OCB NUTRITION – NEW MONITORING AND EVALUATION SYSTEM

Definitions for Ambulatory Therapeutic Feeding Centre (ATFC)

Reminder!

Acute malnutrition represents undernutrition that occurs over a relatively short period of time, frequently
superimposed on chronic micronutrient and macronutrient deficiencies. Individuals with acute malnutrition may be
categorised as having moderate acute malnutrition (MAM) or severe acute malnutrition (SAM). Acute malnutrition
is characterised primarily by wasting and/or oedema, whereas chronic malnutrition is characterised by faltering
ACUTE MALNUTRITION
linear growth (stunting), and/or poor weight gain. Thus, measures used to identify acute losses of weight, such as
weight-for-height or mid-upper arm circumference (MUAC) are most appropriate for the identification of acute
malnutrition1. Different anthropometric measures may be more appropriate for different ages and population
groups, e.g. for pregnant women we only use MUAC as neither WHZ or oedema are specific enough.
Moderate acute malnutrition (MAM) is defined as a weight-for-height (WHZ) or BMI (depending on age) between
-3 and -2 z-scores below the median of the WHO child growth standards. MUAC can also be used, but this has
MODERATE ACUTE MALNUTRITION
different cut-offs according to age or population group (e.g. pregnant and lactating women) - see nutrition
protocols for the appropriate age-group or population group cut-offs
Severe acute malnutrition (SAM) is defined as a weight-for-height or BMI (depending on age) less than -3 z-scores
below the median of the WHO child growth standards. MUAC can also be used, but this has different cut-offs
SEVERE ACUTE MALNUTRITION
according to age or population group (e.g. pregnant and lactating women) - see nutrition protocols for the
appropriate age-group or population group cut-offs

1
https://www.uptodate.com/contents/management-of-moderate-acute-malnutrition-in-children-in-resource-limited-countries

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Guide:
= Optional (contact the nutrition referent and the eHealth Unit if this corresponds to your context)

Patient identifiers

This is a number given to the patient for each admission into the ATFC. The number will be different for each admission. This number will
Patient ID
link information recorded during different consultations to the patient admission and exit.
This is the ID number the patient was given on their first ever admission to a MSF outpatient programme - whether it was in ATFC, SFP etc.
First Patient ID (ATFC/SFP/etc)
This number can be used to trace patients through different admissions

Number of Consultants

Average number of consultants per day in this Average number of consultants working in the ATFC per day in this reporting period. Consultants are the health
reporting period workers who do the medical consultations with the patients. They may be doctors, nurses, nurse aids, etc.
Number of working days in this reporting period (not including any public holidays, strikes or other days that the
Number of working days in this reporting period
ATFC is closed).

Total patients at the end of the reporting period

Total patients at the end of the reporting period Total patients at the end of the reporting period

Total consultations

Admission consultation Total number of new admission consultations

Total number of follow-up consultations planned
Follow up consultation Total number of follow up consultations (does not include NEW patient consultations)

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ATFC Admission
Chose one per patient
categories
Patient is presenting for the first time to this ATFC or exited this ATFC greater than 2 months ago. This also includes patients who were seen in triage of
New admission
an OPD or health centre and referred directly to ATFC.
Referral in from
Patient started treatment in an ITFC and is now nutritionally and medically stable to finish the treatment in this ATFC.
ITFC
Patient defaulted from this ATFC then was readmitted into this ATFC within 2 months of the decided default date.
Patient is counted as a defaulter if:
• They have not attended the ATFC in the last 28 days AND
• They have no ‘next planned visit’ documented
For patients seen weekly, this means: the patient missed last three scheduled appointments and is classed as a defaulter on 4th appointment missed. For
patients seen every two weeks, this means: the patient missed two appointments and is classed as a defaulter on the second follow-up visit missed
Readmission: If a patient is going to be classed as defaulter, but then contact was made with the caretaker who agrees to come back on a certain date, then this date
after defaulting becomes the next planned date and this patient is still considered as active.
NB: All efforts should be made to follow-up this patient and find out reasons for defaulting. If defaulter rate is >15%, then the following three categories
of defaulter must be included in your monitoring (via HP, home visits etc.)
A new Patient ID is given BUT record in the linelist and on the patient card the FIRST Patient ID the patient was ever given (whether they were admitted
into ATFC, SFP etc.), so that they can be tracked for clinical purposes. If this is the third admission for example, go back to the second admission to find
the first Patient ID if it isn't immediately available. It should also be recorded on the patient card how many times the patient has been readmitted into
this ATFC.
Patient who was discharged as cured from this ATFC and has to be re-admitted within 2 months after discharge date, as well as a patient discharged as
non-respondent coming back with the criteria of SAM (write a comment).
Relapse (after A new Patient ID is given BUT record in the linelist and on the patient card the FIRST Patient ID the patient was ever given (whether they were admitted
cured) into ATFC, SFP etc.), so that they can be tracked for clinical purposes. If this is the third admission for example, go back to the second admission to find
the first Patient ID if it isn't immediately available. It should also be recorded on the patient card how many times the patient has been readmitted into
this ATFC.

