Hi, you may find this guidance note helpful: https://www.nutritioncluster.net/resources/bha-supplemental-funding-guiding-principles - though to caution this note was designed for US supplemental funds and it's possible the approach could change again after the WHO wasting guidelines are published.

That's a good point, we have to move torward such definition allowing focused our effort on most at risk MAM.Considering the appeal of WHO Director, let's work hand to hand for saving at least 100 % of them ( 7 countries in the horn of Africa). Why not stay on actual anthropometric measures (Enough strong evidence on the reliability)then add to  the new definition a score (set of criteria) link to: Poverty, area food security etc. Another point is to see how far the definition might be performant to identify the MAM.

Ex MAM: +1 or +2 or +3 etc

Hello. 

Good question. However there is no current definition. There is a study in Sierra Leone which used muac<120, being an orphan, being a twin, and having WAZ<-3 as criteria. Having cough, rash, or fever were also found to indicate high risk.

The WHO are currently working on an analysis of 2ndary data to try come up with some standard criteria. UNICEF have already expanded some SAM programmes to MUAC<120 in order to capture some high risk MAM children. 

So there is much going on in this space, but nothing standard yet. 

Hola todos.

Tema interesante. El resumen de las directrices 2023, para la prevención y tratamiento de la emacición y el edema nutricional, hace referencia a criterios de priorización para niños con desnutrición aguda moderada con mayor riesgo de no recuperación y de muerte; por lo que deberían ser priorizados. Como criterios de selección, menciona factores individuales y sociales para determinar que niños deben recibir alimentación terapéutica.

Factores individuales: MUAC 11.5 - 11.9 cm, puntuación Z peso/edad -<3DE, edad < 24 meses, circunstancias personales graves (ejemplo, muerte de la madre, entre otros), comoborbilidad grave o crónica (VIH, tuberculosis).

Factores del contexto: altos índices de inseguridad alimentaria, indicadores WASH desfavorables, alta incidencia/prevalencia de emaciación/edema nutricional.

Por cierto, sugiera que, ante la posibilidad de garantizar alimentación familiar adecuada, algunos niños con MAM podrían no necesitar alimentación terapéutica. De ahí la imposrtancia de priorizar según los contextos e individualidades previamente citadas.

Espero que esto alimente la discusión.

Saludos.

English

Hello everyone.

Interesting topic. The summary of the 2023 guidelines, for the prevention and treatment of wasting and nutritional edema, refers to prioritization criteria for children with moderate acute malnutrition at increased risk of non-recovery and death; so they should be prioritized. As selection criteria, it mentions individual and social factors to determine which children should receive therapeutic feeding.

Individual factors: MUAC 11.5 - 11.9 cm, weight/age Z-score -<3DE, age < 24 months, severe personal circumstances (e.g. death of mother, among others), severe or chronic comorbidity (HIV, tuberculosis).

Contextual factors: high rates of food insecurity, unfavorable WASH indicators, high incidence/prevalence of wasting/nutritional edema.

Incidentally, suggest that, given the possibility of ensuring adequate family feeding, some children with MAM may not need therapeutic feeding. Hence the impossibility of prioritizing according to the contexts and individualities previously mentioned.

I hope this feeds the discussion.

Best regards

*Please note that the below is an automatic translation of the above reply by Spencer Rivadeneira Danies (ICBF)

Hi all.

Interesting topic. The summary of the 2023 guidelines, for the prevention and treatment of wasting and nutritional oedema, refers to prioritisation criteria for children with moderate acute malnutrition at increased risk of non-recovery and death; therefore they should be prioritised. As selection criteria, it mentions individual and social factors to determine which children should receive therapeutic feeding.
Individual factors: MUAC 11.5 - 11.9 cm, Z-score weight/age <-3, age <24 months, severe personal circumstances (e.g. death of mother, among others), severe or chronic comorbidity (HIV, tuberculosis).
Contextual factors: high rates of food insecurity, unfavourable WASH indicators, high incidence/prevalence of wasting/nutritional oedema.

