Community management of acute malnutrition (CMAM) programme in Pakistan effectively treats children with uncomplicated severe wasting.

Abstract Severe wasting is the most widespread form of severe acute malnutrition, affecting an estimated 17 million children globally. This analysis assesses the effectiveness of Pakistan's community management of acute malnutrition (CMAM) programme. We conducted a retrospective case series analysis of 32,458 children aged 6–59 months who were admitted to the programme with a mid‐upper arm circumference (MUAC) < 115 mm (January 1–December 31, 2014). We found that at admission, 59.6% of the children were girls and 87.4% were in the age group 6–23 months old. While in the programme, 120 children (0.4%) died, 3,456 (10.6%) defaulted, and 28,882 (89.0%) were discharged after a mean length of stay of 69.3 ± 25.7 days. Children's mean weight gain while in the programme was 3.2 ± 2.7 g/kg body weight/day. At discharge, 28,499 children (98.7% of discharged) had recovered (MUAC ≥ 125 mm). The odds of death were significantly higher among children with weight‐for‐height (WHZ) < −3 and/or height‐for‐age (HAZ) < −2 at admission. The odds of recovery on the basis of MUAC ≥125 mm were higher among children with HAZ ≥ −2 at admission. The odds of recovery on the basis of WHZ ≥ −2 were significantly higher among children with WHZ ≥ −3 and/or HAZ < −2 at admission. Pakistan's CMAM programme is effective in achieving good survival and recovery rates. Population‐level impact could be increased by giving priority to children 6–23 months old and children with multiple anthropometric failure and by scaling up CMAM in the provinces and areas where the risk, prevalence, and/or burden of severe acute malnutrition is highest.


| INTRODUCTION
Severe wasting is the most widespread form of severe acute malnutrition (SAM), affecting an estimated 16.4 million children globally (UNICEF, World Health Organization (WHO), & World Bank Group, 2018). Severe wasting in children aged 6-59 months is defined as a weight-for-height z-score (WHZ) < −3 or a mid-upper arm circumference (MUAC) < 115 mm (WHO & UNICEF, 2009). Severe wasting is driven by poor maternal nutrition, poor complementary feeding practices, seasonal food insecurity, environmental enteropathy, and chronic/acute infections (Trehan & Manary, 2015).
Mortality rates in severely wasted children are 9 times higher than in children who are not wasted (Black et al., 2008). Therefore, the early detection and treatment of severe wasting is an evidence-based nutrition intervention that improves child survival, growth, and development (WHO, 2013a). The WHO and UNICEF recommend that children with medically complicated severe wasting be treated as inpatients in a facility, whereas children with medically uncomplicated severe wasting should be treated at home with the support of a community-based programme for the management of acute malnutrition (CMAM; WHO, 2013b). When active case finding and early detection strategies are in place, 90-95% of affected children can be treated in the community using the CMAM approach . Further, programmatic evidence supports the use of ready-to-use therapeutic foods (RUTF) in CMAM programmes (Collins, 2004). The shift from facility-based care to community-based care combined with the effectiveness of RUTF has allowed CMAM programmes to grow rapidly, treating an increasing number of children cost-effectively (Bhutta et al., 2013).
The majority of children suffering from severe wasting live in Asia.
In 2014, five Asian countries were home to about 12 million children with severe wasting (i.e.,~70% of the global burden; Ahmed et al., 2014). Pakistan is at the centre of this crisis. The latest surveys indicated that the proportion of children aged 0-59 months who were wasted ranged between 10.8% and 15.1% whereas the proportion of children who were severely wasted ranged between 3.3% and 5.8% (Government of Pakistan, 2013;National Institute of Population Studies, 2013). In 2014, it was estimated that 3.3 million children aged 0-59 months were wasted and 1.2 million were severely wasted (Ahmed et al., 2014;Government of Pakistan, 2014).
The Government of Pakistan has adopted CMAM to provide care for children with acute malnutrition. National guidelines were initially developed in 2010 and were subsequently updated in 2015 as new evidence emerged (Government of Pakistan, 2014). They provide technical guidance for the management of acute malnutrition both in government-led programmes and in those supported by development partners and non-governmental organizations (NGOs).
The aim of this analysis is to assess the effectiveness of Pakistan's CMAM programme in providing care for children with severe wasting.
The objectives are (a) to estimate death, default, discharge, and recovery rates among children admitted to the programme between January 1 and December 31, 2014; (b) to estimate mean weight gain, length of stay, and number of follow-up visits among such children as a function of their nutritional status at admission and the discharge criteria used; and (c) to make recommendations-on the basis of our findings-for the design and implementation of programmes for children with SAM in Pakistan and South Asia.

