Three days Training on CMAM/IYCF & SBCC Integration

Programme for Improved Nutrition in Sindh (PINS)

Training conducted from 6th May-2019 to 8th May-2019

Objectives of the training
 Objectives of the training
• To understand the role of CMAM and its components to prevent and treat
malnutrition.
• To understand the causes of malnutrition.
• To understand how the malnourished children are identified.
• To know the community outreach, its elements and active case finding.
• To know the criteria / protocols of the CMAM Guidelines.
• To know the proper treatment and care of malnourished child in SC and OTP
• To understand the SBCC (counseling skills).
• To understand data collections tools and reporting tools.
Session 01. Nutrition and Malnutrition
 Nutrition
• Any thing we drink and eat which provide proper nutrients.

• Study of how your body uses the food that you eat.

• Study of relationship of food and drink to health and disease

• The process by which human body utilizes food for the production of
energy, maintenance of health, growth and normal functioning of the body.
 What is a Nutrient?
Nutrient: A nutrient is a chemical substance in food that helps maintain the body. Some
provide energy. All help build cells and tissues, regulate bodily processes.
Food: Anything (solid/liquid) that has a chemical composition, which enables it, when
swallowed to do one or more of the following:
• Provide the body with material from which it can provide heat or any form
of energy
• Provide material to allow growth, maintenance, repair or reproduction to
proceed.
• Supply substances which normally regulate the production of energy or the
process of growth, repair or reproduction
 What is Malnutrition?
Malnutrition: A term used to refer to any condition in which the body does not
receive enough nutrients for proper function

Malnutrition may range from mild to severe and life-threatening.

It can be result of starvation, in which a person has an
inadequate intake of calories, or it may be related to a deficiency
of one particular nutrient (for example, vitamin C deficiency).
Malnutrition can also occur because a person can not properly
digest or absorb nutrients from the food they consume.
 What is Under nutrition?
Under nutrition: A consequence of a deficiency in nutrient intake and/or absorption in the
body. Various forms of under-nutrition are:
• Acute Malnutrition (bilateral pitting oedema and/or wasting)
• Stunting (low height for age)
• Underweight (low weight for age, combined measurement of stunting and
wasting)
• Micronutrient deficiencies
Acute malnutrition: caused by a decrease in food consumption and/or illness resulting in
bilateral pitting oedema or sudden weight loss (wasting). Both MAM and SAM .
Under nutrition?
 Chronic Malnutrition

Chronic malnutrition or stunting, is another form of growth failure. Chronic

malnutrition occurs over time, unlike acute malnutrition.

A child who is stunted or chronically malnourished often appears to be normally

proportioned but is actually shorter than normal for his/her age.
 Nutritional Status
NUTRITIONAL
NEEDS

NUTRITIONAL
INTAKES

THE RESULT IS
OVER NUTRITION
 Nutritional Status

NUTRITIONAL
INTAKES

NUTRITIONAL
NEEDS THE RESULT IS
UNDER NUTRITION
Session 02. Identification of Malnourished
child
 Screening

• Investigation of a great number of something (for instance, people) looking for

those with a particular problem or feature

• In medicine, is a strategy used in a population to detect a disease in individuals

without signs or symptoms of that disease. Unlike what generally happens in
medicine, screening tests are performed on persons without any clinical sign of
disease
 Anthropometry
 Measurement of humans

 Refers to the measurement of the human individual for the purposes of understanding
human physical variation

 Widely used, inexpensive and non-invasive measure of general nutritional status of an

individual or population group
 How to Assess Age (6-59 months)
• Age needs to be confirmed from birth certificate, EPI card

• Ask Mothers/Caretakers-recall (use local events calendar)

• For young children check child’s swallow skills with RUTF

• Use of height sticks (65 cm – 110 cm)

 How to Measure MUAC

• Ask the mother to remove extra clothing that may cover the child’s left arm.
• Calculate the midpoint of the child’s left upper
• Straighten the child’s arm and wrap the tape around the arm at midpoint.
• Insert the tail of the MUAC tape from both slits (as shown in the picture)
• Inspect the tension of the tape on the child’s arm.
• Record MUAC measurement to from the window of the MUAC tape.
MUAC Tape
Steps of MUAC Taking
How to take the MUAC accurately.
Insert MUAC’s tail into the slit 1.
After passing through slit 1, pass it from slit 2 through the window of the
MUAC
Hold the MUAC in a straight way to take the accurate reading.
 How to Assess Bilateral Pitting Oedema
• Gently press both feet for 3 seconds (the time to say 1001,1002,1003) with
your thumb. Remove your thumb from the feet.

• If a yellow pit (depression) remains for several seconds, the child has nutritional
Oedema

• Pitting Oedema is graded as +, ++, +++

• If bilateral pitting oedema is noted then it is important to have a second opinion

to confirm
Bilateral Pitting Oedema
 How to Measure Weight
• Place the scale on a flat surface.
• Remove extra clothing from child as much as possible
• Press the Weighing Scale to turn it on
• Ask Mother/Caretaker to stand on the scale without child
• Store weight of the mother by pressing store button
• Pass child to be weighed to the mother on scale
• The scale indicate the child’s weight.
• Record child's to the nearest 0.1 gm
How to Measure Weight
Session 03. Exercise MUAC Taking
 Exercise: participant will take MUAC !
Trainer should prepare groups of all the participants.

