Day 2: 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.

In-depth course

Detailed methods, a complete worked example, tools, common mistakes and interview questions.

5Organising an outpatient therapeutic programme day: the complete patient flow

A quality OTP can be recognised by its physical organisation and by how smoothly the child moves through it. A poorly organised site produces five-hour waits, children measured in a rush, missed routine treatment and, eventually, defaulting. Here is the reference flow for an OTP day in a health centre, to be adapted to the national protocol.

The child's pathway, station by station

Station	Who	What is done	Points to watch
1. Reception and triage	Reception staff or community volunteer	Registration of arrival, immediate identification of children showing danger signs (lethargy, convulsions, breathing difficulty)	Children in danger go straight to the nurse, without waiting
2. Group education	Nutrition promoter	Short session during the wait: how to take RUTF, hygiene, breastfeeding, warning signs	Messages adapted to the language and level; no more than 15 minutes
3. Anthropometry	Two trained staff	MUAC, weight, height at admission (and at discharge, depending on the protocol), oedema check	Equipment calibrated in the morning; values written on the card immediately
4. Medical consultation	Nurse or clinician	Clinical examination, screening for complications, malaria rapid diagnostic test, routine treatment and treatment of associated conditions	Any complication = referral to stabilisation
5. Appetite test	Nutrition staff	At admission and in case of weight loss: the child eats a minimum amount of RUTF in a quiet corner, over about 30 minutes	Never force; a failed test means referral to stabilisation
6. Distribution	Storekeeper or nutrition staff	Provision of the amount of RUTF according to weight until the next visit, completion of the child's card	Systematic explanation; check of empty sachets brought back
7. Leaving the site and follow-up	Community volunteer	List of absent children passed to volunteers for home visits	Absent once: home visit; twice in a row: defaulter under most protocols

Reference routine treatment

The exact content falls under the national protocol. As a benchmark, the 2013 WHO guideline on the management of SAM, adopted in most protocols, provides for:

Routine oral antibiotic at admission (most often amoxicillin for 5 to 7 days) for children treated as outpatients, even without signs of infection.
RUTF at about 150 to 200 kcal per kg per day, distributed according to a dosage table by weight band. A standard 92 g sachet provides about 500 kcal.
Measles vaccination if the child is not vaccinated, according to the national schedule.
Vitamin A: no routine high dose if the child is receiving RUTF that meets specifications, except in case of eye signs, measles or a contrary national policy.
Deworming (albendazole or mebendazole) for children aged one year and over, generally at the second visit.
Malaria: rapid test and treatment according to the national protocol in endemic areas; bed net if possible.

Follow-up between visits

Each weekly (or fortnightly, depending on the protocol) visit includes re-measurement, checking weight gain, screening for complications, checking appetite and a discussion with the mother. The criteria for transfer to stabilisation during treatment are precise: onset of a complication, worsening oedema, weight loss over two consecutive visits or static weight over three visits, loss of appetite. The criteria for non-response (for example no recovery after 12 to 16 weeks depending on the protocol) lead to a medical and social investigation: tuberculosis, HIV, sharing of RUTF, neglect.

Discharge

According to the 2013 WHO guideline, discharge is based on the same indicator as admission: a child admitted on MUAC is discharged with a MUAC of at least 125 mm; a child admitted on weight-for-height is discharged with a z-score of at least -2; in both cases without oedema for at least two weeks. Percentage weight gain should not be used as a discharge criterion. Many protocols also require a minimum length of treatment and referral to the TSFP after discharge from the OTP.

The discharge criterion is the programme's exit door, but also the denominator of all performance indicators. If two sites in the same programme apply different criteria, their cure rates are not comparable.

6Inpatient stabilisation: the ten steps and the deadly pitfalls

Children with SAM and complications often die during the first 48 hours, and a significant share of these deaths is preventable. The WHO ten steps protocol structures care. It is not reserved for doctors: the night-duty nurse, who is often alone, must master it.

