Making connections: Joint meeting of WaSt Technical Interest Group and MAMI Special Interest Group

Box 1: The WaSt story so far

Tanya Khara (ENN) shared the evolution of the WaST Group, which stemmed from a review of financing arrangements around Community-Based Management of Acute Malnutrition (CMAM) by ENN and has since developed through several phases of work. Phase 1 (2014 to 2016) centred on a review of the evidence of the links between wasting and stunting and a WaSt research prioritisation that subsequently informed phase 2 (2016 to 2017). Phase 2 included Global Nutrition Report panel analysis (2016), several published papers, and a briefing note. An 84-country meta-analysis of prevalence and burden of children aged 6 to 59 months concurrently wasted and stunted found concurrence is prevalent, especially in boys, and concluded that these children are at particularly high risk of death; concurrence should be reported routinely and there is a need to investigate whether these children are being reached. Influence of this work was reflected in the WHO/UNICEF 2016 Joint Estimates report recognising the issue for the first time and noting that a global estimate for the level of concurrence is not known.

A working group of the WaSt TIG was subsequently formed to examine two core questions: what is the risk associated with being concurrently wasted and stunted and how best to detect these children. Two datasets were examined, one consisting of 2,426 (SMART) surveys of almost 1.8 million children from 51 countries and a second from Niakhar, Senegal (McDonald et al). André Briend (University of Tampere) shared key findings from these analyses. This showed that all children who are wasted and stunted are also underweight; ‘multiple anthropometric deficit’ (wasting+stunting+underweight) is not an independent category and this term should be abandoned; when a child experiences both wasting and stunting concurrently there is a strong multiplicative effect on mortality risk; both weight-for-age z-score (WAZ) and mid-upper arm circumference (MUAC) detect WaSt; MUAC and WAZ are both independently associated with risk of death (but not WHZ, HAZ or WaSt); and WAZ <-2.8 detects a group of high-risk children not detected by MUAC. These results suggest that WAZ could be considered as an additional criterion for identifying high-risk children not identified by MUAC for admission into CMAM programmes. Most immediately, testing of these findings on other datasets and further modelling of caseload and programmatic implications are needed.

Pending research questions include: what is the optimal WAZ cut-off avoiding overloading programmes but detecting high-risk children missed by MUAC<115 mm; how to adjust WAZ in programmes using a higher MUAC cut-off; and whether the same findings are repeated when other mortality cohorts are analysed.

Also under the auspices of the WaSt TIG, Sophie Moore (Kings College, London) shared the results of a retrospective cohort analysis of longitudinal data in Gambian children from 1976-2016. This showed that wasting and stunting are closely linked (being wasted increases the likelihood of being stunted); increased susceptibility to wasting continues in a child even after they have recovered from a prior episode (indicating profound metabolic disturbances and/or environmental factors at play); the season in which a child is born strongly predicts their subsequent linear growth and weight gain; and boys are more wasted, stunted and concurrently wasted and stunted than girls.

Box 2: The MAMI story so far

Marie McGrath (ENN) and Marko Kerac (London School of Hygiene and Tropical Medicine (LSHTM)) shared that infants <6m old are now on the international policy agenda, a consequence of MAMI SIG influence. However, country-level policy and programmes are lacking, fuelled by weak evidence. Key issues that still need to be addressed include: how to achieve optimal growth among nutritionally vulnerable infants; how to deal with complex underlying diagnosis through feasible programming; and what does the ‘MAMI’ package of care look like (breastfeeding support is necessary but not sufficient). A reframing of thinking should consider prevention and treatment as one (infant and young child feeding (IYCF) = primary prevention; MAMI = secondary prevention; inpatient care = tertiary prevention); building bridges between MAMI and IYCF approaches; and embedding interventions in wider health programmes, such as integrated management of neonatal and child illness (MNCI). To achieve this, we urgently need strong evidence in the form of phase 3 RCTs and a robust, coordinated network of learning and exchange. The potential around MAMI is huge, but the needs are outstripping current group capacity. Scale up to a Global MAMI Network is needed to galvanise and support collective, collaborative, harmonised efforts on research and policy informed by, and to inform, practice.

An overview of recent key MAMI research and reviews was presented by Martha Mwangome and Jay Berkley (KEMRI-Wellcome, Kenya). How to define SAM in infants < 6m, the top question identified in a 2015 CHNRI MAMI research prioritisation exercise, has been a key focal area for the group. An ENN/LHSTM/ CHAIN review in 2017 identified MUAC and WAZ as the best anthropometric indices to identify at-risk infants <6m. Analysis of data from Keneba, Gambia, found WLZ was a poor predictor of mortality in this age group, while MUAC performed better. Another community cohort study of 2,882 infants admitted in Kilifi hospital, Kenya, with remote follow-up at three month visits of 1,455 discharged infants, showed that WAZ performed slightly better than MUAC at predicting inpatient mortality.

Cohort data (birth to one year of age, anthropometry and mortality data) from Burkina Faso is currently under analysis by the original researcher/ENN/LSHTM/KEMRI-Wellcome to investigate mortality outcomes in infants up to six months of age. This dataset includes anthropometry and mortality data and distinguishes low birth weight (LBW) infants, among whom mortality is significantly higher. Provisional analysis indicates that both MUAC and WAZ screening at vaccination time (two months of age) could pick up a particularly at-risk group.  

An ongoing study by KEMRI/Welcome is exploring the role of breastfeeding in support and recovery of malnourished infants < 6m (Improving Breastfeeding support to treat Acute Malnutrition amongst Infants under 6 months (IBAMI). It aims to apply WHO treatment guidelines rigorously and evaluate impact on breastfeeding, growth, morbidity and mortality after discharge. Analysis of data to date found that infants discharged on the WHO breastfeeding discharge criteria had subsequent higher average MUAC, WLZ and WAZ than those who did not meet the criteria (though not statistically significant). A small study of the supplemental suckling technique in Malawi found perinatal depression was notable among mothers experiencing breastfeeding, which influenced breastfeeding effectiveness and early cessation.

Outstanding questions include: whether to use MUAC or LBW criteria to define risk at birth; the feasibility of introducing screening at every infant contact and how to link to growth monitoring; what package of support is needed for infants after discharge from severe acute malnutrition (SAM) treatment; how to manage infants without possibility to breastfeed; and gaps in guidance regarding non-feeding interventions (e.g. antibiotics, micronutrient supplementation).