evidence-based blog of Filippo Dibari

Posts Tagged ‘severe acute malnutrition’

Mothers screening for malnutrition by mid-upper arm circumference is non-inferior to community health workers: results from a large-scale pragmatic trial in rural Niger

In Under-nutrition on September 14, 2016 at 9:59 pm

by Franck G.B. Alé, Kevin P.Q. Phelan, Hassan Issa, Isabelle Defourny, Guillaume Le Duc, Geza Harczi, Kader Issaley, Sani Sayadi, Nassirou Ousmane, Issoufou Yahaya, Mark Myatt, André Briend, Thierry Allafort-Duverger, Susan Shepherd and Nikki Blackwell



Community health workers (CHWs) are recommended to screen for acute malnutrition in the community by assessing mid-upper arm circumference (MUAC) on children between 6 and 59 months of age. MUAC is a simple screening tool that has been shown to be a better predictor of mortality in acutely malnourished children than other practicable anthropometric indicators. This study compared, under program conditions, mothers and CHWs in screening for severe acute malnutrition (SAM) by color-banded MUAC tapes.


This pragmatic interventional, non-randomized efficacy study took place in two health zones of Niger’s Mirriah District from May 2013 to April 2014. Mothers in Dogo (Mothers Zone) and CHWs in Takieta (CHWs Zone) were trained to screen for malnutrition by MUAC color-coded class and check for edema. Exhaustive coverage surveys were conducted quarterly, and relevant data collected routinely in the health and nutrition program. An efficacy and cost analysis of each screening strategy was performed.


A total of 12,893 mothers and caretakers were trained in the Mothers Zone and 36 CHWs in the CHWs Zone, and point coverage was similar in both zones at the end of the study (35.14 % Mothers Zone vs 32.35 % CHWs Zone, p = 0.9484). In the Mothers Zone, there was a higher rate of MUAC agreement (75.4 % vs 40.1 %, p <0.0001) and earlier detection of cases, with median MUAC at admission for those enrolled by MUAC <115 mm estimated to be 1.6 mm higher using a smoothed bootstrap procedure. Children in the Mothers Zone were much less likely to require inpatient care, both at admission and during treatment, with the most pronounced difference at admission for those enrolled by MUAC < 115 mm (risk ratio = 0.09 [95 % CI 0.03; 0.25], p < 0.0001). Training mothers required higher up-front costs, but overall costs for the year were much lower ($8,600 USD vs $21,980 USD.)


Mothers were not inferior to CHWs in screening for malnutrition at a substantially lower cost. Children in the Mothers Zone were admitted at an earlier stage of SAM and required fewer hospitalizations. Making mothers the focal point of screening strategies should be included in malnutrition treatment programs.

Trial registration

The trial is registered with clinicaltrials.gov (Trial number NCT01863394).

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.


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 […].

Comparison of the effectiveness of a milk-free soy-maize-sorghum-based ready-to-use therapeutic food to standard ready-to-use therapeutic food with 25% milk in nutrition management of severely acutely malnourished Zambian children: an equivalence non-blinded cluster randomised controlled trial

In Under-nutrition on July 7, 2013 at 12:33 pm

by Irena AH, Bahwere P, Owino VO, Diop EI, Bachmann MO, Mbwili-Muleya C, Dibari F, Sadler K, Collins S.

Matern Child Nutr. 2013 Jun 18.


Community-based Management of Acute Malnutrition using ready-to-use therapeutic food (RUTF) has revolutionised the treatment of severe acute malnutrition (SAM). However, 25% milk content in standard peanut-based RUTF (P-RUTF) makes it too expensive. The effectiveness of milk-free RUTF has not been reported hitherto.

This non-blinded, parallel group, cluster randomised, controlled, equivalence trial that compares the effectiveness of a milk-free soy-maize-sorghum-based RUTF (SMS-RUTF) with P-RUTF in treatment of children with SAM, closes the gap. A statistician randomly assigned health centres (HC) either to the SMS-RUTF (n = 12; 824 enrolled) or P-RUTF (n = 12; 1103 enrolled) arms. All SAM children admitted at the participating HCs were enrolled. All the outcomes were measured at individual level. Recovery rate was the primary outcome.

The recovery rates for SMS-RUTF and P-RUTF were 53.3% and 60.8% for the intention-to-treat (ITT) analysis and 77.9% and 81.8% for per protocol (PP) analyses, respectively. The corresponding adjusted risk difference (ARD) and 95% confidence interval, were -7.6% (-14.9, 0.6%) and -3.5% (-9,6., 2.7%) for ITT (P = 0.034) and PP analyses (P = 0.257), respectively. An unanticipated interaction (interaction P < 0.001 for ITT analyses and 0.0683 for PP analyses) between the study arm and age group was observed. The ARDs were -10.0 (-17.7 to -2.3)% for ITT (P = 0.013) and -4.7 (-10.0 to 0.7) for PP (P = 0.083) analyses for the <24 months age group and 2.1 (-10.3,14.6)% for ITT (P = 0.726) and -0.6 (-16.1, 14.5) for PP (P = 0.939) for the ≥24 months age group.

In conclusion, the study did not confirm our hypothesis of equivalence between SMS-RUTF and P-RUTF in SAM management.

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Is community-based treatment of severe acute malnutrition (SAM) at scale capable of meeting global needs?

In Under-nutrition on July 3, 2013 at 5:27 pm


(download Guerrero-Access for All-2013)

“In little over four decades, SAM treatment has gone from a small-scale clinical endeavour to a global public health service reaching over two million cases a year. Much of this scale-up has occurred in the last decade following the introduction of community-based SAM treatment approaches.

“Since the rapid-scale up of such community-based approaches, however, there have been few overarching reviews of their performance over time. This report, the first in a three part series, offers a comparative assessment of the performance and effectiveness of the model during two distinct periods of its development: from 2001-2006 when the majority of community-based treatment projects were implemented by NGOs; and from 2007-2013 when many community-based treatment programmes were integrated by ministries of health into regular health services.

“For each period, three components of the community-based treatment model are assessed: the capacity of treatment services to successfully cure SAM cases, their capacity to reach the highest proportion of the affected population (coverage) and their cost-effectiveness.

“The report has Three main conclusions:

  • “Community-based treatment models deliver exceptional clinical outcomes. The median cure rates of community based models in the 2001-2006 and 2007-2013 periods were 80% and 84% respectively. SAM cases admitted into treatment services today are as likely to be successfully cured today as they were a decade ago.
  • “In areas where SAM services are available, only a third of affected cases actually access treatment. The analysis shows that whilst high coverage can be achieved by community- based SAM treatment, the conditions necessary to do so are seldom met. The capacity of treatment services to meet global SAM needs depends on coverage being significantly and consistently improved.
  • “Community-based models are more cost-effective than in-patient models. Cost-effectiveness analyses show that some community-based models were two times more costeffective than in-patient models. In spite of their dependency on context-specific operational factors, recent evidence suggests that MoH delivered community-based SAM treatment services continue to be cost-effective interventions.”
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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.

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