Manajemen Malnutrisi Infant

Management of Acute Malnutrition in
Infants (MAMI) Project

Technical Review:
Current evidence, policies, practices & programme outcomes
January 2010
Management of Acute Malnutrition in Infants (MAMI) Project
Acknowledgements
Contributing Authors:
Marko Kerac1, Marie McGrath2, Carlos Grijalva-Eternod1, Cecile Bizouerne3, Jenny Saxton1, Heather
Bailey1, Caroline Wilkinson3, June Hirsch3, Hannah Blencowe4, Jeremy Shoham2, Andrew Seal1
1)
2)
3)
4)
UCL Centre for International Health & Development, UK

Emergency Nutrition Network, UK
Action Contre la Faim, France
London School of Hygiene & Tropical Medicine, UK
Acknowledgements
We thank the UNICEF-led Inter-Agency Standing Committee (IASC) Global Nutrition Cluster for
funding and supporting this project, in particular Bruce Cogill and Leah Richardson.
We also thank the many organizations and individuals who made the MAMI Project possible, and are
particularly grateful for inputs from the following:
Chapter authors:
Lead authors: Marko Kerac, Marie McGrath, Andy Seal
Lead authors to specific chapters/sections: Carlos Grijalva-Eternod, Cecile Bizouerne, June Hirsch,
Jenny Saxton, Marko Kerac, Hannah Blencowe, Heather Bailey, Marie McGrath, Caroline Wilkinson.
Editorial team: Chloe Angood, Marko Kerac, Marie McGrath, Jeremy Shoham
Particular sections were greatly informed by related collaborative work by IFE Core Group
members and collaborators, in particular Karleen Gribble, Lida Lhotska, Mary Lungaho, Ali Maclaine,
Marie McGrath and Rebecca Norton (global policy and strategy on infant and young child feeding in
emergencies) and Lida Lhotska, Marie McGrath, Pamela Morrison, Rebecca Norton, Marian
Schilperoord and Caroline Wilkinson (HIV and infant feeding).
Research Advisory Group (RAG)

Professor Alan Jackson, University of Southampton, Chair of RAG
Dr Claire Schofield, London School of Hygiene & Tropical Medicine
Dr Felicity Savage, UCL Centre for International Health & Development
Dr Rukshana Haider, Independent Consultant
Professor Zulfiqar Bhutta, Aga Khan University
Professor James Bunn, College of Medicine, Malawi & Liverpool School of Tropical Medicine
Dr Andre Briend, World Health Organization
Dr James Berkley, Wellcome Research Programme, Kilifi, Kenya
Acknowledgements
Interagency Steering Group (IASG)

Organizations & individuals who shared databases:
Sylvie Chamois, UNICEF; ACF, France (co-authors listed above); MSF (in particular we thank Pascale
Delchevalerie & Valerie Captier); Valid International (Steve Collins, Alistair Hallam & Kate Sadler);
UNHCR (Chris Haskew & UNHCR Daddab team).
Key informants interviewed for Chapter 8:
Gabriel Alcoba-Wright, ex-ACF; Caroline Boyd, Medair; Mary Corbett, Independent; Nicky Dent,
Concern; Chris Haskew, UNHCR; Pascale Delchevalerie, MSF; Bernadette Feeney, Valid; Valerie Gatchell,
Concern; Kate Golden, Concern; Hannah Graveling London Hospital, UK; Caroline Grobler-Tanner, exSave US; Ahmed Hassan UNHCR; Fiona Henderson, Baylor; Olivia Hill, MSF; Joe Jacobs, ex-MSF; Svenja
Jungjohann, HKI; Jane Keylock, Valid; Gloria Kisia UNHCR; Ann Njeri MoH; Nuria Salse, ACF; Dr Clare
Sheehan; Sister Agnes Malamula, MoH; Mr Charles Mutunga Concern; Sister Anne Mwangi; Dr Sahar
Nejat, LSHTM; Allison Oman UNCHR; Dr Mark Patrick, Greys Hospital, South Africa; Dr Kate Sadler Tufts
University; Marie Sophie-Simon, ACF-USA; Professor M Taludker & Dr Khurshid Talukder, Centre for
Woman & Child Health, Bangladesh, Anne Walsh, Valid International; Mr Rogers Wanyama GTZ
Steering group meeting participants:
Franklin Ackbom, MSF; Andre Briend, WHO; Suzanne Brinkman, Save the Children UK; Sarah Carr,
World Vision; Hedwig Deconinck FANTA; Pascale Delchevalerie, MSF; Pamela Fergusson, University of
Chester; Kate Golden, Concern; Alan Jackson, University of Southampton; Jane Keylock, Valid
International; Ali McLaine, Independent; Mirela Mokbel, UNHCR; Flora Sibanda-Mulder, UNICEF;
Gabrielle Palmer, Independent; Claudine Prudhon, SCN; Felicity Savage, UCL Centre for International
Health & Development; Claire Schofield, London School of Hygiene & Tropical Medicine; Anne Walsh,
Valid International.
Others
Lastly, we thank the many colleagues who played an important role in shaping the ideas and concepts
in MAMI. Space does not allow us to name the numerous email, meeting and e-discussion group
correspondents in person; however we would like to mention in particular all participants at the Infant
Feeding in Emergencies Regional Strategy Workshop held in Bali, Indonesia, March 2008. We hope
there will be opportunities to work together more closely in the future as we continue to advance the
care of this vulnerable group of infants.
Photos
Cover & pages 14, 17, 35, 45, 94, 124, 138 ACF, DRC, 2008
page 154 ACF, Burma, 2005
page 177 Marcus Prior/WFP Niger, 2006
Management of Acute Malnutrition

in Infants (MAMI) Project
Technical review
January 2010
Contents
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
Chapter 1: Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
1.1
1.2
1.3
1.4
Background to the MAMI Project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Aim, objectives & long term vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
The process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
MAMI Project framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Chapter 2: Setting the scene. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

2.1 Infants and Malnutrition: A Global Public Health Priority . . . . . . . . . . . . . . . . . . . . 19
2.2 Significance of infants <6m . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.2.1 Infants <6m are unique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
2.2.2 Long term implications of infant <6m malnutrition . . . . . . . . . . . . . . . . . . . . . . 21
2.3 Global strategies, policy and guidance on IFE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
2.4 Definition of Acute Malnutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
2.4.1 Case definitions of acute malnutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
2.4.2 Evolution of case definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
2.5 Management of Acute Malnutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
2.5.1 Supplementary feeding programmes (SFP). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
2.5.2 Therapeutic feeding programmes (TFP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
2.6 Summary findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Chapter 3: How big is the problem?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

3.1 Why population burden of disease matters. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
3.2 Aims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
3.3 Methods of determining population burden of disease . . . . . . . . . . . . . . . . . . . . . 36
3.3.1 Study design, setting and population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
3.3.2 Data handling. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
3.3.3 Data analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
3.4 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38
3.4.1 Country prevalence of infant <6m and child wasting: is it an
emergency? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
3.4.2 NCHS and WHO cut-off curves defining wasting. . . . . . . . . . . . . . . . . . . . . . . . . 39
3.4.3 Differences in severe and moderate wasting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
3.4.4 Implications of prevalence changes for treatment programmes . . . . . . . . . . 40
3.4.5 Summary of NCHS-WHO regression line equations . . . . . . . . . . . . . . . . . . . . . . .41
3.4.6 Basic demographic profile of severely wasted infants. . . . . . . . . . . . . . . . . . . . .41
3.4.7 Size at birth and infant <6m wasting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
3
Contents
3.5 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
3.5.1 Explaining differences in NCHS v WHO-GS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
3.5.2 Clinical profile differences in infants <6 m in NCHS v WHO-GS . . . . . . . . . . . .44
3.5.3 Policy implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
3.5.4 Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45
3.6 Summary findings and recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46
Chapter 4:
Review of MAMI guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

4.1
4.2
4.3
4.4
Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Guidelines overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50
Guideline Comparisons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57
4.4.1 Case definitions of SAM & MAM (general) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
4.4.2 Infant <6m SAM and MAM case definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
4.4.3 Key medical treatments for infants <6m . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
4.4.4 Nutritional treatments for infants <6m . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
4.4.5 Maternal care, preparation for discharge & follow-up . . . . . . . . . . . . . . . . . . . . 83
4.5 An appraisal of current guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90
Chapter 5:
Review of field treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

5.1 Rationale for field data analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
5.2 Aims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
5.3 Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
5.3.1 Identifying field data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
5.3.2 Cleaning & processing field data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .95
5.4 Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .102
5.4.1 Data selection for analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .102
5.4.2 Data analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
5.5 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103
5.5.1 Country and programme distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103
5.5.2 Burden of disease of infant <6m malnutrition: age distribution . . . . . . . . . . .105
5.5.3. Burden of disease of infant <6m malnutrition: sex distribution . . . . . . . . . . .107
5.5.4. Infant malnutrition profile: Oedema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
5.5.5 Infant malnutrition profile: Anthropometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109
5.5.6 Infant malnutrition profile: Anthropometry-based admission
criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
5.5.7 Programme outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .114
5.6 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
5.6.1 Principle findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .119
5.6.2 Strengths and weaknesses of the analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .119
5.6.3 Future directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .122
Chapter 6:
Key informant interviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .124

6.1 Rationale and objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .125
6.2 Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .125
6.2.1 Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
6.2.2 Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
6.2.3 Data collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .126
Contents
6.2.4 Data analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .126

6.2.5 Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .126
6.3 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .126
6.3.1 Participant profiles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
6.3.2 Themes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
6.3.3 Emerging Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .127
6.4 Conclusions and recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .136
Chapter 7:
Review of breastfeeding assessment tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138

7.1 Scope of review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
7.2 What should a breastfeeding assessment tool include? . . . . . . . . . . . . . . . . . . . . . 140
7.3 Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
7.3.1 Literature search strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .141
7.3.2 Tool inclusion/exclusion criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .141
7.4 Results & Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .141
7.4.1 Development and validation of tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
7.4.2 Coverage of breastfeeding domains . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
7.4.3 Tool performance characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
7.5 Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .151
7.6 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Chapter 8:
Psychosocial considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .154

8.1 Psychosocial stimulation in the treatment of malnutrition . . . . . . . . . . . . . . . . . . .155
8.1.1 WHO guidelines on psychosocial stimulation in the
treatment of SAM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .155
8.1.2 Scientific basis for the WHO recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . .156
8.1.3 Feasibility of the WHO recommendations for
psychosocial stimulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
8.1.4 Adaptation of WHO recommendations for infants under
6 months of age and emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
8.1.5 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
8.2 Psychosocial aspects of malnutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
8.2.1 Child care practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .163
8.2.2 Providing nutrients is not enough to nourish infants . . . . . . . . . . . . . . . . . . . . . 166
8.2.3 Malnutrition and attachment: cause or effect? . . . . . . . . . . . . . . . . . . . . . . . . . . .166
8.2.4 Malnutrition and the psychopathology of the child . . . . . . . . . . . . . . . . . . . . . . 167
8.2.5 Mother-child support system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
8.2.6 Control of resources, autonomy, workload and time constraints . . . . . . . . . .168
8.2.7 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
8.3 Maternal Depression & Infant malnutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
8.3.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .169
8.3.2 Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .169
8.3.3 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
8.3.4 Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .171
8.3.5 Implications for MAMI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .172
8.3.6 Conclusions and recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .173
Chapter 9:
MAMI considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177

5
Contents
9.1 Conceptual model of management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178

9.2 Admission criteria: why they matter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .178
9.2.1 Admission criteria as a screening tool . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
9.2.2 Anthropometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
9.3 Community based models of breastfeeding support . . . . . . . . . . . . . . . . . . . . . . . .181
9.3.1 Evidence of effectiveness of community-based breastfeeding
support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
9.3.2 Determinants of effectiveness of community-based
breastfeeding support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .183
9.3.3 Relevance to MAMI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
9.4 Inpatient models of breastfeeding support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .183
9.5 Clinical identification of high risk infants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
9.6 Antibiotic treatment in infants <6m . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .185
9.7 Choice of therapeutic milk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .186
9.8 HIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .187
9.8.1 What is the risk of HIV transmission through breastfeeding? . . . . . . . . . . . . . .188
9.8.2 WHO infant feeding and HIV recommendations (2007) . . . . . . . . . . . . . . . . . . .189
9.8.3 Areas of high HIV prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
9.8.4 Testing for HIV in young infants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .191
9.8.5 Use of antiretroviral (ARV) drugs and cotrimoxazole . . . . . . . . . . . . . . . . . . . . . .191
9.9 Individual v population based feeding recommendations . . . . . . . . . . . . . . . . . . 192
9.10 Summary findings and recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .192
Chapter 10: MAMI recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .196

Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .201
A
B
C
D
E
F
Key resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202

Conceptual framework for causes of malnutrition in infants <6m . . . . . . . . . . . .203
Additional Tables for Chapter 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
Interview schedules and additional tables for Chapter 6 . . . . . . . . . . . . . . . . . . . . 209
D.1 Steering group meeting report, May 2008 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .209
D.2 Introductory letter for sharing of field data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .214
D.3 Interview schedule for Chapter 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .215
D.4 Key informant interviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
D.5 Details of key informant interviews Prevalence and
causes of infant <6m malnutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
D.6 Details of key informant interviews Identification of
malnutrition in infants <6m and admission to programmes . . . . . . . . . . . . . .222
D.7 Details of key informant interviews Programme details . . . . . . . . . . . . . . . . .224
D.8 Details of key informant interviews Challenges . . . . . . . . . . . . . . . . . . . . . . . . .226
D.9 Details of key informant interviews Training and support . . . . . . . . . . . . . . .227
D.10 Details of key informant interviews Ways forward . . . . . . . . . . . . . . . . . . . . . . 228
The Integrated Phase Classification (IPC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
Additional tables for Chapter 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .232
Tables
Tables
Table 1: Contribution of malnutrition treatment and optimal IYCF to meeting Millennium Development
Goals (MDGs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Table 2: WHO classification of acute malnutrition, 1999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Table 3: NCHS and WHO-GS growth norms as applied to the case definition of acute malnutrition . . . . . . . . . . . . . . . . 30
Table 4: Linear regression models showing relationships between key variables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Table 5: Overview of available acute malnutrition guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Table 6: Case definitions of SAM & MAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Table 7: Infant <6m SAM & MAM case definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Table 8: Key medical treatments recommended for infants <6m . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Table 9: Nutritional treatments for infants <6m . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .79
Table 10: Maternal care, preparation for discharge & follow-up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Table 11: Description of the raw databases of children 0 to 59m received for analysis by country . . . . . . . . . . . . . . . . . . 96
Table 12: Details of the data cleaning results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Table 13: Programme type coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Table 14: Number of individuals enrolled in different types of programme . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .98
Table 15: Definition of age categories & frequency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99
Table 16: Re-coding of original discharge codes into a Sphere-compatible code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Table 17: Frequency distribution by age group and programme type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .102
Table 18: Programme and country distribution of the final sample included for analysis and the
sub-sample of infants <6m of age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103
Table 19: Burden of disease: Age distribution by country and by programme, of the sample of
children selected for analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .104
Table 20: Age distribution by country and by programme type of the sample of infant selected for analysis . . . . . . . . .106
Table 21: Male to female ratio by age group, by country and by programme type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .107
Table 22: Male to female ratio by age group, by country and by programme type for infants aged <6m . . . . . . . . . . . . .108
Table 23: Oedema frequency distribution among different age groups and programme types provided
for the sample included for SAM analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .108
Table 24: Frequency and percentage of missing values of anthropometry by age group . . . . . . . . . . . . . . . . . . . . . . . . . . . .111
Table 25: Frequency and percentage of missing values of anthropometry by country and programme
type in infants <6m. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .111
Table 26: Frequency of flagged values using Epi-info criteria by age group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .112
Table 27: Frequency table for different admission criteria: Comparing infants <6m and children
6 to 59m of age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Table 28: Sphere discharge outcomes by country and age group: Values in italics are those meeting the
Sphere standards/MAMI indicator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Table 29: Outcomes by programme type and age group: Values in italics are those meeting the Sphere
standards/MAMI indicator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
Table 30: Prevalence and causes of infant <6m malnutrition: key informant feedback . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
Table 31: Identification of malnourished infants <6m and admission to programme: key informant feedback . . . . . . .129
Table 32: Programme details: key informant feedback . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .130
Table 33: Challenges in managing infants <6m: key informant feedback . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .131
Table 34: Training and support: key informant feedback. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .131
Table 35: Ways forward: key informant feedback . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .132
Table 36: Importance gradient of key properties of breastfeeding assessment tools from community to
clinical contexts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .140
Table 37: Theory-based breastfeeding assessment tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Table 38: Breastfeeding assessment tools validated against maternal and infant outcomes . . . . . . . . . . . . . . . . . . . . . . . . .144
Table 39: Tool coverage of breastfeeding domains and value of use in different contexts . . . . . . . . . . . . . . . . . . . . . . . . . . .148
Table 40: Number of articles by keywords (Medline, February 2009) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Table 41: Research papers included in literature review on maternal depression (Appendix F) . . . . . . . . . . . . . . . . . . . . . . 231
Table 43: Discharge codes by country and by frequency (Appendix C) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .204
Table 44: Oedema by country and programme (Appendix C) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .208
Table 45: Profile of 31 key informants interviewed (Appendix D) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .217
Table 46: Cross-sectional studies on maternal depression and child malnutrition (Appendix F) . . . . . . . . . . . . . . . . . . . . . 233
Table 47: Longitudinal studies on maternal depression and child malnutrition (Appendix F) . . . . . . . . . . . . . . . . . . . . . . . .235
Boxes
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Optimal infant and young child feeding practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Definition of a breastmilk substitute (the Code) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
Guiding principles for feeding infants and young children during emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Key Points of the Operational Guidance on IFE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27
AGREE criteria for guideline appraisal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Case history: Successful supplementary suckling in Liberia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .133
Case history: Using dedicated infant <6m data to support an innovative IYCF programme . . . . . . . . . . . . . . . . . 135
Case history: Integrating mental health and care practices in Afghanistan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Choice of screening strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Breastfeeding counselling in a hospital in Bangladesh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
Triage system for children with severe malnutrition to improve identification of high risk groups . . . . . . . . . . .158
Estimated potential renal solute loads (PRSL) of human milk and infant formulas . . . . . . . . . . . . . . . . . . . . . . . . . . 186
WHO consensus on milks for therapeutic feeding in infants <6m . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
Case studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
Summary of WHO Recommendations on infant feeding and HIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
WHO AFASS conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Vermont-Oxford Network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
GRADE & CHNRI frameworks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
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Interactions between malnutrition and disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Bar chart showing deaths by age group in a feeding programme in Kabul . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
Life course and inter-generational effects of malnutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
Key strategies, policies and guidance related to infant and young child feeding in emergencies . . . . . . . . . .22
UNICEF conceptual framework for the causes of malnutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Complicated and uncomplicated acute malnutrition framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Ten steps for inpatient treatment of severely malnourished children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Structure of and patient 'flow' within a CMAM programme . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Country prevalence of wasting (WHZ <-2) as defined by NCHS and WHO-GS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Weight cut-offs used to define wasting by either NCHS or WHO-GS criteria (boys) . . . . . . . . . . . . . . . . . . . . . . . 39
Scatter plots of country prevalence (NCHS v WHO-GS) of severe and moderate wasting . . . . . . . . . . . . . . . . . 40
Scatter plot on effect of switch from NCHS to WHO-GS on age profile of selective feeding
programme admissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Age profile of severely wasted infants (NCHS and WHO-GS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Sex profile of severely wasted infants (NCHS and WHO-GS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Reported birth size of severely wasted infants <6m (NCHS and WHO-GS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42
Prevalence of severe wasting by reported birth weight category . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Prevalence of moderate wasting by reported birth weight category . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43
Flow diagram of data selection for analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Age frequency distribution at admission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Forest plots of the risk ratio of presenting oedema for infants <6m compared to children aged
6 to 59 m by country and by programme type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
WHZ distribution at admission of children aged 0 to 60m . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .112
Forest plots of the risk ratio of dying for infants <6m compared to children aged 6 to 59m by
country and by programme type using data from the raw datasets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Forest plots of the risk ratio of dying for infants <6m compared to children aged 6 to 59m in Burundi
by different TFC centres and by different programmes, using compiled data from various agencies . . . . . . 118
Hypothetical population showing the relationship between different types of acute malnutrition . . . . . . . 121
Programme with poor outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121
Programme with better outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Programme with good outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Model of extended care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Psychological and sociological factors implicated in malnutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Psychosocial factors that aggravate malnutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Conceptual illustration of the difficulties of categorising continual processes in malnutrition . . . . . . . . . . . . 179
Effect of community based peer support on exclusive breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .182
Acronyms and Abbreviations

ACF (AAH/ACH)
Action Contre la Faim (Action Against Hunger/Action Contre la Hambre)
AFASS
Acceptable, Feasible, Affordable, Sustainable and Safe
AGREE
Appraisal of Guidelines for Research and Evaluation
ARV
Antiretroviral drugs
BF
Breast feeding (or breast-fed)
BFHI
Baby Friendly Hospital Initiative
BMS
Breastmilk substitute
CF
Complementary food
CFR
Case Fatality Rate
CHW
Community Health Worker
CIHD
Centre for International Health & Development, UCL, London
CMAM
Community Management of Acute Malnutrition
CSB
Corn Soy Blend
CTC
Community-based Therapeutic Care (original term for CMAM)
DC
Day Centre
DHS
Demographic and Health Survey
EBF
Exclusive breast-feeding (or exclusively breast-fed)
EBM
Expressed breast milk
ENN
Emergency Nutrition Network
GAM
Global Acute Malnutrition
HA
Height-for-Age
HAM
Height-for-Age % of median
HAZ
Height-for-Aged Z-score
HC
Head Circumference
HCW
Healthcare worker
HT
Home Treatment
IFE
Infant Feeding in Emergencies
IMCI
Integrated Management of Childhood Illness
Infant(s) <6m
Infant(s) aged under 6 months (0 to 5.9 months)
IPC
Integrated Food Security Phase Classification
IUGR
Intrauterine Growth Retardation
IYCF
Infant and Young Child Feeding
LBW
Low Birth Weight
MAM
Moderate Acute Malnutrition
MAMI
Management of Acute Malnutrition in Infants < 6m (in general)
MAMI Project
Management of Acute Malnutrition in Infants < 6m Project
MDG
Millennium Development Goals
MoH
Ministry of Health
MSF
Medecins Sans Frontieres
MUAC
Mid-Upper Arm Circumference
NCHS
National Centre for Health Statistics
NGO
Non-Governmental Organization
NRU
Nutritional Rehabilitation Units
Ops Guidance on IFE Operational Guidance on infant and young child feeding in emergencies
10
OTP
Outpatient Treatment Programme
RCT
Randomised Control Trial
RSL
Renal Solute Load
RUSF
Ready to Use Supplementary Food
RUTF
Ready to Use Therapeutic Food
SAM
Severe Acute Malnutrition
SC
Stabilisation Centre
SFC
Supplementary Feeding Centre
SFP
Supplementary Feeding Programme
SGA
Small for gestational age
SS
Supplementary Suckling
TFC
Therapeutic Feeding Centre
TFP
Therapeutic Feeding Programme
UNHCR
United Nations High Commissioner for Refugees
UTI
Urinary Tract Infection
IASC
Inter-Agency Standing Committee
WA
Weight-for-age
WAM
Weight-for-age % of median
WAZ
Weight-for-age Z-score
WH
Weight-for-height
WHA
World Health Assembly
WHM
Weight-for-height % of median
WHZ
Weight-for-height Z-score
WHZ(WHO)
Weight-for-height Z-score calculated using WHO-GS
WHZ(NCHS)
Weight-for-height Z-score calculated using NCHS references
WHO
World Health Organisation
WHO-GS
World Health Organisation Child Growth Standards, 2006
Executive Summary
Executive Summary
Child malnutrition is a major global public health
problem. In developing countries, it is estimated that
19 million children are severely wasted and
malnutrition is responsible for 11% of the total global
disease burden. Challenges in managing acute
malnutrition in infants <6m (MAMI) have been widely
reported over the past eight years. Non-governmental
organisations (NGOs) have undertaken different
interventions in response, sometimes guided by field
research. Until now, this accumulated body of
experience has remained disparate and largely hidden.
The aim of the MAMI Project was to investigate the
management of acutely malnourished infants <6m in
emergency programmes. The objectives were to:
Establish the burden of acute malnutrition is in this
age-group
Identify what guidelines, policies and strategies
currently stipulate with regard to case
management
Determine practice in the field and make
recommendations for future practice and research.
The MAMI Project focused on available treatment in
selective feeding programmes.
The MAMI Project was implemented from March
2008 to July 2009 in a partnership between the
Emergency Nutrition Network (ENN), University
College London Centre for International Child Health
and Development (CIHD) and Action Contre la Faim
(ACF). A research advisory group (RAG) and an
interagency steering group (IASG) informed research
questions and the process. A draft framework for the
management of acute malnutrition in infants <6m,
modelled on the UNICEF conceptual framework on the
causes of malnutrition, informed early planning and
was further developed during the course of the
project.
Infant <6m burden of disease

To investigate the burden of disease of acute
malnutrition in infants <6m, secondary analysis of 21
Demographic Health Survey (DHS) national datasets
was carried out. This found that wasting in infants <6m
is a prevalent public health problem, whether using
NCHS1 growth references or 2006 WHO Growth
Standards (WHO-GS), but especially with WHO-GS.
Infant <6m wasting prevalence ranged from 1.1% to
15.0% with NCHS and 2.0% to 34.1% using WHO-GS.
Severe wasting increased over three fold and moderate
wasting 1.4 fold when transitioning from NCHS to
WHO-GS. Selective feeding programmes rely on
current size rather than growth monitoring for

admission. On this basis, WHO-GS will result in
particularly large increases in infants <6m eligible for
admission to selective feeding programmes. As many
selective feeding programmes use weight-for-height %
of median (WHM) indicators, the implications of
moving from WHM using NCHS to WHZ based on
WHO-GS needs additional urgent investigation.
Further implications of these findings are that
nutrition surveys should more routinely include
infants<6m to establish local burden of disease, while
feeding programmes should more actively consider
the likely prevalence of infant <6m wasting.
Guidelines review
A review of 14 international and 23 national guidelines
for management of acute malnutrition found wide
variation in the way acute malnutrition in infants <6m
is addressed. Some only implicitly recognise the
problem. Both inpatient and community-based
guidelines recommend inpatient care for severe acute
malnutrition (SAM) in infants <6m. They focus on
nutritional treatments with the aim of restoring
exclusive breastfeeding (using the supplementary
suckling technique). Very few guidelines give details of
moderate acute malnutrition (MAM) management in
infants <6m or infant and young child feeding/
breastfeeding support. MSF guidelines (2006), ACF
Assessment and Treatment of Malnutrition guidelines
(2002) and IFE Module 2 were found to be important
exceptions.
Field data
Based on 33 selective feeding programme datasets
from 21 countries, an analysis of individual and
summary level data on infants <6m found that this
demographic group accounted for 16% of admissions,
ranging from 1.2% in Uganda to 23.1% in Tajikistan.
The majority of infants <6m did not fulfil standard
anthropometric SAM criteria for admission. In line with
expectations, % mortality in infants <6m was
significantly higher than children aged 6 to 59 months
(4.7% vs. 4% respectively, p<0.01). Lack of survey data
on infants <6m meant it was not possible to compare
inpatient mortality figures with those of infants <6m in
the general population. Few countries met all Sphere
exit indicators for therapeutic care (Correction of
Malnutrition Standard 2); current Sphere Standards
have their limitations with regard to this age-group.
The analysis also showed that significant work is
needed to harmonize and improve the quality of field
11
databases. Standardisation in reporting is needed,

including database structure, case definitions, outcome
coding and variable formatting, to facilitate future
research and routine audit.
Field experiences
Key informant interviews found that many therapeutic
feeding programmes struggle in treating malnourished
infants <6m. There is much inter-programme variation
in the profile of admission, with a combination of
clinical judgement and/or anthropometric indicators
often used to determine admission. Nutritional and
psychosocial care of the mother was often lacking.
Experiences with the supplementary suckling
technique were sometimes good but varied; staff time
and experience were important limiting factors.
Interviewees identified ways forward that centred on
admission criteria, guidance development, linking with
other services, building staff capacity and on the job
training and support.
Breastfeeding assessment tools

Fifteen breastfeeding assessment tools were reviewed
to explore their potential application to MAMI in both
inpatient and community-based settings. No one tool
was identified as sufficiently sensitive for community
use and specific for use in inpatient settings. Quality
research studies to test the validity of existing
breastfeeding assessment tools in different settings are
needed. In the interim, UNICEF b-r-e-a-s-t, the UNICEF
2006 breastfeeding observation aid and the aids
described in IFE Module 2 can be used to assess
breastfeeding in programmes managing infants <6m.
Severe maternal wasting and maternal and infant HIV
status are just two of the important wider considerations
when assessing breastfeeding effectiveness.
Psychosocial considerations
WHO 1999 guidelines on treatment of SAM include
guidance on psychosocial support and stimulation for
children under five years and their mothers. The MAMI
Project identified little guidance on specific stimulation
activities for infants <6m, a lack of knowledge
concerning the impact of severe malnutrition in infants
<6m on psychosocial development, and little evidence
of the long term effects of psychosocial support on this
age group. Psychosocial stimulation is not currently
integrated into community-based management of
acute malnutrition (CMAM) recommendations and not
routinely integrated into emergency programmes in
general. Building upon a recent review of maternal
depression and child growth, our review indicates
evidence of the consequences of maternal depression
on breastfeeding, child development and the ability to
seek treatment. The available evidence is sufficient to
recommend detection and appropriate treatment of
maternal depression within the framework of
management of infant malnutrition. Strengthened
psychosocial stimulation/support of the inpatient
12
infant <6m, the mother-infant dyad and their families is

needed. Studies are needed to explore which
psychosocial support activities are most effective,
when they should start, the minimum duration of
intervention, the impact on social and emotional
development of the child and/or on the mother-child
relationship, and how to adapt these activities to the
community care of malnutrition.
Antibiotics review
Our review of antibiotic use in infants <6m shows the
evidence base on antimicrobial treatment in infants
<6m is severely lacking, and for malnourished infants
and children needs urgently updating. Sensitivity to
amoxicillin, which is the commonest currently
recommended antibiotic, is low. There is a lack of
intervention trials. New trials are needed which use
current case definitions of acute malnutrition,
especially in settings where HIV is now prevalent.
Change in model of care?

The population burden of acute malnutrition in infants
<6m, the varied profile of current caseloads and the
challenges in inpatient management suggests a radical
shift in the model for management of acute
malnutrition in infants <6m is needed. A move towards
community-based care is an appropriate model to
consider. Such a development would harmonise acute
malnutrition management for infants <6m with that of
older children and broaden opportunities to tailor care
for larger numbers. It may also offer a more
appropriate and safer setting to manage infants <6m
that present early and with more manageable feeding
problems (uncomplicated cases). Inpatient care could
be reserved for those infants needing specialist clinical
and dietetic care (complicated cases). Research is
needed to explore the safety, practicality and costeffectiveness of such an approach. Improved clinical
assessment strategies are needed to enable triage, to
identify those with urgent need and to enable interprogramme comparisons.
The way forward

In the immediate term, there are many resources, good
practices, and initiatives to consolidate and build upon.
Existing guidelines with strong MAMI components are
MSF guidelines 2006, ACF Assessment and Treatment
of Malnutrition, 2002 and IFE Module 2. Strategies with
potential to improve inpatient outcomes of
complicated infant <6m SAM include implementation
of routine kangaroo care, breastfeeding corners with
skilled breastfeeding support, and tailored
psychosocial stimulation/support of infants <6m.
Strategies with potential for effective outpatient-based
care of infant <6m with MAM and uncomplicated SAM
include community-based breastfeeding support,
psychosocial support programmes and womens
groups programmes. Closer links are needed with
existing programmes that may impact on infant <6m
malnutrition, such as reproductive health services, the

Baby Friendly Initiative, Integrated Management of
Childhood Illness (IMCI) and growth monitoring
programmes. Strategies to treat infant malnutrition in
the context of HIV should not only consider
interventions that seek to avoid HIV transmission, but
also those that support maternal and child survival.
Access to anti-retroviral treatment (ARV) for HIVexposed mothers and infants and safer infant feeding
practices are key determinants of HIV-free child
survival.
The MAMI Project has identified research needs on a
range of topics, from anthropometric indicators
suitable for use in the community, to breastfeeding
assessment tools, to nature and effect of skilled
breastfeeding counselling on severely malnourished
infants. Resources needed monetary, time, skill set
must be quantified to enable cost-benefit analysis and
to ascertain the viability of scale-up of interventions.
Assessment of how well programmes are treating
infant <6m malnutrition needs to be strengthened and
based upon robust data. Critically, performance must
capture the clinical, psychosocial and contextual
complexity of infants treated and establish programme
population coverage of infant <6m SAM/MAM.
is the lack of explicit consideration to infants <6m in

current guidelines and lack of explicit recognition of
this age-group in recent statements on malnutrition
treatment and 2006 WHO-GS rollout. This risks the
presumption that care for older children can safely be
extended to infants <6m and/or perpetuates the
assumption that infants <6m are all well nourished. A
valuable contribution to help address this would be a
statement on MAMI that highlighted the concerns,
gaps and immediate considerations for this age-group
to guide practice in the short-term. Such a statement
could have significant impact if made by the Global
Nutrition Cluster through engagement of Nutrition
Cluster members, the MAMI Project research team, RAG
and IASG members.
In the future, a more radical shift in the model for
MAMI is likely needed. For older children, the evolution
to community based management of acute
malnutrition was driven by a strong vision, a clear
research agenda and well documented field
experiences. The challenge now is how to improve
nutritional, clinical and public health outcomes in
infants <6m.
Key collaborative initiatives to learn from include

the SFP Minimum Reporting Standards Package, the
Vermont-Oxford Network to improve neonatal care,
and experiences from the rollout of the 1999 WHO
guidelines. Data sharing and partnership are needed to
enable continued inter-agency dialogue. Harmonised
databases and coding systems would enable easier
audit. In this regard, an update in the SFP Minimum
Reporting Standards package to include infants <6m is
recommended.
The lack of an evidence base to formulate MAMI
guidelines remains a big gap and a combination of
systematic reviews, high quality randomised control
trial-type studies and operational research is needed.
Formal frameworks, such as GRADE and the Child
Health and Nutrition Research Initiative (CHNRI) might
usefully guide which policies and research projects
should be prioritised. More resources should be
devoted to future guideline development and tools
such as GRADE and AGREE used to better enhance
their quality.
Conclusions
The MAMI Project has found that the burden of care for
infants <6m is significant, the implications of the
rollout of the 2006 WHO Growth Standards for infants
<6m are important and need to be explored urgently,
the current evidence base for treating malnourished
infants <6m is relatively weak and that programmes
struggle using current guidelines to manage
malnourished infants <6m.Of most immediate concern
13
Chapter 1 Introduction
14
Chapter 1 Introduction
Chapter 1: Introduction
1.1 Background to the MAMI Project
The management of acute malnutrition in infants under six months (MAMI) is currently hampered by poor
evidence on which to base guidelines. Both facility-based1 and community-based programmes2, 3 face
challenges in their management. Such challenges have been highlighted in recent published concerns,4, 5
documented field experiences and debate6, a WHO technical review of the management of severe
malnutrition7 and in the proceedings of the Infant Feeding in Emergencies (IFE) Core Group8.
As a result, infants under six months are admitted to programmes with variable capacity and skill to
manage them. Efforts have been made to stop-gap the lack of guidance9, 10 and operational agencies have
undertaken different interventions, sometimes guided by field research. Thus a body of experience in
MAMI has accumulated. However, this remains disparate and often exists as raw data or internal agency
documents. Once collated and formally analysed, however, these data are valuable and worthy of use as
an initial basis for investigation.
The Emergency Nutrition Network (ENN) was established in 1996 by international humanitarian agencies
to accelerate learning and improve institutional memory in the emergency food and nutrition sector.
Many of the challenges around MAMI have been highlighted to ENN in its flagship publication, Field
Exchange, and through its involvement in the IFE Core Group. The MAMI Project was conceptualised by
the ENN and implemented in collaboration with UCL Centre for International Child Health and
Development (CIHD) and Action Contre la Faim (ACF). MAMI was funded by the UNICEF-led Inter-Agency
Standing Committee (IASC) Nutrition Cluster.
Given the background and ENNs mandate, the MAMI Project is located in the emergency nutrition sector
and speaks especially to those concerned with humanitarian response.
1.2 Aim, objectives and long term vision

The MAMI Project focuses on infants aged less than six months (0 to 5.9 months old). From hereon, this
age-group is referred to as infant <6m (plural infants <6m). Older infants and young children aged six to
59 months are referred to as children 6 to 59m.
Aim: The aim of the MAMI Project is to investigate the management of acutely malnourished infants <6m
in emergency programmes, in order to improve practice by contributing to evidence-based, better
practice guidelines.
Objectives: Focused on acutely malnourished infants <6m, the objectives are:
To establish the infant burden of disease. i

To establish what is currently advised in the form of guidelines, policies and strategies
To determine what is carried out in practice
On the basis of this field evidence and other relevant published literature, to make recommendations
for future practice and research.
Vision: Long term, all malnourished infants should receive effective, evidence-based care. There are
multiple competing health needs in vulnerable populations, therefore strategies to treat this group
should also be cost effective and achieve maximal possible public health impact.
Outputs: Evidence presented in the MAMI report will be used to form the basis of:
Summary report targeted at field staff, with an emphasis on content relevant to inform better practice
Published research
i
This first objective was not in the original project objectives, but was added following initial consultations with stakeholders.
15
1.3 The process
It is hoped that the MAMI Project will provide a starting place for the development of a stronger evidence
base through further operational and formal research, leading to more formal best practice guidelines in
future.
Target audience: This report should be of particular interest to:
a) Policy makers, programme managers and clinicians involved in MAMI in emergency contexts and
nutritionally vulnerable settings.
b) Professionals in related disciplines with indirect involvement in MAMI, such as neonatal, reproductive
health, psychosocial, speech and language, breastfeeding counsellors and community development
specialists.
c) Researchers, students and others wishing to gain a rapid overview of current practices and key issues
surrounding MAMI.
1.3 The process

The MAMI Project was implemented from January 2008 to July 2009). The process involved a MAMI core
team comprising the ENN, UCL CIHD and ACF, a research advisory group (RAG) and an interagency
steering group (IASG) of UN agencies, NGOs and independent individuals with relevant experiences (see
acknowledgements for members and contributors). Face to face meetings, e-mail and phone were used to
establish and elaborate on the key questions to be addressed, and how to address them.
The MAMI Project has been an iterative process. Opportunities to explore further emerging key issues
beyond the original remit of the project were taken, such as assessment of disease burden of infant
malnutrition (Chapter 3), review of breastfeeding assessment tools (Chapter 7) and a review of antibiotic
use in infants < 6m (summarised in Section 9.7).
The main outputs of the MAMI Project are this report, a summary report and publication of key findings (in
process and planned). Key findings of the project have been shared at a number of key meetings and a
variety of for a in the UK, Malawi and Bangkok11. With completion of the MAMI Project, the MAMI core
team will continue to actively disseminate findings.
1.4 MAMI Project Framework

From the outset of the MAMI Project, it was considered essential to locate the MAMI Project within a
framework for the management of malnutrition in this age-group. An initial draft framework, modelled on
the UNICEF conceptual framework, informed early discussions with RAG and the IASG, was developed
during the course of the project and finalised in light of project findings (see Appendix 1).
Endnotes
1
2
3
7
8
10
11
16
WHO. (2009) Management of severe malnutrition: a manual for physicians and other senior health workers. Geneva: World Health
Organisation.
Valid International. (2006) Community-based Therapeutic Care (CTC). A Field Manual. Oxford: Valid International.
WHO, WFP, UNSCN & UNICEF. (2007) Community-based management of severe acute malnutrition. A Joint Statement by the World
Health Organization, the World Food Programme, the United Nations System Standing Committee on Nutrition and the United Nations
Childrens Fund.
Seal, A., Taylor, A., Gostelow, L. & McGrath, M. (2001) Review of policies and guidelines on infant feeding in emergencies: common
ground and gaps. Disasters. 2001 Jun; 25(2):136-48.
Seal, A., McGrath, M., Seal, A., Taylor, A. (2002) Infant feeding indicators for use in emergencies: an analysis of current recommendations
and practice. Public Health Nutr. 2002 Jun; 5(3):365-72.
Corbett, M. (2000) Infant feeding in a TFP, Field Exchange 9, p7; ENN (2000) ENN/GIFA Project, summary of presentation, Field Exchange
19, p28; ENN (2003) Diet and renal function in malnutrition, Summary of presentation, Field Exchange 19, p24; McGrath, M., Shoham, J
& OReilly, F. (2003) Debate on the management of severe malnutrition. Field Exchange 20, p16.
WHO. (2004) Severe malnutrition: Report of a consultation to review current literature. Geneva: World Health Organisation..
IFE Core Group (2006) Infant and Young Child Feeding in Emergencies. Making it Matter. Proceedings of an International Strategy
Meeting, 1-2 November 2006. IFE Core Group.
ENN (2004) Infant feeding in emergencies. Module 2. Version 1.0 Developed through collaboration of ENN, IBRAN, Terre des Hommes,
UNICEF, UNHCR, WHO, WFP. Core Manual (for training, practice and reference).
ENN et al. (2009) Integration of infant and young child feeding into CTC/CMAM. Manual.
MAINN (Maternal & Infant Nutrition & Nurture) Conference, UK, workshop session on MAMI led by Marko Kerac; CAPGAN (Commonwealth
Association of Paediatric Gastroenterology & Nutrition), Blantyre, Malawi, August 12th to 16th 2009; Sphere Regional Consultation,
Malawi, August 2009; MSF (Medecins Sans Frontiers) Scientific Day London, UK, June 11th 2009; Infant feeding in emergencies UNICEF
regional training, Nairobi, July, 2009; Working Group on Nutrition in Emergencies, SCN 1 day meeting, Bangkok, 10th October, 2009;
Nutrition Cluster Meeting, London, 20 October 2009; Sphere Core Meeting, London, 22-23 October, 2009
Chapter 2
Setting the scene
17
Chapter 2 Setting the scene
Chapter 2: Setting the scene

This chapter sets the context of the MAMI Project. It opens with an explanation of the importance of
infants and malnutrition as a global public health priority. It explores reasons why infants <6m are an age
group of particular significance. The chapter also lays out the policy framework for infant and young child
feeding (IYCF) in emergencies. Finally the chapter seeks to define acute malnutrition and describe the
context of emergency selective feeding programmes where MAMI is typically located.
2.1 Infants and Malnutrition: A Global Public Health Priority

Around 9.2 million children under the age of five years die each year12, mostly from preventable causes
and mostly in poor countries13. Generally the younger the children the more vulnerable they are; nearly
70% of under five deaths occur in the first year of life and 38% of under one year deaths occur in the first
month of life14. Diarrhoea and pneumonia are the most significant infections causing death, accounting
for about 20% each15.
Child malnutrition is a major global public health problem. The 2008 Lancet Nutrition Series estimated
that in developing countries, out of 555 million children age 0 to five years16:
177 million (95%CI 163 to 193) or 32.0% are stunted (chronic malnutrition)
112 million (95%CI 99 to 126) or 20.2% are underweight (mixed malnutrition)
19 million (95%CI 10 to 29) or 3.5% are severely wasted (acute malnutrition)
Maternal and child undernutrition is responsible for 35% of child deaths
Malnutrition is responsible for 11% of total global disease burden.
The vulnerability of infants and young children to malnutrition, illness and death is heightened in
emergencies. An emergency can be defined as any situation where there is an exceptional and
widespread threat to life, health and basic subsistence, which is beyond the coping mechanisms of
individuals and the community (Oxfam Humanitarian Policy, 2003). Mortality rates and nutritional status
of children under five years are often used as an indicator of the state of crisis of such a population.
Infants and young children contribute greatly to the malnutrition caseload. For example, in a large-scale
therapeutic feeding programme in Niger in 2005, 95% of the 43,529 malnourished cases admitted for
therapeutic care were children less than two years of age17.
Infant and young child feeding practices are a key determinant of vulnerability to malnutrition, disease
and death. The recent Lancet series on Maternal and Child Undernutrition18 reinforced the importance
of breastfeeding and complementary feeding in saving lives of children under five years of age.
Breastfeeding support tops the table of life-saving interventions: 13% of under five deaths could be saved
through exclusive and continued breastfeeding until one year of age and another 6% through appropriate
complementary feeding19. The significance of feeding practice is greatest with the youngest; one-fifth
(22%) of all neonatal deaths could be prevented by early initiation of exclusive breastfeeding
(breastfeeding within the first hour)20. Recommendations on optimal infant and young child feeding
practices reflect this, aiming to maximise health and minimise morbidity and mortality (See Box 1).
18
2.2 Significance of infants <6m
Box 1: Optimal infant and young child feeding practices

Early initiation of breastfeeding: introducing breastfeeding within one hour of birth21.
Exclusive breastfeeding: an infant receives only breastmilk for the first six months of life and no other liquids
or solids, not even water, with the exception of necessary vitamins, mineral supplements or medicines22.
Continued breastfeeding: sustaining breastfeeding to two years of age or beyond23.
Complementary feeding: age-appropriate, adequate and safe solid or semi-solid food is provided in addition
to breastmilk. The complementary feeding period is six months to two years. Appropriate complementary
foods are those that provide sufficient energy, protein and micronutrients to meet the childs growing
nutritional needs24.
Infant and young child feeding in the context of HIV is an added challenge in emergency contexts:
The HIV pandemic and the risk of mother-to-child transmission of HIV through breastfeeding pose
unique challenges to the promotionof breastfeeding, even among unaffected families. Complex
emergencies, which are often characterized by population displacement food insecurity and armed
conflict, are increasing in numberand intensity, further compromising the care and feeding of infant
and young children the world over.
Global Strategy for Infant and Young Child Feeding. UNICEF/WHO, 2003.
Feeding practices are a key determinant of HIV-free child survival and an important MAMI consideration
(See Chapter 9).

2.2.1 Infants <6m are unique
Just as a child is not merely a small adult, an infant <6m is not merely a small child. There are several
reasons for considering infants <6m as a unique subgroup:
Feeding differences
Infants <6m are unique in their dependence on breastfeeding (or a breastmilk substitute in non-breastfed
infants) to meet all their fluid and nutrient needs. The mother (or maternal substitute) is thus critical to
his/her nourishment. This dependence on breastfeeding for survival and the challenges of managing
infants where breastfeeding or breastmilk is not available have immense practical implications for the
management of acute malnutrition in this age-group.
Physiological and developmental differences

Maturation, growth and development are not simple linear processes. Birth and the immediate weeks and
months after birth are a time of significant change. The developmental changes of an infant between one
month and four months of age are vast compared to a period of the same length in an older infant.
Different infants mature at different rates, so that normal progress encompasses wide differences in
timing. Lucas and Zlotkin summarise the main nutrition relevant changes between 0 and six months as:25
Mechanical: Neuromotor development, which permits coordinated sucking, swallowing and, later on,
chewing of more solid foods.
Physiological: Changes in motor, digestive and absorptive functions of the gut, kidneys and other
organs that equip the infant for postnatal feeding.
Biochemical: Changes in enzyme activity and biochemical pathways that enable the infant to survive
as an independent organism after birth, when the transplacental supply of glucose and other nutrients
from the mother suddenly ceases at birth.
Protective: Particularly developments in immune functions and the mucosal barrier of the gut that
occur as food related exposure to potentially pathogenic organisms and antigens occurs postnatally.
These reflect how the period 0 to <6m is period of unprecedented change, and consequently, of both
opportunity and risk.
19
Pathological differences
Because of underlying physiological differences and exposures, infants <6m also suffer from a different r
ange of pathologies compared to older children:
Some are different but overlap with older children, e.g. many bacterial infections occur at all ages but
some are more common in certain ages than others.
Some conditions are unique to infants <6m, e.g. certain types of congenital heart disease may not be
compatible with life much beyond birth.
Some conditions are relatively rare in infants, e.g. severe allergic reactions to food.
Mortality risk differences

Younger infants are at greater risk of death than older children. Feeding practices in infants <6m are
intimately associated with mortality in this age group, even in non-emergencies. A pooled analysis of
statistics from developing countries found that not being breastfed increases the risk of mortality by six
times in infants less than two months old, compared to 1.4 times in infants between nine and 11 months
of age26. Malnutrition increases this risk further, a reflection of the interaction between nutritional
status and disease (see Figure 1). For example, in a therapeutic feeding programme in Afghanistan, the
mortality rate was 17.2% amongst malnourished infants <6m admitted for therapeutic care compared to
12% in six to 11 month olds and 8.3% in 12 to 17 month olds (see Figure 2).27
Figure 1: Interactions between malnutrition and disease
Weight loss
Growth faltering
Immunity lowered
Mucosal damage
Disease:
- incidence
- severity
- duration
Inadequate dietary
intake
Appetite loss
Nutrient loss
Malabsorption
Altered metabolism
Source: Tomkins & Watson, ACC/SCN, Geneva 1989. (In UNICEF State of the Worlds Children, 1998)
Figure 2: Bar chart showing deaths by age group in a feeding programme in Kabul
Deaths as % of admissions
20
15
10
Source: Golden M, 2000
20
0-5
6-11
12-17
18-23
24-29
30-35
36-47
48-59
Impact of Low birth weight

For infants <6m, birth is a more recent event in their life cycle and related issues can have a much more
immediate impact. Low birth weight (LBW) (<2500g) can be a consequence of preterm birth (before 37
weeks completed gestation) or being small for gestational age (SGA) (weight-for-gestation <10th
percentile), or both. Some infants can also have underlying intra-uterine growth retardation (IUGR), which
is not necessarily synonymous with birth weight.28 Risks associated with each of these vary. In practice,
it is often only possible to determine birth weight (and often not even that in many in many developing
countries), and therefore all LBW infants are treated as one group.
Whether or not infants admitted for malnutrition treatment are LBW is important to MAMI since:
LBW infants have an elevated mortality risk compared to same age normal birth weight infants
LBW may confound and complicate the diagnosis of acute malnutrition
LBW infants sometimes require different or additional treatments. Optimal feeding of LBW infants is
reviewed in detail in a 2006 WHO technical review.29
2.2.2 Long term implications of infant <6m malnutrition

Studies show clear links between early life environment and risk of ill health later in life.30 The period 0
to six months is part of a critical window of opportunity, within which the impact of undernutrition has
far reaching implications31. These are manifested at the individual level at all stages of life (Figure 3) and
at the population level through the observed dual burden of malnutrition disease32 33 34. The latter
is often observed in settings of societal, demographic and nutritional transition. Individuals experiencing
undernutrition in early life may later be exposed to nutrient excess. This appears to have particularly
adverse effects.35 36 37 38. Adaptive metabolic responses of conserving and storing developed early on
become maladaptive later on when there is chronic excess of food. Increased rates of obesity and
related conditions such as coronary heart disease, hypertension, stroke and diabetes result. Optimal
nutrition of infants <6m therefore makes a key contribution to health throughout the life cycle.
Figure 3: Life course and inter-generational effects of malnutrition

Impaired mental
development
Higher mortality rate

Reduced capacity to
care for a child
Increased risk of adult

chronic disease
OLDER PEOPLE
Malnourished
Inadequate
food, health
and care
BABY
Low birthweight
Inadequate
catch up
growth
Inadequate
foetal
nutrition
CHILD
Stunted
WOMEN
Malnourished
Reduced mental
capacity
PREGNANCY
Low weight gain
Higher maternal
mortality
Untimely/inadequate
feeding
Frequent infections
Inadequate food,
health and care
Inadequate food,
health and care
ADOLESCENT
Stunted
Inadequate food,
health and care
Reduced physical capacity

and fat-free mass
Source: World Nutrition Situation, 4th Report.

Prepared by Nina Seres for the ACC/SCN-appointed Commission on the Nutrition Challenges of the 21st Century
21
2.3 Global strategies, policy and guidance on IFE

The protection and support of optimal infant and young child feeding (IYCF) is mandated by international
law. It is necessary for meeting international standards and is regulated and detailed in operational and
technical guidance. Figure 4 reflects a schematic overview of key documentation relevant to the
protection and support of IYCF in emergencies (IFE), with some examples of each. Several of these are
particularly relevant to MAMI and are described here in more detail.
Context-specific Application
Universal Application
Figure 4: Key strategies, policies and guidance related to infant and young child
feeding in emergencies
Convention on the Rights of the Child (UNHCR, 1989
Global and
International Innocenti Declaration (1990; 2005)
Conventions, International Code of Marketing of Breastmilk Substitutes
(WHO, 1981) and subsequent relevant World Health Assembly
Declarations
(WHA) Resolutions
and Standards
Guiding
Principles,
Strategies,
and Policies
2002 Global Strategy for Infant and Young Child Feeding

(UNICEF/WHO, 2003)
Planning guide for national implementation of the global
strategy for infant and young child feeding (WHO,2007)
Guiding Principles for Complementary Feeding of the
Breastfed Child/Feeding Non-Breastfed Children 6-24 months
of age (WHO, 2003/2005
Infant and young Child Feeding in Emergencies;

Operational Guidance for Emergency Relief Staff and
Programme Managers v2.1 (IFE Core Group, 2007
Operational Guidance on Infant Feeding and HIV in the Context of
Refugees and Displaced Populations v1.1 (UNHCR, 2009)
and Technical
Food and Nutrition Needs in Emergencies
Guidance
(UNHCR/UNICEF/WFP/WHO, 2002)
Behavioural Change Communication in Emergencies;
a Toolkit (UNICEF, 2006)
Grounded in universal principles,

with universal application, seek
to protect and promote health
and wellbeing of poeple,
ensuring all concerned parties
work towards a common goal
Provide the framework to guide
thinking on how to implement
universal principles when planning
interventions; flexible application
in conjunction with suitable
detailed guidance and practical
field-orientated materials
Practical field-orientated
material; aim to assist with the
practical implementation of
guiding principles
WHO/UNICEF Global Strategy Infant and Young Child Feeding (2002)

The WHO/UNICEF Global Strategy on Infant and Young Child Feeding39 is an international strategic
framework based on respect, protection, facilitation and fulfillment of accepted human rights principles. It
was adopted by consensus in 2002 by all WHO Member States. The Global Strategy identifies the
obligations and responsibilities of governments, organisations, and other concerned parties to infants and
young children and sets operational targets. The Implementation Handbook for the Convention of the
Rights of the Child recognizes the Global Strategy as a cornerstone to achieving the child's right to the
highest attainable standard of health, stipulated in Article 24 of the Convention.
Of particular note to MAMI, the Global Strategy calls for appropriate feeding support for infants and
young children in exceptionally difficult circumstances, related support for caregivers and the
development of the knowledge and skills base of health workers working with carers and children in such
situations. Exceptionally difficult circumstances includes infants of low-birth-weight, mothers who are
HIV-infected and infants in emergency situations.
Many of the WHO Member States are already acting on their official commitment to implement the Global
Strategy, and are developing national action plans based on it. Positioning interventions to treat
malnutrition within the Global Strategy creates opportunities to coordinate with governments and
national level plans.
22
UNICEF Conceptual framework for the causes of malnutrition (1990)

The UNICEF Conceptual framework for the causes of malnutrition40 was first developed in 1990 to guide
analysis of the causes of malnutrition in a given context. Refined versions have since been produced
though retaining the basic elements of the original (see Figure 5). It has been applied widely to
emergency contexts. The UNICEF framework reflects how malnutrition results from a complex mix of
factors at different levels. It recognises the role of IYCF and care practices. Understanding the many
different influences on nutritional status and underlying causes of malnutrition in a particular context
allows the development of appropriate interventions to address malnutrition and can help to transition
emergency interventions into longer term development programming. This framework formed the basis
of a version developed for MAMI (see Section 1.4).
Figure 5: UNICEF conceptual framework for the causes of malnutrition
Child malnutrition,
death and disability
Manifestations
of a problem
Inadequate dietary
intake
Insufficient
access to food
Inadequate and/or
inappropiate knowledge
and discriminatory
attitudes linit household
access to actual resources
Political, cultural, religious,

economic and social
systems, including
womens status, limit the
utilisation of potential
resources
Disease
Poor
water/sanitation
and inadequate
health services
Inadequate
maternal and
child-care
Quantity and quality of actual

resources human, economic
and organisational and the way
they are controlled
Immediate
causes
Underlying
causes at
household/
family level
Underlying
causes at
societal level
Potential resources:
environment, technology,
people
Source: UNICEF, 1998. The State of the Worlds Children.
Millennium Development Goals (2000)

The Millennium Development Goals (MDGs) are eight goals to be achieved by 2015 that respond to the
world's main development challenges41. The benefits of treating acute malnutrition and of optimal IYCF
are relevant to all eight of the United Nations Millennium Development Goals (MDGs)42,43 (see Table 1).
At mid-point towards the 2015 deadline, progress towards some of the MDGs is off track in some regions,
and MDGs 4 and 5 are particularly in danger of not being met. Improvements in MAMI will increase the
changes for achievement of these MDGs.
23
Table 1: Contribution of malnutrition treatment and optimal IYCF to meeting Millennium

Development Goals (MDGs)
Treatment of acute malnutrition
Optimal IYCF44
MDG 1 (Eradicate extreme

poverty and halve hunger)
Malnutrition treatment directly

addresses hunger.
Breastfeeding is a low cost, high quality, safe

food which is key to infant and child
nutrition.45,46
MDG 2 (Universal primary

education)
Malnutrition impairs school

performance.47
Breastfeeding and appropriate

complementary feeding contribute to optimal
neurological and cognitive development.48,49
MDG 3 (Gender equality)
Malnourished girls are less likely

to stay in school and receive the
education so vital to their
empowerment.50
Breastfeeding enables an equal start51 and

empowers women through health and
reproductive benefits, e.g. birth spacing.52
MDG 4 (Reduce child

mortality).
Maternal and child undernutrition

contributes to 35% of under five
deaths.53
If all infants were exclusively breastfed for

six months and were breastfed for one year,
under five mortality would reduce by about
14%. If appropriate complementary feeding
were given to children between six months
and two years under five mortality would
reduce by about 6%.54
MDG 5 (Maternal Health)
Malnourished girls not reaching

their full adult physical potential
are at increased risk of maternityrelated problems.55
The Global Strategy draws attention to

maternal nutritional and social needs related
to IYCF56, and maternal benefits, such as
reduced post-partum haemorrhage through
early initiation of breastfeeding, protection
from anaemia and maternal depletion
through lactational amennhorrea.57,58,59
MDG 6 (Combat HIV/AIDS,

malaria & other diseases)
Nutrition and infection interact.60,61
Optimal IYCF practices reduce morbidity and

mortality in children.62,63
MDG 7 (Ensure
environmental
sustainability)
Initiatives to prevent malnutrition or

intervene early, reduce the need
for external supports that may have
higher environmental impact, e.g.
importing specialised products,
less transport costs, less waste.
Breastfeeding is a sustainable, locally

available feeding option without waste,
packaging or fuel use.64,65
MDG 8 (global partnerships

for development)
The Global Strategy framework, for example, offers an opportunity to develop

global partnerships for development.66
International Code of Marketing of Breastmilk Substitutes (1981)

Upholding the provisions of the International Code of Marketing of Breastmilk Substitutes67 and subsequent
relevant World Health Assembly (WHA) resolutions (collectively known as the Code)68 is a key consideration in any
interventions that involve infant and young child feeding. All provisions of the Code apply in emergencies and
adoption of and adherence to the Code in its entirety is a minimum requirement of member states (WHA 34.22). At
least 48 countries have national legislation based on the Code.
The Code is intended to protect the mothers/caregivers of both breastfed and non-breastfed infants and young
children from commercial influences on their infant feeding choices. The Code sets out the responsibilities of the
infant food industry,health workers, governments and organizations in relation to the marketing of breastmilk
substitutes, feeding bottles and teats. The Code does not ban the use of infant formula or bottles but controls how
they are produced, packaged, promoted and provided.
WHO Guiding Principles for feeding infants and young children during emergencies (2004)
Published in 2004, the WHO Guiding Principles for feeding infants and young children during emergencies69
emphasises both optimal infant and young child feeding practices and the recognition and treatment of acute
malnutrition, detailed in ten guiding principles and summarised here (Box 3).
24
Box 2: Breastmilk substitute definition (the Code)

For the purpose of the Code, breastmilk substitutes are defined as any food being marketed or otherwise
represented as a partial or total replacement of breastmilk, whether or not suitable for that purpose.
A common breastmilk substitute is commercial infant formula, a product that should meet technical
specifications of the relevant Codex Alimentarius Standards. However, any product promoted for use in an
infant under six months of age (or represented as a replacement for breastmilk from six months of age to two
years or beyond), is considered a breastmilk substitute for the purpose of the Code and so fall within its
scope.
Examples of products that may fall within the scope of the Code include milk products such as dried skimmed
milk and condensed milks, therapeutic milks, bottled water, juices, teas, glucose solutions, cereals, ready to
use therapeutic foods and any other foods and fluids marketed for infants under six months.
Box 3: Guiding principles for feeding infants and young children during emergencies
(WHO, 2004)
Principle 1
Infants born into populations affected by emergencies should normally be exclusively breastfed from birth to 6
months of age.
Principle 2
The aim should be to create and sustain an environment that encourages frequent breastfeeding for children
up to two years or beyond.
Principle 3
The quantity, distribution and use of breast-milk substitutes at emergency sites should be strictly controlled.
Principle 4
To sustain growth, development and health, infants from 6 months onwards and older children need
hygienically prepared, and easy-to-eat and digest, foods that nutritionally complement breast milk.
Principle 5
Caregivers need secure uninterrupted access to appropriate ingredients with which to prepare and feed
nutrient-dense foods to older infants and young children.
Principle 6
Because the number of caregivers is often reduced during emergencies as stress levels increase, promoting
caregivers coping capacity is an essential part of fostering good feeding practices for infants and young
children.
Principle 7
The health and vigour of infants and children should be protected so they are able to suckle frequently and
well and maintain their appetite for complementary foods.
Principle 8
Nutritional status should be continually monitored to identify malnourished children so that their condition can
be assessed and treated, and prevented from deteriorating further. Malnutritions underlying causes should be
investigated and corrected.
Principle 9
To minimize an emergencys negative impact on feeding practices, interventions should begin immediately.
The focus should be on supporting caregivers and channelling scarce resources to meet the nutritional needs
of the infants and young children in their charge.
Principle 10
Promoting optimal feeding for infants and young children in emergencies requires a flexible approach based
on continual careful monitoring.
25
Sphere Humanitarian Charter & Minimum Standards in Disaster Response (2004)

During the past decade the humanitarian community has initiated a number of inter-agency initiatives to
improve accountability, quality and performance in humanitarian action. Launched in 1997, the Sphere
Project70 is one such initiative. The Sphere Project comprises a humanitarian charter and a set of standards
that specify the minimum acceptable levels to be attained in humanitarian response. The Sphere 2004
edition provides 17 minimum standards in food security, nutrition and food aid. Each minimum standard
has a set of key indicators to signal how far the standard has been attained71.
There are a number of Sphere indicators that are particularly relevant to infants <6m, for example
indicators on exclusive breastfeeding, support to non-breastfed infants and support to pregnant and
lactating women. Greater clarity is needed on how such indicators can be measured, and generally around
MAMI, for example, criteria for admissions of infants <6m. An update of Sphere is currently underway
(2010 edition) and the MAMI Project is contributing to this process.
Operational Guidance on IFE (2007)

One of the challenges of meeting global recommendations is how to translate them into practical action.
Global instruments typically do not include detailed instruction on action required, a point highlighted in
the recent Lancet Series on Maternal and Child Undernutrition:
The international system provides much normative guidance on nutrition policy, but some of it is
expressed in abstract language that does not easily translate into implementation72.
Lancet Maternal and Child Undernutrition Study Group, Jan 2008.
The Operational Guidance on IFE for emergency relief staff and programme managers (Ops Guidance on
IFE)73 is a concise policy guidance that moves towards operationalising global recommendations on IYCF
for the emergency context. Mandated by global positions it draws on technical guidance, empirical
evidence, and experience from past emergencies. Produced by the IFE Core Group, and housed at ENN,
the Ops Guidance on IFE is managed as a living document and supported by a range of UN agencies,
NGOs and bilateral donors. Key points of the Operational Guidance on IFE are included in Box 4.
26
2.4 Definition of Acute Malnutrition
Box 4: Key Points of the Operational Guidance on IFE

1.
Appropriate and timely support of infant and young child feeding in emergencies (IFE) saves lives.
2. Every agency should develop a policy on IFE. The policy should be widely disseminated to all staff,
agency procedures adapted accordingly and policy implementation enforced.
3.
Agencies should ensure the training and orientation of their technical and non-technical staff in IFE, using
available training materials.
4.
Within the United Nations (UN) Inter-agency Standing Committee (IASC) cluster approach to
humanitarian response, UNICEF is likely the UN agency responsible for co-ordination of IFE in the field.
Also, other UN agencies and NGOs have key roles to play in close collaboration with the government.
5.
Key information on infant and young child feeding needs to be integrated into routine rapid assessment
procedures. If necessary, more systematic assessment using recommended methodologies could be
conducted.
6.
Simple measures should be put in place to ensure the needs of mothers, infants and young children are
addressed in the early stages of an emergency. Support for other caregivers and those with special
needs, e.g. orphans and unaccompanied children, must also be established at the outset.
7.
Breastfeeding and infant and young child feeding support should be integrated into other services for
mothers, infants and young children.
8.
Foods suitable to meet the nutrient needs of older infants and young children must be included in the
general ration for food aid dependent populations.
9.
Donated (free) or subsidised supplies of breastmilk substitutes (e.g. infant formula) should be avoided.
Donations of bottles and teats should be refused in emergency situations. Any well-meant but ill-advised
donations of breastmilk substitutes, bottles and teats should be placed under the control of a single
designated agency.
10. The decision to accept, procure, use or distribute infant formula in an emergency must be made by
informed, technical personnel in consultation with the co-ordinating agency, lead technical agencies and
governed by strict criteria.
11. Breastmilk substitutes, other milk products, bottles and teats must never be included in a general ration
distribution. Breastmilk substitutes and other milk products must only be distributed according to
recognised strict criteria and only provided to mothers or caregivers for those infants who need them. The
use of bottles and teats in emergency contexts should be actively avoided.
Extracted from: Operational Guidance on IFE, v2.1, 2007

In selective feeding programmes anthropometric measurements, namely weight and height, are typically
used to identify and classify the degree of acute malnutrition. This helps to identify those requiring
nutritional care.74 Presence of bilateral oedema indicates nutritional oedema or kwashiorkor that is
classified as severe acute malnutrition, independent of weigh-for-height.
2.4.1 Case definitions of acute malnutrition

WHO case definitions of acute malnutrition (1999)75 are the basis of almost all current national and
international protocols managing acute malnutrition (See Table 2).
27
Table 2: WHO classification of acute malnutrition, 1999

Classification
Moderate acute malnutrition (MAM)
Severe acute malnutrition (SAM)
Nutritional oedema
(symmetrical)
No
Yes
Weight-for-Height
-3 Z-score < -2 (NCHS)**

(or 70- 79% of median NCHS)*
Z-score <-3 (NCHS)**

(or <70% of median NCHS)*
* Weight-for-height percent of median (WHM) is the ratio of the measured value in the individual to the median value of the reference data.
** Weight-for-height Z-scores (WHZ) are where -1 z-score is 1 standard deviation (SD) below the growth norm median and +1 Z is 1SD above.
Weight-for-age indicators are no longer used as a measure of acute malnutrition, however they are still
commonly used in growth monitoring. Related to the above definitions, GAM (Global Acute Malnutrition)
is another commonly used term. GAM = SAM + MAM.
2.4.2 Evolution of case definitions

Since 1999, there have been several important evolutions of the WHO case definitions of SAM and MAM,
as follows:
Mid-upper arm circumference (MUAC)

MUAC is now used as an independent case definition criterion, based on evidence of low MUAC being
highly correlated with mortality. Case definitions are as follows:
Severe acute malnutrition (SAM) = MUAC < 110mm (recently updated to <115mm)76
Moderate acute malnutrition (MAM) = MUAC <125mm
As a case detection method for use in resource poor and emergency settings, MUAC has particular
advantages of age independence, simplicity, acceptability and cheapness. Arguments have been made for
using MUAC as a sole admission criterion for programmes treating children six to59 month
malnutrition.77 MUAC is not currently recommended for use in infants <6m.
Complicated and uncomplicated malnutrition

The division of case definitions into complicated and uncomplicated malnutrition78 recognises that
two children with identical anthropometry do not necessarily have the same mortality/morbidity risks or
treatment needs. Anthropometric status and clinical status are considered in parallel when directing
children to inpatient or outpatient care (Figure 6).
28
2.5 Management of Acute Malnutrition
Figure 6: Complicated and uncomplicated acute malnutrition framework

Acute
malnutrition
Acute malnutrition
<80% of median weight for
height (<-2 SD-score)
or
bilateral pitting oedema
or
mid-upper arm
circumference <110mm
and
one of the following:
Anorexia
Severe
uncomplicated
malnutrition
Moderate
uncomplicated
malnutrition
<70% of median weight for

height (<-3 SD-score)
or
bilateral pitting oedema
or
mid-upper arm
circumference <110mm
and:
70-80% of median weight

for height (-3 SD-score to
<-2 SD-score)
and
no oedema
or
mid-upper arm
circumference 110-125mm
and:
Lower respiratory
tractinfection
Appetite
High fever
Alert
Clinically well
Appetite
Clinically well
Alert
Severe dehydration
Not alert
Inpatient
stabilisation care
Outpatient
therapeutic care
Outpatient
supplementary
feeding
Source: Collins & Yates, 2003
Transition from NCHS to WHO-GS

The 1978 National Centre for Health Statistics child growth reference (NCHS)79 is widely used by selective
feeding programmes as the norm to describe growth in infants and children. However, because of their
limitations NCHS data fail to adequately describe the growth of apparently healthy, normal, breastfed
infants. 80 The 2006 World Health Organisation Growth Standards (WHO-GS)81 are based on a much more
broadly representative dataset and provide an international gold standard of how children should grow
when free of disease and when their care follows healthy practices such as breastfeeding and nonsmoking.82 In May 2009, a joint statement by WHO and UNICEF83 recommended that the WHO-GS is
now used. Table 3 summarises implications of this transition.
Significant to MAMI, both the joint statement and the international consultation on which it is based84
only address children aged six to 59 months. Implications of the transition for infants <6m are not
considered.

Acute malnutrition can be tackled at 3 levels:
i.
ii.
iii.
Primary: reducing the development (incidence) of malnutrition.

