IMCI

INTEGRATED
MANAGEMENT OF
CHILDHOOD ILLNESS

Malnutrition
and anemia
Part 2
WHO Library Cataloguing-in-Publication Data:
Integrated Management of Childhood Illness: distance learning
course. 15 booklets
Contents: – Introduction, self-study modules – Module 1: general danger signs
for the sick child – Module 2: The sick young infant – Module 3: Cough or
difficult breathing
– Module 4: Diarrhoea – Module 5: Fever – Module 6: Malnutrition and anaemia
– Module 7: Ear problems – Module 8: HIV/AIDS – Module 9: Care of the well
child – Facilitator guide – Pediatric HIV: supplementary facilitator guide –
Implementation: introduction and roll out – Logbook – Chart book
1.Child Health Services. 2.Child Care. 3.Child Mortality – prevention and
control. 4.Delivery of Health Care, Integrated. 5.Disease Management.
6.Education, Distance. 7.Teaching Material. I.World Health Organization.
ISBN 978 92 4 150682 3 (NLM classification: WS 200)

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 IMCI DISTANCE LEARNING COURSE | MODULE 6. MALNUTRITION AND ANAEMIA

n CONTENTS
Acknowledgements 4
6.1 Module overview 5
6.2 Opening case study 8
6.3 Introduction to malnutrition 10
6.4 Assess malnutrition 13
6.5 Classify malnutrition 27
6.6 Treat malnutrition 31
6.7 Assess & classify anaemia 36
6.8 Treat anaemia 40
6.9 Provide follow-up care for nutrition 44
6.10 Using this module in your clinic 47
6.11 Review questions 48
6.12 Answer key 49

3
SELF-ASSESSMENT EXERCISE D
Complete the exercises below on steps you will take with children who
have signs of SAM.
1. What are the three signs of severe acute malnutrition?
1.
2.
3.
2. When evaluating a SAM child for hypothermia, how will you evaluate if the
child has a low body temperature?

3. Are the following true or false statements? Circle your answer. If false, write
the correct statement.
a. Aram is 5 months old, and has a z-score of less
than -3. You will immediately begin an appetite TRUE FALSE
test.
b. A child must consume the RUTF within 30
minutes for an appetite test, so the caregiver
should rush the child to finish quickly. TRUE FALSE
c. Masha’s blood sugar level is 52.5 mg/dL.
She is hypoglycaemic. TRUE FALSE
d. Shock is an important clinical complication of SAM
to evaluate for. TRUE FALSE
4. Boniface weighs 9.9 kg. What is the minimum amount of the RUTF
sachet he should consume to pass an appetite test?

4
n How will you assess Noah for acute malnutrition?
You have completed Noah’s IMCI assessment up to malnutrition. You know that you need to check
all children for these conditions. First you will check Noah for the three signs of severe acute
malnutrition. You check Noah for oedema of both feet. You see no swelling. Noah’s weight is 12.7
kg, which you measured at the beginning of the visit using a solar scale. He was able to stand on
this himself for measurement. Noah’s height is 104 cm. What is Noah’s Z-score?
You measure his MUAC, which is 116 cm. While you measure his MUAC, you encourage
Rachel to keep him calm on her lap. Then you explain to Rachel that you need to measure his
height. You ask for her help in doing so, and she agrees. You explain each step as you go.

n Does Noah have any signs of severe acute malnutrition?

Let us review the results of checking Noah for signs of severe acute malnutrition:
1. There is no oedema of both feet
2. WFH z-score is -3Z: this qualifies as SAM
3. MUAC is 116 cm: this is above the 115 cm required for SAM
Noah is showing at least one sign of SAM because he has a WFH Z-score under -3Z. Now you will
need to evaluate him for medical complications. As he is over 6 months of age, you will also conduct
an appetite test.

n How will you check Noah for other medical complications?

You check Noah for common medical complications in children with malnutrition, including shock,
hypothermia, hypoglycemia, and infections. Earlier in your assessment you classified Noah’s cough
as COUGH OR COLD, and not an acute respiratory infection like pneumonia. You do not see any
medical complications.

n How will you conduct an appetite test for Noah?

Noah weighs 12.7 kg, so here is the amount of minimum RUTF he must eat during the appetite
test. You will give him about 30 minutes.
Minimum RUTF amount child should eat within 30 minutes to pass the appetite
test
Number of sachets the child should consume willingly
during the test (sachets = 500 Kcal, or 92 g)a
Weight of the child Minimum Maximum
10 up to 14.9 kg 1/2 3/4

You explain to Rachel that you want to see how strong Noah’s appetite is. Your clinical space is
quiet, so you have Rachel and Noah sit on the side. Rachel washes her hands. You explain to
Rachel how to give the RUTF directly from the packet, and how to encourage Noah. You
emphasize that she should not force Noah. You also provide a cup of water for her to give Noah.
He slowly takes the RUTF and about 20 minutes into the test, he has eaten over ½ of the sachet.
You tell Rachel that he has done a good job eating, and he does not need to anymore.
Now you will learn how to classify Noah based on his signs.
6.5 CLASSIFY MALNUTRITION
HOW DO YOU CLASSIFY SIGNS OF MALNUTRITION?
After you complete the assessment for malnutrition, you will classify. There
are FOUR classifications for malnutrition:
1. COMPLICATED SEVERE ACUTE MALNUTRITION
2. UNCOMPLICATED SEVERE ACUTE MALNUTRITION
3. MODERATE ACUTE MALNUTRITION
4. NO MALNUTRITION

