[pronut-hiv] Malawi Guidelines for nutrition rehabilitation

["Roger Mathisen" <rmathisen@unicef.org>]

The Malawi Interim Guidelines for Management of Acute Malnutrition through
Community Therapeutic Care (CTC/CMAM) suggest use of Ready to Use
Therapeutic Food (RUTF) in HIV positive children with moderate acute
malnutrition. However, these guidelines are interim and might be revised
based on new evidence as well as development and certification of an
appropriate Ready to Use Supplementary Food. Please find a summary of this
component of the guidelines below:

Nutritional Support for Children who are HIV-positive
Children with HIV require more energy and nutrients than children who are
not infected. In addition, HIV positive children are at higher risk for
acute malnutrition, and take longer to recover when they become
malnourished. It is important that nutritional support is given earlier in
the onset of malnutrition in order to give these children the best chance
of recovery. It is recommended that for these children RUTF is used for
both severe and moderate malnutrition.

HTC As many children infected with HIV will initially present with
malnutrition, the ability to offer HTC to all children with acute
malnutrition is important.

HTC in children under 18 months old For children under 18 months the diagnosis of HIV is difficult, as some children may test HIV ELISA positive but not be infected. After 18 months the test reliably indicates the child's HIV status. All ELISA positive children under 18 months should be retested when they reach 18 months.
Regardless of age, children with a positive ELISA test who meet eligibility
criteria should be admitted into OTP. If a retest at 18 months returns a
negative result, they should then be discharged if they no longer meet OTP
criteria.

OTP Admission criteria for HIV positive children 6 months to 11 years

   Children 6 months 11 years W/H < 80% 
   or bilateral oedema + and ++
   or MUAC** <12cm
   AND
   _ Appetite
   _ Clinically well
   _ Alert
   Annex 15
   51
   NRU Admission criteria HIV positive children 6 months to 11 years
   W/H <60%
   or Bilateral pitting oedema +++
   or Marasmic Kwashiorkor
   (= W/H < 70% or MUAC**
   <11.0cm with any grade of oedema)
   OR
   W/H <70%
   or MUAC** <11cm
   or oedema + and ++
   with any of the following complications:
   _ Anorexia, no appetite
   _ High fever
   _ Hypothermia
   _ Vomiting
   _ Severe dehydration
   _ Severe anaemia
   _ Very weak, lethargic, unconscious, convulsions
   _ Moderate to severe skin lesions
   _ Difficult or fast breathing

   Special cases***
   Children >6 months weighing <3 kgAnnex 15
1. Moderately acute malnourished children with both HIV and medical
complications should be referred for medical treatment.

Nutrition treatment for HIV positive children

   Nutritional treatment is given with RUTF using the same rations as in
   the OTP programme for severe malnutrition, at approximately 175 - 200
   kcal/Kg/day.
   Ration amounts are based on the weight of the child, and are the same
   for both moderate and severe malnutrition.

Cotrimoxazole prophylaxis for HIV positive children

   All HIV positive children should receive daily cotrimoxazole
   indefinitely according to national protocol.
   Children under 18 months old should be retested when age 18 months, and
   if HIV negative cotrimoxazole can be stopped.

Discharge criteria and referral onto ARV services

   HIV positive children should be kept in the program for a minimum of one
   month.  Children are discharged as cured after achieving a W/H >85% on 2
   consecutive visits
   Referral to clinician and/or ARV services should occur when the child is
   clearly not responding (5 weeks in program with no weight gain, or
   failure to achieve cure after 3 months in the program).
   If, after 4 months in the programme the child has still not attained the
   target weight, he/she should be discharged as a non-responding case.
   Non-responding children may be provided with RUTF within the ARV
   service, but should be discharged from OTP after 4 months. Those not
   receiving nutritional support through ARV services should be referred to
   SFP (if available), as well as social services, or community support
   services where appropriate.
   A non-responding child must receive a home visit from a community
   volunteer prior to discharge, and should be referred to a clinical
   officer for further assessment after three months.

   (NRU â Nutrition Rehabilitation Unit, OTP â Outpatient Therapeutic
   Programme, HTC â HIV Testing and Counseling, RUTF - Ready to Use
   Therapeutic Food) nnex 16

Regards,

Roger
--
Roger Mathisen
Nutrition and HIV Specialist (MSc, RD)

UNICEF - United Nations Children's Fund
P.O. Box 30375, Lilongwe 3, Malawi
Phone: +265 1 770788, Cell: +265 9 964547
Facsimile: 265 1 773162
email: rmathisen@unicef.org
Web: www.unicef.org
________________________________
For every child
Health, Education, Equality, Protection
ADVANCE HUMANITY

-----"Pamela Fergusson" wrote:                                                                     
      
Dear Zeina,

  Malawi has recently changed their guidelines for nutrition rehabilitation
to include therapeutic feeding with an RUTF at 80% W/H for HIV infected
children. For HIV uninfected children the cut off is 70% W/H.

  Malawi - how is this working? Any feedback or data form Malawi would be
welcome. The hope is to catch moderately malnourished children HIV infected
children and prevent them from becoming severely malnourished. At the
moment I believe these children are receiving a therapeutic ration of RUTF;
would be interesting to see this compared with an RUSF - especially one
designed for HIV infected children.

  Best,
  Pamela.

----Zeina Makhoul wrote:
  Hello,

Does anyone know:

What is the best approach to supplement moderately malnourished (weight for
age z score between -2 and -3) HIV-infected children with PlumpyNut or
Supplementary Plumpy? I read papers where they did it per kg body weight
but the children were severely malnourished. Are there age-specific
guidelines for moderate malnutrition where RUTF is used as a supplement
instead of therapeutic food? Or are there any guidelines for treatment of
moderate malnutrition?

Thanks!!

Zeina Makhoul
Postdoctoral Research Fellow
Fred Hutchinson Cancer Research Center
Seattle, Washington