Secondary: reducing prevalence of malnutrition by earlier detection of or better treatment
shortening the duration of an episode of malnutrition.
Tertiary: reducing the negative impacts of an established episode of malnutrition.
The MAMI Project focuses on secondary and tertiary treatment with specific reference to supplementary
feeding programmes (SFP) and therapeutic feeding programmes (TFP), collectively described as selective
feeding programmes. Primary prevention is critical but is beyond the scope of this investigation. SFP and
TFP (both inpatient and community-based) will now be described.
29
Table 3: NCHS and WHO-GS growth norms as applied to the case definition of acute
malnutrition
NCHS
WHO-GS
Type of growth norm
Reference
Standard
Breastfeeding status of infants

on whom the norm is based
Mixed
Exclusively breast fed until at least four

months of age
Oedematous malnutrition = SAM

(irrespective of weight-for-height)
yes
yes
SAM (% of median)
<70% weight-for-height (WHM)
not used
MAM (% of median)
70% to < 80% WHM
not used
SAM (z-score)
<-3z weight-for-height (WHZ)
<-3z weight-for-height (WHZ)
MAM (z-score)
-3 to <-2 WHZ
-3 to <-2 WHZ
MUAC-defined SAM
( 6 to59m children)
110mm
115mm
Key characterisitics
Acute malnutrition case definitions
Implications for clinical caseload

relative numbers of 6 to 59 month children diagnosed with:
SAM:
WHZ (NCHS) to WHZ (WHO)
1 (reference)
Increase in numbers diagnosed

( 2 to 4x increase )(36)
SAM:
WHM (NCHS) to WHZ (WHO)
1 (reference)
Large increase in numbers diagnosed

( 8x increase in one study )(40)
MAM:
WHZ (NCHS) to WHZ (WHO)
1 (reference)
Slight decrease in numbers diagnosed
Source: WHO & UNICEF (2009)
2.5.1 Supplementary feeding programmes (SFP)

Moderately malnourished children are typically treated in SFPs. They may be admitted directly or
transferred from a therapeutic feeding programme (TFP) as they recover from severe malnutrition.
Admissions are normally stable clinically, so outpatient-based, minimum intensity treatment is possible.
The aim of SFPs is to reduce the risk of death by restoring nutritional status through provision of foods or
rations to supplement the childs home diet. Fortified foods typically distributed in SFPs include corn-soy
blends (CSB), wheat soy blends and more recently, Ready to use Supplementary Foods (RUSF). SFPs may
be targeted to at risk groups in a population, e.g. all children six to 59 months, or restricted to those
children who are moderately malnourished.
Infants <6m who are malnourished do not qualify for supplementary food rations, on the basis they
should be exclusively breastfed. In such cases, the mother of the malnourished infant may receive the
supplementary food ration.
2.5.2 Therapeutic feeding programmes (TFP)

Severely malnourished children are clinically more compromised and require more intensive medical and
nutritional treatment than is possible in SFPs. Such treatment can take place in inpatient and outpatient
settings.
Inpatient treatment
Traditionally, all children with severe acute malnutrition (SAM) were treated in inpatient facilities
(therapeutic feeding centres, nutrition rehabilitation units or paediatric wards). The focus of such
30
treatment is to optimise the quality of care offered to individual children. This was often challenging in
resource limited settings; a 1995 review found case fatality rates (CFR) to be typically 20-30% and
sometimes as high as 60%.85 Poor case management was identified as a major cause. In 1999 the WHO
Management of severe malnutrition: a manual for physicians and other senior health workers was
produced as part of an international initiative to improve case management of SAM.86 87 88 Training
materials support these guidelines.
According to the WHO guidelines, children with SAM are treated in two main phases, following a ten
steps approach to care89 (see Figure 7). During initial treatment (stabilisation phase) therapeutic milk F75
is used; during rehabilitation F100 is used following a short transition period. Medical treatment include
routine use of antibiotics and the importance of psychosocial support is also recognised. In the WHO
(1999) guidelines, infants <6m are implicitly part of the < 5 year old group, but are not dealt with
separately recognising the differences from older children (this is discussed more detail in Chapter 4).
Figure 7: Ten steps of inpatient treatment of severely malnourished children
Stabilisation Phase
Step
Days 1 2
Days 3 7
Rehabilition Phase
Weeks 2 6
1. Hypoglycaemia
2. Hypothemia
3. Dehydration
4. Electrolytes
5. Infection
6. Micronutrients
no iron
with iron
7. Cautious feeding
8. Catch-up growth
9. Sensory stimulation
10. Prepare for follow-up
Source: Ashworth et al, 200390
Community based care

Community-based Management of Acute Malnutrition/ Community Therapeutic Care (CMAM/CTC) is an
outpatient therapeutic feeding strategy developed on the basis of operational research over the past six
to seven years91 92 93 and endorsed by major UN agencies in 2007.94 CMAM/CTC classifies SAM as either
complicated or uncomplicated to distinguish between sick children who need some intensive medical
and nutritional treatment in an inpatient facility and clinically stable children (the majority of cases) who
can be safely treated at home.
The development of ready-to-use therapeutic food (RUTF) made CMAM/CTC a practical possibility. RUTF is
an energy and nutrient dense paste, a therapeutic food that is nutritionally equivalent to F100 milk, but
needs no preparation and can be eaten direct from its container.
The structure and flow through a typical CMAM/CTC programme is illustrated in Figure 8 and involves:
a) Active case finding and community mobilization to identify malnourished children.
b) Referral of children with moderate acute malnutrition to SFP programmes.
c) Direct admission of children with uncomplicated SAM to outpatient treatment (OTP), using RUTF.
d) The minority of children with complicated SAM are admitted first to a stabilization centre (SC) which
follow WHO protocol for phase one (stabilisation).
31
2.6 Summary Findings
e) After stabilisation, patients are returned to the OTP to complete rehabilitation (phase 2) in the
community.
f) Following recovery from OTP treatment, patients are often referred to SFP (if available).
In current guidelines, RUTF is not recommended for infants <6m; infants <6m with SAM are considered
complicated cases and are referred for inpatient treatment (this is explored in more detail in Chapter 4).
Figure 8: Structure of and patient 'flow' within a CMAM programme

Default
Referral
Death
SC
OTP
Stabilisation
Active case
finding
Death
Default
Community
Mobilisation
SFP
OTP: Outpatient therapeutic programme
SFP: Supplementary Feeding Programme
SC: Stabilisation Centre
Death
Default
Source: Valid International, 2006.95
2.6 Summary Findings

Infant <6m malnutrition is an important public health problem. Maternal and child undernutrition
contribute to 35% of the 9.2 million under five deaths per year; infants are vulnerable to higher morbidity
and mortality, particularly in emergencies.
Infants <6m have unique characteristics and should be considered a distinct subgroup.
The protection and support of IFE is mandated by international law, is necessary for meeting international
standards and is regulated by operational and technical guidance.
WHO case definitions of acute malnutrition (1999) form the basis of most protocols on the management
of acute malnutrition. MUAC is now often used as an independent case definition criterion. Case
definitions are now commonly divided into complicated and uncomplicated malnutrition.
A transition is underway from the use of NCHS growth references to the 2006 WHO Growth Standards
(WHO-GS). It is shown that using WHO-GS, higher numbers of children six to59 months will be diagnosed
with SAM.
In emergencies, acute malnutrition is treated in selective feeding programmes. MAM is treated in
Supplementary Feeding Programmes. SAM is treated in Therapeutic Feeding programmes. Complicated
cases of SAM are treated as inpatients using WHO 10 steps protocol and, increasingly, uncomplicated
SAM cases are managed in community-based programmes that use RUTF.
32
Endnotes
Endnotes
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
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Kramer, M. S., F. Aboud, et al. (2008) Breastfeeding and child cognitive development: new evidence from a large randomized trial.
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Mukudi, E. (2003) Nutrition status, education participation, and school achievement among Kenyan middle-school children. Nutrition
19(7-8): 612-6.
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Kennedy, K. I., R. Rivera, et al. (1989) Consensus statement on the use of breastfeeding as a family planning method. Contraception
39(5): 477-96.
Black, R.E., Allen, L.H., Bhutta, Z,A., Caulfield, L.E., de Onis, M., Ezzati, M., et al. (2008) Maternal and child undernutrition: global and
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Jones, G., R. W. Steketee, et al. (2003) How many child deaths can we prevent this year? (Child survival II). In: The Lancet. 65.
KOTHARI, G. (1991) Can low income women in developing countries afford artificial feeding. J Trop Pediatr 37(3): 141-.
Beasley, A. and L. Amir (2007) Infant feeding, poverty and human development. International Breastfeeding Journal 2(1): 14.
Sserunjogi, L., F. Scheutz, et al. (2003) Postnatal anaemia: neglected problems and missed opportunities in Uganda. Health Policy &
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Sobhy, S. I. and N. A. Mohame (2004) The effect of early initiation of breast feeding on the amount of vaginal blood loss during the fourth
stage of labor. Journal of the Egyptian Public Health Association 79(1-2): 1-12.
Geller, S. E., M. G. Adams, et al. (2006) Postpartum hemorrhage in resource-poor settings. International Journal of Gynecology &
Obstetrics 92(3): 202-11.
Group, H. I. V. W., T. L. Miller, et al. (2008) Gastrointestinal and Nutritional Complications of Human Immunodeficiency Virus Infection.
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Mangili, A., D. H. Murman, et al. (2006) Nutrition and HIV infection: review of weight loss and wasting in the era of highly active
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Marazzi, M. C., K. Nielsen-Saines, et al. (2009) Increased infant human immunodeficiency virus-type one free survival at one year of age
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Gupta, A. and J. E. Rohde (1993) Economic value of breast-feeding in India. Economic and Political Weekly 28(26): 1390-93.
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Chapter 3
How big is the problem?
35
Chapter 3 How big is the problem?
Chapter 3: How big is the problem?

This chapter assesses the global burden of acute malnutrition in infants <6m. It summarises the analysis of
country level datasets and examines the potential impact of a transition from the use of the National
Centre for Health Statistics Child Growth Reference (NCHS) to the 2006 WHO growth standards (WHO-GS).
3.1 Why population burden of disease matters

Well defined disease burden epidemiology is important. If poorly defined, populations risk being
marginalised. This chapter addresses a prevailing assumption that malnutrition in infants <6m is
uncommon relative to older age groups.96 The 1995 WHO Field Guide to Nutrition Assessment, for
example, states that children under 6 months of age, apart from being more difficult to measure, are
often still breast-fed and therefore satisfactorily nourished.97 These notions lead to the exclusion of infants
<6m in many nutrition surveys.98, 99 Yet without population data, effectively tackling infant <6m
malnutrition is difficult. Programmes will not know whether actual admissions reflect community disease
burden, which management strategies are most appropriate and the extent of public health impact.
Efforts to improve understanding of the epidemiology of acute malnutrition in infants <6m are therefore
critical. This includes estimating the potential impact of recent changes in case definitions (see Section
2.4.2). Studies examining the 2006 WHO growth standards (WHO-GS) for diagnosing wasting in children
consistently show greater numbers labelled as wasted than with old NCHS references.100, 101, 102 A recent
international consultation reviewed and endorsed the use of WHO-GS for selective feeding programmes103
but did not address infants <6m. This chapter includes an assessment of the effect of WHO-GS-based
diagnosis in this area. Key policy and research implications of findings are discussed.
3.2 Aims
This chapter aims to:
Describe the prevalence of wasting amongst infant <6m in nutritionally vulnerable settings
Examine how new case definitions based on WHO-GS affect the burden of disease
Explore key characteristics of wasted infants <6m
Wasting (weight-for-height <-2 z-scores) was described rather than global acute malnutrition (weight-forheight <-2z and/or bilateral oedema) since analysis was conducted on Demographic & Health Survey
(DHS) datasets that do not gather data on oedematous malnutrition.
3.3 Methods of determining population burden of disease

3.3.1 Study design, setting and population
Secondary analysis was conducted of 21 DHS country datasets.104 Datasets were selected from a reference
population of 36 counties identified in the 2008 Lancet Maternal and Child Undernutrition series as
accounting for over 90% of global malnutrition.105 The 21 datasets selected were those with available
anthropometric data collected in the last ten years and those considered representative of nutritionally
vulnerable populations. Data were available for a total of 163,228 children 0 to59 months (mean 7,773 per
country; range 1,710 to 45,398) and included 15,534 infants <6m.
36
3.3 Methods of determining population burden of disease
3.3.2Data handling
Permission to download DHS datasets was obtained from http://www.measuredhs.com/accesssurveys/
search/start.cfm. Data management and main analyses used SPSSv.15 ( SPSS Inc USA). Weight for height
Z scores (WHZ) (using both NCHS references and WHO-GS), were calculated from weight, height/length,
sex and age using ENA for SMART software (version October 2007).106 Cases with extreme values were
cleaned according to standard criteria.107 These exclude individuals with:
Weight-for-height z-score (WHZ)

Weight-for-age z-score (WAZ)
Height-for-age z-score (HAZ)
Incompatible combinations of HAZ & WHZ
WHZ (NCHS) <-4 or > +6

or
WAZ (NCHS) <-6 or >+6
or
HAZ (NCHS) <-6 or >+6
or
(HAZ >3.09 and WHZ <-3.09) or
(HAZ <-3.09 and WHZ >3.09)
To ensure a balanced comparison, if a childs z-scores were valid by these NCHS criteria, then the same
childs WHZ(WHO) was considered valid.
3.3.3 Data analysis

Prevalence of malnutrition was described by wasting using standard criteria applied to both NCHS and
WHO-GS:
Wasting = WHZ <-2,
Severe wasting = WHZ <-3
Moderate wasting = WHZ -3 to <-2
Four major analyses examined age-specific effects:
a) Prevalence of wasting by country: To aid analysis, countries were classified using the internationally
recognised Integrated Food Security Phase Classification (IPC).108 IPC considers food security, nutrition
and livelihood information to determine the severity of an emergency and guide the need for
interventions. It considers >3% to <10% prevalence of acute malnutrition as moderately food insecure;
10-15% as an acute food and livelihood crisis; >15% as a humanitarian emergency; >30% as famine/
humanitarian catastrophe. We emphasize that IPC is not normally applied to single age groups, nor to
anthropometric indicators alone; it serves here only to illustrate the relative magnitudes of infant/
child and NCHS/WHO differences.
b) Changes in country prevalence of wasting using WHO-GS: Change in prevalence of moderate and severe
wasting using the WHO-GS v NCHS was examined using scatter plots and simple linear regression.
c) Caseload implications for treatment programmes: Any changes in clinical caseloads of infant <6m
and children in selective feeding programmes using NCHS v WHO-GS were investigated. For our
analysis, we assumed that all eligible patients would be identified and appropriately admitted.
d) Characteristics of wasted infants <6m: Preliminary analysis was undertaken of key characteristics of
wasted infants <6m with reference to other variables available in the DHS datasets but detailed
analysis was beyond the scope of the MAMI Project. As a priority this should be explored in more
detail in future work.
Data is presented for all wasted children rather than by country. The focus is on severe wasting, since
mortality and morbidity risks are highest in this group.
Z-score wasting cut-offs are graphically compared for different age groups using NCHS and WHO growth
norms. Reference data were derived from published NCHS109 and WHO tables.110 The length range of 49.0
cm to 79.0 cm was used for comparison, since 49.0 cm is the lowest length included in the NCHS reference
weight for height index, and 79 cm is just above the median for one year old children.
37
3.4 Results
3.4 Results
3.4.1 Country prevalence of infant <6m and child wasting: is it an
emergency?
Wasting was prevalent in the countries examined, but there were large age-group and inter-country
variations (see Figure 9).
Figure 9a shows infant <6m wasting. Countries are ordered by increasing infant <6m wasting prevalence
(NCHS). Prevalence is lowest using NCHS growth references. Even so, only 7/21 countries have acceptably
low infant <6m wasting prevalence (<3% by the IPC classification). One has prevalence of >15% and is
therefore defined a humanitarian emergency. Using WHO-GS for diagnosis, the prevalence of infant <6m
wasting increases markedly: only 1/21 countries remain with an acceptably low <3% prevalence and
11/21 are in the humanitarian emergency class.
Figure 9b, shows that NCHS/WHO changes amongst children aged six to 59 months are minimal. With
NCHS-based diagnosis, 3/21 countries have a low <3% prevalence of child wasting. Two have a high
humanitarian emergency level. Using WHO-GS based diagnosis, the IPC classification of countries does
not change.
Figure 9: Country prevalence of wasting (WHZ <-2) as defined by NCHS and WHO-GS
a) Infants <6m
Famine
% wasting
30%
Humanitarian emergency
NCHS
20%
WHO
Acute crisis
10%
Moderately insecure
India
Burkina Faso
Mali
Nigeria
Egypt
Ethiopia
Ghana
Madagascar
Niger
Kenya
Malawi
Zambia
Cambodia
Cameroon
Bangladesh
Guatemala
Cote DIvoire
Tanzania
Mozambique
Turkey
Peru
0%
b) Infants 6-59m
% wasting
30%
NCHS
20%
WHO
10%
Figure key: NCHS striped bars, WHO-GS solid bars.
38
India
Burkina Faso
Mali
Nigeria
Egypt
Ethiopia
Ghana
Madagascar
Niger
Kenya
Malawi
Zambia
Cambodia
Cameroon
Bangladesh
Guatemala
Cote DIvoire
Mozambique
Turkey
Tanzania
Peru
0%
3.4 Results
3.4.2 NCHS and WHO cut-off curves defining wasting

Figure 10 helps explain the age related effects seen in Figure 9. Vertical dotted lines show median lengths
at age six months and one year for boys. The girls chart follows a similar pattern and so is not included. For
younger, shorter infants <6m, there is a large discrepancy between WHZ-NCHS and WHZ-WHO <-2 cut-off
values. WHO-GS cut-off values are consistently higher, increasing the numbers of infant <6m diagnosed as
wasted. These differences narrow as infants approach one year of age. The patterns for moderate and
severe wasting are similar and are therefore not shown.
Figure 10: Weight cut-offs used to define wasting by either NCHS or WHO-GS criteria (boys)
10.0
tt t
tttt t
nn
nn
nn
nn
nn n
nn
nn
nn
n nn
2.0
1.0
n nn
nnn
1 year
nnn
nn
n
nn
nn
nn n
nnn
nn
6 months
n
nn n
tt
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nn
t tt t
t
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tt
tt
Weight (kg)
5.0
tt
tt
tt
tt
tt
tt
t
tt
6.0
n
nnn
t
tt
tt t
t
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n
nn
tt
-2 z-score NCHS
tt
-2 z-score WHO
8.0
t
tt
tt
tt
tt
tt t
tt
tt
tt
9.0
0.0
49.0
52.0
55.0
58.0
61.0
64.0
67.0
70.0
76.0
79.0
Length (cm)
3.4.3 Differences in severe and moderate wasting

Differences in severe and moderate wasting to overall wasting prevalence are shown in two scatter plots
(Figures 11a) and 11b). Use of WHO-GS increases the prevalence of severe wasting in both infants <6m
and children. The magnitude of increase is consistently greater for infants <6m. Moderate wasting
similarly increases in the infant <6m age group. In contrast, prevalence of moderate wasting in children
decreases when using WHO-GS.
39
3.4 Results
Figure 11: Scatter plots of country prevalence (NCHS v WHO) of severe and moderate
wasting
b) Age-specific prevalence of moderate wasting, by
NCHS or WHO
20
Prevalence of severe wasting (WHO-GS) (%)
Prevalence of severe wasting (WHO-GS) (%)
a) Age-specific prevalence of severe wasting, by

NCHS or WHO
x=y
18
y = 3.54x + 2.30 (R = 0.78)
16
14
12
10
8
y = 1.68x + 0.12 (R2 = 0.96)
6
4
2
Infants (<6 months)

Children (6 to <60 months
0
0
10
12
14
16
18
20
x=y
y = 1.43x + 2.02 (R2 = 0.79)
18
16
14
12
10
8
6
y = 0.86x + 0.01 (R2 = 0.98)
4
2
Infants (<6 months)

Children (6 to <60 months
20
Prevalence of severe wasting (NCHS) (%)
10
12
14
16
18 20
Prevalence of severe wasting (NCHS) (%)
Figure key: Regression and identity lines are shown. Each country survey is represented by one filled and one unfilled circle.
3.4.4 Implications of prevalence changes for treatment programmes

The use of WHZ-WHO-GS rather than WHZ-NCHS to diagnose wasting may be expected to result in large
increases in the proportion of therapeutic feeding (TFP) and supplementary feeding programme (SFP)
admissions who are infants <6m (see Figure 12). For TFP treatment of severe wasting (Figure 12a), there is
not a clear linear trend, but nonetheless, a dramatic upward shift in the percentage of infants <6m who
are eligible for admission. For SFP treatment of moderate wasting (Figure 12b) there is a significant trend
with an expected increase of 1.59 fold in the percentage of admissions who are infants < 6m.
Figure 12: Scatter plot on effect of switch from NCHS to WHO-GS on age profile of selective
feeding programme admissions
a) % of Therapeutic Feeding Programme admissions
b) % of Supplementary Feeding Programme admissions
who are infants<6m, by NCHS or WHO-GS

% of TFP admissions aged <6 months (WHO-GS)
% of TFP admissions aged <6 months (WHO-GS)
who are infants<6m, by NCHS or WHO-GS

40
x=y
36
32
28
24
20
16
12
8
4
0
0
12
16
20
24
28
32
36
% of TFP admissions aged <6 months (NCHS)
40
40
x=y
36
32
28
24
20
16
12
8
4
0
0
12
Figure key: Regression and identity lines are shown. Each circle represents one country survey.
40
16
20
24
28
32
36
% of TFP admissions aged <6 months (NCHS)
40
3.4 Results
3.4.5 Summary of NCHS-WHO regression line equations

Linear regression relationships illustrated in the previous sections are detailed in Table 4. The larger b
values, representing the slopes of the regression lines, emphasize that NCHS/WHO z-score changes are
greater for the infant <6m group than for children.
Table 4: Linear regression models showing relationships between key variables

a) Infant wasting from child wasting prevalence
To predict
From
Infant <6m wasting (NCHS)
Child wasting (NCHS)
Infant <6m wasting (WHO-GS)
Child wasting (WHO-GS)
(95% C.I.)
Constant
r2
0.56
(0.37 0.75)
0.23
0.66
1.42
(1.14 1.72)
1.53
0.84
(95% C.I.)
Constant
r2
b) Change in wasting prevalence

To predict
From
Severe infant <6m wasting

(WHO-GS)
Severe infant <6m wasting

(NCHS)
3.54
(2.63 4.44)
2.30
0.78
Severe child wasting (WHO-GS)
Severe child wasting (NCHS)
1.68
(1.51 1.84)
0.12
0.96
Moderate infant <6m wasting

(WHO-GS)
Moderate infant <6m wasting

(NCHS)
1.43
(1.08 1.79)
2.02
0.79
Moderate child wasting (WHO-GS)
Moderate child wasting (NCHS)
0.73
(-0.05 1.51)
15.28
0.17
(95% C.I.)
Constant
r2
c) Change in admissions for feeding programmes treating wasting

To predict
From
% infant <6m in TFP (WHO-GS)
% infant <6m in TFP (NCHS)
0.73
(-0.05 1.51)
15.28
0.17
% infant <6m in SFP (WHO-GS)
% infant <6m in SFP (NCHS)
1.59
(1.21 1.96)
3.31
0.80
NCHS: National Centre for Health Statistics references; WHO-GS: World Health Organisation growth standards.
3.4.6 Basic demographic profile of severely wasted infants

a) Age profile
Figure 13 shows the detailed age profile of severely wasted infants <6m, classified using NCHS (n=257)
and WHO-GS (n=1337). Using WHO-GS, the age bands are more evenly spread, whereas with NCHS, 44%
of infants <6m are four or five months old. Patterns for moderate wasting are similar and are not shown.
Figure 13: Age profile of severely wasted infants (NCHS and WHO-GS)
a) NCHS
b) WHO-GS
22%
8%
9%
19%
15%
17%
15%
16%
22%
Age in months
21%
18%
17%
0
41
3.4 Results
b) Sex profile
Male: female ratio of severely wasted infants is reasonably balanced (Figure 14), but differs according to
the growth norm used. WHZ-NCHS has a slight excess in females and WHZ-WHO an excess in males.
Figure 14: Sex profile of severely wasted infants (NCHS and WHO-GS)
a) NCHS
b) WHO-GS
47%
52%
48%
53%
Sex of child
Male
Female
3.4.7 Size at birth and infant <6m wasting

Figure 15 shows the reported birth size of severely wasted infants <6m based on NCHS (15a) and WHO-GS
(15b). There are negligible NCHS/WHO differences. Using either case definition, over 50% of wasted infants
are reported as being normal size at birth. Only a modest proportion is ex-low birth weight (LBW).
Patterns with moderate wasting are again similar so are not shown.
Figure 15: Reported birth size of severely wasted infants <6m (NCHS and WHO-GS)
a) NCHS (n=257)
14%
b) WHO-GS (n=1337)
7%
15%
7%
8%
1%
7%
18%
18%
55%
Size of child at birth
53%
Very large
Larger than average
Smaller than average
Very small
Average
DK
Although LBW does not underlie the majority of cases of infant <6m wasting, LBW infants do appear to
have elevated risk of subsequently developing both severe and moderate wasting compared to normal
birth weight infants (see Figures 16 and 17). Interestingly, this is most pronounced in those under six
months and when using WHO-GS diagnostic criteria.
42
3.4 Results
Figure 16: Prevalence of severe wasting by reported birth weight category
a) Infants <6m
12%
10%
Prevalence of severe wasting
8%
NCHS
6%
WHO
4%
2%
0%
b) children 6 to 59m
12%
10%
8%
NCHS
6%
WHO
4%
2%
0%
Very large
Larger
than
average
Average
Smaller
than
average
Very
small
DK
Figure 17: Prevalence of moderate wasting by reported birth-weight category
a) Infants <6m
Prevalence of moderate wasting
15%
10%
NCHS
WHO
5%
0%
b) children 6 to 59m
15%
10%
NCHS
WHO
5%
0%
Very large
Larger
than
average
Average
Smaller
than
average
Very
small
DK
43
3.5 Discussion
3.5 Discussion
The analysis shows that wasting among infants <6m is a prevalent public health problem. The prevalence
of wasting in infants <6m is significant using both NCHS and WHO-GS. Disease burden is greatest,
however, using WHO-GS for diagnosis. With forthcoming international rollout of WHO-GS for feeding
programmes in emergency and other nutritionally vulnerable settings urgent follow-on work is needed to
explore the reasons for and implications of our observations. Some initial ideas follow.
3.5.1 Explaining differences in NCHS v WHO-GS

We hypothesise two possible, likely co-existing, factors underlying observed NCHS/WHO differences. First,
being a gold standard, WHO-GS are simply better at reflecting the true magnitude of population
malnutrition. Exclusive breastfeeding, maternal health services, child health services and food security all
impact wasting and are all known to be suboptimal in many settings.111 112
Second, the methods used to construct WHO growth curves play a role. The WHO-GS technical document
states that to avoid the influence of unhealthy weights for length/height, observations falling above +3 SD
and below -3 SD of the sample median were excluded prior to constructing the standards.113 Given that the
individuals on whom WHO-GS are based were already pre-selected from a much larger number screened
to exclude health, environmental or suboptimal breastfeeding constraints to growth, small but healthy
children might have been further excluded and the variation in the standards greatly reduced. This may
have resulted in the WHO-GS measurements having relatively small standard deviations and the z-score
based thresholds identifying relatively large numbers of infants and children as malnourished.
A further consideration may be errors in anthropometric assessment. This issue has broad implications
beyond NCHS/ WHO-GS assessment, irrespective of which norm is used. With regard to assessment of
weight, weighing scales measuring to the nearest 100g are common,114 and this is a relatively large
percentage of infant total body weight. Random errors either side of the true value are likely to lead to
misclassification of malnutrition. Small errors can make a big difference in weight-for-height z-score. An
evaluation of anthropometric training of emergency nutrition staff found that, while 88% of national
nursing and nutritional staff said they felt very competent at undertaking weight measurements for
children aged between six months and five years, this fell to 29% for infants less than six months115.
The assessment of length may prove even more challenging for this age group. New WHO training
materials note, it is not possible to straighten the knees of newborns to the same degree as older children.
Their knees are fragile and could be injured easily, so apply minimum pressure.116 Since height would
therefore be underestimated, weight-for-height would be falsely increased and true wasting prevalence
underestimated.
3.5.2 Clinical profile differences in infants <6m in NCHS v WHO-GS

There are minor differences in clinical history between infants <6m diagnosed by NCHS and WHO-GS. The
clinical implications of this are uncertain. High wasting prevalence does not appear to be explained just by
LBW as has sometimes been postulated. Though individual risks of subsequent wasting do appear higher
in ex-LBW infants, they do not contribute so significantly to total numbers wasted. Interventions targeted
at minimising LBW (e.g. maternal micronutrients) would not therefore be alone sufficient to tackle infant
<6m wasting.
The month-by-month age distribution of wasting is relatively even. Significant developmental changes
during this time mean that age-tailored interventions and guidelines might have a role to play. What
might be appropriate and useful for a five month old might be inappropriate for a two month old. Since
different infants mature at different rates, clinical expertise and flexibility to manage individuals on a
case-by-case basis would be useful.
44
3.5 Discussion
3.5.3 Policy implications

There are several immediate policy implications of these findings:
a) Nutrition surveys should more routinely include infants <6m
Using simple regression analysis, we have shown that high infant <6m wasting prevalence correlates
strongly with high child wasting prevalence. Extrapolations and estimations are not a replacement for
direct surveys, however, and infants <6m should be included routinely in surveys where this is feasible.
This would require training specific to assessment in this age group to ensure data quality; equipment
such as weighing scales should also be reviewed for suitability.
b) Feeding programmes should more actively consider likely prevalence of infant <6m wasting
Results offer useful interim estimates of infant/child and NCHS/WHO-GS wasting prevalence trends until
wider validation is possible. Findings can be generalised, if cautiously, for a number of reasons. Countries
were chosen as representative of nutritionally vulnerable settings, a full range of high prevalence to low
prevalence countries were included, the strength of correlation was mostly high (R2>0.5), overall trends
were consistent for all countries, trends and absolute numbers are consistent with other research,117 118 119
120
and trends coherent with NCHS and WHO-GS cut-offs.
c) Formal discussion of infant <6m wasting data in local, national and international fora
Appropriate planning is necessary to optimise the rollout of WHO-GS. We have shown that the
introduction of WHO-GS lead to large increases in estimates of infants <6m eligible for admission to
selective feeding programmes. The risk-benefit balance of this for infants <6m should be considered
separately to that of older children. For example, the risks of more 6 to 59 month children enrolling into
selective feeding programmes are minimal, but benefits likely. Focus on outpatient treatment for most
children means that in patient capacity is no longer a major constraint.121 Assuming adequate resources,
scale up of community-based TFPs and SFPs should be possible.
In contrast, the risks of increasing admissions of infants <6m are potentially serious. MAMI is currently
inpatient focused122 and therefore the increase in admissions has serious resource implications. Labelling
infants <6m as malnourished at the community level may introduce further risk, for example, by
encouraging introduction of top up foods or breastmilk substitutes to exclusively or predominantly
breastfed infants.123 124 125 The potential benefits of more admissions are tempered by a weak evidence
base underlying current treatments for infants <6m.126 Skilled breastfeeding support is often scarce in
facility and community based programmes. Inpatient management is resource intensive and cannot be
easily scaled-up. SFP strategies for infant <6m with moderate wasting are not well developed and at
present focus on feeding the breastfeeding mother, the efficacy of which is unknown.
Linear growth is more informative than one-off measures of nutritional status.127 128 However, serial growth
monitoring is often lacking in infants <6m that present to selective feeding programmes; treatment
protocols rely on current size rather than growth monitoring. Research is urgently needed on how
caregivers and healthcare workers in resource limited settings manage and interpret growth assessment
using NCHS v WHO-GS.
3.5.4 Limitations
Future work is needed to address the limitations of data presented in this chapter. TFPs admit cases of
severe wasting and/or oedematous malnutrition. This analysis looks at wasting alone since DHS data do
not include oedema. Thus the full implications for TFP admissions are not reflected here.
There is no data on the timing or nature of the observed wasting to strategise on interventions, e.g. the
contribution of HIV to malnutrition in this age group. It is important to repeat these analyses in different
settings to explore their wider generalisability. Age-specific effects may be very situation dependent.
Further investigation is also needed into how accurately anthropometric measurement in infants <6m is
conducted in routine surveys, such as DHS.
It is critical to note that these analyses have focused on z score comparisons. Z-scores are the international
standard for surveys reporting on the prevalence of wasting and results are used to plan programmes.
However, many selective feeding programmes use a closely related but not identical weight-for-height %
of median (WHM) indicator (<70% WHM = severe wasting; 70 to <80% WHM = moderate wasting). Both z-
45
3.6 Summary findings and recommendations
scores (NCHS) and % of median (NCHS) are recognized in current WHO protocols for the management of
acute malnutrition.129 In contrast, tables using WHO-GS only present z-scores. The magnitude of WHMNCHS to WHZ-WHO changes may differ from WHZ-NCHS to WHZ-WHO changes. This urgently needs to be
explored to determine more accurately how the shift to WHZ-WHO will manifest at field level for infants
<6m.
Lastly, it is important to establish how well different anthropometric indicators predict mortality and
which indicator(s) best identifies infants <6m who will benefit from selective feeding programme
admission. It is also important to know the nature of the risk profile; whether there is a linear increase in
mortality risk with decreasing weight, or whether there is a threshold beyond which there are marked risk
increases.

Summary findings
Wasting in infants <6m is a prevalent public health problem. Infant <6m wasting is strongly and positively
correlated with child 6 to 59m wasting and is significant using both NCHS and WHO-GS.
Use of WHO-GS increases the prevalence of severe wasting in both infants <6m and children, but the
increase is greater for infants <6m. Moderate wasting in children decreases when using WHO-GS, but
increases in the <6m age group.
There are minor differences in clinical profile between infants <6m diagnosed by NCHS and WHO-GS.
Wasted infants <6m are not predominantly ex-LBW and include a relatively even distribution of ages from
0 to five months.
Selective feeding programme treatment protocols generally rely on current size rather than growth
assessment. Used in this way, WHO-GS result in particularly large increases in estimates of the numbers of
infants <6m eligible for admission to selective feeding programmes. This comparison is based on the use
of WHZ; many selective feeding programmes currently use case definitions based on weight-for-height %
of the median (WHM).
Summary recommendations
A risk-benefit analysis of a potential large increase in infants <6m presenting to selective feeding
programmes is needed. A priority investigation is how single and serial growth measures and chart
position is interpreted by health workers using NCHS v WHO-GS based charts.
Feeding programmes should more actively consider likely prevalence of infant <6m wasting, for example,
nutrition surveys should more routinely include infants <6m to establish local burden of disease. This
requires training specific to assessment in this age group and appropriate equipment.
The MAMI analysis could be used to approximate infant <6m wasting prevalence. This should only be
done as a stop gap measure where there is complete absence of other information. Further validation is
needed before this could be considered a reliable or precise approach.
The implications of moving from WHM using NCHS to WHZ based on WHO-GS urgently needs to be
explored to determine more accurately how the shift to WHO-GS will affect individual diagnosis and
outcomes for infants <6m in pre-existing programmes.
Further research is also needed into the prevalence of oedematous infant <6m SAM, whether WHZ is the
best indicator for this age, how well different anthropometric indicators predict mortality, and the clinical
profile of malnourished infants <6m.
46
Endnotes
Endnotes
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
Posting to Child 2015 (Child Healthcare Information and Learning Discussion-group) online discussion group. 2009. [26.3.2009];
Available from: www.hifa2015.org/child2015-forum.
WHO. (1995) Field guide on rapid nutritional assessment in emergencies. World Health Organisation. Regional office for the Eastern
Mediterranean.
Seal, A. & Kerac, M. (2006) Operational implications of using 2006 World Health Organization growth standards in nutrition programmes:
secondary data analysis. BMJ. 2007 April 7, 2007;334(7596):733.
Fenn, B. & Penny, M.E. (2008) Using the New World Health Organisation Growth Standards: Differences From 3 Countries. Journal of
Pediatric Gastroenterology & Nutrition. 2008;46(3):316-21.
Isanaka, S., Villamor, E., Shepherd, S. & Grais, R.F. (2009) Assessing the Impact of the Introduction of the World Health Organization
Growth Standards and Weight-for-Height z-Score Criterion on the Response to Treatment of Severe Acute Malnutrition in Children:
Secondary Data Analysis. Pediatrics. 2009 January 1, 2009;123(1):e54-9.
Transitioning to the WHO Growth Standards: Implications for Emergency Nutrition Programmes. IASC (Inter-agency Standing Committee)
Nutrition Cluster Informal Consultation. Geneva, 25th-27th June 2008.
DHS are large, nationally representative surveys (http://www.measuredhs.com/). Standardized methodologies across and within different
countries help to miniise variable related biases.
Black, R.E., Allen, L.H., Bhutta, Z.A., Caulfield, L.E., de Onis, M., Ezzati, M., et al. (2008) Maternal and child undernutrition: global and
regional exposures and health consequences. Lancet. 2008 Jan 19;371(9608):243-60.
Emergency Nutrition Assessment (ENA) software for Standardized Monitoring and Assessment of Relief and Transitions (SMART). Version
October 2007.
Dean, A.G., Dean, J.A., Coulombier, D., Brendel, K.A., Smith, D.C., Burton, A.H., Dicker, R.C., Sullivan, K., Fagan, R.F., Arner, T.G. (2006)
Epi Info, Version 6: a word processing, database, and statistics program for public health on IBM-compatible microcomputers. Centers for
Disease Control and Prevention, Atlanta, Georgia, U.S.A., 1996. (USER MANUAL).
IPC Global Partners. (2008) Integrated Food Security Phase Classification Technical Manual. Version 1.1. FAO. Rome. ISBN: 978-92-5106027-8 Reprint 2009.
WHO (1983) Measuring change in nutritional status. Geneva: World Health Organisation.
World Health Organization (WHO) Child Growth Standards 2006.
UNICEF. ChildInfo: monitoring the situation of women and children [cited 2009 4th February]: Available from:
http://www.childinfo.org/breastfeeding_countrydata.php.
Jones, G., Steketee, R.W., Black, R.E., Bhutta, Z.A., Morris, S.S. (2003) How many child deaths can we prevent this year? Lancet. 2003
Jul 5;362(9377):65-71.
WHO child growth standards : length/height-for-age, weight-for-age, weight-for-length, weight-forheight and body mass index-for-age :
methods and development. (Technical Report).
Angood, C. (2006) Weighing scales for young infants: a survey of relief workers. Field Exchange. 2006(29):11-2.
Tilley, N. (2008) An investigation of anthropometric training by NGOs, Naomi Tilley, Field Exchange Issue 32, January 2008.
Training Course on Child Growth Assessment, WHO Child Growth Standards, B Measuring a Childs Growth, WHO Department of Nutrition
for Health and Development.
de Onis, M., Onyango, A.W., Borghi, E., Garza, C., Yang, H. (2006) Comparison of the World Health Organization (WHO) Child Growth
Standards and the National Center for Health Statistics/WHO international growth reference: implications for child health programmes.
Public Health Nutr. 2006 Oct;9(7):942-7.
Prost, M.A., Jahn, A., Floyd, S., Mvula, H., Mwaiyeghele, E., Mwinuka, V, et al. (2008) Implication of new WHO growth standards on
identification of risk factors and estimated prevalence of malnutrition in rural Malawian infants. PLoS ONE. 2008;3(7):e2684.
Collins, S., Dent, N., Binns, P., Bahwere, P., Sadler, K., Hallam, A. (2006) Management of severe acute malnutrition in children. Lancet.
2006 Dec 2;368(9551):1992-2000.
WHO, WFP & UNICEF (2007) Community-based management of severe acute malnutrition. A Joint Statement by the World Health
Fund.
WHO. (1999) Management of severe malnutrition: a manual for physicians and other senior health workers. World Health Organisation.
Geneva: World Health Organisation.
Binns, C. & Lee, M. (2006) Will the new WHO growth references do more harm than good? Lancet. 2006 Nov 25;368(9550):1868-9.
Victora, C.G., Smith, P.G., Vaughan, J.P., Nobre, L.C., Lombardi, C., Teixeira, A.M., et al. (1987) Evidence for protection by breast-feeding
against infant deaths from infectious diseases in Brazil. Lancet. 1987 Aug 8;2(8554):319-22.
WHO. (2004) Severe malnutrition: Report of a consultation to review current literature. Geneva, Switzerland, 06 - 07 September, 2004.
Binns, C., Lee, M. (2006) Will the new WHO growth references do more harm than good? Lancet. 2006 Nov 25;368(9550):1868-9.
de Onis ,M. & Onyango, A.W. (2003) WHO child growth standards. Lancet. 2008 Jan 19;371(9608):204.
Ashworth, A., et al. (2003) Guidelines for the inpatient treatment of severely malnourished children. Geneva: World Health Organisation.
47
Chapter 4
Review of MAMI guidelines
48
Chapter 4 Review of MAMI guidelines
Chapter 4: Review of MAMI guidelines

This chapter reviews current guidelines on the management of acute malnutrition, both inpatient and
community-based. The chapter looks at similarities and differences on how infants <6m are treated and
identifies strengths, weaknesses and gaps in guidance materials.
4.1 Why population burden of disease matters

A review of current recommended approaches to managing acute malnutrition in infants <6m was carried
out to:
Contextualise and help interpret quantitative feeding programme data (Chapter 5)
Contextualise and help interpret qualitative data from key informant interviews (Chapter 6)
Help set a baseline for future progress in the management of infants <6m malnutrition by:
- Understanding the range of current practices
- Understanding the focus and emphasis of current guidelines
- Identifying strengths of current guidelines
- Identifying gaps in current guidelines
4.2 Methods
SAM and MAM guidelines and protocols (collectively referred to as guidelines from heron) were identified
by purposive sampling of:
Published guidelines available in print and on-line
Final and draft guidelines, obtained via MAMI steering group members and key informants.
Key themes and topics relevant to infants <6m were identified and tabulated. Internationally recognised
AGREE (Appraisal of Guidelines for Research and Evaluation) criteria were used to appraise guideline
quality130 (see Box 5). A formal AGREE scoring was not applied to each individual guideline, as this was
beyond the scope of the MAMI Project. Instead an overview discussion highlights common issues.
49
4.2 Methods
Box 5: AGREE CRITERIA (Appraisal of Guidelines for Research & Evaluation)

Scope and Purpose
1. The overall objective(s) of the guideline should be specifically described.
2. The clinical question(s) covered by the guideline should be specifically described.
3. The patients to whom the guideline is meant to apply should be specifically described.
Stakeholder Involvement
4. The guideline development group should include individuals from all the relevant professional
groups.
5. The patients views and preferences should be sought.
6. The target users of the guideline should be clearly defined.
7. The guideline should be piloted among end users.
Rigour of Developement
8. Systematic methods should be used to search for evidence.
9. The criteria for selecting the evidence should be clearly described.
10. The methods used for formulating the recommendations should be clearly described.
11. Health benefits, side effects and risks should be considered.
12. There should be an explicit link between recommendations & supporting evidence.
13. The guideline should be externally reviewed by experts prior to publication.
14. A procedure for updating the guideline should be provided.
Clarity and Presentation
15. The recommendations should be specific and unambiguous.
16. Different options for diagnosis and/or treatment of the condition should be presented.
17. Key recommendations should be easily identifiable.
18. The guideline should be supported with tools for application.
Applicability
19. Potential organisational barriers in applying recommendations should be discussed.
20. Potential cost implications of applying the recommendations should be considered.
21. The guideline should presents key review criteria for monitoring and audit purposes
Editorial Independence
22. The guideline should be editorially independent from the funding body.
23. Conflicts of interest of guideline development members should be recorded.
4.3 Guidelines overview

A total of 37 (14 international and 23 national) guidelines were identified for review. Table 5 presents an
overview of the international organizations and countries represented. International guidelines were
defined as generic guidelines, owned and written by one lead agency, UN or NGO, and intended for use in
multiple settings. National guidelines were focused on one particular setting, often led by a Ministry of
Health or other equivalent government body. The list presented is unlikely to be exhaustive. Other
guidelines are known to be in development but were not available for this review.
Similarities between guidelines

The many similarities between documents were striking. This partly reflects common evolutionary origins.
The common ancestor of almost all current guidelines is the 1999 WHO guideline on management of
SAM.131This formalised the phased (stabilisation and rehabilitation) treatment of acute malnutrition and
included a description of the ten steps approach to care (see Figure 8 in chapter 2). Thus WHO (1999) is
widely referenced and often directly summarised in subsequent documents. CMAM approaches represent
another major step forward in the evolution of treatment for SAM and many guidelines also draw on Valid
(2006) as a key source.132
This common origins finding has several implications. If two programmes use the same guidelines then it
is, in theory, possible to compare programme outcomes and assess impact of context factors, such as
50
quality of implementation or patient profiles. Common terminologies and shared understandings also
enable global sharing of ideas and staff exchange. A possible disadvantage of having guidelines that
come as a package, is that individual elements become standard and difficult to withhold, even if the
underlying evidence for them is slim.
Differences between guidelines

There are many minor inter-guideline variations. Mostly these are explanations of particular issues, rather
than major differences in approach. This makes it difficult to disentangle whether guidelines themselves
or other factors (e.g. severity of disease, availability of resources to implement the guidelines, willingness
and ability of staff to implement the guidelines, background social circumstances impacting SAM/MAM)
are responsible for good or bad patient outcomes. It is especially difficult to infer the effects of multiple
minor variations.
IFE Module 2 stands out as different from the other guidelines reviewed here. Whilst created as a training
tool, IFE Module 2 provides a stop gap in MAMI guidance. Chapter 8 of Module 2 is specifically devoted
to the management of SAM in infants <6m, the basis for which is the collation of SAM guidelines and
experiences of NGOs, as well as expert authorship from relevant professionals and field teams.
Consequently IFE Module 2 content on SAM largely reflects many of the NGO approaches and guidelines
reviewed by the MAMI Project, with a strengthened breastfeeding component.
Evolutionary developments across the guidelines

The main development since the WHO (1999) inpatient guidelines is that outpatient approaches to SAM
treatment are now widely accepted for cases without medical complications. The majority of recent
guidelines recognise outpatient-based models of care as complementary to inpatient care.
Also notable is that national SAM/MAM guidelines obtained for this report are very recent, mostly from
the last two to three years, the oldest being Burundi in 2002. It is not known whether there were earlier
guidelines pre-dating these. Whatever the case, there is evidently a clear trend towards both global
rollout of SAM/MAM strategies and increasing national ownership of SAM/MAM guidelines.
Focus on infants <6m in current guidelines

The majority of guidelines have a separate section focusing explicitly on infants <6m, which varies widely
in length. A few, including WHO (1999), recognize infants <6m only indirectly as part of a broader age
group, e.g. children <5 years. In the CTC Manual (Valid, 2006), one of the foundation reference materials
for CMAM, infants <6m are only referred to in one small section.
51
Table 5: Overview of available acute malnutrition guidelines

Guideline type
Region Country
or
Organization
Guideline
Date CMAM
or
Inpatient
only
Authors / contributors
SAM
or
MAM
focus
language
draft MoH UNICEF WHO Internaor

tional NGO
final
or
consultant
Local notes
NGO or
consultant
International guidelines:
Management 1999 Inpatient
of severe
only
malnutrition:
a manual for
physicians &
other senior
health
workers*
SAM
English,
FIN
Spanish,
French,
Portuguese
n/a
n/a
n/a
available on WHO website

http://www.who.int /
nutrition/publications/
severemalnutrition/
9241545119/en/
index.html
WHO
Guidelines for 2003 Inpatient

the inpatient
only
treatment of
severely
malnourished
children *
SAM
English,
French,
Spanish
FIN
n/a
n/a
n/a
n/a
available on WHO website

http://www.who.int
/nutrition/publications/
severemalnutrition/
9241546093/en/
index.html
WHO
Manual for
2008 CMAM
the health
care of
children in
humanitarian
emergencies
both
SAM
and
MAM
English
FIN
n/a
n/a
n/a
n/a
available on WHO
website:
http://whqlibdoc.who.
int/publications/2008/
9789241596879_eng.pdf
WHO
Pocket book 2005 Inpatient

of
only
Hospital care
for children
(Guidelines
for the
management
of common
illnesses with
limited
resources)*
SAM
English,
FIN
French,
Portuguese,
Russian
n/a
n/a
n/a
available on WHO webs

http://www.who.int/
child_adolescent_health/
documents/9241546700/
en/index.html
Noted that this "updates
& expands guidelines in
WHO 2000 'Management
of the child with a serious
infection or severe
malnutrition'"
WHO
Handbook
2005 n/a
IMCI
Integrated
Management
of Childhood
Illness*
MAM
English,
(for SAM French
guidance
is to
refer to
hospital)
FIN
n/a
n/a
available on WHO web

http://www.who.int/child
_adolescent_health/
documents/9241546441
/en/index.html
This is a book focused on
all aspects of paediatric
care at primary care level,
of which assessment &
treatment of malnutrition
is just one chapter
Action
Contre la
Faim
(Claudine
Prudhon)
Assessment & 2002 Inpatient

Treatment of
only
Malnutrition
in Emergency
Situations
(Manual of
Therapeutic
Care & Planning
for a Nutritional
Programme)
both
SAM
and
MAM
English
FIN
n/a
n/a
n/a
n/a
Book covering multiple

aspects of nutrition:
treatment is just one
section
MSF
Nutrition
Guidelines
(1st edition)
both
SAM
and
MAM
English
FIN
n/a
n/a
n/a
n/a

aspects of nutrition:
treatment is just one
section
International
WHO
52
1995 inpatient
only
Table 5 contd
Guideline type
Region Country or
Organization
Guideline
Date CMAM
or
Inpatient
only
SAM language draft MoH UNICEF WHO Internator

or
ional NGO
MAM
final
or
focus
consultant
Local notes
NGO or
consultant
May CMAM
2006
both
SAM
and
MAM
English
FIN
n/a
n/a
n/a
n/a
Update of 1995
guidelines,
though available in
electronic version rather
as a book
International
MSF
Nutrition
Guidelines
MSF
Guideline
Oct n/a
Infants less
2007
than 6months
old (Benson)
MSF - OCBA
SAM
English
n/a
n/a
n/a
n/a
This is a chapter ocused

on infants alone and is
one of a wider set of
guidelines relating to
malnutrition
Valid
International
Communitybased
Therapeutic
Care (CTC), A
field manual
(first edition)
2006 CMAM
both
SAM
and
MAM
English
FIN
n/a
n/a
n/a
n/a
book describing multiple

aspects
UNHCR
Handbook for Feb CMAM

Emergencies 2007
(third
edition)
both
SAM
and
MAM
English
FIN
n/a
n/a
n/a
n/a
Available online
http://www.unhcr.org/
publ/PUBL/ 471db4c92.
html
NB Interesting to note
that 3rd edition has
significantly more IYCF
detail than 2nd
UNHCR
The
2000 Inpatient
management
only
of Nutrition
in Major
Emergencies
both
SAM
and
MAM
English
FIN
n/a
n/a
n/a
book covering multiple

aspects of nutrition
IFE Core
Group
Infant
Dec n/a
Feeding in
2007
Emergencies
IFE module 2,
version 1.1
for health
and nutrition
workers in
emergency
situations, for
training,
practice and
reference
SAM
English
FIN
n/a
n/a
n/a
n/a
Training module
covering externsive
details of IYCF especially
skilled breastfeeding
support produced in UN
and NGO collaboration
with expert collaborators
and review. Includes a
chapter dedicated to
management of acutely
malnourished infants
<6m (Chapter 8),
supported by content in
other chapters. Available
on ENN website:
http://www.ennonline.
net/resources/view.aspx?
resid=4
ICRC
(International
Committee of
the Red Cross)
Nutrition
Aug n/a
Manual for
2008
Humanitarian
Action
English
FIN
n/a
n/a
n/a
n/a

aspects of nutrition.
Includes 1 chapter on
Therapeutic Feeding
and 1 on Supplementary
Feeding Available on
ICRC website:
http://www.icrc.org/
web/eng/siteeng0.nsf/
html/p0820
53
Table 5 contd
Guideline type
Region Country or
Organization
Guideline
Date CMAM
or
Inpatient
only
SAM language draft MoH UNICEF WHO Internaor

or
tional NGO
MAM
final
or
focus
consultant
Local
notes
NGO or
consultant
1. a) Eastern Africa
National guidelines
Burundi
Protocole
National de
Nutrition
Ethiopia
Protocol for
Mar CMAM
the
2007
Management
of Severe
Acute
Malnutrition
Madagascar
Depistage et
prise en
charge de la
malnutrition
aigue
Malawi
Guidelines for 2007 Inpatient

the
only
Management
of Severe
Acute
Malnutrition
(book T3)
Mozambique Manual de
Orientacao
para
Tratamento
da
Desnutricao
Aguda Grave
54
Aug Inpatient
2002 only
Sep CMAM
2007
Jun CMAM
2008
French
FIN
SAM
only
English
FIN
no
both
SAM
and
MAM
French
FIN
SAM
English
FIN
One of a set of
guidelines on acute
malnutrition - others
focus on CMAM.
Separate MAM / CMAM
guidelines available
both
SAM
and
MAM
Portugese Dr
recently replaced 2007

protocol
Tanzania
Management 2008 CMAM

of Acute
Malnutrition
National
Guidelines
both English
SAM
(main
focus)
and
MAM
FIN
includes checklist of
SAM management
Uganda
Integrated
Nov inpatient
Management 2006 only
of Acute
Malnutrition
both
SAM
and
MAM
English
Dr
reference made to
separate guidelines
focused on therapeutic
feeding centres
Zambia
Integrated
2009 CMAM
Management
of Acute
Malnutrition
both English
SAM
(main
focus)
and
MAM
Dr
includes supervision
checklist
Zimbabwe
Guidelines for 2008 CMAM

the
Management
of Severe
Acute
Malnutrition
through
Communitybased
Therapeutic
Care (CTC)
both English
SAM
(main
focus)
and
MAM
FIN
n/s
guidelines include:
1) supervision checklist
2) indicators for
assessing quality &
appropriateness
Reference also made to
the "Zimbabwe
therapeutic feeding
protocol" which outlines
details of infant <6m
care
Table 5 contd
Guideline type
Region Country or
Organization
Guideline
Date CMAM
or
Inpatient
only
SAM language draft MoH UNICEF WHO Internaor

or
tional NGO
MAM
final
or
focus
consultant
Local
notes
NGO or
consultant
1.e) Western Africa
1.d) Southern
Africa
1.b) Middle Africa
National guidelines
DRC
Protocol
Oct
CMAM
National de
2008
Prise en Charge
de la
Malnutrition
Aigue
French
FIN
Acknowledgements
page blank
Sudan
(Southern)
Guidelines for Jul

CMAM
the
2008
Management
of Severe Acute
Malnutrition
SAM
English
Dr
references WHO
(1999), Valid (2006)
& Golden & Grellety
as sources
Sudan
(North)
National
Jan CMAM
Integrated
2008
Manual on the
Management
of Severe Acute
Malnutrition
in health
facilities & at
community
level
SAM
English
Dr
n/s
(for medical doctors

and senior health
workers)
Botswana
Guidelines for Jun CMAM

the
2007
Management
of Severe Acute
Malnutrition in
Children
SAM
English
Dr
noted that developed

in line with WHO
reference manuals,
1999, 2003
Burkina
Faso
None yet - in
draft
both
SAM
and
MAM
French
Dr
only draft outline

available
Cote
D'Ivoire
Protocole
May
National de
2005
Prise en charge
de la
malnutrition
severe
French
FIN
Guinea
Protocole
May CMAM
National de
2008
Prise en Charge
de la
Malnutrition
Aigue
SAM
and
MAM
French
FIN
Mali
Protocole
Dec CMAM
National de la 2007
prise en charge
de la
malnutrition
aigue
SAM
and
MAM
French
Dr
Niger
Protocol
Dec CMAM
National de
2006
Prise en Charge
de la
Malnutrition
Aigue
both
SAM
and
MAM
French
FIN
n/s
CMAM
Inpatient only
(CMAM type
home
treatment
noted in
annex
55
Table 5 contd
Guideline type
notes
Local
NGO or
consultant
Date CMAM
or
Inpatient
only
SAM language draft MoH UNICEF WHO International NGO

or
or
or
final
MAM
consultant
focus
May CMAM
2008
both
SAM
and
MAM
French
FIN
June CMAM
Afghanistan Community2008
based
Management of
Acute
Malnutrition
programme in
Aqcha and
Mardyan
District of
Jawzjan
Province
Northern
Afghanistan
(Stabilization
Centre
Guidelines)
SAM
English
Dr
No
compiled by Save
the Children UK
India
Indian Academy 2006 Inpatient only SAM

of Paeditrics
guidelines
English
FIN
No
Published in
journal 'Indian
Paediatrics,
(2007: 44: 443-61)
Pakistan
Protocol for the Dec Inpatient only SAM

2005
inpatient
treatment of
severely
malnourished
children in the
Pakistan
earthquake
emergency
English
Dr
based on WHO 1999

protocol
Sri Lanka
n/s
None yet - in
draft
Management of
Severe Acute
Undernutrition:
Manual for
Health Workers
in Sri Lanka
both
SAM
and
MAM
French
Dr
only draft outline

available
Region Country or
Organization
Guideline
National guidelines
Senegal
Protocole de
prise en charge
de la
malnutrition
aigue
CMAM
*These WHO resources are the same guideline produced in different formats.
56
4.4 Guideline Comparisons

4.4.1 Case definitions of SAM & MAM (general)
See Table 6 for an overview of case definitions. All guidelines reviewed use anthropometry as the main
indicator for SAM/MAM. All also acknowledge oedematous malnutrition as an indicator of SAM.
Weight-for-height vs. weight-for-age

Most guidelines use weight-for-length criteria as recommended by WHO (1999). Cutoffs for SAM and MAM
are also mostly consistent with WHO (1999). Exceptions are the 2008 WHO Manual on healthcare of
children in emergencies and IMCI guidelines, which both use weight-for-age as the main indicator
(although IMCI also uses visible severe wasting as an alternative). This difference must be addressed.
NCHS vs. WHO-GS (in context of z-score vs. %-of-median)

NCHS growth references are still dominant in the guidelines reviewed. Only Sri Lanka and Mozambique
explicitly use WHO-GS, though several other guidelines do footnote their availability alongside NCHS. It is
only recently, in May 2009 that UNICEF and WHO released a joint statement formally recommending the
new WHO-GS for identifying severe acute malnutrition133. It is likely therefore that their use will increase in
the coming years. Some of the possible implications of this change for infants are discussed in Chapter 3.
MUAC
MUAC is increasingly used in SAM/MAM guidelines. It is an independent admission criterion noted
alongside weight-for-height, and in a small number or guidelines (Valid 2006, Uganda 2006), it is the
major case definition criterion. No guidelines recommend its use in infants <6m.
57
Table 6: Case definitions of SAM & MAM

Case Definitions of SAM & MAM
Country or
Guideline
Organization
Date Growth
'norm'
(alternative,
if noted)
Index
(WH:
weight for
height;
WA:
weight or
age)
Main
Recommended
indicator
(+ alternative, if
noted)
Indicator
presented
in tables
(if shown)
Case
definition
SAM
(in all
guidelines,
oedema
=SAM)
MUACbased case
definition
of SAM
Case
MUACNotes
definition based
MAM
case
definition
of MAM
International guidelines
WHO
Management
of severe
malnutrition:
a manual for
physicians &
other senior
health
workers
1999 NCHS
WH
z-score
(% of median)
WHZ
<-3 WHZ
(NCHS)
(<70%
boys & girls WHM)
split sex
tables
not used
-3 WHZ not used

<-2
(70 to
79%
WHM)
Length
measured if child
<85cm or <2
years.
Height if >85cm
or >2years
WHO
Guidelines for 2003 NCHS

the inpatient
treatment of
severely
malnourished
children
WH
z-score
(% of median)
WHZ
<-3 WHZ
(NCHS)
(<70%
boys & girls WHM)
split sex
tables
not used
-3 WHZ
<-2
(70 to
79%
WHM)
not used
Length
measured if child
<85cm & height
if >85cm
WHO
Manual for
2008 n/s
the health
care of
children in
humanitarian
emergencies
WA
low weight-for- weight-for

age
-age chart
show in
annex, but
lines are
not
labelled
no visible
severe
wasting,
MUAC
>110mm
very low
weightfor-age
n/s
WHO
Pocket book
of Hospital
care for
children
WH
z-score
OR
% of median
WHZ
<-3 WHZ
not used
(NCHS)
OR
boys & girls <70% WHM
split sex
tables
n/s
n/s
Length
measured if child
<85cm & height
if >85cm
WHO
Handbook
2005 n/s
IMCI
Integrated
Management
of Childhood
Illness
WA
Visible severe
wasting
Low weightfor-age
weight-for Low
-age chart weight-forshow in
age
annex, but
lines are
not labelled
not used
n/s
n/s
notes that on
weighing child
should wear light
clothing
Action
Contre la
Faim
(Claudine
Prudohn)
Assessment & 2002 NCHS

Treatment of
Malnutrition
in Emergency
Situations
WH
% of median
(WA is
(z-score)
described)
WHM
<70% WHM
(NCHS/
(<-3 Z-score
WHO 1982)
combined
sex WHZ
(NCHS/
WHO 1983)
split sex
<110mm
(noted as
controversial
if length
<75cm)
WHM
70%
and
<80%
(WHZ 3 and
<-2)
110mm
and
<120mm
Length
measured if <2
years age, height
if >2year
(85cm a proxy if
age unknown)
Noted that WHM
predicts death
better than WHZ.
Use WHZ only
when WHM
rejects a high risk
child
MSF
Nutrition
Guidelines
(1st edition)
WH
WHM
<70% WHM
(NCHS/
(<-3 ZWHO 1982) score)
combined
sex WHZ
(NCHS/
WHO 1983)
split sex
<110mm
(if child >12
months or
>75cm
length)
WHM
70%
and
<80%
(WHZ 3 and
<-2)
<135mm
referred
for screen,
but only
enrolled if
fulfils
WHM or
WHZ
criteria
Length
measured if <2
years age, height
if >2years
(85cm a proxy if
age unknown)
58
2005 NCHS
1995 NCHS
% median
(z-score)
~ MUAC
<110mm
<110mm
(if child >6
(>6months) months old)
~ visible
severe
wasting
Table 6 contd

Country or
Organization
Guideline
Date Growth
'norm'
(alternative,
if noted)
Index
(WH:
weight for
height;
WA:
weight or
age)
Main
Recommended
indicator
(+ alternative, if
noted)
Indicator
presented
in tables
(if shown)
Case
definition
SAM
(in all
guidelines,
oedema
=SAM)
MUACbased case
definition
of SAM
Case
MUACNotes
definition based
MAM
case
definition
of MAM
<70%
WHM
(<-3 Zscore)
<110mm
WHM
(if child >6 70%
months old) and
<80%
(WHZ
-3 and
<-2)
n/s
n/a
MSF
Nutrition
Guidelines
May NCHS
2006
WH
% median
(notes z-scores
used in some
countries
n/a
MSF
Protocol
Infants less
than 6
months old
(Benson)
MSF - OCBA
Oct n/s
2007
WH
% of median
WHM
<70%
(NCHS/
WHM
WHO 1982)
combined
sex WHZ
(NCHS/
WHO 1983)
split sex
n/a (focus is n/a

on infants
<6m)
Valid
Community- 2006 NCHS
International based
Therapeutic
Care (CTC), A
field manual
(first edition)
MUAC*
Unadjusted
MUAC %
median or Zscore noted
no tables
shown
<70%
WHM<-3
WHZ
<110mm
(if length
>65cm)
UNHCR
Handbook for Feb NCHS*

Emergencies 2007
(third
edition)
WH
% of median
OR
z-score
no tables
shown
<70%
WHM (or
<-3 Zscore)
<110mm
70% to
110mm to
(if aged 6 to 79% WHM <125mm
59months) (-3 to -2
WHZ)
also mention
LBW babies (no
details given)
* recognised
WHO & states
that UNHCR is in
process of
assessing the
new standards
UNHCR
The
2000 NCHS
management
of Nutrition in
Major
Emergencies
WA
z-score
(% of median)
WHZ
<-3 WHZ
(NCHS)
(<70%
boys & girls WHM)
split sex
tables
<-3 Z
MUAC-forage /
MUAC-forheight
-3 Z
MUACf-age/
MUAC-fheight to
<-2z
notes that on
weighing child
should wear light
clothing
IFE Core
Group
Infant
Dec NCHS
Feeding in
2007
Emergencies
IFE Module 2,
version 1.1
WH
% of median
tables not
shown
<70%
WHM
(NCHS)
n/a (focus is n/s

on infants
<6m)
n/s
n/s
ICRC
Nutrition
Aug NCHS
Manual for
2008
Humanitarian
Action
WH
z-score
(describes (describes other
other
indicators)
indices,
incl WA,
MUAC)
WHZ
(NCHS)
boys & girls
split sex
tables
(MUAC by
age Z-score
tables also
given)
several
described,
including
<-3 WHZ
(NCHS) and
MUAC-forheight
<-3z (75%
median)
<110mm
(<125mm
also referred
to as
'severe' in
anthropometry
chapter)
140 or
Length
135mm to measured if <2
125mm
years age, height
if >2 years
notes that
anthropometry
should not be
the only basis of
admission
WH
combined
sex, WHM
(NCHS)
<70%
WHM
(NCHS)
<110mm
(if length
>65cm)
WHM
110mm to
70%and <125mm
<80%
(WHZ
-3 and
<-2)
-3 to <2 WHZ
(70 to
79% WHM
* MUAC
emphasised as
primary
measure(WH
noted)
National guidelines
Burundi
Protocole
National de
Nutrition
Aug NCHS
2002
% of median
between <125mm
70 to 79%
WHM
height <65cm
equated with
age <6 months
no reference
given for tables
59
Table 6 contd

Country or
Organization
Guideline
Date
Growth
'norm'
(alternative,
if noted)
Index
(WH:
weight for
height;
WA:
weight or
age)
Main
Recommended
indicator
(+ alternative, if
noted)
Indicator
presented
in tables
(if shown)
Case
definition
SAM
(in all
guidelines,
oedema
=SAM)
MUACCase
based case definition
definition MAM
of SAM
MUACNotes
based
case
definition
of MAM
National guidelines
Ethiopia
Protocol for the Aug NCHS

Management 2002
of Severe Acute
Malnutrition
WH
% of median
combined
sex, WHM
(NCHS)
<70%
WHM
(NCHS)
<110mm
(if length
>65cm)
between <125mm
70 to 79%
WHM
height <65cm
equated with
age <6 months
no reference
given for tables
Madagascar
Depistage et
Sep NCHS
prise en charge 2007
de la
malnutrition
aigue
WH
% of median
WHM
(NCHS)
combined
sex
<70%
WHM
(NCHS)
<110mm
(if length
>65cm)
70 to 79% n/s
WHM
Malawi

the
Management
of Severe Acute
Malnutrition
(book T3)
WH
% of median
WHM
(NCHS)
combined
sex
<70%
WHM
(NCHS)
<110mm 70 to 79% 110 to

(ages 1 to 5
119mm
years)
(NB printed as a
card separate to
the book)
Orientacao
para
Tratamento da
Desnutricao
Aguda Grave
Jun WHO-GS
2008 (2007
protocol
used
NCHS)
WH
% of median
* table
labelled
"% of
median
(WHO2004)
joint sex
<70%
WHM
<110mm
70 to 79% 110 to
WHM
125mm
* appears to
have calculated
weight cut-offs
based on WHO
(2006) boys
median tables
Length
measured if child
<85cm & height
if >85cm
Tanzania
Management
of Acute
Malnutrition
NATIONAL
Guidelines
2008 NCHS
WH
% of median
OR z-score
WHZ
(NCHS)
boys &
girls split
sex tables
<70%
WHM OR
<-3 WHZ
<110mm
(6-59m or
65 to
110cm)
70-79%
WHM or
<-2SD
Length
measured if child
<85cm & height
if >85cm
Uganda
Integrated
Management
of Acute
Malnutrition
Nov n/s
2006
MUAC
Unadjusted
emphasis- MUAC %
ed
median or Zscore noted
no tables
shown
<70%
WHM <-3
WHZ
<110mm
(if length
>65cm
and/or
>6months)
WHM
110mm to
70% and <125mm
<80%
(WHZ -3
and <-2)
Zambia
Integrated
Management
of Acute
Malnutrition
2009 NCHS*
WH
% of median
no tables
shown
<70%
WHM OR
<-3 WHZ
<110mm
(6-59m)
WHM
110 and
70%
<125mm
and<80%
(WHZ 3 and
<-2)
*WHO GS noted
as a footnote in
the introduction
but not
thereafter
**z-score noted
once in
introduction but
not thereafter)
Zimbabwe

the
Management
of Severe Acute
Malnutrition
through
Communitybased
Therapeutic
Care (CTC)
WH
% of median
WHZ
(NCHS)
boys &
girls split
sex tables
<70%
WHM
<110
70 to 80% 110 to
125mm
Length if <85cm
or <2 years,
Height 85cm or
>2years
60
110120mm
Table 6 contd

Country or
Guideline
Organization
Date
Growth
'norm'
(alternative,
if noted)
Index
(WH:
weight for
height;
WA:
weight or
age)
Main
Recommended
indicator
(+ alternative, if
noted)
Indicator
presented
in tables
(if shown)
Case
definition
SAM
(in all
guidelines,
oedema
=SAM)
MUACbased case
definition
of SAM
Case
MUACNotes
definition based
MAM
case
definition
of MAM
National guidelines
DRC
Protocol
Oct NCHS
National de
2008
Prise en Charge
de la
Malnutrition
Aigue
WH
% of median
WHM
(NCHS)
combined
sex
<70%
WHM
(NCHS)
<110mm
(if length
>65cm)
70 to
79.9%
110 to
119mm
Sudan
(Southern)
Guidelines for Jul

NCHS
the
2008
Management
of Severe Acute
Malnutrition
WH
% of median
WHM
(NCHS)
combined
sex
<70%
WHM
(NCHS)
<110mm
(for height
>65cm)
70 to
79.9%
n/s
Length
measured if child
<85cm & height
if >85cm
*WHO GS noted
as a footnote in
the introduction
but not thereafter
** z-score noted
once in
introduction but
not thereafter
Sudan
(North)
National
Jan NCHS
Integrated
2008
Manual on the
Management
of Severe Acute
Malnutrition
in health
facilities and at
community
level
WH
% of median
OR z-score
draft - not <70%

yet
inserted
<110mm
(with length
>65cm or
>1year old)
-3 to
n/s
<-2 WHZ
or
70 to 79%
WHM
Length if <85cm
or <2 years,
Height 85cm or
>2years (tables
state 85cm cutoff,
text gives age OR
85cm cutoff)
Botswana
Guidelines for Jun NCHS

the
2007
Management
of Severe Acute
Malnutrition in
Children
WH
% of median
annexes
<70%
not
WHM
complete (NCHS)
(draft
guidelines)
<110mm
n/s
n/s
Length measured
if child <85cm &
height if >85cm
equates age
<6months with
height <65cm
*z-score noted
once in
introduction but
not thereafter
Burkina
Faso
Guidelines for Jun NCHS

the
2007
Management
of Severe Acute
Malnutrition in
Children
WH
% of median
WHM
(NCHS)
combined
sex
<70%
WHM
(NCHS)
<110mm
70 to
<80%
WHM
110 to
125mm
equates age
<6months with
height <65cm
Cote
D'Ivoire
Protocole
May NCHS
National de
2005
Prise en charge
de la
malnutrition
severe
WH
% of median
WHM
(NCHS)
combined
sex
<70%
WHM
(NCHS)
<110mm
n/s
n/s
Length
measured if child
<85cm & height
if >85cm
equates age
<6months with
height <65cm
Guinea
Protocole
May NCHS
National de
2008
Prise en Charge
de la
Malnutrition
Aigue
WH
% of median
WHM
(NCHS)
combined
sex
<70%
WHM
(NCHS)
<110mm
(if height
>65cm)
70 to
<80%
WHM
110 to
125mm
Length
measured if child
<85cm & height
if >85cm
61
Table 6 contd

Country or
Guideline
Organization
Date
Growth
'norm'
(alternative,
if noted)
Index
(WH:
weight for
height;
WA:
weight or
age)
Main
Recommended
indicator
(+ alternative, if
noted)
Indicator
presented
in tables
(if shown)
Case
definition
SAM
(in all
guidelines,
oedema
=SAM)
MUACbased case
definition
of SAM
Case
MUACNotes
definition based
MAM
case
definition
of MAM
National guidelines
Mali
Protocole
National de la
prise en charge
de la
malnutrition
aigue
Dec NCHS
2007
WH
% of median
WHM
(NCHS)
combined
sex
<70%
WHM
(NCHS)
<110mm
(if height
>65cm)
70 to
<80%
WHM
110 to
119mm
Length <85cm,
Height 85cm
equates age
<6months with
height <65cm
Niger
Protocol
Dec NCHS
National de
2006
Prise en Charge
de la
Malnutrition
Aigue
WH
% of median
WHM
(NCHS)
combined
sex
<70%
WHM
(NHCS)
(WHZ<-3
WHO is
footnoted
as an
alternative
case
definition)
<110mm
(for height
>65cm)
70% to
<80%
WHM
n/s
Length if <85cm
or <2 years,
Height 85cm or
>2years
Senegal
Protocole de
prise en charge
de la
malnutrition
aigue
WH
% of median
OR z-score
WHM
(NCHS)
combined
sex
<70%
WHM
OR
<-3 WHZ
<110mm
-3 to <- 110 to
(if aged 6 to 2 WHZ
125mm
59 months) or
70 to 79%
WHM
Length if <2
years, Height if
>2 years <65cm
length seen as
proxy for
<6months age
Afghanistan CommunityJune not

based
2008 specifited
Management of
Acute
Malnutrition
programme in
Aqcha and
Mardyan
District of
Jawzjan
Province
Northern
Afghanistan
WH
% median
(z-score)
annexes
not
complete
(draft
guidelines)
<70%
WHM
(or <-3
WHZ)
<110mm
n/s
n/s
Length measured
if child <85cm &
height if >85cm
if age unknown,
<65cm length is
proxy for
<6months age
India
Indian Academy 2006 NCHS

of Paeditrics
guidelines
WH
% median
(z-score)
not shown <70%

WHM
(or <-3
WHZ)
<110mm
n/s
n/s
Pakistan
Protocol for the Dec NCHS

inpatient
2005
treatment of
severely
malnourished
children in the
Pakistan
earthquake
emergency
WH
% median
(z-score)
not shown
(footnotes
suggest
that Zscore table
as in WHO
1999
guidelines
likely to be
inserted)
<70%
WHM
(or <-3
WHZ)
not stated
n/s
n/s
Length
measured if child
<85cm & height
if >85cm
Sri Lanka
Management of 2007 WHO

