Dear Anonymous, 

There are currently no WHO guidelines on the mangememt of moderate wasting in children.  This is a recognised guideline gap and it is specifically included in the update of the WHO guidelines on wasting prevention and treatment that is well underway. Recommendations are due end of 2022/early 2023.  You can see more information about the process including the specific questions that are being addressed (some are specific to moderate wasting) here. 

MSF are best placed to elaborate on what basis they make recommendations on medically complicated case mangement of moderate cases in their clincial guidelines. From previous conversations I have had with clincal leads at MSF this has been based on significant case management experience.

Dear Marie MacGrath, 

Many thanks for your quick reply. Indeed, MSF experts should be better placed to explain these recommendations. Would there any of these experts willing to provide further information on what experiences and evidences they have based their recommendations?

Dear Anonymous

MSF will shortly provide some clarity.  Warm regards, Marie

Dear all,

The text from the document referenced above is an internal MSF document; thanks for spotting the error in quoting WHO, it will be corrected. The full text for this section was written to emphasise the importance of assessing each MAM child who is in an inpatient facility on an individual basis, the text quoted here does not reflect the overarching message of this section. In addition, it is a paragraph within the MSF protocol where topics are discussed separately with the instruction: 'Point of reflection or something to think about/discuss in your team or with your nutrition adviser'. The full section is quoted below, but again, this is an internal document which is normally not published outside of MSF.

"The current MSF guidance is to admit MAM patients with medical complications and treat them as SAM with all the accompanying nutritional and medical treatment. Although there is no strong evidence to change this approach and MAMs are more at risk of mortality that non-malnourished children, it is often observed that there can be great variation in the clinical presentation and progress of such MAM patients.

As such, we recommend a pragmatic approach backed-up by a comprehensive clinical evaluation of each case, if necessary, by a senior clinician in the project and if in serious doubt, with the nutrition/paediatric adviser of your section.

We can see that some MAM patients are likely to be suffering from MAM secondary to an acute illness and others have MAM due to a more chronic picture of nutritional deprivation (and likely recurrent infections). This may not always be so easy to differentiate (and can co-exist!), so it is better to focus on how quickly they respond to initial treatment. For some MAM patients, even those who present very unwell in shock or with altered consciousness (e.g. secondary to severe malaria), we often see that with good treatment and monitoring, they quickly improve within 24-36 hours.

MAM patients who show rapid clinical improvement after initial resuscitation/treatment:

- When the patient is cardiovascularly stable, transitioning from IV to enteral feeds can be done according to guidance in section 6.1.

- Re-evaluate their anthropometric measures to see if they are still suffering from MAM.

- Even if they are still suffering from MAM, but have shown significant clinical improvement and stability, restart normal hospital meals with added RUTF (according to their weight, see section 5.3.2) and re-evaluate after the first day.

- If they then show clinical deterioration with the initiation of normal meals - severe diarrhoea, severe abdominal distension and discomfort - consider starting the full nutritional protocol starting with F-75.

- This full treatment may take the normal amount of time recommended in the protocol or may be fast-tracked if improvement seen quickly and the patient evaluated as stable and hungry

- If they remain stable on normal hospital meals and RUTF diet, continue until discharge

MAM patients who poor/no clinical improvement after initial resuscitation/treatment:

- When the patient is cardiovascularly stable, transitioning from IV to enteral feeds can be done according to guidance in section 6.1.

- When the patient is on 100% enteral feeds, start the full nutritional protocol starting with F-75

- If the patient starts to show improvement, try to move them into transition phase and then phase 2 as quickly as is safely possible so that they get adequate protein and calories but watch out for intolerance.

On exit from hospital:

- If the child is still MAM, it is advisable to send them home with RUTF (i.e. we treat children with RUTF until 'cure') as per the outpatient protocol  and review them in ATFC in 1-2 weeks.

- If the child is no longer MAM, they can be sent home with no RUTF, but consider at least one follow-up appointment in ATFC just for clinical review in 2-4 weeks.

- Remember to spend time with the caretaker before discharge to provide counselling on best practices to feed their child and danger signs to look out for if the child becomes unwell and what to do next.

FINALLY Always keep an eye out in the general paediatric inpatient ward/department (IPD) that there are not undiagnosed MAMs present and talk with your colleagues who manage these units to also regularly weigh children with any risk of weight loss or poor appetite. These MAM patients may simply need some extra supplemental food (e.g. RUSF and if not available then RUTF) rather than the full nutritional protocol."

