U S A I D ’ S I N FA N T & YO U N G C H I L D N U T R I T I O N P RO J E C T

This document was produced through support provided by the U. S. Agency for International Development, under the terms of Cooperative Agreement No. GPO-A-00-06-00008-00. The opinions herein are those of the author(s) and do not necessarily reflect the views of the U.S. Agency for International Development.

Diarrhea precipitates SAM• AsshownbyRowlandetal.(1977),wherediarrhea

prevalenceishigh,infantsandchildrendonotgainweightadequatelyandactuallymayloseweight.WeightlossleadstoSAM.

• Weightgainslows,evenbecomesnegative.

• Foramoderatelywastedchild,rapidweightlossduringdiarrheaprecipitatesseverewasting.

• SanitationandhygieneandmanagementofdiarrheathuscontributetoSAMprevention.

MEAN MONTHLY WEIGHT GAIN (REGRESSION LINE) VERSUS GASTROENTERITIS PREVALENCE (%) FOR NINE 2-MONTH PERIODS

400

200

0

–2000 10 20 30

5

53

7

629

8

1

Gastroenteritis prevalence (%)

Wei

ght

gain

(g/

mon

th)

Source: Rowland et al., 1977

Measles precipitates SAM• Likediarrhea,measleshasbeenassociatedwithabrupt

deteriorationofnutritionalstatus.AbruptdeteriorationpredisposesanalreadymalnourishedchildtoSAM.Successfulimmunizationagainstmeasles,coupledwithinterventionstoimproveoverallmalnutrition,thuscanpreventSAM.

• AReddyetal.prospectivestudyoftherelationshipbetweenmeasles,malnutrition,andblindnessfoundthatsevereunderweightdoublesduringmeaslesandremainsatadoubledlevelforsixmonthspostmeasles.

• PreventingmeaslestranslatesintothepreventionofSAM.

Reducing child deaths due to malnutrition requires addressing mild and moderate malnutrition

The epidemiological argument

Other preventable diseases account for more deaths than SAMWhileSAMisresponsiblefor2%ofchilddeaths,otherpreventableandtreatablediseasesaccountforfarmoredeaths:togethermeasles,malaria,anddiarrheaaccountformorethan40%ofalldeaths.

DIRECT CAUSES OF CHILD DEATHS

Lower respiratory infections, 24.7

Diarrheal diseases, 20.9

Protein-energy malnutrition, 1.8

Tetanus, 2.5

Pertussis, 4.0

HIV/AIDS, 4.9

Other, 19.2

Malaria, 14.6

Measles, 7.3

The Case for Preventing Malnutrition Through Improved Infant Feeding and Management of Childhood IllnessAUTHORS : TOM SCHAETZEL , ALBERTHA NYAKU, INFANT & YOUNG CHILD NUTRIT ION PROJECT

TOTAL CHILD DEATHS BY MALNUTRITION SEVERITY

The ethical argument

SAM has a HIGH case-fatality rateThehighmortalityriskassociatedwithSAMisusuallycitedasareasonforuniversalintroductionoftreatmentservices.However,childrendiefromSAMevenwhileundergoingtreatment.

Severe malnutrition is associated with permanent developmental consequencesEvenwithsuccessfulrehabilitation,severemalnutritionisassociatedwithlowerIQ,lowercognitivefunction,lowerschoolachievement,andgreaterbehavioralproblems(Grantham-McGregor,1995).

Reliance on treatment is unethicalIfeffectiveandaffordableinterventionsexistforpreventingSAMandprotectinginfantsfromtheelevatedriskitcarriesandtheriskoflifelongdevelopmentalconsequences,thenitisunethicaltofocusontreatment.

0

10

20

30

40

50

60

Initial (307)

During measles (307)

3 months later (300)

6 months later (220)

Normal

Grade I

Grade II

Grade III

Perc

ent o

f chi

ldre

n

NUTRITIONAL STATUS BEFORE AND AFTER MEASLES INFECTION IN INDIA

SAM often results from illnessImportantly,SAMhasadifferentetiologythanchronicmalnutrition.SAMoftenresultsfromillnessratherthanlackoffood—eventhoughitstreatmentalwaysinvolveschildfeeding.ThefindingsofYipandSharp(1993)underscorethisfact,ashighratesofseverewastingoccurredinarefugeesituationwhereaidactivitiesensuredadequatefoodforthepopulation.Diarrhea,notlackoffood,wasthemaincauseofSAM.

