Introduction

INTEGRATED MANAGEMENT FOR ACUTE MALNUTRITION

Basic Principles
• Each child has the right to food, health
and care to enable optimum potential
• Lack of food, health and care are risk
factors for malnutrition
• Malnutrition is strongly linked with
death
http://1000days.unicef.ph/
Malnutrition
• Body’s dietary or food intake not in balance with nutritional
needs failing to maintain healthy tissues and organ function
• Results in either:
OVERNUTRITION UNDERNUTRITION

http://www.huffingtonpost.co.uk/2015/03/02/obese-baby-india-six-year-old_n_6785324.html https://www.unicef.org/philippines/reallives_19053.html
Causes of Undernutrition
Immediate Causes Individual Inadequate food intake
Disease

Underlying Causes Community Poor access to food

Bad care practices
Poor water, sanitation
and health services

Basic Causes Societal Lack of capital – human,

financial, physical, social

Black et al, 2008, The Lancet

 Types of Undernutrition
1. Acute Malnutrition
• Sudden wasting and/or edema due to:
▪ insufficient food intake
▪ infection
▪ inappropriate childcare practices
• Diagnosed when:
▪ inadequate weight for height (WFH), weight
for age AND/OR
▪ muscle wasting AND/OR
▪ bilateral pitting edema
Low Weight for Height
Philippine Department of Health.
National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years Manual of Operations. 2015.
 Acute Malnutrition (a.k.a wasting)

Moderate Acute Malnutrition (MAM) Severe Acute Malnutrition (SAM)

or Moderate Wasting or Severe Wasting
Weight-for-Height Z-score -3SD to <-2 SD Weight-for-Height Z-score <-3 SD
and/or MUAC 11.5cm to 12.4cm and/or MUAC < 11.5cm
and no bilateral pitting edema and/or with bilateral pitting edema

Global Acute Malnutrition (GAM) is the sum of the

prevalence of SAM plus MAM at population level.
Severe Acute Malnutrition – encompasses
wasting and bilateral edema
MARASMUS KWASHIORKOR Marasmus:
Refers to severe wasting

Kwashiorkor:
Refers to nutritional edema

These can kill.

Children with SAM are 9-12
times more likely to die than well
nourished kids.
Moderate Acute Malnutrition – encompasses
wasting but no bilateral edema

Moderate wasting (Thin)

No nutritional edema

This can also kill.

Children with MAM are 3-4 times
more likely to die than well
nourished kids.
Types of Undernutrition
2. Chronic Malnutrition or Stunting
• “Too short for one’s age”
• Inadequate height/length for age (HFA/LFA)
• In the first 1000 days after conception
• Stunting before the age of 2 years old:
▪ poor cognitive and educational outcomes
▪ mental and physical deficits are potentially
irreversible beyond two years

Low Height for Age

Types of Undernutrition
3. Micronutrient Malnutrition

• Micronutrients - Nutrients
needed in small quantities.

• Deficiencies lead to malnutrition

and disease

• Common deficiencies:
http://dranmolarora.com/

Vitamin A, Iron and Iodine

 Micronutrient Malnutrition
Type I Micronutrient Deficiency Type II Micronutrient Deficiency
e.g. Iron, Calcium, Iodine, Copper, Vit. B complex,
Vit. A, C, D, K e.g. Sodium, Potassium, Magnesium, Zinc,
Phosphorus, Essential Amino acids

• Growth continues in early stages

• Results in growth failure
• With specific clinical signs
• No specific clinical signs

e.g. Anemia, Beri-beri, Pellagra, Scurvy,

Xeropthalmia e.g. stunting, wasting

Source: Golden, M. SCN News 1995 12:10-4)

Other Types of Undernutrition
4. Fetal Growth Restriction
• Abnormal fetal growth
• Low birth weight (LBW) babies (< 2.5 kg)
• Poor maternal nutrition
• 15 times higher risk of death in newborn
period vs. normal weight babies

5. Suboptimal breastfeeding
• Breastfeeding NOT up to standard
• 800,000 child deaths Photo from http://www.zofranlawsuitguide.com/

1 Black RE et al. The Lancet Nutrition Series Part 1. 2013.

EXERCISE!

The 3 children are of the same age

Wasted Stunted

Same height Same weight

Weight for age Normal Low Low

Height for age Normal Normal Low
Weight for Height Normal Low Normal
 Why focus on undernutrition? It Kills!
Cause of undernutrition Attributable deaths Proportion of total deaths among
under 5 year olds
Fetal growth restriction 817,000 11.8%
Suboptimal breastfeeding 804,000 11.6%
(0-23 months)
Stunting (1-59 months) 1,179,000 17%
Underweight (1-59 months) 1,180,000 17%
Wasting (1-59 months) 800,000 11.5%
Severe wasting (1-59 months) 540,000 7.8%
Zinc deficiency (12-59 months) 116,000 1.7%
Vitamin A deficiency (6-59 months) 157,000 2.3%
Joint effects of fetal growth restriction 1,348,000 19.4%
and suboptimum breastfeeding
It causes
Cumulative effects (ALL) 3,149,000 45.4%
45% of childhood deaths
1 Black RE et al. The Lancet Nutrition Series Part 1. 2013.
 For those who survive,

• Lifetime of ill-health
• Unrealized human potential
• Malnutrition spans
generations
This is how our undernourished Filipino children look:
 Both are 2 years old
Naturally Short?
PANDAK??

Our kids
can really
NOT be.

Photo credit: Rosalia Bataclan, MD

The Sustainable Development Goals
(SDGs) 2016-2030
Global Nutrition Report 2015

• Sustainable
Development Goals
(SDGs) – 2 and 3
• Commit to rapid
reduction of
malnutrition by
2025
DOH Strategic Framework for Comprehensive Nutrition Implementation Plan
2014-2025
First 1000 days
Management of Moderate and Severe
Acute Malnutrition – Why?
• Children with SAM are 9 -12 times
more likely to die than those who are
well nourished.

• Children with MAM are 3 - 4 times

more likely to die than those who are
well nourished.