I hope this helps to clarify the issue,

Best regards

Dear all,

The text from the document referenced above is an internal MSF document; thanks for spotting the error in quoting WHO, it will be corrected. The full text for this section was written to emphasise the importance of assessing each MAM child who is in an inpatient facility on an individual basis, the text quoted here does not reflect the overarching message of this section. In addition, it is a paragraph within the MSF protocol where topics are discussed separately with the instruction: 'Point of reflection or something to think about/discuss in your team or with your nutrition adviser'. The full section is quoted below, but again, this is an internal document which is normally not published outside of MSF.

"The current MSF guidance is to admit MAM patients with medical complications and treat them as SAM with all the accompanying nutritional and medical treatment. Although there is no strong evidence to change this approach and MAMs are more at risk of mortality that non-malnourished children, it is often observed that there can be great variation in the clinical presentation and progress of such MAM patients.

As such, we recommend a pragmatic approach backed-up by a comprehensive clinical evaluation of each case, if necessary, by a senior clinician in the project and if in serious doubt, with the nutrition/paediatric adviser of your section.

We can see that some MAM patients are likely to be suffering from MAM secondary to an acute illness and others have MAM due to a more chronic picture of nutritional deprivation (and likely recurrent infections). This may not always be so easy to differentiate (and can co-exist!), so it is better to focus on how quickly they respond to initial treatment. For some MAM patients, even those who present very unwell in shock or with altered consciousness (e.g. secondary to severe malaria), we often see that with good treatment and monitoring, they quickly improve within 24-36 hours.

MAM patients who show rapid clinical improvement after initial resuscitation/treatment:

- When the patient is cardiovascularly stable, transitioning from IV to enteral feeds can be done according to guidance in section 6.1.

- Re-evaluate their anthropometric measures to see if they are still suffering from MAM.

- Even if they are still suffering from MAM, but have shown significant clinical improvement and stability, restart normal hospital meals with added RUTF (according to their weight, see section 5.3.2) and re-evaluate after the first day.

- If they then show clinical deterioration with the initiation of normal meals - severe diarrhoea, severe abdominal distension and discomfort - consider starting the full nutritional protocol starting with F-75.

- This full treatment may take the normal amount of time recommended in the protocol or may be fast-tracked if improvement seen quickly and the patient evaluated as stable and hungry

- If they remain stable on normal hospital meals and RUTF diet, continue until discharge

MAM patients who poor/no clinical improvement after initial resuscitation/treatment:

- When the patient is cardiovascularly stable, transitioning from IV to enteral feeds can be done according to guidance in section 6.1.

- When the patient is on 100% enteral feeds, start the full nutritional protocol starting with F-75

- If the patient starts to show improvement, try to move them into transition phase and then phase 2 as quickly as is safely possible so that they get adequate protein and calories but watch out for intolerance.

On exit from hospital:

- If the child is still MAM, it is advisable to send them home with RUTF (i.e. we treat children with RUTF until 'cure') as per the outpatient protocol  and review them in ATFC in 1-2 weeks.

- If the child is no longer MAM, they can be sent home with no RUTF, but consider at least one follow-up appointment in ATFC just for clinical review in 2-4 weeks.

- Remember to spend time with the caretaker before discharge to provide counselling on best practices to feed their child and danger signs to look out for if the child becomes unwell and what to do next.

FINALLY Always keep an eye out in the general paediatric inpatient ward/department (IPD) that there are not undiagnosed MAMs present and talk with your colleagues who manage these units to also regularly weigh children with any risk of weight loss or poor appetite. These MAM patients may simply need some extra supplemental food (e.g. RUSF and if not available then RUTF) rather than the full nutritional protocol."

I hope this helps to clarify the issue,

Best regards

Dear all,

The text from the document referenced above is an internal MSF document; thanks for spotting the error in quoting WHO, it will be corrected. The full text for this section was written to emphasise the importance of assessing each MAM child who is in an inpatient facility on an individual basis, the text quoted here does not reflect the overarching message of this section. In addition, it is a paragraph within the MSF protocol where topics are discussed separately with the instruction: 'Point of reflection or something to think about/discuss in your team or with your nutrition adviser'. The full section is quoted below, but again, this is an internal document which is normally not published outside of MSF.

