Editorial
We are delighted to mark our 60th edition of Field Exchange with an issue dedicated to the continuum of care for children with acute malnutrition. The process of developing this edition has given us valuable insights into many dimensions of continuum of care, ranging from programme design to institutional politics and policies. We truly appreciate the open, candid contributions and time given by so many to this initiative. We believe that this reflects the continued commitment of the nutrition community to share and learn from each other and that this issue is relevant and topical. As with all special issues of Field Exchange, we have written an extended editorial to reflect our learning in pulling together this special issue. Below is a short summary of the content that we feature.
As ever, we have rich mix of contributions, reflecting different contexts and aspects of continuity of care. These range from the use of expanded protocols in highly vulnerable and insecure areas in Northeast Nigeria, South Sudan and Somalia, integrating moderate acute malnutrition (MAM) treatment within ‘preventive’ blanket supplementary feeding programmes in Cameroon, to UNHCR experiences of facilitating continuity of care in East Africa. Experiences of Positive Deviance (PD) Hearth programming implemented by World Vision in several countries and a supplementary feeding programme (SFP) that integrates severe acute malnutrition (SAM) cases in Zambia add an interesting dimension to continuity in the context of broader child nutrition and longer-term community programmes.
One of the factors that prompted this special edition was the emergence of research exploring simplified/expanded/combined approaches to treat acute malnutrition. Headline findings, implementation experiences and research plans constitute much of the research section, including the COMPAS trial led by the International Rescue Committee in Kenya and South Sudan, the MANGO study by Action Against Hunger, and a considerable research portfolio by ALIMA in the Sahel region. Regional perspectives on simplified approaches in West and Central Africa are shared in an article by UNICEF regional team. Given this is such a dynamic area, No Wasted Lives has launched a Community of Practice on the State of Acute Malnutrition platform to share information about research and implementation of simplified approaches. It is coordinated with a newly launched thematic area on en-net to support the initiative. One challenge we faced in developing this edition was that much emerging research is pending peer review publication, limiting the results we could share. As research is published we will rapidly summarise and share findings through FEX online with links posted on Facebook and Twitter and the ‘newsroom’ section of our website.
Several articles from India provide valuable and additional dimensions to continuity of care. The UNICEF South Asia team raises important questions regarding wasting profile, patterns and associated mortality in India, and discuss the enormous potential for acute malnutrition treatment in the country, leveraging and integrated within existing platforms and services as part of an approach to continuity of care that starts pre-pregnancy. Two articles, also from India, examine and share experiences around information continuity between service providers and users, reflecting how fundamental communication and engagement with caregivers is to enabling continuity of care for their children.
Another important dimension of continuum of care is how wasting treatment and stunting prevention programmes are linked. An article by World Food Programme (WFP) describes how a programme designed to prevent stunting reduced incidence and caseload of wasting (results published soon). Research by ALIMA in Burkina Faso, also due for publication soon, found a high prevalence of stunted children among wasted children admitted under mid-upper arm circumference (MUAC) criteria. While it is no surprise that MUAC selects wasted children, the question remains whether treatment as currently offered is adequate for these particularly high-risk children who are both wasted and stunted.
Over the years we have featured many experiences and much research on SAM treatment, with far less content on moderate acute malnutrition (MAM). This edition has sought to redress this balance. An insightful article by a Médecins Sans Frontières (MSF) practitioner describes experiences and concerns regarding high-risk MAM children who are neglected in guidance and programming. A four-country evaluation by WFP assesses the relationship between treatment and prevention in emergency and post-emergency contexts, while a WFP-led systematic review on treatment of MAM using nutrition counselling or food products highlights the significant gap in comparable evidence. Longstanding reports of disconnects between SAM and MAM treatment services prompted ENN to conduct a basic mapping of UN-supported services in East and West Africa using existing data; a summary of findings is included in this edition.
Anthropometric indicators are useful but have their limitations in identifying children at nutritional risk and in measuring recovery. Several articles explore additional avenues to help address this. Body composition of acutely malnourished hospitalised children through recovery has been examined as part of the Childhood Acute Illness & Nutrition (CHAIN) Network cohort study in Malawi and Uganda (results published soon). Utilisation of a combination of risk predictors to inform care pathways and intensity of treatment is being explored by researchers in Sierra Leone, while MUAC threshold combined with other predictors of risk is explored in an analysis prompted by questions on en-net. The Bill and Melinda Gates Foundation’s Knowledge Integration (KI) initiative will shortly publish a series of papers on analysis of longitudinal wasting and stunting patterns in the first two years of life that will provide valuable insights into patterns around wasting and stunting from birth and including mortality risk.
Much of our content fits within the SAM and MAM programming paradigm. We recognise that thinking is evolving around malnutrition and risk, and official categorisation based on MAM and SAM divisions may well change; programmers are already making changes through use of combined protocols, for example. Our extended editorial examines this area in more detail.
The experiences and research that we share in this edition are largely from Africa, yet South Asia has the highest prevalence and number of children affected by wasting in the world. Characteristics of wasting in Asia, programme approaches and challenges faced in scale-up of prevention and treatment are not the same in this region. Recognising this, we are delighted to announce that ENN is planning to produce a special edition of Field Exchange on wasting in South Asia in mid-2020, in partnership with the UNICEF Regional Office and in collaboration with No Wasted Lives. More details and calls for content will follow soon.
ENN’s raison d’être is to support collective lesson learning; we learn from positive and negative experiences and at times it takes institutional courage to share the latter. In this spirit, our extended editorial uses the rich body of curated material to challenge whether the system (particularly institutional arrangements and related programming modalities) as currently configured are fit for purpose to deliver on a continuity of care for acutely malnourished children. We hope that our frank appraisal of what we think is lacking in the current system and what may help move us towards putting it right is received in the spirit in which it is intended: to challenge the status quo to catalyse necessary change and to improve how we care for malnourished children.
Jeremy Shoham and Marie McGrath, Field Exchange Editors
We welcome feedback on this edition and our editorial reflections; letters to the editor will be published online and in Field Exchange 61. Send to Chloe Angood.