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MUAC out...

This question was posted the Prevention and treatment of moderate acute malnutrition forum area and has 10 replies. You can also reply via email – be sure to leave the subject unchanged.

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Chantal Autotte Bouchard

freelance

Normal user

1 Oct 2013, 16:43

Hello,

I am looking for documentation or national protocol adopting the outside criteria above than 125 if the other constants are reached. I read a lot of discussion on this topic, but I have no written evidence or example of use. thank you
Chantal

Mark Myatt

Consultant Epideomiologist

Frequent user

2 Oct 2013, 11:47

I am not sure what you are asking for. MUAC thresholds for inclusion in SFP and TFP programs seem to have stabilised at 125 mm for SFP (and sometimes for TFP if the child presents with medical complications) and 115 mm for TFP (some countries use 110 mm).

Other thresholds have been used in the past. Sometimes a high MUAC threshold (e.g. 135 mm) is used as part of a two-stage screening for low WHZ but this is a somewhat dated approach to programming as screening using WHZ, even as part of a two-stage screen, usually achieves limited coverages and is probably best suited to the "scarcity" models of therapeutic care such as TFCs which are now seldom used.

Let me know if this is of any help.

Chantal Autotte Bouchard

freelance

Normal user

3 Oct 2013, 08:10

Hello Mark,

I was not very understandable I think. I do not write often enough in English.

So, I'm not looking for documentation for the inclusion of children in the programs, but the "exit thresholds criteria".

PB usually sought is more than 125 with an -2 Z-score.

But I had the opportunity to read discussions or memoranda of NGOs about that kind of thresholds: if -2zscore are reached but not the PB we could let out the child with a PB around 120 by exemple.

Do I explain myself better?

I do not want protocols NGO . But I need documentation.

Kind regards
C

André BRIEND

Frequent user

3 Oct 2013, 08:19

Bonjour Chantal,

Peut être pourrions nous avoir une discussion en français sur ce forum.

Si j'ai bien compris, votre question porte sur l'utilisation du PB comme unique critère de sortie. Veuillez regarder le commentaire que je viens de faire à notre collègue du Pakistan. Le PB comme unique critère de sortie simplifie bien les programmes et évite l'effet pervers observé avec le % de gain de poids qui fait sortir plus tôt les enfants les plus sévèrement malnutris. Voir l'article et le résumé que je viens de mettre en ligne sur ce forum. Le résumé suggère que 125 mm est un bon critère pour éviter les rechutes;

J'espère que cela vous est utile,

AB

Chantal Autotte Bouchard

freelance

Normal user

3 Oct 2013, 08:20

Sorry for the replay....

I just saw this posted by Andre Brien, but this is when MUAC is the only discharged criteria, me I'm looking for documentation with the booth criteria needed.

Chantal Autotte Bouchard

freelance

Normal user

3 Oct 2013, 08:22

Good evening,
In the WHO guide on the calculation of IYCF indicators, it always mentions 'if the sample size allows it' without further precision. I would like to know what is the minimum sample size sufficient to be able to calculate indicators in a stratum during a nutrition survey with the SMART methodology. Are there guidelines on the subject?
Thank you

Chantal Autotte Bouchard

freelance

Normal user

3 Oct 2013, 08:28

Bonjour de nouveau André, les messages se sont croisés. Bref je cherche de la documentation sur les deux critères, mais avec un MUAC autour de 120. Puisque ceux-ci sont préconisé pour le pays avec qui je discute. Mais pour le coup ils ont de longue durée de séjour pour atteindre les deux critères.
Voila

André BRIEND

Frequent user

3 Oct 2013, 08:36

Je ne comprends pas de quels critères vous parlez. Pouvez vous préciser ? Le mieux serait de continuer cette discussion par e-mail. Mon adresse : andre.briendatgmailpointcom

Mark Myatt

Consultant Epideomiologist

Frequent user

3 Oct 2013, 15:31

The most common situations in which dual criteria are used is to discharge when proportional weight gain is 15% or higher or when WHZ exceeds -2 provided that the MUAC admission criteria is also exceeded. That is:

    current weight - admission weight
    ---------------------------------  >= 0.15 AND MUAC >= 115 mm
             admission weight

or:
   WHZ > -2 AND MUAC >= 115 mm

If a "bridging program" is available so that discharge is (e.g.) to SFP then the 115 mm threshold may be quite safe provided that we are sure to pick up relapse to SAM in the bridging program or in the community.

For discharge into the community without ongoing support, a 125 mm threshold has been shown to be safe (or discharge at < 125 mm to be a risk factor for post-discharge relapse or death). André Briend has already posted [url=http://www.en-net.org.uk/question/1157.aspx]here[/ur] on this issue and provided links to articles. Preliminary analysis of a FANTA-III sponsored trial in Malawi (reports currently being prepared) supports this (i.e. low relapse and no excess post-discharge mortality when discharging at MUAC > 125 mm). I believe this data will be presented by Paul Binns at the CMN conference in London later this month (October 2013).

Most documentation around this issue can be found in the early literature on CTC/CMAM. For example, this:
[quote]
Myatt M, Khara T, Collins S, A review of methods to detect cases of severely malnourished children in the community for their admission into community-based therapeutic care programs, Food and Nutrition Bulletin, 2006;27(3):S7-S23
[/quote]
presents a discharge criteria based on proportional weight gain and MUAC (the 115 mm threshold was, at the time of publication 5 mm greater than the most commonly used MUAC admission criteria so I guess the 120 mm criteria you mention may have been adapted from this). Note that proportional weight gain has subsequently proved problematic (my mistake!) and a simple MUAC threshold is a far better option.

Now that we have several years experience with CMAM programs we are in a position to refine discharge criteria. Your question is, therefore, very timely.

I hope this is of some help.

BTW : I think that some of the interest around using combined discharge criteria is to reduce lengths of stay (or to avoid very long lengths of stay). It is often quicker to achieve 15% weight gain than a 125 mm MUAC in a very wasted child or to achieve WHZ > -2 than to achieve a 125mm MUAC in a young child admitted using MUAC. I think that a better way to reduce lengths of stay is to try to achieve timely case-finding and recruitment so that MUAC at admission is not far below the MUAC admission criteria. This is possible with community sensitisation and mobilisation. When this is achieved, median lengths of stay are well below 8 weeks. Another way of achieving shorter lengths of stay is to address compliance by both the clinic and the beneficiary by (e.g.) avoiding drug / RUTF stock-outs and by reducing intra-household sharing of RUTF by (e.g.) monitoring and counselling, peer-to-peer mentoring, mentoring by community workers / volunteers, and the use of a protection ration.

Chantal Autotte Bouchard

AAH

Normal user

14 Oct 2013, 12:31

HI Mark,

Sorry for the delay. Thank you for your help it was really helpful.

C.

Mark Myatt

Consultant Epideomiologist

Frequent user

14 Oct 2013, 14:52

Happy to help.

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