• Recognized and treated early, it can

be reversed with proper food, nutrition
and care.
Philippine Integrated Management
of Malnutrition (PIMAM)
Component of the wider Strategic Framework 2014-2025
Rationale:
• In hospital treatment in “MalWards”
▪ Outdated protocols
▪ Overcrowding in the hospitals
▪ Cross-infection
▪ High default rates - mothers wanted to go home to take care of other
children
▪ Heavy work load of hospital staff
• Intermittent and ineffective supplementary feeding programs
• Malnutrition is a reality in both normal times and emergencies
 Treat Children with SAM with appropriate Care
using UP-TO-DATE treatment protocols
• SAM affects the child’s normal physiological functions
• SAM children cannot be medically treated like other sick children
• Malnutrition alters the SAM child’s physiology
• Old treatment protocol can do more harm than good
• SAM children require specialized treatment
 Treat Children with MAM with appropriate Care
using UP-TO-DATE treatment protocols
• treatment of MAM will prevent deterioration of MAM to SAM

• if there are no programs to address MAM especially during

emergencies, SAM cases tend to increase
PIMAM
(Philippine Integrated Management of Acute Malnutrition)

• PIMAM, or management of MAM

and SAM, is part of routine health
and nutrition services at all levels

• Involves and relies on a strong

community component
PIMAM Four Guiding Principles
1. 1. Maximum Coverage and Access

1. 2. Timeliness

1. 3. Appropriate Care

1. 4. Care: When and Where it is needed

The Innovation in Integrated Management

Targeted
Components of PIMAM
1. Management of SAM
without complications Outpatient Therapeutic Care (OTC)

1. Management of SAM with

complications Inpatient Therapeutic Care (ITC)

1. Management of MAM Targeted Supplementary Feeding

MAM
Program (TSFP)
1. Community Outreach
Community Mobilization
DOH A.O. No. 2015-0055
National Guidelines on the Management of
Acute Malnutrition for Children under 5
years.
Standardized protocols

Emphasis on linkages and referrals, supply networks,

indicators for monitoring, and importance of PIMAM
in emergency settings

Describes our roles

Four components of integrated management of

Moderate and Severe Acute Malnutrition
Summary
• Undernutrition is a neglected condition

• More Filipino children under the age of 5 years are affected

• Cause for 50% of all childhood deaths but unrecognized and untreated

• SAM children risk of death is 9-12 times higher than a well nourished child

• MAM children risk of death is 3-4 times higher than a well nourished child

• Nutrition sensitive and specific interventions now combat malnutrition

• PIMAM manages malnutrition in normal times and emergencies

Which is a case of undernutrition?
A. A child who never reaches full height due to poverty, poor sanitation, lack
of breastfeeding and limited access to nutritious foods
B. A young woman who becomes anemic during her pregnancy and gives
birth to a baby with low birth weight
C. A child made blind by vitamin A deficiency
D. A desperately thin and wasted child, at imminent risk of death
E. A 9-month old baby who has no edema and with MUAC of 12.1cm.

UNICEF. 24 December 2015. The faces of malnutrition. Available at www.unicef.org

Which is a case of undernutrition?
A. A child who never reaches full height due to poverty, poor sanitation, lack of
breastfeeding and limited access to nutritious foods Chronic malnutrition
(stunting)
B. A young woman who becomes anemic during her pregnancy and gives birth
to a baby with low birth weight Micronutrient deficiency (iron) in the
mother, with Intrauterine growth restriction in the baby
C. A child made blind by vitamin A deficiency Micronutrient deficiency
(Vitamin A)
D. A desperately thin and wasted child, at imminent risk of death SAM
E. A 9-month old baby who has no edema and with MUAC of 12.1cm. MAM

All of the above.

UNICEF. 24 December 2015. The faces of malnutrition. Available at www.unicef.org
Are you ready to learn and do your role?

Our Goal is
ZERO SAM
and MAM
Identification of Acute
Malnutrition
Learning Objectives

At the end of the module, you will be able to:

• Identify children with MAM and SAM
• Measure weight and height/length correctly
• Determine the appropriate Z-score based on weight and
height
• Measure the mid-upper arm circumference correctly
• Test for the presence or absence of edema
• Perform the appetite test
Measuring Malnutrition

1. Clinical signs
2. Biochemical testing
3. Dietary intake
4. Anthropometry
Determine Age and Sex

• Record age and sex

• Girls and boys grow and
develop differently
• Record Age in months
Determine Age in Months
• Date of examination minus date of birth in the
following arrangement: year/month/day
2017 03 14 2016 15 14
2013 11 08 2013 11 08
3 4 06
• Borrow 12 months from 2017
• Convert 3 years to 36 months
Therefore: Age in months = 40 months
Exercise!
Age in months computation
Demo-Return Demo

Date of Examination: April 18, 2017

Date of birth: October 22, 2014
Date of Examination: April 18, 2017
Date of birth: October 22, 2014

2016 15 48
2017 04 18 2017 04 18
2014 10 22 2014 10 22
2 5 26
Age in months: 29
Measuring Malnutrition
Anthropometry
• The study and technique of • Basic information and
taking measurements of the body measurements
human body needed to assess an
• Method to assess growth individual’s
based on measures of anthropometric status
physical characteristics of include:
the body (e.g. weight, ✓ Age
height, etc.) ✓ Sex
• Cannot detect micronutrient ✓ Weight
malnutrition ✓ Height/Length
✓ Left Mid-Upper Arm
Circumference
 Measuring Weight
• Measure at eye level
• Measure to the nearest 100g
• A hanging scale, a plastic basin, malong or
others may be used as long as it is secured
by at least 4 ropes
• The carrier should be close to the ground
• Best if the child would not have clothes on
for weighing, ensure s/he will not be cold
• Always record immediately
Measuring Weight
Standardize scales daily or whenever they are moved:
• Set the scale to zero
• Weigh three objects of known weight (e.g. 5, 10, and 15 kg)
and record the measured weights
• Repeat the weighing of these objects and record the
weights again
• Check the scales or replace them when there is a
difference of 0.01 kg or more between duplicate weighing

NOTE: A measured weight differs by 0.01 kg or more from the known standard
Exercise:

Is this Correct
or Incorrect?
Incorrect.
• Scale not at eye level.
• Child is dressed.
 Measuring Length/Height

Measure length Measure height

• Less than 87 cm (or less than 3 • 87 cm or taller
feet) • 2 years and older
• Less than 2 years • Capable of standing up
• Or those too weak to stand
NOTE:
NOTE: For children ≥ 2 y/o or
For children < 2 y/o ≥87cm who are unable
or < 87cm who can to stand, the LENGTH
stand, the HEIGHT is is measured and 0.7cm
measured and 0.7cm is deducted from the
is added to the measurement.
measurement.
Measuring Length
• Requires a partner to help position
child
• Use a length board with:
▪ a fixed head board and
▪ a movable foot plate
• Place on a level floor
• Remove the child’s socks and
shoes
• Remove lower garments/diapers
• Remove any worn hair ornaments
Measuring Length

• Child MUST look straight ahead

with his/her head parallel to the
baseboard
• Legs are straight
• Feet firmly planted on the foot
plate
• Read length/height to the nearest
0.1 cm
How is this position?

50
Incorrect!
Incorrect Hand Position.
Hands Pressing against Ears.
Thumbs Pressing on Shoulders.

51
How is this position?

52
Incorrect!

Incorrect Child Head Position.

