Malnutrition can severely weaken children and leave them vulnerable to common infections. Chronic malnutrition stunts physical and intellectual development in young children, causing irreversible harm that may follow them through life. PIH has made treatment for childhood malnutrition a priority at our program sites.

Malnutrition is the end result of inadequate dietary intake and disease, both of which are rooted in poverty. PIH's nutrition programs seek to combine the best practices in community-based management for malnutrition with hospital-based treatment when necessary. Successful management of pediatric malnutrition does not require sophisticated facilities and equipment. It does, however, require that each child is treated with proper care and attention, and that each phase of treatment is carried out by appropriately trained health personnel working in collaboration with dedicated community health workers.

The goal of PIH's nutrition program is to provide the best available therapy to reduce the risk of death, shorten the length of time spent in the hospital, and facilitate rehabilitation and full recovery from malnutrition. In addition to medical care, our nutrition program focuses on education and direct distribution of food and vitamins. Critical components for prevention of malnutrition are targeted monitoring, nutrition education, and building agricultural capacity at the family and community level.

Planning considerations

• Identify the target patient population's nutritional problems and calculate estimated treatment needs. Are there areas where the incidence of malnutrition is particularly high? How large a catchment area will be served? What are the main causes of malnutrition in this setting? (feeding practices, poor health environment, food insecurity, etc)? What is the average age of the malnourished children? What time of year presents the highest number of malnutrition cases? Estimate cost implications that address these needs and calculate a feasible budget.

• Learn about the local, national and international factors that impact family food security. Engage community leaders and families in ongoing conversations. Ensure that interventions include both the clinical treatment of malnutrition, and preventive efforts such a nutrition education and provision of social and economic assistance.

• Define standardized patient admission and completion criteria and established clinical signs of malnutrition. The World Health Organization provides standardized weight-for-height, weight-for-age, and Body Mass Index calculations.

• Create a system for collecting program data to ensure that the progress and clinical status of each child can be tracked over time. Include information on the child's family situation, health and vaccination records, socioeconomic situation, visits to the health center, and weight measurements at each visit. Ensure a feedback system is in place for CHW reports. In addition to tracking individual patients, regularly assess the program as a whole: keep good records on patients who have died, have abandoned the program, or completed treatment. This data will allow for easy access to important clinical information as well as a concrete measure of the average monthly consumption of products used in the treatment of malnutrition, essential for accurate budgeting and procurement.

• Emphasize family education. A typical curriculum covers information on making the best food choices based on what is available in local markets with very limited financial means; food preparation; potable water options; and hygiene and sanitation practices.

• Work with the community to establish agricultural programs that directly support families of malnourished children. Agricultural initiatives are long-term undertakings.

Suggested staffing for a nutrition program

Affiliated staff should be provided with ongoing nutrition training to reinforce and update their knowledge.

• Clinical oversight (physicians, nurses)
• Pharmacists
• Nutrition program manager
• Staff responsible for distributing therapeutic foods
• Staff responsible for taking weight measurements and tracking the progress of enrolled patients
• Data clerks/manager
• Community health workers

A special note on the role of community health workers

The active involvement of CHWs is critical to ensure that new cases in the community are identified and quickly referred to the health center for care. They also play an important role in patient follow-up once the child is discharged from the hospital.

Suggested equipment

• Scales for weighing neonatal and pediatric patients (mechanical scales are recommended as they do not require electricity or battery power)
• Pharmacy scales for measuring treatment ingredients
• Containers and utensils for preparing and distributing therapeutic treatments
• Weight-for-height charts
• Weight-for-age charts
• Training materials on basic nutrition

Suggested therapeutic foods for malnutrition program

1. Dry cereal legume blend
Zanmi Lasante produces its own dry cereal blend, Nourimil, made from beans and either rice or corn. The dry cereal, a rich source of protein and amino acids, is then ground to a digestible powder and cooked with clean water.

Additionally, a complex of minerals and vitamins in powder form is often given along with the food blend to fortify the diet with micronutrients.

2. Ready-to-use therapeutic food (RUTF): fortified peanut paste
For severe malnutrition, particularly for young children, an effective treatment is a nutrient-rich RUTF such as "plumpy nut", which is commercially available. Zanmi Lasante produces its own therapeutic version, Nourimanba , a mixture of peanuts, powdered milk, sugar, oil, vitamins and minerals that provides approximately 500 calories per 100 grams. Its advantages over powdered milk formulas are that it has a long shelf life, does not have to be mixed by the family at home, and can be used easily in an outpatient setting.