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ATFC Admission
Chose one per patient
categories
Patient is readmitted after being referred out to:
• ITFC (because they deteriorated) or
• Another nutritional service except ITFC (e.g. other ATFC, SFP, etc.) or
Readmission:
• Non-nutritional service (hospital or health facility).
after referral
A new Patient ID is given BUT record in the linelist and on the patient card the FIRST Patient ID the patient was ever given (whether they were admitted
out
into ATFC, SFP etc.), so that they can be tracked for clinical purposes. If this is the third admission for example, go back to the second admission to find
the first Patient ID if it isn't immediately available. It should also be recorded on the patient card how many times the patient has been readmitted into
this ATFC.

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 These are the admission categories used to decide if a child will be admitted into the ATFC, whether the patient is a new admission
spontaneously presenting, or referred from an ITFC or other health structure. One patient can only have one result.
All children referred in from ITFC should be put under the category ‘Referral in from ITFC’, regardless of their anthropometrics.
ATFC admission criteria
Choose the most clinically important result if s/he has more than one results. Oedema (+, ++) is more clinically important than
anthropometric measures (MUAC AND WHZ) and so should always be chosen first. Other nutritional complication is used when the
patient does not meet the anthropometric criteria for admission (no oedema, normal WHZ, normal MUAC).
Referral in from ITFC
Patient started treatment in an ITFC and is now nutritionally and medically stable to finish the treatment in this ATFC.

Oedema +
Bilateral pitting oedema of nutritional origin confined to feet only

Oedema ++
Bilateral pitting oedema of nutritional origin in the feet and lower legs only

MUAC AND WHZ

Patient has both WHZ and MUAC values which meet the admission criteria of this ATFC

MUAC only
Patient has been admitted on the basis of a MUAC value meeting the admission criteria of this ATFC (with a normal WHZ)

WHZ/WAZ only
Patient has been admitted on the basis of a WHZ value meeting the admission criteria of this ATFC (with a normal MUAC).

Patient has been admitted on the basis of a WAZ value meeting the admission criteria of this ATFC – WAZ is currently only used for
WAZ (patients 1 - <6m only)
patients 1 - <6m
This is most often a category used for infants 1m-<6m who have a normal WHZ, but who have feeding problems such as too weak to
suckle, illness or absence of mother, insufficient breast milk, inappropriate feeding alternatives = e.g. orphans, giving goats milk, etc.;
Other nutritional complication who are not sick enough to need admitting into an ITFC, but need follow-up in an ATFC. It can also be used for children >6m with a
normal WHZ and MUAC, if the issue is specifically nutritional and not related to a general paediatric problem. Children with congenital
malformations leading to difficult feeding can be included in this group, details must be added in the comments section.

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ATFC Source of admission: Chose one per patient
Self-referral (spontaneous) Patient decided spontaneously to come to this ATFC
Outreach team Patient has been advised to come by outreach team
Referral in from MSF ITFC (stabilised) Patient started treatment in a MSF ITFC and is now nutritionally and medically stable to finish the treatment in this ATFC.
Patient started treatment in a non-MSF ITFC and is now nutritionally and medically stable to finish the treatment in this
Referral in from non-MSF ITFC (stabilised)
ATFC.
Referral in from other ATFC (MSF or non-MSF) Patient has been referred to this ATFC from another ATFC (MSF or non-MSF).
Patient has been referred to this ATFC from a supplementary feeding programme (SFP), whether it be an MSF or non-MSF
Referral in from SFP (MSF or non-MSF)
programme.
Referral in from non-nutritional service Patient referred in from a non-nutritional service in a different health facility/hospital (e.g. surgery ward, isolation ward,
(hospital or health facility) another primary health care centre, etc.) and now needs outpatient nutritional treatment
Other

