MALNUTRITION – Screening and referral
BALKH Nutrition Team
2014
29 juillet 2017
Objectives of training
 To understand basics about undernutrition: definition,
causes and consequences
 To know how to perform anthropometric measurements –
identify MAM and SAM children / PLW
 To know and understand the management of acute
malnutrition
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Nutrition
Nutritional status: balance
physiological state of an individual, which results from:
the relationship between nutrient intake and requirements, and
the body’s ability to digest, absorb and use these nutrients.
NUTRITIONAL
REQUIREMENTS
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FOOD INTAKE
3
Nutritional Status: not well
balanced diet
NUTRITIONAL
REQUIREMENTS
FOOD INTAKE
Over-nutrition
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Obesity
4
Nutritional Status: not well
balanced diet
FOOD INTAKE
NUTRITIONAL
REQUIREMENTS
Under-nutrition
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Non-balanced nutrition can be
caused by :
 Sufficient quantity but insufficient quality of food
(lack of diversified food)
 Sufficient quality but insufficient quantity of food
(lack of intake)
 Insufficient quantity and quality of food
(lack of intake and diversified food)
MALNUTRITION : Term for bad nutritional status
Definition: situation when the body does not receive the
sufficient quantity and/or quality of nutrients.
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Food intake
 Food intake depends on different factors:
• Availability of the food
— For example: food available in the market
• Accessibility of the food
— For example: cost of the food in the market
 Possible influences??
• Harvest, price, soil, culture/beliefs, etc
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The tree of malnutrition
Malnutrition
unbalanced nutritional status
Over nutrition
Micronutrient deficiency
Under-nutrition
overweight
OBESITY
Chronic malnutrition
stunting
Under-weight
Acute malnutrition
wasting
Installed status
MALNUTRITION
Incorrect definition: Malnutrition= acute
undernutrition
Correct definition: Mal + nutrition= “bad nutrition”
ACF: Focus on Acute malnutrition ++
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MAM
SAM
Episodic status
Consequences of malnutrition
 Short term consequences
• Mortality, morbidity, disability
 Long term consequences
• Intellectual capacity
• Economic productivity
• Reproductive performance
• Diseases
• Future psychological well being
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Consequences and risks of
malnutrition...
Lowered resistance to disease
Even not dangerous disease becomes dangerous
Increased risk of mortality
Learning difficulties
Reduced physical activity
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Acute Malnutrition
 Acute Malnutrition = DISEASE
 Acute malnutrition
• Sudden deprivation / Short-term process
• Sudden weight loss
• More vulnerable population : Children 659 months and PLW
• Consequences if no treatment : DEATH
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Under-nutrition : Causes
Manifestations
Malnutrition & mortality
Insufficient food
intake
Poor acces,
availability and
quality of food
Impairs growth
and development
Inadequate child
care practices and
psychological
environment
Diseases
Poor acces,
availability and
quality of health
services, unhealthy
environment
Quantity, quality, and control of true resources
(human, economic, institutional)
Immediate
Causes
Underlying
Causes
Basic causes
within society
Potential resources
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Classification of Acute malnutrition
2 classifications according to gravity:
 Moderate Acute Malnutrition (MAM)
• Lost of weight is started
• Precede severe acute malnutrition if not treated
 Severe Acute Malnutrition (SAM)
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Severe Acute malnutrition
3 forms
MARASMUS
Severely wasted
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KWASHIORKOR
Bilateral Oedema
MARASMICKWASHIORKOR
Both
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Marasmus
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
Skinny: underweight
Old man’s face, Sunken eyes
Irritability
Subcutaneous fat and muscles loss
Distended abdomen
Impression of too much skin at the buttock
Hungry
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Kwashiorkor


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Nutritional bilateral oedema
Skin lesions
Lethargy
Moon face
Depigmentation: skin and hair
Anaemia
No appetite
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Marasmic-kwashiorkor
Combination of
 Weight loss
AND
 Nutritional bilateral oedema

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Skinny arms and swollen feet
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Different types of severe acute malnutrition
Marasmus
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Marasmuskwashiorkor
Kwashiorkor
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Acute malnutrition
 How can we measure it ??
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Anthropometric measurement
Anthropometry is human body measurement: nutritional
status of a person is estimated by the measure of some
corporeal parameters.
In addition to the clinical picture, malnutrition diagnosis
will be confirmed by anthropometric measurements.
That’s why they need to be taken properly and be
accurate
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Diagnosis of malnutrition
Types of Under-Nutrition
Diagnostic tools
Acute Malnutrition (wasting) Weight, height, bilateral
(Marasmus
oedema, MUAC, age, sex
Kwashiorkor)
Chronic malnutrition
Height, age, sex
(Stunting)
Underweight
Weight, age, sex
Micronutrient deficiencies…
Hemoglobin level, paillor, night
vision reduction, gingival
bleeding, goiter, …
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Anthropometric measurements
What is necessary to do a
good anthropometric
measurement?
