Simplified protocol - kwashiorkor cases?

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.

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.