The ten steps

Treat or prevent hypoglycaemia: feeding from admission and every 2 to 3 hours, including at night; glucose in case of confirmed or suspected hypoglycaemia.
Treat or prevent hypothermia: child dressed, covered, skin-to-skin with the mother ("kangaroo" method), warm room, night feeds.
Treat dehydration with caution: specific rehydration solution (ReSoMal) orally or by nasogastric tube, in small amounts, while monitoring pulse and breathing. Intravenous infusion is reserved for shock only, with a specific protocol.
Correct electrolyte imbalances: therapeutic products already contain the necessary potassium and magnesium; no diuretics for oedema.
Treat infections: routine antibiotic therapy, often by injection in complicated cases; classic signs (fever) are frequently absent.
Correct micronutrient deficiencies: provided by the therapeutic milks; iron is not given in the initial phase.
Start feeding cautiously: F-75 therapeutic milk (75 kcal per 100 ml), in small, frequent amounts, for about 100 kcal per kg per day.
Achieve catch-up growth: gradual switch to RUTF or F-100 as soon as appetite returns and oedema decreases (transition phase), with monitoring of respiratory rate and pulse.
Sensory stimulation and emotional support: play, contact, involvement of the mother; severe SAM is accompanied by apathy and developmental delays.
Prepare for follow-up: return to the OTP as soon as the child is stable, has a good appetite and complications are resolved, generally after only a few days.

The pitfalls that kill

Dangerous practice	Why	Good practice
Intravenous infusion "to rehydrate" a child who is not in shock	The heart of a severely malnourished child tolerates overload poorly: heart failure	Cautious oral rehydration with ReSoMal; infusion only in case of shock, according to the protocol
Feeding that is too rich or too fast from admission	Refeeding syndrome, heart failure	F-75 in small amounts, gradual increase
Iron given in the initial phase	Worsens infections and oxidative stress	Iron only in the rehabilitation phase
Diuretics for oedema	Electrolyte imbalance, death	Oedema resolves with refeeding
No night feeding	Hypoglycaemia and hypothermia in the early morning, the classic time of death	Night feeding schedule, checked by the supervisor
Unjustified transfusion	Circulatory overload	Only in case of very severe anaemia according to the protocol criteria

Monitoring and organisation

Monitoring at least every 4 hours during the acute phase (temperature, pulse, respiratory rate), more frequently during rehydration.
Daily weighing, monitoring chart at the bedside, immediate reporting of sudden weight gain (a possible sign of fluid overload) or an increase in respiratory rate.
Dedicated night team, with a posted protocol and a focal point who can be reached.
Average weight gain to be monitored in the rehabilitation phase: a gain of less than about 5 g per kg per day signals a problem (insufficient feeding, untreated infection).
Systematic analysis of every death in a morbidity and mortality review: time of death, day of hospitalisation, probable cause, deviation from protocol. A death rate concentrated in the first 24 hours often signals arrivals that are too late; a rate concentrated after 48 hours rather points to a quality-of-care problem.

A stabilisation unit is judged by its nights. If supervision has never taken place between 10 p.m. and 6 a.m., the real quality of care is unknown.

7The targeted supplementary feeding programme and care for pregnant and lactating women

MAM generally affects two to four times as many children as SAM. Left untreated, a significant proportion of these children progress to SAM. The targeted supplementary feeding programme (TSFP) is therefore both a treatment and a prevention of the severe form. It is often implemented with the support of WFP, which supplies the supplementary foods.