Oedema of both feet, Pink: Give first dose appropriate antibiotic

OR COMPLICATED Treat the child to prevent low blood
WFH/L less than -3 Z SEVERE ACUTE sugar
score, OR MALNUTRITION Keep the child warm
MUAC less than 115 mm Refer URGENTLY to hospital
(6 months or older)
AND any one of the
following:
Medical complication
present, OR
Breastfeeding problem
(up to 6 months), OR
Not able to finish the
noted amount of RUTF
(6 months and older)
MUAC less than 115 Yellow: Give oral antibiotics for 5 days.
mm, OR UNCOMPLICATED Give ready-to-use therapeutic food for a
WFH/L less than-3 Z SEVERE ACUTE child aged 6 months or more
score MALNUTRITION Re-establish effective breast feeding for a
child aged less than 6 months
AND Counsel the mother on how to feed the
child.
No medical complication
No breastfeeding Assess for possible TB infection
problem (under 6 Advise mother when to return immediately
months) Follow up in 7 days
Able to finish the noted
amount of RUTF (6
months and older)
MUAC between 115 up Yellow: Assess the child's feeding and counsel the
to 125 mm, OR MODERATE ACUTE mother on the feeding recommendations.
WFH/L between -3 and MALNUTRITION If feeding problem, follow up in 7 days
- 2 Z scores and no Assess for possible TB infection.
oedema of both feet Advise mother when to return immediately
Follow-up in 30 days
MUAC over 125 mm, OR Green: If child is less than 2 years old, assess the
WFH/L Z scores are -2 NO ACUTE child's feeding and counsel the mother on
or more and no oedema MALNUTRITION feeding according to the feeding
of both feet recommendations
If feeding problem, follow-up in 7 days

Now you will read about each of these classifications.

COMPLICATED ACUTE SEVERE MALNUTRITION (RED)
Remember that signs of severe acute malnutrition that you have
assessed for include MUAC less than 115 mm, weight-for-height lower than
-3 Z, or include oedema of both feet.
The child is classified as COMPLICATED SEVERE ACUTE MALNUTRITION when
they have severe acute malnutrition and one of the following complications:
• At least one medical complication, including any general danger sign,
any severe classification, or pneumonia with chest indrawing
• No appetite, determined failed appetite test in a child 6 months or older
• A feeding problem in children under 6 months according to the
FEEDING PROBLEM classification for the young infant

What are your actions?

Children classified as having SEVERE COMPLICATED MALNUTRITION are at
high risk of death from pneumonia, diarrhoea, measles, and other severe
diseases. These children need urgent referral to hospital where their
treatment can be carefully monitored. They may need special feeding,
antibiotics or blood transfusions.
Before the child leaves for hospital you should give:
• The first dose of amoxicillin
• 50 ml of 10% glucose or sucrose solution; if you do not have solution
this is one rounded teaspoon of sugar in three tablespoons of water
• Keep the child warm

UNCOMPLICATED SEVERE ACUTE MALNUTRITION (YELLOW)

If the child has at least one sign of severe acute malnutrition, but passed the
appetite test or does not other signs of complication, they are classified as
UNCOMPLICATED SEVERE ACUTE MALNUTRITION.

What are your actions?

These children need urgent treatment-based RUTF, deworming, and
oral antibiotics. These children are at risk of death from serious diseases.
Check if the child is at high risk of HIV infection, whether s/he has been
vaccinated for measles, and test for malaria.
You will learn how to provide treatment-based RUTF later in this module.
You will also learn how to counsel the caregiver on giving RUTF. A child with
SEVERE UNCOMPLICATED MALNUTRITION should return for follow-up after
1 week.
 MODERATE ACUTE MALNUTRITION (YELLOW)
If the child’s weight-for-age is between -3 and -2 Z-score or MUAC between
115 and 125, classify as MODERATE ACUTE MALNUTRITION.

What are your actions?

A child classified as having MODERATE ACUTE MALNUTRITION has a higher
risk of severe disease. Assess the child’s feeding and counsel the caregiver
about feeding her child according to the recommendations in the FOOD box on
the COUNSEL chart and in the WELL CHILD CARE module. You should also
consider screening the child for HIV and TB and same medications as
above.
If the child has a feeding problem, they should follow-up in 5 days. If there
is no feeding problem, the child should follow-up in 30 days.

NO ACUTE MALNUTRITION (GREEN)

If the child has a weight-for-age over -2 Z-scores, and has no other signs
of malnutrition, classify as NO ACUTE MALNUTRITION. If the child is less
than 2 years of age, assess the child’s feeding. Children less than 2 years
of age have a higher risk of feeding problems and malnutrition than older
children. Counsel the caregiver about feeding her child according to the
recommendations in the FOOD box on the COUNSEL chart and in the WELL
CHILD CARE module.

n How will you classify Noah’s malnutrition?

