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Exit criteria and length of stay

This question was posted the Prevention and treatment of severe acute malnutrition forum area and has 7 replies. You can also reply via email – be sure to leave the subject unchanged.

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Suhail

Normal user

17 Jun 2015, 05:42

1. What is exit criteria for severely acute malnourished child if it is recruited in a study/research on basis of MUAC (<115mm) in absence of SFP?
2. If a child recovered at 1st fortnightly visit (15 days after recruitment), for how many months he/she should be in study to exclude the recurrence of SAM (SFP program is not available)?
3. If a child has negligible changes in weight in two or three consecutive fortnightly visits, what should be done with that child?
4. If a child receives insufficient dose of RUTF for incomplete days OR On & Off supply of RUTF then what will be the impact on his/her recovery?
5. Is it possible that child has recovered by MUAC but he has negligible changes in weight? What should be done in this case?
6. If recommended dose of RUTF is being given to child and he has no complication and morbidity, how many mm of MUAC will be changed per day?
7. Has height/length of SAM child role assessing/ evaluating SAM child?

Rosemary Atieno

Nutritionist- MOH

Normal user

22 Jun 2015, 07:38

Hi,
It would be good to know your countries recommendations for exit and entry criteria but 12 in the absence of SFP would be safer. once a child recorver's it's important that you follow them up for two consecutive visits to avoid relapse and after which you give 7 satchets as a weaning off ration. if the changes in weight are negligible it is important that you work as a team with the other members to review in case there are underlying medical conditions or with community volunteers to assess home situation and after ruling out is when you can make a proper judgement. Insufficient dosing of RUTF I would not recommended because the food is given as medication and therefore you may not achieve desirable results after the given period which is usually one month.
MUAC usually measures adipose tissue which means that as MUAC increases the body weight also increases so this is a rare occurrence. This is dificult but I think 6mm would be sufficient in a day. Since we know that MUAC is a good screening tool I would recommend that for good results use height/length, weight because there are reference charts for it and they give more reliable information than MUAC

Mark Myatt

Consultant Epideomiologist

Frequent user

22 Jun 2015, 09:37

Just picking up on the MUAC comments.

(1) MUAC measures bone, skin, neuro-vascular bundle, muscle, and fat in the upper arm. The relative proportion of fat to muscle in the upper arm changes with age (i.e. more fat in younger children). Recently collected data shows that recovery from SAM exhibits deposition of both muscle and fat in the upper arm. The response of MUAC to treatment means that it can be used for screening, admission, monitoring of response, and discussion to discharge. The relationship between MUAC gain and weight gain is consistent and linear so we can use MUAC in place of weight for monitoring. More work is needed to work out how best to do this.

(2) There is no evidence that MUAC is less reliable than W/H. The available evidence is to the contrary. That is, MUAC is measured more accurately and more reliably than W/H. I am interested to know why you think otherwise. Have I missed some key research?

(3) There are MUAC/A and MUAC/H references just as there are W/A, H/A, and W/H references. They are not used much as raw MUAC works well enough at selecting children at high of death if untreated (sometimes better that using MUAC/A or MUAC/H and very much better than using W/H).

Rosemary Atieno

Nutritionist- MOH

Normal user

22 Jun 2015, 10:48

Hi Mark,
It's quite interesting to learn from you that there are MUAC/A and MUAC/H cut offs I would be interested if you shared with me these otherwise from what I know MUAC would only tell you more of increase in adipose tissue and not linear growth. I believe any nutrition programme would be interested in managing the child wholly which involves knowing their height as well as weight (MUAC)

Mark Myatt

Consultant Epideomiologist

Frequent user

22 Jun 2015, 11:36

See for the WHO MUAC/A reference.

See for a MUAC/H reference.

MUAC/H and MUAC/A are not often used as they tend not to preform as well as raw MUAC at the task of predicting survival and are more complicated to use.

You are right in that MUAC is not measuring linear growth that requires repeated measurements of hight and length.

MUAC measures more than adiposity. There is skin, bone, neuromuscular bundle, and fat (non-connective adipose tissue) but there is also muscle. It is also affected by hydration but less so that W/A and W/H.

We are on a SAM forum ... In SAM we are seldom (almost never) interested in height. Some programs still use W/H but this is used as a composite indicator and is measuring weight with a height adjustment. OTP is a child survival program and the best indicator is one that best predicts survival. MUAC does this job pretty well (better than other practicable indicators).

Eucabeth Onyango

Normal user

22 Jun 2015, 11:52

1.The exist criteria still remains >115mm, however in absence of an SFP Program,things will be tricky. wean off ration of 500 kcal/day plus home diet for additional seven days for this case and continued monitoring. Sourcing for adequate diet to meet the needs for the child by the caregiver should be opted to meet the needs of the child.
2. Recovery of the child during the treatment fortnightly progressively during treatment is a clear indication response. For that case observation for additional three days and enrollment of the case in the OTP for management,until the desired cure rate has been achieved. In the absence of the OTP,the same procedure shall apply.
3. The child should be exited as a non recovery. However before that stage,the underlying course for the Non Response should be identified and managed. Haven't had of a non response before.
4. On the impact,the child might not recover within the desired period of time. In this case the child overstays on stands a high chance of relapses.
5. Very tricky, Why not the other way round? which is the reliant indicator in this management.
6. Not sure of that, maybe you can share?

Mark Myatt

Consultant Epideomiologist

Frequent user

22 Jun 2015, 13:33

There has been some work on safe discharge criteria for OTP in the absence of SFP. This has concentrated on the MUAC >= 125 mm threshold. All the work I have seen. Some programs are already using this threshold.

Ahmed-Nur

Health Field Officer Detention program

Normal user

22 Jun 2015, 13:58

in my experience; The exit criteria of OTP MUAC cut off is >11.5 for two consecutive visit weight gain and clinical well. Also there was some indication for discharge criteria of SAM case MUAC >12.5 for two consecutive visit where their is no SFP program.

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