WHO consultation on management of moderate malnutrition in U5s

The WHO, in collaboration with UNICEF, WFP and UNHCR, hosted a second consultation to discuss the programmatic aspects of the management of moderate malnutrition in children under five years of age from 24th to 26th February 2010 (herein called MM2). The purpose of this meeting was to review the evidence on strategies and programmatic approaches to management of moderate wasting not addressed in the first meeting held in 2008 (MM1).

The general objectives of the meeting were:

• To improve overall policy and evidence-based programme guidance on management of moderate malnutrition, with specific emphasis on children with moderate malnutrition.
• To identify knowledge gaps that should be addressed by research, both in the area of dietary management and the modalities for providing that diet.

The specific objectives of the meeting were:

• To determine criteria for admission and discharge from specific programmes for moderately wasted children.
• To estimate the burden of moderate malnutrition (i.e. expected numbers of moderately malnourished children).
• To formulate recommendations on how to improve management of moderate cases of wasting in various settings using, for example, food supplementation and/or dietary counselling. Also to determine when to start and when to stop specific programmes, and how to mainstream programmes in national health systems.
• To formulate recommendations on how to improve monitoring of programmes on management of moderate wasting.

Day 1 and the morning of Day 2 of the meeting were dedicated to presentations and plenary discussion. The afternoon of Day 2 and morning of Day 3 were allocated to working groups in five thematic areas. Each working group was provided with 'consensus' statements largely prepared based on conclusions from presenters. The exception to this was the working group on stunting, as there were no presentations on this issue. Working groups were then tasked with reviewing and revising these draft consensus statements and required to develop key questions for evidence based (systematic) reviews, as well as key areas where there were knowledge gaps that need to be filled by research. Findings were fed back on the afternoon of Day 3. The meeting closed with a brief statement by WHO on next steps.

Below are the conclusions and recommendations of the five working groups (A-E).

Working Group A. Identification, admission and discharge criteria and estimating the burden of moderate acute malnutrition

Consensus statements:

 

1. A Mid Upper arm Circumference (MUAC)-based case-definition: 115 mm ? MUAC < 125 mm without oedema identifies children with low MUAC at elevated risk of mortality. If used, a WHZ¹-based case definition of -3 ? WHZ < -2 without oedema is also possible.
2. Children identified using these case definitions are likely to respond to appropriate treatment.
3. For children > 67 cm and ? 6 months of age, MUAC <125 cm can be used as a stand-alone admission criteria. Discharge can be made at MUAC ? 125 mm for 2 consecutive visits. Children admitted using WHZ should be discharged using percent weight gain (exact level to be confirmed, Prof Mike Golden and Dr Andre Briend in independent approaches both suggest approximately 8-10%).
4. For children < 67 cm and ? 6 months of age, more research is needed to identify the appropriate admission and discharge based on MUAC. In the interim, weight for age z score (WAZ) for admission in place of different MUAC cut-off points (where growth monitoring programmes exist) and percentage weight gain for discharge. The minimum percent weight gain to be achieved for discharge should be used
5. An additional criterion for admission to Supplementary Feeding Programmes (SFP) is discharge from outpatient therapeutic treatment (OTP) of children who had severe acute malnutrition (SAM), according to existing OTP guidelines (with minimum length of stay in SFP of 2 months).
6. Response to treatment should be monitored through weight. A decision tree or algorithm to guide movement through the programme should be developed based on repeated weight measures.
7. The current commonly used methodologies (e.g. SMART surveys) allow for the estimation of the prevalence of moderate acute malnutrition (MAM) but not the incidence. Further research is required better to estimate incidence of MAM in programme settings.

Research questions:

1. How do different anthropometric indicators (HAZ (height for age z score), WHZ, WAZ (weight for age z score), and MUAC) respond to newly developed treatments for MAM in HIV negative and HIV infected children?
2. What is the most appropriate MUAC cut-off for discharge, considering the rate of relapse? Follow-up studies investigating short-term relapse rates should also be undertaken in subsequent pilot programmes that adopt MUAC-based discharge criteria.
3. Among children < 67 cm and above 6 months of age, what are the appropriate admission and discharge criteria?
4. What is an appropriate algorithm for child monitoring within the programme?
5. How can we estimate incidence in programme settings?

