Serum albumin 3.9–5.0 g/dl Malnutrition (< 3.2 g per dl), liver or kidney disease Dehydration Alkaline phosphatase 44–147 international units (IU/l) Malnutrition Paget’s disease, liver cancer, bile duct obstruction Alanine 8–37 IU/l Generally not a concern Toxins such as excess acetaminophen or alcohol, hepatitis Urinary iodine 100 or more in children under 2 and lactating women, in children 6 years or older, 150–249 in pregnant women Iodine deficiency -- Blood tests White blood cell count 4,500–10,000 cells/mcl Autoimmune illness, bone marrow failure, viral infections Infection, inflammation, cancer, stress, intense exercise Red blood cell count Male: 4.7–6.1 ml/mcL Female: ml/mcL Iron, vitamin B12, or folate deficiency; bone marrow damage Dehydration, renal problems, pulmonary or congenital heart disease Hemoglobin (Hb) Male: g/dl Female: g/dl Iron, vitamin B12, or folate deficiency; bone marrow damage Dehydration, renal problems, pulmonary or congenital heart disease Hematocrit Male: Female: 36.1%–44.3% Iron, vitamin B12, or folate deficiency; bone marrow damage Dehydration, renal problems, pulmonary or congenital heart disease Mean corpuscular volume (MCV) 80–95 femtoliters Iron deficiency Vitamin B12 or folate deficiency
Mean corpuscular hemoglobin (MCH) 27–31 picograms Iron deficiency Vitamin B12 or folate deficiency Platelet count Viral infections, lupus, pernicious anemia (due to vitamin B12 deficiency) Leukemia, inflammatory conditions Stool sample analysis Helminth infection (hookworm and ascaris) Anemia Note: Reference numbers are not standardized, and numbers may vary from lab to lab. Anemia cutoff points Group Hemoglobin level less than Children 6–59 months 11.0 g/dl Children 5–11 years 11.5 g/dl Children 12–14 years 12.0 g/dl Pregnant women 11.0 g/dl Non-pregnant women > 15 years 12.0 g/dl Men > 15 years 13.0 g/dl Cholesterol cutoff points Cholesterol type Desirable (mg/dl) Borderline (mg/dl) High risk (mg/dl) Total cholesterol Less than 200 200–239 240 or higher High-density lipoprotein (HDL) 40 or higher N/A < 40 for men < 50 for women Low-density lipoprotein (LDL) Less than 100 130–159 160 or higher
NACS Register from Mawingu Clinic No. Date Sex (M/F) 0–< 6 months 6–59 months 5–< 15 years 15–< 18 years 18+ years Pregnant/ postpartum WHZ BMI-for-age BMI MUAC (cm) HIV status (tick one) Nutritional status (tick one) + – Unknown SAM (inpatient) SAM (outpatient) Moderate MAM Normal Overweight or obese 1. 2. " 3. " 4. " 5. " 6. " 7. " 8. " 9. " 10. "
Source: Adapted from Institute of Medicine. 2009. Weight Gain during Pregnancy: Re-examining the Guidelines. Report Brief. Washington, DC: Institute of Medicine. If pre-pregnancy BMI is not known Weight gain per month (kg) Nutritional status < 1 Moderately malnourished 1–2 Normal > 2 Overweight Note: These average values not apply to women who were obese before pregnancy. HANDOUT 5.2. Energy Needs of Pregnant and Lactating Women Group Average energy intake (kcal) Increased energy requirements for pregnancy and lactation (kcal) Increased energy requirements for HIV (kcal) Total energy intake (kcal) Extra food to meet additional energy requirements Pregnant HIV negative 2,140 200–285 (depends on activity level) N/A One nutritious snack HIV positive, asymptomatic 2,140 280 10% (210) 2,630 One nutritious snack HIV positive, symptomatic 2,140 280 20%–30% (428–642) Two nutritious snacks Lactating HIV negative 2,140 500 N/A 2,640 One small balanced meal HIV positive, asymptomatic 2,140 500 10% (210) 2,850 One small balanced meal and one snack
