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A conceptual A conceptual framework for framework for Project MAMIProject MAMI

(Management of Acute Malnutrition in (Management of Acute Malnutrition in Infants 0-5.9m)Infants 0-5.9m)

Towards a common understanding of the Towards a common understanding of the causes and classification of infant causes and classification of infant

malnutritionmalnutrition

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NB. DRAFT!!!NB. DRAFT!!!

THANK YOU FOR COMMENTS / THANK YOU FOR COMMENTS / FEEDBACK!!!FEEDBACK!!!

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AIMAIM

To investigate To investigate

the management of the management of

acutely (moderately and severely) malnourishedacutely (moderately and severely) malnourished

infants under six months age (0-5.9m)infants under six months age (0-5.9m)

in emergency programmes, in order toin emergency programmes, in order to

establish consensus establish consensus

on (interim) good practice guidelines:on (interim) good practice guidelines:

‘‘DOABLE’DOABLE’

EVIDENCE BASEDEVIDENCE BASED

INDIVIDUAL(CLINICAL) vs INDIVIDUAL(CLINICAL) vs PUBLIC HEALTHPUBLIC HEALTH

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To discussTo discuss

1.1. What do we mean by “malnutrition” What do we mean by “malnutrition” (10mins)(10mins)

2.2. Conceptual framework for causes of acute Conceptual framework for causes of acute malnutrition in infants 0-5.9m (10mins)malnutrition in infants 0-5.9m (10mins)

3.3. Way forward for MAMI: (10mins)Way forward for MAMI: (10mins) FOCUS: FOCUS: What do you need from the projectWhat do you need from the project SCOPE: SCOPE: What data is availableWhat data is available

what is realistic to do within the what is realistic to do within the timeframetimeframe

OUTPUTS: What like to seeOUTPUTS: What like to see OTHER….OTHER….

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Why does MAMI need a Why does MAMI need a conceptual framework?conceptual framework?

Classification of malnutrition in infants 0-5.9m Classification of malnutrition in infants 0-5.9m is not simpleis not simple

Preventative as well as curative interventions Preventative as well as curative interventions are vital for the ‘management’ of acute are vital for the ‘management’ of acute malnutritionmalnutrition

Developing a common understanding of:Developing a common understanding of: What causes are What causes are How to classify cases How to classify cases

is therefore important as we start is therefore important as we start the projectthe project

JOINT UNDERSTANDING JOINT UNDERSTANDING BETTER COMMUNICATION BETTER COMMUNICATION (internal AND external…) (internal AND external…)

MAMI 6

1st: What do we mean by ‘Malnutrition’A (DRAFT) Working Classification

Infant ‘Malnutrition’

WHO: 0-1.9m; 2-3.9m; 4-5.9m

WHAT: ‘looks malnourished’; WA; WH; HA; other

HOW low (cutoff; z-score; %med; NCHS vs WHO)

Low birth weight Post-natal malnutrition

Term(SGA / IUGR)

Preterm (AGA)

Acute Acute (Wasting)(Wasting)

Underweight(mix acute /

chronic)

“Catch-up”growth

Static growth /Further dropDown centile

Growing, but remains onlow centile

1) This row repeats for each box above

2) But…. is growth monitoring available?

Chronic(Stunting)

?? (how) can we distinguish??

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The UNICEF The UNICEF Conceptual FrameworkConceptual Framework

MAMI 8

(DRAFT) Expanded Framework for 0-5.9m

A) CURRENTLY ‘EBF’

B) NOT CURRENTLY

EBF(BMS

=whole/part of diet

Disease- Acute - infection

-BMS related-(pneumo, GE, sepsis)

- Malabsorbtion - Chronic - Syndrome (Downs, other)

- Metabolic-- congenital infection.

-treatable – e.g. syphilis-??treatable-CMV, rubella

- HIV- TB

?constitutional?