Additionally, they suggest that, depending on the possibility of ensuring adequate family feeding, some children with MAM may not need therapeutic feeding. Hence the possibility of prioritising according to the contexts and factors previously mentioned.

I hope this feeds the discussion.

Best regards.

Hi Natasha,

I recently read your study with interest, where ~55% of MAM kids in study sites qualified as High Risk by the study definition. 

Subsequently we have the WHO guidelines with a range of potential criteria that could be applied.

When you are thinking about MAM cases, do you think >50% are high risk? Or what would you think? I'm guessing your study sample might skew towards higher risk / visibly sicker kids and that non-high-risk-MAM kids might not be as likely to be making it to intervention centers in the first place, but curious what you think based on your experience. 

If we're moving in direction of treating high risk MAM cases with RUTF alongside SAM cases, that would be a very large increase in kids being treated with RUTF if it is 50%+ of MAM kids who would need this.

Dear Natasha,
That's very thoughtful of you, thank you for asking
As a senior nutritionist working for more than 12 years in developmental and emergency nutrition. 
I have no idea of the high-risk MAM threshold set. As far as I know, there is no conventionally agreed threshold for high-risk MAM. In Ethiopia, we have more than 22 years of experience in community-based acute malnutrition (MAM and SAM prevention and Treatment), currently, we are piloting the simplified approach, but we still consider the GAM thresholds for low, moderate, high, and critical risk indicators for population-level surveys and nutrition screenings. I have read any guideline that sets MAM thresholds as high risk rather than indicating the cut-off points like "Moderate Acute Malnutrition, or moderate wasting, is defined by a Mid-Upper Arm Circumference Indicator ≥ 11.5 cm and < 12.5 cm or a Weight-for-Height ≥ -3 z-score and < -2 z-score in children aged 6–59 months. Moderate Acute Malnutrition can also be used as a population-level indicator defined by Weight-for-Height ≥ -3 z-score and < -2 z-score (World Health Organization standards). 

I suggest taking a close look at the recommendations and remarks in the 2023 WHO guideline here:

https://app.magicapp.org/#/guideline/noPQkE/rec/ERl17b

https://app.magicapp.org/#/guideline/noPQkE/rec/jlRDda

If you click on the justification tab for each of these recommendations you can see explanations about how the recommendations were made and the evidence underpinning them, including prognostic factor evidence which is shown in Web Annex G.

What gets lost in the discussion of treating MAM kids with RUTF – and its implications on RUTF availability – is the fact that if you treat more cases upstream, you will avert SAM cases downstream and hence not need to use a lot more RUTF on those averted cases. So caseloads – and RUTF needs – will not simply add one on top of the other.

For me, MUAC <125 mm is a sufficient definition for “high risk” MAM because of this impact on reduced SAM incidence. A program with 80% MAM <125 / 20% SAM will use less RUTF than a traditional SAM program as well a program using MUAC <120 as a cutoff all while increasing access to treatment, improving health center and supply chain efficiencies, allowing for easier CHW management, etc.

Of course context matters and the nice thing about MUAC is you can slide admissions criteria up or down depending on the circumstances. But I fear the attempt to look for further targeting criteria may unnecessarily overcomplicate matters.  

What gets lost in the discussion of treating MAM kids with RUTF – and its implications on RUTF availability – is the fact that if you treat more cases upstream, you will avert SAM cases downstream and hence not need to use a lot more RUTF on those averted cases. So caseloads – and RUTF needs – will not simply add one on top of the other.

For me, MUAC <125 mm is a sufficient definition for “high risk” MAM because of this impact on reduced SAM incidence. A program with 80% MAM <125 / 20% SAM will use less RUTF than a traditional SAM program as well a program using MUAC <120 as a cutoff all while increasing access to treatment, improving health center and supply chain efficiencies, allowing for easier CHW management, etc.

Of course context matters and the nice thing about MUAC is you can slide admissions criteria up or down depending on the circumstances. But I fear the attempt to look for further targeting criteria may unnecessarily overcomplicate matters.  

Hi,
The high-risk MAM are those with specific risk factors that increase their vulnerability. 