Nevirapine (NVP) Take with or without food. St. John’s wort Nausea, vomiting, rash, fever, headache, skin reactions, fatigue, stomatitis, abdominal pain, drowsiness, paresthesia, hepatoxicity Protease inhibitors (PIs) (ATV/r) Take with food. Alcohol, St. John’s wort Diarrhea, gas, nausea, vomiting, stomach pain, kidney stones, fat maldistribution, hyperglycemia, hyperlipidemia (LPV-r) Take with or without food. St. John’s wort Nausea, vomiting, weakness, diarrhea, headache, dizziness, abdominal pain, fever, diabetes, anorexia, hepatitis, jaundice TB drugs Rifampin Take 1 hour before or 2 hours after meals. May take with small snack if needed. Take 1 hour before antacids. Alcohol Itching, flushing, headache, drowsiness, dizziness, muscle weakness, heartburn, diarrhea, gas Isoniazid Take 30–60 minutes before food. Eat little and often. Eat plenty of foods. Drink plenty of boiled or treated water. Rich or spicy food Nausea, vomiting, stomach upset, constipation, dry mouth Antifungal drug Fluconazole Take with or without food. Alcohol Nausea, vomiting, diarrhea, stomach upset/pain, headache, dizziness, hair loss HANDOUT 7.3. Drug-Food Plans
retinol 0.70 µmol/l or lower) is ≥ 20% in children 6–59 months of age Children 12–59 months of age (including children) 200,000 IU (60 mg retinol equivalent) Every 4–6 months Infants with measles < 6 months of age In areas of known vitamin A deficiency or where measles case fatality is likely to be > 1%, to help prevent eye damage and blindness 50,000 IU 2 doses 24 hours apart If clinical signs of vitamin A deficiency such as Bitot’s spots, a third dose 4–6 weeks later Children with measles 6–11 months of age 100,000 IU Children with measles ≥ 12 months of age 200,000 IU Calcium Pregnant women Where dietary calcium intake is low and for women at high risk of developing hypertensive disorders during pregnancy 1.5–2.0 g of elemental calcium 3 tablets 3 times a day, preferably with meals Throughout pregnancy Iodine Pregnant and lactating women Where < 20% of households have access to iodized salt, until salt iodization is scaled up 250 µg Daily 400 mg Yearly Women of reproductive age (15–49 years of age) 150 µg Daily 400 mg Yearly
Children 6–23 months of age 90 µg OR 200 mg Daily Yearly Iron and folic acid Menstruating adolescent girls and women Where the prevalence of anemia among women of reproductive age is ≥ 20% 60 mg of elemental iron and 2.8 mg of folic acid Weekly 3 months of then 3 months of no then restart for 3 months, etc. Pregnant women Where prevalence of anemia among pregnant women is ≥ 40% 30–60 mg of elemental iron and 0.4 mg of folic acid Daily Starting early in pregnancy and continuing until 3 months postpartum or Where prevalence of anemia among pregnant women is < 20% 120 mg of elemental iron and 2.8 mg of folic acid Weekly Beginning as early as possible in pregnancy and throughout pregnancy Children 6–23 months of age Where the diet does not include foods fortified with iron or the prevalence of anemia is > 40% 2 mg/kg of body weight/day Daily From 6 to 23 months of age, for 3 months Zinc
HANDOUT 8.4. Entry, Transition, and Exit Criteria for Specialized Food Products [revise according to locally available products and national protocol] Target group Entry criteria Prescription (RUTF or RUSF or FBF) Transition/exit criteria Infants < 6 months Severe acute malnutrition (SAM) Any pitting edema OR Weight-for-length z-score < –3 OR Recent weight loss or failure to gain weight OR Danger sign (inability to drink or breastfeed, severe vomiting, convulsions, lethargy, unconsciousness) OR Ineffective feeding (positioning, attachment, suckling) OR Any medical or social issue needing more detailed assessment or intensive support (e.g., disability, depressed caregiver, other adverse social circumstances) Inpatient treatment: Establish or re-establish effective exclusive breastfeeding, including relactation if possible. If this is not possible, encourage wet nursing. Provide a supplementary feed: Prioritize supplementary suckling if feasible. If no edema: feed expressed breast milk. If this is not possible, feed commercial infant formula or F-75 or diluted F-100, either alone or as the supplementary feed, together with breast milk. If edema: Feed infant formula or F-75 together with breast milk. Do NOT give undiluted F-100. If no realistic prospect of breastfeeding: Use appropriate and adequate replacement products, such as commercial infant formula, with support for safe preparation and use, including at home when discharged. Note: If caregiver declines inpatient treatment, counsel on and support optimal infant feeding, monitor weekly to observe changes, and refer to inpatient treatment if infant is not gaining weight. Transition to outpatient treatment of SAM if: No clinical conditions or medical complications, including edema AND Good appetite AND Clinical wellness and alertness AND Weight gain of > 5 g/kg/day for at least 3 successive days Discharge from all care if: Effective breastfeeding or feeding well with replacement foods AND Adequate weight gain AND Weight-for-length z-score ≥ –2
