Massimo; Working Sudan these days must be quite challenging. The key elements in terms of evaluating children less than 6 mo of age who at a single point in time have a WHZ < -3 is to assess their availability to appropriate food and the assess the rate of weight gain. I would suggest asking the caretaker if the child has access to breast milk as much as the child demands. If the caretaker is the mother with normal MUAC herself and breasts that are not atrophied, you should assume breast milk to be the primary food. If the child is cared for by a grandmother unable breast feed or a mother who looks thin and ill with atrophied breasts, you should consider what foods are available to the child. Do wet nurses exist in the place you work? Does your team work to reestablish breast feeding through supplemental suckling? Is replacement formula available? The age of the child is quite important in this assessment, if the child is over 4 mo of age it is safe, although not an official recommendation, to feed F-100 or RUTF. If the child is less than 2 months of age F-100 or RUTF is deadly. The second key element is rate of weight gain, it sounds like you have some information about birth weight, you might be able to plot the few points you have and determine if the rate of weight gain follows a normal pattern. Are the growth lines roughly parallel to the 50th centile? If there is nothing known about prior weights, and the mother appears to be able to produce breast milk, have the child return in a week for a weight check. The child with SAM less than 6 mo of age is difficult to manage, may require more frequent visits to assess. The growth charts are meant to serve most of the population and thus children with very low birth weights cannot simply be plotted on the standard growth chart and designated as SAM or MAM. Growth charts are used by a variety of health aids and not meant to include the special situation of very low birth weight child

Posted on behalf of Adelheid Werimo Onyango, WHO: Dear Massimo A few things come to mind when I read your posting: - LBW is defined the basis of weight-for-age, not weight-for-length (WL) - Term LBW infants were included in the WHO standards, so the weight for age z scores (WAZ) curves spread down to below 2 kg. In this regard, they accommodate LBW. - I don't quite understand how the curves might be adapted to the event of LBWt/VLBW… - I would suggest that the standards be interpreted taking into account all the available information on the baby’s birth history. Some of the patients in Sudan may be full term LBW but also likely a few or maybe many preterms that have not yet caught up in weight. - Another important consideration is that the distance between the low WL z-scores at 45 to 50 cm is 200g, which may explain why some of the children seen are clinically ok (ie., very slight changes in weight could move a baby up or down >1SD). Which calls for holistic management taking into account as they apparently are already doing, birth history, ability to breastfeed, etc. Bottom line, to use the curves as a tool along with all clinical judgement. Best regards, Adelheid

Please note there was an error in the previous post: The second bullet point “The term LBW infants was included in the WHO standards, so the weight for age z scores (WAZ) curves spread down to below 2 kg. In this regard, they accommodate LBW...” should read: “Term LBW infants were included in the WHO standards, so the WAZ curves spread down to below 2 kg. In this regard, they accommodate LBW” Apologies and hope this is clear to all now, Tamsin

From Massimo: I confess that I'm not able to follow the explanation to my query on LBWt importance when deciding about SAM or MAM. For my weakness...not yours. My point is: a baby born let's say 2 kilos will be 4 kilos when 5 or 6 months old. This being normal growth for each baby. The same is for his length. According to the WHO card W/H this baby is affected by SAM, according to me he is not. However I see these babies being 'treated' for SAM, and F75 given besides BF, this seems to me a great mistake. Thank you.

Dear Massimo, Just to clarify and summarise from the responses above, I think you are correct in thinking that some of these infants do not have SAM and therefore should not be treated as such. As Adelheid concludes, the standards "should be interpreted taking into account all the available information on the baby’s birth history.... holistic management requires taking into account...birth history, ability to breastfeed, etc. Bottom line, to use the curves as a tool along with all clinical judgement". I hope this helps. Best wishes, Tamsin

From Massimo Serventi: Dear of en-net, another case today of 'malnourished' child who isn't in my opinion. Ali is 8/12 old, BWt 5,4kg, active, looking good. According to WHO lenght/weight card he is 'affected' by SAM. However his mother reported that he was 'very small' at birth, no record available...but he was small. Now I ask to my colleagues in the world and to WHO: if a baby is born,say, 2000gr should I expect that he will double his BWt when 5-6 months old, yes? i.e. 4000gr? therefore Ali with his BWt of 5400gr at 8 months is not poorly-nourished, his growing is good, in accordance to his low starting weight. Am I correct? Ali was labelled as SAM, sent to a feeding centre and prescribed with vitamins-zinc-antibiotics. After one month he will be examined by another doctor, he will be diagnosed as 'malnourished', re-sent to a feeding centre, prescribed with drugs and 'treated' with plumpynut. And after another month..... Thanks. Massimo (Serventi) Port Sudan If what I write is correct, why then WHO has delivered reference table that do not consider the event of LBW? after all these children are not few in Africa, between 15 to 20% of all babies at birth.