Why would you not include these persons? Are there lives any less worth saving? I suppose if you took the DALY approach the answer to that is "Yes. Their lives are worth less". No wonder they call economics the "dismal science".

I think the question is asking whether the same assessment criteria apply to these children and the same treatment protocols, not whether they should be treated at all. Thank you.

Sorry if I misunderstood. Presence of bilateral pitting oedema in children is associated with high mortality and if accompanied by irritability, anorexia, ulcerating dermatoses, hair and skin discolouration, and an enlarged liver is extremely likely to be a nutrition oedema. We know that this treatable using the CMAM protocol. So ... I think admission to CMAM and additional clinical screening is indicated. Low MUAC represents low levels of nutrient reserves in muscle and fat and has a high mortality risk. The condition is generally treatable with the CMAM protocol. So ... I think admission to CMAM is indicated. Low W/H is a more difficult case as many disabled children and adults have muscular-skeletal deformities either due to congenital deformity or as a sequela of congenital neurological problems or of neurological problems that sequelae of birth accident. These problems make accurate measurement of height or length problematic. W/H is very susceptible to errors in height. This means that we should probably avoid using W/H in these children. The same applies to H/A. In the past I have tended to treat disabled children with MUAC < 125 mm as complicated malnutrition (as in the CTC protocol) and admit them as SAM cases. The proper discharge criteria for such a child is not a settled issue but I would want them to be clinically well (as much as that is possible) and have demonstrated weight / MUAC gain. Just my tuppence. I hope this helps.

Dear Marie, Your question resonated with experiences I had some years ago working in an inpatient facility with SAM. A number of disabled children fulfilling anthropometric critiera for SAM were admitted for treatment. It transpired that these children all had physical feeding difficulties that were contributing to their state of malnutrition. Whilst attentive support with feeding and some nasogastric feeding support helped to rehabilitate them, this was not sustainable at home. We ended up discharging them, with a sense that we had achieved a short term improvement and they might well return repeatedly. When you admit such cases, community based support is important to invest in. But you may also have to compromise what you can hope to achieve, depending on what resources and capacity you have.

We are currently implementing the CMAM protocol in an urban-based non-emergency set up for the first time. Many of those identified as SAM either have cerebral palsy or congenital heart disease. Some of these children are beyond 5 years old. We are screening children from 0-59 months. There are cases that the child cannot tolerate the plumpy nut but can tolerate the F-100, so we give them the milk. There are cases when the child cannot tolerate both the milk and the consistency of the plumpy nut. Will it be okay to mix the RUTF with a little of clean water before giving it to the child? Is it okay to use spoon and fork as long as it is clean during feeding of RUTF? And for now, we are screening children from 0-59 months. What is the cut-off age for treatment using the CMAM protocol? Can CMAM still be applied to children beyond 5 years old and will the discharge criteria still be the same?

These are, I think, ethical issues. In what I write here I do not mean to accuse with emotive language. I am just trying to be clear. What Marie is proposing triage with the disabled as a reject to die category. This can be a legitimate procedure and is often used in battlefield medicine and in accident and emergency departments during pulses of very high demand such as train wrecks involving many injured. The basis is that for some patients there is nothing we can do so we are released from the ethical demand that we treat the patient in front of us. The other situation when this procedure comes into play is when demand is high and resources very limited. In this case we may have to decide to treat many patients who will responds well as the price of not treating a few patients that will take many resources and may not respond well. Hard decisions but sometimes necessary decisions. My concern is that we may be too quick to triage and that we become stuck within a bunker of our own specialism. I think the example of chronic infections such as HIV and TB are useful examples. It we do not treat the TB or HIV then our nutrition intervention will be a mere sticking plaster but there is a positive compound effect of treating the infection and treating the undernutrition so we arrange to treat both. With the disabled we can treat the underlying malnutrition and make efforts to find treatment for other conditions. Just as we would not reject the TB case because we don't treat TB directlty, I think we should treat the child with cerebral palsy. Organisations like Handicap International may be a good contact point for treatment. As always with ethical questions there may be more than one "truth" or (usually) no simple "truth".

i think mark is spot on about this - these are really complex ethical dilemmas and there probably isn't a 'right answer'. just a context specific 'the very best compromise we can manage' as a professor of ethics once said to me about a really complicated icu case we had asked him to consult on -> the reason these ethical dilemmas are so complex and hard, is because there is no right answer and they are difficult!

Dear all Apologies that I wasn't clear in my posting, I certainly wasn't suggesting the disabled as a reject to die category. What I was suggesting was context specific sensitive care. It can be very difficult for both health workers and carers who may find it difficult to manage feeding difficulties without the many options that would be available in a developed setting. By providing everything you possibly can in terms of SAM treatment for a child in this circumstance, this may be not enough to meet their more complex needs. This is the compromise I was implying, though not clearly enough. Apologies again.

Celna Tejare: In the programmes I’ve worked in, we’ve often mixed the plumpy nut with a small amount of water if the child refused plumpy nut alone.This often worked as it seemed to be more palatable. Using implements such as a fork or spoon to feed the child are fine, as long as this is done carefully to avoid choking, and the child is at the stage where they want to feed.