Noah shows one sign of SAM, a WFH Z score under -3Z. He does not have oedema or any clear medical
complications. He passed his appetite test. You classify him as UNCOMPLICATED SEVERE ACUTE
MALNUTRITION (yellow).

n What treatments are identified for Noah?

Noah needs immediate treatment, as he is at risk of death from serious diseases given his nutrition status.
You identify his treatments for this classification as:
✔ Treatment-based RUTF
✔ Oral antibiotics
✔ Deworming
Now you will learn how to provide these treatments to Noah.
SELF-ASSESSMENT EXERCISE E
Practice classifying malnutrition.
1. How will you classify the following children? Tick the appropriate box.
Complicated Uncomplicated
severe acute severe acute Moderate acute No acute
malnutrition malnutrition malnutrition malnutrition

a. Child has
MUAC of 112
mm and no
complications
b. Child has WFH z-
score less than -3
and failed the
appetite test
c. Child has MUAC of
112 mm
d. Child has MUAC of
117 mm and no
oedema
e. Child’s WFH z-score
is between -1 and -2
f. Child has WFH z-
score between -3 and
-2
g. Child has MUAC of
113 mm and is
showing signs of
shock
h. Child is less than 6
months, has lost
weight and not
breastfeeding
effectively

2. You classify a child as UNCOMPLICATED SEVERE ACUTE

MALNUTRITION. What are the primary treatments you have identified
for this classification?

3. When will you advise this child to return for follow-up?

30
6.6 TREAT MALNUTRITION
WHAT TREATMENTS ARE IDENTIFIED FOR MALNUTRITION?
Review your classification table for malnutrition. It identifies the following
treatments:

Pink: Give first dose appropriate antibiotic

COMPLICATED Treat the child to prevent low blood
SEVERE sugar
ACUTE Keep the child warm
MALNUTRITION Refer URGENTLY to hospital

Yellow: Give oral antibiotics for 5 days.

UNCOMPLICATED Give ready-to-use therapeutic food for a
SEVERE ACUTE child aged 6 months or more
MALNUTRITION Re-establish effective breast feeding for a
child aged less than 6 months
Counsel the mother on how to feed
the child.
Assess for possible TB infection
Advise mother when to return
immediately Follow up in 7 days

Yellow: Assess the child's feeding and counsel the

MODERATE ACUTE mother on the feeding recommendations.
MALNUTRITION If feeding problem, follow up in 7
days Assess for possible TB
infection.
Advise mother when to return
immediately Follow-up in 30 days
Green: If child is less than 2 years old, assess the
NO ACUTE child's feeding and counsel the mother on
MALNUTRITION feeding according to the feeding
recommendations
If feeding problem, follow-up in 7 days
You have already learned about several of the treatments listed in this chart:
➞ Give all children oral antibiotics for 5 days (Module 3)
➞ Treat for low blood sugar if child is being referred (Module 1)
The treatments that you will read about now include:
➞ Give RUTF to children with UNCOMPLICATED SEVERE ACUTE
MALNUTRITION (yellow)
➞ How to manage children with severe acute malnutrition AND dehydration,
as dehydration should be managed differently when the child has
malnutrition (also refer to Module 4)

Counselling on feeding problems is discussed in module 8, care of the well child

HOW WILL YOU GIVE RUTF?

A child classified as UNCOMPLICATED SEVERE ACUTE MALNUTRITION
must receive RUTF. The caregivers will provide RUTF. RUTF is the only food
that thin children need for their recovery. If the child is young and still
breastfeeding, this should continue.
It is important to remember that RUTF is a therapeutic treatment and
must be given in correct quantity. Quantities of RUTF are given
according to the child’s weight, in the table:

Weight of the RUTF RUTF Sachetsa (500 Kcal sachets, or 92

child (kg) paste g)
grams per day grams per week sachets per day sachets per week
4.0–4.9 190 1300 2 14
5.0–6.9 230 1600 2½ 18
7.0–8.4 280 1900 3 21
8.5–9.4 320 2300 3½ 25
9.5–10.4 370 2600 4 28
10.5–14.9 400 2800 4½ 32
15.0–19.9 450 3200 5 35
20.0–29.9 550 3900 6 40
a
Note: quantities should be adjusted if available in containers or in packaging with different weights.

HOW WILL YOU COUNSEL THE CAREGIVER ABOUT GIVING RUTF?

You will start a child immediately on RUTF, and the caregivers will continue
the treatment. There are several key messages for the caregiver about
RUTF:
• Wash hands before giving RUTF
• Sit with child on the lap and gently offer the RUTF
• Encourage the child to eat the RUTF without forced feeding
• Give small, regular meals of RUTF, and encourage child to eat often (5-6
meals per day)
• If still breastfeeding, should continue by offering breast milk first before
every RUTF feed
• Offer plenty of clean water, to drink from a cup, when the child is eating the RUTF

WHEN SHOULD THE CHILD RECEIVING RUTF

RETURN FOR FOLLOW-UP?
A child with UNCOMPLICATED SEVERE MALNUTRITION should return for
follow-up after 1 week. Advise the caregiver to return immediately if the child
does not eat RUTF.