| METHODS
Pakistan's CMAM programme encompasses three components: (a) early detection of children with SAM through community outreach and active case finding to maximize coverage and impact; (b) inpatient therapeutic care in a stabilization centre (SC) for children with medically complicated SAM; and (c) outpatient therapeutic care through the outpatient therapeutic programme (OTP) for children with medically uncomplicated SAM.

| Early detection through community outreach
Wherever the CMAM programme is implemented, the detection of children with SAM is systematically ensured by health workers, which include Lady Health Workers and Community Midwives, sometimes supported by volunteers. Where NGOs operate, community outreach workers are often recruited to assist with case finding and follow-up.
Health workers and community outreach workers systematically screen children at paediatric wards and health facilities, through health campaigns, outreach programmes, child growth monitoring sessions, house-to-house visits, and other opportunities.

| Inpatient therapeutic care at SCs
Children with (a) bilateral pitting oedema +++, (b) children with MUAC < 115 mm and poor/no appetite, and (c) children with MUAC < 115 mm and medical complications are referred to the SC where they are treated following guidelines for the management of SAM based on those by WHO (2013c). Once stabilized (i.e., oedema resolves, medical complications are treated, appetite returns, and weight gain starts), children are discharged to the outpatient component of the programme.

| Outpatient therapeutic care at OTPs
Children (a) who have been discharged from the SC and (b) children with MUAC < 115 mm, with appetite and free of medical complications, are admitted to the OTP, where they receive routine medication,

Key messages
• In 2014, 32,458 children aged 6-59 months were admitted to Pakistan's CMAM programme (MUAC < 115 mm): 60% of the children were girls, and 87% were in the age group 6-23 months old.
At discharge, 98.7% of the children had recovered.
• Pakistan's CMAM programme is effective in achieving good survival and recovery rates. Population-level impact could be increased by scaling up CMAM in the provinces/areas where the risk, prevalence, and/or burden of severe acute malnutrition is highest. standard therapeutic feeding with RUTF (with a nutrient composition as per WHO standards), and regular visits to the health facility or the Health Houses of the Lady Health Workers in the community." Children attend the OTP site every week or every 2 weeks (depending on the OTP site). At each follow-up visit, child's weight is monitored and the caregiver of the child is counselled on optimal infant and young child feeding practices, with a primary focus on how to sustain optimal breastfeeding and improve the quality of complementary foods and feeding practices in infants and young children aged 6-23 months.
Children are discharged from the OTP when they (a) have completed a minimum of 8 weeks in the programme and (b) have an MUAC ≥ 125 mm for two consecutive visits. Children who are absent for two consecutive visits (if OTP runs every 2 weeks) or three consecutive visits (if OTP runs every week) are defaulters. Children who do not reach the discharge criteria within 16 weeks are discharged as nonrecovered.
To evaluate the effectiveness of Pakistan's CMAM programme, we use a retrospective case series design to analyse programme outcomes in 32,458 children aged 6-59 months old who were admitted to the CMAM programme with an MUAC < 115 mm between January 1 and

