Management of MAM and Mortality

Mark,

While we wait for generation of sufficient evidence on this subject via concrete operational research,I see a critical need for interim guidance at the global, regional, national level that will ensure response approaches do not fall short of, or deliberately ignore the problem of MAM. Who can generate this guidance? I think this is the prime time to ensure some level of either national, regional or global coherence in response strategies.

What do you fore see as the specific components for the proposed multi-year research of moderate malnutrition?

Thanks alot for the very useful response, I do indeed concur with you that there is the obvious that can be done to ensure that managment of MAM via SFP approaches work effectively and efficiently, and totally agree with you that commitment from CTC-like small technical team could play some role in resolving part of the problem and I hope something can be done or is being done.

Regarding interim guidance: I am not sure if this has been disseminated to the field, otherwise we wouldn't be concerned by the questionable position of different agencies on this matter. This is particularly worrying where management of MAM is neglected even when substantial needs of MAM have been reported via assessments or regular community screening exercises indicate significant needs amongst the moderates.

It would be useful if this guidance (if available?) could trickle down to the operational level, better still the other alternative could be that the global technocrates (ENN, GNC, UNOs) collate different field experiences on how countries/regions have dealt with this issue (?? I wonder if there is any example -just a thought) and formulate an all encompassing guidance that captures different but broad contextual scenarios.

How can contribute the ENN and the GNC to this important issue????

It is clear that some increased momentum is needed in addressing this issue.

André,

Thanks a lot for this response (very useful), I realy hope that we can get concrete direction in this matter sooner rather than later.

Thanks again

Dear André,

Thank you very much for this clear contribution. However, I think that if we really want to reduce GAM prevalence and not only saving lives, we should go further by applying a new paradigm on child undernutrition. Instead of focusing on SAM and MAM, to make sure in addition that "non-malnourished" children have constant adequate weight gain, through an EFFECTIVE growth PROMOTION strategy using effective INTERPERSONAL COMMUNICATION at community level. Otherwise, we will continue to treat thousand of SAM children, save their lives without reducing GAM prevalence.

management of Moderate Acute Malnutrition is one of the most important area of treatment. This is because it prevent deterioration of MAM child to become severe. The management of this area could be through the direct interaction of the caretakers at the targeted SFP centers whether through the comperhensive health and nutrition education or through the proper management at the SFP centers and it could be more efficient and effective if the SFP allocated and supervised by MoH. The role of MoH is very crucial in terms of creation of partnership with nutrition relevant agencies and provision of updated protocols and guidelines at country level.The supportive materials that help in the implementation of such programme is behind the successful of the programme. The absence of the MoH will bring us to the above mentioned that more agencies refuse to be involved in this area.

I have been involved in a SFP program for over a year now, with a focus of integration into the health services. To be honest I do not see a future in this as they workload is too great with premix rations to be given to the beneficiaries and we have been doing SFP programming for 5 years and the MAM rates remain high each year and are even increasing in teh past year due to unfavourable climatic conditions. The program itself is taking away the focus from the preventative programming, its using up all our resources to support teh logistics of this program. If you think about it - if you were to use those resources you have and put them into growth monitoring and early detection of MAM cases who once identified should receive counselling followed by monitoring - would you not be treating the MAM issue in a sustainable way!!

