Description of the condition
Malnutrition is responsible for more than half of the 10 million deaths annually among children under the age of five in low- and middle-income countries. Both chronic and acute malnutrition are now considered as major threats to public health in these countries (Black 2003; Caulfield 2002; Rice 2000). Sub-Saharan Africa and South-Asia have the highest prevalence, with approximately 73 million children under five suffering from acute malnutrition (Collin 2006a; Schofield 1996). Acute malnutrition includes undernutrition (low weight-for-age) and wasting (low weight-for-height), and is associated with serious morbidity and high mortality (Cauldwell 2004; Collin 2006; Collin 2006a; Pelletier 2003). Severe acute malnutrition (SAM) is a serious and major challenge to achieving the Millenium Development Goals for reducing mortality in under-fives (Mason 2003; Pelletier 2003; UNICEF 2010; WHO 2007). Globaly, around 20 million under-five children are suffering from severe acute malnutrition, mostly in Sub-Saharan Africa and Asia. (UN 2007) The prevalence of SAM is as high as 6% in Pakistan and 2.8% in India. Similarly, in these countries, 1-1.5 million deaths (mortality rate 73 to 187 per 1000 per year) are associated with this condition annually (Andre 2006; Collin 2006, UN 2007).
SAM or wasting is predominantly measured by one or more of the following criteria:
Weight-for-height (WFH) less than -3 Z-scores (i.e. three standard deviations, or more, below the mean);
Weight-for-height less than 70% of the median;
Mid-upper-arm circumference (MUAC) less than 11.5 cm or 115 mm;
In this review we will include only children with uncomplicated SAM, aged from six months to 59 months, with any of the above criteria. SAM requires a very specialised and organised set up of management protocols, treatment guidelines and preventive measure to achieve control and reduction of prevalence in low- and middle-income countries (Collin 2006a).
Management of uncomplicated SAM was based on World Health Organization (WHO) standard protocol(s) that included individual in-patient care, nutritional rehabilitation, medical treatments and family counselling (Carlos 2002; SPHERE 2004; WHO 1999; WHO 2006). Conventionally, uncomplicated SAM cases are managed at the health facility level, commonly known as 'therapeutic feeding centres' (Grobler-Tanner 2004; Khanum 1994), although patients may require admission to the health facility for the entire duration of treatment. Normally, length of stay would be around three weeks, however, this could be longer if the child remains unstable (Bachmann 2010; Gatchell 2006). Prolonged hospital stays utilise more resources in terms of cost, and impose a burden that eventually limits the programme coverage, and, ultimately, reduces beneficial impact on the population (Grobler-Tanner 2004). However, this model has been considered to be very successful because it has been associated with good clinical outcomes and reduced SAM-associated mortality (ENN/FANTA 2008; Khara 2004; Collin 2003).
The health-facility management model, however, has received some criticism in the past few decades; one of its major weaknesses is that it does not take into account certain important factors in hospitalisation of these sick children. Notably, these include socioeconomic factors, such as: workload of women in a rural setting; family size, and other children at home (Carlos 2002); usual health care-seeking behaviour of parents and access of community to health-care services; all of which play a key role in deciding whether or not a child is treated for certain illnesses (Babar 2008). There is also a huge burden on tertiary care, especially in resource-poor settings where primary- and secondary-care level facilities are under utilised (Babar 2008; Carlos 2002).
Furthermore, this in-patient care requires parents or caregivers to stay with the child until complete rehabilitation is achieved (Grobler-Tanner 2004). This can be too much of a burden in a situation where a child has uncomplicated SAM. Such cases can be managed and rehabilitated at community level, without creating any burden on tertiary-care settings or on families. Referral to a tertiary-care setting may have a financial impact on poor families in terms of out-of-pocket expenditure during the hospital stay (Carlos 2002; Khara 2004). In addition, hospitalisation exposes the severely and acutely malnourished child to nosocomial infections (hospital-acquired infections), which can complicate the hospital treatment (Carlos 2002; Khara 2004).
Description of the intervention
In the last few decades, there has been a paradigm shift in the management of acute malnutrition from a facility-based to community-centred approach utilising mobile teams and primary-care health centres (Ashworth 2001; Collin 2001). The modern community approach is usually known as 'community-based management of acute malnutrition' (ENN/FANTA 2008). The focus of this latest approach is to treat the majority of acutely malnourished children in the community utilising the primary health services. The aim of this approach is to reduce the unnecessary referral burden on tertiary or in-patient care, which is frequently overcrowded by acutely malnourished children without complications - cases that can be treated and managed easily at the community level, without referral to hospital (Collin 2006; Deconink 2008).
