That is an interesting report. We would expect a drop in weight for the cases with oedema but not for simple wasting provided the full CTC / CMAM protocol is given. Monitoring data that I have here shows considerable growth in weight and MUAC in the first two weeks of treatment for cases without oedema. There is a problem with proportional weight gain in that the most wasted (lowest weight so lowest absolute weight gain required) get less treatment than the least wasted (highest weight so highest absolute weigh gain required). This is what you are seeing. I would not recommend using minimum weight in cases with admission MUAC below 110 mm as this would make the problem worse. So ... I think you may have a reasonable temporary solution. Work is ongoing to see if MUAC discharge thresholds fix this issue. Published work (and unpublished work that I have seen) suggests that MUAC thresholds do fix the problem and that a discharge threshold of 125 mm (discharging to the community not SFP) is safe. Discharge to SFP could be at 115 mm followed by discharge to the community from SFP at 125 mm. You'd want to be sure that cases in SFP were monitored well and relapse detected and referred by to OTP. I hope this is of some help.

Using MUAC as discharge criteria eliminates the undesirable effet of having long duration of treatment for the least malnoushed children. See the free access paper below: Dale NM, Myatt M, Prudhon C, Briend A. Using mid-upper arm circumference to end treatment of severe acute malnutrition leads to higher weight gains in the most malnourished children. PLoS One. 2013;8(2):e55404. Evidence suggests that 125 mm as only discharge criteria is safe. See also the bastract below of a paper presented at the last International Nutrition Congress in Granada: RELAPSES FROM ACUTE MALNUTRITION IN A COMMUNITY-BASED MANAGEMENT PROGRAM IN BURKINA-FASO Y E. Somasse1, M. Dramaix1, P. Bahwere1, P. Donnen1 1Ecole de Santé Publique, Université Libre De Bruxelles, Brussels, Belgium Background and objectives: Community-based Management of Acute Malnutrition (CMAM) is an effective strategy for treating Severe Acute Malnutrition (SAM) (WHZ<-3) or Moderate Acute Malnutrition (MAM) (WHZ<-2). However, post-discharge follow-up often lacks. We aimed to assess the relapse rate and the related factors in a CMAM program in Burkina-Faso in which children without medical complications and who have good appetite are treated in their village by community volunteers with a Ready-To-Use-Therapeutic food (for SAM) or Corn Soya Flour (for MAM). Methods: In one-stage cluster design, the retrospective cohort data for recovered children (WHZ>-2) who were discharged from the program between January 2010 and July 2011 were collected in 45 villages of 210 in January 2012. Children were asked after discharge to return to the community center for follow-up every three months. A questionnaire including sociodemographic and economic variables and information on household food availability (for Household Food Insecurity Access Scale) and the child’s food consumption in the last 24 hours (qualitative recall for dietary diversity score) was administered. A multivariate Cox model regression was used to identify the relapse predictors. Results: Of the 509 children, 14 have died and 123 were lost to follow-up. Children admitted with SAM were more likely to die after discharge. The relapse rate was 14.2 per 100 childrenyears and the predictors were no oil/fat consumption in the last 24 hours, a mid-upper arm circumference (MUAC) <125mm at discharge, incomplete vaccination and illiteracy of mothers. Conclusions: The CMAM program should avoid premature discharge (before a MUAC of at least 125 mm) to limit relapses. Nutrition education for mothers should focus on the role of nutrients especially fat as important energy component of diet for children. Promoting good immunization and fighting against illiteracy are essential to promote child growth. I hope this helps. André

Hi André Is the full article available for the abstract you posted above? Many thanks, Nicki

Not yet. I discussed with P Donnen who supervised the study. He told me they are currently writing the full paper.

Thanks for the discussion. I also agree that reduction in weight need only be with those children with oedema. As oedema subsides, there should be weight increase gradually. Unless there are other medical conditions that are also contributors to malnutrition. I would also advise we look into the quality of care in the programme- especially the contents of feeds, the feeding patterns,hygiene component and so forth. This could also be contributing to failure to increase but decrease in weight instead. bringing children in the programme does not guarantee the weight gain or unless quality is in place too. two indicators of effectiveness that were set for one review were mortality <5% and weight gain =5g/kg/day. Following the discharge criteria on MUAC and status of oedema and medical complications will help moving from one stage of CMAM to the other. Thanks too for the results given on nutrition- follow-up on the effectiveness of the care given after discharge. I am concerned though that without the presence of a strong community based follow-up, there time specified after discharge was too long leading to high mortality rate, relapse etc. The reason is that: Women or care givers even after being advised on regular basis with important information while in the program, when discharged: Despite on follow up study, you will find that even if majority could remember the messages, a very small proportion of them will be implementing the messages, for example the content, consistency, density of diets and hygiene factors plus implementing the home kitchen gardening. Availability of food is not the only factor but also the caring time while in community and who is entrusted with the care there when the care giver provided by the information did not pass over of passed over but not being taken over. The study was very important but the timing of the study was too long and 14% fatality rate just not expected. If followed earlier, things would have been put in place and many others prevented from dying and relapse. Thanks for the contributions Cornelia Wakhanu,