Changes in the management of SAM observed in ten participating hospitals* at preintervention and 6–12 months postintervention
| Step | Description | Preintervention | 6–12 months postintervention | Difference (Y) | ||||||||
| Y | I | N | N/O | N/A | Y | I | N | N/O | N/A | |||
| 1. Treat/prevent hypoglycaemia | Arrival to admission time (<2 hours) | 4 | 5 | 1 | 9 | 1 | 5 | |||||
| 2. Treat/prevent hypothermia | Children remain covered | 4 | 4 | 2 | 8 | 2 | 4 | |||||
| 3. Treat/prevent dehydration | ReSoMal given instead of ORS | 2 | 7 | 1 | 4 | 6 | 2 | |||||
| 4&6. Correct electrolyte imbalance and micronutrient deficiencies | Salt withheld from additional foods | 3 | 1 | 5 | 1 | 9 | 1 | 6 | ||||
| CMV or source of potassium, magnesium, zinc and multivitamins given. | 6 | 3 | 1 | 9 | 1 | 3 | ||||||
| Iron withheld in the stabilisation phase. | 7 | 1 | 2 | 10 | 3 | |||||||
| Diuretic not given to treat oedema. (Yes, not given; No, given) | 6 | 2 | 2 | 8 | 2 | 2 | ||||||
| 5. Treat infection | Antibiotics given within 30 min of prescription time | 7 | 3 | 10 | 3 | |||||||
| Antibiotic type and dose given according to prescription | 8 | 1 | 1 | 10 | 2 | |||||||
| 5. Hand washing | Staff wash/spray hands between contact with each child | 5 | 5 | 7 | 3 | 2 | ||||||
| Staff wash/spray hands before preparing feeds | 5 | 2 | 3 | 10 | 5 | |||||||
| Mothers wash/spray hands before giving feeds | 1 | 2 | 3 | 2 | 2 | 10 | 9 | |||||
| Soap/spray available for mothers | 4 | 1 | 5 | 9 | 1 | 5 | ||||||
| 5. Ward hygiene | New or sterilised syringes used for each feed given through NG tube | 3 | 1 | 4 | 1 | 1 | 10 | 7 | ||||
| Cups washed with soap between each feed | 7 | 1 | 2 | 10 | 3 | |||||||
| Feeding equipment washed with soap between each feed preparation | 5 | 1 | 4 | 10 | 5 | |||||||
| Clean toilet available for mothers | 4 | 6 | 10 | 6 | ||||||||
| Boiled water used to make feeds | 5 | 2 | 1 | 2 | 10 | 5 | ||||||
| 7&8.Feeding | Correct feed type given to each child according to prescription (F75 or F100 or RUTF) | 3 | 4 | 1 | 2 | 9 | 1 | 6 | ||||
| Correct volume of feed given according to prescription | 5 | 4 | 1 | 10 | 5 | |||||||
| Feeds given on time (within 15 min of prescription) | 3 | 1 | 4 | 1 | 1 | 10 | 7 | |||||
| Actual volume taken charted (ie, leftovers charted) | 2 | 1 | 7 | 1 | 9 | -1 | ||||||
| If child vomits, feed reoffered | 4 | 4 | 1 | 1 | 10 | 6 | ||||||
| Reluctant feeders encouraged to eat | 4 | 2 | 1 | 2 | 1 | 10 | 6 | |||||
| Children on F100 fed until full | 6 | 1 | 1 | 2 | 9 | 1 | 2 | |||||
| Additional foods withheld in stabilisation phase | 5 | 3 | 2 | 8 | 2 | 3 | ||||||
| 9. Sensory stimulation | Colourful pictures/displays on walls | 4 | 6 | 4 | 6 | 0 | ||||||
| Toys are available in/around beds | 1 | 9 | 1 | 9 | 0 | |||||||
| Structured play sessions held for children. | 2 | 8 | 1 | 9 | -1 | |||||||
| 10. Follow-up | Mothers given a follow-up letter on discharge† | 4 | 6 | 4 | 6 | 0 | ||||||
| General: Monitoring | Weighing scales present | 6 | 1 | 3 | 10 | 0 | 4 | |||||
| Good technique used to weigh children | 3 | 1 | 5 | 1 | 8 | 1 | 1 | 5 | ||||
| Length board present or MUAC tapes available | 4 | 6 | 9 | 1 | 5 | |||||||
| Good technique used to measure height/length OR to measure MUAC | 3 | 1 | 3 | 2 | 1 | 8 | 1 | 1 | 5 | |||
| General: Ward | Separate ward or ‘corner’ available to treat severe malnutrition | 1 | 7 | 2 | 1 | 8 | 1 | 0 | ||||
| Charts for each child kept at end of their bed | 3 | 7 | 8 | 2 | 5 | |||||||
| Equipment on ward in good working order | 6 | 3 | 1 | 10 | 4 | |||||||
| General: Staff | Minimum of one nurse to five children available during day | 4 | 6 | 10 | 6 | |||||||
| Doctor/s visit ward at least once per day outside of ward rounds/emergencies | 7 | 1 | 2 | 9 | 1 | 2 | ||||||
*Preintervention observation data were not collected from the participating hospital in El Salvador. The postintervention observation data from this hospital were excluded from the analysis.
†Verbal follow-up instructions were given to mothers at five hospitals at preintervention and six hospitals at 6–12 months postintervention.
CMV, combined mineral and vitamin mix; I , inconclusive/inconsistent; MUAC, mid-upper arm circumference; N, no; NG, nasogastric; N/O, not observed; N/A, not applicable; ORS, oral rehydration solution; ReSoMal, rehydration solution for malnutrition; RUTF, ready-to-use therapeutic food, SAM, severe acute malnutrition; Y , yes .