Working group B: Strengthening approaches and decisionmaking for management of MAM in various settings

Consensus statements:

1. The specific context that precipitates MAM in children must be considered to determine what approaches and interventions should be instigated. Chronic poverty, child caring practices, disease epidemics and political or natural catastrophe can all result in child hood MAM, but will require different responses. Prevention strategies should always be considered when formulating approaches in childhood MAM. The most common food-based approach, targeted SFPs, may not always be the most effective strategy to combat childhood MAM in a specific context. Use of specialised food-based approaches, blanket rations, general rations, cash transfer programmes, education and promotion of good infant and young child feeding (IYCF) practices, agricultural interventions, and poverty alleviation interventions and social protection should be considered.
2. Targeted SFP performance data from a range of programmes, including coverage data, should be prospectively collected, collated and reviewed over a period of time to increase the knowledge of targeted SFP impact at the individual and population levels. These data should be integrated with national nutrition reporting systems. The Minimum Reporting Package (MRP) developed by the Emergency Nutrition Network (ENN)/Save the Children UK strives to provide a tool and a mechanism to accomplish this.
3. Programmes for the management of MAM should link with programmes providing care services to children, such as Integrated Management of Childhood Illnesses (IMCI), programmes on the promotion of appropriate IYCF practices and more generally programmes aimed at preventing MAM.
4. Evidence is needed to evaluate the effectiveness and costeffectiveness of a range of approaches for prevention and treatment of children with MAM. These may include modified/expanded general rations, targeted supplementary food distribution, blanket distribution of specialised food products to children < 2 or < 5 years of age (either all year round or at critical junctures in the agricultural calendar), cash transfer/voucher programmes, and micro-credit initiatives. Review of evidence should consider distinctions between individual and population level outcomes.
5. Evidence is needed on the role that implementation mechanisms and service delivery settings play in the effectiveness of interventions to manage and prevent MAM.
6. Evidence is needed on the relative cost-effectiveness of various food products for management of MAM.
7. In establishing an evidence base, randomised studies are optimal but are not always possible in many contexts. Non-randomised comparative studies can contribute significantly to the evidence base about the impacts of various food products, interventions, and delivery mechanisms on the management of MAM. Observational studies can also add to the body of knowledge in this area.
8. Based on findings about effectiveness and cost-effectiveness, there is a need for decision-making criteria and frameworks to inform choice of optimal interventions in a variety of contexts.
9. Programmes addressing moderate malnutrition and programs addressing HIV are synergistic but may have distinct objectives, and they should be linked and harmonised.
10. Prevention of mother to child transmission of HIV (PMTCT) and paediatric HIV services should perform nutrition assessment and counselling and should establish linkages to refer children for nutrition support services as needed, especially where nutrition support services are not available as part of the HIV services. Programmes managing acute malnutrition should establish linkages to refer children (and parents) for HIV counselling, testing, treatment and care. Children failing to gain weight or MUAC in programmes managing MAM in geographic areas of high HIV prevalence should be tested for HIV and provided with treatment and care as needed.

Question for evidenced-based review:

What is the evidence base to recommend the use of targeted SFPs, modified/expanded general rations, cash transfer/voucher programmes, microcredit initiatives, and/or blanket distribution of specialized foods for children < 2/5 years of age in MAM? Within each type of approach, what is the evidence-base to recommend the use of a specific food formulation?

Knowledge gaps and research needs:

Treatment

1. Define response to treatment of children admitted on MUAC and clarify discharge percent weight gain.
2. Document duration of treatment and duration of MAM episode from various contexts.
3. Clarify spontaneous recovery of MAM cases from Michel Garenne dataset².
4. Continue defining nutritional requirements of MAM cases.
5. Define appetite test for MAM cases.
6. Define nutritional, microbiological, chemical etc. specifications for foods aimed at treating MAM.

Programme

7. Measure effectiveness (outcomes, impact, coverage, etc.) and efficacy (physiological, clinical, etc.) of new products filling MAM specifications in various contexts.
8. Measure effectiveness of 'non food' approaches in preventing and treating MAM in contexts where MAM determinants are not food related.
9. What is the most effective way to target cash transfer programmes in order to have an impact on MAM? Cash transfer programmes may be a part of poverty reduction, social protection programmes or emergency responses.
10. What specific types of cash transfer programmes contribute to food and nutritional status in children under 5 years?
11. What is the most effective approach to monitor the impact of cash impact on the nutritional status of children under 5 years?

