Management Of Moderate Acute Malnutrition (MAM): Current .
Collaborating to improve the management ofacute malnutrition worldwideManagement of Moderate AcuteMalnutrition (MAM): Current Knowledgeand PracticeReginald A. Annan1, Patrick Webb2, Rebecca Brown31. Kwame Nkrumah University of Science and Technology,KNUST, Kumasi, Ghana2. Friedman School of Nutrition Science and Policy, TuftsUniversity, Boston, USA3. CMAM ForumCMAM Forum Technical Brief:September 2014
AcknowledgementsThe authors would like to thank the following experts for their very helpful comments and contributionsduring the development of this brief: Susan Fuller, Erin Boyd, Hatty Barthorp and Maureen Gallagherand all members of the CMAM Forum Steering Committee. Special thanks also go to the followingpeople who shared valuable information of their experiences of MAM management: Cecile Basquin,Shahid Fazal and David Doledec. Patrick Webb would also like to acknowledge the support provided byUSAID’s Office of Food for Peace through its Food Aid Quality Review (FAQR) grant to the FriedmanSchool at Tufts, as well as the entire FAQR team.This technical brief was produced with funding from ECHO. The final content is the responsibility ofthe authors and does not formally represent the position of the CMAM Forum in relation to issuesdiscussed.AbbreviationsACFAction Contre la Faim / Action Against HungerARTAntiretroviral TherapyBCCBehaviour Change CommunicationBSFBlanket Supplementary FeedingBSFPBlanket Supplementary Feeding ProgrammesCMAM Community based Management of Acute MalnutritionCSBCorn Soy BlendCSMCorn Soy MilkDSMDried Skimmed MilkEFAEssential Fatty AcidsENNEmergency Nutrition NetworkFANTA Food and Nutrition Technical AssistanceFAOFood and Agriculture Organisation of the United NationsFBFFortified Blended FoodsFFPUSAID Office of Food For PeaceGFDGeneral Food DistributionGAMGlobal Acute MalnutritionGNCGlobal Nutrition ClusterHEBHigh Energy BiscuitsHFAHeight-for-AgeHIVHuman Immunodeficiency VirusIAEAInternational Atomic Energy AgencyIASCInter-Agency Standing CommitteeIMTFInternational Malnutrition Task ForceIPCIntegrated Food Security Phase ClassificationIYCF-E Infant and young child feeding - EmergenciesLNSLipid-based Nutrient SupplementMAMModerate Acute Malnutritionwww.cmamforum.org1
MNPMicronutrient PowderM&EMonitoring and EvaluationMSFMédecins Sans FrontièresMUACMid-Upper Arm CircumferenceNCHSNational Centre for Health StatisticsNGONon-Governmental OrganisationPDCAAS Protein Digestibility Corrected Amino Acid ScorePLWPregnant and Lactating WomenPUFAPolyunsaturated Fatty AcidsRCTRandomised Controlled TrialcRCTcluster Randomised Controlled TrialRDARecommended Daily AllowanceRNIRecommended Nutrient IntakeRSBRice Soya BlendRUFUnited Nations UniversityRUSFReady-to-Use Supplementary FoodRUTFReady-to-Use Supplementary FoodSAMSevere Acute MalnutritionSDStandard DeviationSFPSupplementary Feeding ProgrammeTSFPTargeted Supplementary Feeding ProgrammeTFPTherapeutic Feeding ProgrammeUNUnited NationsUSUnited StatesUSDAUnited States Department of AgricultureUSAIDUnited States Agency for International DevelopmentUNHCRUnited Nations High Commission for RefugeesUNICEFUnited Nations Children’s FundUNSCNUnited Nations Standing Committee on orld Food ProgrammeWSBWheat Soy BlendWSMWheat Soy MilkWHOWorld Health Organisationwww.cmamforum.org2
Table of Contents1 Introduction.51.1 Brief Methodology .51.2 The Global Burden of MAM .52 The Management of MAM: Recent History .72.1 Nutrition Counselling and Education .72.2 Supplementary Feeding .72.3 Specialised Foods used for Supplementary Feeding .83 An Overview of Current Guidance for MAM Management.103.1 Principles of MAM Management .103.2 MAM Management Decision Making Framework .113.3 Recommended Nutrient Requirements for MAM .123.4 Targeted Supplementary Feeding Programmes (TSFPs).153.4.1 Target Population Groups .163.4.2 Admission and Discharge Criteria.163.4.3 Routine Medical Care.183.4.4 Monitoring and Evaluation (M&E) .183.4.5 Referrals .183.4.6 Coverage.193.5 Capacity Strengthening and Exit Strategy.193.6 Overview of Specialised Foods Currently used for MAM Management .193.6.1 Fortified Blended Foods (FBF) .193.6.2 Lipid-based Nutrient Supplement (LNS) .204 Effectiveness of specialised food products: recent reviews/meta-analyses.214.1 Effectiveness of targeted SFP .214.2 Effectiveness of Specially-Formulated Foods in the treatment of MAM.215 Challenges Faced in MAM Management .225.1 Low profile and lack of consensus .225.2 Focus on products .235.3 Inconsistent definitions in MAM Management programmes.235.4 Evidence gaps .235.5 Limited understanding of Nutrient Requirements for MAM .245.6 Gaps in consensus around MAM management protocols .245.7 Lack of provision of basic medical treatment.255.8 Constraints in monitoring and reporting of MAM management data .256 Way forward and conclusion.25References.27ANNEXES.31ANNEX 1: MAM PROGRAMMATIC GUIDANCE .31ANNEX 2: SUMMARY OF PRODUCTS FOR MAM MANAGEMENT .33ANNEX 3: RESOURCES RELATING TO THE MANAGEMENT OF MAM .37TRAINING MANUALS AND GUIDELINES .37www.cmamforum.org3