Indeed, the High-risk MAM are those children who, in addition to moderate wasting, have additional risk factors such as being non-breastfed, having a low weight-for-age Z-score (WAZ ≤ -3.5), or having a caregiver who is not the mother . These children are at greater risk of progressing to severe wasting.

Best,

Dr. Nawid/ AFG

Hi Kevin,

Refer to the below link:

https://www.childwasting.org/_files/ugd/2b7a06_0af45406dc45454d8a068741b01ed3d5.pdf

Regards,

Hi Kevin,

Refer to the below link:

https://www.childwasting.org/_files/ugd/2b7a06_0af45406dc45454d8a068741b01ed3d5.pdf

Regards,

Allison - indeed - and on a personal note, Web Annex G is one of my favorite Web Annexes from these guidelines. 

Biruk - my understanding is the approach being piloted in Ethiopia includes providing all MAM/SAM children in the pilot woredas with supplementary or therapeutic foods - with no attempt to subdivide those MAM children using individual factors and restrict use of RUSF/RUTF to only a portion of them. I would be curious whether this would ultimately be rolled out broadly in the country, or only in regions with highest vulnerability. 

Kevin - indeed the SAM/MAM caseloads don't stack on top of each other in the long term, in theory addressing MAM will reduce SAM prevalence. In the short term there would definitely be a bump. Is there experience that rigorously documents the impact of MAM treatment on SAM levels, in a way that demonstrates this is more cost-effective than withholding therapeutic foods until the kids cross the SAM threshold?

With MAM kids of any type already at heightened risk of death and other adverse outcomes, it feels the burden of proof should be on why to restrict the use of proven interventions like treatment with LNS products. But we are where we are, which is that expanding use of these products to MAM kids is an incremental process and the latest guidelines have moved things towards identifying high risk MAM cases for prioritization. 

Hi Jack,
Thank you for your question. 

Just to give you a brief overview of the context in Ethiopia and answer for the question

The management of acute malnutrition in Ethiopia has undergone significant changes over the past two decades, transitioning from facility-based to community-based approaches to improve coverage and effectiveness. Here's an overview based on the provided information:

Timeline and Evolution of Acute Malnutrition Management in Ethiopia

Pre-2000

Acute Malnutrition (AM) management was restricted to facility-based approaches.

Only Severe Acute Malnutrition (SAM) cases were treated in health facilities.

2001-2003

The Community-Based Therapeutic Care (CTC) approach was developed in 2001.

Adopted in 2003 to manage acute malnutrition in a community setting.

2008

The CTC approach was scaled up countrywide.

Integrated into the routine Health Extension Program (HEP).

SAM services are provided in Stabilization Centers (SC) and Outpatient Therapeutic Programs (OTP) under the existing health system.

Moderate Acute Malnutrition (MAM) services were not available in health facilities until 2018.

From 2008 to date the MAM cases are getting service only in selected hotspot priority 1 woredas.  

Hotspot Priority Woreda Classification

Ethiopia uses a classification system to identify and prioritize areas (woredas) needing immediate attention due to food, livelihood, and nutrition insecurity. This classification, carried out bi-annually, helps target interventions effectively.

Hotspot Levels:

Priority 1 (P-1): Very Severe

Equivalent to Humanitarian Emergency.

High levels of damaging hazards affect lives and livelihoods, leading to severe food insecurity, high malnutrition, and potential excess mortality.

Priority 2 (P-2): Severe

Equivalent to Acute Food and Livelihood Crisis.

Significant stress and food insecurity, resulting in high levels of malnutrition and rapid depletion of livelihood assets.

Priority 3 (P-3): Moderate

Equivalent to Moderately Food Insecure or Chronically Food Insecure.

Moderate impact on lives and livelihoods, risking stable food security.

Expansion and Current Coverage of MAM Services

2018

Introduction of Integrated Management of Acute Malnutrition (IMAM) services in 55 woredas.