HIV

12. Do HIV-infected MAM children need a different food to recover from MAM compared with HIV-negative MAM children?
13. Do HIV-infected mothers need a different food to recover from MAM compared with HIV-negative mothers?
14. What would be the ideal timing to start anti-retroviral treatment (ARVs) in HIV-infected children with MAM (and SAM) in the absence of other signs requiring ARV treatment?
15. Could the identification and treatment of diarrhoea pathogens on admission improve treatment of MAM in HIV-infected children (faster recovery, higher weight gain, etc.)?

Working Group C: Considerations to address in MAM in infants <6 months

Consensus statements:

1. Prevention of malnutrition in infants <6 months is intimately linked to infant feeding management. Exclusive breastfeeding is the norm for infants <6 months. Informed interventions at population and individual level should be taken to restore and protect this norm. Infants with no access to breastmilk are especially vulnerable and need early identification and appropriate support.
2. The survival and well being of the infant <6 months is intimately linked to the nutritional, medical and psychosocial well being of the mother. Any intervention that targets infants<6 months needs to consider and intervene to support the mother and the child as one unit providing support to both.
3. It is recommended that 'children under 5 years' should be used to refer to the full age range 0-59 m. The age range 6-59m (or 6m - <5 years) should be used when infants<6 months are not in consideration.
4. There is an urgent need for a multi-disciplinary initiative to formulate strategy to address the management of acute malnutrition in infants < 6 months as part of MAM and identify common ground, gaps and way forward. This should include, for example, the Baby Friendly Initiative (BFI), IMCI, growth groups, UNICEF community based support and Essential Nutrition Actions.
5. A key gap area is how to define and identify moderate acute malnutrition in infants <6 months, and how this should inform treatment.
6. Further investigation on the MAM burden of infants <6 months by country is needed urgently, that includes longitudinal data and investigation of underlying causes in different contexts.
7. More detailed investigation of the underlying factors (such as feeding practices, clinical conditions, psychosocial, contextual) of malnutrition in infants <6 months is needed to inform the management of acute malnutrition in this age group.
8. More research is urgently needed to help in identifying infants <6 months at high risk of mortality. For example, early studies indicate that MUAC may aid in this regard for infants between 2 and <6 months old.
9. Any statements on MAM should explicitly refer to infants<6 months in terms of guidance and/or key considerations and gaps in knowledge base.
10. Potentially better practices/complementary initiatives to improve management of MAM in infants <6 months that should be coupled with operational research are:

• Any admissions of infants<6 months to MAM programmes should be documented.
• Admission and discharge indicators for infants < 6 months should include breastfeeding status on admission and on discharge.
• A single measurement of weight should not be used to classify an infant as malnourished; assessment should always be accompanied with clinical and feeding assessment and ideally with serial weight measurement.
• MAM infants <6 months and infants < 6 months of mothers admitted to programmes should be enrolled in growth monitoring (weight gain).
• The IYCF guidance in CMAM training³ should be used to strengthen the IYCF component of community services, including SFPs.
• IFE Module 2⁴ should be used to strengthen individual level assessment and support at facility and of community support/ referral services, e.g. stabilisation centres, breastfeeding 'corner's/tents.
  • Where infants are < 45cm (the bottom limit for WHO-GS weight-for-length charts) then clinical assessment, level of development and feeding status should be used to decide on admission and treatment.
  • It is essential to identify and build the capacity and enable linkages of key people at community level who can support mothers, such as traditional birth attendants or peer counsellors.
  • Where appropriate, infants <6 months should be included in nutrition surveys to determine programme coverage and burden of disease. This has implications for equipment and training needs, and capacity to manage cases identified.
  • Integrated support for optimal IYCF in acute malnutrition treatment for all children <2 years is needed, in both community and facility based care. This will strengthen staff capacity to manage infants <6m as well as benefit older children.
  • For infants < 6 months with access to breastmilk, case management should aim to restore exclusive breastfeeding. Breastfeeding statuses on admission and on discharge are essential outcome measures.

Questions for evidence-based review:

1. Do anthropometric criteria for MAM in children >6 months apply equally to infants < 6 months?
2. How should infants <67cm but >6 months be managed?

