Multi-pronged approach to the management of moderate acute malnutrition in Guinea

By Dr Jean-Pierre Papart and Dr Abimbola Lagunju

Dr. Jean-Pierre Papart MD, MPH, is Health advisor, Fondation Terre des hommes, Lausanne, Switzerland

Dr Abimbola Lagunju MD, is Regional Health Advisor, Fondation Terre des hommes (West Africa)

The authors acknowledge the support of the team in Guinea, in particular Mamadi Kaba (MD), Mariama Ba, Sonia Panzani (Fondation Terre des hommes), Marie-Jeannne Haubois (former Fondation Terre des hommes).

This article describes the experience of Fondation Terre des hommes in the management of moderate acute malnutrition in supplementary nutrition centres supported by the organisation in Guinea.

 

Fondation Terre des hommes (Fondation Tdh) is a Swiss Child Rights advocacy organisation based in Lausanne, Switzerland and founded in 1960. The Foundation employs the UN Convention on the Rights of the Child as its guiding principle in its two principal domains of action, maternal and child health (MCH) and child protection. Its intervention strategy in these two domains is predicated on empowerment of beneficiaries, system reinforcement and advocacy. Fondation Tdh has nutrition-focused MCH and child protection projects in five countries in the West Africa sub-region - Benin, Burkina Faso, Mauritania, Togo and Senegal

Management of acute malnutrition in Guinea

In Guinea, the management of acute malnutrition is undertaken at three different levels of facility, depending on the severity of the case:

• Therapeutic nutrition centres (CNT) manage phase 1 of complicated severe acute malnutrition (cSAM)
• Outpatient nutrition centres (CNA) treat severe acute malnutrition without complications (sSAM) and also phase II of cSAM
• Supplementary nutrition centres (CNS) manage patients with moderate acute malnutrition (MAM).

This management strategy alongside the model for interventions (see Figure 1) was developed by the Ministry of Public Health (MSPH) and published in The National Guidelines of Management of Acute Malnutrition in May 2008. National guidelines admission criteria at health facility level are shown in Table 1.

Table 1: National guidelines admission criteria and health facility level
	Admission criteria*	Health facility level for care
Moderate Acute Malnutrition	• W/H between 70% and 79.9% of the median • MUAC between 11 and 12 cm (for length > 65 cm) • Absence of oedema	CNS
Severe Acute Malnutrition	• W/H < 70% of the median • MUAC < 11 cm (for length > 65 cm) • Absence of medical complications)	CAN
	• W/H < 70% of the median • MUAC < 11 cm (for length > 65 cm) • Presence of medical complications	CNT

W/H: weight for height *Based on the NCHS references

Fondation Tdh in Guinea

Fondation Tdh has been supporting government health facilities in Conakry, Guinea in the management of MAM since 2005. This decision was informed by the reported increase in the global acute malnutrition (GAM) rates between 1999 and 2003 in the city of Conakry. The 1999 Demographic and Health Survey reported 10.9% GAM prevalence in children aged less than 5 years. The QUIBB (Enquete sur le Questionnaire des Indicateurs de Base du Bien-etre) survey of 2003 showed that global acute malnutrition was 14.4% among the same age group. Conakry had the second highest rate of global acute malnutrition among the eight regions in the country in 2003.

In December 2007, Fondation Tdh supported two communal medical centres (CMCs) (Ratoma and Flamboyant), both located in the Commune of Ratoma and a private medical facility (St. Gabriel Dispensary) in the adjoining commune of Matoto to adopt and put into practice the new national guidelines on the management of acute malnutrition in the treatment of sSAM. This involved use of RUTFs and health facility based management of MAM. In December 2008, two additional health centres (CS) in Ratoma commune (Lambandji and Wanindara) also introduced these activities using the national management guidelines. Fondation Tdh supported these facilities by putting in place a monitoring system to follow up on performance and provide necessary technical advice. This article is based on the monitoring of the performance of these four health facilities between 2008 and 2010. See Figure 2 for map reflecting Conakry communes.

