evidence-based blog of Filippo Dibari

Posts Tagged ‘moderate acute malnutrition’

The role of dairy in the comparative effectiveness and cost of fortified blended foods versus ready-to-use foods in treatment of children with moderate acute malnutrition

In Under-nutrition on June 6, 2016 at 8:41 pm

from FASEB journal

Authors:Devika J Suri, Denish Moorthy and Irwin H. Rosenberg1



Objective Recent meta-analyses found treating young children with MAM using ready-to-use foods (RUF) versus fortified blended foods (FBF) resulted in higher recovery rates and weight gain. This analysis aimed to compare studies of RUF and FBF with and without dairy to determine whether the addition of dairy to these food supplements modified the comparative effectiveness and cost of treatment.


Methods A review of literature on the comparative effectiveness of FBF and RUF in treatment of MAM was conducted. Outcomes of recovery from MAM, weight gain and length gain were compared among study cohorts, which included FBF with dairy (FBF+), FBF without dairy (FBF−), RUF with dairy (RUF+) and RUF without dairy (RUF−). Data on recovery from MAM was pooled among the 4 supplement categories. The cost per 500 kcal of each category of food supplement was averaged among studies that reported cost data.


Results Among the 7 studies included, 9 RUFs were tested, of which 5 contained dairy, and 9 FBFs were tested, of which 3 contained dairy. Children treated with RUF+ had higher recovery rates compared with FBF− in 5 out of 5 study cohorts, higher weight gain in 4 out of 4, and significantly higher length gain in 1 out of 4. Children treated with RUF+ vs FBF+ had higher recovery rates in 1 out of 2 study cohorts, with no differences in weight or length gain. No differences were found in the 2 studies comparing RUF− and FBF+. Finally, children treated with RUF− had higher recovery rates compared with FBF− in 1 of 2 studies, higher weight gain in 2 out of 2, and no differences in length gain. Recovery from MAM among the 7 studies was 65% (FBF−), 79% (FBF+), 82% (RUF−), and 80% (RUF+). Four of the 7 studies included cost data; on average per 500 kcal costs were $0.15 (FBF−), $0.18 (FBF+), $0.17 (RUF−), and $0.35 (RUF+).


Conclusion Our results suggest that addition of dairy to FBF make it comparative in effectiveness to both RUF with and without dairy, but does not appear to be a factor between the RUF categories. RUF with dairy was twice the cost per kcal compared with the other food supplement categories. Cost-effectiveness analysis will be useful to help determine the most appropriate food supplement for treatment of MAM.

WHO: Updates on the management of severe acute malnutrition in infants and children Guideline

In Under-nutrition on April 27, 2015 at 7:02 am

(from WHO website)

Publication details

Editors: World Health Organization – 2013
Number of pages: 111
Languages: English, French

(Full document)


This guideline provides global, evidence-informed recommendations on a number of specific issues related to the management of severe acute malnutrition in infants and children, including in the context of HIV.

The guideline will help Member States and their partners in their efforts to make informed decisions on the appropriate nutrition actions for severely malnourished children. It will also support Member States in their efforts to achieve global targets on the maternal, infant and young child nutrition comprehensive implementation plan, especially global target 1, which entails achieving 40% reduction by 2025 of the global number of children under 5 years who are stunted and global target 6 that aims to reduce and maintain childhood wasting to less than 5%.

The guideline is intended for a wide audience, including policy-makers, their expert advisers, and technical and programme staff in organizations involved in the design, implementation and scaling-up of nutrition actions for public health. The guideline will form the basis for a revised manual on the management of severe malnutrition for physicians and other senior health workers, and a training course on the management of severe malnutrition.


Preventing Acute Malnutrition among Young Children in Crises: A Prospective Intervention Study in Niger

In Under-nutrition on September 15, 2014 at 11:14 am

Céline Langendorf, Thomas Roederer, Saskia de Pee, Denise Brown, Stéphane Doyon, Abdoul-Aziz Mamaty, Lynda W.-M. Touré, Mahamane L. Manzo, Rebecca F. Grais

PLoS Med. 2014 Sep 2;11(9):e1001714



Finding the most appropriate strategy for the prevention of moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) in young children is essential in countries like Niger with annual “hunger gaps.” Options for large-scale prevention include distribution of supplementary foods, such as fortified-blended foods or lipid-based nutrient supplements (LNSs) with or without household support (cash or food transfer). To date, there has been no direct controlled comparison between these strategies leading to debate concerning their effectiveness. We compared the effectiveness of seven preventive strategies—including distribution of nutritious supplementary foods, with or without additional household support (family food ration or cash transfer), and cash transfer only—on the incidence of SAM and MAM among children aged 6–23 months over a 5-month period, partly overlapping the hunger gap, in Maradi region, Niger. We hypothesized that distributions of supplementary foods would more effectively reduce the incidence of acute malnutrition than distributions of household support by cash transfer.

