Management of At risk Mothers and Infants (MAMI) meeting
A one-day meeting of the Management of At risk Mothers and Infants (MAMI)1 Special Interest Group (SIG) took place in London on 17 January 2018. The meeting was hosted by ENN in collaboration with the London School of Hygiene and Tropical Medicine (LSHTM) and Save the Children and funded by ENN (with Irish Aid funding) and Save the Children.
The aim of the meeting was to identify synergies, opportunities, priorities and next steps to help develop the evidence base on MAMI, building on the 2016 meeting of this interest group (see www.ennonline.net/mamimeetingreport). The meeting was also informed by the proceedings of a one-day shared meeting with the ENN-led Wasting & Stunting Technical Interest Group (WaSt TIG) that took place the day before the MAMI gathering.
The meeting was opened by ENN with a reminder of the call for actions presented at the shared MAMI/WaSt meeting on 16 January:
- Support to develop a global MAMI Network, a coordinated network for capture and learning (research and operational experience); a vision was outlined that requires financing.
- Robust evidence (in the form of randomised controlled trials is now needed to complement the strong operational research that is ongoing.
- The need to scale up. Lessons can be learnt from the CMAM scale-up process; pilots are critical, informed by country agendas.
- A greater MAMI voice (advocacy).
A morning of presentations directly spoke to priority areas worked on since 2016 and informed four afternoon working groups.
Sharing experiences and research
Natasha Lelijveld (ENN consultant/ACF/LSHTM) shared the results of a systematic review by ENN, LSHTM and CHAIN of anthropometric and clinical methods for detecting severe acute malnutrition (SAM) in infants under six months (infants <6m) (see www.ennonline.net/mamicasedetectionreview and www.ennonline.net//fex/55/methodstodetectcases). The authors propose the use of mid-upper arm circumference (MUAC) and weight-for-age z-score (WAZ) alongside simple, clinical indicators and identification of kwashiorkor as the standard indicators for this age group. Infants born small or preterm should have the same anthropometric indicators of admission due to their heightened risk of mortality.
Tim Campion-Smith (ENN consultant, University of Oxford, KEMRI-Wellcome) presented findings from a review of non-feeding interventions (micronutrient supplementation, deworming, antibiotics, maternal supplementation) undertaken by ENN, LSHTM and KEMRI-Wellcome. Scant direct evidence and weak evidence overall meant clear recommendations to inform programmers could not be made. Next steps were identified in a dedicated afternoon working group.
Jay Berkley (KEMRI-Wellcome) presented preliminary findings of a secondary data analysis of a cohort of 1,103 infants from birth to 12 months in Burkina Faso by ENN, LSHTM, KEMRI-Wellcome and others. The analysis aims to identify the anthropometric indicator that best identifies infants at highest risk of death; if MUAC measured at birth can be used as a marker of risk (like low birth weight (LBW)); and if LBW influences the interpretation of anthropometry. Babies were born more wasted than stunted (30% wasted; 10% stunted; 17% underweight). Twenty-one per cent of babies were LBW. MUAC <9 cm measured at birth identifies infants at high risk of death. Measuring MUAC at one month of age and severe underweight (WAZ <-3) shows good predictability for mortality (WAZ <-3). Results are due for publication in mid-2018.
Mary Lung’aho and Louise Day (Save the Children consultants/Nutrition, Policy and Practice) shared preliminary results of an evaluation of the C-MAMI tool (www.ennonline.net/c-mami) in Bangladesh and Ethiopia. Findings will be used to develop an updated version of the tool, available mid-2018.
Katie Beck (Partners in Health) presented the results of a study to examine outcomes of preterm and LBW infants discharged between 2011 and 2013 from neonatal units in Rwanda. One to three years later, of 86 children with median age 22.5 months, 47% had feeding difficulties and 40% reported signs of anaemia; 79% were stunted, 9% wasted and 38% underweight. The Rwanda Ministry of Health has since established paediatric developmental clinics (PDCs) in 2014, with support from Partners in Health and UNICEF, to provide integrated clinical, nutritional, social and developmental services to infants born with perinatal complications. This service provision was updated in 2017 to include more nutrition counselling and interventions and an adapted C-MAMI tool; this work is ongoing.
