Decision No. 3779/QD-BYT 2019 management of acute malnutrition in children being 0-72 months of age

DECISION

On the promulgation of the Guideline for management of acute malnutrition in children who are 0-72 months of age

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THE MINISTER OF HEALTH

Pursuant to the Government’s Decree No. 75/2017/ND-CP dated June 20, 2017, defining the functions, tasks, powers and organizational structure of the Ministry of Health;

Pursuant to the Prime Minister’s Decision No. 226/QD-TTg dated February 22, 2012, approving the National Strategy on Nutrition for the 2011-2020 period, with a vision toward 2030;

At the proposal of the Director of the Maternal and Child Health Department under the Ministry of Health,

DECIDES

Article 1. To promulgate together with this Decision the Guideline for the management of acute malnutrition in children who are 0-72 months of age.

Article 2. This Decision takes effect on the date of its signing and promulgation.

Article 3. The Chief of Office of the Ministry of Health, Director of the Maternal and Child Health Department, Director of the Medical Services Administration, Chief Inspector of the Ministry of Health, Directors of Departments and General Departments under the Ministry of Health; Directors of medical examination and treatment facilities under the Ministry of Health; Directors of Health Departments of provinces and centrally-run cities; and leaders of other relevant units shall be responsible for the implementation of this Decision.

For the Minister

The Deputy Minister

NGUYEN VIET TIEN

GUIDELINE

MANAGEMENT OF ACUTE MALNUTRITION IN CHILDREN

WHO ARE 0-72 MONTHS OF AGE

(Promulgated together with the Decision No. 3779/QD-BYT

dated August 26, 2019 of the Minister of Health)

I. NEEDS OF THE GUIDELINE

Acute malnutrition (AM) refers to a medical condition in which the body does not receive enough energy and protein compared to its needs due to deficiencies or diseases, causing rapid weight loss (severe thinness) or oedema in children. The mortality risk of children with severe acute malnutrition is 5 to 20 times higher than that of normal children. It may be a direct cause of death in children or may play an indirect role in prolonging the treatment duration, rapidly increasing the mortality risk in children with common illnesses such as diarrhea and pneumonia. Over the years, Viet Nam has reduced the rate of underweight malnutrition reaching the Millennium Development Goals but acute malnutrition remains at a range of 6-7% with a slow reduction rate that is higher than the rate expected in the Sustainable Development Goals and the National Nutrition Action Plan till 2020. The burden of acute malnutrition is concentrated in disadvantaged areas, ethnic minorities and densely populated areas, and this rate increases when urgent nutrition problems occur.

Children with acute malnutrition may be subject to both in-hospital and community-based management and treatment according to the Guideline for diagnosis and treatment of acute malnutrition in children who are 0-72 months of age, promulgated together with the Decision No. 4487/QD-BYT dated August 18, 2016 of the Minister of Health. Children who suffer from acute malnutrition with complications shall receive inpatient treatment at district-level or higher-level hospitals. Children who suffer from acute malnutrition without complications, depending on the severity, shall be received and treated at commune-level health stations: Severe acute malnutrition (SAM) will receive outpatient treatment while moderate acute malnutrition (MAM) will receive prophylactic/maintenance treatment. Management and treatment of acute malnutrition is one of the professional activities in health facilities.

This Guideline will provide practical contents and tools to take actions for improving management quality through increasing recovery rates, reducing moralities/dropouts or failures in treatment, improving access to services and coverage of interventions. The Guideline also contributes to improving the standardization of management, treatment, monitoring and reporting of interventions integrated into the health/nutrition activities of grassroots health-care units and other medical examination and treatment facilities.

The target users of this Guideline are health workers, nutrition officers and managers at all levels from grassroots level upwards.

II. SCOPE OF IMPLEMENTATION, SUBJECTS OF APPLICATION

1. Scope of implementation: This Guideline provides guidance on the management of acute malnutrition in children at health stations of communes, wards, townships and hospitals (from the district level upwards), including implementation contents, facilities and capability.

