Wasting in West Africa

Roos Verstraeten, Dieynab Diatta, Lieven Huybregts, Jef Leroy, and Elodie Becquey

Wasting and wasting management

Globally, 49 million children under the age of five suffer from wasting (1). Child wasting dramatically increases the risk of death, killing 875,000 under-fives annually (2). All member states of the World Health Assembly (WHA) agreed to reduce and maintain the prevalence of child wasting to below 5% by 2025 (3). The prevalence of wasting, however, remains high in all West African countries (4), and time trends suggest the target will not be met in several of these countries, despite the commitment to address wasting expressed in their nutrition policies (5).

The Community-based Management of Acute Malnutrition (CMAM), which involves the screening and treatment of severe acute malnutrition at the level of community, is the current standard of care for uncomplicated severe acute malnutrition cases in low-income countries (6). Most countries have extended the CMAM approach to include treatment of children with moderate acute malnutrition (7). Scaling up CMAM for moderate and severe acute malnutrition is one of the most effective strategies to reduce child mortality with an estimated annual 450,000 deaths averted in children younger than 5 years if implemented at a coverage of 90% (8). Unfortunately, the treatment coverage of CMAM remains low in many settings (9). On the supply side, constraints include the complexity of treatment procedures and treatment platforms (both of which are specific to the severity of wasting) and frequent stockouts of treatment products. On the demand side, low participation in screening and poor uptake and adherence to treatment are key constraints to treatment effectiveness.

Recent research evidence on wasting management from the West African region

Transform Nutrition West Africa’s quarterly evidence tracker identified new evidence in the West African region related to wasting screening and treatment: one review synthesized evidence on new approaches to screening, another focused on a neglected clinical aspect of treatment and several primary studies provided insight on the optimization of treatment products. There was also a special issue on the “CMAM Surge” approach.

Reviews

The evidence tracker identified two different types of reviews which compiled and synthesized evidence from primary studies. A systematic review and meta-analysis synthesizes the evidence on dysglycemia in hospitalized children treated for SAM. The analysis of 16 studies revealed a 9% prevalence of hypoglycemia in SAM treated children and a higher likelihood of mortality in hypoglycemic children. UNICEF has released a rapid review that looks at the evidence on the Family-MUAC approach or “MUAC by mothers.” This method is mostly used in West and Central Africa and gives caregivers the tools to identify early signs of malnutrition in children. The authors reviewed 46 pieces of evidence (six peer-reviewed) and found that briefly trained caregivers are generally capable of correctly identifying wasting using a user-friendly mid-upper arm circumference (MUAC) tape. Refresher trainings might be required, and simplified measurement procedures might perform equally. The approach has potential to increase coverage of child screening for wasting. Further studies are needed though, to assess its effectiveness on timing of detection and quality of treatment, and its cost-effectiveness. Based on the review of operational documents, the author provides recommendations on the integration and approaches to training, monitoring and evaluation of the Family-MUAC approach.

Primary studies on MAM treatment

Our evidence tracker retrieved a randomized controlled trial on treatment for MAM in Burkina Faso. The trial compared the effectiveness on child development of 12 experimental supplementary food supplements based on Corn-Soy Blends (CSBs) or Lipid-based Nutrient Supplements (LNS), with either dehulled soy or soy isolate and with 0%, 20%, or 50% of total protein from milk. The authors found that after 12 weeks of treatment, all supplements improved child development indicators, and those supplements containing milk protein were more beneficial for fine motor and language development compared to supplements without milk protein. Twelve weeks post-treatment, child development indicators continued to improve in all groups, however, differences between supplements did not persist.

Primary studies on SAM treatment

Several studies were published on the use of RUTF to treat children with severe acute malnutrition. In Sierra Leone, a triple-blind, randomised controlled clinical trial compared oat-RUTF with standard RUTF and showed the oat-RUTF to be superior to the standard RUTF. These results are potentially due to the beneficial bioactive components or the absence of hydrogenated vegetable oil in oat-RUTF. Kangas et al. examined the change in body composition during outpatient treatment of Burkinabe children with severe acute malnutrition compared with community controls. They found that almost half of the weight gain during SAM treatment was fat free mass. There was no evidence of a differential effect of a reduced RUTF dose on body composition at recovery when compared to the standard treatment. Another manuscript on the same study assessed the changes in vitamin A and iron levels of children treated for SAM with RUTF, and explored the effect of a reduced RUTF dose. The findings reveal that reducing the dose of RUTF resulted in reduced hemoglobin concentration compared to receiving standard doses of RUTF but did not result in poorer vitamin A or iron status in children. Even though there was improvement in the vitamin A and iron status, they remained sub-optimal among successfully treated children. The authors use these results to argue a reconsideration of the RUTF fortification levels or test other potential strategies to restore the micronutrient status in children with SAM.

