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Is there recommended threshold for Average weight Gain?

This question was posted the Management of wasting/acute malnutrition forum area and has 10 replies.

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Anonymous 22505

Normal user

10 Feb 2024, 18:18

Different CMAM Guideline shows average weight gain only for management of severe acute malnutriiton programs which is about 8gm/kg/day for inpatient (full recovery), whereas for outpatient about 4 to 5gm/kg/day. my question is, is there any guide that shows recomedned Average weigh gain for combined SAM+MAM program (complete SAM+MAM recovery.  

Kemal Jemal Tunne

Emergency Nutrition Project Coordinator

Normal user

11 Feb 2024, 16:07

The recommended average weight gain for combined SAM+MAM program (complete SAM+MAM recovery). However, some resources offer insights that might be helpful:

1. Combined Protocol vs. Separate Guidelines:

Currently, many programs adopt a combined protocol (CMAM) for managing both SAM and MAM, instead of using separate guidelines for each. This means a single set of admission, monitoring, and discharge criteria apply to both categories. Therefore, specific weight gain recommendations for "combined SAM+MAM recovery" might not be explicitly stated.

2. Different Discharge Criteria:

Instead of focusing solely on weight gain, CMAM programs often rely on a combination of criteria for discharge, including:

Mid-Upper Arm Circumference (MUAC): Reaching a specific MUAC threshold (e.g., ≥125mm) indicates recovery.
Weight Gain: While not the sole focus, weight gain is still monitored. The WHO and UNICEF recommend 15% weight gain as a discharge criterion for MUAC-based programs, but they also acknowledge that 20% might be necessary in specific contexts.
Clinical Indicators: Absence of edema, improvement in appetite, and absence of complications suggest recovery.
3. Context-Specific Variations:

It's important to remember that recommended weight gain can vary depending on several factors, including:

Program setting: Inpatient vs. outpatient facilities have different management strategies and expected weight gain patterns.
Age of the child: Younger children often have faster catch-up growth rates.
Severity of malnutrition: SAM requires more weight gain compared to MAM.
Underlying medical conditions: Comorbidities can affect weight gain progress.
Resources for Further Exploration:

WHO Guidelines for the Management of Acute Malnutrition: https://platform.who.int/docs/default-source/mca-documents/policy-documents/guideline/LBN-CH-38-01-GUIDELINE-2016-eng-National-Guidelines-for-the-Management-of-Acute-Malnutrition.pdf
Management of Severe and Moderate Acute Malnutrition in Children: https://www.ncbi.nlm.nih.gov/books/NBK361900/
Combined protocol for severe and moderate acute malnutrition in emergencies: https://pubmed.ncbi.nlm.nih.gov/31773867/
Remember: Consulting with relevant healthcare professionals and national/regional CMAM guidelines for your specific context is crucial for determining appropriate weight gain goals for combined SAM+MAM programs.
I think this is some help.

Feel free to reach out to me.

Kemal J Tunne
from Ethiopia
 Emergency Nutrition Coordinator 

Anonymous 22505

Normal user

11 Feb 2024, 16:52

Thanks Kemal for your response

I am aware of various factors  that determins weight gain. The reason why i am interested on weigh gain is because of the ongoing reseach we have in one of the location.

Regarding 15% or 20% percentage weight gain as discharge criteria, WHO has released guide in 2013 and recomeded to stop using as discharge criteria as some chidren with very low MUAC admission could reach 15% while they still SAM.  

Kemal Jemal Tunne

Emergency Nutrition Project Coordinator

Normal user

11 Feb 2024, 17:21

I fully understand your situation,but I would suggest that you have to sticky to your country or one country specific national guidelines.

Unfortunately, there isn't a single, universally accepted guideline that specifically outlines the recommended average weight gain for combined SAM+MAM program (complete SAM+MAM recovery). However, some resources offer insights that might be helpful:

WHO/Joint guidelines for SAM and MAM even WFP guide for moderate malnutrition cause's management for furthermore.

Kemal 

Kemal Jemal Tunne

Emergency Nutrition Project Coordinator

Normal user

11 Feb 2024, 17:33

You're absolutely right. Determining the recommended average weight gain for a combined SAM+MAM program isn't straightforward due to several factors:

Varying definitions of recovery: Recovery criteria differ depending on the program and malnutrition type. Different organizations like WHO and UNICEF might have slightly different guidelines for discharge based on weight gain, mid-upper arm circumference (MUAC), or other indicators.

Individuality of cases: Each child presents differently, with varying degrees of malnutrition severity, underlying illnesses, and responses to treatment. A "one-size-fits-all" approach risks overlooking individual needs.

Challenges in measurement: Accurately measuring weight gain, especially in resource-limited settings, can be challenging. Factors like weighing scales or measurement techniques can introduce variability.

Emphasis on holistic outcomes: While weight gain is a crucial indicator, programs increasingly consider comprehensive recovery, including regaining muscle mass, reducing edema, and improving appetite and development.

