Correction of malnutrition standard 2: severe malnutrition
Severe malnutrition is addressed.
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Key indicators (to be read in conjunction with the guidance notes)
From the outset, clearly defined and agreed criteria for set-up and closure of the programme are established (see guidance note 1).
Coverage is >50% in rural areas, >70% in urban areas and >90% in camp situations (see guidance note 2).
- The proportion of exits from therapeutic care who have died is less than 10%, recovered is more than 75% and defaulted is less than 15% (see guidance notes 3-5).
Mean weight gain is >8g per kg per person per day (see guidance note 6).
Nutritional and medical care is provided according to internationally recognised therapeutic care protocols (see guidance note 7).
As much attention is attached to breastfeeding and psychosocial support, hygiene and community outreach as to clinical care (see guidance note 8).
There should be a minimum of one feeding assistant for 10 in-patients.
Constraints to caring for malnourished individuals and affected family members should be identified and addressed (see guidance note 9).
Guidance notes
1. Starting therapeutic care: factors which should be taken into account in the opening of centres for the treatment of severe malnutrition are the numbers and geographical spread of affected individuals; the security situation; recommended criteria for setting up and for closing centres; and the capacity of existing health structures. Therapeutic feeding programmes should not undermine the capacity of health systems, nor allow governments to abdicate their responsibilities for providing services. Wherever possible, programmes should aim to build on and strengthen existing capacity to treat severe malnutrition. The purpose of the programme should be clearly communicated and discussed with the target population (see Participation standard). A therapeutic care programme should only be started if there is a plan in place for remaining patients, at the end of the programme, to complete their treatment.
2. Coverage is calculated according to the target population and can be estimated as part of an anthropometric survey. It can be affected by the acceptability of the programme, location of treatment centres, security for staff and those requiring treatment, waiting times and service quality.
3. Exit indicators: the time needed to achieve the exit indicators for a therapeutic feeding programme is 1-2 months. Exits from a feeding programme are those no longer registered. The population of exited individuals is made up those who have defaulted, recovered (including those who are referred) and died (see previous standard, guidance note 3 for how to calculate exit indicators). Mortality rates should be interpreted in the light of coverage rates and the severity of malnutrition treated. The extent to which mortality rates are affected in situations where a high proportion of admissions are HIV-positive is unknown; for this reason, the figures have not been adjusted for these situations.
4. Recovery rates: a discharged individual must be free from medical complications and have achieved and maintained sufficient weight gain (e.g. for two consecutive weighings). Established protocols suggest discharge criteria which should be adhered to, in order to avoid the risks associated with premature exit from the programme. Protocols also define limits for the mean length of stay for patients in therapeutic feeding, aimed at avoiding prolonged recovery periods (e.g. typical lengths of stay may be 30-40 days). HIV/AIDS and TB may result in some malnourished individuals failing to recover. Options for longer-term treatment or care should be considered in conjunction with health services and other social and community support (see Control of communicable disease standards 3 and 6). Causes of readmission, defaulting and failure to respond should be investigated and documented on an ongoing basis. Individuals should be followed up wherever possible after discharge and referred for supplementary feeding where possible.
5. Default rates can be high when the programme is not accessible to the population. Accessibility may be affected by the distance of the treatment point from the community, an ongoing armed conflict, a lack of security, the level of support offered to the care giver of the individual treated, the number of care givers who are left at home to look after other dependants (this may be very few in situations of high HIV/AIDS prevalence), and the quality of the care provided. A defaulter from a therapeutic feeding programme is an individual who has not attended for a defined period of time (e.g. for more than 48 hours for in-patients).
6. Weight gain: similar rates of weight gain can be achieved in both adults and children when they are given similar diets. Average rates of weight gain, however, may mask situations where individual patients are not improving and are not being discharged. Lower rates may be more acceptable in out-patient programmes because the risks and demands on the community, e.g. in terms of time, can be much lower. Mean weight gain is calculated as follows: (weight on exit (g) minus weight on admission (g))/(weight on admission (kg)) x duration of treatment (days).
7. Protocols: internationally accepted protocols, including definitions of failure to respond, are found in the references in Appendix 9. In order to implement treatment protocols, clinical staff require special training (see Health systems and infrastructure standards). Individuals admitted for therapeutic care who are tested or suspected to be HIV-positive should have equal access to care if they meet the criteria for admission. This is also applicable to TB cases. PLWH/A who do not meet admission criteria often require nutritional support, but this is not best offered in the context of treatment for severe 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.
8. Breastfeeding and psychosocial support: breastfeeding mothers require special attention to support lactation and optimal infant and young child feeding. A breastfeeding corner may be set up for this purpose. Emotional and physical stimulation through play is important for severely malnourished children during the rehabilitation period. Care givers of severely malnourished children often require social and psychosocial support to bring their children for treatment. This may be achieved through outreach and mobilisation programmes (see General nutrition support standard 2).
9. Carers: all carers of severely malnourished individuals should be enabled to feed and care for them during treatment through the provision of advice, demonstrations and health and nutrition information. Programme staff should be aware that discussions with care givers may expose individual human rights violations (e.g. deliberate starvation of populations by warring parties) and they should be trained in procedures for dealing with such situations.
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