MANAGING ACUTE MALNUTRITION IN INFANTS (MAMI): WHERE ARE WE NOW? Nicki Connell, Emergency Nutrition Advisor, SCUS Date: 19 th October 2016

MANAGING ACUTE MALNUTRITION IN INFANTS (MAMI): WHERE ARE WE NOW? Nicki Connell, Emergency Nutrition Advisor, SCUS Date: 19 th October 2016

Managing Acute Malnutrition in Infants (MAMI) Presentation Flow Background on the problem Updates: Research in Bangladesh on obtaining evidence on risk factors for infant malnutrition Prevalence survey data Prospective follow-up study Development of Community-MAMI (C-MAMI) guidance note 2

Prevalence of wasting (< 2 WLZ) in < 6m infants 3 Arch Dis Child 2011;96:1008 1013

Deaths as % of admission in TFC in Afghanistan 4 Field Exchange, Vol 37, 2009

Background Acute malnutrition is a major global public health problem causing ~45% of all child deaths each year =6.3 mil in 2013 (WHO, Sept 2014) Over the last decade, management of Severe Acute Malnutrition (SAM) and Moderate Acute Malnutrition (MAM) in children aged 6 59 months has been revolutionized by a public health orientated model of care, "Community based Management of Acute Malnutrition" (CMAM) not the case for infants under 6 months 5

Background Typically the current national SAM guidelines only recommend inpatient/clinical care for infants <6m with SAM This is problematic: Cost to health system Cost to family Adherence to protocols High number of defaulters Risk of infection 6

Recent Updates by WHO in late 2013! Recommend outpatient management of malnutrition in infants BUT Lack of practical guidance on how to identify those at risk and how to manage those identified 7

Current definition of severe acute malnutrition (SAM) in infants <6m old Weight for length of less than 3 Z score Visible severe wasting Edema (bilateral pitting edema) 8

MAMI Research in Bangladesh Margaret A. Cargill Foundation December 2013 November 2016 Phased approach.. Now in Phase aviii, data analysis and dissemination 9

MAMI Research in Bangladesh Objectives To estimate the prevalence of infants<6m with acute malnutrition in the community av To develop an assessment tool/case definition checklist for infants<6m with acute malnutrition Anthropometric criteria/breastfeeding assessment/clinical criteria/ Other criteria e.g. lack of social support; disability; maternal education; source of water, sanitation, housing, maternal anthropometry To describe current outcomes following infant <6m with acute malnutrition 10

MAMI Research in Bangladesh Study components Prevalence survey: A group of infants have been identified from house to house searching for anthropometric measurements; in two distinct seasons av Prospective follow-up study: 3 groups of infants who are SAM (WFH <-3 and/oedema), Not SAM (WFH >-2, no oedema, MUAC >115) and with Low MUAC (MUAC <115); will be followed up until they are 180 days old 11

MAMI Research in Bangladesh Study Place av 12

MAMI Research in Bangladesh Methodology Prevalence Survey x2 (pre and post harvest) Study participants: infants aged <6months of either sex Targeted sample size: 742, Identified randomly among 106 villages av Check for age using appropriate documents Anthropometric measurements (Weight, Length, MUAC etc.) Check for edema Calculate the weight-for-length and Length-for-Age Z-score and Weightfor-Age Z-score using WHO Growth Standards 2006 Data entry electronically at field, transferred to central server in real time 13

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15 Please note, all data presented in this webinar are provisional the team are still completing final analyses. These will be published in the coming months, so final results will be shared then.

Results Post Harvest 4.9% (BDHS 2014) Weight for Length 19.9% (BDHS 2014) %below 3 SD % below 2 SD % above + 2 SD Mean Z score n <1 mo 1.1 3.3 0 0.36 91 1 <2 mo 0 0 1.0 0.30 103 2 <3 mo 0 1.9 6.8 0.33 103 3 <4 mo 0.5 3.0 2.5 0.08 200 4 <5 mo 0.7 5.1 2.9 0.04 137 5 <6 mo 0 3.0 0 0.11 100 Overall 0.4 2.8 2.3 0.04 734 Sex Male 0.27 2.7 2.4 0.06 373 Female 0.55 3.0 2.2 0.03 361 16

Results Pre Harvest 4.9% (BDHS 2014) Weight for Length 19.9% (BDHS 2014) %below 3 SD % below 2 SD % above + 2 SD Mean Z score n <1 mo 17.9 26.2 0 1.13 145 1 <2 mo 3.1 7.1 0.8 0.35 127 2 <3 mo 4.5 7.2 1.8 0.36 111 3 <4 mo 2.5 5.7 1.9 0.31 157 4 <5 mo 2.5 4.9 2.5 0.32 81 5 <6 mo 2.5 5.9 4.2 0.15 119 Overall 5.9 10.1 1.8 0.46 740 Sex Male 5.5 9.2 1.7 0.45 401 Female 6.5 11.2 1.8 0.47 339 17

