Training course on the inpatient management of severe acute malnutrition: facilitator’s guide

T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A LN U T R IT IO N G u id e Facilitator’s guide

T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A LN U T R IT IO N G u id e Facilitator’s guide Training course on the inpatient management of severe acute malnutrition: facilitator’s guide (Training course on the inpatient management of severe acute malnutrition) ISBN 978-92-4-002996-5 (electronic version) ISBN 978-92-4-002997-2 (print version) © World Health Organization 2021 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc- sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization (http://www.wipo.int/ amc/en/mediation/rules/). Suggested citation. Training course on the inpatient management of severe acute malnutrition: facilitator’s guide. Geneva: World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who. int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. CONTENTS Preface v Acknowledgements xii Abbreviations xiii Introduction to this guide 1 What methods of instruction are used in this course? 1 How is the course conducted? 1 For whom is this course intended? 1 What is a facilitator? 2 What is your role as a facilitator? 2 How can this facilitator’s guide help you? 4 Facilitator guidelines for Module 1: Introduction 7 Facilitator guidelines for Module 2: Principles of care 10 Facilitator guidelines for Module 3: Initial management 20 Facilitator guidelines for Module 4: Feeding 31 Facilitator guidelines for Module 5: Daily care 41 Facilitator guidelines for Module 6: Monitoring and problem solving 50 Facilitator guidelines for Module 7: Involving mothers in care 59 Facilitator guidelines for Module 8: Outpatient management of severe acute malnutrition 66 Guidelines for all modules: facilitator techniques 68 Web Annexes Web Annex A. Answer sheets (WHO/HEP/NFS/21.1) Web Annex B. Photographs (WHO/HEP/NFS/21.2) | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N iii

PREFACE The World Health Organization (WHO) Training course on the inpatient management of severe acute malnutrition includes training modules, training guides, and supporting materials. The training package is based on the 2002 WHO Training course on the management of severe malnutrition1, which was updated in 20092 to include the WHO Child Growth Standards, the use of mid-upper arm circumference to assess wasting, and the provision of ready-to-use therapeutic foods (RUTF) for the management of severe acute malnutrition, which enabled early transfer of children from inpatient to outpatient care. In 2013, WHO issued the Guideline: updates on the management of severe acute malnutrition in infants and children3, which provided updated recommendations on the following: a. admission and discharge criteria for children aged 6–59 months with severe acute malnutrition; b. where to manage children with severe acute malnutrition who have bilateral pitting oedema; c. use of antibiotics in the management of children with severe acute malnutrition in outpatient care; d. changes in the provision of vitamin A supplementation in the treatment of children with severe acute malnutrition; e. options for therapeutic feeding approaches in the management of severe acute malnutrition in children aged 6–59 months; f. fluid management of children with severe acute malnutrition and dehydration with and without shock; g. management of HIV-infected children with severe acute malnutrition; h. identifying and managing infants who are less than 6 months old with severe acute malnutrition. The training course has been updated to incorporate these updates. Table 1 lists the key technical updates made for each module. 1 Training course on the management of severe malnutrition. Geneva: World Health Organization; 2002 (WHO/NHD/02.4; http:// apps.who.int/iris/handle/10665/70449). 2 Training course on the management of severe malnutrition, update – 2009. Geneva: World Health Organization; 2009 (WHO/ NHD/02.4_update 2009; http://apps.who.int/iris/handle/10665/70449). 3 Guideline: updates on the management of severe acute malnutrition in infants and children. Geneva: World Health Organization; 2013 (https://apps.who.int/iris/handle/10665/95584). | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N v Ta b le 1 . K ey t ec h n ic al u p d a te s fo r ea ch m o d u le M o d u le P ro ce d u re 20 0 9 v er si o n N ew v er si o n M o d u le 2 : P ri n ci p le s o f ca re A d m is si o n cr it er ia f o r in p a ti en t ca re fo r ch ild re n a ge d 6 m o n th s o r o ld er U se o f vi si b le se ve re w a st in g a s a s ig n o f se ve re a cu te m a ln u tr it io n V is ib le s ev er e w a st in g is n o lo n ge r re co m m en d ed a s a s ig n o f se ve re a cu te m a ln u tr it io n , d u e to it s su b je ct iv e n a tu re A d m it a ll se ve re ly m a ln o u ri sh ed c h ild re n fo r in p a ti en t ca re • S ev er el y m a ln o u ri sh ed c h ild re n w it h m ed ic a l c o m p lic a ti o ns o r fa ile d a p p et it e te st s h o u ld b e a d m it te d f o r in p a ti en t ca re (o r se ve re ly m a ln o u ri sh ed c h ild re n w h o h av e m it ig a ti n g c ir cu m st a n ce s su ch a s d is a b ili ty ,s o ci a li ss u es ,o r d iffi cu lt ie s w it h a cc es s to c a re ) • S ev er el y m a ln o u ri sh ed c h ild re n w it h o u t th es e si g ns o r m it ig a ti n g ci rc u m st a n ce s sh o u ld b e m a n a ge d in o u tp a ti en t ca re E m p h a si s o n a p p et it e te st a s a n im p o rt a n t p ro ce d u re t o d ec id e w h et h er se ve re ly m a ln o u ri sh ed c h ild re n s h o u ld b e a d m it te d f o r in p a ti en t o r o u tp a ti en t ca re O ed em a o f b o th f ee t • C h ild re n w it h s ev er e a cu te m a ln u tr it io n w h o h av e se ve re b ila te ra l o ed em a (+ + + ) sh o u ld b e a d m it te d f o r in p a ti en t ca re ,e ve n w h en t h ey d o  n o t p re se n t w it h m ed ic a l c o m p lic a ti o ns a n d h av e a p p et it e • C h ild re n w h o h av e o n ly + o r + + b ila te ra l p it ti n g o ed em a b u t p re se n t w it h m ed ic a l c o m p lic a ti o ns o r h av e n o a p p et it e, o r a re w a st ed , s h o u ld b e a d m it te d f o r in p a ti en t ca re • C h ild re n a ge d 6 m o nt hs o r o ld er w h o h av e + o r + + b ila te ra l p it ti n g o ed em a b u t n o m ed ic a l c o m p lic a ti o ns a n d h av e a p p et it e sh o u ld b e m a n a ge d in o u tp a ti en t ca re vi M o d u le P ro ce d u re 20 0 9 v er si o n N ew v er si o n M o d u le 2 : P ri n ci p le s o f ca re C ri te ri a f o r tr a ns fe r to o u tp a ti en t ca re fo r ch ild re n a ge d 6 m o n th s o r o ld er Tr a ns fe r to o u tp a ti en t ca re w h en : • m ed ic a l c o m p lic a ti o ns h av e b ee n t re a te d , a n d • th e ch ild h a s m in im a l o ed em a , a n d • th e ch ild is a le rt , a n d • th e ch ild e a ts 7 5 % o f th e p ro p o se d d a ily a m o u n t o f re a dy -t o -u se th er a p eu ti c fo o d ( R U T F ); T h e d ec is io n s h o u ld b e d et er m in ed b y a ss es sm en t o f cl in ic a l c o n d it io n a n d n o t a n th ro p o m et ri c o u tc o m es C ri te ri a f o r d is ch a rg e fr o m a ll ca re f o r ch ild re n a ge d 6 m o n th s o r o ld er D is ch a rg e fr o m a ll ca re w h en : • w ei g h t- fo r- h ei g h t/ le n g th Z -s co re is ≥ – 2, a n d • n o o ed em a f o r a t le a st 2 w ee ks , o r • m id -u p p er a rm c ir cu m fe re n ce is ≥ 1 25 m m , a n d • n o o ed em a f o r a t le a st 2 w ee ks T h e a n th ro p o m et ri c in d ic a to r u se d t o c o n fi rm s ev er e a cu te  m a ln u tr it io n s h o u ld a ls o b e u se d t o a ss es s w h et h er a c h ild h a s re a ch ed n u tr it io n a l r ec ov er y C h ild re n a d m it te d w it h o n ly b ila te ra l p it ti n g o ed em a + + + s h o u ld b e d is ch a rg ed f ro m t re a tm en t b a se d o n w h ic h ev er a n th ro p o m et ri c in d ic a to r is ro u ti n el y u se d in p ro g ra m m es P er ce n ta ge w ei g h t ga in s h o u ld n o t b e u se d a s a d is ch a rg e cr it er io n | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N vii M o d u le P ro ce d u re 20 0 9 v er si o n N ew v er si o n M o d u le 3 : In it ia l m a n a ge m en t D o se s o f ro u ti n e a n ti b io ti cs • A m ox ic ill in 2 5 m g /k g • G en ta m ic in 5 m g /k g • A m p ic ill in 5 0 m g /k g T h e d o se s o f ro u ti n e a n ti b io ti cs h av e b ee n a d ju st ed , f o r ex a m p le : a m o xi ci lli n 2 5 – 4 0 m g /k g ,g en ta m ic in 7 .5 m g /k g ,t o r efl ec t th e la te st  re co m m en d a ti o ns f ro m t h e 20 13 W H O P o ck et b o o k o f h os p it a l c a re fo r ch ild re n V it a m in A C h ild re n w it h s ev er e a cu te m a ln u tr it io n s h o u ld r ec ei ve t h e d a ily re co m m en d ed n u tr ie n t in ta ke o f vi ta m in A (5 0 0 0 IU ) th ro u g h o u t th e tr ea tm en t p er io d . I f th e ch ild re n a re r ec ei vi n g F -7 5, F -1 0 0 o r R U T F t h a t co m p ly w it h W H O s p ec ifi ca ti o n s (a n d t h er ef o re a lr ea d y c o n ta in s u ffi ci en t vi ta m in A ), o r vi ta m in A is p a rt o f o th er d a ily s u p p le m en ts ,t h e ch ild re n d o  n o t re q u ir e a d d it io n a l v it a m in A C h ild re n w it h s ev er e a cu te m a ln u tr it io n s h o u ld b e g iv en a h ig h d o se o f vi ta m in A (5 0 0 0 0 IU ,1 0 0 0 0 0 IU o r 20 0 0 0 0 IU ,d ep en d in g o n a g e) o n  a d m is si o n ,o n ly if t h ey a re g iv en t h er a p eu ti c fo o d s th a t a re n o t fo rt ifi ed  a s re co m m en d ed in W H O s p ec ifi ca ti o n s a n d v it a m in A is n o t p a rt o f o th er  d a ily s u p p le m en ts H ig h d o se o n ly in d ic a te d in co rn ea l u lc er a ti o n G iv e a h ig h d o se (5 0 0 0 0 IU , 1 0 0 0 0 0 IU o r 20 0 0 0 0 IU , d ep en d in g o n a g e) o f vi ta m in A t o c h ild re n w it h s ev er e a cu te m a ln u tr it io n a n d e ye s ig ns o f vi ta m in A d efi ci en cy o r re ce n t m ea sl es in in p a ti en t ca re o n D ay s 1, 2 , a n d 1 5 (o r a t d is ch a rg e to o u tp a ti en t ca re ), ir re sp ec ti ve o f th e ty p e o f th er a p eu ti c fo o d t h ey a re r ec ei vi n g A tr o p in e 1% 3 t im es a d ay T h e co n ce n tr a ti o n o f a tr o p in e h a s b ee n a d ju st ed t o 0 .1 % 3 t im es a d ay fo llo w in g d is cu ss io n w it h a n d g u id a n ce f ro m s ev er a l e xp er ts a s w el l a s th e W H O M o d el L is t o f E ss en ti a l M ed ic in es . viii M o d u le P ro ce d u re 20 0 9 v er si o n N ew v er si o n M o d u le 4 : Fe ed in g Tr a ns it io n t o R U T F Tw o o p ti o ns f o r tr a ns it io n in g c h ild re n f ro m F -7 5 t o R U T F a re s u gg es te d : a . S ta rt f ee d in g b y g iv in g R U T F a s p re sc ri b ed f o r th e tr a ns it io n p h a se . If t h e ch ild d o es n o t ta ke t h e p re sc ri b ed a m o u n t, t h en t o p u p t h e fe ed w it h F -7 5 . I n cr ea se t h e a m o u n t o f R U T F o ve r 2– 3 d ay s u n ti l t h e ch ild ta ke s th e a p p ro p ri a te a m o u n t o f R U T F t o m ee t en er gy n ee d s, o r: b. G iv e th e ch ild t h e p re sc ri b ed a m o u n t o f R U T F f o r th e tr a ns it io n p h a se . If t h e ch ild d o es n o t ta ke a t le a st h a lf t h e p re sc ri b ed a m o u n t in t h e fi rs t 12 h o u rs , t h en s to p g iv in g R U T F a n d g iv e F -7 5 a ga in . R et ry t h e sa m e a p p ro a ch a ft er a n o th er 1 –2 d ay s u n ti l t h e ch ild t a ke s th e a p p ro p ri a te a m o u n t o f R U T F t o m ee t en er gy n ee d s Tr a ns it io n fo r ch ild re n w it h o ed em a C h ild re n w it h b ila te ra l p it ti n g o ed em a s h o u ld t ra ns it io n t o R U T F w h en a p p et it e re tu rn s a n d o ed em a is r ed u ci n g R eh a b ili ta ti o n p h a se f o r ch ild re n o n F -1 0 0 C h ild re n w h o a re t a ki n g F -1 0 0 a n d a re a ch ie vi n g r a p id w ei g h t ga in d u ri n g r eh a b ili ta ti o n s h o u ld b e ch a n ge d t o R U T F . E ns u re t h a t th ey a re fi n is h in g u p t h e a p p ro p ri a te a m o u n t o f R U T F b ef o re t ra n sf er ri n g t h em f o r o u tp a ti en t ca re A d m is si o n cr it er ia f o r in fa n ts a ge d 0 – 6 m o n th s • W ei g h t- fo r- h ei g h t Z -s co re < – 3, a n d /o r • B ila te ra l o ed em a • W ei g h t- fo r- le n g th Z -s co re < – 3, o r • P re se n ce o f b ila te ra l p it ti n g o ed em a , o r • R ec en t w ei g h t lo ss • P ro lo n ge d f a ilu re t o g a in w ei g h t • S er io u s b re a st fe ed in g d iffi cu lt ie s a ft er m o th er ’s c o u n se lli n g Fe ed in g f o r in fa n ts a ge d 0 – 6 m o n th s F -7 5 a s a s u p p le m en t to b re a st m ilk • In fa n ts w it h s ev er e a cu te m a ln u tr it io n b u t n o o ed em a s h o u ld b e g iv en ex p re ss ed b re a st m ilk .W h er e th is is n o t p o ss ib le ,c o m m er ci a l( g en er ic ) in fa n t fo rm u la o r F -7 5 o r d ilu te d F -1 0 0 m ay b e g iv en , e it h er a lo n e o r a s th e su p p le m en ta ry f ee d t o ge th er w it h b re a st m ilk • In fa n ts w it h s ev er e a cu te m a ln u tr it io n a n d b ila te ra l p it ti n g o ed em a sh o u ld b e g iv en F -7 5 a s a s u p p le m en t to b re a st m ilk | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N ix M o d u le P ro ce d u re 20 0 9 v er si o n N ew v er si o n M o d u le 4 : Fe ed in g C ri te ri a f o r tr a ns fe r to o u tp a ti en t ca re fo r in fa n ts a ge d 0 – 6 m o n th s Tr a ns fe r to o u tp a ti en t ca re w h en : • a ll cl in ic a l c o n d it io ns a re r es o lv ed , a n d • th e in fa n t h a s go o d a p p et it e, is c lin ic a lly w el l a n d a le rt , a n d • w ei g h t ga in is s a ti sf a ct o ry , a n d • th e in fa n t h a s b ee n c h ec ke d f o r im m u n iz a ti o ns , a n d • th e m o th er o r ca re g iv er is li n ke d w it h c o m m u n it y- b a se d f o llo w -u p a n d s u p p o rt C ri te ri a f o r d is ch a rg e fr o m a ll ca re f o r in fa n ts a ge d 0 – 6 m o n th s D is ch a rg e fr o m a ll ca re w h en t h e in fa n t: • is b re a st fe ed in g e ff ec ti ve ly o r fe ed in g w el lw it h r ep la ce m en t fe ed s, a n d • h a s a d eq u a te w ei g h t ga in , a n d • h a s a w ei g h t- fo r- le n g th Z -s co re ≥ – 2 M o d u le 5 : D a ily c a re S im ila r u p d a te s a s th o se m a d e to m o d u le s 3 a n d 4 , w h er e a p p lic a b le M o d u le 6 : M o n it o ri n g a n d p ro b le m so lv in g N o m a jo r te ch n ic a l u p d a te s. M in o r u p d a te s, f o r ex a m p le w h er e R U T F re p la ce s F -1 0 0 M o d u le 7 : In vo lv in g m ot h er s in c a re C ri te ri a f o r re fe rr a l t o o u tp a ti en t ca re fo r ch ild re n a ge d 6 m o n th s o r o ld er S im ila r u p d a te s a s in m o d u le 2 C ri te ri a f o r d is ch a rg e fr o m a ll ca re f o r ch ild re n a ge d 6 m o n th s o r o ld er S im ila r u p d a te s a s in m o d u le 2 x M o d u le P ro ce d u re 20 0 9 v er si o n N ew v er si o n M o d u le 8 : O u tp a ti en t m a n a ge m en t o f se ve re a cu te m a ln u tr it io n N ew m o d u le S u p p o rt in g m a te ri a ls C ri ti ca l c a re p a th w ay s a n d a ns w er s to e xe rc is es A ll cr it ic a l c a re p a th w ay s a n d a ns w er s to e xe rc is es h av e b ee n u p d a te d t o re fl ec t th e u p d a te s in m o d u le s O rg a n iz a ti o n o f su p p o rt in g m a te ri a ls T h e su p p o rt in g m a te ri a ls h av e b ee n in co rp o ra te d w it h in t h e m o d u le s a n d g u id es c o n ce rn ed | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N xi ACKNOWLEDGEMENTS This updated version was coordinated by Zita Weise Prinzo, Department of Nutrition for Health and Development, together with Chantal Gegout (formerly in the Department of Nutrition for Health and Development), in collaboration with Wilson Were, Department of Maternal Child and Adolescent Health. Thanks are due to Jaden Bendabenda, Department of Nutrition for Health and Development, for finalizing this version and preparing it for publication. Special thanks are due to Diana Estevez, who helped during the finalization process. Acknowledgements are also due to Adelheid Onyango, Hana Bekele and Férima Coulybaly-Zerbo from the WHO Regional Office for Africa, and to Marina Adrianopoli from the WHO Regional Office for the Eastern Mediterranean for their tireless support and valuable inputs, and for organizing the pilot trainings in Togo, Uganda and Zambia. In addition, special thanks are due to Beatrice Amadi, Teaching Hospital, Lusaka, Zambia, for her contribution during the pilot testing and for reviewing the course, and to Professor Michael Golden and Dr Yvonne Grellety for reviewing and providing invaluable technical inputs to the course. WHO is grateful to all those involved in the production of the first version of the training course in 2002, and would like to thank ACT International, United States of America, for having developed the manuscript of the training course. WHO acknowledges the substantial technical contribution and advice of Professor A. Ashworth-Hill from the London School of Hygiene and Tropical Medicine, who also acted as one of the first course facilitators. Special thanks are extended to Dr S. Khanum (former Director of Health Services, WHO Regional Office for South-East Asia in New Delhi), for her technical contribution, comments, and advice during the development of the first version of the training modules and for organizing the first field testing at the International Centre for Diarrhoeal Disease Research, Bangladesh. FINANCIAL SUPPORT WHO gratefully acknowledges the financial support from the French Muskoka Fund and the Bill and Melinda Gates Foundation for the update of the training materials. xii ABBREVIATIONS CCP critical care pathway CMV combined minerals and vitamins IU international unit IV intravenous MUAC mid-upper arm circumference NG nasogastric ORS oral rehydration solution ReSoMal rehydration solution for malnutrition RUTF ready-to-use therapeutic food SD standard deviation WHO World Health Organization | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N xiii

INTRODUCTION TO THIS GUIDE What methods of instruction are used in this course? This course uses a variety of methods of instruction, including reading, written exercises, discussions, role plays, video, and demonstrations and practice in a real severe acute malnutrition ward. Practice, whether in written exercises or on the ward, is considered a critical element for learning. How is the course conducted? • Small groups of participants are led and assisted by “facilitators” as they work through the course modules (booklets that contain units of instruction). The facilitators are not lecturers, as in a traditional classroom. Their role is to answer questions, provide individual feedback on exercises, lead discussions, structure role plays, and perform other relevant tasks. • The modules provide the basic information to be learned. Information is also provided through demonstrations, photographs and videos. • The modules are designed to help each participant develop specific skills necessary for case management of severely malnourished children. Participants develop these skills as they read the modules, observe live and video demonstrations, and practise skills in written exercises, group discussions, oral drills or role plays. • After learning the theory in the modules, participants practise the skills in a real hospital setting, with supervision to ensure correct patient care. A clinical instructor supervises the clinical practice sessions in the severe acute malnutrition ward of the hospital. • To a great extent, participants work at their own pace through the modules, although in some activities, such as role plays and discussions, the small group will work together. Each participant discusses any problems or questions with a facilitator and receives prompt feedback from the facilitator on completed exercises. (Feedback includes telling the participants how well they have done the exercise and what improvements could be made.) For whom is this course intended? This course is intended for paediatricians, nurses, nutritionists, dietitians and doctors who manage severely malnourished children in hospitals. These professionals must work closely together as a team, so they should have consistent training in the use of the same case management practices. Because of their different backgrounds, some may find different parts of this course more interesting and applicable to their work than others. However, learning about the steps to manage severe acute malnutrition will be helpful to understand and provide comprehensive care. When forming the groups, facilitators should try to put different professions to work together to enhance learning and sharing. In some exercises people from the same hospital can work together to discuss exercises for their hospital. | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 1 Throughout this guide, there are notes for groups. These notes suggest how facilitators can adapt the course materials to have a different approach when appropriate. What is a facilitator? A facilitator is a person who guides the participants to learn the skills presented in the course. The facilitator spends much of the time in discussions with participants, either individually or in small groups. For facilitators to give enough attention to each participant, a ratio of one facilitator to three to six participants is desired. In your assignment to teach this course, you are a facilitator. As a facilitator, you need to be very familiar with the material being taught. It is your job to give explanations, do demonstrations, answer questions, talk with participants about their answers to exercises, conduct role plays, lead group discussions, assist the clinical instructor with clinical practice in the hospital, and generally give participants any help they need to successfully complete the course. You are not expected to teach the content of the course through formal lectures but to create an environment of openness and productive discussions to share knowledge and learn. What is your role as a facilitator? What the facilitator does As a facilitator, you do three basic things: 1. You instruct: - make sure that participants understand how to work through the materials and know what they are expected to do in each module and each exercise; - answer the participants’ questions as they occur; - explain any information that the participants find confusing, and help them understand the main purpose of each exercise; - lead group activities, such as group discussions, oral drills, video exercises and role plays, to ensure that learning objectives are met; - promptly review each participant’s work and give correct answers; - discuss with the participant how they obtained those answers in order to identify gaps where more discussion or additional reading may be useful; - provide additional explanations or practice to improve skills and understanding; - direct participants to understand how to use the procedures learned in this course in their own hospitals; - assist the clinical instructor as needed during clinical practice sessions. 