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Triggers for deciding on CMAM programming

This question was posted the Prevention and treatment of severe acute malnutrition forum area and has 9 replies. You can also reply via email – be sure to leave the subject unchanged.

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Tamsin Walters

en-net moderator

Forum moderator

26 Sep 2014, 13:48

From Peter Antony:

Dear Friends

I would like to get your opinion about coming up with a guidance on deciding a CMAM programming in the communities. As you know that there is no clear guideline on how to decide the CMAM programme the field. Therefore i am planning to give this to help the field and programme staff to decide based on the GAM rate and aggravating factors.

Particularly, whenever come on the border level there would be a confusion to decide the programming. therefore i would like to take the SAM and and oedema rates to decide the severity of the nutrition situation. Please find the table below and advise me on this..

Thank very much in advance
Antony

Situation: GAM > 14%, or GAM 10-14% with aggravating factors
Severity Status: Serious
Action recommended: Blanket feeding and/or CMAM (prevention and treatment)

Situation: GAM 10-14%, or 8-10% with aggravating factors or SAM > 3% and/or > 1% of kwashiorkor (oedema)
Severity Status: Critical
Action recommended: Alert Targeted feeding CMAM (prevention and treatment)

Situation: 8-10% with aggravating factors SAM < 3% and/or < 1% of kwashiorkor (oedema)
Severity Status: Cautious
Action recommended: Alert Targeted feeding. No need to have CMAM but recommended prevention activities (IYCF)

Situation: GAM < 9% without any aggravating factors
Severity Status: Acceptable
Action recommended: Alert nutrition education. No need to have CMAM recommended prevention mostly focus on IYCF

Alexandra Rutishauser-Perera

International Medical Corps

Normal user

30 Sep 2014, 18:04

Dear Peter Antony,

Have you looking at the GNC decision tool for emergencies?
It looks to me that it's very similar to what you are suggesting:

http://www.medbox.org/under-5-nutrition/moderate-acute-malnutrition-a-decision-tool-for-emergencies/preview

Best Regards,

Alexandra

Antony Peter

Emergency Nutrition Specialist

Normal user

1 Oct 2014, 18:36

Dear Alexandra
Thank you very much for your response in this regards. Of course yes, i did review MAM decision making tool but I would like to get some guidance to have CMAM programming not just only for the MAM prevention or treatment.

Many thanks
Peter Antony

Antony Peter

Emergency Nutrition Specialist

Normal user

10 Oct 2014, 12:51

Dear Friend
I was just wondering that does it make any sense or not, I did not see any comments on this Triggers for deciding on CMAM programming so far. I really appreciate if any of you would be able to give some comments (positive or negative) on this to move forward.

Dear Mark Myatt, as I follow your valuable comments, please let me know is it OK to use this guide line to make decision on CMAM programming or if there is any better way that I can consider on this trigger?
Many thanks
Antony Peter

Mark Myatt

Consultant Epideomiologist

Frequent user

13 Oct 2014, 09:56

The document focusses on MAM. This has a wide range of interventions (many with little evidence of coverage or effectiveness) aimed at prevention and / or treatment.

With SAM, due to high mortality in untreated cases, we should (almost) always have a treatment intervention. Even when prevalence of SAM is low we should aim to treat SAM as part of the IMCI delivery package. In vulnerable populations this provides a base for expansion should a problem arise. This strategy is now employed (and supported by UNICEF) in many countries.

This is not much help. I think we can say that if there is a need for an intervention against MAM there will definitely be a need for SAM treatment.

Sorry not to be of more help.

Antony Peter

Emergency Nutrition Specialist

Normal user

13 Oct 2014, 14:16

Dear Mark Myatt
Thank you very much for comment on this, much appreciated. It’s really helpful.
You are right that we treat the SAM children regardless of prevalence rate under IMCI guideline but may or may not under Stabilization Centres. I had an idea intendsion to more focus on SAM children and you mentioned that is more towards MAM. However, I am wondering how should I modify these selection criteria to capture more SAM children with cost effective way of designing program?

Can I consider GAM 8-10% with at least 2 aggravating factors or SAM > 2 % and/or > 1% of kwashiorkor (oedema) to capture more SAM children?

My concern is as we ended up with very low caseload in many OTP centres in some countries after we are establishing OTP centers. Particularly, inversing more time, money and efforts on capacity building on staff, including health facilities staff.

Many thanks

Regine Kopplow

Sen. Advisor Food& Nutrition Security

Normal user

13 Oct 2014, 14:56

In ideal all children suffering from severe acute malnutrition (SAM) should have access to treatment regardless of the current prevalence. Training of health workers in the management of diarrhoea or respiratory infections is the standard and is not decided based on the percentage of children suffering. Therefore my question - do we need SAM thresholds to decide whether it is justifiable to train health workers on the management of acute malnutrition? I don't think so. To me SAM treatment should be a standard skill health workers have and the services to treat should be available at all health facilities all year round. Unfortunately this is not yet standard and we see spikes in SAM prevalence in areas where there is no or very low treatment capacity existing. The decision on whether to work on SAM treatment or not should be made after having assessed the context and not based on any thresholds. Such an assessment is also helping with defining the right approach.

Antony Peter

Emergency Nutrition Specialist

Normal user

14 Oct 2014, 19:05

Dear Regine Kopplow,
Thank you very much for your comment on this. I agreed with you that each SAM child has right to get treatment regardless prevalence. But please note this trigger for CMAM program designing that means to decide to start a new OTP program in new area/country; not to decide to treat a SAM child or not.
As you know that we should justify with reasonable prevalence to prove in an efficient way to a donor to get money. Eg. According to WHO, Management of Malnutrition in Major Emergencies, 2000, GAM >= 14% is Critical and <5% is acceptable (also we may have SAM children in this 5% GAM) but it does not mean these 5% children are no need to be treated but I hope that all these around cost effectiveness and efficiency of the program designing.
Please let me know if I got your point right or not. Much appreciated your time on this and looking forward to hearing from you.
Thank you again.
Antony

Mark Myatt

Consultant Epideomiologist

Frequent user

15 Oct 2014, 09:21

It may be that my focus of work on CMAM has shifted from "simple" emergencies but CMAM is now often rolled out as iCMAM (i.e. SAM treatment delivered though MoH and related facilities as part of IMCI and case-finding done in GMP, EPI, and all clinics). I think this is probably the correct model to adopt in other contexts and CMAM integrated with health provision.

Antony Peter

Emergency Nutrition Specialist

Normal user

21 Oct 2014, 10:39

Thank you very much Mark for your input, much appreciated.

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