Chin against Chest.

53
Feet flat, heels against board

54
How is this position?

55
Correct

56
How is this position?

57
Incorrect

58
Correct or Incorrect?

Incorrect
• No partner.
• Child's neck is not
straight. Head not
facing forward
• Feet are not flat
on the foot plate.
 Measuring Height
• Requires a partner
• Use a height board with
▪ a vertical backboard,
▪ a fixed base board, and
▪ a movable head board
• Place on a level floor
• Remove the child’s socks and
shoes for accurate
measurement
• Remove any worn hair
ornaments
Exercise!

94.2 cm
What is the
height?
Is this position correct or incorrect?

62
Incorrect

63
Is this position correct or incorrect?

64
Incorrect

65
Determining the Z-score

What is the Z-score?

• It is a way to compare a child’s
weight-for-length (WFL) or weight-
for- height (WFH) to an “average”

• Use the WHO Child Growth

Standards Table
▪ 0-23 months (boys and girls)
▪ 24-60 months (boys and girls)
 Remember!

Normal MAM SAM

WFL/H
-2 to + 2 < - 2 to -3 < -3
Z-score

WFL/H Z = Weight for Length/Height

Z-score
Steps in determining the Z-score

Do this after measuring weight and length/height

1. Take note of child’s sex
2. Determine the child’s age (in months preferably)
3. Use the correct WHO Child Growth Standards Table
4. Round off measured length or height for child's sex
and age in month to the nearest 0.5 cm
Rounding off Length/Height in centimeters (cm):

a. Subtract/Add 0.2 cm up and down from 81 cm

to get the lower and upper limits
80.8
80.9
81
81
81.1
81.2

b. Round off values between 80.8 and 81.2 to 81

Rounding off Length/Height in centimeters (cm):
 Steps in determining the Z-score
Do this after measuring weight and height/length:
Locate the length/height on the correct WHO Growth Standard Table

Example: a 25 month old boy with length 66.0 cm and weight 6.3 kg. Use the CGS form for
BOYS ages 24-60 month:

NOTE: see if it is under

category “Severely Wasted”,
“Moderately Wasted”,
“Normal”, “Overweight” or
“Obese”
Steps in determining the Z-score
Do this after measuring weight and height/length:

Example: a 25 month old boy with length 66.0 cm and weight 6.3 kg.

✓ Note the Z-score

✓ Record
✓ 25 month old boy
✓ L 66.0 cm
✓ W 6.3 kg
✓ WFH Z between -3 and <-2 SD

A>
Exercise!
A 32 month old girl’s height is 95.3 cm and her weight is 10.0 kg.
What is her WFH Z-score?
Do the steps:
1. Secure correct WHO Child Growth
Standards Table for age and sex.
2. Round off height to nearest 0.5 cm.
3. Round off 95.3 cm to 95.5 cm.
4. Locate 95.5 on Table.
5. Locate 10 kg along line i.e. < 10.7
kg
6. Classify nutritional status “severely
wasted” and record.
7. Record Z-score “< -3SD”
8. A> SAM
 Remember!

Normal MAM SAM

WFL/H
-2 to + 2 < - 2 to -3 < -3
Z-score

WFL/H Z = Weight for Length/Height

Z-score
Measuring the Left Mid Upper Arm
Circumference (MUAC)
• Measured in children older than 6 to 60 months of age
• A simple measure of muscle wasting
• An independent measure of SAM
• Strongly predicts risk of dying from SAM
Measure the MUAC

Palpate the tip of

Always measure the shoulder
the left upper arm’s
midpoint between
shoulder and elbow
Landmarks – always measure from behind
using the left arm
1. Palpate the tip of the left shoulder
2. Palpate the tip of the bent elbow
3. Measure the distance between these two
landmarks.
4. Divide this measurement by 2.
5. This is the midpoint of the left upper arm.
6. Assistant marks the spot.
Example:
Measured distance is 15 cm.
15 cm ÷ 2 = 7.5 cm
Mark this point.
Measure the MUAC at this level.
Measuring the MUAC
Remember!

Normal MAM SAM

WFL/H
-2 to + 2 < - 2 to -3 < -3
Z-score
11.5 cm to
MUAC ≥ 12.5 cm < 11.5 cm
12.4 cm
Testing for Edema
Edema – a large amount of fluid gathers so that the tissues look
swollen or puffed up

Bilateral edema is the sign of kwashiorkor, a severe form of

acute malnutrition.

These children are at high risk of dying and need to be treated

in a therapeutic feeding program urgently.
Testing for Edema
To Both Feet:
• Apply normal thumb pressure
for at least three seconds
• If a shallow print persists on
both feet, record as (+)
edema

Edema on both feet (i.e. bilateral) is nutritional edema.

What is wrong here?

84
Classification of Acute Malnutrition for children over
6 to 59 months based on MUAC, WFL/H Z-score,
Edema
Parameter Normal MAM SAM

MUAC ≥ 12.5 cm 11.5 to 12.4 cm < 11.5 cm

and and/or and/or
WFL or WFH
-2 to +2 SD < -2 to -3 SD < -3 SD
Z-Score
and and and/or

Edema None None Present

Classification of Acute Malnutrition for Infants
less than 6 months based on WFL Z-score and
Edema
Parameter Normal MAM SAM

WFL Z-Score -2 to +2 SD < -2 to -3 SD < -3 SD

and and and/or

Edema None None Present

You can now identify SAM.
Next, identify the child with SAM for OTC or ITC,
or
the child with MAM for TSFP

Targeted
Supplementary
Feeding
The Appetite Test
• Loss of appetite is the best sign of
severe metabolic malnutrition
• Appetite test is a critical part of the
assessment of the child with SAM
• It helps distinguish whether the child
with SAM needs a referral to Out-
patient Therapeutic Care (OTC) or
In-patient Therapeutic Care (ITC)
• Appetite is tested using Ready to
Use Therapeutic Food (RUTF)
Testing appetite
1. Explain to the caregiver on why the
test will be done.
2. Instruct caregiver to wash hands
properly.
3. Sit caregiver and child in a quiet
space. YOU will observe the entire
process.
4. Have the caregiver offer a small
amount of RUTF on his/her finger
or directly to the child from the
sachet.
Testing appetite
5. Offer water or breastfeed
after the child takes RUTF.
6. If the child is not taking it,
gently encourage intake.
Do not force feed.
7. Record amount that child
has eaten.
Testing appetite of a child with SAM

Pass Fail
The child takes 3 - 4 mouthfuls The child takes less than 3 - 4
or more of RUTF mouthfuls of RUTF. S/he is
considered to lack sufficient
appetite for OTC and should be
referred to the ITC.
Do we still need to do Appetite test
to a child with MAM?
NO, because appetite test is just
for children with SAM
 Exercise!