INADEQUATE INTAKE +INADEQUATE ACCESS

MAMI 9

(DRAFT) Expanded Framework for 0-5.9m

INSUFFICIENT HEALTH SERVICES &

UNHEALTHY ENVIRONMENT1)Myths & misconceptions

-’stress’ & BF2)TREATABLE disease not adequately

treated 3)Inadequate clean water (quality;

quality)

INADEQUATE CARE 1) Reduced time for infant feeding

-economic factors-- employment law / conditions

2)BF ‘Environment’ difficult- cultural / employment / religious

issues3) Orphans

4) Myths & Misconceptions

?constitutional?

MAMI 10

(DRAFT) Expanded Framework for 0-5.9m

A) CURRENTLY EBF

i) Suboptimal BF performance:

a) Infant reasons-- ‘skills’ e.g. dev. delay/CP -- illness (acute)-- Congenital problem - e.g cleft palate

b) Maternal reasons:- Skills- Lack of emotional support- Psychological (clinical depression)- Severe maternal malnutrition (macronuts)-Severe maternal malnutrition (micronuts)

ii) Ex premature inf - increased micronut needs

B) NOT CURRENTLY EBF

- Inadequate quantity of BMS (formula/other milk/ solid food)- Inadequate quality of BMS - inappropriate dilution - inappropriate BMS - inadequate equipment - inadequate fuel

a) No chance resume BF

-orphan, no wetnurse

ib Possibility to resume BF - HIV related choice

Frequent pregnancy

INSUFFICIENT HEALTH SERVICES &

UNHEALTHY ENVIRONMENT

1)Myths & misconceptions -’stress’ & BF

2)TREATABLE disease not adequately treated

3)Inadequate clean water (quality; quality)

INADEQUATE CARE 1) Reduced time for infant

feeding-economic factors

-- employment law/conditions

2)BF ‘Environment’ difficult- cultural / employment /

religious issues3) Orphans

4) Myths & Misconceptions

Disease- Acute - infection

-BMS related-(pneumo, GE, sepsis)

- Malabsorbtion - Chronic - Syndrome (Downs, other)

- Metabolic-- congenital infection.

-treatable – e.g. syphilis-??treatable-CMV, rubella

- HIV- TB

?constitutional?

INADEQUATE INTAKE +

INADEQUATE ACCESS

MAMI 11

Other Aspects - Critical but outside project scope

Factors to note:

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WAY FORWARDWAY FORWARD

FOCUS: FOCUS: What do you need from What do you need from the the project?project?

SCOPE: SCOPE: What data is available?What data is available?

What is realistic to What is realistic to do within the do within the timeframe?timeframe?

OUTPUTS: OUTPUTS: What would you like What would you like to see?to see?

OTHER….OTHER….

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Invitation to CollaborateInvitation to Collaborate

Please help us develop the evidence base to Please help us develop the evidence base to improve the management of malnourished young improve the management of malnourished young infantsinfants

Project websites:Project websites:

http://www.ucl.ac.uk/cihd/research/nutrition/mamihttp://www.ucl.ac.uk/cihd/research/nutrition/mami

http://www.ennonline.net/ife/ http://www.ennonline.net/ife/

Contact: Marko KeracContact: Marko Kerac

Email: marko.kerac@gmail.comEmail: marko.kerac@gmail.comomom

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MAMIMAMI(Management of Acute Malnutrition (Management of Acute Malnutrition

in Infants)in Infants)

Funded by UNICEF-led IASC Funded by UNICEF-led IASC Nutrition Cluster Nutrition Cluster

A retrospective review A retrospective review

of the current field management of of the current field management of

acutely malnourished infants under 6 acutely malnourished infants under 6 months of agemonths of age

http://www.ucl.ac.uk/cihd/research/http://www.ucl.ac.uk/cihd/research/nutrition/maminutrition/mami

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AIMAIM

To investigate To investigate the management of the management of

acutely (moderately and severely) acutely (moderately and severely) malnourishedmalnourished

infants under six months age (0-5.9m)infants under six months age (0-5.9m)in emergency programmes, in order toin emergency programmes, in order to

establish consensus establish consensus on (interim) good practice guidelineson (interim) good practice guidelines