TablesTable 1: Wasting Prevalence (MAM and SAM) among Children under 5 Years of Age in the 10Most Affected Countries Worldwide (based on -2 SD WFH) .6Table 2: Milestones in the Development of Specialised Food Products for MAM Treatment.9Table 3: Principles of Nutritional Management of MAM.11Table 4: Proposed Recommended Nutrient Intake (RNI) for Children with MAM Living in PoorEnvironments Expressed as Nutrient Energy Densities (amount of nutrient/1000 kcal) .12Table 5: Recommendations on Diets Suitable for Children with MAM .13Table 6: Nutritional Recommendations for the Management of Moderate Acute Malnutrition.14Table 7: Recommendations for Counselling Caregivers with MAM Children on Appropriate useof Household/Family Foods.15Table 8: Counselling Practices on Moderate Acute Malnutrition by Selected UN Agencies,Implementation Partners and National Programmes .15Table 9: Decision-Making Framework for Selective Feeding Programmes.16Table 10: Suggested Admission and Discharge Criteria for MAM Treatment .17Table 11: Practices Among Implementing Partners and National Programmes regarding MAMManagement.17Table 12: Gaps in MAM Management Programming .24FiguresFigure 1: Percentage of Children under 5 Wasted (MAM) in 2012.6Figure 2: Decision-making Tree for Acute Malnutrition .11www.cmamforum.org4
1 IntroductionThis Technical Brief is one of three commissioned by the Community-Based Management of AcuteMalnutrition (CMAM) Forum. The Brief focuses on current principles and approaches to Moderate AcuteMalnutrition (MAM) management, highlighting key constraints, gaps in knowledge and areas still lackingconsensus. It is intended to inform ongoing debates among practitioners, national partners, donors andanalysts on what information and evidence on best practices are currently available, where the gaps are,and priorities for knowledge generation going forward.1.1 Brief MethodologyTo understand current knowledge and practice relating to the management of MAM, recent systematicreviews, meta-analyses and other major narrative reviews on the management of MAM were considered.Additionally, a manual search of unpublished literature, including consultation meeting reports, technicalreports, decision making tools, training manuals and modules on MAM management was conducted.Information was reviewed from the United Nations agencies and international Non-GovernmentalOrganisations (INGOs) involved in managing MAM management programmes for any reports andguidance materials on MAM management. Websites, including those of the Emergency NutritionNetwork (ENN) and Epicentre, CMAM forum, International Malnutrition Task Force (IMTF), WorldHealth Organisation (WHO), United Nations Children Fund (UNICEF), International Atomic EnergyAgency (IAEA), World Food Programme (WFP), Food and Agriculture Organisation (FAO), and theWorld Bank were visited to locate resources and reports on MAM management.In addition to the literature review, a short questionnaire was sent to key informants in specific agencies,to facilitate sharing of their experience on MAM management from a practitioners’ perspective.Information collected in these questionnaires included the following: Level of attention: whether MAM issues are receiving adequate attention. Guidance: which guidelines are being used (including definition of MAM and its detection, screening,referral, diagnosis and treatment protocols). Consensus: areas of consensus around the management of MAM, and where consensus does notcurrently exist. Knowledge Gaps: areas where more empirical information is urgently required to inform MAMmanagement policies and practices. Effectiveness: effectiveness of MAM treatment. Areas for improvement: means of improving MAM management.Information from all sources was collated and summarized in draft form for comment on, and discussionwith, numerous experts including various practitioners, national