As CMAM gets to celebrate its twentieth anniversary the latest Field Exchange publication includes a special issue on the “CMAM surge” approach. A series of articles highlights the accomplishments and experiences of implementing the approach which aims to “improve the efficiency and effectiveness of treatment services for wasting during both normal and emergency periods. The approach uses routine CMAM services as an entry point to strengthen the capacity of health systems to better anticipate, prepare for and respond to peaks in caseloads of wasted children.”

Knowledge gap on prevention and upcoming research in the West African region

Besides the need to increasing screening and treatment coverage, effectiveness, and cost-effectiveness, further progress in reducing the burden of wasting will require a shift toward more effective prevention. However, programmatic evidence on how to prevent wasting remains limited (10). There is a growing body of evidence on the effectiveness of food supplements to prevent wasting, but little is known about the effectiveness of other strategies such as social behavior change communication (SBCC) (with or without food supplements), cash transfers, and water and sanitation interventions. In addition, the integration of prevention and treatment has received very little attention.

To fill this knowledge gap, UNICEF and IFPRI recently engaged in the Integrated Research on Acute Malnutrition (IRAM) partnership. In four countries in West and Central Africa, the partnership will study interventions that integrate wasting prevention and treatment. In Chad and Mali, following in-depth context analysis, IFPRI is designing randomized controlled impact evaluations that will generate robust evidence on the effectiveness of integrated interventions to address the persistently high levels of child wasting. The interventions, implemented by UNICEF and partner NGOs, will cover the full continuum of care for wasting, i.e. from prevention, screening, and treatment to the prevention of relapse. Community-level platforms will be leveraged to deliver these interventions in collaboration with first-line health services and NGOs active in the study districts.  The impact evaluation in these countries will be supplemented with a costing study and in-depth implementation research to assess implementation quality and to identify facilitators and barriers to effective implementation. In Mauritania and Niger, research will be limited to implementation studies. The IRAM evidence is expected to inform national, regional (West and Central Africa), and global policy on wasting.

Wasting rapid review

TNWA is currently performing a systematic mapping review The evidence mapping of wasting programmes and their impact along the continuum of care for wasting in low- and middle-income countries: a rapid review protocol which aims to give an appreciation of both the quantity and effectiveness of existing interventions and programmes on wasting while identifying research gaps in the management of wasting. This will be applied to low-and middle income countries and can be used as a guide for future programming decisions and guidelines.

References

1. UNICEF/WHO/The World Bank Group joint child malnutrition estimates: levels and trends in child malnutrition: key findings of the 2020 edition [Internet]. [cited 2020 Oct 3]. Available from: https://www.who.int/publications/i/item/jme-2020-edition
2. Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, De Onis M, Ezzati M, Grantham-Mcgregor S, Katz J, Martorell R, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 2013;382:427–51.
3. Resolution WHA65.6. Comprehensive implementation plan on maternal, infant and young child nutrition. Sixty-fifth World Health Assembly, Geneva, 21–26 May 2012 [Internet]. Geneva; 2012 [cited 2020 Jan 6]. Available from: https://www.who.int/nutrition/topics/WHA65.6_resolution_en.pdf?ua=1
4. World Health Organization. Global Database on Child Growth and Malnutrition [Internet]. Available from: https://www.who.int/nutgrowthdb/en/
5. World Health Organization. Global Database on the Implementation of Nutrition Action [Internet]. Available from: https://extranet.who.int/nutrition/gina/en/policies/summary
6. World Health Organization, World Food Programme, United Nations System Standing Committee on Nutrition, United Nations Children’s Fund. Community-based management of severe acute malnutrition. A Jt Statement by World Heal Organ World Food Program United Nations Syst Standing Comm Nutr United Nations Child Fund. 2007;7.
7. World Health Organization. Technical note: Supplementary foods for the management of moderate acute malnutrition in infants and children 6–59 months of age. 2012 Dec.
8. Bhutta ZA, Das JK, Rizvi A, Gaffey MF, Walker N, Horton S, Webb P, Lartey A, Black RE. Evidence-based interventions for improvement of maternal and child nutrition: What can be done and at what cost? Lancet. 2013;382:452–77.
9. IFPRI. Taking Action: Progress and Challenges in Implementing Nutrition Policies and Programs. 2016 Global Nutrition Report – From Promise to Impact: Ending Malnutrition by 2030. Washington DC;
10. ENN. The Current State of Evidence and Thinking on Wasting Prevention Final Report About MQSUN +. 2018;72. Available from: https://www.ennonline.net/attachments/3045/MQSUN-_State-of-Evidence-and-Thinking-on-Wasting.pdf