‘Severe malnutrition’: thinking deeply, communicating simply

Kerac, Marko; McGrath, Marie; Connell, Nichola; Kompala, Chytanya; Moore, William; Bailey, Jeanette; Bandsma, Robert; Berkley, James A.; Briend, André; Collins, Steve; Girma, Tsinuel; Wells, Jonathan C. K.

doi:10.1136/bmjgh-2020-003023

Cited by 43 publications

(39 citation statements)

References 13 publications

(12 reference statements)

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“…In eleven included trials, anthropometry and in particular recovery of ‘normal’ weight was the main outcome measure. Whilst anthropometry is widely used as the key measure of nutritional status, it is malnutrition-associated risk of mortality and morbidity that really matters rather than body size alone 44 . Wasting, low WHZ, which defines MAM is strongly associated with high risk of mortality 45,46 .…”

Section: Discussionmentioning

confidence: 99%

The management of Moderate Acute Malnutrition (MAM) in children aged 6-59 months: A systematic review and meta-analysis

Gluning

Kerac

Bailey

et al. 2021

Preprint

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BackgroundMalnutrition is a leading cause of morbidity and mortality in children aged under five years, especially in low- and middle-income countries (LMICs). Although severe acute malnutrition (SAM) is considered the most serious form of malnutrition, moderate acute malnutrition (MAM) affects greater numbers globally and, unlike SAM, guidelines lack a robust evidence-base. This systematic review and meta-analysis assessed the evidence for lipid-based nutrient supplements (LNS), fortified-blended-flours (FBF) and nutrition counselling, in the treatment of MAM.MethodsFive databases were systematically searched for studies conducted in LMICs that compared the effectiveness of food-based products versus any comparator group in promoting recovery from MAM in children aged 6-59 months. Where appropriate, pooled estimates of effect were estimated using random-effects meta-analyses.ResultsA total of thirteen trials were identified for inclusion. All used active controls rather than ‘standard care’, which is often minimal in most settings. There was evidence of increased probability of recovery (as assessed by gaining normal weight-for-height and/or MUAC) among children treated with LNS compared to children treated with FBF (RR 1·05, 95%CI 1·01-1·09, p=0·009). Treatment with an LNS was also associated with a lower risk of persistent MAM at the end of treatment compared with a FBF (RR 0·82, 95%CI 0·71-0·95, p=0·007).ConclusionBased on a relatively small number of studies mainly from Africa, LNS are superior to FBF in improving anthropometric recovery from MAM. The true benefit of MAM treatment may be underestimated due to all studies using active controls rather than usual care which is minimal.More high-quality evidence is needed to evaluate nutrition education/counselling alone as a MAM intervention. Studies should also assess a wider range of outcomes including body composition, morbidity and development – not weight-gain alone.

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Section: Discussionmentioning

confidence: 99%

The management of Moderate Acute Malnutrition (MAM) in children aged 6-59 months: A systematic review and meta-analysis

Gluning

Kerac

Bailey

et al. 2021

Preprint

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“…at-risk of adverse outcomes, notably mortality and morbidity [17]. Despite differing designs and contexts, most of these studies on infants u6m agree that WLZ is poor at identifying high-risk infants and that WAZ or MUAC are better and more practical.…”

Section: The Utility Of Simple Measurements: Muac and Wazmentioning

confidence: 99%

“…We took on the recent call for using aggregate measures to quantify malnutrition and quantify the burden of malnutrition as any manifestation of anthropometric deficit as indexed by CIAF [17]. Published research on malnutrition in infants u6m has focused strongly on severe wasting as denoted by a WLZ <-3 [29,30,33,36], but our data adds to growing calls for more inclusive case definitions for identifying infants at risk of malnutrition, mortality or impaired development.…”

Section: Implications For Research and Programmingmentioning

confidence: 99%

Malnutrition in Infants Aged under 6 Months Attending Community Health Centres: A Cross Sectional Survey

