Tag: smrhub

Background

• Traditionally, children who had wasting (also called acute malnutrition) were treated in hospitals.
• Hospital stays were inefficient, expensive, and forced caregivers to leave behind work and other responsibilities.
• This inefficiency meant very few kids received treatment, which increased the risk of illness and death from malnutrition.
• Starting in the early 2000s, international aid organizations and national health systems began treating wasted kids at home using packaged, nutrient-dense food called Ready-to-use Therapeutic Food (RUTF). These programs are called Community-Based Management of Acute Malnutrition (CMAM).
• CMAM programs are more cost-effective than hospitalization and allow more children to get the treatment they need, but the program quality varies and we still aren’t reaching nearly enough children.
  • Inefficiencies in the CMAM model include an arbitrary cutoff between moderate and severe cases which often leads to fragmented treatment, difficulty in reaching Health Facilities on a weekly basis to receive treatment, etc.
• Today, less than 25% of even severely wasted children receive the treatment they need.

Finding new and better ways to treat wasted children

• Researchers have recently started looking for new ways to simplify and improve CMAM programs so that they can reach and save more kids.
• Most ideas for “simplified CMAM protocols” include:
  • Treating all wasted kids with the same product (integrated protocol). In the past, organizations gave different therapeutic foods to kids who were more severely malnourished (SAM) compared to kids who were only moderately malnourished (MAM). New research is showing that it is not only possible to treat all malnourished kids with the same product, but that this can cut down on treatment costs by making supply chains more efficient.
  • Training and empowering parents to screen their own children for wasting at home for malnutrition rather than leaving screening up to healthcare workers who see kids a lot less often.
  • Changing to an easier way to screen for malnutrition (mid upper arm circumference or MUAC) that relies less on fancy equipment which is expensive and harder to use, transport, and maintain (such as the scale and height board needed to measure weight-for-height z score, another way of diagnosing wasting).
  • Simplifying the dosage of therapeutic food so that it is easier for low-literacy parents and healthcare workers to administer.
  • Reducing the amount of therapeutic food prescribed. New research is showing that children might need less therapeutic food to recover than they have traditionally been given. Safely reducing doses can help each shipment of therapeutic food go further and reach more children.

Recent Studies/Evidence supporting Simplified CMAM protocols

• The Optimising treatment for acute Malnutrition (OptiMA) proof of concept study in Burkina Faso trained mothers to use a simpler way to screen their children for malnutrition and treated all kids – regardless of how malnourished they were – with the same product at a gradually reduced dose. The recovery rate for even the most severely malnourished children was 86.3% – higher than the global standard for successful recovery (greater than 75%.)
• A recent systematic review found that caregivers can effectively detect severe malnutrition in their kids. On average, caregivers noticed that their children were malnourished earlier and more often than health workers did, which meant children were able to get treatment sooner.
• A randomized controlled trial in Sierra Leone found that treating all malnourished kids with the same product and using the simpler way of screening for malnutrition an integrated protocol had higher coverage and a higher recovery rate compared to a standard protocol
• The Combined Protocol for Acute Malnutrition Study (ComPAS) tested how treating all malnourished kids with the same product (a combined protocol for MAM and SAM) compared to the traditional way of treating kids. The study found no difference in recovery rate. The combined protocol was cheaper and just as effective.

Main takeaways

• There are a number of ways to simplify the way kids are treated for severe malnutrition.
• This simplification could potentially allow more kids to access high-quality programs which would, in turn, save more lives.
• A number of studies have shown that simplified protocols have a number of benefits compared to standard treatment protocols, including equivalent or better recovery rates, higher coverage, and lower cost per child treated.
  • Simplified protocol programs:
    • Are more efficient in terms of logistics and supply chain systems
    • Have cheaper administrative costs
    • Reduce the time and equipment required by health workers.
  • Research is still limited and a number of trials are ongoing. More research is needed on how to implement simplified treatment programs at scale and to understand issues around coverage, cost, and supply in different contexts.

References

1. Briend, A., Collins, S. Therapeutic nutrition for children with severe acute malnutrition: Summary of African experience. Indian Pediatr 47, 655–659 (2010).
2. Lenters L, Wazny K, Bhutta ZA. Management of Severe and Moderate Acute Malnutrition in Children. In: Black RE, Laxminarayan R, Temmerman M, et al., editors. Reproductive, Maternal, Newborn, and Child Health: Disease Control Priorities, Third Edition (Volume 2). Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2016 Apr 5. Chapter 11. Available from: https://www.ncbi.nlm.nih.gov/books/NBK361900/ doi: 10.1596/978-1-4648-0348-2_ch11

Published: September 23, 2020

Publication: Maternal & Child Nutrition

Authors: Amy Brown and Natalie Shenker

Read the original paper here.

