Malnutrition remains a significant public health challenge in Kenya, especially among vulnerable populations such as children under five, pregnant and lactating women, and the elderly. Effective management of malnutrition cases requires systematic identification and appropriate enrollment of clients into care programs that suit their clinical and social circumstances. This chapter focuses on the criteria used to admit malnourished clients either as inpatients or outpatients, and the treatment protocols applicable in each setting. Nutrition and dietetics professionals play a critical role in ensuring that clients receive timely and tailored interventions to improve nutritional outcomes and reduce morbidity and mortality.

2.1 Admission Criteria

Admission criteria are essential to determine which malnourished clients require inpatient care due to severity or complications and which can be managed safely as outpatients. In Kenya, adherence to standardized criteria ensures efficient use of limited healthcare resources and improves patient outcomes in facilities such as county hospitals, clinics, and nutrition rehabilitation centers.

2.1.1 Inpatient Admission Criteria

Inpatient admission is reserved for malnourished clients who exhibit severe clinical complications or are unable to tolerate outpatient care. The criteria focus on clinical signs, anthropometric measurements, and the presence of medical complications.

Clinical Severity Indicators

Clients with severe acute malnutrition (SAM) accompanied by medical complications such as severe oedema, hypoglycaemia, hypothermia, or infections require inpatient care. For example, children admitted to Kenyatta National Hospital with SAM often present with clinical signs like lethargy or shock that necessitate close medical supervision.

Anthropometric Thresholds

Admission is indicated when weight-for-height z-score (WHZ) is below -3 standard deviations or mid-upper arm circumference (MUAC) is less than 11.5 cm in children under five. These measurements identify those at highest risk of mortality who need intensive nutritional and medical management.

Feeding Difficulties

Clients who are unable to feed orally due to anorexia, vomiting, or neurological impairments must be admitted for assisted feeding methods such as nasogastric tube feeding. This is common in malnourished children with cerebral palsy attending rehabilitation centers in Nairobi.

Presence of Medical Complications

Complications like pneumonia, diarrhoea with dehydration, severe anaemia, or sepsis require stabilization in an inpatient setting. For instance, at county referral hospitals, malnourished clients with severe infections receive intravenous antibiotics and fluid therapy alongside nutritional support.

Social Factors

Clients without adequate caregiver support or those living in environments unsuitable for outpatient follow-up may be admitted to ensure continuous care. In rural areas, malnourished children from families with limited access to transport are often admitted to county hospitals for close monitoring.

2.1.2 Outpatient Admission Criteria

Outpatient management is appropriate for malnourished clients who are clinically stable and can consume therapeutic foods at home. This approach facilitates access to care while reducing the burden on inpatient facilities.

Mild to Moderate Acute Malnutrition

Children with weight-for-height z-score between -2 and -3 or MUAC between 11.5 cm and 12.5 cm qualify for outpatient therapeutic programs. Such clients are regularly enrolled in community-based management of acute malnutrition (CMAM) clinics, including those supported by NGOs in informal settlements.

Absence of Medical Complications

Clients without severe oedema, infections, or feeding difficulties can be safely managed as outpatients. For example, malnourished children attending outpatient nutrition clinics at sub-county hospitals in Kisumu receive ready-to-use therapeutic foods (RUTF) and routine health monitoring.

Ability to Feed and Caregiver Availability

Outpatient admission requires that clients can feed voluntarily and have caregivers capable of administering home-based therapies. This is critical in urban settings where caregivers attend nutrition education sessions at health centers.

Access to Follow-Up Services

Stable clients must live within reasonable distance from health facilities to allow weekly monitoring and prompt referral if complications develop. County governments in Kenya promote community health volunteer involvement to facilitate follow-up in outpatient programs.

Compliance Potential

Clients and caregivers demonstrating willingness and ability to adhere to treatment protocols, including attendance at scheduled visits, are considered for outpatient care. This is emphasized in nutrition rehabilitation programs run by organizations such as the Kenya Red Cross Society.

Chapter Summary

This chapter focused on the process of enrolling malnourished clients by first defining clear admission criteria for both inpatient and outpatient care. Inpatient admission criteria were detailed to identify clients requiring intensive medical and nutritional support, while outpatient criteria targeted those suitable for community-based management with less severe conditions. The treatment protocols for both settings were thoroughly explained, emphasizing tailored interventions to address the specific needs of admitted clients. Inpatient treatment involved close medical monitoring and therapeutic feeding, whereas outpatient care focused on regular follow-up and nutritional rehabilitation. The chapter also highlighted the importance of meticulous documentation during enrolment to ensure accurate client records and continuity of care. Understanding these procedures is essential for effective management and improved outcomes in malnutrition cases.