|Nutrition Guidelines (MSF, 1995, 191 p.)|
|Part III Selective feeding programmes|
Proper registration should allow close monitoring and management of individual case progress (changes in nutritional and health status, treatment phase and diet, etc.), but should also easily provide information necessary to monitor the functioning of the programme at feeding centre level.
Examples of a registration book and an individual patient chart are given in Annexes 18, 19. Children are weighed and examined daily in TFPs and all this information should be recorded over time. Children are not weighed and measured every day in SFPs, but they do need to attend daily for food distribution (wet SFP) - therefore 2 registration books may be required for attendance and individual monitoring of health status.
ATTENDANCE REGISTER BOOK
Based on the register book, the statistics for overall attendance, admission, discharge and average child performance can be followed. A good registration system can rapidly detect defaulters, who can then be followed up by a home visit. Registration includes:
Identification: Bracelet number, name, age, sex, name of parents, address/section of camp.
Admission weight, height, W/H%, clinical signs of malnutrition (oedema, vitamin deficiencies, etc.), other medical remarks.
Attendance indicators: Admission, present, absent, defaulter, discharged, death, transfer.
- Admission: all new entries, including children who relapse after being successfully discharged from the programme. It does not include defaulters who were only absent for some days.
TFP - physical presence for at least four meals during the day.
SFP - physical attendance for at least one meal during the day.
Dry SFP - physical presence for ration distribution
WET - absent for 2 consecutive days; on the third day of absence the defaulter will be visited at home by the outreach worker.
DRY - absent for 2 consecutive distributions, after the second distribution the child will be followed up.
Defaulters readmitted in the month are not included in end of month defaulter statistics.
any child who died while participating in the programme. It is important to follow up defaulters to see if the reason for not attending is death and include them in the mortality statistics.
TFP - to hospital, or intensive care feeding centre.
SFP - to hospital or TFP Blanket SFP - to hospital, targetted SFP or TFP.
any child who was discharged from the programme after having reached the official discharge criteria (may have been discharged to another programme i.e. TFP-> SFP).
INDIVIDUAL PATIENT CHART - TFP
The patient chart (Annex 19) gives a clear overview of the changes in nutritional status of each child (weight, height, and clinical signs: oedema, vitamin deficiencies etc.), health status (medical consultations, treatments, immunization), as well as the treatment phase and calculated food requirements.
Weights should be graphed on the chart, enabling regular monitoring of weight gain or loss. Weight gain together with the registered clinical observations (both positive and negative) enables prompt action in case of failure to respond to treatment. The chart also makes it easier to decide when to discharge the child.
INDIVIDUAL PATIENT CHART - SFP
In an SFP, the monitoring data can all be entered in a registration book as there is far less information that needs recording (Annex 18). Individual cards may be used (Annex 19)
Nutritional status monitoring:
- Weight assessment: every 1 - 2 weeks
- Height assessment: every 4 weeks
- W/H% calculation: every 1 - 2 weeks
Remarks: medical treatments, prophylaxis, special circumstances.
· Informations recorded on the individual card:
- Bracelet number, name, address, admission date.
- Health indicators:
Age, sex, weight, height, target weight, Weight - for - Height category, oedema, medical diagnosis & treatment.
- Food distribution:
Main Child Surveillance Procedures
There are 3 main procedures:
Correct application of admission and discharge criteria
The different treatment phases and transition criteria
Surveillance of the individual child
For a TFP the surveillance of each individual child is particularly crucial and should include:
* During the First phase, close medical and nutritional surveillance of the child should be daily. Surveillance should consist of:
- daily weight measurement,
- growth curve,
- oedema assessment,
- clinical examination,
-treatment scheme (medical and nutritional).
Food needs and meal frequency have to be calculated individually and marked on the child's individual chart.
* During the Second phase, nutritional and medical surveillance is given every 2 days. A nurse should make daily rounds to identify any children that may be ill. Surveillance should consist of:
- weight measurement every 2 days,
- growth curve,
- monthly height measurement,
- oedema assessment,
- clinical examination,
- treatment scheme (medical and nutritional).
Food needs (minimum requirements) should also be calculated and registered individually, although feeding is ad libitum.
Depending on the child's age and degree of malnutrition, a severely malnourished child should gain 10 - 20g/kg/day during the Second Phase. At this growth rate the discharge criterium of 85% W/H should be achieved after about 1 month. A moderately malnourished child should gain 5 - 10g/kg/day. At this growth rate 85% W/H should be achieved within 4 - 6 weeks, and discharge after 6 - 10 weeks.
Failure of children to gain weight may be attributed to:
- irregular attendance to the feeding programme,
- poor organization and supervision of the feeding programme, leading to inadequate supplementary rations, or incorrect recipes,
- unequal distribution of food within the family (substitution or sharing),
- specific nutrient deficiency,
- acute infection,
- undiagnosed psychological problem,
- TB or AIDS.
Any child who fails to gain weight should be investigated for all possible causes.
· If the child has not gained weight for 3 or more weeks, while receiving correct medical and nutritional care (including 2 full courses of antibiotics),
· If all other causes of failure to gain weight have been excluded, AIDS or TB may be the causes.
These cases should be seen by a medical doctor.
· If AIDS is the suspected diagnosis, this does not alter the treatment strategy: the child should be treated as any other child on the programme.
· If tuberculosis is suspected, the decision to initiate treatment should be taken by a doctor and only if there is a fully functioning and well supervised TB programme. Diagnosis of TB in children is difficult (see Ref. 22).