Criteria, products and duration

Group	Indicative admission criterion	Indicative product and ration	Follow-up
Children aged 6 to 59 months	MUAC from 115 to less than 125 mm and/or weight-for-height from -3 to less than -2 z-score, without oedema	Ready-to-use supplementary food (RUSF, about one 92 g sachet and 500 kcal per day) or fortified blended flour such as Super Cereal Plus (about 200 g per day)	Every two weeks; discharge after MUAC ≥ 125 mm (or weight-for-height ≥ -2) at two consecutive visits depending on the protocol
Pregnant and lactating women	MUAC below the national threshold (often 230 mm)	Fortified blended flour (often about 250 g per day of Super Cereal) and fortified oil according to WFP and national guidelines	Monthly; until MUAC is above the threshold or until 6 months after delivery depending on the protocol
Children discharged cured from the OTP	Discharge from SAM treatment	As for MAM	Minimum duration set by the protocol

Specific performance indicators

For the management of MAM, Sphere sets: a cure rate above 75%, a death rate below 3% and a default rate below 15%. The expected death rate is lower than in the OTP: a high death rate in a TSFP suggests misclassified children (undetected SAM) or complications that were not referred.

The sensitive points

Pipeline breaks: supplementary foods often depend on different funding from RUTF. A TSFP break leads a few weeks later to an increase in OTP admissions. Joint monitoring of both pipelines is essential.
Sharing within the household: even more frequent than with RUTF, because the product looks like ordinary food. Hence the value of household protection rations in situations of severe food insecurity.
No TSFP in the area: a frequent situation. Children with MAM must then at a minimum receive counselling, MUAC monitoring and immediate referral if their condition worsens; the cluster must document this gap.
Simplified approaches: some countries authorise a combined protocol, tested in particular under the names ComPAS or simplified approaches, in which SAM and MAM are treated with a single product (RUTF), with a reduced dosage as MUAC improves, and admission based on MUAC and oedema only. The 2023 WHO guideline opens the way to context-adapted approaches for MAM. These approaches apply only if the national protocol and the cluster have adopted them, with rigorous monitoring.

Pregnant and lactating women: beyond the ration

The service package includes: antenatal care, iron and folic acid supplementation (or multiple micronutrient supplementation depending on national policy), MUAC screening, breastfeeding support, prevention of malaria in pregnancy, birth spacing and, increasingly, psychosocial support. A TSFP that distributes flour to women without any link to antenatal care misses a large part of its effect.

8Full example: analysing the quarterly report of six OTP sites and deciding

Fictional context: the NGO "Horizon Nutrition" supports six health centres in the fictional province of Kel-Tamar, which is in a protracted crisis with seasonal peaks. You are the programme manager and are preparing the quarterly review with the health district and the cluster. The data cover April to June.

Step 1: gather the monthly data from each site

Site	Admissions	Total exits	Cured	Deaths	Defaulters	Non-responders	Average length of stay (days)
Amdal	212	180	151	2	19	8	44
Bir-Lafa	305	262	165	4	81	12	52
Doukou	148	131	110	1	14	6	41
Erka	96	90	83	0	4	3	39
Ganat	187	160	118	9	22	11	58
Houro	131	117	96	1	15	5	46
Total	1,079	940	723	17	155	45	-

Step 2: calculate the indicators

Indicators are calculated on programme exits (cured + deaths + defaulters + non-responders), generally excluding medical transfers to stabilisation who later return, according to the definition in the national protocol. Here, all 940 exits are final exits.

Site	Cured	Deaths	Default	Interpretation
Amdal	83.9%	1.1%	10.6%	Meets standards
Bir-Lafa	63.0%	1.5%	30.9%	Default far above the standard
Doukou	84.0%	0.8%	10.7%	Meets standards
Erka	92.2%	0.0%	4.4%	Very good, but to be verified: small volume, no deaths
Ganat	73.8%	5.6%	13.8%	Cure rate below the standard, abnormally high death rate for an OTP, long stay
Houro	82.1%	0.9%	12.8%	Meets standards
Overall	76.9%	1.8%	16.5%	Overall default rate outside the standard, driven by Bir-Lafa

An overall indicator that meets the standard can hide a failing site, and an overall indicator outside the standard can be due to a single site. The analysis is always done site by site, then month by month.