Severe Acute
Undernutrition:
Manual for
Health Workers
in Sri Lanka
WH
z-score
WHZ
(WHO)
split sex
<-3Z WHZ
(WHO)
no
n/s
n/s
Length
measured if child
<2years &
height if >2years
62
May NCHS
2008
4.4.2 Infant <6m SAM and MAM case definitions

See Table 7 for overview.
Infant <6m severe acute malnutrition (SAM)

In all of the guidelines infants <6m with SAM are treated as inpatients. This includes CMAM guidelines
where the management strategy is referral of malnourished infants <6m for inpatient care. Weight-forlength criteria are always the same as for older children, though sometimes this is implied rather than
directly stated.
Infants >6m but <3 or 4kg
There is often a secondary criterion of a child >6 months but <3 or 4 kg. Some guidelines recommend
these should have the same initial treatment as an infant <6m.
Infants <6m and length <65cm
Several guidelines implicitly or explicitly equate age <6 months and length <65cm, sometimes using
length as a proxy for age. However confusion arises when these measures conflict, e.g. infant is known to
be >6 months but length is <65cm. It is not clear which treatment protocol should be applied and if a
MUAC measurement is valid if length is <65cms.
Length < 49cm
Some guidelines make an allowance for where length <49cm and so W/H cannot be measured. For
example, IFE Module 2 recommends visibly severe thinness where measurement of W/L is not possible,
and mentions that some agencies use a criterion of <2.1kg irrespective of length. WHO-GS go down to
45cm as the minimum length in length-for-height tables. This represents almost -3 z length-for-age at
birth: not being able to determine a weight-for-length should therefore be much less of an issue in the
future.
Measurement of weight in infants <6m
None of the guidelines draws attention to particular considerations in the anthropometric assessment of
infants <6m (see Section 9.3.2). Research has shown weighing scales used in emergencies to be largely
unsuitable for weighing infants <6m.134
Assessment of age
Since birth is a recent event in an infant <6m, it is in theory easier to accurately assess age than for older
children. None of the guidelines gives details of age assessment of how to best do this e.g. use of calendar
to elicit exact age in months.
Infant <6m moderate acute malnutrition (MAM)

I
dentifying and treating infants <6m with MAM is not specifically dealt with in any of the guidelines except
one (Burkina Faso). Infant MAM is only recognized implicitly, by assuming that the same MAM weight-forlength criteria applicable to older children are applicable to infants. Management therefore requires
inference from other sections of the guidelines, e.g. where lactating mothers with infants <6m are
admitted to SFP. IFE Module 2 focuses on skilled breastfeeding support for moderately malnourished
infants (implicitly including infants <6m).135 Burkina Faso stands out by explicitly stating that infants
with MAM should be treated by their mothers receiving SFP rations and health and nutrition education.
Further assessment recommended for infants <6m
Some guidelines recommend initial admission to an assessment area where breastfeeding can be more
closely observed. No current guideline differentiates complicated vs. uncomplicated infant <6m acute
malnutrition.
Clinical admission criteria for infants <6m
Many guidelines recommend clinical admission criteria, in addition to anthropometry. Common criteria
include an infant who is too weak or feeble to suckle and mother not producing enough milk. Minor
variations of emphasis and phrasing (e.g. not enough milk with weight loss vs. not enough milk alone)
make it likely that there are significant inter-programme variations in terms of which infants <6m are
admitted to care. It is also not clear whether carer reports or clinician assessments should carry the greater
weight. Inter-user variations in interpreting even the very same guidelines are very likely.
63
Table 7: Infant <6m SAM & MAM case definitions

Separate
guideline for
infants <6m?
Country or
Guideline
Organization
Infant
<6m
SAM
Infant
<6m
MAM
Case Definition (Infants)

~ for admission
Pages of
guideline
devoted
to infants
/ total
pages (excl.
annexes)
% of
guideline
devoted
to infants
Who apart
from
infants
<6m
should
follow
infant
guidelines
Anthropometric
Clinical criteria
criteria
(except for MUAC,
which is not used for
infant <6m, assume
same case definitions
of SAM, MAM unless
otherwise stated)
Notes
Preface states that

protocol refers to
"malnourished children
under 5 years of age"
WHO
Management of not specifically

severe
mentioned.*
malnutrition: a
manual for
physicians &
other senior
health workers
1999
n/a
n/a
n/a
n/a
n/a
WHO
Guidelines for
the inpatient
treatment of
severely
malnourished
children, 2003
not specifically
mentioned.
n/a
n/a
n/a
n/a
n/a
WHO
Manual for the

health care of
children in
humanitarian
emergencies
2008
not specifically
mentioned
n/a
n/a
n/a
n/a
n/a
~ noted that patients

needing inpatient care
should be treated
following "current WHO
guidelines"
WHO
Pocket book of yes

Hospital care for
children 2006
n/s
1/24
4%
no other
groups
noted
same
not specified
separate chapter on
"supportive care" gives
details of breastfeeding
issues, including
supplementary suckling
WHO
Handbook IMCI yes

Integrated
Management of
Childhood
Illness 2005
yes
n/a
no other
groups
noted
n/a
Recommends that
infants and children with
severe malnutrition are
referred urgently too
hospital, and does not
cover their specific
treatment
Action
Contre la
Faim
(Claudine
Prudohn)
Assessment &
yes
Treatment of
Malnutrition in
Emergency
Situations, 2002
yes
5/58
9%
(of section
on
treatment)
<4kg
same
1) Too weak to
suckle effectively;
and/or
2) Mother not
producing enough
milk
~ notes that infant <6m

should be nursed in a
separate area of the ward
~ also suggests pressing
on mothers breasts to
check for presence of
milk
MSF
Nutrition
Guidelines (1st
edition), 1995
yes
n/s
1/46
2%
no other
groups
noted
same
Not specifically
stated
in "Infant feeding"
section, infant not
defined to mean infant
<6m alone
MSF
Nutrition
yes
Guidelines, 2006
n/s
14/191
7%
no other
groups
noted
WHM <70%
1) Weight loss or
growth stagnation
(1 to 2 weeks)
2) Too weak to
suckle
3) Insufficient
breastmilk
4) Inappropriate
alternative infant
feeding
whole chapter in the

book devoted to infant
<6m
recognised LBW, preterm
infants
notes need for
mechanical scales
accurate to 10g
64
Table 7 contd
Separate
guideline for
infants <6m?
Country or
Guideline
Organization
Infant
<6m
SAM

~ for admission
Infant
<6m
MAM
Pages of
guideline
devoted
to infants
/ total
pages (excl.
annexes)
% of
guideline
devoted
to infants
Who apart
from
infants
<6m
should
follow
infant
guidelines
Anthropometric
Clinical criteria Notes
criteria
(except for MUAC,
infant <6m, assume
of SAM, MAM unless
otherwise stated)
yes
n/s
(10/10)
(100%)
<3kg being WHM <70%

breast-fed
1) Infant too
weak or feeble
to suckle
effectively
(independent of
WHM)
one chapter from a wider

set of guidelines notes
need for a 'breastfeeding
corner'notes no growth
standards for infants whose
length <49cm and that the
nutrition unit is not
appropraite for treating
premature and LBW infants
<49cm. These should be
referred to nursery for
appropriate care
yes
n/s
0.5/13
pages on
inpatient
care
4%
no other
groups
noted
WHM <70%
visible wasting
Guideline does not attempt

to directly address infant
<6m treatment, referring
instead to other guidelines,
notably the 2001
Operational Guidance on
Infant & Young Child
Feeding in Emergencies,
volume 1
not
directly
infant U6m
mentioned
in several
paragraphs
mixed in
main text
no other
groups
noted
same
"visible severe
wasting in
conjunction with
difficulties in BF"
- notes that infantsU6 SAM

treatment is based on
promotion of BF (if
possible)
- details not described
no other
groups
noted
same
not specifically
stated
States that "for

malnourished infants
<6m, it is the mother who
should be included, NOT
the infants (infants should
be exclusively breastfed)"
MSF
Protocol
Infants less
than 6
months old
(Benson)
MSF OCBA
2007
Valid
CommunityInternational based
Therapeutic
Care (CTC), A
field manual
(first edition)
2006
UNHCR
Handbook for yes

Emergencies
(third edition)
2007
UNHCR
The
management
of Nutrition in
Major
Emergencies
2000
infant <6m
malnutrition
recognised, but not
split into SAM &
MAM
1/24
IFE Core
Group
Infant
Feeding in
Emergencies
IFE Module 2,
version 1.1
2007
yes
17/114
(15%)
pages
focus just
on infant
with SAM
(see notes)
>6months
old but
<65cm
~ 4kg
WHM <70%
failure to gain
weight at home
or under
management at
a breastfeeding
corner
One chapter (8) focuses

exclusively on infant <6m
severe malnutrition.
Chapter 5 adrresses low
birth weight infants,visibly
thin/moderately
malnourished infants and
malnourished mothers. The
whole 223 page manual
directly or indirectly
addresses this age group
through guidance on
skilled assessment and
support for breastfeeding.
ICRC
Nutrition
Manual for
Humanitarian
Action 2008
no
no
(notes
TFP often
restricted
to
<5years)
n/a
n/a
n/a
n/a
no separate section for care

of infant <6m.
Does however have a
paragraph on BF. Notes it as
an "absolute priority, and
every effort should be
made to encourage or
restore it"
yes
4%
n/a
65
Table 7 contd
Separate
guideline for
infants <6m?
Country or
Guideline
Organization

~ for admission
Infant
<6m
SAM
Infant
<6m
MAM
Pages of
guideline
devoted
to infants
/ total
pages (excl.
annexes)
% of
guideline
devoted
to infants
Who apart
from
infants
<6m
should
follow
infant
guidelines
Anthropometric
Clinical criteria
criteria
(except for MUAC,
infant <6m, assume
of SAM, MAM unless
otherwise stated)
Notes
National guidelines:
Burundi
Protocole
National de
Nutrition
2002
yes
n/s
5/33
15%
<6m or
same
<3kg being
BF
1) Mother does
not have enough
milk AND infant
loosing weight
2) Infant too
weak to suckle
and loosing
weight even if
mother does have
milk
Ethiopia
Protocol for yes

the
Management
of Severe
Acute
Malnutrition
2007
n/s
8/81
10%
no other
groups
noted
WHM <70%
too weak or
feeble to suckle
effectively
(any WH)
Madagascar
Depistage et yes
prise en
charge de la
malnutrition
aigue 2007
n/s
3/52
6%
<3.5kg
WHM <70%
1) Too weak or
feeble to suckle
effectively or
2) Mother does
not have enough
milk and infant is
loosing weight
Malawi
Guidelines
yes
for the
Management
of Severe
Acute
Malnutrition
(book T3)
2007
yes (in
10/38
group
'infants
<6m with
nutrition
problems
but not
SAM')
26%
<3kg
WHM <70%
1) Infant not
gaining or loosing
weight but not
SAM or
2) Mother
reports
insufficient BM or
3) Weak or feeble
and not suckling
well but not SAM
yes
n/s
8/91
9%
<3kg
WHM <70%
1) Too weak or
feeble to suckle
effectively or
2) Not gaining
weight at home
Management yes
of Acute
Malnutrition
NATIONAL
Guidelines
2008
n/s
1/67
1%
same
not stated
Orientacao
para
Tratamento
da
Desnutricao
Aguda Grave
2008
Tanzania
66
Protocol notes no growth

standards for infants
whose length <49cm and
that the nutrition unit is
not appropriate for
treating premature and
LBW infants <49cm. These
should be referred to
nursery and given infant
formula.

whose length <49cm and
that the nutrition unit is
not appropriate for
LBW infants <49cm should be referred to
nursery for appropriate
care
Protocol has only 1

paragraph which states "If
the mother is
breastfeeding, assist her to
breastfeed or express
breastmilk. Give the
prescribed amount of F75
in addition to the
breastmilk"
Table 7 contd
Separate
guideline for
infants <6m?
Country or
Guideline
Organization

~ for admission
Infant
<6m
SAM
Infant
<6m
MAM
Pages of
guideline
devoted
to infants
/ total
pages (excl.
annexes)
% of
guideline
devoted
to infants
Who apart
from
infants
<6m
should
follow
infant
guidelines
Anthropometric
Clinical criteria
criteria
(except for MUAC,
infant <6m, assume
of SAM, MAM unless
otherwise stated)
Notes
Uganda
Integrated
Management
of Acute
Malnutrition
2006
yes
n/s
1/53
2%
2%
same
not stated
reference made to
separate guidelines
feeding centres reference
also make to link with
IMCI guidelines
Zambia
Integrated
Management
of Acute
Malnutrition
2009
yes
n/s
(but see
notes)
1/35
3%
<3kg
WHM <70%
1) Infant <6m
unable to
breastfeed
~ Though infant <6m

SAM recognised briefly as
"special cases", stated
elsewhere that these
guidelines are targeted at
6 to 59m children. Thus
no separate section or
chapter for infant <6m.
~ Also references
separate "National
guidelines" for full
details of treatment
during (inpatient)
stabilisation
Zimbabwe
Guidelines for yes

n/s
the
(but see
Management notes)
of Severe Acute
Malnutrition
through
Communitybased
Therapeutic
Care (CTC) 2008
1/56
2%
n/s
n/s
not stated
~ reference made to
separate guidelines
feeding centres
~ infants <6m not
otherwise focused on in
this guideline in the
chapter on "Stabilisation
Centre" care
DRC
Guideline
yes
National de
Prise en Charge
de la
Malnutrition
Aigue 2008
n/s
5/68
7%
<3.5kg
<70% WHM
1) Too weak or
feeble to suckle
effectively (any
WH) or
2) Mother does not
have enough milk
to feed her child or
3) Not gaining (or
loosing) weight at
home
Sudan
(Southern)
Guidelines for yes

the
Management
of Severe Acute
Malnutrition
2008
n/s
7/103
7%
<3kg being <70% WHM

breast-fed
1) Too weak or
feeble to suckle
effectively (any WH)
2) Not gaining (or
loosing) weight at
home
noted that RUTF

inappropriate as "reflex
of swallowing is not yet
present"
Sudan
(North)
National
yes
Integrated
Manual on the
Management
of Severe Acute
Malnutrition
in health
facilities and at
community
level 2008
n/s
7/103
7%
<3kg
being
breast-fed
1) Too weak or
feeble to suckle
effectively (any
WH)
2) Not gaining
weight at home
notes that infant <6m

should be ideally be
nursed in a separate area
of the ward
<70% WHM
67
Table 7 contd
Separate
guideline for
infants <6m?
Country or
Guideline
Organization
Infant
<6m
SAM

~ for admission
Infant
<6m
MAM
Pages of
guideline
devoted
to infants
/ total
pages (excl.
annexes)
% of
guideline
devoted
to infants
Who apart
from
infants
<6m
should
follow
infant
guidelines
Anthropometric
Clinical criteria
criteria
(except for MUAC,
infant <6m, assume
of SAM, MAM unless
otherwise stated)
Notes
n/s
6/28
21%
<3kg being same

breast-fed
1) Too weak or feeble

to suckle effectively
(any WH) or
2) Mother does not
have enough milk to
feed her child

whose length <49cm
and that the nutrition
unit is not appropriate for
LBW infants <49cm.
These should be referred
to nursery and given
infant formula.
Botswana
Guidelines
yes
for the
Management
of Severe
Acute
Malnutrition
in Children
2007
Burkina Faso None yet - in

draft
yes
yes
5/57
9%
<3kg
OR
length
<65cm (a
proxy for
age)
same
1) Mother does not

have enough milk and
baby loosing weight
2)Infant too weak to
suckle and loosing
weight even if
mother has milk
SFP recommended for

mothers of MAM infants
<6m. General health and
nutrition education also
recommended
Cote D'Ivoire Protocole

National de
Prise en
charge de la
malnutrition
severe 2005
yes
n/s
10/65
15%
<3kg
OR
length
<65cm (a
proxy for
age)
<70% WHM (NCHS)

(for non-breastfed
infant)
1) Mother does not

have enough milk
and baby loosing
weight (does not
matter what exact
WHM is at
assessment)
2)Infant too weak to
suckle and loosing
weight even if
mother has milk

whose length <49cm
and that the nutrition
unit is not appropriate for
LBW infants <49cm.
These should be referred
to nursery and given
infant formula
Guinea
Protocole
National de
Prise en
Charge de la
Malnutrition
Aigue 2008
yes
n/s
8/98
8%
<3kg
<70% WHM (NCHS)
1) Mother does not

have enough milk
and baby loosing
weight (does not
matter what exact
WHM is at
assessment)
2) Infant too weak to
suckle and loosing
weight even if
mother has milk
Mali
Protocole
National de
la prise en
charge de la
malnutrition
aigue 2007
yes
n/s
4/97
4%
<3kg
<70% WHM (NCHS)
1) Mother does not

baby loosing weight
suckle and loosing
weight even if
mother has milk
Niger
Protocole de
prise en
charge de la
malnutrition
aigue 2008
yes
yes
7/93
(mother
referred
to SFP)
8%
<3kg
<70% WHM (NCHS)
Main criterion is
notes that infant <6m
"failure of effective
should be nursed in a
breastfeeding":1) Too separate area of the ward
weak or feeble to
suckle effectively (no
matter what weightfor-height)2) Not
gaining (or loosing)
weight at home
68
noted that RUTF

inappropriate as "reflex
of swallowing is not yet
present"
Table 7 contd
Separate
guideline for
infants <6m?
Country or
Guideline
Organization

~ for admission
Infant
<6m
SAM
Infant
<6m
MAM
Pages of
guideline
devoted
to infants
/ total
pages (excl.
annexes)
% of
guideline
devoted
to infants
Who apart
from
infants
<6m
should
follow
infant
guidelines
Anthropometric
Clinical criteria
criteria
(except for MUAC,
infant <6m, assume
of SAM, MAM unless
otherwise stated)
<70% WHM (NCHS)
Notes
Senegal
Protocole de
prise en charge
de la
malnutrition
aigue 2008
yes
n/s
3/45
7%
not
mentioned
Afghanistan
Communityyes
based
Management of
Acute
Malnutrition
programme in
Aqcha and
Mardyan District
of Jawzjan
Province
Northern
Afghanistan
2008
n/s
5/26
19%
<3kg being same

breast-fed
Main criterion is
"failure of effective
breastfeeding":
1) Too weak or feeble
to suckle effectively
2) Not gaining weight
at home
Guinea
Protocole
yes
National de Prise
en Charge de la
Malnutrition
Aigue 2008
n/s
8/98
8%
<3kg
<70% WHM (NCHS)
1) Mother does not

baby loosing weight
(does not matter
what exact WHM is at
assessment)
suckle and loosing
weight even if mother
has milk
India
Indian Academy
of Paeditrics
guidelines 2006
Not
n/s
explicitly.
Intro
does
mention
children
aged 0 to
4 years
0/14
0%
n/a
n/a
n/a
Pakistan
Protocol for the not

n/s
inpatient
exlplicitly
treatment of
severely
malnourished
children in the
Pakistan
earthquake
emergency 2005
n/s
n/s
n/s
n/s
n/s
Sri Lanka
Management of
Severe Acute
Undernutrition:
Manual for
Health Workers
in Sri Lanka
2007
no
separate
section for
infant
<6m
n/s
not
mentioned
same
not specified
target
n/s
group for
protocol
is
0 to 59
months
1) Too weak to suckle

and loosing weight
even if mother has
milk
2) Loosing weight
with mother who has
insufficient milk
Protocol notes no
growth standards
for infants whose
length <49cm and
that the nutrition
unit is not
appropriate for
treating premature
and LBW infants
<49cm. These
should be referred
to nursery and
given infant formula
No specific details
of infant <6m
treatment noted in
protocol summary.
Outpatient care
noted as only for 6
to 59 month old
children
69
4.4.3 Key medical treatments for infants <6m

Admission procedures
Admission procedures for SAM and MAM include a basic medical history and clinical examination. Some
guidelines annex a template history/examination proforma, thereby standardizing admission practices.
Few guidelines suggest significant extra or different admission procedures for infants <6m. Exceptions
and possible models for future guidelines include:
IFE Module 2 provides the most detail of various aspects of presentation, including recognizing low
birth weight infants, infant feeding status (e.g. breastfed or not) and full assessment of breastfeeding
(with dedicated sections and a standard checklist).
MSF 2006 highlights Additional history, including feedings other than EBF; presence and attitude of
the mother, state of the infant, flow of mothers milk and attachment and suckling.
Botswanas national guidelines note the need to observe breastfeeding position, attachment, suckling,
breast conditions
Cote dIvoire suggests that suck can be assessed by inserting a finger into the infants mouth.
Adequacy of current admission procedures will be reviewed in detail in Chapter 9.
Treatment guidelines
All guidelines recognize a phased approach to care. Many go into significantly more detail on the WHO
(1999) ten steps. There is, however, no specific focus on infants <6m with the exception of IFE Module 2.
Specific treatments
Where sections on infant <6m exist in guidelines, they commonly recommend vitamin A, folic acid, iron
(usually mixed into the therapeutic milk, but only once the child has improved and is in recovery phase) at
appropriate doses. For malaria, local guidelines are referred to. Antibiotics are universally recommended.
The most common first line therapy is amoxicillin, with several minor variations in dose/ dose regimen.
Second line therapy is often not directly covered in the infant section of the guideline. If noted, initial
ampicillin (with switch after two days to oral amoxicillin) plus gentamycin is common.
Kangaroo careii for nursing young / small infants is noted in many guidelines, but often only as a
treatment for hypothermia rather than as a default ideal position for infants <6m. One exception is IFE
Module 2, where Kangaroo care is recommended to prevent or treat hypothermia in severely
malnourished infants, and also as the default treatment of low birth weight infants, supported by detailed
content136.
HIV
Details of HIV-related issues are limited in most guidelines. Those written most recently seem to have
greater detail, which probably reflects increased availability of antiretroviral treatments. Where HIV is
mentioned, explicit links and references to local HIV-specific guidelines are not made. This is an area for
future developers to address, to ensure closer links between services (see Section 9.9 for more HIV
considerations).
ii
70
Kangaroo care is a technique where the infant is held in continuous skin-to-skin contact with an adult, usually the mother. It facilitates
temperature regulation, reduces infant stress, and helps establish and maintain breastfeeding.
Table 8: Key medical treatments recommended for infants <6m

Country or
Guideline
Organization
Treatment Admission
objective
Vitamin
A
Folic acid 1st line

antibiotic
2nd line Antiantibiotic malarial
Iron
Other
Kangaroo
care
WHO
Management n/a
of severe
malnutrition:
a manual for
physicians &
other senior
health
workers
1999
Clinical
50,000IU
assessment (on
admission)
followed
by small
daily doses
5mg dose cotrimoxazole ampicillin Recommends

at
x2 per day
(50mg/kg/ following
admission, for 5 days
6hrs im for national
then daily
2 days)
guidelines
dose of
then
1mg
amoxicillin
15mg/kg/
8hrs orally
for 5days
plus
gentamycin
7.5mg/kg
daily for 7
days
WHO
Guidelines for n/a

the inpatient
treatment of
severely
malnourished
children,
2003
Clinical
50,000IU
assessment (on
admission)
followed
by small
daily doses
50,000IU
(on
admission)
followed
by small
daily
doses
WHO
Manual for
n/a
the health
care of
children in
humanitarian
emergencies
2008
n/a
WHO
Pocket book n/s

of Hospital
care for
children 2005
Clinical
50,000IU
assessment (on
admission)
then small
daily dose
5mg on
cotrimoxazole as above
admission x2 per day
then
for 5 days
1mg/day
not specified 3mg/kg/

day (once
improved)
also
not
notes
specified
2mg/kg/
day zinc
and
0.3mg/
kg/day
copper
WHO
Handbook
n/a
IMCI
Integrated
Management
of Childhood
Illness 2005
n/a
n/a
n/a
n/a
n/s
n/a
n/a
n/a
ACF
Assessment &
Treatment of
Malnutrition
in Emergency
Situations
2002
Increase
mothers
milk supply
until BM
alone
sufficient
for growth
clinical
examination
mentioned
but no
details
given
50,000IU
on days
1,2 and at
discharge
5mg
single
dose at
admission
amoxicillin
20mg/kg
x3 per day
for 10 days
not
specified
according to
national
protocol
in F100
dilute
(once
improved)
MSF
Nutrition
Guidelines
(1st edition)
1995
stated that
BF should
be
promoted
and
continued
during the
whole
treatment
course
no
additional
details
specified
notes that no specific no specific

vit A
details
details given
should not given
be given
due to
possible
toxicity
not
specified
no specific
no specific
details given details
given
50,000IU not
(on
routinely
admission)
all get iron

on
completion
of
stabilisation
phase
not
specified
If no complications
cotrimoxazole
x2 per day
for 5 days
if complications amp +
gent as above
not specified 3mg/kd/

day
(once
improved)
not
specified
amoxicillin
according to
national
guideline
not
specified
not
specified
not
routinely
n/a
noted as
part of
hypothermia
prevention
not
specified
71
Table 8 contd
Country or
Guideline
Organization
Treatment Admission
objective
Vitamin
A
Folic acid 1st line

2nd line
antibiotic antibiotic
AntiIron
malarial
Other
Kangaroo
care
daily or weekly
supplementation
described in
micronutrients
chapter
yes
- diagram
included
MSF
Nutrition
Guidelines
2006
MSF
reduce
mortality &
morbidity
- discharge
on EBF
- additional
history:
- feeds other
than EBF;
presence +
attitude of
mother;
- state of
infant,
- flow of
mother's milk,
- attachment,
suckling
50,000 IU
(further
doses if
xeropthalmia)
5mg
not
single
specified
dose at
admission
Protocol
To return
Infants less
infants to
than 6
full EBF
months old
(Benson) MSF
- OCBA 2007
no additional
details
specified
50,000 IU
(further
doses if
xeropthalmia)
5mg
single
dose at
admission
amoxicillin not
35-50mg/ specified
kg x2 per
day for 5
days plus
gentamicin
not
in F100dil
specified (once improved)
yes
- diagram
included
Valid
Communitybased
Therapeutic
Care (CTC), A
field manual
(first edition)
2006
no additional
details
specified
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
UNHCR
Handbook for n/s

Emergencies
(third edition)
2007
n/s
n/s
n/s
n/s
n/s
n/s
n/s
n/s
n/s
UNHCR
The
treat
treat mother
management mother not not infant
of Nutrition
infant
in Major
Emergencies
2000
n/a
n/a
n/a
n/s
n/a
n/a
n/a
n/a
IFE Core
Group
Infant
Feeding in
Emergencies
IFE Module 2,
version 1.1
2007
Details
described
50,000IU
(admission
only)
5mg
single
dose
n/s
n/s
n/s
ferrous
sulphate,
in F100
dilute
(once
improved)
Gives
extensive
details of
supportive
care for
breastfeeding
Yes,
including to
prevent as
well as
treat
hypothermia
ICRC
Nutrition
n/a
Manual for
Humanitarian
Action 2008
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
no additional
details
specified
50,000 IU at
admission
5mg
single
dose at
admission
amoxycillin not
from 2kg, specified
20mg/kg
x3 per day
not
ferrous sulphate, in
specified F100dilute (once
improved)
not
specified
no additional
details
specified
50,000IU
(admission
only)
2.5mg
single
dose
amoxycillin
from 2kg,
30mg/kg
x2 per day
plus
gentamycin
national
protocol
(coartem
from 3
months)
not
specified
n/a
treat only if
infant has
malaria
- need for
nets to
prevent
transmission also
noted
National guidelines
Burundi
Protocole
National de
Nutrition
2002
Ethiopia
Protocol for
To return
the
infants to
Management full EBF
of Severe
Acute
Malnutrition
2007
72
n/s
not
specified
not clear
whether
gentamycin
is 1st or 2nd
line
treatment
ferrous
sulphate,
in F100
dilute
(once
improved)
Table 8 contd
Country or
Guideline
Organization
Treatment
objective
Admission
Vitamin
A
Folic
acid
1st line
2nd line
antibiotic antibiotic
AntiIron
malarial
not
specified
not
specified
not
specified
not
not
specified specified
ampicillin not
in F100dil
iv
specified (once
and
improved)
gentamycin
im
Other
Kangaroo
care
National guidelines
Madagascar
Depistage et
prise en
charge de la
malnutrition
aigue
2007
To ensure
mother can
produce milk
of sufficient
quantity and
quality for
infant to
grow
normally
no additional not
details
specified
specified
Malawi
Guidelines
for the
Management
of Severe
Acute
Malnutrition
(book T3)
2007
To stimulate
BF until
sufficient to
allow the
infant to
grow
properly
no additional 50,000IU 5mg

details
(admission single
specified
only)
dose
amoxycillin
15mg/kg
x3 / day,
phase 1 +
4 days
extra)
n/s
no additional not
details
specified
specified
amoxycillin not
20mg/kg
specified
x3 per day
plus
gentamycin
Orientacao
para
Tratamento
da
Desnutricao
Aguda Grave
2008
5mg
single
dose
noted in
general
section on
hypothermia
noted as
treatment
for
hypothermia
in general
section
not
in F100dil HIVspecified (once
related
improved) treatments
noted for
exposed
infants
noted in
general
section on
hypothermia
Tanzania
Management n/s
of Acute
Malnutrition
NATIONAL
Guidelines
2008
not stated
50,000 IU 5mg
d1 (+d2, single
d14 if
dose
clinical
signs
deficiency)
amoxycillin
15mg/kg
x3 per day
for 5 days
ampicillin not
3mg/kg/day elemental
plus
specified iron once improved
gentamycin
7.5mg/kg
daily for 7
days
noted as a
treatment
for
hypothermia
in general
section
Uganda
Integrated
n/s
Management
of Acute
Malnutrition
2006
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Zambia
Integrated
n/s
Management
of Acute
Malnutrition
2009
no additional 50,000IU
details
at
specified
admission
not
specified
not
specified
not
specified
not
not
specified specified
not
specified
not specified
Zimbabwe
Guidelines
n/s
for the
Management
of Severe
Acute
Malnutrition
through
Communitybased
Therapeutic
Care (CTC)
2008
n/s
5mg at
amoxycillin from 2kg,
admission 20mg/kg x3 per day
for 7-10 days
not for
<4kg
infants
not
specified
not specified
DRC
Protocol
n/s
National de
Prise en
Charge de la
Malnutrition
Aigue 2008
no additional 50,000 IU
details
at
specified
admission
only
(not if
oedema)
not
specified
not
not
specified specified
Notes
'health
education
and social
care' (for
all
children)
not specified
50,000IU
at
admission
amoxycillin not
from 2kg, specified
30mg/kg
x2 per day
n/a
not
specified
73
Table 8 contd
Country or
Guideline
Organization
Treatment
objective
Admission
Vitamin
A
Folic acid 1st line

antibiotic
2nd line Antiantibiotic malarial
Iron
Other
Kangaroo
care
National guidelines
Sudan
(Southern)
Guidelines
To improve or
for the
re-establish
Management BF
of Severe
Acute
Malnutrition
2008
no additional
details
specified
(though
disability,
maternal
illness,
maternal
trauma noted
as problem
which can
affect infant
feeding)
50,000 IU
at
admission
only
2.5mg
single
dose at
admission
amoxycillin not
from 2kg,
specified
30mg/kg
x2 per day
plus
gentamycin
not
specified
F100dilute, once
improved
not
specified
Sudan
National
To return
no additional
Integrated
infants to full details
Manual on
EBF
specified
the
Management
of Severe
Acute
Malnutrition
in health
facilities and
at
community
level 2008
50,000 IU
at
admission
only
2.5mg
single
dose at
admission
amoxycillin not
from 2kg,
specified
30mg/kg
x2 per day
plus
gentamycin
not
specified
F100dilute, once
improved
noted as
treatment
for
hypothermia in
general
section
Botswana
Guidelines
for the
Management
of Severe
Acute
Malnutrition
in Children
2007
~ Treat SAM
~ Restore to
health
~ Reduce
mortality
~ Treat
complications
& associated
diseases
~ Maintain
or improve
maternal
milk
production
~ Observe
breastfeeding
(position,
attachment,
suckling,
breast
conditions)
~ medical
consultation
(history,
examination)
50,000 IU
at
admission
only
2.5mg
single
dose
at
admission
amoxycillin not
from 2kg,
specified
20mg/kg
x3 per day
according ferrous
to national sulphate
guidelines 6mg
elemental
iron/kg/
day (once
improved,
growing)
Burkina Faso None yet - in

draft
To increase
the quality
and quantity
of BF
no additional 50,000 IU
details
at
specified
admission
only
5mg
single
dose at
admission
amoxycillin, not
from 2kg
specified
25mg/kg
x3 per day
not
specified

National de
Prise en
charge de la
malnutrition
severe
2005
To reestablish
effective EBF
(NOT
necessarily to
regain 85%
WHM)
Note
not
~ Whether specified
preterm
~ Birth
weight
~ Feeds
(aside from
BM)
~ Strength of
infant suck
(by inserting
finger into
mouth)
5mg
single
dose at
admission
amoxycillin not
from 2kg,
specified
20mg/kg
x3 per day
no
in F100dil
treatment (once
if tests
improved)
negative
7 days
artesunate
if positive
Guinea
To
no additional
supplement details
maternal BF specified
and get to
the point
where infant
growing well
on BF alone
2.5mg
single
dose at
admission
amoxycillin, not
from 2kg
specified
30mg/kg
x2 per day
+
gentamycin
not
specified
74
Protocole
National de
Prise en
Charge de la
Malnutrition
Aigue 2005
50,000 IU
at
admission
only
Briefly
mentions
'health
education
and social
care' (for all
children)
ferrous sulphate
(once improved)
in F100dil
(once
improved)
noted as a
treatment
for
hypothermia in
general
section
not
specified
Notes that not

risk of
specified
hypothermia &
hypoglycaemia high
==>
infants to be
nursed close
together
and
monitored
closely
noted as a
treatment
for
hypothermia in
general
section
Table 8 contd
Country or
Guideline
Organization
Treatment Admission
objective
Vitamin
A
Folic acid 1st line

antibiotic
2nd line
antibiotic
Antimalarial
Iron
Other
Kangaroo
care
National guidelines
Mali
Protocole
n/s
National de la
prise en
charge de la
malnutrition
aigue 2007
no
additional
details
specified
50,000 IU
at
admission
only
2.5mg
amoxycillin, from 2kg
single
20mg/kg
dose at
x3 per day
admission
not
specified
in F100dil
(once improved)
noted as a
treatment for
hypothermia
in general
section
Niger
Protocol
National de
Prise en
Charge de la
Malnutrition
Aigue 2006
To return
infants to
full EBF
no
additional
details
specified
50,000 IU
at
admission
only
2.5mg
single
dose at
admission
amoxycillin, not
from 2kg
specified
30mg/kg
x2 per day
not
specified
in F100dil
(once improved)
not specified
Senegal
Protocole de
prise en
charge de la
malnutrition
aigue 2008
To return
infants to
full EBF
no
additional
details
specified
not noted
2.5mg
single
dose at
admission
amoxycillin not
from 2kg,
specified
20mg/kg
x2 per day
for 7 days
not
specified
not
specified
not specified
Afghanistan
Community- To return
based
infants to
Management full EBF
of Acute
Malnutrition
programme
in Aqcha and
Mardyan
District of
Jawzjan
Province
Northern
Afghanistan
(Stabilization
Centre
Guidelines)
2008
no
additional
details
specified
50,000 IU
at
admission
only
2.5mg
single
dose
at
admission
amoxycillin
from 2kg,
30mg/kg
x2 per day
add
gentamycin
(do not use
chloramphenicol)
according in F100dil
to
(once improved)
national
guidelines
noted in
section on
hypothermia,
with
implication
that is
recommended
for all children
India
Indian
Academy of
Paeditrics
guidelines
2006
n/s
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Pakistan
Protocol for
n/s
the inpatient
treatment of
severely
malnourished
children in
the Pakistan
earthquake
emergency
2005
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Sri Lanka
Management n/s
of Severe
Acute Undernutrition:
Manual for
Health
Workers in Sri
Lanka
2007
no
additional
details
specified
"according not
to
specified
national
protocol"
amoxycillin
15mg/kg
x3 per day
for 5 days
gentamycin not
7.5mg/kg specified
for 7 days
plus
ampicillin iv
for 2 days
then
3mg/kg/day once
improving/gaining
weight
noted in
section on
hypothermia
as prevention/
treatment
75
4.4.4 Nutritional treatments for infants <6m

Careful attention to infant feeding and support for good practice can save lives.
Preserving breastfeeding, in particular, is important not just for the duration of any
emergency, but may have lifelong impacts on child health and on womens future
feeding decisions.
Every group of people has customs and traditions about feeding infants and young
children. It is important to understand these and work with them sensitively while
promoting best practice.
Operational Guidance on IFE, v2.1, 2007 &
UNHCR Handbook for Emergencies, 3rd Edition
See Table 9 for summary. Most guidelines divide infants into those who have the opportunity to breastfeed and
those who do not. These will be dealt with in turn.
Treatment objective
Restoration of effective exclusive breastfeeding (or similar phrasing implying the same) is a commonly
stated treatment objective for infants <6m. This differs from the goal for older children, who aim for a
nutritional cure (commonly >80 or 85% weight-for-height / >-2 or -1 z-scores).
Breastfed infants
Most guidelines encourage the continuation of breastfeeding. However, details of breastfeeding support
are rarely described. Exceptions are IFE Module 2 and the WHO pocket handbook of hospital care (2005).
For infants <6m who can breastfeed, three hourly breastfeeding of ten to 20 minutes is generally
recommended in guidelines. Some encourage more frequent feeds as demanded by the infant. Practical
details of how to support and optimize breastfeeding are very limited. This makes prior specialist skills
necessary to be able to implement and build on guidelines. Existing materials on breastfeeding support
are rarely referenced.
All guidelines imply that infants <6m admitted to treatment would need at least short term supplemental
feeds, with the exception of IFE Module 2 that gives the option of breastfeeding/expressed breastmilk
alone where an infant is suckling and breastmilk supply is adequate. Diluted F100 was the most
frequently recommended supplemental milk. Some guidelines mention F75 for infants with oedema. IFE
Module 2 includes commercial infant formula as an option and advises against home prepared F75 in this
age-group.
The supplementary suckling (SS) technique as a means of supplemental feeding is widely referenced and
thoroughly described in guidelines, including with pictures and diagrams in many137. Using SS, weight
gain criteria (20g per day cited by many guidelines) are used to signify that breastmilk production is
improving. After a few days with good weight gain, the volume of supplemental milk is reduced. If weight
gain continues, supplemental milk is stopped entirely and the infant is monitored to see whether he/she
continues to gain weight on exclusive breastfeeding alone.
A minimum admission length is sometimes specified (e.g. nine to 11 days minimum, which includes two
to three days each for phase one and two, plus five days for exclusive breastfeeding). Other guidelines
urge a short as possible admission, depending on weight gain. All emphasise a need to ensure the infant
is gaining adequate weight and is clinically well on exclusive breastfeeding alone, prior to discharge.
Non-breastfed infants
Possible reasons for not breastfeeding are not generally listed, with the exception of IFE Module 2. Though
rare, none of the guidelines reviewed mention medical contra-indications to breastfeeding 138. The
same supplemental milk recommended for breastfed infants is often recommended for this group: diluted
F100 or sometimes F75 for infants with oedema, fed by cup. Only a small number of guidelines explicitly
warn of the hygiene risks of bottle/teat feeding.
The major difference for non-breastfed infants <6m arises in the rehabilitation phase of treatment. Here,
volume of supplemental milk doubles to enable catch-up growth. Non-breastfed infants may also require
transition to an appropriate breastmilk substitute, e.g. transition from diluted F100 to a commercial infant
76
formula. Rather than an adequate weight gain discharge criterion, the non-breastfed infant is typically
expected to reach the same anthropometric targets as older children prior to discharge (>80% or >85%
weight-for-length).
Very few guidelines go into details about the challenges of long term use of infant formula, follow-up
needs and resources required, and how to source supplies. Likewise, few note alternatives, such as wet
nursing or modified animal milks. No guideline suggests that complementary foods or RUTF be started
before six months.
Infant and young child feeding support in older age-group

The lack of breastfeeding-specific guidance in current guidelines also has implications for older severely
malnourished children, where breastmilk should continue to contribute significantly to their energy and
nutrient intake. This compromises achievement of the Sphere indicator as much attention is attached to
breastfeeding and psychosocial support, hygiene and community outreach as to clinical care (Correction
of malnutrition standard 2: severe malnutrition).
77
78
>6month
but <4kg
infants are
separate
yes
yes
Assessment &
Treat-ment of
Malnutrition in
Emergency
Situations 2002
Nutrition
Guidelines (1st
edition) 1995
Nutrition
Guidelines
2006
ACF
MSF
MSF
Every 3 hours
Every 2 hours for
<1.5kg more often
if infant wants
In order of
preference:
1) BM alone
2) Infant
formula
3) F100 dilute
~ BF for 10-20 SDTM

(therapeutic
mins
~ Give BMS one milk)
hour after BF
Reconstituted
enriched
formula milk
(recipie given)
~ BF for 10-20 Diluted F100

mins
~ Give BMS one
hour after BF
"should be
BMS AFTER
promoted and
each session on
continued during the the breast
whole of treatment"
Every 3 hours
"if child is breastfed, separate

continue with this" chapter on
supportive care
has details on
supporting BF
Pocket book of
Hospital care for
children 2005
WHO
no
not noted
Manual for the

n/a
health care of
children in
humanitarian
emergencies 2008
WHO
n/a
"breastfeed as often noted in section n/a

as child wants"
on preparation
for discharge
Guidelines for the n/a

inpatient
treatment of
severely
malnourished
children, 2003
WHO
Noted in section n/a

on preparation
for discharge
Management of
severe
malnutrition,
1999
n/a
n/a
n/a
n/a
5-6 times per

day
105
kcal/kg/day
8 times per day 130ml/kg/day

(=100kcal/
kg/day)
8 times per day details not

specified
n/a
n/a
n/a
supplementary 8 times per day 100-120

suckling
kcal/kg/day
small spoon or
syringe
supplemental
suckling
(described)
not specified
(SS described
in different
chapter)
n/a
n/a
n/a
start Transition on
day 10 (max d.15).
When BM
output increases,
weight increasing,
decrease STDM by
50%. If still gaining
weight by 5g/kg/day,
stop SDTM
no specific details
~ if weight
increasing for 15 days
then half amount
F100dil ~ stop SS
after further 3 days
phase 1
10-15 days
then
according
to progress
not
specified
minimum
stay would
be 15 + 3
+ 5 = 23
days
not
specified
n/a
n/a
details not specified
n/a
n/a
Once gaining
weight for 5
days without
SS
not specified
Once gaining
weight for 5
days without
SS
not specified
n/a
n/a
n/a
duration Discharge
of phases (BF infant)
(BF infant)
n/a
n/a
Breastfeeding Supplemental Supplemental Supplemental Supplemental rehab phase

milks
(details)
milk route
milk feed
feed
(BF infant)
(BF infant)
(BF inf.ant)
frequency
amount
(BF infant)
(BF infant)
WHO
"should be
continued"
Division
Breast feeding
into 'breastfed' and
'non-BF'
Country or Guideline
Organization
Table 9: Nutritional treatments for infants <6m
SDTM
(therapeutic
milk)
Enriched
formula milk
(recipe given)
Diluted F100*
(protocol for
>6month but
<4kg infants)
expressed
breastmilk (if
available);
formula milk or
infant formula;
modified
animal milk
n/a
n/a
n/a
No maternal
breast
feeding
available
Manual for the

health care of
children in
humanitarian
emergencies 2008
The management non BF

infants not
of Nutrition in
Major Emergencies recognised
2000
Infant Feeding in
Emergencies IFE
Module 2, version
1.1 2007
Nutrition Manual
for Humanitarian
Action 2008
UNHCR
UNHCR
IFE Core
Group
ICRC
Every 3
hours
yes
Ethiopia
Protocol for the

Management of
Severe Acute
Malnutrition 2007
Every 3
hours
n/a
yes
Protocole National yes

de Nutrition 2002
n/a
yes
n/a
n/s
n/a
F100dil
(F75 if
oedema)
n/a
n/s
n/a
n/a
n/s
n/a
~ BF for at least 20
mins
~ BF more often if
infant wants
~ Give BMS 30 to
60min after BF
~ BF for 20 mins
~ Give BMS one
hour after BF
n/a
supplemental
suckling
(described)
n/a
supplemental
F100 dilute
or commercial suckling
(described)
formula
(F75 for infants
with oedema)
F100 dilute
n/a
n/a

(=100kcal/kg
/day)

(=100kcal/kg/
day)
n/a
volume per kg
varies
according to
weight
(tables given)
n/a
n/s
n/a
supplementary 8 times per day 100-120

suckling
kcal/kg/day
n/a
if gaining
weight, each
reduction of
BMS volume
by 1/3
occurs every
2-3 days
n/a
n/s
n/a
n/a
Once gaining
weight for 5
days on BF
alone
n/a
n/s
n/a
n/a
F75 (preferred
option)
F100dil or formula
also OK
n/a
n/s
n/a
F100 dilute OR F75

for marasmus
f75 for kwashiorkor
No maternal
breastfeeding
available
decrease to 50% of
maintenance once
baby gaining 20g/
day, stop completely
once gaining
>10g/day
"as short as
possible"
Once gaining
weight on BM
alone
F100 dilute
(F75 for infants
with oedema)
not specified Once gaining

decrease to 50% of
F100 dilute OR F75
weight for 5
maintenance once
for marasmus
days without SS f75 for kwashiorkor
baby gaining 20g/day
n/a
if infant gaining
weight for 2-3days, at
least 20g/ day then
reduce SS by 1/3 and
feed for further 2-3
days. Continue to
reduce volumes if
infant gaining weight.
n/a
n/s
n/a
few more days

without SS
- can also go
once child BF
greedly if
mother wishes
duration of Discharge
phases
(BF infant)
(BF infant)
according to
decrease to 50% of
progress
maintenance once
stop completely once
gaining >10g/day
Supplemental Supplemental Supplemental Supplemental rehab phase

milk feed
milks
milk route
feed amount (BF infant)
frequency
(BF infant)
(BF inf.ant)
(BF infant)
(BF infant)
Extensive discussion F75 or

supplementary at least 8x /day
of BF issues. Breast F100 dilute or suckling
feeding or expressed Infant formula
breastmilk given as
treatment option.
Supplementary
feeds may be
indicated.
discussed n/a
in annex
"treatment should
include support for
BF
n/a
n/a
Burundi
National guidelines
Handbook for
n/a
Emergencies(third
edition) 2007
Valid
~ BF for 10-20 mins

~ Give BMS 3060mins after BF
Breastfeeding
(details)
Every 3
hours
more
often if
infant
wants
recognised yes
but not
described in
detail
Protocol Infants
yes
less than 6 months
old (Benson) MSF OCBA 2007
Division
Breast
into'breastfeeding
fed' and
'non-BF'
MSF
Country or
Guideline
Organization
Table 9 contd
79
80
Breast
feeding
n/a
not
specified
Integrated
n/a
Management of
Acute Malnutrition
2006
Integrated
not specified
Management of
Acute Malnutrition
2009
Guidelines for the

Management of
Severe Acute
Malnutrition
through CTC 2008
Uganda
Zambia
Zimbabwe
not specified
not
specified
"assist to
breastfeed
or express
breastmilk"
Management of
Acute Malnutrition
NATIONAL
Guidelines 2008
Tanzania
no
Relactation of
other female
carer (e.g aunt)
recommended)
Every 3
hours
Guidelines for the

Management of
Severe Acute
Malnutrition
(book T3) 2007
yes
Orientacao para
Tratamento da
Desnutricao Aguda
Grave 2008
Malawi
Every 3
hours
Depistage et prise Recognised but Every 3

en charge de la
not detailed
hours
malnutrition aigue
2007
Division
into'breastfed' and
'non-BF'
yes
Madagascar
Country or
Guideline
Organization
supplementary 9 times per day 130ml/kg/day

suckling
(=100kcal/kg/
(described)
day)

suckling
(=100kcal/kg/
(described)
day)
not specified
not specified
not specified
Infant formula not specified

OR F100 dilute
(F75 dilute for
infants with
oedema)
not specified
not specified
8 times per day not specified
n/a
n/a
n/a
n/a
8 times per day as per F75

protocol
Give prescribed not specified

amount of F75 in addition
to breastmilk
F100 dilute
(F75 for infants suckling
(=100kcal/kg/
with oedema) (described)
day)
F100 dilute
F100 dilute
~ "as short
as possible"
~ 2-3 days
for each
reduction of
1/3
F100dilute
maintenance
not specified
not specified
n/a
Relactation of
other female carer
(e.g aunt)
recommended)
n/a
not specified not

specified
not specified
not specified
n/a
as for older not separately

children,
detailed
>85%WHM
or >-1WHZ
or MUAC
>125mm
Once
F100 dilute
gaining
(F75 for infants
weight for 5 with oedema)
days
without SS
Once
F75
gaining
weight for 5
days
without SS
not specified not

specified
n/a
Encourage mothers to not specified

BF. Give additional
diluted F-100. As BM
production increases,
gradually reduce
amount diluted F100
decrease to 50% of
not specified
maintenance once
gaining >10g/day
decrease F100 dilute

by 1/3 the
maintenance once
baby gaining
20g/day, decrease by
a further 1/3 if still
gaining weight after
2-3 days, stop
F100dilute if still
gaining weight
Once
gaining
weight for 5
days
without SS
duration of Discharge No maternal

phases
(BF infant) breastfeeding
(BF infant)
available
decrease to 50% of
not specified
maintenance once
gaining >10g/day
Supplemental Supplemental Supplemental Supplemental rehab phase

milk route
milks
milk feed
(BF inf.ant)
(BF infant)
frequency
(BF infant)
(BF infant)
not specified
n/a
~ BF for 20 mins
~ BF more often if
infant wants
~ Give
supplemental feed
one hour after BF
~ BF for 20 mins
~ BF more often if
infant wants
~ Give BMS one
hour after BF
~ BF for 20 mins
~ Give BMS one
hour after BF
Breastfeeding
(details)
Table 9 contd
yes
no
Guidelines for the

Management of
Severe Acute
Malnutrition in
Children 2007
Botswana
Burkina Faso None yet - in draft
Cote D'Ivoire
National
yes
Integrated Manual
on the
Management of
Severe Acute
Malnutrition
in health facilities
and at community
level 2008
Sudan
(North)
Protocole National yes

de Prise en Charge
de la Malnutrition
Aigue 2005
Every 3
hours
Every 3
hours
as often
as
possible /
frequently
Every 3
hours
Every 3
hours
Guidelines for the

Management of
Severe Acute
Malnutrition 2008
Sudan
(Southern)
yes
Every 3
hours
Protocol National yes

de Prise en Charge
de la Malnutrition
Aigue 2008
Division
Breast
into'breastfeeding
fed' and
'non-BF'
DRC
Country or
Guideline
Organization
F100 dilute
~ BF for 20 mins F100 dilute

~ BF more often
if infant wants
~ BF for 20 mins diluted F100

~ Give
supplemental
feed one hour
after BF
"Educate and
demonstrate
proper BF
technique"
decrease to 50% not specified Once gaining weight on

of maintenance
EBF alone
once baby
gaining 20g/day.
stop completely
once gaining
>10g/day
duration of Discharge
phases
(BF infant)
(BF infant)
supplemental
suckling
(described)
supplemental
suckling
(described)
F100 dilute
(F75 for infants
with oedema)
F100 dilute
(F75 for infants
with oedema)
F100 dilute
(F75 for infants
with oedema)
No maternal
breastfeeding
available
Once gaining weight on

EBF alone
F100 dilute
(F75 for infants
with oedema)
not specified
When gaining weight (5 to F100 dilute

10g/kg/day) on EBF alone (F75 for infants
for 5 consecutive days after with oedema)
SS stopped
NB some discrepancy in
different sections of
guideline as to lengths of
stay recommended
8 times per day 130ml/kg/day decrease to 50% "as short as

(=100kcal/kg/ of maintenance possible"
once baby
day)
gaining 20g/day
10-15 days
intial phase
2 days rehab
phase
Minimum 4
days final
phase
Once gaining weight for 5

days without SS
70 ml/kg/day
Once gaining weight on

EBF alone
8 times per day 130ml/kg/day decrease to 50% Not

(=100kcal/kg/ of maintenance specified
once baby
day)
gaining 20g/day

suckling
decrease to 50% as short as

of maintenance possible
once baby
gaining 20g/day
stop completely
once gaining
>10g/day
supplementary 8 times per day 130ml/kg/day decrease to 50% not specified Once gaining weight on
suckling
EBF alone
(=100kcal/kg/ of maintenance
(described)
once baby
day)
gaining 20g/day
stop completely
once gaining
>10g/day

~ BF more often (F75 for infants suckling
(=100kcal/kg/
if infant wants
day)
~ Give
supplemental
feed 30-60 mins
after BF

~ BF more often
if infant wants
~ Give
supplemental
feed one hour
after BF

(=100kcal/kg
~ BF more often (F75 for infants suckling
/day)
if infant wants
~ Give
supplemental
feed one hour
after BF
Breastfeeding Supplemental Supplemental Supplemental Supplemental rehab phase

milks
milk route
(details)
milk feed
(BF infant)
(BF inf.ant)
(BF infant)
frequency
(BF infant)
Table 9 contd
81
82
Protocol National de Prise

yes
Every 3 hours
en Charge de la Malnutrition ~ non-BF
Aigue 2006
protocol
describes
finding wetnurse if
possible
Every 3 hours
Every 3 hours
n/a
n/a
Protocole de prise en charge no

de la malnutrition
aigue2008
Protocol for the inpatient

treat-ment of severely
malnourished children in
the Pakistan earthquake
emergency 2005
Management of Severe
Acute Undernutrition:
Manual for Health Workers
in Sri Lanka 2007
Senegal
no
Afghanistan Community-based
Management of Acute
Malnutrition programme in
Aqcha and Mardyan District
of Jawzjan Province Northern
Afghanistan (Stabilization
Centre Guidelines) 2008
Indian Academy of
n/a
Paediatrics guidelines on
hospital based management
of Severely Malnourished
Children 2006
Niger
India
Pakistan
Sri Lanka
no
n/a
n/a
n/a
~ for at least
20mins
~ more often if
child wants
supplemental
suckling
(described)
n/a
n/a
not specified.
By implication,
infant U6 will
be treated with
F75
n/a
n/a
n/a
n/a
130ml/kd/day
(100kcal/kg/
day) (amount
NOT increased
as infant gains
weight)
n/a
n/a
n/a
decrease to 50%
of maintenance
once baby gaining
20g/day
n/a
n/a
n/a
if weight
gain
maintained,
then stop SS
n/a
n/a
n/a
n/a
n/a
n/a
F100 dilute
When
(F75 for infants
gaining
weight on with oedema)
EBF alone
(no matter
what weight
or WFL)
Once
not detailed
gaining
weight for 5
days
without SS
8 times per day 130ml/kg/day decrease to 50%

once baby gaining
day)
20g/day, stop
completely once
gaining >10g/day
as short as
possible to
minimise
risk of
nosocomial
infection
F100 dilute
Once
(F75 for infants
gaining
weight for a with oedema)
few days
without SS
n/a
n/a
F100 dilute
(F75 for infants
with oedema)
Once
F100 dilute
gaining
weight for 5
days
without SS
Once
gaining
weight on
EBF alone
8 times per day 130ml/kg/day decrease to 50% not

specified
day)
once baby gaining
20g/day, stop
completely once
gaining >10g/day
n/a
n/a
n/a
decrease to 50% "as short as

of maintenance
possible"
once baby gaining
20g/day
duration of Discharge No maternal

phases
(BF infant) breastfeeding
(BF infant)
available
8 times per day 130ml/kg/day decrease to 50% not

specified
day)
once baby gaining
20g/day, stop
completely once
gaining >10g/day

(=100kcal/kg
/day)
F100 dilute
Supplementary 8 x per day
(F75 for infants suckling
(0.5 to 1 hr
with oedema)
after BF)
F100 dilute
supplemental
suckling
(described)

~ BF more often
if infant wants
~ Give
supplemental
feed 60mins
after BF
~ BF for 20
mins~ Give
supplemental
feed 60mins
after BF
supplemental
suckling
(described)
supplemental
suckling
(described)

~ Give BMS
60mins after BF

~ BF more often
if infant wants
noted that "BF no other details

should be
continued for
all infants &
young children"
Every 3 hours
Protocole National de la
prise en charge de la
malnutrition aigue 2007
Mali
yes
Protocole National de Prise yes

en Charge de la Malnutrition
Aigue 2005
Every 3 hours
Division
Breast feeding Breastfeeding Supplemental Supplemental Supplemental Supplemental rehab phase
into'breastmilk route
(details)
milks
milk feed
fed' and
(BF inf.ant)
(BF infant)
frequency
(BF infant)
'non-BF'
(BF infant)
Guinea
National guidelines
Organization
Table 9 contd
4.4.5 Maternal care, preparation for discharge & follow-up

Maternal diet
Many guidelines recommend that lactating mothers receive increased food rations to give a total intake of
2500kcal/day, and increased fluid intake to >2 litres/day. Vitamin A for the mother is recommended by
many guidelines as a single large dose if the infant is <2 months old. Mothers of older infants may be
pregnant so either it is withheld or a course of low dose Vitamin A is given. A small number of guidelines
mention that general maternal micronutrient stores should be replenished though a high quality diet
during breastfeeding.
Psychosocial care
Play therapy and psychosocial support of the malnourished child is one of WHOs essential ten treatment
steps. It is still recognized in many guidelines, often in dedicated sections, but none focus specifically on
infants <6m.
The impact of severe infant malnutrition on feeding-associated interactions and feeding cues between a
mother and her infant <6m, e.g. reduced demands for breastfeeding, and how to manage these are not
generally addressed. IFE Module 2 does include content on this in the section concerned with
breastfeeding support in malnourished infants but not specifically in the SAM chapter.
Specific psychosocial care for the mother/carergiver of either infants <6m or children, including
assessment and treatment, is not included in the guidelines apart from general statements about being
supportive, explaining treatments and avoiding blame for the infants malnutrition. The exception is IFE
Module 2 that gives a more practical description of assessment and care for mothers. Given the relevance
of psychosocial aspects of care to MAMI, Chapter 8 of this report undertakes a detailed review.
Follow-up care and supplementary feeding

Follow-up on discharge from a TFP (inpatient or community-based) is almost universally recommended.
SFP referral (if available) on discharge is almost universal and, by implication, this includes infants <6m
where the mother benefits from supplementary food rations.
Promoting optimal infant and young child feeding

Taking advantage of a captive in-programme audience to work towards prevention of future malnutrition
has obvious potential. Many guidelines highlight health and nutrition education as part of the discharge
package, but few are specific on what topics should be covered. Very few guidelines take advantage of the
large body of IYCF literature available.
Feeding programmes for pregnant & lactating mothers

SFP target groups frequently include pregnant women (in last trimester of pregnancy) and lactating
women who are malnourished. However it is often not clear in guidelines whether the mothers of
malnourished infants <6m should be admitted to SFPs, independent of the nutritional status of the
mother.
83
84
Maternal diet
not specified
not specified
n/a
Manual for the

health care of
children in
humanitarian
emergencies 2008
Pocket book of
Hospital care for
children 2005
Handbook IMCI
Integrated
Management of
Childhood Illness
2005
Assessment &
Treatment of
Malnutrition in
Emergency
Situations 2002
WHO
WHO
WHO
ACF
~ Drink 2l water
per day
~ Eat ~
2600kcal/day
~ Supplement with
vitamins & minerals
(ensure type 1
nutrient stores
adequate)
not specified
Guidelines for the

inpatient
treatment of
severely
malnourished
children, 2003
WHO
not specified
Management of
severe
malnutrition: a
manual for
physicians & other
senior health
workers 1999
WHO
International Guidelines
Organization
To support BF:
1) Listen to any
problems
2) Assess BF
3) Help during BF
n/a
importance of
psychological factors
noted
mental health and

psychosocial support
discussed in separate
chapter
not specified
not specified
Preparation
for discharge
(general)
n/a
If gaining wt 15days: -->

halve milk -->stop BMS aftr 3
days --->keep for 5 more
days to ensure progress
maintained
n/a
Show parent/carer to:

~ feed frequently with
energy and nutrient dense
foods
~ give structured play
therapy
not specified
Show parent/carer to:

~ feed frequently with
energy and nutrient dense
foods
~ give structured play
therapy
not
Ensure child fully immunized
specified Ensure mother or carer:
~ able to feed child
appropriately
~ able to make appropriate
toys & play with child
~ knows how to give home
treatment & recognise signs
to seek medical assistance
Maternal
Other
(caregiver) psychosocial issues
Table 10: Maternal care, preparation for discharge and follow-up
Yes notes that:

~ field treatments are
generally inadequate
~ re-feeding treatment
is same
n/a
Yes
Separate chapter of
book details HIV issues
other chapter or
manual is devoted to
HIV
Yes:
"recovery may take
longer & treatment
failure is more
common
~treatment same as
for HIV neg. child
Yes:
~ should not be done
routinely; ~ HIV status
has no role in
management;
~ result should be
confidential, not
revealed to staff
HIV noted
not noted
Extra home
food ration?
yes, to
~ weigh infant,
~ provide
supplementary
food to mother
n/a
yes
1 week,
2 weeks, 1
month, then
monthly for
6months
not specified
detailed section on
infant feeding
ch2.2: Breast milk,

The practice of BF;
BMS; Assessing
feeding practices
weekly
(1500kcal/day)
1st month;
fortnight
(700kcal/day)
2nd month;
monthly
(350kcal/day) 36months
breastfeeding and
young child feeding
described
~ WHO IYCF
document not
referenced
Noted, but reader

referred elsewhere
for details
None
none
Referral to SFP
(but evidence of
effectiveness
discussed)
not described
not described
not described
not described
not described
Details of any IYCF Feeds for

guidance
pregnant
&lactating women
n/a
not noted
not specified
Yes
not noted
"regular followup checks"
advised
Yes
1 week,
2 weeks, 1
month, 3
months & 6
months after
discharge
Follow up
visits
Maternal diet
Infant Feeding in ~ Drink extra 1l water per

Emergencies IFE day
Module 2,
~ Eat ~ 2500kcal/day
version 1.1
2007
Separate chapter is several chapters focus on care for

on "mother
mother
traumatised, in
emotional crisis or
rejecting infant"
When BF well (if

BF)
Mother trained
to give BMS
correctly (non-BF
infants)
noted in other
chapters, but
not in section on
malnourished
infant
IYCF noted, but

reader referred
elsewhere for
details
SFP if
available
targeted SFP if
MUAC<22cm;
blanket SFP
otherwise
Many chapters of
manual focus on
good IYCF practices
reference to other
guidelines given
Guiding Principles SFP

for feeding infants details depend on
and young children the situation
during emergencies
referenced
SFP for all

Has detailed
discharged
outlining IYCF
SAM patients issues, including
use of milk products
SFP if
available
at least
SFP if
weekly for available
a
miniumum
of 3 month
n/a
IFE Core
Group
yes
~ discussed in
detail in annex,
including issues
of BF & HIV
Tnotes that
mothers/carers
may need help and
encouragement
Additional supplementary
ration (not specified)
suggested
The
management of
Nutrition in
Major
Emergencies
2000
UNHCR
Notes: "When a mother is severely

n/a
malnoursihed or suffering from
severe infection or overwork, she
may produce inadequate breastmilk,
leading to malnutrition of infant.
Breastmilk production may also be
affected by psychosocial factors
yesdetails about n/s

HIV and
nutrition
described
n/s
n/s
n/s
Handbook for
Emergencies
(third edition)
2007
UNHCR
not
specified
yes
section in
"future
developments"
chapter
discusses HIV
SFP if:
~ MUAC <210mm
& pregnant (3rd
trimester)
~ MUAC <210mm
& infant <6m
SFP or TFP or
supportive feeding
(according to
situation)
SFP
(in particular cases
of food insecurity)
Feeds for
pregnant &
lactating
women
not described
part of infant
chapter describes
support for BF +
alternatives to BF
infants are
None
eligbile for
SFP after TFP
care
Extra home Details of any

food ration? IYCF guidance
not discussed in not

not specified not specified in this
specified in in this
this chapter
chapter
this
chapter
chapter
1) Section on
HIV/AIDs,
focuses on
nutrition;
2) Described in
infant feeding &
HIV section
n/a
not specified in
this chapter
Follow
up visits
not
yes
~ noted that this specified
does not alter
the treatment
strategy
HIV noted
notes need for

psychological care
of mothers (details
not specified)
~ need to engage Need to nurse infants in quiet,

mother with
separate room noted
treatment
programme
described
~ need to reassure
& support
described
~ Drink 2l water per day;

~ Eat 2500kcal per day
~ Supplement with vitamins
+ minerals (ensure type 1
nutrient stores adequate)
~ Vit A: 200,000 IU (single
dose) if infant <2months;
else 25,000 (weekly)
Protocol Infants
less than 6
months old
(Benson) MSF OCBA 2007
MSF
~ stimulate
emotional and
physical
development
~ prepare patient
for notmal
feeding practices
Protocol notes:
~ need for
psychosocial
stimulation
Preparation
for discharge
(general)
Valid
Communitynotes need for nutritional
International based
care of mothers (details not
Therapeutic
specified)
Care (CTC), A field
manual (first
edition) 2006
notes
psychological
support and
encouragement to
mothers; also the
need for privacy
and rest
~ Drink 2l water per day

~ Eat 2500kcal/day
Nutrition
Guidelines
2006
MSF
States "stress is
important factor
reducing the
quantity of breast
milk;
Other
Nutrition
Guidelines (1st
edition) 1995
~ mentions need for extra

0.5 to 1 litre fluids/day
~ eligible for SFP if one is
available
Maternal
(caregiver)
psycho-social
issues
MSF
Country or
Guideline
Organization
Table 10 contd
85
86
Maternal diet
Nutrition Manual
for Humanitarian
Action 2008
Guidelines for the

Management of
Severe Acute
Malnutrition
(book T3)
2007
Orientacao para
Tratamento da
Desnutricao
Aguda Grave
2008
Malawi
Depistage et prise not specified

en charge de la
malnutrition
aigue 2007
Madagascar
not specified
~ Explain aim of
treatment/what is
expected; reassure
SS works; be
attentive to mother
& introduce her to
other mothers
~ need to engage
mother with
treatment
programme
described
~ need to reassure &
support mother
described
Section on
psychological
support focuses on
child rather than
carer
~ Drink at least 2l water per

need to reassure
day
mother and explain
treatments noted
~ If infant <2 months, mother
should have Vit A 200,000IU; if
<2months, then
25,000IU/week
~ Need to replenish type I
micronutrient stores noted
If EBF not
possible,
alternatives
listed include:
- modified cow
or goat milk
- infant formula
importance of
good ward
environment
described
Maternal
Other
(caregiver) psychosocial issues
~ Drink at least 2l water per

need to reassure
day
mother noted
~ If infant <2 months, mother
should have Vit A 200,000IU

~ Supplement with vitamins &
minerals (ensure type 1
dose) if infant <2months
Protocol for the

Management of
Severe Acute
Malnutrition
2007
Ethiopia

~ Supplement with vitamins &
minerals (ensure type 1
dose) if infant <2months;
25,000 (weekly if >2months)
Protocole
National de
Nutrition
2002
Burundi
National Guidelines
ICRC
Country or
Guideline
Organization
noted in list of
causes of failure
to respond to
treatment
no
yes. Details
include:
1)Need for
testing;
2)TB co-infection
3)ARV & start of
ARV
no
yes
HIV noted
~ Has detailed chapter yes

Whole chapter
on psycho-social
devoted to HIV
stimulation & care
issues
~ need for loving care,

play and stimulation
noted
~ If EBF not possible,
alternatives listed
include:
modified cow or goat
milk, infant formula
~ Health & nutrition

education
no specific details
~ has had health

education
~ immunizations up
to date
~ immunizations up
to date
Preparation
for discharge
(general)
for 3
months
after
discharge
referral for
growth
monitoring
noted
specific
infant
follow-up
not noted
briefly noted in a list

of health and
nutrition education
topics
Annex 12 gives 9
key BF messages;
Annex 13 gives 7
key messages on
nutrition & growth
Has messages on:

EBF; continued BF
until 2 years age;
appropriate
complementary
foods; key childcare
practices
Chapter is devoted
to feeding infants
and small children
Referral to SFP has detailed section

recommended in annexes outlining
IYCF issues
for all
discharged SAM
patients
SFP referral for:

~ pregnant &
lactating women with
MUAC <220mm
SFP for:
~ pregnant &
lactating women, up
to 6 months after
birth, with MUAC
<210mm
SFP for:
~ pregnant (3rd
trimester) & lactating
women with MUAC
<210mm
not described
SF for:
pregnant woman in
3rd trimester if MUAC
<210mm; also
women with infant
<6m if MUAC
<210mm
according to
nutritional state
Details of any IYCF Feeds for pregnant

guidance
& lactating
women
Referral to SFP none

recommended
for all
discharged SAM
patients
Referral to SFP
recommended
for all
discharged SAM
patients
~ monthly Mother in SFP ~

follow-up monthly until
until aged 6 6months age
months
at least 3
months
follow-up
at health
centre level
Follow up Extra home

visits
food ration?
Table 10 contd
not specified
need to reassure
and support
mother stated
not specified
Guidelines
for the
Management
of Severe
Acute
Malnutrition
through CTC
2008
Protocol
National de
Prise en
Charge de la
Malnutrition
Aigue 2008
Guidelines
for the
Management
of Severe
Acute
Malnutrition
2008
Zimbabwe
DRC
Sudan
(Southern)
~ Drink 2l water
per day
~ Eat ~
2500kcal/day
~ Supplement with
micronutrients
~ Vit A 200,000IU if
infant <2 months
paragraph on
supportive care
for mothers
mentions mental
and emotional
support for
trauma /
depression
not specified
not specified
Integrated
Management
of Acute
Malnutrition
2009
Zambia
~ Eat ~
2500kcal/day
~ Vit A: 200,000 IU
(single dose) if
infant <2months
not specified
Integrated
not specified
Management
of Acute
Malnutrition
2006
Uganda
not specified
Maternal
(caregiver)
psycho-social
issues
Management not specified

of Acute
Malnutrition
NATIONAL
Guidelines
2008
Maternal diet
Tanzania
National Guidelines
Organization
not specified
Other
yes
Protocol describes: yes

~ Health and
details given
nutrition education
~ Play therapy &
psychosocial
support
~ Immunizations
up-to-date
Protocol describes: no
~ Health and
nutrition education
~ Play therapy &
psychosocial
support
Extra home
food ration?
Referral to SFP
recommended
for all
discharged
SAM patients.
not specified
briefly noted in a list of

health and nutrition
education topics, also
notes that feeding
bottles and artificial
teats should be banned
None
Referral to SFP None

recommended
for all
discharged
SAM patients
Need to link with

other national child
programmes noted
None
Details of any IYCF

guidance
SFP for:
~ mothers of infants
with MAM
~ lactating women
with MUAC <210mm
SPF for P&L with

MUAC<185mm;
OTP for MUAC <185mm
SFP for:
~ All pregnant (3rd
trimester) & lactating
women (with infant
<6m & children on
PMTCT coming from food
insecure households
~ MUAC <225mm
SFP referral
not described
Feeds for pregnant &

lactating women
yes
Referral to SFP IYCF noted, but reader not described
"At regular intervals recommended referred elsewhere for
following discharg for all
details
discharged
SAM patients.
Specific infant
follow-up not
detailed
n/s
not specified
Referral to SFP
recommended
for all
discharged
SAM patients
every 2 months for not specified

6 months (continue/
complete any
medications;
continue BF if
child BF)
Follow up visits
yes, Whole
not specified
chapter devoted
to HIV issues,
with separate
guidelines for
HIV+ patients.
(NB focused at
>6month olds)
mentioned in
history; HIV
screening is
"necessary
laboratory
investigation"
HIV noted
~ Health &
yes
nutrition education details given
~ Links with
institutions,
organizations &
support groups
(e.g. social welfare,
home based care)
Protocol notes:~
basic health
education
messages
Protocol focuses on
RUTF-related
messages for older
children
Protocol describes:
~ Ensure
immunizations
done
~ Play therapy &
sensory stimulation
Preparation
for discharge
(general)
Table 10 contd
87
88
Guidelines for the

Management of
Severe Acute
Malnutrition in
Children 2007
None yet - in draft ~ Drink 2l water per

day
~ Supplement with
vitamins & minerals
(ensure type 1 nutrient
stores adequate)
~ Vit A 200,000IU;
Iron&folate
(60mg+400mcg) for 3
months after admission
Botswana
Burkina
Faso
~ Vit A: 200,000 IU
(single dose) if infant
<2months
Protocole
National de Prise
en Charge de la
Malnutrition
Aigue 2005
Guinea
~ Drink at least 2l
water per day
~ Rat ~ 2500kcal/day
~ Mother should be
adequately
supplemented with
vitamins & minerals
(type 1 nutrient stores
adequate) - Vit A
200,000IU

National de Prise
en charge de la
malnutrition
severe 2005
~ Drink 2l water per

day
~ Supplement with
vitamins & minerals
(ensure type 1 nutrient
stores adequate)
National
Integrated
Manual on the
Management of
Severe Acute
Malnutrition
in health facilities
and at community
level 2008
~ Drink 2l water per

day
~ Supplement with
micronutrients
~ Vit A 200,000IU if
infant <2 months,
25000IU weekly
otherwise
Maternal diet
Sudan
(North)
National Guidelines
Organization
need to reassure and support

mother stated
2 pages of protocol devoted to

psychosocial care & support
~ need to engage mother with

treatment programme described
~ need to reassure & support
mother described
~ importance of good
environment described
~ need to engage mother with
treatment programme described
~ need to reassure & support
mother described
~ importance of good
environment described

mother (e.g. 'be attentive')
emphasised
Mother should receive medical
treatment if needed

mother stated
Maternal (caregiver) psychosocial issues
no
noted in
list of 6
causes of
poor
weight
gain
noted in
list of
multiple
causes of
treatment
failure
Protocol describes: no
~ Health and
nutrition education
~ Play therapy &
psychosocial
support
Extra home
food ration?
Details of any IYCF

guidance
Says "feed frequently

with energy and
nutrient dense foods"
Feeding bottles and
artificial teats should
be banned
briefly noted in a list of

education topics, also
notes that feeding
bottles and artificial
teats should be banned
~ Mother should None

have
supplementary
feeds to maintain
quantity and
quality of milk
supply
Referral to SFP
None
recommended for
all discharged
SAM patients.
Specific infant follow- Referral to SFP

up not detailed
recommended for
all discharged
SAM patients.
follow up for at least

3 months postdischarge
follow up noted but

not detailed
~ weekly for 1 month no noted

~ fortnightly next
month
~ monthly for next 2
months
~ as needed
thereafter
~after 1 week, 2
Referral to SFP
None
weeks, 1 month, 3
recommended for
months and 6months all discharged
SAM patients.
(SFP for mother in
case of infant
<6m)
HIV noted Follow up visits
~ counselling and yes

heath education
completed (good
childcare practices
are described in
detail)
~ immunization
up-to-date
~ arrangements
made for follow-up
Protocol mentions:
~ Childcare
practices
~ Parenting
capacity
~ Play therapy
~ counselling and
heath education
completed
~ immunization
up-to-date
~ arrangements
made for follow-up
~ ensure child is
fully re-integrated
in family &
community
~ fully immunized
~ health and
nutrition education
Other Preparation
for discharge
(general)
SFP for:
~ mothers of infants
with MAM
~ lactating women
with MUAC <210mm
not described
SFP if MUAC <210mm

or if her infant <6m
has MAM
not described
not described
Feeds for pregnant &

lactating women
Table 10 contd
Protocole de prise en charge

de la malnutrition aigue
2008
Senegal
Indian Academy of Paeditrics not specified

guidelines on hospital based
management of Severely
Malnourished Children 2006
Protocol for the inpatient

not specified
treatment of severely
malnourished children in the
Pakistan earthquake
emergency 2005
Management of Severe Acute not specified

Undernutrition: Manual for
Health Workers in Sri Lanka
2007
Pakistan
Sri Lanka
Mother should be
adequately supplemented
with vitamins & minerals
(type 1 nutrient stores
adequate)
India
Afghanistan Community-based
Management of Acute
Malnutrition programme in
Aqcha and Mardyan District
of Jawzjan Province Northern
Afghanistan (Stabilization
Centre Guidelines) 2008
~ need to
engage mother
with treatment
programme
described
~ need to
reassure &
support mother
described
Protocol National de Prise en ~ Drink 2l water per day;

Charge de la Malnutrition
Aigue 2006
~ Supplement with vitamins
& minerals (ensure type 1
~ Vit A 200,000IU if infant
<2months old; Iron & folate
(60mg+400mcg) for 3
months after admission
Niger
not specified
not specified
not specified
not specified
~ Drink 2l water per day ~ need to

engage mother
with treatment
programme
described
has paragraph
on psychosocial
environment
Maternal
(caregiver)
psycho-social
issues
Protocole National de la prise ~ Drink 2l water per day

en charge de la malnutrition ~ Eat ~ 2500kcal/day
aigue 2007
~ Supplement with
vitamins & minerals
~ Vit A 200,000IU if infant
<6 weeks
Maternal diet
Mali
National Guidelines
Organization
need for regular

follow-up
emphasised
yes
~ Details of HIV and
related issues
discussed
annex has section on

play therapy
Protocol mentions:
~ completing
immunizations
~ sensitizing carers to
home care
~ play therapy
Protocol describes:
~ Health and nutrition
education
~ Play therapy &
psychosocial support
not specified
no
yes:
~ noted that "recovery
may take longer and
treatment failure is
more common
~ treatment should be
same as for HIV
no
no
referral for followup noted
yes
~ weekly for 1
month
~ fortnightly for 2
months
~ monthly for 3
months
Specific infant
follow-up not
detailed
monthly until aged

6 months
not specified
as for older children:

for 3 months
~ weekly for 1
month
~ fortnightly
thereafter
None
guide to family
None
foods for children
aged 1 to 5 years
given in annex
not specified
not described
SFP for
pregnant and
lactating
women (with
infant <6m) if
MUAC <210mm
SFP for
pregnant and
lactating
women (with
infant <6m) if
MUAC <210mm
not described
not described
briefly noted in a list not described

of health and
nutrition education
topics, also notes
that feeding bottles
and artificial teats
should be banned
None
referral to SFP (if None

available)
recommended for
all discharged
SAM patients
not specified
Feeds for
pregnant &
lactating
women
noted within list of SFP if MUAC

<210mm
health and
education topics for
community health
workers to cover
Details of any
IYCF guidance
Referral to SFP
None
recommended for
all discharged
SAM patients.
Referral to SFP
recommended for
all discharged
SAM patients.
Follow up visits Extra home

food ration?
yes
~ A chapter is
devoted to HIV &
related issues
HIV noted
Protocol mentions:~ play yes

therapy~ nutritional
advice to mother~
ensure mother can
recognise 'danger signs'
of clinical deterioration
Protocol mentions:
~ play therapy
~ health and nutrition
education
Protocol mentions:
~ play therapy
~ health and nutrition
education
Other Preparation
for discharge
(general)
Table 10 contd
89
4.5 An AGREE appraisal of current guidelines

Using the AGREE appraisal framework (boxed), these are the common issues identified in this review:
a) Scope and purpose of guidelines in addressing infant <6m malnutrition

1.
2.
3.
The overall objective(s) of the guideline should be specifically described.

