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Field Article Preparation of enriched porridge as part of the programme to manage moderate acute malnutrition Multi-pronged approach to the management of moderate acute malnutrition in Guinea By Dr Jean-Pierre Papart and Dr Abimbola Lagunju Dr. Jean-Pierre Papart MD, MPH, is Health advisor, Fondation Terre des hommes, Lausanne, Switzerland Dr Abimbola Lagunju MD, is Regional Health Advisor, Fondation Terre des hommes (West Africa) The authors acknowledge the support of the team in Guinea, in particular Mamadi Kaba (MD), Mariama Ba, Sonia Panzani (Fondation Terre des hommes), Marie-Jeannne Haubois (former Fondation Terre des hommes). Guide to acronyms used (equivalent in generic CMAM terminology) cSAM sSAM MAM CNT CNA CNS CMC MSPH CS complicated severe acute malnutrition uncomplicated SAM moderate acute malnutrition Stabilisation Therapeutic centre (manage Phase I cSAM) Outpatient Therapeutic centre (treat sSAM and phase II cSAM) Supplementary Feeding centres (manage MAM) Communal Medical Centres Ministry of Public Health Health Centre This article describes the experience of Fondation Terre des hommes in the management of moderate acute malnutrition in supplementary nutrition centres supported by the organisation in Guinea. Fondation Terre des hommes (Fondation Tdh) is a Swiss Child Rights advocacy organisation based in Lausanne, Switzerland and founded in 1960. The Foundation employs the UN Convention on the Rights of the Child as its guiding principle in its two principal domains of action, maternal and child health (MCH) and child protection. Its intervention strategy in these two domains is predicated on empowerment of beneficiaries, system reinforcement and advocacy. Fondation Tdh has nutrition-focused MCH and child protection projects in five countries in the West Africa sub-region – Benin, Burkina Faso, Mauritania, Togo and Senegal Management of acute malnutrition in Guinea In Guinea, the management of acute malnutrition is undertaken at three different levels of facility, depending on the severity of the case: • Therapeutic nutrition centres (CNT) manage phase 1 of complicated severe acute malnutrition (cSAM) • Outpatient nutrition centres (CNA) treat severe acute malnutrition without complications (sSAM) and also phase II of cSAM • Supplementary nutrition centres (CNS) manage patients with moderate acute malnutrition (MAM). This management strategy alongside the model for interventions (see Figure 1) was developed by the Ministry of Public Health (MSPH) and published in The National Guidelines of Management of Acute Malnutrition in May 2008. National guidelines admission criteria at health facility level are shown in Table 1. Fondation Tdh in Guinea Fondation Tdh has been supporting government health facilities in Conakry, Guinea in Fondation Tdh, Guinea, 2011 the management of MAM since 2005. This decision was informed by the reported increase in the global acute malnutrition (GAM) rates between 1999 and 2003 in the city of Conakry. The 1999 Demographic and Health Survey reported 10.9% GAM prevalence in children aged less than 5 years. The QUIBB (Enquete sur le Questionnaire des Indicateurs de Base du Bien-etre) survey of 2003 showed that global acute malnutrition was 14.4% among the same age group. Conakry had the second highest rate of global acute malnutrition among the eight regions in the country in 2003. In December 2007, Fondation Tdh supported two communal medical centres (CMCs) (Ratoma and Flamboyant), both located in the Commune of Ratoma and a private medical facility (St. Gabriel Dispensary) in the adjoining commune of Matoto to adopt and put into practice the new national guidelines on the management of acute malnutrition in the treatment of sSAM. This involved use of RUTFs and health facility based management of MAM. In December 2008, two additional health centres (CS) in Ratoma commune (Lambandji and Wanindara) also introduced these activities using the national management guidelines. Fondation Tdh supported these facilities by putting in place a monitoring system to follow up on performance and provide necessary technical advice. This article is based on the monitoring of the performance of these four health facilities between 2008 and 2010. See Figure 2 for map reflecting Conakry communes. Health facility network in Ratoma Commune The Commune of Ratoma has 20 quarters (administrative units). The public health system consists of sixteen health facilities: two CMCs and 14 CS. The CMCs, which have the same facilities as district hospitals (surgery, paediatric and internal medicine units, hospitalisation), serve as referral units for the health centres. Of the 16 health facilities in the commune, none has a CNT, five have a CNA and all 16 have a CNS (five facilities have both a CNA and a CNS). All these health facilities have a nutrition unit manned by trained government staff. All identified cSAM cases are referred to the Institute National de Santé de l’Enfant (INSE) for stabilisation. After stabilisation, they are referred back to the health centres for ambulatory management of phase 2. Fondation Tdh presently provides technical support to all the health facilities in Ratoma Commune. Fondation Tdh support to health facilities All the activities of the nutrition programme (anthropometric assessment using measurements of weight, mid-upper arm circumference (MUAC)), cooking demonstrations, counselling) are carried out by the government staff of the nutrition units of the health facilities. Fondation Tdh provides techni- Table 1: National guidelines admission criteria and health facility level Admission criteria* Health facility level for care Moderate Acute Malnutrition Severe Acute Malnutrition • W/H between 70% and 79.9% of the median • MUAC between 11 and 12 cm (for length > 65 cm) • Absence of oedema • W/H < 70% of the median • MUAC < 11 cm (for length > 65 cm) • Absence of medical complications) • W/H < 70% of the median • MUAC < 11 cm (for length > 65 cm) • Presence of medical complications W/H: weight for height *Based on the NCHS references CNS CAN CNT 65
