Introduction

Learning Objectives
• At the end of the session, you will be able to:
• Explain what malnutrition is and its related concepts
• Discuss the problem of childhood deaths due to undernutrition - moderate
acute malnutrition (MAM) and severe acute malnutrition (SAM)
• Describe the Global and PPAN Goals on Acute Malnutrition
• Describe the Philippine Integrated Management of Acute Malnutrition
(PIMAM) program
• Explain the four guiding principles of PIMAM
• Explain the four (4) components of the integrated management of severe
acute malnutrition within the PIMAM
Basic Principles
• Each child has the right to food, health
and care to enable optimum potential
• Lack of food, health and care are risk
factors for malnutrition
• Malnutrition is strongly linked with
death
http://1000days.unicef.ph/
Malnutrition
• Body’s dietary or food intake not in balance with nutritional
needs failing to maintain healthy tissues and organ function
• Results in either:
OVERNUTRITION UNDERNUTRITION

http://www.huffingtonpost.co.uk/2015/03/02/obese-baby-india-six-year-old_n_6785324.html https://www.unicef.org/philippines/reallives_19053.html
Causes of Undernutrition
Immediate Causes Individual Inadequate food intake
Disease

Underlying Causes Community Poor access to food

Bad care practices
Poor water, sanitation
and health services

Basic Causes Societal Lack of capital – human,

financial, physical, social

Black et al, 2008, The Lancet

 Types of Undernutrition
1. Acute Malnutrition
• Sudden wasting and/or edema due to:
▪ insufficient food intake
▪ infection
▪ inappropriate childcare practices
• Diagnosed when:
▪ inadequate weight for height (WFH), weight
for age AND/OR
▪ muscle wasting AND/OR
▪ bilateral pitting edema
Low Weight for Height
Philippine Department of Health.
National Guidelines on the Management of Severe Acute Malnutrition for Children under Five Years Manual of Operations. 2015.
 Acute Malnutrition (a.k.a wasting)

Moderate Acute Malnutrition (MAM) Severe Acute Malnutrition (SAM)

or Moderate Wasting or Severe Wasting
Weight-for-Height Z-score -3SD to <-2 SD Weight-for-Height Z-score <-3 SD
and/or MUAC 11.5cm to 12.4cm and/or MUAC < 11.5cm
and no bilateral pitting edema and/or with bilateral pitting edema

Global Acute Malnutrition (GAM) is the sum of the

prevalence of SAM plus MAM at population level.
Severe Acute Malnutrition – encompasses
wasting and bilateral edema
MARASMUS KWASHIORKOR Marasmus:
Refers to severe wasting

Kwashiorkor:
Refers to nutritional edema

These can kill.

Children with SAM are 9-12
times more likely to die than well
nourished kids.
Moderate Acute Malnutrition – encompasses
wasting but no bilateral edema

Moderate wasting (Thin)

No nutritional edema

This can also kill.

Children with MAM are 3-4 times
more likely to die than well
nourished kids.
Acute Malnutrition in the Philippines

Nearly 1 million under-

7.1 % 5
Filipino children are
Over 700,000
wasted

Nearly 260,000
New UNICEF-WHO-WB Prevalence
Thresholds (2018):
Very Low: <2.5%
Low: 2.5 - <5%
*Source: NNS 2015
Medium: 5- <10%
High: 10 - <15%
Very High: ≥15%
 Case Fatality
Rate Although the risk of dying in children
with MAM is 3-4X and that of SAM is
Severe Acute
Malnutrition 9-12X higher than well-nourished
4.4%
(SAM) children,

the absolute number of death in

children with MAM is higher because
Moderate Acute
Malnutrition 10.2% of the higher number of children with
(MAM) MAM.