"The current MSF guidance is to admit MAM patients with medical complications and treat them as SAM with all the accompanying nutritional and medical treatment. Although there is no strong evidence to change this approach and MAMs are more at risk of mortality that non-malnourished children, it is often observed that there can be great variation in the clinical presentation and progress of such MAM patients.

As such, we recommend a pragmatic approach backed-up by a comprehensive clinical evaluation of each case, if necessary, by a senior clinician in the project and if in serious doubt, with the nutrition/paediatric adviser of your section.

We can see that some MAM patients are likely to be suffering from MAM secondary to an acute illness and others have MAM due to a more chronic picture of nutritional deprivation (and likely recurrent infections). This may not always be so easy to differentiate (and can co-exist!), so it is better to focus on how quickly they respond to initial treatment. For some MAM patients, even those who present very unwell in shock or with altered consciousness (e.g. secondary to severe malaria), we often see that with good treatment and monitoring, they quickly improve within 24-36 hours.

MAM patients who show rapid clinical improvement after initial resuscitation/treatment:

- When the patient is cardiovascularly stable, transitioning from IV to enteral feeds can be done according to guidance in section 6.1.

- Re-evaluate their anthropometric measures to see if they are still suffering from MAM.

- Even if they are still suffering from MAM, but have shown significant clinical improvement and stability, restart normal hospital meals with added RUTF (according to their weight, see section 5.3.2) and re-evaluate after the first day.

- If they then show clinical deterioration with the initiation of normal meals - severe diarrhoea, severe abdominal distension and discomfort - consider starting the full nutritional protocol starting with F-75.

- This full treatment may take the normal amount of time recommended in the protocol or may be fast-tracked if improvement seen quickly and the patient evaluated as stable and hungry

- If they remain stable on normal hospital meals and RUTF diet, continue until discharge

MAM patients who poor/no clinical improvement after initial resuscitation/treatment:

- When the patient is cardiovascularly stable, transitioning from IV to enteral feeds can be done according to guidance in section 6.1.

- When the patient is on 100% enteral feeds, start the full nutritional protocol starting with F-75

- If the patient starts to show improvement, try to move them into transition phase and then phase 2 as quickly as is safely possible so that they get adequate protein and calories but watch out for intolerance.

On exit from hospital:

- If the child is still MAM, it is advisable to send them home with RUTF (i.e. we treat children with RUTF until 'cure') as per the outpatient protocol  and review them in ATFC in 1-2 weeks.

- If the child is no longer MAM, they can be sent home with no RUTF, but consider at least one follow-up appointment in ATFC just for clinical review in 2-4 weeks.

- Remember to spend time with the caretaker before discharge to provide counselling on best practices to feed their child and danger signs to look out for if the child becomes unwell and what to do next.

FINALLY Always keep an eye out in the general paediatric inpatient ward/department (IPD) that there are not undiagnosed MAMs present and talk with your colleagues who manage these units to also regularly weigh children with any risk of weight loss or poor appetite. These MAM patients may simply need some extra supplemental food (e.g. RUSF and if not available then RUTF) rather than the full nutritional protocol."

I hope this helps to clarify the issue,

Best regards

Dear all,

The text from the document referenced above is an internal MSF document; thanks for spotting the error in quoting WHO, it will be corrected. The full text for this section was written to emphasise the importance of assessing each MAM child who is in an inpatient facility on an individual basis, the text quoted here does not reflect the overarching message of this section. In addition, it is a paragraph within the MSF protocol where topics are discussed separately with the instruction: 'Point of reflection or something to think about/discuss in your team or with your nutrition adviser'. The full section is quoted below, but again, this is an internal document which is normally not published outside of MSF.

"The current MSF guidance is to admit MAM patients with medical complications and treat them as SAM with all the accompanying nutritional and medical treatment. Although there is no strong evidence to change this approach and MAMs are more at risk of mortality that non-malnourished children, it is often observed that there can be great variation in the clinical presentation and progress of such MAM patients.

As such, we recommend a pragmatic approach backed-up by a comprehensive clinical evaluation of each case, if necessary, by a senior clinician in the project and if in serious doubt, with the nutrition/paediatric adviser of your section.