Health facility network in Ratoma Commune

The Commune of Ratoma has 20 quarters (administrative units). The public health system consists of sixteen health facilities: two CMCs and 14 CS. The CMCs, which have the same facilities as district hospitals (surgery, paediatric and internal medicine units, hospitalisation), serve as referral units for the health centres. Of the 16 health facilities in the commune, none has a CNT, five have a CNA and all 16 have a CNS (five facilities have both a CNA and a CNS). All these health facilities have a nutrition unit manned by trained government staff. All identified cSAM cases are referred to the Institute National de Santé de l’Enfant (INSE) for stabilisation. After stabilisation, they are referred back to the health centres for ambulatory management of phase 2. Fondation Tdh presently provides technical support to all the health facilities in Ratoma Commune.

Fondation Tdh support to health facilities

All the activities of the nutrition programme (anthropometric assessment using measurements of weight, mid-upper arm circumference (MUAC)), cooking demonstrations, counselling) are carried out by the government staff of the nutrition units of the health facilities. Fondation Tdh provides technical, material and equipment support to the nutrition units of the health facilities.

The staff of Fondation Tdh comprises two medical doctors and a nutritionist. Technical support includes training and on the job supervision. Fondation Tdh also invests in quarterly nutrition programme supervision of all the health facilities by the higher authorities of the Conakry City Health Directorate. Fondation Tdh staff also assist the health facilities in collating and analysing data generated from their nutrition activities. Through these analyses, weaknesses are jointly identified and decisions are reached on corrections. Further, on the request of the health authorities, Fondation Tdh acts as an active interface between the health authorities and agencies like UNICEF and World Food Programme (WFP) for supplies to the health facilities. This is a temporary arrangement pending the time the authorities study the reporting mechanisms of these agencies and identify a liaison person for this activity.

In addition to the technical support, Fondation Tdh also provides material support to the nutrition units, such as stationery, IEC (information, education, communication) materials, cooking materials, MUAC tapes and weighing scales.

Urban Community Health Workers in Ratoma commune

In six of the 20 quarters of Ratoma, Fondation Tdh in collaboration with the communal health authorities, recruited and trained 32 urban community health workers (UCHW). The UCHWs participate in the community screening of children for acute malnutrition in their neighbourhoods, follow up on defaulting cases and engage in the promotion of healthy nutrition practices through cooking demonstrations, counselling on breastfeeding and hygiene (See Figure 3).

Screening of children for acute malnutrition

Screening of children for acute malnutrition takes place at two levels - in the neighbourhoods (active screening) and at the health facility level (passive screening). See Figure 3.

Active screening

Each of the UCHWs is assigned an area within their neighbourhoods. The UCHWs compile a list of all the children within their area and visit their homes on a monthly basis. In the course of the visits, MUAC of children 6-59 months is measured and recorded. Children with MUAC of <125mm are referred and accompanied by the UCHW to the health facility in their area. The nutritional status of referred children is further assessed (weight and height are measured, MUAC re-measured) by trained government health workers and then children assigned an appropriate treatment regime as directed by the National Guidelines. The National Guidelines stipulate that children with cSAM are immediately referred and accompanied to the INSE. Children with sSAM are put on the ready to use therapeutic food (RUTF) regime (see below). Children with MAM are given rations (when available) and their mothers advised to come for weekly cooking demonstration and training on appointed days.

Passive screening

This is conducted in the health facilities by health workers (nurses and doctors) for all the children (0-5 years) who have come for consultations due to an illness or to well-baby clinics (0-11 months). The weights and heights of all these children are measured and recorded and in the case of children between 6-59 months (or whose lengths are >65 cm), MUAC is also measured. Children between 6-59 months presenting with acute malnutrition are assigned to the appropriate treatment as directed by the National Guidelines.

The total case load of malnutrition for Ratoma Comune and St Gabriel is shown in Table 2.