Grijalva-Eternod¹,

Beaumont²,

Rana³

et al. 2021

Preprint

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Poor understanding of malnutrition burden is a common reason for not prioritizing the care of small and nutritionally at-risk infants aged under-six months (infants u6m). We aimed to estimate the anthropometric deficit prevalence in infants u6m attending health centres, using the Composite Index of Anthropometric Failure (CIAF); and to assess the overlap of different individual indicators. We undertook a two-week survey of all infants u6m visiting each of 18 health centres in two zones of the Oromia region, Ethiopia. We measured weight, length, and MUAC (Mid upper arm circumference); and calculated weight-for-length (WLZ), length-for-age (LAZ), and weight-for-age z-scores (WAZ). Overall, 21.7% (95% CI: 19.2; 24.3) of infants u6m presented CIAF and of these, 10.7% (95% CI: 8.93; 12.7) had multiple anthropometric deficits. Low MUAC overlapped with 47.5% (95% CI: 38.0; 57.3), 43.8% (95% CI: 34.9; 53.1), and 42.6% (95% CI: 36.3; 49.2) of the stunted, wasted and CIAF prevalence, respectively. Underweight overlapped with 63.4% (95% CI: 53.6; 72.2), 52.7% (95% CI: 43.4; 61.7), and 59.6% (95% CI: 53.1; 65.9) of the stunted, wasted and CIAF prevalence, respectively. Anthropometric deficits, single and multiple, are prevalent in infants attending health centres. WAZ overlaps more with other forms of anthropometric deficits than MUAC.

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“…Past reviews have examined interventions to promote breastfeeding but most of these focus on broad IYCF (<2 years) practices applied to the general infant population [ 15 , 16 , 17 , 18 ]. This review aims to address the evidence gap on how to best support breastfeeding in a subpopulation of small and nutritionally at-risk infants < 6 m, defined as those with wasting, underweight or other forms of growth failure [ 19 , 20 ]. Specific objectives include to: identify and describe details of currently available breastfeeding support packages from LMICs for infants < 6 m, assess the impact of breastfeeding support packages on breastfeeding practices, and assess the impact of existing breastfeeding support packages on the knowledge/skills/practices of healthcare staff and caregivers.…”

Section: Introductionmentioning

confidence: 99%

Effectiveness of Breastfeeding Support Packages in Low- and Middle-Income Countries for Infants under Six Months: A Systematic Review

Rana

McGrath²,

Sharma

et al. 2021

Nutrients

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Small and nutritionally at-risk infants under six months, defined as those with wasting, underweight, or other forms of growth failure, are at high-risk of mortality and morbidity. The World Health Organisation 2013 guidelines on severe acute malnutrition highlight the need to effectively manage this vulnerable group, but programmatic challenges are widely reported. This review aims to inform future management strategies for small and nutritionally at-risk infants under six months in low- and middle-income countries (LMICs) by synthesising evidence on existing breastfeeding support packages for all infants under six months. We searched PubMed, CINAHL, Cochrane Library, EMBASE, and Global Health databases from inception to 18 July 2018. Intervention of interest were breastfeeding support packages. Studies reporting breastfeeding practices and/or caregivers’/healthcare staffs’ knowledge/skills/practices for infants under six months from LMICs were included. Study quality was assessed using NICE quality appraisal checklist for intervention studies. A narrative data synthesis using the Synthesis Without Meta-analysis (SWiM) reporting guideline was conducted and key features of successful programmes identified. Of 15,256 studies initially identified, 41 were eligible for inclusion. They were geographically diverse, representing 22 LMICs. Interventions were mainly targeted at mother–infant pairs and only 7% (n = 3) studies included at-risk infants. Studies were rated to be of good or adequate quality. Twenty studies focused on hospital-based interventions, another 20 on community-based and one study compared both. Among all interventions, breastfeeding counselling (n = 6) and education (n = 6) support packages showed the most positive effect on breastfeeding practices followed by breastfeeding training (n = 4), promotion (n = 4) and peer support (n = 3). Breastfeeding education support (n = 3) also improved caregivers’ knowledge/skills/practices. Identified breastfeeding support packages can serve as "primary prevention" interventions for all infants under six months in LMICs. For at-risk infants, these packages need to be adapted and formally tested in future studies. Future work should also examine impacts of breastfeeding support on anthropometry and morbidity outcomes. The review protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO 2018 CRD42018102795)

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‘Severe malnutrition’: thinking deeply, communicating simply

Cited by 43 publications

References 13 publications

The management of Moderate Acute Malnutrition (MAM) in children aged 6-59 months: A systematic review and meta-analysis

The management of Moderate Acute Malnutrition (MAM) in children aged 6-59 months: A systematic review and meta-analysis

Malnutrition in Infants Aged under 6 Months Attending Community Health Centres: A Cross Sectional Survey

Effectiveness of Breastfeeding Support Packages in Low- and Middle-Income Countries for Infants under Six Months: A Systematic Review

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