The clinical question(s) covered by the guideline should be specifically described.
The patients to whom the guideline is meant to apply should be specifically described.
Guideline objectives to address child malnutrition are generally well stated. Titles alone are often enough
to determine whether all types of acute malnutrition or only SAM is the focus.
Guidelines are generally much poorer at explicitly stating the needs of infants <6m. Infant <6m MAM is
almost universally neglected (except by Burkina Faso guideline and IFE Module 2). In some guidelines
infants <6m are only indirectly addressed, including in the WHO 1999 and 2003 guidelines. Some
guidelines usefully state the objective of infant treatment (e.g. to restore exclusive breastfeeding). As
infant <6m management is different from that of older infants and children it seems sensible that future
guidelines deal with it specifically.
b) Stakeholder involvement
4.
The guideline development group should include individuals from all the relevant
professional groups.
It is not possible to say which professional groups had inputs into guideline writing without detailed
probing with guideline sources. Many current guidelines have minimal detail of how to clinically assess
infants <6m and focus heavily on supplemental feeds as the core treatment option. This possibly reflects
predominantly nutrition-focused writing groups. Other professionals that may be relevant in the writing
of future guidelines on infants <6m include dieticians, paediatricians, obstetricians, nurses, midwives,
speech & language therapists, HIV specialists, lactation specialists, psychologists and community health
workers.
5.
The patients views and preferences should be sought.
IYCF is a family affair and a severely malnourished infant <6m needs involvement of not just the mother or
primary caregiver, but the father, family and community to support treatment. It is clearly difficult for
international guidelines to include users, however, this should certainly be a feature of national guidelines.
Some CMAM guidelines note the importance of community engagement as an essential element of
SAM/MAM management. This should be encouraged and made universal. Even basic understanding of
local context factors influencing malnutrition may make big differences to acceptance and acceptability of
treatments.
6.
The target users of the guideline should be clearly defined.
Target users are often not clear in guidelines reviewed. Many guidelines, for example, combine details of
clinical management with details of programme management, which can confuse content. Future authors
should consider and ideally research the pros and cons of a comprehensive vs. targeted approach. For
example, small, clinically focused case management pocket size handbooks are often liked by front line
clinical staff. Managers, meanwhile, might appreciate a large file with step-by-step instructions about
troubleshooting programme databases.
90
7.
The guideline should be piloted among end users.
There is a clear evolution of guidelines, which suggests a process of testing and refining. However, results
of piloting and testing are not clearly stated in any of the guidelines reviewed. This would be helpful for
users and could be housed in a, probably web-based, repository of guidelines and evaluations for others
to learn from.
c) Rigour of Development
8.
9.
10.
11.
12.
13.
Systematic methods should be used to search for evidence.

The criteria for selecting the evidence should be clearly described.
The methods used for formulating the recommendations should be clearly described.
Health benefits, side effects and risks should be considered.
There should be an explicit link between recommendations & supporting evidence.
The guideline should be externally reviewed by experts prior to publication.
Guidelines reviewed are end-products. Separate documents outlining the guideline development process
and articulating the underlying evidence base behind individual recommendations were not available. A
2004 WHO consultation to Review the literature on Severe Malnutrition139 is probably reflective of most
current approaches to malnutrition guideline development. Expert consultations and critical reviews are
used to identify, interpret and translate available research into policy. Guidelines for the development of
guidelines (e.g. GRADE140 and SIGN141) could be used in future.
In considering health benefits, side effects and risks, it is important to consider the implications of
therapeutic treatment of infants <6m amongst the wider infant population. For example, are there risks
that supplemental feeding of malnourished breastfed infants <6m will carry mixed messages to the
caregiver and community regarding causes of malnutrition and benefits of exclusive breastfeeding? And,
if so, how should these risks be managed? None of the guidelines reviewed address these broader issues
of spillover and population impact. Locating strategies to treat SAM and MAM in infants <6m within a
broader infant and young child feeding framework (see Chapter 2) can help to identify wider risks and
inform risk management.
14.
A procedure for updating the guideline should be provided.
No guideline noted its expiry date. This probably reflects the short term and uncertain nature of funding
in international nutrition. However, for optimal future impact, regular guideline updates are needed and
processes for this should be clearly stated.
d) Clarity & presentation

15.
16.
17.
The recommendations should be specific and unambiguous.

Different options for diagnosis and/or treatment of the condition should be presented.
Key recommendations should be easily identifiable.
There were considerable variations in how easy guidelines were to follow and how much detail they
contained. Varying formats made guideline comparisons difficult, with some recommendations often hard
to find. Management of infants <6m was sometimes explicitly stated, (e.g. antibiotic choice), other times
not, e.g. diagnosis of fluid overload. This issue needs to be addressed in future guidelines by stating
explicitly when and how infants <6m should be treated differently throughout and when treatment is the
same.
91
18.
The guideline should be supported with tools for application.
A key strength of WHO 1999 and its wide acceptance and use is that it was accompanied by a training
programme to aid implementation. Limited information was available as to whether reviewed guidelines
were actively promoted to target audiences and if tools were given to aid rollout.
Chapter 8 of IFE Module 2 is actually a training resource that has become a guidance material, due to the
gap in formal guidance. An evaluation of IFE Module 2 amongst users (2006) found that content on SAM
<6m was typically used as reference material for programmes more than a training content142.
e) Applicability
19.
20.
Potential organisational barriers in applying recommendations should be discussed.

Potential cost implications of applying the recommendations should be considered.
These were not directly addressed in the majority of guidelines reviewed. This is most probably because
all guidelines identified were primarily targeted at front-line field staff rather than policy-makers deciding
on whether or not they wanted to implement the programme in the first place.
21.
The guideline should presents key review criteria for monitoring and audit purposes
A few recent guidelines (e.g. Tanzania, Zambia, Zimbabwe) include a checklist to help programme
managers to ensure that all factors relevant to high quality care were being considered. There is some
evidence that checklist strategies can have a positive impact on patient outcomes143, so this might be
useful for other guidelines to replicate in future. Ideally research should be done to develop an evidencebased checklist for infant <6m malnutrition, as well as for child malnutrition.
f) Editorial Independence
22.
23.
The guideline should be editorially independent from the funding body.

Conflicts of interest of guideline development members should be recorded.
Organizations like WHO and UNICEF often play dual roles as both funders of guideline development and
technical experts advising on guideline details. UNICEF also contributes funds and resources to inpatient
programmes in some settings. Any risk of conflicts of interest can be minimized by having independent
individuals on the guideline writing team. This is currently the case for many national guidelines, which
have a variety of authors involved. It would be good practice for future guidelines to name all contributing
individuals and organizations.
Future guidelines would be improved by aiming towards AGREE standards at the time of writing. This will
require more person-time resources for writing / guideline development but may have positive impacts in
terms of individual outcomes.

Summary findings
A total of 37 guidelines (14 international and 23 national) were identified for review. Most share a common
origin in the WHO 1999 guideline and describe the ten steps approach to care.
Community-based management of Acute Malnutrition (CMAM) is rapidly being recognised as the norm
for the management of acute malnutrition for children aged 6 to59m. The Valid International field manual
(2006) is a key reference.
92
MUAC is frequently used in the guidelines as an independent admission criterion, though in no guidelines
is it recommended for use in infants <6m.
There is wide variation in how current guidelines address acute malnutrition in infants <6m and some only
implicitly recognise the problem.
There is inconsistency in age, weight and length cut-offs used to identify infants <6m for admission and
their subsequent treatment.
All guidelines recommend inpatient care for SAM in infants <6m and focus on nutritional treatments with
the aim of restoring exclusive breastfeeding. Very few guidelines give details of the MAM in infants <6m.
Few guidelines include details of IYCF/breastfeeding support. MSF guidelines 2006, ACF Assessment and
Treatment of Malnutrition, 2002 and IFE Module 2 are important exceptions.
Future guidelines and guideline updates should build on and expand MAMI guidance, both SAM and
MAM, and should give more details on IYCF/ breastfeeding support.
The following three guidelines could be considered a good reference/ template for future MAMI
guidelines: MSF guidelines 2006, ACF Assessment and Treatment of Malnutrition, 2002 and IFE Module 2
Strategies with potential to improve outcomes of infant <6m SAM include implementation of routine
kangaroo care144 for inpatient complicated cases of SAM.
MAMI strategies should be located within a framework of safe and appropriate IYCF; synergies in
programming between <6m and 6 to 24m age groups must be better reflected in the guidelines.
In the context of international rollout of CMAM programmes, it is noteworthy that MAMI is predominantly
inpatient-focused. Options for outpatient based care in infants <6m should be considered in future
guidelines.
Greater clarity is needed on anthropometric criteria, measurement cut-offs and age assessment for SAM &
MAM infants <6m.
More resources should be devoted to future guideline development. Tools such as GRADE and AGREE
should be used to better enhance the quality of future guidelines. An open access online guideline library
might facilitate development of future documents.
Endnotes
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
http://www.gradeworkinggroup.org/
WHO (1999) Management of severe malnutrition: a manual for physicians and other senior health workers. World Health Organisation.
Geneva: World Health Organisation.
Valid International (2006) Community-based Therapeutic Care (CTC). A Field Manual. Oxford: Valid International.
statement by the World Health Organization and the United Nations Children's Fund. May 2009.
Angood, C. (2006) Weighing scales for young infants: a survey of relief workers. Field Exchange. 2006(29):11-2.
IFE Core Group (2007) Chapter 5. Section 5.3 Babies who are visibly thin or underweight. IFE Module 2. Oxford: Emergency Nutrition
Network.
IFE Core Group (2007) Chapter 5. IFE Module 2. Oxford: Emergency Nutrition Network.
SS involves an initial attempt at normal BF. 30 to 60 minutes later the infant tries suckling again. But the breast this time has a small
nasogastric tube taped near to the nipple. The idea is that the process of suckling helps stimulate progressively increasing breastmilk
production. Acknowledging that this takes time - but that infantU6m nutritional needs are urgent - BMS provides maintenance nutrients
at 100kcal/kg/day.
WHO (2009) Acceptable medical reasons for use of breast-milk substitutes. WHO/NMH/NDH/09.01. Available via
http://www.who.int/nutrition/publications/infantfeeding/WHO_NMH_NHD_09.01_eng.pdf
WHO. (2004) Severe malnutrition: Report of a consultation to review current literature. Geneva, Switzerland, 06 - 07 September, 2004.
Jaeschke, R., Guyatt, G.H., Dellinger, P., Schunemann, H., Levy, M.M., Kunz, R., et al. (2008) Use of GRADE grid to reach decisions on
clinical practice guidelines when consensus is elusive. BMJ. 2008;337:a744.
SIGN. Scottish Intercollegiate Guidelines Network. Available from: http://www.sign.ac.uk/.
IFE Core Group (2007) Chapter 5. IFE Module 2. Oxford: Emergency Nutrition Network.
Haynes, A.B., Weiser, T.G., Berry, W.R., Lipsitz, S.R., Breizat, A-H.S., Dellinger, E.P., et al. (2009) A Surgical Safety Checklist to Reduce
Morbidity and Mortality in a Global Population. N Engl J Med. 2009 January 29, 2009;360(5):491-9.
Kangaroo care consists of skin-to skin contact between mother and infant. Key features are continuous and prolonged skin-to-skin contact
between the mother and baby, accomplished by the baby being firmly attached to the mother chest both day and night, allowing frequent
and exclusive breastfeeding (or breastmilk substitute if required).
93
Chapter 5
Review of field treatment
94
Chapter 5 Review of field treatment
Chapter 5: Review of field treatment

5.1 Rationale for field data analysis
Describing infant <6m patient profile and outcomes associated with current management is central to the
MAMI Project. From analysis of field data, hypotheses can be generated, and where possible, inferences
made about the effectiveness of current management strategies. This chapter presents data on infants
<6m gathered from therapeutic feeding programmes (TFPs) and supplementary feeding programmes
(SFPs), with a particular emphasis on individual level data. This is complemented by qualitative key
informant data in Chapter 6.
5.2 Aims
To analyse available TFP and SFP databases to determine:
% of current feeding programme admissions that are infants <6m
anthropometric and clinical profile of malnourished infants <6m
outcomes from current programmes, that use current management guidelines, for infants <6m.
5.3 Methods
5.3.1 Identifying field data
An open invitation was given to share databases of programmes targeting acute malnutrition in infants
<6m and contacts were actively pursued from May 2008 to December 2008. This generated two types of
database:
a) Raw databases with individual-level data on each patient admitted for treatment
A total of 33 datasets with information on individual children and infants <6m were obtained. These were
mostly from Action Contre la Faim (ACF), from 12 countries, with a total of 118,180 individuals aged 0 to 59
months. Data was available in Excel format which had been previously entered in the field, and further
sorted and cleaned at organizational headquarter level. For 11 countries, a detailed description of the
datasets received, grouped by country of origin, was provided. The number of individuals aged 0- 59m
included in each dataset ranged from 59 to 22,473 with an average of 3,812 per dataset. This data is the
main focus of the chapter.
b) Summary databases reporting overall programme outcomes by age category
Two different sources of compiled data were made available to the MAMI Project. First, routine databases
compiled by MSF of various non-contiguous dates, spanning between July 2003 and December 2008, of
seven programmes located in Sierra Leone (two programmes), Niger (four programmes) and Somalia (one
programme). Secondly, a dataset of compiled data from 15 programmes in Burundi from various
organizations, covering the period September 2001 to December 2002. These compiled data were used to
assess the difference in mortality as an outcome between infants <6m and children.
5.3.2 Cleaning & processing field data

In all datasets, complete data was available for most individuals only at admission and discharge. Data
from multiple follow-ups were also available, but there was large heterogeneity of values, so these were
not included. Data at admission included date, age, weight, length/height, MUAC and the presence of
oedema. Data at discharge included date, weight, height and MUAC and outcome. Since our main aim was
to evaluate the disease burden and outcomes, only variables at admission and outcomes were selected.
95
5.3 Methods
All variables at admission and discharge were cleaned and coded for analysis. Data were checked for
errors which may have occurred during data entry or database merging. Data cleaning was done twice by
the same person, each at different times. Agreement in data cleaning results was assessed and when
differences arose, corrected. Data were recoded to simplify the large number of initial outcomes
described by field programmes.
Table 11: Description of the raw databases of children 0-59m received for analysis by
country
Country
Organisation
Year
Sites
Type of care
Afghanistan
ACF
2002-04
Kabul
TFC, DC, SC
1,096
Burundi
ACF
2006-07
Buye
Gikomero
Kabarore
Kayanza
Kinini
Matongo
Mubuga
Muhanga
Musema
Ngozi
Rukago
Ruyigi
CJ, PTA
5,481
Ethiopia
MSF
2006-08
Kuyera
SC
59
Kenya
ACF
2005-07
Banisa
Malkamari
Mandera
Takaba
TFC, OTP,
SFC
8,466
Liberia
ACF
2006-08
Monrovia
TFC
2,797
Myanmar
ACF
2006-08
Buthidaung
Moungdaw
SC, HT, OTP
2,011
Niger
ACF
2006-08
Abalak
Keita
Mayahi
CRENAS,
CRENI
7,110
DRC
ACF
2005-07
Baraka
Buta
Baraka
Dubie
Kilembwe
Malemba
Mitwaba
Sampwe
Uvira
CNT, CNS, HT
24,155
Somalia
ACF
2005-07
Baraka
Buta
Baraka
Dubie
Kilembwe
Malemba
Mitwaba
Sampwe
Uvira
CNT, CNS, HT
24,155
Somalia
ACF
2005-08
Mogadishu
Wajid
TFC, OTP, SC
8,355
Sudan
ACF
2005-08
Nyala
El Fasher
Kalma
Bentiu
TFC, OTP, SC
8,355
Tajikistan
ACF
2005-06
Kulyab
Kurgan Tyube
SFC, TFC
9,329
Uganda
ACF
2005-07
Amuru
Apac
Gulu
Lira
Oyam
SFC, TFC,
TFP, CBC
45,591
118,180
33
Total
96
DRC: Democratic Republic of the Congo;

ACF: Action Contre la Faim;
MSF: Mdecins Sans Frontires;
CBC: Community-based Care;
CJ: Centre du Jour;
CNS: Centre de Nutrition Supplmentaire;
CNT: Centre de Nutrition Thrapeutique;
CRENAS: Centre de
Rcupration Nutritionnelle
Ambulatoire pour Svres;
CRENI: Centre de Rcupration
Nutritionnelle en Interne;
DC: Day Centre;
HT: Home treatment;
No. of datasets
OTP: Out-Patient Therapy; PTA:

Programme Thrapeutique
Ambulatoire;
SC: Stabilisation centre;
SFC: Supplementary Feeding Centre;
TFC: Therapeutic Feeding Centre;
TFP: Therapeutic Feeding Program
5.3 Methods
Table 12: Details of the data cleaning results

Action taken
Variable with errors/Type of error
Deleted
Double data entry/duplicates

Age at admission
Admission date
Corrected*
Missing values
1,389
19
128
93
Admission weight
57
1,606
608
Admission height
160
1,047
874
Admission MUAC
2,067
13,001
1,919
Discharge weight
40
1,421
3,029
Discharge height
94
919
3,855
413
2,010
12,223
2,181
9,200
35,602
Discharge date
Discharge MUAC
Total
* See the body of the text for an explanation of the types of errors corrected.
Data cleaning
Table 12 details the distribution of errors in all variables and whether the error was deleted or corrected.
From a total of 118,180, 1,389 (1.2%) individuals were found duplicated in the datasets and eliminated. All
duplicates came from the same dataset. A total of 11,381 errors were found that were either corrected
(80.8%) or deleted (19.2%). The large majority of errors were clustered around anthropometric
measurements (9,834 or 86.4%), MUAC data being the most predominant source of error (35.8%).
Common errors were incorrect use of punctuation (e.g.: 12...5, 12:5, etc.) or the combination of text and
number (e.g.: 4mo, 2y4m, etc.). Additionally, missing values in the dataset (usually anthropometric
measurements) were more common at discharge than at admission. MUAC at admission and discharge
accounted for the greatest proportion of missing values (70.8%). These missing MUAC measurement
reflect two issues:
MUAC is not currently recommended for infants <6m so was less commonly measured in this age
group
MUAC has only been gaining widespread acceptance in the last few years; at the time these datasets
were collected the main focus / admission criterion was weight-for-height.
Data coding
Three variables were coded to reduce variability and cluster similar groups, and so facilitate analysis:
a) Programme type
The type of programme was indicated in the dataset by either a separate variable or as the title of the
dataset. Table 13 provides detail of the original coding provided for each programme and the new code
for MAMI Project analysis. Re-coding reduced the number of categories from 14 to seven. The number of
individuals included in each category is detailed in Table 13. The majority of individuals (62.9%) were
admitted in Supplementary Feeding Centres (SFC), followed by Therapeutic Feeding Centres (TFC) and
Out-Patient Therapy Programmes (OTP). We could not determine the type of programme for 1,020 (0.9%)
enrolled individuals.
b) Age group
Individuals were classified according to their age in six categories based on the criteria defined in Table 15.
Of the total of 116,791, 0.1% had missing data on age and 12.9% were classified as having an age at
admission greater than 60 months. Since there was evidence of rounding up of age to 60 months, children
at 60 months (n=2712) were included in some of the analysis as a separate group.
c) Discharge outcome
A total of 101 different codes were used to classify the discharge outcome. Of these 101 codes, only 31
were used in more than one country (Table 43 in Appendix C). Cured, defaulter, admission mistake, death
and transfer were the outcomes more commonly used. Overall, countries varied widely in the number of
discharge outcome codes used, ranging from six to 48 different codes.
97
5.3 Methods
The original discharge outcomes codes were grouped into Sphere-compatible discharge codes as
detailed in Table 13. Where the final outcome was unclear and coded only as end of follow-up discharge
codes were re-coded as cured if their WHM was 80% or as non-recovery if it was < 80%.145
Table 13: Programme type coding

Original*
Meaning
New
Meaning
CBC
Community-based Care
CBC
Community-based Care
CJ
Centre du Jour
DC
Day Centre
DC
Day Centre
DC
Day Centre
HT
Home treatment
HT
Home Treatment
CRENAS
Centre de Rcupration Nutritionnelle Ambulatoire OTP

pour Svres
Out-Patient Therapy
CS
Centre de Rcupration Nutritionnelle Ambulatoire OTP

pour Svres
Out-Patient Therapy
OTP
Out-Patient Therapy
OTP
Out-Patient Therapy
PTA
Programme Thrapeutique Ambulatoire
OTP
Out-Patient Therapy
SC
SC & HT
Stabilisation centre
Stabilisation centre - Home treatment
SC
SC
CNS
Centre de Nutrition Supplmentaire
SFC
SFC
SFC
CI
Centre de Rcupration Nutritionnelle en Interne
TFC
CNT
Centre de Nutrition Thrapeutique
TFC
CRENI
Centre de Rcupration Nutritionnelle en Interne
TFC
TFC
TFC/DC/HT
TFC-HT
TFP

Therapeutic Feeding Program
TFC
TFC
TFC
TFP

Therapeutic Feeding Programme
* As it appears in the original datasets.
Table 14: Number of individuals enrolled in different types of programme

Programme type
CBC
1,091
0.93
DC
HT
3,365
1,311
2.88
1.12
11,916
10.20
505
74,342
23,241
1,020
116,791
0.43
63.65
19.90
0.87
OTP
SC
SFC
TFC
Missing
Total*
DC: Day Centre;
HT: Home treatment;
*1,389 records were excluded as duplicates
98
OTP: Out-Patient Therapy;

SFC: Supplementary Feeding
Centre;
TFC: Therapeutic Feeding Centre.
5.3 Methods
Table 15: Definition of age categories & frequency

Age group
Missing
<6 months
6 to 59 months
60 months
Confirmed >60 months*
Not confirmed >60 months

Total
N %
112
5,033
93,929
2,712
7,720
7,285
116,791
Definition
0.10 Age data at admission missing
4.31 Age at admission <6 months
80.42 Age at admission 6 months but <60 months
2.32 Age at admission = 60 months
6.61 A combination of at least two values. Age at admission
>60 months, weight at admission >33 kg and height at
admission >130 cm
6.24 Age at admission >60 months
* An individual with and age value <60 months but with a combination of weight and height at admission greater that 33 kg and 130 cm
respectively was considered as older than 60 months. These values correspond to approximately 6 and 4.4 z-scores for weight and height
for age respectively for a 60 months old male and 5.5 and 4.9 z-scores for a 60 months old female.
99
5.3 Methods
Table 16: Re-coding of original discharge codes into a Sphere-compatible code

Sphere discharge code
Original discharge
code*
Admission New
error
Defaulter
Died
Cured
Nonrecovery
End of CBC follow up
End of TFC
90
End of TFC follow up
2,090
End of follow up
711
End of transit
Fin suivi CNT
2,660
902
Cured
50,483
End OTP
End of CBC
End of OTP follow up
Guri
23,921
Total
86
Dead
294
Death
691
Dcd
35
Died
14
Dcs
710
13
Autres
72
C.N.R
276
CNR
613
Critres non-atteints
163
D/Regestration
DNG
45
Inconnu
44
Medical referal
Medical transfer
201
NR
51
Non guri
47
Non rpondant
1,645
Non respond
Non respondant
362
Non respondant
9,355
Non response
317
OTP transfer
Other
545
Others
15
R,Creni
10
R,Transfert
68
Refus Creni
Refus de transfert
Refus transfert
Refused to go TFC
SFC transfer
43
T, Creni
21
TFC
20
To other OTP
Transfer
863
Transfer CTC / TFC
12
Criteria not reached
100
Missing
23
5.3 Methods
Table 16 contd
Original discharge
code*
Admission New
error
Defaulter

Died
Cured
Nonrecovery
Missing
Total
Transfer HP
139
Transfer SFC
46
Transfer TFC
26
Transfer other
Transfer others
Transfer to CBC
101
Transfer to CTC
32
Transfer to Health Ce
Transfer to OPT
Transfer to OTP
59
Transfer to OTP / TFC
414
Transfer to SFC
249
Transfer to TFC
786
Transfer to other CTC
Transfer to other OTP
Transfer to other SFC
965
Transfert
584
Transfert CNS
1,494
Transfert CNT
619
Transfert CS
Transfert Centre de S
Transfert H
Transfert hpital
161
Transfert medical
33
Transfert vers crenam
Transfert vers creni
31
Transfr
31
Transit
Unknown
Wrong discharge
31
non responder
136
Abandon
2,061
104
Def
Default
76
8,531
Defaulter
AM
Admission error
Admission mistake
449
CH
45
Cheating
36
Erreur admission
Erreur d'admission
283
Error
Mistake
Mistake admission
Mistake of admission
Wrong admission
Wrong child
14
Missing value
Total
+
862
10,773
1,757
80,174
21,614
1,611
1,611
116,791
* As originally appear in the databases. End of follow-up were classified as either cured if weight for height at discharge was at least 80%,
or non-recovery if it was less than 80%
101
5.4 Analysis
5.4 Analysis
5.4.1 Data selection for analysis
From an original dataset of 118,180 individuals, we excluded all duplicate records, individuals >60m or
with either age or sex missing (Figure 19) leaving a sample of 100,688 individuals aged >0 to 60 months.
The distribution of infants <6m, children 6 to 59m and 60m for each programme type are described in
Table 17. As expected, programmes providing CBC, OTP and SFC care have none or very few infants in
their datasets (0, 0.21 and 1.52% respectively). Data from these three groups were excluded from the
analysis of infant acute malnutrition (Figure 18). DC, HT, SC and TFC care presented 24.67%, 9.97%, 23.91%
and 14.78% of infants <6m respectively. The final sample for analysis of acute malnutrition was 25,195
children aged 0 to 60 months.
Table 17: Frequency distribution by age group and programme type

Programme type
CBC
DC
HT
OTP
SC
SFC
TFC
Total
<6 months
6 to 59 months
60 months
Total*
1,071
99.63
0.37
1,075
100
2,992
738
2,053
201
24.67
68.62
6.72
100
114
1,009
20
1,143
9.97
88.28
1.75
100
24
11,047
116
11,187
0.21
98.75
1.04
100
99
306
414
23.91
73.91
2.17
100
963
60,213
2,055
63,231
1.52
95.23
3.25
100
3,051
17,299
296
20,646
14.78
83.79
1.43
100
4,989
92,998
2,701
100,688
4.95
92.36
2.68
100

CJ: Centre du Jour;
DC: Day Centre;
HT: Home treatment;

OTP: Out-Patient Therapy;
SFC: Supplementary Feeding Centre;

* As originally appear in the databases. End of follow-up were classified as either cured if weight for height at discharge was at least 80%,
or non-recovery if it was less than 80%
Figure 18: Flow diagram of data selection for analysis

Original dataset
n = 118,180
Exclusion of duplicates (1,389)

Exclusion if older than 60 months or age missing (15,117)
Exclusion if sex missing (15)
Exclusion if programme care data missing (971)
n = 100,688
Exclusion if children in SFC (63,231)
Exclusion if children in OTP (11,187)
Exclusion if children in CBC (1,075)
Data for analysis

n = 25,195
102
5.5 Results
5.4.2 Data analysis

Simple comparisons were carried due to the nature and quality of the data. Meta-analysis was carried for
comparison between infants <6m, children aged 6 to 59m and children=60m months for the presence of
oedema and death as an outcome of the programme.
5.5 Results
5.5.1 Country and programme distribution
A total of 25,195 children, of whom 4,002 were infants <6m, were included in the MAMI Project analysis.
The distribution of infants <6m and children according to the type of programme and country of origin
are detailed in Table 18. The contribution to our final 0 to 60 month sample ranged, by country, from 57
(0.2%) from Ethiopia to 6,229 (24.7%) from DRC. Most of this sample of children were managed in TFCs (n
= 20,646, 81.9%), and a minority in SCs (n = 414, 1.6%). A similar distribution pattern was observed for
infants <6m
Table 18: Programme and country distribution of the final sample included for analysis* and
the sub-sample of infants <6m
0 to 60 months
Type of programme
Country
DC
Afghanistan
HT
SC
TFC
633
Burundi
Total
460
1,093
539
539
2,436
2,436
2,359
Ethiopia
57
57
Kenya
Liberia
Myanmar
1,143
248
1,391
Niger
1,108
1,108
DRC
6,229
6,229
Somalia
2,997
2,997
5,218
5,327
Sudan
109
Tajikistan
Uganda
Total
0 to 60 months
2,992
1,143
414
373
373
1,286
1,286
20,646
25,195
Type of programme
Country
DC
HT
Afghanistan
592
Burundi
146
SC
TFC
Total
438
146
Ethiopia
33
Kenya
Liberia
Myanmar
1,030
114
33
37
37
167
167
66
180
Niger
145
145
DRC
1,400
1,400
Somalia
402
402
Sudan
360
360
Tajikistan
86
86
Uganda
16
16
3,051
4,002
Total
DRC: Democratic Republic of the Congo

DC: Day Centre
HT: Home treatment
738
114
99
SC: Stabilisation centre

TFC: Therapeutic Feeding Centre
* 92,985 records were removed from the original 118,180 sample.
103
5.5 Results
Table 19: Burden of disease. Age distribution by country and by programme, of the sample
of children selected for analysis*
Age group
Country
Afghanistan
Burundi
Ethiopia
Kenya
Liberia
Myanmar
Niger
DRC
Somalia
Sudan
Tajikistan
Uganda
Total
<6 months
6 to 59 months
60 months
Total
1,030
63
94.2
5.8
1,093
146
2,012
201
2,359
6.2
85.3
8.5
100.0
n
%
33
57.9
24
42.1
100.0
57
100.0
37
494
539
6.9
91.7
1.5
100.0
n
%
167
6.9
2,249
92.3
20
0.8
2,436
100.0
180
1,189
22
1,391
12.9
85.5
1.6
100.0
145
963
1,108
13.1
86.9
100.0
1,400
4,634
195
6,229
%
n
%
n
%
n
%
n
%
n
22.5
402
13.4
360
6.8
86
23.1
16
1.2
4,002
74.4
2,563
85.5
4,928
92.5
287
76.9
1,261
98.1
20,667
3.1
32
1.1
39
0.7
9
0.7
526
100.0
2,997
100.0
5,327
100.0
373
100.0
1,286
100.0
25,195
15.9
82.0
2.1
100.0
Age group
Country
DC
HT
SC
TFC
Total
<6 months
6 to 59 months
Total
738
24.7
114
10.0
99
23.9
3,051
14.8
4,002
2,053
68.6
1,009
88.3
306
73.9
17,299
83.8
20,667
201
6.7
20
1.8
9
2.2
296
1.4
526
2,992
100.0
1,143
100.0
414
100.0
20,646
100.0
25,195
15.9
82.0
2.1
100.0

DC: Day Centre;
HT: Home treatment;

104
60 months
n
%
n
%
n
%
n
%
n
5.5 Results
5.5.2 Burden of disease of infant <6m malnutrition: age distribution

Overall 15.9% of total admissions were infants <6m, with a wide range from 1.2% in Uganda to 37% in
Kenya and 94.2% in Afghanistan. By programme type, infant <6m malnutrition ranges from 10% in HT care
to 24.7% in DC care.
Acute malnutrition in infants <6m forms part of the normal phenomenon of malnutrition early in life, as
shown form the age distribution in Figure 19. The pattern remains, even after the exclusion of Afghanistan
and Ethiopia datasets where data on infant <6m is concentrated. For children 12 months, the rounding
of age to the nearest three and six months period was common, with rounding to the nearest six most
common. The prevalence of admissions in children decreases with age, markedly after the age of 36
months.
Figure 19: Age frequency distribution at admission

a) Excluding data from Afghanistan and Ethiopia (n = 24,045)
b) Including data from Afghanistan and Ethiopia (n = 25,195)
a)
Frequency (%)
15
10
b)
12
18
24
12
18
24
30
36
Age (months)
42
48
54
60
42
48
54
60
Frequency (%)
15
10
0
30
36
Age (months)
Infants <6m were grouped by age as <2 months, 2 to 3.9 months and 4 to 5.9 months and the distribution
was analysed by country and by programme type provided (Table 20). Overall infant malnutrition is evenly
distributed across the age range in infants, between 36% (< 2 months) and 31% (4.5.9 months). However,
there is great variation across countries and programmes. No clear or consistent pattern was evident.
105
5.5 Results
Table 20: Age distribution by country and by programme type of the sample of infant
selected for analysis*
Age group
Country
Afghanistan
Burundi
Ethiopia
Kenya
Liberia
Myanmar
Niger
DRC
Somalia
Sudan
Tajikistan
Uganda
Total
< 2 months
2 to 3.9 months
4 to 5.9 months
Total
126
495
409
1,030
12.2
48.1
39.7
100.0
50
57
39
146
34.3
39.0
26.7
100.0
n
%
4
12.1
17
51.5
12
36.4
33
100.0
19
15
37
8.1
51.4
40.5
100.0
n
%
49
29.3
64
38.3
54
32.3
167
100.0
91
73
16
180
50.6
40.6
8.9
100.0
71
41
33
145
49.0
28.3
22.8
100.0
832
305
263
1,400
%
n
%
n
%
n
%
n
%
n
59.4
5
1.2
189
52.5
9
10.5
2
12.5
1,431
21.8
121
30.1
93
25.8
29
33.7
10
62.5
1,324
18.8
276
68.7
78
21.7
48
55.8
4
25.0
1,247
100.0
402
100.0
360
100.0
86
100.0
16
100.0
4,002
35.8
33.1
31.2
100.0
Age group
Programme type
DC
HT
SC
TFC
Total
< 2 months
2 to 3.9 months
Total
138
18.7
65
57.0
30
30.3
1198
39.3
1,431
338
45.8
42
36.8
48
48.5
896
29.4
1,324
262
35.5
7
6.1
21
21.2
957
31.4
1,247
738
100.0
114
100.0
99
100.0
3051
100.0
4,002
35.8
33.1
31.2
100.0

DC: Day Centre
HT: Home treatment

106
4 to 5.9 months
n
%
n
%
n
%
n
%
n
5.5 Results
5.5.3. Burden of disease of infant <6m malnutrition: sex distribution

A slightly higher proportion of male than female infants <6m compared to older children were admitted
for care (Table 21). Evaluation by country and programme type found a higher male:female ratio in infants
<6m than in 6 to 59m group. No correlation was found between the sex ratio exhibited in infants <6m and
older children. Grouping infants <6m by age (22) showed that overall the male:female ratio increased with
age in infants. This pattern, however, was not consistent once frequency was analysed by country or
programme type.
Table 21: Male to female ratio by age group, by country and by programme type
Age groups
<6 months
Country
Afghanistan
6 to 59 months
M:F
60 months
M:F
466
564
1.2
27
36
1.3
Burundi
79
67
0.8
933
1,079
1.2
Ethiopia
18
15
0.8
18
0.3
Kenya
17
20
1.2
218
276
Liberia
76
91
1.2
1,131
1,118
Myanmar
97
83
0.9
765
M:F
94
107
1.1
1.3
0.6
1.0
11
0.8
424
0.6
11
11
1.0
Niger
71
74
1.0
448
515
1.1
DRC
720
680
0.9
2,234
2,400
1.1
88
107
1.2
Somalia
191
211
1.1
1,229
1,334
1.1
16
16
1.0
Sudan
160
200
1.3
2,458
2,470
1.0
23
16
0.7
42
44
1.0
150
137
0.9
1.0
605
656
1.1
1.25
1,945
2,057
1.1
10,216
10,451
1.0
252
274
1.1
Tajikistan
Uganda
Total
Age groups
<6 months
Programme type
6 to 59 months
M:F
60 months
M:F
M:F
DC
356
382
1.1
950
1,103
1.2
94
107
1.1
HT
58
56
1.0
648
361
0.6
11
0.8
SC
57
42
0.7
196
110
0.6
1.3
TFC
1,474
1,577
1.1
8,422
8,877
1.1
143
153
1.1
Total
1,945
2,057
1.1
10,216
10,451
1.0
252
274
1.1

DC: Day Centre
HT: Home treatment

M: Male
F: Female
M:F: Male to Female ratio
107
5.5 Results
Table 22: Male to female ratio by age group, by country and by programme type for infants
aged <6 months
Age groups
< 2 months
Country
2 to 3.9 months
M:F
4 to 5.9 months
M:F
M:F
Afghanistan
52
74
1.4
221
274
1.2
193
216
1.1
Burundi
23
27
1.2
36
21
0.6
20
19
1.0
Ethiopia
0.3
1.1
0.7
Kenya
0.5
12
1.7
0.9
Liberia
21
28
1.3
34
30
0.9
21
33
1.6
Myanmar
49
42
0.9
44
29
0.7
12
3.0
Niger
35
36
1.0
20
21
1.1
16
17
1.1
DRC
447
385
0.9
148
157
1.1
125
138
1.1
1.5
60
61
1.0
129
147
1.1
Somalia
Sudan
84
105
1.3
44
49
1.1
32
46
1.4
Tajikistan
1.3
18
11
0.6
20
28
1.4
Uganda
0.0
1.0
3.0
724
707
1.0
645
679
1.1
576
671
1.2
Total
Age groups
< 2 months
Programme type
2 to 3.9 months
M:F
4 to 5.9 months
M:F
M:F
DC
61
77
1.3
167
171
1.0
128
134
1.0
HT
33
32
1.0
23
19
0.8
2.5
SC
19
11
0.6
29
19
0.7
12
1.3
TFC
611
587
1.0
426
470
1.1
437
520
1.2
Total
724
707
1.0
645
679
1.1
576
671
1.2

DC: Day Centre
HT: Home treatment

M: Male
F: Female
M:F: Male to Female ratio
5.5.4. Infant malnutrition profile: Oedema

The presence of oedema was more common in children than in infants <6m (Table, Table 44, Appendix B).
This difference cannot be accounted for by a difference in the proportion of missing values, as these
percentages are similar between different age groups.
Based on Table and Table 44 data, forest plots were used to assess the risk ratio of presenting with oedema
for infants <6m when compared with their six to 59 months olds (20). The presence of oedema in infancy
ranged from 0 to 8.3%, whereas the presence of oedema in children ranged from 2% to 66%. The overall
risk ratio was 0.1 (0.08, 0.12, p < 0.001). There was evidence of heterogeneity of the data when analysed by
country or by programme type (p<0.01 in both cases). When evaluated by programme, the risk of
presenting oedema for infants <6m was lowest for infants admitted to DC care and greatest for those in
HT care. The presence of oedema in infants <6m did not correlate to the presence of oedema in their older
counterparts.
Table 23: Oedema frequency distribution among different age groups and programme
types provided for the sample included for SAM analysis
Oedema
Age group
<6 months
6 to 59 months
60 months
Total
108
No oedema
%
Missing values
%
140
3.5%
3,812
95.3%
50
1.2%
7,261
35.1%
13,077
63.3%
329
1.6%
317
60.3%
205
39.0%
0.8%
7718
30.6%
17,094
67.8%
383
1.5%
5.5 Results
5.5.5 Infant malnutrition profile: Anthropometry

The quality of anthropometric data was evaluated. The number of missing values was used as a proxy of
the quality of anthropometric data procurement and its recording. Overall, infants <6m had a higher
proportion of measurements missing or wrongly recorded (Table 24). No difference was seen for weight,
but missing values for length were greater in infants <6m. This meant that more infants <6m had missing
HAZ indicators. Conversely, data for MUAC in infants <6m, a measurement not routinely recommended for
this age group, showed to be present in almost 40% of the sample. This measurement was mostly
clustered in SC and TFC programmes (Table 25).
For over 40% of the sample of infants <6m, it was not possible to calculate WHZ and WHM. This was
mostly due to infants having height of <49 cm, for which there are no WHZ and WHM references. The
range of missing data for infants <6m varied widely between countries and programme type (Table 25).
The number of anthropometric values that were flagged using the Epi-Info criteria was also investigated.
Here, more anthropometric values were flagged for children >6m than for infants <6m (Table 26). Epi-Info
flagging criteria might not be appropriate for a malnourished population, as it singles out a significant
proportion of a roughly normally distributed sample of malnourished children. Flagging outliers using
other criteria might be more appropriate. This is explored in Figure 20, where the Grubbs method for
outlier identification was used to evaluate between true and false outliers.
5.5.6 Infant malnutrition profile: Anthropometry-based admission criteria

Different anthropometric criteria used for admission to different programmes were investigated (Table
27). Due to the lack of WHZ and WHM data in infants <6m, it was difficult to compare them with 6 to 59m
children. More than one anthropometric indicator was used in many cases for admission of infants <6m.
The majority of infants <6m did not fulfil standard anthropometric SAM criteria, (<-3 WHZ or <70%WHM)
so must have been admitted to programmes on the basis of clinical or other criteria. Many guidelines
noted using <4kg or <3.5kg as an admission criterion for this age group. Weight <4kg was observed in
90.5% of all infants <6m and weight <3.5kg in 81.8% (Table 27).
We did not tabulate how many infants and children had more than one criterion. More importantly, nor
did we have any available data to say how many children had complications of malnutrition and other
background risk factors such as decreasing weight on growth charts or recently stopped breastfeeding.
109
5.5 Results
Figure 20: Forest plots of the risk ratio of presenting oedema for infants <6m compared
to children aged 6 to 59 months by country and by programme type
a) Country
Study
Risk ratio
(95%CI)
Afghanistan
0.73 (0.10,5.56)
Burundi
0.01 (0.00,0.08)
8.1
DRC
0.13 (0.10,0.15)
70.7
Kenya
0.23 (0.03,1.64)
0.4
Liberia
0.03 (0.00,0.18)
3.7
Myanmar
0.29 (0.12,0.70)
1.5
Niger
0.04 (0.01,0.26)
2.3
Somalia
0.01 (0.00,0.12)
7.1
Sudan
0.03 (0.01,0.12)
6.1
Overall (95%CI)
0.10 (0.08,012)
.001
% Weight
0.1
10
Risk ratio
a) Programme type
Risk ratio
(95%CI)
DC
0.00 (0.00,0.02)
26.0
HT
0.36 (0.12,1.14)
0.6
SC
0.14 (0.04,0.58)
0.9
TFC
0.13 (0.11,0.15)
72.5
Overall (95%CI)
0.13 (0.11,0.15)
.001
110
% Weight
Study
10
Risk ratio
5.5 Results
Table 24: Frequency and percentage of missing values of anthropometry by age group
Variable/Indicator missing at admission
Age group
Weight
Length/
Height
< 6 months
n
%
n
%
n
%
15 0.4% 227 5.7% 2,486 62.1%
6 to 59 months
60 months
130 0.6% 133 0.6% 5,156 24.9% 138

0 0.0%
1 0.2%
12 2.3%
0
MUAC: Mid-Upper Arm Circumference

WAZ: Weight-for-age z-score
HAZ: Height-for-age z-score
MUAC
WAZ
n
19
HAZ
WHZ
WHM
Total
%
n
%
n
%
n
%
n
0.5% 233 5.8% 1,607 40.2% 1,605 40.1% 4,002
0.7% 149 0.7%
0.0%
2 0.4%
198 1.0%
3 0.6%
192 0.9% 20,667

3 0.6%
526
WHZ: Weight-for-height z-score

WHM: Weight-for-height percentage of
the median
Table 25: Frequency and percentage of missing values of anthropometry by country and
programme type in infants <6m
Country
Weight
Length/
Height
%
0.0%
0.0%
0.0%
0.0%
0.0%
%
n
%
0.1% 1,030 100.0%
2.7% 143 97.9%
12.1%
4 12.1%
16.2%
25 67.6%
3.6% 163 97.6%
Afghanistan
Burundi
Ethiopia
Kenya
Liberia
0
0
0
0
0
Myanmar
0 0.0% 110 61.1%
Niger
DRC
1
4
4
6
6
MUAC
WAZ
n
180 100.0%
HAZ
0
0
0
0
0
%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0% 111 61.7%
15 10.3%
0 0.0%
n
3
4
4
7
6
WHZ
%
0.3%
2.7%
12.1%
18.9%
3.6%
n
252
72
11
7
40
%
24.5%
49.3%
33.3%
18.9%
24.0%
WHM
n
252
72
11
7
40
Total
%
n
24.5% 1,030
49.3% 146
33.3%
33
18.9%
37
24.0% 167
147 81.7%
147 81.7%
180
32 22.1%
2 0.1%
72 49.7%
811 57.9%
72 49.7% 145
809 57.8% 1,400
15 10.3%
0 0.0%
31 21.4%
2 0.1%
145 100.0%
27 1.9%
Somalia
Sudan
Tajikistan
0 0.0%
0 0.0%
0 0.0%
22 5.5%
40 11.1%
0 0.0%
378 94.0%
352 97.8%
34 39.5%
0
0
0
0.0%
0.0%
0.0%
22 5.5%
41 11.4%
0 0.0%
23 5.7%
156 43.3%
8 9.3%
23 5.7%
156 43.3%
8 9.3%
402
360
86
Uganda
0 0.0%
1 6.3%
5 31.3%
0.0%
1 6.3%
8 50.0%
8 50.0%
16
WHZ
WHM

Programme
type
Weight
n
DC
HT
SC
TFC
Total
0
0
0
15
15
Length/
Height
MUAC
%
n
%
n
%
0.0%
5 0.7% 735 99.6%
0.0% 51 44.7% 114 100.0%
0.0% 63 63.6%
70 70.7%
0.5% 108 3.5% 1,567 51.4%
0.4% 227 5.7% 2,486 62.1%

DC: Day Centre
HT: Home treatment
WAZ
n
0
2
0
17
19
HAZ
Total
%
n
%
n
%
n
%
n
0.0%
6 0.8% 235 31.8% 235 31.8% 738
1.8% 52 45.6%
87 76.3%
87 76.3% 114
0.0% 63 63.6%
71 71.7%
71 71.7%
99
0.6% 112 3.7% 1,214 39.8% 1,212 39.7% 3,051
0.5% 233 5.8% 1,607 40.2% 1,605 40.1% 4,002

WHZ: Weight-for-height z-score
WHM: Weight-for-height percentage

of the median
* The percentages in this table are based on the total sample of 4002 infants <6m and 20,667 children aged 6 to 59 months.
111
5.5 Results
Table 26: Frequency of flagged values using Epi-info criteria by age group
Flag criteria
Age group
Flag 1
n
< 6 months
6 to 59 months
60 months
Flag 2
Flag 3
Flag 4
%
0.1%
n
95
%
2.4%
62
%
1.5%
392
2
1.9%
0.4%
626
42
3.0%
8.0%
1803
23
8.7%
4.4%
Flag 1: HAZ <-6 or >+6

Flag 2: WHZ <-4 or > +6
Any flag
Total
%
0.0%
n
159
%
4.0%
n
4,002
3
0
0.0%
0.0%
2548
64
12.3%
12.2%
20,667
526
Flag 3: WAZ <-6 or >+6

Flag 4: HAZ >3.09 & WHZ <-3.09 or HAZ <-3.09 & WHZ >3.09
Figure 21: WHZ distribution at admission of children aged 0 to 60 months

a) Distribution excluding values using Epi-Info flagging criteria
6
Density
0
-8
-6
-4
-2
0
WHZ at admission (NCHS)
a) Distribution excluding values using Epi-Info flagging criteria

5
Density
4
3
2
1
0
-8
112
-6
-4
-2
0
WHZ at admission (NCHS)
6.3%
25
19
155
43
13
Kenya
Liberia
Myanmar
Niger
Somalia
Sudan
Tajikistan
Uganda
401
524 13.1%
SC
TFC
Total
16
26.6%
76.3%
67.5%
52.6%
43.0%
213
19.6%
45.2%
54.2%
31.2%
7.1%
7.0%
28.9%
1,181 29.5%
953
51.8%
31.3%
27.9%
<6 months
24
17.8%
75.9%
305
64
24.1%
5.6%
33.5%
43.2%
15.2%
35
10
49.6%
16
5
56
8,909 43.1%
7,817
166
523
403
19.2%
20.9%
28
293
33.0%
340
<6 months
45.4%
62.3%
16.7%
20.2%
19.5%
25.4%
6 to 59 months
336
219
3,326
1,347
414
590
1,020
308
936
393
6 to 59 months
25
23.2%
82.6%
65.4%
56.5%
44.7%
47.4%
38.8%
45.0%
49.3%
49.1%
17.2%
8,785 42.5%
7,785
151
495
354
6 to 59 months
292
237
3,225
1,449
430
563
872
58.5%
16.7%
4
289
22.8%
16.9%
39.7%
1,058
341
6 to 59 months
<70% WHM
79.1%
93.9%
93.9%
95.6%
95.3%
3,622 89.1%
2,717
93
109
703
<6 months
16 100.0%
68
88.9%
90.5%
364
320
73.1%
106
96.1%
91.0%
152
173
67.6%
87.9%
89.3%
98.6%
94.7%
25
29
1,250
144
975
<6 months
57
62
1.4%
15.3%
2.7%
8.6%
9.2%
4.9%
2.9%
3.4%
87.5%
5.5%
2.8%
98.4%
33
46
98
1,037
860
5.0%
5.0%
10.8%
4.6%
4.8%
6 to 59 months
18
44
132
220
89
58
65
17
21
254
6 to 59 months
<4 kg weight
58.1%
77.2%
72.6%
69.0%
95.0%
76.6%
54.1%
81.8%
85.8%
96.6%
82.4%
80.3%
90.9%
94.7%
84.8%
3,273 81.8%
2,449
90
108
626
<6 months
16 100.0%
50
278
292
100
171
128
20
27
1,201
141
849
<6 months
39
46
23
26
66
487
372
2.4%
2.2%
7.5%
2.6%
3.2%
93.8%
94.2%
87.2%
91.8%
63.4%
37.8%
92.2%
56.8%
84.8%
91.4%
95.9%
98.4%
90.2%
35.4%
53.5%
98.8%
3,576 89.4%
2,751
35
61
729
<6 months
15
81
10.5%
0.5%
314
369
92
68
154
21
28
1,280
140
1,014
62
4.0%
29.3%
9.0%
19.8%
15.4%
8.7%
11.4%
7.5%
87.5%
9.9%
5.1%
98.4%
11.6%
13.1%
8.5%
7.0%
2,278 11.0%
2,008
40
86
144
6 to 59 months
50
84
444
508
148
104
256
37
21
461
103
6 to 59 months
<65 cm height
<6 months
1.0%
2.8%
5.6%
2.8%
1.0%
1.8%
66.7%
2.4%
1.9%
73.0%
6 to 59 months
30
49
73
54
33
23
16
109
6 to 59 months
<3.5 kg weight
DRC: Democratic Republic of the Congo; DC: Day Centre; HT: Home treatment; SC: Stabilisation centre; TFC: Therapeutic Feeding Centre.WHZ: Weight-for-height z-score;
WHM: Weight-for-height percentage of the median.
13.1%
4.0%
0.9%
HT
16.0%
118
<6 months
11.9%
38.6%
13.1%
1.1%
15.0%
18.9%
9.1%
DC
Programme
15.1%
Ethiopia
5.9%
9.6%
14
82
DRC
15.5%
160
Afghanistan
Burundi
<6 months
Country
<-3 WHZ
Variable / Indicator
Table 27: Frequency table for different admission criteria, comparing infants <6m and children 6 to 59 months of age*
5.5 Results
113
5.5 Results
5.5.7 Programme outcomes

Programme outcomes were compared between infants <6m and children aged 6 to 59m by country and
by programme type (Table 28 and Table 29). Overall, 75% of infants <6m (and 74% of 6 to 59m olds) were
discharged as cured and 4.7% of infants <6m (and 4% of 6 to 59m olds) died.
Taken as a whole, few countries met all Sphere standards (Table 28, values in italics). Only 25% (3) of
countries reached the required Sphere standard of >75% cured rates in infants <6m compared to 42% (5)
in children six to 59 months old. 66% (8) of countries met the mortality Sphere standard (<10%) for infants
<6m, compared to 60% (9) for six to 59 month olds. Conversely, all countries met the defaulting Sphere
standard (<15%) for infants <6m, compared to 75% (9) for children six to 59 months of age. In addition to
the Sphere standards, only 25% (3) of the countries presented an acceptable non-recovery rate (<10%) for
infants compared to 50% (6) for children aged six to 59 months. Applying the WHO inpatient guidelines
on mortality standards to infants <6m, 50% (6) had mortality < 5% (good), 16% (2/12) had moderate
rates (5-10%) and 33% (4/12) had or exceeded poor rates (11-20%). For children 6 to 59m, the rates were
67% (8/12), (1/12) and 3/12) for good, moderate and poor mortality, respectively.
Interestingly, this pattern changes when outcomes are grouped by programme type (Table 29, values in
italics) where DC and HT programme types met the Sphere standard cured rate for infants <6m, but only
DC in children aged five to 59 months. Similarly, only TFC programme type for infants <6m failed to met
the non-recovery rate while HT, SC and TFC programmes failed for older children. All different programme
types met the Sphere standards for mortality.
A Forest plot (Figure 22) displays the same data (from Tables 28 and 29) by evaluating the risk ratio of
death as an outcome for infants <6m compared to children aged six to 59 months. Overall, the risk of
death for infants <6m is 1.3 (1.08 1.53) if analysed by country, and 1.2 (1.05 1.44) if analysed by
programme. There was a significant degree of heterogeneity on the data (p<0.01). However, the pattern
remained unchanged after controlling for random effects.
Mortality as outcome data was available in some summary databases provided to the MAMI Project.
Results were analysed and are shown in Figure 23. The mortality risk seen for infants <6m in TFC
programme type within Burundi (Figure 23a) was 2.2 (1.69 2.96, p<0.01). There was no evidence of
heterogeneity (p=0.16) in the data and the pattern remain unchanged after controlling for random effects.
On the other hand, the infant mortality risk from MSF compiled data was 1.1 (0.83 1.45; p=0.5), with no
evidence of heterogeneity (p=0.4) and the pattern did not change after controlling for random effects.
114
5.5 Results
Table 28: Sphere discharge outcomes by country and age group

Values in italics are those meeting the Sphere standards/MAMI indicator*
<6 months
Sphere discharge outcomes
Country
Cured
n
Afghanistan
Burundi
Ethiopia
Kenya
Liberia
Myanmar
Niger
DRC
Somalia
Sudan
Tajikistan
Uganda
Total
5 to 59 months
Country
108
21
17
117
135
101
1,099
327
245
68
8
3,015
74.0%
63.6%
45.9%
70.1%
75.0%
69.7%
78.5%
81.3%
68.1%
79.1%
50.0%
75.3%
%
4.8%
17
7
9
5
5
11
50
5
26
0
6
190
11.6%
21.2%
24.3%
3.0%
2.8%
7.6%
3.6%
1.2%
7.2%
0.0%
37.5%
4.7%
Cured
32
1,710
22
295
1,827
821
555
3,752
2,000
3,329
141
836
15,320
%
50.8%
85.0%
91.7%
59.7%
81.2%
69.0%
57.6%
81.0%
78.0%
67.6%
49.1%
66.3%
74.1%
Excluded
49
769 74.7%
n
Afghanistan
Burundi
Ethiopia
Kenya
Liberia
Myanmar
Niger
DRC
Somalia
Sudan
Tajikistan
Uganda
Total
Died
Died
n
4
38
1
58
15
11
116
183
42
222
4
137
831
%
6.3%
1.9%
4.2%
11.7%
0.7%
0.9%
12.0%
3.9%
1.6%
4.5%
1.4%
10.9%
4.0%
%
0
0.0%
Non-recovery
n
96
Defaulter
9.3%
115 11.2%
0.7%
8 5.5%
4 2.7%
0.0%
1 3.0%
0 0.0%
0.0%
6 16.2%
5 13.5%
0.0%
33 19.8%
12 7.2%
1.1%
7 3.9%
22 12.2%
2.8%
1 0.7%
13 9.0%
0.2%
202 14.4%
46 3.3%
0.0%
4 1.0%
40 10.0%
0.3%
33 9.2%
34 9.4%
0.0%
7 8.1%
11 12.8%
0.0%
0 0.0%
2 12.5%
0.3%
398 9.9%
304 7.6%
Excluded
Non-recovery
Defaulter
n
%
n
%
n
%
0 0.0%
11 17.5%
15 23.8%
7 0.3%
30 1.5%
61 3.0%
0 0.0%
1 4.2%
0 0.0%
0 0.0%
43 8.7%
98 19.8%
2 0.1%
213 9.5%
192 8.5%
46 3.9%
172 14.5%
95 8.0%
6 0.6%
90 9.3%
77 8.0%
23 0.5%
497 10.7%
179 3.9%
6 0.2%
142 5.5%
222 8.7%
11 0.2%
678 13.8%
498 10.1%
0 0.0%
79 27.5%
63 22.0%
4 0.3%
151 12.0%
133 10.5%
105 0.5% 2,107 10.2% 1,633 7.9%
1
0
0
0
2
4
3
0
1
0
0
11
Missing
n
Total
%
1
0.1%
1,030
8 5.5%
4 12.1%
0 0.0%
0 0.0%
9 5.0%
15 10.3%
0 0.0%
26 6.5%
21 5.8%
0 0.0%
0 0.0%
84 2.1%
146
33
37
167
180
145
1,400
402
360
86
16
4,002
Missing
n
%
1 1.6%
166 8.3%
0 0.0%
0 0.0%
0 0.0%
44 3.7%
119 12.4%
0 0.0%
151 5.9%
190 3.9%
0 0.0%
0 0.0%
671 3.2%
Total
63
2,012
24
494
2,249
1,189
963
4,634
2,563
4,928
287
1,261
20,667

* Sphere standard exit indicators are cure, death, defaulter and transfer. For the purpose of this analysis, excluded, non-recovery and missing
are also reported (MAMI Indicator).
115
5.5 Results
Table 29: Outcomes by programme type and age group

Values in italics are those meeting the Sphere standards/MAMI indicator*
<6 months
Programme
Cured
n
DC
HT
SC
TFC
Total
6 to 59 months
Programme
DC
HT
SC
TFC
Total
Died
%
605 82.0%
89
67
2,254
3,015
78.1%
67.7%
73.9%
75.3%
%
84.5%
71.4%
62.4%
73.3%
74.1%
%
17
2.3%
4
8
161
190
3.5%
8.1%
5.3%
4.7%
Cured
n
1,735
720
191
12,674
15,320
Excluded
Died
n
38
7
6
780
831
%
1.9%
0.7%
2.0%
4.5%
4.0%
%
1
0.1%
Non-recovery
n
%
39
5.3%
Defaulter
n
%
68
9.2%
1.8%
6 5.3%
13 11.4%
0.0%
2 2.0%
9 9.1%
0.3%
351 11.5%
214 7.0%
0.3%
398 9.9%
304 7.6%
Excluded
Non-recovery
Defaulter
n
%
n
%
n
%
7 0.3%
35 1.7%
72 3.5%
44 4.4%
161 16.0%
77 7.6%
2 0.7%
32 10.5%
30 9.8%
52 0.3% 1,879 10.9% 1,454 8.4%
105 0.5% 2,107 10.2% 1,633 7.9%
2
0
8
11
Missing
n
Total
%
8
1.1%
738
0 0.0%
13 13.1%
63 2.1%
84 2.1%
114
99
3,051
4,002
Missing
n
%
166 8.1%
0 0.0%
45 14.7%
460 2.7%
671 3.2%
Total
2,053
1,009
306
17,299
20,667
DC: Day Centre; HT: Home Treatment; SC: Stabilization Centre; TFC: Therapeutic Feeding Centre
* Sphere standard exit indicators are cure, death, defaulter and transfer. For the purpose of this analysis, excluded, non-recovery and
missing are also reported (MAMI Indicator).
116
5.5 Results
Figure 22: Forest plots of the risk ratio of dying for infants <6m compared to children aged 6
to 59 months by country and by programme type using data from the raw datasets
a) Country
Study
Risk ratio
(95%CI)
Afghanistan
Burundi
Ethiopia
Kenya
Liberia
Myanmar
Niger
DRC
Somalia
Sudan
Tajikistan
Uganda
0.75 (0.28,2.01)
6.17 (3.57,10.65)
5.09 (0.67,38.69)
2.07 (1.12,3.84)
4.49 (1.65,12.20)
3.00 (1.06,8.54)
0.63 (0.35,1.14)
0.90 (0.67,1.23)
0.79 (0.30,1.91)
1.60 (1.08,2,37)
0.37 (0.02,6.76)
3.45 (1.80,6.63)
Overall (95%CI)
1.29 (1.08,1.53)
.01
Risk ratio
% Weight
4.0
2.7
0.6
4.3
1.1
16.0
1.5
44.9
6.0
16.0
1.1
1.8
50
a) Programme type
Study
Risk ratio
(95%CI)
DC
1.24 (0.71,2.19)
7.8
HT
5.06 (1.50,17.01)
0.6
SC
4.12 (1.47,11.59)
1.1
TFC
1.17 (0.99,1.38)
90.5
% Weight
Overall (95%CI)
.1
Risk ratio
18
117
5.5 Results
Figure 23: Forest plots of the risk ratio of dying for infants <6m compared to children aged 6
to 59 months in Burundi by different TFC centres and by different programmes,
using compiled data from various agencies
a) by different TFC centres

Study
Risk ratio
(95%CI)
Bubanza
Cankuza
Cibitoke
Gatumba
Gitega
Kabezi
Kayanza
Kirundo
Mabayi
Muramvya
Mutoyi
Muyinga
Ngozi
Nkuba
Rutana
0.57 (0.08,2.16)
3.07 (0.47,20.24)
1.45 (0.09,24.57)
1.16 (0.45,3.04)
2.10 (0.96,4.59)
8.21 (2.12,31.84)
1.18 (0.38,3.70)
1.94 (0.32,16.59)
2.32 (0.32,16.59)
1.89 (0.26,13.85)
2.76 (0.24,32.41)
5.38 (3.04,9.51)
0.71 (0.04,11.25)
4.68 (0.67,3.96)
1.74 (0.67,3.96)
Overall (95%CI)
1.29 (1.08,1.53)
.01
Risk ratio
% Weight
7.0
1.4
1.4
15.5
12.8
2.6
10.3
14.5
1.8
2.2
0.8
12.7
2.9
0.4
13.8
90
a) by different programmes
Study
Risk ratio
(95%CI)
Niger
1.33 (0.84,2.09)
30.5
Niger Multiple
0.96 (0.31,2.99)
7.3
Niger SC-1
1.63 (0.13,20.64)
0.8
Niger SC-2
0.25 (0.07,0.92)
17.5
Sierra Leone SC
1.21 (0.41,3.61)
6.3
Sierra Leone TFP
1.30 (0.85,1.35)
36.7
Somalia
1.33 (0.10,18.35)
0.9
Overall (95%CI)
1.10 (0.83,1.45
.048455
20.6376
Risk ratio
118
% Weight
5.6 Discussion
5.6 Discussion
5.6.1Key findings
In our analysis of data from 33 datasets from 12 countries we showed that an approximate 16% of
admissions for severe malnutrition care are infants <6m ranging from 10% in Home Treatment (HT) to 25%
Day Centre (DC) programmes. This range of variability was greater when analysed by country. We also
showed that the burden of malnutrition in infants <6m forms part of the distribution of malnutrition in
children less than 60 months old, starting immediately after birth, which seems to peak between the ages
of six to 24 months and presents a significant decline after 36 months of age. In addition, the proportion
of severely malnourished males is greater in infants <6m than that in their older counterparts.
One significant and consistent difference found was that infants <6m are less likely to present oedema.
The risk ratio for presenting oedema in infants <6m was 0.1 (ranging from 0.08 0.12, p<0.01) when
compared to children aged six to 59 months. This risk varied widely by country and programme type, but
was consistently lower in infants <6m.
Operationally, we showed that even within one agency, there is a significant variation in the way data is
recorded, structured, entered and coded. This makes data cleaning, analysis and interpretation resource
intensive and challenging, highlighting the importance for the development and implementation of
minimum reporting standards. Within this variation patterns emerged. Infants <6m in general, showed
more missing variables/indicators at admission, height being the most commonly missed, clustered
mostly in HT and Stabilisation Centre (SC) programme types. Weight-for-height % median (WHM) was also
difficult to calculate in this group mostly due to a significant proportion having lengths of <49cm.
As expected, infants <6m presented higher rates of mortality with a risk ratio of 1.29 (ranging from 1.081.53, p<0.01). This increased rate was also observed in compiled data from different Therapeutic Feeding
Centres (TFCs) in Burundi but was not observed in MSF complied data from various sources. It is not
known how much of this difference in mortality is to be expected, due to the greater background
vulnerability of this age group. It is also important to note that the lack of contextual and survey data on
infants <6m meant it was not possible to compare inpatient mortality with mortality amongst infants <6m
in the general population.
Few countries met all Sphere exit indicators for therapeutic care of severely malnourished infants <6m
(Correction of Malnutrition Standard 2). Variations in outcome between different programmes need
exploration to find out how much this reflects programme/ guidelines performance and how much
patient clinical profile on admission. Current indicators to achieve Sphere Standards (2004) to correct
malnutrition have their limitations with regard to infants <6m. It is not clear whether Sphere exit
indicators for children under five years include infants< 6m. While a Sphere indicator is included on the
importance of breastfeeding and psychosocial support in SAM treatment, there is no clear guidance on
how to measure this. The staff: patient ratio (1:10) recommended may also not be applicable, given the
level of support warranted for infants <6m. A process of quality improvement in programming will help
inform development of Sphere Standards for infants <6m.
There is an absence of standard infant feeding indicators in programme data such as breastfeeding status
on admission and on discharge. Exclusive breastfeeding has been identified as a main treatment outcome
in infants <6m (Chapter 5). Continued breastfeeding to two years and beyond significantly contributes to
infant and young child food security. Sub-optimal feeding practices may contribute to acute malnutrition.
Therefore standardised feeding status data is needed to both inform treatment and audit.
5.6.2Strengths and weaknesses of the analysis

The size of the database analysis in this chapter is a major strength of our work. It allowed us to compare
and contrast different programmes, from different countries, from different time periods. Limitations are
as follows:
Data source: Data analysed is primarily from one relatively well resourced, highly experienced,
technically able non-governmental organisation (NGO) whose programmes likely represents the top
end of a wide range of field practices.
119
5.6 Discussion
Need for intensive data cleaning with time & resource limitations: Databases required intensive
processing before analysis, which required months of dedicated person-time. This is possible within a
research setting, but difficult within a field-focused organization where the time delay would limit the
application of learning.
Validity and reliability issues: Given the extent of cleaning and processing that were needed to
harmonize the field databases, it is likely that field practices also varied significantly between sites and
programmes. In an ideal analysis, quality and validity of the whole data flow system, from patient to
final database, would be verified.
Coverage data: There was no available data on programme coverage. This makes it impossible to assess
population impact, i.e. a hypothetical programme with 100% coverage but 50% death rate makes a
greater impact than a programme with 50% coverage but 10% deaths.
Interpretation of outcome data given limited variables: Many programmes did not reach Sphere
standards to correct severe malnutrition. However, given lack of even basic context data on clinical
condition of children presenting to care, it is not possible to say how much of that shortfall represents
suboptimal programme effectiveness and how much reflects a high risk patient caseload. This is
presented visually in Figures 25-28.
TFP/SFP outcome = programme effectiveness x 1/risk of death at admission
(i.e. good outcome = highly effective programme x low risk patient)
120
5.6 Discussion
TFP/SFP outcome = programme effectiveness x 1/risk of death at admission

(i.e. good outcome = highly effective programme x low risk patient)
Figure 24: Hypothetical population showing the relationship between different types of
acute malnutrition.
Normal
MAM
SAM (uncomplicated)
SAM (complicated)
Treatable SAM
Terminal
Whether or not these standards are achieved is

often seen as a function of programme
performance. Indeed, ensuring that humanitarian
response programmes were working effectively
and safely (e.g. by following accepted/acceptable
clinical guidelines) was part of the orginial drive
behind Sphere. However, it should not be
forgotten and it is of great relevance to
interpretation of MAMI data that patient
caseload can also play a major part in how
effective a programme may appear:
Figure 25: Programme with poor outcomes

This programme may actually have very good
staff/case management yet it performs badly
because patients present too late to benefit from
even the best of treatments.
Normal
MAM
SAM
SAM
Figure 26: Programme with better outcomes

Staff in this programme may manage their cases
of SAM worse than in the 1st programme, yet still
get better outcomes simply because patients are
less sick and less vulnerable at admission
Normal
MAM
SAM
Figure 27: Programme with good outcomes

Normal
MAM
SAM
Focus on uncomplicated SAM is likely lead to

good outcomes. Programme coverage is also
high and has higher probability of public health
impact. However, numbers of deaths actually
averted will vary according to risk of death in
each category
Key to Figures 24-27

Normal: nourished sub-population
MAM: sub-population with moderate acute
malnutrition
SAM: sub-population severe acute malnutrition
(with or without complications)
SAM (terminal): SAM presenting at such a late stage that any

treatment, however high quality, is unlikely to prevent mortality
Sub-population in treatment programme
121
5.6.3 Future directions

The results provide a good baseline for future work. Future analyses are important to continue to monitor
trends and patterns in MAMI and to indicate effects of future management guideline changes. However,
this will require significant changes to current data systems, as follows:
Quality of data throughout the entire system monitored and enhanced, from data collection to data
entry.
More structured, probably specially constructed, databases with validation and consistency crosschecks at data entry stage.
Harmonised database structures and coding strategies.
Ascertain what are the most appropriate variables to measure in infants <6m and collect routinely.
In the area of moderate malnutrition management, there is work well in progress to standardise reporting
and establish minimum reporting standards in SFPs, focused on children 6 to 59m146. This approach
could be applied to infants <6m. In addition, an update in the SFP reporting package to include
infants<6m is recommended.
Data on infants <6m must be included in nutrition surveys to assess initial needs and later programme
coverage. Clinical variables should also be collected to enable better interpretation of programme
outcomes.
Lastly, different approaches to field data could be considered. Rather than a long term audit of routine
data, short term, more focused, periods of data collection might be considered. These would aim to
answer specific operational research questions (e.g. how many malnourished infants <6m are LBW?)
during a set period of time, after which normal minimal data collection could resume.