decision makers, academics,development agency staff, and members of the CMAM Forum Steering Committee. The currentdocument reflects broad consensus views, but highlights gaps in knowledge and areas where differencesof opinion remain (in terms of approaches to the management of MAM).1.2 The Global Burden of MAMAcute malnutrition (often referred to as wasting) is a major global health problem.1,2 According to theWorld Health Statistics report, a global total of 52 million children under 5 could be classified as havingacute malnutrition in 2012, of which 33 million had MAM (defined as weight-for-height (WFH) between-3 to -2 Standard Deviations).3 Thus, MAM affects roughly one in ten children under 5 years of age inthe least developed countries.4There are significant regional variations in the prevalence of MAM (Figure 1). Approximately one in 6children under 5 years in South Asia suffered from MAM in 2013 (i.e. 17%), followed by West andwww.cmamforum.org5
Central Africa (11%) and Middle East and North Africa, (8%). MAM prevalence is 10% or higher in 19out of 80 countries with recent estimates. These children are at increased risk of Severe AcuteMalnutrition (SAM), and even with MAM have a roughly three times higher risk of mortality fromcommon communicable diseases than if they were well-nourished.5,6 Indeed, MAM and SAM togetheraccount for roughly 11.5% of total deaths of children under 5 (representing roughly 875,000 preventabledeaths each year).1Figure 1: Percentage of Children under 5 Wasted (MAM) in 2012Source: United Nations Children’s Fund, World Health Organization, The World Bank, UNICEF-WHO-World Bank Joint ChildMalnutrition Estimates, 2013.The top 10 countries most affected by MAM and SAM as of 2013, in terms of prevalence rates, arepresented in Table 1. The majority of these countries have a prevalence of MAM greater than 10%. SouthSudan tops the list with a prevalence of 23%, while Indonesia has a prevalence of 13%. In absolutenumbers however, India has the highest burden, with over 25 million children under 5 with MAM orSAM, followed by Nigeria, with close to 4 million children.The distribution and prevalence of MAM has not changed a great deal in recent decades3,4 althoughnotable reductions have been recorded in Latin America.6-8 In 1990, the global estimate of childrensuffering from MAM or SAM was 58 million according to UNICEF,9 implying that between 1990 and2011, the prevalence of acute malnutrition reduced by only 11%.Table 1: Wasting Prevalence (MAM and SAM) among Children under 5 Years of Age in the10 Most Affected Countries Worldwide (based on -2 SD WFH)Ranked th i 02011201020112006–200720082010MAM prevalence SAM prevalence Number of MAM and(%)(%)SAM children 5,461388172,2513203,3392773,7832,820Source: United Nations Children’s Fund, World Health Organization, The World Bank, UNICEF-WHO-World Bank Joint ChildMalnutrition Estimates, 2013.uploads/2012/07/GHA Report 2012-Websingle.pdfwww.cmamforum.org6
Both moderate and severe acute malnutrition have serious consequences, contributing to increasedmorbidity and mortality, impaired intellectual development, suboptimal adult work capacity and increasedrisk of disease in adulthood.1,2,5 Interventions to address undernutrition should therefore include a strongcomponent of MAM management, where possible, not only treatment.2 The Management of MAM: Recent HistoryAlthough there are still gaps in current understanding of prevention and treatment of acute malnutrition,there is a greater level of consensus around the management of SAM10 than of MAM.11 There are toofew studies, and numerous inconsistent findings, on the effectiveness of MAM management.12-14 Severalreviews have highlighted the apparent lack of effectiveness of targeted SFPs aimed at treating MAM inemergencies, noting high rates of defaulting, low coverage and high associated costs.14 That said, thedevelopment of new practices under the rubric of Community Based Management of Acute Malnutrition(CMAM), also sometimes known as Community-based Therapeutic Care (CTC) or even IntegratedManagement of Acute Malnutrition (IMAM), has prompted growing interest in the evidence base foreffective action.CMAM was designed to address the limitations inherent in facility-based care of low access, lowcoverage and high cost associated with inpatient management of SAM, by providing care to the majorityof children with uncomplicated SAM as outpatients.10 Many programs have claimed evidence of success,and this has fuelled