Table 2: Screening1 of children and cases of malnutrition in Ratoma Commune (+ St. Gabriel)
	Children screened	MAM2 cases	MAM3 cases
2008	87,739	9,316 (10.6%)	1,953 (2.2%)
2009	101,197	9,371 (9.3%)	2,259 (2.2%)
2010	100,047	6,793 (6.8%)	1,393 (1.4%)

 

¹This includes children screened at community level UCHW as well as children identified through passive screening. St. Gabriel does not have a UCHW network for active screening.

²MUAC 110 - 120 mm or 70% - 80% of the median % weightfor- height

³MUAC <110mm or <70% of the median weight-for-height

Management of SAM

The child with sSAM is prescribed Ready to use therapeutic foods (RUTF)¹ and routine drugs like Vitamin A, antibiotics and anti-helminthics. RUTF is given on a weekly basis to the children and at the end of each week, the child presents at the health facility for a check-up until the child attains and maintains the target weight (85% of the median % weight-for-height) at two consecutive weekly checkups (option 1) or option 2 (discharge on reaching 85%) without two consecutive check-ups.

Monitoring reports indicate that St Gabriel Dispensary has had major problems with defaulting in the treatment of sSAM. In 2010, of a total number of 1,133 recorded exits, 35.6% were cases of defaulting. The reason for this is that, unlike the four other CNAs supported by Fondation Tdh, St. Gabriel Dispensary has a reputation for inexpensive and quality medical treatment which extends far beyond Ratoma commune. The dispensary charges a flat rate which includes costs for consultation, laboratory tests and medicines. Many people travel great distances, sometimes up to 200 km, to seek treatment is this dispensary. Normally, parents do not recognise signs of acute malnutrition in their children and come to the healthcare centre expecting treatment for illnesses rather than for malnutrition. The healthcare centre staff identify malnourished cases through routine measurement of the children. When a child is diagnosed as suffering from acute malnutrition and the parents are told that treatment is necessary and that this will involve several weekly check ups (a total of 5 to 10 visits), many of them fail to return to the centre after one or two follow-up visits. This is due to the distance they have to travel each time. These cases present a problem for the Dispensary, because there are no CNAs or CNS in the villages of origin of these children to which they can be referred.

All identified cases of cSAM are referred to INSE. Fondation Tdh supports the patients through the payment of transport costs from the referring health facility to INSE. Further, Fondation Tdh pays the treatment costs of cSAM cases referred from any of its intervention centres. cSAM cases are managed with F75 formula until stabilisation and then referred back to referring centre for Phase 2 management as prescribed by the National Guidelines.

Management of MAM

Breastfed children <6 months, identified by weight for age, suffering from MAM are treated for any underlying illness and their mothers are counselled on appropriate breastfeeding techniques and practices. The children are discharged from the programme when consistent weight gain is established through breastfeeding.

Children between 6-59 months suffering from MAM (identified using W/H) are treated with enriched porridge, prepared twice a week at the health facility and distributed to children. The porridge is constituted to deliver 100kcal/100mls. The children are fed there.

Mothers are advised and shown how to prepare the enriched porridge for their children at home and to give them the porridge twice a day in addition to family foods. Depending on availability (through the World Food Programme supplies), there is a weekly distribution of premixed food (Corn Soy Blend (CSB), sugar, oil, salt).

Anthropometric measurements of these children are taken and recorded weekly and a child is discharged from the programme in accordance with either option 1 or 2 (outlined above under SAM management). Although option 2 is less reliable, most facilities supported by Fondation Tdh adopt this approach.

Programme monitoring

This monitoring report is based on data collected over a period of 36 months (1st January 2008 to 31st December 2010) from CMC Ratoma and CMC Flamboyant. Additional data were collected over a 12- month period (1st January 2010 to 31st December 2010) from two CS in Ratoma Commune - CS Wanindara and CS Lambandji. Data from St Gabriel (Matoto commune) were not available for analysis.

A total of 7,033 cases of malnutrition in children 0-59 months were treated by the four health facilities during the period under review. Of this number, 2,343 (33.3%) presented with SAM, while 4,690 (66.7%) were treated for MAM. Of the total number of children treated for MAM, 162 (3.5%) were <6 months of age, 4,207 (89.7%) were aged 6- 23 months and 321 were aged 24 - 59 months.