Children 6–23 months Severe acute malnutrition (SAM) Bilateral pitting edema grade + or ++ (treat as outpatient) or +++ (treat as inpatient) OR WHZ < –3 OR MUAC < 11.5 cm Outpatient treatment: 200 kcal/kg/day of RUTF to last until the next visit See dosage table below. Transition to MAM if: No bilateral pitting edema for more than 2 weeks AND WHZ ≥ –3 OR MUAC ≥ 11.5 cm Moderate acute malnutrition (MAM) WHZ ≥ –3 and < –2 OR MUAC ≥ 11.5 and < 12.5 cm FBF: 100 g /day to last until the next visit OR RUSF: 1 packet/day to last until the next visit Transition to normal nutritional status if: WHZ ≥ –2 OR MUAC ≥ 12.5 cm
HANDOUT 10.2. Sample NACS Register Sample NACS Register Date ___⁄___⁄___ ID Client name Age (months or years) Sex (M/F) Length/height (cm) Weight (kg) WHZ MUAC (cm) BMI or BMI-for-age HIV status Tick if yes Nutritional status (tick one ) Quantity of specialized food product prescribed Exit reason (tick one ) + − Unknown Medical complications? Bilateral pitting edema? Pregnant/postpartum? Counseled on nutrition? SAM Inpatient SAM Outpatient MAM Normal F-75 F-100 RUTF FBF or RUSF Graduated Lost to Died Transferred Treatment failure 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
HANDOUT 10.3. Sample NACS Client Card Facility name ______________________________ Facility code ________________________ Client name _________________________ Client number ________ Sex (tick one ): ☐ M ☐ F Age (years) ____ Age group (tick one ): ☐ 0–< 6 months ☐ 6–59 months ☐ 5–14 years ☐ 15–17 years ☐ ≥ 18 years Transferred from __________ Date ___⁄___⁄__ Transferred to ___________ Date ___⁄___⁄__ Referred to ________________________ Date ___⁄___⁄__ Visit no. Date Length/height (cm) Weight (kg) MUAC (cm) WHZ, BMI, or BMI-for-age Tick if yes Nutritional status (tick one ) Quantity of specialized food product prescribed Exit reason (tick one ) Medical complications? Bilateral pitting edema? Pregnant or up to 6 months postpartum? Counseled on nutrition? SAM Inpatient SAM Outpatient MAM Normal Overweight/obese F-75 F-100 RUTF FBF or RUSF Graduated Lost to follow-up Died Transferred Treatment failure 1 2 3 4 5 6 7 6 7 8 9 10
NACS Monthly Report Form Province: District: Facility: Reporting period: Month [__][__] 20[__][__] Person reporting: Contact telephone: Email: Group Number of clients Number of malnourished clients Number of clients receiving specialized food products Number of clients exiting, by reason Assessed Counseled Severely Moderately F-75 F-100 RUTF RUSF or FBF Graduated Lost to follow-up Died Transferred Treatment failure 0–< 6 months 6–59 months 5–14 years 15–17 years ≥ 18 years Pregnant/ postpartum Total male Total female Total Remarks HANDOUT 10.4. Sample NACS Monthly Report Form
HANDOUT 10.5. NACS Information from Nelson Clinic NACS Register Date ___⁄___⁄___ ID Client name Age (months or years) Sex (M/F) Length/height (cm) Weight (kg) WHZ MUAC (cm) BMI or BMI-for-age HIV status Tick if yes Nutritional status (tick one ) Quantity of specialized food product prescribed Exit reason (tick one ) + − Unknown Medical complications? Bilateral pitting edema? Pregnant/postpartum? Counseled on nutrition? SAM inpatient SAM outpatient MAM Normal Overweight/obese F-75 F-100 RUTF FBF or RUSF Graduated Lost to follow-up Died Transferred Treatment failure 1 35 m F −3 2 59 m M −3 3 9 m M −3 11.9 4 8 m F < −3 10.5 5 21 m M < −3 10.9 6 16 y M 20.0 7 14 y M 15.0 8 27 y F 22.0 26 9 46 y M 25.0 31 10 19 y F 22.0 19 11 12 13 14 15