Methods and Findings

We conducted a prospective intervention study in 48 rural villages located within 15 km of a health center supported by Forum Santé Niger (FORSANI)/Médecins Sans Frontières in Madarounfa. Seven groups of villages (five to 11 villages) were allocated to different strategies of monthly distributions targeting households including at least one child measuring 60 cm–80 cm (at any time during the study period whatever their nutritional status): three groups received high-quantity LNS (HQ-LNS) or medium-quantity LNS (MQ-LNS) or Super Cereal Plus (SC+) with cash (€38/month [US$52/month]); one group received SC+ and family food ration; two groups received HQ-LNS or SC+ only; one group received cash only (€43/month [US$59/month]). Children 60 cm–80 cm of participating households were assessed at each monthly distribution from August to December 2011. Primary endpoints were SAM (weight-for-length Z-score [WLZ]<−3 and/or mid-upper arm circumference [MUAC]<11.5 cm and/or bipedal edema) and MAM (−3≤WLZ<−2 and/or 11.5≤MUAC<12.5 cm). A total of 5,395 children were included in the analysis (615 to 1,054 per group). Incidence of MAM was twice lower in the strategies receiving a food supplement combined with cash compared with the cash-only strategy (cash versus HQ-LNS/cash adjusted hazard ratio [HR] = 2.30, 95% CI 1.60–3.29; cash versus SC+/cash HR = 2.42, 95% CI 1.39–4.21; cash versus MQ-LNS/cash HR = 2.07, 95% CI 1.52–2.83) or with the supplementary food only groups (HQ-LNS versus HQ-LNS/cash HR = 1.84, 95% CI 1.35–2.51; SC+ versus SC+/cash HR = 2.53, 95% CI 1.47–4.35). In addition, the incidence of SAM was three times lower in the SC+/cash group compared with the SC+ only group (SC+ only versus SC+/cash HR = 3.13, 95% CI 1.65–5.94). However, non-quantified differences between groups, may limit the interpretation of the impact of the strategies.


Preventive distributions combining a supplementary food and cash transfer had a better preventive effect on MAM and SAM than strategies relying on cash transfer or supplementary food alone. As a result, distribution of nutritious supplementary foods to young children in conjunction with household support should remain a pillar of emergency nutritional interventions. Additional rigorous research is vital to evaluate the effectiveness of these and other nutritional interventions in diverse settings.

Trial registration

ClinicalTrials.gov NCT01828814


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IAEA Malnutrition Symposium Ends With Calls for Action

In Under-nutrition on June 1, 2014 at 9:15 am


from the IAEA website:

Following four days of intense discussions and detailed presentations, the IAEA International Symposium on Understanding Moderate Malnutrition in Children for Effective Interventions came to a close on 29 May 2014.

The Symposium brought together health professionals, policymakers, the private sector, research institutes and universities, national and international organizations.

The more than 350 participants from 65 countries and 50 agencies discussed a wide range of issues including: what works in the management of moderate acute malnutrition (MAM); maternal malnutrition and its effects on infant growth; nutrition-specific and nutrition-sensitive approaches to preventing MAM; the usefulness of cash transfers under different circumstances; and how to formulate national policy and address the concerns of governments seeking to tackle MAM in the face of information gaps.

Countries that are successfully addressing MAM presented their case studies, giving advice and accepting suggestions.

“This Symposium was filled with people who are passionate about the field of nutrition, so there was quite a lot of interaction for potential collaborations between the many experts from different areas of the field,” said Najat Mokhtar, Head of the IAEA Nutritional and Health-Related Environmental Studies Section, which organised the gathering in association with the World Food Programme, Valid International, and Micronutrient Initiative.