2. Subjects of application: This Guideline applies to children who are 0-72 months of age with acute malnutrition according to the diagnostic criteria of the Guideline for diagnosis and treatment of acute malnutrition in children who are 0-72 months of age.

III. MANAGEMENT OF ACUTE MALNUTRITION AT THE COMMUNE LEVEL

Children identified with acute malnutrition without complications shall be managed and treated at commune-level health stations. The health stations shall promote community mobilization and nutrition education communication before implementing and maintaining throughout the time of managing and treating children. Then the health establishments shall perform specialized tasks, including screening and referral; admission and management of children at the health stations; home-based monitoring of children; follow-up and reporting.

1. Community mobilization – Nutrition education communication

1.1. Implementation contents:

- Inviting leaders of departments and mass organizations to attend media sessions.

- Reporting implementation contents in briefings with local authorities and interdisciplinary meetings.

- Integrating propaganda contents in interdisciplinary activities of departments and mass organizations (Farmers’ Union, Women’s Union, Fatherland Front, etc.).

- Coordinating with village heads in mobilizing people to participate in such activities.

- Organizing direct communication (consultation or group activities of child carers) and indirect communication (radio, leaflets, and posters).

+ Performing on a weekly basis at health stations at the time of admission and re-examination of children.

+ Performing on a monthly basis in villages through organizing activities and propaganda sessions.

+ Performing whenever interacting with mothers/caregivers in the community.

- Media contents:

+ Concept, causes and consequences of acute malnutrition.

+ How to identify children with acute malnutrition.

+ Interventions to treat children with acute malnutrition.

+ Roles of therapeutic products in treatment of acute malnutrition, messages for caregivers when children use therapeutic products.

+ Practices of child nurturing: Breastfeeding, complementary feeding and nutritional care for sick children.

1.2. Equipment and supplies: Training materials on management and treatment of acute malnutrition, leaflets, posters, and communication materials on child care and nurturing.

1.3. Resources: Health workers of commune-level health stations and village health-care workers who have been trained in nutrition and communication skills in the community.

2. Screening and referral

2.1. Implementation contents:

- Health workers of commune-level health stations shall coordinate with village health-care workers to weigh children and measure the mid-upper arm circumference (MUAC) twice a year (in June and December) for all children under 5 years of age, identify children who meet the treatment criteria for admission to an appropriate intervention program at the commune level or for referral.

- Village health-care workers shall measure the MUAC of children under 2 years of age every 3 months and children with acute malnutrition monthly to detect children with yellow or red arm circumference, refer them to commune-level health stations for examination and determination of nutritional status.

- Health workers of commune-level health stations shall measure the MUAC for children who are 60-72 months of age through routine health-care activities once a year to detect acute malnutrition in this age group.

- Health workers and other community workers shall measure the MUAC of children under 5 years of age in any situation where they are exposed to children so that they can detect children with yellow or red arm circumferences, refer them to commune-level health establishments for examination and determination of nutritional status.

2.2. Equipment and supplies:

- Health stations shall be equipped with scales, measures of standing height/lying length, paper arm measures, lookup tables to determine acute malnutrition (weight-for-height).

- Health workers of commune-level health stations, village health-care workers and other community workers shall be equipped with paper arm measures.

2.3. Resources:

- Having health workers of commune-level health stations who have been trained in weighing and measuring techniques, measuring arm circumference and assessing nutritional status.

- Having village health-care workers and other community workers who have been trained in measuring arm circumference and identifying acute malnutrition.

3. Admission and management of children at health stations

3.1. Implementation contents:

- Health workers of commune-level health stations shall carry out the admission of children with MAM and SAM in accordance with the protocol of the Ministry of Health whenever detecting children with acute malnutrition.

- With regard to children with SAM, health stations shall re-examine their health on a weekly basis, provide them with therapeutic products and medicines, and give advice on the home-based treatment of acute malnutrition, use of therapeutic products, and child nurturing and hygiene. With regard to children with MAM, health stations shall strengthen propaganda and guidance on child care at home, and provide nutritional supplements (if any).

- Health workers of commune-level health stations shall discharge children from the program if they are eligible. Children shall be transferred from outpatient treatment (SAM) to prophylactic/maintenance treatment (MAM) or inpatient treatment (acute malnutrition with complications) if meeting the conditions under the treatment protocol and vice versa.

