Changing the way we address severe malnutrition during famine

Treating severe acute malnutrition seriously

Severe acute malnutrition (SAM) affects approximately 13 million children under the age of 5 and is associated with 1-2 million preventable child deaths each year. In most developing countries, case fatality rates (CFRs) in hospitals treating SAM remain at 20-30% and few of those requiring care actually access treatment. Recently, community-based therapeutic care (CTC) programmes treating most cases of SAM solely as outpatients have dramatically reduced CFRs and increased the numbers receiving care. CTC uses ready-to-use therapeutic foods and aims to increase access to services, promoting early presentation and compliance, thereby increasing coverage and recovery rates. Initial data indicate that this combination of centre-based and community-based care is cost effective and should be integrated into mainstream child survival programmes.

Globalisation, complex humanitarian emergencies and health

A new political economy of conflict has emerged in the aftermath of colonialism and the Cold War. Complex political emergencies have been simmering in the post-colonial world for more than three decades. Intra-country armed conflict, often combined with natural disasters, at present contributes to the displacement of over 20 million people world-wide. The international community remains profoundly uncomfortable with the complex political emergencies of the new era, torn between the respect for national sovereignty upon which the international political system of the United Nations and other agencies is built, and the growth of concern with human rights and a burgeoning International Humanitarian Law. Globalisation may have brought many benefits to some but there are also many losers. The Word Bank and the International Monetary Fund imposed structural adjustment policies to ensure debt repayment and economic restructuring that have resulted in a net reduction in expenditure on health, education and development. A downward spiral has been created of debt, disease, malnutrition, missed education, economic entrapment, poverty, powerlessness, marginalization, migration and instability. Africa's complex political emergencies are particularly virulent and tenacious. Three examples that are among the most serious humanitarian emergencies to have faced the world in recent times--those in Angola, the Democratic Republic of Congo and Sudan--are reviewed here in detail. The political evolution of these emergencies and their impact on the health of the affected populations are also explored.

Efficacy and effectiveness of community-based treatment of severe malnutrition

BACKGROUND

There is a long tradition of community-based rehabilitation for treatment of severe malnutrition: the question is whether it is effective and whether it should be advised for routine health systems.

OBJECTIVE

To examine the effectiveness of rehabilitating severely malnourished children in the community in nonemergency situations.

METHODS

A literature search was conducted of community-based rehabilitation programs delivered by day-care nutrition centers, residential nutrition centers, primary health clinics, and domiciliary care with or without provision of food, for the period 1980-2005. Effectiveness was defined as mortality of less than 5% and an average weight gain of at least 5 g/kg/day.

RESULTS

Thirty-three studies of community-based rehabilitation were examined and summarized. Eleven (33%) programs were considered effective. Of the sub-sample of programs reported since 1995, 8 of 13 (62%) were effective. None of the programs operating within routine health systems without external assistance was effective.

CONCLUSIONS

With careful planning and resources, all four delivery systems can be effective. It is unlikely that a single delivery system would suit all situations worldwide. The choice of a system depends on local factors. High energy intakes (> 150 kcal/kg/day), high protein intakes (4-6 g/kg/day), and provision of micronutrients are essential for success. When done well, rehabilitation at home with family foods is more cost-effective than inpatient care, but the cost effectiveness of ready-to-use therapeutic foods (RUTF) versus family foods has not been studied. Where children have access to a functioning primary health-care system and can be monitored, the rehabilitation phase of treatment of severe malnutrition should take place in the community rather than in the hospital but only if caregivers can make energy- and protein-dense food mixtures or are given RUTF. For routine health services, the cost of RUTF, logistics of procurement and distribution, and sustainability need to be carefully considered.

Evaluation of health, nutrition and food security programmes in a complex emergency: the case of Congo as an example of a chronic post-conflict situation

OBJECTIVE

To describe the case of Congo as an example of the assessment and appropriateness of donor operational and sectoral strategies in a complex emergency.

DESIGN AND SETTING

The paper reports the findings of an external evaluation of operations financed by the European Commission Humanitarian Office in the Democratic Republic of Congo (DRC).

RESULTS

The Congolese health system is suffering from severe deterioration. What is functioning in the public health context is donor-dependent with high costs and limited coverage. Despite a relatively favourable agro-climatic situation, food shortage and famine severely affect the nutritional status of large population groups. In this context, humanitarian programmes have generally improved access to health care and the nutritional status of beneficiaries. The reduction of malnutrition in project areas is often demonstrated even though the context did not permit consolidation of these results. Malnutrition continues to claim a massive cost of lives owing to the effect of widespread food insecurity that follows a circular cause-and-effect pattern of very low food production and extreme poverty.