Symposium Conclusions

Noting that the Symposium has started an important conversation, Kwaku Aning, IAEA Deputy Director General and Head of the Department of Technical Cooperation, highlighted the key conclusions:

“First of all, strong government commitment and country ownership of initiatives to address moderate malnutrition are essential, particularly in efforts to improve the nutritional status of adolescent girls for a good start to motherhood.

“More evidence-based, cost-effective interventions are needed, and this will require the establishment of links with multiple sectors. The quality of data must be improved to inform policy. The use of stable isotope techniques as well as anthropometrics to evaluate the effectiveness of nutritional intervention programmes must be optimised.

“It is also important to take into account the range of agencies working in the area of malnutrition, and to avoid multiple, parallel actions to treat malnutrition.

“Capacity building is going to be key to addressing moderate malnutrition in childhood. Here, national governments must take ownership. Partnerships with academia will be important for programme formulation and evaluation,” Aning said.

– By Sasha Henriques, IAEA Office of Public Information and Communication

(Note to Media: We encourage you to republish these stories and kindly request attribution to the IAEA)

International Symposium on Understanding Moderate Malnutrition in Children for Effective Interventions

In Under-nutrition on March 30, 2014 at 8:56 am



Vienna 20 – 29 May 2014

I will be there. If you also participate and wish to link up in Vienna,

send an email to this email address.

(for detailed info see the conference web site or download the flyer)

Objectives of the conference
The symposium will have the following objectives:
• To share experience related to the implementation and evaluation of programmes to prevent and treat MAM in infants and children, particularly during the first 1000 days;
• To support overall policy and specific evidence-based programmes dealing with the management of MAM;
• To identify knowledge gaps and define needs for future research to improve the management of MAM;
• To issue recommendations on how to improve the monitoring and evaluation of programmes dealing with the management of MAM; and
• To identify the role of the IAEA in addressing knowledge gaps and evaluating programmes to prevent and treat MAM.




UNICEF – 2013 Global: Evaluation of Community Management of Acute Malnutrition (CMAM): Global Synthesis Report

In Under-nutrition on March 29, 2014 at 5:29 am

from UNICEF web page

Executive summary



Approximately 20 million children are affected by severe acute malnutrition (SAM) worldwide – some residing in countries facing emergencies and many others in non-emergency situations. Children suffering from malnutrition are susceptible to death and disease and they are also at greater risk of developmental delays.
Treatment of SAM has evolved as a major development intervention over several decades. Alongside other partners, UNICEF works to ensure that women and children have access to services, including through timely provision of essential supplies – especially therapeutic foods for the treatment of SAM. The advent of ready to use therapeutic food (RUTF) and a community-based approach – community management of acute malnutrition (CMAM) – has made it possible to treat the majority of children in their homes.
CMAM is generally a preventive continuum with four components: 1) community outreach as the basis; 2) management of moderate acute malnutrition (MAM); 3) outpatient treatment for children with SAM with a good appetite and without medical complications; and, 4) inpatient treatment for children with SAM and medical complications and/or no appetite. A key objective of CMAM is progressive integration of all four preventive components into national health systems. By the end of 2012, governments in 63 countries had established partnerships with UNICEF, WFP, WHO, donors, and NGO implementing partners (IPs) for CMAM. The Ministries of Health (MoH) assume leadership and coordination roles and provide the health facilities.
UNICEF’s inputs for CMAM include policy development, commitment of funds, coordination, and technical support available to the MoH and other implementing partners. UNICEF has made significant investments to scale up treatment of SAM through CMAM including procurement of therapeutic foods, medicines, and equipment. UNICEF currently procures approximately 32,000 MT of RUTF annually which represents an investment of over 100 million dollars.

Purpose/ Objective:

This evaluation is the first systematic effort by UNICEF to generate evidence on how well its global as well as country level CMAM strategies have worked, including their acceptance and ownership in various contexts and appropriateness of investments in capacity development and supply components. The evaluation was conducted by a team of independent external evaluators and included comprehensive assessments of CMAM in five countries (Chad, Ethiopia, Kenya, Nepal and Pakistan) and drawing synthesized findings and recommendations based on broader research and a global internet survey targeting all countries implementing CMAM. A wide range of stakeholders, including national and international partners, beneficiaries, and donors, participated in the exercise. The resulting conclusions and recommendations are intended to strengthen UNICEF’s contributions to CMAM and to support governments, UN agencies, NGOs and other stakeholders in modifying CMAM policy and technical guidance for both emergency and non-emergency contexts.