Summary findings
Infants <6m are admitted to feeding programmes, and do therefore warrant attention and resources.
Significant work is needed to harmonize and improve the quality of field databases. Standardisation in
reporting is needed, including database structure, case definitions, outcome coding and variable
formatting, to facilitate future research and routine audit.
Overall, infants <6m had a higher proportion of measurements missing or wrongly recorded. Missing
values for length were greater in infants <6m. MUAC is being measured in infants <6m in SC and TFC
programmes against current recommendations. Staff training and appropriate equipment are needed to
improve the quality of anthropometric assessment in this age-group.
Feeding programme data should be disaggregated by age, to enable closer analysis. Routine indicators of
feeding status on entry and exit to programmes are necessary.
Percentage mortality in admitted infants <6m was significantly higher than admitted children aged 6 to
59m (4.6% vs 4% respectively, p<0.01). There was no data on mortality of infants <6m not admitted.
Few countries met all Sphere exit indicators for therapeutic care of infants <6m (Correction of Malnutrition
Standard 2). Current indicators to achieve Sphere Standards (2004) to correct malnutrition have their
limitations with regard to infants <6m.
Presence of oedema was consistently lower in infants <6m. The risk ratio of presenting oedema was 0.1
(range: 0.08 0.12) when compared to children aged six to 59 months.
There are significant inter-database variations in structure, coding and data entry, even within agencies.
Data cleaning, analysis and interpretation is thus time intensive and challenging.
Attention and resources should be diverted to MAMI in feeding programmes and a process of quality
improvement should be implemented to help programmes to reach Sphere Standards for infants <6m
and to reduce the proportion of deaths in this age group.
122
Staff training and appropriate equipment are needed to improve the quality of anthropometric
assessment of infants <6m.
Feeding programme data should be disaggregated by age, to enable closer analysis. Routine indicators of
feeding status on entry and exit to programmes are necessary.
Standardisation in reporting is needed, including database structure, case definitions, outcome coding
and variable formatting, to facilitate future research and routine audit. Significant work is needed to
harmonize and improve the quality of field databases. There are lessons to learn from the SFP Minimum
reporting Standards Package under development and an update in the SFP reporting package to include
infants <6m is warranted.
Few countries met all Sphere exit indicators for therapeutic care of infants <6m (Correction of
Malnutrition Standard 2). Current Sphere indicators to correct malnutrition have their limitations with
regard to infants <6m. The MAMI report findings should inform Sphere Standards update. A process of
quality improvement should be implemented to help programmes to reach Sphere Standards for infants
<6m.
Endnotes
145
146
None of these recoded cases where WHM <80% reached the final analysis.
Minimum Reporting Standards for SFP project. http://www.ennonline.net/research/sfp.aspx
123
Chapter 6
Key informant
interviews
124
Chapter 6 Key informant interviews
Chapter 6: Key informant interviews

6.1 Rationale and objectives
This chapter comprises a review of field experiences and front-line perspectives on MAMI from qualitative
data sources. The purpose is to explore priority areas for improving MAMI outcomes and to identify
relevant issues not captured by the quantitative data examined in Chapter 5.
Objectives are to identify context factors that:
facilitate good outcomes from MAMI;
are barriers to good outcomes/underlie poor outcomes;
are potentially modifiable vs. those which are not easily modifiable.
6.2 Methodology
6.2.1 Design
There were three distinct parts to the field experiences review:
a) A steering group meeting of key experts and representatives of partner organizations, where key
MAMI issues were identified and discussed.
b) A series of semi-structured key informant interviews by telephone on themes identified in a).
c) Two field visits to clinical settings (Kenya & Malawi).
6.2.2 Participants
Contributions were sought via:
a) Individual and organizational contacts identified by ENN, UCL CIHD and ACF, and further contacts on
the advice of these.
b) Information on MAMI and a call to collaborate was posted on the following websites:
The UN Interagency Standing Committee Global Nutrition Cluster147
UCL Centre for International Health & Development148
ENN (Emergency Nutrition Network)149
c) Information was posted to E-lists and e-discussion groups including:
Child 2015150
Pronut Nutrition and HIV/AIDS (ProNut-HIV).151
Method of approach
Contacts were followed up by telephone and email. Information about the MAMI Project and key themes
to be discussed was sent in advance of an interview (see appendix C).
Sample size
The steering group meeting was of all those able to attend. Key informant interviews continued until
saturation, when themes were consistently repeated and no new issues emerged. Every attempt was
made to hear from a range of different staff working in different organizations.
Non-participation
Nobody approached for key informant interview declined to participate. However, not all potential
interviews took place, principally due to overseas travel commitments.
Aside from the Kenya & Malawi field trips, most key informant interviews were conducted by telephone by
MK lead MAMI researcher (London, UK).
125
6.2 Methodology
6.2.3 Data collection

A semi-structured interview questionnaire was developed by the principle researcher with input from the
MAMI Project core group. This was formed around key themes identified at the initial steering group
meeting (see Appendix D). The questionnaire followed a patient care pathway from onset of disease to
discharge and follow up. Written notes were made during interviews.
6.2.4 Data analysis

Using interview notes, key sub-themes were documented under each step of the patient care pathway.
Contributors are named as members of the MAMI Project steering group, but individual quotes remain
anonymous to keep the focus on common issues, rather than highlighting inter-organizational
differences.
Possible research and policy implications arising from themes identified ere elaborated by the MAMI
Project writing team. These are not meant to be definitive but to highlight key issues for future work.
6.2.5 Limitations
It is important to note that the sample of key informants is purposive and not necessarily representative.
The possibility of bias cannot therefore be excluded. Given this, quantitative analysis of interview
responses was not undertaken.
6.3 Results
6.3.1 Participant profiles
(a) Steering group meeting
A meeting of key agencies involved in MAMI in emergencies took place in London on 28th May 2007. A
total of 23 participants representing 16 different organizations attended. A summary of this meeting
along with participants is included in appendix C.
(b) Key informant interviews and (c) field visit observations
A total of 33 key informants were interviewed (see Acknowledgements). Key characteristics (country
location of programme described; interviewee position; type of organization/programme) are detailed in
Table 45, appendix C. Some participants described issues in multiple settings, so that the number of
countries and projects represented in the table is greater than the number of individuals interviewed.
6.3.2 Themes
Key feedback, emerging policy implications and research questions from key informant interviews and
field visits are summarised in Tables 30-35:
Prevalence & causes of infant <6m malnutrition (Table 30)

Identification of malnourished infants <6m and admission to programme (Table 31)
Programme details (Table 32)
Challenges in managing infants <6m (Table 33)
Training and support (Table 34)
More detailed feedback for each is included in Appendices D.5-D.10. Two case studies describe interesting
innovations: a study on supplementary suckling in Liberia (Box 6) and pilot experiences in including
disaggregated data on children less than two years in the UNHCR health information system in Dadaab,
Kenya (Box 7).
126
6.3 Results
6.3.3 Emerging Issues

Prevalence and causes of infant <6m malnutrition
There is little information on programme coverage of MAMI, as infants <6m are not routinely included in
nutrition surveys. There are many contextual factors that influence the onset of SAM in infants <6m, such
as birth history and medical state, maternal psychosocial influences, community influences socioeconomic factors, access to health services and HIV. There are large inter-programme variations in the
perceptions of these influences. Up to date guidance on HIV is often not reflected in TFP guidelines, with
outdated and sometimes risky practices result.
Identification of malnourished infants <6m and admission

Not all programmes actively seek malnourished infants <6m and instead only deal with those that
present. Not all presentations or admissions of infants <6m are recorded. In some cases they are cleaned
from datasets as they are considered non-standard data, or medical cases. In some instances, infants <6m
were assessed and treated outside the TFP, e.g. in a paediatric ward. This highlights the importance of
cross-clinical training and skills sharing.
A combination of clinical judgement and anthropometric indicators are often used to determine
admission. The nature and relative contribution of both varies greatly by programme. Assessing growth
history on admission is difficult due to lack of serial measures on admission, use of different indicators in
the community (weight-for-age) for community screening (MUAC) and for admission (weight-for-height),
absence of birth weight record, and quality of anthropometric measurements (e.g. staff aptitude, lack of
appropriate weighing scales, lack of standardised weighing).
There appear to be two types of infant <6m presentation: those who present with reported feeding
problems (and may be requesting food) but are clinically stable and those who present medically unwell.
Some programmes have found it beneficial to use a pre-admission breastfeeding corner to observe
breastfeeding in infants that present.
Programme details
Programme guidelines are not consistent and need harmonisation, allowing for local variations.
Nutritional and psychosocial care for mothers/ caregivers is important and should be included in
guidelines. This should include guidance on good communication between staff and caregivers and
clarity of expectations.
Opinion is divided about the effectiveness of supplementary suckling (SS) and on which therapeutic milk
to use for infants <6m. Clarity is needed on both. Inadequate staff time and skills to support breastfeeding
in infants <6m was as one of the perceived key limiting factors in MAMI. Managing orphans and nonbreastfed infants was identified as a major challenge, both in treatment and longer term follow-up.
Challenges in MAMI
Links to other clinical services need to be improved. MAMI should be seen as a cross-cutting issue.
Community-based care for infants <6m, for MAM cases and those too sick to attend inpatient facilities, is
poor. Guidance on CMAM for infants <6m is needed. SFP is often not available for pregnant and lactating
mothers.
Some programmes reported introduction of complementary foods or RUTF in infants <6m, where there
was felt to be no other option. Clarity is needed on optimal feeding where BF is not possible.
Cost data
No documented evidence were offered on the time or cost implications associated with providing skilled
inpatient or outpatient breastfeeding support in inpatient or outpatient feeding programmes.
Documented experiences have tended to focus on the technical aspects and challenges.
Training and support

There is very little content on infants <6m in formal training or in induction courses. On the job training
and support and easy access to key resources and visuals would be especially valuable to field staff. More
emphasis is needed on critical thinking and reflective learning in the field. Support materials are useful
and should be available to field programmes.
127
6.3 Results
Ways forward
Interviewees identified ways forward that centred on admission criteria, guidance and tools
development, linking with other services and building staff capacity (see Table 35).
Table 30: Prevalence and causes of infant <6m malnutrition

Sub-theme
Synopsis of feedback
Emerging policy implication/research question
Population
Information often lacking on
surveys focusing
community prevalence of acute
on infants <6m
malnutrition in infants <6m
Technical guidance on including
infants < 6m in surveys is lacking
Assumptions are sometimes
made on the basis of admissions
Nutrition surveys need to more routinely include

infants <6m
Need technical/policy guidance on inclusion of
infants <6m in surveys
Should determine rather than estimate programme
coverage for infants <6m
Infant <6m
factors
underlying
malnutrition
Common problems include twins,

ex-LBW, chronic illness (TB, HIV),
acute illness (diarrhoea,
respiratory), disability
There are large inter-site variations
in what is common presentation
profile
Future guidelines to give more details for identifying

and addressing common infant related issues
Better (locally adapted) guidance on infant-specific
medical screening needed
Maternal factors
underlying
malnutrition
Mothers and caregivers often

have problems themselves,
range from medical to
psychological to social
Care for orphans who have no
mother/nobody to breastfeed is a
significant problem; their long
term care is especially challenging
Future guidelines to give more details for

identifying and addressing common
maternal/caregiver related issues
Specific guidelines needed to manage orphans
long-term, after discharge
Family factors
underlying
malnutrition
Family environment sometimes

unconducive to good infant
feeding practices
Future guidelines to give more details for identifying

and addressing common family related issues
HIV
Up-to-date HIV diagnosis and

management guidelines,
especially for infants <18m are
limited
Some outdated and potentially
dangerous practices persist (e.g.
blanket use of replacement
feeds)
Where prevalent, HIV should be described in

TFP/SFP guidelines and/or clear reference made
to latest locally appropriate HIV guidelines
Urgent dissemination of latest recommendations
for infant feeding in HIV exposed infants needed
Health services
Access can be difficult

There are poor links with other
services that might have
prevented malnutrition
Emphasise coverage of services and improve

access (e.g. CMAM-type approach)
Improve communications with other services,
especially those focusing on primary prevention of
malnutrition e.g Baby Friendly Initiative
Societal and
cultural factors
underlying
malnutrition
A wide variety of social and

cultural factors influencing
malnutrition
Some positively impact infant
nutritional status/increase
chances of successful treatment
for malnutrition
Some adversely impact
nutritional status/decreased
changes of successful
treatments
Many factors and issues are
common to many situations,
though prevalence and impact
varies widely by setting
Immediate term: Ensure Operational Guidance on

IFE is disseminated and implemented in all
emergencies (e.g prevent inappropriate distribution
of breastmilk substitues); rapid assessment to
understand local contextual factors contributing to
malnutrition. A quantifiable Sphere indicator needed
to ensure these steps done.
Medium term: Engage with local communities/
advocacy to address relevant social and cutural
factors (encourage postive practices; discourage
negative ones)
Longer term: Build on medium term actions,
addressing indirect/structural factors affect infant
feeding, e.g. insecurity, access to food, need for
mothers to work, protection at a policy level. Crosssectoral protection of and support for optimal infant
feeding are essential to complement and support
therapeutic interventions.
128
6.3 Results
Table 31: Identification of malnourished infants <6m and admission to programme
129
Sub-theme
Emerging policy implication/research

question
Case finding in
the community
Not all programmes actively seek to identify

malnutrition in infants <6m
Clinical judgement is often involved in
determining which infants <6m to refer/admit
Active case finding of infants <6m with

clear diagnostic criteria would be more
consistent with CMAM strategies
Clearer diagnostic criteria/checklists are
needed, in particular to help community
level health workers to identify cases in
the community:
a) Anthropometric (e.g. use of MUAC)
b) Clinical criteria (including breastfeeding
assessment)
Growth Charts
Utility of growth monitoring to support the

diagnosis of acute malnutrition is variable
between settings. Issues include: lack of
birth-weight record, validity of previous
weights, different anthropometric indicators
used in growth monitoring v feeding
programmes (weight for age v weight-forheight or MUAC)
Harmonise growth monitoring tools with

entry criteria to therapeutic and
supplementary feeding programmes
Assessment
logistics and
practicalities
Many current guidelines not clear on infantspecific issues to look for, so child criteria are
used, often supported by clinical judgement
(this often includes assessment of mother)
Several centres found pre-admission
assessments useful (e.g. admit first to
breastfeeding corner prior to full admission)
Clarify admission criteria for infant <6, and

include assessment of relevant factors
such as maternal/caregiver health
Anthropometry,
measuring
There is variation in how much importance

different programmes attach to clinical and
anthropometric criteria for admitting infants
<6m
Many field scales are not sufficiently precise
for infants (accurate only to 100g)
Technical problems with measuring
sometimes occur (e.g. uncalibrated scales,
infants clothed, 65cm cut-off confusion)
Better evidence needed into ideal case

definition for TFP/SFP admissions
Programmes should have scales accurate
to 10-20g (NB University of Southampton
is currently developing new infant scales)
Tighter quality control of existing
anthropometry guidelines
Reasons for
presentation to
feeding
programme
Two main patterns of presentation occur:

1) Infants with reported breastfeeding
problems/wanting food (often to well
resourced NGO projects), but clinically
relatively stable
2) Infants with clinical complications (often to
less well resourced projects/established
(government) hospitals)
Better case definitions needed to identify

those whose anthropometry is acceptable
but who report feeding problems
Active case finding and community
engagement along lines of CMAM strategy
would encourage appropriate presentation
Ward layout/
assessment
environment
Programmes with a separate assessment/

pre-admission area found it helpful
As far as is possible, ensure this is space

is available
6.3 Results
Table 32: Programme details

Sub-theme
Emerging policy implication/research

question
Caregiver
expectations
Caregivers usually expect receipt of

something from the programme (food,
medicine etc.)
Caregiver expectations not always clear
Short admission usually preferred
Guidelines should emphasise asking all

caregivers basic clinical history questions:
What do you think is the problem?/what do
think is the solution?/what do you think we can
(or will) do? This would reduce any
expectation/reality mismatch.
Guidelines
Many guidelines are currently in use

Large agencies tend to use own guidelines,
government settings use international
guidelines
Need to harmonize guidelines, allowing for local

variations as appropriate (see Chapter 4)
Staff time
Staff time often major limiting factor in

treating infants <6m (much more timeintensive than other groups to care for,
especially when proving breastfeeding
support)
Programmes need to budget and plan for infantspecific staff (~1 full time support staff per 5-10
nursing mothers)
Staff
supervision
Good support and supervision are vital for

high quality care
Invest time and resources into optimizing

organizational leadership and management
Medical
treatments
Not a major problem in most programmes

Drug dosing can be difficult
Some uncertainty regarding drug choice
(antibiotics, micronutrients)
Ideally would have medications in syrup as well

as tablet form
Review guidelines and, where infant/child
differences apply, clarify guidelines
Maternal
issues
Direct support (food, psychosocial) to

mother was well received if available
Care for infant and self (notably drinking
enough water) sometimes suboptimal
Kangaroo care worked well in some
settings
Assessment and care for mother needs to be

better highlighted and detailed in new guideline
editions (extra resources / specialist staff may
be needed)
Ensure infant feeding education/support in
place
Feeding
methods
Opinion was sharply divided on

supplementary suckling (SS) as key
nutritional intervention; either worked very
well or hardly at all
Expert support often helped solve difficult
feeding problems
Training package needed for centres wanting to

use SS
Research needed to distinguish SS field
effectiveness from its efficacy in ideal/expertled setting
Improve availability of expert support/more
infant-specific training
Type of milk
used for
therapy
Lots of confusion regarding best therapeutic Randomised controlled trials needed to explore
milk for various phases (F100 dilute, F75
which milk is best
most common used). Modified animal milks Need better systems to manage infant formula
rarely used.
supplies when needed as last resort
Major challenge is longer term feeding for
orphans and others not breastfed
Physical
space on
ward
Having areas dedicated to infants worked

well
Programmes to ensure that as far as possible,

infant areas are available
Length of
stay
Average ~10days, often discharged on

feeding criteria rather than anthropometric
criteria
Mothers prefer shorter stay
Long term follow-up studies needed to ensure

safety of current discharge criteria
Community based programmes would be more
in line with CMAM/caregiver preferences/
would better ensure safety if discharged when
weight still low
Follow-up
Can be difficult, especially for orphans
Integrate infants <6m into community (CMAM)

systems set up for 6 to 59m children
130
6.3 Results
Table 33: Challenges in managing infants <6m

Sub-theme
Links to other Initial assessment often done in other

clinical
clinical areas outside of nutrition ward
services
Breastfed infant referred to paediatric
ward rather than managed in nutrition
ward in some programmes
Local guidelines should emphasise smooth links

between different clinical services
Need to emphasise in all child health training and
practice that optimal nutrition is a cross cutting issue
relevant to all
Community
care
Services were poor for moderately

malnourished infants/those not sick
enough to warrant immediate
admission
Develop community based models of care for infants

<6m
SFP
Whilst many guidelines specify SFP

for pregnant and lactating women (and
those whose infants have MAM), it is
not often available
Research and greater clarity re optimal care for

mothers/MAM infants and ensure care is universally
available if shows to be cost-effective
Nonadmissions
Often referred to paediatric ward or

Better documentation and shared audit/clinical
local primary healthcare services, but
records between various child health services
difficult to know what final outcomes are
(perhaps greater use of patient-held health records)
Unsolicited
donations
No donations of breastmilk substitutes

were noted in sample of key informants
Ensure Operational Guidance on IFE implemented

(include as a quantifiable Sphere standard)
Treating
infants <6m
as if older
Some programmes report early

introduction of complementary food
(including RUTF) in exceptional cases
where breastfeeding is not possible
Optimal feeding for infants<6m who cannot be

breastfed needs to be formally explored in clinical
studies (ideally randomised controlled trials)
Reporting
issues, Audit
Records and databases were often

poor quality, so any audit is difficult
Not all databases and reporting
systems capture infants <6m
Infants with medical or structural
causes of malnutrition (e.g. cleft
palate) sometimes excluded from
reports
Ensure high quality data systems (including staff to

ensure they function well)
Ensure databases record infants <6m as a subgroup
Ensure all malnutrition is reported. Either qualitative
additional report or extra column on database could
identify numbers with complications likely to affect
final outcomes (this would affect programme
performance judged by Sphere standards)
Table 34: Training and support

Sub-theme
Formal training
Overall there is very little training

in formal nutrition courses (MSc,
diploma, other) on infants <6m
Greater engagement with training institutions to add

infant feeding material to course syllabus
Induction courses
Sometimes limited in clinical

content, infants <6m covered
briefly if at all
Induction could be longer (or where not possible in

emergency could be replaced by early supervision
visit)
Induction pack could be given to all new feeding
programme staff for self directed learning/reference.
Would contain key manuals, books, instructional
DVDs and other support material
Field visits by
supervisor or other
expert (on-the job
vs. workshop type
training)
On-the-job training and support

found to be useful
Workshops can divert valuable
staff away from field duties and
are arguably not as effective as
field-based training
Close supervision and support of field programmes

should be a priority (some guidelines have a
programme checklist this could be initial basis of
field assessment and support strategy)
Critical thinking and Needs to be more emphasis on

reflective learning
critical thinking rather than blind
guideline following
More field-based training around real scenarios and

real patients
Useful materials
131
More field support, less workshops
WHO guidelines found useful

Ensure support materials are readily available to
field programmes (e.g. via central library, online or
Posters and other visual
via organizations such as TALC Teaching Aids at
materials found useful (especially
Low Cost)
when adapted for local situation)
6.3 Results
Table 35: Ways forward: Key informant feedback

Sub-theme
Identification
of infants
<6m for
admission to
TFP/ SFP
Better assessment tools and guidelines

needed
More emphasis on active case finding
and early identification of malnourished
infants (this facilitates CMAM-style
outpatient care by finding infants with
uncomplicated SAM/at high risk of SAM)
Need to link more with other related
clinical services (e.g. growth monitoring,
post-natal services)
Explore use of more detailed and wider ranging

assessment framework: infant factors (better
clinical, better anthropometric guidance needed),
maternal factors and social/family factors
More direct community engagement on infant <6m
malnutrition
Establish regular forum for information exchange/
cooperation
Guidelines
Need to move towards communitybased models of care

More guidance needed in specific areas
(e.g. which milk product, what to do for
orphans, HIV issues) yet need to avoid
guideline overload by having too many
different guidelines covering same topics
Need for simple and easy-to-follow
guidelines (poster materials, flow charts)
Can be difficult to manage breastmilk
substitutes and get the balance right
between being available for those few
who need them and ensuring no
leakage/spillover to infants who do not
need them
Modify guidelines to be more consistent with

CMAM uncomplicated/complicated SAM
Strengthen guidelines in these areas.
Link more closely to existing initiatives such as
IMCI, BFI, growth monitoring programmes and
country-specific HIV guidelines
Emphasise support tools/materials alongside
guideline books
Clearer guidelines/stronger systems for managing
those infants who cannot be breastfed and who
need breastmilk substitutes
Links with
other
services
Need to create more opportunities to link Ensure coordination and dialogue between different
with related services which would both
programme coordinators at field level
enhance treatment of established
Set common targets
malnutrition and play a role in primary
prevention of malnutrition
Staff
Motivation, training, prioritization of

clinical workload are all important
Some staff overburdened with work/
cannot realistically fulfil all current duties
to a high standard
Programme leadership, organization and

management (including field supervision) should be
given greater emphasis
Task shifting could lead to increased productivity/
efficiency
132
6.3 Results
Box 6: Case history: Successful supplementary suckling in Liberia
Infant feeding in a TFP

MSc Thesisa by Mary Corbett, Concern, HQ Nutritionist
The benefits of breastfeeding are widely-know. In conditions characteristic of most emergencies breastfeeding
becomes even more important for infant nutritional health and survival. However there are times when
alternatives to breastmilk are necessary. It is important that they are used appropriately and do not replace
breastmilk unnecessarily. Up until about 6 months breastfed infants' nutritional security is critically linked to
the maternal supply of milk. This is why it is so important to protect that supply. However mothers and health
workers' confidence in breastfeeding is often shaken when they see a malnourished infant attached to the
breast. If there is a rush to rehabilitate the infant forgetting about the mother then there is a risk of discharging
a healthy infant with no secure supply of 'food'. Mary Corbett as part of her MSc thesis carried out a study to
assess the effectiveness of rehabilitating malnourished infants while maintaining or improving maternal milk
supply.
This study was conducted in a therapeutic feeding centre run by Action Contre la Faim (ACF) in Liberia
between mid May and mid July 1998. Twenty-five severely malnourished infants with weight for length less
than 70% and less than 6 months of age were included in the study. A combination of breastmilk and
supplemental milk was used to rehabilitate these infants using a special technique adapted for the study: -the
"Supplemental Suckling" technique. This technique has been used previously in well babies.
On admission a detailed history was taken to ascertain the main reasons why the infants were not gaining
weight. Routine medications were commenced as per protocols used for malnourished children over six
months old. These included Vitamin A and a broad spectrum antibiotic.
The infant was started on three hourly breastfeeds. A supplemental feed was given after one hour following
each breast feed. The tip of a naso-gastric tube was attached to the mother's breast at the nipple with the
other end of the tube in the cup of supplemental milk (F100 diluted). The breast was offered to the infant.
When the baby was attached to the breast it was important to ensure that the tip of the naso-gastric tube was
in the infant's mouth. When the baby suckled at the breast the milk was sucked up the tube and then ingested
by the infant. The amount given was calculated individually for each infant as per body weight (see below for
calculations).
All supplemental milk consumed was recorded. Infants were weighed daily. Records were maintained of any
vomiting or diarrhoea. It was assumed that the extra suckling at the breast would stimulate an increase in
breastmilk output.
To estimate required caloric intake from breastmilk it was necessary to calculate energy needs for body
maintenance, Basal Metabolic Rate (BMR), and expected weight gain for each infant. It was assumed that
110 kcal/kg were required for BMR but for infants with high fevers it was estimated that extra energy was
required, increasing the BMR to 120 kcal instead of 110kcal. It was assumed that five calories were required
for each gram of weight gained. The calories supplied by the supplemental milk (enough for maintenance)
were established. It was assumed that the balance of calories taken was from breastmilk and would be used
for catch-up growth. Finally deductions were made for any vomiting or diarrhoea. Once the infants reached
85% weight for height the supplemental milk was reduced by half the amount for one day and then stopped
completely.
The infants remained in the centre for a minimum of 4 more days and were exclusively fed breastmilk.
Results
Of the 25 patients admitted one was excluded from the study as the mother was dead while three others were
subsequently excluded due to insufficient data as they had been admitted late in the study. During the study a
total of 16 infants were discharged exclusively breastfeeding and gaining weight while five were transferred to
the local hospital.
With the combined supplemental milk and breastmilk the mean of all the infants maximum daily weight gain
was 17.9g/kg/day. Normal weight gain for this age group would be 2g/kg/day while 5g/kg/day would be the
minimum weight gain for catch up growth for malnourished infants with 10g/kg/day being the target to aim for.
The mean weight gain for the period when the infants were receiving both supplemental feeding and
breastfeeding was 14.7g/kg, while the mean weight gain for the period on exclusive breastfeeding was
9.4g/kg/day. This suggests that the weight gain although reduced on exclusive breastfeeding was still
adequate for maintenance and catch-up growth. The mean breastmilk output on exclusive breastfeeding
reached 204ml/kg (sd 31) with the volume ranging from 390ml to 1131mls but this considerable difference was
due to differences in weights of the infants. The mean number of days on supplemental feeding was 13 days.
a
133
Corbett M. Severe Malnutrition in the Infant less than 6 months: Use of Supplemental Suckling Technique. Department of Medicine &
Therapeutics. Fosterhill, Aberdeen.
6.3 Results
Box 6 contd
Tips
Supplemental Suckling Technique
The cup is kept at least 20-30cms below the level of the baby's mouth so that the baby can
control the flow of milk from the tube. If the presence of the tube is discouraging the baby from
attaching: slip the tube into the mouth once the infant is suckling.
Be patient: it may take one to two days for the mother and baby to adapt to this technique.
Calculating the amount of supplemental milk given

Calorie requirements for infants <6months:
For body maintenance without growth requirements = 110kcal/kg/day
For each additional gram of weight gain an extra 5kcals are required
Feed amount required:
Breast-milk or supplemental milk contains 70Kcals per 100mls approx.
Therefore amount of breastmilk/supplemental milk required =(110*100)/70 160mls/kg/day
Calculate enough supplemental-milk needed for body maintenance (BMR) to allow for situations where
breast milk is extremely low.
Example of Supplemental-milk calculation:
Infants weight = 3.5 kg
Supplemental milk required = 160 x 3.5 = 560mls in 24hrs
Amount of Supplemental-milk per feed = 560mls 8 feeds = 70mls per feed
As the infant's weight increases the calorie requirements will increase but the supplemental feed will
remain the same. The breast-milk produced will increase due to stimulation using the supplemental
suckling technique. The infant will receive the calories needed to grow and catch up from the breastmilk.
Feeding Practices
Mothers should offer breastfeeds to babies at least three hourly.
Make sure that baby is attached correctly and mother is comfortable.
Baby should empty one breast before the second is offered so that both the fore and hind milk is
removed. (Emptying the breast stimulates the production of more milk thus improving breastmilk output.)
Mothers should offer alternate breasts at the start of each feed. (This ensures both breasts are
emptied at each alternative feed).
Monitor breastfeeds encouraging and supporting mothers and checking the babies' position and
attachment.
Give first time mothers extra support to build up their confidence in their ability to breastfeed
Confidence building
Explain the benefits of breastfeeding to the mother. Spend time with the mother encouraging and
answering questions.
Explain to the mother the principle of breastmilk quantity being determined by the demand/supply
mechanism.
Reassure mothers, informing them that most mothers in fact can produce adequate milk supply
(more than 99%), even if underweight.
Other mothers in the TFP using this supplemental suckling technique are of great support and
encouragement to new admissions.
Encourage women to talk about experiences.
Regularly update mothers on their infant's progress in the programme.
Ensure all health staff working in the centre are well informed of the principles and techniques of
breastfeeding and supportive to the mothers. Regular training and support for staff is essential
Source: Corbett M 2000.152
134
6.3 Results
Box 7: Case history: Using dedicated infant <6m data to support an innovative IYCF
programme
Synergies between information & action: UNHCR Health Information System (HIS) &
Infant and Young Child Feeding
HIS is a multi country reporting package which is currently being rolled out by UNHCR. The package consists
of training materials; standardized data & tally sheets; a system of monthly data entry; standardized indicators
and reporting / recording requirements; a central database at central HQ with data across 16 different
countries. A key feature of this HIS tool is collecting age disaggregated data on infants <6m. This provides
invaluable data because:
1) Infant <6m mortality is likely high, as is infant acute malnutrition prevalence (see MAMI Chapter 3). So
monitoring is justifiable in public health terms.
2) Reducing infant mortality is a key part of making progress towards MDGs.
3) In terms of normal physiology, nutritional needs and common pathologies, there is large variation in the 0
to 59m age group. Therefore, grouped data can easily be confounded by age profile and is not nearly as
informative as age-specific data.
4) Acute malnutrition prevalence will increase with new WHO-GS - with unknown effects on what both carers
and health workers do in response , so now is more important than ever to keep on top of infant <6m
admissions and outcomes.
5) BF status (whether EBF or not) will have the greatest impact for outcomes for <6m infants. Improving
% EBF is itself very important, but in high mortality settings, it matters most in this youngest age group,
and it is important to see whether BF promotion and support programmes are having this intended end
effect
6) In terms of nutrition, infants are managed very differently from older children in nutrition guidelines, so
again, to assess the effect of this separate management you really need to disaggregate.
7) The age disaggregated database allows indirect audit of a groundbreaking programme improving infant
and young child feeding through a multifaceted intervention. This CARE-USA led initiative includes
community support groups; training health workers and community health volunteers. It provides the critical
link between preventing acute infant malnutrition and a community-based support network to which
malnourished infants <6m who need support but not necessarily admission can be referred:
Though there is large monthly variation, monitoring overall admission patterns of infants to therapeutic
feeding gives some indication of the overall impact of the IYCF programme. Because numbers of infants
are low, it can be particularly important and informative to audit individual cases and reflect on whether
might have been prevented, or whether future treatments can be further improved.
Admissions to therapeutic feeding centres, Daddab camp, Kenya
Age Group
<6m
6 to <60m
% <6m
August 07
34
17.6%
September 07
20.0%
October 07
52
15.4%
November 07
25
4.0%
December 07
32
25.0%
January 08
24
12.5%
February 08
79
5.1%
March 08
17
5.9%
April 08
14
0.0%
May 08
17
0.0%
June 08
15
26.7%
July 08
14
7.1%
August 08
0.0%
October 08
19
0.0%
37
353
10.5%
Source: UNHCR HIS data
135
6.4 Conclusions and recommendations
6.4 Conclusions and recommendations

A large number of challenges and issues related to the management of infants <6m have been noted. All
are consistent with issues noted in previous chapters of this report. The following are particularly
important points:
There are aspects of current care which work well. These can be learnt from and replicated elsewhere. The
breastfeeding corner to aid pre-admission assessment is one such simple measure. Supplementary
suckling has also been reported to work well in many settings. Agencies could consider including such
examples as models for success in programme planning.
There are some aspects of care which need to be improved and evolved in future guidelines. Often
discussions can focus more on technical aspects, such as which therapeutic milk to use. Whilst still
important, this did not come across as central in key informant interviews. Predominant issues included
the need for development of guidelines on MAMI with specific components to address key issues (e.g.
support for caregivers/ mothers, therapeutic milks, supplementary suckling, care for orphans and HIV) and
for greater staff capacity and skills. On the job training, formal training, tools and materials alongside
guidelines and on the job supervision and support were all seen as important. Further research is needed
to determine the efficacy of supplementary suckling, the best therapeutic milks to use and the efficacy of
community-based models of care for infants <6m.
Key informants suggested guidelines for infants <6m move towards community-based models of care
(CMAM), to bring consistency with the complicated/uncomplicated approach, to improve active case
finding and community follow-up. A shift in this direction may be timely given the increase in admissions
likely as a result of the new WHO-GS. The availability and quality of community-based care for MAM cases
in this age group also needs to be addressed.
No data or evidence were identified on the time and costs associated with providing skilled inpatient or
outpatient breastfeeding support in inpatient or outpatient feeding programmes documented
experiences in topical areas like supplementary suckling have tended to focus on the technical aspects
and challenges. It is critical that a move towards improving inputs to support infants <6m in inpatient care
and developing outpatient support is informed by the costs and resource implications of such
developments.

Summary findings
Many therapeutic feeding programmes struggle in treating malnourished infants <6m.
Good examples of MAMI exist, such as the use of breastfeeding corners to assess breastfeeding preadmission and supplementary suckling. Experiences with supplementary suckling varied; staff time and
experience were important limiting factors.
Information is lacking on community prevalence of malnutrition in infants <6m, as this group is not
included in surveys. Not all programmes actively seek to identify malnutrition in this age group and
admission criteria are often unclear.
Assessment of growth history of infants <6m is complicated by use of different indicators in the
community vs for admission, and poor quality of anthropometric measurements.
Guidelines for MAMI are inconsistent and lack information on supporting mothers/ caregivers and on
specific issues (e.g. supplementary suckling, therapeutic milks, orphans and HIV).
Managing orphans and non-breastfed infants was identified as a major challenge, both in treatment and
longer term follow-up.
There is a lack of staff capacity and skills to support breastfeeding and an absence of formal MAMI training
and staff induction.
Links to other clinical services are often not smooth.
Community-based care for infants <6m and mothers with MAM, for non-admitted infants <6m and
discharged infants <6m are generally lacking.
136
6.5
Summary findings and recommendations
The identification of infants <6m for admission must be improved. Technical guidance for the inclusion of
infants <6m in nutritional surveys is needed. Better assessment tools for the mother-child pair are also
needed. Guidance and better equipment will enable anthropometric assessment of infants <6m e.g.
better weighing scales. Growth monitoring tools could be harmonised with entry criteria to feeding
programmes.
Strategies with potential to improve SAM assessment and management in infants <6m include
breastfeeding corners/ separate mother and baby areas where skilled breastfeeding support is available
and peer-to-peer support is facilitated.
Guidelines for MAMI must be improved that include guidance on specific problem areas and make links
with relevant initiatives.
MAMI training should be integrated into formal courses and on the job training and support provided to
field staff with simple tools and materials.
Further research is needed to determine the efficacy of supplementary suckling, the best therapeutic
milks to use, and the efficacy of community-based models of care for infants <6m.
The cost and resource implications of interventions should be included as a key element of investigations
into expanded models of inpatient and outpatient care.
Endnotes
147
148
149
150
151
152
137
http://www.humanitarianreform.org/humanitarianreform/Default.aspx?tabid=74
http://www.ucl.ac.uk/cihd/research/nutrition/mami
http://www.ennonline.net/research/mami.aspx
Child 2015 is an independent forum to stimulate debate and propose pragmatic solutions for improving child healthcare worldwide
http://www.dgroups.org/groups/ child2015/
Pronut Nutrition and HIV/AIDS (ProNut-HIV) is an electronic forum which aims to share up-to-date information, knowledge and
experiences on nutrition and HIV/AIDS. http://www.pronutrition.org/discgroups-hiv.php
Mary Corbett (2000). Infant feeding in a TFP. Field Exchange, 9, p7. http://fex.ennonline.net/9/tfp.aspx
Chapter 7
Review of breastfeeding
assessment tools
138
Chapter 7 Review of breastfeeding assessment tools
Chapter 7: Review of breastfeeding

assessment tools
Many malnourished infants present with reports of breastfeeding problems (Chapter 6) and exclusive
breastfeeding in infants <6m is the treatment goal of most guidelines (Chapter 4). Therefore breastfeeding
assessment to identify feeding problems and monitor recovery is an important part of MAMI. Since most
current SAM guidelines do not include or refer to specific breastfeeding assessment tools, this chapter
reviews those tools currently available and their potential application to the MAMI contextiii.
7.1 Scope of review

Existing reviews, focused on developed countries, have identified a number of breastfeeding assessment
tools with none clearly identified as a gold standard.153 This chapter identifies areas of consensus between
tools, gaps in coverage and advantages and disadvantages in different settings. To do so, a framework is
used that identifies three aspects or settings of severe acute malnutrition (SAM) care: community
screening/case detection, case finding in clinical contexts, and diagnosis in clinical contexts.154 We
conceive that there is a gradient of importance of different tool characteristics from community to clinical
contexts. For example a community-health worker (CHW) with responsibility for treating malnourished
infants would want a highly sensitive tool to identify women experiencing breastfeeding problems, but a
clinician diagnosing a reported breastfeeding problem in a hospital-setting would benefit from using a
tool with higher specificity so that false positives did not result in unnecessary inpatient admission.
Objectives of the review are as follows:
To identify published breastfeeding assessment tools, and document which breastfeeding domains are
covered and which omitted (adapted from Hall Moran, 2000155).
To consider tool value in emergency settings and other nutritionally vulnerable contexts, looking at
performance characteristics for identifying breastfeeding problems in community and clinical settings
(adapted from Myatt et al, 2006156).
To grade the tools based on the quality and level of evidence underlying their development and
validation.
When talking about case-finding, we envisage that the tools would be used in combination with
anthropometric assessment. Exact use will depend on context. In MAMI, their main importance is
identifying the immediate cause of poor anthropometric status. The better the diagnosis, the faster and
better the patient can be directed to treatment services. For example, a young infant may be identified in
the community as having a simple breastfeeding problem due to poor positioning. He/she might benefit
from early referral to a breastfeeding support group before severe malnutrition and clinical complications
develop. Another infant may have a low weight-for-length but no identified breastfeeding problem; in this
case clinical referral and assessment is needed. Other approaches, such as establishing HIV status, should
be considered. Maternal factors may also determine breastfeeding success and other strategies will be
needed as a result, e.g. a severely malnourished mother who is exclusively breastfeeding will require
nutritional rehabilitation of the mother to enable adequate nourishment of her infant; children of HIVinfected mothers who are ill or die are more likely to die themselves, independent of the HIV status of the
infant157.
iii
139
This review was carried out as an additional activity beyond the scope of the original MAMI Project, undertaken by Jenny Saxton and
supported by the MAMI Research Team. We acknowledge valuable feedback from Felicity Savage and Ann Ashworth on content, to inform
this and future write-up of this work.
7.2 What should a breastfeeding assessment tool include?
7.2 What should a breastfeeding assessment tool include?

Effective breastfeeding can be divided into several essential elements that are important for overall
success. One study that critically analysed six breastfeeding assessment tools identified the following
elements: babys behaviour, mothers behaviour, positioning, attachment, effective feeding (e.g. audible
swallow), health of the breast, health of the baby and mothers perception of the breastfeeding
experience.158 Other elements, such as severe maternal wasting and maternal HIV status, are important
considerations in emergency settings. Determining the main issues for an individual mother/infant dyad
matters: more precise diagnoses will direct infants and their carers to more tailored and ultimately more
effective treatment. Simple issues can be pinpointed and rapidly resolved (e.g. attachment difficulty).
More complex issues can be referred for further care (e.g. breastfeeding support alone is unlikely to address
maternal depression). Good assessment can also help rule out breastfeeding problems as the main cause of
infant SAM (e.g. an infant may be breastfeeding well yet be malnourished due to underlying HIV disease).
Table 36: Importance gradient of key properties of breastfeeding assessment tools from
community to clinical contexts
Context (score)a
Tool Property
Case
Diagnosis
finding in clinical
in clinical contexts
contexts
Simplicity is important in community settings as CHWs have

lower education/training. Simplicity is less important in clinical
contexts unless there is a high caseload & limited time/resources.
Acceptability (by 3
mothers)
BFc assessment by definition is intimate. Male CHWs or

insufficient privacy/comfort are likely to be unacceptable. Some
tools rely on questions alone, not assessment, and are likely to
be more acceptable to mothers.
Cost/Time
Resource-poor settings would demand that assessment be cost

& time-effective in all contexts, although at diagnosis there is
potentially more time to spend identifying specific problems.
Objectivity
Most tools are observational & will be subjective. Objectivity may

be more crucial in diagnostic settings if decisions about
admission are being made.
Quantitativeness 1
Assessment scores give useful indication of risk (e.g. BF

cessation). A total score is less useful for diagnosis as specific
problems would be masked, but may be helpful in making
decisions about admission. Some scoring systems are arbitrary
& could detract from finding ways to overcome specific problems.
Precision
(reliability)
Important that a tool can pick out specific BF problems in a

reliable consistent way, although CHWs may just refer all SAM
infants with a breastfeeding problem to more specialised care, or
for specific diagnosis of a breastfeeding problem.
Accuracy
(Validity)
Very important to be able to pinpoint which aspects of BF are

causing problems in order to provide simple solutions. Timing of
feed & emotional state could affect the ability to pinpoint a
problem if only one assessment is made.
Sensitivity
(Identifying true
cases)
Sensitivity is less important in clinical contexts because the

infant is already present at hospital.
Specificity
(identifying true
negatives)
False positives' could overload the health system; make mothers

feel inadequate & unlikely to resume BF. Unnecessary inpatient
care could increase risk of infection, & may cause mother to
leave other children unattended, or lose money through not
being able to go to work.
Predictive value 1
Important that assessments predict infant nutritional outcomes &

preventable mortality. For a CHW involved in referral to more
specialist BF services, predictive value is less important, better
that they identify as many potential true cases as possible to
refer for further help.
Simplicity (for
CHWsb &
doctors)
a
b
c
Reasons for grading
Community
screening/
case
detection
Scoring: 1=least important 2=medium importance 3=most important

Community Health Worker;
Breastfeeding
Table and scoring system adapted from Myatt et al, 2006159
140
7.3 Methods
7.3 Methods
7.3.1 Literature search strategy
Pubmed was systematically searched for articles with no date parameters set using AND/OR combinations
of the following key words and MeSH (medical subject headings) terms:
Breastfeeding, breastfeeding problems, breastfeeding technique, breastfeeding performance assessment,
breastfeeding skill, breastfeeding ability, breastfeeding assessment tool, breast milk, human, actual or
perceived milk insufficiency, insufficient milk supply, latch, root, suck, swallow, position, milk transfer.
Needs assessment, risk assessment, nutrition assessment, psychometrics, nursing diagnosis, index,
checklist, questionnaire, diagnostic tools, guidelines.
Infant nutrition disorders, infant nutritional physiological phenomena, infant very low or low birth
weight, infant welfare, infant behaviour, infant premature, infant postmature, infant newborn, infant
small for gestational age, infant diseases, infant care, infant growth, developing countries.
Reference lists of breastfeeding assessment tools fitting the inclusion criteria were searched for further
relevant tools. Due to the small number of tools identified that were designed for use in developing
countries and emergency contexts, a purposive search of WHO/UNICEF and initiatives on infant and
young child feeding in emergencies (IFE) in the emergency nutrition sector was conducted. A secondary
search was conducted to identify any studies attempting to validate or examine the underlying properties
and predictive value of these tools.
7.3.2 Tool inclusion/exclusion criteria

Criteria for inclusion in the current review were articles written in English that described the development of
breastfeeding tools applied in clinical or community contexts that were designed to assess breastfeeding
performance of the mother-infant dyad through observations or questionnaires. Tools were excluded if they
were designed to assess bottle-feeding or breastfeeding problems of women who have undergone breast
surgery. Tools using complex assessment methods (e.g. analysis of feeding behaviour with direct linear
transformation160) were also excluded on the basis that these would be unavailable in developing country
settings. Single item and survey questions seeking population-level data about infant feeding were not
considered to function as diagnostic tools and were also excluded. Tools assessing frenulum function were
considered beyond the scope of this review. Maternal self-reported questionnaires assessing maternal
perceptions of breastfeeding are summarised in this paper but not explored in detail.
7.4 Results and Discussion

Fifteen tools were identified in the literature search. The Lactation Assessment Tool (LAT) fitted our
inclusion criteria, however we were unable to obtain sufficient information about the development and
validation of the tool to include it in the final review. Generally, the methodological quality of studies was
suboptimal. At best, tools were tested in observational studies; at worst tools were not tested at all. There
was some consensus between tools about breastfeeding domains for inclusion in assessment, but few
tools achieved comprehensive coverage and particular domains were frequently neglected. Most were
designed for newborn infants, often preterm, whose breastfeeding problems are likely to differ from those
of SAM infants. In terms of suitability of tools for different contexts, no single tool would be suitable for
use without adaptation.
7.4.1 Development and validation of tools
141
The majority of tools (9/15) have not been tested against short or long-term nutritional or breastfeeding
outcomes and it is therefore difficult to make recommendations for their use. Five were developed purely
from existing literature and clinical experience, whilst a further three have been internally assessed for
inter-rate consistency and test re-test reliability with results ranging from poor to excellent (Table 37).
Overall, just three tools were designed for use by CHWs in developing settings and the majority were
developed for North American neonatal populations for use by highly trained health professionals (e.g.
NOMAS), although some were also used by mothers (e.g. LATCH). None of the tools was developed for or
tested on acutely malnourished infants.
Compared %
readmissions
w/ BF
problems of
women
receiving home
visits vs not.
Readmission
rate higher
if no home
visit was
made.
Limited information given re evidence MBA items based on.

Positioning, fixing & milk transfer items from published work
describing common signs. Tool not validated in this study,
although was in a further study.
Instrument based on scientific understanding of lactation &
clinical experience. Not psychometrically tested or
validated against maternal or infant nutritional or BF
outcomes.
5 steps in BF assessed: signalling, USA, not

positioning; fixing; milk transfer;
stated
ending. Scores for mother &
infant separately.
Shrago & Observation of: alignment; areolar USA, not

Bocar,
grasp; areolar compression;
stated
1990164
audible swallowing. No scoring
system.
Systematic
Assessment of
the Infant at the
Breast (SAIB)
Tool based on 2 published & 4 unpublished BF references. No

reference to clinical experience or attempted validation of tool against
measurable outcomes, or internal reliability.
Readmission
rate w/ BF
problems.
Mulford,
1992163
8 sub-scales: Feedings,
positioning, latch, suck, milk flow,
intake, output, weight gain.
Not
stated
Mother-Baby
Assessment
(MBA)f
A BF Evaluation Tobin,
& Education
1996162
Tool (BEET)
Mother & infant scored on 8 items

to indicate BF failure risk: latch (2
items), suck, nipple type,
frequency of nursing/wet nappies,
previous success w/ BF,
supportive partner.
n=981;
not
stated
Johnson
et al,
1999161
Mother-infant
BF assessment
tool
USA,
home
visit
Training material developed on the basis of 'existing best practice &

published evidence where it exists. Where it does not it draws upon
extensive experience & a broad base of expert opinion.' BF
assessment sections based extensively on the WHO 40 hour
breastfeeding counselling course (2004).
SRA: Age appropriate feeding, BF

ease, baby's condition. Refer
problems for FA: observe:
attachment, suckling, mothers
confidence, feed end. Listen/learn
from mother re BF
practices/beliefs/worries. Observe
artificial feed if relevant.
IFE Core
Group
(2004)d
IFE Module 2 (SRAa& FAb of

BFc).
Results
Summary
Country, Sample Infant Infant/

Statistical
setting
size &
age
maternal Analysis
partici- (mean, outcomes
pants
sd)
Author(s) Tool Description

& Date
BF Tool*
Table 37: Theory-based breastfeeding assessment tools
Tool tracks
BF in hospital
triage/referral
or research
Can use tool

prenatally, by
phone or in
hospital.
Tool is a
useful guide
for novice
nurses.
Field workers
should
systematically
record &
identify most
effective
methods.
Author
Comments
/notes
Rationale for items

discussed but not
tested against
measurable
outcomes.
Requires module 1
training (1-3 hours) &
module 2 (5 hours).
Developed for CHWse
in emergency/
developing country
settings.
Our comments
142
143
8 items observe:
responsiveness to feeding
cues; timing of feeds;
nutritive suckling;
positioning/latching factors;
nipple trauma, infant
behaviour state & mother/
parent response to infant.
Mother-Infant
Breastfeeding
Progress Tool
(MIBPT)
21 dichotomous items: signs

that BF going well vs
possible difficulty. General
items and items assessing:
breast condition,
positioning, attachment,
suckling.
BF Support
UNICEF,
guidelines for a 2006168
Baby- Friendly
Hospital: BF
Observation
Aid
Sample
size &
participants
Statistical
Infant Infant/
maternal Analysis
age
(mean, outcomes
sd)
Material
field tested
in
Zimbabwe
Sweden,
hospital
USA,
hospital
Not stated
n/a
2 hours n/a
to 5
days
old
n=24;
Not
Full/preterm stated
infants in
neonatal
intensive
care,
transitional/
maternity
units.
n=62;
Healthy
mother
&baby; 3542 weeks
GA7.
Inter-rater reliability
of observers, &
observers/
mothers. Unclear
analysis testing
tool ability to detect
different
GA/maturity of
infant BF.
% agreement
between raters
Results
Summary
Good inter-rater
reliability for
observers
(0.64-1.00), but
poor for
observers vs
mothers (0.270.86). Poorer
items revised.
Inter-rater
agreement 7995%.
Not stated, although designed for CHW w/ WHO/UNICEF BF training.
Country,
setting
* Includes tools developed on the basis of expert opinion and literature searching; tools may have been internally validated
6 items assess pre-term

infants on: rooting, areolar
grasp; duration of latch;
sucking; longest sucking
burst; swallowing.
Pre-term Infant Nyqvist et

Breastfeeding al, 1996167
Behaviour
Scale (PIBBS)
Johnson
et al,
2007166
27 items/6 scales: signs

that BF going well vs
possible difficulty: Body
position, Responses,
Emotional Bonding,
Anatomy, Suckling, Time
suckling.

& Date
UNICEF b-r-e-a- WHO/

s-t
UNICEF,
observational
1993165
checklist
BF Tool*
None stated
Caution if
relying upon
single scores
because
mother/infant
progress with
BF over time.
None stated
Author
Comments
/notes
Tool is revised
UNICEF
checklist.
Piloting in
Sierra Leone
early 2009.
Rationale for
items discussed
but not tested
against
nutritional/BF
outcomes.
Tool covers
wide range of
BF domains,
but no evidence
of development/
validation
against external
outcomes.
Our
comments
Table 37 contd
Hall et al,
2002169
BFa
Assessment
Score (BAS)
Italy,
hospital
Furman,
2006172
Evaluation of VLBWj:
can we use the IBFAT?
USA,
hospital
Infant
Matthews, 6 items measure 4
Canada,
infant behaviours:
Breastfeeding 1988171
hospital
readiness to feed,
Assessment
rooting, fixing & sucking.
Tool (IBFAT)
Two non-scoring items:
infant state & maternal
satisfaction w/ BF.
Gianni et Usefulness of an
al, 2006170 assessment score to
predict early EBFf
cessation.
Not
reported.
Mean
hospital
stay 2.2
days
n=34; Mothers 35 weeks

of VLBW
corrected
infants
GA
Early
n=60;
Spontaneous neonatal
period'
delivery.
APGARi score
8 after 5 mins;
appropriate
weight for GA.
n=175;
Mothers of
healthy EBF
infants. Birth
weight
2500g, GAg
37-42 weeks.
Baseline scores of EBF

mothers at 1 month sig
lower than non-EBF. NSh
difference if complementing BF at 1 month vs
no BF. Latching problems
& no prior BF success
negatively associated w/
BF duration.
Chi2 & Mann-Whitney U

Tests to test for
differences in BAS scores
by BF behaviour 1 month
postpartum.
Milk intake
(testweighing)
Correlation of IBFAT
scores w/ milk intake,
compared with association
of a feeding observation
form designed to assess
efficiency of BF vs bottle
feeding.
IBFAT positively
correlated w/ feeding
observation & milk
intake; IBFAT sucking
score sig correlated w/ %
time sucking/suck bursts.
IBFAT scores did not

predict BF status at 4
weeks. Limited variability
as 80% still BF. Interrater agreement 91%.
10.5% of mothers
reported cessation of BF;
All BAS items sige
predicted BF cessation.
Results Summary
Single variable logistic

regressions identified
candidate predictors.
Predictors entered into
multiple logistic model;
evaluated with ORb & RRc
to give optimal ROCd
Statistical Analysis
BF status at inter-rater reliability (%

agreement)
4 weeks
BF
cessation,
introduction
of complementary
feeding,
continued
EBF at 1
month
BF
cessation
rate 7-10
days after
birth
Infant age Infant/

maternal
(mean,
outcomes
sd)
n=1108; No
Mean 40
information on hours
maternal or
(sd=13)
infant health
indicators.
Country, Sample size

&
setting
participants
Risk of BF cessation
USA,
(first 7-10 days). 5 items: hospital
mothers age, previous
BF experience, latching
problems, BF interval,
formula bottles. 2 extra
items: breast surgery,
hypertension, vacuum
vaginal delivery.

& Date
BF Tool*
Table 38: Breastfeeding assessment tools validated against maternal and infant outcomes
IBFAT does not

discriminate
between
adequate/
inadequate milk
intake.
IBFAT scores did

not predict BF
status at 4
weeks. Limited
variability as 80%
still BF. Inter-rater
agreement 91%.
Author
Comments
/notes
144
145

& Date
Reliability & validity

testing of 3 BF
assessment tools.
USA,
hospital
& home
visit
Maternal &
professional
assessment of BF
Adams,
1997178
First 2
weeks
postpartum
n=182 (4 days) Newborn

n=188 (6
weeks);
Mothers of
healthy term
new borns
USA,
LATCH scoring
system & prediction of hospital
BF duration.
Kumar,
2006177
n=35; First
time BF
mothers
n=133; Mothers 39 hours

of healthy
singletons (3842 weeks GA)
intending to BF
6 weeks
Predicting BF duration USA,

using the LATCH BF hospital
assessment tool.
USA,
hospital
Compared validity &

reliability (inter-rater &
test/re-test) of IBFAT, MBA &
LATCH w/ Spearmans
correlations.
Paired t-tests to assess score

improvement 12 hours-1
week postpartum. Compared
correlation strength of IBFAT
& LATCH w/ maternal
satisfaction & BF problems
Inter-rater correlations: IBFAT
(r=0.27-0.69), LATCH (0.110.46), MBA (0.33-0.66).
Test-re-test correlations 0.640.88).
Low predictive validity for

maternal satisfaction & BF
problems (ns=0.06-0.50) w/
both tools.
Results Summary
n/a
Maintenance of BF
at 4 days &
6 weeks
Not BF at 8
weeks (no
BF in past
24 hours)
Inter-rater reliability of
lactation consultants using
LATCH & correlation w/
mothers LATCH scores.
Wilcoxon Rank Test to

compare LATCH scores of BF
vs not BF women at 6 weeks.
ROC analysis & Youden's J to
evaluate specificity/sensitivity.
Correlation of mother/nurse
ratings to assess validity/
subscale independence.
Fishers Exact test: LATCH

scores of women BF vs not
BF at 6 weeks. Stepwise
regression to id variables
associated w/ BF duration.
85-100% agreement of
lactation consultants.
Correlation w/ maternal
reports very low-moderate
Sig diff LATCH scores 0-48

hours postpartum in BF vs not
BF at 6 weeks. ROC analysis:
score of 9 at 16-24 hours =1.7*
more likely to BF at 6 weeks.
Nurse/mothers scores sig
correlated & w/ BF duration.
Subscales independent except
audible swallow/latch on.
Regression model: LATCH

score, mothers age, intended
BF duration & delivery type all
sig related to BF at 6 weeks.
This instrument was based on scientific understanding of lactation & clinical experience. It was not
psychometrically tested or validated against any maternal or infant nutritional or BF outcomes,
although it has since been tested.
n=28; Mothers 1st week

n/a
of healthy, term postpartum
new borns.
12 hours & Maternal

satisfaction
1 week
postpartum & BF
problems
Infant age Infant/

(mean,
maternal
sd)
outcomes
Riordan,
20011176
LATCHk
Jensen et 5 items: Latch; Audible USA
Assessment al, 1994175 swallowing; Type of
nipple; Comfort of
mother's breasts/
nipples; Help needed
to hold baby to breast.
Riordan,
1997174
n=30; First
time BF
mothers of
term infants

setting
&
participants
Schlomer, Evaluating the

USA,
Infant
1999173
Breastassociation of two BF hospital
feeding
assessment tools with
Assessment
BF problems &
Tool (IBFAT)
satisfaction.
(contd)
BF Tool*
Mothers
evaluate BF
experience
somatically,
not by
observation.
Audible
swallowing
not a viable
variable until
day 4.
Methodological issues
using taped
BF sessions.
Author
Comments
/notes
Table 38 contd
Psychometric
characteristics of
NOMAS in healthy preterm infants
BF = Breastfeeding;
OR = Odds Ratio;
RR = Relative Risk;
ROC = Receiver Operating Characteristic;
EBF = Exclusive Breastfeeding;

GA = Gestational Age;
NS = Not statistically significant (p>0.05);
8 guidelines to guide
UK,
n=395;
mothers in 'hands off'
hospital Mothers were
way to position & attach
BF on
baby. Includes leaflet
discharge.
w/ pictures &
explanationse about
BF.
Sig = Statistical
significance (p<0.05);
Ingram,
2002183
Hands off
technique
(HOT)
BF rate &
Group comparisons (Chi2 or
pacifier use
Fisher's exact test) of BF
(hours/day) at technique & duration.
2 weeks, 1, 2,
3 & 4 months
Cohens Kappa reliability

coefficient
Reliability of
normal/disorganised scales
& correlation w/ infant
feeding skills. NOMAS ability
to detect change in feeding
skills over time (SRMSm) &
sig of change scores.
% percentage agreement of
3 coders
Pacifier-users sig higher

BF at 4 months in
correct vs incorrect
sucking groups but sig
lower than non-users.
Non-users no difference
in BF at 4 months in
correct vs incorrect
sucking groups.
Test-retest of NOMAS
with 4
raters=moderate-near
perfect (0.33-0.94)
Acceptable reliability of
normal category (32-35
PMA) & disorganised
category (32 weeks
PMA). All categories
moderately correlated
w/ transitional milk rate.
Inter-rater reliability:
80% agreement.
Results Summary
Incorrect sucking
technique may
not be corrected
if pacifiers used.
Adjust tool to
improve reliability
& incorporate
new knowledge
of infant
suck/swallow
Moderate
convergent
validity for
normal &
disorganised
categories.
Author
Comments
/notes
BF (any
BF/EBF) 2 &
6 weeks post
partum
VLBW = Very Low Birth Weight;

LATCH was assessed against external outcomes by 2 further
Not
reported
PMA = Postmenstrual age;

SRMS - Standardised Response Means.
Chi2 to identify factors sig

High BF technique
Short, pragmatic
associated w/ BF at 6 weeks. score associated w/ BF training for
Logistic regressions to
at 6 weeks.
midwives to
identify independent variables
teach good BF
associated w/ BF & factors
technique.
assocActivity,
w/ BFRespiration;
at 6 weeks & BF studies - Riordan 1997 and Schlomer 1999. These
APGAR = Appearance, Pulse, Grimace,
scores.
studies are detailed in the IBFAT portion of Table 2b;
score used to assess the health ofassessment
newborn children;
n=82; EBF
4-5 days
mothers w/
postpartum
intention to BF
6 months.
Healthy
mothers
/infants, normal
delivery/birth
weights.
16 observations: breast Sweden,

offering (3 items),
hospital
sucking at the breast (8
items), after feeding (2
items), & conclusions (2
items)
Inter-rater
agreement.
n=75; Healthy
& VLBW
infants. Some
risk of other
health
problems
26-36
PMA.
Infant feeding
performance:
transitional
rate & volume
of milk
consumed
from bottle.
35-49
n/a
weeks
PMAl; term
& preterm
Infant age Infant/

(mean,
maternal
sd)
outcomes
n=147;
32-36
mothers of pre- weeks
term, but
PMA
otherwise
healthy infants
Righard,
1997182
Holland,
not
stated
USA,
medical
centre
Checklist
from paper:
'BF & the
use of
pacifiers'
da Costa, The reliability of

2008181
NOMAS
Howe,
2007180
n=35; Infants
35-49 weeks
GA, 1900g.

&
setting
participants
28 items: nutritive/
USA,
non-nutritive sucking.
hospital
Outcomes: normal,
disorganised or
dysfunctional. Latter two
graded by severity
(mild, moderate, severe)

& Date
Neonatal
Palmer et
Oral-Motor
al, 1993179
Assessment
Scale
(NOMAS)
BF Tool*
Table 38 contd
146
Six tools have been validated against a range of outcomes, although none of these include infant
nutritional status (Table 38). Outcomes include immediate assessment of milk transfer through testweighing, cessation of breastfeeding from the first days of life up to four months, introduction of
complementary feeding, maternally reported breastfeeding satisfaction and problems. On the basis of
consistency and volume of existing evidence, the NOMAS and BAS emerge as the strongest tools. NOMAS
categories have been associated with transitional rate of milk, and its key properties (Table 37) are
adequate. In two studies, BAS scores predicted early breastfeeding cessation in newborns. However, these
tools include the least comprehensive coverage of breastfeeding domains and the NOMAS is arguably the
most complex and least user-friendly tool overall. The Hands-off technique checklist technique score was
associated with breastfeeding at six weeks, therefore this may be a good way to teach newly delivered
mothers good breastfeeding technique. Interventions from this checklist are also more empowering to
the mother as she corrects her own technique and there are pictures to help identify problematic aspects
of the feed.
The LATCH should be considered a weaker tool because of contradictory findings and questionable
reliability and validity. Similarly, the IBFAT (Infant Breastfeeding Assessment Tool) lacks predictive validity
for a range of outcomes and is unable to adequately discriminate between sufficient and insufficient milk
intake. Righards assessment184 of correct vs incorrect sucking was associated with breastfeeding status at
four months if pacifiers were used, but not in the non-pacifier group.
7.4.2 Coverage of breastfeeding domains

It is striking that only one tool (BEET (Breastfeeding Evaluation and Education Tool)) achieves full coverage
of domains (Table 39). The tools that achieve the widest coverage (IFE Module 2, BEET, UNICEF b-r-e-a-s-t
and UNICEF Breastfeeding Observation Aid) are generally those that have been developed with
developing country settings in mind. However, although these tools are based on extensive clinical and
field experience, they suffer from a lack of validation, and some miss important domains (e.g. IFE Module 2
misses positioning, UNICEF b-r-e-a-s-t misses health of the baby). These shortfalls could be addressed
with appropriately designed studies and modifications. Furthermore, tools would need to take into
account whether and how acute malnutrition in the infant affects assessment of any of the breastfeeding
domains.
There is general consensus among the tools for inclusion of attachment and effective feeding domains.
What is not clear, however, is the best way to assess these aspects of the breastfeed given the lack of
validation against measurable outcomes. The important domain health of the baby, is only captured by
4/15 tools. It is crucial that this be included as an infant can be effectively breastfed but malnourished for
another reason (e.g. HIV infected, severe wasting in the mother). Only half of the tools assess mothers own
behaviour towards the baby, which may be very telling about her psychosocial status and could help
guide appropriate management. Furthermore, the influence of severe malnutrition on the mothers
interaction with her infant is not addressed in any tool reviewed.
147
Checklist from
paper: 'BF &
the use of
pacifiers'
Neonatal Oral
Motor
Assessment
Scale (NOMAS)
Mother-infant
BF
assessment
tool
LATCH
Assessment
Infant BF
Assessment
Tool (IBFAT)
BF
Assessment
Score (BAS)
BFc Tool
Extra domains that may be

important
previous
BF
experience,
supportive
partner
previous
BF
experience
Effective Health
Health Mother's Number, other
Feeding of Breast of Baby Experience timing or
duration
of feed
of feeds
Baby
Mother
Position AttachBehaviour Behaviour
ment
Domains covereda
Table 39: Tool coverage of breastfeeding domains and value of use in different contexts
General: Pros - acceptable, cheap, quick to administer; covers

different stages of BF from before starts to after finish. Some
predictive validity. Cons - 1/16 items objective, not quantitative.
Relevance of sucks/minute is unclear & difficult to count.
Community setting: medical terminology needs clarification,
not simple to use.
General: Pros - Identifies specific sucking problems. Cons:

designed for neonates; sole focus on oral-motor patterns, does
not assess overall BF. Only 5/28 items objective. Complex &
time-consuming. Categorisations potentially unacceptable to
mother (e.g. dysfunctional). Variable reliability, no validity data.
Community setting: Not simple to use, complex terminology.
General: Pros - cheap & quick to administer. Quantitative 'risk'

score generated. 2/8 objective items re milk intake, (e.g. wet
nappies-but misleads if infant given other liquids). Cons - some
items subjective/ unclear descriptions of behaviours.
Validity/reliability unknown. Diagnosis: General items do not
allow specific diagnosis or treatment decision.
Pros simple, quick, cheap & quantifiable. Identifies specific BF

problems. Mother can use modified version for self-monitoring.
Some predictive validity. Cons - Reliability/validity inconsistent.
Audible swallow n/a to colostrum. Acceptability of nipple
stimulation is questionable. No objective items.
General: Pros - simple (includes definitions), acceptable,

cheap, & quick to administer. Scores weakly associated w/ milk
intake. Cons - only 1/6 items objective. Some items vague.
Limited predictive value & variable reliability. Diagnosis: Does
not discriminate underlying causes of not BF.
General: Pros - simple, acceptable, cheap & quick to

administer. 3/5 items objective, quantitative. Some predictive
validity. Cons: non-comparable setting; does not assess
nutritional status; only aimed at 1st 7-10 days of life.
Diagnosis: Does not discriminate underlying causes of not BF.
Contexts in which BF assessment tools may be

appliedb
148
149
UNICEF B-R-EA-S-T
observational
checklist
Systematic
Assessment of
Infant at
Breast (SAIB)
Mother-Baby
Assessment
(MBA)
A BF
Evaluation &
Education Tool
(BEET)
IFE - Simple,
rapid & full BF
assessment
Checklist from
paper: 'BF &
the use of
pacifiers'
BFc Tool
Baby
Mother
ment
Domains covereda
signs of
milk
transfer
in mother
signs of
milk
transfer
in mother
Mixed
feeding,
feed end,
pacifier
use
Effective Health
of feed
duration
of feeds
General: Pro - quick, simple, cheap & acceptable. Identifies

specific BF problems. Con - developed for intensive training
module & involves cost & time. No reliability/validity data. Not
quantitative, only 1 objective item. Community setting: some
items need clarification for CHWs. Hospital setting: identifies
specific BF problems & treatments that could ease e.g. nipple pain.
General: Pros - Simple, acceptable & quick to administer.

