Management of acute malnutrition

1The community-based approach (CMAM)

Community-based management of acute malnutrition (CMAM) rests on four components:

• Community mobilisation: active screening by community volunteers and mothers, referral, defaulter tracing.
• Targeted supplementary feeding programme (TSFP) for MAM: supplementary foods, follow-up every two weeks.
• Outpatient therapeutic programme (OTP) for SAM without complications: ready-to-use therapeutic food (RUTF), systematic treatment, weekly visit.
• Inpatient stabilisation (TFC or SC) for SAM with medical complications or without appetite.

This approach makes it possible to treat the vast majority of children at home, earlier and at greater scale.

2Admission, treatment and discharge

When admitting a child with SAM, always check three things: medical complications (convulsions, lethargy, intractable vomiting, high fever, pneumonia, severe dehydration), severe oedema and the appetite test with RUTF. If the child eats well and has no complications, they are followed as an outpatient; otherwise, they are stabilised in hospital.

Outpatient treatment includes RUTF according to weight, a systematic antibiotic, deworming and vaccination according to the protocol. Discharge as cured follows national criteria, for example a MUAC of at least 125 mm at two consecutive visits and no oedema. Each child has a follow-up card and a unique number.

3Performance indicators

The Sphere standards set benchmarks for SAM treatment programmes:

• Recovery rate: more than 75%.
• Death rate: less than 10%.
• Defaulter rate: less than 15%.
• Coverage: more than 50% in rural areas, more than 70% in urban areas, more than 90% in camps.

A high defaulter rate calls for investigation: distance, waiting time, hidden costs, perception of the service, mothers' farm work. Coverage is measured with specific methods (SQUEAC, SLEAC) which also identify barriers.

4Supplies and the supply chain

An RUTF stock-out interrupts treatment and pushes families to drop out. Requirements are calculated from the population, SAM prevalence, expected incidence and target coverage, with a safety stock. Supplies are stored in a cool, dry place, tracked by batch number and expiry date, and distributed on a “first expired, first out” basis.

RUTF is a medicine: it is not to be shared with siblings. Explain this to mothers and, if necessary, coordinate with food security so that the family also receives a ration or a cash transfer.