Knowledge gaps and research needs:

1. For infants with no access to breastmilk, the feeding option that poses the least risk in a given individual context must be established. Research is needed to investigate how to achieve this in programmes in resource limited settings.
2. There is no evidence on the safety, effectiveness and tolerance of ready to use foods (RUF) in MAM infants< 6 months. Review of current experiences is needed urgently.
3. The impact of support to IYCF in CMAM.
4. There are different possibilities to adapt current training content such as on the use of growth standards coupled with breast-feeding counselling, IYCF counselling, community care of the newborn, IYCF in CMAM, at field level and in different contexts.
5. Breastfeeding assessment tools (see MAMI Project Report⁵) in field setting for individual level assessment ('appetite test').
6. How to manage infants >6 months that are <67cm - should they be treated as older or younger infants?
7. Field tests of WHO growth velocity tables in the context of infants <6 months that are moderately malnourished, to investigate expected weight gain by age in treatment.
8. Studies are needed to explore which psychosocial support activities for different settings are most effective.
9. Interpretation of 2006 WHO Growth Standards growth charts by health workers.

Working Group D: Improving monitoring and evaluation of programmes

Consensus statements:

Background

1. Nutrition programmes aim to reduce the prevalence of malnutrition at the population level and to maximize benefits to the individual child. This can only be achieved by high-quality programmes with good coverage. Monitoring and evaluation is essential and should evaluate both quality and coverage of programmes.
2. Active screening for moderate wasting in children is a crucial aspect of quality programmes.
3. Coverage should be assessed by community-based surveys including nutritional assessments.
4. Programmes that offer good quality services at scale have well trained staff in sufficient numbers at all levels (including planning and implementation) who are adequately supervised and retrained. This includes checking the quality of anthropometric measures (including regular calibration of instruments), counselling, as well as adequacy and amount of food or non-food interventions provided. Supervisors should analyse programme data and use it proactively to make good decisions.
5. The same principles of quality services apply also to projections, procurement, and supply chain management.
6. Breastfeeding support and dietary counselling that are nutritionally sound are an integral part of successful nutrition programmes. The adequacy of dietary counselling should be checked against the adequacy of the diet through the use of food composition tables.
7. If food supplements are used, these should provide nutrients that are missing in the diet and have prior demonstrated effect on nutritional recovery.
8. If non-food based approaches are used, the impact on nutritional recovery must be ensured.
9. These objectives can be achieved through either individual or population-based nutritional interventions.

Monitoring and Evaluation:

10. The objective of monitoring and evaluation is to improve programmes and to inform decision makers to adapt policies and ultimately to maximise the programme's benefits to the child.
11. Clearly defined indicators are important for both facility-and population-based monitoring.
12. Facility-based monitoring indicators: The number of children in different exit categories should be monitored using the following categories: cured, died, defaulter, transferred, relapsed, and noncured. Clear definition and implementation of admission and discharge criteria are important. Mistakes related to admission and discharge need special attention. Average weight gain, possibly MUAC gain, and median length of stay in the programme are the core indicators of response to treatment. The expected average weight gain will be context specific, i.e. it is related to the mean WHZ of the population. Another important indicator is the proportion of children who fail to respond within one month (at most) and who are referred for medical evaluation in a timely manner. The change in HAZ is an optional indicator for routine programme contexts. These performance indicators should be interpreted by taking into account the prevalence of HIV and tuberculosis infection, especially with regard to relapse and nonresponders.
13. Population based monitoring indicators: Such programmes should consider the percentage of children who were screened for wasting. In addition, these programmes need to monitor the coverage of the programme, i.e. the proportion of malnourished children who receive treatment.
14. Combined facility based and population-based monitoring indicators: A combined indicator of facility-and population-based-performance is the change in prevalence of malnutrition. This should be assessed by surveys conducted during the mid-point or latter half of the lean season. Other indicators, such as those related to procurement and supply management, also apply to both levels.

Knowledge gaps and research needs:

 

1. Develop community-based survey techniques to measure programme coverage with regard to coverage of screening as well as treatment.
2. Examine new and feasible reporting tools (e.g. Rapid SMS) to strengthen monitoring and evaluation in a timely manner.
3. Assess the usefulness of MUAC as an indicator for treatment response in settings with different levels of wasting.
4. Develop tools that can improve reliability of anthropometric measures (e.g. better scales, length/height boards, more appropriate MUAC tapes)
5. Develop and pilot the use of linear programming in the formulation of dietary recommendations for moderately wasted children.