Identifies specific BF problems. Positioning diagrams provided
could be an adjunct to assessment & to mothers. Cons - No
reliability/validity data. No quantifiable/objective items.
Community setting: Medical terminology would need
clarification (e.g. iliac crest, mandible etc).
Pros simple & quick to administer. Quantitative, meaningful

items (e.g. odd number score indicates progress of one of the
dyad but not the other) Acceptable. Cons - contains only 1
objective item (amount of areola that infant should take into
mouth). Poor to moderate reliability. No validity data.
General: Pros - 13/36 objective items. Many items indicate milk

transfer, could reassure mother about milk adequacy; acceptable;
Cons - Not simple/quick to administer. Some items need accurate
self-report of quantifiable items. No reliability/validity data. Some
items monitor infant over weeks, but in our setting only 1
opportunity to assess. Hospital setting: Easier to monitor inpatient on some items on hospital chart compared to CHW.
Pros - designed for developing/emergency settings. Clear &

suitable for use by CHWd w/ 1 training day. Acceptable.
Identifies underlying causes of BF problems & promotes maternal
confidence. Mixture of objective questions (13/32) & subjective
assessment. Cons - Time-consuming, training costs, no
reliability/validity data, not quantitative.
General: Pros - acceptable, cheap, quick to administer; covers

different stages of BF from before starts to after finish. Some
predictive validity. Cons - 1/16 items objective, not quantitative.
Relevance of sucks/minute is unclear & difficult to count.
Community setting: medical terminology needs clarification, not
simple to use.
Extra domains that may be Contexts in which BF assessment tools may be appliedb
important
Table 39 contd
Baby
Mother
ment
Effective Health
of feed
duration
of feeds
Extra domains that may

be important
Pros simple, acceptable & quick to administer. Includes leaflet w/

pictures to aid BF assessment & for mothers to keep. Good
predictive validity & identifies specific BF problems. Cons - cost of
leaflets (if used), training required. Assumes optimal surroundings
& relaxation
General: Pros - simple, acceptable, quick & cheap to administer.

Identifies problems that directly translate into intervention (e.g.
nipple cream for nipple trauma). Cons - some items vague (e.g.
'mother looks healthy'). Not quantitative. No reliability/validity data,
but tool being used in Sierra Leone 2009 & may provide relevant
data. Community setting: need to clarify 'oxytocin reflex'
General: Pros - identifies specific BF problems. Assesses BF from

start to finish. Acceptable & quick to administer. Reliability is good
between health professionals. Cons - only 3 objective/quantifiable
items. No clear scoring. Reliability between mothers & health
professionals is poor. No validity data. Community setting:
Designed for premature infants & neonates in hospital & n/a to
general populations. Hospital setting: Maybe useful in specialised
nursery setting.
General: Pros - Acceptable, cheap & quick to administer. Good

reliability. Cons - Items need defining. Tool tested w/ mothers w/
good BF so may not identify problems well. 1/8 items objective.
Some ambiguous items (e.g. 'redness' to identify nipple trauma).
No validity data or quantitative scoring. Community setting: May
not be suitable for CHWs. Hospital setting: could identify specific
problems & treatments (e.g. attachment advice; nipple care).
Contexts in which BF assessment tools may be appliedb
adapted from Hall Moran et al (2000)

adapted from Myatt et al (2006) to include: population screening (by community volunteers of primary level healthcare workers) case finding in clinical context & diagnosis in clinical contexts
Breastfeeding
Community Health Worker
Hands off
technique
(HOT
UNICEF 2006:
BF
Observation
Aid
Pre-term
Infant BF
Behaviour
Scale (PIBBS)
Mother-Infant
BF Progress
Tool (MIBPT)
BFc Tool
Domains covereda
Table 39 contd
150
7.4.3 Tool performance characteristics

We were unable to apply a formal grading procedure (e.g. GRADE185) to the tools, given the largely
observational study designs of which none would have achieved higher than a GRADE 2, or the complete
lack of tool testing. Other reviews of breastfeeding assessment tools have excluded studies on the basis of
design and validation issues. We, however, deliberately included as many tools as possible, though this meant
we were unable to assign formal grades. Instead, we analyse here a number of performance characteristics:
a) Community-based care
Community-based management of acute malnutrition (CMAM) is increasingly the approach of choice for
the management of SAM in children six to 59 months with no co-existing medical complications. If such a
model of care was extended to infants <6m, breastfeeding assessment tools to help CHWs identify, resolve
and refer breastfeeding problems would be needed. Such tools should also benefit children to two years
or beyond, to support sustained and continued breastfeeding.
Eight of the tools are either not relevant to a community setting or would require adaptation for use by a
CHW. Many items also involve complex medical terminology, so some adaptation or the provision of clear
definitions would be of benefit. Training lasting several days would be necessary for some of the tools,
which is a time and financial cost that may not be feasible in an emergency setting. However one tool, the
BAS, could be a useful basis to help CHWs to decide on referral to a facility. A study to test the BAS tool in a
community based setting for managing acute malnutrition would be valuable.
b) Hospital-based care
Eight of the tools appear to be useful in a clinical context. One tool, the BAS, was considered to be of
limited use in a hospital setting as it would not provide extra information about specific elements of the
breastfeed to diagnose specific problems. Currently most cases of SAM in infants <6m are managed in
inpatient settings. We suggest a study to evaluate a tool(s) for breastfeeding assessment and problem
identification in a clinical setting where MAMI takes place.
The recent implementation of a checklist to ensure simple guidelines were followed during surgery
resulted in significant reduction of patient mortality and morbidity.186 We believe a breastfeeding
checklist as part of admission assessment could operate in a similar way by highlighting simple problems
that could be easily overlooked.
Overall, few of the tools were sufficiently versatile to be used across community and hospital contexts
without substantial modification.
c) Lack of gold standard treatment of malnourished infants <6m

The success of a breastfeeding assessment tool in relation to nutritional/mortality outcome is dependent
on the interventions available to address the problems identified. As stated in earlier chapters, there is
currently no gold standard treatment for MAMI. Intensive, inpatient programmes as suggested in current
guidelines might be enhanced by a tool that identifies breastfeeding problems and appropriate remedial
action. Community-based programmes have a larger potential capacity for provision of treatment; the
question remains which infants <6m with SAM can be managed in the community.
d) Continued breastfeeding in older infants and children

Breastfeeding assessment and support is not just a consideration for infants <6m. Actions to support and
sustain breastfeeding as part of complementary feeding should feature in the therapeutic management
and rehabilitation of children up to two years of age and beyond. One promising initiative is the
development of a training content to integrate training on infant and young child feeding into CTC/CMAM
programming, piloted in Sierra Leone Feb/March 2009 (ENN/Valid/UNICEF) and in Zimbabwe in June 2009
(ENN/SCUK/UNICEF) (personal communication, Mary Lungaho).187 Reliable and valid breastfeeding
assessment tools developed for infants <6m could have wider application in children up to two years of
age and build upon current initiatives to address shortfalls in infant and young child feeding support
available to this older age-group.
7.5 Limitations
151
This review was systematically conducted, but it was not exhaustive due to time and resource constraints.
Formal grading of each of the breastfeeding assessment tools was not possible due to a lack of appropriately
designed study, and no gold standard for treatment of SAM in the <6m age group. The review is therefore
more subjective than ideal, which limits any strong recommendations about which tools perform best in
each context.
7.5 Limitations
7.6 Conclusions
This review highlights the need for simple, accurate and valid assessment tools predictive of breastfeeding
and infant nutritional outcomes. Different tools, or different versions of the same tool, are necessary for
several related but separate purposes:
A short, sensitive and quick version to identify breastfeeding problems and actions at community level.
A more specific, detailed tool to aid diagnosis and appropriate treatment in an inpatient/clinical context
A tool with intermediate balance of sensitivity and specificity for use in diagnosis and management for
outpatient primary healthcare services
At present, there is no single tool or set of tools that meets these ideals. Many existing tools are too narrow
in scope or have not been robustly validated, especially in nutritionally vulnerable developing country /
emergency settings. This is an important gap that warrants future research.
In the interim, UNICEF b-r-e-a-s-t, the UNICEF 2006 BF observation aid and the aids described in IFE
Module 2 offer the most promise for field use in programmes managing infants <6m. Operational research
could be useful in confirming their utility as best currently available tools. They could also form the basis
of future tools optimised to meet the needs of malnourished infants <6m. There is a need to identify the
most appropriate outcome(s) for validating new tools (e.g. rate of weight gain after stabilisation).

Summary findings
15 breastfeeding assessment tools were identified in the literature search. No single tool or set of tools
was identified for use in MAMI. Many tools are either too narrow in scope or have not been robustly
validated against nutritional or health outcomes, or applied in nutritionally vulnerable developing
country/emergency settings.
The influence of infant SAM on the mothers interaction with her infant is not addressed in any tool
reviewed.
The Breastfeeding Assessment Tool (BAS) could be tested for its suitability to community settings (e.g. use
by community health workers for case finding and assessment). Half of the tools reviewed could be useful
for inpatient assessment.
There is no tool that is sufficiently sensitive for community use or specific for use in inpatient settings. It is
likely that different tools will be needed for each setting, and possibly a third that is a balance of both for
use in primary healthcare services.
In the interim, UNICEF b-r-e-a-s-t, the UNICEF 2006 breastfeeding observation aid and the aids described in
IFE Module 2 were identified as most useful to assess breastfeeding in programmes managing infants <6m.
There is a need for simple, accurate and valid assessment tools that are predictive of breastfeeding and
infant nutritional outcomes. Such tools could also have wider application for children up to two years.
Quality research studies to test the validity of existing breastfeeding assessment tools are needed. For
example, the Breastfeeding Assessment Tool (BAS)188 could be tested for its suitability to community
settings (e.g. use by community health workers for case finding and assessment). Half of the tools
reviewed could be useful for inpatient assessment.
New tools should be developed, possibly based on existing tools, to meet the needs of malnourished
infants <6m, suitable for use in case finding in the community, inpatient settings and outpatient primary
healthcare programmes.
The success of a breastfeeding assessment tool and how it relates to nutritional/morbidity outcomes is
dependent on the interventions available to address problems identified. The lack of a gold standard
treatment for infants <6m is a limiting factor in this regard.
Severe maternal wasting and maternal and infant HIV status are important considerations in assessing
breastfeeding effectiveness.
152
Endnotes
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
153
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Pediatr 2002;141:659-64
Chapter 8
Psychosocial aspects of
malnutrition management
154
Chapter 8 Psychosocial aspects of malnutrition management
Chapter 8: Psychosocial aspects of

malnutrition management
The chapter opens with a review of the scientific basis and feasibility of stimulation activities in the
treatment of malnutrition, with particular reference to the WHO 1999 guidelines. The chapter then
explores child care practices and some key influences of the maternal-child relationship on child
malnutrition. It concludes with a look at the influence that maternal depression has on child malnutrition,
building upon a recent review of maternal depression and child growth and again, considering
implications for emergency programmes and infants <6m specifically. Overall recommendations are
included at the end.
Much of the evidence base is not specific to infants <6m and/or emergency contexts a reflection of the
evidence gap to guide programming in this age group - but shares and applies relevant evidence from
malnourished children and their mothers/caregivers.
8.1 Psychosocial stimulation in the treatment of malnutrition

8.1.1 WHO guidelines on psychosocial stimulation in the treatment of SAM
Children hospitalized for severe malnutrition have low levels of cognitive development and low school
performance which last into adolescence.189 Section 5.3 of the WHO 1999 guidelines190 recommends
integrating both emotional and physical stimulation into the treatment of severely malnourished children
to reduce the risk of permanent mental retardation and emotional impairment, to promote the
development of the childs motor skills and to enhance growth in the rehabilitation phase. Sections 5.4
and 5.5 deal with teaching parents the importance of preventing recurrence, as well as preparing for
discharge and return home.
The following is a summary of the recommendations:
The mother/ caregiver is a key resource person and partner with the medical team and should remain
with the malnourished child.
Sensory deprivation should be avoided.
Centres should be decorated with the interests of children in mind.
The number of adults interacting with the child should be kept at a minimum and contacts should be
warm and affectionate.
Local toys should be available.
There should be both informal group play and individual play activities.
Physical activity should be encouraged.
Parenting skills should be taught to help prevent malnutrition.
The home should be visited by medical or paramedical personnel before discharge to prepare for the
childs reintegration into the home.
Both sections are relatively short and contain little information on how to provide the different activities,
particularly staff training. The appendix contains examples of toys created out of ordinary and inexpensive
materials that families can find easily at home. The WHO Guidelines for the Inpatient Treatment of
Severely Malnourished Children191 provide a much more comprehensive list of activities. There is also
added information in the appendix with more suggestions of games and activities that could be used.
From here on we will call the activities recommended by WHO Stimulation and support activities
155
8.1.2 Scientific basis for the WHO recommendations

Relevant studies and experiences are few and often dated. For studies prior to 1990, we will use the
Grantham-McGregor literature review. After 1990, only studies that use stimulation activities in the
treatment of severely malnourished children are discussed. Two studies met our criteria: The 14 year
follow-up study of a cohort of severely malnourished children by Grantham-McGregor192 and research
recently conducted in Bangladesh.193 The two studies compared the development of severely
malnourished children that did and did not have stimulation activities included in their treatment, though
the full WHO recommendations on psychosocial stimulation were not implemented in either.
The question of the scientific basis for the WHO recommendations is best answered when considered
according to outcomes expected from implementation of the recommendations. Outcomes include:
Improvements in the effectiveness treatment for severely malnourished children.
Reduced risk of irreversible mental retardation and emotional impairment and to promotion of motor
skills development in the child.
Parents taught how to prevent a recurrence through a better understanding of what causes
malnutrition.
Preparation for discharge and return home.
Improvements in the effectiveness of the treatment of severely malnourished children

According to WHO, one of the goals of introducing stimulation and support is to promote growth during
the rehabilitation phase, and if we delve further, to improve the treatment of severely malnourished
children. Indicators of this may be increased weight gain, decreased duration of treatment and fewer
children being discharged before full recovery.
The two studies that incorporated stimulation in the treatment for severely malnourished children did not
specifically take these indicators into consideration. Nahar194 shows a similar length of stay for the
intervention group of children as for the control group, but the return home is explained by the mothers
tasks at home and not by the childs recovery criteria. More children from the intervention group were lost
to the study compared to the control group (39 versus 14%, P = 0.006). In spite of the fact that the overall
treatment led to significant change in the childrens nutritional status (weight at six months of age), 64%
of the children remained severely malnourished (WAZ < -3 SD) and another 25% had WAZ < -2 SD at the
six month follow-up. The intervention group improved more than the control group by a mean of 0.4
(P=0.029; 95%CI: 0.1, 0.8) weight-for-age z scores, controlling for background variables.
In the Grantham-McGregor cohort,195 malnourished children had the same height-for-age ratio 24
months after admission, whether they received stimulation or not. They were also smaller than the
children in the group hospitalized for other causes (control). This difference from the control group was
still significant at 72 months after admission. The three groups showed no difference in their weight-forheight ratio at 24 and 72 months after admission.
It is important to consider programmes that apply all of the WHO recommendations (these above studies
did not). A holistic program introduced in Afghanistan by Action Contre la Faim (which includes numerous
psychosocial activities, individual psychological support and upgrading of training for personnel) has led
to a net improvement in nutritional program results. These include a decrease in those stopping their
treatment and an increase in those recovering, though it is still impossible to identify the specific factors
causing the improvement. (See Box 8). Other countries have included stimulation activities and support
but these have not led to such a clear improvement in the rehabilitation of the child. None have been the
subject of rigorous research to identify determining factors and resulting changes.
Additional research is needed to measure the impact of stimulation and/or support activities on the childs
growth during the rehabilitation phase and on the effectiveness of the medico-nutritional treatment.
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Box 8: Case history: Integrating mental health and care practices in Afghanistan
Integrating mental health and care practices in the treatment of SAM:

A project by Action Contre la Faim in partnership with the Afghan Ministry of Public Health
Background
ACF has treated severe acute malnourished children in Afghanistan since 1997. The country has suffered
from decades of armed conflicts, displacements of the populations, human and material losses. Few months
after the 11th September 2001 and the fall of the Taliban Regime, the situation became more peaceful in most
of the country; refugees started to return to Kabul. The economic situation was poor. In Kabul, ACF was
running three therapeutic feeding centres in hospitals and 12 day-cares for about 1700 children per year.
At the End of 2002, the mission requested the visit of a psychologist to assess the mental health situation of
the mothers in the nutrition centres: they were described as very sad and crying a lot. The evaluation
confirmed that many of the women were suffering from psychological distress for many reasons including the
war and its consequences in terms of loss of personal belongings, loss of landmarks, change of life, family
separation, deaths, bombings, shootings, terror, the poor economic situation and job insecurity, feelings of
powerlessness, and the powerful role of the mother-in-law. Poor mental health status of the population was
confirmed by different surveys published in the following years.
Two other important facts were noted during the initial visit: 20% of the families defaulted before the end of
treatment; this rate was described as the minimum rate because of cultural barriers that limit the access of the
women to the health structures (especially at night). About 30% of children admitted for severe malnutrition
were infants <6m, explained by mothers as due to their lack of milk.
These findings were surprising since breast-feeding usually protects the infant and severe malnutrition
appears after the age of six months, following weaning. In Afghanistan this protection does not seem to
function properly. One hypotheses for this was that mothers who complain about insufficient milk are in fact
trying to say something else about their relationship with their child, their isolation, or other factors affecting
their mental health.
Description of the research programme
The project in Afghanistan has become a pilot project for a holistic approach for these children and their
families, in combination with surveys to better understand the problem and assess the impact of the
intervention. The research project includes:
a nutrition survey on infants <6m in Kabul (n = 507 ; 2004)
a KAP survey to compare maternal mental health, care and breastfeeding practices of mothers in three
groups: mothers without lactation difficulties and well-nourished infants, mothers with lactation difficulties
and well-nourished infant and mothers with lactation difficulties and wasted infants (n=105 per group; 2005).
2204 psychosocial files completed by the psychosocial workers for children admitted in the TFC
480 files on breastfeeding that were filled by the psychosocial workers for the infants <6m admitted in the
centres
focus group discussions on different topics
collection of data from the psychological interviews that have been put in place in the TFC
a study for assessing the survival and nutrition situation of children one year after discharge from
treatment (n=100)
Main research outputs
The prevalence of severe acute malnutrition was small in the general population, demonstrating an overrepresentation of this age-group in the centres. However, 40% of women interviewed complained of lack of
milk. Lack of milk was accepted by communities and not associated with a depreciation of the recognition of
the caring capacity of the mothers. When confronted with milk insufficiency (real or perceived), all the women
applied the same coping strategies: no advice seeking and the introduction of, or increase in quantity, of other
milks and complementary foods. The level of hygiene used (clean bottle and teat and boiled water) and
knowledge (number of spoons of powder to add, etc) were determinant factors for malnutrition.
Care practices and breastfeeding practices were not optimum for the continuation of breastfeeding: the early
initiation of breastfeeding is rarely done, infants are not always fed on demand, mothers dont know that
production of milk increases with the stimulation of the breast by babies, skin-to-skin contact is not facilitated
(children are swaddled, women wear a burka), etc. The medical staff and the mullah dont understand
lactation mechanisms and recommend artificial milk when women encounter difficulties. All these factors were
important and should be addressed but were not different in the three groups.
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Box 8 contd
Many children that were malnourished had been low-birth weight babies according to their mothers or
presented handicaps. These points might directly affect their capacity of suckling, but also their capacity to
attract their caregiver. The child might as well not correspond to the wishes of the parents, who might,
consciously or not, neglect him.
Finally, the criteria that distinguished the groups from each other the most was level of family support (through
the organisation of the workload at home, the support provided to the mothers for her to be able to take care
of the baby and to breastfeed), family violence and the family conflict and maternal depression, all of which
were interconnected.
Programme changes on the basis of research
At the national level, a close collaboration with the Nutrition Department of the Ministry of Public Health and
UNICEF was established. A training of trainers of the WHO Breastfeeding Counselling Course was organised
and trainers disseminated new knowledge to medical teams. Breastfeeding campaigns were carried out using
very specific messages regarding milk production and mother milk insufficiency.
In the feeding centres, psychosocial workers were recruited to complete the medico-nutrition team. Their
activities were:
Systematic use of the suckling technique.
Psychological assessment for all women and children admitted
Permanent support to mothers and psychological follow-up when needed
Support for breastfeeding and during feeding time
Family interviews to reduce risk of defaulting, to explaining the treatment to the fathers and to the rest of
the families, in case of family conflict. These interviews were also very important to help the families find
solutions for organising their stay in the centre with the malnourished child and taking care of the rest of
the family at home in the same time
Relaxation sessions for women
Stimulation of the babies through massages and play sessions that reinforce the mother-child bond
These interventions were combined with a reinforcement of the training of the medical staff, a closer
collaboration with the hospitals and the Ministry of Health, a constant reflection and adjustments of the
guideline, and the progressive development of home-treatment.
Results
At the national level, psychosocial aspects of malnutrition were recognized as important by the different
partners and the Department of Nutrition in the Ministry of Public Health. The breastfeeding counselling
course has been disseminated to more than 100 professional staff.
In nutrition centres, most of the fathers and the families invited came to the centres. They become partners in
the treatment of their children. This partnership greatly reduced defaulting and helped families find solutions
for treating the malnourished child without creating risk for the rest of the family.
Women used the opportunity to talk and to share their daily life and problems with the psychosocial workers
and amongst themselves. Very good results were observed in terms of maternal mental health and mother
and child relationships, even if it is very difficult to attribute this improvement to the child recovery and/or to
the psychosocial support.
The impact of these interventions was also clearly observed in the nutrition indicators:
The proportion of cured beneficiaries increased from 74% between April to August 2004 to 95% between
September 2004 and March 2005.
Percentage of defaulters has decreased from 19% to 3.8% in the equivalent periods.
The death rate has decreased from 8% to 1.3% in the equivalent periods.
To assess the longer term impact of the treatment on the children, the team searched for 100 children that
were severely malnourished when <6m and cured one year before. 75 families were found. Amongst them, 11
children were dead, four moderately malnourished and one severely malnourished. As the study was
retrospective, it was not possible to establish clearly the reasons of the death of the children. These findings
have to be put in perspective with the infant mortality rate in Afghanistan; they question the mid-term impact of
treatment for severely malnourished children on survival (even without taking onto consideration the
consequences on child development). The recommendation is to develop and ensure an adequate follow-up
of the children <6m and their mothers after the discharge of the nutrition centres, focusing on lactation support
and other-child bonding.
Source: C.Bizouerne, ACF France
158
8.1
Psychosocial stimulation in the treatment of malnutrition
Reduced risk of irreversible mental retardation and emotional impairment, and

promotion of motor skills development in the child
In order to measure the impact of stimulation and support activities on the medium and long term child
development, it is necessary to compare two groups of severely malnourished children receiving the same
medico-nutritional treatment with, or without stimulation.
The impact of short stimulation programs during malnutrition episodes is temporary, and this is not
surprising given the conditions of extreme poverty to which these children return.196 Results are better
when both parents and children are involved rather than the children by themselves.
To study the long term impact and to control for the hospitalization variable, Grantham-McGregor
compared three groups of hospitalized children between the ages of six and 24 months:
16 severely malnourished children received the standard nutritional rehabilitation treatment in the
hospital and took part in a three-year home visit program. (The intervention consisted of daily
structured play while in hospital and then weekly at home. Mothers were also taught how to play with
their child.)
18 severely malnourished children received only the standard nutritional rehabilitation treatment in
the hospital.
20 well nourished children hospitalized for other illnesses.
Hospitalized malnourished children had a lower development quotient (measure of the childs
development compared to others of the same age) than children hospitalized for other illnesses. Children
of all three groups showed improvement in performance while in hospital, however, there was still a
marked difference between the groups of severely malnourished children and children hospitalized for
other illnesses.
The non-stimulated malnourished group of children demonstrated a markedly low development score
while in hospital as well as six months after discharge from hospital compared to the group of children
hospitalized for other illnesses. The non-stimulated group did not improve during the 14 year follow-up,
while 24 months after being admitted to hospital, the score for the stimulated group of children
continued to improve and was even higher than the control group. During the third year (when home
visits were down to every 15 days), the development score for the stimulated group began to decline and
then remained stable, maintaining a middle position with the other two groups. After the 14 year followup, scores for the stimulated severely malnourished group of children remained significantly higher than
the malnourished group who did not receive stimulation, and significantly lower than the control group,
once the initial differences were taken into consideration and adjusted for.
Once socio-economic and hospitalizationvariables were controlled for, the stimulation program had a
significant impact on the mental development of the severely malnourished child. This improvement
lasted beyond the intervention itself, without however reaching the level of children hospitalized for other
causes or compensating for the benefits of a better socio-economic status. This last point was un
derscored in studies of children who had been adopted and who had regained their development in a
better socio-economic and loving environment.197
The Bangladesh study aims to show the impact of a shorter stimulation programme integrated into the
treatment of severe malnutrition. Forty-three severely malnourished children aged six to 24 months
(weight-for-age <50% or weight-for-length <70% or with nutritional edema) were enrolled in the study
and received the standard medico-nutritional treatment. An intervention group of 54 children were also
exposed to individual play sessions during their two weeks in hospital followed by visits at home for six
months (two visits in the first month and then monthly; total of 18 supervised play-sessions). Meetings
were held daily with mothers during the hospital stay. 27 children were lost to the study. Among the
remaining children, the two groups had equivalent developmental scores and anthropometric results.
After six months, the intervention group had improved more than the control group by a mean mental
development score of 6.9 (P< 0.001; 95% CI: 3.9, 10.0), by a motor development score of 3.1 (P=0.024; 95%
CI: 0.4, 5.7) and a mean weight-for-age z score of 0.4 (P=0.029; 95% CI: 0.1, 0.8) controlling for other
variables. The mental development of children remains extremely low in the two groups, which is not the
case when the same tests are used for a population of well-nourished children. No difference has been
noted on child behaviour.
The results of these two studies underscores the fact that a stimulation protocol improves the
development of severely malnourished children well into adolescence, compared to severely
159
malnourished children not receiving stimulation, even if development levels remain low. These results
correlate with those of the more numerous studies conducted with chronically malnourished children.
Studies conducted by Pelto, Dickin et al198 Engle, Black et al199 consistently demonstrate that the most
effective programs are those that combine nutritional supplements with psychosocial activities, that treat
children early, that are based on several types of interventions, and integrate children-led activities with a
parental guidance component.
There are sufficient data to confirm the necessity of incorporating stimulation interventions into mediconutritional programs in order to reduce the risk of developmental delay of severely malnourished
children. The intervention must not be limited to the duration of the medico-nutritional treatment and
must include parents in the activities. More study is needed to gain a better understanding what are the
best stimulation and support activities, the length of the intervention, the factors at play, how long the
developmental changes last, and what aspects of development are most affected, etc.
To assess the impact on the social and emotional development of the child we need to look at more
qualitative and empirical data based on observations. Geber200 insists on the different levels of recovery of
the children, whether they are nutritional or emotional recovery: The improvement in behaviour does
not correspond exactly to the physical or biochemical improvement. Some children who are hospitalized
for severe malnutrition remain sad and woeful despite their physical improvement. Others exhibit normal
behaviour in spite of the fact that there is no physical improvement. They interact well with others and are
able to feed themselves without difficulty. Nevertheless, it is important to keep monitoring the
appetite of these children (p. 19).
The quality of the mother-child relationship at the time of first testing is a prognostic indicator of
nutritional recovery and development into the adolescence stage of seven children with kwashiorkor in
South Africa.201
These differences alert us to a too simplistic understanding of the links between malnutrition and child
development for a more complex comprehension where the severe malnutrition appears in a broader
context of social, emotional and material deprivation.
If it is necessary to integrate stimulation within the treatment of severely malnourished children, it is
urgent that research be conducted on the effect it has on mental, emotional and social development, on
more holistic approaches to strengthen mother-child bonding, on parental skills and/or attachment
and/or the capacity to care for the childs immediate surroundings.
Better parental understanding of malnutrition, how to prevent its recurrence, and how to
prepare for discharge and return home.
No studies have been found that evaluate whether or not the development support activities
recommended by WHO actually improve families understanding of the causes of malnutrition, which
would prevent recurrence and prepare for the return home. Grantham-McGregor202 demonstrate that
in spite of including mothers in stimulation programs, the latter give little stimulation or objects to play
with. Children who had received a stimulation program attended school earlier than the group of children
who had no stimulation. The programs resulted in significant improvement in the mental performance
of 0previously malnourished children but without any real changes in the maternal behaviour.
Studies that measure the impact of nutritional programs on the medium and long term nutritional status
of the child are rare. There are two possible methodologies:
1) Do a follow-up of a cohort after treatment for a given period of time, or search after a few months or
years for children who were previously treated for an episode of severe malnutrition,
2) Keep track of children who have a recurrence and who need to be treated again for an episode of
severe malnutrition. This approach involves children returning to the same centre where they had
been admitted previously.
There is no explicit mention in the previously cited studies of differences in recurrences between children
who had received stimulation or not. Nahar203 indicates only that many children remained severely
malnourished six months after hospital discharge.
A study was conducted in Afghanistan on the outcome of a psychosocial approach in combination with
medico-nutritional treatment given to severely malnourished children under six months of age.204
Seventy-five out of 100 families included in the sample were located six to 12 months after the end of the
160
treatment (children who had recovered by the time they left hospital). Among them, 11 children had died,
representing 14% of the total sample, four children were moderately malnourished, and one was severely
malnourished.
In the Sudan,205 21.5 % of families with children admitted to the nutritional centre for severe malnutrition
already had the same child or another sibling admitted before for severe malnutrition, even though health
education sessions were suggested daily during the childs treatment. Recurrences correlated with the
quality of the mother-child relationship at admission and with the presence of family conflict.
There are almost no data on whether or not mothers change their practices at home in order to prevent
recurrences of malnutrition after receiving advice during the course of treatment. Very often, the advice
consists of basic standard health messages given to groups. To what extent this transmission of
information promotes changes in the home and prevents recurrences, remains an area to be explored.
8.1.3 Feasibility of the WHO recommendations for psychosocial stimulation

Existing data on feasibility
Few articles recount the inclusion of play or stimulation programmes in the treatment of acute
malnutrition. Articles describing the set up of treatment programmes for SAM, particularly in public
services, do not mention integrating psychosocial support into treatment and some specifically mention
not having included them.
The only studies which describe stimulation activities in treatment programmes of severe acute
malnutrition are those whose aim is assessment of their impact on child development. These have set up
systems which exceed the medico-nutritional protocol framework by a minimum of six months home
follow-up. Grantham-McGregors approach206 consisted of a long follow-up of three years after discharge
from hospital with home visits once a week for two years then twice a month during the third year. In the
Nahar study, the stimulation programme was adapted to the length of mothers stayin hospital (around
two weeks) and home-visits for six months. Activities revolved mainly around mothers and the inclusion
of development activities into daily care such as bathing or preparing the meal. The intention is to offer a
service which could be set up within the existing health system. No difference has been observed
between children discharged from hospital when this was the case after six months intervention, which
emphasises the necessity of conducting other investigations to find out the respective influence of
inpatient or clinic intervention where mothers regularly attend or home visits. In addition, the control
group did not receive any home visits. It would also be important to determine whether it is the play
activities in themselves which have had an impact or regular home visits.
Investigations regarding the feasibility stimulation programmes are essential to find out how best they
can be integrated, costs, which staff are more qualified to implement, staff training required and how best
to ensure follow-up of children and their families.
Transition from hospital care to community-based management

WHOs recommendations are based on inpatient treatment of malnutrition. In rare studies on the
inclusion of stimulation, children were inpatients for long periods, which is no longer the case in the
community-based treatment of acute malnutrition. In CTC programmes, children come with their mothers
once per week to a follow-up site for medical consultation, anthropometric checks and collection of RUTF.
At times, some programmes add home visits particularly for specific subgroups such as children who
have not attended the weekly visit or who are losing weight despite treatment.
The recent recommendations of the United Nations agencies on CMAM207 make no mention of
stimulation and support programmes. How can stimulation be included into community care of
malnutrition against the humanitarian background context and/or in the health systems? There is
probably not a single model that can be adapted to all situations. CMAM varies according to type of living
conditions, standard of health services, etc. Above and beyond published literature, some NGOs such as
ACF,208 IMC (International Medical Corps) and probably some government health services include play
activities and health education for mothers in nutritional care. These systems are possible but require
modifications in organisational, equipment and human terms. For example, play activities can be offered
at the clinic during the weekly visit, home visiting teams can be trained in psychosocial support and
criteria on the mother-child relationship can be included in referral criteria to different aspects of the
161
programme. Participating in groups set up in the community can be suggested to families of

malnourished children to prevent malnutrition or encourage child development and to train mothers in
the community to support mothers of malnourished children.209 Projects must be developed and tested to
assess the method in which stimulation and support programmes are feasible in the home-based
treatment of malnutrition.
8.1.4 Adaptation of WHO recommendations for infants under 6 months of

age and emergencies
Adaptations for infants <6m
MAMI concentrates on infants <6m. Is there a particular effect of an acute severe episode of malnutrition
for this age group? As early as 1995, Grantham McGregor summarised, It is not clear whether age of onset
of the severe episode affects the outcome because there is little data from children under six months of
age. Few things have changed since and it would be useful to assess the longer-term effects of an acute
severe episode of malnutrition in the first six months of life on survival, development and the childs
growth. Studies have demonstrated that serious malnutrition in utero increased the risk of
schizophrenias210 and hospitalisation for major affective disorders in adulthood.211 On the other hand, no
correlation has been demonstrated between IQ when entering the army and antenatal nutritional
deficiencies.212, 213 Studies on nutritional supplementation and stimulation have shown a better outcome
from early intervention (before the birth and throughout early childhood).
From the activities recommended by the WHO (1999), some may benefit infants under the age of six
months: constant maternal presence, design of the centre, limit of the number of nursing personnel,
advisors and mothers education on childcare. On the other hand, toys and the example of treatment
through play in annex 7 all refer to children over the age of six months. Could there be more specific
activities to offer infants under the age of six months? One can imagine that appropriate carrying, holding
and handling, the way in which treatment is given, massage and mobiles are stimulation adapted to the
age of the child. What is most striking during this crucial period of development is the possibility of
building a stable relationship with a person in the family circle and afocus of support and stimulation for
infants <6m is most likely to reinforce the dyad between the mother (or maternal substitute) and infant.
Adaptations for emergencies

If environmental conditions are greatly impaired, the effects of SAM may be more serious. In war or
conflict situations, family break-ups and displacements, the ability to care for the child, respond to their
needs, stimulate them and show affection may be hindered.214 Problems such as breastfeeding difficulties
are likely to come to the fore in these circumstances and put newborn babies in danger and risk of
malnutrition. Published evidence on stimulation in the treatment of acute severe malnutrition is even
scarcer in emergency situations. However, it is without doubt that in this kind of situation, that a package
of care is required to overcome environmental deficiencies, stimulate the infant, and support the parents
in their role. Programmes of this nature do exist; it is important to assess their nature and impact.
8.1.5 Conclusions
WHO recommends including stimulation and support activities for the care of the severely malnourished
child. The expected effects of stimulation and support are numerous, including accelerated growth during
the recovery phase, reduced risk of mental retardation and irreversible affective disorders, and
encouraging development of the childs motor skills. They teach parents how to anticipate a relapse and
avoid recurrences by better understanding of the causes of malnutrition, and prepare for discharge and
return to the family.
Review of literature has revealed the virtual absence of scientific data to confirm whether stimulation and
support activities enable set objectives to be achieved. Only two studies have been considered. These two
studies have focused on limited stimulation activities, without developing all activities recommended by
the WHO and have assessed the effect on infant development (particularly intellectual). Both of them
demonstrate that children receiving stimulation have significantly superior intellectual development than
children who have not received any stimulation. These results are sufficiently significant to recommend
the routine inclusion of stimulation in the care of the severely malnourished children during and after
162
8.2 Psychosocial aspects of malnutrition
medico-nutritional treatment. A large number of studies are still to be carried out to find out which
activities are the most effective, when should they be started, the minimum duration of intervention, the
impact on social and emotional development of the child and/or on the mother-child relationship, and
how to adapt these activities to the community care of malnutrition.
We have not found any studies confirming or invalidating the other anticipated effects from stimulation
and support programmes recommended by the WHO but empirical experiments and more qualitative
studies215, 216 describe the feasibility. However, these are scarce and are rarely published.
Stimulation and support can be adapted to suit infants <6m by focusing on strengthening the quality of
the family-infant relationship and breast-feeding support when mothers wish to breast-feed. Specific and
comparative studies on more holistic approaches of malnutrition in infants <6m are required to confirm
their effect on growth, survival and infant development, on milk produced and on the mother-child
relationship.
There are few examples of psychosocial support integrated into SAM treatment programmes. Some
activities are relatively easy to establish in hospital settings and are likely to bring improved well-being to
severely malnourished children. Their adaptation to community-based treatment is more complex but
different strategies can be considered, such as including stimulation activities during clinic visits or home
visits and setting up patient group sessions.

The psychosocial causes of malnutrition are dependent on geopolitical, cultural, social and psychological
contexts. In general, it is the mother-child relationship that is the main determinant of childcare practices
and which relationship is especially important in infants <6m. In general, the mother-child relationship is
influenced by six main (overlapping) elements: the infant/child, the mother or caregiver, relationship of
the child to his caregivers, support system, resource constraints and cultural beliefs and practices.
Considerations around child care practices and some of the influences of and on the mother-child
relationship are explored here.
8.2.1 Child care practices

Child care practices are recognized as a key consideration in the causes of malnutrition, which scope is
reflected in this comprehensive definition.217
the behaviours and practices of those who provide care (mothers, siblings, fathers and all other
caregivers) that ensure that the child is fed and receives the stimulation and emotional support
necessary for growth and development. These practices ensure that food security and health services
result in the well-being of the child. It is not only the practices that are essential for the survival, growth
and development of the child, but it is also the way they are implemented (with attention and adequately
meeting the needs of the child). It is impossible for caregivers to provide care without sufficient resources
such as time and energy.
Such considerations are reflected in a model for the extended care of infants (Figure 29) where child care
practices are considered alongside food and health security and also influenced by social, psychological,
or cultural factors, etc.218 This reflects how malnutrition is not an isolated medical-nutritional problem, but
a consequence of factors related to context, environment, and family, amongst others (reflected in Figure
30). Its causes and treatment especially concerns the childs caregivers, particularly for infants < 6m whose
survival depends entirely on their caregiver (usually their mother).
163
Figure 28: Model of extended care
Child survival
Health
Adequate food supply
Care practices
Food security
in the home
Food and financial

resources
Food production
Income
Employment
Land ownership
Care for women

Breastfeeding and feeding practices
Psychosocial and mental stimulation
Hygiene practices
Home Health behaviour
Preparation and preservation of food
Caregiver resources
Knowledge, beliefs
State of health and nutrition
Mental health, stress
Control of resources, autonomy
Workload and time constraints
Social supports
Health care services and a

healthy environment
Health resources
Water supply
Sanitation equipment
Availability of health
services
Security of the home and
surroundings
CULTURAL, POLITICAL,
SOCIAL CONTEXT
urban / rural environment
Source: Martin-Prvel Y, 2002219
164
Figure 29: Psychological and sociological factors implicated in malnutrition

Recent
urbanization
/acculturation
Isolation of
mother/caregiver
Other causes:
- Death of a loved one
- Family conflict
- Poverty as a
predisposing factor
.
Traumatized parents
Absence of
support group
Maternal
depression
Factors unique to the

child:
Child is unattractive and peu
tonique, especially following
malnutrition in the mother
during the pregnancy
Dysfunctional
mother/child
relationship
Emotionally distance:
changes in eating habits,
less physical contact
with the mother.
Malnutrition
in the child
Separated from
the mother
Figure 30: Psychosocial factors that aggravate malnutrition

Recent
urbanization
/acculturation
Anxious, depressed or
traumatized parents
Less available to children
Less stimulation
Depressed or
traumatized children
Deterioration of the
childs health
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Child care practices during emergencies

Individuals treated in humanitarian programmes are often socially and psychologically vulnerable. They
have have often suffered recent losses, including homes, loved ones, families and communities, and have
often experienced or witnessed violence. Mental health problems are common in these situations, for
example, anxiety, post-traumatic stress and depression. Social and family structures are often shattered
and people may find themselves isolated, without the support of the community or extended family that
they usually rely on. We can hypothesize that emergency situations have a negative impact on the
mother-child relationship and thereby on nutrition. The infant no longer finds in his mother the partner he
or she needs to communicate with and develop. The infants problems reflect the mothers difficulties and
also those of the father, family and community.
Such factors can severely limit or hamper the capacity of the support circle to give care, particularly to
children.220 In Juba, in the Sudan, in the late 1990s and early 2000s, for example, recurring conflicts and
insecurity forced families to become displaced and separated. Many men joined the military as the only
means of earning income and were away from home. Women were forced to work by selling wood and
grass to sell at the local market. Older children had to look after the youngest during the day and mothers
spent very little time on childcare.221 Children born of rape in conflict situations can also present
difficulties, as the will of the parent to provide adequate childcare can be compromised.222 We can
hypothesize that conflict situations, crisis, and traumatic events have a negative impact on the caregiverchild relationship and thereby on nutrition. Children themselves are directly impacted by war and
conflicts and also have to live with their parents sufferings and their inability to protect them. The infant
reflects the problems experienced by its mother, father and family.223
Traumatizing a population can affect child care practices dramatically during and after emergencies.
Social and caring behaviour can have a critical impact on the nutritional well-being of dependants
following an emergency when physical resources are no longer a limiting factor. In addition, societies
need to be mentally healthy to make optimal use of rehabilitation resources that are available from
agencies during emergencies to improve nutritional and food security224
8.2.2 Providing nutrients is not enough to nourish infants

What a baby cannot vocalize will be expressed by the body, for example in sleep disturbances, eating
problems, skin problems and repetition disorders. Mother/child bonding and the feeding relationship are
interconnected. Simply providing care to infants in a mechanical way is not enough for proper
development.225 Attachment to the mother, or another maternal figure, is as essential a need for the childs
survival as daily care. Attachment is described as secure when a child feels confident and secure enough
to explore the outside world and to try new experiences.226, 227 Feeding provides special times of
interaction between a child and its mother figure and how it is carried out is important. Feeding
represents a vital issue around which difficulties can crystallize. A malnourished infant <6m (excluding sick
children) should alert us to consider relationship difficulties.
8.2.3 Malnutrition and attachment: cause or effect?

An attachment problem can be a risk factor for malnutrition (or failure-to-thrive), and changes in the
relationship are possible if the child demonstrates delayed development or malnutrition. Research into
cause (prospective studies) and effect on malnutrition in infants <6m specifically was not identified.
However research in malnourished infants and children is of relevance and key work is summarized here.
Insecure attachment as a cause of malnutrition

During systematic longitudinal observations in a part of Abidjan with a high level of malnutrition,228
insecure attachment seen in children was linked to the relative unavailability of the attachment figure, an
insistence by the infant on remaining close to the mother (refusing to leave the breast) and anger and
opposition (anorexic behaviour). This contributed to the onset of ongoing symptoms of light and
moderate malnutrition. Children with secure attachment were able to use their mother as a secure base
from which to explore their surroundings, including a variety of foods. Other research has found that
mothers of malnourished children responded less to their child, and were less affectionate and
communicative even before the onset of malnutrition.229
166
Attachment issues in the malnourished child

There is a lot of research available on the link between attachment issues, emotional deficit and
malnutrition. Grappe230 found an increase in acute malnutrition in north-east Brazil when there were
attachment issues between mother and child. Geber231 shows how changes in the mother-child
relationship can affect the onset and prognosis of malnutrition. Buffet et Mazet232 recount the story of a
malnourished child who presented with anaclitic depression (childhood depression caused by separation
from mother following a normal relationship in the first few months of life).
Ainsworth233 observed 28 children in Uganda, 16 of which had secure attachment, seven insecure
attachment and five no attachment. Unattached children had mothers who were absent for long periods
of time, while the mothers of children with secure attachment remained with their children. Unattached
children overall received the least care. In terms of feeding, none of the unattached mothers reported
finding pleasure in breastfeeding, whilst 14 out of 16 mothers with secure attachment did. Similarly, the
mothers who believed they had enough milk were mainly those whose child had a secure attachment.
Miquel-Garcia234 compared 30 pairs of mother-malnourished children to 30 pairs of mother-healthy
children in Mali. Amongst mother-malnourished child pairs, children had difficulty separating from their
mothers and interactions were sporadic, rarely mutual, tinged with sadness and indifference, and even
hostility. Interactions between mother-health child pairs, interactions were mutual and pleasurable.
Pollitt et al.235 compared mothers of healthy children to mothers of children with delayed development
(failure-to-thrive). Mothers of children with delayed development had less verbal interaction and
socialized less.
Interacting with malnourished children

Bouville236 cites several studies that examine the specifics of behaviours and interactions of malnourished
children in their natural environment. In India, time spent breastfeeding was the same for malnourished
and healthy children, but breastfeeding was more frequent for moderately malnourished children and
there was less stimulation, such as speaking, playing with the child, or fondling. In Mexico, malnourished
infants over six months were clingier, more passive and explored less, attracting less parental attention as
children who were well. In Cameroon, early weaning was noted among malnourished children who were
entrusted to younger mothers figures who were distant relatives. Malnourished children had less social
interaction, but would seek their mothers attention more through looks and verbal sounds during meals.
These children showed very little interest in food.
These studies show that mother-child interactions are few and less positive even before the onset of
malnutrition in the child, or during the course of the malnutrition episode. Some authors talk about
negligence in cases of malnutrition. This may often be due to social interpretations of malnutrition which
give parents a sense of powerlessness and inhibit positive reactions.237 Multiple risk factors may be at
work. In considering the issue of negligence, however, it should be remembered that inferring blame for
having a malnourished infant (especially for infants <6m where mothers may be considered responsible)
is important to avoid, particularly in the context of therapeutic programmes.
8.2.4 Malnutrition and the psychopathology of the child

Some authors go further and suggest that malnutrition should be regarded as a psychopathology
syndrome (or form of mental illness) (Guedeney, 1986, 2000). An accurate differential diagnosis must be
based on in-depth analysis of individual situations and their progression. The nature of interactions
between the child and caregiver may provide a good diagnostic and prognostic indicator.238 The
diagnosis will help to decide whether or not to incorporate a psychological approach to the classic
medical-nutritional treatment.
8.2.5 Mother-child support system

Mental health and social support are inter-related and therefore the social support system of mothers
seems to be particularly important for their mental health and therefore the care of their children. Various
studies highlight this, for example:
167
Risk factors for malnutrition identified in Mali 239 were an unwanted child born in an unhappy marriage
serious economic crisis, moving death of a close parent, and the number of hardships since the childs
conception.
8.3 Maternal depression & infant malnutrition
Studies of medical records of malnourished children in Senegal240 showed that kwashiorkor can result
from changes in the social, familial, and cultural environment that occur when having to adapt to
urban surroundings following recent migration from rural communities. Similarly a study from Burkina
Faso241 showed that amongst people who migrate to urban settings, for those who are not adapted to
modern life, the loss of traditional family life can lead to poverty and depression for the mother and
child malnutrition.
Mothers with a malnourished child in the Ivory Coast242 were either very young and rejected by their
family due to early pregnancy, had had to leave their mother abruptly without severing emotional ties,
were mature with many children and pregnant again, or abandoned, divorced or in the midst of family
conflicts. All did not have the usual extended family support. This is reinforced by research in the
Congo on reasons why mothers are not properly bonded with their children.243
So what appears to be irresponsible or negligent behavior on the part of the mother, may actually reflect
her suffering experienced in a social situation that has become unbearable.
8.2.6 Control of resources, autonomy, workload and time constraints

Caregivers require resources to provide for the children in their care. Mothers often also have limited
access to financial resources and have limited budgets from which all family needs must be provided for.
The needs of individual children can be lost in this. Caregivers also require a level of autonomy to make
decisions about their welfare. Research in Kabul showed extended family members to be very involved in
decisions made about childcare practices, which some mothers found difficult when there were points
that they didnt agree on, but were powerless to change.244
Society also imposes norms that families follow (consciously or not). For example, if malnutrition is
thought to be the result of a transgression of a sexual taboo245 or as the result of a djinn (spirit)
intervention, then the family will seek help within that framework, for example from local traditional
healers246 and will go to the hospital only as a last resort. Research on mothers and children hospitalized in
Niger247 reveals a popular belief that malnutrition is caused by djinns and witch doctors attempting to
make the essence the person disappear, thus the loss of weight. In addition, hunger can be synonymous
with shame, as it shows the family network to be dysfunctional. In this context it is easy to understand the
difficulties of seeking treatment for the malnourished child.
Workload and time constraints of mothers also influence their ability to adequately care for their children.
For Longhurst248 childcare refers to the time, attention and support given in the household and
community to provide physical, emotional, intellectual and social needs for the development of the child.
According to Longhurst, it is important for the community to ensure the well-being of its children.
Community activities can have a positive impact on childcare practices at the household level, for
example, through programmes that generate revenue to allow women to have more control over that
income, family literacy and nutrition education. The presence of such psychological and sociological
factors underscores the importance of considering the surrounding environment of the child in order to
target appropriate support and treatment for recovery.
8.2.7 Conclusions
Current humanitarian programs should incorporate child care practices and psychosocial causes of
malnutrition in their knowledge base and intervention plans.

Post-natal depression is inadequately detected and treated in developed countries as well as in
developing countries. Its impact on child development is widely recognised249, 250 but its role in physical
development and malnutrition has been researched to a lesser degree. Stewart251 recently published an
exhaustive review of the literature on maternal depression and child growth. Here we build on this with
the articles that have appeared since, and then refocus on the treatment of severely malnourished infants
<6 m in emergency situations.
168
8.3.1 Methodology
A Medline search was carried out using the following criteria of inclusion: articles published in French or
English between 1993 and 2009. The keywords and number of articles referenced are shown in Table 40.
Table 40: Number of articles by keywords (Medline, February 2009).

Keywords
Number of articles
Maternal mental health and infant malnutrition
Maternal mental health and infant malnutrition
Maternal mental health and infant growth
Maternal mental health and growth
10
Maternal mental health and infant growth
218
Maternal depression and infant growth
186
Maternal depression and infant malnutrition
28
The titles and summaries are graded first. A small number of articles corresponded to our research theme.
As many articles as possible were included despite the methodological differences and variations in the
definition of maternal mental health and malnutrition. Although the MAMI project mainly focuses on
acute malnutrition as determined by anthropometric assessment, research studies using malnutrition
indicators other than weight/height were kept. Similarly, we have broadened the review of the literature
to include research on infants over six months. Lastly, the mothers mental health has generally been
based on scales of maternal depression but research that has used more general scales of psychological
distress have also been retained. The authors concentrate mainly on maternal depression because
depressive symptoms are the most common on the international level and a number of studies have
highlighted that they constituted a major risk factor in child development252, 253 These differences
necessitate a certain amount of prudence in the analysis of the results and the recommendations.
In all, 11 research items were included in this review of the literature; the indicator and target populations
are listed in Appendix F (Table 41).
8.3.2 Results
Two types of approach are implemented in the studies on maternal depression and child growth:
In cross-sectional studies, the children are recruited (in general in primary health care centres) and
classified according to their nutritional state (malnourished v not malnourished). In the majority of
studies, a certain number of variables are checked: the age, gender of the child and socio-economic
level. Then the prevalence of maternal depression is assessed and compared between both groups.
This type of methodology does not enable identification of causes of maternal depression. For
example, maternal depression could result in child malnutrition or indeed malnutrition and maternal
depression may be the result of a third variable not assessed in the study (poverty, family isolation,
family conflicts, etc.).
Longitudinal studies try to avoid this bias by recruiting mothers during pregnancy or in the first
months following the birth of the infant. The prevalence of maternal depression is assessed and
compared to different periods of growth of breastfed infants of both depressed and non-depressed
mothers.
The results of the different studies are presented in Tables 47 and 48 (see Appendix E, for detailed analysis
of this data, refer to Stewart 254). In South Asia, research has shown correlations between perinatal mental
disorders and child malnutrition, including after allowing for confounding factors, particularly birth
weight. A single prospective study in Pakistan 255 specifically took ante-natal depression into
consideration. Children of mothers who were depressed during pregnancy were four times more at risk of
being underweight (CI: 2.1-7.7) and 4.4 times more at risk of being stunted at six months of age (1.7-11.4).
This risk was increased when the mothers were depressed at each assessment (chronic depression).
169
The results are less congruent in studies carried out in other continents. A cross-study in several
countries256 did not find significant correlations between psychological distress of mothers and
malnutrition of their children between six and 18 months of age, in Peru and in Ethiopia. If a correlation
was observed between maternal depression and malnutrition in Jamaica257 it was diminished after taking
into account unanticipated factors revealing poverty as a risk factor. In Brazil258 30% of children with
depressive mothers were stunted compared to 18% of children of non-depressed mothers but no
significant association was observed between maternal depression and child growth. The longitudinal
study conducted in South Africa259 also highlights that post-natal or present depression was not
correlated significantly at two months, once the variable birth weight was accounted for, nor at 18
months. The sample from this study is relatively small, which limits its impact. On the other hand, De
Miranda260 found more depressive mothers in the group of malnourished children than in the children in
the control group, a difference which persisted after taking into account the confounding factors. A
longitudinal study in Nigeria261 found that children of depressed mothers at six weeks post-partum had
breastfed infants more underweight and stunted at three and six months of age. In Malawi,262 the heightfor-age Z-score of the child and the presence of current maternal mental problems correlated
significantly, including after adjustment of confounding factors. The average weight-for-age of children of
mothers experiencing mental health problems was smaller than that of children whose mothers were not
experiencing mental health problems, but this difference was not significant.
8.3.3 Discussion
While the impact of maternal depression on child development is well established, especially in
developed countries, the number of studies published on the impact of maternal depression on physical
development and child growth remains low. However there is increasing interest in this problem. Research
in South Asia strongly correlates maternal depression and infant malnutrition. The results are less clear in
other continents and require more research. The heterogeneous nature of the results may be explained by
methodological differences, factors linked to local specificities of malnutrition and to cultural data,263 and
on interpretation of the links between maternal depression and malnutrition.
There were methodological differences between the studies, for example indicators of malnutrition. The
majority of studies rely on the weight-for-age ratio but some also take into account height-for-age or even
weight-height ratios. The thresholds separating children in good health from malnourished children also
vary between studies. Similarly, mental health of mothers sometimes refers to pre- or post-natal or chronic
maternal depression and sometimes to common mental problems. Finally, the age of the child, method of
assessment of the mental health of the mother and the cofounding factors retained also differ widely.
Associations between maternal depression and malnutrition may be explained by three different
mechanisms:
1. Contextual factors
Poverty undoubtedly plays an important role since it leads both to an increase in depressive symptoms
and is a risk factor for infant malnutrition. Other variables such as endemic infections or, for example,
certain deficiencies in micronutrients could cause psychological distress and child growth delays. More
contextual factors also contribute. For example, mothers recently arrived in urban environments may
be unaccustomed to one-to-one contact with their baby without extended family support. Isolation
may have a negative psychosocial impact and may also lead to resource constraints.264
2. Maternal depression as a direct and indirect cause of malnutrition
Maternal depression is a risk factor for child malnutrition. The depressed mother stimulates her child
less, has more difficulty quickly and adequately meeting his needs and seeks less help from health
services. More indirectly, depressed mothers have more risk of having babies of low birth weight or
babies which are premature, who for their part may have suckling problems, making breastfeeding
more difficult and a tendency for the mother to wean their child earlier.
3. Low birth weight as a cause of maternal depression
The child with a low birth weight, or with difficulties sucking or who cries a lot, presents certain risk
factors which can lead to and/or contribute to maternal depression.265
This method of exploring the links between maternal depression and child malnutrition risks implies a
linear causality. However malnutrition and psychological problems in the mother are explained much
170
better by circular causalities. We can envisage, for example, a child experiencing a period of partial
anorexia at the time of the introduction of additional food. The mother then feels a little depressed and
does not manage to adequately respond to her childs difficulties. The latter then starts to refuse more
foods, the mother worries and her depression increases in the face of her childs refusal to eat. This
concept of circular causalities may help us to better understand differences observed between different
countries and regions and may help to pinpoint appropriate interventions.
8.3.4 Implications for MAMI

These findings have important application for MAMI in emergency situations, where the context is highly
pressurised (for example, social and family networks have been lost) and where infants are extremely
vulnerable and highly dependent on their mothers. In these circumstances the psychological availability
of the mother and her ability to care for and breastfeed her infant is critical and therefore, we believe the
relationship between maternal depression and child growth may be even more marked.
Detection of maternal depression

Although perinatal depression is insufficiently detected and treated in developed and developing
countries, detection tools and appropriate treatments do exist.266 What are these tools and can we use
them within the framework of interventions of prevention and/or treatment of child malnutrition?
Ideally, identification of women with post-natal depression should be done through an in-depth clinical
interview carried out by qualified personnel. Unfortunately, this approach is rarely possible and screening
remains the most common method for early detection. Several depression screening tools exist but they
have limited use in screening pre and post-natal depression, as some questions (e.g. concerning sleep
difficulties and lack of appetite) can be lined to normal changes connected with pregnancy and birth.
Among the tools specifically developed for the detection of post-natal depression267 the EPDS (Edinburgh
Post-Natal Depression Scale) is the most widely-used in the research. It is a self-report scale of ten
questions268 (Cox, 1996). Each item is coded from 0 to three with a total ranging 0 to 30. A threshold of
12/13 suggests major depressive symptomatology but it is recommended that all women with a score of
9/10 are considered for an in-depth clinical interview. EPDS scores do not constitute diagnosis but rapid
identification of potential cases. The scale has been translated and adapted in numerous contexts; the
thresholds vary depending on the country.269, 270 Its use is relatively easy, interview time is short and it is
well accepted by the women.
Whilst many studies report positively on the impact of EPDS, a recent review of the literature271 shows that
detection of depression (not only post-natal depression) does not result in improved recognition of
depression by medical teams, or increased treatment of depression. On this basis the author recommends
not systematically including screening for depression in routine treatment procedures. These conclusions
are comparable to those defended by Dennis,272 currently, there is limited information about the harms of
screening and despite a wealth of studies concerning the prevalence of postpartum depression and
screening accuracy, key elements of the evidence base for screening remains insufficiently developed. As
such, a strong recommendation to implement procedures cannot be justified until further research has
been completed. A review of over 16 recent studies also resulted in a lack of conclusive evidence for
recommending the use of systematic screening in pre-natal treatment. It is therefore necessary to specify
with extreme precision the depression screening framework so that screening is effective and results in
suitable treatment.
Treatment of maternal depression

Effective treatments exist and may even be integrated into the routine services. In a recent study,
Rahman273 compared the impact of a cognitive-behavioural approach versus routine follow-up by the
primary health agents in the rural communities of Pakistan. At six months, 23% of the women of the
intervention group and 53% of the women of the control group still had a diagnosis of major depression
(significant difference between the intervention group and the control group). These effects would
endure at 12 months. This study illustrates the feasibility of integrating treatment for pre-natal depression
with primary health services.
171
8.3.5 Interventions on maternal depression and child malnutrition

Several types of intervention can be envisaged depending on the whether detecting and treating
developing depression in order to prevent child malnutrition, or detecting and treating maternal
depression and child malnutrition simultaneously.
Detecting and treating maternal depression to prevent child malnutrition

The aim of this type of intervention is to intervene even before the appearance of malnutrition in order to
prevent it developing. This requires the identification of risk factors and suitable responses. Since
depression constitutes a risk factor of infant malnutrition, we can make the assumption that the treatment
of maternal depression will decrease the risk of infant malnutrition. To our knowledge, only one study has
tested this hypothesis. In Rahmans study274 the cognitive-behavioural approach in the primary health
care services had an impact on the rate of maternal depression, but no significant difference was observed
on the growth of the child at six and 12 months. However, the number of children stunted at 12 months
was much greater in the control group compared to the intervention group. Analysis of the intervention
group revealed that children whose mothers were still depressive at six months had a weight-age and
height-age ratio significantly lower at six and 12 months of age than children whose mothers had
recovered. Untreated maternal depression contributed substantially and independently to infant
malnutrition even in cases of cognitive-behavioural intervention. The intervention had by contrast
positive effects on the number of episodes of diarrhoea and on vaccination. The mothers were more
willing to use a means of contraception and the parents reported that they played with their child more.
These data are insufficient, however, to draw recommendations from and further research is needed.
Research into the effect of treatment for maternal depression and of other potential risk factors, such as
maternal support, is required. Independently of its impact on malnutrition, perinatal depression is a public
health challenge for women and populations and justifies appropriate management.
Detecting and treating maternal depression and child malnutrition simultaneously

This type of approach aims to treat both infant malnutrition and maternal depression in a combined way.
It poses however certain methodological problems. Severe malnutrition in the child can be a cause of
maternal depression, caused by anxiety. In such cases, the mother's depressive symptoms are likely to
disappear as the childs health improves. Chronic and reactive depression both require psychological
support but the methods and length of treatment will vary. Here follow a number of interventions
published in the research.
Celia and Nudelman275 describe a programme of global treatment of malnourished children and their
depressed mothers in a favela in Brazil that included dissemination of information and paediatric,
psychological and social monitoring at home. The first results are positive for maternal depression and the
nutritional and psychological condition of the babies.
Mdecins Sans Frontires (France) has put in place a programme of individual malnourished mother-baby
psychological support in addition to nutritional monitoring in Hebron (Palestine). The results show a very
positive impact, on the baby in the first instance, then on the mother-child interaction and finally on the
mother herself. The baby recovers quicker and then contributes to his mother's recovery.276
Buffet and Mazet277 report the case of a child under two years of age hospitalised for anaclitic depression.
The child presented characteristics of marasmus. Medical staff worked with the family to understand the
difficulties and value the mother and managed to end hospitalisation, following which the childs appetite
returned and psychological health improved.
Miquel-Garcia,278 following research on maternal depression and child malnutrition, offered to mothers
psychological treatment and medical treatment. The authors note "a parallel development of mother and
child. Within three weeks, the latter became active and sociable; interacting profoundly with his mother,
even though the nutritional recovery still appeared incomplete (p. 223).
Psychological support programmes, in addition to medico-nutritional treatment of severe malnutrition,
have positive effects both on maternal depression and on the nutritional and psychological health of the
children. However, research studies are still too few. Further research is needed to discover the most
effective psychological aids (psychotherapies for the mother, mother-baby psychotherapies, drug
treatment, etc.) and how these can be adapted to the extreme environments of humanitarian
emergencies.
172
8.3.6 Conclusions and recommendations

Maternal depression has an impact on child growth in the countries of South-East Asia. The results are
more contradictory in other continents. The mechanisms between depression and malnutrition are
probably multiple and are both direct and indirect. A better understanding is necessary to identify the
processes and factors at play. However, the consequences of maternal depression on breastfeeding, child
development and the ability to seek treatment are sufficient to recommend detection and appropriate
treatment of maternal depression within the framework of management of infant malnutrition.
Additional studies are to be undertaken to assess the most effective methods and tools of intervention in
both the prevention and treatment of severe acute malnutrition. The feasibility of the treatment of
maternal depression and/or treating jointly malnutrition and maternal depression in developing countries
has been demonstrated in different programmes.
It is unlikely that a single model is suitable for all contexts. The causes of maternal depression and/or
malnutrition vary, as do available resources. Qualitative analyses also including socio-anthropological data
are recommended for devising appropriate interventions in different circumstances (possibly also
including other social players as well as mothers). The specificity of infants <6m and emergency situations
are not taken into account in the studies which we have come across but the assumption can be made
that breastfeeding constitutes a cornerstone between maternal depression and infant malnutrition and
that the interventions facilitating starting and continuing breastfeeding are crucial.
More research is needed in the following areas:
Longitudinal research on maternal depression and child growth in different countries to assess the
causality of maternal depression on infant malnutrition and better grasp geographical and contextual
differences.
Differentiating the impact of pre- or postnatal depression and common mental disorders to see if there
are notable differences on child growth.
Synthesis of qualitative research to better understand the causal links and risk factors of maternal
depression on infant malnutrition.
Research study on the impact of treatment of maternal depression on child growth and the prevention
of malnutrition.
Several programmes have shown the relevance of managing maternal depression and infant
malnutrition simultaneously, but data are lacking to understand the most effective interventions and
their objectives.

