Hi Ahmed,

1. Typically a child with low weight for height AND oedema will be diagnosed as having "marasmic kwashiorkor" and under most (if not all) CMAM protocols this is an indication for inpatient treatment whether or not there are other complications or appetite for RUTF.
When fed with the correct diet 2+ oedema can be expected to resolve within 2-3 weeks. Generally oedema loss occurs more quickly with F100 / RUTF than with F75 so in the stabilisation centre progress may appear to be slower. As the 2+ oedema resolves you might expect a significant loss of weight (and weight for height). If the oedema is prolonged check that the therapeutic milk is being prescribed and prepared correctly or that the RUTF is being given as directed at home. Advise the carer not to use salt in any family foods that the child may be eating.

Since you used Weight for Height and oedema for diagnosis you should use those for discharge. The oedema should have been completely resolved AND the weight for height should be above -2 z-scores for 2 consecutive visits (assuming treatment is continued as an outpatient). If the patient is in hospital the oedema must have been completely resolved for a minimum of 10 days and the WFH be above discharge criteria for 3 consecutive days.

2. Firstly the child should be discharged according to the admission criterion. If the child was admitted on MUAC then discharge on MUAC, if admitted on WFH then discharge on WFH.

MUAC and weight respond in a similar way to treatment and can be expected to increase or decrease together in lock-step. There is no lag effect on the part of weight or MUAC. See this reference: http://www.ncbi.nlm.nih.gov/pubmed/26693279.

Typically only around 40% of cases of SAM that can be identified using WFH and MUAC will be classified as SAM by both criteria. If a child has a low weight for height (< -3 z-score) and a MUAC > 11.5cm at admission then you might expect the child to reach the "MUAC discharge criteria" of 12.5cm quite quickly, however since the child was admitted using weight for height you must wait until the child reaches > -2 z-score irrespective of what the MUAC measurement might be.

The length of time it takes for a child to be cured depends on how malnourished they were when they were admitted. A child with a MUAC of 10 cm on admission will typically take 10 weeks or more to reach > 12.5 cm for discharge. A child with a MUAC of 11.3 cm on admission will typically recover much more quickly. The same applies to children admitted with low weight for height. A child with a WFH < -3 z-score will recover more quickly than a child with WFH < -4 z-score.

In a study in Malawi all children admitted to OTP with a MUAC < 11.5 cm and discharged from OTP with a MUAC > 12.5cm also had a WFH > -2 z-score (many had WFH > -1 z-score).

I hope this helps

thank you Poul, in the OTP program, the discharge criteria of MUAC is >11.5cm after attending 2 consecutive visit, for example if a child's MUAC is 11.2cm and W/H is <-3 Z-score, it will take to reach the cut-of point of MUAC probably 4 weeks in the OTP program, so how many weeks will it take to reach the cut-of point of W/H >-2 Zscore for this child?

Hi Ahmed,

The current WHO recommendation for MUAC discharge is MUAC > 12.5cm for 2 consecutive visits.

Previously MUAC > 11.5cm had been used but ALWAYS in combination with another criterion such as "minimum stay of 2 months" or "15-20% weight gain". The use of proportional weight gain was demonstrated to be problematic and is now NOT recommended.

I would recommend that you revise your discharge criteria to met WHO recommendations which can be found here:

http://www.who.int/nutrition/publications/guidelines/updates_management_SAM_infantandchildren/en/

In the case of this specific child you should discharge the child at MUAC > 12.5cm. If you cannot revise your MUAC discharge criterion immediately I would suggest that for this particular child s/he should be kept in the programme until WFH > -2 z-scores. If possible discharge the child to SFP for continued nutritional support.

Z scores only classify a child so I cannot tell you how long it will take for a child of < -3 Z score to reach > -2 z-score. Each child will be different depending on how much weight they need to gain for that height classification.

However, if we think about expected weight gain we can expect around 5g / kg / day or more for a child fed on RUTF in the outpatient setting. A 5kg child should gain around 175g (or more) each week. If you want to make a specific calculation for this child look at the child's weight at the next visit and see how much weight it needs to gain to reach WFH >-2 Z-scores (for a child of that height category). Divide that figure by the average weekly weight gain and you will find an estimated length of stay.

