Thanks Mark to open this discussion.

A new element: Mark Manary’s group just published a trial from Sierra Leone comparing an integrated protocol with a standard one. The tested integrated protocol gives the same treatment to SAM and MAM children with different RUTF doses in relation to MUAC. See:

Maust A, Koroma AS, Abla C, Molokwu N, Ryan KN, Singh L, Manary MJ. Severe and Moderate Acute Malnutrition Can Be Successfully Managed with an Integrated Protocol in Sierra Leone. J Nutr. 2015 Sep 30. pii: jn214957

http://www.ncbi.nlm.nih.gov/pubmed/26423737

The integrated protocol tested by this group is actually a MUAC only protocol.

The approach is elegant, it makes sense, I am sure it will attract attention by its simplicity and its impact. The conclusion is that the integrated MUAC based protocol works better. I am sure this is the way forward, and this kind protocol, maybe with some variations in the RUTF dosage or type of product, and also with detection of MAM/SAM by mothers, is likely to become the “standard” in the few years to come, especially if repeated in other settings and showing similar results.

So this paper reinforces the impression that MUAC-only programmes is the way to go. However, it does not directly address the question of relevance of WFH as additional criteria as both groups differ in other aspects than just patient selection. But we can build on that to propose a protocol which can directly test whether adding WFH is of any use. I would see something like:

Group 1: integrated MUAC only protocol as proposed in the Sierra Leone paper

MUAC < 115 RUTF 200 kcal/kg/day
MUAC >115 < 125 : RUTF 75 kcal/day

Group 2: standard approach with WFH

Patients selected by MUAC < 125 mm

If WFH > -3 same protocol as above
MUAC < 115 RUTF 200 kcal/kg/day
MUAC >115 < 125 : RUTF 75 kcal/day

If WFH < -3, RUTF 200 kcal/kg/day till WFH > -2

Main outcome: ideally, mortality. Else recovery at 3 mo assessed by MUAC > 125 mm.

There should be a cost analysis, as the WFH protocol will be more expensive to run (more training, more measuring equipment).

We can also attempt to fine tune the design. As described above, group 2 will receive slightly more RUTF than group 1 and can get higher weight gains just for that. We can increase the dose in group 1 in the 115-120 mm to balance the RUTF dose between the two groups.

R2HC is seeking a consultant with expertise in public health and climate change to conduct a situational analysis of the impacts of climate emergency on humanitarian health, to map out what other funders and organisations are doing in this space, and to recommend a potential niche for R2HC. 

Approx 25 days between March and October.

Application deadline Feb 5

https://www.elrha.org/career/request-for-proposals-climate-emergency-and-humanitarian-health-situational-analysis/

Hello folks,

Here is a very interesting piece of work by Grellety E and Golden MH:

[url]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6138885/[url].

Cheers,

Sameh

Not sure if the previous link worked. Below is a new one just in case:

https://nutritionj.biomedcentral.com/articles/10.1186/s12937-018-0384-4

and the title is:

"Severely malnourished children with a low weight-for-height have a higher mortality than those with a low mid-upper-arm-circumference: I. Empirical data demonstrates Simpson’s paradox"

For the attention of ENN colleagues: I tried to use the [url] thingy for the previous link but it did not work. Thoughts appreciated. Cheers, Sam

Dear Sameh,

Grellety and Golden have a point in saying that MUAC < 115 mm fails to identify all children with a high risk of death. This has been known for years. But there are more efficient ways than using weight-for-height to detect these additional high risk children, either to increase the MUAC threshold (1) or to use weight-for-age (2) in addition to MUAC. None of these options are examined in the Grellety and Golden paper.

This paper is based on samples of children selected for treatment programmes. This approach is unreliable to make statements about community screening as this type of samples is subject to the Berksonian bias, i.e. these samples are not representative of what happens in the community (3).

1. Briend A, Maire B, Fontaine O, Garenne M. Mid-upper arm circumference and weight-for-height to identify high-risk malnourished under-five children. Matern Child Nutr. 2012;8:130–3.
2. Myatt M, Khara T, Dolan C, Garenne M, Briend A. Improving screening for malnourished children at high risk of death: a study of children aged 6-59 months in rural Senegal. Public Health Nutr. 2018;1–10.
3. Berkson J. Limitations of the application of fourfold table analysis to hospital data. Int J Epidemiol. 2014;43:511–5.

Identification, admission and discharge criteria
There were three presentations on aspects of identification, admission and discharge criteria for
MAM. Mark Myatt (UCL) presented a paper on the use of a MUAC-based case definition for MAM.
The direct use of MUAC in screening for MAM has many advantages, e.g. simplicity and easily used
in community settings, acceptability, child survival prediction, cost, age independence, precision,
accuracy, sensitivity and specificity. A review of the evidence suggests that based on mortality risk a
125mm threshold for admission of MAM cases to SFPs is most appropriate. As yet there are
insufficient data for the use of MUAC for monitoring and discharge criteria. A percentage weight gain
approach may be the most useful alternative, however, the percentage weight gain threshold for
discharge needs more research and the practicability of the response curve approach needs further
exploration. In the meantime, Mark Myatt argued that an “entitlements” approach be adopted, where
children are discharged after set periods on the basis of specified responses to treatment.
Susan Shepherd (MSF) then presented on the advantages of MUAC as an admission and discharge
criterion in an MSF selective feeding programme implemented in Burkina Faso over a two year
period. In this programme a MUAC case definition of <120mm was used for admission. Choice of
this threshold was based on Epicentre analysis of over 60.000 cases comparing number of admissions
based on different MUACs and weight for height. Two cohorts were studied, one using 15% weight
gain for discharge and the other using 125 mm MUAC for discharge. Findings challenge the current
case definition of moderate acute malnutrition using WHZ<-2 and >=-3 and suggest that current case
definitions underestimate MAM in some populations. Furthermore, using MUAC <120mm for
admission allows resources to be directed more to young children. In terms of monitoring and
discharge, MUAC trends mirror weight gain trends and therefore MUAC seems to be a suitable tool
to use for this purpose. However, the 15% weight gain discharge criterion should be reconsidered, as
it is insufficient for most severely wasted children. During plenary discussion a caution was sounded
about setting the discharge criterion for % weight gain based on plateaus of weight gain observed in
treated populations as this plateau might not reflect maximum weight gain
Andy Seal (CIHD) presented on the operational implications of using the WHO Growth Standards
(WHO-GS) on programmes addressing MAM. A recent review of a cross-section of 40 programmes
found that most SFPs are still admitting on the basis of NCHS-WHM (<80%), although a mix of
other admission criteria are also used, including NCHS-WHM, NCHS-WHZ, MUAC, weight for age.
While more programmes are likely to use WHO-WHZ in the future, it is likely that programmes will
continue to use a mix for some years to come. Analysis of the transition from NCHS-WHM to WHO-
WHZ, using a dataset made up from 560 nutrition surveys, showed that median prevalence of MAM
increases slightly from 6.85% to 7.78%. This increase in case load is likely to translate into additional
funding requirements of approximately four percent. However, for those programmes using weight
for age criteria the transition is likely to lead to a large increase in the diagnosis of ‘failure to thrive’
and may result in increased referrals of infants less than 6 months of age to SFPs During the following plenary discussion, it was suggested that 15% weight gain may not be an
appropriate measure of treatment progress for infants >6 months and <67cm. In this age group 15%
weight gain may lead to obesity and therefore weight for age criteria may be more appropriate.
Evidence of a reversal of stunting (growth in height) as a result of new diets was also highlighted with
the implication that this may make weight for age a more suitable discharge criteria to use (as it is
sensitive to wasting and stunting). The need to train those health workers who will screen children in
the appropriate use of MUAC was emphasized. It should not be assumed to be easy and simple. Poor
measurements at community level can lead to rejected referrals and undermined programmes.
Fahd yahya

Identification, admission and discharge criteria
There were three presentations on aspects of identification, admission and discharge criteria for
MAM. Mark Myatt (UCL) presented a paper on the use of a MUAC-based case definition for MAM.
The direct use of MUAC in screening for MAM has many advantages, e.g. simplicity and easily used
in community settings, acceptability, child survival prediction, cost, age independence, precision,
accuracy, sensitivity and specificity. A review of the evidence suggests that based on mortality risk a
125mm threshold for admission of MAM cases to SFPs is most appropriate. As yet there are
insufficient data for the use of MUAC for monitoring and discharge criteria. A percentage weight gain
approach may be the most useful alternative, however, the percentage weight gain threshold for
discharge needs more research and the practicability of the response curve approach needs further
exploration. In the meantime, Mark Myatt argued that an “entitlements” approach be adopted, where
children are discharged after set periods on the basis of specified responses to treatment.
Susan Shepherd (MSF) then presented on the advantages of MUAC as an admission and discharge
criterion in an MSF selective feeding programme implemented in Burkina Faso over a two year
period. In this programme a MUAC case definition of <120mm was used for admission. Choice of
this threshold was based on Epicentre analysis of over 60.000 cases comparing number of admissions
based on different MUACs and weight for height. Two cohorts were studied, one using 15% weight
gain for discharge and the other using 125 mm MUAC for discharge. Findings challenge the current
case definition of moderate acute malnutrition using WHZ<-2 and >=-3 and suggest that current case
definitions underestimate MAM in some populations. Furthermore, using MUAC <120mm for
admission allows resources to be directed more to young children. In terms of monitoring and
discharge, MUAC trends mirror weight gain trends and therefore MUAC seems to be a suitable tool
to use for this purpose. However, the 15% weight gain discharge criterion should be reconsidered, as
it is insufficient for most severely wasted children. During plenary discussion a caution was sounded
about setting the discharge criterion for % weight gain based on plateaus of weight gain observed in
treated populations as this plateau might not reflect maximum weight gain
Andy Seal (CIHD) presented on the operational implications of using the WHO Growth Standards
(WHO-GS) on programmes addressing MAM. A recent review of a cross-section of 40 programmes
found that most SFPs are still admitting on the basis of NCHS-WHM (<80%), although a mix of
other admission criteria are also used, including NCHS-WHM, NCHS-WHZ, MUAC, weight for age.
While more programmes are likely to use WHO-WHZ in the future, it is likely that programmes will
continue to use a mix for some years to come. Analysis of the transition from NCHS-WHM to WHO-
WHZ, using a dataset made up from 560 nutrition surveys, showed that median prevalence of MAM
increases slightly from 6.85% to 7.78%. This increase in case load is likely to translate into additional
funding requirements of approximately four percent. However, for those programmes using weight
for age criteria the transition is likely to lead to a large increase in the diagnosis of ‘failure to thrive’
and may result in increased referrals of infants less than 6 months of age to SFPs During the following plenary discussion, it was suggested that 15% weight gain may not be an
appropriate measure of treatment progress for infants >6 months and <67cm. In this age group 15%
weight gain may lead to obesity and therefore weight for age criteria may be more appropriate.
Evidence of a reversal of stunting (growth in height) as a result of new diets was also highlighted with
the implication that this may make weight for age a more suitable discharge criteria to use (as it is
sensitive to wasting and stunting). The need to train those health workers who will screen children in
the appropriate use of MUAC was emphasized. It should not be assumed to be easy and simple. Poor
measurements at community level can lead to rejected referrals and undermined programmes.
Fahd yahya

Dear all

i just want to have an update about this topic.Not to added some discussion but better to know how we have move forward so for about the topic

1-Are there any working group ?

2-Are there any on going research

If  you have any on going job about this topic i will be happy to be part of