO) OR OR OR MUAC <125mm & 115mm MUAC < 125mm MUAC < 115mm OR MUAC <125mm and HIV positive AND AND AND ANY of the following: Anorexia (no appetite) ALL of the following: ALL of the following: Lower respiratory tract infection Fever (>39 C) Appetite Appetite Severe dehydration Clinically well Clinically well Severe anemia Alert Alert Hypoglycemia Hypothermia (<35 C) Not alert INPATIENT CARE OUTPATIENT CARE SUPPLEMENTARY FEEDING Give F-75 in Phase I Give RUTF Give CSB Plus Plus to children between 6 Give F-100/RUTF in Phase II Give routine medicines and 24 months of age Give routine medicines Give CSB Plus to children over the age of 24 months Give routine medicines Provide health and nutrition counseling and continued follow up 10 P a g e

11 ACTION DIAGNOSES CHILDREN AND ADOLESCENTS (6 TO 18 YEARS OF AGE) WITH COMPLICATIONS WITHOUT COMPLICATIONS Bilateral pitting oedama (any grade) Bilateral pitting oedema (grade one or BMI for AGE <-2 SD & -3 SD (WHO) OR two) BMI for AGE <-3 SD (WHO) OR BMI for AGE <-3 SD (WHO) AND AND AND ANY of the following: ALL of the following: ALL of the following: Anorexia Respiratory tract infections Appetite No bilateral pitting oedema Fever Clinically well Appetite Severe dehydration Alert Clinically well Severe anemia Alert Hypoglycemia Hypothermia Not alert INPATIENT CARE OUTPATIENT CARE SUPPLEMENTARY FEEDING Give F75 in Phase I Give RUTF Give CSB Plus Give F 100/RUTF in Phase II Give routine medicines Give routine medicines Give routine medicines Provide health and nutrition counseling and continued follow up 11 P a g e Admission Criteria

12 ACTION DIAGNOSES Admission Criteria WITH COMPLICATIONS Adults Bilateral pitting oedema (any grade) OR BMI <16 kg/m 2 ADULTS (ABOVE 18 YEARS OF AGE) WITHOUT COMPLICATIONS Adults Adults Bilateral pitting oedema (grade one or two) BMI <18.5 kg/m2 & 16 kg/m 2 and OR BMI <16 kg/m 2 Pregnant & lactating women Bilateral pitting oedema (any grade) OR MUAC < 190mm with weight loss in past 4 weeks Pregnant & Lactating women Bilateral pitting oedema (grade one or two) OR MUAC < 190mm with NO weight loss in past 4 weeks Pregnant & Lactating women MUAC <230mm & 190mm AND AND Complications which affect food intake, in ALL of the following: addition to: ALL of the following: Anorexia No bilateral pitting oedema Lower Respiratory tract infections Appetite Appetite Fever Clinically well Clinically well Severe dehydration Alert Alert Severe anaemia Hypoglycemia Hypothermia Not alert INPATIENT CARE OUTPATIENT CARE SUPPLEMENTARY FEEDING Give F75 in Phase I Give RUTF Give CSB Plus Give F 100/RUTF in Phase II Giver routine medicines Give routine medicines Give routine medicines Provide health and nutrition counseling and continued follow up AND 12 P a g e

13 Inpatient Therapeutic Care SECTION 4A INPATIENT THERAPEUTIC CARE (STABILIZATION CARE) Patients with severe or moderate acute malnutrition AND complications should be admitted for inpatient care. Complications should be managed according to national protocols for different age groups. Inpatient Therapeutic Feeding Recommendations Phase 1 (Stabilization care) Age Group Product and Prescription Children <6 Months Give Diluted F-100 at 130 ml/kg of body weight per day Breastfed children should always be offered breast milk before the therapeutic milk, and always on demand Give F-75 at 130 ml/kg of body weight per day until the patient re-gains appetite. Children 6 to 59 Months Start with 2 hourly feeds (12 feeds per day) and gradually decrease the frequency of feeding and increase the volume of each feed until the patient is receiving 3-hourly feeds (8 feeds per day) Breastfed children should always be offered breast milk before the therapeutic milk, and should always be breastfed on demand Children and Adolescents (6 to 18) For years give 3.5ml/kg of body weight per hour (calculate for 24hrs) For years give 2.8ml/kg of body weight per hour (calculate for 24 hrs) Adults (Above 18) For years give 2.2ml/kg of body weight per hour (calculate for 24hrs) For >75years give 2.0ml/kg of body weight per hour (calculate for 24 hrs) 13 P a g e

