SAM treatment in children older than 5 years – Case of Myanmar – Dec 2015

1. Brief overview of the situation

In November 2015 ACF implementing partner in three townships of Rakhine State reported that since April 2015 (switch from NCHS to WHO growth standards) the proportion of children < 120 cm and older than 5 years of age admitted for SAM treatment increased 3 to 10 fold (compared to 2014 admissions based on NCHS). The proportion of older children admitted in ACF program (60- to 119-month old) varies across locations e.g., it represents 40% of total new admissions in Buthidaung township and 20% of total new admissions in Maungdaw township.

For more details, see ACF’s analysis report. One can note notably that:

· Among older children admitted, average age is 6.6 to 7 years[1],

· Only 0.72% of children > 59 months admitted have a height > 120 cm,

· Current practice: children > 59 months and with a height 59 months and with a height > 120 cm are screened with NCHS table.

2. Compilation of various experts’ recommendations and inputs from the implementing partner

The government of Myanmar have recognized that older children (more than 5 years of age) and adolescents suspected to be affected by the condition of SAM must have their weight-for-height measured, oedema checked, and are entitled to receive treatment. Therefore, it was agreed to include technical guidance accordingly in the national CMAM protocol notably on age range, admission criteria and therapeutic product dosage.

The table 1 compiles all the various experts’ recommendations and considerations from the implementing partner that were reviewed in order to provide recommendations.

Table 1: Compilation of recommendations for management of SAM in older children

			UNICEF	WHO	Partner	M. Golden	EAPRO recommendations for Myanmar
a) age range			5 to 9 yrs	5 to 9 yrs	through 9 yrs? Would rather not go beyond over fear of high caseload		5 to 18 yrs
			10 to 18 yrs	10 to 14 yrs
				10 to 19 yrs
b) admission criteria	5 to 9 yrs	MUAC	<129 mm	not recommended	concerns over using MUAC unmanageable caseload	research needed to derive MUAC cut off for older children in Myanmar	Not recommended for > 59 months children
	10 to 18 yrs		<160 mm
	5 to 18 yrs	BMI-for-age	< -3 z-score	< -3 z-score			BMI-for-age < – 3 z-score
		W/H	Not recommended for > 59 months children	Use WHO  standards up to 120 cm and then BMI for age z-scores	Use WHO standards up to 120 cm and NCHS for children above 120 cm	Use WHO standards up to 120 cm and NCHS for children above 120 cm through 10 years of age	Not recommended for > 59 months children
c) therapeutic product				Same than dosage used for < 5; based on kcal per kg body weight		Same than dosage used for < 5; based on kcal per kg body weight; BP100 preferred	Same than dosage used for < 5; based on kcal per kg body weight

3. UNICEF EAPRO conclusions and recommendations for Myanmar

Based on the review of recommendations from various experts (Table 1), taking into account practical considerations (relevant in the context of SAM services delivery in Rakhine State), and the fact that these will be used for the development of national guidelines, UNICEF EAPRO proposes:

a) Age group:

Most preferred recommendation:

Given that the needs and the severity of the situation call for inclusion of all children (regardless their age) affected by SAM in the treatment protocol and based on the assumption that the admission criteria recommended below is adopted, it is recommended that all 5- to 18-year children be eligible for treatment.

Less preferred recommendation[2]:

If SAM services providers were to decide to put an age limit given the limited resources and to prevent a situation where the program caseload would become difficult to manage, the recommended age group would then be all 5- to 9-year children be eligible for treatment.

b) Admission criteria:

· MUAC:

Given there is no international agreed / recommended MUAC cut off to diagnose SAM in > 59-month children yet and that more research is needed in that area, it is recommended not to use MUAC as admission criteria among older children.

· BMI-for-age:

It is recommended to use BMI-for-age < -3 SD to classify SAM in older children (above 5 and up to 18 years of age) and simplified tables for use in field are available (link here).

· WFH:

UNICEF does not recommend the use of WFH z-score to diagnose SAM among children older than 59 months[3].

· Edema

As for 6- 59-months children, bilateral pitting oedema and visible wasting are also clinical signs of SAM in this age group.

c) Therapeutic food

It is recommended to use the same RUTF dosage used for 6-59 month old, i.e., based on kcal per kg body weight.