Summary findings
WHO 1999 guidelines on treatment of SAM include guidance on psychosocial support and stimulation for
children and mothers.
Evidence shows that stimulation during and after treatment improves the development of severely
malnourished children well into adolescence compared to non-stimulated children, even if development
levels remain low.
Evidence is lacking on the medium and long term impact of stimulation programmes on childs growth
and effectiveness of SAM treatment, on mothers practices at home and on the impact on malnourished
infants <6m. Most of the experience and evidence to date comes from inpatient settings.
Impact of severe malnutrition in infants <6m is not known, there is little guidance on specific stimulation
activities for this age group and little evidence of the long term effects of psychosocial support on this age
group.
Psychosocial stimulation is not currently integrated into CMAM recommendations and not routinely
integrated into emergency programmes of all kinds.
The mother-infant relationship is vital for the proper health and development of the child. This is
compromised in emergencies and is both a cause and consequence of malnutrition. Mothers need
support to protect this relationship.
173
Postnatal depression has a negative impact on child development and an association between maternal
depression and infant malnutrition can be inferred.
Psychosocial support for mothers and infants should be routinely included in both inpatient and
outpatient programmes on the treatment of SAM.
Projects should be developed and tested to assess appropriate methods of providing social support and
stimulation in community-based management of acute malnutrition programmes.
Existing emergency programmes that incorporate psychosocial elements should be described and
assessed for effectiveness.
A large number of studies are needed to explore which psychosocial support activities are the most
effective, when should they be started, the minimum duration of intervention, the impact on social and
emotional development of the child and/or on the mother-child relationship, how to adapt these
activities to the community care of malnutrition.
Studies are also required on the nature and impact of treatment of maternal depression on infant
malnutrition.
174
Endnotes
Endnotes
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175
Grantham-McGregor, S., Baker-Henningham, H. Review of the evidence linking protein and energy to mental development. Public Health
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Grantham-McGregor, S., Desai, P. (1975) A home-visiting intervention programme with jamaican mothers and children. Developmental
Medicine and Child Neurology. 1975;17:605-13; Grantham-McGregor, S., Powell, C., Walker, S., Chang, S., Fletcher, P. (1994) The long
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severely malnourished children: an interim report. Pediatrics. 1983;72(2):239-43; Grantham-McGregor, S., Schofield, W., Powell, C.
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Martin-Prvel, Y. (2002) "Soins" et nutrition publique. Cahiers Sant. 2002;12(1):86-93.
Specific humanitarian psychiatric programmes that treat people who have been traumatized are increasing in number, but unfortunately
there is a lack of coordination and collaboration with other disciplines (medical, nutritional, etc.). The head and the body are treated, but
there is still little interest in treating the individual as a whole (body, spirit, as member of a family, cultural, social, religion, etc.).
Dissertation paper for DEA in anthropology Rorganisations familiales, pratiques de soins infantiles et malnutrition svre dans les
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Lachal, C., Moro, M-R., Fernandez, S. (1997) Les bbs de Hbron (Palestine) - Effets des traumatismes prcoces sur le dveloppement.
La Revue Franaise de Psychiatrie et de Psychologie Mdicale. 1997 Novembre 1997;12:8-12.
Van der Kam, S. (2002) Mental health needed for caring capacity. 2002.
Spitz, R. (1992) Maladies de carence affective chez le nourrisson. Devenir. 1992;4(2):110-22.
This description of the key notion of the childs psychology is a bit schematic but it helps us to understand the research data of the
following studies.
Bowlby, J. (1969) Attachement et perte Vol. 1. L'attachement. Paris: PUF 1969.
Bouville, J-F. (2001) Malnutrition, attachement mre-enfant et environnement familial en milieu urbain africain (Abidjan, Cte d'Ivoire)
[Thse de Doctorat en Psychologie Clinique]. Paris: Universit Paris VIII - Saint Denis; 2001.
Grantham-McGregor, S. (1995) A review of studies of the effect of severe malnutrition on mental development. The Journal of nutrition.
1995;125(8 Suppl):2233S-8S.
Grappe, M. (2000) Malnutrition du nourrisson dans le Nordeste du Brsil. De la pdiatrie la psychiatrie. MSF News : special psy n1.
Paris: MSF-F 2000.
Geber, M. (2000) Kwashiorkor : prise en charge nutritionnelle et psychologique, Notes cliniques 40 ans aprs et perspectives pour le
terrain. MSF News : special psy n1. Paris: MSF-F 2000.
Endnotes
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Buffet, Y., Mazet, P. (1983) "Ca va, Awa?" Nutritional deficiency, emotional deprivation, severe depressive state in an child under 2 years
of age. Diagnostic and therapeutic problems]. Sem Hop. 1983 Dec 15;59(47):3270-3.
Ainsworth, M.D.S. (1967) Variables influencing the development of attachment. Infancy in Uganda Infant Care and Growth of love.
Baltimore, Maryland: The Johns Hopkins Press 1967:387-99.
Miquel-Garcia, E., Keita, B., Koumar, B., Soula, G. (1992) Malnutrition et troubles relationnels mre-enfant en milieu urbain au Mali.
Psychopathologie africaine. 1992;XXIV(2):205-28.
Pollitt, E., Eichler, A.W., Chan, C.K. (1975) Psychosocial development and behavior of mothers of failure-to-thrive children. The American
journal of orthopsychiatry. 1975;45(4):525-37.
Bouville, J-F. (1996) L'approche relationnelle de la malnutrition infantile en milieu tropical. Sciences Sociales et Sant. 1996 Mars 1996;14
n1:103-15.
Bonnet, D. (1996) Prsentation. La notion de ngligence sociale propos de la malnutrition de l'enfant. Sciences Sociales et Sant. 1996
Mars 1996;14 n1:5-15.
Geber, M. (1989) Psychothrapie d'un enfant atteint de kwarshiorkor. Psychopathologie africaine. 1989;XXII:171-90.
Miquel-Garcia, E., Keita, B., Koumar, B., Soula, G. (1992) Malnutrition et troubles relationnels mre-enfant en milieu urbain au Mali.
Psychopathologie africaine. 1992;XXIV(2):205-28.
Collomb, H., Valantin, S., Mattei, J-F., Dan, V., Satg, P. (1969) Circonstances d'apparition des kwarshiorkors hospitaliss dans le service
de pdiatrie de l'hpital universitaire de Dakar. Bulletin socio-mdicale d'Afrique Noire en langue franaise. 1969 1969;XIV, 4:809-20.
Roger-Petitjean, M. (1999) Soins et nutrition des enfants en milieu urbain africain : paroles de mres. Paris ; Montral: d. l'Harmattan
1999.
Dubois le Bronnec. (1986) Dimension psycho-affective et culturelle de la malnutrition en Cte d'ivoire. Lieux de l'Enfance. 1986
1986;n6/7:193-204.
De Suremain, C-E. (2000) Dynamiques de l'alimentation et socialisation du jeune enfant Brazzaville (Congo). Autrepart. 2000;15:73-91.
Martin-Prvel, Y. (2002) "Soins" et nutrition publique. Cahiers Sant. 2002;12(1):86-93.
Kwashiorkor is frequently thought to be a result of a sexual deviancy. Partners must abstain while the mother is breastfeeding. Not
abstaining, it is believed, can lead to kwashiorkor.
Bonnet, D. (2001) Malnutrition : a subject-matter for anthropology. In: children II-ISt, editor. Promoting growth and development of
under fives; 2001 28-29-30 novembre 2001; Antwerp, Belgique; 2001. p. 14-5.
Jaffr, Y. (1996) Dissonances entre les reprsentations sociales et mdicales de la malnutrition dans un service de pdiatrie au Niger.
Sciences Sociales et Sant. 1996;14 n1:41-69.
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369(9556): 145-57.
Stewart, R. C. (2007). "Maternal depression and infant growth: a review of recent evidence." Matern Child Nutr 3(2): 94-107.
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prinatale. Paris, PUF: 287-298.
For a detailed analysis of this data, refer to Stewart.
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Psychiatry 61(9): 946-52.
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this is associated with stimulation provided in the home." Eur J Clin Nutr 57(6): 786-92.
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98(1): 125-32.
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population parisienne." Devenir 7(2): 69-92
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176
Chapter 9
MAMI Considerations
177
Chapter 9 MAMI Considerations
Chapter 9: MAMI Considerations

Informed by the key investigations of the MAMI Project outlined in Chapters 3-8, a number of additional
considerations were explored to contribute towards identifying ways forward in MAMI. The concept of a
community-based approach to managing acute malnutrition is raised, and in turn, consideration given to
issues around admission criteria, inpatient and outpatient breastfeeding support, and clinical criteria to
identify high risk infants. Two other topics choice of therapeutic milk and antibiotic treatment in infants
<6m are considered as flagged in MAMI discussions and guidelines review. HIV is relevant in many
contexts where emergency programmes operate but was found to have limited coverage in current
guidelines. Hence some key considerations around infant feeding recommendations and HIV-free child
survival, antiretroviral treatment and the impact of HIV on the burden of acute malnutrition in infants <6m
are introduced.
9.1 Conceptual model of management: Inpatient and Outpatient

MAMI
The population burden of acute malnutrition in infants <6m suggests a radical shift in the model for
management of acute malnutrition in infants <6m is needed. A move towards community-based
management of acute malnutrition in infants <6m is an appropriate option to consider, and would have a
number of advantages. First, it would increase programme capacity. Secondly, it would broaden
opportunities to tailor care according to exact problem underlying the malnutrition: admission is unlikely
to be universally needed and for some patients may even post more risks than benefits. Thirdly, it would
harmonise acute malnutrition management for infants <6m with that of older children. Lastly it would
also offer a more appropriate and safe setting to manage infants <6m that present earlier and with more
manageable feeding problems (uncomplicated cases). Inpatient care could be reserved for those infants
needing specialist clinical and dietetic care (complicated cases).
Learning from the evolution of CMAM for older children is useful. Before such a shift in the paradigm of
therapeutic care can happen, research is needed to explore the safety, practicality and cost-effectiveness
of this approach.
9.2 Admission criteria: why they matter

Many current guidelines recommend using clinical admission criteria in addition to anthropometric
criteria in infants <6m. These focus on breastfeeding problems, however details of how to define these are
often not given. The same anthropometric criteria is usually recommended for infants <6m as for older
children, however, this is not the case with MUAC, which is not suitable for the <6m age group.
As discussed in Chapter 3, with the rollout of the new WHO-GS, numbers of infants <6m admitted is likely
to rise substantially. A change in anthropometric cut-offs may be warranted in this context. WHO-GS
rollout may also warrant the adoption of the complicated vs uncomplicated model and a shift to
community-based approaches to management of uncomplicated cases of acute malnutrition in infants
<6m along with other age groups. This in turn has implications for admission criteria to community v
inpatient care. Such considerations are dealt with in this section.
9.2.1 Admission criteria as a screening tool

Both anthropometry and clinical status have limited intrinsic relevance. They matter because they reflect
other more important risks, the most important of which is death. Risk of death is linked to progressively
declining physiological and clinical status. This is strongly related to but not synonymous with declining
nutritional state (see Figure 31).279, 280 Defining continual processes in distinct categories is challenging.
178
Figure 31: Conceptual illustration of the difficulties of categorizing continual processes

in malnutrition
Clinical
status
Nutritional
status
well
Moderately impaired
physiology
increased
disease vulnerability
( appetite OK )
Severe impaired
physiology
high risk of disease
normally
nourished
mild/moderate
malnutrition
Severe malnutrition
Risk of death
Death
The arrow indicates the progressive nature of the risks. The boxes indicate that for practical programme use, categories are necessary, yet
they do not truly reflect the continuum.
Admission criteria are best seen as screening tools to identify patients whose death will be averted by
particular therapeutic interventions. This is different to a prognostic tool that simply identifies patients at
high risk of death. In the former, the characteristics of treatment are also critical in determining optimal
approach. To illustrate, if a treatment is associated with very high risks compared to the potential benefits,
then specificity of admission criteria should be prioritized. Though some cases may be missed, it
important not to wrongly expose a patient to treatment they do not need. In contrast, treatments with
low risks compared to benefits can prioritise sensitivity. It does not matter so much if some wrongly
receive treatment they do not need. It is more important to ensure that nobody misses out on a
treatment.
The many possible clinical symptoms and signs and combinations of anthropometric indicator, cut-off and
growth norm should thus be judged against screening strategy criteria (see Box 9).281
Box 9: Choice of screening strategy

Are the recommendations valid?
1) Is there randomized trial evidence that earlier intervention works?
2) Were the data identified, selected and combined in an unbiased fashion?
What are the recommendations and will they help you in caring for your patients?
3) What are the benefits?
4) What are then harms?
5) How do these compare in different people and with different screening strategies?
6) What is the impact of peoples values & preferences?
7) What is the impact of uncertainty?
8) What is the cost-effectiveness?
Barrat et al, JAMA 1999
179
Assessing current criteria against this framework reveals important issues for future discussion and research:
1) Is there randomized trial evidence that earlier intervention works?
This is a biologically plausible assumption, based on increased mortality risk with declining nutritional
status in -all known observational studies.282, 283, 284 The nature of the increased risk, whether it is linear or
whether there is an important mortality threshold effect, can still be debated. A randomized trial to
firmly settle the issue would be unethical to do since it would not be possible to withhold treatment.
However, as a next best proxy, trials could potentially be done whilst, for example, rolling out the 2006
WHO-GS, which are more inclusive than NHCS.
2) Were the data identified, selected and combined in an unbiased fashion?
This would be important to verify. The problem with some studies on anthropometry and risk is that
they are based on samples of children already admitted to a nutrition programme.285, 286 Declining
anthropometry measures that predict death for these children are different from the question of which
indicator and cut-off would best select children for admission/non-admission to programme.
3) What are the benefits?
TFP / SFP admission has an implicit objective of reducing the mortality risk through restoring normal
nutritional status. This is plausible for both infants <6m and children. However, since there has been
less research on infants <6m, the benefits for this group of current interventions on offer are less
certain than for older children, for whom well delivered treatment programmes (both inpatient ten
steps287 and outpatient CMAM288) have been shown to be consistent with good final outcomes.
4) What are the harms?
The risks of outpatient care for children >6m are minimal. In contrast, inpatient admissions (as currently
recommended for all infants <6m with SAM) are potentially serious. Infants treated as inpatients are
exposed to risks of nosocomial infection and carers have to spend precious time away from home. In
addition, introduction of therapeutic feeds as routine treatment for all infants <6m introduces potential
risks (e.g. mixed feeding increases risk of HIV transmission) but may not always be warranted (e.g. a
mother presenting with reported milk insufficiency that may need skilled breastfeeding support
alone). Defining potential harms is a key step in reviewing current and possible interventions.
5) How do these compare in different people and with different screening strategies?
It might be possible to look at historical data to see how outcomes varied prior to use of current
weight-for-height criteria. Given the current homogeneity of anthropometric criteria it is not possible
to compare different screening strategies. Future, prospective work would be needed.
6) What is the impact of peoples values & preferences?
Key informants and experience from CMAM generally indicate that carers prefer outpatient treatment
(or at very least, short inpatient treatment). With this move towards community-based models of care,
criteria aimed at selecting infants <6m for inpatient admission are likely to be different to those aimed
at selection for admission to a community based approach.
7) What is the impact of uncertainty?
Given the need to rely on observational evidence rather than that from intervention studies, there is
considerable uncertainty about ideal admission criteria.
8) What is the cost-effectiveness?
To our knowledge, this has not been formally evaluated for the treatment of infant<6m malnutrition.
9.2.2 Anthropometry
Are current anthropometric criteria a good screening tool for admission to TFP care?
It is beyond the scope of the MAMI Project to address this question in detail, however it is a question that
needs to be formally reviewed.
There are practical advantages in using the same criteria across all age ranges. However, there are pathophysiological arguments for believing that equivalent weight-for-heights do not reflect the same
mortality risk across all age ranges. Similar confounding may occur with different heights-for-age or
weights-for-age. Historically such complex, combined risk indices would not have been practical for field
use, especially in a resource poor and busy emergency settings. However, this may be changing with the
increasing use of electronic data capture devices. Perhaps there is future potential for more sophisticated,
specific admission indicators.
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9.3 Community based models of breastfeeding support
Treatment capacity allowing, a move towards managing more complicated v uncomplicated model of
care would facilitate a more conservative inpatient admission threshold where the focus is on
complicated cases to admit.
Linear growth vs. body size

Linear growth over time and cross sectional measures of body size must be distinguished. In early infancy,
linear growth often moves across centile lines as infants either catch up or catch down to a stable centile
from a low or high birth weight. Such moves can be entirely normal and do not necessarily imply
underlying problems. This makes purely anthropometric indicators of adequate growth more difficult to
interpret in infants <6m. Clinical skills of staff assessing and screening infants are therefore important.
Novel indicators: MUAC, chest circumference, head circumference

MUAC is increasingly used as an independent case definition criterion to diagnose malnutrition in children
six to 59 months.289 There is increasing evidence of its utility as a predictor of mortality. Combined with its
simplicity and suitability for community-based heath workers in CMAM settings, MUAC is ideal for and
increasingly popular in TFP/SFP settings. It was beyond the scope of this report to comment on the utility
of MUAC in infants <6m. This work is however being done and is in process of being published (J. Berkley,
personal communication290). An adequately simple, specific and sensitive MUAC-based TFP/SFP admission
criterion would be a critical step forward and would harmonize infant <6m care with CMAM for 6 to 59m
programmes.
Weight, height and age are the most commonly used indicators, though other anthropometric measures
have been used. For example, chest circumference and foot circumference are sometimes used as proxy
indicators of LBW when actual birth weight is unavailable. In one study, among LBW infants, chest
circumference measures <30.3 cm were 91% sensitive and 83% specific. Similar levels of sensitivity for foot
length were achieved only with considerable loss of specificity (<45%). Foot length measurements <6.9
cm were 88% sensitive and 86% specific for the identification of VLBW infants.291 Head circumference is
often routinely measured in western neonatal units to classify LBW type. Intra-uterine growth retardation
(IUGR) of certain types will result in symmetrical growth retardation, where weight and HC are both low.
Other types of LBW will results in asymmetrical growth retardation whereby brain (head) growth is
preserved relative to the body. This may have prognostic as well as diagnostic implications.
There is need for systematic review of such studies before recommendations can be made for widespread
use. There is also a need for closer links to maternity services to ensure that actual birth-weights (and day
ten weights292) are available.

This section explores community-based support of breastfeeding mothers as a treatment option for
uncomplicated cases of malnutrition in infants <6m.
It is important to note at the outset that the focus here is on breastfeeding counseling, not on merely
advising mothers how to breastfeed. A trained breastfeeding counsellor has clinical skills (e.g. to attach a
baby to the breast, to express milk, and to cup feed, and to overcome common difficulties), knowledge of
safe and appropriate feeding patterns to inform, guide and reassure mothers, and counselling skills to
build mother's confidence. Counsellors do not tell mothers what to do, but help them to come to their
own decision. In some contexts, counselling may be new concept that is not easily translated.
There is a large community burden of disease of acute infant <6m malnutrition (Chapter 3). Many key
informants have reported that programmes are struggling to find the time, space and staff to give infants
<6m the necessary support, even before the expected increase in cases when the WHO-GS are applied
(Chapter 6). Currently guidelines recommend that all acutely malnourished infants <6m are treated as
inpatients. However, there is a strong argument for applying the complicated vs. uncomplicated (inpatient
vs. outpatient) treatment model to this age group. Possible benefits include:
Better nesting of infants <6m treatment within overall CMAM model of acute malnutrition care
Greater programme coverage for infants <6m
More sensitive case detection/screening tools to be used in the community
Earlier detection and diagnosis of acute malnutrition, ideally before onset of complications, and
therefore raised probability of successful outcomes.
A review of the evidence of effectiveness of community-based breastfeeding support follows, to assess its
viability as a treatment option in this context.
181
9.3.1 Evidence of effectiveness of community-based breastfeeding support

Several reviews suggest that community based support improves rates of exclusive breastfeeding.
Exclusive breastfeeding (EBF) is a cure criterion for discharge from TFP in several guidelines, and is a key
target outcome. These findings are therefore relevant to MAMI.
One study in Bangladesh used peer counsellors delivering 15 home-based counselling visits, two before
birth, one within 48 hrs of birth, one on day five, another on days ten to 14 and fortnightly thereafter until
the infant was aged five months.293 The results were dramatic, even more so when one considers that the
counsellors were local mothers who had received only ten days training (See Figure 32).
Figure 32: Effect of community based peer support on exclusive breastfeeding

100
Infants exclusively breastfed (%)
Intervention
90
Control
80
70
60
50
40
30
20
10
0
Month 1
Month 2
Month 3
Month 4
Month 5
Source: Haider et al, Lancet, 2000
Other studies have demonstrated similar effects, such as one from Ghana.294 This used two intervention
groups where Group 1 (IG1) received exclusive breastfeeding support pre-, peri-, and postnatally (n = 43)
and Group 2 (IG2) received EBF support only peri- and postnatally (n = 44). Both groups had an equal
amount of contact with breastfeeding counsellors. A control group (C) received health educational
support only (n = 49). Two educational sessions were provided prenatally, and nine home follow-up visits
were provided in the six month postpartum period. Infant feeding data were collected monthly at the
participant's home. The three groups did not differ in socio-demographic characteristics. At six months
postpartum, 90.0% in IG1 and 74.4% in IG2 had exclusively breast-fed during the previous month. By
contrast, only 47.7% in C had (P = 0.008). Similarly, the percentage of EBF during the six months was
significantly higher (P = 0.02) among IG1 and IG2 (39.5%) than among C (19.6%).
Work in the area of infant feeding and HIV has also yielded evidence of increasing exclusive breastfeeding
rates through community support. For example, in South Africa, intensive support was given to mothers
of infants <6m in the community (with the aim of improving exclusive breastfeeding rates in HIV-infected
women who chose to breastfeed, and in HIV uninfected women). High rates of exclusive breastfeeding
were achieved. Of 1034 mothers who initiated breastfeeding, 82% initiated exclusive breastfeeding at
birth, 67% exclusively breastfed for at least three months and 40% for six months. One of the conclusions
was that optimal feeding practices were achievable with good support.295
There is limited data on increasing exclusive breastfeeding rates in emergency contexts. One example
does come from Indonesia post earthquake, amongst non-malnourished infants <6m. Here a cascade
method of breastfeeding support was developed by UNICEF/MOH to minimise the risks of untargeted
distribution of breastmilk substitutes in the emergency response. Trainers were located in the community
182
9.4 Inpatient models of breastfeeding support
to train counsellors who, in turn trained mothers as peer educators. The training was modelled on the
WHO four hour breastfeeding counselling course. Follow up of fifty-four mothers who gave birth after the
earthquake and who received the counselling revealed that almost all of these mothers initiated
breastfeeding in the first hour after birth and 63% were exclusively breastfeeding regardless of access to
free BMS. In November 2006, 247 mothers with babies born after the earthquake (all infants under six
months of age) were assessed on their breastfeeding practices. Amongst the mothers surveyed, the rate of
exclusive breastfeeding rate was 49.8%., higher than pre-earthquake rates in the population296.
9.3.2 Determinants of effectiveness of community-based breastfeeding

support
A recent review highlighted key elements of successful community based programmes to improve
breastfeeding practices297:
The community offers essential resources for breastfeeding promotion and support.
Continued reinforcement to sustain changes in breastfeeding practices.
Effective communication and advocacy to set priorities, influence community norms, and improve
household practices.
Training in interpersonal counselling skills.
Partnerships, leadership, evidence-based programmes, resources to facilitate scale up.
Monitoring and evaluation to measure progress, identify successful and unsuccessful strategies, and
make appropriate programme adjustments.
Not every breastfeeding support programme will necessarily be successful. Failures of well delivered,
plausible interventions have also been noted alongside the many successes298, 299. Learning from the
failures as well as the successes is important.
9.3.3 Relevance to MAMI

Research is needed to determine the effectiveness of community based breastfeeding support
programmes in treating established malnutrition in infants <6m. This might be different to preserving or
re-establishing exclusive breastfeeding and preventing new onset malnutrition. What is clear is that
overlaps between prevention and treatment are likely to be significant. Breastfeeding support should also
extend to and benefit older children through the complementary feeding period and who comprise a
considerable burden of malnutrition.
Investigations of new interventions need to include costings. There are likely considerable resource
implications in terms of staff skill set, staff time and training needs. Lack of cost data will hinder rollout of
community-based support.
9.4 Inpatient models of breastfeeding support

Breastfeeding support is a key indicator of therapeutic treatment in the Sphere Standards. Yet significant
details of who should provide this or how it should be provided are not given. Furthermore, breastfeeding
support rarely features in the treatment guidelines for acute malnutrition for infants <6m or children six to
24 months. Yet there is evidence that skilled breastfeeding counselling can have significant added value
in improving exclusive breastfeeding rates and outcomes in sick infants (see Box 10).300
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9.5 Clinical identification of high risk infants
Box 10: Breastfeeding counselling in a hospital in Bangladesh

125 mother-infant pairs received at least three lactation counselling sessions on the benefits of exclusive
breastfeeding. Researchers compared data on these 125 pairs with data on 125 other mother-infant pairs who
were also at ICDDRB due to diarrhoea but did not receive any counselling. Infants in the intervention group
had a shorter hospital stay than those in the control group (4.3 vs. 3 days; p .001). The controls left before
diarrhoea ended, while cases were discharged after diarrhoea ended. At discharge, mothers in the
intervention group were more likely than controls to be predominantly breast feeding (breast milk plus oral
rehydration solution [ORS]) (30% vs. 19%) as well as exclusively breast feeding (60% vs. 6%) (p .001). Two
weeks after discharge, when ORS was stopped, mothers in the intervention group were more likely to be
exclusively breast feeding than those in the control group (75% vs. 8%), while those in the control group were
more likely to bottle feed than cases (49% vs. 12%) (p .001). Infants in the control group were more likely to
have another episode of diarrhoea within two weeks than those in the intervention group (15 vs. 4; p = .05;
odds ratio = 2.92). These findings indicate that individual lactation counselling had a strong influence on
mothers to begin exclusive breastfeeding during hospitalization and to continue to do so at home. Thus, staff
at maternal and child health facilities should integrate lactation counselling into their program to improve infant
feeding practices.
Haider et al, Bull WHO, 1996
It is plausible that skilled breastfeeding counselling and support would also be effective for malnourished
infants, though this needs to be tested. It is essential that cost data are gathered. Several key informants
(Chapter 6) noted that time and staff skills were sometimes limited. Breastfeeding support was implicitly
seen as a non-core activity that could be dropped when resources and time were tight. This also suggests
that the resource implications were not considered in programme planning. Budgeting for extra staff with
sufficient time and skills to provide breastfeeding support as a core resource is needed, but there is a
currently a gap in knowledge of what are the costs to factor in.
9.5 Clinical identification of high risk infants

There is a need to consider clinical criteria for admission to treatment programmes for infants <6m, in
order to:
Make fair inter-programme outcome comparisons by accounting for severity of illness at admission (i.e.
taking out the confounding effect of differing patient profile)
Triage patients with different needs, and different urgency of need.
Ensure infants are not unnecessarily exposed to risk through inappropriate or disproportionate
interventions, e.g. introducing therapeutic milks where skilled breastfeeding support only is warranted.
Enable development of a complicated v uncomplicated (inpatient v community) based model of care.
To date, tools aiding clinical identification have been mainly focused on older age groups. It is important
to adapt these to infants <6m. One major criterion for uncomplicated SAM in older age-groups poses
particular problems: the appetite test using ready-to-use therapeutic food (RUTF). Breastfeeding
assessment would be an infant equivalent. The need for well validated breastfeeding assessment tools is
therefore all the more urgent, if outpatient treatment for uncomplicated infant <6m SAM is to be a viable
treatment option.
As a first step, it is perhaps easier to identify very high risk infants with immediate risk of death and
definite need for inpatient admission and intensive care/monitoring. A recent paper from Kenya
although not focused on infants <6m, highlights clinical signs which might also be useful for this age
group.301 Future infant adaptations are needed, particularly to aid non-specialist front-line heath workers
(see Box 11).
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9.6 Antibiotic treatment in infants <6 months
Box 11: Triage system for children with severe malnutrition to improve
identification of high risk groups
Immediate risk of early death and greatest requirement for close observation and monitoring
Depressed conscious state
- Prostration (inability to sit up) or
- Coma (inability to localize a painful stimulus)
Bradycardia (heart rate 80 beats per minute)
Evidence of shock with or without dehydration (see below)
- Capillary refill time _ 2 s or
- Temperature gradient
- Weak pulse volume
Hypoglycaemia, 3 mmol/l
Moderate Risk - Need for close supervision
Deep acidotic breathing
Signs of dehydration (plus diarrhoea: 3 watery motions /24 h)
- Sunken eyes or
- Decreased skin turgor
Lethargy
Hyponatraemia (sodium, 125 mmol/l)
Hypokalaemia (potassium, 2.5 mmol/l)
Low Risk - Limited requirement for close supervision
None of the above
Note: In-hospital mortality in the three groups at Kilifi, where this study was set, were:
high-risk group
34%
moderate-risk
23%
low-risk
7%
Matiland et al, PLoS 2006.
9.6 Antibiotic treatment in infants <6 months

All current guidelines recommend empirical antibiotics for infants and children with SAM. However, it is
not clear to some key informants whether these recommendations are still valid today, nor whether this
regimen is suitable for infants <6m. In response, the prevalence of bacterial infections and associated
antibiotic sensitivity patterns were reviewed.
Review methodology
MEDLINE & Embase were searched for all studies reporting on the prevalence of bacterial infection in
malnourished infants <6m. Differentiating urinary tract infections (UTI), pneumonia and septicaemia, we
examined all available data on causative organisms and antibiotic sensitivity patterns. Initial results were
presented at the CAPGAN meeting (Commonwealth Association of Paediatric Gastroenterology and
Nutrition), Malawi, 2009.302 A full report will be released separately and is available from the MAMI group.
Key findings
Most studies identified were old and few focused exclusively on malnutrition.
Only one study reported on infants <6m; the rest presented aggregate data on infants and children
of varying ages and varying nutritional status.
Prevalence of UTI in 14 studies ranged from 3.3-38%. Of 197 positive cultures, 51.8% were E.coli and
17.3% Klebsiella sp.Gram negative bacteria accounted for 92.4% of isolates.
Prevalence of pneumonia in ten studies ranged from 11-63%. Of 167 isolates, 61.1% were Gram
negative bacteria. Staphylococcus aureus made up the majority of Gram positive isolates (21.6%)
185
9.7 Choice of therapeutic milk
Prevalence of bacteraemia ranged from 5.5-36%. Commonest organisms were Salmonella sp.(20.3%),
Staphylococcus aureus (12.6%), Klebsiella sp.(12.3%), E.coli (12.1%) and Streptococcus pneumoniae
(10.5%).
Outcomes in malnourished children with bacteraemia were poor, with CFR(cumulative fraction of
response) ranges reported as 13-78% and 22-31% compared to 5-11% in non-bacteraemic children.
Younger children were more at risk of bacteraemia in one study, children <1 year having a relative risk
of 1.77(95% CI 1.43-2.18) of bacteraemia compared to older children.
Of the studies reviewed, median in vitro sensitivity of isolates was 24% for amoxicillin, 25% for ampicillin.
Key conclusions
The evidence base on antimicrobial treatment must be urgently updated. The evidence base on antimicrobial treatment for infants <6m is lacking. The evidence base on antimicrobial treatment for
malnourished children is also limited. It is concerning that even in these old studies, sensitivity to
amoxicillin, which is the commonest currently recommended antibiotic, is low. New trials are needed
which use current case definitions of acute malnutrition rather than the heterogeneous mix of definitions
noted in this review. New evidence is especially vital in settings where HIV is now prevalent.
There is a paucity of and a need for intervention studies. Whilst observational work is useful to guide and
plan an intervention and to monitor microbial resistance trends, the strength of evidence is not the same
from the two types of study design. In-vitro antibiotic sensitivities are not always the same as in-vivo
effects. Randomised control trials (RCTs) would offer the strongest evidence for informing future
guidelines and intervention strategies.
There are likely to be geographical variations. International guidelines on antibiotic use are likely to
benefit from local adaptations considering local pathogen prevalence and sensitivity patterns.
9.7 Choice of therapeutic milk

Infants <6m have less mature kidney function and therefore cannot handle as high a renal solute load
(RSL) as older children. This creates a dilemma about which therapeutic milk to use in this age group.
Box 12: Estimated potential renal solute loads (PRSL) of human milk and infant
formulas
Type of milk Estimated PRSL (mOsmol/L)
Human milk
Milk-based infant formulas
F75
F100
Diluted F100
93
135-177
154
360
238
Source: WHO (2004)285
The lower the renal solute load (RSL) the better, to lesson the risk of hypernatreamic dehydration.
However, this must be balanced against the need for adequate protein for growth; it is the protein
metabolite, urea, which contributes most to RSL. Whilst therapeutic milk like F100 may be best for growth,
it is also the riskiest in terms of hypernatraemic dehydration. Many programmes use F100-dilute, perhaps
as a compromise between growth and RSL. More evidence is needed.
At a 2004 WHO consultation on management of SAM,303 more research on optimal milk was
recommended. Data are so far limited. To our knowledge, only one RCT has been done: a Comparative
study of the effectiveness of infant formula and diluted F100 therapeutic milk products in the treatment of
severe acute malnutrition in infants under six months of age.304 Though a very well designed study, the
final sample size ended up markedly underpowered. Group sizes of 74 and 72 children were well below
the 150 per group originally planned. No significant differences in weight gain (g/kg/day) or length of stay
were observed, but a false negative effect cannot be ruled out.
In the absence of new evidence, the conclusions of WHO 2004 should still stand and are repeated
verbatim here for the purpose of informing future guideline development (see Box 13).
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9.8 HIV
Box 13: WHO consensus on milks for therapeutic feeding in infants <6m
Stabilization phase. The Consultation proposed that until definitive data are forthcoming, the guidelines set
out for stabilization with F75 should be followed for infants under six months of age. Diluted F100 was
considered inappropriate because its PRSL is marginal and its higher protein, sodium and lactose content is
disadvantageous. Where available, expressed breastmilk was seen as a possible alternative to F75.
Rehabilitation phase. The actual renal solute load is related to the rate of weight gain. The PRSL is high for
F100 and some members of the Consultation felt it should not be used, as its PRSL exceeds the upper limit
recommended by LSRO. Some felt that F100 should not be used for infants < 4 months of age. Expressed
breastmilk, infant formula or diluted F100 were seen as possible alternatives. Others considered that F100
may be appropriate if weight gain is rapid. The results of comparative randomized trials will guide future
decisions about appropriate formulations for feeding infants under six months of age.
Breastfeeding. The Consultation agreed that human milk is the preferred food for young infants, although in
HIV-affected populations decisions about breastfeeding are complex. The Consultation agreed that in infants
with severe malnutrition, who are acutely and severely ill, resuscitation and stabilization with therapeutic milk
take precedence over breastfeeding. Participants reported that in Bangladesh and Sierra Leone, exclusive
breastfeeding in managing severe malnutrition had been unsuccessful, resulting in the deaths of infants.
Experience has also shown that when no effort is made to re-establish successful lactation, infants often end
fully weaned, which can compromise their longer-term survival. Therapeutic feeding combined, where
appropriate, with supportive care to re-establish successful lactation, is recommended. Supportive care is
described in IMCI.
Low-birth-weight infants. The Consultation clarified that low birth- weight infants who are not severely
wasted or oedematous should be managed according to guidelines provided by WHO specifically for such
infants: Management of the child with a serious infection or severe malnutrition: guidelines for care at the
first- referral level in developing countries (99104).
Source: WHO (2004)
The MAMI Project found that diluted F100 is most commonly used by operational agencies in stabilization
of infants<6m. During rehabilitation, options used include breastmilk, infant formula, and diluted F100.
IFE Module 2 includes breastfeeding and expressed breastmilk as therapeutic milk options, in addition to
infant formula, F75 and F100-dilute. The option of breastfeeding as a first line nutritional treatment in IFE
Module 2 reflects consideration of uncomplicated cases admitted to feeding programmes; the WHO
guidelines may be more tailored to treatment for complicated SAM infants <6m.
9.8 HIV
Guidelines for the management of acute malnutrition, reviewed in Chapter 4, vary in their coverage of HIV.
This may in part reflect different prevalence in different countries. The influence of infant feeding practices
and use of anti-retroviral treatment (ARV) are key determinants of HIV-free child survival. Feeding
practices and HIV status of infants and mothers are key considerations in HIV prevalent populations where
infants <6m present acutely malnourished. Strategies to treat infant malnutrition in the context of HIV
should not only consider interventions that seek to avoid HIV transmission, but also those that support
maternal and child survival.
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9.8 HIV
9.8.1 What is the risk of HIV transmission through breastfeeding?

Appreciating and assessing the relative risks and benefits of different infant feeding practices in the
context of HIV is essential in any programme involved in MAMI. Inappropriate practices will contribute to
the burden of acute malnutrition, morbidity and death.
Risk of HIV transmission depends on breastfeeding pattern, use or not of anti-retroviral drugs and the
health and nutritional status of the mother and baby. The risk of HIV transmission through breastfeeding is
about 5-20% if a baby were to receive any breastfeeding for two years and neither the baby nor the
mother received any antiretroviral drugs305. The risk of HIV transmission has been found to be as low as 2%
in infants <6m, with exclusive breastfeeding and anti-retroviral treatment306, 307.
HIV-free child survival considers the combined risk of HIV infection and death from any other cause.
While breastfeeding by an HIV-infected mother or caregiver carries a risk of HIV transmission, not
breastfeeding, poor breastfeeding practices, and the use of breastmilk substitutes all carry risks of illness
and death, especially for people living in poverty. Poor breastfeeding practices increase risks of both HIV
transmission and illness in HIV-exposed infants:
Mixed feeding before six months (combining breastfeeding and formula feeding and/or too-early
introduction of complementary foods) increases both the risk of HIV transmission and infections due to
other causes, like diarrhoea.308, 309, 310
In one study, mixed breast and formula feeding before or after 14 weeks nearly doubled HIV
transmission risk and the addition of solids increased the risk 11-fold.311
With complete breastfeeding avoidance, the risk of HIV transmission is nil. Replacement feeding is feeding
infants who are receiving no breastmilk with a diet that provides the nutrients infants need until the age
at which they can be fully fed on family foods. During the first six months of life, replacement feeding
should be with a suitable breastmilk substitute, usually infant formula. After six months this should be
complemented with other foods. But in resource limited settings and in emergency contexts, the risks of
death from other causes, like diarrhoea, rise when infants are not breastfed. Studies in non-emergency
settings have found that:
Avoidance or early cessation of breastfeeding in children of HIV-infected mothers has been associated
with increased morbidity, especially from diarrhoea.312
Mortality by three months of age for replacement-fed babies was almost double that of those who
were exclusively breastfed.313
In a study of the survival of 182 infants born to HIV-infected mothers in Uganda, by one year of age,
18% of replacement fed infants were likely to die, compared to 3% of breastfed infants.314
Children who are HIV-infected have better chance of survival if they are breastfed.315
The risks of replacement feeding in resource limited settings are reflected in experiences from Botswana in
2005/06 and in a study from rural Uganda (2008) (See Box 14). The Botswana experience highlights the
extreme vulnerability of non breastfed children when conditions deteriorate. In Uganda, heightened
household level support was provided to mothers of infants already established on replacement feeding.
Even then, mothers failed to follow critical guidelines on hygiene, preparation and storage to minimize
risk of artificial feeding in this context. This reflects the reality of meeting and sustaining acceptable,
feasible, affordable, sustainable and safe (AFASS) conditions for replacement feeding in resource-limited
settings, even with support.
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9.8 HIV
Box 14: Case studies

Botswana
In Botswana, replacement feeding using infant formula was offered to all HIV-infected mothers as part of a
national programme to prevent transmission of HIV from mother to child (PMTCT). But flooding led to
contaminated water supplies, a huge rise in diarrhoea and national under five mortality increased by at least
18% over one year. An investigation by the Centre for Disease Control (CDC) into admissions in one hospital
found that non-breastfed infants were 50 times more likely to need hospital treatment than breastfed infants,
and much more likely to die. Many of the children admitted had developed severe acute malnutrition during or
after bouts of diarrhoea. Use of infant formula spilled over to 15% of HIV-uninfected women, exposing their
breastfed infants to unnecessary risk. (Creek et al, 2006)316
Uganda
In a study of the survival of 182 infants born to HIV infected mothers according to feeding mode, the cumulative
12 month probability of mortality was 18% in artificially fed infants, compared to 3% in breastfed infants
(adjusted for maternal age and use of ARVs).The survival of HIVinfected infants was severely compromised by
artificial feeding. All 3/69 artificially fed infants who tested HIV positive at one month of age had died by one year
of age but all 12/92 breastfed HIV infected infants were alive at one year. (Kagaayi et al, 2008)317
9.8.2 WHO infant feeding and HIV recommendations (2007)

Considerations on HIV-free child survival and the balance of risks and benefits of different feeding options
are reflected in the most recent WHO recommendations (2007)318 (see Box 15). Early initiation, exclusive
breastfeeding for six months, continued breastfeeding and safe and appropriate complementary feeding
are recommended, unless replacement feeding meets all the AFASS conditions (see Box 16). When an
infant reaches six months of age, it is no longer recommended to rapidly or abruptly cease breastfeeding,
because of the possible negative effects on both the mother and infant.
The WHO recommendations reflect that breastfeeding, particularly optimal breastfeeding practices such
as exclusive breastfeeding, has an important role to play in HIV-free child survival. These
recommendations, in turn are reflected in the Operational Guidance on IFE v2.1, Feb 2007) and UNHCR
Guidance on Infant Feeding and HIV (v1.1, June 2009). Infant feeding guidance and counselling by health
workers needs to be consistent with current WHO recommendations.
Box 15: Summary of WHO Recommendations on infant feeding and HIV (2007)
HIV status of the mother is unknown or she is known to be HIV-negative:
Exclusive breastfeeding for the first six months of life. At six months, introduce nutritionally adequate
and safe complementary foods while breastfeeding continues for up to two years of age or beyond.
For a HIV-infected woman:
Exclusive breastfeeding for the first six months of life unless replacement feeding* is acceptable, feasible,
affordable, sustainable and safe (AFASS) for a woman and her infant before that time.
At six months, if replacement feeding is still not acceptable, feasible, affordable, sustainable and safe,
continuation of breastfeeding with additional complementary foods, while the mother and baby continue to
be regularly assessed.
When replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all
breastfeeding by HIV-infected women is recommended.
The most appropriate infant feeding option for a HIV-infected mother should continue to depend on her
individual circumstances, including her health status and the local situation, but should take greater
consideration of the health services available and the counselling and support she is likely to receive.
Whatever the feeding decision, health services should follow-up all HIV-exposed infants, and continue to
offer infant feeding counselling and support, particularly at key points when feeding decisions may be
reconsidered, such as the time of early infant diagnosis and at six months of age.
Breastfeeding mothers of infants and young children who are known to be HIV-infected should be strongly
encouraged to continue breastfeeding.
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9.8 HIV
Box 16: AFASS Conditions

The first alternative to prolonged breastfeeding consists of the complete avoidance of breastfeeding, which is
then usually replaced by commercial infant formula (WHO, 2007). AFASS = acceptable, feasible, affordable,
sustainable and safe.
UN definitions of AFASS conditions:
Acceptable: The mother perceives no barrier to replacement feeding. Barriers may have cultural or social
reasons, or be due to fear of stigma or discrimination. According to this concept, the mother is under no
social or cultural pressure not to use replacement feeding - she is supported by family and community in
opting for replacement feeding, or she will be able to cope with pressure from family and friends to
breastfeed, and she can deal with possible stigma attached to being seen with replacement food.
Feasible: The mother (or family) has adequate time, knowledge, skills and other resources to prepare the
replacement food and feed the infant up to 12 times in 24 hours. According to this concept, the
mother can understand and follow the instructions for preparing infant formula, and with support
from the family can prepare enough replacement feeds correctly every day, and at night, despite
disruptions to preparation of family food or other work.
Affordable: The mother and family, with community or health-system support if necessary, can pay the
cost of purchasing/producing, preparing and using replacement feeding, including all ingredients, fuel,
clean water, soap and equipment, without compromising the health and nutrition of the family. This concept
also includes access to medical care if necessary for diarrhoea and the cost of such care.
Sustainable: Support for adequate replacement feeding is needed throughout the period for which
breastmilk is normally recommended and during which the child is at greatest risk of malnutrition that is for
the first two years of life (WHO, 2007). Availability of a continuous and uninterrupted supply and
dependable system of distribution for all ingredients and products needed for safe replacement feeding, for
as long as the infant needs it. According to this concept there is little risk that formula will ever be
unavailable or inaccessible, and another person is available to feed the child in the mothers absence, and
can prepare and give replacement feeds.
Safe: Replacement foods are correctly and hygienically prepared and stored, and fed in nutritionally
adequate quantities, with clean hands and using clean utensils, preferably by cup. This concept means
that the mother or caregiver:
- has access to a reliable supply of safe water (from a piped or protected-well source)
- prepares replacement feeds that are nutritionally sound and free of pathogens
- is able to wash hands and utensils thoroughly with soap, and to regularly boil the utensils to sterilise
them
- can boil water for preparing each of the babys feeds
- can store unprepared feeds in clean, covered containers and protect them from rodents, insects and
other animals.
Sources: HIV and infant feeding. 2003. A guide for health-care managers and supervisors. UNICEF, UNAIDS, WHO, UNFPA, 2003. WHO,
2007. HIV and infant feeding update
9.8.3 Areas of high HIV prevalence

Irrespective of the prevalence of HIV in the population, where the HIV status of individual mothers is
unknown or the mothers is HIV negative, then recommended feeding practices are the same optimal
feeding practices as for the general population (Box 16).
In an emergency situation, it is likely that the risks of not breastfeeding and of replacement feeding to
infant survival outweigh the risks of HIV transmission:
The risks of infection or malnutrition from using breastmilk substitutes are likely to be greater than the
risk of HIV transmission through breastfeeding. Therefore, support to help all women to achieve early
initiation and exclusive breastfeeding for the first six completed months and the continuation of
breastfeeding into the second year of life are likely to provide the best chance of survival for infants and
young children in emergencies. (Ops Guidance 5.2.8, v2.1, Feb 2007)
190
9.8 HIV
The contribution of HIV-infected infants and mothers to the burden of nutrition and medical care in
feeding programmes is significant in areas of high HIV prevalence. In a hospital-based HIV prevalence
study in Southern Malawi, for example, 40% of the malnourished children were HIV infected and HIV
infection contributed to over 40% of all paediatric deaths.319 HIV infection may contribute to malnutrition
in an infant <6m either directly through the HIV infection of the infant and associated morbidities,
through associated risky feeding practices, e.g. replacement feeding where AFASS is not in place, and/or
by HIV infection compromising the mothers capacity to feed and care for her infant.
Where malnourished infants <6m present to programmes, it is therefore important to investigate whether
HIV-associated feeding practices (e.g. replacement feeding) are a contributing factor. The current absence
of breastfeeding status as a standard indicator in treatment programmes, highlighted in Chapter 5, makes
it difficult to determine the contribution of replacement fed infants to admissions.
9.8.4 Testing for HIV in young infants

Rapid tests are increasingly cheap and available for field use. These detect HIV antibodies in a finger prick
sample of whole blood.320 Because maternal antibodies can persist in the circulation of an uninfected
infant and thus give a false positive result, some programmes have been reluctant to use the tests for
infants <18m. After 18 months maternal antibodies should have cleared and the test therefore will
represent true infant HIV sero-status. PCR, the definitive test in young infants, is expensive and often
unavailable in resource poor settings.
Latest HIV-specific guidance should be sought as to how to manage these HIV exposed infants. It should
also be noted that any positive test is more likely to be a true positive in malnourished infants than in the
general population. This is because the background prevalence of HIV is higher among malnourished than
normally nourished infants and thus the positive predictive value of a test is higher.
For guidance on testing of infants, visit,
http://www.who.int/hiv/paediatric/EarlydiagnostictestingforHIVVer_Final_May07.pdf
9.8.5 Use of antiretroviral (ARV) drugs and cotrimoxazole

Strong evidence supports early treatment strategies using antiretroviral drugs that treat both the mother
and infant. Early treatment of HIV-infected pregnant women and lactating mothers and their infants321
reduces the risk of infant HIV infection by lowering breastmilk viral load and so reducing vertical
transmission.322 Maternal ARV treatment also improves the health and chance of survival for the mother,
which is fundamental to the survival of her infant; children of HIV-infected mothers who are ill or die are
more likely to die themselves, independent of the HIV status of the infant.323
Recent WHO recommendations state that all infants (<12 months) with confirmed HIV infection should be
initiated on ARV, regardless of clinical or immunological stage. Where PCR is unavailable, infants with
clinically diagnosed presumptive severe HIV should start ARVs, and confirmation of HIV status should be
obtained as soon as possible.324 There are indications from recent research that a specific combination of
ARV provided in late pregnancy and until six months into breastfeeding is likely to further reduce HIVtransmission through breastfeeding. Updated recommendations are expected by end 2009325. ARV
treatment in already malnourished infants poses several challenges and questions for future research,
including optimal timing of ARV start and optimal drug dose. Nevertheless, early ARV treatment for
mothers and infants is beneficial to both and should be a priority response.
Cotrimoxazole (when ARVs are not available)

Infants with a positive rapid test for HIV should start long term cotrimoxazole treatment. Cotrimoxazole is
low risk, low cost, and is widely available. It is especially useful in settings without ARVs or other HIVspecific resources. In spite of the proven benefits, it is currently underused.326, 327 This could also prove
critical in situations where ARVs are temporarily unavailable, by extending life until supplies resume.
To keep abreast of the latest recommendations in a quickly evolving technical area, management
guidelines should direct to key sources, e.g. WHO, rather than propose to update content in detail that
may become quickly outdated.
191
9.9 Individual v population based feeding recommendations
9.9 Individual v population based feeding recommendations

For a long time, international WHO guidelines recommended exclusive breastfeeding for the first four to
six months of life, before moving to the current recommendation of six months. A key document justifying
the shift to six months systematically reviewed the evidence that breastmilk alone can provide for
adequate growth from four months onwards.328 The conclusion was:
We found no objective evidence of a weanlings dilemma. Infants who are exclusively breastfed for 6
months experience less morbidity from gastrointestinal infection than those who are mixed breastfed
as of 3 or 4 months, and no deficits have been demonstrated in growth among infants from either
developing or developed countries who are exclusively breastfed for 6 months..
It also stated that:
Infants should still be managed individually so that insufficient growth or other adverse outcomes are
not ignored and appropriate interventions are provided Large randomized trials are recommended in
both types of setting to rule out small adverse effects on growth and to confirm the reported health
benefits of exclusive breastfeeding for 6 months.
To our knowledge, no such RCTs have been done.
Current optimal infant feeding recommendations reflect practices that maximize population benefits and
risks. They inform but should not dictate or limit individual management.329 It is conceivable that an
individual five month old, for example, may fail to adequately gain weight whilst exclusively breastfed.
Similarly, an extended period of exclusive breastfeeding beyond six months may benefit another child.
Trials to determine the effectiveness of various feed options in individual management for this borderline
age group would therefore be important and relevant to MAMI. It is important to consider that
individualized treatment that seems to contradict optimal feeding recommendations may send out the
wrong message to the wider community and undermine public health recommendations. Actions will be
needed to protect against this risk.
A priority group to trial interventions on (and may help minimize the risk of undermining optimal feeding
practices in the community) is infants who have no possibility of being breastfed, e.g. orphans with no wet
nurse available. This group were identified by all key informants as a major challenge.

Summary findings
Admission criteria are screening tools to identify patients whose death will be averted by particular
therapeutic interventions. There is uncertainty about admission criteria for malnourished infants <6m.
Many current guidelines recommend the same anthropometric admission criteria for infants <6m as for
older children, with the exception of MUAC. Benefits of current interventions on offer are less certain for
infants <6m than for older children. Cost effectiveness of treating malnourished infants <6m has not been
formally evaluated.
A shift to the complicated vs uncomplicated model of treatment in this age group would require revised
inpatient admission criteria for complicated cases and new criteria for outpatient treatment of
uncomplicated cases.
Based on current evidence, it is plausible that skilled breastfeeding counseling and support would also be
effective for malnourished infants; this needs to be tested in both inpatient and community-based
settings.
There is a lack of clinical assessment strategies to diagnose and address underlying infant or maternal
disease, and breastfeeding problems that are primarily maternal/ infant related.
The evidence base for current guidelines on antibiotic treatment in infants <6m with SAM is largely absent
and for malnourished children is lacking. Resistance to amoxicillin is of concern.
There is uncertainty and varying practice in which therapeutic milk to use in the infant <6m age group.
Research is so far limited.
192
The evidence base for current guidelines on antibiotic treatment in infants <6m with SAM is largely absent
and for malnourished children is lacking. Resistance to amoxicillin is of concern.
There is uncertainty and varying practice in which therapeutic milk to use in the infant <6m age group.
Research is so far limited.
The contribution of HIV-infected infants and mothers to the burden of nutrition and medical care in
feeding programmes is significant in areas of high HIV prevalence. Access to ARVs for HIV-exposed
mothers and infants and safer infant feeding practices are key determinants of HIV-free child survival.
Where malnourished infants <6m present to programmes, risky feeding practices (e.g. replacement
feeding where AFASSiv conditions are not in place) may be a contributing factor.
Current optimal infant feeding recommendations reflect practices that maximize population benefits and
risks; they inform but should not limit individual management. It is important to consider that
individualized feeding practice could send out mixed messages to the wider community on optimal
feeding practices.
Key areas of research include:
Systematic review of studies of different anthropometric indicators suitable for use in the
community in infants <6m, including a review of the suitability of MUAC for this age group.
Investigate the nature and effectiveness of skilled breastfeeding counseling and support in
inpatient treatment of severely malnourished infants <6m.
Review of the effectiveness and costs of community-based breastfeeding support, to assess its
viability as a treatment option for uncomplicated cases of SAM in infants <6m.
Review the effectiveness of breastfeeding assessment tools for use in the community to identify
uncomplicated and complicated cases of SAM in infants <6m.
Develop a triage tool based on a set of clinical signs for complicated cases, to identify those with
urgent need.
Update the evidence base on antimicrobials through randomised controlled trials to update
guidelines.
Research the choice of therapeutic milk for infants <6m.
An alternative to the appetite test used in CMAM is needed for the <6m age group; validated
breastfeeding assessment tools could enable this.
Access to HIV counselling and testing and early ARV treatment for mothers and infants is a priority in HIV
prevalent areas. Cotrimoxazole should be used when ARVs are not available.
To keep abreast of the latest recommendations on HIV, guidelines should direct to key sources.
Infant feeding counselling in the context of HIV needs to be consistent with current WHO
recommendations.330 Strategies to treat infant malnutrition in the context of HIV should not only consider
interventions that seek to avoid HIV transmission, but also those that support maternal and child survival.
Trials of programme interventions need to include and report on costs, staff time and skill sets to inform
programme planning. This is especially important in considering the cost-benefits and viability of scale-up
of interventions.
iv
Acceptable, feasible, affordable, sustainable, safe.
193
Endnotes
279
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281
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283
284
285
286
287
288
289
290
291
292
293
294
295
296
297
298
299
300
301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
316
317
194
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Collins, S., Yates, R. (2003) The need to update the classification of acute malnutrition. Lancet. 2003 Jul 19;362(9379):249.
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Lapidus, N., Luquero, F.J., Gaboulaud, V. Shepherd, S., et al. (2009) Prognostic Accuracy of WHO Growth Standards to Predict Mortality in
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Myatt, M., Khara, T., Collins, S (2006). A review of methods to detect cases of severely malnourished children in the community for their
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measures, foot length and chest circumference and birth weight among newborns of Sarlahi, Nepal. Eur J Clin Nutr. 2007 Jan;61(1):40-6.
By day ten infants should have regained their birth weight. Failure to do so indicates a problem.
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response in Indonesia: evidence and actions. Field Exchange October 2008. Issue 34. Full article available at: www.ennonline.net
WHO, UNICEF & AED. (2008) Learning from large-scale community-based programmes to improve breastfeeding practices. Geneva:
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Hoddinott, .P, Britten,.J., Prescott, G.J., Tappin, D., Ludbrook, A., Godden, D.J. (2009) Effectiveness of policy to provide breastfeeding
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2009;338(jan30_1):a3026.
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Highest Risk of Death Be Identified with the WHO Protocol? PLoS Medicine. 2006 December 01, 2006;3(12):e500.
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intervention cohort study. Lancet 2007; 369: 110716
Kagaayi, J., Gray, R.H., Brahmbhatt, H., Kigozi, G., Nalugoda, F., et al. (2008) Survival of Infants Born to HIV-Positive Mothers, by Feeding
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Modality, in Rakai, Uganda. PLoS ONE 3(12): e3877. doi:10.1371/journal.pone.0003877
Endnotes
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321
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323
324
325
326
327
328
329
330
WHO, 2007. HIV and Infant Feeding: Update based on the Technical Consultation held on behalf of the Inter-agency Task Team (IATT) on
Prevention of HIV Infection in Pregnant Women, Mothers and their Infants Geneva, 2527 October 2006
K, Sadler. et al. (2008). Operational study on SAM management in high HIV prevalence area. Field Exchange, Issue No 34, October 2008.
p12. http://fex.ennonline.net/34/operational.aspx
Franco-Paredes, C., Tellez, I., del Rio, C. (2006) Rapid HIV testing: a review of the literature and implications for the clinician. Curr
HIV/AIDS Rep. 2006 Nov;3(4):169-75.
WHO currently recommends that mothers should receive zidovudine (AZT) from 28 weeks of pregnancy (or as soon as possible
thereafter); single dose nevirapine and AZT/3TC during labour, and AZT/3TC for seven days after delivery, while infants should receive
single dose nevirapine and AZT for one week after birth.
Giuliano, M., Guidotti, G., Andreotti, M., Pirillo, M.F., Villani, P., Liotta, G., et al. (2007) Triple antiretroviral prophylaxis administered during
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Sewankambo, Nelson MD; Kiduggavu, Mohamed MD; Wawer, Maria MD; Gray, Ronald MD (2006). Epidemiology and Social Science
Mortality in HIV-Infected and Uninfected Children of HIV-Infected and Uninfected Mothers in Rural Uganda. JAIDS: 1 April 2006 - Volume
41 - Issue 4 - pp 504-508
2008 Report of the WHO Technical Reference Group, Paediatric HIV/ART Care Guideline Group Meeting,
http://www.who.int/hiv/pub/paediatric/WHO_Paediatric_ART_guideline_rev_mreport_2008.pdf,
Guidance on infant feeding and HIV in the context of refugees and displaced populations. V1.1, June 2009.
Chintu, C., Bhat, G.J., Walker, A.S., Mulenga, V., Sinyinza, F., Lishimpi, K., et al. (2004) Co-trimoxazole as prophylaxis against
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Zachariah, R., Harries, A.D., Luo, C., Bachman, G., Graham, S.M. (2007) Scaling-up co-trimoxazole prophylaxis in HIV-exposed and HIVinfected children in high HIV-prevalence countries. Lancet Infect Dis. 2007 Oct;7(10):686-93.
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195
Chapter 10
The way forward
196
Chapter 10 The way forward
Chapter 10: The way forward

The MAMI Project has shown that the burden of care for infants <6m is significant, the implications of the
rollout of the 2006 WHO Growth Standards for infants <6m are important and need to be explored
urgently, the current evidence base for treating malnourished infants <6m is relatively weak and that
programmes currently struggle using current guidelines to manage this age-group.
Some recommendations are made throughout the MAMI report in response to identified gaps, in
particular by highlighting key resources, good practices, and complementary initiatives to consolidate and
build on. To highlight here:
Existing guidelines with strong MAMI components are MSF guidelines 2006, ACF Assessment and
Treatment of Malnutrition, 2002 and Module 2 on IFE and are good reference tools (see Annex A).
Strategies with potential to improve inpatient outcomes of complicated infant <6m SAM include
review of current first and second line antibiotic choices, implementation of routine Kangaroo care,
breastfeeding corners/ separate mother and baby areas where both skilled and peer-to-peer
breastfeeding support is available, and psychosocial support of the malnourished infant, the motherinfant dyad and support to families.
Strategies with potential for effective outpatient-based care of infant <6m MAM & uncomplicated SAM
include community-based breastfeeding support, psychosocial support programmes & womens
groups programme and routine community-mobilization and identification of context-specific factors
underlying infant <6m malnutrition.
Closer links are needed with existing programmes that may impact on infant <6m malnutrition,
particularly reproductive health services (e.g. recording birth weight and follow-up weight at first
immunisation), existing interventions promoting exclusive breastfeeding (e.g. Baby-Friendly Initiative),
those improving quality care to sick children (e.g. Integrated Management of Childhood Illness), and
growth monitoring programmes.
The MAMI Project findings should inform the update of Sphere Standards, currently underway (due out
2010).
The MAMI findings have also highlighted key research areas to consider, including:
Systematic review of studies of different anthropometric indicators suitable for use in the community in
infants <6m, including a review of the suitability of MUAC for this age group.
Review of the effectiveness of community-based breastfeeding support to assess its viability as a
treatment option for uncomplicated cases of SAM in infants <6m.
Review the effectiveness of breastfeeding assessment tools for use in the community to identify
uncomplicated and complicated cases of SAM in infants <6m.
Develop a triage tool based on a set of clinical signs for complicated cases in need of urgent inpatient
treatment.
Investigate the nature and effectiveness of skilled breastfeeding counselling and support in inpatient
treatment of severely malnourished infants <6m.
Research into the choice of therapeutic milk for infants <6m.
Studies on the therapeutic treatment and follow-up of malnourished non-breastfed infants.
Intervention studies into antibiotics to use in infants <6m and older children.
Studies to explore which psychosocial support activities are most effective, and their timing, duration,
impact and adaptation to community models for malnutrition treatment.
There are undoubtedly resource implications to strengthened inpatient and expanded outpatient
treatment of malnourished infants <6m. This is reflected in reported field experiences but not supported
by formal cost data. Trials of programme interventions need to include and report on cost to inform
programme planning. This is especially important in considering the cost-benefits and viability of scale-up
of interventions.
197
Assessing programme performance treating infant <6m malnutrition needs to be strengthened. Critically,
performance should not be judged solely on core outcomes (e.g. death rate, nutritional cure rate) but
needs to:
Capture the clinical, psychosocial and contextual complexity of infants treated
Ensure robustness of data, audit and management systems to identify problems that may occur, and
Establish programme population coverage of SAM. MAM in infants <6m.
Key initiatives that may provide lessons in taking initiatives forward include the SFP minimum reporting
standards project (MRP), the Vermont-Oxford Network to improve neonatal care,331 and experiences
from the rollout of the 1999 WHO guidelines.
The MRP is an ENN-led interagency initiative that involves developing and implementing a
standardised Minimum Reporting Package on SFPs, including data collection tools, training and multiagency data collection.332
The mission of the Vermont-Oxford Network333 is to improve the quality and safety of medical care
for newborn infants and their families through a coordinated programme of research, education and
quality improvement projects. (see Box 17)
Long-term follow up of hospitals involved in the 1999 WHO guideline piloting showed marked
discrepancies in outcomes.334 Systems, staff and leadership were key influences on the effective
implementation of the guidelines. This need to address systems factors came out strongly in MAMI key
informant interviews. Tools supporting management quality would benefit not only malnourished
infants <6m, but all patient groups.
Box 17: Vermont-Oxford Network

The Vermont Oxford Network was set up to address a poor evidence-base with which to formulate effective
guidelines and any common practices between different treatment centres, yet also important differences of
unknown effectiveness.
The network has a membership of over 700 neonatal units worldwide. It has a unique and confidential
database on care and outcomes of high-risk newborn infants, used for quality management, process
improvement, internal audit and peer review.
Member institutions participate in clinical trials, long-term follow-up studies and epidemiologic and outcomes
research. Results are widely disseminated through network publications, scientific articles in peer reviewed
medical journals, web site postings and an annual meeting.
Use of core approaches and standardised paperwork across multiple sites enables pooling data, analysis by
strata (or similar) and exploration of inter-site variations.
The lack of an evidence base to formulate MAMI guidelines remains a big gap. Key research questions
include medium and long-term survival of the treated infants, effectiveness of different feeding regimens
and impact of psychosocial and community interventions. A combination of systematic reviews (e.g. of
current guidelines), high quality RCT-type studies (e.g. on antibiotic choice; what type of breastfeeding
support programme has maximal impact) and operational research is needed to strengthen guidelines.
More resources should be devoted to future guideline development and tools such as GRADE and AGREE
used to better enhance their quality.
Our review suggests that formal frameworks might usefully guide which policies and research projects
should strongly (and more urgently) be recommended, and which might be less critical. With this in mind,
two frameworks GRADE (introduced in Chapter 4) and Child Health and Nutrition Research Initiative
(CHNRI)335 may be of particular use (see Box 18).
198
Box 18: GRADE & CHNRI frameworks

Using the GRADE framework, factors influencing the strength of recommendation for action are:
Balance between desirable and undesirable effects: The larger the difference between the desirable
and undesirable effects, the more likely a strong recommendation is warranted. The narrower the gradient,
the more likely a weak recommendation is warranted
Quality of evidence: The higher the quality of evidence, the more likely a strong recommendation is
warranted
Values and preferences: The more variability in values and preferences, or more uncertainty in values
and preferences, the more likely a weak recommendation is warranted
Costs (resource allocation): The higher the costs of an intervention (that is, the more resources
consumed) the less likely a strong recommendation is warranted
Using Child Health and Nutrition Research Initiative (CHNRI), all possible research options are listed and
assigned scores in the following categories:
Is the question answerable in an ethical way?
Is the intervention likely to be effective?
Is the intervention likely to be deliverable, affordable & sustainable?
What is the likely disease burden reduction?
Is the intervention equitable?
To enable continued inter-agency dialogue, data sharing and partnership is needed. In particular:
Focused prospective audits are needed interpreting retrospective data is challenging and yields
relatively limited information.
Age-disaggregated data collection on infant <6m, currently implemented in the minority of cases,
should be rolled out and continue.
Harmonised databases and coding systems would enable easier audit. In this regard, an update in the
MRP to include infants <6m in SFP reporting is recommended.
A mechanism for data sharing and lesson learning forums should be established to inform future field
guidance.
MAMI strategies should be located within a framework of safe and appropriate IYCF; programme synergies
between IYCF support of infants <6m and child 6 to 24m must be better reflected in the guidelines.
Locating interventions to treat infant and child malnutrition within global policy frameworks, e.g. the
WHO/UNICEF Global Strategy on IYCF, creates opportunities to coordinate with governments and national
level plans and to synergise interventions that treat malnutrition with those that seek to prevent it. Such
strategic approaches may be possible in many emergency contexts.
Of most immediate concern is the lack of explicit consideration to infants <6m in current guidelines or
their explicit recognition in recent statements on malnutrition treatment336 and 2006 WHO GS rollout.337, 338
This risks the presumption that care for older children can safely be extended to infants <6m and/or
perpetuates the assumption that infants <6m are all well nourished. A valuable contribution to help address
this would be a statement on MAMI that highlighted the concerns, gaps and immediate considerations for this
age-group to guide practice in the immediate term. Such a statement would be well placed as an output of
the Global Nutrition Cluster through engagement of Nutrition Cluster members, the MAMI Project
research team, RAG and IASG members.
In the future, a more radical shift in the model for MAMI is likely needed. A move towards communitybased management of acute malnutrition in infants <6m is an option that should be actively considered.
Further applied and operational research is required to provide the evidence base for such a transition. For
older children, the evolution to community based management of acute malnutrition was driven by a
strong vision, a clear research agenda and well documented field experiences. The challenge now is how
to improve nutritional, clinical and public health outcomes in infants <6m.
199
Endnotes
331
332
333
334
335
336
337
338
200
http://www.vtoxford.org/home.aspx
See www.ennonline.net/research
http://www.vtoxford.org/home.aspx
Puoane et al, 2008. Why do some hospitals achieve better care of severely malnourished children than others? Five-year follow-up of rural
hospitals in Eastern Cape, South Africa. HPP 2008;23(6):428-37.
http://www.chnri.org
Community-based management of severe acute malnutrition A Joint Statement by WHO, WFP, the UNSCN and UNICEF.
http://www.who.int/nutrition/topics/statement_commbased_malnutrition/en/index.html
WHO Child Growth Standards and the identification of severe acute malnutrition in infants and children. A Joint Statement by WHO and
UNICEF. http://www.who.int/entity/nutrition/publications/severemalnutrition/9789241598163_eng.pdf
IASC Global Nutrition Cluster, and Standing Committee on Nutrition (SCN) Task Force on
Assessment, Monitoring, and Evaluation. Fact sheet on the implementation of 2006 WHO Child Growth Standards for emergency nutrition
programmes for children aged 6-59 months. March 2009.
http://oneresponse.info/GlobalClusters/Nutrition/publicdocuments/WHO%20GS%20Factsheet%20English.pdf
Appendices
201
Appendix A
Appendix A Key Resources

Online links are provided to electronic versions where available. All resources listed are also located at
www.ennonline.net/resources and select MAMI.
202
ACF Assessment and Treatment of Malnutrition in Emergency Situations, Claudine Prudhon, 2000 (Book
available for purchase via http://www.aahuk.org/publications.htm)
IFE Core Group (2009) Infant Feeding in Emergencies Orientation Package (Module 1), updated 2009.
(Download free from http://www.ennonline.net/resources/view.aspx?resid=1)
IFE Core Group (2007) Infant feeding in emergencies. Module 2. Version 1.1 Developed through
collaboration of ENN, IBFAN-GIFA, Fondation Terre des hommes, UNICEF, UNHCR, WHO, WFP. Core Manual (for
training, practice and reference). English and French. (Download free
http://www.ennonline.net/resources/view.aspx?resid=4 or in print from ENN, Oxford, UK or UNHCR, Nairobi)
IFE Core Group (2007) Operational Guidance on IFE, version 2.1, May 2007. 11 languages. (Download free
from http://www.ennonline.net/resources/view.aspx?resid=6)
International Code of Marketing of Breastmilk Substitutes (1989) (Available at

http://www.who.int/nutrition/publications/code_english.pdf)
MSF Nutrition Guidelines (2006) (Download from http://www.msf.org.uk/books.aspx)
Sphere Humanitarian Charter & Minimum Standards in Disaster Response (2004) http://www.sphereproject.org/
Valid International (2006) International. Community-based Therapeutic Care (CTC). A Field Manual.
Oxford: Valid International. (Available at http://www.fantaproject.org/ctc/manual2006.shtml)
WHO/UNICEF (2003) Global Strategy on Infant and Young Child Feeding. Geneva: World Health
Organisation. (Available at http://www.who.int/nutrition/publications/infantfeeding/9241562218/en/index.html)
WHO (2003) Training course on the management of severe malnutrition. Geneva: World Health Organisation.
(Available at http://www.who.int/nutrition/topics/severemalnutrition_training_courses/en/index.html)
WHO (2004) Severe malnutrition: report of a consultation to review current literature. Geneva, World Health
Organization, 6-7 September 2004. (Available at http://www.who.int/nutrition/publications/malnutrition/en/index.html)
WHO (2004) Guiding Principles for feeding infants and young children during emergencies (Available at
http://www.who.int/nutrition/publications/emergencies/9241546069/en/index.html)
WHO (1999) Management of severe malnutrition: a manual for physicians and other senior health
workers. World Health Organisation. Geneval: World Health Organisation. (Available at
http://www.who.int/nutrition/publications/malnutrition/en/index.html)
WHO (2003) Guidelines for the inpatient treatment of severely malnourished children. Geneva: World
Health Organisation. (Available at http://www.who.int/nutrition/publications/malnutrition/en/index.html)
WHO & UNICEF (2009) WHO child growth standards and the identification of severe acute malnutrition in
infants and children. A joint statement by the World Health Organization and the United Nations Children's
Fund. (Available at http://www.unicef.org/nutrition/files/stmt_child_growth_sam_final.pdf)
World Health Organization. The WHO child growth standards. (Available at

http://www.who.int/childgrowth/standards/en/)
WHO, WFP & UNICEF (2007) Community-based management of severe acute malnutrition. A Joint
Statement by the World Health Organization, the World Food Programme, the United Nations System
Standing Committee on Nutrition and the United Nations Childrens Fund. (Available at
http://www.who.int/nutrition/topics/statement_commbased_malnutrition/en/index.html)
UNICEF, UNAIDS, WHO, UNFPA (2003) HIV and infant feeding. A guide for health-care managers and
supervisors. (Available at http://www.who.int/child-adolescent-health/publications/NUTRITION)
WHO (2007) HIV and Infant Feeding: Update based on the Technical Consultation held on behalf of the
Inter- agency Task Team (IATT) on Prevention of HIV Infection in Pregnant Women, Mothers and their
Infants Geneva, 2527 October 2006
UNHCR (2009) Guidance on infant feeding and HIV in the context of refugees and displaced
populations. (Available at http://www.ennonline.net/resources)
WHO, UNICEF (2009) Acceptable medical reasons for using breastmilk substitutes.
(Available at http://whqlibdoc.who.int/hq/2009/WHO_FCH_CAH_09.01_eng.pdf)
WHO UNICEF (2006) Integrated IYCF Counselling Course. Trainers Guide. (Available at
http://www.ennonline.net/resources)
CARE, URC, CHS (2007) Infant and Young Child Feeding Counselling - Community Focused Approach.
Trainers Guide. (Available at http://www.ennonline.net/resources)
ENN/IFE Core Group (2009) Integration of IYCF support into CTC/CMAM. Facilitators Guide and handouts.
ENN, IFE Core Group & collaborators. October 2009. (Available at http://www.ennonline.net/resources)
large scale
migration
Residence in
overcrowded
settlements
Natural disaster
destruction of
infrastructure
reduced access
to food
Contraindications to
breastfeeding*
War
breakdown
of essential
services
lack of
hygiene,
sanitation
Maternal
Problem with
breastmilk
substitute
(BMS)
Breastfeeding
not possible
social disruption
families split
Infant
Political / economic shock
loss of property
and business
loss of earnings
and access to
health services
Inadequate maternal & childcare practices
Problems which Problems which

are primarily
are primarily
maternal-related infant-related
Breastfeeding/potential
to Breastfeed
(constitutional small size)
? True malnutrition
Disease
Infant <6m malnutrition, death & disability
Inadequate dietary intake
*acceptable, feasible, affordable, sustainable and safe conditions
Triggers
Impact on
population
Impact at
household
& family
level
Immediate
causes
Outcome
Appendix B
Appendix B Conceptual framework for causes of malnutrition in infants <6m
Key references:
Breastfeeding and Human Lactation, Riordan & Wambach, 4th Edition, 2010
Behavioural & Metabolic Aspects of Breastfeeding. International trends. Eds Simopoulos, Dutra de Oliveira, Desai, 1995
Fast Facts - Infant Nutrition. Lucas & Zlotkin, 2003
Forfar & Arneil's Textbook of Pediatrics. Sixth Edition
Breastfeeding and Human Lactation, Riordan & Auerbach, 2nd Edition, 1998
Breastfeeding. A guide for the medical profession. Lawrence & Lawrence. 6th ed, 2005
IASC Nutrition cluster Harmonized training package
203
204
Autres
Others
+
+
NR
Non response
non responder
Inconnu
Died
Default
Critres non-atteints
CNR
Non rpondant
Transfert medical
+
+
Erreur d'admission
Guri
End of TFC follow up
Dcs
Abandon
Non respondent
+
+
+
+
Medical transfer
Dead
Myanmar Niger Somalia Sudan Tajikistan Uganda
Other
Transfer
+
+
Death
Admission mistake
Defaulter
Afghanistan Burundi DRC Ethiopia Kenya Liberia
Missing code data
Cured
Discharge code*
Table 43: Discharge codes by country and by frequency
33
15
51
317
44
136
14
76
163
613
3
3
1,645
72
Countries
using this code
23,921
283
2,090
710
2,061
9,355
201
294
545
863
691
449
1,611
8,531
50,483
Appendix C
Appendix C Additional Tables for Chapter 5 (Review of field treatment)
End of transit
Fin suivi CNT
Error
Erreur admission
End of OTP follow up
End of TFC
End OTP
End of follow up
13
2,660
90
711
3
86
45
9
35
23
104
1
36
45
1
1
5
902
276
Countries
using this code
584
End of CBC follow up
59
786
End of CBC
DNG
Def
Dcd
D/Regestration
D
+
Cheating
Criteria not reached
CH
C.N.R
+
+
AM
Admission error
Unknown
Transfert
Transfer to TFC
Transfer to OTP
Discharge code*
Appendix C
Table 43 contd
205
206
+
Refus transfert
+
+
+
+
Transfer TFC
Transfer to CBC
Transfer to CTC
Transfer SFC
Transfer others
Transfer other
+
Transfer CTC / TFC
To other OTP
Transfer HP
1
1
1
1
26
101
32
6
46
139
12
20
21
43
1
2
5
1
68
TFC
T, Creni
SFC transfer
Refused to go TFC
10
Refus de transfert
Refus Creni
5
326
R,Transfert
47
+
+
R,Creni
Non respondant
OTP transfer
Non respond
Non guri
Mistake admission
Mistake of admission
Countries
using this code
Mistake
Medical referal
Discharge code*
Appendix C
Table 43 contd
1,096
59
2,797
3,730
8,355
9,329
Transfert CS
DRC: Democratic Republic of the Congo.
* As originally appear in the datasets
Number of outcome
codes used in each
country
Wrong discharge
5,481 24,155
9
13
5
18
8,466
16
25
2,011 5,721
16
48
45,591
Wrong admission
Wrong child
Transfert vers creni
Transit
Transfert vers crenam
Transfert hopital
Transfert CNT
Transfert H
1,494
Transfert CNS
116,79
13
7
14
1
2
9
31
161
619
31
1
249
414
Transfert Centre de S
Transfr
Transfer to OTP / TFC
965
Transfer to SFC
1
5
Transfer to other OTP

+
Transfer to other SFC
Countries
using this code
Transfer to other CTC
Transfer to OPT
Ethiopia Kenya Liberia

+
Afghanistan Burundi DRC
Transfer to Health Ce
Discharge code*
Appendix C
Table 43 contd
207
Appendix C
Table 44: Oedema by country and programme

6 to 59 months
< 6 months
Country
Oedema
n
Afghanistan
12
No oedema
n
Missing values
n
Oedema
n
No oedema
n
Missing values
98.8%
0.0%
1.6%
62 98.4%
0.0%
Burundi
0.7%
145
99.3%
0.0%
1,209
60.1%
803 39.9%
0.0%
Ethiopia
0.0%
30
90.9%
9.1%
4.2%
22 91.7%
4.2%
Kenya
2.7%
32
86.5%
10.8%
57
11.5%
377 76.3%
Liberia
0.6%
165
98.8%
0.6%
534
23.7%
1,715 76.3%
0.0%
Myanmar
2.8%
175
97.2%
0.0%
114
9.6%
1,075 90.4%
0.0%
Niger
0.7%
108
74.5%
36
24.8%
178
18.5%
534 55.5%
8.3% 1,284
91.7%
0.0%
3,069
66.2%
1,564 33.8%
0.0%
DRC
116
60 12.1%
251 26.1%
Somalia
0.2%
398
99.0%
0.7%
524
20.4%
2,034 79.4%
0.2%
Sudan
0.6%
358
99.4%
0.0%
905
18.4%
4,020 81.6%
0.1%
Tajikistan
0.0%
83
96.5%
3.5%
1.7%
274 95.5%
2.8%
Uganda
0.0%
16 100.0%
0.0%
664
52.7%
597 47.3%
0.0%
50
1.2%
7,261
35.1% 13,077 63.3%
329
1.6%
Total
140
3.5% 3,812
95.3%
< 6 months
Programme
Oedema
n
No oedema
n
6 to 59 months
Missing values
n
Oedema
No oedema
n
Missing values
58.9%
844 41.1%
0.0%
DC
0.3%
736
99.7%
0.0%
1,209
HT
2.6%
111
97.4%
0.0%
73
7.2%
936 92.8%
0.0%
SC
2.0%
94
94.9%
3.0%
43
14.1%
262 85.6%
0.3%
TFC
133
4.4% 2,871
94.1%
47
1.5%
5,936
34.3% 11,035 63.8%
328
1.9%
Total
140
3.5% 3,812
95.3%
50
1.2%
7,261
35.1% 13,077 63.3%
329
1.6%