2. You motivate: - compliment the participants on their correct answers, improvements or progress; - make sure that there are no major obstacles to learning (such as too much noise or not enough light); - create an atmosphere of collaborative work, open discussion and productive learning. 2 3. You manage: - plan ahead and obtain all supplies needed each day, so that they are available in the classroom or taken to the hospital ward when needed; - monitor the progress of each participant and provide timely feedback. How do you do these things? • show enthusiasm for the topics covered in the course and for the work that the participants are doing; • be attentive to each participant’s questions and needs; • encourage the participants to come to you at any time with questions or comments, and be available during scheduled times; • observe the participants as they work, and offer individual help if you see a participant looking troubled, staring into space, not writing answers, or not turning pages, indicating that they may need help; • promote a friendly, cooperative relationship, for example by responding positively to questions (by saying, for example, “Yes, I see what you mean,” or “That is a good question”); • listen to the questions and try to address the participant’s concerns, rather than rapidly giving the “correct” answer; • always take enough time with each participant to answer questions completely (that is, so that both you and the participant are satisfied). What not to do … • during times scheduled for course activities, do not work on other projects or discuss matters not related to the course; • in discussions with participants, avoid using facial expressions or making comments that could cause participants to feel embarrassed; • do not call on participants one by one as in a traditional classroom, with an awkward silence when a participant does not know the answer – instead, ask questions during individual feedback; • do not lecture about the information that participants are about to read, but provide only the introductory explanations that are suggested in the facilitator’s guide – too much information, too early, may confuse participants; • do not review text paragraph by paragraph (this is boring and suggests that participants cannot read for themselves) – as necessary, review the highlights of the text during individual feedback or group discussions; • avoid being too much of a showperson – enthusiasm (and keeping the participants awake) is great, but learning is most important; • keep watching to ensure that participants are understanding the materials – difficult points may require you to slow down and work carefully with individuals; • do not be condescending; • do not talk too much, but rather encourage the participants to talk; • do not interrupt or distract the clinical instructor who is conducting a clinical session – the instructor has certain objectives to cover in a limited time; • do not be shy, nervous, or worried about what to say – this facilitator’s guide will help you remember what to say, so just use it! | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 3 How can this facilitator’s guide help you? This facilitator’s guide will help you teach the course modules, including the video segments. For each module, the guide includes the following: • a list of the procedures to complete the module, highlighting the type of feedback to be given after each exercise; • a list of any special supplies or preparations needed for activities in the module; • guidelines describing: - how to do demonstrations, role plays, and group discussions - how to conduct the video exercises - how to conduct oral drills - points to make in group discussions or individual feedback; • notes on how to adapt the procedures to work in groups, if needed; • a place to write down points to make in addition to those listed in the guidelines. Answer sheets are provided in Web Annex A. These should be printed out and given to each participant after exercises, during individual feedback or after a group discussion. In this guide there is a section titled “Guidelines for all modules”. This section describes training techniques to use when working with participants during the course. It provides suggestions on how to work with a co-facilitator. It also includes important techniques to use when: • participants are working individually • you are providing individual feedback • you are leading a group discussion • you are coordinating a role play. To prepare yourself for each module, you should: • read the module and work the exercises; • check your answers by referring to the answer sheets (provided in Web Annex A); • read in this guide all the information provided about the module; • plan with your co-facilitator how work on the module will be done and what major points to make; • collect any necessary supplies for exercises in the module, and prepare for any demonstrations or role plays; • think about sections that participants might find difficult and questions they may ask; • plan ways to help with difficult sections and answer possible questions; • ask participants questions that will encourage them to think about using the skills in their own hospitals. 4 Checklist of instructional materials needed in each small group Item needed Number needed Facilitator’sguide 1 for each facilitator Set of 8 modules and photographs (Facilitator’sguide.WebAnnexB) 1 set for each facilitator and 1 set for each participant Sample discharge card (Module7.WebAnnex) 1 for each facilitator and 1 for each participant, plus a few extras for use in classroom Set of 4 reference cards: • Module 2. Web Annex A • Module 3. Web Annex B • Module 4. Web Annexes A and C 1 set for each facilitator and 1 set for each participant Answersheets(Facilitator’sguide. WebAnnexA) 1 packet for each facilitator and 1 packet for each participant WHO guidelines relevant to the management of children with severe acute malnutrition1 1 for each facilitator and 1 for each participant Extra copies of critical care pathway (CCP)(Module3.WebAnnexA) (all5pages,stapled) 1 for each facilitator and 1 for each participant Extra copies of initial management page of CCP,loose(touseinexercises) 4 for each participant Extra copies of daily care page of CCP, loose(touseinexercises) 3 for each participant Extra copies of monitoring page of CCP, loose(touseinexercises) 2 for each participant Monitoringchecklists(3pages) (Module6.WebAnnexB) 1 set for each facilitator and 1 set for each participant If projector is available you can also have the CCPs in a visual presentation Alternative: enlarged photocopies of forms 1 set per group Videos 1 per group Schedule for the course 1 for each facilitator and participant Schedule for clinical practice sessions 1 for each facilitator and participant 1 See, for example: Pocket book of hospital care for children: guidelines for the management of common childhood illnesses, second edition. Geneva: World Health Organization; 2013 (http://apps.who.int/iris/bitstream/10665/81170/1/9789241548373_ eng.pdf?ua=1). Also see: Guideline: updates on the management of severe acute malnutrition in infants and children. Geneva: World Health Organization; 2013 (http://apps.who.int/iris/bitstream/handle/10665/95584/9789241506328_eng. pdf?sequence=1). | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 5 Checklist of supplies needed for work on modules Supplies needed for each person include: • name tag and holder • 2 pens • 2 pencils with erasers • paper • highlighter • folder or large envelope to collect answer sheets. Supplies needed for each group include: • paper clips • pencil sharpener • stapler and staples • 1 roll masking tape • extra pencils and erasers • flipchart pad and markers or blackboard and chalk • laptop computer and projector. Discuss with your course director if all these supplies are available. In addition, certain exercises require supplies such as therapeutic foods or rehydration solution for malnutrition (ReSoMal), mixing containers and spoons. These supplies are listed at the beginning of the guidelines for each module. Collect the supplies needed from your course director before these exercises. 6 FACILITATOR GUIDELINES FOR MODULE 1: INTRODUCTION Procedures (see notes on following pages) Feedback 1. Introduce yourself. 2. Explain your role as facilitator. 3. Ask participants to introduce themselves. Participants tell where they work and describe brieflytheirresponsibilityforcareofseverely malnourished children. 4. Do any necessary administrative tasks. 5. Distribute the Introduction module for participants to read. Also have available relevant WHO guidelines on the management of children with severe acute malnutrition.2 6. Answer any questions about the Introduction. 7. Continue immediately to next module, Principles of care. 2 See, for example: Pocket book of hospital care for children: guidelines for the management of common childhood illnesses, second edition. Geneva: World Health Organization; 2013 (http://apps.who.int/iris/bitstream/10665/81170/1/9789241548373_ eng.pdf?ua=1). Also see: Guideline: updates on the management of severe acute malnutrition in infants and children. Geneva: World Health Organization; 2013 (http://apps.who.int/iris/bitstream/handle/10665/95584/9789241506328_eng. pdf?sequence=1). | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 7 1.1 Introducing yourself Introduce yourself as a facilitator of this course and write your name on the blackboard or flipchart. You can present some of your background and experience. 1.2 Explaining your role as facilitator Explain to participants that, as facilitator (and along with your co-facilitator, if you have one), your role throughout this course will be to: • guide them through the course activities • answer questions as they arise or find the answer if you do not know • clarify information they find confusing • give individual feedback on exercises where indicated • lead group discussions, drills, video exercises and role plays • observe and help as needed during their practice in clinical sessions. Explain that there will be a separate clinical instructor who will organize and lead the clinical practice sessions held at the hospital. 1.3 Asking participants to introduce themselves and describe their responsibilities related to the management of severely malnourished children As the participants introduce themselves, ask them to write their names on the blackboard or flipchart. (If possible, also have them write their names on large name cards at their places.) Leave the list of names where everyone can see it. This will help you and the participants learn each other’s names. Explain to participants that you would like to learn more about their responsibilities for caring for severely malnourished children. This will help you understand their situations and be a better facilitator for them. For now, you will ask each of them to tell where they work and what their job is. During the course you will further discuss what they do in their hospitals. Begin with the first participant listed on the flipchart and ask the two questions below. Note the answers on the flipchart. • What is the name of the hospital where you work, and where is it? • What is your position or responsibility for severely malnourished children? Note: Have the participant remain seated. You should ask the questions and have the participant answer you, as in a conversation. It is very important at this point that the participant feels relaxed and not intimidated or put on the spot. (Though it may be interesting to you to ask the participants more questions about their responsibilities, do not do that now. This should not be a long discussion.) 1.4 Administrative tasks There may be some administrative tasks or announcements that you should address. For example, you may need to explain the arrangements that have been made for lunches, transportation of participants, or payment of per diem. 8 This is a good time to distribute the course schedule and point out when your group will be visiting the hospital’s severe acute malnutrition ward for clinical practice. 1.5 Introduction of module and manual Explain that the short Introduction module briefly describes the problem of severe acute malnutrition in childhood, the purpose of the course, the methods and learning objectives. Explain that this module, like all the modules that the participants will be given, is theirs to keep. As they read, they can highlight important points or write notes on the pages if they wish. Explain that the modules are designed to accompany the WHO guidelines relevant to the management of children with severe acute malnutrition (see above). Ask the participants to read the Introduction module now. They should continue reading to the end of the module. 1.6 Answering questions When everyone has finished reading, ask if there are any questions about the Introduction. Participants may have questions about the equipment and supplies listed in Annex 2 of the module. They may be concerned that some items are not available in their hospitals, or they may wonder why certain items are needed. Explain that the need for each item will be explained in the modules. Explain that many hospitals would lack some of these items and need to obtain them. There will be opportunities in the course to discuss problems such as lack of supplies. 1.7 Continuing to the next module Proceed directly to the next module, Principles of care. | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 9 FACILITATOR GUIDELINES FOR MODULE 2: PRINCIPLES OF CARE Procedures(seenotesonfollowingpages) Feedback 1. Distribute the module titled Principles of care, the photographs, and the weight-for-height/ length reference card. Introduce the module. Group discussion 2. Participants read through the module as far as Exercise A. Demonstrate how to measure mid‑upperarmcircumference(MUAC),weigh the child, measure length or height, and use the weight-for-height/length reference card. Modulate discussion of skills in accordancewithparticipants’ previous experience 3. Participants do Exercise A using their weight- for-height/length reference card. Individual feedback 4. Participants continue reading and do Exercise B using the photographs. Group discussion, Exercise B 5. Participants continue reading and do Exercise C. Discuss answers to Exercise C 6. Lead group discussion and oral drill on admission criteria and complementarities between hospitals and communities for the management of severe acute malnutrition. Drill 7. Participants read section 4 of the module and do the short answer exercise. Group-checked 8. Participants read section 5.1 of the module and do the short answer exercise. Group-checked 9. Participants read sections 5.2 and 5.3 of the module and do the short answer exercise, checking their own answers. Self-checked 10. Participantsreadsection6andfinishreading the module. 11. Video: Transformations. Discuss video and photos 21–29. Group discussion 12. Summarize the module. 10 Preparations for the module For each module, prepare carefully by reviewing the exercises and developing a strategy to lead the group discussions, role plays, etc. This section of the facilitator guidelines describes special supplies or preparation needed for a module. At the end of Principles of care, you will present a video showing signs of severe acute malnutrition and transformations that can occur with correct case management. Depending on arrangements made by your course director, you may need to take the participants to another room to view the video. Find out what arrangements have been made. Make sure the following equipment and supplies are available. Learn how to operate the equipment and practise using it: • copy or link to the video • projector • electrical outlets. 2.1 Introducing the module Explain that this module describes how to recognize a child with severe acute malnutrition and how to weigh and measure a child. The module gives an overview of correct case management and provides a rationale for the essential components of case management. The module also describes how the severely malnourished child is different, and why this affects care. Participants will use the photographs in this module to see signs of severe acute malnutrition. Later, in the clinical session, they will look for these signs in children in the hospital. Section 2.1 of the module explains how to carefully measure MUAC, weigh the child, and measure the length or height of the child. Participants will then learn how to use the information on MUAC, weight and height to determine whether a child is severely malnourished. Hold up the weight-for-height/length reference card and explain that participants will need to refer to this. Ask participants to start reading the module and do Exercise A. 2.2 Reading, demonstration Some groups will easily understand the reading and how to use the weight-for- height/length reference card. These groups should complete the reading and go on to Exercise A independently. Some other groups may need a demonstration of how to use the weight-for- height/length reference card. | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 11 Demonstration of how to use the weight-for-height/length reference card (when appropriate) Before Exercise A, review the content of section 2.1 of the module, and demonstrate how to use the weight-for-height/length reference card. Hold up the card and point to the appropriate columns as you speak. Talk through the examples of Z-scores provided in this section. Be sure that participants understand that the left side of the card is for boys and the right is for girls. Show how the lowest weights are in the outside columns on both the boys’ and girls’ sides, furthest away from the median. Talk through several more examples such as the following. Ask a participant to tell you the Z-score (also known as a standard deviation score or SD-score): Girl, 73 cm, 7.4 kg ............... –2 SD Boy, 94 cm, 11.0 kg ............. –3 SD Girl, 67.2 cm, 5.8 kg ........... –3 SD *Boy 75 cm, 7.6 kg ............. < –2 SD *Girl, 81 cm, 7.9 kg .............. < –3 SD Participants may be confused by negative numbers, so use an example of a boy who is 70 cm in length. Ask participants to look along the row of weights and check the top of the column each time, so they see that 8.4 kg is the median, 7.8 kg is –1 SD and 7.2 kg is –3 SD, etc. Use this example to show that a child who is –3 SD has a lower weight-for-length than a child who is –2 SD. Suggest that, if participants ever forget about the negative numbers, they can always look at the weights and work out the system for themselves. * When a weight falls between the weights listed on the card, it may help to first point on the card to the space between the columns where the child’s weight falls. Then look at the top of those columns to see which Z-scores the weight lies between. Then look back at the weights to see where the sign should go. In the example of the boy who is 73 cm, suppose that his weight is 7.6 kg, which is between 7.2 kg (–3 SD) and 7.7 kg (–2 SD). The weight 7.6 kg is obviously not less than 7.2 kg but is less than 7.7 kg, so the score is written as < –2 SD. 2.3 Exercise A. Determining Z-scores (individual work followed by individual feedback) Since this is the first time that you will give individual feedback to participants, be sure to make them feel comfortable. Some techniques to use while giving individual feedback are described at the end of this facilitator’s guide. Participants may understand the concept of “percentage of the median” but not be familiar with Z-scores. If a participant is interested in the concept of Z-scores, encourage them to read Annex 1 of Module 2: Explanation of Z-scores (SD-scores). If a participant is uncomfortable with statistics, reassure them that a complete understanding of Z-scores is not necessary. The important thing is to know how to use the weight-for-height/length reference card to determine how the child 12 compares to other children of their length or height. Children whose Z-score is less than –3 SD are considered severely malnourished. Compare the participants’ answers to those given on the answer sheet for this exercise. Discuss any differences and correct any misunderstandings. If necessary, make up another example and have the participants try it. For example, ask: “If a girl is ___ cm long and weighs ___ kg, what is her Z-score?” Point out the first footnote at the bottom of the weight-for-height/length reference card. “Recumbent” means the same as “supine” or “lying down”. This footnote explains that children aged less than 2 years (or less than 87 cm if age not known) should be measured lying down, while children aged 2 years and above (or 87 cm and taller if age not known) should be measured standing up. If it is impossible to measure a taller child standing up (for example, if the child is too weak to stand), subtract 0.7 cm from the length lying down. Give participants a copy of the answer sheet Web Annex A for Exercise A and ask them to continue reading and to do Exercise B using the photographs. Encourage participants to ask questions as needed while they are reading or doing the exercise. Working in groups (when appropriate) Ask the groups to continue reading the module and tell you when they have reached Exercise B. Instruct them to discuss several photos in Exercise B as a group before asking the participants to work individually on the exercise. This exercise can be very time consuming. If you expect that the group will work slowly, you may assign two or three photos to each person rather than having everyone review all of the photos. Then the assigned person can present those photos in the group discussion at the end of the exercise. 