Thanks Mark to open this discussion.
A new element: Mark Manary’s group just published a trial from Sierra Leone comparing an integrated protocol with a standard one. The tested integrated protocol gives the same treatment to SAM and MAM children with different RUTF doses in relation to MUAC. See:
Maust A, Koroma AS, Abla C, Molokwu N, Ryan KN, Singh L, Manary MJ. Severe and Moderate Acute Malnutrition Can Be Successfully Managed with an Integrated Protocol in Sierra Leone. J Nutr. 2015 Sep 30. pii: jn214957
http://www.ncbi.nlm.nih.gov/pubmed/26423737
The integrated protocol tested by this group is actually a MUAC only protocol.
The approach is elegant, it makes sense, I am sure it will attract attention by its simplicity and its impact. The conclusion is that the integrated MUAC based protocol works better. I am sure this is the way forward, and this kind protocol, maybe with some variations in the RUTF dosage or type of product, and also with detection of MAM/SAM by mothers, is likely to become the “standard” in the few years to come, especially if repeated in other settings and showing similar results.
So this paper reinforces the impression that MUAC-only programmes is the way to go. However, it does not directly address the question of relevance of WFH as additional criteria as both groups differ in other aspects than just patient selection. But we can build on that to propose a protocol which can directly test whether adding WFH is of any use. I would see something like:
Group 1: integrated MUAC only protocol as proposed in the Sierra Leone paper
MUAC < 115 RUTF 200 kcal/kg/day
MUAC >115 < 125 : RUTF 75 kcal/day
Group 2: standard approach with WFH
Patients selected by MUAC < 125 mm
If WFH > -3 same protocol as above
MUAC < 115 RUTF 200 kcal/kg/day
MUAC >115 < 125 : RUTF 75 kcal/day
If WFH < -3, RUTF 200 kcal/kg/day till WFH > -2
Main outcome: ideally, mortality. Else recovery at 3 mo assessed by MUAC > 125 mm.
There should be a cost analysis, as the WFH protocol will be more expensive to run (more training, more measuring equipment).
We can also attempt to fine tune the design. As described above, group 2 will receive slightly more RUTF than group 1 and can get higher weight gains just for that. We can increase the dose in group 1 in the 115-120 mm to balance the RUTF dose between the two groups.