Working group E. Stunting

Consensus statements:

1. Stunting in young children is an outcome of a complex set of circumstances and determinants, including ante-natal, intrauterine and post-natal nutritional deficits. Significant reductions in stunting can be achieved through a comprehensive set of interventions that effectively link management and prevention, and address underlying determinants. These not only prevent stunting but lead to improvement in human potential (improved motor and cognitive development, reduced risk of non-communicable diseases, and improved educational attainment, productivity and income).
2. A window of opportunity exists during the prenatal period and the first two years of life to prevent stunting and achieve optimal development. A large percentage of stunting appears to be due to poor maternal nutrition resulting in low birth weight (LBW) newborns, as well as normal birth weight infants that are at greater risk for stunting. Women's and adolescent nutrition has been neglected in recent years. Women's and adolescent girls' nutrition should be revisited in order to break the inter-generational cycle of growth retardation and its consequences.
3. Stunting is a proxy indicator for longer term nutritional deprivation that results not only in linear growth retardation but also gives rise to a series of functional deficits, including loss of psychomotor and cognitive skills with lifelong functional consequences.
4. Stunting should be defined not only in terms of height-for-age but it should encompass aspects such as growth velocity and incremental growth in length or height.
5. To prevent and manage stunting effectively a broad integrated package of strategies and interventions is required. Three critical dimensions include social and behavioural change, food-based approaches (including fortified products) and care for infectious diseases and malnutrition.
6. There is evidence that specific foods, including breastmilk, and nutrients will promote linear growth. The inclusion of animal source foods in children's diets is particularly appropriate because these foods contain significant amounts of micronutrients, especially zinc, iron, fat, vitamin B 12, riboflavin and vitamin A. There is some evidence that milk promotes linear growth.
7. Population-based approaches are needed in combination with individual targeting to prevent and manage deficits in linear growth, however, this is context specific. Regular nutritional surveillance is needed to detect a potential problem of growth faltering and monitor change. This could be used in combination with active case detection and referral.
8. An agreed upon set of effective strategies and interventions exists. However, access to these delivery platforms (health infrastructure, supply chains, health worker capacity) is weak in many settings, especially where the problem of stunting is greatest. Delivering effective behaviour change interventions is more complex than delivering vitamin A capsules and well trained staff in adequate numbers are required.

Research questions based on knowledge gaps:

1. What proportion of stunting will be prevented through management of SAM and MAM?
2. What key nutrition and medical interventions for pregnant women will prevent intrauterine growth retardation and prenatal programming for stunting? What is the timing of these interventions during pregnancy that will result in the most cost-effective impact?
3. While a set of interventions to prevent stunting is available, there is currently little knowledge about the best set of options in different settings. Also the most cost-effective timing of interventions for maximum impact needs to be researched. The development and refining of evidence-based decision making tools for programme managers is recommended to guide the type and timing of interventions in different contexts.
4. What is the specific profile of macro and micronutrients (and specific foods, e.g. milk) needed to improve and maintain adequate linear growth? The development of a strategic short-term operational research agenda is recommended and the identification of ongoing research and gaps.
5. What are appropriate indicators and assessment tools to identify children at risk of linear growth retardation? What is currently done, what are the gaps and what complementary measures are needed? A background study/literature review is recommended as well as the identification of gaps, convening of a technical advisory group (TAG) and identification of gaps for operations research.
6. Currently there is little guidance for field programme personnel to formulate and recommend the best possible diets based on locally available foods and determine the nutrient gaps that may need to be addressed through fortified food products (including micronutrient powders). The development of an easy to use linear programming tool is recommended to enable field-based nutrition staff and programme managers to formulate good diets and identify the determinants where the limitations/gaps are.
7. Intrauterine growth retardation is likely to be (at least partly) reversible through appropriate care and nutrition. Information is needed on the best maternal interventions and their timing during pregnancy. A back-ground study/literature review is recommended as well as the identification of gaps, convening of TAG and identification of gaps for operations research.
8. Information on the most cost-effective (and DALYs⁶) set of interventions and their timing during the first 24 months can prevent and manage stunting. Also, what are the options after 24 months? Under what conditions can catch-up growth occur?
9. How to strengthen delivery platforms for effective interventions to prevent stunting. Lessons learning from other countries successful in reducing stunting is recommended (e.g. Thailand, Vietnam, Brazil) and investment in delivery science operational research (quality assurance, quality improvement).