2.4 Exercise B. Identifying signs of severe acute malnutrition in photographs (individual work followed by group discussion) An answer sheet for this exercise is provided in a separate package. The answers are also repeated in this guide for your convenience. Refer to the answers as you lead this discussion. Remember that the answers given are possible answers. There is room for discussion of almost all of the photos. In many cases the degree of a problem cannot accurately be judged without examining the child. • First, point out the signs in photo 1 (answered as an example in the exercise). • Next, for each photo in turn, ask a different participant what signs are visible. Ask the more confident participants first. If a participant does not mention all of the signs, ask “Does anyone see another sign?” • Avoid discussing irrelevant signs at length. Remind them to look for severe wasting, oedema, dermatosis, and eye signs. | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 13 Possible answers to Exercise B Photo Comments Photo 1 Moderateoedema(++)seeninfeetandlowerlegs(rememberthatyou willneedtophysicallyexamineachildtoconfirmpresenceofoedema). Severewastingofupperarms;ribsandcollarbonesclearlyshow(severe wastingshouldbeconfirmedbyanthropometry–eitherbyMUAC orweight‑for‑height). Photo 2 Severedermatosis(+++).Notefissureonlowerthigh.Moderateoedema (++)atleast.Feet,legs,handsandlowerarmsappearswollen.Thechild’s faceisnotfullyshowninthephoto,buttheeyesmayalsobepuffy, inwhichcasetheoedemawouldbesevere(+++). Photos 3 and 4 These show the front and back of the same child. The child may have severe wasting. From the front, the ribs show, and there is loose skin on the arms and thighs. The bones of the face clearly show. From the back, theribsandspineshow;foldsofskinonthebuttocksandthighslooklike “baggypants”.Wastingwillneedtobeconfirmedbyanthropometry. Photo 5 Generalizedoedema(+++).Feet,legs,hands,arms,andfaceappear swollen.Probablymoderatedermatosis(++).Severalpatchesarevisible, but you would have to undress the child to see if there are more patches oranyfissures.Theremaybeafissureonthechild’sankle,butitis difficulttotell. Photo 6 Severe wasting. The child looks like “skin and bones”. Ribs clearly show. Thechild’supperarmsareextremelythinwithlooseskin.(Alsonote the sunken eyes, a possible sign of dehydration, which will be discussed later.)Thereissomediscolorationontheabdomen,whichmaybemild dermatosis;itisdifficulttotellfromthephoto. Photo 7 Milddermatosis(+).Thischildhasskindiscoloration,oftenanearlyskin change in malnutrition. There is some wasting of the upper arms, and the shoulder blades show, but wasting does not appear severe. Photo 8 Pus, a sign of eye infection. Photo 9 Cornealclouding,asignofvitaminAdeficiency. Photo 10 Bitot’sspot,asignofvitaminAdeficiency.Inflammation(redness),asign of infection. Photo 11 Cornealclouding,asignofvitaminAdeficiency.Theirregularityinthe surface suggests that this eye almost has an ulcer. Photo 12 Cornealulcer(indicatedbyarrow),emergencysignofvitaminA deficiency.IfnottreatedimmediatelywithvitaminAandatropine, the lens of the eye may push out and cause blindness. This photo also showsinflammation,asignofinfection. Photo 13 Since only the legs are visible, we cannot tell the extent of oedema. Both feet and legs are swollen, so it is at least ++. Notice the “pitting” oedema in lower legs. Photo 14 Moderate(++)dermatosis.Notepatchesonhandsandthigh.Youwould have to undress the child to see how extensive the dermatosis is. Generalizedoedema(+++).Legs,hands,armsandfaceappearswollen. Photo 15 Severe(+++)dermatosisandwasting(upperarms).Moderate(++) oedema(bothfeet),lowerlegs,possiblyhands. 14 Point out the following additional photos and discuss them in relation to eye signs: Photo 16 shows a photophobic child; his eyes cannot tolerate light due to vitamin A deficiency. Point out that the child’s eyes must be opened gently for examination. He is likely to have corneal clouding as in photo 9. For contrast, photo 17 shows a baby with healthy, clear eyes. 2.5 Exercise C. Determining whether a child should be admitted (individual work followed by group discussion) Participants look at photos and use the following criteria to decide whether a child should be admitted in the case of diagnosis of severe acute malnutrition. They should diagnose severe acute malnutrition if the child has: • weight-for-height/length Z-scores less than –3 SD • oedema of both feet (+ oedema or worse) • MUAC less than 115 mm. Further explain that children aged 6 months or older who have severe acute malnutrition and medical complications should be admitted for inpatient care. As soon as the children are stabilized – their medical complications have resolved, their oedema is decreasing, they have regained their appetite, and they are clinically well and alert – they should be transferred to outpatient care to continue treatment. Children who have severe acute malnutrition, but who are without medical complications and are clinically well and alert, should be treated in outpatient care. Infants aged less than 6 months with severe acute malnutrition and bilateral pitting oedema, or who are losing weight and unable to breastfeed, should be admitted for inpatient care (regardless of whether they have a medical complication or not). For each photo in turn, ask a different participant what the child’s Z-score is, whether or not there is oedema of both feet, and what decision should be made. Add to the discussion as needed based on the comments below. (These comments are in the answer sheet provided.) Possible answers to Exercise C Photo Comments Photo 18 This child has severe acute malnutrition. Her weight-for-length Z-score is above –3 SD, but she has oedema of both feet, as well as lower legs (atleastmoderate++oedema).Conductappetitetest(withready‑to‑ usetherapeuticfood(RUTF)).Ifthechildfailsanappetitetest,shewillbe admitted for inpatient care. If the child passes the appetite test, she will be given RUTF and followed up during outpatient care. Photo 19 This infant should be admitted to the severe malnutrition ward. Her weight-for-length Z-score is below –4 SD. Note: If you were to look onaweight‑for‑agechart,youwouldfindthatthischild’sweight‑for‑age is very low. This child is stunted. She is small for her age. | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 15 Photo Comments Photo 20 Thischild’sweight‑for‑lengthZ‑scoreislessthan–4SD.Aftertesting the appetite and checking for signs of medical complications, it will be decided whether the child will be admitted for inpatient care or can be followed up during outpatient care. Note: It will be important to remove his shirt to examine him. Notice that the mother in this photo is also extremely thin. After discussing the photos in relation to the admission criteria recommended in this course, discuss the admission criteria currently used in participants’ own hospitals for severely malnourished children. For example, ask: • What admission criteria are used for severely malnourished children in your hospitals? What are the reasons for these criteria? • Would the children in photos 18, 19, and 20 be admitted to your hospitals? If so, would they be admitted to a severe acute malnutrition ward, or to some other area of the hospital? • If the hospital is not currently using the recommended admission criteria, could these criteria be adopted? At the end of the discussion, give each participant a copy of the answer sheet for this exercise. Then do the following oral drill. 2.6 Oral drill: admission criteria and complementarities between hospitals and communities for the management of severe acute malnutrition Tell participants that the drill is a fun, lively group exercise. It is not a test, but rather an active way to practise using information. Ask participants to sit around the table. They will each need their weight-for- height/length reference card. Tell participants that you will call on them one by one to participate. You will usually call on them in order, going around the table. If a participant cannot answer, you will just go quickly to the next person and ask the question again. Participants should wait to be called on and should answer as quickly as they can. Begin the drill. Call out the information in the left column of the table below and ask the first participant to use the reference card and tell the child’s Z-score. Then give the additional information in the third column and ask whether the child should be admitted to the severe acute malnutrition ward. If a participant cannot answer or makes a mistake, let the next person try. Keep the pace rapid. You may make up additional cases if needed. Some blank spaces are allowed for this. 16 Information for Z-score drill Sex, length, height Z-score? Additional information Admit? Girl, 82 cm, 7.8 kg < –3 SD no oedema no Boy, 74 cm, 7.9 kg = –2 SD no oedema, MUAC 115 mm no Girl, 73.8 cm, 6.2 kg < –3 SD no oedema no Boy, 67 cm, 6.1 kg = –3 SD ++ oedema yes Girl, 55.5 cm, 3.9 kg < –2 SD ++ oedema no Girl, 67.1 cm, 4.9 kg < –4 SD no oedema, MUAC 109 mm no Boy, 90 cm, 10.8 kg < –2 SD +oedema(bothfeet) no Girl, 70.5 cm, 6.1 kg < –3 SD no oedema no Girl, 87 cm, 9.8 kg < –2 SD one swollen foot no Boy, 79.3 cm, 9.4 kg < –1 SD no oedema no Girl, 69.5 cm, 6.8 kg < –2 SD +oedema(bothfeet) no Boy, 99 cm, 11.2 kg < –3 SD no oedema, MUAC 110 mm no When finishing this exercise, review together the chart that presents the complementarities between hospitals, health centres and communities for the identification and management of cases with severe acute malnutrition. 2.7 Reading and short answer exercise (group-checked) Section 4 provides the rationale for some of the case management procedures taught in the rest of the course. Ask the group to read these pages and do the short answer exercise as a review. The group will discuss the answers together. Keep the discussion simple and brief. The point is to break up the reading and check participants’ understanding. Some participants may wish to discuss or question some of the principles of treatment described in the module. Some questions about reductive adaptation may be answered in Annex 2 of the module. You are not expected to know the answer to every question asked. If there are questions that you cannot answer, take note, discuss with the course director and bring an explanation the next day if necessary. Possible answers to short answer exercise at end of section 4 of module 1. The systems of the body slow down with severe acute malnutrition (reductive adaptation). Rapid changes (such as rapid feeding or fluids) would overwhelm the systems, so feeding must be started slowly and cautiously. 2. Nearly all children with severe acute malnutrition have bacterial infections, even if the usual signs of infection (such as inflammation or fever) are not apparent. 3. Because the severely malnourished child makes less haemoglobin than usual, they already have extra iron stored in the body. If iron is given at this point, it may lead to free iron in the body, which can cause problems. | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 17 4. In severe acute malnutrition the “pump” that controls the balance of potassium and sodium in the cells runs slower. As a result, severely malnourished children have excess sodium in their cells and have lost potassium. ReSoMal has more potassium and less sodium than regular oral rehydration solution (ORS) and is thus better for children with severe acute malnutrition. 2.8 Reading and short answer exercise (group-checked) Ask participants to continue reading section 5.1 of the module and do the following short answer exercise. The group will discuss the answers together. Brief answers are given below. Keep the discussion simple and brief. The point is to break up the reading and check participants’ understanding. The details of how to prepare the feeds will be covered in Module 4 on feeding. Possible answers to short answer exercise following section 5.1 1. F-75 contains fewer calories than F-100 or RUTF (75 kcal per 100 ml instead of 100 kcal per 100 ml). F-75 contains less protein than F-100 (0.9 g per 100 ml instead of 2.9 g per 100 ml). 2. Severely malnourished children cannot tolerate usual amounts of protein and sodium, or high amounts of fat. F-75 is needed as a “starter” formula so that the body will not be overwhelmed in the initial stage of treatment. When the child is stabilized, they can tolerate more protein and fat. RUTF (or in rare cases, F-100) is then used to “catch up” and rebuild wasted tissues. 3. & 4. Ready-to-use therapeutic food (RUTF) is an energy-dense food equivalent to F-100. It is made from peanut butter paste, vegetable oil, skimmed milk, maltodextrin, sugar, and combined minerals and vitamins (CMV) mix. Since no water is added during preparation, bacteria cannot grow on it and it has a shelf-life of 24 months. It is often packaged in a 92 g packet, which contains 500 kcal. It is similar in composition to F-100, with the major difference being the added iron in RUTF. RUTF is given with clean drinking water, and the number of sachets to be consumed per day is based on the severely malnourished child’s weight. 2.9 Reading and short answer exercise (self-checked) Ask participants to read sections 5.2 and 5.3 of the module. Point out the short answer exercise following section 5.3 of the module. Explain that participants should do this exercise on their own and check their own answers. 2.10 Reading last section Participants should continue reading section 6. They should then finish the module. 2.11 Transformations (video and photos) In a short training course, participants may not be able to observe in the hospital ward the dramatic changes that can occur over time in severely malnourished children who are correctly managed. Thus, photos and a video are provided to show these changes. 18 Before or after the video, discuss photos 21–29 with participants. These photos show changes in three children over a period of weeks. Information about each photo is provided in the photographs booklet (Web Annex B of this guide). Note: weight-for-age is given for photos 24 and 25 since height information was not available. Nevertheless, the changes are obvious. Show the video segment titled Transformations. This part of the video provides a review of the signs of severe acute malnutrition as well as two success stories – children named Babu and Kenroy. After the video ask participants what signs of recovery they noticed in the children. They may mention such signs as smiling, standing up or moving around, or more flesh. It is fine if participants want to view this brief video segment again. 2.12 Summary of module 1. Remind participants that the purpose of this module was to give an overview of case management for severely malnourished children and explain some of the reasons for these case management practices. Participants will learn more about each practice in later modules. Participants will practise actually weighing and measuring children and determining Z-scores in clinical sessions. 2. Briefly review the process for successful management of the severely malnourished child described in section 5.2 of the module. Also review the important things not to do in section 5.3. 3. Stress the importance of emergency room personnel knowing correct case management procedures for severely malnourished children. Also, new hospital staff must be trained. 4. Review any points that you have noted below and answer any questions that participants may still have. (If you cannot answer a question, offer to obtain more information and discuss it later.) | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 19 FACILITATOR GUIDELINES FOR MODULE 3: INITIAL MANAGEMENT Procedures(seenotesonfollowingpages) Feedback 1. Distribute the Initial management module, the F-75 reference card, and the antibiotics reference card. Introduce the module. Participants read up to section 4.4 of the module. 2. Demonstration: use of the critical care pathway (CCP),initialmanagement. Read sections 5, 6, and 7. 3. Participantsfinishreadingsections5,6,and7of the module and do Exercise A. Individual feedback 4. Exercise B: group and individual work, preparing and measuring ReSoMal. Group discussion 5. Participants read section 8 and do Exercise C: individual work on two cases, group work on one case. Individual and group feedback 6. Participants read section 9 and complete Exercise D. Individual feedback 7. Video: Emergency treatment. 8. Participants read section 10 of the module and prepare for the role play in Exercise E. Conduct the role play. Individual feedback on CCP Group discussion of role play 9. Summarize the module. Preparations for the module If a projector is available, you will use it to introduce the critical care pathway (CCP) and demonstrate how to use the initial management page. Practise using the projector and the presentation of the CCP pages. Alternatively, make sure that you have an enlarged copy of the CCP that the group can look at together. 20 In Exercise B the group will prepare ReSoMal. You will need the following ingredients and supplies, as well as soap and water for handwashing, and clean towels (or paper towels) for drying hands. The course director should tell you where to obtain supplies. Have them ready before Exercise B. Ingredients for preparation of ReSoMal If using: Ingredients Supplies Commercial ReSoMal ReSoMal packet Cooled, boiled water (at least 1 L fora1Lpacket) Mixing spoon Container to hold 1 or 2 L Measuring cup or medicine cup with ml markings, or 50 ml syringe Small cups or spoons for tasting ReSoMal made from standard WHO low- osmolarity ORS 1 L packet of standard WHO low-osmolarity ORS Sugar(atleast50g) Combined minerals and vitamins(CMV) Cooled,boiledwater(atleast2L) Same as above, plus: Container to hold > 2 L Dietary scale that weighs to 5 g The second segment of the video (Emergency treatment) will be shown during this module. For Exercises C and E, you will need extra copies of the initial management page of the CCP. Make sure that you have at least three copies per participant (preferably more, in case mistakes are made). 3.1 Introducing the module Explain that this module describes measures that should be taken immediately to prevent death while stabilizing the severely malnourished child. Some of the procedures described in this module may take place in the emergency room, before the child is admitted to the severe acute malnutrition ward. If so, emergency room personnel must be taught to recognize severely malnourished children and treat them correctly. They must understand why severely malnourished children must be treated differently from other children. Point out the learning objectives of this module. Explain that participants will first read about recognizing danger signs related to pulse and respiratory rate (Annex 1), and how to treat hypoglycaemia (low blood glucose) and hypothermia (low body temperature). These two conditions are life threatening and often occur together in severely malnourished children. | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 21 Ask participants to read through the module up to section 4.4. When everyone has finished reading to that point, you will look together at the CCP, a recording form that will be used as an aid in this course. Working in groups (when appropriate) Ask the group questions to check their understanding, such as: • What is hypoglycaemia? • How do you know if a child has hypoglycaemia? • If the child does not have hypoglycaemia, how can it be prevented? Hold up the F-75 reference card. Be sure that everyone is looking at the front of the card (the side for children without oedema or with moderate oedema). Point to the columns to show how to read the card. Focus only on how to use the 2-hourly feed column now. The other columns will be used later. Do a few examples with the group. For example, ask, “How much F-75 would you give a child who weighs 8.2 kg every 2 hours?” (Answer: 90 ml). Explain that the reverse side of the form is only for children with severe (+++) oedema. The amounts for these children are less because their weights are falsely high. The amounts are appropriate for their estimated true weights. Talk through section 3.3 of the module, which explains how to treat hypoglycaemia. Briefly cover the main points. • The hypoglycaemic child needs glucose quickly. • How to give it: - If the child can drink, give a 50 ml bolus of 10% glucose orally. - If alert but not drinking, give the 50 ml bolus by nasogastric (NG) tube. - If lethargic, unconscious or convulsing, give 5 ml/kg body weight sterile 10% glucose by intravenous (IV) line, followed by 50 ml 10% glucose by NG tube. • Start feeding with F-75 immediately after giving glucose and follow the feeding schedule (2-hourly feeds). Recheck blood glucose after 2 hours. If blood glucose is still low, verify that F-75 and the antibiotics were given correctly. Ask participants to read section 3.1 of the module (to review the concepts that you have just presented) and then continue reading until the example CCP at the end of section 4. 3.2 Demonstration: use of the critical care pathway (CCP) Tell participants that the CCP (shown in Web Annex A of the module) will be used in this course as an aid to remember steps in treatment and monitoring, and also as a record of care. Participants may use different recording forms in their own hospitals. The CCP is an example of a very complete form. Participants may eventually wish to incorporate parts of this form in their own record-keeping systems; however, this is not required. 