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Simplified protocol - kwashiorkor cases?

This question was posted the Prevention and treatment of severe acute malnutrition forum area and has 4 replies. You can also reply via email – be sure to leave the subject unchanged.

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Anonymous 24408

Normal user

5 Mar 2019, 21:42

There appears to be increasing interest in simplified protocols that treat all children with MUAC <125mm with an optimised dose of specialised nutrition commodity that is correlated with MUAC category.

In areas where this is being piloted with aim of wider scale implementation how are the kwashiorkor cases (+ or ++) treated that would have been admitted to standard protocol OTP?

Can the optimised RUTF dose (2 sachets/ day MUAC <115mm) in the simplified protocol also be considered optimal for the kwashiorkor (+ or ++) cases?

Paul

Technical expert

6 Mar 2019, 10:48

Hi Anonymous,

The simplified protocol considers children with both SAM and MAM (MUAC <125mm). However the treatment for each category remains different (as you note: 2 packets / day RUTF for cases <115mm).

Cases of oedema are always considered to be cases of SAM. Cases of oedema (+1 or +2) should continue to be treated as SAM cases and discharged when the oedema has resolved (x 2 visits).

If the MUAC remains below 125mm after the oedema has resolved, you can continue to treat according to the nutritional status giving the RUTF ration according to whether the child is still SAM or MAM according to MUAC.

The question on whether treatment is 'optimal' is different altogether. Currently 'optimal' treatment for SAM cases is considered to be 175 - 200 kcal/kg/day. Studies with reduced doses through the simplified protocol have shown effective outcomes are possible (cure rate and coverage).

MUAC tends to recruit younger / stunted children and, on average, 2 packets per day is an appropriate ration that meets the recommended dosage for children less than 2 years. This would not be considered 'optimal' for older children that should receive 3 or more packets per day according to the standard weight based protocol. I think we should be cautious in suggesting that 2 packets of RUTF is an "optimised" dose.

The simplified protocols are not yet standard practice, but are currently being recommended / used to compensate for SHORT-TERM logistical issues where RUTF / RUSF is in short supply or there is a break in logistics.

Namesius

Dietitian

Normal user

6 Mar 2019, 14:01

Hello, team.
From my observation the practice being carried out for SAM kwashiorkor infants with MUAC <11.5CM . They are managed as inpatient case with F- 75 therapeutic milk till oedema subsidies. Which seems taking long in the wards, if there is a more simplified way, I may also like to know.

Lindah

Nutrition officer

Normal user

7 Mar 2019, 04:11

I believe I have not come across a simplified way especially for infants below 6 months of age .the only solution is the F75 and diluted F 100 . Though encouraging frequent breastfeeding has been observed to induce quick recovery. That's why here in uganda we council those clients who have stopped breastfeeding so much and encourage them to relactate with our support off course.

Am interested to know more in line with this subject.

Thank you

Paul

Technical expert

7 Mar 2019, 10:35

Hi Namesius,
For infants with oedema we should use F75 for recovery until the oedema has resolved, however if a child is able to breastfeed then this should be used as part of a protocol (e.g. supplementary suckling technique) that promotes breastmilk production or relactation as a first preference. If breastfeeding is not an option, and national guidelines allow, once the oedema has resolved the infant can be switched to diluted F100 (never full strength F100).

For children aged greater than 6 months, the F75 can be changed to F100 / RUTF in the transition phase, which will likely speed up the rate of the loss of oedema vs. F75.

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