Progress 2010 to 2011

Following the 2010 consultation, work has been implemented on guideline development and research.

Guideline development

Based on the discussions and consensus statements from MM1 and MM2, the following areas were identified for guideline development:

1. Detection of children with acute malnutrition
   1. Coverage of screening for acute malnutrition.
   2. Efficacy of screening
2. Health system in the prevention and management of undernutrition
3. Effectiveness and safety of a food supplement formulated along the proposed technical specifications for children with MAM
4. Population vs. individual targeting of nutritional programmes for children with MAM
5. Discharge from programmes
6. Essential nutrition actions for children with MAM
7. Cash transfer or other non-food based interventions for children with MAM

These questions were further discussed and reviewed by the WHO Steering Committee for Nutrition Guidelines Development and formatted into the Population, Interventions, Control and Outcome (PICO) framework. The questions and PICO tables were sent to key external experts and stakeholders for comments through the WHO Micronutrients Mailing List, the Standing Committee of Nutrition (SCN) mailing list and also shared with the IASC Nutrition Cluster. Additionally, an open 'Call for Public Comments' was posted on the WHO website. Feedback was reviewed and the questions were modified accordingly.

The WHO Nutrition Guidance Expert Advisory Group (NUGAG) was entrusted to develop the recommendations. The NUGAG Sub- Group on Nutrition in the Life Course and Undernutrition met in Geneva from 2 to 4 June 2010. Following the ranking of outcomes and critical questions to be addressed in the guideline development, the Nutrition in the Life Course Unit started working with the Institute for Child Health IRCCS Burlo Garofolo, Unit of Research on Health Services and International Health, Trieste, Italy, to map the existing reviews and to carry out systematic reviews on the questions.

NUGAG met in March 2011 to review the evidence and made recommendations on updating guidelines on SAM and on developing guidelines on the programmatic aspects of the management of MAM. These recommendations will be finalised in the next NUGAG meeting in November 2011 and examined by the WHO Guideline Review Committee for final approval.

Principles and recommendations on the specifications for food supplements used in the dietary management of MAM have been developed and are being published.

Coordinated research

The MM1 and MM2 meetings also concluded that knowledge gaps need to be identified and that coordinated research to address them should be promoted. This would involve harmonising research protocols, documenting and making available all relevant information in a single knowledge management system, promoting and moderating discussions and regularly updating relevant information.

Supported by WHO and partners, the UN Standing Committee on Nutrition (UNSCN) has established an e-based web portal to attempt to fulfil this function. The objective of the SCN portal on research as a follow up of MM1 and MM2 is to share information and to provide a discussion forum on protocols for operational research with the aim of harmonising research and reducing duplication of efforts. Information from the discussions and posted research studies can feed into the process of the development of recommendations by WHO and its partners.

The expected outputs are improved research methodology and its adaptation according to different outcomes and settings, a repository which contains all relevant documents and information on previous and ongoing research studies, and a list of terms to define and unify their use (definitions, specifications of different products etc).

Visit the UNSCN portal at:
http://www.unscn.org/en/nut-working/ moderate_malnutrition/mam.php.

The report of the MM2 consultation can be accessed here.

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¹Weight for height z score

²Michel Garenne (Institut Pasteur & IRD, Paris) presented data on the estimation of duration of episodes of moderate acute malnutrition using multi-state life tables, which allow the conversion of population based data into cohort estimates based only on transition rates.

³Integration of IYCF support into CMAM. October 2009. Nutrition, Policy, Practice, ENN, IFE Core Group, Global Nutrition Cluster. http://www.ennonline.net/resources/722

⁴Module 2 Infant feeding in emergencies. For health and nutrition workers in emergency situations, Version 1.1, December 2007. http://www.ennonline.net/resources/4

⁵Chapter 7. Breastfeeding assessment tools. MAMI Project. Technical Review: Current evidence, policies, practices & programme outcomes. Jan 2010. http://www.ennonline.net/resources/741

⁶Disability adjusted life years