MAM services, including the provision of Ready-to-Use Therapeutic Foods (RUTF) for children and Corn-Soy Blend Plus Plus (CSB++) for Pregnant and Lactating Women (PLW), were initiated in selected hotspot woredas under the Ministry of Agriculture and later the Ethiopian Disaster Risk Management Commission.

2023

IMAM services expanded to 155 woredas, including both SAM and MAM treatment in health facilities.

In the recent hotspot woreda classification, of the 1080 woredas in Ethiopia, 201 were classified as P-1, targeted specifically for MAM services.

Hi Jack,
Thank you for your question. 

Just to give you a brief overview of the context in Ethiopia and answer for the question

The management of acute malnutrition in Ethiopia has undergone significant changes over the past two decades, transitioning from facility-based to community-based approaches to improve coverage and effectiveness. Here's an overview based on the provided information:

Timeline and Evolution of Acute Malnutrition Management in Ethiopia

Pre-2000

Acute Malnutrition (AM) management was restricted to facility-based approaches.

Only Severe Acute Malnutrition (SAM) cases were treated in health facilities.

2001-2003

The Community-Based Therapeutic Care (CTC) approach was developed in 2001.

Adopted in 2003 to manage acute malnutrition in a community setting.

2008

The CTC approach was scaled up countrywide.

Integrated into the routine Health Extension Program (HEP).

SAM services are provided in Stabilization Centers (SC) and Outpatient Therapeutic Programs (OTP) under the existing health system.

Moderate Acute Malnutrition (MAM) services were not available in health facilities until 2018.

From 2008 to date the MAM cases are getting service only in selected hotspot priority 1 woredas. With the support from the World Food Program Under the Ministry of Agriculture and later under the Ethiopian Disaster Risk Management Commission. 

Hotspot Priority Woreda Classification

Ethiopia uses a classification system to identify and prioritize areas (woredas) needing immediate attention due to food, livelihood, and nutrition insecurity. This classification, carried out bi-annually, helps target interventions effectively.

Hotspot Levels:

Priority 1 (P-1): Very Severe

Equivalent to Humanitarian Emergency.

High levels of damaging hazards affect lives and livelihoods, leading to severe food insecurity, high malnutrition, and potential excess mortality.

Priority 2 (P-2): Severe

Equivalent to Acute Food and Livelihood Crisis.

Significant stress and food insecurity, resulting in high levels of malnutrition and rapid depletion of livelihood assets.

Priority 3 (P-3): Moderate

Equivalent to Moderately Food Insecure or Chronically Food Insecure.

Moderate impact on lives and livelihoods, risking stable food security.

Expansion and Current Coverage of MAM Services

2018

Introduction of Integrated Management of Acute Malnutrition (IMAM) services in 55 woredas.

MAM services, including the provision of Ready-to-Use Supplementary Foods (RUSF) for children and Corn-Soy Blend Plus Plus (CSB++) for Pregnant and Lactating Women (PLW), were initiated in selected hotspot woredas under the Ministry of Agriculture and later the Ethiopian Disaster Risk Management Commission.

2023

IMAM services expanded to 155 woredas, including both SAM and MAM treatment in health facilities.

In the recent hotspot woreda classification, of the 1080 woredas in Ethiopia, 201 were classified as P-1, targeted specifically for MAM services.

According the Ethiopian guideliness On the definition of high-risk MAM. High risk MAM refers to a child with moderate acute malnutrition whose MUAC measurement falls between 11.5 cm and 12.0 cm. This distinction is crucial for our understanding and identification of at-risk children. 

Regards.

According the Ethiopian guideliness On the definition of high-risk MAM. High risk MAM refers to a child with moderate acute malnutrition whose MUAC measurement falls between 11.5 cm and 12.0 cm. This distinction is crucial for our understanding and identification of at-risk children. 

Regards.

Hi Jack, 

Thanks for your question in this very interesting thread ("Kevin - indeed the SAM/MAM caseloads don't stack on top of each other in the long term, in theory addressing MAM will reduce SAM prevalence. In the short term there would definitely be a bump. Is there experience that rigorously documents the impact of MAM treatment on SAM levels, in a way that demonstrates this is more cost-effective than withholding therapeutic foods until the kids cross the SAM threshold?")