Table 3 shows the relevant centre, case numbers and year of data collection for the SAM and MAM cases.

Table 3: Sources, case numbers and year of data for SAM and MAM cases
	2008	2009	2010	Total
CMC Ratoma	1314	1047	851	3212
CS Wanindara	0	0	509	509
CS Lambandji	0	0	302	302
CMC Flamboyant	858	1187	965	3010
TOTAL	2172 (30.9%)	2234 (31.7%)	2627 (37.4%)	7033 (100%)

 

Anthropometric profile and admission criteria of the children (0-59 months) treated for MAM

The criteria for identification of MAM used were weight for age for children <6 months and 70% - 80% of the median W/H index for children aged 6-59 months Of the 4,690 cases identified as MAM at these centres during the reference period, 35 (0.7%) were false positive diagnoses and five (0.1%) were SAM cases that were eventually referred to CNT.

The average weight for height (W/H) percentage of the median (NCHS unisex curve) at admission was 77% for boys and girls combined (p=0.509). Applying the gender specific NCHS W/H references, the average W/H z score on admission was -2.8 for boys and -2.5 for girls (p<0.001). The same differential is found using the 2006 WHO growth standards: W/H z score -3.3 for boys and -2.8 for girls (p<0.001).

The programme criteria are based on NCHS references. For comparative purposes, the 2006 WHO growth standards were used as a test reference for analysis. Of those admitted to the programme, 5.2% were judged not acutely malnourished (W/H z score >-2), half (50.7%) of admissions were moderately acutely malnourished and 44.4% were severely malnourished based on 2006 WHO standards. With the NCHS bi-sex curves, the figures are 12.6%, 70.5% and 16.9% respectively. Thus use of the WHO Growth Standards would greatly increase the numbers of children considered severely malnourished, and reduce the number of those classified as moderately malnourished.

Performance record of MAM case management

In the management of MAM, the national case management guidelines of malnutrition stipulate that children should be discharged on attainment of 85% of the median of the W/H index. However, some mothers abandoned treatment before their children could attain the discharge weight. Table 4 shows the status of children on exit from the MAM management programme that reflects 5.8% of mothers of MAM children defaulted from treatment. The default rate from treatment varied little between Ratoma and Flamboyant (p=0.867). Reasons for default varied from change of location of residence (within the city) by the mother, lack of time, and return to their village of origin. The vast majority (94.1%) attained the anthropometric criterion for recovery. Five cases were referred to CNT for treatment for SAM.

Table 4: Status of MAM children on exit from the programme
YEAR	Status at discharge (according to National Guidelines)			Total
	Recovery	Default	Transfer to CNT
2008	1320 (92.6%)	106 (7.4%)	0	1426
2009	1435 (95.3%)	65 (4.3%)	5 (0.4%)	1505
2010	1660 (94.4%)	99 (5.6%)	0	1759
TOTAL	4415 (94.1%)	270 (5.8%)	5 (0.1%)	4690

 

Time needed to attain target weight

The mean time needed for a child to attain 85% of the median was 3.5 weeks. The length of stay varied from year to year and from health facility to health facility as shown in Table 5.

Table 5: Duration of treatment to attain target weight in MAM children
	CMC Ratoma			CMC Flamboyant			CS Wanindara			CS Lambandji
	Max	Min	Mean	Max	Min	Mean	Max	Min	Mean	Max	Min	Mean
2008	6	1	4.1	7	2	5.1	n/a	n/a	n/a	n/a	n/a	n/a
2009	6	0	3.2	7	1	3.2	n/a	n/a	n/a	n/a	n/a	n/a
2010	9	1	3.7	5	2	3.3	8	2	3.6	6	2	3.2
TOTAL	9	0	3.6	7	1	3.7	8	2	3.6	6	2	3.2

 

The longest period of stay recorded was nine weeks in CMC Ratoma in 2010. This may be partially explained by the fact that some of the children admitted into the programme were borderline cases (MUAC 110mm or slightly above or 70% of the median % weight-for-height or slightly above). Further, some mothers did not regularly attend the twice-weekly cooking demonstration and training. The duration of stay in the programme also depends on the ability of the mother to source and prepare appropriate food for the child at home in the period between the cooking demonstration and food distribution in the health facilities. The lowest duration of stay recorded was 1 week - these were also borderline children with MUAC at 123 mm or above or 79% of the median % weight for height or slightly below.

