Severe Acute Malnutrition – what is the best way forward for the region

– A panel Discussion

Colombo 19th November 2009

Extent of the problem in Bangladesh

• 500,000 cases of SAM (WHZ<-3.00)• Total under-5 deaths 216,000• 75,600 deaths from malnutrition (35% of all

U5 deaths)• So how many die from SAM?• Don’t know.

Movie

Why does it happen?

Data from 39 developong countries 1987-1996

-2.00

-1.75

-1.50

-1.25

-1.00

-0.75

-0.50

-0.25

0.00

0.25

0.50

0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60

Age (months)

Weig

ht

for

ag

e Z

-sco

re (

NC

HS

) Latin America and Caribbean

Africa

Asia

Appropriate infant feeding practices result in better growth of infants and young children in rural

Bangladesh

Kuntal Saha, AJCN 2008

Comparisons between South Asia and Sub-Saharan Africa

UNICEF: The State of the World’s Children 2009

240 U-5 DEATHS EVERY DAY FROM MALNUTRITION

Death is also a nutrition parameter

The tragic story of Shathi and Bithi

• Birth weight 800 and 650 g

• More than doubled to 1.7 kg by 3 months of age on exclusive breastfeeding

• Then formula fed• And died of

pneumonia and sepsis soon afterwards

11

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IYCF challenges

• efforts to improve breastfeeding practices have not reached the majority of mothers

• Only 15% of women deliver in a health facility• Community-based activities through the National

Nutrition Program extend to 20 % of the country• only women in government service—a small fraction

of the work force—are eligible for maternity leave• lack of overall program coordination and oversight• weak national commitment and sporadic donor

support

IYCF challenges cont.

• lost momentum due to bureaucratic delays• high staff turnover• inadequately trained communitybased workers• missed opportunities within the health system to

counsel women on IYCF• lack of a standardized monitoring system• decline in the quality of baby-friendly hospitals• No national IYCF working group

Best way forward

• Optimal IYCF monitoring and promotion in the community

• If not optimal – then weigh/measure MUAC• If SAM – refer to hospital

– If SAM and sick – admit to hospital– If SAM and not sick - home management

Food-health-care educational intervention to prevent malnutrition. Roy et al: FNB 2007

Reducing moderate malnutritionRoy et al: JHPN 2005

Reducing moderate malnutritionRoy et al: JHPN 2005

Home treatment studies for SAM• Khanum S, Ashworth A, Huttly SRA. Controlled trial of three

approaches to the treatment of severe malnutrition. Lancet 1994;344(8939–8940):1728–32.

• Ashworth A, Khanum S. Cost-effective treatment for severely malnourished children: what is the best approach? Health Policy Plan 1997;12:115–21.

• Khanum S, Ashworth A, Huttly SRA. Growth, morbidity, and mortality of children in Dhaka after treatment for severe malnutrition: a prospective study. Am J Clin Nutr 1998;67:940–5.

• Ahmed T, Islam MM, Nahar B, Azam MA, Salam MA, Ashworth A, Fuchs GJ. Home-based nutritional rehabilitation of severely-malnourished children recovering from diarrhea and other acute illnesses. Paper presented at the 10th Annual Scientific Conference, ICDDRB, Dhaka. 11–13 June 2002.

Home-based foodsAdvantages Disadvantages

Cost-effective Families must have food resourcesLiked by caregivers; few defaulters Caregiver must be at home full-timeTeaches mothers about child-feeding Requires formative research to develop

adviceFamily foods for rehabilitation also form the basis for good

Requires clinic nearby or community health workers to monitor progress and provide timely treatment for ill children

complementary foods Need to provide micronutrient supplements

Potential to prevent malnutrition in the long term by teaching mothers to prepare good food mixtures, and to feed frequently and responsively

Requires motivated staff and good communicators

Potential ripple effect

Responsive to fluctuating numbers

Costs of domiciliary care 1990-91

How to feed hungry children

Omar ibn KhattabAmir-ul-Muminin 1,400 years agoin Saudi Arabia

Feeding people in emergencies

Cooking food for 2 million people in Tongi

awi gvQ bv QzB cvwbcatch the fish

but don’t get my hands wet

Thank you for your attention