Dear Anirudra, Thanks for asking this question on this forum and I want to quickly share with you my knowledge in the subject by the following points: 1. I want to disagree with your assertion that “In CMAM project, there is no supplementary feeding to prevent and treat moderate acute malnutrition”. A comprehensive CMAN programme would always address SAM (through out-patient treatment of malnutrition in children without medical complications and in-patient treatment of malnutrition in children with medical complications) and MAM (through SFP). Both components benefit from community outreach activities that will include nutrition and health education sessions, screening and appropriate referral of acutely malnourished children for treatment. 2. It is important to address MAM in children (by prevention and treatment) because this is likely to reduce a significant number of children likely slip to severe malnutrition and positively contributing to the overall objective of CMAM: To reduce morbidity and mortality associated with malnutrition among <5 years old children I want to insist that treatment of MAM is part of CMAM, should be addressed. I leave the debate of how and suitable products for another time. Good luck!

In Nepal, UNICEF has been supporting government to implement CMAM programme since last two years. The performance of CMAM in terms of treatment of SAM is quite outstanding (87% recovery rate and less than 1% death rate, about 8% defaulter rate and less than 2% relapsed rate. Out of four components of CMAM, we have weak part on MAM that we don't haven't initiated supplementary feeding programme for the management of MAM. We are just planning to develop national guideline for the management of MAM in Nepal. Now, I need some support from ENN members to provide me the evidences of MAM management in diufferent countries. Can you please forward your experiences on MAM and MAM guidelines developed in different countries??

Dear ENN colleagues, As I mentioned in previous explanation, currently we are working to develop national MAM guideline with supplementary feeding programme for Nepal by emergency nutrition cluster. we have some guidelines from some countries but also trying to find other some relevant documents with evidence of management of acute malnutrition from different experiences/countries. If you have such documents/evidences, please send to me. My email address is ansharma@unicef.org.

cmam without supplementary feeding programme is impossible,all partners are advise to come together to solve this issue,more especially WORLD FOOD PROGRAMME and UNICEF,so that the supply of commodities for SFP,OTP AND S/C can be put in pipeline

CMAM in Nepal is integrated in the routine health services (IMCI) provided by government health workers in government managed health facilities without any NGO support. Children are assessed and receive SAM treatment (if indicated) like they are treated for any other childhood illness. Children with diarrhoea receive ORS, children with malaria receive anti-malarials, SAM children are treated using CMAM protocols. This approach is well adopted to the development context of Nepal and pretty unique. And it seems to work. Before bringing in SFP we should ask: 1.) is there enough evidence that MAM in Nepal is actually caused by a food shortage? 2.) is there enough evidence that SFP is the right tool to address MAM? and 3.) how will SFP affect the current health service delivery system? For me the answers to the first two questions are clearly NO. My recommendation is to 1.) try to really understand Nepal's nutrition situation and 2.) to be a bit more creative in finding context specific solutions and 3.) to make a cost-benefit analysis for the country in regard to the SFP introduction. In the long-run unintended negative effects might easily eat up the initial good intentions.

If you go to the link: [url]http://www.en-net.org.uk/question/240.aspx[/url] there is a lot of discussion on this by the forum members. I think you will get answers for your questions that support the above (Regine's argument). Thanks.

In Nepal, the preliminary findings of DHS-2011 says that the prevalence of wasting among 6-59 months children is 11% (boys: 12% and girls 9.7%) and SAM (boys: 3.4% and Girls: 1.8%). In five CMAM pilot districts, the formative research completed and report is being prepared. The endline survey is carried on in those districts and the report will be prepared and reported by March 2012. the facts of MAM situation will be highlighted once we get the report of CMAM formative research and endline survey. From the monitoring visits to CMAM pilot districts, there is too many demands to address the issues of MAM. The current situation says that MAM issues needs to be addres through SFP in selected areas/districts based on the evidence of other countries and situation of Nepal. The upcoming MAM guideline will help nutrition cluster and stakeholders to go ahead on it. We had many discussions in nutrition cluster meetings and finally agreed to develop national guideline to address MAM situation. CMAM guideline doesn't cover the whole process of SFP intervention. Therefore, thought to develop a MAM guideline, considering a component of CMAM as well. We are under discussion further among the cluster members, stakeholders and national authorities and will come up with the appropriate solution. Another good news from Nepal is that IMCI technical working group has recommended to endorse the diagnostic criteria of acute malnutrition as recommended by WHO and UNICEF through joint statement based on WHO new growth standard. We hope that, once we develop the MAM guideline, opportunities will be provided to national stakeholders and cluster members for situation based guidance to address the issues of MAM.