WHEN SHOULD THE CHILD STOP RUTF?

RUTF should be given until the weight-for-height is above -2 z scores for
2 consecutive visits OR there is 15% weight gain. The child should be well
and alert.
If the child presents with oedema, he will lose weight as the swelling goes
down and he begins to improve. RUTF should not be stopped until the child
has achieved weight gain as described above, AND the oedema has
disappeared and been gone for at least two weeks.

RUTF is stopped after the child gains appropriate weight, AND

there have been no signs of oedema for at least 2 weeks.
SELF-ASSESSMENT EXERCISE F
Answer the following questions about RUTF treatment.
1. How much RUTF should the following children be given for a week’s supply?
a. 3.7 kg, paste available
b. 16.7 kg, sachets available
c. 7.8 kg, sachets available
d. 11.6 kg, paste available
2. When should the child receiving RUTF follow-up?

3. List three important counselling messages about providing RUTF at home:

1.
2.
3.
4. List three checking questions to see if the caregiver understands how to
provide home treatments:
1.
2.
3.
5. Should the following children stop RUTF? Tick your answer.
CONTINUE RUTF STOP RUTF
a. Tsepi (boy) now weighs 13.5 kg, and is 96 cm
in height. Last visit he weighed 13 kg.  
b. Rakim’s weight has changed from 20.5 kg to 23 kg.  
c. Angie (girl) weighs 15.5 kg and is 109 cm in
height. Last visit she weighed 14.5.  
d. Sheena’s weight has changed from 32.5 kg to 38.0  
kg.
e. Maria (girl) now weighs 17.2 kg and is 116
cm in height. Last visit she weighed 17.3 kg.  
 HOW YOU MANAGE CHILDREN WITH SAM AND DEHYDRATION?
In Module 4 you have learned to assess for dehydration. If a child has severe
acute malnutrition and signs of dehydration, they must be managed differently.
There are two classifications for dehydration. Let us revisit these and the
actions to be taken.

SEVERE DEHYDRATION
All children with severe dehydration should be urgently referred.

SOME DEHYDRATION
If the child has some dehydration they can be treated in the health facility.
Children with SAM and some dehydration should not be treated with
normal ORS. This is because normal ORS has high sodium and low
potassium content, which is not suitable for severely malnourished children.

n Treating dehydration in children with SAM

PREFERRED: ReSoMal
If available, give ReSoMal 5 ml/kg every 30 minutes the first 2 hours, and 5-10 ml/kg per hour for the next 4-10
hours on alternate hours with RUTF.
IF ReSoMal NOT AVAILABLE: ½ STRENGTH ORS
If ReSoMal is not available prepare half strength ORS with concentrated electrolyte/mineral solution in same
doses as ReSoMal.
NEITHER AVAILABLE: REFER
If ReSoMal is not available and half strength ORS cannot be prepared, urgently refer to the nearest hospital.

HOW LONG WILL YOU GIVE RESOMAL OR HALF STRENGTH ORS?

A child with SAM and some dehydration cannot be sent home
before improvement is seen. The child should be assessed every 30 minutes
for the first 2 hours and every hour for the next 4–10 hours.
If the child improves the caregiver can be sent home with ReSoMal/half
strength ORS for two days. She should give 50–100 ml after each loose stool.
Tell the caregiver to return urgently if the child is not improving and to come
back for follow-up after the two days.
If the child is deteriorating or not improving she/he should urgently be referred.

You have completed assessing, classifying, and treating malnutrition.

Now you will learn about the IMCI process for anemia.
6.7 ASSESS & CLASSIFY ANEMIA
WHAT IS ANEMIA?
Anemia is a reduced number of red cells or a reduced amount of
hemoglobin in each red cell. Iron deficiency anemia is considered to be
the most common cause of anemia, but other causes include deficiencies in
folate, Vitamin B12, and Vitamin A. Besides iron deficiency, a child can also
develop anaemia as a result of:
✔ Infections
✔ Parasites, such as hookworm or whipworm, that can cause blood loss
from the gut
✔ Malaria, which can destroy red cells rapidly. Children can develop anemia if
they have repeated episodes of malaria or if malaria was inadequately
treated. The anemia may develop slowly. Often, anemia in these children is
due to both malnutrition and malaria.

HOW DO YOU CHECK FOR ANAEMIA?

Open your ASSESS chart for anemia. What instructions do you observe?

Check for anemia Do a malaria test

Decide Malaria Risk: High or If high malaria risk
and Low some pallor present
Look for palmar pallor. Is it:
Severe palmar pallor?
Some palmar pallor?

HOW WILL YOU DETERMINE MALARIA RISK?

Before you begin, determine is the malaria risk is high or low.
Remember that you learned about high and low risk malaria areas in the
beginning of Module 5 on Fever. It is also important to remember that a child
can live in a low risk area, but you need to check if the child has travelled to a
high risk area. You will do a malaria test if the child has high malaria risk and
shows sign of some pallor.

HOW WILL YOU LOOK FOR PALMAR PALLOR?