Pregnant or lactating status at admission

Pregnant or lactating Patient is pregnant or lactating

Laboratory tests Malaria ON ADMISSION TO SERVICE

RDT for malaria A RDT is performed to check for the presence of malaria

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ATFC Clinical form of
Chose one per patient
malnutrition at admission
Severe wasting with loss of muscle and fat mass. Patients are extremely emaciated with thin, flaccid skin and prominent scapulae, spine and
Marasmus ribs. Loss of facial fat results in the characteristic elderly appearance of affected children. Other signs include anorexia (although not always
the case) and behavioural changes (apathy and irritability). WHZ < -3 z-scores and MUAC <115mm. No oedema.
Bilateral pitting oedema of the lower legs and feet; generalized oedema in advanced cases (face, hands, arms, trunk). Loss of muscle and fat
mass (that can be hidden by oedema). Skin lesions: atrophy, patches of erythema, hypo- or hyper-pigmentation, desquamation, exudative
Kwashiorkor lesions that resemble burns, fragile skin prone to ulceration and infection. Changes in hair colour (lightening or becoming reddish) and
texture (dry, thin, brittle, sparse hair). Behaviour: apathy or lethargy; irritability when handled. Anorexia. WHZ and MUAC may be normal or
abnormal.
Marasmic-kwashiorkor is a mixed form of both marasmus and kwashiorkor and is characterized by the presence of both muscle wasting
Marasmic-Kwashiorkor
(usually most prominent in the upper body) and bilateral pitting oedema
MAM Moderate Acute Malnutrition (MAM) is categorised by a MUAC of ≥ 115mm and < 125mm and/or a WHZ ≥ -3 and < -2
This is most often a category used for infants 1m-<6m who have a normal WHZ, but who have feeding problems such as too weak to suckle,
illness or absence of mother, insufficient breast milk, inappropriate feeding alternatives = e.g. orphans, giving goats milk, etc.; who are not
Other nutritional
sick enough to need admitting into an ITFC, but need follow-up in an ATFC. It can also be used for children >6m with a normal WHZ and
complication
MUAC, if the issue is specifically nutritional and not related to a general paediatric problem. Children with congenital malformations leading
to difficult feeding can be included in this group, details must be added in the comments section.

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Morbidity ON ADMISSION TO This is the morbidity/medical problem that the patient was suffering from on their admission visit and not on any further visits.
SERVICE (1 per admission) Chose one per patient.
No morbidity
The patient has no medical problems/morbidities except malnutrition

Passage of 3 or more loose or watery stools without visible blood in the past 24 hours, with or without dehydration, lasting for less than
Diarrhoea, non-bloody
2 weeks. NB - this is the same as "watery diarrhoea"
Infection, moderate to severe, caused by bacteria, fungi, or viruses, which occurs either on the external surface of the eye or
Eye infection
intraocularly with probable inflammation, visual impairment, or blindness.
Intestinal parasitosis (confirmed)
A patient who either:- complains of visible worms in the stool- has microscopically demonstrated parasites or eggs in the stool

a positive malaria rapid diagnostic test or demonstrable parasites by microscopy in a patient either - with fever or history of fever within
Malaria, uncomplicated the last 48 hrs accompanied by where other infectious diseases have been excluded and without clinical or laboratory criteria for severe
malaria OR - who has undergone a screening test (e.g. routine screening of pregnant women)
Any skin lesion of presumed infectious aetiology (bacterial, fungal, viral, or parasitic) that is limited to skin surface or underlying dermis
Skin diseases (infectious)
- i.e. excluding cutaneous manifestations of underlying or systemic pathologies such as chicken pox, abscesses, or leprosy.
Infections of the ear, nasal passages and throat, not involving the lower respiratory tract. Includes rhinitis, rhino pharyngitis, sinusitis,
Upper respiratory tract infection
laryngitis, tonsillitis and otitis.
Patient has a condition not under epidemiologic surveillance - i.e. one not present elsewhere on the surveillance list. This can also be
Other Morbidity
used if the patient presents with a morbidity which needs referral to ITFC, write details in the comments box

