KZN Integrated Management of Acute Malnutrition (IMAM) Guidelines PDF

 GUIDELINES ON THE INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION (IMAM) IN KWA-ZULU NATAL January 2014 IMPLEMENTERS O...

 GUIDELINES ON THE INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION (IMAM) IN KWA-ZULU NATAL January 2014 IMPLEMENTERS OPERATIONAL GUIDE 1 IMAM 2.indd 1 2/4/2014 6:24:20 PM  Table of Contents......................................................................................................................2    Acknowledgements............................................................................................................3    List of Appendices..............................................................................................................3 CONTENTS    List of Tables......................................................................................................................3    List of Figures.....................................................................................................................4    List of Abbreviations...........................................................................................................4 1. BACKGROUND....................................................................................................................5 1.1 The Problem........................................................................................................................5 1.2 Purpose of the Guideline.....................................................................................................5 1.3 Principles of Integrated Management of Acute Malnutrition............................................... 6 2. ASSESS & CLASSIFY...........................................................................................................9 2.1 What is acute malnutrition?.................................................................................................9 2.2 Pathophysiology of SAM.....................................................................................................9 2.3 Why are SAM cases treated differently?...........................................................................10 2.4 Assess, Classify and Treat...............................................................................................10 3. INPATIENT MANAGEMENT OF SAM IN CHILDREN 0 – 59 MONTHS............................ 13 3.1 Treat / Prevent Hypoglycaemia........................................................................................14 3.2 Treat / Prevent Hypothermia...........................................................................................16 3.3 Treat / Prevent Dehydration............................................................................................17 3.4 Correct Electrolyte Imbalances.......................................................................................20 3.5 Treat / Prevent Infection...................................................................................................21 3.6 Correct Micronutrient Deficiencies..................................................................................23 3.7 Start Cautious Feeding...................................................................................................24 3.8 Achieve Catch up Growth................................................................................................26 3.9 Provide Sensory Stimulation and Emotional Support..................................................... 29 3.10 Prepare for follow up after recovery..............................................................................30 4. OUTPATIENT MANAGEMENT OF MALNUTRITION........................................................ 31 4.1 Outpatient Supplementary Programme (OSP 6 - 59 MONTHS)...................................... 31 4.2 Growth Monitoring and Promotion Support (GMPs)......................................................... 36 4.3 Nutrition Supplementation Programme    (5 - 14 years, Adults, Pregnant & Lactating Women)....................................................... 38 4.4 Community Outreach and the Referral Pathway.............................................................. 41 5. MONITORING AND EVALUATION FRAMEWORK........................................................... 