22 If you are using a projector, use a presentation when showing the pages of the CCP. Otherwise, have the group gather closely around the table where they can see enlarged copies of the CCP pages (or use a flipchart, if available). In this demonstration you will focus on the initial management page. Other pages will be explained later. Show the initial management page and describe it as follows. Point to the relevant section of the page as you talk. (Do not go into too much detail, especially about sections that have not been covered in the module. This is just an introduction.) It may be helpful for the facilitator to talk while one of the participants writes on the chart. Initial management page This module will focus on this first page of the CCP. It has space to record the signs of severe acute malnutrition, the child’s temperature, and blood glucose level (point to each section). Later in this module, participants will learn about recording haemoglobin, eye signs, signs of shock, and diarrhoea. Notice there is also space to record the initial feeding and the antibiotics prescription. For some children, this page will be used only briefly. However, if the child is in shock or needs rehydration, this page may be used for several hours as the child is given IV fluids or ReSoMal. Tell the story of a child named Dikki as you (or a volunteer) record the following information on the CCP in front of participants. Dikki is a boy age 20 months. He was admitted on 16 December at 09:00. His hospital number is 502. Dikki appears severely wasted. He has oedema of both feet and lower legs (++). He has mild dermatosis (+). He weighs 7.0 kg and is 70 cm long. Ask a participant to look up Dikki’s Z-score. It is < –2 SD. Record it. His MUAC is 109 mm. Ask if Dikki should be admitted. Answer: He should be admitted because of his oedema and MUAC < 115 mm. Dikki’s rectal temperature is 36°C. Ask a participant if Dikki is hypothermic. Answer: No, but he should be kept warm. Dikki’s blood glucose level is less than 3 mmol/L, but he is alert. Ask a participant if Dikki has hypoglycaemia. Answer: Yes. Ask another participant what should be done. Answer: Give Dikki 50 ml bolus of 10% glucose orally. Dikki’s haemoglobin is 90 g/L. His blood type is B+. He has no eye problems and has not had measles. He does not have signs of shock. He does not have diarrhoea. There is no blood in the stool and no vomiting. Dikki is first fed 75 ml of F-75 at 09:30. Point out the spaces for recording monitoring while a child receives IV fluids or ReSoMal, but do not try to explain these sections now. Participants will learn about them in the next sections of the module. | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 23 Dikki needs antibiotics, but do not record those now. Participants will learn about antibiotics later in the module. Daily care page Show the daily care page. The Feeding and Daily care modules will focus on this page of the CCP. This page is used every day once the child has been admitted to the ward. Notice there is room for 21 days on the form. Monitoring record Show the monitoring record. This page is used to record results of monitoring respiratory rate, pulse rate, and temperature. This record will be explained in the Daily care module. Weight chart This graph is used daily to plot the child’s weight so that increases and decreases can easily be seen. It will be explained in detail in the Daily care module. Point out that it can be used for 30 days. Do not try to explain the weight chart in detail now. Comments/outcome page This page is used as needed to record comments on any special instructions or training given to parents. It is also where immunizations are recorded. When a child is discharged, departs early, is referred, or dies, the outcome is registered on this page. The patient outcome section can be very useful in evaluating the processes on the ward and identifying and solving problems. Return to the initial management page and refocus the group on this page. This is the only page of the CCP that participants will use in this module. They should not be concerned about the other pages at this point. Ask participants to continue reading the module, and then do Exercise A, in which they will use parts of the initial management page of the CCP. 24 Working in groups (when appropriate) If the group includes slow readers, you may talk through sections 5, 6 and 7 instead of asking them to read these sections. Explain the main points in the module. Point to the relevant sections of the initial management page as you talk. The signs of shock box of the initial management page is a reminder of the signs of shock and the actions to take. The haemoglobin section tells when a transfusion is needed. If the reading skills of the group are good, ask them to read sections 5, 6 and 7 and then stop. Ask the group questions to check understanding such as: • What signs of shock must be present for a severely malnourished child to receive IV fluids? • What amount of IV fluids should be given? • How often should the respiratory and pulse rate be monitored? Why? 3.3 Exercise A. Identifying initial treatments needed and recording on the CCP (individual and group work) Participants should ask you for individual feedback after doing the first case (Tina). Giving feedback at this point will allow you to ensure that the participant is on the right track and to correct any misunderstandings. Before participants continue with the next two cases, be sure that they know where to look on the initial management page for calculations of amounts of IV glucose and IV fluids needed. Working in groups (when appropriate) Those who quickly finish the first case (Tina) and receive feedback may continue to work independently on the rest of the exercise. When everyone has received individual feedback on Tina, continue the rest of the exercise (Kalpana and John) as a group. Read the case description aloud and point out the signs on the CCP excerpts given in the module. Ask the questions aloud and discuss each answer. When discussing John, it will be helpful to show an enlarged copy of the initial management page, record on it, and point to the relevant sections as you talk. Be sure to discuss special notes about Kalpana and John given on the next page. When giving individual feedback on Kalpana and John, discuss each case with the participants and compare their answers to the answer sheet provided. If there are errors, do not simply correct them, but try to find the reason for the misunderstanding and clarify. Special note re Kalpana: be sure that participants understand that diuretics should never be used to reduce oedema. | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 25 Special note re John: Because John has hypoglycaemia and signs of shock, and is lethargic, he needs 10% glucose by IV. He does not then need the 50 ml bolus NG since he will be on IV fluids, which will continue to provide glucose. If John did not have signs of shock, and would thus not receive IV fluids, he would also need the 50 ml bolus NG. At the end of feedback, give participants the answer sheet. Rounding (or lack of rounding) may cause some discrepancies between participants’ answers and those on the answer sheet. Do not be overly concerned about these discrepancies. Explain to participants that they may need to round answers in order to have an amount that can be practically measured. For example, they will need to round amounts of ReSoMal at least to the nearest ml. 3.4 Exercise B. Preparing and measuring ReSoMal (group and individual work) While participants are working, make sure that you have all of the supplies needed for making ReSoMal in the next exercise. Arrange the supplies where everyone will be able to see and participate. When they have finished reading, ask all participants to wash their hands. Prepare the ReSoMal using cooled, boiled water so that it can be used in the ward. Prepare ReSoMal according to package directions, or according to the instructions in the module. Let a different participant do each step. When the ReSoMal has been prepared, allow each person to taste it. Next, ask each participant to complete Exercise B of the module individually. When they have finished, distribute the answer sheet and review the answers as a group. After checking each answer, ask a different participant to measure the amount of ReSoMal in that answer. Use a small medicine cup or a 50 ml syringe to measure. Point out that these are very small amounts that will not overwhelm the child’s system. They should not be tempted to give more or give it too quickly. 3.5 Exercise C. Identifying more initial treatments needed and recording on the CCP (individual and group work) Ask participants to continue reading from section 8 of the module and begin Exercise C. Point out that section 8 of the module relates to the eye signs box of the initial management page. During this section of reading, participants should refer to photo 12 (corneal ulceration). In Exercise C participants may need extra copies of blank initial management pages. Show participants where these copies are kept in the classroom. Read out to participants the rest of the information for Marwan and ask them to fill his CCP. Remember that the information recorded on the CCP initial management page is related to actions taken in the ward. Participants should see you for individual feedback after the second case of this exercise (Ram). Giving individual feedback on the first two cases will allow you to see how well each participant understands the material. 26 When everyone has received individual feedback on the first two cases, do the third case (Irena) together as a group. Working in groups (when appropriate) If you identify that the group is having difficulties, ask participants to do only the first case (Marwan) individually. Then do both Ram and Irena as a group. Instructions for Irena are given below. Use a similar process for Ram. Individual feedback (Marwan and Ram) When giving individual feedback, discuss each case with the participant and compare their answers to the answer sheet provided. If you identify mistakes, do not simply correct them, but try to find the reason for the misunderstanding and clarify. Group work (Irena) Show a blank initial management page. Ask participants to complete a blank initial management page with the information provided. Have participants take turns reading aloud the background information given for this case and check that they are recording this information on the CCP. Next, ask participants in turn to answer questions on the exercise. Discuss or correct misunderstandings as needed. (Refer to the answer sheet given in the packet.) They should record information about amounts of IV glucose and IV fluids on the initial management page. Continue to the end of the exercise using the following process. 1. Ask participants in turn to read the information given about the case and let them write it down on their own forms. 2. Ask participants the questions given in the exercise and discuss the answers. Stress the importance of monitoring the child carefully whenever IV fluids or ReSoMal are being given. Emphasize the importance of monitoring every 10 minutes while on IV fluids and every 30 minutes or 1 hour while on ReSoMal. Some participants may feel that such frequent monitoring is impossible; however, it is important because the child may go into heart failure if hydrated too fast. It is critical to notice quickly signs of possible heart failure such as increasing pulse and respiration. Hospital staff should do their best to monitor at the suggested intervals. At the end of the exercise, give each participant an answer sheet that includes all three cases. Ask the group to continue reading section 9 and to do Exercise D. The antibiotics reference card (Web Annex B) will be used in this exercise. | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 27 Working in groups (when appropriate) Not all participants will have the responsibility to prescribe drugs. Therefore, they do not need to spend a great amount of time learning how to select antibiotics (section 9.1 of the module). Before Exercise D, review the following key points with the group. • Antibiotics are needed for every severely malnourished child. • The choice of antibiotic will depend on the complications present (as well as antibiotics recommendations for the local area). • The dose should be based on the child’s weight, not age. Ask participants to complete Exercise D and then come to you for individual feedback. 3.6 Exercise D. Selecting antibiotics and determining dosages (individual work followed by individual feedback) When several drug formulations are listed on the antibiotics reference card, participants should choose the one that is most likely to be available in their own hospitals. Answers are given for all the formulations on the answer sheet. Be sure that the participants understand the summary table given at the top of the antibiotics reference card. This table tells what drugs to use, depending on the severity of complications and other factors. The dosage tables show the dosages of each drug for different body weights and drug formulations. Remind the participants where antibiotics prescriptions should be recorded on the initial management page of the CCP. Some participants may be concerned about resistance to the recommended antibiotics in their areas. The antibiotics recommendations need to be adapted according to local resistance patterns. Give the participant an answer sheet. When everyone has finished this exercise, the group will see a video about emergency treatment. In the meantime, participants can continue to work on section 10 of the module and the written part of Exercise E. 3.7 Emergency treatment (video) The video can be shown at any point after participants have finished Exercise D of this module. Introduce the video as follows. • This brief video will show many of the steps described so far in this module. In real life, these steps must occur very quickly, almost simultaneously. The video will show an emergency team working together rapidly and efficiently. • This video shows a child will die without immediate treatment. Watch carefully as the team quickly follows emergency procedures. You will see the process once; then you will see it again with commentary. 28 After the video, lead a discussion. Ask participants questions such as the following. • What did you see the emergency team check and why? What did you not see them check for? Note: Checking eyes is not shown. Use of dextrostix is not shown, but this is not required in this case; when the child is in shock and semi- conscious, he should get the IV glucose. • This child has chest indrawing and appears to have fast breathing. What are these signs of? Answer: Severe pneumonia. • What antibiotic should be given? Answer: Refer to the antibiotics reference card. • What was different from the guidelines given in the module? Note: The child is left uncovered. This is because he has a fever of 38°C and the room is extremely hot. Usually the child should be covered. • Can the emergency team at your hospital do these procedures? Be sure that the following points are raised in the discussion. • This child is in shock, so he will receive IV fluids. Only give IV fluids when a child is in shock. (Ask: “What are signs of shock?” Answers could include: Cold hands with slow capillary refill or weak, fast pulse.) • Notice that glucose, fluids, and antibiotics are all given through the same IV line. • Notice that pulse and respiration are monitored. • The mask is too big because it covers the child’s eyes. A paediatric mask or nasal catheter would be preferable for a good oxygen flow. • We do not know if this child has diarrhoea. The skin pinch is done to assess dehydration; however, this is not a reliable sign of dehydration as oedema may mask diminished elasticity of the skin. Also, in severely malnourished children, the loss of supporting tissues and absence of subcutaneous fat make the skin thin and loose. Additional notes: make these points only if participants raise these questions. • Participants may ask why the child’s arm is shaking. That is unusual, and the reason is unknown. One would expect the arm to be limp. The shaking may be due to hypoglycaemic seizure. • Participants may also ask why femoral blood is taken. That is also unusual. One would expect blood to be taken from the scalp when the IV is inserted. • Participants may ask why the team checks for palmar pallor. They are trying to see if the child is anaemic. They should determine the haemoglobin level before deciding on a transfusion. However, they may be trying to predict the likelihood that the child will need a transfusion. After the discussion, ask participants to continue reading the module and doing the written part of Exercise E. When everyone is ready, there will be a role play in which an admitting doctor briefs the head nurse on a child’s conditions and needs. | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 29 3.8 Exercise E. Briefing staff on a child’s condition and needs (individual work followed by individual feedback, then role play and discussion) This exercise shows how a CCP can be a helpful tool in communicating with staff about what has happened during initial management, and what needs to happen during daily care. Participants will need blank copies of the initial management page of the CCP for this exercise. Since this is the first role play in the course, review the general facilitator guidelines about role plays at the end of this guide. When a participant has finished the initial management page for Rayna, they should show it to you. Check it quickly and give the participant the CCP page provided in the answer sheets. Then ask the participant to list points that the admitting doctor should make, and questions that a nurse might ask, as instructed in section 10 of the module. Select a participant to play the role of the doctor and another to play the role of the nurse. For this first role play, select participants who appear to be confident and comfortable in front of a group. Check to make sure that they have listed some reasonable points and questions in their modules. If necessary, give them some hints from the answer sheet. Ask the participants playing roles to behave as a normal doctor and nurse might behave. The doctor should refer to the initial management page for Rayna as an aid. The doctor should inform the nurse what to do next, including when to feed the child and how much. The nurse should ask realistic questions that a nurse might have. During the role play, other participants should observe and make notes on things done well and suggestions for improvement. In the discussion following the role play, be sure that the tone is positive. If some points listed on the answer sheet were not made, mention those points. Distribute the answer sheet. 3.9 Summary of module 1. Remind participants of the learning objectives for this module. The skills taught in this module are those intended to prevent death while stabilizing the child. Stress that emergency room staff need to know these skills, including what to do and what not to do. 2. Remind participants that all severely malnourished children need antibiotics. The presence or absence of complications determines the type of antibiotics. Recommendations may vary locally due to bacterial resistance to certain antibiotics in some areas. 3. Stress that the initial management page of the CCP is meant to be an aid, to help remember emergency steps. When used as a record, it is also a valuable monitoring tool. 4. Review any points that you have noted below and answer any questions that participants may still have. (If you cannot answer a question, offer to obtain more information and discuss it later.) 30 FACILITATOR GUIDELINES FOR MODULE 4: FEEDING Procedures(seenotesonfollowingpages) Feedback 1. Distribute the Feeding module and the F-100 reference card. Introduce the module. Participants read the introduction and learning objectives. 2. Participants read section 1. 3. Participants read sections 2.1 and 2.2 of the module and do the short answer exercise at the end of section 2.2. Lead group oral drill on determining amounts of F-75 to give. Self-checked and oral drill in groups 4. Participants read from section 2.3 to section 2.5. Demonstration: 24-hour food intake chart. 5. Participants do the short answer exercise following section 2.5. Self-checked 6. Participants read section 2.6 and do Exercise A. Individual feedback 7. Participants continue reading section 3 and do Exercise B. Individual feedback 8. Participants read sections 4 and 5 and complete Exercise C. Group discussion and individual feedback 9. Participants read section 6, on feeding severely malnourished infants aged less than 6 months, andcompleteExerciseD.Highlightdifferences in the management of severe acute malnutrition for infants. Group discussion 10. Participants read section 7.1 and do Exercise E (preparingaschedulefortheward).Theymay work with others from their own hospital on this exercise.* Group discussion 11. Participants continue reading section 7.2 and do Exercise F. Individual feedback 12. Participants read sections 7.3 and 7.4 and prepare for the group discussion in Exercise G. Group discussion 13. Summarize the module. * If desired, this activity may be done on the half day in the middle of the course (Day 4), to enable groups from the same hospital to work together. | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 31 Preparations for the module You will need a projector and slides of the 24-hour food intake chart and daily ward feed chart (or enlarged copies of these forms). These can be used for demonstrations to the whole group on how to complete the forms. 4.1 Introducing the module Explain that this module describes what is obviously a very critical part of managing severe acute malnutrition, that is, feeding. However, as explained in the Principles of care module, feeding must begin cautiously with F-75, in frequent small amounts. This module describes how to start feeding on F-75 and transition to RUTF, after which the children are transferred to outpatient care. This module focuses on preparing the feeds, planning feeding, and giving the feeds according to plan. This module also describes the feeding principles for severely malnourished infants aged less than 6 months. 