3.2. Equipment and supplies:

- Therapeutic products for children with SAM: meeting the technical standards of the Guideline promulgated together with the Decision No. 4487/QD-BYT dated August 18, 2016. The daily therapeutic dose shall be calculated according to their weight. The average therapeutic dose of a child is equal to 13.8 kg for 6 to 10 weeks. In the event that therapeutic products are not available, caregivers shall be instructed to use equivalent or nutrient-rich foods at home to restore nutrition for the children.

- Nutritional supplements for children with MAM: using products manufactured for children with moderate malnutrition or nutritional and micronutrient supplement products combined with nutritious food at home.

- Essential medicines according to the protocol of the Guideline promulgated together with the Decision No. 4487/QD-BYT dated August 18, 2016 (antibiotics, dewormers, antimalarial medicines, measles vaccination) and normal therapeutic medicines at the grassroots level.

- Forms for monitoring outpatient treatment for children with SAM.

3.3. Human resources: Health workers of health stations who have been trained in community-based management of acute malnutrition.

4. Home-based monitoring of children

4.1. Implementation contents:

- Based on the management results of children with SAM at health stations, health workers of commune-level health stations shall identify children that need to be visited at their household and transmits the list of such children to village health-care workers along with the checklist.

- Village health-care workers shall visit the households, fill in the checklist, then bring the checklist to the commune-level health stations, and discuss with health workers of health stations the causes and solutions for each case. Such household visits aim to assess issues related to the nutritional rehabilitation of children at home, including adherence to treatment with therapeutic nutritional products, home-based childcare enhancement, and child hygiene and household food security.

- Health workers of commune-level health stations and village health-care workers shall cooperate to assist such cases. If failing to resolve problems, they shall ask district and provincial-level health workers to help find solutions or connect with other local support programs.

4.2. Equipment and supplies: Checklist of household visits by village health-care workers.

4.3. Resources: Health workers of commune-level health stations and village health-care workers who have been trained on community-based management of acute malnutrition.

5. Follow-up and reporting

5.1. Implementation contents:

- Monitoring and supporting the activities of village health-care workers in the community.

- Sending monthly reports to the district level.

5.2. Monitoring indicators:

- Total number of admissions to the program.

- Number of newly-admitted children.

- Number of previously-admitted children (being transferred from another level or having dropped out treatment but being re-admitted to the program).

- Number of recovered children (meeting the discharge criteria).

- Number of mortalities.

- Number of treatment dropouts (Outpatient treatment: Being absent at 2 consecutive visits while health workers have visited them at their household).

- Number of children who do not respond to treatment (Outpatient treatment: Failing to meet the criteria to be discharged from the program after 3 months of treatment and being transferred to another program).

- Number of transferred children (being transferred to another level or being transferred but not yet recovered).

5.3. Criteria for evaluating the effectiveness of activities: comply with the Sphere standards

- Outpatient treatment (at commune-level health stations)

+ Coverage: over 50% for rural areas and over 70% for urban areas.

+ Mortality rate: less than 10%.

+ Treatment dropout rate: less than 15%.

+ Recovery rate: over 75%.

- Maintenance/prophylactic treatment:

+ Coverage: over 50% for rural areas and over 70% for urban areas.

+ Mortality rate: less than 3%.

+ Treatment dropout rate: less than 15%.

+ Recovery rate: over 75%.

IV. MANAGEMENT OF ACUTE MALNUTRITION AT THE DISTRICT LEVEL

1. District-level health centers

District-level health centers shall provide direction, professional support, and periodic monitoring for commune-level health units. The district-level health centers shall be responsible for summing up periodical reports of health stations (on a monthly basis) and medical treatment facilities (every 6 months) in the localities under their management and reporting to the provincial-level Center for Disease Control every 6 months.

Monitoring indicators:

- Total number of admissions to the program.

- Number of newly-admitted children.

- Number of previously-admitted children (being transferred from another level or having dropped out treatment but being re-admitted to the program).