44 5.1 Inpatient Monitoring and Evaluation..................................................................................45 5.2 Outpatient Monitoring and Evaluation...............................................................................46 5.3 Indicators to report to District Health Information System................................................. 49 References.........................................................................................................................52 Appendices.........................................................................................................................53 2 INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN KWA-ZULU NATAL IMAM 2.indd 2 2/4/2014 6:24:22 PM  Acknowledgements This operational guide has been largely constructed from WHO Scientific Recommendations, CONTENTS with input from:- National Department of Health: Nutrition Directorate KZN Department of Health Provincial Nutrition Directorate, District Nutrition Co-ordinators, and Facility Based Dietitians and Nutritionists KZN CMAM Guidelines 2012 Cover picture copyright to World Health Organisation 2014 List of Appendices Appendix 1: Physiological basis for treatment of severe acute malnutrition Appendix 2: Case definitions of Medical complications with SAM Appendix 3: Recipe for stabilizing (F75) and catch-up (F100) feed Appendix 4: Stabilizing Feed (F75) Feeding chart Appendix 5: Stabilizing Feed (F75) Feeding chart for children with gross (+++) oedema Appendix 6: Ranges of catch-up feed (F100) Appendix 7: Elemental iron preparation Appendix 8: Weight chart Appendix 9: 24 hour food intake chart Appendix 10: Daily ward feed chart Appendix 11: Death review form for SAM Appendix 12: Action Protocol in Outpatient Care Appendix 13: Infant Feeding Assessment, Counselling and Support in 0 – 6 months Appendix 14: Weight for Height/Length Charts (WHO 2006 Growth Standards) 6 – 23 months Appendix 15: Weight for Height/Length Charts (WHO 2006 Growth Standards) 24 - 59 months Appendix 16: Clinical Audit of the WHO Ten Step Protocol and Emergency Management Protocol Appendix 17: WHO Resource Checklist and Case Fatality Review Appendix 18: Outpatient Therapeutic Protocol for SAM without complications Appendix 19: NRAST 0 – 59 Months Appendix 20: NRAST > 5 years Appendix 21: Referral Pathway Appendix 22: Severe Acute Malnutrition Emergency Treatment in South Africa Appendix 23: Protocol for the inpatient management of children with severe acute malnutrition Appendix 24: BMI for age charts 5 – 14 years List of Tables Table 1: Classification of SAM in children 5g/ Persistent and good weight gain (>10g/ day) over 5 days kg/day) over 5 days Ideally, severe wasting resolved ( WHZ Ideally, severe wasting resolved (MUAC >-2 SD) ≥ 11.5cm or WHZ >-3 SD) Before Discharge: Investigate for TB. Repeat the tuberculin skin test and read it within 48 hours. Record the findings. Ensure Counselling and Test for HIV was done. Record the findings. Ensure that information on family background and socio-economic status was obtained. Refer to Social Services (SASSA, Social Development, Home Affairs) and / or hospital social work- ers Give health and nutrition education and enrol the child into the outpatient supplemen- tation programme (OSP). Share educational messages about the child and caregiver using the 16-Key Family Practices booklet which contains information about when to return urgently to Clinic, hygiene, infant feeding and complementary feeding advice, stimulation, family plan- ning, HIV, immunization, role of male partner. Work with Dietitian to counsel mothers/caregiv- ers on how to modify family foods, how often to feed and how much to give and emphasize that these practices will help to prevent the child developing malnutrition again. FOR CHILDREN 0 – 6 MONTHS, investigate feeding practices as per IMCI protocol – see Ap- pendix 13. Ensure the child was registered on the Severe Acute Malnutrition Inpatient care register. En- sure the child is counted onto the District Health Information System (DHIS) and Admissions, Discharges and Deaths (ADD) Register. Establish a link with local PHC Clinic (Nutrition Advisor) and family’s local Community Care Givers (CCG’s) for home follow-up (See Referral Pathway). Prepare a Discharge Summary and write a brief clinical summary in the RtHB. Make follow- up plans to see the child in one week at hospital outpatient department or at local PHC clinic. 