Step 3: formulate hypotheses and verify them

Bir-Lafa (default 30.9%): volunteers report that the distribution day coincides with the weekly market and that many families live more than 10 km away. A review of the cards shows that 60% of defaults occur after the third visit, at the time of agricultural work. Hypotheses: distance, timing, opportunity cost.
Ganat (deaths 5.6%, stay 58 days): an audit of 9 death records reveals that 6 children had lost weight at two consecutive visits without being transferred to stabilisation, and that an amoxicillin stock-out lasted three weeks in May. Hypotheses: failure to apply transfer criteria, supply stock-out, insufficient supervision.
Erka (excellent results): to be verified by re-measurement during a supervision visit. Results that are too good sometimes signal premature discharges or children misclassified at admission (MAM children admitted as SAM).

Step 4: the action plan

Problem	Action	Responsible	Deadline	Monitoring indicator
Defaulting in Bir-Lafa	Change the distribution day after consulting mothers; open two monthly outreach sites in the most remote villages; home visit from the first absence	Site manager and community volunteer supervisor	Within one month	Monthly site default rate < 15% within three months
Deaths in Ganat	Practical training on transfer criteria; posting of the algorithm; fortnightly supportive supervision; review of every death	Supervising nutritionist and district medical officer	Immediate	100% of children with weight loss over two visits transferred; death rate < 2%
Amoxicillin stock-out	Stock alert threshold at one month of consumption; order through the district and inter-agency loan; report to the cluster	Logistician and district pharmacist	Immediate	Zero stock-out days per quarter
Verification in Erka	Re-measurement of 20 admitted children and 10 discharged children by the supervisor	Supervising nutritionist	Next visit	Consistency of classifications

Step 5: link performance and coverage

A programme can show an 85% cure rate and treat only a third of the children who need it. The SQUEAC coverage assessment conducted the previous year estimated coverage at 38% (credible interval 29 to 47%), below the Sphere benchmark of 50% in rural areas. The main barriers identified were distance, lack of awareness of malnutrition as a treatable disease, and refusals linked to negative experiences of how people were received. The actions in Bir-Lafa partly address these barriers; the "Family MUAC" approach (training mothers in screening) is proposed for the whole province. The real impact of the programme is measured by the number of children cured relative to the number of children who needed treatment, and not by the cure rate alone.

9Common mistakes, contextual variations and donor requirements

Common mistakes

Calculating indicators on admissions instead of exits, or excluding defaulters from the denominator to improve the cure rate. Auditors and cluster coordinators spot this immediately.
Confusing default and non-response: a child who does not recover after the maximum duration is not a defaulter. When misclassified, these children distort both indicators and mask medical problems (tuberculosis, HIV).
Not tracing absentees: without a home visit after the first absence, some "defaulters" are in fact unrecorded deaths. Some evaluations have shown that a notable proportion of children classified as defaulters had died.
Applying inconsistent admission criteria between community screening and the health centre: a child referred by the volunteer with a MUAC of 114 mm and re-measured at 116 mm at the centre is sent home, which discourages families and volunteers. A double check and a procedural tolerance defined with the district prevent these situations.
Distributing RUTF without explanations or checking empty sachets.
Neglecting the register: an incomplete register makes any audit impossible, and many quarterly reports are hastily reconstructed. The register must be kept on every OTP day and checked by the supervisor.

Variations by context

Context	Adaptations
Sudden-onset crisis, influx of displaced people	Mobile or temporary OTP sites set up within a few days, exhaustive screening at registration, stabilisation in a reinforced existing hospital, prepositioned RUTF; minimal documentation but a register from day one
Protracted crisis	Integration into the health system: OTP run by Ministry staff, NGO in a support role (supervision, training, supplies), transition and sustainability plan
Camp	Expected coverage above 90%; regular door-to-door screening; close links with general food distribution and WASH
Urban area	Expected coverage above 70%; extended hours for working mothers; transport costs; high residential mobility that increases apparent defaulting
Limited access, remote management	Rations for four weeks instead of one or two if the protocol allows; training mothers in MUAC and warning signs; supervision by phone and photographs of registers (without identifying data over unsecured channels); third-party monitoring
Insecurity	Limited stocks at sites to reduce the risk of looting; frequent resupply; community workers from the area; continuity plan in case the site closes
Local partner with low capacity	Practical on-site training, joint supervision, simplified tools, support for stock management; gradual transfer of responsibilities with verifiable milestones