3. ReSoMal Rehydration Solution for Malnutrition
ReSoMal is used to treat dehydration in children prompted by severe malnutrition. Because severely malnourished children are deficient in potassium and have abnormally high levels of sodium, the solution used for oral rehydration should contain less sodium and more potassium than the standard WHO-recommended solution, (ORS), used for non-acutely malnourished children. Magnesium, zinc and copper should also be given to correct deficiencies of these minerals.

4. Therapeutic milk (F-75 and F-100)
These two formula diets are used for severely malnourished children who are unable to tolerate the usual amounts of dietary protein, fat and sodium. They are prepared from basic ingredients: dried skimmed milk, sugar, cereal flour, oil, mineral mix and vitamin mix and are also commercially available as powdered milk formulas to which water is added. F-75, providing 75kcal per 100 ml is mainly used in the initial phase of treatment for malnourished children, while F-100, providing 100 kcal per 100 ml is given once appetite has returned. See more detailed information about the preparation of all the suggested therapeutic foods mentioned above.

Implementation: Case finding and diagnosis

Community surveillance of malnutrition

Many families do not seek care until a child is very ill, whether because of the difficulty of reaching a health center or inability to pay user fees. One of the greatest strengths of PIH's model of community-based care is that it enables early case detection in the community. Community health workers can identify at-risk children and families before their conditions become life-threatening. By utilizing home visits to detect malnutrition, health center staff are also able to monitor the health of the siblings of an affected child and evaluate the socioeconomic conditions and needs of the family.

Community health workers conduct regular home visits to families (example: home visit form) who live in their geographic area. They are trained to identify the signs of malnutrition and instructed to refer sick children to the health center.

During home visits to families with young children, CHWs check each child's health record to be sure that they are up-to-date on their vaccinations and to record age, height, and weight. The CHW plots each child's "weight-for-age" on a growth curve, which will determine if the child is malnourished, at risk for malnutrition, or developing normally. The weight-for-age indicators are typically standardized nationally.

Children and families who are at risk for malnutrition are monitored and provided with nutrition education; depending on additional factors, such as the individual family's ability to secure food, the child may be referred to the health center for additional care. Those who are malnourished are immediately brought to the health center for care.

Clinical evaluation of a malnourished child

Children are evaluated for any complications associated with malnutrition, (example: nutritional assessment form) such as dehydration, infection or edema. If such complications are detected, the child is admitted for inpatient care. If no complications are detected, the child is enrolled in the ambulatory malnutrition program.

Implementation: Treatment

Outpatient care at Inshuti Mu Buzima, Rwanda

Children who are 70 to 80 percent of the median weight-for-height (weight-for-height classification) receive a bi-monthly food package that includes beans, oil, sosoma and sugar.

Mothers or caregivers bring their children to the health center every two weeks where the children are weighed and food packages are collected. While at the health center, staff involved with the nutrition program provide mothers and caregivers with nutrition education and counseling, including the topics of hygiene and food preparation. Home visits are also carried out. After two months, the child is re-evaluated. The food packages end once there is sufficient weight gain, though follow-up visits continue. If there is little improvement in the child’s health, the child continues in the outpatient program. If the child’s condition has worsened, he or she is admitted for inpatient care.

Inpatient care at Inshuti Mu Buzima, Rwanda

Any child who is less than 70 percent of the median weight-for-height receives inpatient care for malnutrition. Treatment is started immediately in order to prevent common infections and correct metabolic abnormalities, and intensive feeding is begun in order to recover lost weight. Initial treatment includes: trimethoprim/sulfamethoxazole, mebendazole, Vitamin A, folic acid and zinc cream. Therapeutic milk (F-75) is given until the patient's appetite returns. Once a child starts to gain weight, treatment is changed to include multivitamins and therapeutic milk (F-100).

Children are weighed every day in order to monitor progress. Throughout the treatment, all mothers or caregivers of inpatient children attend education sessions on nutrition, food preparation, continuation of malnutrition care at home, family planning and malaria.

Once a child is determined to be at least 80 percent of the median weight-for-height, he/she is discharged from hospital (discharge checklist) and enrolled in the ambulatory malnutrition program described above.

The child and family are followed by community health workers to prevent relapse and assure continued physical, mental, and emotional development.