Nicki Connell (Save the Children) shared experiences from two strands of MAMI work in Bangladesh. First, Save the Children is piloting the C-MAMI tool in Barisal, Bangladesh until November 2018. Intervention and control clusters (two distinct sub-districts in Bangladesh) have been established, using the tool in intervention clusters and existing Ministry of Health protocols in controls. In addition, Save the Children is piloting the C-MAMI tool in the Rohingya response in Bangladesh. Funded by UNICEF and with UNHCR support, a camp-based, broad, multi-sector approach has been established between sectors which includes Food Security, Nutrition (encompassing blanket supplementary feeding programmes, infant and young child feeding, water, sanitation, and hygiene (WASH)) and Health.
Martha Mwangome (KEMRI-Wellcome, Kenya) shared interim findings of a clinical trial to explore the role of breastfeeding support in recovery of malnourished infants <6m . Results so far show that a strategy to use peer supporters to support breastfeeding in an inpatient setting is acceptable and effective to re-establish exclusive breastfeeding. On average, infants receiving breastfeeding support gained weight and MUAC after discharge but this was not sufficient to improve WAZ and weight-for-length z-scores (WLZ); infants discharged after meeting WHO exclusive breastfeeding discharge criteria may have improved growth after discharge.
Collective thinking
The meeting divided into four working groups to examine policy, programming and research informed by the morning’s presentations and to agree on priority next steps for MAMI. Groups reconvened in plenary to share their conclusions, discuss each area and agree on priorities and next steps.
Group one examined what anthropometric indicators should be used in programming and research to identify nutritionally vulnerable infants. MUAC and WAZ were agreed as anthropometric indicators of choice to identify at-risk infants; further analysis is needed to identify MUAC thresholds. There is good potential to build the evidence gap on thresholds and caseload through analysis of existing data sets. Further primary research should test non-anthropometric discharge criteria; in infants <6m, health and feeding criteria are key determinants rather than anthropometric status. Research should include follow up of discharged infants <6m.
Group two examined how to address gaps around MAMI programming faced by implementing agencies in the immediate and longer term. Actions to address immediate gaps include a call for a global UN/cluster joint statement of MAMI and development of an inter-agency forum/mechanism to share learning, experiences and resources. Longer term, buy-in from wider coordination structures to ensure assessment of this age group and inclusion in emergency response and external advocacy, including donors, is needed.
Group three examined key questions, interventions and outcomes to assess MAMI. The key research question to answer is where does a MAMI intervention ‘sit’ (e.g. health, CMAM programme) and how does the delivery platform of a MAMI package vary by context? Research should test a broader package of interventions to examine the effectiveness/added value of each component for specific target groups; test refinements to the C-MAMI tool; test discharge criteria; demonstrate effectiveness and cost-effectiveness; and examine delivery mechanisms and continuum of care. The primary outcome should be growth; mortality would be ideal, but likely not feasible. Research should be conducted in different geographies and contexts, including emergencies.
Group four discussed findings of the non-feeding review in more depth and examined means to achieve consensus on recommendations for programmers. Discussion points included: the importance of context when examining evidence; antibiotics and resistance; community versus inpatient treatment; and questions on case fatality in infants < 6m. The group identified the need for urgent research on prioritised questions and the need for policy (WHO) and political (to influence donors) advocacy on critical gaps that currently ‘paralyse’ programmers. It was agreed that a Delphi consultation process could be used to secure consensus.
Reflections and conclusions
Through plenary discussion, priority next steps were identified: actions the MAMI SIG can undertake; actions that involve collaboration with the WaST TIG; and actions deemed a priority but beyond current capacity of the MAMI SIG to take forward. Specific actions were themed around further examination of existing datasets to provide more evidence; next steps for the C-MAMI tool; advocacy; and opportunities for joint analysis with the WaST TIG.
Plenary voiced that the move to discussion of ‘failure to thrive’ in this age group, rather than ‘acute malnutrition’ is welcome. WHO should take the lead in clarifying language/terminology.
Implementation research needs to be conducted with rigour, be systematic and seek to avoid loss to follow-up. A short window of opportunity exists for MAMI to conduct research within the context of programmes and recruit control populations; an opportunity that must be seized. Care must be taken as there are risks as well as benefits of identifying at-risk infants, depending on what intervention is prompted. An appeal was made from ENN for funders to step up and help move the MAMI collective work to achieve the vision of a MAMI global network.
The meeting was closed by Nicki Connell, who reinforced the value of the MAMI SIG collective as a group that challenges the status quo, brings ideas and is not afraid to discuss and question them.
The full meeting report can be downloaded here.
The meeting report for the MAMI-WaSt meeting can be found here.
Endnotes
1Formerly “management of acute malnutrition in infants under 6 months”, the term “MAMI” has been updated to reflect evolution in thinking and scope of the initiative.