- Number of recovered children (meeting the discharge criteria).

- Number of mortalities.

- Number of treatment dropouts (Outpatient treatment: Being absent at 2 consecutive visits while health workers have visited them at their household).

- Number of children who do not respond to treatment (Outpatient treatment: Failing to meet the criteria to be discharged from the program after 3 months of treatment and being transferred to another program).

- Number of transferred children (being transferred to another level or being transferred but not yet recovered).

2. District-level hospitals

2.1. Implementation contents:

- Performing the management and treatment of children with acute malnutrition at the Pediatric Department of district hospitals in accordance with the inpatient treatment protocol approved by the Ministry of Health.

- Carrying out assessment of nutritional status and nutritional risk screening for all pediatric patients upon their check-up in order to promptly detect children with acute malnutrition.

- Treating comorbidities (if any) according to the instructions of the higher-level health units (referral letter). Nurturing children with acute malnutrition with nutritional products and using medicines in accordance with the instructions.

- Providing guidance on child care and hygiene, monitoring children on a daily basis, and detecting danger symptoms for timely handling.

- Providing guidance on monitoring and stimulating psychomotor development, and rehabilitation (psychotherapy, motor rehabilitation for children with motor delays, practice and rehabilitation of swallowing and chewing). Carrying out individual counseling for each pediatric patient to stabilize and maintain appropriate child nurturing in the future.

- Managing follow-up examination for children who are discharged from such hospitals by providing therapeutic products and medicines for children within 2 weeks, if they are stable, transferring to the commune level for monitoring and outpatient treatment.

- Implementing the process for discharging from the program if the children are eligible. Enhancing propaganda and guidance on home-based child care, and providing nutritional supplements (if any). Guiding to continue to nourish children with nutritional products available in the locality.

- Transferring the children to a higher level upon treatment failure or serious complications beyond the treatment capacity of district-level hospitals.

2.2. Facilities and equipment:

- District-level hospitals shall establish the pediatric department that has a separate room for treatment and rehabilitation for children with acute malnutrition to avoid cross-contamination during hospital stay. A separate room for treatment of children with acute malnutrition must be sufficiently warm and protected from drafts; have a separate toilet, hand wash basin, clean water; have a place to prepare nutritional products for children to eat on the spot, ensuring that children may eat all day and night. Arranging re-examination rooms for children with acute malnutrition by appointment.

- Ensuring sufficient tools to assess the nutritional status of children on a weekly basis, including standing scales and lying scales. Depending on the conditions, they may choose one of the types of scales such as trough scale, electronic scale, meter scale, etc. The scale must be sensitive (the minimum graduation needs to reach 0.1kg) accurate. Measures of standing height (for children over 2 years of age) or lying length (for children under 2 years of age): wooden rulers or microtoise rulers (the minimum graduation of 0.1 cm); arm circumference measures, including soft non-elastic rulers with 0.1 cm accuracy or paper rulers; and the 2006 WHO nutritional status assessment table.

- Tools for preparation of therapeutic products, ReSoMal (rehydration solution for children with acute malnutrition).

- Medicines: In addition to essential medicines and fluids necessary for treatment, there should be nutritional products for treatment and multi-micronutrient products (or equivalent products) according to the treatment protocol of the Ministry of Health.

- Communication materials: Leaflets, posters on the benefits of breastfeeding, complementary feeding, expanded immunization, instructions for home-based monitoring, appointment slips, etc. Such documents shall be compiled by local authorities and/or added from documents of provinces or central governments.

2.3. Resources: At least 1 pediatrician in charge of nutrition and 2 nurses who have been trained in child care and nurturing, and health workers with a certificate of training in clinical nutrition for at least 3 months.

2.4. Reporting: Sending reports to the district-level health center every 6 months

- Total number of admissions to the program.

- Number of newly-admitted children.

- Number of previously-admitted children (being transferred from another level or having dropped out treatment but being re-admitted to the program).

- Number of recovered children (meeting the discharge criteria).

- Number of mortalities.

- Number of treatment dropouts (Inpatient treatment: Dropping out the hospitals and not accepting therapeutic products).

