Community-based management of acute malnutrition in Bangladesh: Feasibility and constraints
Nuzhat Choudhury, Tahmeed Ahmed, Md. Iqbal Hossain, Barendra Nath Mandal, Golam Mothabbir, Mustafizur Rahman, M. Munirul Islam, Mohammad Mushtuq Husain, Makhduma Nargis, and Ekhlasur Rahman Abstract Background. To achieve the United Nations Millennium Development Goals, particularly reduction in child mortality (Millennium Development Goal 4), effective interventions to address severe and moderate acute malnutrition (SAM and MAM) among children under 5 years of age must be implemented and brought to scale alongside preventive measures. Bangladesh has an estimated 600,000 children with SAM, for a prevalence of 4%, while 1.8 million children suffer from MAM. Objective. To assess the feasibility and constraints of community-based management of acute malnutrition (CMAM), a relatively new approach, in managing SAM and MAM among children in Bangladesh. Methods. The methodology involved desk reviews of documents by searching through PubMed and other databases for published literature on CMAM in Bangladesh. We also did a hand search of policy and program documents, including the draft National Nutrition Policy 2013; the Health, Nutrition, Population Sector
Nuzhat Choudhury, Tahmeed Ahmed, Md. Iqbal Hossain, and M. Munirul Islam are affiliated with the Centre for Nutrition and Food Security, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka; Tahmeed Ahmed and Md. Iqbal Hossain are also affiliated with the James P. Grant School of Public Health, BRAC University, Dhaka; Barendra Nath Mandal and Makhduma Nargis are affiliated with Revitalization of Community Health Care Initiatives in Bangladesh, Ministry of Health and Family Welfare, Dhaka; Golam Mothabbir is affiliated with Save the Children, Dhaka; Mustafizur Rahman and Ekhlasur Rahman are affiliated with the Institute of Public Health and Nutrition, Ministry of Health and Family Welfare, Dhaka; Mohammad Mushtuq Husain is affiliated with the Institute of Epidemiology, Disease Control and Research, Ministry of Health and Family Welfare, Dhaka. Please direct queries to the corresponding author: Tahmeed Ahmed, Centre for Nutrition and Food Security, icddr,b, 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh; e-mail: [email protected].
Development Program document of the Ministry of Health and Family Welfare, Government of Bangladesh; the Sixth Five Year Plan; and the Operational Plans of the National Nutrition Services of Bangladesh. Results. The conventional approach in Bangladesh has been to treat children suffering from SAM and associated complications in hospital settings. There is no program to take care of children with MAM. There is a dearth of local evidence to operationalize and implement CMAM in the context of Bangladesh. This paper summarizes the scientific literature and rationale for the implementation of CMAM in Bangladesh. It also provides recommendations to improve health strategies related to CMAM, discusses diets being developed that may result in better implementation of CMAM, and offers recommendations for areas of additional necessary research. Conclusions. A recommended approach for Bangladesh on the management of acute malnutrition would be to integrate CMAM into the rollout of the National Nutrition Services so that screening, identification, referral, and treatment of acutely malnourished children could be effectively managed within the communitybased health service delivery system. Given that the vast majority of children are suffering from MAM and could be treated with locally developed food supplements, a significant emphasis of the CMAM approach in Bangladesh should be to screen and treat MAM. Over time, this would also result in fewer SAM cases. However, even with this approach, there would still be a small number of children who have SAM and who ideally should be treated with specialized therapeutic foods. While the Government of Bangladesh is awaiting full-scale production of a local ready-to-use therapeutic food (RUTF), an interim strategy is needed to effectively treat these severely wasted children on an outpatient basis.
Key words: Acute malnutrition, Bangladesh, CMAM, health system
Food and Nutrition Bulletin, vol. 35, no. 2 © 2014, The Nevin Scrimshaw International Nutrition Foundation.