The evaluation scope consists of two interrelated components. First, the evaluation undertook detailed analyses of CMAM in Chad, Ethiopia, Kenya, Nepal and Pakistan. The criteria of relevance, effectiveness, efficiency, sustainability and scaling up were applied to CMAM components and to cross-cutting issues. Data were obtained from secondary sources, health system databases, and observations during visits to CMAM intervention areas. The community perspective was analysed through collection of opinions from caretakers, extended family, community leaders, and community-based health workers in addition to stakeholders from government and assistance agencies. Quantitative data were analysed to determine whether performance targets were met and qualitative data supported the analysis. Secondly, building upon case study evidence, broader research resulted in compiled lessons, good practices and recommendations for UNICEF and partners globally. A global internet survey targeting all 63 countries implementing CMAM, helped to triangulate and validate conclusions from the five country case studies.

Findings and Conclusions:

1. Relevance of CMAM Guidance and Technical Assistance
• The CMAM approach is appropriate to address acute malnutrition, particularly to the degree that CMAM is being sustainably integrated into the national health system.
• Demand for CMAM services has increased; efficient use of community resources for prevention and identification and referral of children with MAM and SAM contributes to demand.
• National contributions to CMAM are growing but scale up (expansion) is challenged by funding constraints for regular programming and reliance on emergency funds and external sources of assistance.
• Global UNICEF and WHO guidance for SAM treatment has contributed to development of national guidelines which offer high value in promoting district ownership. However, lack of agreement on the best approach to address MAM has contributed to inconsistency among countries for MAM management and concomitantly, prevention of SAM.
• Global and national guidance is generally adequate for treatment protocols but lacking or fragmented regarding: planning and monitoring, integration of CMAM, equity and gender, community assessment and mobilization, and MAM management.
• Technical support has resulted in significant gains in process, coverage and outcomes; creation of parallel systems is not sustainable and slows national ownership.
• Within UNICEF overall, there has been effective support for fund mobilization, emergency nutrition response, and supporting nutrition protocols; expansion of regional roles is important to meet national technical assistance needs.
• Capacity development has significantly promoted quality of services […]

2. CMAM Effectiveness and Quality of Services

3. Promoting Equity in Access

4. Progress and Issues related to National Ownership

5. Efficiency – Costs, Supply and Delivery of RUTF

6. Sustainability and Scaling Up (Expansion of CMAM)

[see Executive Summary for more information]


Overall, the evaluation recommends that UNICEF continue to promote and support CMAM as a viable approach to preventing and addressing SAM, with an emphasis on prevention through strengthening community outreach and integrating CMAM into national health systems and with other interventions.

Ownership and Integration, Strategy and Policy, Guidelines
• UNICEF should continue to work with governments, WFP, WHO, IPs, and other stakeholders to secure a common understanding on the most effective means of addressing MAM in order to unify approaches, to strengthen community-based preventive measures, and to prevent SAM and relapses into SAM.
• Establish a guideline or framework for integration of CMAM into the health system and with other interventions that is useful at national level when based on capacity assessments and integrated with national health, nutrition and community development strategies.
• Facilitate coordination and technical support at regional/national level to expand or develop national CMAM guidelines as CMAM is integrated with other interventions such as IYCF.

Performance and Quality of Services
• Strengthen community outreach by ensuring adequate investment in CMAM awareness raising activities and their integration with outreach for other public health interventions.
• Decentralize nutrition information systems to strengthen data collection and analysis at district level supporting and reinforcing the MoHs’ lead role and joint accountability among the MoH and partners for improving quality.
• Define a standardized monitoring system to assess the quality of the CMAM services to inform the MoH, UN partners, IPs and other stakeholders where more capacity is needed.

Equity in Planning and Coverage
• Strengthen planning for CMAM through conducting community assessments, and greater use of joint integrated results-based planning exercises and mapping information […].


