Community based management of severe malnutrition in children

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1 Community based management of severe malnutrition in children WHO (CAH and NHD), UNICEF and SCN Informal Consultation Geneva November 2005 André Briend World Health Organization, Child and Adolescent Health and Development, Geneva

2 Objectives of the meeting 1- To identify areas of consensus on the community based management of severe malnutrition 2- To identify knowledge gaps that should be addressed by research

3 Organisation of the meeting 50 participants from UN agencies, NGOs, academic institutions, ministries of health Preparation of 5 background papers circulated to participants in advance of the meeting Oral presentations Formulation of consensus statements (final editing) Revision and publication of the background papers (on going) Publication of the report (on going)

4 Identification of severely malnourished children in the community in order to provide for treatment 1 - In addition to weight-for-height < 70% or < -3 Z-scores of the median NCHS/WHO reference values and/or bilateral oedema, MUAC < 110 mm can be used independently as a criterion for admission to a therapeutic feeding programme for children aged 6-59 months 2 - MUAC is a simple and practical tool which should be used by community workers to identify severely malnourished children.

5 Identification of severely malnourished children in the community in order to provide for treatment (continued) 3 - In infants less than six months of age, it is recommended that "visible severe wasting" and/or oedema, in conjunction with difficulties in breastfeeding, be used as admission criteria until further studies are undertaken to develop more precise admission criteria for treatment. 4 - High coverage (both temporal and spatial) of the programmes, achieved through active case-finding activities, as established in the SPHERE minimum standards must be a key objective for therapeutic feeding programmes.

6 Management of severely malnourished children in the community 1- It is desirable that therapeutic feeding programs should usually have a community-based and a facility-based component, in order that severely malnourished children with no complications be treated in the community while those with complications are referred to an inpatient treatment facility with trained staff. 2 - It is highly desirable to manage severely malnourished children with no complications in the community without an inpatient phase. These are severely malnourished children who are alert, have good appetite, are clinically well, are not severely oedematous, and have reasonable home-care circumstances.

7 Management of severely malnourished children in the community (continued) 3 - Children with severe malnutrition and complications should be referred to an inpatient treatment facility with trained staff. These children include severely malnourished children with anorexia, children with severe oedema or children who are clinically unwell. 4 - Ready to Use Therapeutic Foods (RUTF) is useful to treat severe malnutrition without complications in communities with limited access to appropriate local diets for nutritional rehabilitation.

8 Management of severely malnourished children in the community (continued) 5 - When families have access to nutrient-dense foods, severe malnutrition without complications can be managed in the community without RUTF, by means of carefully designed diets using low-cost family foods, provided appropriate minerals and vitamins are given. 6 - Efficacy of local therapeutic diets should be tested clinically 7 - Treatment of young children should include support for breastfeeding and appropriate infant and young children feeding practices.

9 Community-based management of severe malnutrition in the context of high HIV prevalence 1 - The general principles and guidelines for the care of severely malnourished children in areas of high HIV prevalence do not fundamentally differ from those where HIV is rarely seen 2 - In areas where HIV prevalence is high, there should be unfettered access to HIV services (e.g. VCT, cotrimoxazole prophylaxis, nutritional counselling, ART) and seamless articulation from the onset between levels of care (community, health centre and hospital) and between HIV treatment and malnutrition programs. 3 - All therapeutic foods used, including RUTF, should be chosen to be appropriate for HIV infected, severely malnourished children, based on current scientific evidence.

10 Next steps 1 WHO to develop guidelines for the community based management of severe malnutrition including specifications for RUTF production 2 WHO and partners (UNICEF, WFP, UNHCR) to advocate for community-based management of severe malnutrition and assist countries to introduce community-based management into health policy and health systems. 3 - The potential value of establishing a technical advisory group on severe malnutrition will be revitalised, possibly in collaboration with the International Union of Nutritional Sciences' task force on severe malnutrition.

11 Next step (continued) 4 WHO and partners will explore whether the Ending Child Hunger Initiative, led by WFP, in collaboration with UNICEF and the World Bank, would provide a platform for partners to coordinate actions and lead a global effort to introduce community-based management of severe malnutrition 5 Inclusion of RUTF as a therapeutic food, along with F75, F100 and RESOMAL will be discussed with donors. 6 - UNICEF s ability to provide mineral and vitamin mix for production of local RUTF will also be discussed.

12 Knowledge gaps 1 Identification of children less than 6 months in need of therapeutic feeding and treatment of these children 2 Assessment of the risk of death of untreated children from archive data (for advocacy) 3 Need of antibiotic for children with uncomplicated forms of severe malnutrition 4 Standardisation of the appetite test