- Number of children who do not respond to treatment (Inpatient treatment: Failing to meet the criteria to be discharged from the hospitals after 4 months of treatment and being transferred to another program).

- Number of transferred children (being transferred to another level or being transferred but not yet recovered).

2.5. Criteria for evaluating the effectiveness of inpatient treatment (at hospitals)

- Mortality rate: less than 10%.

- Treatment dropout rate: less than 15%.

- Recovery rate: over 75%.

V. MANAGEMENT OF ACUTE MALNUTRITION AT THE PROVINCIAL LEVEL

1. Departments of Health:

- Directing district/provincial-level treatment facilities to report every 6 months to district-level health centers/provincial-level centers for disease control in accordance with regulations.

- Directing provincial-level centers for disease control, district-level health centers, and their affiliated hospitals in term of professional expertise.

- Integrating the management of acute malnutrition in children into the sector plan to implement activities based on legal resources.

- Implementing integrated monitoring at all levels.

2. Centers for Disease Control:

- Summing up reports of district/city health centers and provincial-level treatment facilities, and reporting to the provincial-level Departments of Health and the Institute of Nutrition every 6 months.

- Organizing training and re-training for units.

- Carrying out the procurement and allocation of equipment and materials related to the implementation of activities at the grassroots level.

- Implementing integrated monitoring at all levels.

3. Provincial/city hospitals

3.1. Implementation contents

- Performing nutritional rehabilitation treatment and management of children with acute malnutrition at the Department of Nutrition (if any) or the Pediatric Department of provincial-level hospitals, carrying out the same contents as the district level and receive cases transferred from the lower levels in accordance with the guidance of the Ministry of Health.

- Having a form of nutritional status assessment and nutritional risk screening for all pediatric patients within the first 48 hours of admission. All data and assessment forms shall be kept in the medical records.

- If possible, putting nutritional status assessment parameters into electronic medical records and having software to classify nutritional status for each pediatric patient upon examination and admission.

- When the children have been diagnosed, it is necessary to strictly adhere to the treatment protocol, discharge or referral criteria in accordance with the promulgated technical guidance. With regard to the provincial level, the admission shall comply with the following criteria:

+ SAM or MAM with complications or severe manifestations

+ Being unresponsive to lower-level treatment.

+ Failing in outpatient treatment (no weight gain after 2 visits or weight loss or oedema associated with severe skin lesions)

+ SAM has been stably treated: They are transferred from the upper level to continue to take care of nutrition and treat comorbidities if any.

- Nutritional products for the treatment of children with acute malnutrition include F75 and F100. If F75 and F100 are not available, using nutritionally equivalent products or products that can be made from locally available food sources. The hospital director shall be responsible for prescribing nutritional formula used to treat children as well as foods prepared with locally available products (porridge, powder, sonde soup, etc.)

- The Department of Nutrition shall be responsible for providing nutritional products to treat patients such as medicines. Diet must be recorded in the medical records. In cases where the canteen bids for meals, the entire hospital diet, especially the pathological diet, must be put under the control of the Department of Nutrition. Nutritional formula must be dispensed by the Department of Nutrition as prescribed by medicines in treatment. Bidding canteens are not allowed to sell nutritional products for children, except for the pharmacy and nutrition departments

- Consulting/examining co-morbidities and deciding/guiding for monitoring, treatment, care and follow-up.

- Treating comorbidities (if any) in accordance with the corresponding pathological protocol.

- Strengthening nutrition education communication for patients and directing training and supporting the lower-level units.

- Implementing the process of discharging children from the program if they are qualified according to the protocol of the Ministry of Health.

- Transferring the children to the upper level when the following criteria are met:

+ Failing in treatment.

+ Having serious complications beyond the treatment capacity of the provincial level

+ Patients need nutritional support with specialized pathological products or long-term intravenous route.

3.2. Facilities and equipment:

In addition to the same contents as district-level hospitals, the following facilities and equipment are required:

- Provincial-level hospitals must have the Department of Nutrition with a separate unit for nutritional rehabilitation. The room must be clean, cool in summer, and warm in winter. It must be equipped with a wash basin, clean water, and a separate toilet area.