30 INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN KWA-ZULU NATAL IMAM 2.indd 30 2/4/2014 6:24:59 PM  4.1 O  UTPATIENT SUPPLEMENTATION PROGRAMME (OSP) FOR CHILDREN 6 – 59 MONTHS WITH MODERATE ACUTE MALNUTRITION (MAM) OUTPATIENT MANAGEMENT OF OSP Admission: Type 1: Recovered SAM cases referred from Inpatient care to OSP MALNUTRITION Type 2: Newly Diagnosed, MAM cases referred from the community (PhilaMntwana Centres, NA / CCG Home visits) - MUAC >11.5cm – 6 months, wash the child’s hands and face before feeding. Counsel mother on identifying danger signs as in RtHB (Vomiting, Unable to breastfeed, diar- rhoea with sunken eyes or sunken fontanelle, diarrhoea with blood, chest indrawing, child < 2 years not feeding and has fever, child lethargic or unconscious, cough and breathing rate more than 50 breaths per minute). Counsel mother on preparation of ORS at home and how to treat diarrhoea to prevent dehy- dration. Seek information to identify poor feeding practices or social circumstance that may have re- sulted in growth faltering. Refer to social worker if necessary 32 INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN KWA-ZULU NATAL IMAM 2.indd 32 2/4/2014 6:25:01 PM  AGE CATEGORY: Birth – 6 months  Assess and counsel on feeding as per Appendix 17 for both the breastfed and non – breast- fed infant. Exclusive breastfeeding is recommended (i.e. give only breast milk and no other OUTPATIENT MANAGEMENT OF liquids or solids, not even water, with the exception of drops or syrup consisting of vitamins, mineral supplements or medication. Do not give other fluids. MALNUTRITION Breastfeed on demand i.e. as baby wants, both day and night. Feed at least 8-12 times a day. When away from the baby, leave expressed breast milk to feed with a cup. Avoid using bottles or artificial teats as these may interfere with suckling. Teats or dummies may cause nipple confusion. They are also difficult to clean and may carry germs that can make your baby sick. Clean baby’s mouth regularly Take baby to the clinic every month. AGE CATEGORY: 6 – 8 months From the age of 6 months, baby needs complementary foods in addition to breast milk, in order to grow well. Always breastfeed first before giving complementary foods. Introduce one new food at a time. Wait a few days before introducing another new food, to make sure he/ she can tolerate the new food Start by giving 2-3 tablespoons of thick porridge or infant cereal or mashed vegetables or meat 2-3 times a day. Give vegetables before fruit. Increase gradually to ½ cup per meal. By 8months, give baby small chewable foods. Let baby try to feed him/herself, but provide help. Avoid foods that can cause choking e.g. nuts, sweets, grapes, raw carrots Give one or two snacks (smaller meals) between main meals depending on baby’s appetite. Add sugar, margarine or oil or powdered full cream milk to increase energy intake. Take your baby to the clinic every month IMPLEMENTERS OPERATIONAL GUIDE 33 IMAM 2.indd 33 2/4/2014 6:25:02 PM  AGE CATEGORY: 9 – 11 months Give 3 – 4 meals per day of finely chopped, mashed or finger foods, OUTPATIENT MANAGEMENT OF Give mashed dried beans, egg yolk, minced meat, fish, chicken, chicken livers Increase portion size gradually to ½ cup Give one or two snacks (smaller meals) between main meals depending on baby’s appetite. MALNUTRITION Feed baby from his/her own plate or bowl. Patiently help baby to eat, do not force him/ her to eat. Keep baby interested in the meal by removing distractions while he/ she is eating. Offer your baby clean, safe water after eating. Water must be boiled and cooled. Add sugar, margarine or oil, peanut butter or full cream milk powder to increase energy intake. Take your baby to the clinic every month. AGE CATEGORY: 12 – 23 months Continue to breastfeed as often as the child wants, until he/she is 2 years and beyond If not breastfed, give at least 2 cups of full cream milk or maas every day. Continue to give 3 – 4 nutritious main meals and 1 – 2 smaller meals, depending on child’s appetite. Give a variety of family foods. Give ¾ to 1 cup of mashed, chopped or soft foods. Breast milk should still be an important source of nutrition for the baby. Give foods rich in iron, Vitamin A and C Iron-rich foods: Liver, kidney, dark green leafy vegetables, egg yolk, dry beans, fortified cere- als. Avoid drinking tea when eating these foods as it interferes with absorption of iron. Iron is best absorbed when taken with Vitamin C rich foods. Vitamin A-rich foods: Liver, dark green leafy vegetables, mango, paw paw, yellow sweet po- tato, full cream milk. Vitamin C-rich foods: Guavas, tomatoes, Citrus fruit e.g. oranges, naartjies Offer clean safe water regularly. Encourage your child to be active every day. Add sugar, oil or margarine, full cream milk and peanut butter to increase energy intake Teach baby to drink from a cup. If you offering sweets, treats or drinks, offer small amounts at / after meals. Take your child to the clinic every month. 