An SFP that is well implemented will have high coverage and efficacy in preventing further SAM and stabilizing the situation thereby reducing mortality risks at a greater proportion, but this is as long as conflicts emergencies and other food shocks are concerned, But how about recurrent malnutrition cases where there is always high relapse for non programmatic reasons? I happen to have worked on a pilot MAM management program- a model based on the use of RUSF (Ready to Use Supplementary Food--a more compact and nutritious product which eases off the huge logistics needs with premix rations and favors the effective management of MAM within existing local capacity), where the objective of the program was to integrate the management of MAM into government health facilities (Health posts and Health centers) and foster a sustainability approach in MAM management programming, like the initiative with the management of SAM which has proved to be very effective in situations where there is a significant political commitment from the part of government (MOH).
As the CTC initiative has been a substantial step in SAM management, I believe the current focus or future initiatives in revitalizing MAM management should be on capacitating local health facilities from Growth monitoring and Promotion to early detection, referral and treatment of pocket malnutrition cases (mostly MAM if it is detected at a very early stage) at community level and prepositioning of resources for treatment in health facilities during shocks and targeting on infection treatment with strong focus on delivery of primary prevention packages. The site based treatment of MAM cases (with SFPs) seems to be a conventional approach that everyone else wants to stick to in most cases.
At the point where we have MAM cases that need extensive SFPs with huge logistics and other operational needs (except with conflict and complex emergencies and non recurrent food shocks), we would already have high contributions of the situation to mortality due to the infection-malnutrition cycle. An area with high caseload of MAM is obviously expected to already have high infectious disease prevalence, which is more likely to be exacerbated by MAM as a complementary incidence. Though the relation between MAM and Mortality is indirect (due to the crucial role of morbidity effects), its contribution to Mortality is yet significant as opposed to the conventional mindset that SAM is the single most contributor to Mortality. The above situation would have been easily averted if the community based management of MAM approach mostly focusing on providing capacity building support was in place in the first place.
It would be sound an approach to consider these paradigms and others in the context of sustainability and adoptability of programming approaches while “revolutionizing” the management of MAM. That is;
-the product for treatment…at this point RUSF is coming in handy
-Capacity to manage and still maintain sustainability…political commitment +model of intervention
-Integration with other PHCS packages…more reliable and strong monitoring opportunity
-the CMAM approach is one way to see the way forward with MAM programming

Dear Massimo,

To start with I believe any intervention should be culturally sound, and context-wise innovative in order to be effective. However we are talking about the management of MAM in emergencies (given that the nature of emergency differs from place to place). However in other contexts there are more sustainable approaches already implemented and proved to be effective like for example the PD-Hearth model, meanwhile this kind of intervention approach is not yet feasible in life-saving emergency responses. And in the management of SFPs in emergencies the need for highly nutritious/LNS products is critical-one which provides easy logistic workload, and easy storage, minimizes sharing, that is perceived as a medicine by beneficiaries than food-as a result avoids the issues of cultural unacceptability, more hygienic (avoids hygiene issues during household preparation like in case of premix ration) and with better taste (appetite of malnourished child is affected by infection). In my opinion RUSF is just an alternative approach in MAM management and there will be and are supposed to be more alternative, effective approaches in place that take into account local contexts…as for example opportunities for local production(UNICEF has done it in a number of countries) and local food cultures. BTW I am not affiliated with the group producing Supplementary Plumpy doz/RUSF and nor am I promoting the product, I am only sharing the field experience because I found it more effective as opposed to the conventional premix ration based SFPs.

This is all secondary prevention and usually happens in emergency contexts. However in situations where there is not an emergency and yet the situation is detected at a late stage that requires massive SFPs, there rises the need for more innovative programming. This is where other preventive measures come in (surveillance systems included- though not preventive) and to say the least GMP is only part of these measures, but even so, would any two articles (as a result of perhaps two isolated incidents in some settings) mean anything in terms effective programming (you are talking about a failure probability of may be 1/100,000th or more?). You are right on the fact that indigenous local talent works better, but only if complemented by research based strategies, regarding issues of cultural soundness- that is why program strategies need to stem from the field and polished by desk officers than the contrary, and let’s hope this idea of local solutions becomes part of our programming approaches, more with political commitment of local governments taking the initiative…the technical expertise can always be pooled from elsewhere if not available.

Last, does it really matter who is presenting ideas in this forum as long as the target is improving intervention models in life-saving responses? (FYI -I happen to be an African in this case if not professionally…lol)