Integrated Management of Acute Malnutrition Session 4: Screening, diagnosis, referral and admission/enrollment
Session 4: Training Objective Enable health workers to quickly and accurately screen, diagnosis, refer and admit/enroll children with acute malnutrition
Session 4: Learning objectives By the end of the session, participants should be able to • Understand how to screen and diagnose acute malnutrition • Understand the referral system for the different cases of acute malnutrition • Understand how to measure nutritional status • Know the key steps to admit/enroll a child
Session 4: Content • Overview • Screening • Diagnosis and referral • How to measure nutritional status • Admission/enrollment procedures
Overview • Frequent screening of children is essential to identify cases before complications arise. • After screening, the diagnosis is confirmed at any RCH clinic. • Depending on the diagnosis, a decision is made on the type of treatment. • ITC (child with SAM and medical complications) • OTC (child with uncomplicated SAM) • RCH Clinic/SFP (child with MAM)
Screening • Screening is the rapid process used to assess whether a child have acute malnutrition. • Screening is conducted at every possible opportunity in the community and at health facilities. • Screening can be done by community-based workers or health service providers. • If a child is found to have acute malnutrition, he/she is referred to a health facility (PHCU, PHCC, hospital) to confirm the diagnosis and determine what type of treatment is required.
Screening methods Children aged 6-59 months are screened using: • Mid-upper arm circumference (MUAC) • Bilateral pitting oedema. Children aged <6 months are screened using • Bilateral pitting oedema • Visible signs of acute wasting. • MUAC should not be used for children <6 months
Where screening takes place Community • Outreach health services (e.g. EPI, VAS) • Campaigns (e.g. immunization campaigns, twice yearly VAS) • Community meetings (e.g. women’s groups), pre-schools • Home visits • Any other opportunities available in the community
Where screening takes place All health facilities (PHCU, PHCC and hospitals) • Children should be routinely screened at every visit to a health facility. • Screening should be integrated into the following health services: • RCH services (IMCI, EPI, vitamin A supplementation, growth monitoring) • PMTCT and HIV care and treatment • Inpatient services (paediatric ward) • Any other contact with children aged less than five years
Who can screen and how often Who? • Any of the following persons, who have been trained: • Health service providers • CORPS and other community-based workers • Preschool teachers • Caregivers themselves How often? • As often as possible, preferably once a month • Frequent screening is important to identify cases before medical complications develop
What is diagnosis? • Diagnosis is used to confirm the screening result and to determine the appropriate type of treatment
Where & when diagnosis takes place Where: health facilities • Diagnosis takes place at any health facility • Diagnosis is conducted by a trained health service provider When: • When a child has been screened and is suspected to have acute malnutrition
Diagnosis methods Children aged 6-59 months are screened using: • Mid-upper arm circumference (MUAC) • Weight-for-height z-score (WHZ) (optional) • Bilateral pitting oedema. • Medical history and examination to check for medical complications Children aged <6 months are screened using • Bilateral pitting oedema • Visible signs of acute wasting. • MUAC should not be used for children <6 months
Diagnosis methods The following measures should NOT be used to identify children with acute malnutrition: • Weight-for-height percentiles (old method) • Underweight (plotted on growth monitoring cards) • Neither of the above methods will accurately identify children with acute malnutrition
SCREENING and DIAGNOSIS Child with moderate acute malnutrition One of the following MUAC≥11.5 cm and <12.5 cm WHZ ≥-3 SD and <-2 SD Child with severe acute malnutrition One of the following: MUAC <11.5 cm WHZ <-3 SD Bilateral pitting oedema Infant <6 months with visible wasting 6-59 months <6 months Check for medical complications and do the Appetite Test Improvement Deterioration If patient has no complications and passes appetite test If patient has complications or failes appetite test Outpatient therapeutic care using RUTF for children 6-59 months only Inpatient therapeutic care Stabilization and transition phases Outpatient management of MAM Nutritional counseling and supplementary feeding, if available Inpatient therapeutic care Rehabilitation phase, if child aged <6 months and/or if not possible to refer child for OTC Discharge and routine follow up at RCH clinic Improvement in condition Deterioration in condition
Anthropometric Measures Mid-upper arm circumference (MUAC) Height Weight
Take a look!Annex 1: How to take anthropometric measurements and screen for oedema
Mid-upper arm circumference • MUAC is used for children aged 6-59 months only. • MUAC is always taken on left arm. • Remove clothing on left arm. • Measure the length of the child’s upper arm, between the bone at the top of the shoulder and the elbow bone. The child’s arm should be bent. Divide the number by two to get the midpoint. • Alternatively, use a piece of string to measure the length of the arm, and fold the string in half to determine the mid-point of the arm. • Mark the middle of the child’s upper with pen
Mid-upper arm circumference • The child’s arm should then be relaxed, falling along the body. • Place the MUAC tape around the mid-point of the arm so that it is flat around the skin not too tight or too loose. • Take the measurement.