34 INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN KWA-ZULU NATAL IMAM 2.indd 34 2/4/2014 6:25:04 PM  AGE CATEGORY: 24 – 59 months Give at least 2 cups of full cream milk or maas every day. OUTPATIENT MANAGEMENT OF Encourage your child to eat a variety of foods. Feed your child 5 meals a day. Children need plenty of vegetables and fruit every day. MALNUTRITION Make starchy foods the basis of your child’s main meals. Children can eat plenty of chicken, fish, eggs, beans, soya or peanut butter every day. Give foods rich in iron, Vitamin A and C (See above food lists) If your child has sweets, treats or drinks, offer small amounts at meals. Offer clean safe water regularly. Encourage your child to be active every day. Add sugar, oil or margarine, full cream milk and peanut butter to increase energy intake If you offer sweets or treats give small amounts with meals. Take your child to the clinic or Philamntwana site every 3 months. Immunization , Vitamin A Prophylaxis Schedule and Deworming is up to date Ensure immunizations are caught up. Record all doses given in the RtHB. Malaria Treatment (for malaria prevalent areas) Routinely screen all children for malaria in endemic areas on admission regardless of their body temperature, if diagnostic tests are available. If in clinical doubt or symptoms, repeat the malaria test in the weeks following the initial test. If no diagnostic test is available but malaria symptoms are diagnosed, treat the child. Treat malaria according to the national treatment protocol with first-line artemisinin-based combina- tion therapy (ACT) in compliance with Integrated Management of Childhood Illnesses (IMCI) treatment. In all cases of diagnosed or suspected malaria, the child is referred to inpatient care and treatment with a second-line antimalarial drug is provided Note: A child with SAM cannot auto-regulate his/her body temperature well and tends to adopt the temperature of the environment; thus the child will feel hot on a hot day and cool on a cool day. In malaria-endemic areas, children with SAM should be provided with insecticide-treated bed nets to prevent malaria infection. Criteria for discharge from OSP: Note: A child should not remain on supplementation for > 6 months (across all categories). If there is no improvement after 2 months, investigate failure to response to treatment. MUAC ≥ 12.5cm or WHZ ≥ -2SD Referral Process The child exits the OSP and enters GMPs. IMPLEMENTERS OPERATIONAL GUIDE 35 IMAM 2.indd 35 2/4/2014 6:25:05 PM  4.2 GROWTH MONITORING AND PROMOTION SUPPORT (GMPs) FOR CHILDREN 6 – 59 MONTHS (Not Acutely Malnourished but at risk) GMPs Admission: OUTPATIENT MANAGEMENT OF Type 1: Recovered MAM cases referred from the same PHC. Type 2: Newly Diagnosed, NAM cases referred from the community / PhilaMntwana Centre MALNUTRITION MUAC ≥ 12.5cm or WHZ between -2SD & -1SD and Poor weight gain, no weight gain or weight loss following 2 successive visits on the RtHB. Dietary Treatment Age 6 – 11 Months: GMPs – Fortified Infant Cereal & RUTF A deficit in the home diet of 50kcal is assumed. Supplement to provide additional 50kcal / kg / BW per day to prevent further growth faltering. Average taken weight taken in each category Recommendation would be to use infant cereal independently. Add RUTF to other foods Infant Cereal (with RUTF milk) Monthly Daily Daily 4.0 – 4.9kg 50g 1.5tsp (22g) 2 x 450g RUTF 225kcal / day 120kcal 116kcal 6 x 250g boxes 5.0 – 6.9kg 50g 2 tsp (30g) 2 x 450g RUTF 300kcal / day 120kcal 156kcal 6 x 250g boxes 7.0 – 9.9kg 50g 4 tsp (60g) 4 x 450g RUTF 400kcal / day 120kcal 315kcal 6 x 250g boxes Age 12 – 59 Months: GMPs – Enriched Maize Meal (EMM) and RUTF EMM Daily RUTF Daily Monthly 4.0 – 4.9kg 50g 1tsp (15g) 2 x 1kg pkt EMM 225kcal / day 179kcal 79kcal 1 x 450g RUTF 5.0 – 6.9kg 50g 1.5tsp (22g) 2 x 1kg pkt EMM 300kcal / day 179kcal 116kcal 2 x 450g RUTF 7.0 – 9.9kg 100g 1tsp (15g) 