*Source: Black, et al., 2008

Types of Undernutrition
2. Chronic Malnutrition or Stunting
• “Too short for one’s age”
• Inadequate height/length for age (HFA/LFA)
• In the first 1000 days after conception
• Stunting before the age of 2 years old:
▪ poor cognitive and educational outcomes
▪ mental and physical deficits are potentially
irreversible beyond two years

Low Height for Age

Types of Undernutrition
3. Micronutrient Malnutrition

• Micronutrients - Nutrients
needed in small quantities.

• Deficiencies lead to malnutrition

and disease

• Common deficiencies:
http://dranmolarora.com/

Vitamin A, Iron and Iodine

 Micronutrient Malnutrition
Type I Micronutrient Deficiency
e.g. Iron, Calcium, Iodine, Copper, Vit. B complex,
Vit. A, C, D, K
Type II Micronutrient Deficiency
e.g. Sodium, Potassium, Magnesium, Zinc,
Phosphorus, Essential Amino acids

• Growth continues in early stages

• Results in growth failure
• With specific clinical signs
• No specific clinical signs

e.g. Anemia, Beri-beri, Pellagra, Scurvy,

Xeropthalmia e.g. stunting, wasting

Source: Golden, M. SCN News 1995 12:10-4)

Other Types of Undernutrition
4. Fetal Growth Restriction
• Abnormal fetal growth
• Low birth weight (LBW) babies (< 2.5 kg)
• Poor maternal nutrition
• 15 times higher risk of death in newborn
period vs. normal weight babies

5. Suboptimal breastfeeding
• Breastfeeding NOT up to standard
• 800,000 child deaths Photo from http://www.zofranlawsuitguide.com/

1 Black RE et al. The Lancet Nutrition Series Part 1. 2013.

EXERCISE!

The 3 children are of the same age

Wasted Stunted

Same height Same weight

Weight for age Normal Low Low

Height for age Normal Normal Low
Weight for Height Normal Low Normal
 Why focus on undernutrition? It Kills!
Cause of undernutrition Attributable deaths Proportion of total deaths among
under 5 year olds
Fetal growth restriction 817,000 11.8%
Suboptimal breastfeeding 804,000 11.6%
(0-23 months)
Stunting (1-59 months) 1,179,000 17%
Underweight (1-59 months) 1,180,000 17%
Wasting (1-59 months) 800,000 11.5%
Severe wasting (1-59 months) 540,000 7.8%
Zinc deficiency (12-59 months) 116,000 1.7%
Vitamin A deficiency (6-59 months) 157,000 2.3%
Joint effects of fetal growth restriction 1,348,000 19.4%
and suboptimum breastfeeding
It causes
Cumulative effects (ALL) 3,149,000 45.4%
45% of childhood deaths
1 Black RE et al. The Lancet Nutrition Series Part 1. 2013.
 For those who survive,

• Lifetime of ill-health
• Unrealized human potential
• Malnutrition spans
generations
Trends in Childhood Wasting, Philippines
FNRI DOST, National Nutrition Survey (NNS), 2015
8.0
Among Filipino children, those < 12 months
of age are most affected

Prevalence of wasting among 0-60 months from 2008-2013

FNRI DOST, 8th National Nutrition Survey, 2013
This is how our undernourished Filipino children look:
Trends in Childhood Stunting in the Philippines
FNRI-DOST National Nutrition Survey (NNS),
2015

11% decrease in 25 years

 Both are 2 years old
Naturally Short?
PANDAK??

Our kids
can really
NOT be.

Photo credit: Rosalia Bataclan, MD

The Sustainable Development Goals
(SDGs) 2016-2030
Global Nutrition Report 2015

• Sustainable
Development Goals
(SDGs) – 2 and 3
• Commit to rapid
reduction of
malnutrition by
2025
PPAN 2017-2022 TARGET for Wasting
To reach the goal…
DOH Strategic Framework for Comprehensive Nutrition Implementation Plan
2014-2025
First 1000 days
Management of Moderate and Severe
Acute Malnutrition – Why?
• Children with SAM are 9 -12 times
more likely to die than those who are
well nourished.

• Children with MAM are 3 - 4 times

more likely to die than those who are
well nourished.

