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MUAC only programming

This question was posted the Prevention and treatment of severe acute malnutrition forum area and has 5 replies. You can also reply via email – be sure to leave the subject unchanged.

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Tarig Abdulgadir

CMAM Specialist / UNICEF

Normal user

1 Jul 2010, 13:44

Hi, I would like to ask about any experience or operational document to refer to regarding MUAC only programming in relation to therapeutic feeding programs and supplementary feeding programs?

Mark Myatt

Consultant Epideomiologist

Frequent user

3 Jul 2010, 22:10

One of the complicated things about "MUAC only programming" is defining what is meant by the term. There are two "modes" ...

(1) Using MUAC and oedema alone (i.e. no use of W/H) for case-finding, referral, and admission. Monitoring and discharge is done using weight gain and / or clinical criteria.

(2) Using MUAC and oedema alone for case-finding, referral, and admission AND using MUAC for monitoring and discharge.

Mode (1) is common. Mode (2) is less common as there is, as yet, no consensus regarding discharge criteria.

The advantage of using MUAC alone for case-finding, referral and admission is that it is now pretty clear that W/H usually leads to problems with recruitment and this results in low coverage (hence low impact) programs. For therapeutic feeding (SAM) it is common to use 110 mm or 115 mm as case-defining thresholds. For supplementary feeding it is common to use 125 mm as the case-defining threshold. Discharge may be on 15% or 18% weight gain.

For mode (2) the same case-definitions are used for case-finding &c. and (e.g.) transfer TFP cases to SFP at MUAC > 115 mm and discharge from SFP at MUAC > 125 mm. If no SFP is running then discharge is from TFP could be at MUAC > 125 mm. Discharge from SFP can be at MUAC > 125 mm for two visits. I will leave it to others to give other examples and report their experiences.

I hope this helps.

Brent Scharschmidt

Malnutrition Coordinator

Normal user

5 Jul 2010, 08:19

Dear Mark, this is very helpful - thanks for sharing. Has this (evolving) MUAC-only criteria been published or is this from field experience? If the former could you provide any relevant references.

Mark Myatt

Consultant Epideomiologist

Frequent user

5 Jul 2010, 10:28

It's a bit of both ... some of it has been published and some is from experience. Most of mode (1) is documented in the original CTC documents (e.g. the HPN and Lancet articles by Steve Collins, Tanya Khara, Kate Sadler, and others; the CTC manual; &c.), in the documents arising from the CTC conferences which were published as ENN supplements and in a FNB supplement, and in the WHO/UNICEF/WFP joint statements on CMAM. The problems with using W/H are described briefly in some of the FNB articles and in a recent paper by Saul Guerrero and others:

http://www.ncbi.nlm.nih.gov/pubmed/20002705

VALID International have been very active in CTC / CMAM programming (they also invented and finessed the model) and have a vast store of reports spanning over a decade which either address these issues directly or in passing. If you contact them they may be able to send you some reports and provide advice.

The parts of mode (2) that are additional to mode (1) are less documented. I presented a paper at the Washington CTC / CMAM conference on MUAC response in CTC programs which should be available from the FANTA website. Some programs have adopted a MUAC-only strategy (contact VALID, SC-US, and WVI (I think) for details). FANTA-2 is funding a project to research MUAC discharge thresholds ... present knowledge suggests that 125 mm is safe but that a lower threshold (e.g. 120 mm without SFP or appropriate bridging program; 115 mm with SFP or appropriate bridging program).

The main thrust for MUAC-only programming is MoH delivered CMAM which is usually devolved to the PHC level. Use of W/H is problematic here as height boards are not standard equipment, height is quite difficult to measure, and height measurements and W/H look-up / calculation are not covered in the IMCI syllabus. W/H is also not possible in CHW delivered CMAM programming as has recently been proved very effective (something like 96% recovery on 90% coverage) by by a joint research program by Tufts, SC-US, and the Government of Bangladesh.

I hope this helps.

Ranjith

Normal user

8 Jun 2011, 17:19

Dear Dr. Mark Myatt, I just wanted to clarify whether you are referring to OTP or SFP or both when you say discharge may be 15-18% weight gain. Could you please advise? Thank you once again for all your expert advise on this forum.

Mark Myatt

Consultant Epideomiologist

Frequent user

8 Jun 2011, 17:58

Sorry to have been unclear ... 15% - 18% weight gain on admission weight is something that has been recommended for therapeutic feeding programs (e.g. OTP). There are problems with this approach in that it tends to lead to the most malnourished getting shorter treatment than the least malnourished. This is the opposite of what we want.

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