• 48 months old boy

• WFH Z is < -2 SD to – 3 SD
• MUAC 13.5 cm
• Grade 2 edema
• What is your assessment? SAM

• Next Step?
Perform appetite test.
Exercise!
Name Age Z-Score MUAC Edema Assessment
(months) (SD) (cm)
John 48 <-2 to -3 12.5 None
Mary 24 -2 to +2 13.0 None
Anne 35 -2 to +2 12.3 None
Juan 42 <-2 to -3 11.9 +
Jane 48 <-2 to -3 11.7 None
Exercise!
Name Age Z-Score MUAC Edema Assessment
(months) (SD) (cm)
John 48 <-2 to -3 12.5 None MAM (Z-Score)
Mary 24 -2 to +2 13.0 None
Anne 35 -2 to +2 12.3 None
Juan 42 <-2 to -3 11.9 +
Jane 48 <-2 to -3 11.7 None
Exercise!
Name Age Z-Score MUAC Edema Assessment
(months) (SD) (cm)
John 48 <-2 to -3 12.5 None MAM (Z-Score)
Mary 24 -2 to +2 13.0 None Normal
Anne 35 -2 to +2 12.3 None
Juan 42 <-2 to -3 11.9 +
Jane 48 <-2 to -3 11.7 None
Exercise!
Name Age Z-Score MUAC Edema Assessment
(months) (SD) (cm)
John 48 <-2 to -3 12.5 None MAM (Z-Score)
Mary 24 -2 to +2 13.0 None Normal
Anne 35 -2 to +2 12.3 None MAM (MUAC)
Juan 42 <-2 to -3 11.9 +
Jane 48 <-2 to -3 11.7 None
Exercise!
Name Age Z-Score MUAC Edema Assessment
(months) (SD) (cm)
John 48 <-2 to -3 12.5 None MAM (Z-Score)
Mary 24 -2 to +2 13.0 None Normal
Anne 35 -2 to +2 12.3 None MAM (MUAC)
Juan 42 <-2 to -3 11.9 + SAM (Edema)
Jane 48 <-2 to -3 11.7 None
Exercise!
Name Age Z-Score MUAC Edema Assessment
(months) (SD) (cm)
John 48 <-2 to -3 12.5 None MAM (Z-Score)
Mary 24 -2 to +2 13.0 None Normal
Anne 35 -2 to +2 12.3 None MAM (MUAC)
Juan 42 <-2 to -3 11.9 + SAM (Edema)
Jane 48 <-2 to -3 11.7 None MAM (MUAC, Z-Score)
 Summary
• Identification of MAM and SAM is an important skill for all who work in
health and nutrition, from the barangay to the hospital level.
• Acute Malnutrition is also known as Wasting.
• Moderate Acute Malnutrition (MAM) is also known as Moderate Wasting;
Severe Acute Malnutrition (SAM) is also known as Severe Wasting
• The classification of malnutrition to moderate or severe is dependent on
anthropometric measurements and testing for edema.
• It is important to accurately measure weight and length/height, determine
the appropriate Z-score, alternatively to measure the MUAC.
• Testing appetite is critical in deciding whether a child with SAM needs OTC
or ITC treatment.
• Correct identification of MAM and SAM can save that child’s life.
Outpatient Therapeutic
Care (OTC)
Module Description
Discusses what the health worker will do when a SAM
child & mother/caregiver visits an OTC facility or OPD
facility of an ITC facility

Sessions:
1. Admission
2. Treatment
3. Weekly monitoring
4. Discharge
What is Outpatient Therapeutic Care
(OTC)?
✓ Provides treatment for infants/children with SAM with:
• adequate appetite and
• no medical complication(s)
✓ Treated at home with:
• Optimized breastfeeding and complementary feeding
practices
• Simple routine medicines and
• Ready-to-Use Therapeutic Food (RUTF)
 Remember!

- Children with SAM cannot be treated like other sick children

- Malnutrition alters the SAM child’s physiology (i.e. cardiac,
liver, kidney, immune systems and more are compromised)
- Previous routine treatment does not work and can do more
harm than good
- Children with SAM require specialized treatment using
specially designed commodities such as RUTF
What is RUTF
(Ready-to-Use Therapeutic Food)?

• An energy dense
mineral/vitamin enriched food
nutritionally equivalent to F-100
• Recommended by WHO (for
SAM children ≥ 6 months)
• Meets particular technical and
quality specifications for its
composition and production
Session 1:
Admission Objectives
Steps for OTC Admission
Do initial assessment
and intervention

Identify severe acute

malnutrition

Classify patient to
OTC or ITC

Admit to Refer to nearest ITC

OTC for admission
 A. Initial Assessment
In triage
1. Give 10% sugar-water solution immediately
to obviously sick patients to prevent
dehydration and low blood sugar levels.

■ Prepare 10% SUGAR SOLUTION by

mixing 10g or 1 tablespoon of sugar in
100ml of water.
 A. Initial assessment
2. Explain to the caregiver
▪ Assessment to determine if
treatment needed
▪ What to expect
3. Determine age
▪ Confirm birth dates (birth
certificate, child health card,
ECCD card, local events
calendar)
▪ Do not use a height cut-off (65
cm) as proxy for 6 months
 A. Initial assessment
4. Take anthropometric measurements
▪ 6-59 mos. of age
• Take MUAC, weight, height/length measurements.
• Weight-for-height/length Z-scores.
• Check for edema, temperature and no. of breaths per minute
▪ Infants less than 6 mos. of age
• Weight and length measurements.
• Weight-for-length Z-scores.
• Check for edema, temperature and no. of breaths per minute.
 5. Identify if the child has SAM or MAM.
In children 6-59 mos.
Parameter Normal MAM SAM

MUAC ≥ 12.5 cm 11.5 to 12.4 cm < 11.5 cm

and and/or and/or

WFL or WFH
-2 to +2 SD < -2 to -3 SD < -3 SD
Z-Score
and and and/or
Edema None None Present
 5. Identify if the child has SAM or MAM.
Infants younger than 6 mos.

Parameter Normal MAM SAM

WFL Z-Score -2 to +2 SD < -2 to -3 SD < -3 SD

and and and/or

Edema None None Present
 A. Initial assessment
6. Refer non-SAM patients
Non-SAM patients should have
access to:
IMCI for counseling and medical
1.

care
Blanket or Targeted Supplemental
2.

Feeding Program (TSFP) if in place

Advice/counseling on proper IYCF
3.

practices - continued breastfeeding,

appropriate complementary feeding
 A. Initial assessment

7. If the infant/child has SAM, immediately

Register in Target Client List (TCL) for sick children/registration

■

book/hospital admission chart or start OTC chart admission

column.
RECORD Child’s ECCD number, existing household number or TCL
■

number on OTC/ITC charts.