What donors and auditors look at

The Sphere indicators and their correct calculation, disaggregated by sex, site and month. ECHO, BHA and country-based pooled funds generally require these indicators in reports, together with the cluster's key indicators.
Coverage, or at a minimum an estimate of the proportion of the expected caseload actually treated.
Traceability of supplies: reconciliation between RUTF received, distributed and in stock, and the number of children treated. A significant discrepancy (for example more sachets distributed than needed for the number of children) triggers an audit.
Compliance with the national protocol and participation in the cluster reporting system.
Links with other sectors: referral to cash transfers, WASH kits, health.
Accountability to affected populations: existence of a complaints mechanism accessible to mothers, and evidence that feedback is taken into account.

10Interview questions and key references

1. "An OTP reports a 92% cure rate and 0% deaths over three months. Are you satisfied?"

A strong answer does not accept the figure without verification: sample size, consistency of admission criteria (MAM children admitted as SAM), premature discharges, classification of defaulters, unrecorded deaths among absentees, comparison with other sites. It proposes re-measurement and an audit of patient cards.

2. "What are the criteria for referral to stabilisation, and what do you do if the hospital is 80 km away and the family refuses?"

The candidate cites medical complications, severe oedema, a failed appetite test, and the criteria during treatment. Faced with a refusal, they explore the obstacles (transport, care for the other children, cost), look for practical solutions, document the informed refusal, ensure reinforced outpatient follow-up and alert the district to the need for closer stabilisation services.

3. "Explain the switch from F-75 to RUTF."

The answer describes the transition phase: appetite returned, oedema decreasing, complications under control; gradual introduction of RUTF; monitoring of respiratory rate and pulse to detect overload; return to the OTP as soon as possible.

4. "How would you reduce a 25% default rate?"

The answer starts with analysis (when defaulting occurs, sites, profiles), consults mothers, then proposes targeted actions: decentralisation, adjusting the days, longer rations, active tracing of absentees, better reception, covering hidden costs. It sets a monitoring indicator and a deadline.

5. "What is a SQUEAC assessment and what is it used for?"

A Semi-Quantitative Evaluation of Access and Coverage, which combines routine data, qualitative inquiries and small field surveys, followed by a Bayesian estimate. Its main value is to identify barriers and boosters, not just to produce a figure.

6. "Your national protocol does not authorise simplified approaches, but the TSFP has closed for lack of funding. What do you do?"

Respect the national protocol; alert the cluster with the figures; advocate for funding or a documented temporary waiver; in the meantime, reinforced follow-up of children with MAM by community volunteers and immediate referral in case of deterioration.

Key references

The Sphere Handbook (2018), standards 2.1 (moderate acute malnutrition) and 2.2 (severe acute malnutrition): Sphere Association.
WHO Guideline: Updates on the management of severe acute malnutrition in infants and children (2013).
WHO Guideline on the prevention and management of wasting and nutritional oedema (acute malnutrition) in infants and children under 5 years (2023).
National protocols for the integrated management of acute malnutrition in the country of intervention.
Joint Statement by WHO, WFP, the United Nations System Standing Committee on Nutrition and UNICEF on community-based management of severe acute malnutrition (2007).
SQUEAC and SLEAC technical reference and tools: FANTA and the Coverage Monitoring Network.
Reference documents on simplified approaches for the treatment of wasting: Global Nutrition Cluster and technical partners.
WFP guidelines on targeted supplementary feeding.

Management of acute malnutrition