Continuum of care for acute malnutrition
The 60th issue (July 2019) of the Emergency Nutrition Network (ENN) publication, Field Exchange (FEX), is dedicated to the ‘Continuum of Care (CoC)’ of children with acute malnutrition and includes a special editorial as well as three items on work in South Sudan.
There is emerging discussion and research on simplified approaches to the prevention and treatment of acute malnutrition – which at present is usually classified into severe acute malnutrition (SAM) and moderate acute malnutrition (MAM). The editors of FEX note that much more emphasis has been given to SAM and much less to MAM although there is evidence that many MAM children are at high risk of developing SAM and of dying, and that acute malnutrition is better considered as a spectrum.
The need for rethinking on SAM and MAM is driven by the stark fact that a huge proportion (~>75%) of children with acute malnutrition in 2018 did not receive any treatment (WHO et al 2019). As well as discussing the CoC needed by all children with acute malnutrition the editorial covers the anthropometric indicators used to classify wasting and stunting, and gives a good overview of the usual division of labour in the prevention and management of acute malnutrition by the UN agencies (UNICEF, WFP, WHO and sometimes UNHCR). Often, especially in emergency situations (as occurred on South Sudan), UNICEF is the primary agency for SAM and WFP for MAM.
The editorial is mindful of the many barriers to a more simplified joined up approach to the prevention and treatment of acute malnutrition, and the need for more research (some of which is covered in articles within this issue of FEX). It recommends that one UN agency has overall responsibility for CoC for the spectrum of acute malnutrition, and that there is co-ordinated research into ways to manage at risk malnourished children, especially those presently categorised as MAM.
The following articles cover work carried out in South Sudan:
ComPAS trial in South Sudan and Kenya. Page 16-18. Stage 1 of this trial tested a combined approach to treat uncomplicated SAM and MAM using a simplified dosage protocol based on using mid-upper arm circumference (MUAC) to diagnose malnutrition. It lists the benefits (e.g. it eliminates the need for different treatment products, requires less time and equipment, reduces administration and documentation, and is preferred by health staff) and the need for further testing (in Stage 2 whose results will be shared by ENN).
Factors affecting decision-making on the use of combined/simplified acute malnutrition protocols in Niger, north-east Nigeria, Somalia and South Sudan. Page 34-37. This research was carried out by the International Rescue Committee by interviewing respondents from Ministries of Health, UN agencies and NGOs in these countries - where simplified protocols have been implemented in exceptional circumstances. Respondents appreciated some of the benefits of the combined protocols (e.g. treatment in the same location) but there was a reluctance for national governments to depart from global guidance without more evidence and WHO endorsement. There seemed to be greater reluctance to combined/simplified protocols in more stable governments than where there was higher physical or food insecurity (e.g. South Sudan).
Scaling-up of care for children with acute malnutrition during emergency nutrition response in South Sudan between 2014 and 2018. Page 62-65. In 2014, impelled by overwhelming needs, UNICEF and WFP initiated a unified approach to scale-up treatment of malnourished children. This lead to a 2.6-fold increase in children reached, greater geographical coverage, and alignment between outpatient therapeutic programmes and targeted supplementary feeding programmes. This approach required, among other things, a dedicated co-ordinator, joint shared data management and needs analysis, leadership by the Nutrition Cluster, support by senior levels in the Ministry of Health and UNICEF and WFP, and goodwill on all sides.