The community-based approach uses a network of out-patient treatment sites to provide a take-home food ration known as 'ready-to-use therapeutic food' along with essential medicines (7 days course oral Amoxicillin) as prophylaxis against pneumonia and other respiratory illnesses in uncomplicated SAM case. (Carlos 2002; ENN/FANTA 2008; Manary 2004). The results of community-based management of acute malnutrition are satisfactory; overall it produces improved clinical outcomes and reduced mortality rates in acutely malnourished children (Collin 2003,Collin 2003). Community-based management of acute malnutrition involves direct community engagement. It provides a framework for an integrated public-health response to address acute malnutrition by managing, treating and preventing deterioration in most children with a moderate level of acute malnutrition and uncomplicated SAM at the household level, and reserving in-patient care for complicated cases (Deconink 2008) (Figure 1). Its decentralised approach minimises geographical barriers to access to care in both humanitarian and non-humanitarian situations (Collin 2001; Deconink 2008; UN 2008).
How the intervention might work
The WHO had classified acute malnutrition into moderate and severe malnutrition based on anthropometric measures and the presence of bilateral pitting oedema (Collin 2003; Deconink 2008; WHO 1999). With the paradigm changing from facility-based to community-based management of acute malnutrition, the classification, referral criteria and management protocol were re-visited. The new classification now splits acute malnutrition into 'moderately malnourished', 'SAM without complications' and 'SAM with complications'. Referral criteria have been re-designed according to this new classification in order to be operationally compatible with community-based management of malnourished children in middle- and low-income countries (Collin 2003). (The new classification is presented in detail in Figure 2) Hence, by using this new strategy proposed by the WHO, the United Nations Children's Fund (UNICEF), Save the Children etc, a large number of children with uncomplicated SAM can easily be managed at the community level, without being admitted to a health facility or a therapeutic feeding centre (Allen 2001). The community-based management approach encompasses timely detection of SAM in children, and ensures provision of treatment for those without medical complications (Collin 2002).
Community-based management has four core components that address the basic referral system according to the classification of SAM:
'Community mobilisation or outreach' is a broad component that focuses on strengthening the role of traditional leaders, healers and other people within the community to enhance mobilisation, participation and engagement in the programme, thus maximising beneficial outcomes of the intervention (Bandawe 2003; Collin 2003).
The 'supplementary feeding program', focuses on moderately malnourished children and uses standard protocols to manage them with ready-to-use supplementary food. This component has mostly mobile health coverage, and provides follow-up treatment at home, within the community, or, in some cases, at the health facility.
The 'out-patient therapeutic program' rehabilitates and follows children with uncomplicated SAM in the community within existing primary health-care infrastructure at static sites (Collin 2003). The main focus is to manage the child with high energy food supplements, ready-to-use therapeutic food and other community-based protocols for treatment.
'Stabilisation centres' are specialised centres that provide in-patient care for stabilisation and rehabilitation of children with SAM and its complications, and identify and treat life-threatening problems, specific deficiencies and metabolic abnormalities, using standard feeding formulas of F100/F75 and treatment protocols (Bachmann 2010; Collin 2003; WHO 1999). Once a child meets the discharge criteria, its follow-up will be conducted at out-patient treatment sites and through other components of the community-based management system, until it reaches the point of complete recovery (Collin 2006).
Why it is important to do this review
There are a few fundamental questions that will form the core of this review. Firstly, is not clear at present how the outcomes compare for children with uncomplicated SAM treated through the out-patient component of the community-based approach compared to those treated through the old health facility-based approach.
Secondly, at present large investments are being used to promote community-based management of acute malnutrition in low- and middle-income countries, especially during humanitarian crises. However, whether the community-based approach is applicable and feasible within routine health programmes in non-emergency situations is not clear. There are strong recommendations to scale-up the community-based approach for children with uncomplicated SAM. Very few studies have looked at the effectiveness of community-based management of acute malnutrition compared to the traditional approach of facility-based treatment for uncomplicated SAM. Community-based care with ready to-use therapeutic food has been suggested as being a virtuous way to confront uncomplicated SAM in low- and middle-income settings, but the efficacy, effectiveness, and cost-effectiveness of this modern approach compared to the traditional approach of a health facility based in poor health districts with local staff is still unproven (Ashworth 2001; Ashworth 2006; Collin 2006).
Lastly, other aspects, including the coverage and effective implementation of the community-based approach, and a review of existing programmes run by routine health services, need to be compared with traditional approaches in order to generate the most robust evidence on uncomplicated SAM (Ciliberto 2005; Collin 2006), therefore, we want to look at both approaches from every critical aspect of managing uncomplicated SAM.
Comparison of management of uncomplicated SAM through a health facility-based approach against a community-based approach is imperative, and there is a strong need for policy direction for all the key stakeholders who may require more robust evidence for the decisions required to scale-up community-based management of acute malnutrition at national level, and to integrate it into the existing health system.