However, some existing research and guidelines offer insights:

1. Percentage Weight Gain:

Moderate Acute Malnutrition (MAM): The WHO and UNICEF recommend a 15% weight gain from admission weight for MUAC-based MAM programs. However, they acknowledge that a 20% gain might be necessary depending on the context.
Severe Acute Malnutrition (SAM): While some programs rely on percentage gain, others like those using MUAC for admission might not have specific weight gain criteria.
2. Daily Weight Gain:

For SAM programs using weight-for-height score (WHZ) for discharge, a daily weight gain of 5-10 grams per kilogram (g/kg) of body weight is considered moderate and >10 g/kg as good.
3. MUAC Measurement:

For both SAM and MAM, programs increasingly use MUAC for admission and discharge. Specific protocols might define recovery by achieving a certain MUAC threshold (e.g., MUAC ≥ 125mm).
4. Holistic Assessments:

Beyond weight gain, programs consider factors like appetite, edema, and developmental milestones to assess recovery comprehensively.
Research:

A study in Ethiopia explored using % weight gain for SAM discharge and concluded that while it simplified monitoring, it might not always reflect holistic recovery compared to MUAC-based criteria.
Remember:

These are just general insights, and consulting a healthcare professional or program guidelines is crucial for specific cases.
Individualized assessments and monitoring are essential for effective treatment in combined SAM+MAM programs.
I hope this information helps! While I cannot provide specific recommendations, I encourage you to consult qualified healthcare professionals or program manuals for detailed guidance
Kemal J Tunne 
Ethiopia 

Sultan Ahmed

Coordinator. Balochistan Nutrition Directorate

Normal user

13 Feb 2024, 02:21

Thanks Kemal, 

I also secound you, same criteria we are applying in combined program and it is producing timely and accurate results. best 

Paul

Action Against Hunger UK

Technical expert

13 Feb 2024, 08:57

Hi Sultan / Kemal,

I would like to emphaise that WHO does not recommend percentage weight gain as a discharge criterion for either MUAC or Weight-for-Height. Please consult either the relevant national guidelines or the new WHO guidance (2023) WHO guidance (2023)

Paul

Kemal Jemal Tunne

Emergency Nutrition Project Coordinator

Normal user

13 Feb 2024, 09:33

The question of using percentage weight gain as a discharge criterion for malnutrition programs using either MUAC or Weight-for-Height (WHZ) is complex, with nuanced considerations depending on national guidelines, WHO recommendations, and specific contexts. Here's an overview:

Current WHO Recommendations (2023):

  • WHO does not officially recommend a specific percentage weight gain for discharge.
  • Their 2023 guidelines emphasize individualized assessments and avoiding rigid cut-offs.
  • They advocate for using a combination of tools and clinical judgement, considering MUAC, WHZ, appetite, oedema, and other factors.

National Guideline

  • Many countries have their own established guidelines for managing malnutrition, which may or may not include specific weight gain targets.
  • It's essential to consult and adhere to the official guidelines of your specific country/region.

Considerations for Percentage Weight Gain:

  • Advantages: Easy to measure, promotes weight gain, potentially reduces treatment duration.
  • Disadvantages: Doesn't consider individual variations, risks overfeeding or underfeeding some children, ignores other indicators of recovery.
  • Research findings:
    • Studies suggest 15% weight gain might not be sufficient for all children, especially those severely malnourished.
    • Using MUAC as discharge criterion with weight gain targets can have limitations.

Conclusion:

While percentage weight gain has been used in some contexts, it's crucial to prioritize individualized assessments and follow country-specific guidelines. Consider the limitations of a single weight gain target and rely on a combination of tools and clinical judgement for optimal discharge decisions.

For further details, please clarify:

  • Your specific country/region: Knowing the relevant national guidelines is crucial.
  • Whether you're focusing on MUAC or WHZ: Each approach has different considerations.

Additional resources:

Remember, I cannot provide medical advice. Consult with healthcare professionals for specific guidances.

Anonymous 22505

Normal user

13 Feb 2024, 11:55

Lets avoid going round and round. Lets also avoid referring by mixing old and recent guidelines in one basket as it create confusion among practitionaries. we know context varies from region to region or from country to country, even within Country Or between emergency and development context. in view of this situation, we have global institutions like WHO that can regulate or harmonize protocols as per evidences across the globe. So, our benchmark is WHO. Countries can adapt/adopt the WHO guide accordingly but can't redfine or change the scientic facts/evidences stated in WHO guideline. 

In short statment, WHO (2013 and 2023 guides), does not recomned percentage weight gain as discharge/exit criteria. the reason why it is not recomended is already stated in the guideline. 

Back to my original question, i was asking just any one who have data or report of average weight gain of children attended combined SAM+MAM intervetion (after full recovery from SAM and MAM). 

Natasha Lelijveld

Normal user

13 Feb 2024, 13:28

Hi, I am not aware of any guideance on suggested average daily weight gain for a combined programs ... and this might now never happen since new WHO guidelines do not support the idea of combined programs. 

But I can highlight that ComPAS study result published average daily weight gain for combined vs normal program - which was 1.9 g/kg/day for both programmes; see table 3. The discussion sections mentions a couple of factors that may explain the low rate of weight gain for both programmes:

https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1003192

Notably, the rate of weight gain wasnt different between the 2 types of program, so maybe you can just assume the same guideance as for standard programs? 

Just to throw this info into the mix too: there is some discussion around whether faster weight gain is better or not - see recent paper that suggests that faster weight gain may have detrimental effects for survivors in the future https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0002698

 

Anonymous 22505

Normal user

13 Feb 2024, 15:46

Dear Natasha Lelijveld

Thank you very much for sharing the very relevant article to my request. Much appreciated. 

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