IMCI Approach: Malnutrition & Feeding (2m-5y)

Clinical assessment

Assessment based on presence of bilateral pitting oedema, measurement of WFH/L Z-score, MUAC, or WFA Z-score, combined with feeding assessment and check for medical complications.

Investigations

• Anthropometric measurements (Weight, Height/Length, MUAC).
• Plotting on WHO Growth Standards charts.
• Appetite test (using RUTF) for SAM classification.
• Assessment of feeding practices.
• Check for medical complications (as per IMCI assessment).

Diagnostic criteria

IMCI Classification based on findings: - Complicated Severe Acute Malnutrition (SAM): Oedema OR WFH/L <-3z OR MUAC <115mm AND (Any Medical Complication OR Failed Appetite Test OR Breastfeeding Problem <6m). - Uncomplicated Severe Acute Malnutrition (SAM): WFH/L <-3z OR MUAC <115mm OR Very Low WFA AND No Medical Complications AND Passed Appetite Test (if >=6m). - Moderate Acute Malnutrition (MAM): WFH/L between -3z and -2z OR MUAC 115mm up to <125mm OR Low WFA. - No Acute Malnutrition: WFH/L >= -2z AND MUAC >= 125mm.

Non-pharmacological management

• Complicated SAM:
• - Prevent low blood sugar (breastfeed/EBM/sugar water).
• - Keep child warm.
• - Refer URGENTLY to Hospital for inpatient therapeutic care (stabilization phase).
• Uncomplicated SAM (>=6m):
• - Outpatient Therapeutic Care (OTC) program.
• - Provide weekly supply of RUTF (Ready-to-Use Therapeutic Food) based on weight.
• - Counsel mother on RUTF use, hygiene, continued feeding, danger signs.
• - Assess for possible TB.
• - Follow up weekly initially, then bi-weekly.
• Uncomplicated SAM (<6m): Focus on optimizing exclusive breastfeeding. Refer to specialized support (lactation consultant/nutritionist).
• Moderate Acute Malnutrition (MAM):
• - Assess feeding and provide intensive counseling based on age-appropriate recommendations (See PED020).
• - If feeding problem identified, follow up in 7 days.
• - Provide supplementary feeding if available through programs (e.g., Corn Soya Blend - CSB).
• - Assess for possible TB.
• - Follow up monthly for reassessment and counseling.
• No Acute Malnutrition:
• - If child <2 years or feeding concerns: Assess feeding and counsel on age-appropriate recommendations.
• - If feeding problem identified, follow up in 7 days.
• - Promote continued good feeding practices.

Pharmacological treatment

• Complicated SAM:
• - Give FIRST DOSE pre-referral antibiotic (Ampicillin 50mg/kg IM + Gentamicin 7.5mg/kg IM OR Benzylpenicillin 50,000 IU/kg IM).
• - Hospital management includes therapeutic milk (F-75, F-100), electrolytes, micronutrients, antibiotics.
• Uncomplicated SAM:
• - Give routine Amoxicillin DT 40 mg/kg PO BID for 5 days at initiation of OTC.
• - RUTF contains necessary micronutrients; DO NOT give separate iron initially.
• - Routine deworming (Albendazole/Mebendazole if >1 year).
• - Measles vaccine if due.
• MAM: Routine deworming, Vitamin A if due.
• All Malnutrition: Assess immunization status and vaccinate as needed.

Monitoring

Weekly follow-up initially for Uncomplicated SAM (weight, MUAC, appetite, complications). Monthly follow-up for MAM. Monitor feeding practices and provide ongoing counseling.