We can see that some MAM patients are likely to be suffering from MAM secondary to an acute illness and others have MAM due to a more chronic picture of nutritional deprivation (and likely recurrent infections). This may not always be so easy to differentiate (and can co-exist!), so it is better to focus on how quickly they respond to initial treatment. For some MAM patients, even those who present very unwell in shock or with altered consciousness (e.g. secondary to severe malaria), we often see that with good treatment and monitoring, they quickly improve within 24-36 hours.

MAM patients who show rapid clinical improvement after initial resuscitation/treatment:

- When the patient is cardiovascularly stable, transitioning from IV to enteral feeds can be done according to guidance in section 6.1.

- Re-evaluate their anthropometric measures to see if they are still suffering from MAM.

- Even if they are still suffering from MAM, but have shown significant clinical improvement and stability, restart normal hospital meals with added RUTF (according to their weight, see section 5.3.2) and re-evaluate after the first day.

- If they then show clinical deterioration with the initiation of normal meals - severe diarrhoea, severe abdominal distension and discomfort - consider starting the full nutritional protocol starting with F-75.

- This full treatment may take the normal amount of time recommended in the protocol or may be fast-tracked if improvement seen quickly and the patient evaluated as stable and hungry

- If they remain stable on normal hospital meals and RUTF diet, continue until discharge

MAM patients who poor/no clinical improvement after initial resuscitation/treatment:

- When the patient is cardiovascularly stable, transitioning from IV to enteral feeds can be done according to guidance in section 6.1.

- When the patient is on 100% enteral feeds, start the full nutritional protocol starting with F-75

- If the patient starts to show improvement, try to move them into transition phase and then phase 2 as quickly as is safely possible so that they get adequate protein and calories but watch out for intolerance.

On exit from hospital:

- If the child is still MAM, it is advisable to send them home with RUTF (i.e. we treat children with RUTF until 'cure') as per the outpatient protocol  and review them in ATFC in 1-2 weeks.

- If the child is no longer MAM, they can be sent home with no RUTF, but consider at least one follow-up appointment in ATFC just for clinical review in 2-4 weeks.

- Remember to spend time with the caretaker before discharge to provide counselling on best practices to feed their child and danger signs to look out for if the child becomes unwell and what to do next.

FINALLY Always keep an eye out in the general paediatric inpatient ward/department (IPD) that there are not undiagnosed MAMs present and talk with your colleagues who manage these units to also regularly weigh children with any risk of weight loss or poor appetite. These MAM patients may simply need some extra supplemental food (e.g. RUSF and if not available then RUTF) rather than the full nutritional protocol."

I hope this helps to clarify the issue,

Best regards

Dear all,

The text from the document referenced above is an internal MSF document; thanks for spotting the error in quoting WHO, it will be corrected. The full text for this section was written to emphasise the importance of assessing each MAM child who is in an inpatient facility on an individual basis, the text quoted here does not reflect the overarching message of this section. In addition, it is a paragraph within the MSF protocol where topics are discussed separately with the instruction: 'Point of reflection or something to think about/discuss in your team or with your nutrition adviser'. The full section is quoted below, but again, this is an internal document which is normally not published outside of MSF.

"The current MSF guidance is to admit MAM patients with medical complications and treat them as SAM with all the accompanying nutritional and medical treatment. Although there is no strong evidence to change this approach and MAMs are more at risk of mortality that non-malnourished children, it is often observed that there can be great variation in the clinical presentation and progress of such MAM patients.

As such, we recommend a pragmatic approach backed-up by a comprehensive clinical evaluation of each case, if necessary, by a senior clinician in the project and if in serious doubt, with the nutrition/paediatric adviser of your section.

We can see that some MAM patients are likely to be suffering from MAM secondary to an acute illness and others have MAM due to a more chronic picture of nutritional deprivation (and likely recurrent infections). This may not always be so easy to differentiate (and can co-exist!), so it is better to focus on how quickly they respond to initial treatment. For some MAM patients, even those who present very unwell in shock or with altered consciousness (e.g. secondary to severe malaria), we often see that with good treatment and monitoring, they quickly improve within 24-36 hours.

MAM patients who show rapid clinical improvement after initial resuscitation/treatment:

- When the patient is cardiovascularly stable, transitioning from IV to enteral feeds can be done according to guidance in section 6.1.