I hope this helps.

Hi poul,

Thank you, if you look at a IMAM guideline that UNICEF and Somalia government published at 2009. it tells that the discharge criteria of OTP program is >11.5cm, while >12.5 is the discharge criteria of TSFP, so please look at this.
https://www.humanitarianresponse.info/system/files/Guideline%2520for%2520Integrated%2520management%2520of%2520Acute%2520Malnutrition.pd.

on other hand the weight gain of OTP child is 4-5g/kg/day, so what is average gain in Height for OTP child per CM?

i hope you get my point.

where is Mark myatt?

Hi Ahmed,
you can find a copy of the Somalia National Guidelines (2010) here:

http://www.cmamforum.org/resource/628

The discharge criteria from OTP are:
MUAC > 125mm
WFH > -2Z
No oedema
For 2 consecutive visits

In light of your own reference and the WHO recommendations from 2013, I think it should be a priority to reconsider your MUAC discharge criteria.

Averaging weight gain and height gain to estimate a length of stay is a complicated way of going about the management of a child. In this circumstance (and based on the currently available evidence) I think the 11.5cm cut off without any other qualifier is an unsafe discharge criterion. For the particular child you mentioned (admitted with low MUAC and WFH < -3z) you should keep them in the programme as long as it takes to discharge them safely with WFH > -2.

The average LOS for children discharged by MUAC or WFH criteria approximates 6-8 weeks. Some will recover more quickly and some will take longer depending on their individual condition.

If you wish to follow up with Mark personally you might try to contact him on his email address.

Cheers
Paul

Hi Poul,
thank you, yes, I have this document, so if you look at page 39 table Field Card 7. Admission criteria for children 6 to 59 months, it is written as follows:

admission of OTP by MUAC <115
Admision of TSFP by MUAC <125

So, if you look these by means >115 mm, it is the discharge criteria of OTP, while >125mm is the discharge criteria of TSFP.

I hope you get the point.

Ahmed-Nor

Dear Ahmed,
You have referenced ADMISSION CRITERIA and decided that discharge should occur once the child has 'recovered' above the cut of set for admission. THIS IS INCORRECT.

You need to look at the discharge criteria which have been set for SAM cases and are written in the same guidelines. The MUAC discharge criterion for both SAM and MAM cases is MUAC >12.5cm.

I am afraid that I do not "get your point". You are not discharging children according to the guidelines you have set as your standard. I am not aware of any guideline which suggests that discharge of a SAM case with MUAC >11.5cm as a sole criterion is safe.

At this point I do not think I can add anything which makes the case more clearly. Your current MUAC discharge criterion is unsafe and you should consider changing it to follow WHO recommendations at the earliest possible opportunity.

Thanks
Paul

Hi Paul,

Many thanks for the substantial information on the discharge criteria for SAM and MAM children and for the useful references you have provided. Just wondering if you can share the Guidelines for the management of Acute Malnutrition for Sudan.

Thanks in advance,
Issack.

Hi Issack,
S.Sudan guidelines was under revision a few months ago and I am not sure that it is already finalized. I advice you to consult the nutrition cluster website or contact an organisation working there
https://sites.google.com/site/nutritionclustersouthsudan/

Hi Issack,
In a google search I couldn't find any recent guidelines for Sudan. The most recent i could find were some interim guidelines from 2009:
http://www.fantaproject.org/focus-areas/nutrition-emergencies-mam/sudan-interim-national-guideline-cmam
I also found a presentation from 2011 which suggested that guidelines were being updated:
http://www.fantaproject.org/focus-areas/nutrition-emergencies-mam/sudan-training-inpatient-acute-malnutrition

I found a Sudan Nutrition Cluster update (2014) with the following contact details:

Cluster coordinator:
Samson Desie sdesie@unicef.org

Government lead:
Federal Ministry of Health (FMOH)
Salwa Sorkti ssorkti@gmail.com

I don't know if these details remain current but perhaps worth checking.

Cheers
Paul

Thank Lio!.Appreciated.

Thanks Paul for the quick feedback.Appreciated!