Field Article Figure 1: Model of intervention for the management of acute malnutrition in Guinea Figure 2: Map of Guinea focused on Conakry communes Community screening Referal g CS Screening in CS Transfer g CNT cSAM CM in CNT SAM cSAM cSAM Treated cSAM Stabilised Transfer g CNA < 5years AM Suspected AM Referred sSAM sSAM Treated sSAM Recovery MAM Recovery MAM Treated MAM Referral g CNS Transfer g CNA sSAM CM in CNA MAM CM Activity Child RATOMA MATOTO Key to figure: AM: acute malnutrition; SAM: Severe acute malnutrition; MAM: moderate acute malnutrition; CS: health centre; cSAM: complicated SAM; sSAM: Uncomplicated SAM; CNA: ambulatory nutrition centres; CNS: supplementary nutrition centres; CM: case management KALOUM DIXIN MATAM cal, material and equipment support to the nutrition units of the health facilities. The staff of Fondation Tdh comprises two medical doctors and a nutritionist. Technical support includes training and on the job supervision. Fondation Tdh also invests in quarterly nutrition programme supervision of all the health facilities by the higher authorities of the Conakry City Health Directorate. Fondation Tdh staff also assist the health facilities in collating and analysing data generated from their nutrition activities. Through these analyses, weaknesses are jointly identified and decisions are reached on corrections. Further, on the request of the health authorities, Fondation Tdh acts as an active interface between the health authorities and agencies like UNICEF and World Food Programme (WFP) for supplies to the health facilities. This is a temporary arrangement pending the time the authorities study the reporting mechanisms of these agencies and identify a liaison person for this activity. In addition to the technical support, Fondation Tdh also provides material support to the nutrition units, such as stationery, IEC (information, education, communication) materials, cooking materials, MUAC tapes and weighing scales. Urban Community Health Workers in Ratoma commune In six of the 20 quarters of Ratoma, Fondation Tdh in collaboration with the communal health authorities, recruited and trained 32 urban community health workers (UCHW). The UCHWs participate in the community screening of children for acute malnutrition in their neighbourhoods, follow up on defaulting cases and engage in the promotion of healthy nutrition practices through cooking demonstrations, counselling on breastfeeding and hygiene (See Figure 3). Screening of children for acute malnutrition Screening of children for acute malnutrition takes place at two levels – in the neighbourhoods (active screening) and at the health facility level (passive screening). See Figure 3. Active screening Each of the UCHWs is assigned an area within their neighbourhoods. The UCHWs compile a list of all the children within their area and visit their homes on a monthly basis. In the course of the visits, MUAC of children 6-59 months is measured and recorded. Children with MUAC of 65 cm), MUAC is also measured. Children between 6-59 months presenting with acute malnutrition are assigned to the appropriate treatment as directed by the National Guidelines. The total case load of malnutrition for Ratoma Comune and St Gabriel is shown in Table 2. Management of SAM The child with sSAM is prescribed Ready to use therapeutic foods (RUTF) 1 and routine drugs like Vitamin A, antibiotics and anti-helminthics. RUTF is given on a weekly basis to the children and at the end of each week, the child presents at the health facility for a check-up until the child attains and maintains the target weight (85% of the median % weight-for-height) at two consecutive weekly checkups (option 1) or option 2 (discharge on reaching 85%) without two consecutive check-ups. Monitoring reports indicate that St Gabriel Dispensary has had major problems with defaulting in the treatment of sSAM. In 2010, of a total number of 1,133 recorded exits, 35.6% were cases of defaulting. The reason for this is that, unlike the four other CNAs supported by Fondation Tdh, St. Gabriel Dispensary has a reputation for inexpensive and quality medical treatment which extends far beyond Ratoma commune. The dispensary charges a flat rate which includes costs for consultation, laboratory tests and medicines. Many people travel great distances, sometimes up to 200 km, to seek treatment is this dispensary. Normally, parents do not recognise signs of acute malnutrition in their children and come to the healthcare centre expecting treatment for illnesses rather than for malnutrition. The healthcare centre staff identify malnourished cases through routine measurement of the children. When a child is diagnosed as suffering from acute malnutrition and the parents are told that treatment is necessary and that this will involve several weekly check ups (a total of 5 to 10 visits), many of them fail to return to the centre after one or two follow-up visits. This is due to the distance they have to travel each time. These cases present a problem for the Dispensary, because there are no CNAs or CNS in the villages of origin of these children to which they can be referred. All identified cases of cSAM are referred to INSE. Fondation Tdh supports the patients through the payment of transport costs from the referring health facility to INSE. Further, Fondation Tdh pays the treatment costs of cSAM cases referred from any of its intervention centres. cSAM cases are managed with F75 formula until stabilisation and then referred back to referring centre for Phase 2 management as prescribed by the National Guidelines. Management of MAM Breastfed children
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January 2012 Issue 42 ISSN 1743-508
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