- Having a pediatric resuscitation unit.

- Having a hospital diet supply unit for patients controlled by nutritionists about the composition and nutritional value of each pathological meal.

- Having sufficient means to assess nutritional status such as scales and rulers at the Department of Nutrition, clinics, and pediatric treatment units.

- Having forms to assess nutritional status and screen for nutritional risks for children.

3.3. Human resources: Having at least 2 pediatricians specializing in nutrition and 2 full-time nurses who have been trained in the care and nurturing of children with acute malnutrition (with a certificate of clinical nutrition for at least 3 months), 1 bachelor in Nutrition - Dietetics in charge of controlling and building pathological diets. The head of the Department of Nutrition must be a treating doctor and have a clinical nutrition certificate for at least 6 months.

3.4. Reporting: Sending a report to the provincial-level Department of Health every 6 months

- Total number of admissions to the program.

- Number of newly-admitted children.

- Number of previously-admitted children (being transferred from another level or having dropped out treatment but being re-admitted to the program).

- Number of recovered children (meeting the discharge criteria).

- Number of mortalities.

- Number of treatment dropouts (Inpatient treatment: Dropping out the hospitals and not accepting therapeutic products).

- Number of children who do not respond to treatment (Inpatient treatment: Failing to meet the criteria to be discharged from the hospitals after 4 months of treatment and being transferred to another program).

- Number of transferred children (being transferred to another level or being transferred but not yet recovered).

3.5. Criteria for evaluating the effectiveness of inpatient treatment (at hospitals)

- Mortality rate: less than 10%.

- Treatment dropout rate: less than 15%.

- Recovery rate: over 75%.

VI. MANAGEMENT OF ACUTE MALNUTRITION AT THE CENTRAL LEVEL

1. The Maternal and Child Health Department:

- Directing provincial-level Departments of Health, provincial-level Centers for Disease Control, and hospitals with pediatric patients to follow technical instructions and operational instructions promulgated by the Ministry of Health.

2. The National Institute of Nutrition:

- Summing up reports of all levels into an annual report of the program, reporting to the Ministry of Health and related agencies, and sending responses to reporting units.

- Providing technical and professional support for all levels.

- Providing capacity improvement training for management of acute malnutrition in the community and hospitals at all levels.

- Performing periodic support and monitoring, and integration with other nutrition activities.

3. Children's hospital:

3.1. Implementation contents:

In addition to the same contents as the provincial level, the following contents shall be supplemented:

- Having regulations on nutritional status assessment and nutritional risk screening on electronic medical records for all patients upon their check-up and admission.

- Having software for nutritional status assessment and nutritional risk screening for all patients upon their check-up and admission. Anthropometric indicators and nutritional status classification must be clearly printed on the admission and discharge papers.

- Having regulations that the information technology department must make a monthly report on outpatient and inpatient children with acute malnutrition according to the prescribed, and send it to the nutrition department.

- Training and directing lower-level hospitals

- Conducting scientific research for application in clinical practice

- Advising superiors on the development of malnourished child care procedures, and output standards for each malnourished disease.

- Having a technical process to care for children with acute malnutrition, a process of preparing and processing nutritional treatment products.

- Developing communication procedures and leaflets on nutritional care for each specialty disease.

- Treating children with SAM who have complications and do not respond to the provincial-level treatment. Children who require nutritional support with specialized nutritional interventions such as full-ingredient parenteral nutrition, enteral nutrition with home-made nutritional products or specially-formulated products that have been clinically proven.

- Conducting diagnosis and treatment of underlying diseases. Clinical evaluation must be carried out carefully, frequently and repeatedly to ensure that all health problems are detected and treated promptly.

- Providing individual counseling for each pediatric patient to stabilize and maintain appropriate child care in the future.

- Managing follow-up examination for children with acute malnutrition who are discharged from such hospitals by providing therapeutic products and medicines for children within 1 month, if they are stable, transferring to outpatient treatment or if acute malnutrition has gone in remission and needs long-term nutrition, transferring to the lower level for monitoring and outpatient treatment.