4 x 1kg pkt EMM 400kcal/ Day 358kcal 79kcal 1 x 450g RUTF 10.0 – 14.9kg 100g 3tsp (45g) 4 x 1kg pkt EMM 625kcal / day 358kcal 236kcal 3 x 450g RUTF 15.0 – 19.9kg 150g 4 tsp (60g) 5 x 1kg pkt EMM 875kcal / day 537kcal 315kcal 4 x 450g RUTF 36 INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN KWA-ZULU NATAL IMAM 2.indd 36 2/4/2014 6:25:06 PM  Nutrition Education As per OSP Protocol OUTPATIENT MANAGEMENT OF Immunization and Vitamin A Prophylaxis Schedule is up to date Ensure immunizations are caught up. Record the dose given in the RtHB. MALNUTRITION Malaria Treatment (for malaria prevalent areas) As per OSP protocol (Pages 31 - 33) Criteria for discharge from GMPs: MUAC ≥ 12.5cm or WHZ > -1SD and growing well The child should remain on supplementation for 2 months after recovery to prevent relapse how- ever a child should not remain on supplementation for > 6 months (across all categories). If there is no improvement after 2 months, investigate failure to response to treatment. IMPLEMENTERS OPERATIONAL GUIDE 37 IMAM 2.indd 37 2/4/2014 6:25:07 PM  4.3 NUTRITION SUPPLEMENTATION PROGRAMME (≥ 5 YEARS) Nutrition Assessment, Counselling and Support (NACS) is essential for improved nutrition and health outcomes. Health care facilities can provide NACS services at different contact points, OUTPATIENT MANAGEMENT OF including antenatal care, maternity wards, paediatric wards, outpatient departments, antiretroviral therapy (ART) clinics for people with HIV, and TB clinics. Clients can be referred by other clinical services or by community health workers, community nutrition surveillance, home based care providers, and programs for orphans and vulnerable children. In all counselling sessions, atten- MALNUTRITION tion should be given to enhancing food security and modifying family meals to increase energy and nutrient value. Classification of the patient as SAM or MAM is based on anthropometric data, however clinicians should also assess a patient’s risk to becoming SAM if the patient presents with dysphagia, se- vere mouth sores, vomiting, nausea and / or diarrhea. Assessment and Classification: See NRAST POSTER FOR > 5 years (Appendix 20) MAM SAM MUAC < 13.5cm or MUAC 13.5 - 14.5cm OR BMI for age 15 years category LFED: 150g – 537kcal prescription Monthly Issue: 6 pkt EMM Monthly Issue: 3pkt EMM 6kg LFED 5 kg LFED 1130kcal 1760kcal EMM: 100g – 358kcal EMM: 200g – 716kcal Lactating Women LFED: 150g – 537kcal LFED: 200g – 716kcal Additional 500kcal / day RUTF: 45g – 236 kcal RUTF: 60g – 314kcal Monthly Issue: 3pkt EMM Monthly Issue: 6 pkt EMM 6kg LFED 6kg LFED 3 x 450g RUTF 4 x 450g RUTF IMPLEMENTERS OPERATIONAL GUIDE 39 IMAM 2.indd 39 2/4/2014 6:25:10 PM  Criteria for discharge: Discharge OUTPATIENT MANAGEMENT OF MUAC >14.5cm or 5 – 9 years BMI for age between -2SD & -1SD MUAC >18cm or 10 – 14 years MALNUTRITION BMI for age between -2SD & -1SD BMI > 18.5kg / m2 or >15 years MUAC >23cm MUAC > 23cm Pregnant Women: For the duration of pregnancy or Pregnant & Lactating Women until MUAC > 23cm. Lactating Women: MUAC > 23cm or if not improving, for the first years of child’s life. Referral Process The patient remains on supplementation for 2 months after recovery to prevent relapse (exclud- ing pregnant and lactating woman). The patient should not remain on supplementation for longer than 6 months. If no improvement after 2 months, investigate failure to respond to treatment. 40 INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN KWA-ZULU NATAL IMAM 2.indd 40 2/4/2014 6:25:11 PM  4.4 COMMUNITY OUTREACH Community outreach mobilises communities; it raises awareness of the burden of malnutrition and aims of services, and builds support for them. Moreover, it strengthens the community’s OUTPATIENT MANAGEMENT OF awareness of causes, signs and treatment of acute malnutrition, and promotes health and nutri- tion behaviour change and improved hygiene. Through community outreach, health care pro- viders can better understand the needs of the local community and the factors that may act as barriers to accessing care, while promoting and supporting infant and child nutrition and care MALNUTRITION practices in the communities to prevent malnutrition. An understanding needs to be established of the link between the patient, health facility and community based care initiative, and the roles and responsibilities of the relevant healthcare workers. 