Summary:

• Study looks at the experiences of breastfeeding mothers in the UK during COVID-19 lockdowns.
• The study wanted to especially understand how the pandemic impacted mothers’ decisions and attitudes on infant feeding.
• Of the mothers they surveyed, they found: 58.6% were breastfeeding exclusively, 22.5% practiced breastfeeding and formula feeding, and 18.9% stopped.
• The most common reason people stopped breastfeeding was because they didn’t have enough access to professional support.
• Of the participants who stopped breastfeeding just 4.7% stated they stopped when planned.
• Interestingly, participants who stopped breastfeeding were more likely to be told by a health professional that breastfeeding was not safe, despite WHO’s guidelines on breastfeeding during COVID-19.
• Mothers who described the experience as more positive (42%) were more privileged in their living circumstances – Black and minority ethnic mothers (BAME) were less likely to describe the experience as positive and were much less likely to report having enough practical support to breastfeed.
• There was a strong relationship between a positive experience and university‐level maternal education, high‐speed Wi‐Fi access, living in a house/ground floor flat, having a private garden and living in an area where it was easy to get out for walks/fresh air.
• Ultimately, the survey outcomes further confirm that misinformation, separation at birth, and lack of access to physical and early professional support greatly impact mothers’ infant feeding decisions.
• Some of the anecdotal information also suggests that more time at home with baby gave some mothers a better chance of starting breastfeeding early and sustaining it. This is important to understand for building better paid leave policies and programs to encourage breastfeeding.
• The paper recommends further studies to better understand how to properly and equitably provide breastfeeding support during a global pandemic.

Key Quotes:

“Newborn lost a lot of weight due to tongue tie and bad latch. Breast feeding class cancelled due to COVID. Husband not permitted in hospital when breast feeding advice was given and I was recovering from giving birth so struggled to take in information. When midwife identified low weight, we were put on a feeding plan with formula and I was advised I may not be able to breast feed. I expressed a lot to ensure I could build up my supply and had very sore nipples. After contacting 111 we thought I had thrush and I was given cream. Turns out I had bad positioning which was identified via video call two weeks post birth. Face‐to‐face support e.g. somebody physically helping you to position and latch your baby is far more effective than a zoom video call on a mobile device.”

“Many participants talked about missing meeting other breastfeeding mothers and socialising in baby groups or out with friends. Sometimes, this was about asking others questions or seeking reassurance, but often, it was just about connection and feelings of community. Many talked about the isolation they felt, which was impacting their well‐being and mental health.”

“I was Lucky to have a Whatsapp group of breastfeeding mothers—that I had met in a baby group pre lockdown. If I had a younger baby and did not have this I would have struggled.”

Useful Facts:

• Mothers from Black and minority ethnic (BAME) backgrounds were significantly more likely than White women to attribute a lack of face‐to‐face support to breastfeeding cessation.
• Of the 103 mothers who had a baby in neonatal intensive care unit (NICU), 19.4% were told they could not visit their baby and at the time of the survey completion a majority of these women were no longer breastfeeding.
• Those who stopped breastfeeding were more likely to associate their breastfeeding experience during lockdown as negative due to a perceived lack of social and emotional support.
• Participants who felt their experience was positive identified having more time focus, fewer visitor, more privacy, increased responsive feeding, greater partner support, and a delayed return to work as reasons.
• Of the participants who felt their breastfeeding experiences were a negative, one noted a lack of face-to-face support, lack of social support, stress of caring for other children, intense focus on breastfeeding, and no experience of feeding in public and work as concerns.

Today, an estimated 7.3% (50 million) of all children under five suffer from wasting at any given time and less than 1 in five of them are receiving treatment. In an effort to realize the Sustainable Development Goal (SDG) target of reducing the proportion of children suffering from wasting to <3% by 2030, five UN agencies^[1] are developing an updated plan to more effectively prevent and treat child wasting. On March 9, 2020, these agencies released a Global Action Plan (GAP) on Child Wasting. Here, Dr. Steve Collins provides his initial reflections on the GAP. The UN agencies are expected to release a more action-oriented ‘Roadmap for Action’ in late 2020.

Key Points:

• We have failed to address wasting at a global scale and the coverage of interventions remains extremely low.
• The GAP attempts to address this failure by moving away from a central focus on treating wasting, to a larger emphasis on prevention.
• Though he agrees that measures to address wasting should be more holistic and include both prevention and treatment, Dr. Collins argues that the failure to address wasting doesn’t mean that our strategy so far is wrong, just that our system failed to adequately implement it:
  • Global nutrition stakeholders have consistently under-prioritized wasting.
  • The way we deliver treatment to wasted children is not fit for purpose and has evolved little in decades.
• The GAP is unfocused and provides no vision of how the wide variety of different actors and sectors, in particular the private sector, can be included and harnessed in practical action. Without a clear vision of how this can happen, he fears that little will change and the GAP will be little more than “business as normal”.
• By ignoring the massive implementation failures at the heart of the system and instead focusing on strategy, the draft GAP fails to grasp a critical opportunity for reform.

Key recommendations for the Roadmap for Action:

1. Narrow the geographic scope: preventative interventions should be tightly targeted to communities and individuals at the highest risk of wasting, rather than spread homogeneously across the developing world, as this plan appears to suggest.
2. Implement targeted reform: Instead of fundamentally changing the strategy and massively broadening the range of interventions, focus on fixing what is manifestly wrong with the way we intervene, the coalitions of stakeholders with whom we engage, and the products we use.
3. Focus on fundamental research: Direct limited research dollars to addressing the most foundational issues first: expanding coverage, increasing impact and improving cost-effectiveness.