 Good measurement
equipment
 Standardized
measurement procedure
 Well trained personnel
 …
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MUAC Measurement
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MUAC measurement
MUAC : Mid Upper Arm circumference
CHILDREN >6 months
 On the left folded arm, between
shoulder bone and tip of the elbow
 Put the tape to the length of the
folded arm,
 Mark midpoint
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MUAC measurement
 Left arm is unfolded and
relaxed;
 Tape is wrapped aroune the
arm,at the midpoint, neither
too tighten or too loose/slack.
Do not lean fingers on the
tape or the arm
 Read the measure between
the arrows of 1mm for precise
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How check oedema ?
Observe the depression on both
feet = pit
If it is the case => check the legs,
then hands, then face
Have a light pressure for 3
seconds on the top of the feet
at the same time
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Oedema
 Graduation of oedema according severity:
• Grade 1+ : Bilateral pitting oedema of the feet
• Grade 2+(or ++) :Bilateral oedema of the feet
and lower limbs / hands
• Grade 3+(or +++) : Generalised oedema of
feet, lower limbs, hands and periorbital
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Bilateral oedema
 Immune and inflammatory fonctions are severly
affected for kwashiorkor children, in such a way
that cutaneous lesions aren’t painful for them.
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Height measurement
 For all children < 87cm
 Child straight along the
scale, chin raised and
feet down flat on the
cursor
 Read the measure on
the cursor level of 1mm
for precise
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Height measurement
Correct position
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Height measurement
Ideal position
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Standing height measurement
 For all children > 87cm
 Child straight along the
scale, joint feet
 Straight head, maintain
the chin
 Arms along the body
 Read the measure on the
cursor level of 1mm for
precise
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Standing height measurement
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Weight measurement
 SALTER scale
 Tare the scale before each
weighing, with the empty basin
or pants (the needle need to be
in front of the 0)
 Put the child in the pants
 Calm down the child if needed
 Place yourself in front of the
scale, your eyes at the same
level as the needles
 Read the weight indicated, of
100g for precise
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What are the common mistakes?
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How identify malnourished children?
 Using combination of indexes : Index = difference
between the value of the measured parameter and the
reference value (mean or median) in the international
standards
 2 indexes:
• MUAC index
• W/H index
• + oedema
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Weight for Height
 Emaciated child has a lower weight than a « standard »
child, who has the same Height and Sex.
 Weight for Height (W/H) measure the child’s corpulence .
 Weight gain is sensitive to the actual situation.
 So W/H reflects a recent situation.
 It is a reliable and admitted.
 Doesnt require age estimation
 It is used for show recent food or health situation.
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W/H reference table
 Exercice
Boys' weight (kg)
Girls' weight (kg)
Length
-4 Z
-3 Z
-2 Z
-1 Z
Median
(cm)
Median
-1 Z
-2 Z
-3 Z
-4 Z
1.7
1.9
2.0
2.2
2.4
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2.5
2.3
2.1
1.9
1.7
1.8
2.0
2.2
2.4
2.6
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2.6
2.4
2.2
2.0
1.9
2.0
2.1
2.3
2.5
2.8
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2.8
2.6
2.4
2.2
2.0
2.1
2.3
2.5
2.7
2.9
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3.0
2.7
2.5
2.3
2.1
2.2
2.4
2.6
2.9
3.1
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3.2
2.9
2.6
2.4
2.2
2.4
2.6
2.8
3.0
3.3
50
3.4
3.1
2.8
2.6
2.4
2.5
2.7
3.0
3.2
3.5
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3.6
3.3
3.0
2.8
2.5
2.7
2.9
3.2
3.5
3.8
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3.8
3.5
3.2
2.9
2.7
2.9
3.1
3.4
3.7
4.0
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4.0
3.7
3.4
3.1
2.8
3.1
3.3
3.6
3.9
4.3
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4.3
3.9
3.6
3.3
3.0
3.3
3.6
3.8
4.2
4.5
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4.5
4.2
3.8
3.5
3.2
3.5
3.8
4.1
4.4
4.8
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4.8
4.4
4.0
3.7
3.4
Weight for Height Reference Card (WHO, 2006)
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Identification of malnourished children
6-59 months
Classification of acute malnutrition in children 6-59
months based on anthropometry
Age
Criteria
Moderate Acute
Malnutrition (MAM)
Severe Acute Malnutrition
(SAM)
 MUAC: less than 12.5 to  MUAC less than 11.5cm
11.5 cm
OR
OR
 W/H less than -3Z scores
 W/H less than -2Z to -3Z
OR
6 to 59 months
scores
 Bilateral oedema is present
(+, ++ or +++)
AND
 Oedema is absent
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Identification of malnourished children
less than 6 months or < 4Kg
Criteria for referral of infants aged less than 6 months to
inpatient SAM treatment
Age
Criteria
Moderate Acute Malnutrition
Severe Acute Malnutrition
