August 2016

Summary of experiences on optimized RUTF dosage for SAM and use of RUTF for MAM treatment.

Why this note?: Several COs have recently asked whether RUTF could be used for MAM treatment and if yes, at what dosage. Nutrition Specialists also often inquire whether any international guidance or suggested good practices are available on optimized RUTF dosage throughout SAM treatment that could reduce RUTF amounts required and hence reduce treatment cost.

Content of the note: The note includes considerations and suggestions on:

1.       RUTF dosage reduction through the course of SAM/MAM treatment and use of RUTF for MAM treatment

2.       The management of MAM with non-product based approaches

1.       Considerations on the treatment of MAM with RUTF:

At time of writing, the EAPRO Nutrition section is not aware of any national guidelines or recommendations that would include special procedures to use RUTF for MAM treatment despite the fact it’s a practice observed in some countries for many years already (See textbox 1). When no targeted supplementary feeding program (TSFP) are available, i.e., when MAM treatment with RUSF or Fortified Blend Food (FBF) (traditionally supported by WFP) is not available, various alternative measures can be taken:

o   Acute emergency situations: There is a scenario used in emergencies and only for a temporary period of time (e.g., Niger 2006 crisis, post 2010 floods in Pakistan or in South Sudan currently, see also textbox 1) during which the so-called the “expanded criteria” approach can be implemented. This approach involved admitting MAM cases in out-patient therapeutic care or OTP, i.e., in programs that traditionally treat SAM. On one
hand adopting such a measure has huge implications linked to a significantly higher program caseload and additional quantity of RUTF. On the other hand, the same system (facilities, partners, staff, supply chain, information etc) used to treat SAM also covers MAM in a continuum, rather than having two separate systems for OTP and TSFP, and the logistics may be streamlined, given that RUTF is substantially less bulky than FBFs. The “CMAM expanded admission criteria” approach[1] is intended for implementation during acute crisis,  and proposes to follow simplified protocols whereby:

§ Admission criteria into the OTP is expanded to MUAC < 125 mm.

§ Discharge criteria from the OTP is MUAC = 125 mm on two consecutive visits, with a 3-week minimum stay.

§ Children with a MUAC < 115 mm are treated with 2 RUTF sachets/day, and children with 115 = MUAC <125 mm are treated with 1 RUTF sachet/day.

To note that admissions can also be based on Weight-for-height (< -3 z-scores for SAM, <2 z-scores for MAM) wherever this is already being done. The use of MUAC alone is for simplification when the use of WFH is not feasible / measuring height and weight a challenge.

o   Another approach that has been used by UNICEF in a humanitarian situation in the
absence of a TSFP (DPR Korea, 2013 onwards) is the treatment of MAM cases with medical conditions (e.g. diarrhea or other illnesses) in the hospitals providing SAM treatment, initially as in-patients using therapeutic milk until the illness resolves, and then continuing as outpatients with RUTF (1 sachet/day). However, this approach has not been documented, does not yet have formal guidelines, and is not fully clear on the definition of “medical conditions”, which they actually call “medical complications”, which in the accepted definition in SAM treatment guidelines they are not limited to. It is
unlikely that the type of documentation required to show results of this approach will be possible to obtain in the DPR Korea context, but the approach may be worth refining and trying out in other countries for documentation. Since not all MAM children receive RUTF, it would be less costly than providing it to all cases.

o   What does the research show?: Research is ongoing to look at the condition of acute malnutrition as a continuum and fully treated with RUTF (at revised dosage compared to standard protocol). For example Mark Manary recently published the results of such a study done in Sierra Leone (see here). The protocol treated SAM and MAM cases with a decreasing ration of RUTF (and health education messages delivered by peers). Results showed that this combined SAM/MAM treatment achieved similar to higher treatment outcomes (percentage of recovered/cured) and a higher program coverage than the traditional (OTP+TSFP) approach. Some also showed that RUTF amounts can be decreased at end of treatment (once weight gain velocity slows, after 4 to 5 weeks of treatment, ACF Myanmar link here). Others are investigating what optimized RUTF dosage throughout treatment could reduce cost of treatment (for similar treatment outcomes than with standard protocols). A research consortium led by IRC carried out a study that analyzed growth trends and energy requirements of 8,000 children recovering from acute malnutrition in OTP and SFP in Chad, Kenya, Pakistan, South Sudan, and Yemen (research summary link here). Their preliminary findings seemed to confirm that as rate of weight and MUAC gain slows, children need fewer kcal/kg/day to achieve observed growth. In other words, children need fewer supplemental calories as they recover because their rate of growth slows. This is in line of M. Manary research results and confirms the potential adequacy of a simplified protocol of 2 RUTF sachets/day to treat the condition of SAM with a switch to 1 RUTF sachet/day once MUAC is greater than or equal to 115 mm and below 125 mm. The research consortium is currently implementing a two-cluster randomized trial to test this SAM/MAM Combined Protocol against the standard OTP + SFP. However, all this has not yet resulted in official revision of current protocols.

2. Alternative to the management of MAM, the non-product based approach:

As stated in the GNC MAM decision tool, “more evidence is required before recommendation can be made to use cash transfers or vouchers to facilitate access of the recommended food requirements for treatment of MAM.”[2]

The MAM decision tool also recommends that “only in circumstances where access and availability [of the recommended food requirements] are not constrained should IYCF-E alone be recommended for management of MAM in emergency settings. Similarly, for non-emergency settings where the specialized products are not available or not the policy to use for MAM, assessment of availability and access to nutritious foods need to be undertaken when IYCF-focused approaches are pursued, and linkages with social protection schemes or other support for the most vulnerable, food insecure families may be needed.

In a series of papers developed with the CMAM forum, P. Webb also concluded that more research is required on the management of MAM and referring to the 2014 International
Symposium on MAM[3] noted that “more evidence on effective programmatic approaches to manage moderate wasting is needed. The Global Nutrition Cluster’s MAM Task Force
concurs, suggesting that the effectiveness (and cost) of various MAM interventions needs much more attention.^”

This paper concludes that the current state of evidence does not allow us to conclude with any confidence on the cost-effectiveness of a range of approaches such as for example:

· the potential contribution of home-based diets to improving outcomes, the effectiveness of existing products and approaches to the prevention of MAM (i.e. containing mild wasting such that it does not evolve into MAM),

· the role of intensive behavior change communication,

· the effect of provision of cash/vouchers with or without food in the management of MAM, or

· the relative dose-response of food treatments containing various levels of animal source protein, specific amino acids, different forms of micronutrients, or probiotics.

While little is currently known about the nutrient requirements for MAM children, some recommendations have been proposed and are well summarized in the CMAM forum technical brief on the management of MAM[4]. This technical brief series includes notably key principles and recommendations for caregivers of MAM children (see tables below) and as well as two papers on preventing MAM through nutrition-sensitive[5] and through nutrition-specific interventions[6].