FAILED APPETITE TEST – REFER to ITC

PASSED APPETITE TEST – to OTC

Session 1: Admission

B. Classify 6-59 mos. old infant/child to OTC or ITC.

Criteria for Admission to ITC or OTC (6-59 months)

DIAGNOSIS OF SAM Plus

OTC ITC
Appetite test PASS FAIL
and and/or
Medical NONE With
Complications complications
Clinical assessment - Check for IMCI danger
signs
• Any general danger sign
• Any signs of severe or very severe disease
• Be careful in DEHYDRATION assessment:
some signs (e.g. dry mouth, sunken eyes,
decreased skin turgor) can occur in severe
wasting without dehydration.
➢ Instead, focus on:
➢ history (vomiting/diarrhea/not drinking/thirst);
➢ poor urine output (absent or very dark/concentrated
urine);
➢ recent weight loss; fast/weak pulse
 Criteria for Admission to ITC or OTC
(less than 6 months)
Factor Inpatient care Outpatient Breastfeeding
Support (C-MAMI Tool, IMCI,
supplementary feeding for mother,
where available)
Anthropometry Bilateral pitting edema WFL < -3 Z-scores
OR WFL < -3 Z-scores AND none of the complications
AND one of the below requiring inpatient care
History Recent weight loss/ inability to
gain weight
 Factor Inpatient Care Outpatient Breastfeeding
Support
Medical Any medical complications or any
medical issue needing more detailed
reassessment or intensive support
(e.g. disability)
Feeding Ineffective feeding (attachment,
practices positioning and sucking) directly
observed;
Infant is lethargic and unable to
suckle;
No possibility of breastfeeding (e.g.
death of mother)
Condition of Depression of the mother/ caregiver, OR mother is malnourished
mother or other adverse social circumstances or ill
C-MAMI: Community Management of
Acute Malnutrition in Infants < 6
months of age
In C-MAMI, assessment is outlined in 2 parts:
C-MAMI assessment for nutritional vulnerability in
1.

Infants < 6 months: Infant

C-MAMI assessment for nutritional vulnerability in
2.

Infants < 6 months: Mother

C-MAMI Assessment
Assessment Steps: Infant Assessment Steps: Mother
TRIAGE: Check for general
1.

(A)nthropometric/ Nutritional
1.

clinical danger signs or Assessment

signs of severe disease
(A)nthropometric/ Nutritional
2.
(B)reastfeeding assessment
2.

Assessment (C)linical Assessment

3.

(B)reastfeeding Assessment
3.
(D)epression/ Anxiety/
4.

(C)linical Assessment
4.
Distress
Feeding assessment for infants less than 6 months

▪ Breastfeeding must be supported closely and mother

helped in her confidence and if necessary, her
resumption of breastfeeding or re-lactation.
▪ All means to continue with breastfeeding and/or
breastmilk feeding must be exhausted.
*http://files.ennonline.net/attachments/2435/C-MAMI-Tool-Web-FINAL-Nov-2015.pdf
Types of OTC Admission

New New SAM cases identified during screening or self-

Admissions referral
Relapse a.Admission after absence of more than 2 months
b.Admission after previously discharged as cured

Readmission Admission after absence of less than 2 months

(Return Defaulter)
Types of OTC Admission
Admissions a. Transfer from another OTC
of patients b. Transfer from ITC
already c. Return from ITC, back to OTC (i.e. OTC-ITC-OTC)
under SAM
treatment

Others a. SAM with med complications whose caregiver

refuses inpatient (ITC) care
b. SAM cases greater than 5 years old
Exercise:
To Admit or Not Admit
to OTC
 Bilateral
Infant/ Age MUAC
Appetite Pitting WFH Z-score Admit to OTC?
Child (mos.) (mm)
Edema
Anna 50 Yes No 102 Less than -
3SD

Buboy 45 Yes Yes 111 Less than -

(+) 3SD

Carmela 7 Yes No 117 Greater than

-3SD but less
than -2SD
Daniel 12 Yes No 95 Greater than
-3SD but less
than -2SD
Edel 18 No No 104 Less than -
3SD
 Bilateral
Infant/ Age MUAC
Appetite Pitting WFH Z-score Admit to OTC?
Child (mos.) (mm)
Edema
Anna 50 Yes No 102 Less than - YES (MUAC,
3SD WFH, and
appetite)
Buboy 45 Yes Yes 111 Less than -
(+) 3SD

Carmela 7 Yes No 117 Greater than

-3SD but less
than -2SD
Daniel 12 Yes No 95 Greater than
-3SD but less
than -2SD
Edel 18 No No 104 Less than -
3SD
 Bilateral
Infant/ Age MUAC
Appetite Pitting WFH Z-score Admit to OTC?
Child (mos.) (mm)
Edema
Anna 50 Yes No 102 Less than - YES (MUAC,
3SD WFH, and
appetite)
Buboy 45 Yes Yes 111 Less than - YES (MUAC,
(+) 3SD WFH, edema, and
appetite)
Carmela 7 Yes No 117 Greater than
-3SD but less
than -2SD
Daniel 12 Yes No 95 Greater than
-3SD but less
than -2SD
Edel 18 No No 104 Less than -
3SD
 Bilateral
Infant/ Age Appetit MUAC
Pitting WFH Z-score Admit to OTC?
Child (mos.) e (mm)
Edema
Anna 50 Yes No 102 Less than - YES (MUAC,
3SD WFH, and
appetite)
Buboy 45 Yes Yes 111 Less than - YES (MUAC,
(+) 3SD WFH, edema, and
appetite)
Carmela 7 Yes No 117 Greater than NO (MUAC, WFH,
-3SD but less do not indicate
than -2SD not SAM)
Daniel 12 Yes No 95 Greater than -
3SD but less
than -2SD
Edel 18 No No 104 Less than -
3SD
 Bilateral
Infant/ Age MUAC
Appetite Pitting WFH Z-score Admit to OTC?
Child (mos.) (mm)
Edema
Anna 50 Yes No 102 Less than - YES (MUAC,
3SD WFH, and
appetite)
Buboy 45 Yes Yes 111 Less than - YES (MUAC,
(+) 3SD WFH, edema, and
appetite)
Carmela 7 Yes No 117 Greater than - NO (MUAC, WFH,
3SD but less do not indicate
than -2SD not SAM)
Daniel 12 Yes No 95 Greater than - YES (MUAC and
3SD but less appetite)
than -2SD
Edel 18 No No 104 Less than -
3SD
 Bilateral
Infant/ Age MUAC
Appetite Pitting WFH Z-score Admit to OTC?
Child (mos.) (mm)
Edema
Anna 50 Yes No 102 Less than - YES (MUAC,
3SD WFH, and
appetite)
Buboy 45 Yes Yes 111 Less than - YES (MUAC,
(+) 3SD WFH, edema, and
appetite)
Carmela 7 Yes No 117 Greater than NO (MUAC, WFH,
-3SD but less do not indicate not
than -2SD SAM)
Daniel 12 Yes No 95 Greater than YES (MUAC and
-3SD but less appetite)
than -2SD
Edel 18 No No 104 Less than - NO (no appetite
3SD → admit to ITC)
Referring to ITC
ITC Referral for
Children 6-59
months:
Failed Appetite Test
and/or with medical
complications
 Criteria for ITC referral (<6 mos. old)
Any of:
General danger sign or sign of severe or very severe disease (IMCI)
•