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ObjectivesObjectives

1)1) To establish what currently is To establish what currently is advised or recommended in the advised or recommended in the form of guidelines, policies and form of guidelines, policies and strategies by different strategies by different organisations.organisations. Particularly to consider: Particularly to consider:

- admission and discharge criteria- admission and discharge criteria- therapeutic management- therapeutic management- care practices & psychosocial - care practices & psychosocial

supportsupport- breastfeeding support- breastfeeding support

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ObjectivesObjectives

2)2) To determine what is carried out in To determine what is carried out in practicepractice- are policies reflected by practice?- are policies reflected by practice?- numbers and % of TFP/SFP admissions 0-5.9m age- numbers and % of TFP/SFP admissions 0-5.9m age- numbers admitted vs numbers expected - numbers admitted vs numbers expected (DHS (DHS surveys)surveys) (proxy measures of (proxy measures of coverage)coverage)

To examine current outcomes for 0 – To examine current outcomes for 0 – 5.9m infants5.9m infants- what affects outcomes? - what affects outcomes? - key contextual factors - key contextual factors ((modifablemodifable vs non-modifiable)vs non-modifiable)- what are key challenges and constraints?- what are key challenges and constraints?

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CollaborationCollaboration

TO BE OF TO BE OF PRACTICAL RELEVANCE PRACTICAL RELEVANCE

TO FIELD-BASED PROGRAMMES:TO FIELD-BASED PROGRAMMES: We need your inputs We need your inputs NOW…NOW…

*** INVITATION TO COLLABORATE ****** INVITATION TO COLLABORATE ***

The closer our collaboration… The closer our collaboration… The better & more useful the final The better & more useful the final

outputs…outputs…

Interagency Steering GroupInteragency Steering GroupResearch Advisory GroupResearch Advisory Group

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BackgroundBackground

Very few formal research studies Very few formal research studies investigating acute malnutrition in investigating acute malnutrition in infants 0- 5.9 months of ageinfants 0- 5.9 months of age

Poor evidence base upon which to base Poor evidence base upon which to base field guidance materialsfield guidance materials

Difficult to know how best to support Difficult to know how best to support these infants in practicethese infants in practice

Many current malnutrition strategies Many current malnutrition strategies do not specifically address the needs of do not specifically address the needs of this age groupthis age group

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BackgroundBackground Over 6 years of published concerns, Over 6 years of published concerns,

documented field experiences and debate by documented field experiences and debate by ENN and by the IFE Core Group ENN and by the IFE Core Group

WHO Technical review of the Management of WHO Technical review of the Management of Severe Acute Malnutrition (2004):Severe Acute Malnutrition (2004):

“ “ No new research was identified No new research was identified pertaining to the optimum dietary pertaining to the optimum dietary management of severely malnourished management of severely malnourished infants aged < 6 months. The evidence infants aged < 6 months. The evidence base for defining the most base for defining the most advantageous formulations for feeding advantageous formulations for feeding this age group remains weak ”this age group remains weak ”

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Field RealityField Reality Young infants still present to field based Young infants still present to field based

programmes !programmes !

Variable capacity and skills to manage Variable capacity and skills to manage them:them: Some programmes good Some programmes good we need to learn from we need to learn from

them them Some ‘could be better’Some ‘could be better’

Lactating women with infants 0-5.9 months Lactating women with infants 0-5.9 months may be admitted to Supplementary Feeding may be admitted to Supplementary Feeding Programmes (SFPs),Programmes (SFPs), But…But… No standard guidance on the breastfeeding & infant No standard guidance on the breastfeeding & infant

feeding support that should form part of the package feeding support that should form part of the package of care.of care.