Pallor is unusual paleness of the skin, and is a
sign of anemia. Palmar pallor means it is identified in
the palm of the hand.
LOOK at the skin of the child’s palm. Hold the child’s
palm open by grasping it gently from the side. Do not
stretch the fingers backwards. This may cause pallor
by blocking the blood supply. Compare the color of the
child’s palm with your own palm and with the palms of
other children.
The child has some palmar pallor if the skin of the child’s palm is pale.
The child has severe palmar pallor if the skin of the palm is very pale or
so pale that it looks white. A good example of severe palmar pallor is in the
picture to the right.
HOW DO YOU CLASSIFY SIGNS OF ANEMIA?
What do you observe about the classification chart for anemia? You will see
how palmar pallor is the important sign. There are 3 classifications for anemia.
These are:
1. SEVERE ANEMIA
2. ANEMIA
3. NO ANEMIA

Severe palmar pallor Pink: Refer URGENTLY to hospital

SEVERE
ANEMIA
Some pallor Yellow: Give iron**
ANEMIA Give oral antimalarial if malaria test postive*
Give mebendazole if child is 2 years or older
and has not had a dose in the previous 6
months
Advise mother when to return immediately
Follow-up in 14 days
No palmar pallor Green: If child is less than 2 years old, assess the
NO ANEMIA child's feeding and counsel the mother according
to the feeding recommendations
If feeding problem, follow-up in 5 days

SEVERE ANEMIA (RED)

A child with severe palmar pallor has severe anemia and should be referred urgently.

ANEMIA (YELLOW)
A child with some palmar pallor should be classified as having ANEMIA.
The child should be given iron. Asses for malaria with in all children
with some palmar pallor.
In addition, the anemia may be due to malaria, hookworm, or
whipworm. If the child’s malaria test is positive, you should give oral
antimalarials. Hookworm and whipworm infections contribute to anemia
because the loss of blood from the gut results in iron deficiency. Give the child
mebendazole only if there is hookworm or whipworm in the area. Only give
mebendazole if the child with anemia is 1 year or older and has not had a
dose of mebendazole in the previous 6 months. You can review the dosage
in your TREAT charts. You will also learn more about deworming in in the
WELL CHILD CARE module.

NO ANEMIA (GREEN)
If the child has no palmar pallor, classify the child as having no anemia and
not very low weight. Children less than 2 years of age have a higher risk of
feeding problems and malnutrition than older children do. If the child is less
than 2 years of age, assess the child’s feeding.
Watch “Assess for malnutrition, anemia, & ear problems” (disc 2) This video clip reviews
all steps of assessing for malnutrition and anemia. You will return to watch the ‘ear
problems’ portion.
NOTE: video also covers feeding problems, which you will learn about in the WELL CHILD
CARE module.

SELF-ASSESSMENT EXERCISE G
Answer the following questions about malnutrition and anemia.
1. Match the following key terms with their definitions. These are
important concepts for nutrition.
MATCH THIS TERM … … WITH A DEFINITION

Anemia A food product that is used for the safe

therapeutic feeding of SAM children.
Edema A sign that is identified by looking at a child’s palm.
Pallor A reduced number of red cells or a reduced
amount of hemoglobin in each red cell, caused
by not eating foods rich in iron, folate, Vitamin
12 and A; parasites, malaria; or other
infections.
RUTF Unusual paleness of the skin, and a sign of anemia.
Palmar pallor When an unusually large amount of fluid gathers in
the child’s tissues. The tissues become filled with
the fluid and look swollen or puffed up.
2. Ned has severe palmar pallor – his hands are nearly white. How will you
classify him?

3. You classify a child as SOME PALMAR PALLOR. What treatments are

identified for this classification?

4. Lisa has been classified as SOME DEHYDRATION and SEVERE

ACUTE MALNUTRITION. How will you take action now?
a. Give ORS and zinc as per the diarrhea charts
b. Give ReSoMal in the clinic
c. Advise the caregiver on how to give half strength ORS and RUTF at home
n How will you check Noah for anemia?
You take Noah’s hands and survey his palms. You fold his fingers back and tell Rachel that you want to compare the
color of their palms. Rachel also puts her hand out. Noah’s palms are quite a bit paler than his mother’s. They are pale,
but not white.
How will you classify Noah?
Noah did show some palmar pallor, a sign of anemia. You review your classification chart for anemia and classify Noah
with SOME ANEMIA (YELLOW). If his palmar pallor was severe--that is, his hands were white-- you would have
classified him with SEVERE ANAEMIA.

n How does Noah’s recording form look now?

MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS

Name: Noah Age: 26 Weight (kg): 12.7 Temperature (°C): 37 °C
Ask: What are the child's
problems?
Cou mo kg Initial Visit? Follow-up Visit?

