Dear Florence, I just wonder where this recommendation of 20% weight gain for children with a « yellow » MUAC (115-125 mm I guess) comes from. There is a recommendation in the 2009 WHO UNICEF joint statement about a 15 to 20% weight gain for children with severe acute malnutrition admitted to programmes with a MUAC < 115 mm, but this is not applicable to children with higher MUAC. A weakness of this recommendation is that it requires a higher weight gain for children who are the less malnourished and children just below 115 mm often require a long time to achieve it. On the other hand, a 15% to 20% weight gain may be insufficient for children with very low MUAC. A solution to all these problems would be to use MUAC > 125 mm as discharge criteria for children admitted in programmes based on MUAC as you suggest

Thanks Andre for your guidance, It is a national guideline to enrol moderately malnourished HIV positive children on OTP and the target weight is set at 20%.... If you have any literature on management of MAM among HIV positive children using RUTF, kindly share with me. I will propose the use of MUAC to the stakeholders for discussion.

Dear Florence, In 2008 MSF presented data at a WHO meeting from a programme, I think it was Burkina Faso, where they gave RUTF to SAM and MAM children with this kind of % weight gain as exit criteria and they clearly showed that this resulted in very long treatment duration in MAM children (and too short treatment for the most malnourished). Most children were HIV negative. The implication was that 20% weight gain in MAM is too high as a target even in HIV negative children. I don’t think this has been published, but maybe someone from MSF reading this forum can give more detail on this study.

Dear André. I know the issue of percentage weight gain in MAM management is a bit outdated, but I have a question: In the consultation paper on MAM management by WHO, UNICEF and other actors in 2010, you and Mike Golden are mentioned as having looked at 8-10% weight gain as possible targets. I have looked all around but can't find the documents. Could yo help me out?

Dear Emmanuel, I guess you refer to this report of the WHO 2010 meeting: http://www.who.int/nutrition/topics/moderatemalnutrition_consultation_programmaticaspects_MM_report.pdf with the following statement: “ For children > 67 cm and = 6 months of age, MUAC <125 cm can be used as a stand-alone admission criteria. Discharge can be made at MUAC = 125 mm for 2 consecutive visits. Children admitted using WHZ should be discharged using percent weight gain (exact level to be confirmed, Golden and Briend by independent approaches both suggest approximately 8-10%) “ In preparation of this meeting I did some work suggesting this figure indeed. I later looked further into the target weight gain we should aim at for MAM children. This is not a simple issue, as detailed analysis showed that the target weight gain should be related to the initial weight deficit of the individual and also on the average WHZ of the population. This is described in some detail in the article: P Briend A, Van den Broeck J, Fadnes LT. Target weight gain for moderately wasted children during supplementation interventions - a population-based approach. Public Health Nutr. 2011 Dec;14(12):2117-23. To answer specifically to your question, a single % weight gain does not seem to be a good option to define a target weight gain. As mentioned in a previous post, the % weight gain was proposed as exit criteria in the 2009 WHO UNICEF Joint statement on SAM for children admitted on MUAC and for whom WHZ was not a good option. Experience showed however that this is not a good option either and in the last NUGAG meeting (report not yet published) it was advised not to use this approach. % weight gain requires higher weight gain for children who are the less malnourished, which is not desirable. I hope this helps

Thanks Andre' and Emmanuel for carrying on with this discussion. Indeed there are still several issues on target weight Vs MUAC as disharge criteria for MAM. Andre' thanks for sharing the paper, when do we expect the NUGAG report? It will be nice to read the details. Florence