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Field Reality & Field Field Reality & Field EvidenceEvidence

Operational agencies undertake different Operational agencies undertake different types of intervention sometimes guided by types of intervention sometimes guided by applied / operational research. applied / operational research.

field field experience is experience is growing / significantgrowing / significant……

But…But…

Field evidence too often hidden…Field evidence too often hidden… Programme data collected Programme data collected

but not formally analysedbut not formally analysed Internal reports written Internal reports written

but not routinely disseminated / sharedbut not routinely disseminated / shared

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Why field evidence is Why field evidence is vitalvital

‘‘Background’ for changes in official guidance Background’ for changes in official guidance (WHO)(WHO) Knowing about current field practices Knowing about current field practices

helps inform, target, and manage changehelps inform, target, and manage change Stronger understanding of ‘who does what, where’ for MAMI Stronger understanding of ‘who does what, where’ for MAMI

directly facilitates future collaborations and research directly facilitates future collaborations and research

Project ownershipProject ownership Collaborations and partnerships during the review process Collaborations and partnerships during the review process

project more focused, more relevant to field project more focused, more relevant to field organizationsorganizations

Shared project ownershipShared project ownership

guidelines & recommendations more likely to be taken guidelines & recommendations more likely to be taken upup

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Planned Project OutputsPlanned Project Outputs (Interim)(Interim) ‘Best Practice’ guidelines ‘Best Practice’ guidelines

~ Based on best ~ Based on best currently availablecurrently available evidence evidence~ Explicit about underlying evidence (or lack of) ~ Explicit about underlying evidence (or lack of)

for each step for each step

Research AgendaResearch Agenda~ Understanding of gap areas ~ Understanding of gap areas can suggest can suggest

specific studiesspecific studies

Bigger IYCF pictureBigger IYCF picture~ Consider management strategy in the context of ~ Consider management strategy in the context of

IYCF recommendations for general populationIYCF recommendations for general population

Strengthened organizational linkages / ongoing Strengthened organizational linkages / ongoing collaborative effortscollaborative efforts

~ Supporting guideline implementation~ Supporting guideline implementation~ Facilitating new or ongoing research / ~ Facilitating new or ongoing research /

operational researchoperational research

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Results DisseminationResults Dissemination

ENN Special Supplement ENN Special Supplement

Peer reviewed paper(s)Peer reviewed paper(s)

International fora:International fora: IASC Nutrition Cluster meetingsIASC Nutrition Cluster meetings UN SCN meeting in 2009 UN SCN meeting in 2009

Inputs into review / update of WHO Inputs into review / update of WHO guidance for Management of Acute guidance for Management of Acute MalnutritionMalnutrition

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Some contextual issuesSome contextual issues

The rise of CMAM (CTC)The rise of CMAM (CTC) What place for young infants within current What place for young infants within current

CMAM contexts?CMAM contexts? What place for young infants in future What place for young infants in future

projects?projects?

Rollout of new WHO standardsRollout of new WHO standards Numbers diagnosed with SAM/MAM differ if Numbers diagnosed with SAM/MAM differ if

NCHS referencesNCHS references vsvs new WHO new WHO standardsstandards

% of median % of median vsvs Z-scoreZ-score

Understand likely effects of change in Understand likely effects of change in diagnostic criteriadiagnostic criteria

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Other issues to discuss..Other issues to discuss..

? Disaggregate? Disaggregate age groups (0-1.9m, 2-3.9m, 4-5.9m)age groups (0-1.9m, 2-3.9m, 4-5.9m)

? ‘malnutrition’ aetiology: ? ‘malnutrition’ aetiology:

ex-premature infants; LBW infants; postnatal growth failure aloneex-premature infants; LBW infants; postnatal growth failure alone

? Infants older than six months but less than 4kg? Infants older than six months but less than 4kg

? HIV related issues? HIV related issues

‘‘rapid weaning’ of breastfed infants at ~6 months of agerapid weaning’ of breastfed infants at ~6 months of age

? Focus on NGO programmes (?context of other ? Focus on NGO programmes (?context of other

services/providers) services/providers)

? Other ? Other YOUR inputs /ideas / comments are YOUR inputs /ideas / comments are

CRITICAL…CRITICAL…

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Please get involved…Please get involved…

*** ‘INVITATION TO COLLABORATE’ *** ‘INVITATION TO COLLABORATE’

document *** document ***

** Special session MAMI WEDNESDAY ** Special session MAMI WEDNESDAY

7pm **7pm **

* email: * email: marko.kerac@gmail.com * *