CONCLUSIONS

The current context in DRC does not correspond yet to 'post-crisis': neither at population level with regard to indicators of poverty, malnutrition, disease and death, nor at institutional level, with regard to state support to institutions. In these situations, the international community is often called upon to replace the state as service provider. Integrated humanitarian actions should be the future of relief projects in DRC. Health, nutrition and food security components should be considered a standard public health intervention strategy representing the most sensible approach to address the needs of the affected population.

Management of severe acute malnutrition in children

Severe acute malnutrition (SAM) is defined as a weight-for-height measurement of 70% or less below the median, or three SD or more below the mean National Centre for Health Statistics reference values, the presence of bilateral pitting oedema of nutritional origin, or a mid-upper-arm circumference of less than 110 mm in children age 1-5 years. 13 million children under age 5 years have SAM, and the disorder is associated with 1 million to 2 million preventable child deaths each year. Despite this global importance, child-survival programmes have ignored SAM, and WHO does not recognise the term "acute malnutrition". Inpatient treatment is resource intensive and requires many skilled and motivated staff. Where SAM is common, the number of cases exceeds available inpatient capacity, which limits the effect of treatment; case-fatality rates are 20-30% and coverage is commonly under 10%. Programmes of community-based therapeutic care substantially reduce case-fatality rates and increase coverage rates. These programmes use new, ready-to-use, therapeutic foods and are designed to increase access to services, reduce opportunity costs, encourage early presentation and compliance, and thereby increase coverage and recovery rates. In community-based therapeutic care, all patients with SAM without complications are treated as outpatients. This approach promises to be a successful and cost-effective treatment strategy.

Nutrition in conflict situations

High prevalence of malnutrition is often linked to conflict situations. Conflicts affect local livelihoods, impair productive activities and limit access to safe foods and basic services. Strategies to protect and promote nutrition of affected households and communities must be based on an understanding of this impact. While nutrition rehabilitation and food aid are clearly essential to preserve lives in the short run, they cannot provide lasting solutions. Impaired nutritional status ultimately reflects livelihood degradation but anthropometric indicators cannot be used to target timely interventions. They should be combined with simple indicators of food consumption which react more quickly to both crisis and relief/rehabilitation interventions. Local institutions should be encouraged to share information and build causality models of malnutrition for the main vulnerable livelihood groups as a basis for an integrated response. A communication component will systematically be needed to allow people to make informed decisions in a context with which they are often not familiar.

Community-based therapeutic care in HIV-affected populations

Community-based therapeutic care (CTC) is a community-based model for delivering care to malnourished people. CTC aims to treat the majority of severely malnourished people at home, rather than in therapeutic feeding centres. This paper describes the potential of the CTC approach to provide effective care and support for people living with HIV and AIDS (PLWHA). CTC includes many of the components of a home-based care model for PLWHA. It provides outpatient treatment for common complications of HIV and AIDS, such as acute malnutrition and simple infections, and an energy-dense ready-to-use food that could be made with the appropriate balance of micronutrients for the HIV-infected patient. Through the de-centralisation of outpatient treatment sites, CTC improves accessibility by moving treatment closer to people's homes and helps to promote the sustainability of care by building on the capacity of existing health infrastructure and staff. The CTC model contains many features that are appropriate for the care and support of HIV-affected people and, in its present form, can provide effective physical care for many HIV-affected individuals. We are currently working to adapt the CTC model to make it more suitable for the support of PLWHA in the longer term.

Public nutrition in complex emergencies

Public nutrition is a broad-based, problem-solving approach to addressing malnutrition in complex emergencies that combines analysis of nutritional risk and vulnerability with action-oriented strategies, including policies, programmes, and capacity development. This paper focuses on six broad areas: nutritional assessment, distribution of a general food ration, prevention and treatment of moderate malnutrition, treatment of severe malnutrition in children and adults, prevention and treatment of micronutrient deficiency diseases, and nutritional support for at-risk groups, including infants, pregnant and lactating women, elderly people, and people living with HIV. Learning and documenting good practice from previous emergencies, the promotion of good practice in current emergencies, and adherence to international standards and guidelines have contributed to establishing the field of public nutrition. However, many practical challenges reduce the effectiveness of nutritional interventions in complex emergencies, and important research and programmatic questions remain.