In Under-nutrition on November 16, 2013 at 7:14 pm

by Andrew K. Amegovu, Patrick Ogwok, Sophie Ochola, Peter Yiga, Juliet H. Musalima, Emma Mutenyo

from Journal of Food Chemisty and Nutrition – Vol 1, No 2 (2013)



Infant and young child feeding practices in low-income countries are still inadequate leading to high rates of acute malnutrition. Formulas from local food materials are vital in formulations for management of child malnutrition in poor countries because they are affordable. Nutrient composition of sorghum-peanut blend (SPB) mixed with honey and ghee, and micronutrient-fortified corn-soy blend (CSB), a traditional food supplement, were analyzed. Proximate components and beta-carotene amounts were high in both products. Vitamin A level was higher in CSB than SPB. Proportions of essential fatty acids were low. Levels of iron, zinc, calcium, magnesium, phosphorus, potassium, manganese and sodium were adequate for recovery from moderate acute malnutrition (MAM). Energy content of CSB was 421kcal/100g while that of SPB was 430kcal/100g. Levels of condensed tannin, phytates, trypsin inhibitors and aflatoxins were below prescribed limits. In conclusion, levels of nutrients in SPB and CSB were adequate for treatment of MAM in children.

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International Conference: A Decade Of Community-based Treatment of Severe Acute Malnutrition

In Under-nutrition on June 3, 2013 at 8:57 pm

by Coverage Monitoring Network

Action Against Hunger (ACF International) and the Coverage Monitoring Network are pleased to invite you to a unique, two-day Conference titled “What We Know Now: a Decade of Community-based Treatment of Severe Acute Malnutrition”. The two day conference will bring together technical experts, field practitioners and policy makers to help identify priority areas for research and action. The event will review available evidence and emerging performance data of community-based SAM treatment.

SAVE THE DATE: October 17th – 18th  2013  London, UK

Field practitioners, academics and nutrition organisations are invited to submit proposals for presentations.  Abstracts should be sent to: Sophie Woodhead [s.woodhead@actionagainsthunger.org.uk] by Friday August 2nd 2013.

For more info click here.

Children successfully treated for moderate acute malnutrition remain at risk for malnutrition and death in the subsequent year after recovery

In Under-nutrition on February 27, 2013 at 7:50 pm

J Nutr. 2013 Feb;143(2):215-20. doi: 10.3945/jn.112.168047. Epub 2012 Dec 19.

by Chang CYTrehan IWang RJThakwalakwa CMaleta KDeitchler MManary MJ.


Moderate acute malnutrition (MAM) affects 11% of children <5 y old worldwide and increases their risk for morbidity and mortality. It is assumed that successful treatment of MAM reduces these risks.

A total of 1967 children aged 6-59 mo successfully treated for MAM in rural Malawi following randomized treatment with corn-soy blend plus milk  and oil (CSB++), soy ready-to-use supplementary food (RUSF), or soy/whey RUSF were followed for 12 mo. The initial supplementary food was given until the child reached a weight-for-height Z-score (WHZ) >-2. The median duration of feeding was 2 wk, with a maximum of 12 wk.

The hypothesis tested was that children treated with either RUSF would be more likely to remain well-nourished than those treated with CSB++.The primary outcome, remaining well-nourished, was defined as mid-upper arm circumference ≥12.5 cm or WHZ ≥-2 for the entire duration of follow-up.

During the 12-mo follow-up period, only 1230 (63%) children remained well-nourished, 334 (17%) relapsed to MAM, 190 (10%) developed severe acute malnutrition, 74 (4%) died, and 139 (7%) were lost to follow-up.

Children who were treated with soy/whey RUSF were more likely to remain well-nourished (67%) than those treated with CSB++ (62%) or soy RUSF (59%) (P = 0.01).

A seasonal pattern of food insecurity and adverse clinical outcomes was observed. This study demonstrates that children successfully treated for MAM with soy/whey RUSF are more likely to remain well-nourished; however, all children successfully treated for MAM remain vulnerable.


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WHO: Supplementary foods for the management of moderate acute malnutrition

In Under-nutrition on October 12, 2012 at 12:34 pm

Original title: Supplementary foods  for the management of moderate acute malnutrition in infants and children 6–59 months of age (Technical note)

by WHO (2012)

(download here a brief version of the document)

This document proposes the nutrient composition of supplementary foods to manage moderate acute malnutrition (MAM) in children under 5 years of age.

Experimental data were used to inform the estimates, taking into consideration the effect of different levels of nutrients and their bio-availability.

The document also lists the principles of nutritional management of children with MAM and reports the assumptions considered to set up the proposed recommendations, suggesting  which uses the latter can be applied for and topics for further research in this area.

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