- Implementing the process for discharging children from the program if they are qualified:

+ Solving or controlling complications and underlying diseases.

+ Having appetite.

+ Families/caregivers have enough capacity to raise and care for the children at a lower level or outpatient facility.

3.2. Facilities and equipment:

- Establishing the Department of Nutrition that has an isolation area for high-risk cases of infection, and an emergency room for monitoring severe patients. The room must be warm, avoid drafts, and have its own toilet, wash basin, clean water, hand soap, tissue paper, and adequate first aid facilities. The department must have a clean and hygienic room for milk preparation, food preparation and ReSomal/ORS preparation for patients.

- Having a unit to process nutritional products and deliver meals to patients (sonde soup, postoperative soup, soup for malabsorption) or providing specially-formulated nutritional products for treatment of each disease (specially-formulated nutritional products for children with disorders of metabolism and absorption, etc.). The Department of Nutrition shall be responsible for providing or managing such products (if the processing unit bids).

- Nutritional formula must be managed as therapeutic medicines (prescribing, selling, dispensing, etc.) in compliance with the process of medicine dispensing. The Department of Nutrition shall be responsible for managing such products.

- Having a pharmacy department that prepares full-ingredient intravenous nutrition products according to the requirements of clinical departments.

- Ensuring sufficient tools to assess the nutritional status of children every day at health examination and treatment departments.

- The Department of Nutrition must have a compass to measure the thickness of subcutaneous fat layer (the most commonly used type of compass is Harpenden, with two heads being two planes with a cross section of 1cm2), have a manometer attached to the compass to ensure that when the compass is clamped to the skin, there is always a constant pressure of about 10 - 20 g/mm2; have a small scale to measure in processing and dividing pathological meals; and have equipment and tools to prepare milk.

- The nutritional rehabilitation department for pediatric patients must have scales to measure the patient’s food intake and waste, standing and lying scales to assess nutritional status.

- Having a nutrition communication corner at examination and treatment departments. There are guidelines for mothers to take care of their children’s nutrition according to each disease, ensuring that at least each specialty has guidance on pathological nutrition.

- Having acute malnutrition management software or applying information technology in nutritional status screening and assessment.

- Having software to control the patient’s nutrition

- Nutrition counseling clinic for children: Performing re-examination for children with acute malnutrition by appointment and providing menu planning advice.

- Medicines: In addition to essential medicines and infusion fluids, there shall be multi-micronutrient preparations, nutritional formula, and nutritional products made at hospitals.

- Communication materials: Leaflets, posters about the benefits of breastfeeding, expanded vaccinations, complementary foods, Instructions for home-based monitoring, follow-up appointment slips, and nutrition guidelines for some diseases.

3.3. Human resources:

- Having at least 5 doctors, 5 pediatric nurses in charge of nutritional treatment, care and counseling (obtaining a clinical nutrition certificate for at least 3-6 months)

- Having at least 2 bachelors in abstinence nutrition with the task of developing and controlling the patient’s pathological diet.

- The head of the nutrition department must be a pediatrician and obtain a post-graduate degree in nutrition or a clinical nutrition certificate for at least 6 months and do a post-graduate thesis on nutrition.

3.4. Reporting: Sending a report to the National Institute of Nutrition every 6 months

- Total number of children with acute malnutrition in the hospital and the level of malnutrition by month

- Number of newly-admitted children.

- Number of previously-admitted children (being transferred from another level or having dropped out treatment but being re-admitted to the program).

- Number of recovered children (meeting the discharge criteria).

- Number of mortalities.

- Number of treatment dropouts (Inpatient treatment: Dropping out the hospitals and not accepting therapeutic products).

- Number of children who do not respond to treatment (Inpatient treatment: Failing to meet the criteria to be discharged from the hospitals after 4 months of treatment and being transferred to another program).

- Number of transferred children (being transferred to another level or being transferred but not yet recovered).

3.5. Criteria for evaluating the effectiveness of inpatient treatment (at hospitals)

- Mortality rate: less than 10%.

- Treatment dropout rate: less than 15%.

- Recovery rate: over 75%