4.2 Section 1. Preparing therapeutic milk Point out the learning objectives of this module and ask participants to read through section 1 of the module. Point out that participants will practise how to prepare therapeutic milk from pre-packaged F-75 and F-100 during the tour of the severe acute malnutrition ward. 4.3 Drill: determining amounts of F-75 to give (reading and short answer exercise) Ask participants to read sections 2.1 and 2.2 in preparation for the short answer exercise and following drill. Participants will use the F-75 reference card in this part of the module. Be aware that the reverse side of the card is for children with severe (+++) oedema. While participants are working, prepare for the drill below. Ask participants to gather around for the drill. They will need their F-75 reference cards. The purpose of this drill is to practise using the reference cards to determine amounts of F-75 to give. Remind participants of the procedure for drills. You will call on each person in order. If a participant cannot answer, you will go quickly to the next person and ask the question again. Participants should wait until it is their turn and should answer as quickly as they can. It should be a fun, lively exercise. Begin the drill. Use the case information below. Call out the case information; then ask the first participant to use the reference card and tell how much F-75 should be given. Explain that, unless specified otherwise, the weight given is the weight on admission (or after initial rehydration). Unless otherwise specified, the degree of oedema is also what was present on admission. If a participant cannot answer or makes a mistake, let the next person try. Keep the pace rapid. You may make up additional cases if needed. Some blank spaces are allowed for this. 32 Determining amounts of F-75 to feed: practice drill Case information for drill Amount of F-75 per feed 7.2 kg, no oedema, 2-hourly feeds 80 ml 8.4 kg, no oedema, 2-hourly feeds 90 ml 6.1 kg, no oedema, 2-hourly feeds 65 ml (use amount for 6.0 kg, thenextlowerweightonchart) 7.9 kg, no oedema, 2-hourly feeds 85 ml 6.4kg,mild(+)oedema,3‑hourlyfeeds 105 ml 8.6 kg, no oedema, 4-hourly feeds 190 ml 9.15kg,moderate(++)oedema,3‑hourlyfeeds 145 ml 10.6kg,severe(+++)oedema,2‑hourlyfeeds 90 ml 8.4kg,severe(+++)oedema,3‑hourlyfeeds 105 ml 8.8kg,mild(+)oedema,4‑hourlyfeeds 195 ml 8.6kgwithsevere(+++)oedemaonadmission; now weighs 6.4 kg and has no oedema, 4-hourly feeds 145 ml (continue using severe oedema chart and starting weight for this child while onF‑75) 7.5kg,hypoglycaemia,moderate(++)oedema,half‑ hourly feeds 20mlperhalf‑hour(80ml÷4) 7.4kg,hypoglycaemia,severe(+++)oedema,half‑ hourly feeds 15mlperhalf‑hour(60ml÷4) 9.0kgwithsevere(+++)oedemaonadmission; now weighs 6.8 kg and has no oedema, 4-hourly feeds 150 ml 6.9kg,severe(+++)oedema,2‑hourlyfeeds 55 ml After the drill, tell participants that the next section of reading will explain how to record feeds on the 24-hour food intake chart and on the daily care page of the CCP. Hold up both of these forms for everyone to see. The 24-hour food intake chart will be used to provide the details for each feed of the day. The daily care page simply provides a brief summary of the feed plan and the amount taken during the day. Participants will use only a small part of the daily care page at this point, that is, the three lines related to the feed plan. Point out these three lines on the daily care page. 4.4 Reading, demonstration using 24-hour food intake chart Participants read sections 2.3 to 2.5 of the module about feeding and recording feeds. Possible question about breastfeeding. Participants may raise a question about feeding F-75 to babies who are “exclusively” breastfeeding. Explain that special | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 33 care for infants aged under 6 months will be presented in section 6. Highlight the importance of breastfeeding to prevent malnutrition. Low-birth-weight babies are not likely to meet the definition for severe acute malnutrition used in this course. They are not usually severely wasted or oedematous. Low-birth-weight babies should be breastfed. Their management is not taught in this course. Additional work in groups (when appropriate) After participants read sections 2.3 to 2.5, ask how they will know if a child needs an NG tube. Answer: The child needs an NG tube if they do not take 80% of the F-75 orally (that is, more than 20% is left) for two or three consecutive feeds. A visual exercise may help understand that 80% means “almost all” of the feed. Show examples using a glass of drinking water, as follows. • Put 100 ml of water in a clear glass. Ask a participant to imagine where the water would be after drinking 80 ml and draw a line on the glass at that spot. Then ask the participant to drink 80 ml. Show the amount left to the group. Ask the group what percentage the participant took (80%) and what was left (20%). Measure the amount left to see how accurate the participant’s guess was. If about 20 ml is left, the guess was accurate. • Again, put 100 ml in a glass and show the amount to the group. This time have a participant mark where half would be and drink half. Show the group the amount left. Ask participants what percentage was taken (50%). Ask participants if enough was taken. It should be clear, just from looking in the glass, that half (50%) is less than 80% and clearly not enough. In many cases, it will be obvious whether or not 80% has been taken. However, if unsure, one can use simple mathematics or a calculator. To make the calculation, it is important to remember the relationship between percentages and decimal fractions. Write the following on the flipchart: 80% = 80/100 = 0.80 Ask a participant to use a calculator to figure out what 80% of 60 ml is. (Multiply 0.80 × 60 ml. Answer: 48 ml). If 60 ml is offered, any amount less than 48 ml is not enough. 60ml – 48 ml = 12 ml. Likewise, if more than 12 ml is left, the child has not taken enough. Give one more example. A child is offered 75 ml of F-75 orally. Show this amount in a glass. The child takes 55 ml (pour out this amount) and leaves 20 ml. Show the amount left in the glass. Ask: Did the child take enough? Let half the group judge based on appearance, and the other half by doing a calculation (0.80 × 75 ml = 60 ml). Compare the results. Answer: The child took 55 ml, which is less than 60 ml (80%) and not quite enough. Note: If F-75 is not given in graduated cups or marked glasses, it will take extra effort to measure the amount left after each feeding. Leftovers will need to be poured into a graduated cup or syringe for measuring. If a syringe will 34 be used for NG feeding, leftovers may be measured in the syringe, and then dripped through the NG tube. Demonstration of 24-hour food intake chart Do the following demonstration to show how a 24-hour food intake chart can help staff to notice feeding problems early. Use a visual slide or an enlarged copy of the form and complete the form in front of the group. A participant can record while you tell the following story. The child is a girl named Marina who weighed 5.4 kg on admission. It is her second day in the hospital, and she still weighs 5.4 kg. She is supposed to receive 12 feeds of 60 ml F-75 today. Record this information at the top of the form. The feeding day starts at 08:00 and ends at 06:00 the next morning, so the 2-hourly feeding times are 08:00, 10:00, 12:00, 14:00, etc. List all 12 feeding times in the “time” column. At 08:00 the nurse offers Marina 60 ml of F-75. She leaves 5 ml, so the amount taken is 55 ml. She does not vomit any of the feed, and she does not have any watery diarrhoea. Record that 60 ml was offered, 5 ml was left, and 55 ml was taken. Ask: Did she take enough? Answer: Yes, she took more than 80%. 55 ml is “almost all” of 60 ml. (80% of 60 ml is 48 ml.) Marina did not need NG feeding, so record 0 in the NG column. Tell participants that you are going to continue to record what happened at the next feeds. Ask them to stop you if they think something different should be done: 10:00 60 ml offered, 0 ml left, 60 ml taken, 0 NG, no vomiting, no diarrhoea 12:00 60 ml offered, 10 ml left, 50 ml taken, 0 NG, no vomiting, no diarrhoea 14:00 60 ml offered, 0 ml left, 60 ml taken, 0 NG, vomited 30 ml, no diarrhoea 16:00 60 ml offered, 20 ml left, 40 ml taken, 0 NG, no vomiting, no diarrhoea* 18:00 60 ml offered, 30 ml left, 30 ml taken, 0 NG, no vomiting, no diarrhoea** * If no one stops you here, go on to record the next feed. Someone may stop you here and suggest NG feeding. Since Marina took all of the previous feed before vomiting, it may be best to wait one more feed before deciding to put in an NG tube. ** Someone should stop you here and suggest that an NG tube be used. The child vomited half of the 14:00 feed and took less than 80% of the next two feeds. Night is coming, and she will need to be fed well through the night or she is likely to become hypoglycaemic. If no one stops you, record more feeds in which Marina takes less than 80%. Someone should stop you soon. Discuss the point of this demonstration, which is that staff should not simply record the feeds; they should also notice feeding problems and act promptly by calling a doctor or using an NG tube to finish feeds. They should not wait 24 hours before noticing a problem and taking action. 4.5 Short answer exercise Participants read and do a short answer exercise about feeding and recording feeds on the 24-hour food intake chart. They check their own answers. | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 35 4.6 Exercise A. Determining F-75 feeding plans for the next day (individual work followed by individual feedback) Participants read section 2.6 and do Exercise A. The criteria mentioned in section 2.6 are repeated in the footnotes at the bottom of the F-75 reference card. After giving individual feedback, be sure to give each participant a copy of the answer sheet. It is important to finish Exercise A by the end of Day 3 if possible. Some groups may be able to finish Exercise B as well. Working in groups (when appropriate) Let participants do cases 1 and 2 (Delroy and Pedro) of Exercise A independently and come to you for individual feedback. Do case 3 (Rositha) orally as a group. If the group is working slowly, case 4 (Suraiya) may be omitted. Alternatively, you may use Suraiya as another demonstration in which participants stop you when an NG tube is needed. Describe Suraiya’s first 2 days in the hospital and use the ensuing information to complete the 24-hour food intake chart, feed by feed, for Suraiya for Day 3. Participants should stop you and tell you to insert an NG tube at 22:00 or 24:00 when Suraiya feeds poorly for the second or third time. If they stop you, congratulate them for doing better than Suraiya’s “real” intervention, leaving her for the rest of the night without food. Discuss Suraiya’s feed plan for Day 4. 4.7 Exercise B. Feeding during transition (individual work followed by individual feedback) Ask participants to continue doing individual work by reading section 3 and doing Exercise B. If it is already the end of Day 3, Exercise B may be assigned for homework to be done on the middle day of the course (Day 4). The course director will inform you of any other work to be done on Day 4; for example, participants from the same hospital may work together on Exercise E (preparing a ward schedule), or there may be an opportunity to observe a play session or an educational session with mothers. If Exercise B is given as homework, remember to give individual feedback when the group returns. When giving individual feedback, be sure that participants understand the importance of feeding slowly and gradually during transition. Be sure that they understand the schedule for feeding during transition given in section 3.3 of the module. Monitoring is very important during transition. Possible question. Participants may ask if it is permissible to give a child more F-100 if they are crying with hunger. During transition, it is very important to be cautious. If 4 hours is too long for a child to wait between feeds, it is fine to give 3-hourly feeds, keeping the total daily amount the same. If a child continues to cry for more, it is acceptable to give more only if the staff are able to monitor the 36 child very closely for danger signs. Later, after transition, more food can be given according to the child’s appetite without the need for such close monitoring. After individual feedback give the participant a copy of the answer sheet. 4.8 Exercise C. Feeding on F-100 (individual work followed by individual feedback) Ask participants to continue doing individual work by reading sections 4 and 5 and doing Exercise C. Explain that the F-100 reference card will be used in Exercise C.  Working in groups (when appropriate) Instead of having participants read sections 4 and 5 individually, you may talk through this section. Hold up the F-100 reference card. Explain that, after transition, this card is used to determine the appropriate range of feeds of F-100. Point out that the first set of ranges is for 4-hourly feeds of F-100, and the second set of ranges is for daily volumes. The child can have as much as desired within these ranges. Carefully talk through the important points. (Omit the alternative method of calculating the range for Delia.) Give examples of children who have finished transition and ask participants to tell you what to write on the top of the 24-hour food intake chart. Examples: Weight 6.4 kg, finished all feeds yesterday, last feed was 200 ml. Write: Give 6 feeds of 210   ml. Do not exceed 235 ml. Weight 8.3 kg, did not finish feeds yesterday, last feed was 250 ml. Write: Give 6 feeds of 250   ml. Do not exceed 300 ml. (Note that the range for the next lower weight was used, 8.2 kg.) In Exercise C, do cases 1 and 2 (Delroy and Pedro) orally as a group. Ask participants to do case 3 (Rositha) independently and come to you for individual feedback. When giving individual feedback, be sure that the participant understands how to use the F-100 reference card. The child should be gaining weight at this point, and the child’s current weight should be used to determine the appropriate range of volume for feeding. Within this range, the child’s appetite determines how much to offer. After individual feedback, give the participant a copy of the answer sheet for Exercise C. | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 37 4.9 Feeding a severely malnourished infant aged less than 6 months Ask participants to read section 6 carefully. This section describes the management of infants under 6 months of age with severe acute malnutrition, from initial assessment to special care, feeding, breastfeeding and relactation. When they have finished reading this section you can ask them to compare the differences in management of severe acute malnutrition for children over 6 months of age. Discuss Exercise D. Some points for discussion 1. Alinafe is a breastfed infant with a length of 51 cm and a weight of 2.7 kg. Alinafe lost weight in the previous 2 days and looks unwell. Her mother is very worried and complains of breastfeeding difficulties despite the support she received on infant feeding from health workers in her community. Example: Alinafe has severe acute malnutrition and is unwell. The emergency assessment is expected to decide to give glucose. A full assessment will be conducted to diagnose infections and other medical conditions and define a comprehensive treatment plan that will start immediately. Feeding may start as soon as possible with 25 ml of diluted F-100 given every 2 hours by supplementary suckling. A health worker of the severe acute malnutrition ward is appointed to support the mother with breastfeeding, teach her the supplementary suckling technique and monitor the feeding of the infant. Breastfeeding should be offered between the feeds and on demand. In the following days, depending on Alinafe’s drinking ability she may be shifted to eight feeds a day. The mother receives food, treatment and breastfeeding counselling or psychosocial support as needed. Alinafe’s weight will be monitored and as soon as she starts gaining weight, the amount of diluted F-100 will be gradually diminished by one third until she gains good weight on breast milk alone. 2. Thomu is an infant aged 2 months whose mother died during childbirth. Thomu has a length of 54 cm and weighs 3.2 kg. Thomu is taken care of in the orphanage. His carer informs us that Thomu has suffered from frequent episodes of diarrhoea since his arrival in the orphanage. Yesterday, after Thomu passed several loose stools, the carer became worried because she noticed Thomu was not well and the look of his eyes had changed. Example: The initial assessment and treatment may have diagnosed dehydration and proposed oral ReSoMal for the first 2 hours. Then, feeding will start with 40 ml of diluted F-100 every 2 hours given by cup (or NG tube), and in alternate hours ReSoMal will be given until rehydration is completed. A health worker of the severe acute malnutrition ward is appointed to support the carer and monitor the feeding of the infant. As soon as Thomu takes all his milk feeds he is shifted to eight feeds a day, receiving 60 ml per feed. As soon as Thomu takes all milk feeds eagerly he will be ready for transition. During transition, a sustainable care and feeding plan will be discussed with the carer and preparations for discharge should start. 38 4.10 Exercise E. Preparing a schedule for activities on the ward (followed by group discussion) Note: This exercise may be done on Day 4 by groups from the same hospital. If so, you may be assigned to facilitate a hospital group for this exercise rather than your usual small group. Ask the participants to read section 7.1 of the module. Explain that Exercise E involves making a schedule for the ward. If arrangements have been made so that participants from the same hospital can work together on this exercise, explain these arrangements. Depending on how much time is available, you may need to fix a time limit for this exercise. One hour may be suitable. Stress that the schedule does not have to be perfect. This is an opportunity to discuss options and draft a possible schedule. Some participants may feel that they are powerless to change the schedule at their hospitals. If this is the case, suggest that they develop a schedule that accepts absolute constraints, but perhaps incorporates some changes that others in the hospital might be able to make if they were convinced of its importance. When most people are ready, lead a group discussion. (Some participants may wish to continue work on their schedules later on their own.) Ask participants: • Was there a need to adjust shifts, kitchen hours, or other aspects of your hospital’s schedule to accommodate feeds? What adjustments did you make? • How did you provide times in the schedule for play and educating parents about feeding their children? 4.11 Exercise F. Planning feeding for the ward (individual work followed by individual feedback) Ask participants to continue reading section 7.2 and do Exercise F. In this exercise participants complete a daily ward feed chart by adding three children to the chart and doing the calculations at the bottom of the form. After the exercise, conduct individual feedback as usual. Give the participants a copy of the answer sheet. Note: On the answer sheet, at the bottom, the blank line should be filled with “12” since feeds are prepared every 12 hours on this ward. The amount for 24 hours is divided by 2 to determine the amount for 12 hours. Ask the participants to read sections 7.3 and 7.4 and prepare for the discussion in Exercise G. The discussion will focus on ways to prepare hospital staff to do new tasks related to feeding. 4.12 Exercise G. Preparing staff to do tasks related to feeding (group discussion) Before leading this discussion, review the general guidelines for leading group discussions given at the end of this guide. | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 39 Use the questions given in Exercise G of the module to structure the discussion. In answering the questions, try to focus on one task at a time. For example, you may discuss how to prepare staff to do one of the following tasks: • prepare F-75 and F-100 • measure F-75 and F-100 • record feedings on a 24-hour food intake chart • feed through an NG tube. The above are specific tasks. If you try to discuss “feeding” as a whole, the discussion will become general and less helpful. Of course, answers will vary greatly. Participants may have some very creative ideas. As a model, here are some possible answers to the questions in Exercise G, focusing on one task. Example 1. Nurses do not know how to prepare F-75 and F-100 properly. 2. Nurses on duty at 07:00 and 19:00 will be responsible for this task. Two nurses from each of these shifts need to be selected to be responsible for preparing feeds. They need to be informed by the head nurse. 3. Information can be provided by written recipes. 4. Examples can be provided by demonstrations. A skilled person should demonstrate how to prepare the recipes. 5. The nurses should have supervised practice. A skilled person watches them prepare the recipes and corrects any problems. 6. A problem might be lack of ingredients. The kind of milk available might vary from day to day. Several recipes should be available for different kinds of milk. Training should be provided on how to make all of these recipes. 4.13 Summary of the module 1. Point out that participants have learned about management of severe acute malnutrition and feeding for infants aged under 6 months, planning feeding for children aged over 6 months and for the ward. It is important to set aside a planning time every day. Once each patient’s 24-hour food intake chart is reviewed and plans made for the day, then a daily ward feed chart can be completed for the entire ward. 2. Remind participants of the importance of: - starting with small frequent feeds of F-75; - having a gradual transition to RUTF (or F-100); - supporting breastfeeding and relactation when possible, as it is essential in children aged under 2 years. 3. Stress the need to carefully prepare hospital staff to do new feeding tasks, provide special care for infants and support mothers and caregivers. 4. Review any points that you have noted below. Answer any questions that participants may still have. (If you cannot answer a question, offer to obtain more information and discuss it later.) 40 FACILITATOR GUIDELINES FOR MODULE 5: DAILY CARE Procedures(seenotesonfollowingpages) Feedback 1. Distribute the Daily care module. Introduce the module. 2. Participants start reading and do a short answer exercise. Demonstration: daily care page of CCP. Self-checked 3. Participants read from section 2 up to section 3.3 and do the following short answer exercise. Self-checked 4. Participants continue reading from section 3.4 to section 4 and do Exercise A on treatment of eye problems. Individual feedback 5. Participants do Exercise B on use of the daily care page of the CCP as a group. Group feedback 6. Demonstration: monitoring record of CCP. Participants read sections 5 and 6 and do a short answer exercise. Self-checked 7. Participants do Exercise C on use of the daily care page and monitoring record. Individual feedback 8. Participants do Exercise D on identifying danger signs. Individual feedback 9. Optional demonstration: weight chart. Participants read section 7 and do a short answer exercise. Self-checked 10. Participants do Exercise E on preparing and using a weight chart. Individual feedback 11. Summarize the module. | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 41 Preparation for the module Be sure that you have a supply of blank daily care pages and monitoring records in the classroom. Each participant will need one of each of these forms for exercises in the module. 5.1 Introducing the module Explain that this module will focus on the routine tasks, besides feeding, that occur in the ward each day. These tasks, such as bathing, weighing, giving eye drops, and giving antibiotics, are very important for the child’s recovery. This module also focuses on monitoring the severely malnourished child, specifically monitoring pulse, respiration, and temperature. Monitoring is critical so that problems can be identified, and treatment can be adjusted as needed. Point out the learning objectives of the module. Most of these tasks will be practised on the ward. In the module participants will learn to use three pages of the CCP: the daily care page, the monitoring record, and the weight chart. (Hold up the enlarged copies or project them in a visual presentation.) 