Module 5_Essential Information

Outpatient Therapeutic Care: Module 5
Essential Information
Management of SAM without Complications
By the end of this module, you should be able to:
• Triage, admit, manage and discharge a child

• Know when to transfer a child to Inpatient Therapeutic Care
• Discuss recent developments in the management of SAM
Treatment for children with SAM with adequate appetite and no medical complications can be managed
at home with regular visits to a local health facility providing SAM services.
Triage
Check for medical complications.
Look out for Integrated Management of Childhood Illness (IMCI) danger signs, including oedema;
Global Health Media video on Danger Signs.
Infants and children with any of the following characteristics should be referred and admitted for
inpatient care:
i. one or more Integrated Management of Childhood Illness (IMCI) danger signs
ii. acute medical problems or conditions under severe classification as per IMCI
iii. oedema (nutritional)
iv. recent weight loss.
Infants and children 6-59 months who do not meet any of the criteria from above but who do have any of
the following characteristics are likely to benefit from an in-depth assessment to inform the decision on
possible referral to inpatient:
i. medical problems that do not need immediate inpatient care but do need further examination and
investigation (e.g. bloody diarrhoea, hypoglycaemia, HIV-related complications);
ii. medical problems needing mid or long-term follow-up care and with a significant association with
nutritional status (e.g. congenital heart disease, cerebral palsy or other disability, HIV,
tuberculosis);
iii. failure to gain weight or improve clinically in outpatient care;
iv. previous episode(s) of severe wasting and/or nutritional oedema.
The decision to refer a child to inpatient care will depend on the outcome of the health worker's in-depth
assessment and clinical judgement.
• Treat visibly sick children who can take oral fluids by providing energy (5g or one teaspoon of
sugar in 50 ml of water) to prevent hypoglycemia and warmth (using the kangaroo method or
warm, dry clothing and hat to prevent hypothermia.
• Take measurements and check for bilateral oedema (refer to Module 3:

• Conduct an Appetite Test (refer to your national guidelines for products and tests)
o Wash hands, both child and carer, with soap
o Sit the child and carer in a calm place and encourage the child to eat without forcing.
o While the child is eating, offer clean water to drink.

o Give the child time: the test is usually short but can take up to 30 minutes.
o Decide if the child passes or fails the test
o If a child eats more than 1/3 of the packet of RUTF, they pass and should be referred to
Outpatient Therapeutic Care
o If a child eats less than 1/3 of the packet of RUTF, they fail and should be referred to
Outpatient Therapeutic Care
When referring a child with SAM with complications to inpatient care, provide sugared water and keep the
child warm. Stabilize the child by initiating emergency treatment to the extent possible at your facility
before transport is taken.
Infants and children with the following characteristics should be enrolled into outpatient care.
i. good appetite (passed the appetite test); and

ii. no IMCI danger signs or any of the acute medical problems
iii. no criteria needing in-depth assessment or criteria present, but an in-depth assessment has been
completed, and no inpatient admission is needed (e.g. diarrhoea with no dehydration, respiratory
infections with no signs of respiratory distress, malaria with no symptoms of severity).
Assessment, triage, treatment, or referral of infants and children with SAM can be carried out by
community health workers as long as they receive adequate training and regular supervision.
Enrollment
• Routine Medical Treatment

o Give oral antibiotic (e.g. Amoxycillin at admission)
o Give deworming at the first follow up visit (or week 3) unless it was given in the last month
o Give measles vaccination: if 9-12 months with no vaccination card, give the first
dose or if measles outbreak or signs of eye problems
• Provide RUTF Ration

o Provide ration based on the current weight of the child (or on reduced dosage charts)
[Refer to your National Guidelines for products and ration tables
Follow-up visits.
• Repeat every visit:
• Appetite test
• Medical checkup (history, temperature, respiration, check for complications)
• Weight, MUAC, presence of bilateral oedema,
• Provide routine medicines, e.g. deworming
• Using new weight, check the RUTF amount (from the table) and provide the ration
• Counsel/Give health and nutrition education [Refer to Module 9: Supporting Carers]
• Complete records and give the date of the next visit
If a child has static weight or weight loss:

• Check that the carer is giving RUTF correctly
• Check appetite and child eating full ration; if needed, refer to Inpatient Therapeutic Care
for supervised feeding and monitoring

• Check the home situation, and if there are any social or mental health issues, visit home if
possible.
• Check if the child is sick: treat or refer for investigation. malaria, diarrhoea, TB, HIV
• If there is still no improvement, refer to a higher-level hospital/referral centre
• Refer to Inpatient Therapeutic Care if:
 Failed appetite test
 Deteriorated medically / developed IMCI danger sign(s)
 Increasing oedema
 Weight loss (3 consecutive weights) or no weight gain (5 consecutive weights)

• Arrange home visits by a health worker especially if:
 Child has medical complications/no appetite, but carer refuses inpatient care
 Child is not responding to treatment (in the last 2 weeks, they has lost weight
or not gained weight)
 There is concern about a home situation or the mental state of the carer
 Child has been absent repeatedly or defaulted.
 Child is diagnosed with TB/HIV or recently discharged from hospital care
 Offer counselling on child care and link to a social worker or other
available support services
• Exit Procedure (Cured Criteria: No bilateral oedema, MUAC: ≥ 12.5 cm for two weeks
and/or WLZ/ WHZ: ≥ -2, (measurements used to admit child should be used to
determine exit ), Clinically well)
 For cured children, tell the carer that the child is better and congratulate them; for
non-cured, readmit if falls within outpatient criteria again.
 Check that any remaining vaccinations or medications are given
 Give a final ration of RUTF
 Give appropriate health education and link to other services
 Record anthropometric measurements and outcomes.

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Outpatient Therapeutic Care: Module 5

By the end of this module, you should be able to:

• Triage, admit, manage and discharge a child

Check for medical complications.

• Take measurements and check for bilateral oedema (refer to Module 3:

o While the child is eating, offer clean water to drink.

i. good appetite (passed the appetite test); and

• Routine Medical Treatment

• Provide RUTF Ration

If a child has static weight or weight loss:

for supervised feeding and monitoring

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