Re: [pronut-hiv] Malawi Guidelines for nutrition rehabilitation (2)

["Charlotte Walford" <charlotte@chiswe.com>]

Well done for getting in on this debate - a pity CAS are in there!!
When are we meeting?
Charlotte

-----  "Roger Mathisen" wrote:

>
> 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
>
>