Dear All, I read all are of your questions .As i am previously working as a field nutrition officer with save the children and now i am working as a nutrition project officer with concern worldwide ,i have practical experience of working on CMAM .Hopefully you will be satisfy with the answers . With the objective to simplify CMAM protocols the Concern South Sudan team is interested in experiences using MUAC as the only admission criteria into SFP. Who has done it where? Ans: i had worked with save the children from oct till june .the criteria we were using according to national guideline was to enroll the child in CMAM programme by using MUAC tape .According to my experience and opinion was the best when you were going to enroll lot of children ,because it is easily understandable by all the beneficries and the staff .all staff can understand it easily .So according to my opnion it is the best method to enroll the child according to MUAC IN sfp programme. From the Minimum length of stay required? Ans:Most of the that have been discharge from the OTP programme were enroll in SFP programme .If a new child have been enroll in SFP programme the minimum length of stay required will be 2 month ,because if we are going to discharge a child before 2 month realistically there will be chances that the child will be going to moderate malnourish again .So the length of stay for a child enroll in sfp programme must be of 2 month. How was nutritional recovery process assessed? Ans:The nutrition recovery process can be assessed by using weight and MUAC criteria .Means if a child were getting weight in 2 consective visit means his/her nutritional status will be going to improved.We can practically check it out by measuring the MUAC And weight . What admission and discharge criteria used? Ans:Their are 2 criteria for enrollement in sfp programme ,1 for children and another for children: The admission criteria for children in sfp programme is Muac 11.5-12.4 cm. and the discharge criteria is MUAC >12.4 cm and the child must stay in sfp programme for 2 month (mean 4 to 5 vist as in sfp programme the follow up visit will be after 2 weeks). the admission criteria for PLW(Pregnant lactating mother)is MUAC <21 cm pregnant mother of 2nd and 3rd Trimaster and lactating mother who is brest feeding her child. the exit criteria for PLW is MUAC >21 cm but a lactating mother should stay in our programme untill her child reach upto 6 month. Any evaluation done to support findings? Ans:Yes in the mid of programme i myself done an evaluation and seen that lot of children and mothers had been improved and they were very happy with the treatment that we have provided to them but for a statistical data you have to see the other programme that were conducted in different countries. Hope my answers will help you in some extent.

Quez. Who has done it where? Ans: We are here in pakistan doing work about CMAM with Concern Worldwide. Ques2. Minimum length of stay required? Ans. Minimum two months are required for stay a patient in SFP. Quez3. How was nutritional recovery process assessed? Ans. Through Anthropomrtrict measurment,RUTF(ready to use theraputice food). Quez4. What admission and discharge criteria used? Ans. :Admission criteria is for SFP :MUAC from 11.5cm to12.4cm :Discharge criteria is for SFP :MUAC increase up to12.5cm or equal to 12.5cm Regards, --------------------------------------- Zubaida Ajab Project Nutrition Officer Concern Worldwide Sukkur Pakistan

You can ask UNICEF for a copy of the interim final Southern Sudan Protocol for the Integrated Management of Severe Acute Malnutrition. It does not address MAM in depth unfortunately, but it does make it clear NGOs can use MUAC only for admissions to IMSAM. WFP is taking the lead in developing a MAM protocol. They may be a good point of contact for advice for your program. Good luck!

From Ann Burgess: A copy of the South Sudan Interim Guidelines on the Integrated Management of Severe Acute Malnutrition is available on the website of the Southern Sudan Medical Journal ([url]www.southernsudanmedicaljournal.com[/url]) See: [url]http://southernsudanmedicaljournal.com/assets/files/misc/GOSS_IMSAM_Guidelines.pdf[/url] Do let me know if you find them useful - or want to contribute to the journal (email annpatriciaburgess@yahoo.co.uk )

i am student of food science technology, already gain training of nutrition in emergency and aim to work in UNICEF, for help of vulnerable population.

Dear all, I am working as Nutrition Officer in Save the Children Badin,along with my field experience I am also a Pediatrician I have observed personally those PLWS whose MUAC was greater than 21 but they were malnourished according BMI,so I suggest along with MUAC ,BMI should also be used for assesing malnutrition.

Dear all, I am working as Nutrition Officer in Save the Children Badin,along with my field experience I am also a Pediatrician I have observed personally those PLWS whose MUAC was greater than 21 but they were malnourished according BMI,so I suggest along with MUAC ,BMI should also be used for assesing malnutrition.

Dear all, I am working as Nutrition Officer in Save the Children Badin,along with my field experience I am also a Pediatrician I have observed personally those PLWS whose MUAC was greater than 21 but they were malnourished according BMI,so I suggest along with MUAC ,BMI should also be used for assesing malnutrition.

