MANAGEMENT OF ACUTE MALNUTRITION IN INFANTS (MAMI) PROJECT

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Management o Acute Malnutrition inInants (MAMI) Project

Summary Report

October 2009


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This summary report presents the key fndings and recommendations o the Management o Acute

Malnutrition in Inants (MAMI) Project.

The MAMI Project was implemented in collaboration between the Emergency Nutrition Network

(ENN), University College London Centre or International Child Health and Development (CIHD) and

Action Contre la Faim (ACF).

The MAMI Project was unded by the UNICEF-led Inter-Agency Standing Committee (IASC) Global

Nutrition Cluster.

Contributing Authors: Marko Kerac1, Marie McGrath2, Carlos Grijalva-Eternod1, Cecile Bizouerne3, Jenny

Saxton1, Heather Bailey1, Caroline Wilkinson3, June Hirsch3, Hannah Blencowe4, Jeremy Shoham2,

Andrew Seal1

1) University College London, Centre or International Health & Development, UK2) Emergency Nutrition Network, UK

3) Action Contre la Faim, France

4) London School o Hygiene & Tropical Medicine, UK

Editorial team: Chloe Angood, Marko Kerac, Marie McGrath, Jeremy Shoham.

A ull list o the research advisory group (RAG) and interagency steering group (IASG) members and

report contributors is included in the ull MAMI Report (available rom the ENN, see below).

Acknowledgements

We thank the IASC Global Nutrition Cluster or unding and supporting the MAMI Project.

We thank the many organisations and individuals who made the MAMI Project possible, and are

particularly grateul or inputs rom the RAG, the IASG, chapter authors, key inormants, and those who

gathered, cleaned and openly shared programme data.

Lastly, we thank the many colleagues who played a less obvious but key role in shaping the ideas and

concepts in the MAMI Project, in particular all participants at the Inant Feeding in Emergencies

Regional Strategy Workshop in Bali, March 2008, and numerous email, meeting and e-discussion

group correspondents.

FeedbackTo eedback on these fndings, contact the ENN, 32, Leopold Street, Oxord, OX4 1TW, UK,tel: +44 (0)1865 324996

email: [email protected]

The ull MAMI report is available at www.ennonline.net/research

Cover: Mothers with malnourished inants under 6 months, managed in a TFC in the Democratic Republic o the Congo. C

Wilkinson/ACF, DRC, 2007.

Design and layout www.holytrousers.com


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1.0 Overview o MAMI Project. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

2.0 Setting the scene. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

3.0 Key fndings & recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63.1 Burden o acute malnutrition in inants


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Management o Acute Malnutrition in Inants (MAMI) Project

1.0 Overview o MAMI Project

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1.0 Overview o MAMI Project

Objectives

The aim o the MAMI Project was to investigate the management o acutely malnourished inants

under six months o age (inants


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2.0 Setting the scene

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2.0 Setting the scene

A global perspective

Child malnutrition is a major global public health problem. In developing countries, it is estimated that

19 million children (3.5%) are severely wasted and malnutrition is responsible or 11% o total globaldisease burden. Undernutrition is responsible or 35% o child deaths. In some regions, notably in sub-

Saharan Arica, HIV is an added challenge, requently underlying and contributing to malnutrition.

Inants


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3.0 Key fndings & recommendations

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3.0 Key fndings & recommendations

3.1 Burden o acute malnutrition in inants


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3.2 Review o current MAMI guidelines

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only be a stop gap measure where there is an absence o other inormation; urther validation is needed

beore estimates could be considered reliable or precise.

Many selective eeding programmes use weight-or-height % o median (WHM) indicators. The

implications o moving rom WHM using NCHS to WHZ based on WHO-GS urgently needs to be explored

to determine more accurately how the shit to WHO-GS will maniest at feld level or inants


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3.3 Review o feld treatment o malnourished inants


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3.3 Review o feld treatment o malnourished inants


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3.4 Key inormant interviews

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3.4 Key inormant interviews

Key inormant interviews were used to urther understand feld experiences and ront-line perspectives

on the management o acute malnutrition in inants


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3.5 Review o breasteeding assessment tools

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Strategies to improve SAM assessment and management in inants


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3.6 Psychosocial aspects o MAMI

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3.6 Psychosocial aspects o MAMI

The MAMI Project considered some key inuences around the maternal-child relationship with regard to

malnutrition. A review was conducted o the scientifc basis and easibility o stimulation activities in the

treatment o severe malnutrition, with particular reerence to the WHO 1999 guidelines. The inuencethat maternal depression has on child malnutrition was also investigated, building upon a recent review o

maternal depression and child growth and considering implications or emergency programmes and

inants


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4.0 Other MAMI considerations

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A large number o studies are needed to explore which psychosocial support activities are most eective,

when they should start, the minimum duration o intervention, the impact on social and emotional

development o the child and/or on the mother-child relationship, and how to locate these activities in

the community care o malnutrition.

4.0 Other MAMI considerations

4.1 Inpatient and outpatient MAMI

The population burden o acute malnutrition in inants


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25 http://www.capgan.org/10ccdm.htm


4.4 Clinical identifcation o high risk inants

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There is evidence that skilled breasteeding counseling can have signifcant added value in improving

exclusive breasteeding rates and outcomes in sick inants. Little consideration is given to skilled

breasteeding support in current SAM guidelines, including or older inants and young children where it

is also important.

Based on current evidence, it is plausible that skilled breasteeding counseling and support would also beeective or malnourished inants; this needs to be tested in both inpatient and community-based

settings. Investigations need to also take account o sta time, skill sets and intervention costs to inorm

cost-beneft analysis.

4.4 Clinical identifcation o high risk inants

As reected in 4.2, clinical identifcation o high risk inants is lacking. Improved clinical assessment

strategies are needed to diagnose and address underlying inant or maternal disease (e.g. HIV, TB),

breasteeding problems that are primarily inant related (e.g. oromotor dysunction, prematurity, clet

palate), or breasteeding problems which are primarily mother related (e.g. poor technique, depression).

A number o dierent problems may co-exist in the same inant-carer dyad, or one may be dominant.

To date, tools aiding clinical identifcation have been mainly ocused on older age groups. An appetite

test equivalent used in CMAM triage is needed or inants


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4.6 Choice o therapeutic milk

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There is a paucity o and a need or intervention studies. Randomised control trials (RCTs) would oer the

strongest evidence.

There are likely to be geographical variations. International guidelines on antibiotic use are likely to

beneft rom local adaptations considering local pathogen prevalence and sensitivity patterns.

4.6 Choice o therapeutic milk

Which therapeutic milk to use has, and continues to be, a key consideration in programmes treating

inants


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5.0 The way orward

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5.0 The way orward

The MAMI Project has shown that the burden o care or inants


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Management of Acute Malnutrition in Infants (MAMI) Project

5.0 The way forward

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Key initiatives that may provide lessons in taking initiatives orward include the SFP minimum reporting

standards project (MRP)29, the Vermont-Oxord Network to improve neonatal care30, and the rollout o the

1999 WHO guidelines that refected the importance o addressing management, systems and sta in

eective implementation31.

To enable continued inter-agency dialogue, data sharing and partnership is needed. In particular: Focused prospective audits interpreting retrospective data is challenging and yields relatively limited

inormation.

Age-disaggregated data collection on inant


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Management of Acute Malnutrition in Infants (MAMI) Project

Appendix A

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lossoearnings

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Impactat

household&

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Impacton

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Triggers

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Documents

MANAGEMENT OF ACUTE MALNUTRITION IN INFANTS (MAMI) PROJECT