• The research agenda must acknowledge that extremely low coverage is the main factor limiting impact and answer the question: “How do we deliver support to the greatest numbers of children in the most cost-effective manner possible?”

1. Fully engage both the public and private sector:

• Private sector: leverage the private sector’s scale, capability and capacity along the entire chain of service delivery, up to and including last-mile delivery to those suffering from wasting.
• Public sector: focus on ensuring that the services delivered meet the needs of those affected by wasting by improving targeting, transferring entitlements to ensure equitable coverage, and imposing ethical standards to prevent exploitation.

Key Quotes:

• “The fact that our interventions have failed to attain an acceptable level of coverage is not, per se, evidence of a flawed strategy. It is merely an observation that we have failed. In my opinion, our collective failure to address wasting at scale is not primarily a strategic issue, but rather a failure to execute the existing strategy effectively, and it is a severe indictment of the system charged with doing this.”
• “We still engage too little (if at all) with affected communities to ensure that interventions are understandable, acceptable and appropriate for them. The market for nutritional products targeting wasting remains non-transparent and dysfunctional, dominated by a single supplier and single customer that is also the de facto market regulator.”
• “Is ‘focusing’ resources on several billion people who require clean water, better sanitation, universal healthcare, improved food systems and more appropriate nutritional behaviours a cost-effective way to help more than 50 million children affected by wasting each year? I do not think it is and I believe that, by casting the net so widely while ignoring key structural issues that undermine implementation, the plan inevitably turns into an unrealistic wish list.”

^[1] The five agencies are United Nations Children’s Fund (UNICEF), World Food Programme (WFP), the World Health Organization (WHO), the Food and Agriculture Organization (FAO) and the United Nations High Commission for Refugees (UNHCR)

Published: September 11, 2019
Publication: The Lancet: Child and Adolescent Health
Authors: Prof Jonathan C K Wells, PhD, Prof André Briend, PhD, Erin M Boyd, MSc, Prof James A Berkely, FRCPCH, Andrew Hall, PhD, Sheila Isanaka, ScD, Prof Patrick Webb, PhD, Tanya Khara, MSc, Carmel Dolan, MSc

Read the original article here.

Summary

• Since the 1970s, nutritionists have categorized undernutrition[1] in two major ways, either as wasting or stunting.
  • Stunting as an indicator of being too short for one’s age
  • Wasting as an indicator of being too thin for one’s height
• Wasting and stunting are proxies, or signs, for the more complicated less obvious physiological effects of malnutrition.
• Though categorizing children as wasted or stunted can be useful in identifying at risk populations, it is problematic to use these categories on individual children because they draw an artificial distinction between these two types of undernutrition
• Because of this distinction, stunting and wasting are often addressed by separate programs/approaches.
• Recently, research has shown that individual children are at risk of having both stunting and wasting simultaneously or of moving back and forth between the two conditions over time.
• Wasting is often described as the result of acute episodes of malnutrition, while stunting is portrayed as the consequence of chronic malnutrition. However, stunting and wasting can co-exist over time, so this nomenclature is incorrect.
• Children who are both stunted and wasted are at a much greater risk of premature death than children who only have one condition.
• The emphasis on classifying children as either stunted or wasted and then treating them with interventions designed to address one or the other of those conditions doesn’t account for the complexity of the causes and interconnectedness of the outcomes of wasting and stunting.
• We need to change the way we understand and manage child undernutrition to acknowledge that individuals can experience both conditions at the same time.

Specifically:

• We need more research on the relationship between weight and height faltering and how the interaction between the two increases a child’s susceptibility to death and long-term disability, including looking at the role a mother’s nutrition plays in her child’s weight and height.
• We need better ways to predict, identify, and monitor children at risk of weight and height faltering, not just those children who currently are wasted or stunted.
• We need to evaluate preventative and therapeutic interventions to ensure that they address the diverse causes and individual biological processes that result in undernutrition.

Key Quote

“We argue that these views [about the distinction between stunting and wasting] have become entrenched, leading to the separation of these outcomes in terms of policy, guidance, programme interventions, and financing: at the individual level, acute and chronic undernutrition are now viewed as separate conditions, and are routinely reported as distinct outcomes among policy makers. What is poorly recognised is that the anthropometric indices used to categorise individual children as wasted and stunted are only superficial proxies for the physiological and functional consequences of the underlying processes of undernutrition.”

Useful Facts

• Globally, 15.9 million children worldwide are experiencing being both wasted and stunted.
• Children who are both wasted and stunted have the same risk of dying as children with the most severe form of wasting.
• Initial research shows that being wasted increases a child’s risk of stunting.
• There is little evidence to support the concern that intensive use of therapeutic foods to treat wasting in stunted children will pre-dispose these children to obesity later in life.

[1] Defined by the WHO as the outcome of insufficient food intake and repeated infectious disease