4.1.1 REFERRAL PATHWAY (Nutrition Care) Figure 2: Referral Pathway of the SAM Child Dietitian, SAM Inpatient Paediatrician, Paediatric Ward OM, Social Worker Severe Acute Malnutrition, Medical Complications Nutrition Advisor, IMCI Trained District Nurses, Operational Clinical PHC Clinic for Outpatient Manager Specialist Supplementary Programme Team Immunization, Growth Monitoring and Promotion Philamntwana Centre (CCG), Family Health HOME Team IMPLEMENTERS OPERATIONAL GUIDE 41 IMAM 2.indd 41 2/4/2014 6:25:13 PM  4.4.1 ROLES & RESPONSIBILITIES Dietitian OUTPATIENT MANAGEMENT OF The Dietitian will form part of the multidisciplinary team in the inpatient management of SAM pa- tients. The Dietitian will review the assessment and classification of the patient, and prescribe and manage the nutritional care of the patient. All consultations should be recorded in the patient file. Upon discharge the Dietitian should ensure that appropriate follow up of the child will con- MALNUTRITION tinue at PHC level and a link is established with the Nutrition Advisor at the PHC. The Dietitian should monitor how SAM patients are been followed up at PHC level when conducting PHC Monitoring and Evaluation visits. The dietitian will participate in clinical audits and death reviews pertaining to SAM < 5 years. Paediatrician (medical officer should be involved in the absence of paediatrician) The paediatrician will form part of the multidisciplinary team in the inpatient management of SAM patients and provide support on the medical management of SAM patients to doctors at POPD to ensure that emergency treatment protocol of SAM patients is followed and not delayed due to late diagnosis of SAM. The paediatrician will review the medical assessment and classification of SAM and manage the medical care of the patient. All consultations should be recorded in the patient file. The paediatrician will also participate in clinical audits and death reviews pertaining to SAM in children < 5 years. Paediatric Nurse The paediatric nurse will form part of the multidisciplinary team in the inpatient management of SAM patients and provide support on the monitoring of the patient, and recording of all relevant information pertaining to the patient. Paediatric Operational Manager The Paediatric Ward Operational Manager will be responsible for the overall requirements for the management of SAM patients. The Paediatric OM should be involved in the monthly death reviews conducted by the MDT and be made aware of the challenges experienced by the MDT in the management of SAM. The Paediatric OM will be also be responsible for collation of statis- tics on severe malnutrition and ensuring that sustainable referral systems of SAM patients are in place. The Paediatric OM will report to the Hospital Management on the above. PHC IMCI Trained Professional Nurses PHC based IMCI trained nurses will be involved the assessment and classification of all children attending their facilities. They will be involved in educating mothers on IMCI danger signs, SAM and MAM and educating mothers accordingly. They will be involved in monitoring patients regis- tered in the outpatient supplementation programme where there is no available nutrition advisor. They will record all patient details and collect all data pertaining to child health and nutrition. Nutrition Advisors The PHC based Nutrition Advisor is responsible for the implementation of nutrition related inter- ventions and works as part of the PHC based team. The Nutrition Advisor will be responsible for the following with regards to IMAM: ensure growth monitoring and promotion of all children under 5 years at the facility ensure nutrition assessment by taking MUAC measurements, weights, lengths, and interpre- tations of Z-scores. nutritional management of patients and ensuring that therapeutic supplements are available and issued according to protocol nutritional management of all patients registered on the outpatient supplementary programme 42 INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN KWA-ZULU NATAL IMAM 2.indd 42 2/4/2014 6:25:14 PM  (OSP) and growth monitoring and promotion (GMPs). follow up on down referred cases of SAM. Link up with relevant CCGs to ensure household visits of discharged SAM cases OUTPATIENT MANAGEMENT OF proper keeping of records and reporting on the issuing of nutrition supplements.     