- Re-evaluate their anthropometric measures to see if they are still suffering from MAM.

- Even if they are still suffering from MAM, but have shown significant clinical improvement and stability, restart normal hospital meals with added RUTF (according to their weight, see section 5.3.2) and re-evaluate after the first day.

- If they then show clinical deterioration with the initiation of normal meals - severe diarrhoea, severe abdominal distension and discomfort - consider starting the full nutritional protocol starting with F-75.

- This full treatment may take the normal amount of time recommended in the protocol or may be fast-tracked if improvement seen quickly and the patient evaluated as stable and hungry

- If they remain stable on normal hospital meals and RUTF diet, continue until discharge

MAM patients who poor/no clinical improvement after initial resuscitation/treatment:

- When the patient is cardiovascularly stable, transitioning from IV to enteral feeds can be done according to guidance in section 6.1.

- When the patient is on 100% enteral feeds, start the full nutritional protocol starting with F-75

- If the patient starts to show improvement, try to move them into transition phase and then phase 2 as quickly as is safely possible so that they get adequate protein and calories but watch out for intolerance.

On exit from hospital:

- If the child is still MAM, it is advisable to send them home with RUTF (i.e. we treat children with RUTF until 'cure') as per the outpatient protocol  and review them in ATFC in 1-2 weeks.

- If the child is no longer MAM, they can be sent home with no RUTF, but consider at least one follow-up appointment in ATFC just for clinical review in 2-4 weeks.

- Remember to spend time with the caretaker before discharge to provide counselling on best practices to feed their child and danger signs to look out for if the child becomes unwell and what to do next.

FINALLY Always keep an eye out in the general paediatric inpatient ward/department (IPD) that there are not undiagnosed MAMs present and talk with your colleagues who manage these units to also regularly weigh children with any risk of weight loss or poor appetite. These MAM patients may simply need some extra supplemental food (e.g. RUSF and if not available then RUTF) rather than the full nutritional protocol."

I hope this helps to clarify the issue,

Best regards

I wish to comment on this exchange and would be grateful if you would post this. I have taken the liberty of copying to persons at WHO and their advisory panel.

How to manage MAM with complications.

To address this question we have to consider the reason for the differences in the treatment of complications in normal and SAM children; and then whether MAM children's physiology has changed sufficiently to be similar to that of children with SAM. 

In severely malnourished children reductive adaptation leads to a slowing of the sodium pump which in turn leads to an increase in intracellular sodium in all cells and a corresponding reduction in potassium.  The result is a change in electrical and transport function that affects all cells in all organs. There are major changes in renal, hepatic and cardiac function. 

Detailed, pertinent, physiological studies have not been made on MAM children, to my knowledge. Therefore there is, at present, no basis for deciding whether MAM children's complications should be treated similarly to normal or SAM children.  The data are simply not available for anybody to make a definitive recommendation.

Nevertheless there are considerations to take into account.

The physiological studies were conducted between 1950 and 1990 on children when the definitions for SAM were much more stringent than those today (NCHS vs WHO weight-for-height). The MUAC definition has moved from <110mm to 115mm although MUAC was not generally used when the physiological studies were conducted.  In other words there are a great many children who would be considered SAM today who would have been classified as MAM previously and therefore not included in the previous physiological studies.

The only physiological test that is routinely applied to SAM (and sometime MAM) children is a test of their appetites.  With the new definitions of SAM the majority of children have good or reasonable appetites. This not only is used as a criterion for management as outpatients but also indicates that the majority of these children have relatively mild SAM and do not have a major metabolic disturbance, infection or specific deficiency sufficient to impair their physiological capacity.  Virtually all the MAM children have good or reasonable appetites (unless they have an acute infection in which case the cause of the loss of appetite is different to that encountered in SAM).

By definition 2.5% of children in a perfectly normal population without any malnutrition would be classified as MAM.  Thus, if the prevalence of MAM in a population is 5 to 10%, which is the usual situation in many stressed populations, then between one half (2.5/5) and one quarter (2.5/10) of the children classified as MAM are in fact perfectly normal children who happen to fall into the tail of the normal distribution. These children at least should be treated as normal children and not as SAM children.  For example, they will need WHO-oral rehydration solution and not ReSoMal; they should be given IV fluids according to the protocol for normally nourished children with dehydration and not have their fluids restricted as one should do for a SAM child*.