ASSESS (Circle all signs present)

CHECK FOR GENERAL DANGER gh SIGNS X CLASSIFY
General danger sign
NOT ABLE TO DRINK OR BREASTFEED VOMITS LETHARGIC OR present?
EVERYTHING
CONVULSIONS
UNCONSCIOUS CONVULSING
NOW
Yes No X
Remember to use
Danger sign when
selecting
classifications
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING?
For how long? 14 Count the breaths in one Yes X No
35
minutebreaths per minute. Fast breathing?
Look for chest
Days
No
indrawing
Look and listen for stridor Cough or
Look and listen for
wheezing
cold
Look for oedema of both
THEN CHECK FOR ACUTE MALNUTRITION Uncomplicat
AND ANEMIA
feet.
Determine WFH/L <-3z Z
ed severe
For children 6 months or older measure MUAC
Look for palmar pallor.
116 acute
score.
Severe
mm. palmar pallor? Some palmar pallor? malnutrition
If child has MUAC less than 115 mm or Is there any medical complication?
WFH/L less than -3 Z scores or oedema of General danger sign? Any severe classification?
both feet:
Pneumonia with chest indrawing? Some
For a child 6 months or older offer RUTF to eat. Is the child: Not
able to finish or able to finish? anaemia
For a child less than 6 months is there a breastfeeding
problem?
6.8 TREAT ANEMIA
WHAT TREATMENTS ARE IDENTIFIED FOR ANEMIA?
Review your classification table for anemia. What treatments do you identify?

Pink: Refer URGENTLY to hospital

SEVERE
ANEMIA
Yellow: Give iron**
ANEMIA Give oral antimalarial if malaria test postive*
Give mebendazole if child is 2 years or older
and has not had a dose in the previous 6
months
Advise mother when to return immediately
Follow-up in 14 days
Green: If child is less than 2 years old, assess the
NO ANEMIA child's feeding and counsel the mother according
to the feeding recommendations
If feeding problem, follow-up in 5 days

The identified treatments you have already learned about include:

➞ Give oral antimalarials – you learned steps in Module 5
Some new important treatments are identified here. You will learn
more about these in Module 9 (well child care):
➞ Give iron
➞ Give mebendazole if child is over one year: a dose of 500 mg is given to
children age 12–59 months, every 6 months.
As you read about these treatments, follow along in your TREAT THE CHILD
section of your chart booklet.

Counselling on feeding problems is discussed in module 9 on well child care.

40
 HOW WILL YOU GIVE IRON?
A child with SOME PALMAR PALLOR may have anemia. A child with anemia needs
iron. Give syrup to the child under 12 months of age. If the child is 12
months or older, give iron tablets. Iron should not be given if the child is also
receiving RUTF for severe acute malnutrition, since there is adequate iron and
folic acid in RUTF to treat mild anemia and folate deficiency. Remember to
test all children for malaria.
It is important you counsel the caregiver on continuing regular iron
treatments at home. Give the caregiver enough iron for 14 days. Tell her
to give her child one dose daily for the next 14 days. Ask her to return for
more iron in 14 days. You should also tell her that the iron may make the
child’s stools black. Sometimes this scares caregivers and they might stop the
treatment if they do not expect it. It is also important to tell the caregiver to
keep the iron out of reach of the child. An overdose of iron can be fatal or
make the child very ill.

Iron/folate tablet grams per day Iron syrup sachets per day
Ferrous sulfate 200 mg + 250 µg Ferrous fumarate 100 mg per 5
Age or weight folate (60 mg elemental ml (20 mg elemental iron per
iron) ml)
2– 4 mths or 4–6 kg 1 ml (< ¼ tsp.)
4 –12 mths or 6–10 kg 1.25 ml (¼ tsp.)
12 mths–3 yrs or 10–14 kg ½ tablet 2 ml (< ½ tsp.)
3–5 years or 14–19 kg ½ tablet 2.5 ml (½ tsp.)
Note: Children with Severe Acute Malnutrition and on RUTF should not be given iron

HOW WILL YOU GIVE MEBENDAZOLE?

If the child is 1 years of age or older and has not had a dose of
mebendazole in the past 6 months, the child should also be given a dose
of mebendazole for possible hookworm or whipworm infection. These
infections contribute to anemia because of iron loss through intestinal
bleeding. If hookworm or whipworm is a problem in your area: an anemic
child 2 years of age or older needs mebendazole.
Give 500 mg mebendazole as a single dose in the clinic. Give either one 500
mg tablet or five 100 mg tablets. Refer to the dosage chart below, and to your
TREAT charts.

HOW WILL YOU GIVE ORAL ANTIMALARIALS?

If a child with pallor has a positive malaria test, the child should also be given
an oral antimalarial. This is done even if the child does not have a fever. Refer
to Module 5 on Fever to refresh your skills on giving oral antimalarials.
n What treatments do you identify for Noah?
You have 3 classifications for Noah: COUGH OR COLD (green), UNCOMPLICATED SEVERE
ACUTE MALNUTRITION (yellow), and SOME ANEMIA (yellow). Using your classification tables,
you have identified the following treatments:
✔ Home remedy for cough
✔ Oral antibiotics
✔ RUTF home treatment
✔ Mebendazole: if Noah hasn’t had within 6 months
You will not give iron because Noah is taking RUTF

n What treatments will you provide Noah today?