| Outcomes among children with MUAC data at admission
The following outcomes were recorded among 32,458 children with MUAC < 115 mm at admission. Deaths: 120 children (0.4%) died while in the programme. Their mean length of stay in the programme was 39.7 ± 24.6 days. Defaulters: 3,456 children (10.6%) defaulted the programme. Their mean length of stay in the programme was 52.8 ± 33.4 days. Discharged: 28,882 children (89.0%) were discharged after a mean length of stay of 69.3 ± 25.7 days and 3.2 ± 3.5 follow-up visits (Tables 2 and 3).    Table 4).
Children's mean weight gain during their stay in the programme was 3.4 ± 6.8 g/kg body weight/day. Mean weight gain was higher among children who were discharged recovered (MUAC ≥ 125 mm) than among children who had not recovered (MUAC < 125 mm) at discharge (3.4 ± 6.9 vs. 1.4 ± 2.3 g/kg body weight/day; p < .05), whereas the mean length of stay in the programme was longer in children who had not recovered at discharge (MUAC < 125 mm) than among children who had recovered (MUAC ≥ 125 mm) at discharge (97.4 ± 35.2 vs. 63.6 ± 19.9 days; p < .05) and so was the mean number of follow-up visits tended to be greater (7.8 ± 4.7 vs. 5.2 ± 3.2; p < .05). Similarly, mean weight gain and length of stay in the programme tended to be higher among children who were admitted with WHZ < −3 and were discharged recovered with WHZ ≥ −2 than among children who were admitted with WHZ < −3 and were discharged nonrecovered with WHZ < −2 (3.9 ± 6.2 vs. 2.6 ± 1.2 g/ kg body weight/day; p < .05) despite a similar mean length of stay in the programme (67.7 ± 22.3 vs. 68.7 ± 22.0 days; Table 5).

| Outcomes among children with HAZ data at admission
Of the 11,272 children for whom data on height and weight were available at admission, 7,825 (69.4%) were stunted (height-for-age zscore [HAZ] < −2). Death rates were 2.2-fold higher among stunted  Table 6).
Mean weight gain while in the programme tended to be greater among children who were admitted with HAZ < −2 than among children who were admitted with HAZ ≥ −2 both when discharge criteria was MUAC ≥ 125 mm or WHZ ≥ −2 (Table 7).

| Predictors of death, default, discharge, and recovery (MUAC ≥125 mm or WHZ > −2)
The exposure (independent) variables that were significantly associated with a given outcome (dependent variable) in bivariate analyses were included in linear regression models to identify the main predictors of key outcomes in children admitted to the CMAM programme (

