Hi Anonymous, 

Good luck in such a challenging situation. I would say try your best and use your best judgment as such a context has no easy answers. 

ALIMA just had a study accepted for publication looking at the question of non responders. What we found was that 80% of the children classified as non responders actually had a similar growth trajectory as those who recovered but just didn't reach recovery criteria in the 12-16 weeks of program attendance. We think calling these kids slow or patrtial responders better reflects the reality of the situation. The other 20% could be considered treatment failures, and alas they would need hospital referral as much as possible. These children were younger and very stunted and showed minimal MUAC gain (and even MUAC loss) over the course of treatment, especially in the first few weeks. I would ficus on these stunted kids not showing any MUAC  or weight gain in the first few weeks of treatment rather than all of the kids who get categorized as non responders. 

I will share the paper as soon as it is published. I also know the WaSt Technical Advisory Group has a pooled analysis of non responders submitted for peer review and comes to a similar conclusion that or current definition of non reponse does not reflect the reality of the situations we face. 

Again, good luck to you, your colleagues, and all of the families facing what sounds like an awful context..

Kevin

We should also exclude any form of chronic malnutrition or a psychomotor problem.

Here is a summary of the literature on SAM non-respondents and recommendations for program staff in situations with limited access to referral services:

The traditional definition of a SAM non-respondent is a child with severe acute malnutrition (SAM) who does not reach the discharge criteria (typically weight-for-height z-score >-2 or 15% weight gain) after a standard course of treatment, including referral to inpatient care if needed. Common reasons for non-response include underlying medical conditions, poor adherence to treatment, and inadequate nutritional intake.

However, in conflict-affected areas with limited access to inpatient services, the definition of non-response may need to be adapted. Program staff may need to rely more on clinical assessment and mid-upper arm circumference (MUAC) instead of weight-based criteria. A proposed updated definition could be:

A SAM non-respondent is a child who, after 2-4 weeks of outpatient SAM treatment, has any of the following:

- No improvement or worsening of clinical condition (e.g. increased edema, decreased appetite, lethargy)

- No increase in MUAC or MUAC continues to decrease

In such contexts with access constraints, program staff can try the following to prevent and manage non-response:

1. Strengthen inpatient care linkages as much as possible, even if access is limited. Advocate with authorities to maintain or expand available services.

2. Provide more intensive outpatient treatment, with more frequent follow-up visits (e.g. weekly rather than biweekly).

3. Ensure adequate supplies of ready-to-use therapeutic food and medications, and train staff on optimizing outpatient management.

4. Enhance caregiver education and support to improve adherence and home-based care practices.

5. Establish clear criteria and protocols for identifying non-responders, and train staff on assessing clinical signs, not just anthropometric indicators.

6. Develop referral pathways and provide transportation support, even if full inpatient admissions are not possible. Explore options for stabilization and supportive care closer to the community.

7. Document and share learnings on adaptations to the SAM treatment protocol in your context to inform global guidance.

The key is to be proactive, flexible, and focused on the child s clinical status rather than relying solely on standard discharge criteria. Let me know if you need any clarification or have additional questions!

Dear Colleagues, 

Thanks indeed for so much with for very good answers and swift replies. I am really looking forward to reading the paper you will be shared, and could you please also share the document from wasting Technical advisory group in terms of non-responder studies.