Lessons learned from complex emergencies over past decade

Major advances have been made during the past decade in the way the international community responds to the health and nutrition consequences of complex emergencies. The public health and clinical response to diseases of acute epidemic potential has improved, especially in camps. Case-fatality rates for severely malnourished children have plummeted because of better protocols and products. Renewed focus is required on the major causes of death in conflict-affected societies--particularly acute respiratory infections, diarrhoea, malaria, measles, neonatal causes, and malnutrition--outside camps and often across regions and even political boundaries. In emergencies in sub-Saharan Africa, particularly southern Africa, HIV/AIDS is also an important cause of morbidity and mortality. Stronger coordination, increased accountability, and a more strategic positioning of non-governmental organisations and UN agencies are crucial to achieving lower maternal and child morbidity and mortality rates in complex emergencies and therefore for reaching the UN's Millennium Development Goals.

Home based therapy for severe malnutrition with ready-to-use food

BACKGROUND

The standard treatment of severe malnutrition in Malawi often utilises prolonged inpatient care, and after discharge results in high rates of relapse.

AIMS

To test the hypothesis that the recovery rate, defined as catch-up growth such that weight-for-height z score >0 (WHZ, based on initial height) for ready-to-use food (RTUF) is greater than two other home based dietary regimens in the treatment of malnutrition.

METHODS

HIV negative children >1 year old discharged from the nutrition unit in Blantyre, Malawi were systematically allocated to one of three dietary regimens: RTUF, RTUF supplement, or blended maize/soy flour. RTUF and maize/soy flour provided 730 kJ/kg/day, while the RTUF supplement provided a fixed amount of energy, 2100 kJ/day. Children were followed fortnightly. Children completed the study when they reached WHZ >0, relapsed, or died. Outcomes were compared using a time-event model.

RESULTS

A total of 282 children were enrolled. Children receiving RTUF were more likely to reach WHZ >0 than those receiving RTUF supplement or maize/soy flour (95% v 78%, RR 1.2, 95% CI 1.1 to 1.3). The average weight gain was 5.2 g/kg/day in the RTUF group compared to 3.1 g/kg/day for the maize/soy and RTUF supplement groups. Six months later, 96% of all children that reached WHZ >0 were not wasted.

CONCLUSIONS

Home based therapy of malnutrition with RTUF was successful; further operational work is needed to implement this promising therapy.

Supplementary feeding of underweight, stunted Malawian children with a ready-to-use food

OBJECTIVE

Maize and soy flour mixes are often used in the treatment of moderate malnutrition in Malawi. Their efficacy has not been formally evaluated. A recently developed ready-to-use food (RTUF) effectively promotes growth among severely malnourished children. The authors compared the effect of maize and soy flour with that of RTUF in the home treatment of moderately malnourished children.

METHODS

Sixty-one underweight, stunted children 42 to 60 months of age were recruited in rural Malawi, in southeastern Africa. They received either RTUF or maize and soy flour for 12 weeks. Both supplements provided 2 MJ (500Kcal) of energy daily but had different energy and nutrient densities. Outcome variables were weight and height gain and dietary intake.

RESULTS

Before intervention, the mean dietary intake and weight and height gain were similar in the two groups. During the supplementation phase, the consumption of staple food fell among children receiving maize and soy flour but not among those receiving RTUF. There was thus higher intake of energy, fat, iron, and zinc in the RTUF group. Both supplements resulted in modest weight gain, but the effect lasted longer after RTUF supplementation. Height gain was not affected in either group. Periodic 24-hour dietary recalls suggested that the children received only 30% and 43%, respectively, of the supplementary RTUF and maize and soy flour provided.

CONCLUSIONS

RTUF is an acceptable alternative to maize and soy flour for dietary supplementation of moderately malnourished children. Approaches aimed at increasing the consumption of supplementary food by the selected recipients are needed.

Comparison of the efficacy of a solid ready-to-use food and a liquid, milk-based diet for the rehabilitation of severely malnourished children: a randomized trial

BACKGROUND

The World Health Organization recommends a liquid, milk-based diet (F100) during the rehabilitation phase of the treatment of severe malnutrition. A dry, solid, ready-to-use food (RTUF) that can be eaten without adding water has been proposed to eliminate the risk of bacterial contamination from added water. The efficacies of RTUF and F100 have not been compared.

OBJECTIVE

The objective was to compare the efficacy of RTUF and F100 in promoting weight gain in malnourished children.

DESIGN

In an open-labeled, randomized trial, 70 severely malnourished Senegalese children aged 6-36 mo were randomly allocated to receive 3 meals containing either F100 (n = 35) or RTUF (n = 35) in addition to the local diet. The data from 30 children in each group were analyzed.