| DISCUSSION
In this paper, we analyse programme outcomes in 32,458 children  CMAM programme and died), the death rate in the programme (1.9%) would still be below the national standard of care. Mortality rates observed in Pakistan's CMAM programme are comparable with those reported in CMAM programmes in India (Aguayo et al., 2013;Burza et al., 2015) and lower than those observed in CMAM programmes elsewhere . Reasons for this apparent lower mortality among children with SAM in Pakistan and India deserves further investigation.
The proportion of defaulters (10.6%) is lower than national and international standards of care (<15%) and lower than the default rates reported by programmes in India, where the proportion of defaulters ranged from 32% to 38% (Aguayo et al., 2013;Burza et al., 2015). Outcomes among children who defaulted the programme are unknown. Recovery rates on the basis of MUAC ≥ 125 mm (87.8% of the admitted and 98.7% of the discharged) were above national and international standards of care (>75%). Mean weight gain while in the programme (3.2 ± 2.7 g/kg body weight/day), which was slightly lower in CMAM programmes elsewhere (4-5 g/kg body weight/day; Burza et al., 2015;Collins et al., 2006), combined with a mean length of stay of about 10 weeks (7.3 ± 5.6 and 8.7 ± 6.1 weeks in India; Burza et al., 2015) resulted in recovery rates that were higher than those reported by CMAM programmes in India, where the proportion of children discharged recovered ranged from 53.4% to 65.0% (Aguayo et al., 2013;Burza et al., 2015). , can be safely used in CMAM programmes , can ensure survival rates >95%, and can bring about recovery rates of up to 90% (Diop et al., 2003).
In most populations, children identified as severely wasted by MUAC will generally be at higher risk of death than those identified by WHZ (Briend, Maire, Fontaine, & Garenne, 2012). It has been recommended that where resources are limited, it is preferable to screen by MUAC than by WHZ . However, global evidence also indicates that when children with SAM are identified on the basis of both MUAC < 115 mm or WHZ < −3, the populations identified by these two criteria do not overlap uniformly (Trehan & Manary, 2015). Further, some researchers have alerted that a significant number of children in need could be missed when MUAC is used as the only admission criteria and recommend that both MUAC and WHZ be used (Grellety & Golden, 2016). We looked at differential programme outcomes among stunted and nonstunted children. About 70% of the children in our analytical sample were stunted (HAZ < −2). Children who were stunted at Note. Pakistan, January 1-December 31, 2014. MUAC = mid-upper arm circumference; HAZ = height-for-age z-score; WHZ = weight-for-height z-score.
admission had poorer survival outcomes (i.e., 2.2-fold higher death rates) than children who were not stunted (HAZ ≥ −2) when they were admitted, which is in line with previous research findings indicating higher mortality rates among stunted children. However, recovery rates on the basis of WHZ ≥ −2 at discharge were higher among stunted children than among nonstunted children (82.1% vs. 63.4%, respectively). Reasons for these differential recovery rates between stunted and nonstunted rates deserve future attention.
Multivariate regression analysis indicates that the odds of death were higher among children with WHZ < −3 and/or HAZ < −2 at admission indicating that children with indicators of anthropometric failure other than MUAC < 125 mm (i.e., WHZ < −3 and/or HAZ < −2) were at a significantly higher risk of death. The odds of recovery on the basis of MUAC ≥ 125 mm were higher among children with HAZ ≥ −2 at admission, whereas the odds of recovery on the basis of WHZ ≥ −2 were significantly higher among children with WHZ ≥ −3 and/or HAZ < −2 at admission.
South Asia is the epicentre of the global burden of wasting. However, the coverage of effective interventions remains unacceptably low (UNICEF, 2013). There is growing consensus among scientists and practitioners that South Asian countries need to recognize SAM as a major public health problem and mobilize internal resources for its management (Ahmed et al., 2014). Particular attention needs to be given to the detection of children with SAM as early as possible, when children are younger and less severely wasted (WHO & UNICEF, 2009). In areas where active surveillance and case finding are conducted effectively, the vast majority of children with SAM are identified early in their illness, have no medical complications, and can be treated in their communities as outpatients (Trehan & Manary, 2015). Over 50 countries have adopted CMAM to address SAM as a public health problem (Field Exchange, 2012).

| CONCLUSION
Our analysis shows that Pakistan's CMAM programme is effective in achieving good survival and recovery rates. Population-level impact can be increased by placing greater emphasis on children 6-23 months old, children with multiple anthropometric failure, and girls and by scaling up CMAM in the provinces and areas where the risk, prevalence, and/or burden of SAM is highest. The experience in Pakistan demonstrates that governments and their partners can strengthen the existing health systems with situation-specific adjustments to provide timely and quality care for children with SAM through an integrated approach that combines facility-based therapeutic care and CMAM.

CONFLICTS OF INTEREST
The authors declare that they have no conflicts of interest. The opinions expressed on this paper are those of the authors and do not necessarily represent an official position of the organizations that they are affiliated with.

CONTRIBUTIONS
VMA designed the study, led data analysis, and wrote the paper; NB led data management; SSQ, ANG, MMA, NN, and MG contributed to data interpretation and paper writing. All authors have read and approved the final manuscript.

SOURCE OF FUNDING
United Nations Children's Fund (UNICEF) Regional Office for South Asia (ROSA).