 MUAC: Do not use
 MUAC: Do not use
 WFH/L: Less than -3Z
 WFH/L: Less than -2Z to
scores
-3Z scores*
or
and
 Bilateral pedal oedema
 Oedema is absent
 Visible severe wasting
Less than 6 months
* Assess WFH/L if infant is more
* Assess WFH/L if infant is more
than 45cm
than 45cm
 Infant is too weak to suckle effectively
 Infant is not gaining weight despite breastfeeding
counselling
 Visible severe wasting
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Identification of malnourished PLW
Category
Criteria
Pregnant women
 From the 2nd Trimester
Lactating Women
 Breastfeeding infant aged less
than 6 months
MUAC < 23cm
Eligibility criteria for identification of malnourished
PLW is only MUAC
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IMAM Implementation
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
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IMAM = Integrated Management of Acute Malnutrition
Integrated to BPHS (and EPHS at provincial level)
Target children 0-59 months and PLW
2 levels
• Community
• Health Facility
Community
Health Facility
- Active screening and referral
- Sensitization
- Follow-up (home visits)
- Passive screening / orientation
- Treatment / Follow-up
- Sensitization
CHWs
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CHS
Health staffs
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IMAM Implementation : COMMUNITY
Goals of community outreach
1. Maximize coverage and access
2. Maximize the timeliness of treatment
3. Maximize compliance with treatment
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IMAM Implementation : COMMUNITY
 Focal point in community : CHWs
 Main activities:
• Active case finding => screening (house to house /
massive screening) : MUAC and Oedema
• Early Referral => referral slip
• Sensitization / health education => to raise knowledge
about malnutrition and its treatment (prevention ++)
• Follow-up => home visits (Beneficiaries, absentees,
defaulters..) : increase the impact and sustainability of
nutrition activities
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ACTIVE CASE FINDINGS/SCREENING and EARLY
REFERRAL
COMMUNITY LEVEL
MUAC measurement and
verification of edema
MUAC >= 12.5 cm
&
No oedema
IF MAM TREATMENT
MUAC < 12.5cm
and / or
Bilateral oedemas
IF NO MAM TREATMENT
MUAC < 11.5cm
and/ or
Bilateral oedemas
Reference to the health centre for
confirmation of MUAC and oedema and
possibly having the weight and height taken
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IT IS ALSO…
 The HOME VISITS for the high-risk cases
Non-response/ absents/ defaulters of the program…
 AWARENESS SESSIONS/SENSITIZATION/HEALTH
EDUCATION
Nutrition, health, hygiene promotion...
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© ACF, Christina Lionnet - Tchad
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IMAM : HEALTH FACILITY
1. Reception of referral from community : check again
anthropometric measurements to confirm diagnosis
2. Passive screening : each child from 0-59 months and
PLW (from 2nd trimester of pregnancy to 6 months of
breastfeeding)
3. Orientation : MAM/SAM identified => orientation to the
right service (OPD-MAM / OPD-SAM / IPD-SAM)
4. Treatment and follow-up : nutritional product and
systematic medical treatment, follow-up of nutritional
status (referral if needed)
Transversal => Sensitization-Counseling nutrition /
health topics
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In HF where treatment is available
PASSIVE
SCREENING
All children 0-59m
TREATMENT
&
FOLLOW-UP
All the children who
fit the criteria for
acute malnutrition
ORIENTATION
TO THE
RIGHT
SERVICE
(OPD-MAM/SAM
or IPD-SAM)
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Depending on:
- Anthropo measures
- Appetite result
- Clinical result
APPETITE
TEST
CLINICAL
EXAM
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Appetite test
For each child identified as acutely malnourished (MAM/SAM)
Aim:
 To see if the child is able to eat sufficient quantity of
nutritional product to recover
 The loss of appetite in a child with acute malnutrition may
indicate a serious pathophysiology
 Appetite test:
• Part of the initial diagnosis
• At every follow-up visit
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Complications associated to acute
malnutrition (during clinical exam)
Clinical complication
Criteria
High fever
Greater than 39 C (102.2 F)
Hypothermia
Persistent vomiting
Severe dehydration
Severe anaemia
Less than 35.5 C (96 F)
Vomits all food and fluids
Clinical signs + recent history of fluid loss
Severe palmar pallor
Unconscious / convulsing
Reduced level of consciousness / lethargy / fitting
Difficult or fast breathing
2 to 12 months => Greater than 50 breaths / min
12 to 59 months => Greater than 40 breaths / min
Skin lesions
Extensive skin ulceration requiring IV / IM
antibiotics
+ any other diseases that need to be treated at the hospital (inpatient)
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Referral and treatment of acute
malnutrition
Acute Malnutrition
Child has SAM and
- Any complications and/or
- No appetite for RUTF
Inpatient Department for
SAM (IPD-SAM)
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Child has SAM and
- No complications and
- Appetite for RUTF
Outpatient Department
for SAM (OPD-SAM)
Child has MAM and
- No complications
- Appetite for RUSF
Outpatient Department for
MAM (OPD-MAM)
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