Dear all, I am working as Nutrition Officer in Save the Children Badin,along with my field experience I am also a Pediatrician I have observed personally those PLWS whose MUAC was greater than 21 but they were malnourished according BMI,so I suggest along with MUAC ,BMI should also be used for assesing malnutrition.

Currently available evidence indicates that the relationship between MUAC and negative outcomes (e.g. death) is consistent between populations and settings for all age-groups. This means that we can say with some confidence that about X% of cases with MUAC < Y mm will experience event Z no matter where we happen to be. In children, where evidence is strongest and easiest to collect, we know (e.g.) that about 20% of children with MUAC < 110 mm will die within 12 months. The issue is more complicated with measures such as W/H or BMI. These indicators have very different meaning in different populations. People from high altitudes or from cold places tend (for different reasons) to have higher BMIs than people from low altitudes or hot climates. It is a body-shape issue, We observe this in ALL mammals. The difference in BMI is independent of nutritional status. It is not, however, independent of diet. Populations with high milk availability also tend to have lower BMIs than those with low milk access (it is a limb length issue). In Ethiopia, for example, Somali populations (low altitude, hot climate, high milk availability) have lower BMIs than highland populations (high altitude, temperate climate, low milk availability). We can get round this problem by correcting for body-shape. This requires sitting height to be measured and factored into the BMI calculation. It is NEVER legitimate to use uncorrected BMI for case-identification. What this means is BMI (uncorrected for body shape) selects people different levels of risk in different settings. In some settings it will select very many low risk individuals. Not ideal unless you are very well resourced. In other setting sit will fail to detect very many high-risk individuals. Not ideal either. The above applies to children and adults but your post mentions "PLWS" which I take to mean pregnant and lactating women. BMI is not appropriate for this group (particularly pregnant women). See: [url]http://www.en-net.org.uk/question/348.aspx[/url] [url]http://www.en-net.org.uk/question/169.aspx[/url] [url]http://www.en-net.org.uk/question/261.aspx[/url] [url]http://www.en-net.org.uk/question/215.aspx[/url] [url]http://tng.brixtonhealth.com/node/37[/url] There are additional problems with using BMI with the elderly and the disabled. BMI is (almost) an idea whose time has passed and is now falling out of use and being replaced by measures such as waist:hip ratio for the detection of overweight and obesity. If you have resources and are concerned about sensitivity then I recommend raising the MUAC threshold to (e.g.) 230 mm. Adding BMI is not a good thing to do. Just my tuppence.

Who has done it where? CMAM is running here in Pakistan from a long time (more than 15 years) and we are using MUAC is the only admission and discharge criteria. There are differences in cases assessed by MUAC and Z score. I have my personal experience working with various international organization on various positions noted the difference between MUAC and Z Score. A child assessed via MUAC declares malnourished but z score shows normal. There is a difference between MUAC and Z score sensitivity. MUAC is an emergency based tool used for the assessment of malnutrition, easy to used by a common man and required no technicality during usage. Global cluster decided that MUAC will be the only admission and discharge criteria for the assessment of malnutrition. It is better if you have trained, technical staff and they can calculate z score. Minimum length of stay required? As it is one of the objective of CMAM program that CARE FOR AS LONG AS NEEDED. so we provide maximum care services in the program. The minimum length of stay in CMAM program (OTP, SFP Children and SFP PLW) is 2 months and maximum 4 months. A patient can stay in a program for the aforementioned time. You can used FANTA for technical assistance. How was nutritional recovery process assessed? After the admission in program the patient takes follow up visits on weekly (OTP Program) or biweekly basis (SFP Program) On follow up visit the patient is history , MUAC, Weight and Height is taken (Height is taken once in a month) new ration food + Medicines is provided and call for the next visit (mentions date and day) until recovery (min 2 months and max 4 months) What admission and discharge criteria used? The admission and discharge criteria for SFP Program For Children Admission criteria MUAC 11.5 cm to < 12.5 cm Discharge criteria MUAC greater than or equal to 12.5 cm for 2 consecutive visits. Evidence of weight gain, clinically well and minimum 2 month in program For PLWs Admission criteria MUAC < 21 cm Discharge criteria MUAC greater than or equal to 23 cm Yes UNICEF and Department of Health here in Pakistan conducted surveys and recently UNICEF head quarter conducted an nutrition evaluation survey in one province of Pakistan but the result is not shared up till now Hope the aformentioned informations will take you to the right track Regards Fazal Dad Nutrition Coordinator Merlin International Pakistan Mobil: +92 (0) 331 9027685 +92 (0) 332 9236592 Skype: Nutrition336 Email: fazaldadnutritionist@gmail.com

From Asfand Yar: Dear Fazal, Thanks for sharing the as usual protocols for CMAM. i wnt to add regrding survey. the survey has been conducted in punjab as well as in sindh and their prevalance has been sahred on time. on the basis of these surveys we are working now.