Each group must consists of 2 participants.

Each group will come forward and take the MUAC of one an other and record on a white
paper.

The audience will be instructed to check whether the group is taking MUAC correctly or not.

At the end of taking MUAC practice by the group, audience will give their feedback on how
the group took MUAC and where they needed improvement.

Finally the instructor will give his/her feedback wherever the group needed improvement.

Thus, each participant will have an opportunity to take MUAC

Session 04. CMAM and its components,
 Community based Management of Acute Malnutrition

SCREENING,REFE MAM CHILDREN

RAL AND AND SAM WITHOUT SAM WITH
FOLLOWUP MALANOURISHE COMPLICATION COMPLICATION
D PLW
Session 05. Community outreach
 Purpose of Community Outreach
• To increase effectiveness of Programme
• Promote understanding and ownership
• Increase program coverage
• Ensure early detection of cases
• Strengthen early case finding, referral and follow up
• Understand barriers to access, reason for absence and default so that they can
be addressed
Community Outreach-Elements
 Understanding the community

Understanding the community structure and perception is valuable for effective

outreach. It is important to know who takes key decision as well as community
attitude to health and malnutrition
 CMAM messaging
The community should understand what the program does and how to access the
services. The messages include:

• The program targets children under 5 and PLW( if TSFP component)

• The program treat and children and PLW with (acute) malnutrition
• Most children can stay at home while the acute malnutrition is managed
• The program held at the BHU ( adapt accordingly)
• How the community can link with program through LHW
 Community engagement

Having assessed the community structure and developed key CMAM messages
dialogues can be held with the community about what the program does, who it
targets and how to access the service.
 Case finding and referral

Infants, children, and PLW with acute malnutrition need to be identified as early as
possible and referred for treatment.
Cases can be screened through

• House to house visit

• Screening at health facilities and during outreach program
• Screening at community meeting, health campaigns in the community and other
opportunity
• Growth monitoring sessions, health facilities, pediatric ward
 Linking with CMAM components

In order for referral and follow up to be effective, there must be good linkages
between
the facility, community health worker and volunteers. This is to ensure timely and
accurate follow up.
 IYCF and maternal Nutrition
IYCF and maternal nutrition is already a part of the role of LHWs, This
is advantageous because:

Mothers and children that the LHW meets through IYCF home visits and
mother support groups can be screened for admission to the program
The LHW can ensure that mothers in the program or with children in the
program who required IYCF support receive it through home visits and
group support
 Follow up
Community outreach worker play important role in tracing and follow up through
home visits

• Children and PLW who are absent or who have defaulted should be traced referred
back to the program to complete treatment
• The reasons for absence should be understood
• Children who have static weight or have lost weight also required follow up at home
Session 06. Multiple Micronutrient
Supplementation
 Multiple Micronutrients Supplementation
• Micro Nutrient Sachet. (MNP)
• Prepare a list of 6 to 23 months children in your assigned area.
• Child who is screened and without SAM, will receive 15 sachets of MNP for a month to use on alternative day.
Continue this dose for six month with the gap of 6 months in a year. In this way a circle of year will be completed. In
next year again follow the same dose until the child reaches the age of 24 months.
• Arrange a counselling session with the mothers of 6 to 23 month children. Involve mother to mother support groups
(MTMSG) in these sessions.
• Give the MNP to the children of 6 to 23 months and keep their record in order to ensure the follow ups on monthly
bases.
• Ask the mother to wash her and child’s hands before the consumption of the MNP.
• Cut the sachet from the marked corner with scissors and mix with the child’s food.
• Ensure to mix the MNP sachet with the food which child can eat.
• Mix the sachet with solid or semi-solid food. It should not be mixed with the liquid like (water, milk etc. )
 Multiple Micronutrients Supplementation
• Iron Folic Acid (IFA)
• Prepare a list of (PLWS) pregnant and Lactating women (having child less than 3 months)
in your assigned area.
• Give 30 tablets of IFA to pregnant and lactating woman (child having baby less than 3
months) on monthly bases to consume one tablet daily. A pregnant and lactating woman
will continue this dose for 12 months and will receive 360 tablets. 9 months during
pregnancy and 3 initial months of lactation.
• Arrange a counselling session with the pregnant and lactating women. Involve mother to
mother support groups (MTMSG) in these sessions.
• Ask the mother to wash her hands before the consumption of the IFA.
• Give Iron Folic Acid to PLWs and keep their record in order to ensure the follow ups on
monthly bases.
Session 07. Group Activity/Exercise
 Group Activity
Trainer should spilt the participants in four to five groups, comprising of four to five participants each
group.

Trainer has to give a topic to each group studied in the day.

Trainer needs to give 20 minutes to the groups to prepare the presentation and present after 20 mints.

Two participants from each group will come forward to present their topic with the help of flip
chart/white board.

Each group will be given 5 to 6 minutes for their presentation.

Trainer should use stop watch to monitor/judge groups time.

Once all the groups present their part, trainer should give his/her feedback for each group.

Topics for the presentations (Identification of malnourished child, Taking MUAC and Oedema, CMAM and
its components, Community outreach, MM Supplementation)