• “Inthiscrisis,severeandacute‘malnutrition’orwasting…wasprimarilyaconsequenceofprolongeddiarrheaandcanberegardedassecondarymalnutrition.Therewasnoevidenceofprimarymalnutritionorstarvationresultingfromaprolongedshortageoffood.”

• “Thistragicexperiencereinforcestheimportanceofthebasicpublichealthconceptofpreventioninthemanagementofdisastersituations.”

• Criticalpreventioninterventionsincludesafewatersupply,sanitationmeasures,andeffectivediarrheacontrolprograms.

Whiletheriskofdeathduetoseveremalnutritioniseighttimesgreaterthannormal,thenumberofchildrenwhodieduetoanassociationwithmalnutritionismuchgreaterformoderateandmildmalnutrition.Thatis,asmallerriskappliedtoamuchlargernumbergivesmoreevents.Toreducechilddeathsduetomalnutritionnecessarilyrequiresaddressingmildandmoderatemalnutrition.

INDIVIDUAL RISK OF DEATH BY MALNUTRITION SEVERITY

2.4

4.6

8.4

0

1

2

3

4

5

6

7

8

9

Mild Moderate Severe

Source: Pelletier et al. ,1995

ConclusionsWhenSAMprevalenceislow,introductionofuniversalSAMtreatmentisnotrationalinepidemiological,cost,orethicalterms.Investmentinmorecost-effectiveinterventionsthatreachmorechildren,savemorelives,protectchildrenfromdeathanddevelopmentaldelay,andalsopreventSAMisabetteruseofpublicfunds.

ReferencesEvansDB,LimSS,AdamT,EdejerTT;WHOChoosingInterventionsthatareCost

Effective(CHOICE)MillenniumDevelopmentGoalsTeam.Evaluationofcurrentstrategiesandfutureprioritiesforimprovinghealthindevelopingcountries.British Medical Journal.2005;331(7530):1457–1461.

Grantham-McGregorS.Areviewofstudiesoftheeffectofseveremalnutritiononmentaldevelopment.Journal of Nutrition.1995;125(Suppl.8):2233S–2238S.

HortonS.The Cost of Scaling up Nutrition Programming.2009.

MasonJ,HuntJ,ParkerD,UJonsson.InvestinginChildNutritioninAsia.Asian Development Review.1999;17(1,2):1–32.

NationalStatisticalOffice(NSO)[Malawi],andORCMacro.2005.Malawi Demographic and Health Survey 2004.Calverton,Maryland:NSOandORCMacro.

PelletierDL,FrongilloEA,SchroederDG,JPHabicht.Theeffectsofmalnutritiononchildmortalityindevelopingcountries.Bulletin of the World Health Organization.1995;73(4):443–448.

ReddyV,BhaskaramP,RaghuramuluN,etal.Relationshipbetweenmeasles,malnutrition,andblindness:aprospectivestudyinIndianchildren.American Journal of Clinical Nutrition.1986;44(6):924–930.

RowlandMGM,ColeTJ,WhiteheadRG.AquantitativestudyintotheroleofinfectionindeterminingnutritionalstatusinGambianvillagechildren.British Journal of Nutrition.1977;37(3):441–450.

SantosI,VictoraCG,MartinesJ,etal.NutritionCounselingIncreasesWeightGainamongBrazilianChildren.Journal of Nutrition.2001;131(11):2866–2873.

WorldHealthOrganization(WHO)/WorldFoodProgramme/UnitedNationsSystemStandingCommitteeonNutrition/TheUnitedNationsChildren’sFund.Community-BasedManagementofSevereAcuteMalnutrition:AJointStatementbytheWHO,theWorldFoodProgramme,theUnitedNationsSystemStandingCommitteeonNutritionandtheUnitedNationsChildren’sFund.2007.

WHO.The World Health Report: 2003: Shaping the Future.Geneva:WHO;2005.

WHO.Malawi National Health Accounts (NHA) 2002/2003–2004/2005.Lilongwe:WHO;2007.

YipR,SharpTW.Acutemalnutritionandhighchildhoodmortalityrelatedtodiarrhea.Lessonsfromthe1991Kurdishrefugeecrisis.Journal of the American Medical Association.1993;270(5):587–590.

The economic argument

How much does it cost to treat SAM in Malawi?AccordingtotheWHO(MalawiNationalHealthAccounts,2007)currentchildhealthexpenditureis$15/child.ThefoodcostsfortreatmentofSAMaredoublethatamount(WHO/WFP/UNSCN/UNICEF,2007).Thetotalcostsoftreatment,eveninthecommunity,havebeenestimatedat$200/child(Horton,2009).