Results Post Harvest 3.6% (BDHS 2014) Weight for Age 19.0% (BDHS 2014) %below 3 SD % below 2 SD % above + 2 SD Mean Z score n <1 mo 6.3 18.8 0 1.14 96 1 <2 mo 8.7 16.5 0 1.15 103 2 <3 mo 1.9 6.9 0 0.78 103 3 <4 mo 6.5 17.0 0 1.03 200 4 <5 mo 2.9 15.3 0 0.97 137 5 <6 mo 3.0 10.0 0 1.00 100 Overall 5.0 14.4 0 1.01 739 Sex Male 5.9 14.9 0 1.05 375 Female 4.1 14.0 0 0.97 364 18

Results Pre Harvest 3.6% (BDHS 2014) Weight for Age 19.0% (BDHS 2014) %below 3 SD % below 2 SD % above + 2 SD Mean Z score n <1 mo 7.6 20.0 0 1.28 145 1 <2 mo 9.3 17.8 0 1.17 129 2 <3 mo 5.4 13.5 0 1.01 111 3 <4 mo 5.1 17.8 0.6 1.04 157 4 <5 mo 4.9 12.3 0 0.89 81 5 <6 mo 3.4 13.4 0 0.81 119 Overall 6.1 16.3 0.1 1.05 742 Sex Male 7.2 19.2 0.2 1.05 402 Female 4.7 12.9 0 0.95 340 19

Results Post Harvest Mid Upper Arm Circumference (mm) % below 115 mm % 115 <125 mm % 125 mm and above Mean MUAC n <1 mo 89.6 7.3 3.1 101.9 ± 10.2 96 1 <2 mo 39.8 39.8 20.3 116.4 ± 11.2 103 2 <3 mo 9.7 30.1 60.2 125.8 ± 10.4 103 3 <4 mo 7.9 24.6 67.5 129.4 ± 11.3 203 4 <5 mo 3.6 18.2 78.1 133.0 ± 11.3 137 5 <6 mo 1.0 13.0 86.0 134.3 ± 9.8 100 Overall 21.4 22.5 56.1 124.9 ± 15.0 742 Sex Male 19.4 21.8 58.8 126.3 ± 15.6 376 Female 23.5 23.2 53.3 123.4 ± 14.3 366 20

Results Pre Harvest Mid Upper Arm Circumference (mm) % below 115 mm % 115 <125 mm % 125 mm and above Mean MUAC n <1 mo 86.9 13.1 0 101.4 ± 10.7 145 1 <2 mo 34.9 40.0 24.8 116.2± 12.7 129 2 <3 mo 14.4 37.8 47.7 124.3 ± 10.1 111 3 <4 mo 5.1 26.1 68.8 129.3 ± 10.7 157 4 <5 mo 2.5 18.5 79.0 133.8 ± 11.9 81 5 <6 mo 2.5 9.2 88.2 136.4 ± 11.3 119 Overall 27.0 24.3 48.8 122.5 ± 16.6 742 Sex Male 27.0 21.4 51.5 123.4 ± 16.7 402 Female 26.8 27.6 45.6 121.3 ± 16.4 340 21

Results Breastfeeding status Did you feed anything to the baby other than breast milk in last 24 hours? (No/Yes) Post Harvest No 397 (53.5%) Yes 345 (46.5%) Pre Harvest No 470 (63.3%) Yes 272 (36.6%) 22

Prospective Follow-up Study Objective To take infants with acute malnutrition and compare them with infants without acute malnutrition, to identify what the risk factors for malnutrition are av Looked at a large number of variables in order to identify which are the critical risk factors Once we know the risk factors, we will know what to look for to identify nutritionally vulnerable infants and also ensure these are addressed when managing nutritionally vulnerable infants 23

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25 av

MAMI Research in Bangladesh Methodology Prospective follow up study Group A: - Weight-for-length <-3 z-score and or - with presence of bilateral pitting oedema av - 4-8 weeks old of either sex Group B: - Weight-for-length -2 to <2 z-score - absence of bilateral pitting oedema - 4-8 weeks old and same sex of the corresponding child A Group C: - Mid Upper Arm Circumference <115 mm - Absence of any other signs of SAM - 4-8 weeks old of either sex 26

The results.. av 27

Socio economic Variables Infants were older in Group B compared to Groups A and C (will adjust for age) Household income per month was significantly lower in Group A compared to Groups B&C ($89 vs. $114) Lower number of households had electricity in Group A compared to groups B&C (61% vs. 78 80%) 28

WASH Variables/ Mothers Anthropometry Type of toilet was significantly different between the groups Group A had more people with a pit latrine vs. a flushing toilet compared to groups B&C NB: Hand washing and source of water were not significantly different between the groups Both mother s BMI and MUAC were less in Group A compared to groups B&C 29

Infant Feeding Variables Duration of exclusive breastfeeding was shorter in Groups A&C at enrolment and end line (at end line Group B had an average of 20 weeks, vs Group A with 13 weeks and Group C with 16 weeks) At end line, significantly less infants were still being breastfed in Groups A&C than in Group B More infants in Group A and C were fed anything other than breastmilk at enrolment and end line 30

