2. Criteria for admission and discharge to selective feeding programmes
In contrast to <<normal>> situations, where the
decision to admit an acutely malnourished child to a regular hospital may be
based on subjective clinical criteria, the large numbers of malnourished
children needing attention during emergency situations means that admission to
TFPs and targeted SFPs must be based on clearly defined objective criteria
The <<cut-off points>> to be used have to be set in
agreement with national relief policies, taking into consideration the capacity
of the programme and the possibilities for follow-up.
Blanket SFPs must serve clearly defined vulnerable groups - the
members of which must be registered in a fair and systematic way. This chapter
will not deal with registration of vulnerable groups but will focus on specific
individual criteria for entry to targeted feeding programmes.
Admission criteria depend on the objectives of the programme and
available resources. If programme resources are not certain or limited, it is
necessary to employ more restricted admission criteria. In the course of a
programme, admission criteria can be changed to reflect changing circumstances
like increased general food availability. Admission criteria reflect
characteristics of the individual child and are based on age and nutritional
Children are admitted along with an attendant, who should also
receive food. If more than one severely malnourished child is found in a family,
make sure that all other young children of that family are fed.
- Under 5 years or, if age is unknown, height below 110 cm.
- In the case of malnourished infants below 6 months of age, the
mother should be admitted to the targeted feeding programme together with the
infant, because the nutritional status of young infants mainly depends on the
nutritional status of the mother, and rehabilitation of the infant should take
place through improved breast feeding.
- Malnourished older persons (children above 5 years, adults,
elderly) may also be admitted depending on the situation and available
b. Nutritional status
- Weight-for-Height < 70% of the median (or <-3 Z-Scores
below the median reference value) = TFP
70 - < 80% of the median (or - 3 to < - 2 Z-Scores below
the median reference value) = SFP
- Nutritional oedema: bilateral oedema on the lower legs and/or
feet = TFP.
- If malnourished persons above 5 years of age are also
admitted, nutritional status may be assessed clinically, since clear,
unambiguous anthropometric criteria do not exist.
Treatment in TFCs is usually divided into 2 phases. All newly
admitted severely malnourished children with associated pathology should start
their treatment in a 24- hour intensive care unit (Phase I) according to the
treatment schedule. Those without complications can usually start in day-care
Severely malnourished children usually die from complications.
If the capacity of 24-hour intensive care units is limited, complications should
be considered as a priority for admission. Suggested guidelines are listed
below. However, use of clinical criteria requires more skilled staff.
Criteria for the selection of cases to be admitted to 24-hour
intensive care units in TFCs
Less than 70% (or - 3 Z-Scores) weight-for-height in combination
with one or more of the following complications:
- marasmic kwashiorkor
- severe dehydration
diarrhoea and/or vomiting
- extreme pallor, hypothermia, or
- signs of systemic, lower respiratory tract or other
- severe anaemia
- persistent loss of
- severe lethargy
- age less than 12 months
- young children
are particularly at risk from the adverse effects of malnutrition.
Children aged 5 years or more who are clinically assessed as
suffering from malnutrition are usually admitted to SFPs, unless they also show
signs of the more serious associated pathologies.
Criteria for transfer from 24-hour intensive care units (Phase
I) to the day-care programme (Phase II) are given in Chapter 4, Part III.
During food crises, it is important to keep a logical coherence
in entry and exit criteria between SFPs and TFPs. This is necessary in order to
define which children will receive which level of treatment and to set firm
conditions for referral.
It is usual to discharge a child from the TFP to the SFP after
he has reached > 80% W/H (or > - 2 Z-Scores) over 2 consecutive weighings.
If there is no SFP, children should only be discharged once they have reached
> 85% W/H (or > -1.5 Z-Scores) over 2 consecutive weeks. The most
important criteria, however, is that the child shows a clearly ascending growth
curve and is in a good general condition when he leaves the programme.
Discharge criteria from targeted SFPs are based on a W/H which
is not associated with an unacceptable risk of morbidity or death under
conditions prevailing in the community. The discharge criterium is usually 2 85%
W/H (or 2 -1.5 Z-Score) during two - four consecutive weeks. If resources are
limited, it may be decided to discharge children as soon as they reach 85% W/H.
In situations where general food rations are grossly inadequate
(<1500 Kcal/person/day) and/or malnutrition prevalence is 2 20%, it is
preferable not to discharge children from a SFP (blanket or targeted), until
general food availability has improved. Centres should be organized so as to
give maximum attention to the moderately malnourished children.
An example of a logical structure for criteria allowing
integration of selective feeding programmes is given below:
Figure 13. Criteria for entry and exit from supplementary and
therapeutic feeding programmes
Targeted feeding programmes prioritize malnourished children
under 5, because of their greater vulnerability and because of their increased
risk of dying. Nevertheless malnourished children exceeding this age limit or
adolescents/adults may also be admitted as individual cases.
Only when the numbers of adolescents/adults needing treatment
becomes of public health significance is it necessary to consider their
treatment in a separate unit (see Annex 3).
If there is significant malnutrition in other age groups, this
must to be taken into account in