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ATFC Exit categories Chose one per patient
Cured
Patient has reached the anthropometric and clinical criteria for discharge from the ATFC

Patient who has deteriorated and needs admission to an ITFC. e.g. child with no weight gain after 3 weeks of ATFC treatment, new/worsening
Deteriorated (->ITFC) bilateral nutritional oedema, new case pneumonia, severe malaria etc. - see Nutrition Protocol for full criteria. This child needs ongoing nutritional
treatment and has the criteria for inpatient admission.
Patient who exits the ATFC after 12 weeks of treatment with: stagnant weight = no weight gain for 2 consecutive weeks or "yoyo" children (who gain
a little weight one week, then loose it the next, etc.), dietary treatment is reported as well observed at home, WHZ > -3 z-score; absence of any
Non-respondent pathology that may benefit from treatment (medical opinion is needed). ALL EFFORTS must be made to investigate why the child is not responding. It
may be that the child is simply not receiving the RUTF prescribed and so there should be psychosocial follow-up for the family with a home visit as a
minimum. Congenital malformations must be ruled out.
This is a rarely used category. One example for its use could be to remove an admission number, not necessarily a patient: if a patient who is already
admitted in the service is brought in with another caretaker and under another name then that individual may be given another admission number
Disqualified from
and given more RUTF than is appropriate if they come on different days to the ATFC and if the staff don't initially recognise that it is the same child.
service
This could be also used for a child who was mis-measured on admission and does not meet admission criteria and then this mistake is quickly
recognised.
Patient is counted as a defaulter if:
• They have not attended the ATFC in the last 28 days AND
• They have no ‘next planned visit’ documented
For patients seen weekly, this means: the patient missed last three scheduled appointments and is classed as a defaulter on 4th appointment missed.
For patients seen every two weeks, this means: the patient missed two appointments and is classed as a defaulter on the second follow-up visit
Defaulter
missed
If a patient is going to be classed as defaulter, but then contact was made with the caretaker who agrees to come back on a certain date, then this
date becomes the next planned date and this patient is still considered as active.
NB: All efforts should be made to follow-up this patient and find out reasons for defaulting. If defaulter rate is >15%, then the following three
categories of defaulter must be included in your monitoring (via HP, home visits etc.)
Defaulter (lost to
defaulter: no information available regarding the reason patient did not complete treatment
follow up)

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ATFC Exit categories Chose one per patient
Defaulter (death) defaulter: patient died
Defaulter (left
defaulter: patient stops treatment because his/her perception of cost vs benefit of staying in the service. Examples: perceived quality of care, stigma,
against medical
distance of the ATFC, security concerns in accessing the ATFC … and this is confirmed via a home visit or some other contact with the caretaker
advice, confirmed)
Referral out (does
Patient referred out to other service apart from ITFC. For example, to ATFC, SFP, or a non-nutritional service (e.g. surgery ward, isolation ward,
not include
another primary health care centre, etc.) either within in the same health facility or another one
deteriorated)

ATFC Exit
Chose one per patient
destination
Home
Patient who has deteriorated and needs admission to a MSF ITFC. e.g. child with no weight gain after 3 weeks of ATFC treatment, new/worsening
Referral to MSF ITFC
bilateral nutritional oedema, new case pneumonia, severe malaria etc. - see Nutrition Protocol for full criteria. This child needs ongoing nutritional
(deteriorated)
treatment and has the criteria for inpatient admission.
(OPTIONAL) Patient who has deteriorated and needs admission to a non MSF ITFC (run by another organisation, NGO, MoH etc.). e.g. child with no
Referral to non-MSF
weight gain after 3 weeks of ATFC treatment, new/worsening bilateral nutritional oedema, new case pneumonia, severe malaria etc. - see Nutrition
ITFC (deteriorated)
Protocol for full criteria. This patient needs ongoing nutritional treatment and has the criteria for inpatient admission.
Referral to other
Patient referred out of this ATFC to another ATFC (MSF or non-MSF) to continue their nutritional treatment. Reasons could be geographical proximity
ATFC (MSF or non-
to patient's home, closure of a centre etc.
MSF)
Referral to SFP (MSF Patient referred out of this ATFC to a Supplementary Feeding Programme (SFP) (MSF or non-MSF) to continue nutritional support. Reasons likely to
or non-MSF) be project-specific
Referral to non-
nutritional service Patient transferred to a non-nutritional service (e.g. surgery ward, isolation ward, another primary health care centre, etc.) either within in the same
(hospital or health health facility or another one
facility)