With severe feeding problems/risk based on breastfeeding assessment

•

• Severe maternal malnutrition or mother is ill

• Severe maternal depression/anxiety
C. REFER to the nearest ITC, if needed, in a
timely manner
1. Explain that child is very sick and needs to be
treated immediately and can easily become sicker.
2. Fill out appropriate two-way referral form
3. Communicate personally with inpatient facility
4. Make arrangements for transportation
OTC/ITC
Referral
Form
Admitting to OTC
D. Do the following steps on admission at
the OTC.
1. REVIEW referral form, RECORD information on OTC
chart.
2. Use the same patient’s registration number.
3. Confirm referral form information.
4. Identify any issues during the transfer.
5. Complete existing registration documentation and OTC
chart.
 OTC Treatment
Card
1. Fill out the OTC Card even if
the child will be referred to ITC
2. Use the child’s unique
registration number (on OTC
card)
Municipality/District/Health Center/
Program/Year-SAMNumber
Province/Municipality/Program/Year-SAM Number

Examples
Maguindanao/SouthUpi-RHU/OTC/13-0044
•

Leyte/Tacloban-EVRMC/ITC/13-0005
•

DCTN/ SJHC / OTC / 16-0010

•

Davao City Talomo North/St. John Health Center/

Outpatient Therapeutic Care/2016-0010
Session 1: Admission

Session 2:
OTC Treatment Objectives
Steps for OTC Treatment
Choose appropriate medical
management.

Choose appropriate nutritional

management according to age.

Demonstrate how to orient

caregiver on OTC treatment.
A. Choose the appropriate medical
management for the child with SAM.

1. ALL cases admitted to OTC should be treated according to the

following routine treatment schedule
▪ treat probable and potential underlying illnesses not showing
classical signs and symptoms.
Routine treatment on OTC
admission
Treatment upon OTC admission
2. Check
• child’s immunization status. Refer to the BHS for any
vaccinations due (including for measles vaccination).
• date of the child’s last deworming. Refer to BHS.
3. Diagnose and treat
• malaria, per national guidelines.
• tuberculosis, per national guidelines.
Treatment upon OTC admission
4. Record any supplementation/ treatment given on child’s
ECCD chart if they have one.
5. Treat other medical conditions/symptoms – eye infections,
ear discharge, mouth ulcers, fungal infections, minor skin
infections and lesions – per IMCI guidelines.
 Treatment upon OTC admission
Additional medication should be prescribed
conservatively.
Do not give iron and folic acid routinely.
•

Severe anemia: Refer to ITC

•

Moderate anemia: TREAT ONLY after 14 days in OTC; IF

•

EARLIER, high doses may increase risk of severe infections.

(IMCI protocol one dose daily for 14 days)
 Do Not Give
• Zinc to patients taking RUTF.
• Medicines against vomiting (anti-emetics) in OTC.
• Cough suppressants.
• Paracetamol routinely (toxic in a malnourished child).
• Aminophylline in OTC.
• Metronidazole in normal/high dosages. Reduce dosage as
indicated.
• Ivermectin in any edematous child.
 B. Choose the appropriate nutritional
management for the infant/child with SAM
1. Determine amount of RUTF required based on current weight,
as indicated in RUTF ration table.
Preparing RUTF to eat

Wash both hands and

packet.
Massage packet for
30 seconds
 One half One third

Measure the
portions

One fourth
Tear RUTF packet Fingers mark the portion
as the child eats
Or caregiver gives a small amount on her
finger
 2. Do NOT give RUTF if:

A. Infant is less than 6 months old.

▪ Instead, provide intensive breastfeeding counseling to the mother/
caregiver (C-MAMI Tool).
B. Child has known peanut allergy.
▪ Refer to ITC for treatment with therapeutic milk (F-75/F-100).
C. Orient the mother/caregiver on the
treatment
1. Explain how much RUTF to give each day. Ask to repeat
instructions.
2. Discuss simple key messages on RUTF use:
▪ For breastfeeding infants older than 6 months, advise
mother to continue breastfeeding as before and give the
RUTF after each feeding.
▪ For older children, always give plenty of safe water with
RUTF as it doesn’t contain any itself. But do not mix RUTF
with water.
C. Orient the mother/caregiver on the
treatment
RUTF is all the food needed to recover. Give no other foods
until full daily ration is consumed.
• Follow proper timing/amount of RUTF ration
• Report improved infant/child’s appetite -- may need increased RUTF
• May give fresh fruits/ vegetables if requested once ration consumed
 C. Orient the mother/caregiver on
the treatment
• Encourage child to take small amounts of RUTF frequently
directly from the packet.
• NOT to share RUTF with other family members (RUTF -
medicinal food for thin and swollen children)
• Weekly health center visits for monitoring
• Return empty RUTF packets to the health center each week
and receive the next weekly ration
 C. Orient the mother/caregiver on
the treatment
• Explain how to give home medicines. Ask to repeat.
• Explain importance of hygiene and sanitation. Wash child’s
hands/face before eating and after stooling.
• Explain that malnourished children need to be kept warm
(ensure adequate clothing).
 C. Orient the mother/caregiver on
the treatment
• Inform of local volunteer/ health worker support.
• Inform of local BHW/BNS home visits among those who refuse
transfer to inpatient care facilities
• When concerned about child’s condition, health facility visit for
medical assessment is a MUST.
 C. Orient the mother/caregiver on
the treatment
• Encourage them to ask questions. Give them sufficient time.
• On later visits, additional counseling:
▪ IYCF topics based on IMCI guidelines
▪ Handwashing with soap and water
▪ Growth monitoring
D. OTC Management of Infants < 6
months
✓ Course of broad-spectrum oral antibiotic, such
as amoxicillin
✓ Detailed assessment of underlying cause(s) of
malnutrition + tailored action
✓ Plotting & appraisal of growth chart
OTC Management of Infants < 6 months

Refer for intensive Outpatient Breastfeeding Support.

Does NOT use RUTF.
a.