The evidence I am aware of includes Isanaka et al who found MAM treatment to be cost-effective compared to withholding therapeutic foods until the kids cross the SAM threshold. (Isanaka S, et al. BMJ Glob Health 2019;4:e001227. doi:10.1136/bmjgh-2018-001227). And if I remember correctly something like 10% of kids with MAM deteriorated to SAM absent treatment. ALIMA has some cost effectiveness manuscripts under review or almost submitted for our OptiMA RCTs in DRC and Niger, and in OptiMA DRC I think 16% of kids with MAM deteriorated to SAM, mainly absent treatment. (Cazes et al DOI:https://doi.org/10.1016/S2214-109X(22)00041-9).

In terms of incidence, in Ethiopia, more than a quarter (28.7) of kids with MAM deteriorated to SAM MUAC <115 mm absent treatment (James et al, PLoS One. 2016; 11(4): e0153530. doi: 10.1371/journal.pone.0153530). The first OptiMA trial in Burkina Faso (Daures et al, Br J Nutr. 2020 Apr 14; 123(7): 756–767. doi: 10.1017/S0007114519003258) treated about 5 000 kids overall, 1 778 of whom had SAM. And for 4 300 recovered cases, the program distributed 1 682 cartons of RUTF. While anecdotal, the previous year those same health centers admitted 3 500 kids just for SAM for likely 3 000 + cartons of RUTF.

ALIMA currently has several prospective cohorts of OptiMA at the scale of districts, with some manuscripts in the pipeline. But a simplified, combined protocol like OptiMA (or ComPAS) theoretically allows you to double or triple caseloads for the same amount of RUTF as the current ‘wait and treat at a more life threatening stage’ approach. This doubling or tripling of a caseload with no additional RUTF needed has largely played out in our cohorts. I mean a well-functioning MAM and SAM treatment program under the current system would achieve the same outcome even with a dual supply chain. But those programs are unfortunately rare. And while I am not a health economist, it seems like one supply chain for one product would likely be more cost effective than the current two supply chains for two separate products.

And there are factors in addition to health economy that need consideration. For ALIMA, these combined protocols are a way to get kids with MAM seen by a clinical officer because of the huge burden of largely overlooked morbidity among these kids (Cichon et al. BMC Nutrition (2016) 2:57 DOI 10.1186/s40795-016-0096-0) rather than just a supplementation program. And Family MUAC is more effective when the rules of eligibility for treatment line up with current MUAC tapes. In fact, both treatment and Family MUAC can be undermined by any discordances. Finally, with regards to age and high risk MAM, in many of our OptiMA cohorts, something like 67-85% of the kids admitted at 120-125 mm MUAC are less than 2 years of age. It seems like it would be unnecessarily costly to try to find ways to withhold RUTF from that 15-33% of kids who are presenting to health centers because their moms are worried about their health just because they are like 25 months old.

As to where we are with regards to RUTF, I would argue that the consistent lack of sufficient and predictable financing is the real culprit behind fears of expanded RUTF use to kids further upstream. It leads us to construct complicated algorithms for already overburdened health personnel in resource limited settings. All to keep RUTF from kids who would benefit from it. The guidelines are welcome – and Appendix G is indeed elegant – but I fear this underlying issue may not only impede progress, but deny it. I mean last year was a good year because of a sizeable, one-time infusion of cash from USAID and philanthropies in 2022. 2023 and 2024 reverted back to severe under financing, leading to a scandalous situation where RUTF manufacturers have full warehouses while health centers have empty stores (leading health personnel to scramble to deal with widespread stock outs.) The recent infusion of financing again from USAID, will help close these gaps somewhat, but the wildly oscillating RUTF financing from year to year continues.

I think the nutrition community needs borrow a page from our comrades fighting HIV and be much more demanding. We need something like the Global Fund or PEPFAR to predictably finance RUTF in line with the needs. Then perhaps we can begin to take for granted something like Test and Treat at the earliest sign of malnutrition.