5.2 Reading, short answer exercise, demonstration Ask participants to start reading section 1 of the module and to do the following short answer exercise. Participants check their own answers. Tell them that, after the short answer exercise, there will be a demonstration of how to use the daily care page of the CCP. Demonstration of daily care page Note: The focus of this demonstration is on how to use the form, not on the treatments, which will be discussed later in the module. Project a slide (or show an enlarged copy) of the daily care page. Point out that one column is used every day. There are enough columns for 21 days or 3 weeks. Point out the items in the left column on this page. Not every child will have something recorded for every item. For example, some children will not have eye problems. When a row will not be used, it can be shaded out, or you can write “none”. Some items on the daily care page require that information be recorded (for example, the child’s weight, the degree of oedema, the volume of feed taken). Others require that the staff initial when a task is performed. For example, when the nurse gives an antibiotic or multivitamin, that should be registered on the form. Write on the visual presentation or on the enlarged copy to set up a daily care page for a 2-year-old girl named Bianca. You will set up the left column of the form like the example on page 4 of module 5 by entering appropriate times and doses. You will also record information for Bianca’s first day in the hospital. Talk as you write, for example: 42 • Bianca’s first day in the hospital is 8 January, so I record the date as 8/1 for Day 1. • Bianca’s weight is 8.8 kg. • She has no oedema, so I record 0. • Bianca has diarrhoea (three loose stools) but no vomiting, so I record only “3” on diarrhoea. • She will be taking F-75. • She will be fed 2-hourly, so I record that she will receive 12 feeds daily. • At the end of the day, or the next morning, I will record the total volume that she took during Day 1. (Question: Where can I look to find the total volume? Answer: On the 24-hour food intake chart.) • Bianca will be taking gentamicin and ampicillin intravenous or intramuscular (IV or IM) so I record the drugs, their dosages, and times for administering them. These are times when medications are normally given in the hospital. I draw boxes to show that these routine antibiotics should be given according to their recommended schedules. The boxes will show the nurses when to give the antibiotics and when to stop giving. For some children, it may be necessary to draw more boxes for more drugs. • I give Bianca her first doses of gentamicin and ampicillin and register to show that they have been given. Someone else will give the next dose of ampicillin and write down their initials at 14:00, then 20:00, and so on. • Bianca has not had a dose of vitamin A in the past month. She is aged 2 years, so I record that she needs a dose of 200 000 international units (IU). (Explain that participants will learn more about when to give vitamin A later in this module. Do not discuss vitamin A now.) • I give Bianca 200 000 IU vitamin A. • She has no worms, so I write “none” by “drug for worms”. • Bianca needs tetracycline drops, so I circle that and write that drops should be given at 08:00, 14:00, 20:00, and 02:00. I indicate that the drops are needed in her right eye. Bianca does not need atropine, so I write “none”. (Explain that participants will learn about treatment for eye problems later in this module. Do not discuss treatment of eye problems now.) • I give Bianca a drop of tetracycline in her right eye and initial. Other nurses will give the later doses and initial. • I record +++ to show that Bianca has severe dermatosis. • I circle that she will need zinc oxide ointment for dermatosis. Then I initial on the form. Participants can see how Bianca’s daily care page was filled for 9 days by looking at the example on page 3 of module 5. 5.3 Reading and short answer exercise Ask participants to read from section 2 up to section 3.3 of the module and do the short answer exercise at the end of section 3.3. Participants may ask why children with signs of eye infection (pus, inflammation) need additional doses of vitamin A. The reason is that pus and inflammation may hide the signs of vitamin A deficiency. It is best to be safe and give these children the additional doses of vitamin A. | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 43 The short answer exercise is about vitamin A. Look to see that participants are completing it correctly. Working in groups (when appropriate) Before participants do the short answer exercise following section 3.3, review the guidelines for giving vitamin A and answer any questions. It may be helpful for the group to do the short answer exercise together orally. To do this exercise as a group, ask each participant in turn to answer a question. If participants do the short answer exercise independently, you may want to give individual feedback to ensure that each participant understands when to give vitamin A. 5.4 Reading and Exercise A. Deciding on treatment for eye signs (individual work followed by individual feedback) Ask participants to continue reading from section 3.4 to section 4 of the module and do Exercise A on treatment of eye problems. Have your photographs booklet out when you give individual feedback. The next exercise will be done as a group. Those who have received feedback on Exercise A may continue reading in the module until everyone is ready for Exercise B. 5.5 Exercise B. Using the daily care page of the CCP (group work followed by group feedback) The purpose of this exercise is simply to set up a daily care page properly. Although the exercise could be done individually, it will be easier and more interesting if done as a group. Give each participant a blank daily care page. Participants will complete this page as you prompt them. After each prompt, allow enough time to record, but do not go so slowly that participants become bored. If you see that a participant is not writing, look to see what the problem is and explain. First, ask everyone to look at the initial management page for Lani on page 13 of module 5. Most of the information needed about Lani is on her initial management page. Lani is severely malnourished and has been admitted to the severe acute malnutrition ward. Ask participants to look for her date of admission. Ask them to record this date for Day 1 on the daily care page. Then continue prompting as follows. • Look for Lani’s admission weight on the initial management page. Record this as her weight for Day 1. • Record Lani’s degree of oedema. • Record whether she has diarrhoea (number of loose stools) or vomiting. 44 • Record the type of feed that she should be given on Day 1. • Record the number of feeds that Lani should receive on Day 1. • You do not know how much she will take during the day, so leave the “total volume taken” blank. • Look at the antibiotics that Lani will receive. Recorded on the initial management page, these are gentamicin for 7 days, along with ampicillin for 2 days followed by amoxicillin for 5 days. • Notice the times that medications are given on the ward. These are listed on page 12 of module 5: 08:00, 14:00, 16:00, 20:00, 24:00, 02:00. • On the daily care page for Lani, write the dose of gentamicin, the route of administration, and the time it will be given, and draw a box to show when it should be given. (Do not initial on the form yet. You are simply setting up the form, not giving the drugs.) • Write the dose of ampicillin, the route of administration, and the times that it will be given, and draw a box to show when it should be given. • Write the dose of amoxicillin, the route of administration, and the times that it will be given, and draw a box to show when it should be given. (Note: Check that participants indicate that amoxicillin is not given until Day 3.) If more space is needed, you can register amoxicillin in the space left on the bottom of the page under “others”. • Record the time at which folic acid will be given. Choose a time when another medication will be given. • Record the dose of vitamin A (if any) that Lani needs. • Lani does not have worms, so write “none” by “drug for worms”. • Look at the information on Lani’s eye signs given on the initial management page. Decide what type of eye drops, if any, Lani needs. Record the type(s) of eye drops and the times to give them. (Allow more time here as participants will need to record times to give two drugs.) • Record Lani’s dermatosis classification and circle if she needs zinc oxide ointment. • Lani has pus draining from her ear, and it needs to be wicked at least twice daily. Indicate this need on the daily care page at the bottom. Distribute copies of the answer sheet for this exercise. Let participants compare their forms to the answer sheet. Discuss any differences or any questions that participants may have. Note: The times selected by participants for wicking the ear may vary, although 08:00 and 02:00 seem logical choices given the times that nursing rounds are done in this example. Wicking should be done as often as needed, but by marking certain times on the form, it is more likely to be done. 5.6 Demonstration, reading and short answer exercise Participants will learn about use of the monitoring record in this section. Have participants read sections 5 and 6 of the module (or orally cover the points in these paragraphs). | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 45 Demonstration of monitoring record Present a blank monitoring record in a visual presentation (or use an enlarged copy). Point out that the child’s respiratory rate and pulse rate are recorded at the top, and temperature is graphed so changes can easily be seen. This monitoring should be done every 4 hours until the patient is stable. One page can be used for about 7 days if monitoring is done this frequently. If necessary, additional pages can be attached. Use the following story to show how the form is completed. You can ask one participant to record while you read the following story. • Dikki’s temperature at 09:00 on Day 1 is 36°C. Plot temperature with an X on the line for 36°C in the middle of the left-most column of the graph. Record time below the column. • Dikki’s respiratory rate is 35 breaths per minute. Record in left-most box at the top of the form. His pulse rate is 90 beats per minute. Record the pulse rate below the respiratory rate. Point out that the temperature is on the line to the left of the boxes where the rates are recorded. • Dikki’s temperature at 13:00 is 36.5°C. His respiratory rate is still 35 and his pulse rate is 95. Record these on the monitoring record. Connect the points for the temperature graph. • Dikki’s temperature at 17:00 is 37°C. His respiratory rate is still 35 and his pulse rate is back to 90. Record these on the monitoring record. Connect the points for the temperature graph. Point out that it is easy to see the increase in temperature. Explain that participants will practise using the monitoring record in the next exercises. Point out the example of a monitoring record on page 19 of module 5. Ask participants to do the short answer exercise following section 6. Working in groups (when appropriate) Review the summary of danger signs with the group and, after the group has done the short answer exercise independently, review the answers with them as a group. 5.7 Exercise C. Use of the daily care page and monitoring record (individual work followed by individual feedback) In this exercise participants will make entries on the daily care page that they set up for Lani in Exercise B. If their own work was correct, they may make entries on the form that they set up earlier. If there were many mistakes, they may use the answer sheet provided for Exercise C instead of their own work. Participants will also need a blank monitoring record for this exercise. 46 Give individual feedback as usual. The purpose of this exercise is mainly to learn how to use the forms. In the next exercise participants will practise interpreting the monitoring record to identify danger signs. Give the participants copies of the answer sheets. Ask the participants to start working on Exercise D. Working in groups (when appropriate) Exercise C may be done as a group exercise in the same way that Exercise B was done. Read aloud the information about Lani as each participant records on a monitoring record. Discuss the questions at the end of the exercise. Distribute the answer sheet and discuss any differences. 5.8 Exercise D. Reviewing monitoring records to identify danger signs (individual work followed by individual feedback) This is a very important exercise. The monitoring records illustrate several different danger signs. At the end of individual feedback, review these danger signs with the participant: • Lani – sudden drop in temperature (possibly became uncovered or missed a feed, possible infection). • Carla – increase in both respiratory and pulse rates (possible heart failure). • Bijouli – temperature increase, fast breathing (possible pneumonia). Monitoring is recommended every 4 hours until the patient is stable. Ask whether the participant thinks that monitoring can be done every 4 hours in their hospital. If not, how often does the participant think that monitoring can be done? Give the participants copies of the answer sheet. They may continue to read and work independently on the module. Working in groups (when appropriate) Do case 1 of Exercise D (Lani) as a group. Then have participants continue the exercise independently. Give individual feedback on Carla and Bijouli. 5.9 Optional demonstration, reading, and short answer exercise Section 7 of the module describes how to complete a weight chart for a severely malnourished child. Most participants will be familiar with weight charts and will be able to work independently to the end of the module without a demonstration. However, if you anticipate that your group will find the weight chart difficult, you may do a demonstration of how to complete it. | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 47 Optional demonstration of weight chart Use a visual slide or an enlarged copy of the weight chart. Point out that the vertical axis will show the possible range of weights for the child, and the horizontal axis will show the days that the child is in the hospital. Each point plotted on the graph will show the child’s weight on a certain day. As facilitator you should tell the story of a child and describe the graphing process using the narration below. You can ask a participant to record information, label the graph, and plot weights following the directions given. • Opu is a 9-month-old boy. His weight on admission was 6.1 kg, and his length was 67.0 cm. He had moderate (++) oedema on admission. Record this information in the spaces to the left of the weight chart. • Now we need to set up the vertical axis of the graph. Point to the vertical axis. Each heavy line going across will represent an even weight such as 5.0 kg, 6.0 kg, etc. Each lighter line will represent 0.1 kg. Point to the heavy lines and lighter lines. • Since Opu has some oedema, he will lose some weight before he gains. So we cannot put his starting weight at the bottom of the vertical axis. We have to leave some room for weight loss. Since Opu has moderate oedema, we will allow for 1 kg weight loss. If he had severe oedema, we would allow for a 2 kg or 3 kg loss. His starting weight is 6.1 kg so we will write 6.0 kg by the first heavy line from the bottom of the chart; 6.1 kg will be on the first light line above this. Label the heavy line for 6.0 kg. • We can now label the other heavy lines that intersect the vertical axis. There is no need to label the lighter lines. We will just remember that each one represents 0.1 kg. Label the remaining heavy lines 5.0 kg (bottom line), 7.0 kg, 8.0 kg, and 9.0 kg (top line). • Now the graph is set up, we can plot the admission weight of 6.1 kg. To do this, we follow the line up from Day 1, and across from the weight 6.1 kg, and make a mark at the intersection. The mark can be a heavy dot or an X. Point to show how to find the intersection of lines above Day 1 and across from weight 6.1 kg. Make a mark such as an X to plot the point. • On the next day we would plot a point for the weight on Day 2. The weight on Day 2 is the same, 6.1 kg. We then connect the points with a line. Plot a point for this weight and connect the points. • On Day 3 Opu has lost some weight. He weighs 5.9 kg. Plot the weight for Day 3 and connect the points. • On Day 4 Opu has lost some more weight. He weighs 5.5 kg. He starts F-100 on Day 4. Plot the weight for Day 4 and connect the points. Underneath the point for Day 4 write “F-100”. • On Day 5 Opu has gained some weight. He weighs 5.6 kg. Plot the weight for Day 5 and connect the points. • On Day 6 Opu has gained some more weight. He weighs 5.7 kg. Plot the weight for Day 6 and connect the points. • Over the next days, Opu continues to gain weight. Plot points for Day 7 (5.8 kg), Day 8 (5.9 kg), Day 9 (5.9 kg), and Day 10 (6.1 kg). Connect the points. 48 • You can easily see from looking at the graph that Opu first lost some weight due to oedema and then gained weight once he started on F-100. Point to show the line going down and then up again. Participants should do the short answer exercise following section 7. They should check their own answers and continue to Exercise E. Individual check (when appropriate) Facilitators may want to check answers to the short answer exercise individually to be sure that participants understood how to read the weight chart. 5.10 Exercise E. Preparing a weight chart (individual work followed by individual feedback) When giving individual feedback, be sure that participants understand why Daniel lost weight, i.e., because he was losing oedema fluid. Remind participants that children are not expected to gain weight until they are in the transition phase. Ask participants if weight charts like this one are kept in their hospitals. Ask if they can see the usefulness of this type of chart in showing a “picture” of weight gains and losses. Give the participant a copy of the answer sheets. 5.11 Summary of the module 1. Ask participants to tell you why it is important to keep good records of daily care, weight, and results of monitoring. They may have a number of ideas. For example, good records are important for communicating with other staff (for example, when the shift changes). Monitoring is important to quickly identify danger signs. 2. Review the learning objectives of the module and explain that participants will have a chance to do some of these tasks during clinical practice. 3. Review any points that you have noted below and answer any questions that participants may still have. (If you cannot answer a question, offer to obtain more information and discuss it later.) | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 49 FACILITATOR GUIDELINES FOR MODULE 6: MONITORING AND PROBLEM SOLVING Procedures(seenotesonfollowingpages) Feedback 1. Distribute the Monitoring and problem solving module. Introduce the module. 2. Participants start reading the module up to section 2.1 and do the two short answer exercises(followingsections1.1and2.1). Self-checked 3. Participants do Exercise A on identifying progress and problems in two cases. Individual feedback 4. Participants continue reading sections 2.3 and 2.4 and prepare for group discussion in Exercise B. Group discussion 5. Participants read section 3 and complete the weight gain tally sheet in Exercise C. Then they prepare for group discussion by answering questions at the end of section 3. Group discussion 6. Participants read from section 4.1 to section 4.3 and do Exercise D on determining common factors in deaths. Group discussion 7. Participants read section 4.4 and do the short answer exercise. Self-checked 8. Participants read section 5 and 6 and prepare for the role play in Exercise E. Conduct the role play. Group discussion 9. Lead discussion following use of monitoring checklists in the ward (timing of this activity willvary). Group discussion 10. Summarize the module. 50 Preparation for the module Calculators will be very helpful for some of the written exercises in this module. Exercise E of this module is a role play of a problem-solving session. A problem is described in these guidelines. Several roles are also described. You will need to photocopy the role descriptions and provide them to participants who will play those roles. Optional: If the problem-solving role play in Exercise E is successful, and if time allows, you may lead an additional role play using a real problem observed in the hospital ward. So be alert during clinical practice sessions to identify any problems that might be discussed. If time allows, during the clinical practice sessions on Day 6 or Day 7, participants will complete monitoring checklists like those given in Web Annex B of the module. Take copies of the monitoring checklists on Days 6 and 7. 6.1 Introducing the module Monitoring is important both for identifying progress and for identifying problems. This module focuses on monitoring to identify problems so that they can be solved. First, the module describes a general process for identifying and solving problems. Next, the module shows how problems can be identified by monitoring individual patient progress, weight gain and care. Then, the module shows how to identify problems by monitoring weight gain and patient outcomes on the whole ward. Finally, the module discusses monitoring of ward procedures. Point out the learning objectives of the module. Stress that an important concept in this module is to look for the root cause of a problem before deciding on a solution. The example in section 1.3 of the module will show the importance of this concept. 6.2 Reading and short answer exercises Ask participants to start reading the module and do the short answer exercises at the end of sections 1.1 and 2.1. Then they can do Exercise A. As participants work individually, notice whether they are doing the short answer exercises easily. If they are having difficulty, assist as needed. The second short answer exercise is about calculating daily weight gain. A calculator will be very helpful. | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 51 Detailed reading (when appropriate) Depending on the skills of the group, divide the reading into shorter segments and check understanding after each segment as follows: • Have participants read section 1.1, then pause. Do the short answer exercise together as a group. • Participants continue reading up to section 1.4, then pause. Discuss the examples of causes and solutions under section 1.3. Be sure that participants understand the concept that the solution to a problem must be appropriate to its cause. • Have participants pause at the end of page 7 of module 6. Following the process described for calculating daily weight gain, use the flipchart to present the example on page 7 of module 6 for the group. You may also wish to do the first problem of the short answer exercise as a demonstration for the group. • Have participants complete the short answer exercise on page 8 of module 6 independently. Individually check participants’ answers to the short answer exercise. 