• Recognized and treated early, it can

be reversed with proper food, nutrition
and care.
Philippine Integrated Management
of Malnutrition (PIMAM)
Component of the wider Strategic Framework 2014-2025
Rationale:
• In hospital treatment in “MalWards”
▪ Outdated protocols
▪ Overcrowding in the hospitals
▪ Cross-infection
▪ High default rates - mothers wanted to go home to take care of other
children
▪ Heavy work load of hospital staff
• Intermittent and ineffective supplementary feeding programs
• Malnutrition is a reality in both normal times and emergencies
 Treat Children with SAM with appropriate Care
using UP-TO-DATE treatment protocols
• SAM affects the child’s normal physiological functions
• SAM children cannot be medically treated like other sick children
• Malnutrition alters the SAM child’s physiology
• Old treatment protocol can do more harm than good
• SAM children require specialized treatment
 Treat Children with MAM with appropriate Care
using UP-TO-DATE treatment protocols
• treatment of MAM will prevent deterioration of MAM to SAM

• if there are no programs to address MAM especially during

emergencies, SAM cases tend to increase
PIMAM
(Philippine Integrated Management of Acute Malnutrition)

• PIMAM, or management of MAM

and SAM, is part of routine health
and nutrition services at all levels

• Involves and relies on a strong

community component
PIMAM Four Guiding Principles
1. 1. Maximum Coverage and Access

1. 2. Timeliness

1. 3. Appropriate Care

1. 4. Care: When and Where it is needed

The Innovation in Integrated Management

Targeted
Components of PIMAM
1. Management of SAM
without complications Outpatient Therapeutic Care (OTC)

1. Management of SAM with

complications Inpatient Therapeutic Care (ITC)

1. Management of MAM Targeted Supplementary Feeding

MAM
Program (TSFP)
1. Community Outreach
Community Mobilization
DOH A.O. No. 2015-0055
National Guidelines on the Management of
Acute Malnutrition for Children under 5
years.
Standardized protocols

Emphasis on linkages and referrals, supply networks,

indicators for monitoring, and importance of PIMAM
in emergency settings

Describes our roles

Four components of integrated management of

Moderate and Severe Acute Malnutrition
Summary
• Undernutrition is a neglected condition

• More Filipino children under the age of 5 years are affected

• Cause for 50% of all childhood deaths but unrecognized and untreated

• SAM children risk of death is 9-12 times higher than a well nourished child

• MAM children risk of death is 3-4 times higher than a well nourished child

• Nutrition sensitive and specific interventions now combat malnutrition

• PIMAM manages malnutrition in normal times and emergencies

Which is a case of undernutrition?
A. A child who never reaches full height due to poverty, poor sanitation, lack
of breastfeeding and limited access to nutritious foods
B. A young woman who becomes anemic during her pregnancy and gives
birth to a baby with low birth weight
C. A child made blind by vitamin A deficiency
D. A desperately thin and wasted child, at imminent risk of death
E. A 9-month old baby who has no edema and with MUAC of 12.1cm.

UNICEF. 24 December 2015. The faces of malnutrition. Available at www.unicef.org

Which is a case of undernutrition?
A. A child who never reaches full height due to poverty, poor sanitation, lack of
breastfeeding and limited access to nutritious foods Chronic malnutrition
(stunting)
B. A young woman who becomes anemic during her pregnancy and gives birth
to a baby with low birth weight Micronutrient deficiency (iron) in the
mother, with Intrauterine growth restriction in the baby
C. A child made blind by vitamin A deficiency Micronutrient deficiency
(Vitamin A)
D. A desperately thin and wasted child, at imminent risk of death SAM
E. A 9-month old baby who has no edema and with MUAC of 12.1cm. MAM

All of the above.

UNICEF. 24 December 2015. The faces of malnutrition. Available at www.unicef.org
Are you ready to learn and do your role?

Our Goal is
ZERO SAM
and MAM