14 Inpatient Therapeutic Care Transition Phase Age Group All Age Groups Product and Prescription Once stabilized, replace F-75 with F-100. The quantity of formula provided should remain the same as in Phase 1 Age Group Children <6 Months Children 6 to 59 Months Phase 2 (Rapid Recovery) Product and Prescription Give twice the volume of formula offered during phase I Give F-100 at 200ml/kg of body weight per day. Child should consume a minimum of 150 ml/kg of bodyweight each day Gradually introduce RUTF in small amounts until patient can consume ¾ of recommended allocation per day When accepted, provide RUTF at 200 kcal/ kg of body weight per day Children and Adolescents (6 to 18) Adults (Above 18) For years give 2.5ml/kg of body weight per hour (calculate for 24hrs) For years give 2.0ml/kg of body weight per hour (calculate for 24 hrs) Please Note: Individual needs may vary by up to 30 percent from these recommendations For years give 1.7ml/kg of body weight per hour (calculate for 24hrs) For >75years give 1.5ml/kg of body weight per hour (calculate for 24 hrs) Please Note: Individual needs may vary by up to 30 percent from these recommendations 14 P a g e

15 Inpatient Therapeutic Care Discharge Criteria from Inpatient Care, by Age Age Group Children <6 Months Discharge Criteria Successful lactation in mother is re-established; Infant achieves 20 grams weight gain per day on breastfeeding alone for 5 days; and Infant is clinically well and alert All Other Age Groups Appetite has returned that is, the patient eats at least 75 percent of allocated RUTF as observed for a period of 24 hours; and, Medical complications are resolved or controlled; and, Oedema is resolving Discharged patients should be referred immediately to outpatient therapeutic care for continued treatment and follow up discharge with a one week supply of RUTF Children under 6 months of age should NOT receive RUTF. IF breastfeeding is not possible, provide replacement feeding according to national guidance Other Exits from Inpatient Care Status Criteria Default Absent for 2 consecutive days Death Died during stay in inpatient facility Non-Cured In program for 6 weeks without reaching inpatient discharge criteria 15 P a g e

16 Inpatient Therapeutic Care Routine Medicines to Accompany Inpatient Therapeutic Care Product When Patient Age Prescription Dosage VITAMIN A (Do not provide vitamin A if child is readmitted or has received recommended dose within last 30 days) On Admission < 6 months 50,000 IU 6 months to < 1 year 100,000 IU 1 year (>8kg) 200,000 IU 1 drops (1/4 capsule) 3 drops (1/2 capsule) 6 drops (1 capsule) Do NOT provide Vitamin A to children with Oedema Length of Treatment Single dose on admission IRON Do NOT Provide (contained in RUTF). Severe anemia to be treated according to national protocol from wk 3. FOLIC ACID* On Admission All 5 mg Single dose Single dose on admission AMOXYCILLIN On Admission (presumptive) All weighing >2 Kg Refer to EDLIZ Refer to EDLIZ 7 days (or 10 days if needed) COARTEM ARTEMETER LUMEFANTRINE On Admission (if positive for malaria) All weighing 4kg Refer to EDLIZ Refer to EDLIZ Refer to EDLIZ ALBENDAZOLE or MEBENDAZOLE On Discharge from Inpatient Care < 2 years Do NOT Provide 2 years (Alb) 400 mg (Meben) 500 mg Single dose Single dose 16 P a g e

17 Outpatient Therapeutic Care SECTION 4B OUTPATIENT THERAPEUTIC CARE Patients with severe acute malnutrition WITHOUT complications should be enrolled in the outpatient therapeutic care program. Assessment of Appetite Prior to admission, it is critical to assess the patient s appetite if the patient lacks appetite or cannot for some reason consume the RUTF; the patient should be referred for inpatient care (see Section 4A). Lack of appetite may indicate poor liver or gastrointestinal function. Furthermore, a patient with poor appetite may not consume the RUTF per recommendation. Assessing Appetite: Give patient RUTF to try The patient may refuse due to the strange environment or strange product provide positive encouragement If it is a young child the care giver should try feeding in a quiet place (allow plenty of time) The health worker should observe the patient eating RUTF before admitting to the outpatient program Patients who refuse or cannot eat RUTF should be admitted to inpatient care until appetite is restored. Outpatient Therapeutic Feeding Recommendations Patients in the outpatient program should be provided with RUTF in accordance with recommendations for their age and weight (see table below). The patient should be provided a one week supply of RUTF at each visit. Each week, the patient should return to the clinic for follow up and additional supply of RUTF. 17 P a g e