Of the treatments you have identified for Noah, you will give him the following today:
✔ Oral antibiotics: initiate today for 5 days following guidelines in TREAT charts
✔ RUTF home treatment: Noah weighs 12.7 kg, and you have sachets of RUTF available, so he
requires 32 sachets for the week’s supply. He needs to consume 4 ½ sachets a day.
✔ Mebendazole: Noah hasn’t had within 6 months, so you will give him a dose of 500 mg today
according to your TREAT charts.
First, you explain to Rachel your concerns with Noah. You explain that you think his cough is not
showing signs of severe infection, but that she will need to keep an eye on it. You also tell her that
Noah’s weight is low and that getting him to a higher weight is very important to improve his nutrition
and protect his body from other serious diseases. Malnutrition seriously weakens children’s bodies.
Rachel looks very frightened by this but you reassure her that the RUTF treatment, and making
some changes to his regular diet, should help this.

n How will you counsel Rachel?

There are five key topics that you need to counsel Rachel on today:
1. Home care for cough, including a safe local remedy for cough
2. Providing oral antibiotics for 5 days, including the dosage and schedule
3. Providing RUTF at home, including the dosage, schedule, and how to give. You will also
explain the special tips below:
• Wash hands before giving RUTF
• Sit with child on the lap and gently offer the RUTF
• Encourage the child to eat the RUTF without forced feeding
• Give small, regular meals of RUTF
• Encourage child to eat 5–6 meals per day
• Offer plenty of clean water from a cup when the child is eating the RUTF
4. Feeding recommendations for his age, which you will learn about in module 8
5. When to return to the clinic
n How will you help teach Rachel?
Here you remember your 3 basic teaching steps: give information, demonstrate, and allow Rachel to
practice. You do this now to show her how to give the RUTF safely from the sachet, and providing
water in a cup to drink.

n When should Rachel and Noah return to the clinic?

You explain to Rachel the signs that she should look for that would require Noah to come back to the
clinic immediately. This includes the signs you normally discuss in your Chart Booklet, but in Noah’s
case this also includes if he does not eat RUTF. You also tell her to return to the clinic in 7 days or
sooner in 5 days if Noah’s cough does not improve. In 7 days you need to check Noah’s weight and
nutrition status.

n You check Rachel’s understanding with checking questions

✔ How will you prepare a safe cough remedy at home?
✔ How will you provide the RUTF to Noah?
✔ What are important things to remember about giving RUTF while at home?
✔ What kinds of foods and servings can you provide to Noah, can you give me an example of one
day’s feeding schedule?
✔ When will you come back to the clinic with Noah?
Rachel seems a little confused when she tries to explain how to provide RUTF. However, she
remembers the tips well, especially about not giving the RUTF to others in the house. You again
explain RUTF to Rachel,
demonstrate how to feed from the sachet, and let her practice. When you ask checking questions
again, you are satisfied with her responses.

n Reassuring Rachel
Rachel says she is worried she will forget to do something for Noah, because he has many
treatments. You help her by providing a dosage schedule for her to reference. You reassure Rachel
that she is a good mother for noticing Noah’s illness and bringing him to the clinic, and that they
treatments should help him quickly. Rachel collects her things and leaves the clinic with Noah.
6.9 PROVIDE FOLLOW-UP CARE FOR NUTRITION
WHEN WILL CHILDREN FOLLOW-UP FOR PROBLEMS
RELATED TO NUTRITION?
Notice that there are several different follow-up times related to nutrition. You
will read about each of these follow-up visits in this section.
➞ Follow-up in 1 week: the child classified as UNCOMPLICATED SEVERE
ACUTE MALNUTRITION that is receiving RUTF
➞ Follow-up in 5 days: See module 8 for more information on feeding
problems. If a child has a feeding problem and you have recommended
changes in feeding, to see if the caregiver has made the changes. You
will counsel more if needed.
➞ Follow up in 14 days:
• If a child is classified as MODERATE ACUTE MALNUTRITION
• If a child has pallor, to give more iron.

PALLOR (follow-up 14 days)

During this visit, follow these instructions:

✔ Give the caregiver iron for the child. Advise her to return in 14 days for
more iron.
✔ Continue to give the caregiver iron when she returns every 14 days for
2 months.
✔ If the child still has palmar pallor after 2 months, refer the child for
assessment.

UNCOMPLICATED SEVERE ACUTE MALNUTRITION

(follow-up 1 week)

The child should return to the facility every week to have a health check-up
and to receive their supply of RUTF. During each follow-up visit, the health
worker at the clinic should assess the following:
1. Measure weight and MUAC at each visit. Measure height every four
weeks. Determine WFH z-score at every visit.
2. Check for oedema of both feed
3. Vital signs (temperature, pulse, respiration rate) and medical check
4. Appetite test with RUTF
5. Provide RUTF ration and review counselling messages with caregiver
  NO LONGER SEVERELY MALNOURISHED
The child has improvements in MUAC and/or weight-for-height/length. Praise
the caregiver. Continue with RUTF until the weight for length/height is
above
-2Z or the child has gained 15 % weight.