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HIV and TB status
Chose one per patient.
(recorded at exit)
NB! On the patient card for ATFC,'RVS' is used as a code for HIV for confidentiality and cultural sensitivity.
HIV Positive: Positive HIV test
HIV Negative: Negative HIV test
HIV status
HIV Unknown: This category refers to there being no information about a patient's HIV status. This could be because the patient has not been asked
about their status, not been tested (either in MSF structure or elsewhere) or has refused testing if offered or testing revealed an indeterminate result
(rare). If there are greater than 15% of patients with HIV status unknown, further investigation should be made into the reason behind this.
TB Positive: Includes confirmed and unconfirmed pulmonary and extra-pulmonary TB. (confirmed TB = the number of patients started on a TB
treatment who have TB bacteriologically confirmed by a laboratory test (either smear, Xpert, culture or LPA). Unconfirmed TB = includes all forms
without bacteriological confirmation (as the smear neg and EPTB) which are started on treatment on clinical and/or radiological grounds)
TB status TB Negative: Negative TB screening
TB Unknown: This category refers to there being no information about a patient's TB status. This could be because the patient has not been asked
about their status, not been screened (either in MSF structure or elsewhere) or has refused to be screened. If there are greater than 15% of patients
with TB status unknown, further investigation should be made into the reason behind this.

Record the vaccination status of each patient using their vaccination card, the MSF/national vaccination calendar and
Vaccination status at exit
their ATFC notes
Number of patients who before exiting the ATFC have either received the appropriate vaccinations for their age in the
No. patients with up-to-date immunization
ATFC, or have documented evidence that they are up-to-date with their vaccinations done in other health facilities or as
status at exit
part of campaigns, through vaccination cards and patient notes.
No. of patients (≥6m - <9m) exiting ATFC that Number of patients who were greater than or equal to 6 months but less than 9 months on admission to this ATFC who had
had NOT received an MCV prior to admission not received MCV 0 (no vaccination card/proof of vaccination available)
Number of patients who were greater than or equal to 6 months but less than 9 months at exit from the ATFC and had
No. of patients (>=6m < 9m) exiting ATFC that
received MCV 0 either in this ATFC or there is documented evidence that they received it in another health facility at the
HAVE received MCV 0 prior to exit
appropriate age

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ATFC records by sampling
No. of sampled children for calculation of WG At the end of each week, randomly select 10 children 1m-<6m who exited the ATFC as "cured". If there are <10 children,
& LS (cured 1m-<6m) select all of them.
Sum of lengths of stay from sampled children Add up all the lengths of stay (in ATFC) for each child sampled (length of stay is from the day of admission into ATFC until
(cured 1m-<6m) (in days) the day declared "cured" (inclusive) for all the sampled children)
Sum of weight gains from sampled children Add up all the weight gains (in gr) for each sampled child 1m-<6m (weight gain is the difference between the weight on the
(cured 1m-<6m) (in gr) day of admission into ATFC (phase 2 outpatient) and weight on the day the patient is declared as "cured")
Sum of weights at admission from sampled
Add up all the weights on admission into ATFC, for each sampled child (cured 1m-<6m) (in kg)
children (cured <6m) (in kg)
No. of sampled children for calculation of WG At the end of each week, select randomly 10 children 6-59m who exited the ATFC as "cured". If there are <10 children,
& LS (cured 6-59m) select all of them.
Sum of lengths of stay from sampled children Add up all the lengths of stay (in ATFC) for each child 6-59m sampled (length of stay is from the day of admission into ATFC
(cured 6-59m) (in days) until the day declared "cured" (inclusive) for all the sampled children)
Sum of weight gains from sampled children Add up all the weight gains (in gr) for each sampled child 6-59m (weight gain is the difference between the weight on the
(cured 6-59m) (in gr) day of admission into ATFC (phase 2 outpatient) and weight on the day the patient is declared as "cured")
Sum of weights at admission from sampled
Add up all the weights on admission into ATFC, for each sampled child (cured 6-59m) (in kg)
children (cured 6-59m) (in kg)

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