Child weight – Hanging scale • Take child’s clothes off • Zero the weighing scales • Place the child in the weighing pants and make sure s/he is not touching anything. • Do not hold the weighing scales. • Read the child’s weight at eye level when the arrow is steady. • Dress the child immediately
Child weight – Mother/child electronic scale • Switch on the scale. Wait until the display 0.0 appears • Take child’s clothes off. • Stand on the scale without the child. • Press the blue mother-and baby key. 0.0 and the display TARE appear in the display • Now take the child onto the scale. You can step off the scale to get the child, in which case - - - - appears in the display • Once the value is stable for about 3 seconds, the weight is displayed. • Dress the child immediately
Height/length • Use a measuring board • Measure LENGTH for • children aged <2 years • Children or <87 cm if age is not known • Children who are too weak to stand, • Measure STANDING HEIGHT for • Children >87 cm • Children 2+ years • Need two people to take correct measurement • One person holds the child’s legs and feet, and the other holds the child’s head
Length for children <2 years (<87 cm) • Lay the board flat on a table • Position child on his back, with head against headboard. • The child’s eyes should be looking straight up.
Length for children <2 years (<87 cm) • Hold down child’s knees • Press the sliding piece against the heels of the child’s feet. • The child’s arms should be lying alongside his/her body. • Measure the length to the nearest 0.1 cm.
Height for children ≥2 years (≥87 cm) • Height is taken when child is standing • Heels should be flat on the floor, and the feet should be close together. • Heels, back legs, buttocks, shoulders and head should all touch the back of the board • Child’s arms should be straight down by his/her sides • Measure the height to nearest 0.1 cm.
How do you check whether a child has oedema that is caused by malnutrition?
Dermatitis is common in children with oedema • Patches of skin abnormally light or dark • Shedding of skin, ulceration of skin and/or weeping lesions
Classification of oedema Oedema must be in both feet/legs
How to determine WHZ z-score • WHZ is optional - MUAC alone can be used to diagnosie acute malnutrition • Some people may find WHZ difficult to determine. • Benefit of using both WHZ and MUAC is that some children may have a normal MUAC but low WHZ: using both methods picks up all children with acute malnutrition. • Tables are used to determine the weight-for-height values from the height and weight measurements of the child. • Two sets of tables are provided • NCHS Growth References 1977 (currently in use) • WHO Growth Standards 2006 (soon to be adopted in Tanzania).
Example • A girl is 77.8 cm long and weighs 8.1 kg. Determine the WHZ using the WHO Growth Standards • The height measurement has to be rounded to the nearest cm • Round down all ≤0.4 cm • Round up all values that ≥0.5 cm). • The rounded value for 77.8 cm is 78 cm.
77.8 cm long and weighs 8.1 kg Answer is >-3SD and <-2SD (moderate acute malnutrition)
Example 2 • This is a girl, age 20 months. She is 67cm in length and weighs 6.5kg • To which programme should she be admitted?
Exercise 2 - answer • Girl has oedema, therefore she should be admitted to ITC
Exercise 3 • This is a boy, age 18 months. He is 65cm in length and weighs 4.8g. He has no medical complications • To which programme should she be admitted?
65 cm long and weighs 4.8 kg • Answer is WHZ is <-3 SD (severe acute malnutrition) • As the child has no complications, he can be admitted to OTC