Results Infant Feeding Variables Variables Breastfeeding currently, at end line, n (%) Yes Group A (n=77) Group B (n=77) Group C (n=77) P value n=69 n=77 n=71 <0.001 60 (87) a 72 (93) b, d 70 (98) c, d Fed anything other than BF in last 24 hours, at enrolment, n (%) Yes 26 (34) a 10 (13) b, d 18 (23) a, d Fed anything other than BF in last 24 hours, at end line, n (%) Yes Frequency of BF (times/d), at enrolment* n=65 57 (88) a 11.8 ± 3.5 a (n=74) n=72 56 (78) a, b 13.5 ± 2.6 b (n=77) n=70 64 (91) a, c 12.4 ± 2.5 a (n=77) 0.01 0.058 0.001 Frequency of BF (times/d), at end line* 9.9 ± 2.9 (n=60) 10.2 ±3.6 (n=72) 9.5 ± 2.9 (n=70) 0.93 *Mean ± SD; Median (IQR); ANOVA and Tukey test (as appropriate); Kruskal Wallis H test and Mann-Whitney U test (as appropriate); All tests of significance are Pearson Chi-Square test, unless mentioned; Level of significance <0.05; **Cells with different superscript letters are significantly 31 different;

Infant Feeding Variables Mothers in Groups A&C breastfed their infant less often than in Group B at enrollment and end line Mothers in Groups A&C were significantly less satisfied with how breastfeeding was going compared to Group B (showing confidence is extremely important) 32

Results Infant Feeding Variables Variables Mother's satisfaction with breastfeeding, at enrolment, % (n) Very satisfied Satisfied Neither satisfied nor dissatisfied Dissatisfied Very dissatisfied Mother's satisfaction with breastfeeding, at end line, % (n) Very satisfied Satisfied Neither satisfied nor dissatisfied Dissatisfied Very dissatisfied Group A (n=77) n=74 8 (6) a 48 (36) 22 (16) 19 (14) 3(2) n=63 6 (4) a 37 (23) 35 (22) 17 (11) 5(3) Group B (n=77) n=77 47 (36) b 33 (25) 10 (8) 5 (4) 5(4) n=72 28 (20) b, c 39 (28) 11 (8) 11 (8) 11 (8) Group C (n=77) n=77 24 (18) c 49 (38) 18 (14) 9 (7) 0 (0) n=70 9 (6) a, d 40 (28) 22 (16) 20 (14) 9 (6) *All tests of significance are Pearson Chi-Square test, unless mentioned; Level of significance <0.05; Cells with different superscript letters are significantly different P value <0.001 0.001 33

Infant Feeding Variables Infants in Groups A&C were given animal milk at an earlier age compared to infants in Group B NB: Duration of breastfeeding was not significantly different between the groups 34

Clinical Illness and Maternal Mental Health More infants in Group A had at least 1 episode of illness that required hospitalization at enrolment and it further raised up to 40% at the end line Proportionately more mothers were depressed in Group A than in Groups B&C 35

Outcomes of all Groups at 6 months? Around a quarter of the infants remained suffering from SAM in Group A Infant deaths were more in Group A and the cause of death found to be SAM Five percent of the infants in Group C became SAM at the end of the follow up period who were not diagnosed as SAM with the current existing criteria 36

Key Next Steps With prevalence survey data, will adjust for all variables to determine if seasonality is a key driver For cohort data, will combine use of infant formula with use of animal milks, as this will be good for policy work For cohort outcomes, critical to note that at 6 months 1/3 had negative outcomes (death, SAM, loss to follow up) so current treatment protocols are not working 37

Community-MAMI Guidance Note INFANT: TRIAGE: CHECK FOR GENERAL CLINCIAL DANGER SIGNS OR SIGNS OF VERY SEVERE DISEASE (for infant only) (A)NTHROPOMETRIC / NUTRITIONAL ASSESSMENT (B)REASTFEEDING ASSESSMENT (C)LINICAL ASSESSMENT av MOTHER: (A)NTHROPOMETRIC / NUTRITIONAL ASSESSMENT (B)REASTFEEDING ASSESSMENT (C)LINICAL ASSESSMENT (D)EPRESSION/ ANXIETY/ DISTRESS 38

Community-MAMI Guidance Note ASSESS CLASSIFY ACT Ask, Identify, (MANAGE) Listen Analyze Inpatient referral and care Priority 1 enrolment av into C- MAMI outpatient-based care Priority 2 enrolment into C- MAMI outpatient-based care Reassurance and discharge with general advice only 39

Piloting the C-MAMI Tool Margaret A. Cargill Foundation II Piloting the C-MAMI tool in Bangladesh and Myanmar Operational pilot comparing two av districts with the existing protocol vs. the C-MAMI tool Rigorously evaluated, tool updated and finalised Long-term objective is to roll out a package of outpatient care for nutritionally vulnerable infants globally 40

C-MAMI Tool Available on en-net http://www.ennonline.net/c-mami av 41

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