RESULTS

The mean (+/- SD) daily energy intake in the RTUF group was 808 +/- 280 (95% CI: 703.8, 912.9) kJ x kg body wt(-1) x d(-1), and that in the F100 group was 573 +/- 201 (95% CI: 497.9, 648.7) kJ. kg body wt(-1) x d(-1) (P < 0.001). The average weight gains in the RTUF and F100 groups were 15.6 (95% CI: 13.4, 17.8) and 10.1 (95% CI: 8.7, 11.4) g x kg body wt(-1) x d(-1), respectively (P < 0.001). The difference in weight gain was greater in the most wasted children (P < 0.05). The average duration of rehabilitation was 17.3 (95% CI: 15.6, 19.0) d in the F100 group and was 13.4 (95% CI: 12.1, 14.7) d in the RTUF group (P < 0.001).

CONCLUSIONS

This study indicated that RTUF can be used efficiently for the rehabilitation of severely malnourished children.

Macrolevel approaches to improve the availability of complementary foods

Large numbers of infants and young children suffer from the short- and long-term health effects of poor breastfeeding and complementary feeding practices. Strategies to improve the availability of and access to low-cost fortified complementary foods can play an important corresponding role to that of behavior change in improving nutritional status of young children. However, the nutritional quality of complementary foods used in publicly funded programs is not always optimal, and such programs are costly and reach only a tiny fraction of those who could benefit. To broadly reach the target population, such foods need to be commercially available at affordable prices and promoted in a way that generates demand for their purchase. A sensible long-term policy for the promotion of low-cost fortified complementary foods calls for attention to their nutritional formulations and cost, the economics of production, and the legislative, regulatory, and competitive framework in which marketing occurs. This paper provides information on how to improve the nutritional formulations of fortified complementary foods and outlines the necessary conditions for a market approach to their production and promotion.

Outpatient care for severely malnourished children in emergency relief programmes: a retrospective cohort study

BACKGROUND

In emergency nutritional relief programmes, therapeutic feeding centres are the accepted intervention for the treatment of severely malnourished people. These centres often cannot treat all the people requiring care. Consequently, coverage of therapeutic feeding centre programmes can be low, reducing their effectiveness. We aimed to assess the effectiveness of outpatient treatment for severe malnutrition in an emergency relief programme.

METHODS

We did a retrospective cohort study in an outpatient therapeutic feeding programme in Ethiopia from September, 2000, to January, 2001. We assessed clinical records for 170 children aged 6-120 months. The children had either marasmus, kwashiorkor, or marasmic kwashiorkor. Outcomes were mortality, default from programme, discharge from programme, rate of weight gain, and length of stay in programme.

FINDINGS

144 (85%) patients recovered, seven (4%) died, 11 (6%) were transferred, and eight (5%) defaulted. Median time to discharge was 42 days (IQR 28-56), days to death 14 (7-26), and days to default 14 (7-28). Median rate of weight gain was 3.16 g kg(-1) x day(-1) (1.86-5.60). In patients who recovered, median rates of weight gain were 4.80 g kg(-1) day(-1) (2.95-8.07) for marasmic patients, 4.03 g x kg(-1) x day(-1) (2.68-4.29) for marasmic kwashiorkor patients, and 2.70 g x kg(-1) x day(-1) (0.00-4.76) for kwashiorkor patients.

INTERPRETATION

Outpatient treatment exceeded internationally accepted minimum standards for recovery, default, and mortality rates. Time spent in the programme and rates of weight gain did not meet these standards. Outpatient care could provide a complementary treatment strategy to therapeutic feeding centres. Further research should compare the effectiveness of outpatient and centre-based treatment of severe malnutrition in emergency nutritional interventions.

Possible use of spreads as a FOODlet for improving the diets of infants and young children

Spreads are high-viscosity fat products prepared by mixing dried powdered ingredients with a vegetable fat chosen for its viscosity. Spreads are not traditionally used for feeding infants or young children and were initially proposed for feeding severely malnourished children during the recovery phase. The advantages of these products include a high energy and nutrient density, a very good acceptability, and resistance to bacterial contamination. Adapted spreads could be designed to boost the nutritional density of diets of young children from poor communities. Spreads could be mixed with the meals or porridges traditionally given to infants or eaten by themselves as snacks. Formulation of spread products is flexible, and acceptability and efficacy trials are required to optimize their composition and fortification levels and to select the best-adapted ingredients for each setting.