Average weight gain

The average weight gain for children treated for MAM in CMC Flamboyant was 7.7g/kg/day, whereas in Ratoma, it was 7.6g/kg/day over the three year period. There were fluctuations in this average weight gain depending on the CMC and the year in question. Table 6 shows the average weight gain in the two CMC and the two CS over a period of three years.

Table 6: Average weight gain in two CMCs and two health centres
	2008	2009	2010
CMC Flamboyant	8g/kg/day	9.7g/kg/day	7g/kg/day
CMC Ratoma	10.7g/kg/day	5.7g/kg/day	5.9g/kg/day
CS Wanindara	-	-	6.5g/kg/day
CS Lambandji	-	-	5.8g/kg/day

 

Weight gain and length of stay in the programme

Normally the length of stay should be inversely proportional to weight gain. However, this correlation could not be established in this study because there were external factors beyond the control of the programme managers despite their efforts to contain them. These factors included the regularity of mothers at the twice-weekly cooking demonstration sessions, quality and quantity of food which they gave to their children inbetween the twice-weekly visits to the health facilities and episodes of illness like malaria, diarrhoea or respiratory tract infections. Efforts to contain these external factors included:

• Home visits for defaulting mothers by CHWs
• Support to mothers of children during an episode of illness
• Distribution of premixes (CSB, oil, sugar and salt) to mothers of MAM children after each weekly cooking demonstration in the health facility when available.

The role of mothers in the management of moderate acute malnutrition

The compliance of mothers to advice on the preparation of enriched porridge, feeding practices at home and their attendance record at the twice-weekly food preparation demonstrations played an important role in the favourable exit outcome of moderate acute malnutrition. Despite the challenges of increases in the prices of basic foodstuffs, many mothers were able to mobilise resources to purchase ingredients and prepare enriched porridge for their children irrespective of supplies of premix via the programme.

Conclusions

Government health facilities when given the appropriate technical, material and equipment support can deliver good results in the management of MAM cases. On the job training and supervision, feedback on performance and regular higher level supervision of nutrition activities played an important role in the quality of results posted by the four health facilities that were considered in this study.

To many mothers, MAM is not an illness and compliance with treatment, particularly when it requires weekly presence in a health facility, is a challenge. The multi-pronged approach of community sensitisation, information and education, home visits and facility-based management of MAM children through weekly weighing and cooking demonstration adopted by Fondation Tdh and the authorities of the health facilities of the project, improved the knowledge of mothers about acute malnutrition in general, and MAM in particular.

Cooking demonstrations that included feeding MAM children in health facilities and education and counselling on good household infant and young feeding practices were acceptable services to mothers. Compliance with treatment and the recovery rate was high and the rate of default was low. Lack of knowledge amongst mothers on appropriate feeding practices is likely to have been a significant factor in causing malnutrition in those children admitted to the MAM programme.

The role of UCHWs is pertinent even where there is a wide network of private and public health facilities. Through the active screening of children in their homes in the quarters, many children who otherwise would not have been brought to the health facility because they were not perceived as being ill by their mothers, were identified and sent to the health facility for treatment for MAM.

Finally the management of MAM in an urban setting demands a multi-pronged approach that involves trained health workers, community health workers, information education and counselling of mothers, good supervision and an adequate level of food security.

For more information, contact: Dr. Abimbola Lagunju, email: abimbola.lagunju@tdh.ch and Dr. Jean Pierre Papart, email: jeanpierre.papart@tdh.ch

---

¹The management of sSAM has also been the subject of several monitoring reports, which may be consulted. Contact the authors for details.