DC: Day Centre;
HT: Home treatment;

208
1.2% 1,018
Appendix D
Appendix D Interview schedules and additional tables for Chapter 6

Appendix D.1 Steering group meeting report, May 2008
Project MAMI
Management of Acute Malnutrition in Infants
A retrospective review of the current field management of
acutely malnourished infants under six months of age
Implemented in a collaboration between Emergency Nutrition Network (ENN),
UCL Centre for International Health and Development (CIHD) and Action Contre la Faim
Funded by the UNICEF-led Inter-Agency Standing Committee (IASC) Nutrition Cluster
( http://ocha.unog.ch/humanitarianreform/Default.aspx?tabid=74 )
Report of the 1st Research Advisory Group (RAG) and Interagency Steering Group (ISG) meeting
UCL Centre for International Health and Development, London,
Wednesday 28th May 2008
Presentations
(Copies of PowerPoint slides are available on request [email protected])
1. 1. Project background Jeremy Shoham, ENN

The IFE (Infant and Young Child Feeding in Emergencies) Core Group, coordinated by ENN, has in its work
since 1999 identified a lack of specific guidance for the management of acutely malnourished infants less
than six months old. The MAMI project was conceived to address this need. Funding is from the UNICEFled IASC Nutrition Cluster and is secured until December 2008.
1.2. Conceptual framework and project scope Marko Kerac, CIHD

MAMI aims to document current practice in the management of acutely (moderate & severe)
malnourished infants under six months, in emergency programmes, in order to learn from recent
operational experience and identify further research needs. The immediate project outcome will be a
detailed project report that will be produced at the end of 2008. Outputs planned for the longer term
include interim Best Practice guidelines based on currently available evidence and a research agenda
suggesting studies that are needed to inform future practice. Project reports will be targeted at specific
audiences:
A technical document aimed at policy makers and researchers describing in detail the various issues
related to the management of infant malnutrition (and explicit about underlying quality/grade of
evidence).
A short summary document targeted at fieldworkers.
A conceptual framework (see appendices) for defining and understanding the causes of infant
malnutrition was presented. The purpose of this is to facilitate communication and common technical
understanding of the classification and aetiology of malnutrition in this age group which is often more
complex than malnutrition in older ages. Challenges include the use of multiple indicators
(anthropometric/clinical) and the difficulty of differentiating acute malnutrition from low birth weight
(LBW) or premature infants in contexts where longitudinal growth data is often unavailable.
209
Appendix D.1
Main discussion points

a) Sub-categorisation of infants by age there was discussion about:
Usefulness of sub-categorization of 0 to 5.9m infants: rationale is to recognise that physiologically
and patho-physiologically infants at different ends of this age spectrum are a very heterogenous
group. To what extent, and how any such differences impact on management was discussed.
If adopted, what cut-offs should be used: There was discussion about the choice of cut-offs and
about whether to have two or three age subcategories. One option was to follow IMCI with a two
phase cutoff: 0- 1.9m to identify the youngest infants; and a second group 2 to 5.9m. This was to be
further discussed in the MAMI report in light of published or field evidence.
Action
Further feedback/evidence welcome. Will be explored in detail in the MAMI literature review
Age data to be kept as a continuous variable wherever possible to allow flexibility and exploration of
the pros/cons of different cut-off options
b) Defining cases it was ascertained that agencies use many different indicators (anthropometry,
clinical status and feeding adequacy) in the field, with no current consensus on best practice in infants
below six months. The difficulty of distinguishing acute malnutrition from prematurity/LBW, given the
frequent lack of longitudinal patient records in the field, was highlighted. Some agencies, as well as DHS
surveys, ask mothers Was your child small at birth?, though the subjectivity of this method was
acknowledged. The possibility of a pre-admission period of monitoring to ascertain risk and prioritise
admission was suggested.
Action
Pros/cons of various definitions to be explored during analysis of field data and related literature
c) Understanding aetiology the general usefulness of a conceptual framework was acknowledged,

but there was much discussion about terminology, format, and about the extent to which knowing cause
changes patient management (e.g. breastfeeding support likely needed whatever other causes).
Action
Individuals & agencies to feed back to Marko all suggestions for evolving the initial draft framework
1.3. Review of progress & overview of proposed methodologies Marko Kerac,

CIHD
Progress to date includes initial literature searches, an online letter in the Lancet and workshops in
Vietnam and Bali. One of the next steps will be to identify specific questions which MAMI can address
using currently available evidence, including agency data. Interim best practice guidelines will be written
with explicit reference to the level of evidence used graded according to the Oxford Centre for EvidenceBased Medicine (see www.cebm.net/levels_of_evidence.asp)
Action
Marko to liaise with agencies re availability of data on 0 to 5.9m children this will be central to
determining what questions/issues MAMI can and cannot address in the initial project timeframe
1.4. Review of currently available field data Caroline Wilkinson and Cecile
Bizouerne, ACF
This presentation reviewed current field challenges in management of 0 to 5.9m malnourished infants. An
example field database was also shown and discussed to help the group focus on what questions might
be answerable through the review of field data. Key points included an observation that this age group is
often not specifically targeted by feeding programmes and surveys (with infants <6m included in only an
estimated 10% of surveys). There are therefore many unknowns both about the scale of the problem, and
about how best to look after malnourished children who are identified. Adverse implications are likely
210
Appendix D.1
given known higher mortality rates of young infants and the specific resources/skills (e.g. staff training,
time) needed to best care for mothers and infants in this group. It was postulated that the proportion of
malnutrition caseload below six months might increase with the roll-out of CMAM, as more infants are
identified. Lastly, psycho-social and preventative interventions were discussed, and examples reviewed.
Main discussion points

a) Availability of data
Asking those present at the meeting, it was established that many agencies do not routinely collate
data on 0 to 5.9m infants though it may be available by going to field records. Limitations of the
data (e.g. grouping) that is available was acknowledged
Action
Data analysis should be supported by some qualitative work to better understand the nature of that
data and its utility in informing future practice e.g. by interviewing those who collected the data;
Analysis of individual-level, raw data is important wherever possible
b) Determining programme impact & effectiveness: the importance of context

There was much discussion about how context can affect programme outcomes. Which are
universal factors relevant everywhere; which are more localised issues; is it possible / how to
distinguish the two? These are important challenges when assessing programme effectiveness
especially of psychosocial and other more indirect interventions.
Action
Qualitative work & literature review will be important to try to identify key/universal contextual factors
c) Database linking & coordination

Linking different databases was identified as a challenge. Some questions (e.g. the effect of
supporting pregnant/lactating women so as to improve infant nutrition) are difficult to address
without such linking.
Also discussed were the challenges of comparing outcomes from different management strategies
difficult if different admission criteria are used. There was some feeling that a useful outcome from MAMI
would be to build agency consensus on admission criteria for malnourished infants as this would be a
good basis for future work and harmonisation of practice.
The characteristics of a good admission criterion were discussed.
Action
MAMI to be a forum for agencies to meet/ share experiences initial steps towards database
harmonization
1.5. Networking for progress: lessons from the Vermont Oxford Network
Prof Alan Jackson, RAG
Key points included the fact that scientific literature on the feeding of infants below six months is sparse,
and that standardised approaches to the gap such as randomised controlled trials are unlikely to be the
way forward. MAMI needs to ascertain the level of evidence needed to make judgements for better care
standards, and to decide the best way of capturing such data for this purpose. The Vermont Oxford
Network (VON) may be a useful model of how a related discipline has moved forward.
VON is a collaboration of health care professionals dedicated to improving the quality and safety of
medical care for newborn infants and their families through a coordinated programme of research,
education and quality improvement projects. It maintains a database of information about the care and
outcomes of high-risk newborn infants. This can be used by participating units for quality management,
process improvement, internal audit and publication in peer reviewed journals (see www.vtoxford.org).
211
Appendix D.1
Research questions/issues for MAMI to address: Summary of key areas identified:

Three working groups (+informal discussions during the day) helped identify and frame possible
questions that MAMI might address.
Research question
+ why important
Data needed/available
Backround
What is the scale of the problem of 0 to 5.9m malnutrition?
- ? A paradigm shift that malnutrition is a problem in this age group
- Helps determine where on the spectrum of (public health vs individual &
(therapeutic vs preventative) efforts should be mainly (but not exclusively)
focused
National DHS databases;

MICS databases
Current Guidelines
What do current management protocols recommend for 0 to 5.9m
malnutrition?
- To understand the range and variety of current practices so as to be able to:
- compare & contrast different approaches
- better understand baselines before recommending future work/research
What are constraints to some current programmes admitting/managing
0 to 5.9m olds
Review of agency protocols

Review of agency data
Qualitative work & field visits
Admission Criteria
- Need a criterion that is optimally sensitive & specific against programme
aims (as well as taking into account likely resource constraints)
What is best way of identifying cases (e.g. rapid assessments; surveys;
other)
(How) can LBW/prematurity/post-natal malnutrition be differentiated?
(and is there a weight or other cut-off below which treatment needed
regardless)
What % of cases of malnutrition are 0 to 5.9m (in relation to 6 to 59.9m)
What are the best admission criteria:
- Which indicators (e.g. anthropometric/clinical status/feeding adequacy)?
- WHO growth standards or NHCS growth references?
- Do the criteria reflect risk of mortality? (ideally preventable mortality vs
just mortality alone)
What are technical / practical limitations of different admission criteria
(e.g. age assessment; weight assessment if scales only weigh to nearest
100g)
Literature review
Review of agency data/
agency admission criteria
Estimating expected caseload
from DHS data would allow
some prediction of the effects
of changing admission criteria.
Reference ENNs/University of
Southampton work on field
equipment (weighing scales)
ROC curves constructed using
field data to look at mortality
predictors. (ideally
supplemented by prospective
work in future to look at
clinical/other markers of risk)
Management Protocols
What are the outcomes from 0 to 5.9m malnutrition using current
protocols?
What nutritional treatments are currently recommended/used (& how
effective are they) e.g. breastfeeding support/ re-lactation/ breast-milk
replacements/therapeutic milks
What medical treatments are currently recommended/used (& how
effective are they)
Should (and does) regimes differ for LBW/prematurity/acute
malnutrition?
What is the role of psychosocial support? What is its effectiveness?
212
- Literature review
- Review of agency data
- Studies comparing treatment
regimens (such as ACFs study
comparing F100-diluted and
infant formula).
Appendix D.1
Table contd
Research question
+ why important
Data needed/available
Discharge Criteria
- Need a criterion that is optimally sensitive & specific against programme
aims (as well as taking into account likely resource constraints)
What are the best discharge criteria:
- Which indicators (e.g. anthropometric/clinical status/feeding
adequacy/% weight gain)?
- WHO standards of NCHS norms
- Do the criteria reflect risk of preventable mortality
What length of follow-up is ideal (and what is done in practice)
What are longer term outcomes following an episode of malnutrition
What are current default rates
Literature review
Review of agency data /
agency discharge criteria
Estimating expected caseload
from DHS data would allow
some prediction of the effects
of changing discharge criteria.
Rasource & StaffF Issues/Requirements

What staff skills/training is needed? (esp. for breastfeeding related
interventions)
Is there a minimum (and/or optimal) staff: patient ratio?
Qualitative work / interviews

with agencies
Service Organization
What is coverage of present programmes
What is the right balance between facility-based and community based
programmes/interventions
What is right balance btw preventative (e.g. nutritional support of
pregnant & lactating women) vs treatment approaches
Is there a role for active community case-finding in the community?
How would this be carried out?
Is there an essential minimum package of resources/staff to be able to
successfully carry out MAMI-related programmes ~ is it possible to
decentralise this?
How can data collection be improved for future use? How can this data
be shared between key players at country level?
compare expected numbers

(e.g. from DHS surveys) vs
actual numbers enrolled into
feeding programmes to get
very rough estimate of
coverage
Literature reviews (+case
examples from CTC/CMAM,
BFHI etc)
ACF interviews with mothers
Cultural and Contexttual Issues

What are key factors affecting the management of infant malnutrition?
How does contact/culture affect prevalence/ treatment/ followup/mortality?
What is the impact of maternal factors (stress, illness, community
support)?
Qualitative work (e.g. field

visits/interviews with
agencies)
213
Appendix D.2
Appendix D.2 Introductory letter for sharing of field data
MAMI Project
(Funded by the UNICEF-led IASC Nutrition Cluster)
(sent to participants in advance of interview)
Dear Colleague,
To understand the issues and challenges relating to MAMI, Management of Acute Malnutrition in Infants, we are
conducting telephone consultations with a number of key informants and field-based organizations. To make these
focused and time-efficient, we hope it is helpful for you to see this rough agenda of points we would like to hear
about.
A few things:
i) Our interest is not only in how infants 0 to 6m are managed - but also in challenges faced and in understanding
reasons why they may not be currently admitted or actively managed.
ii) Copies of any project proposals/reports etc would be much appreciated would save asking many obvious
questions!
iii) Information you give will be used in MAMI related publications only. You/your organization will have the
opportunity to see and comment on relevant reports before finalisation. You will also have the option of being
named co-authors representing the MAMI Steering group (please see data sharing document)
vi) If part of our interviews includes describing a programme which has contributed past data to MAMI, it would be
helpful to focus on conditions/issues at the time data was collected - as well as any important current/new
issues.
v) Our main aim is to describe details of and outcomes from the wide variety of current patient management
practices. It is not to judge whether different programmes do or do not meet a gold standard (which does not
exist hence the need for MAMI in the first place!)
Capturing actual experiences is critical to helping us understand how we can move forwards. Only in light of
field realities can a sensible field ideal be developed
Many thanks in advance for your great help and support, I look forward to talking soon,
Best wishes,
Marko
MAMI Lead Researcher.
214
Appendix D.3
Appendix D.3 Interview Schedule for Chapter 6 (Key informant Interviews)
MAMI Project
Field experiences: key informants interviews
Topics to discuss
(Funded by the UNICEF-led IASC Nutrition Cluster)
N.B
A)
Intro/General:
i)
ii)
iii)
iv)
B)
a) Infants refers to infants < 6m (0 to 5.9m) unless otherwise stated

b) Present tense is used ~ but if there are important past programmes, it is just as important for us to
hear about those
What sort of nutrition programme(s) is your organization operating i.e. NRU, CTC/CMAM, SFP, other, etc?
Where (geographically) are the programmes operating?
How do the programmes link with other / local health service structures?
Which kind of staff are involved in your programmes (e.g. expat/local; clinicians/volunteers, etc)?
Infant SAM/MAM prevalence & causal factors

i) Do you consider acute malnutrition in infants (0 to <6m) to be a public health problem in the
location(s) where you work?
ii) What are the main direct factors underlying infant malnutrition in your area(s) (if able to say)?
iii) Which context (indirect) factors commonly affect infant malnutrition?
Either positively (reducing disease burden) or negatively (increasing disease burden)
Does your programme currently admit or directly manage infants?
If yes:
Continue with section C
If no:
Skip direct to section E
C)
Identification of malnourished infants & admission to programme

i) How are infants with possible malnutrition identified in your programme / area?
ii) How is it decided/ confirmed which children are malnourished and which are not? What is the case
definition?
iii) What happens to those in whom the diagnosis is not confirmed?
iv) What are major context factors affecting how infants with malnutrition present/arrive to the
programme (either positive or negative influences).
D)
Programme specifics
i) What are carers/community expectations from an infant SAM/MAM programme? (if able to say)
ii) In brief, how do you currently manage a malnourished infant, & what is the basis of this? For example,
written guideline (e.g. international, national; organizational; local); informal local guideline; case-bycase clinical judgement.
iii) At present, how well do you feel your current protocols / patient management practices meet the
needs of infants with SAM / MAM?
What works well and why? (e.g. which patient groups respond well to treatment?)
Are there any specific situations / patient groups where difficulties occur?
iv) What (if any) are specific challenges relating to medical treatments for infant SAM/MAM?
v) What (if any) are specific challenges relating to nutritional treatments for infant SAM/MAM?
215
Appendix D.3
vi) What (if any) are specific challenges relating to psycho-social and family support?
vii) What are discharge criteria / how do you decide if an infant has been successfully treated
E)
Challenges & reasons for non-admission/infrequent admission

i) How/to what extent do each of the following lead to non-admission or low admission of infants <6m:
- no infants/low numbers of infants presenting for care
- insufficient programme resources (e.g. physical space, equipment, supplies, staff, budget)
- suboptimal programme processes (e.g. nothing to offer children in current guidelines)
ii) If malnourished infants do present but are not admitted to TFP/SFP, where are they referred instead?
iii) How often are infants almost 6m old treated as >6m olds, according to normal SAM/MAM protocols?
iv) Are infants <6m reported in current M&E systems?
F)
Training & support for infant malnutrition

i) Have you ever had formal training on the management of infant malnutrition? What? Where? When?
ii) Which literature / whose expert advice (either in, or external to your organization) would you seek for
support /advice about infant malnutrition?
G)
Context
i) Which context factors would make the most difference to infant SAM/MAM if addressed?
ii) Which context factors are most easy / realistic to change (even if public health impact not be great)?
NB context is often key to many questions. Possible factors to consider in this & other context questions
include:
geographical
- is the programme area rural/urban?
- what is access/transport like?
characteristics of the emergency - duration, causes
socio-cultural context (e.g. religious issues, traditional beliefs/customs)
- at country/national level
- at local level
political context (e.g. national leadership;/political will, presence or absence of other related
programmes like baby-friendly hospital initiative)
- international level (e.g. UNICEF, WHO, etc)
- national level
- local level
programme
- nature of the programme (e.g. stand alone integrated into govt system)?
H)
Finally. . . .
i) What do you see as the three biggest challenges in terms of managing malnourished infants in the
field?
ii) What three (realistic) outputs would you like to see from the MAMI Project in order to make the biggest
difference to malnourished infants in the field?
iii) Can you suggest any resources or literature or words of wisdom from your own field experience which
you think would help others in the MAMI network?
Thank you very much for your help & support!!!
216
Appendix D.4
Appendix D.4 Key informant interviewee

Table 45: Profile of 31 key informants interviewed
Several informants described more than one programme: hence >31 countries and projects represented
Country
Interviewee position
Type of organization/programme
(at the time of programme being described)
Burundi
Nutritionist
International NGO
Nutrition programme manager
International NGO
Ethiopia
Country programme manager (UK based)
NGO (mainly providing technical advice to

government health system)
Kenya
Project officer
International NGO
Community Health workers
Government Health Centre
Nursing Officer in-charge
Government Health Centre
Camp Nutritionist
UN refugee camp
Stabilization centre supervisor
UN refugee camp
Nutrition supervisor
UN refugee camp
Nutritionist
UN refugee camp
Nutrition specialist (regional advisor)
International NGO
All above programmes were CMAM-based, with
combinations of inpatient & outpatient care
Malawi
Nutritionist
NGO (mainly providing technical advice to

government health system)
International NGO
Somalia
Clinician in-charge of Nutrition project
NGO
Tanzania
Supervisor of paediatric ward

(Regional referral hospital)
Paediatric ward, regional referral hospital
Uganda
Paediatrician in charge
Inpatient stabilization centre (part of CMAM

Programme), set in section of general paeds ward
but staffed by large international NGO
Angola
International NGO
Guinea
Nutritionist
(overseas-based, in charge of several
countries)
International NGO
DRC
Nutritionist (USA-based)
NGO (mainly providing capacity building/

programme support)
International NGO
Clinician in-charge of Nutrition project
NGO
International NGO
Doctor (in charge of health/nutrition

programme, involving front-line clinical work)
International NGO
Nutrition advisor
International NGO
Nutritionist
International NGO
Nutritionist (overseas-based, in charge of

several countries)
International NGO
Sudan
Lesotho
Country programme manager (UK based)
Swaziland Paediatrician
Working in MoH hospital, part of international HIV

support initiative

several countries)
International NGO
South
Africa
Paediatrician
Government Hospital
Burkina
Faso
Nutrition coordinator (in-charge several

countries)
International NGO
Gambia
Paediatrician In-charge
(Central Government hospital)
217
Appendix D.4
Table 45 contd
Country
Type of organization/programme
(at the time of programme being described)
Liberia
Nutritionist
International NGO
Mali

several countries)
International NGO

countries)
International NGO
Programmes manager
NGO (technical advisor)

several countries)
International NGO

countries)
International NGO
Senegal

countries)
International NGO
Sierra
Leone
Nutrition advisor
International NGO
Nutritionist
International NGO
Niger
Afghanistan Nutritionist (USA-based)

Nutritionist
Nutritionist
Bangladesh Professor and Doctor
NGO-led NRU
Myanmar
Nutrition programme manager
International NGO
Nepal
Nutritionist
International NGO
Nutritionist
International NGO
Nutritionist (USA-based)

programme support)
Programme manager
International NGO
Nutritionist
International NGO
Pakistan
218

programme support)
Appendix D.5
Appendix D.5 Details of key informant interviews Prevalence and Causes of Infant
<6m malnutrition
Subtheme
emerging
(at the time of programme being described) Quotations/examples
Lack of
population
focusing on
infant <6m to get
true estimate of
the problem
No idea of prevalence of acute malnutrition in infants <6m in the community, some making
assumptions based on admission numbers.
We do see occasional cases, though cannot say what the true extent of the problem is in
the community.
No info on prevalence, though not uncommon on ward (approx four to five infants out of
30 on the ward at a time).
Infant <6m malnutrition not a problem here rare (on basis of cases seen in
programme).
There can be a bit of a mindset that infant <6m malnutrition is not a problem, so surveys
dont include this age group, and we never really know whether or not the assumptions
are valid.
Even if we wanted to include infants in surveys, there are important technical and practical
barriers, like what sample size is needed for a valid result.
Difficult to say whether infant SAM a problem no surveys available. Admissions of
infants <6m were uncommon, perhaps 1-2% of total (Sudan).
Infant <6m admissions not common maybe one per month or 2-3% of admissions
impossible to know how well this reflects community disease burden.
Difficult to get good guidance on how to do surveys focused on <6m infants (e.g. sample
size, measurement techniques)
Infant <6m
factors
underlying
malnutrition
Low birth weight/preterm babies especially those who are too weak or premature to
suckle.
Twins (often because LBW, premature).
Twins, triplets seemed particularly common in some areas (impression from Democratic
Republic of Congo).
Diarrhoea, respiratory disease, other acute child illness.
TB, HIV other chronic infant illness.
Cerebral palsy (including post malaria or post meningitis) or other disability
There were some cases of recurrent malnutrition possibly due to underlying
malabsorbtion
Maternal factors
underlying
malnutrition
Orphan (mother died) so no chance of child being breastfed (orphaning noted by the
majority of respondents as a major challenge)
Early weaning is very common and rates of EBF are very low.
Even mothers who have been taught about the benefits of exclusive breastfeeding in
practice, often introduce other foods well before 6m.
Severe maternal illness (obstetric complications, HIV noted by several respondents)
leading to a prolonged period when mother cannot breastfeed.
Mother is dysfunctional.
Young and inexperienced mothers were found to sometimes struggle with caring for their
infant.
Some mothers just never get breastfeeding well established, and they present for
malnutrition treatment with infant aged one to two months but presumably have had
some inputs (from health centre or other) previously.
Maternal depression (with range from clinical depression to poor coping strategies, to
worries about other children), all contributing to likelihood of introducing complementary
foods early and infant becoming malnourished.
Mothers value their business more than their infant, and even if the infant is with her,
feeds and care get neglected.
If women have the urge and desire, breastfeeding is generally not difficult. Other women
however are lazy and do not look after infants well.
Maternal milk insufficiency though difficult to tell how much of this is real and how
much perceived by mother.
Mother has poor knowledge about infant feeding practice
Mother does not drink enough fluids and so breastmilk production suffers.
219
Appendix D.5
Table contd
Subtheme
emerging
(at the time of programme being described) Quotations/examples
Health services
Current health services do very little for those infants who genuinely have no access to
breastmilk (e.g. orphans). No formula is available; advice on other alternatives is limited
meaning infants that are already at high risk of malnutrition become even higher risk
because of lack of support.
Other services related to early feeding support are unavailable in the area (e.g. Baby
Friendly Hospital Initiative)
Access to healthcare is difficult (distance too far, transport too expensive so carers either
wait for too long or dont go at all).
People often go to pharmacists or private clinicians first, these prefer to sell drugs which
may not be appropriate rather than to refer.
Family factors
underlying
malnutrition
Dysfunctional families, (e.g. father unsupportive or in some cases even abusive of

mother).
Single mothers sometimes find it difficult to cope alone, feel that breastmilk alone is
insufficient and start giving complementary foods too early.
Male and female infants valued differently that affects care seeking behaviour (e.g. not
spending time/money on a girl); different problems (boys given complementary foods
earlier).
Women often need male family members permission to leave house/seek medical care.
HIV
National protocols did not allow for testing of under 18 month olds plus did not have
treatment for this age anyway.
There has been a change of policy for infants of HIV infected mothers. Previously the
option to replacement feed with formula was emphasised; currently EBF is the preferred
option for 0 to 6m olds. This change has led to much confusion for both mothers and staff
still perceptions persist that it is best not to breastfeed to prevent HIV transmission.
One key informant reported observing a 2008 programme in Rwanda which was providing
replacement feeds to all infants of HIV infected mothers.
HIV is a sensitive issue both for patients and organizations.
Despite the fact that mothers may die of many different causes, orphaned infants are often
assumed to be AIDS orphans can be cause of stigma.
HIV is major factor that has led to numbers of malnourished infants <6m increasing,
possibly associated with replacement feeding message.
Societal factors
underlying
malnutrition
Poverty and employment mother has to go out for work, and cannot take infant with her,
so breastmilk substitutes given and/or complementary foods started much too early (NB
sometimes infants left with other family, sometime in care centres).
Not sure of scale of problem, but is likely given food price rises, loss of livelihoods and high
chance of mothers becoming malnourished.
Infant formula has strong image of being a modern way of feeding, thus becomes popular
and demanded by mothers.
Mothers work on land during the day, and even though infants are often carried with the
mother, she is often too busy to take time to breastfeed.
Nutritional status has improved since peace agreement signed, roads opened and health
services resumed (including significant NGO services (DRC).
Mothers value their business more than their infant, and even if the infant is with her, feeds
and care gets neglected.
Background conflict, insecurity and poor sanitation.
Grandmothers can provide useful support and care for infants <6m (other respondents
noted that grandmothers sometimes encouraged and perpetuated practices which
adversely influenced exclusive breastfeeding).
Infant feeding bottles/formula milks were available in the local market no mechanism for
monitoring & ensuring compliance with International Code.
220
Appendix D.5
Table contd
Subtheme
emerging
(at the time of programme being described)Quotations/examples
Cultural practices Strong, deeply engrained traditions, encouraged especially by grandmothers, to introduce
(negative)
complementary feeds (e.g. porridges) at a few weeks of age.
Adverse care practices, including not feeding infants during illness there is a perception
that it is normal for one twin to be less well nourished than the other, so a disparity is
often not noticed or acted on.
Malnutrition is NOT linked to inadequate intake of food (milk in case of infants <6m) but to
breaking of cultural taboos (e.g. sex outside of marriage; sex too soon after childbirth;
being cursed by the evil eye). Thus is difficult to suggest a nutrition-based solution to the
problem.
A senior male relative needs to give consent for a woman to receive support or treatment
this can lead to delays in seeking care, and also can contribute to making it less
effective when give due to late presentation.
An ideal baby is seen as engaged and beginning to acquire adult-like characteristics
hence babies are often given tea, sugar and water, and exclusive breastfeeding is difficult
to promote.
Child illness is not recognised unless there are specific symptoms such as diarrhoea or
vomiting, thus malnutrition alone might not get picked up
Being subdued and quiet is seen as desirable characteristic of an infant and thus an
infant who is subdued due to underlying malnutrition might not be easily identified as
having a problem.
Often treated beforehand by traditional healers with herbs and other local medicines, e.g.
removal of infant teeth; feeding stopped during illness; as soon as mother pregnant again,
stops breastfeeding current infant; mothers encouraged to discard colostrum; mothers
confined to home for 40 days after delivery (though possible to go out for medical advice
if needed).
Mothers perceived that breastfeeding would make their breasts droop and become
unattractive and so breastfeeding is not popular.
Cultural practices - Cows milk often given at home to infants as a supplement, malnutrition seems rarer in
(positive)
these families (NB unknown if modified or unmodified milk likely unmodified).
Community support programmes by local healthcare workers have done much to
increase breastfeeding, so infant malnutrition not a problem here (refugee camp with
active infant feeding support programme).
Breastfeeding was common in the community, and most infants presenting for care were
anyway breastfeeding
Traditional healer, whilst often first attempting to treat infants with malnutrition ( and other
problems) do often refer for further care if their treatments are unsuccessful. Depending
on the individual healer, this may/may not result in delayed presentation.
221
Appendix D.6
Appendix D.6 Details of key informant interviews Identification of malnourished

infants <6m and admission to programme
Subtheme
Quotations / examples
Case finding in
the community
Community health workers often dont look for the problem of infant <6m malnutrition, so
wont see it even if there (NGO nutritionist).
Infants <6m not a priority group for most nutrition programmes often not the focus of
community screening either.
There was active case finding in the community by community health workers. They used
hanging scales and clinical judgement to idenfity at-risk infants <6m.
No strict guidelines available for identifying infants <6m its a matter of judgement.
Cases normally identified if clinically obvious.
Community health workers are aware of need to consider malnutrition in all under five
year old children, but definityions and criteria for infants <6m are not clear. Therefore rely
a lot on clinical judgement.
Community health workers (CHW) in one place visited noted infant <6m malnutrition not
a problem however, no data, only clinical impressions to back up that statement.
CHWs are already overburdened from other programmes looking for malnourished
infants would further increase existing pressures.
Majority of cases referred in from active screening in community (NGO programme, DRC).
Staff in health centres helped identify and refer vulnerable infants.
Maternity services referred LBW and other vulnerable infants.
Growth charts
Experiences variable, considered valauble but often not acted on, inaccurate measures
and birth weight often not measured or a later weight taken as a proxy for birth weight.
Often filled, but not so often acted on, since infant appears to have been failing to thrive
for some time before arriving at programme. Maybe not understood by community health
workers.
Despite many mothers having growth charts with previous weights, these are often
unreliable (e.g. different, uncalibrated scales; previously weighed with clothes or nappy on).
Growth monitoring is poor and cannot be relied on.
Birth weight often unavailable, so cannot interpret trends.
Birth weight is not always taken at birth, but as soon as possible, in 1st week of life.
Second weight is taken at ~ one month of life, when traditional birth attendant hands over
care to the community outreach team (or taken sooner if infant unwell). This system
seems to work OK (Kenyan refugee camp).
There is mismatch between growth monitoring, which generally looks at weight-for-age,
and TFP/SFP admission which relies on weight-for-height indices.
Growth monitoring does seem to work well and infants are referred to feeding
programmes having been identified through growth monitoring programmes (DRC).
Assessment
logisitics and
practicalities
There were no clear official criteria, so staff had to make their own decisions (response of
staff member working for NGO which did note infants <6m in some of its guidelines,
though maybe not in the version used in this particular country/programme).
Admission is done by nurses in many programmes.
Used to admit infants for assessment (to see if growing fine these were given vit A, folic
acid but only abs if lethargic/any risk signs assessment infants had less strict discharge
criteria.
In absence of other guidelines, infants are assessed using same criteria as older children,
using weight-for-height. Normally not a problem unless height is out of range of chart.
Then go on clinical appearance and history.
Maternal problems (e.g. mastitis) are often assessed at programme admission.
To avoid prolonged admissions for all infants, most are admitted for one to two days
observation to assess directly how breastfeeding is going and avoid having to make a
decision on supplementary feeds based on maternal reports of milk insufficiency only.
Maternal report of difficulty breastfeeding alone is taken as valid reason for admission to
programme. It does not need to be backed up by objective evidence of this fact
(assessment is difficult).
Limited time is available for assessment.
222
Appendix D.6
Table contd
Subtheme
Anthropometry,
measuring
Despite clinical admission criteria, anthropometry is regarded as more of a gold standard

to decide about who to admit.
Weight-for-height is often used, but mainly to back up pre-existing clinical suspicions
rather than routine for all infants <6m.
Scales accurate to 100g are insufficiently precise.
Scales are often not calibrated.
Scales are often not well maintained.
Length rarely measured.
Balance scales were more precise and worked well.
Many health workers weight infants clothed or with heavy nappies still on so cannot rely
on previous weights.
Cannot carry scales into field so difficult to identify malnourished infants <6m (in contrast
for children >6m, for whom MUAC can be used).
Length is very rarely done for infants <6m.
The use of 65cm as a proxy for <6m causes significant confusion for field staff.
Most carers of young infants WILL be able to give a relatively exact age, especially since
birth is more recent.
There is a widespread fear of cold so mothers (and some healthcare staff) are reluctant
to undress infants for weighing; clothes can contribute some 20% of body weight.
Reasons for
presentation to
feeding
programme
Most infants present sick / because of other clinical problems and the malnutrition
identified during clinical assessment - Tanzania, MoH hospital, Kenya MoH, Malawi MoH
hospital, Swaziland MoH hospital
Weight loss combined with adverse clinical picture.
Wanting food (from NGO).
Referred in by community health workers (including from growth monitoring programmes
DRC).
Carers had heard that feeds were available for young infants and came to see if their child
might be eligible (so infants were often NOT sick at presentation) NGO programme.
Often presented at few days/weeks of age with feeding problems had heard of service
and wanted food (NGO programme).
Present with breastfeeding difficulties.
Infant identified in the community on clinical grounds is referred to nutrition centre for
more detailed assessment.
Infants often not admitted unless special cases, since programme focus is on 6 to 59.9m
age group
Can be difficult to distinguish which mothers really have breastmilk insufficiency, and
which are saying so in the hope of getting formula milk or other treatments.
Ward layout /
assessment
environment
Malnutrition unit often next to paeds ward / a side bay of the main paediatric ward.
No set area for observation / assessment.
Assessment area was part of main ward. Infants admitted for assessment were thus also
at risk of nosocomial infection. Deciding whether to admit for assessment was hence very
difficult.
223
Appendix D.7
Appendix D.7 Details of key informant interviews Programme detail

Subtheme
Carer
expectations
Expect food for the infant (but not specific about what food).
Expect infant formula (they heard it was available from the programme).
Expect some form of medication and often unhappy if given nothing except advice.
Cannot say what carers expect, never asked.
Dont expect, and dont like the idea of, a long admission (beyond five to ten days is
unpopular).
Guidelines
Followed own agency guidelines.

Occasionally refer to internet for difficult cases and management challenges.
Use WHO 1999 SAM guidelines (MoH hospital, Gambia).
Was sometimes confusion about which guidelines to follow, as several different ones and
several different versions were available.
Exactly which guidelines were followed was dependent on the supervising nutrition
coordinator (emphasis changed with the arrival of a new coordinator).
Staff time
Time to support BF is a luxury for staff and often not possible (MoH, Tanzania).
Not an issue in our NGO programme, but was an issue with other NGOs who had less /
less experienced staff.
About one member of staff per ten babies worked OK to support the needs and extra
inputs required for infants admitted to programme (one per five to six infants would have
been better).
one carer for five to six mothers worked well.
Field staff often complained of not enough time to look after infants properly / follow
current protocols well.
Staff supervision Staff supervision is lacking but nobody trusts anybody to do a job, so work ineffecitive
(MoH, Tanzania)
Having staff whose sole job it was to monitor feeds (phase supervisors) worked well
(NGO, DRC)
There was a problem of excess deaths at night, possibly due to staff sleeping/being less
proactive at patient management and letting issues like rehydration after diarrhoea slip.
Medical
Giving drugs to small infants is difficult, often no liquid medications (have to divide tables
or capsules).
Can be challenging to adapt drug does to very small infants.
Drug doses seem to be very variable some are consistently under-dosed (e.g.
ceftriaxone), others frequently overdosed.
Choice of antibiotics uncertain for this age group.
No specific challenges most treatment fairly straightforward.
Sometimes there was lack of specific pieces of equipment such as i.v. lines in the few
cases where oral rehydration had failed or resuscitation needed.
Guidelines on which micronutrients to give were not clear.
Maternal issues
Carers sometimes try to make the infant swallow by cupping milk into mouth and blocking
nose.
Culturally difficult for mums to use Kangaroo care since were used to leaving infants by
themselves for periods.
Mums often slept with infants to help keep them warm / encourage breastfeeding where
possible.
Mothers were encouraged to drink at least 2l fluids per day whilst on ward to help with
hydration and milk supply.
Providing supplementary rations to lactating mothers was popular and well received by
patients.
Psychosocial support would have been ideal for women who were in shock (report from
programme based in conflict situation).
Psychological support was provided through role play and group work (conflict situation,
NGO programme).
Specialist staff led a programme of psychosocial support, but all staff were involved.
Same NGO ran a strong mental health programme which helped assess and care for
mothers.
224
Appendix D.7
Table contd
Subtheme Quotations / examples

Feeding
methods
If child too weak to suck, initially used syringe later replaced with cup on advice of visiting expert.
Successfully used supplementary sucking (SS) no difficulties at all. Read about technique in
book, never used before. WHY: success-culturally acceptable (though wet nursing was not the
norm) nurses motivated, had time (healthcare assistants, two per 30 patients; one doctor; one
nurse, one medical officer)
All tried breastfeed first, then top-up with supplementary sucking (SS)/breastmilk substitute (BMS).
Supplementary suckling was not successful but only tried once and that mother was reluctant.
SS sounds good, but too time intensive, difficult and results in milk spillage, much mess.
SS supervision would be a problem, since staff numbers are so low that even existing tasks often
are difficult to do.
SS worked very well, successful in most cases, (but needed time & support) (DRC, NGO
programme; NGO programme, Niger; Tanzania Govnt Hospital)
There were difficulties with implementing the supplementary suckling technique.
Tables in the malnutrition manual were difficult to follow.
SS works reasonably well (~60% success rate in re-establishing full EBF). It is managed by a
in-charge nutritionist.
Achieving weight gain criteria which are part of SS guidelines took long time to achieve.
SS is NOT practical or feasible (often not done despite said that done).
Tried SS and found it did not work; too complex, too much staff time. May be possible in different
context.
Worked extremely well, though not always easy initially. Large part of success was down to a well
motivate and highly skilled midwife who led and supervised the SS programme.
Still not sure about best feeding method cup, spoon, syringe?
One mother had stopped breastfeeding and started infant formula, initially saying the child was
refusing breastfeeds. The baby then developed diarrhoea and had to be admitted to feeding
centre for support. During this time, relactation was successfully started.
It is very difficult to get the balance between adequate, formal supply of infant formula for orphans
and those who cannot breastfeed (with risk of increasing demand for the formula/leakage to
those who could breastfeed) vs. minimizing the availability of formula, but thereby also risking
inadequate supplies for those who do need it.
Sometimes confusing about which milk to use: infant formula, F75 F100 diluted?
Type of
milk used Used diluted F100 worked well.
for
When nurses busy, sometimes used to delegate making up F75 and F100 to mothers this was
therapy
not always supervised and maybe not always done well.
Good to have option to use local foodstuffs (MoH Tanzania infant formula too expensive,
supplies limited).
Occasionally F75 used, occasionally adapted cows milk.
Cost infant formula very high not realistic to start in programme since difficult to maintain longer term.
Leakage of infant formula milk is a huge problem whenever give to targeted population, ends
up in wider use among others in the community.
No problems with treatment whilst on ward (use dilute F100). Problem arises when infant who is
unable to breastfeed (e.g. orphan) goes home. Family cannot afford to buy infant formula;
programme provides only small quantities to small numbers of patients.
One challenge is to provide milk and safe water to those carers who are using infant formula.
Although officially discouraged, sometimes do give mothers a supply of F100 to take home. This
is because breastfeeding is not possible, and infant formula or other milk is not available.
For those who could not breastfeed, a one month supply of infant formula was given on discharge
(these were very small numbers).
Modified animal milks worked well, and were cheap and acceptable.
Physical
space on
ward
Was a problem having the assessment unit as a bay on main paeds ward big danger of cross
infection and dilemma about whether or not to admit. No space available for assessment of
borderline cases.
Having a separate area of the ward for lactating mothers worked well
Separate building away from the main feeding centre worked well
Length of
stay
Average ten days - Mothers often want to, or do, leave if try to keep for much longer.
Infants are kept in until starting to gain weight.
Stayed as inpatients until breastfeeding well and two repeated measures were >70% median (for
SAM) or >80% of median (for MAM).
Follow-up Community health workers follow up discharged infants in the community (stable emergency,
Kenya). Reinforce health education messages
Long term care of orphans difficult go home on infant formula, but have to buy themselves. No
specific follow-up of how successful this is.
225
Appendix D.8
Appendix D.8 Details of key informant interviews Challenges

Subtheme
Links to other
clinical services
Infants and children often assessed initially in admissions or paediatric ward. Only
referred to nutrition ward if needed. This system worked well in most places described.
If still breastfeeding, referred to paediatric ward rather than managed in nutrition centre.
Community care
Difficult to know what to do / recommend for patients not sick enough to be admitted, but
who appear vulnerable no extra foods (e.g. supplementary feeding) that is easily
available as it is for older children. Mothers feel that no treatment is being given, do not
see advice only as treatment.
SFP
SFP does exist on paper and is recommended in national guidelines for pregnant and
lactating women, but is not active in practice.
Non-admissions
Referred to local child health (primary healthcare) clinics.

Referred to paediatric inpatient wards.
Its difficult to say what ultimately happens to infants referred elsewhere.
Unsolicited/
poorly
coordinated
donations
A batch of RUTF arrived one day, which nobody seemed to know anything about.
Treating infants
<6m as if they
were >6m
Some respondees were clear that programmes never gave RUTF to infants <6m.
Others occasionally started infants approaching 6m on RUTF if breastfeeding was not
available as an option.
In our NGO programme, infant <6m always treated according to infant <6m guidelines,
but this was not the case for many other NGOs in area.
Sometimes do give RUTF to infant aged > five months only if no other alternative, and no
breastfeeding is possible.
RUTF is used for HIV positive infants from four months of age.
Reporting
issues,
databases &
audit
Recording on charts is poor, so would be very difficult to do good audit.

Infants <6m were reported by the NGO, but not by local UN/MoH systems.
Infants with underlying conditions such as cleft palate are often labelled as not
malnutirition so as to avoid adversely influencing programme statistics.
Current databases do not always separate out infants <6m, so difficult to audit and learn
from the data.
Outcome codes on current databases often complex, again leading to difficulty auditing
and learning from databases.
Difficult to know what long term outcomes are since follow-up is poor.
Use local government reporting systems rather than own databases does include infant
<6m.
226
Appendix D.9
Appendix D.9 Details of key informant interviews Training and Support

Subtheme
Formal training
There is very little focus on infants during nutrition related diplomas, degrees (reported by
many respondents).
Infant feeding is a bit of a Cinderella subject in university nutrition courses, not a major
priority within nutrition.
The majority of experience / expertise on infant <6m malnutrition is developed through
field experience, and very little during training prior to going out.
In-hospital training course on WHO guidelines had significant impact on improving
practice.
Refresher training during CMAM rollout was useful and mentioned infants <6m.
Most training is on-the-job rather than formal classroom training. Handovers help
familiarize new staff with key protocols.
Induction
Had brief handover from previous person who set up nutrition unit themselves not very
experienced, so not optimal handover.
NGO induction course focuses on management issues like financial systems, reporting
etc very little focus on patient management of conditions which were new to us (doctor
trained in developing country, going out to emergency setting and treating SAM for the
first time).
There are pre-deployment training courses run by the NGO, but it is not always possible
for staff to attend since they may be required to go to emergency situations at very short
notice.
Field visit by
supervisior or
other expert
Several instances were desribed where a on-site visiting expert has big role in changing
practice.
- e.g. syringe feed to spoon feed to promote more oro-motor skills
- e.g. better phase transition
- very limited experience, helped focus on the issue after visit of consultant who was
assessing the programme.
- visit from an international expert on malnutrition management made a big practical
difference to daily patient care and also helped motivate.
On-job vs
workshop
training
Having no specific infant training is a big consraint.

Too many staff spend time on workshops, which diverts valuable staff from the wards.
Leant a small amount during (professional) training, rest of IYCF training was delivered by
international NGO with links to the centre.
Critical thinking
skills, reflective
learning
Staff need to develop more critical thinking/refletive learning skills, often just ignore rather
than work around challenges.
Useful materials
Most useful materials are those which have been locally adapted (e.g. wall posters in local
language).
WHO 1999 manual.
WHO pocketbook of paeds care (has useful pages on breastfeeding).
Agency protocols were useful (section dedicated to infants <6m).
National guideline followed (by international NGO).
NB No interviewee who was not involved in IYCF policy making (i.e. all the field-based
respondents) had seen or was aware of IFE Module 2 probably the most detailed
manual focused on management of infants <6m available to date.
Not useful
materials
Leaflets often just put up on wall may not be used or appreciated if just gave out, plus
would quickly run out.
Information on infant feeding is limited in current guidelines for managing acute
malnutrition.
227
Appendix D.10
Appendix D.10 Details of key informant interviews Ways forward

Subtheme
Identification
More nutrition suveys need to include infants <6m: this would help both trigger and plan
specific responses.
Need better tools for assessing nutritional status (ideally not needing WH, WA) e.g.
MUAC.
Obvious (and therefore advanced) cases of infant <6m SAM do mostly get picked up, but
would be good to have tools to be more proactive and better identify earlier / less severe
cases.
Need clearer anthropometric guidelines (e.g. what to do about the 65cm rule; how to
measure length in infants <6m) and need to eliminate confusion over weight-for-age
growth monitoring and WH feeding programme admission.
Criteria need to be clearer than at present but also flexible enough to allow for clinical
judgement and occasional case-by-case decisions for particular individuals.
Need better guidance on how to identify who is really malnourished and who has some
other underlying condition (e.g. cleft palate).
Need to link more with other community activities, notably growth monitoring, to ensure
timely and appropriate referrals for malnutrition treatment.
Link with post-natal services (e.g. routine six week post-natal check) would allow infants
with problems to be identified earlier than happens now.
Protocols
Need community-based treatment options.

Protocols need to be simple and easy to follow (especially by field-level health workers
who will be delivering the front-line care).
Management protocols, especially for infants who CANNOT be breastfed need to be
better defined.
Needs to be more clarity about which milk product to use (e.g. F75, F100 or F100dilute).
Needs to be more clarity about feed options for those infants for whom breastfeeding is
unavailable.
Need more guidance /evidence on how programmes to support infant feeding might work
in populations who are widely dispersed / living over a large geographical area.
Need to better link with other guideline systems like IMCI otherwise there is guideline
overload, with several guidelines covering similar topics but all saying slightly different
things and thus causing confusion at field level about which options are best for which
patients.
Need a more evidence based approach. There are presently too many misconceptions
e.g. one head of a nutrition department cited as stating that feeding the mother was all
that was necessary to address infant <6m malnutrition.
Needs to be a broader focus with description of wider issues causing infant , 6m SAM
notably HIV
Many SFPs include ration for pregnant and lactating women need to determine if this
works/how well it works.
Should be more emphasis on general IYCF issues, including safe and effective
complementary feeds. By the time they are cured, many infants will be coming up to six
months of age and will need to start CF. It is a lost opportunity if this has not been
discussed during programme admission.
Management of
ward and staff
Strong management and supervision would make big difference often little space to take
initiative, becomes undermining.
Staff would have regular mid-term evaluations there was a risk of being fired if
performance were seriously concerning (well performing NGO unit, where supplementary
suckling went well).
Need to find better ways of motivating staff to perform well (NOT workshops, which
distract and take staff away from busy wards, leaving staff levels even lower than before).
Well motivated
staff
Everybody wanted to work for and was proud of being employed by NGO X things
seemed to change after another agency took over (?less staff; less pay).
Also need enough staff to make the project a success.
228
Appendix D.10
Table contd
Subtheme
Staff (gereral)
Community health workers responsible for indenitifying infants are overworked and
involved in many different projects.
CHW often prioritize work for which they get incentives and are rewarded for.
Supplementary suckling is time intensive and requires staff with special experience.
Greater staff numbers are needed on nutrition programmes if more infants are to be
admitted; would not be able to cope give n current resources.
Need to be more staff whose role is dedicated to infants <6m; present numbers are
inadequate to start adding extra roles.
Task shifting can be considered use of support workers and other non-specialist staff to
take on particular, closely defined roles and free up time for experienced clinical staff to
concentrate on supervision and overall programme leadership.
Community
support
Community treatments (e.g. support groups) need to be more widely available.

Difficult to know what to offer after discharge from ward.
Community support programmes often only focus on HIV infected patients hard to find
an equivalent for HIV negative.
Would be good to develop ambulatory approaches to care (similar to CMAM model).
Need to optimise coverage of infant feeding programmes (likely through community rather
than purely centre-based approaches to care).
Community health workers need clearer guidelines how to promote and support
breastfeeding.
HIV
Need better and earlier identification and treatment of HIV to prevent malnutrition
developing in the first place.
There is a need to clarify AFFAS criteria as lots of confustion at present.
There are few community support groups for HIV negative patients.
Many mothers have misconceptions about HIV, and stop breastfeeding before six months
despite counselling.
Standard counselling tools are needed to help convey correct messages, especially about
the risks/benefit balance of replacement feeding. Maybe this would also facilitate more
mother to mother communication, reinforcing key messages.
Set of SIMPLE
guidelines/
flow charts
Wall chart & simple flow charts helpful big manuals often not used so much for day-day work
Formulas
Would be important to have options for use when neither breastmilk or infant formula
milks available.
Need to ensure guidelines are locally owned and account for local circumstances often
seem imposed from outside without much understanding of setting and knowledge of
effect on other services.
Consider formulas using local foodstuffs, however supply of minerals for fortification would
be impossible. Infant formula itself is much too expensive for most families.
If formula is used, is big challenge to avoid leakage.
Links to other
service
Need to link better with other services, such as maternity despite having maternity
services in same hospital, current relationship is limited
There are too many new, vertical initiatives. Dont always link well and cause fragmented,
extra work. Need to be more integration and coordination of new initiatives such as MAMI.
Need more links to maternal health programmes tackling issues like low-birth-weight in
order to minimize the number of infants becoming malnourished.
Needs to be a continuum of care, joining up existing services.
Rather than separate mother/baby health patient held health records, baby information
should be recorded on the child health card; this would make birth weight and other early
history more easily accessible.
Need links with growth monitoring programmes (anthropometric indicators need to be
harmonized, since growth monitoring uses weight-for-age whereas feeding programmes
use weight-for-height).
Need closer links with health centres and other local care structures.
Overall
Maybe need to distinguish complicated SAM who need hospital care with uncomplicated
who do not.
Overall management and coordination of infant feeding issues need ownership by a lead
individual or agency. Else everybodys good intentions too easily drift into nobodys
responsibility and the job does not get done.
More advocacy is needed for infants <6m. Having major agencies involved would
strengthen calls for increased attention and increased resources.
Need to ensure that programmes have high coverage.
229
Appendix E
Appendix E The Integrated Phase Classification (IPC)

Phase
Classification
Key Reference Outcomes
Strategic Response Framework
Current or imminent outcomes on lives and livelihoods.

Based on convergence of direct and indirect evidence
rather than absolute thresholds. Not all indicators must be
present for classification..
Objectives:
(1) mitigate immediate outcomes,
(2) support livelihoods, and
(3) address underlying causes
1A
Generally
Food
Secure
Crude Mortality Rate

Acute Malnutrition
Stunting
Food Access/Availability
1B
Generally
Food
Secure
Dietary Diversity
< 0.5 / 10,000 / day

<3 % (w/h <-2 z-scores)
<20% (h/age <-2 z-scores)
usually adequate (> 2,100
kcal ppp day), stable
consistent quality and quantity
of diversity
usually adequate (> 15 litres
ppp day), stable
moderate to low probability
and vulnerability
prevailing and structural
peace
Assets generally sustainable
utilization (of 6 capitals)
Strategic assistance to pockets of

food insecure groups.
Investment in food and economic
production systems.
Enable development of livelihood
systems based on principles of
sustainability, justice, and equity.
Prevent emergence of structural
hindrances to food security.
Advocacy.
<0.5 / 10,000 / day; U5MR<1 /

10,000 / day
>3% but <10 % (w/h <-2 zscore), usual range, stable
>20% (h/age <-2 z-scores)
borderline adequate (2,100
kcal ppp day); unstable
chronic dietary diversity deficit
borderline adequate (15 litres
ppp day); unstable
recurrent, with high livelihood
vulnerability
Unstable; disruptive tension
insurance strategies
stressed and unsustainable
utilization (of 6 capitals)
Pronounced underlying
hindrances to food security
Design & implement strategies to

increase stability, resistance and
resilience of livelihood systems, thus
reducing risk.
Provision of safety nets to high risk
groups.
Interventions for optimal and
sustainable use of livelihood assets.
Create contingency plan.
Redress structural hindrances to
food security.
Close monitoring of relevant
outcome and process indicators
Advocacy
0.5-1 / 10,000 / day, U5MR 12 / 10,000 / dy

10-15 % (w/h <-2 z-score), >
than usual, increasing
epidemic; increasing
lack of entitlement; 2,100 kcal
ppp day via asset stripping
acute dietary diversity deficit
7.5-15 litres ppp day,
accessed via asset stripping
emerging; diffuse
limited spread, low intensity
conflict
crisis strategies; CSI > than
reference; increasing
accelerated and critical
depletion or loss of access
Support livelihoods and protect

vulnerable groups.
Strategic and complimentary
interventions to immediately food
access/availability AND support
livelihoods.
Selected provision of complimentary
sectoral support (e.g., water, shelter,
sanitation, health, etc.).
Strategic interventions at community
to national levels to create, stabilize,
rehabilitate, or protect priority
livelihood assets.
Create or implement contingency
plan.
Use crisis as opportunity to redress
underlying structural causes
Advocacy
Water Access/Avail.
Hazards
Civil Security
Livelihood
Moderately/
Borderline
Food
Insecure

Acute Malnutrition
Stunting
Dietary Diversity
Water Access/Avail.
Hazards
Civil Security
Coping
Livelihood Assets
Structural
Acute Food
and
Livelihood
Crisis

Acute Malnutrition
Disease
Dietary Diversity
Water Access/Avail.
Destitution/Displacement
Civil Security
Coping
Livelihood Assets
230
Appendix E
Table contd
Humanitarian
Emergency
Acute Malnutrition
Disease
Dietary Diversity
Water Access/Avail.
Civil Security
Coping
Livelihood Assets
Structural
5
Famine /
Humanitarian
Catastrophe

Acute Malnutrition
Disease
gap; much
Water Access/Avail.
Civil Security
Livelihood Assets
1-2 / 10,000 / day, >2x

reference rate, increasing;
U5MR > 2 / 10,000 / day
>15 % (w/h <-2 z-score), >
than usual, increasing
Pandemic
severe entitlement gap;
unable to meet 2,100 kcal
ppp day
Regularly 3 or fewer main
food groups consumed
< 7.5 litres ppp day (human
usage only)
concentrated; increasing
widespread, high intensity
conflict
distress strategies; CSI
significantly > than reference
near complete & irreversible
depletion or loss of access
Pronounced underlying
Urgent protection of vulnerable

groups
Urgently food access through
complimentary interventions
Selected provision of
complimentary sectoral support
(e.g., water, shelter, sanitation,
health, etc.)
Protection against complete
livelihood asset loss and / or
advocacy for access
Use crisis as opportunity to
redress underlying structural
causes
Advocacy
> 2 / 10,000 / day (example:

6,000 / 1,000,000 / 30 days)
> 30 % (w/h <-2 z-score)
Pandemic
extreme entitlement
below 2,100 kcal ppp day
< 4 litres ppp day (human
usage only)
large scale, concentrated
widespread, high intensity
conflict
effectively complete loss;
collapse
Support livelihoods and protect

vulnerable groups.
Strategic and complimentary
interventions to immediately food
access/availability AND support
livelihoods.
Selected provision of complimentary
sectoral support (e.g., water,
shelter, sanitation, health, etc.).
Strategic interventions at
community to national levels to
create, stabilize, rehabilitate, or
protect priority livelihood assets.
Create or implement contingency
plan.
Use crisis as opportunity to
redress underlying structural
causes
Advocacy
(Source, FAO website)
231
232
Crosssectional
Harpham and al,

2007
Rahman and al,

2003
BakerHenningham and
al, 2003
Surkan and al,

2007
Stewart and al,

2008
Yes but no statistical

analysis at 2 months,
only at 6 months
2 and 18 months
Patel and al,

2003
Rahman and al,

2004
Tomlinson and al,

2005
Yes
Yes
No
No
No
Adewuya and al,

2008
Cohort studies
No
De Miranda and
al, 1996
No
No
Anoop and al,

2004
No (in files but direct

measures taken at first
at 6 months)
Nutrition
measurement when
Cohort child under 6 months
Types of research
Cross-sectional studies
Authors
Weight
Weight
for height for age
x
(common
mental
disorder)
x
(psychiatric
morbidity)
General
distress
Types of maternal psychological troubles
Major
Height
Weight
Prenatal
Postnatal
for age and length depression depression depression
Types of malnutrition
Table 41: Research papers included in literature review on maternal depression
Appendix F
Appendix F Additional tables for Chapter 8
Author(s)
and Date
Underweight :
66%
Cases: history of
WAZ <-2 and
current WAZ<-1,5
Controls: WAZ>-1,
no history of
malnutrition
[NCHS references]
210 : 139
undernourished
children and 71
adequately
nourished
children
Cases :
18,5 (5,0)
Controls :
19,4 (4,8)
Mother's mental
Rahman and Case
health and infant
al, 2003
-control
growth: a case-control
from Rawalpindi,
Pakistan
CaseJamaica
Mothers of
Bakerundernourished
Henningham control
Jamaican children have and al, 2003 [matched]
poorer psychosocial
functioning and this is
associated with
stimulation provided in
the home
SRQ Cut-off: 7/8
Underweight :
23%
Stunting: 16%
CES-D (modified)
SRQ Cut-off: 11/12
Structured Clinical
Interview for DSM-III R
(SCID, patient edition) for
major depressive episode
(current and recalled
early postpartum)
Revised Bathia's Short
battery of performance
test (for adult IQ)
SRQ Cut-off: 7/8
Maternal mental
health measure
50% amongst
the cases: 65,3%
with grade I
malnutrition,
25% with grade
II malnutrition
and 9,7% with
grade III
malnutrition
Underweight :
45%
Stunting: 27%
% of sample
who were
cases
Underweight:
48%
Weight for age
<3rd centile
Controls: weight for
age>10th centile
1570
Harpham
Community Vietnam
and al, 2005 -based
survey
Underweight
Cases:
weight-for-age
50-80% of
expected
controls:
weight-for-age
>80% of expected
Infant Growth
outcome
measures
12 (range Underweight:
cases: WAZ<-2
6-18)
Stunting: cases:
HAZ<-2 1977
NCHS references
12 (range Underweight:
6-18)
cases: WAZ<-2
Stunting: cases:
HAZ<-2 1977
NCHS references
Cases :
10,5 (1,6)
Controls:
10,6 (1,5)
Infant
age in
months
[mean
(SD)]
172 (82 cases Cases : 9,7

and 90 controls) (0,9)
Controls:
9,7 (0,9)
1823
Community India
Harpham
and al, 2005 -based
survey
144
Country Sample Size

setting and
participants
CaseIndia
control
(matched)
Study
design
Pakistan
Maternal mental
health and child
nutritional status in
four developing
countries
Maternal mental
health and child
nutritional status in
four developing
countries
Maternal depression Anoop and

and low maternal
al, 2004
intelligence as risk
factors for malnutrition
in children: a comunity
based case-control
study from south india
ASIA
Survey
Table 46: Cross-sectional studies
3,9 (1,9-7,8)
Underweight: 1,5
(1,2-1,9)
stunting: 1,4 (1,11,7)
Underweight: 1,3
(1,1-1,7)
Stunting: 1,6 (1,31,9)
Current major
depression: 3,2
(1,1 -9,5)
Recalled
postpartum major
depression: 5 (1,024,0)
2,8 (1,2-6,8)
Underweight
1,4 (1,1-1,8)
Stunting: 1,3
(0,9-1,7)
Underweight:
1,1 (0,9-1,4)
Stunting: 1,4
(1,2-1,6)
Current major
depression:
3,1(0,9 -9,7)
Recalled
postpartum
major
depression: 7,4
(1,6-38,5)
Uncorrected
Association
association
corrected for
between infant cofounders
outcome and
maternal
depression
NonCases: 26 (SD 0-91) t-test for

significant
Controls: 16,5 (SD 0- difference
between mean
86)
scores on modified
CES-D P<0,01
Overall: 40% even

with high cut-off
Cases : 57%
Controls: 25%
Overall 21%
Cases: current major

depression: 14
(19,4%) postpartum
depression: 9
(12,5%)
Controls: current
major depression: 5
(6,9%) postpartum
depression: 2 (2,8%)
Overall 30%
Prevalence of
maternal mental
health problems
Appendix F
233
234
Community- Ethiopia
based
survey
Case-control Rural
malawi
Maternal mental Harpham

health and child and al,
nutritional status 2005
in four developing
countries
Maternal common Stewart

mental disorder and al.,
and infant growth 2008
- a cross sectional
study from
Malawi
AFRICA
Surkan and Case-control Brazil

Maternal
al, 2008
Depressive
Symptoms,
parenting SelfEfficacy and Child
Growth
Community- Peru
based
survey
501 infants
and mothers
1722
595 mothers of
children aged
6 to 24 months
randomly
selected from
9 low-income
communities
representing 4
geographic
areas
1949
139
Underweight: cases:
< 75% expected
weight- for-age
[according to the
Gomez criteria]
9,9
months
Lentgh-for-age
Weight for age in Zscore
12 (range Underweight: cases:

WAZ<-2
6-18)
Stunting: cases: HAZ<2
1977 NHCS references
Prevalence of weight
for height too low
(0.9% n = 5) short
stature and underweight defined as less
than -2 standard
deviations of the WHO
reference height -forage and
weight-for-age z
scores respectively
12 (range Underweight: cases:

6-18)
WAZ<-2
Stunting: cases: HAZ<2 1977 NCHS
references
Cases :
10,9 (6,9)
Controls :
8,4 (4,8)
Country Sample Size Infant Infant Growth

setting and
age in outcome measures
participants months
[mean
(SD)]
De Miranda Case-control Brazil

and al.,
1996
Author(s) Study
and Date design
Maternal mental Harpham

health and child and al,
nutritional status 2005
in four developing
countries
Mental health of
the mothers of
malnourished
children
AMERICAS
Survey
CES-D (Center for

Epidemiological
Studies Depression
Scale) score 16
corresponding to
depressive
symptomatology
Parenting self-efficacy
assessed using a 10items scale with a
4-point scale
Overall 33%
56% of
mothers
scored as high
depressive
symptoms
range (16)
49% fell into
low maternal
self efficacy
Overall 30%
CMD measured by SRQ: 29.9%

score >=8 indicates
CMD
Under- SRQ Cut-off: 7/8

weight :
42%
Stunting:
38%
Short
stature:
25% of
the
sample
and 4%
underweight
Prevalence Uncorrected association

of maternal between infant outcome and
maternal depression
mental
health
problems
Length-for-age Z-score when

mothers with CMD : -1.5 SD 1.24
Mothers without CMD: -1.11 SD 1.12
Student's T-test: P=0.001
Mean weight-for-age when
mothers with CMD: -1.77 SD 1.16
Mothers without CMD : -1.59 SD
1.09 (difference not significant)
Underweight: 1,2 (1,0-1,4)

Stunting: 0,9 (0,8-1,2)
Added to the multivariate model:

high maternal depressive
symptomatology related to a nearly
2-times greater odds of short
stature OR= 1.8 95% CI 1.1, 2.9
No relationship between maternal
depression symptoms and
underweight.
Underweight: 1,1 (0,8-1,4)

Stunting: 1,2 (1,0-1,5)
QMPA [Adult Psyhiatric Cases: 63%

2,8 (1,2-6,9)
Morbidity
Controls: 38%
Questionnaire, Brazilian
screening instrument]
Under- SRQ Cut-off: 7/8

weight:
10%
Stunting:
25%
57%
% of
Maternal mental
sample health measure
who
were
cases
Association
confirmed for
the length for
age
Underweight:
1,1 (0,9-1,4)
Stunting: 0,9
(0,7-1,2)
Relationship
between
maternal
depressive
symptoms and
child short
starure persisted
after controling
of sociodemographic
indicators.
Underweight:
0,8 (0,6-1,2)
Stunting: 1,1
(0,9-1,4)
2,6 (CI not

given)
Association
corrected for
cofounders
Appendix F
Table 46 contd
Appendix F
Table 47: Cohort studies

Survey
Impact of postnatal depression on

infant growth in Nigeria
Postnatal depression and infant

growth and development in low
income countries: a cohort study from
Goa, India
Author(s) and Date
Adewuya and al, 2008
Patel and al, 2003
Study design
Longitudinal case-control (matched)
Longitudinal case-control (matched)
Country
Nigeria
India
Country setting
Participants to a previous study on

maternal postnatal depression attending
the infant immunisationclinics in 5 health
centres in Ilesa Township
Infant health clinic, urban/rural population

Participants to a PND research and patients
seen after birth of the child at 6-8 weeks
postpartum
Sample Size and

participants
242 women completed the study: 120

depressed and 122 matched non
depressed postpartum women
171
Timing of
recruitment
Participants to a postnatal depression

survey at 6 weeks post-partum
6-8 weeks post-partum
Infant Growth
outcome
measures
Birht weight recorder ; Weight and Length
Underweight: weight-for-age<5th centile

Stunting: height for age <5th centile
Infant age at
follow(up (in
months)
6 weeks ; 3-6 and 9 months after delivery
Maternal mental
health measure
The non patient version of Structured

Interview for DSM III-R (SCID-NP)
assessed by two psychiatrists
EPDS
Cut-off 11/12
Prevalence of
maternal mental
health problems
14,6% from the total number of women

tested
22% (n=37)
Uncorrected
association
between infant
outcome and
maternal
depression
Poorer growth for infants of depressed

mothers. Difference statistically
significative at 3 and 6 months [OR (CI)]:
6 weeks: Weight 2.60 (0.87-7.62); length
1.55 (0.43-5.65)
3rd month: Weight 3.19 (1.21-8.40);
length 3.28 (1.03-10.47)
6th month : Weight 4.21 (1.36-13.20);
length 3.34, (1.18-9.55)
9th month: Weight 2.84 (0.98-8.24);
length 2.68 (0.82 - 8.80)
Underweight [RR (CI)] : 2,3 (1,1-4,7)

Stunting [RR(CI)]: 2,9 (1,3-6,8)
Association
corrected for
cofounders
Reported adjusted for individual

confounders. All associations remained
significant
235
Appendix F
Table 47 contd
236
Survey
Impact of maternal depression on infant nutritional

status and illness
Post-partum depression
and infant growth in a
south african peri-urban
settlement
Author(s) and Date
Rahman and al, 2004
Tomlinson and al, 2005
Study design
Prospective cohort study (matched)
Longitudinal case-control
(matched)
Country
Prospective cohort study (matched)
South Africa
Country setting
Rural community in Rawalpindi
Peri-urban community-based
Sample Size and

participants
All the women in the area during the third trimester of

their pregnancy during a 4-month period
320 women: 160 depressed prenatally matched with
160 non-depressed women. At 1 year post-partum, 129
depressed women and 136 non depressed women were
still participating to the study.
147 women and complete

measures for 122 infants (At 18 months: 98 women
and 96 infants)
Timing of
recruitment
During the third trimester of pregnancy
2 months postpartum
Infant Growth
outcome
measures
Underweight: WAZ<-2
stunting: HAZ<-2
NCHS references
Weight: mean WAZ (SD)

Height: mean HAZ (SD)
Infant age at
follow(up (in
months)
2,6, and 12
Due to the small number of children stunted and
underweight at 2 months, this timing has not been
considered in the multiple statistical analysis.
2 and 18
Maternal mental
health measure
Schedules for clinical Assessment in Neuropsychiatry

(SCAN) developed by WHO and based on ICD-10 done
in the third semester of pregnancy + 2, 6 and 12 months
postnatally
Structured Clinical Interview

for DSM-IV
Prevalence of
maternal mental
health problems
25% in the total population at the third month of

pregnancy
56% of mothers depressed in the postnatal period were
depressed at all points of assessement in the postnatal
period
34,7% at 2 months postpartum and 12% at 18

months post-partum
Uncorrected
association
between infant
outcome and
maternal
depression
Underweight [RR (CI)] : 6 months: 4,0 (2,1-7,7)

12 months: 2,6 (1,7-4,1)
Stunting [RR(CI]: 6 months: 4,4 (1,7-11,4)
12 months: 2,5 (1,5-4,0)
Weight [mean WAZ (SD)]:

Cases: -0,8 (1,74)
Non-cases: -0,31 (1,13)
P=0,051
Height [mean HAZ (SD)]:
Cases: -0,89 (1,91)
Non-cases: -0,34 (1,28)
P=0,13
Association
corrected for
cofounders
Underweight [OR (CI)] : 6 months: 3,5 (1,5-8,6)

12 months: 3,0 (1,5-6,0)
Stunting [OR(CI]: 6 months: 3,2 (11,1-9,9)
12 months: 2,8 (1,3-6,1)
When chronically depressed mothers (n=72) and
mothers not depressed at any time (n=108):
Underweight [RR (CI)] at 6 months: 5,9 (2,7-12,8)
At 12 months: 3,5 (2,2-5,6)
stunting [RR (CI)] - at 6 months: 5,5 (1,9-16,0)
At 12 months: 3,2 (1,9-5,4)
Weight [mean WAZ (SD)]:

Cases: -0,8 (1,29)
Non-cases: -0,31 (1,13)
P=0,26
Height : non significant

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Management of Acute Malnutrition in

Infants (MAMI) Project

Management of Acute Malnutrition in Infants (MAMI) Project

UCL Centre for International Health & Development, UK

Research Advisory Group (RAG)

Management of Acute Malnutrition in Infants (MAMI) Project

Interagency Steering Group (IASG)

Management of Acute Malnutrition

Background to the MAMI Project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Chapter 2: Setting the scene. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Chapter 3: How big is the problem?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Management of Acute Malnutrition in Infants (MAMI) Project

Review of MAMI guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Review of field treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

Key informant interviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .124

Management of Acute Malnutrition in Infants (MAMI) Project

6.2.4 Data analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .126

Review of breastfeeding assessment tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138

Psychosocial considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .154

MAMI considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177

Management of Acute Malnutrition in Infants (MAMI) Project

9.1 Conceptual model of management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178

Chapter 10: MAMI recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .196

Key resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202

Management of Acute Malnutrition in Infants (MAMI) Project

Management of Acute Malnutrition in Infants (MAMI) Project

Optimal infant and young child feeding practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Interactions between malnutrition and disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Management of Acute Malnutrition in Infants (MAMI) Project

Acronyms and Abbreviations

Acronyms and Abbreviations

Action Contre la Faim (Action Against Hunger/Action Contre la Hambre)

Acceptable, Feasible, Affordable, Sustainable and Safe

Appraisal of Guidelines for Research and Evaluation

Breast feeding (or breast-fed)

Baby Friendly Hospital Initiative

Case Fatality Rate

Community Health Worker

Centre for International Health & Development, UCL, London

Community Management of Acute Malnutrition

Corn Soy Blend

Community-based Therapeutic Care (original term for CMAM)

Demographic and Health Survey

Exclusive breast-feeding (or exclusively breast-fed)

Expressed breast milk

Emergency Nutrition Network

Global Acute Malnutrition

Infant Feeding in Emergencies

Integrated Management of Childhood Illness

Infant(s) aged under 6 months (0 to 5.9 months)

Integrated Food Security Phase Classification

Intrauterine Growth Retardation

Infant and Young Child Feeding

Low Birth Weight

Moderate Acute Malnutrition

Management of Acute Malnutrition in Infants < 6m (in general)

Management of Acute Malnutrition in Infants < 6m Project

Millennium Development Goals

Medecins Sans Frontieres