6.3 Exercise A. Identifying progress and problems with cases (individual work followed by individual feedback) Participants may give slightly different answers from those on the answer sheets. They may find additional evidence of progress or problems. Their answers should be similar to those given and should be reasonable. For some of the signs of progress or problems listed by a participant, ask: “How do you know this?” Participants should be able to show where they got the information from the CCP. For example, it is important to note that Ceri is not eating well. This is evident on her 24-hour food intake chart. It is also important to notice that Ceri has not started to lose her oedema even on Day 5. This is evident on the daily care page. It is important to note too that Lennox is not gaining weight on F-100. One can see this by looking at the recorded weights on the daily care page and by looking at Lennox’s weight chart. According to the possible criteria in section 2.2 of the module, both Ceri and Lennox are failing to respond. These criteria are simply a guide to help identify children who are having problems. Give the participants a copy of the answer sheet. Ask the participants to read sections 2.3 and 2.4, which discuss possible causes of failure to respond and possible solutions. They should then prepare for the group discussion in Exercise B by writing answers to the questions listed. 52 6.4 Exercise B. Identifying causes and solutions of problems (individual work followed by group discussion) If there are time constraints: Just do case 1 (Ceri) in Exercise B. Omit case 2 (Lennox). Be sure that participants prepare individually for this exercise by writing answers to the questions listed. Use the questions in this exercise to structure the discussion. Use the answer sheet as a guide for possible answers. If participants do not raise the ideas listed on the answer sheet, mention them yourself. Stress that the causes are just possible causes. Investigation will be needed to determine the real causes. Note of caution related to case 2, Lennox. Tuberculosis is often overtreated in severely malnourished children. Participants should not be too eager to jump to a diagnosis of tuberculosis just because a child is not gaining weight. Usually, if a child is not gaining on F-100, the reason is inadequate intake. The clues in this case are as follows: benzylpenicillin is not helping; there is no weight gain in spite of good intake; a chest X-ray shows a shadow on the lungs; and there is a household contact who has tuberculosis. Stress that low weight gain is usually due to inadequate intake, so always check intake first. At the end of the discussion, give participants a copy of the answer sheet. Ask them to read section 3 of the module in preparation for doing Exercise C. This exercise focuses on monitoring weight gain for the ward as a whole. Since only children on F-100 are expected to gain weight, participants will look at weight gain only among these children. 6.5 Exercise C. Determining whether there is a problem with weight gain on the ward (individual work followed by group discussion) Completing the weight gain tally sheet for the ward may seem like a cumbersome process to some participants. Point out that it only needs to be done once a month, preferably for the same week each month. The tally sheets can be a good basis for discussion and problem solving with staff. As participants do individual work to prepare for the discussion, they may ask you to check their calculations and their tally sheets. Do so using the first part of the answer sheet provided. (Do not give the answer sheet to the participant yet; wait until after the group discussion.) Be sure that participants prepare for the discussion by writing answers to questions on page 27 of module 6. Use these questions to structure the discussion. Participants should raise the points given on the answer sheet. If they do not, raise these points yourself. | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 53 Other possible questions to discuss: • Do you think that the problem of poor weight gain on this ward would have been noticed without completing a tally sheet? • Is it practical to use this process (calculating and tallying weight gains) once a month in your hospital? If not, how could you still be aware of problems? 6.6 Exercise D. Determining common factors in deaths (individual work followed by group discussion) Ask participants to read section 4 up to section 4.3 and do Exercise D, which will also be followed by a group discussion. Use the questions given in the exercise to structure the discussion. Participants should mention the points made in the answer sheet. They may have other ideas as well. Be sure to mention any points from the answer sheet that the participants do not raise. Stress that it is very important to review the circumstances of deaths. Common factors in these deaths may suggest major problems that need to be solved, such as extensive problems in the emergency room at this hospital. At the end of the discussion, give participants a copy of the answer sheet, following which they will continue to section 4.4. 6.7 Reading and short answer exercise This section is about calculating case-fatality rates for a ward. Ask participants to read section 4.4 and do the following short answer exercise about calculating case-fatality rates for a ward. Use of flipchart (when appropriate) Using the flipchart, do the first problem in the short answer exercise as an example for the group. As the group works individually on the rest of the short answer exercise, look to see if participants are having difficulty and help as needed. Optional: You may wish to get the group’s attention and hold a very brief discussion. Ask participants if they know the case-fatality rate for severely malnourished children at their hospitals. Ask how they could obtain the necessary information and calculate the rate. Could they do it on a regular basis? 54 6.8 Exercise E. Role play: problem-solving session Ask participants to read sections 5 and 6 and then get ready for the role play in Exercise E. In this role play, participants will each take the role of someone who might be on the staff of a hospital. When participants come to you, assign them one of the roles below: • physician in charge (this person will lead the problem-solving session) • senior nurse (or “matron”) on duty in the morning • senior nurse on duty in the afternoon • night nurse • junior auxiliary nurse • hospital administrator. Prior to this exercise, photocopy the role descriptions on the following pages and cut them out. Give each person a role description. In front of each person, place a card or folded piece of paper showing that person’s role. These cards will help participants remember who is playing what role. Tell the “physician in charge” that he or she should take the lead in the discussion and should follow the process outlined in section 6 of the module. Try not to interrupt. Assist only if the discussion becomes very much “off track”. Ask someone to help by recording on the flipchart. The format below will help provide structure. Example of flipchart format Problem: Causes: Solutions: After the role play, discuss what went well and what could have been improved. Ask if participants could conduct such a session in their hospitals. Ask if all of the solutions identified appear to be appropriate for the causes of the problem. If there is time, you may do another role play using a real problem observed in ward visits. | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 55 Descriptions of roles Physician in charge From December through February there were no deaths in the severe acute malnutrition ward. In the past week, there have been two deaths. Kari, a 15-month-old girl, died during her second night in the hospital (last Monday). She was dead when you arrived in the morning. Ramon, a 24-month-old boy, died during his third night in the hospital (last Wednesday). His NG tube had been removed and it was his first night to feed orally. Both children were supposed to be taking F-75 every 2 hours. There are no monitoring data for the nights of the deaths, and the 24-hour food intake charts were not kept during the night. You suspect that the children were not fed during the night, and that they became hypoglycaemic and died. You want to know more about what happened so that this will not happen again. Senior nurse (morning), also known as the matron You are on duty from 07:00 until 15:30. You remember the deaths of Kari and Ramon last week, although you were not present at night when they occurred. When you arrived in the morning after Kari had died, the night nurse and junior nurse (who had been on duty all night) were visibly upset. They had been trying to reach the physician in charge for over 2 hours. You are not sure what happened during the night, but you are very protective of the nursing staff, and you do not want to lose any more nurses. You feel that the ward is understaffed and overworked. On the morning after Ramon’s death, you found the junior nurse alone in the ward. The other night nurse had not reported for duty. Senior nurse (afternoon/evening) You are on duty from 15:00 until 22:30. You heard about the deaths of Kari and Ramon last week, although you were not present when they occurred. When you left at 22:30 on Monday night, Kari was fine and was taking F-75 well at 2-hourly feeds. 56 On Wednesday evening at about 18:00 you removed Ramon’s NG tube so that he could take F-75 orally. He had two successful oral feeds before you left for the night. When you left, the junior nurse had arrived, but the other night nurse had not arrived. Night nurse You were recently moved from the infectious disease ward to the severe acute malnutrition ward. You have been on the night shift for only 2 weeks, and you are not yet used to the schedule. You get very tired at night. You do not understand why children should be awakened every 2 hours to eat when they are sleeping soundly. When you wake the children, they often refuse to eat anyway. You received no special training when you were moved to the severe acute malnutrition ward. You were simply told to feed the children according to their charts throughout the night. On Monday night, when Kari died, the junior auxiliary nurse woke you at 04:30 in a panic. You were not surprised when you couldn’t reach the doctor. On Wednesday night, when Ramon died, you did not come to work because your husband did not come home, and there was no one to stay with your own children. It was too late to find a substitute. Junior auxiliary nurse You work in the ward at night and were on duty when both Kari and Ramon died. You try very hard to stay awake all night and feed the children, but sometimes you fall asleep. You are very conscientious, and you were extremely upset when the children died. In Kari’s case, you went to feed her at about 04:00 and she was dead. She was uncovered when you found her. Her mother had gone home for the night and was to return in the morning. You woke the other nurse and called the physician, but he could not be reached. In Ramon’s case, you were alone because the other nurse did not show up. You realized that he was not taking his feeds well at 24:00 and 02:00, but you could not spend a lot of time with him because you had other children to feed. Ramon’s mother was very ill and was not with him in the hospital. You do not know how to insert an NG tube. At 04:00 you had trouble rousing Ramon and tried to call the physician, but he could not be reached. Ramon never woke up. | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 57 Hospital administrator The hospital has recently lost some funding from the government, and you have had to decrease staff. You have decreased the number of night staff, since the patients are sleeping then anyway. You are not happy with the severe acute malnutrition ward because patients stay there so long. You wish they could be released after a week, or at most 2 weeks, and fed at home. Recently the senior nurses approached you about providing better accommodation for mothers at night, so that mothers would be more likely to stay with their children. You said there was simply no money for this. However, you realize during the problem-solving discussion that additional cots for mothers would be less expensive than hiring more night staff. 6.9 Results of monitoring food preparation and ward procedures (group discussion) If there is time during a clinical practice session (Day 6 or 7), participants will use monitoring checklists (like those in Web Annex B of this module) to monitor food preparation and ward procedures. After the monitoring session, lead a group discussion. It would be inappropriate to discuss problems in front of the ward staff, so the discussion should take place back in the classroom. (Note: If there was no time to use the checklists while in the ward, participants may be able to complete them back in the classroom from memory of what they have observed during the visits. Or they may complete them from memories of their own hospitals.) Ask participants what problems they observed (“no” answers on the checklist). Select one or two important problems and discuss possible causes and possible solutions. You may use the problems in another role play as in Exercise E. 6.10 Summary of the module 1. Review the problem-solving process outlined in the introduction to the module. Stress the importance of investigating causes before deciding on solutions. 2. Review any points that you have noted below and answer any questions that participants may still have. (If you cannot answer a question, offer to obtain more information and discuss it later.) 58 FACILITATOR GUIDELINES FOR MODULE 7: INVOLVING MOTHERS IN CARE Procedures(seenotesonfollowingpages) Feedback 1. Distribute the module titled Involving mothers in care. Introduce the module. 2. Participants start reading the module and prepare for the discussion in Exercise A. Group discussion 3. Participants read section 2 of the module and prepare for the role plays in Exercise B. Conduct the role plays. Group discussion 4. Participants read sections 3 and 4. Show video: Teaching mothers about home feeding.* Conduct a group discussion of the video and Exercise C. Group discussion 5. Participants continue reading section 5 of the module. Show video: Malnutrition and mental development.* Group discussion 6. Participants read section 6 of the module, study the sample discharge card, and prepare for the role play in Exercise D. Conduct the role play. Group discussion 7. Participantsfinishreadingthemodule. Optional: Exercise E, group discussion about early discharge. Groupdiscussion(optional) 8. Summarize the module. * If it is more convenient, the group may do all of the reading in these steps and then view both videos. | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 59 Preparation for the module Two video segments are shown in this module. Be sure that you have the videos and know when and where the video player is available. For the role plays in Exercise B, it will be helpful to have some props: a baby doll with clothes, a basin for bathing, a towel, a cup and saucer for feeding. If these are not available, be creative about substitutions. For example, a rolled-up sweater can be a “baby”. Photocopy and cut out role descriptions for role play Exercises B and D. Blank sample discharge cards are provided with this course. Before the role play in Exercise D, complete one of the discharge cards with the following information. The “nurse” will use this card in the role play to give instructions to a mother. All of the information should be appropriate for the local area: • name, date of birth, and address for a 2-year-old boy; • admission and discharge dates showing child has been in the hospital 18 days; • admission weight 7.6 kg, length 78 cm, weight-for-height Z-score < –3 SD; discharge weight 9.4 kg, length same, weight-for-height Z-score –1 SD; • what to feed: local cereal staple, local vegetables and fruits, local sources of protein, local snacks; • how much/how often: describe serving size in local terms, give family foods at meals 3 times each day, plus two nutritious snacks between meals; • medications and supplements: fill in blanks with appropriate information for local formulations; • enter a place and date for planned follow-up at outpatient care clinic 1 week from discharge date; • enter a place and date to come for vitamin A 6 months from discharge date; • tick to show that the child has received all immunizations. Decide whether your group will have the optional discussion in Exercise E. Your decision may be affected by such factors as the time available, the number of participants who work in hospitals where early discharge is common, or typical hospital policies in the area. 7.1 Introducing the module Explain that emotional, mental, and physical stimulation are critical for children who have been severely malnourished. This module describes ways that hospitals can involve mothers to ensure that children receive such stimulation, both in the hospital and later at home. It is hoped that participants have observed or will observe examples of how to involve mothers in the hospital ward. For example, they may have seen a teaching session or a play session that involved mothers. They will also see a video showing these types of sessions with mothers. Point out the learning objectives of the module. 60 7.2 Exercise A. Ways to involve mothers and other family members (group discussion) Ask participants to start reading the module (section 1) and prepare for the group discussion in Exercise A. From personal experience and from ward visits, participants are sure to have many ideas of ways to involve family members, and things that can hinder involvement. You may wish to structure the discussion by asking each participant in turn for one idea. Record the ideas on the flipchart. Note: No answer sheets are given for the exercises in this module as they are all discussions or role plays for which there are no definite “right” answers. 7.3 Exercise B. Teaching a mother to bathe or feed a child (role play) Ask participants to read section 2 of the module and then come to you for instructions for the role play. You will need to assign roles to four people for this exercise. For role play 1, assign someone to be a “bossy nurse” and someone to be the mother. For role play 2, assign someone to be the “nice nurse” and someone to be the mother. Others will observe and take notes. Provide props as needed (for example, a baby doll, a basin for bathing, a towel, a cup and saucer) or creative substitutions for these. Give role descriptions to those who will play roles. Role descriptions are provided below. After each role play, lead a brief discussion using the questions given in the module. Review the teaching process outlined in section 2 of the module. You may need to explain about “checking questions”. These are questions asked to ensure that the learner understands. They should not be questions that are simply answered with “yes” or “no”. They should be more open-ended questions that ask, for example, “how”, “what”, “how many”. For example, if a nurse has taught a recipe, the nurse might then ask the mother checking questions such as: What ingredients will you use? How much oil will you put in? How much will you feed your child? | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 61 Role descriptions for Exercise B Role play 1: Nurse You are a bossy and cold nurse. You are experienced, and you feel that you know better than all of the mothers. You tend to feel it is their fault that their children are malnourished. You are supposed to teach a mother how to bathe her child. Instead of first showing her how, you start off by saying, “Let’s see how you do it.” Then you are critical of how she undresses the child, holds the child, etc. You end up taking over the procedure. Role Play 1: Mother You are a young mother and this is your first child. You have no husband to help you, and you are very poor. Your 15-month-old daughter has been on the ward for 2 days. She is better and is taking F-75 well by mouth now. She will be given a bath today. Although you are accustomed to bathing your daughter at home, you are nervous about doing it with the nurse watching you. You fear that the nurse will criticize you. Role Play 2: Nurse You are a helpful and kind nurse. You feel it is important for mothers to learn how to feed and care for their children in the hospital. You are going to teach a mother how to feed her child and encourage the child to eat. You first explain what you are going to do; then you show the mother how to hold the child; then you encourage her to try. You give helpful, positive suggestions. If the mother asks a question, you assure her that it is a good question, and you answer it carefully. Role Play 2: Mother You are very timid and frightened about being in the hospital. You are afraid your son, aged 20 months, will die. Your son was unable to eat on arrival at the hospital and was fed by NG tube for the first day. At the last two feeds, the nurse fed him successfully orally. At this feed, she will show you how to feed him. 62 7.4 Video and Exercise C. Teaching mothers about home feeding (group discussion) Participants read sections 3 and 4. Explain that the video will show a teaching session for the preparation of khichuri (a home food described in the module). In the video, the mother is preparing a large amount of food for a hospital ward. Amounts used in the home would be smaller, as in the recipe in the module. Explain that some things have been done before the video begins; for example, the rice and dal have been thoroughly washed, and the mother has washed her hands. After the video, ask participants what they thought was done well in the teaching session and what could have been done better. You can refer them to section 3 of the module – how were examples given in the teaching session? How did mothers practise? And, how they can apply a teaching session into their services? Participants may wish to view the video again. This is fine as long as other groups are not waiting. Ask participants to read section 4 and think about how they will teach mothers about feeding in their own hospitals. Use the questions in Exercise C to structure a discussion. Remember that Module 8 will describe the outpatient therapeutic programme for severe acute malnutrition. This means that, where an outpatient programme is in place, mothers and caregivers can be referred to continue the follow-up in those services. 