a demand for wide dissemination of evidence-based best practice, a) in sustainingrecovery from SAM through MAM, b) in treating MAM (thereby preventing SAM), and c) in seekingto prevent MAM from occurring. While considerable attention is often focused on curative measures, itis increasingly acknowledged that multiple integrated interventions are often needed to address underlyingcauses as well as immediate symptoms. Thus, while this Brief focuses on Nutrition Counselling andEducation and Supplementary Feeding as the two main established forms of MAM management currentlywidely implemented, this does not negate the need in many MAM contexts for broader complementaryactions aimed at disease prevention, psychosocial care, shelter, etc.2.1 Nutrition Counselling and EducationNutrition counselling has long been used as an approach to MAM management in situations wherecaregivers may have access to affordable food, and knowledge of appropriate care practices is not aconstraint. This approach is predicated on the assumption that nutritious food is available, but also thatcaregivers do not have sufficient awareness of how to combine foods into appropriate diets formalnourished or at-risk children.15 This approach focuses on disseminating information on appropriatefeeding practices which can increase dietary diversity and meet nutritional requirements, as well asimprovements in sanitation and hygiene practices.16 In later sections of this Brief, guidance for carryingout dietary counselling and a review of its effectiveness will be discussed.2.2 Supplementary FeedingSupplementary feeding (the provision of specially formulated supplementary foodsi) has long been acomponent of emergency food aid interventions, mostly implemented by non-governmental and UnitedNations agencies to treat moderately malnourished children or to prevent a deterioration of nutritioni“Supplementary foods” refer to specially-formulated foods in ready-to-eat or milled form, which are modified in theirenergy density, protein, fat
September 2014 Reginald A. Annan1, Patrick Webb2, Rebecca Brown3 1.Kwame Nkrumah University of Science and Technology, KNUST, Kumasi, Ghana 2.Friedman School of Nutrition Science and Policy, Tufts University, Boston, USA 3.CMAM Forum C . .
out while patients remain at home, and involves intermittent health facility visits and/or community outreach. Community-based management of acute malnutrition (CMAM): Sometimes also referred to as Integrated Management of Acute Malnutrition (IMAM). This approach aims to maximize coverage and access of the population detection and treatment.
19 Data Collection: November 2014 Patients identified with malnutrition: – 83 patients identified with malnutrition – 71 (86%) were coded with a malnutrition code by HIMS Malnutrition added to problem list by provider on day of dietitian evaluation
2 4 1.Nutrition Status and Malnutrition Prevalence of Malnutrition in Liver Disease Current estimates are 15-60% 90%of pts with cirrhosis 20%of compensated cirrhosis cases 50%of decompensated cases 57%of cirrhotic inpatients had malnutrition during their admission Everypatient with alcoholic hepatitis/cirrhosis has malnutrition of varying severity
Around 11 in 3 inpatients14 and 1 in 5 outpatients 5 with COPD are at risk of malnutrition. Malnutrition may develop gradually over several years or might develop or progress following exacerbations. Sarcopenia (loss of skeletal muscle mass and strength) affects 15% of patients with stable
supplements (ONS) is available to decision makers and practitioners, thereby demonstrating the value of ONS in improving patient outcomes and lowering the significant financial costs associated with malnutrition. MNI also offers an annual grant for the most innovative national initiative to fight malnutrition and increase awareness of malnutrition.
kwashiorkor which is an oedematous malnutrition and marasmus which is a significant emaciation with a mid-upper arm circumference (MUAC) 115 mm. In between, mixed malnutrition is described [1]. Each year, SAM af-fects at least 19 million under-5 children globally. In these
Acute pain management has seen many changes in the assessment and the available therapies. Acute pain is being identified as a problem in many patient populations. Beyond postoperative, traumatic and obstetric causes of pain, patients experience acute on-chronic pain, acute cancer pain or acute pain from medical conditions.
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