18 Outpatient Therapeutic Care Daily Consumption of RUTF, by Age and Weight Age Group Children < 6 months Children 6 to 59 Months (200 kcal/kg/day) Children and Adolescents (6 to 18 Years) Adults (Above 18 Years) Pregnant or Lactating Women Patient Weight (Kg) Sachet/Day Do NOT provide RUTF RUTF Sachet/Week ½ ½ ½ < ½ ½ ½ ½ ½ ½ Any weight P a g e

19 Outpatient Therapeutic Care How to Give RUTF at Home It is important to ensure RUTF will be administered appropriately at home. Please convey the following key messages to the caretaker or patient prior to discharge: RUTF should not be mixed with water or other food - it should be consumed whole and does not need to be heated; The patient should finish the entire allocated daily ration; RUTF should be fed in small frequent quantities; and, Once tolerating and finishing the daily allocation of RUTF, the patient should be gradually re-introduced to other family foods. Discharge criteria from Outpatient Care, by Age Age Group Children < 6 Months Children 6 to 59 Months Do NOT provide RUTF Discharge Criteria No bilateral pitting oedema for 2 consecutive assessments; and, Weight for height >-2 SD for 2 consecutive assessments; or, 15 percent weight gain in first follow up visit without oedema (if admitted based on MUAC) Clinically well Children and Adolescents (6 to 19 Years) No bilateral pitting oedema for 2 consecutive assessments BMI for AGE >-2 SD for 2 consecutive assessments Clinically well Adults (Above 18 Years) No bilateral pitting oedema for 2 consecutive assessments BMI > 16/m2 Clinically well Pregnant and Lactating Women No bilateral pitting oedema for two consecutive visits MUAC > 190 if there is an SFP and infant 6 months Clinically well Discharged patients should be referred immediately to the supplementary feeding program for continued treatment and follow up 19 P a g e

20 Outpatient Therapeutic Care Other Exits from Outpatient Care Status Criteria Default Absent for 3 consecutive visits Death Died during time registered in outpatient care Non-Cured Minimum of 4 months if weight is static and all available treatment options have been pursued refer for further care 20 P a g e

21 Routine Medicines to Accompany Outpatient Therapeutic Care Product When Patient Age Prescription Dosage VITAMIN A (Do not provide vitamin A if child is readmitted or has received recommended dose within last 30 days) IRON On Admission 6 months to < 1 year 100,000 IU 1 year (>8kg) 200,000 IU Length of Treatment 3 drops (1/2 capsule) Single dose on 6 drops admission (1 capsule) Do NOT provide Vitamin A to children with Oedema Do NOT Provide (contained in RUTF) FOLIC ACID* On Admission All 5 mg Single dose Single dose on admission AMOXYCILLIN On Admission (presumptive) All weighing >2 Kg Refer to EDLIZ Refer to EDLIZ 7 days (or 10 days if needed) 21 P a g e COARTEM ARTEMETER LUMEFANTRINE ALBENDAZOLE or MEBENDAZOLE On Admission (if positive for malaria) On Admission (if not provided in inpatient care) All weighing 4kg Refer to EDLIZ Refer to EDLIZ Refer to EDLIZ < 2 years Do NOT Provide 2 years (Alb) 400 mg (Meb) 500 mg Outpatient Therapeutic Care Single dose Single dose

22 Supplementary Feeding SECTION 4C SUPPLEMENTARY FEEDING Patients with moderate malnutrition WITHOUT complications should be admitted to the supplementary feeding program. Supplementary Feeding Recommendations, by Age Age Group Children 6 to 24 months of age Children 24 to 59 months of age Children and Adolescents (6 to 18) Adults years (Above of age) 18 Years) HIV+ Adults Pregnant/Lactating Women Commodity Ration Per Day (g) Ration Per Month (Kg) CSB Plus Plus 100g 3 Kg CSB Plus 200g 6 Kg CSB Plus 200g 6 Kg CSB Plus 200g 6 Kg CSB Plus 250g 7.5 Kg CSB Plus 250g 7.5 Kg Refer SFP patients to a local food security partner for assessment of household food security status and possible family ration Note: Rations may differ between organizations this is acceptable as long as the ration allocation meets the recommended minimum quantity per day 22 P a g e