7.5 Malnutrition and mental development (reading and video) Participants read section 5 of the module and the relevant sections of the manual, following which they will watch a video on Malnutrition and mental development. Explain that this video shows how mental development can be encouraged through play in the hospital ward, at home, and in the community. At three points in the video there are opportunities for discussion. Questions for discussion will appear on the screen. These questions are printed below for your reference. Stop the video and take a moment to discuss these questions. First discussion point in video How can you: • make parents feel welcome? • show your respect? • encourage play and interaction? • make the ward friendly? What should parents be allowed to do? | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 63 Second discussion point in video Can you use any of these ideas (from the video)? How will you: • use everyday activities? • involve mothers? Third discussion point in video Talk about: • toys • how to start a programme of play and interaction. Stress that mental stimulation may be achieved during normal, everyday activities (such as washing and cooking) and by playing with simple, home-made toys. It does not require great amounts of time or expense. 7.6 Exercise D. Giving discharge instructions (role play) Ask participants to read section 6 of the module, study the sample discharge card, and then come to you for instructions about the role play in Exercise D. Assign one person to be the nurse and one person to be the mother. Give the nurse the discharge card that you prepared earlier. Give the nurse and the mother the role descriptions that follow, and orient them to the purpose of the role play. Role descriptions Nurse Follow the order of the discharge card carefully, covering all of the information on the card. In this example, the child will not receive RUTF. Ask the mother checking questions to ensure that she understands. Specific information that this mother needs includes the following. • Give family foods at three meals each day, plus two nutritious snacks between meals. Include (local cereal staple) with oil or other energy-rich food added, a variety of (local) vegetables and fruits, and (local) sources of protein. Good snacks include (local examples). • Continue multivitamins (give her a supply to last 1 week until first follow-up; tell how to give). • Continue folic acid (give her a supply to last 1 week until follow-up; tell how to give). • Continue iron twice daily (give her a supply to last 1 week until follow-up; tell how to give). • This child is up to date on immunizations. • The child needs a follow-up visit in 1 week. 64 Also given information on danger signs, how to play with the child, etc. You are consistently courteous and helpful to the mother, correcting her nicely if she misunderstands. Mother You are very eager to go home after 18 days in the hospital with your 2-year- old son, but you are concerned that you may not have all the necessary foods at home to keep him healthy. For example, you may not have (meat or local source of protein). You wonder if you can feed him something else. You understand most of what the nurse says, but you miss a few points when she asks you checking questions. (This will allow the nurse to correct you in a nice way.) During the role play observers should refer to their discharge cards and make notes in order to answer the questions in the module. After the role play, use these questions to structure a brief discussion. Also ask whether this type of discharge card would be useful in participants’ own hospitals. How would they need to modify it? 7.7 Optional Exercise E. Issues related to early discharge (group discussion) Ask participants to finish reading the module (section 7). If you will do the optional discussion in Exercise E, ask participants to prepare for the discussion. Use the questions given in the module to structure the discussion. Throughout this discussion emphasize the importance of transferring the children to outpatient care as soon as they can tolerate RUTF. 7.8 Summary of the module 1. Emphasize the importance of involving mothers and family members in care at the hospital, as well as the importance of preparing them to continue good care at home. 2. Perhaps ask each participant to say one thing they will do in their hospital to encourage families to participate in care or to make the ward more stimulating for children. This can be a small thing, such as providing chairs for parents or putting colourful pictures on the walls. Or it may be a large task, such as changing a hospital policy. 3. Review any points that you have noted below and answer any questions that participants may have. | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 65 FACILITATOR GUIDELINES FOR MODULE 8: OUTPATIENT MANAGEMENT OF SEVERE ACUTE MALNUTRITION Procedures(seenotesonfollowingpages) Feedback 1. Distribute the module titled Outpatient management of severe acute malnutrition. Introduce the module. 2. Participants read up to the learning objectives. Group discussion 3. Participants continue reading the principles for outpatient management of severe acute malnutrition. 4. Participants read section 3. 5. Participants read section 4. 6. Participants read section 5. 7. Participants read section 6. 8. Participant read sections 7 and 8 66 8.1 Introducing the module All facilities providing inpatient management of severe acute malnutrition should ensure that outpatient care services for the management of severe acute malnutrition are in place to ensure continuity of care. This module will help understand the principles of the outpatient service and the similarities in the medical and nutrition management of uncomplicated cases of severe acute malnutrition. It will also be helpful when making decisions to transfer children from inpatient care to outpatient care. 8.2 Working through the module As this is a new module, we recommend that after each section you open the floor for group discussions. You can also compare the medical treatment and the nutrition treatment for outpatient and inpatient services. This module also mentions monitoring and reporting in section 8. These aspects are important to keep track of the process in the service and to identify where there is a need to improve. Tell participants that you have enjoyed working with them. If there are any further activities, such as a closing ceremony or a questionnaire to complete, give participants the relevant instructions. Note: There may be an end-of-course evaluation questionnaire and a post- course test. The course director should provide the questionnaire for participants to complete. | T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A L N U T R IT IO N 67 GUIDELINES FOR ALL MODULES: FACILITATOR TECHNIQUES A. Techniques for motivating participants Encourage interaction 1. During the first day, you will talk individually with each participant several times (for example, during individual feedback). If you are friendly and helpful during these first interactions, it is likely that the participants will (a) overcome their shyness; (b) realize that you want to talk with them; and (c) interact with you more openly and productively throughout the course. 2. Look carefully at each participant’s work (including answers to short-answer exercises). Check to see if participants are having any problems, even if they do not ask for help. If you show interest and give each participant undivided attention, the participants will feel more compelled to do the work. Also, if the participants know that someone is interested in what they are doing, they are more likely to ask for help when they need it. 3. Be available to talk with participants as needed. Keep participants involved in discussions 4. Frequently ask questions of participants to check their understanding and to keep them actively thinking and participating. Questions that begin with “what”, ”why”, or “how” require more than just a few words to answer. Avoid questions that can be answered with a simple “yes” or “no”. After asking a question, pause. Give participants time to think and volunteer a response. A common mistake is to ask a question and then answer it yourself. If no one answers your question, rephrasing it can help to break the tension of silence. But do not do this repeatedly. Some silence is productive. 5. Acknowledge all participants’ responses with a comment, a “thank you” or a definite nod. This will make the participants feel valued and encourage participation. If you think a participant has missed the point, ask for clarification, or ask if another participant has a suggestion. If a participant feels their comment is ridiculed or ignored, they may withdraw from the discussion entirely or not speak voluntarily again. 6. Answer participants’ questions willingly and encourage participants to ask questions when they have them rather than to hold the questions until a later time. 7. Do not feel compelled to answer every question yourself. Depending on the situation, you may turn the question back to the participant or invite other participants to respond. You may need to discuss the question with the course director or another facilitator before answering. Be prepared to say, “I don’t know but I’ll try to find out.” 8. Use names when you call on participants to speak, and when you give them credit or thanks. Use the speaker’s name when you refer back to a previous comment. 9. Maintain eye contact with the participants so everyone feels included. Be careful not to always look at the same participants. Looking at a participant for a few seconds will often prompt a reply, even from a shy participant. Keep the session focused and lively 10. Present information conversationally rather than reading it. 11. Speak clearly. Vary the pitch and speed of your voice. 12. Use examples from your own experience, and ask participants for examples from their experience. 13. Write key ideas on a flipchart as they are offered. (This is a good way to acknowledge responses. Speakers will know their suggestions have been heard and will appreciate having them recorded for the entire group to see.) When recording ideas on a flipchart, use the participant’s own words if possible. If you must be more brief, paraphrase the idea and check it with the participant before writing it. You want to be sure that participants feel that you have understood and recorded their ideas accurately. Do not turn your back to the group for long periods as you write. 14. At the beginning of a discussion, write the main question on the flipchart. This will help participants stay on the subject. When needed, walk to the flipchart and point to the question. Paraphrase and summarize frequently to keep participants focused. Ask participants for clarification of statements as needed. Also, encourage other participants to ask a speaker to repeat or clarify their statement. Restate the original question to the group to get the participants focused on the main issue again. If you feel some will resist getting back on track, first pause to get the group’s attention, tell them they have gone astray, and then restate the original question. Do not allow several participants to talk at once. When this occurs, stop the talkers and assign an order for speaking. (For example, say: “Let’s hear Dr Samua’s comment first, then Dr Salvador’s, then Dr Lateau’s.”) People usually will not interrupt if they know they will have a turn to talk. Thank participants whose comments are brief and to the point. 15. Try to encourage quieter participants to talk. Ask to hear from a participant in the group who has not spoken before or walk towards someone to focus attention on them and make them feel they are being asked to talk. Manage any problems 16. Some participants may talk too much. Here are some suggestions on how to handle an overly talkative participant: - Do not call on this person first after asking a question. - After a participant has gone on for some time say, “You have had an opportunity to express your views. Let’s hear what some of the other participants have to say on this point.” Then rephrase the question and invite other participants to respond, or call on someone else immediately by saying, “Dr Samua, you had your hand up a few minutes ago.” - When the participant pauses, break in quickly and ask to hear from another member of the group or ask a question of the group, such as, “What do the rest of you think about this point?” - Record the participant’s main idea on the flipchart. As that person continues to talk about the idea, point to it on the flipchart and say, “Thank you, we have noted your idea.” Then ask the group for another idea. - Do not ask the talkative participant any more questions. If the participant answers all the questions directed to the group, ask for an answer from another individual specifically or from a specific subgroup. (For example, ask, “Does anyone on this side of the table have an idea?”) 17. Try to identify participants who have difficulty understanding or speaking the course language. Speak slowly and distinctly so you can be more easily understood and encourage the participants in their efforts to communicate. - Discuss with the course director any language problems that seriously impair the ability of a participant to understand the written material or the discussions. It may be possible to arrange help for the participant. - Discuss disruptive participants with your co-facilitator or with the course director. (The course director may be able to discuss matters privately with the disruptive individual.) Reinforce participants’ efforts 18. As a facilitator, you will have your own style of interacting with participants. However, a few techniques for reinforcing participants’ efforts include: - avoiding use of facial expressions or comments that could cause participants to feel embarrassed; - sitting or bending down to be on the same level as participants when talking to them; - answering questions thoughtfully, rather than hurriedly; - encouraging participants to speak to you by allowing them time; - appearing interested, saying “That’s a good question/suggestion.” 19. Reinforce participants who: - try hard; - ask for an explanation of a confusing point; - do a good job on an exercise; - participate in group discussions; - help other participants (without distracting them by talking at length about irrelevant matters). B. Techniques for relating modules to participants’ jobs 1. Discuss the use of these case management procedures in participants’ own hospitals. The guidelines for giving feedback on certain exercises suggest specific questions to ask. Be sure to ask these questions and listen to the participants’ answers. This will help participants begin to think about how to apply what they are learning. 2. Reinforce participants who discuss or ask questions about using these case management procedures by acknowledging and responding to their concerns. C. Techniques for adapting to the requirements of the group 1. Use the suggestions provided in the facilitator’s guide for adapting materials when appropriate. These suggest additional demonstrations or explanations that may be needed. They also suggest parts of exercises that may be omitted, or that may be discussed as a group rather than done individually. 2. Be sensitive to the needs of your group. Give enough explanation that participants do not become frustrated. However, be aware that too much explanation can be boring and can appear condescending. 3. If your group becomes very frustrated, or is very far behind in the schedule, talk with the course director about adjustments that may be needed, such as omitting additional exercises or sections of reading. D. Techniques for assisting co-facilitators 1. When the resources allow, there might be a co-facilitator supporting the implementation of the course. In this case, some of the activities during the classes can be shared. 2. Spend some time with the co-facilitator when assignments are first made. Exchange information about prior teaching experiences and individual strengths, weaknesses and preferences. Agree on roles and responsibilities and how you can work together as a team. 3. Assist one another in providing individual feedback and conducting group discussions. For example, one facilitator may lead a group discussion, and the other may record the important ideas on the flipchart. The second facilitator could also check the facilitator’s guide and add any points that have been omitted. 4. Each day, review the teaching activities that will occur the next day (such as role plays, demonstrations, and drills) and agree who will perform various tasks, such as preparing the demonstration, leading the drill, playing each role, or collecting the supplies. E. Techniques to apply when participants are working 1. Look available, interested and ready to help. 2. Watch the participants as they work, and offer individual help if you see a participant looking troubled, staring into space, not writing answers, or not turning pages. These are clues that the participant may need help. 3. Encourage participants to ask you questions whenever they would like some help. 4. If important issues or questions arise when you are talking with an individual, make note of them to discuss later with the entire group. 5. If a question arises that you feel you cannot answer adequately, obtain assistance as soon as possible from another facilitator or the course director. 6. Review the points in this facilitator’s guide so you will be prepared to discuss the next exercise with the participants. F. Techniques when providing individual feedback 1. Before giving individual feedback, refer to the appropriate notes in this guide to remind yourself of the major points to make. 2. Compare the participant’s answers to the answer sheet provided. 3. If the participant’s answer to any exercise is incorrect or is unreasonable, ask the participant questions to determine why the error was made. There may be many reasons for an incorrect answer. For example, a participant may not understand the question, may not understand certain terms used in the exercise, may use different procedures at their hospital, may have overlooked some information about a case, or may not understand a basic process being taught. 4. Once you have identified the reason for the incorrect answer to the exercise, help the participant correct the problem. For example, you may only need to clarify the instructions. On the other hand, if the participant has difficulty understanding the process itself, you might try using a specific case example to explain. After explaining, ask the participant questions to be sure they understand. 5. Give the participant a copy of the answer sheet, if one is provided. 6. Always reinforce the good work of the participant by (for example): - commenting on their understanding - showing enthusiasm for ideas for application of the skill in their work - telling the participant that you enjoy discussing exercises with them - letting the participant know that their hard work is appreciated. G. Techniques when leading a group discussion 1. Plan to conduct the group discussion at a time when you are sure that all participants will have completed the preceding work. Wait to announce this time until most participants are ready, so that others will not hurry. 2. Before beginning the discussion, refer to the appropriate notes in this guide to remind yourself of the purpose of the discussion and the major points to make. 3. Always begin the group discussion by telling the participants the purpose of the discussion. 4. Often there is no single correct answer that needs to be agreed on in a discussion. Just be sure the conclusions of the group are reasonable and that all participants understand how the conclusions were reached. 5. Try to get most of the group members involved in the discussion. Record key ideas on a flipchart as they are offered. Keep your participation to a minimum but ask questions to keep the discussion active and on track. 6. Always summarize, or ask a participant to summarize, what was discussed in the exercise. Give participants a copy of the answer sheet, if one is provided. 7. Reinforce the participants for their good work by (for example): - praising them for the list they compiled - commenting on their understanding of the exercise - commenting on their creative or useful suggestions for using the skills on the job - praising them for their ability to work together as a group. H. Techniques when coordinating a role play 1. Before the role play, refer to the appropriate notes in this guide to remind yourself of the purpose of the role play, roles to be assigned, background information, and major points to make in the group discussion afterwards. 2. As participants come to you for instructions before the role play: - Assign roles. At first, select individuals who are outgoing rather than shy, perhaps by asking for volunteers. - Give role play participants any props needed, for example, a baby doll, a discharge card. - Give role play participants any background information needed. (There is usually some information for the “mother” or “nurse” that can be photocopied or clipped from this guide.) - Suggest that role play participants speak loudly. - Allow preparation time for role play participants. 3. When everyone is ready, arrange the seating or placement of the individuals involved. Have the players stand or sit apart from the rest of the group, where everyone can see them. 4. Begin by introducing the players in their roles and stating the purpose or situation. For example, you may need to describe the age of the child, assessment results, and any treatment already given. 5. Interrupt if the players are having considerable difficulty or have strayed from the purpose of the role play. 6. When the role play is finished, thank the players. Ensure that feedback offered by the rest of the group is supportive. First discuss things done well. Then discuss things that could be improved. 7. Try to get all group members involved in discussion after the role play. In many cases, there are questions given in the module to help structure the discussion. 8. Ask participants to summarize what they learned from the role play.

T R A IN IN G C O U R S E O N T H E IN PA T IE N T M A N A G E M E N T O F S E V E R E A C U T E M A LN U T R IT IO N For more information, please contact: Department of Nutrition and Food Safety World Health Organization Avenue Appia 20 CH-1211 Geneva 27 Switzerland Email: nutrition@who.int Website: https://www.who.int/health-topics/nutrition