 STILL SEVERELY ACUTE MALNOURISHED

This child still has very low weight for height. Children who fail to respond
to the treatment could be followed-up at home to determine the family
circumstances and if there are concerns with the care or sharing of food.
Ask the caregiver to come back after one week.
After one month of non-response to treatment, these children should be
referred for further medical review and laboratory tests as required to
diagnose underlying illnesses. Some of the potential problems are:

COMMON PROBLEMS IN MANAGEMENT OF MALNUTRITION

Problems related to the ✔ Inappropriate evaluation of health condition, or missed medical complication
quality of treatment
✔ Poorly conducted appetite test
✔ Inadequate instructions given to parent/caregiver on home care
✔ Inaccurate quantity of RUTF is given to child
✔ Protocol for routine medicines is not followed
✔ Health facility is a long distance from the patient’s home
Problems related to the home ✔ Low frequency of visits to the health facility
environment or child
✔ Insufficient RUTF given to child, or RUTF sharing with family members
✔ Inadequate intake of routine medicines
✔ Sharing of the family food
✔ Micronutrient deficiency
✔ Malabsorption
✔ Psychological trauma
✔ Infection/underlying disease
✔ Unwilling parent/caregiver

 IF CHILD CONTINUES TO LOSE WEIGHT

Refer the child to hospital or to a feeding program.

REMEMBE
R!
A child can be discharged from outpatient malnutrition treatment if:
• No signs of edema for at least two weeks
• He/she has gained 15 %
• He/she is above -2 Z score for two consecutive visits
n How will you provide follow-up care for Noah?
Rachel returns with Noah in 7 days, as you discussed during the initial visit. You are happy to see
her. During this visit you will do an IMCI assessment and check for:
✔ If any new symptoms or signs are present
✔ If his cough is improving, the same, or worse
✔ If his weight is improving, the same, or worse
✔ If his palmar pallor has improved
✔ You will also discuss any issues Rachel has had with the treatments. You will check to be
sure she’s provided all of the medications according to schedules.

n How will you re-assess Noah?

In your IMCI re-assessment, you find the following:
1. Noah has no new symptoms.
2. Noah’s cough has cleared.
3. Noah’s weight is now 13 kg. He is still 104 cm tall. His MUAC is 117 cm. His new z-score is slightly
between
-2 and -3, which is positive news. Although he has improved you will continue the treatment with
RUTF. In order to stop RUTF, Noah needs to have a z-score higher than -2Z for 2 consecutive
visits. He will need to continue taking RUTF in the same amounts, 4 ½ sachets a day.
4. Noah’s palms look improved. You reclassify as NO ANAEMIA.

n How will you treat Noah and counsel Rachel?

Rachel needs to continue providing RUTF treatment to Noah. You give her new supplies, and
ask her to explain how she has been providing the RUTF. You also ask her to demonstrate for
you. You are pleased.
Rachel also needs to continue recommended feeding practices for Noah. You discuss the average
day of food she has provided to Noah in the past week. You ask her about any foods that you
recommended in the last visit, but that she was not able to give. You discuss if they are too
expensive, or not available, and reasonable other options.
You praise Rachel for the progress so far. You counsel her on continuing this important nutrition
for Noah. She seems a little worried that he needs to continue the RUTF. She was hoping he would
be all better by now. You explain that gaining weight needs time, and a lot of nutrition. You
encourage her to continue giving as she has.

n When should Rachel and Noah return to the clinic?

You also counsel on when to return to the clinic next: either immediately, or in 1 week.
6.10 USING THIS MODULE IN YOUR CLINIC
HOW WILL YOU BEGIN TO APPLY THE KNOWLEDGE
YOU HAVE GAINED FROM THIS MODULE IN MANAGING
CHILDREN WITH MALNUTRITION AND ANAEMIA?
In the coming days, you should focus on these key clinical skills. Practicing
these skills and using your job aids will help you to better understand how
to use IMCI for malnutrition and anemia.

ASSESS & CLASSIFY

✔ What commonly causes malnutrition in your country?
✔ Does malnutrition change by season? By region?
✔ Check every child for malnutrition.
✔ Look for edema of both feet.
✔ Determine children’s weight for height or length.
✔ Determine a child’s z-score using growth charts.
✔ Measure the child’s MUAC and determine if less than 115mm
✔ If child has severe acute malnutrition, check for medical complications.
✔ Conduct appetite test for children over 6 months.
✔ Check every child for anemia by looking for palmar pallor.
✔ Use your chart booklet to classify malnutrition.
✔ Use your chart booklet to classify anemia.

TREAT
✔ Treat children with severe malnutrition for low blood sugar.
✔ Give RUTF to children with severe malnutrition.
✔ Give iron to children with anemia.
✔ Give mebendazole.
✔ Determine feeding recommendations for your area (also refer to Module 8)
✔ Determine the nutritional resources in your area. Is there nutrition counselling
at your clinic or in an organization nearby? Where can you refer families for
food support? What services in your area work on issues related to food and
nutrition?

COUNSEL
✔ Counsel a caregiver on providing RUTF safely at home.
✔ Counsel a caregiver on feeding recommendations.
✔ Use clinic resources to teach a caregiver about nutrition and food. Also refer
to module 8.

FOLLOW-UP
✔ Use IMCI instructions for follow-up of classifications of malnutrition and/or
anemia.