Individualized breastfeeding counseling for

b.

mother/caregiver:
•C-MAMI Tool
Specific for the mother

c. Advise on recommended:
i. nutrition practices
ii. health services
iii. care practices
iv. WASH practices
v. Health education/information
D. OTC Management of Infants younger than 6 months

d. After individual counseling, if no improved breast milk intake

or if fails to gain weight, refer to ITC.
e. Relactation should be supported (trained lactation counselor,
human milk bank).

Wet Nursing Drip-drop method Cross nursing

Session 1: Admission
Session 2: OTC Treatment Objectives

Session 3:
Weekly Monitoring
Objectives
 Steps for Weekly Monitoring
Monitor child weekly and record on OTC chart.

Identify OTC patients needing ITC referral and

conduct it.

Identify OTC patients needing further clinical or

social assessment and make appropriate referral.

Identify OTC patients needing home visits.

A. MW/BNS/BHW should do the following
at each weekly visit:
1. Ask about medical history of the infant/child,
progress of the child, including IMCI danger signs.
2. Wash hands
3. Examine the child. Check:
• Temperature
• For edema
• MUAC
• Weight
• Height/ length
• Check Z-scores for discharge criteria
ASK
• Persistent cough
• Persistent diarrhea
• Persistent fever
• Any fever in a malaria area
• Vomits everything
LOOK
• Chest in-drawing
• Fast breathing
• Very sleepy or unconscious
• Red MUAC
• Swelling both feet
A. MW/BNS/BHW should do the following
at each weekly visit:
1. Routine appetite test for all children 6-59
months.
2. For infants less than 6 months old to at least
two years old, ask about breastfeeding
practice and any improvement in milk
production.
3. Give routine treatment at appropriate visits
(if a visit is missed, give at next visit).
4. Complete recording on OTC chart.
A. MW/BNS/BHW should do the following
at each weekly visit:
5. Recalculate the weekly RUTF ration according to current
weight. Provide the ration.
6. Arrange for home visit or further clinical/ social investigation,
where required.
Assess need for ITC referral.
B. Identify OTC patients needing ITC
referral
Steps for ITC referral on follow-up:

1. Write reason for transfer on patient’s chart

2. Complete referral form - patient number, all details

of child’s condition, summary of treatments given.

3. Give referral form to patient’s mother/caregiver to

take with them to ITC.
OTC/ ITC
Referral Form
B. Identify OTC patients needing ITC
referral
4. Call relevant ITC supervisor regarding transfer

a. Facilitate direct admission to ITC ward.

• Process direct admission - not through emergency
department.
• Provide policy/procedures for direct admission.

b. When patient returns to OTC, avoid losing patient

during transfer via similar communication.
• Take any steps to avoid transport trauma.
C. Refer for further clinical or social
investigation if infant/ child not
responding to treatment (loss or
static weight for 2 weeks)
Screening
TB testing, counseling and treatment
1.

Screening and assessment of congenital abnormalities

2.

HIV counseling and testing

3.

Assessment of family functioning and capacity for care

4.
D. Refer for home visit, if any of
following is present:
1. OTC SAM patients but with medical complications who have
refused transfer to ITC
2. Not responding to program (loss or static weight for 2 weeks)
and suspicious home environment
3. Repeated absences from treatment
4. Infants < 6 months of age not gaining weight despite visits
Session 1: Admission
Session 2: OTC Treatment Objectives
Session 3: Weekly Monitoring

Session 4:
Discharge Objectives
Steps for OTC Discharge

Identify patients for discharge from OTC.

Classify outcome of OTC treatment and

record in registration book and chart.

Demonstrate discharge procedure.

A. Identify patients for discharge from
the OTC
Discharge criteria: Cured
A. Identify patients for discharge from
the OTC
Discharge criteria: Cured
Exercise:
To Discharge or Not to
Discharge from OTC
 Bilateral Discharge as
Age Well-being/ MUAC WFH/WFL
Infant/Child pitting cured from
mos. appetite (cm) Z-score
edema OTC
Greater than -
Breastfeeding
Allan 6 None - 2SD but less
effectively
than -1SD

Bea 24 Clinically well None 13.5 Equal to -2SD

Greater than -
Chris 18 Fair appetite Present 12.5
2SD

Breastfeeding
Delta 4 None - Equal to -2SD
effectively

Increase in rate of
Edwin 36 breathing None 11.5 Less than -3SD
Poor appetite
 Bilateral Discharge as
Age Well-being/ MUAC WFH/WFL
Infant/Child pitting cured from
mos. appetite (cm) Z-score
edema OTC
Greater than -
Breastfeeding
Allan 6 None - 2SD but less Yes
effectively
than -1SD

Bea 24 Clinically well None 13.5 Equal to -2SD

Greater than -
Chris 18 Fair appetite Present 12.5
2SD

Breastfeeding
Delta 4 None - Equal to -2SD
effectively

Increase in rate of
Edwin 36 breathing None 11.5 Less than -3SD
Poor appetite
 Bilateral Discharge as
Age Well-being/ MUAC WFH/WFL
Infant/Child pitting cured from
mos. appetite (cm) Z-score
edema OTC
Greater than -
Breastfeeding
Allan 6 None - 2SD but less Yes
effectively
than -1SD

Bea 24 Clinically well None 13.5 Equal to -2SD Yes

Greater than -
Chris 18 Fair appetite Present 12.5
2SD

Breastfeeding
Delta 4 None - Equal to -2SD
effectively

Increase in rate of
Edwin 36 breathing None 11.5 Less than -3SD
Poor appetite
 Bilateral Discharge as
Age Well-being/ MUAC WFH/WFL
Infant/Child pitting cured from
mos. appetite (cm) Z-score
edema OTC
Greater than -
Breastfeeding
Allan 6 None - 2SD but less Yes
effectively
than -1SD

Bea 24 Clinically well None 13.5 Equal to -2SD Yes

Greater than - NO (still with

Chris 18 Fair appetite Present 12.5
2SD edema)

Breastfeeding
Delta 4 None - Equal to -2SD
effectively

Increase in rate of
Edwin 36 breathing None 11.5 Less than -3SD
Poor appetite
 Bilateral Discharge as
Age Well-being/ MUAC WFH/WFL
Infant/Child pitting cured from
mos. appetite (cm) Z-score
edema OTC
Greater than -
Breastfeeding
Allan 6 None - 2SD but less Yes
effectively
than -1SD

Bea 24 Clinically well None 13.5 Equal to -2SD Yes

Greater than - NO (still with

Chris 18 Fair appetite Present 12.5
2SD edema)

Breastfeeding
Delta 4 None - Equal to -2SD Yes
effectively

Increase in rate of
Edwin 36 breathing None 11.5 Less than -3SD
Poor appetite
 Bilateral Discharge as
Age Well-being/ MUAC WFH/WFL
Infant/Child pitting cured from
mos. appetite (cm) Z-score
edema OTC
Greater than -
Breastfeeding
Allan 6 None - 2SD but less Yes
effectively
than -1SD