PHC Operational Manager MALNUTRITION The PHC Operational Manager will be responsible for submission of NA monthly report, CCG Monthly Summary Report (collated) and PHC facility statistics pertaining to child health and nutri- tion to the district. Community Care Givers CCG’s will be expected to conduct home visits and report on the progress if:- Child is absent or defaulting Child is not gaining weight or losing weight on follow-up visit at PhilaMntwana Centre Child has returned from inpatient care or refuses referral to inpatient care CCG’s based at Philamntwana Centres will submit weekly and monthly reports that include all children diagnosed with SAM and MAM. District Clinical Specialist Team (DCST) The DCST will conduct regular visits to facilities to ensure that clinical protocols and guidelines are followed and adhered to. They will conduct quality improvement visits, perform clinical audits and provide data on causes of death and modifiable factors to the hospital based MDT’s. DCST will also work with the dietitians and NAs to support PHC Operational Managers on improving the quality of care provided to malnourished children and adults. IMPLEMENTERS OPERATIONAL GUIDE 43 IMAM 2.indd 43 2/4/2014 6:25:15 PM  MONITORING AND EVALUATION 5 MONITORING AND EVALUATION FRAMEWORK Monitoring is the periodic and timely collection of data to determine if activities are being imple- mented as planned. The monitoring process tracks indicators and is a means of verification at the output level. The Evaluation process assists in determining the achievement of goals and objectives. Evalu- FRAMEWORK ation will give an opportunity to assess comprehensively and document the effectiveness of the inpatient management of SAM and to use the lessons learnt. An effective M&E Framework (Fig- ure 3) will help to identify desired outcomes from implementation. In the context of the current guidelines, monitoring will take place at inpatient level by the hospital based MDT and at outpa- tient level by the PHC team. All relevant team members should be familiar with and able to use the monitoring tools. Figure 3: Monitoring and Evaluation Framework Integrated Management of Acute Malnutrition Inpatient Management of SAM Outpatient Management of Moderate Acute Malnutrition Malnutrition Individual Patient Monitoring CCG Monthly Summary Report SAM Audit Tool on the WHO Ten Step Nutrition Advisor Monthly Report Protocol and Emergency Treatment Dietitian PHC M & E Report Sam Death Review (Death Review Form) Responsible Persons: CCG’s, NA’s, Clinical Dietitians, PHC Operational Data Interrogation (ADD & DHIS) Managers Responsible Persons: Paediatric Ward SAM MDT Final Report: Paediatric Operation Manager District Clinical Specialist Team District Nutrition Co-ordinators Malnutrition Report 44 INTEGRATED MANAGEMENT OF ACUTE MALNUTRITION IN KWA-ZULU NATAL IMAM 2.indd 44 2/4/2014 6:25:17 PM  5.1 INPATIENT MONITORING AND EVALUATION Inpatient M & E involves monitoring individual patient progress, clinical audit and interrogation of inpatient data. The tools used will be:- MONITORING AND EVALUATION Daily Monitoring of Individual Patient Progress - Standard patient monitoring tools for vital signs, fluid input and output, weight gain chart. Clinical Audit - Compliance to the WHO ten step protocol and emergency management proto- FRAMEWORK col (Appendice 22 and 23), Death Review (Appendix 11) Interrogation of Data - A-D-D Triplet Register, DHIS Daily Hospital Data Collection Tools The MDT managing SAM in the paediatric ward should be implementing the above, and reporting to the operation manager on the results. The malnutrition / child health committee should meet monthly to discuss gaps and challenges in the management of SAM. The Paediatric Operational Manager should review the data on the ADD Triplet and DHIS Monthly Data Reports. 5.1.1. Monitor Vital signs. Monitor and record pulse, respirations and temperature every 4 hours Danger signs are: Pulse rate increase by 25 or more beats / min Respiratory rate increase by 5 or more breaths/min Temperature drops below 35°C axillary Temperature increases suddenly to > 37.5°C axillary 5.1.2 Monitor Weight Gain Weigh at the same time each day Record daily weights on weight chart (Appendix 8) Plot weights Indicate where F100 began Indicate desired discharge weight Calculate weight gain Calculate daily after child is on F100 Calculate weight gain in grams per kilogram body weight (g/kg/day) Good: 10g/kg/day + Moderate: 5-10g/kg/day Poor: