on concept of nutrition protocols there is no moderate malnutrition cases with complications only SAM cases treated in inpatient care level MAM cases treated through SFP program like selective feeding program by using CSB( Corn Soya Blended or other food items supported by WFP for your case you must to run SFP program near the hospital and start to refer MAM cases from Inpatient care after complications treated Salam

Hi Boldon, You can download clear guidelines from the WHO website on management of Acute Malnutrition. This should offer you the different categories of Acute Malnutrition, their admission and discharge criteria and the commodities used for management. Please note that the protocols are very clear and must be followed to the letter for a good cure rate. If you lack the commercial formulations, recipes have been provided in the guidelines for making preparations using locally available ingredients.

Dear Boldon, You are absolutely right. Internationally, there is no guideline to provide F100/Plumpy nut to the MAM children with medical complication. Now, the question is what we will give when a child refer to inpatient. In inpatient or SC, your medical doctor can make a thorough medical check-up for the MAM children and prescribe necessary medicine for treatment. If the medical doctor diagnose a complication that needs inpatient care, the child need to be discharged from SFP as medical transfer and admitted to the hospital as a regular patient. Please remember, child will not be enrolled in SC unless classified as SAM. In hospital, the child will be treated as a regular patient (may be with special care). After discharge from hospital the child will be readmitted in the SFP as readmission after medical transfer. Please let me know, whether the above circumstances is clear to you or not. Regards

Dear Ellen, I forwarded your question to colleagues at WHO and received this response: WHO recommends RUTF only for children with SAM during the rehabilitation phase and for children with SAM who do not have medical complications. Children with MAM who have medical complications need to be admitted to a health facility so that the medical complications can be treated. They should be given nutrient dense foods, ideally based on locally available ingredients, and breastfed so that the caretaker can continue feeding the child appropriately after discharge from hospital. Please also see the Technical Note on Supplementary foods for the management of MAM: [url]http://www.who.int/nutrition/publications/moderate_malnutrition/9789241504423/en/index.html[/url] I hope this helps. Best wishes, Tamsin

Dear Ellen, In practice some inpatient facilities are treating the MAM children with RUTF, some are not. The critical part is that MAM children need to have the same medical treatment as SAM children, so it is easier but not vital that they are given the same nutritional treatment as SAM children. Where appropriate supplementary foods or a nutrient dense diet are not available, then RUTF is a safe option to prevent deterioration of their nutritional status. There are normally very few MAM children that require an inpatient phase, and this should only be for a very short period, but if this is still an issue for limited nutritonal supplies is there any scope to recieve supplementary foods for them from WFP?

Hi, I thought it might be helpful to share experience of Nepal regarding this. In 2009-2011, I were working for CMAM program of Nepal and we were admitting complicated MAM children in the Stabilization Centre (SC) for the management/stabilization of complication. Because MAM children needs special medication for management of their complications like severe diarrhoea, high fever and others which are definitely different from normal children with diarrhoea or high fever. Regarding foods, we were providing nutritious foods from hospital canteen as per their age and acceptability but in rare cases we were also providing RUTF as there were not possibility of preparing highly nutritious foods in some remote districts due to various reasons. After stabilization of complication that children were transferred out to community for the management of MAM and further nutrition counselling. Thanks Sanjay

Thank you all for your thoughtful replies. I have reached an agreement with the physicians that we will supply a homemade fortified milk for the moderately malnourished sick children to supplement the food they receive, and will seek support for that from our private donors. The hospital has a long history of not differentiating between moderate and severe and treating them all with whatever supplies we had. Apparently there had been no repercussions from the donor of the Plumpy'nut or F100/F75 in the past. Now the country has a new protocol reflecting the international standards and it is a struggle to get the staff to adjust. Rightly, they want to care for the children no matter their status and resent that there are now restrictions in place on the stock. Our contract with UNICEF is explicitly for severely malnourished children and I want to honor that as losing the supply would hurt all of the children. It will be a struggle, but supplying the medical staff with an option is the best place to start. I am also looking at support from WFP for our community based program for moderate malnutrition and this may be able to provide some Supplementary Plumpy for the inpatient moderates as well. We'll see