Bea 24 Clinically well None 13.5 Equal to -2SD Yes

Greater than - NO (still with

Chris 18 Fair appetite Present 12.5
2SD edema)

Breastfeeding
Delta 4 None - Equal to -2SD Yes
effectively

Increase in rate of
NO (Refer to
Edwin 36 breathing None 11.5 Less than -3SD
ITC)
Poor appetite
 B. Classify the infant/child’s outcome of
treatment
Cured Reached the criteria for discharge cured

Dead Died during treatment in the OTC or in transit to the ITC

Defaulter Not returned for three consecutive visits and

a home visit, neighbor, village volunteer, or other reliable source
confirms that the patient is not dead

Discharged as non-cured Does not reach the discharge criteria within four months and all
referral and follow-up options have been tried (e.g. home visit
conducted and household situation assessed)

Refer for assessment of possible medical complications if not yet

done (e.g. TB) and link with the MAM program where possible and
to social support systems.
Recap: OTC Discharge
Procedure
1. Explain to the caregiver that the child
has recovered sufficiently
2. Refer for vaccination if required
▪ 9 months of age and not yet
received vaccination against
measles
▪ If child > 9 months of age, without
measles vaccination administer
measles-containing vaccine.
▪ For infants who have already
received their first dose of
measles-containing vaccine at 9
months, the 2nd measles
vaccination should be given at
12-15 months
3. Get a last RUTF ration of 7 sachets
(1 sachet per day x 1 week) to aid the
child’s transition
4. IYCF counseling. If enrolled in 4Ps
program, ensure attendance in the Family
Development Sessions.
5. Link patient to SFP and/or other
services available.
6. Link caregivers with other appropriate
services which support on-going
rehabilitation.
7. Record discharge details on OTC
card.

C
Registry Book Example (page 2)
Summary:
Discharge
Procedure
Learning Activity: Exercise
 Activity: Fill-up Registry Book
Patient: Carlo M. Mendoza Referral from: community
Age/Sex: 36 mos./Male Date of Birth: 08/01/13
Registration No.: Weight: 7 kg
DavaoCity/St.JohnHealthCenter/OTC/16- Height: 72 cm
0010 WHZ: lower than -3SD
Date of Admission: 08/15/16 Edema: both feet only
Mother: Maria Morales MUAC: 11.4 cm
Address: Barangay St. John, Talomo
North District, Davao City
Phone No.: 0922-345-9678
 Activity: Fill-up ITC Referral Form
Patient: Carlo M. Mendoza Referral from: community
Age/Sex: 36 mos./Male Date of Birth: 08/01/13
Registration No.: Date of Referral: 08/15/16
DavaoCity/St.JohnHealthCenter/OTC/16 Weight: 7 kg
-0010 Height: 72 cm
Date of Admission: 08/15/16 WHZ: lower than -3SD
Mother: Maria Morales Edema: both feet only
Address: Barangay St. John, Talomo MUAC: 11.4 cm
North District, Davao City Breastfeeds poorly
Phone No.: 0922-345-9678 Difficulty of breathing
M.
 Activity: Fill-up OTC chart
Patient: Carlo P. Mendoza 4Ps Beneficiary: Yes
Age/Sex: 36 mos./Male No IMCI danger signs
Registration No.: DCTN/SJHC/OTC/16- Wt: 7 kg, Ht: 72 cm, WHZ: < -3SD
0010 MUAC: 11.4 cm
Date of Birth: 08/01/13 HR: 89, RR: 24, Temp.: 36.7 C
Equal chest expansion, clear breath
Date of Admission: 08/15/16 sounds, no retractions, no rales
Referral from: community Extremities full pulses, warm, edema
Mother: Maria Morales +, no skin lesions
Address: Barangay St. John, Talomo Passed appetite test
North District, Davao City Eats regular table foods
Phone No.: 0922-345-9678 Good urine output
Activity: Fill-up OTC chart on follow-up after 2 weeks

Patient: CPM Present Wt: 7.2kg, Present Ht: 72cm

Age/Sex: 36 mos./Male WHZ: > -3SD but < -2SD
Registration No.: DCTN/SJHC/OTC/16- MUAC: 11.4 cm
0010 HR: 90, RR: 20, T: 36.8oC
Referral from: community Extremities full pulses, warm,
Date of Admission: 08/15/16 no edema, no skin lesions
Date of Follow-up: 08/30/16 Passed appetite test
No IMCI danger signs Previous RUTF: 3 sachets/ day
or 20 sachets/ week
 Activity: RUTF Ration Card
Patient: CPM Referral from: community
Age/Sex: 36 mos./ Male Date of Birth: 08/01/13
Registration No.: DCTN/SJHC/OTC/16-0010 Wt: 7 kg, Ht: 72 cm, WHZ: <-3SD
Date of Admission: 08/15/16 Target Wt: 7.7 kg (-2SD)
Mother: Maria M MUAC: 11.4 cm
Address: Barangay St. John, Talomo North Edema: +
District, Davao City Passed appetite test
Phone No.: 0922-345-9678 RUTF ration: 3 sachets per day
or 20 sachets per week
Ration Card
OTC Registration NumberDCTN/SJHC/OTC/16-0010
Brgy. St. John Talomo, North District, Davao
OTC Site Address City
Name Carlo P. Mendoza Age 36 months
Target Weight7.7 kg (-2SD)

Date Weight (kg) Height (cm) W/H MUAC (mm) Edema RUTF Others
Z score
Received Per day

August 15, 2016 7 kg 72 cm < -3SD 11.4 cm + 20 sachets 3 sachets per

per week day
 Activity: Fill-up discharge details on the
OTC chart and Registry book
Patient: CPM Referral from: community
Age/Sex: 39 mos./Male No IMCI danger signs
Registration No.: DCTN/SJHC/OTC/16-0010
Date of Birth: 08/01/13 Wt: 8.8 kg, Ht: 73 cm
Date of Admission: 08/15/16 WHZ: greater than -2SD & less than
+2SD
Date of Discharge: 11/04/16
MUAC: 12.5 cm
Mother: Maria Mortel
HR: 94, RR: 24, T: 36.6 C
Address: Barangay St. John, Talomo North
District, Davao City Edema: none
Phone No.: 0922-345-9678 Appetite test: passed
Type of Exit: cured
Summary
OTC is for SAM infants/children with good appetite & no medical
•

complication
OTC involves counseling on IYCF practices, giving routine meds
•

& RUTF
Close monitoring needed
•

Family/community support, and

•

Proper counseling of mother/caregiver essential to successful

•

management
END