Aid strategies for treating children suffering moderate acute malnutrition (MAM) have remained virtually unchanged for 30 years. As part of UN-led efforts to revamp policy, several initiatives in West Africa are examining how best to treat the condition, a major cause of death and disease worldwide.
Across the Sahel - where MAM strikes an estimated six million children, according to UN Children’s Fund (UNICEF) - aid agencies are evaluating new approaches. Among them is distribution of new ready-to-eat nutrient-rich pastes, which some NGOs urge, but are yet to be rigorously researched as MAM treatment.
“Unless we can give sound advice backed by scientific research, and translate that knowledge into programmes that reach the majority of children, we will not be able to tackle MAM, which is really one of the forgotten and missing parts of [what we face in the region],” said UNICEF nutrition adviser for West and Central Africa Felicite Tchibindat.
In a number of current projects, including a randomized, community-based study in Mali, UNICEF and aid agencies are examining the efficacy of several products and strategies.
One product being evaluated in Mali is CSB++, a more nutrient-rich version of the corn-soya blend long used by the UN World Food Programme (WFP) for children with moderate acute malnutrition. Nutrition experts say the original CSB does not contain the nutrients to stem MAM.
The Mali study, by UNICEF, WFP, University of Bamako and University of California-Davis, is also evaluating Supplementary Plumpy (a nutrient-rich peanut paste), Misola and local foods plus a nutrient powder.
“It’s very hard to ask donors to invest in these approaches without proof they work,” said Kenneth Brown, HKI regional adviser for nutrition and child survival and U-C Davis professor, told IRIN.
One aim is to contribute to the development of a global protocol for treating moderate acute malnutrition, as exists for severe, principal researcher Robert Ackatia-Armah told IRIN in the Mali capital, Bamako.
A less formal evaluation is under way in Niger, where this year's emergency nutrition response has spotlighted questions over CSB’s efficacy for MAM, UNICEF’s Tchibindat told IRIN.
“When we treat with CSB, some children with MAM are cured, but the vast majority are not cured,” Tchibindat said. “We decided, why not use [the lean period] to test some of the new knowledge globally - because we have the money, we have the system in place and let’s learn from there.” UNICEF in a revised strategy in Niger is doing blanket feeding with a combination of CSB and ready-to-eat peanut pastes.
“This will give us an idea in the Sahel context. Do we have something here that would work and is it cost-effective?”
UNICEF for the first time is distributing Plumpy’doz, a nutrient-rich supplement, to prevent severe acute malnutrition in Chad, where in some regions one in four children suffer from MAM. Agency officials said they are monitoring the operation closely for guidance in future programmes.
Nutrition advisers say tackling MAM calls for huge resources, given the numbers, but that effective prevention and treatment could save a significant number of children from becoming severely malnourished.
“It is clear that if we just concentrate on treating severely acute malnourished children we will never solve the issue, because we will not deal with these high numbers of moderately malnourished children,” Tchibindat told IRIN. “We have a lot of children in the region who are highly vulnerable, who are just about to go over the edge [from moderate to severe].”
She said one challenge in developing strategies for MAM is that the category encompasses a wide range of conditions, and simply giving foods that add energy is not the answer. “Moderately malnourished children range from children close to normal to those who are close to severe; if you give the same product, which is just adding energy [without necessary nutrients], this does not address the problem.”
It is difficult finding funding for the research such as that taking place in Mali, which is backed by Office of US Foreign Disaster Assistance (OFDA), Tchibindat said. This illustrates one of the challenges of developing nutrition assistance that goes beyond urgent therapeutic feeding once children are in a critical state.
"Donors are used to funding supplies and the like. And they have to convince their governments; that's not easy. Governments prefer to fund things that are tangible, not fuzzy," she said.
WFP regional nutrition adviser Anna Horner said managing MAM requires a longer commitment than most donors contributing to malnutrition programmes are prepared to make. She added: “It is sometimes an activity that is difficult to classify as it can be considered both emergency and development, and touches many different sectors… As such it is sometimes hard to fit into the traditional funding mechanisms.”
Tchibindat said the nutrition community has also failed to convince donors. "It's coming now but for a long time you were happy to get funds to buy the Plumpy'nut [another ready-to-use supplement]. We were not strong enough in convincing donors that they need to fund the operational research, the capacity-building, the mid- and long-term activities."
Acute malnutrition is rapid weight loss, “wasting”, and can be either moderate or severe (SAM). SAM, which commonly kills if untreated, is distinguished by three major clinical characteristics: marasmus (“skin and bones”); kwashiorkor (bloated appearance due to water accumulation and a combination of both. Moderately malnourished children are highly prone to illness and vulnerable to the slightest shocks – and this in a region where the climate and natural disasters regularly cause shocks to the economy and food supply.
She added that aid partners must avoid the turf battles that can hamper the close collaboration needed for sound nutrition programmes.
Generally nutrition programmes are run by humanitarian agencies, but nutrition is integral to development, aid workers said. WFP’s Horner said given the numerous causes of malnutrition, “there is no single way forward for preventing and treating MAM. Success [is possible only by] reducing causes including food insecurity, morbidity, inappropriate feeding practices for infants and young children and limited access to clean water and hygiene.”
In Chad Action Against Hunger head Jean-François Carémel said interventions must encompass all these factors.
“The frustration is that the response is focused on curative actions. Acute malnutrition is indeed a medical pathology but it is also social, economic and cultural.
“The statistics justify urgent action but also the need for real in-depth, coordinated work on access to and quality of health care.” Many approaches exist for preventing malnutrition, including improving food production and livestock breeding and boosting women’s status, he said.
Nutrition experts say managing moderate malnutrition ultimately should be a task for government, but that varies across the region depending on political commitment, infrastructure and stability. UNICEF’s Tchibindat would add civil society as a major player: “We need to educate civil society to question the UN, NGOs and the government on what they are doing to tackle malnutrition.”
She said donors and NGOs are coming around to linking nutrition with broader development issues.
“Let’s not forget that even managing severe acute malnutrition has improved immensely very, very recently, with ready-to-eat therapeutic foods,” she said. The aid community has not had a good understanding of MAM. Most nutrition NGOs deal with severe acute malnutrition, and nutrition was not really high on the global agenda some 10 years ago. Now people are recognizing that if we don’t tackle malnutrition we may not be able to achieve most of the Millennium Development Goals.”