Hi everyone,
Glad to share the information for discharge criteria. In context to our country i.e Nepal .Now a days we are practicing the following criteria for discharge of SAM cases.
1) MUAC >11.5 cm.
2) All SAM cases should be enroll minimum for 42 days in OTP.
After the achievement of both criteria than the SAM (marasmus) case will be discharged.
For oedema (++) after the healing of ++ for the 2 consecutive visit the case will be discharge form OTP.

Hi Sunil
thanks for your addition.

The length of time it takes for a child to recover will vary from child to child. The more malnourished they are on admission the longer it takes to make a full nutritional recovery.

Example: To achieve full recovery to MUAC > 12.5 cm as recommended by WHO

- A child with MUAC 11.0 to 11.4cm has a median recovery time of around 40 to
50 days
- A child with MUAC 10.0 to 11.0cm takes around 60 - 70 days
- A child with MUAC less than 10.0cm may take around 100 days to recover

The old Valid International discharge criteria (2006) used MUAC > 11.5 cm + 2 months minimum stay. Unless you have remarkably good case finding and admit all of your cases with a MUAC > 11.0cm there is a chance that a fixed length of stay of 42 days may not be enough for all children to make a satisfactory recovery. You may wish to consider adjusting the fixed length of stay in your programme. Better still would be to update discharge criteria according to WHO recommendations.

Cheers
Paul

When I went to the South Sudan nutrition cluster website https://sites.google.com/site/nutritionclustersouthsudan/ (to see if the SAM/MAM guidelines were finalised) the latest post seems to be 2014. Does anyone know if the cluster is still operational, and the status of the SAM/MAM guidelines? If allowed, we would like to announce the finalised guidelines in a future issue of the South Sudan Medical Journal (www.southsudanmedicaljournal.com .

Dear Ann,

Thank you for following up the status of the nutrition cluster in South Sudan.
I would like to update you as follows:
1) The cluster is functional and fully staff with a team of 5 full time personnel:
2) The nutrition cluster site that you are referring to is no longer the nutrition cluster website since November 2014. The new nutrition cluster website for South Sudan is: http://www.humanitarianresponse.info/operations/south-sudan/nutrition

The MOH in collaboration with partners is currently developing a new CMAM guideline that is currently being reviewed under the leadership of the MOH. Once the guideline is finalized it will be posted on the MOH website and possibly the nutrition cluster website if government approves.

I do hope this clarifies.

Dear Isaac
Many thanks – the new nutrition cluster website for South Sudan at http://www.humanitarianresponse.info/operations/south-sudan/nutrition is excellent and very useful. I will be checking it from now on – and hoping we can share some items in the South Sudan Medical Journal.
Ann

Thanks Paul for sharing the valuable information. Your opinion supports our field experience.

Thanks Poul for the valuable information you gave me, if you discharge SAM cases with MUAC >12.5, what will I do in the tSFP cases (INS)? Because you know there is Individual Nutrition Support those who are OTP graduate (Cured).
On other hand I did not mean that if I discharge a SAM case with MUAC >11.5, and then release to the community Not, it is forbidden, so a SAM cases when they cured the OTP program, we completed in the tSPF (INS) program. What do you think?

Regards
Ahmed-Nur

Hi Ahmed,
my apologies for the delay to my reply; I have been travelling.

In the case of SFP, nutritional recovery is still defined for a MAM case as MUAC >125 mm or WFH > -2z. This is what is indicated in the Somalia guidelines you referenced earlier in the discussion.

In terms of the transfer of the SAM child to SFP when they reach MUAC equal or greater than 115 mm, recent evidence shows promising results for a regime where the child undergoing treatment for SAM is given the standard RUTF dose (200 kcal/kg/day) while they are < 115 mm and reduced doses of RUTF during the period they are 115 mm or greater until discharge with MUAC > 125 mm.

http://publichealth.wustl.edu/wp-content/uploads/2014/08/NnekaPubJN.pdf

The integrated approach described achieved higher recovery and coverage rates than the standard treatment protocol which involves transferring the child to SFP for treatment with cereal flours. The authors suggest that care should be taken in extrapolating these results to other contexts.

Cheers
Paul