23 Supplementary Feeding Discharge Criteria from Supplementary Feeding, by Age Age Group Discharge Criteria Children 6 to 24 months of age Weight for Height > -2 SD (WHO) for two consecutive visits OR OR MUAC >125mm for two consecutive visits Children 24 to 59 months of age Weight for Height > -2 SD (WHO) for two consecutive visits OR OR MUAC >125mm for two consecutive visits Children and Adolescents (6 to 18 years) Adults (Above 19 Years) HIV+ Adults BMI for Age > -2 SD (WHO) for two consecutive visits BMI > 18.5 kg/m2 Pregnant or Lactating Women MUAC greater than 230 mm Provide health and nutrition counseling prior to discharge Other Exits from Supplementary Feeding Status Criteria Default Absent for 3 consecutive visits Death Died during time registered in supplementary feeding program Non-Cured Minimum of 6 months if weight is static and all available treatment options have been pursued refer for further care 23 P a g e

24 Supplementary Feeding Routine Medicines to Accompany Supplementary Feeding Product When Age of Patient Prescription Dosage VITAMIN A (Do not provide vitamin A if child is readmitted or has received recommended dose within last 30 days) On Admission 6 months to < 1 year 100,000 IU 1 year (>8kg) 2 Years to 5 Years 200,000 IU 3 drops (1/2 capsule) 6 drops (1 capsule) Length of Treatment Single dose on admission IRON/FOLATE On Admission 6 Years to 11 Years Refer to EDLIZ Refer to EDLIZ Refer to EDLIZ Adults ALBENDAZOLE or MEBENDAZOLE On Admission (if not provided in inpatient care) < 2 years Do NOT Provide 2 years (Alb) 400 mg (Meben) 500 mg Single dose Single dose 24 P a g e

25 Look Up Tables SECTION 5A LOOK UP TABLES: CHILDREN 6 TO 59 MONTHS OF AGE (Girls) Weight for Length (Lying) - GIRLS 6 to 59 Months using WHO Standard (Z-Score) Lenth (cm) -3 SD -2 SD Length (cm) -3 SD -2 SD P a g e

26 Look Up Tables SECTION 5A LOOK UP TABLES: CHILDREN 6 TO 59 MONTHS OF AGE (Girls) Weight for Height (Standing) - GIRLS 6 to 59 Months using WHO Standard (Z-Score) Height (cm) -3 SD -2 SD Height (cm) -3 SD -2 SD P a g e

27 Look Up Tables SECTION 5A LOOK UP TABLES: CHILDREN 6 TO 59 MONTHS OF AGE (Boys) Weight for Length (Lying) - BOYS 6 to 59 Months using WHO Standard (Z-Score) Lenth (cm) -3 SD -2 SD Length (cm) -3 SD -2 SD P a g e

28 Look Up Tables SECTION 5A LOOK UP TABLES: CHILDREN 6 TO 59 MONTHS OF AGE (Boys) Weight for Height (Standing) - BOYS 6 to 59 Months using WHO Standard (Z-Score) Height (cm) -3 SD -2 SD Height (cm) -3 SD -2 SD P a g e

29 Look Up Tables SECTION 5B LOOK UP TABLES: CHILDREN & ADOLESCENTS 6 TO 18 YEARS OF AGE BMI for AGE - GIRLS 6 to 18 years using WHO Standard (z-score) Year: Month Month -3 SD -2 SD Year: Month Months -3 SD -2 SD 5: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : SECTION 5B 29 P a g e

30 Look Up Tables SECTION 5B LOOK UP TABLES: CHILDREN & ADOLESCENTS 6 TO 18 YEARS OF AGE BMI for AGE - GIRLS 5 to 19 years using WHO Standard (z-score) Year: month Month -3 SD -2 SD Year: Month Month -3 SD -2 SD 11: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : P a g e

31 Look Up Tables SECTION 5B LOOK UP TABLES: CHILDREN & ADOLESCENTS 6 TO 18 YEARS OF AGE BMI for AGE - BOYS 5 to 19 years using WHO Standard (z-score) Year: Month Month -3 SD -2 SD Year: Month Month -3 SD -2 SD 5: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : P a g e

32 Look Up Tables SECTION 5B LOOK UP TABLES: CHILDREN & ADOLESCENTS 6 TO 18 YEARS OF AGE BMI for AGE - BOYS 5 to 19 years using WHO Standard (z-score) Year: Month Month -3 SD -2 SD Year: Month Month -3 SD -2 SD 11: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : P a g e

33 Look Up Tables SECTION 5C LOOK UP TABLES: ADULT BMI Height (m) BMI for 18 years and above Severe malnutrition Moderate P a g e

34 Look Up Tables SECTION 5C LOOK UP TABLES: ADULT BMI Height (m) BMI for 18 years and above Severe malnutrition Moderate P a g e

35 Look Up Tables SECTION 5D LOOK UP TABLES: 15% Percent Weight Change (for MUAC Admissions) 35 P a g e