$15$30

$200

$0

$50

$100

$150

$200

Current childhealth expenditure

per child

Per episodeRUTF cost

to treat SAM

Per episodeto treat SAMin community

COST OF SAM TREATMENT PER CHILD IN MALAWI

Source: WHO, 2007; WHO/WFP/UNSCN/UNICEF, 2007; Horton, 2009

COST OF SAM TREATMENT IN RELATION TO TOTAL CHILD HEALTH EXPENDITURES IN MALAWI

Other child health expenditure

SAM treatment expenditure

Source: WHO, 2007

• TheseperepisodecoststranslatetoatotalnationalSAMtreatmentcostthatrepresentsapproximately25%ofallchildhealthexpenditure.

• Isitrationaltospend25%ofallchildhealthfundsforlessthan2%ofthepopulation?

• Isitrationaltospend25%ofchildhealthfundstotreataconditionresponsiblefor<2%ofchilddeaths?

Addressing illnesses that cause SAM is more cost-effective than treatment• TheWorldHealthOrganization’sChoosingInterventions

thatareCostEffective(CHOICE)projectteamrankedthese“highlycost-effective”interventions(below)allmorecost-effectivethantreatmentofSAM(2005).

• AnyofthemwouldcontributetoreductionsinSAM.

• AnyofthemwouldeliminatemorechilddeathsthanwoulduniversalSAMtreatment,regardlessoftheeffectonSAM.

• Priorityshouldbegiventointerventionsproventobecost-effectiveandtosavemorelives.Importantly,thesesamecost-effectiveinterventionscouldsubstantiallylowertheincidenceofSAMatthesametime.

Intervention (coverage) presented in order of decreasing cost-effectiveness

Case management of malaria with artemisinin-based combination treatment (95%)

Measles vaccination (80%)

Measles vaccination (expanded to 95%)

Case management for childhood pneumonia (80%)

Oral rehydration therapy for diarrhea (80%)

Source: Evans et al., 2005

Do preventive nutrition interventions exist?

Nationalcommunity-basedprogramsestablishingalowratioofhouseholdstolocalcommunityworker(e.g.,10:1)haveachievedrapidreductionsinmalnutrition(Mason,etal.1999).

• Theseprogramstypicallynearlyeliminateseverecasesrapidly.

• Asupportivepolicyenvironmentimprovessuccessthroughimprovedstatusforwomen,reducedsocialexclusion,consistentpoliticalcommitment,sustainablecommunityorganization,andimprovedliteracy.

Withappropriatetrainingandsupervision,nutritioncounselingdeliveredthroughfacility-basedcasemanagementofchildhoodillness(i.e.,IMCI)hasbeenshowntoreducewastingbyapproximately0.25WHZ-score(Santos,etal.2001).

www.iycn.org

0 2010 30 40 50 60 70

Percentage of child deaths

India

Bangladesh

Nepal

Pakistan

Indonesia

Tanzania

Nigeria

Philippines

Thailand

Uganda

China

Egypt

N.E. Brazil

Côte D’Ivoire

Zimbabwe

Peru

Nicargua

Jamaica

Jordan

Paraguay

Weighted average

severe malnutrition

mild/moderate malnutrition

IntroductionTheadventofready-to-usetherapeuticfood(RUTF)productshasgreatlyimprovedthecoverageandeffectivenesstreatmentforsevereacutemalnutrition(SAM).TheexcitementsurroundingthisdevelopmenthasledtorapidexpansionofSAMtreatmentactivities,oftenwithoutregardtotheprevalenceofSAM,thecapacityoflocalhealthsystemstoabsorbexpansion,orthecontributionofSAMtooverallchildmortality.Inthecontextoflimitedhealthbudgets,onepidemiologicalandethicalgroundstreatmentapproachesareinmostsituationsalessrationalpublichealthinvestmentthanapproachesthatpreventSAMandothertypesofmalnutrition.

Aims:ToconsidervariousapproachesforaddressingSAMandhighlightthemostrationalapproachinconstrainedfundingenvironments.Methods:LiteraturesearchoncausesandconsequencesofSAM,andcost-effectivenessinrelationtoSAMtreatmentofinterventionsaddressingthosecauses.

Richard Lord

Christine Demmelmaier

Source: WHO, 2003 Source: Pelletier et al., 1995

Source: Reddy et al., 1986 Mamorena Namane, a community health worker in Lesotho, works with the Infant & Young Child Nutrition Project to support mothers to learn good infant feeding practices and ensure that their babies grow up healthy.