I presume that the MSF staff who stated in their internal guideline that MAM children with complications should be treated as SAM children make this suggestion on the basis that this is the safest option in the absence of any data.  This is not necessarily the case.  In Niger in about 2006 I explained the reasons for fluid and sodium restriction in SAM to the MSF physician. There was an immediate drop in his mortality rate when this was introduced. He then introduced the same regimen for the MAM children, and there was an increase in mortality to almost equal that of the SAM children.  This was largely due to under treatment of dehydration in the MAM children and prior overtreatment in the SAM children.

Another reason for not treating MAM children as if they had SAM is logistical.  For each SAM child there are usually about 10 MAM children.  If all these MAM children with complications are admitted and treated with F75 and then put into transition phase with RUTF, there is a grave danger of the staff being overwhelmed and not differentiating the SAM from the MAM children so that the SAM children fail to get the increased care and attention they need.  In many situations there are shortages and stock-outs of the materials to treat SAM children. This will be greatly exacerbated if all MAM children are treated as if they are actually SAM children.

I presume that the authors of the MSF guideline, and those who checked the draft, attributed their instruction to WHO in order to give it authority.  If deliberate that would amount to malpractice and WHO should take action to correct this misinformation.  The only instruction that WHO has given on MAM management is that MAM children should not be given any special diets **. In other words they are to be treated as normal children.  I understand that there has been considerable resistance to this WHO guideline by those managing MAM children; nevertheless, it would be difficult for WHO to advocate a policy which directly contradicts its published guidelines.

Michael H Golden

* It may be that with the inclusion of many children that have a much milder form of SAM than the children whose data was used to formulate the guidelines for management of SAM that some of them, for example those meeting the criteria for outpatient treatment, should have their complications treated as if they did not have the metabolic disturbance of the more severely malnourished children.  This consideration should not, at the moment, lead to any change in SAM management.

**World Health Organization. Guideline assessing and managing children at primary health-care facilities to prevent overweight and obesity in the context of the double burden of malnutrition.   2017

Dear Mike 

Many thanks for your detailed comments, which on sharing directly with WHO and ENN on the 29th, prompted a quick reaction by WHO to contact MSF for clarification that in turn led to Roberta's very helpful response.

Both comments reflect the complexities of case management of moderate cases both at an individual level and for systems and services.  There is much work afoot to try to address this with risk stratification being a very promising direction of travel. For example, pooled data analysis being led by WHO on what are the factors including but also beyond anthropometry that identify children most at risk of death and other adverse outcomes. 

A recent paper from the CHAIN Study also highlights the complexities and how pivotal individual circumstance is to both causation and case management of malnutrition and that anthropometry is a useful but blunt instrument in identifying risk and evidencing recovery.

For example, the CHAIN Network found that admission to hospital was often in the context of a long series of interactions with various health providers regarding the child’s illness. Nearly half of all deaths occurred after discharge from hospital regardless of anthropometric classification. Anthropometry was an important predictor of mortality risk capturing many risk exposures besides food security and diet. Risks such as maternal mental health and independent employment, household characteristics and access to care had direct effects on mortality risk but were not captured by anthropometry. Risks among severely, moderately, or non-wasted children markedly overlapped based on other domains of risk. Importantly, many admitted children were found to be at very low risk of death.

Clinicians and families usually believed that children were ‘recovered’ at the time of discharge, and clinicians could not reliably predict post-discharge mortality. Where children continued to be ill or developed new symptoms after discharge, families felt ‘disconnected’ from the health system, even when they were attending nutrition or other clinics. Consequently, among the post-discharge deaths, more than half occurred at home rather than during a readmission to hospital.

Pathways towards cause and care and sustained recovery are complex.  The ultimate challenge being how to create guidelines and guidance to handle this along a spectrum of anthropometric deficit that includes moderately wasted cases.  But coming back to Mike and Roberta's points, all moderate cases are not the same, and there remain significant evidence gaps on case management. But practitioners cannot wait when faced with children in their care and make the best possible judgements based on what is known and experience.

We look forward to further contributions on this very critical area of programming.

Does this mean that there are MAM cases with complications that can be accepted in TFC? and the doctor in the health facility who determines, according to the patient's condition and the type of complication, whether the MAM case with complication needs treatment in TFC or OTP-MAM؟