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Introduction If the United Nations Millennium Development Goals are to be met, particularly the reduction in child mortality (Millennium Development Goal 4), effective interventions to address acute malnutrition among children under 5 years of age must be implemented and brought to scale alongside preventive measures. Childhood malnutrition continues to be a significant public health problem in the world, especially in Asia, and is recognized as the leading underlying cause of mortality among children in developing countries. Acute malnutrition, including moderate acute malnutrition (MAM) and severe acute malnutrition (SAM), is responsible for 14.6% of all deaths of children under 5 years of age globally [1, 2]. In Asia, SAM among children under 5 years of age remains a major embarrassment and impediment to optimal human capital development [3]. The World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) diagnostic criteria for SAM in children 6 to 59 months of age include any of the following: weight-for-height z-score < –3 SD of WHO child growth standards, presence of bilateral pedal edema, and mid-upper-arm circumference (MUAC) < 115 mm [4]. According to the weight-forheight criterion, globally close to 4% (19 million) of all children under 5 years of age are affected by this serious nutritional disorder [1, 5]. India alone is home to an estimated 8 million children living with SAM, while Bangladesh has about 600,000 children (4%) with SAM [6, 7]. SAM is one of the important comorbidities leading to hospital admissions and deaths. The mortality associated with SAM is also high, ranging from 73 to 187 per 1,000 [1, 8]. The risk of death sharply increases with the severity of malnutrition. Besides prevention of SAM, early detection and treatment of SAM and MAM are equally crucial in reducing mortality and morbidity. The diagnostic criteria for MAM in children 6 to 59 months of age are weight-for-height z-score between –3 and –2 SD of the WHO child growth standards or MUAC between 115 and 125 mm. There are about 1.8 million children under 5 years of age in Bangladesh with MAM. The current WHO recommendations for management of SAM are based on facility-based treatment for initial stabilization and nutritional rehabilitation followed by continued management at home. Facilitybased treatment is based on providing frequent, small feedings initially of a fortified milk diet that is rich in energy but low in protein (e.g., F-75), as well as preventing and treating hypoglycemia, judicious use of rehydration fluids when required (ReSoMal), broadspectrum antibiotic therapy, providing the appropriate micronutrients (including iron during nutritional rehabilitation), and timely identification and management of complications [9]. Children with SAM, however, do not require hospital admission unless they are suffering
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from acute complications; these children are about 4% or 5% of the total number of children with SAM [2]. Home-based management with ready-to-use therapeutic food (RUTF) in children suffering from SAM without any complications has been found to be associated with good outcomes [2] but is yet to be used in the public sector of Bangladesh. RUTF has been used in Bangladesh by few international nongovernmental organizations [10, 11]. Moreover, inpatient care for children with SAM has encountered several problems in Asian countries [3, 12], which include poor quality of hospital care and shortage of trained health staff [13, 14]. These problems largely account for the reluctance of families to keep their children in the hospital for a prolonged period of time until discharge criteria are reached. Children with MAM have different nutritional requirements from children with SAM. The dietary management of MAM should be based on the optimal use of locally available foods to improve the nutritional status of children and prevent their condition from deteriorating to SAM. In situations of food insecurity, or where nutrients are not sufficiently available from local foods, supplementary foods with various nutrient compositions have been used to facilitate the recovery of children with MAM [15]. Since there is a huge caseload of SAM and MAM in Asia, incorporation of alternative strategies such as home-based management of uncomplicated SAM and provision of management of MAM is essential. Currently there is a dearth of evidence-based information on the management of MAM in children. The current consensus is that children with MAM should receive 25 kcal per kilogram per day in addition to what is needed for a healthy child and that their diet should include animal-source foods [16]. In Bangladesh, children with SAM have traditionally been treated as inpatients in a few healthcare facilities. A national guideline has been published to streamline and facilitate the treatment of children with SAM [17]. This guideline has been developed for doctors, senior nurses, and other senior health professionals responsible for inpatient care of children with SAM in health facilities. It was designed for circumstances where community-based management of acute malnutrition (CMAM) is not available. Nevertheless, the district and subdistrict facilities have a substantial case load of acutely malnourished children, which includes SAM and MAM. In view of this burden of acute malnutrition, a national guideline for a community-based approach to manage acute malnutrition has recently been developed to complement the inpatient guidelines [18]. However, there is universal consensus that acute malnutrition without complications does not require inpatient treatment and can be effectively managed at the community level, provided that the health system has the capacity to identify children with acute malnutrition in the community and can provide effective counseling to parents, and that children with SAM
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can access RUTF, preferably made locally from locally available food ingredients. This review summarizes the scientific literature and government policies to facilitate the implementation of CMAM through the national health system to treat children suffering from acute malnutrition in Bangladesh. It attempts to assess the health facility and community capacity to manage acute malnutrition in the country, discusses new techniques that may result in implementation of CMAM and highlights areas of research needs. It also includes an analytical discussion on the feasibility of and constraints to implementing CMAM in the country.
Methods The methodology involved desk reviews of documents by searching through PubMed and other databases for published literature on CMAM in Bangladesh. We also did a hand search of policy and program documents, including the draft National Nutrition Policy 2013; the Health, Nutrition, Population Sector Development Program document of the Ministry of Health and Family Welfare, Government of Bangladesh; the Sixth Five Year Plan; and the Operational Plans of the National Nutrition Services of the Government of Bangladesh.
Results and discussion Community-based management of acute malnutrition (CMAM)
CMAM is a relatively new approach to early diagnosis and treatment of SAM and MAM in ambulatory primary healthcare settings. It includes four primary components: community mobilization and case finding, outpatient therapeutic care for SAM without complications, inpatient therapeutic care for SAM with complications, and management of MAM where appropriate services are in place. This paper is structured into two separate pieces. One is on policy issues and financing, and the other is on past and current programmatic activities and operational research. Policy issues and financing of CMAM
CMAM emphasizes integration of the management of acute malnutrition into existing health services so that it may be better sustained with government budgets over the longer term. It aims to establish outpatient therapeutic care within the community that will eventually improve coverage of and access to nutrition services and strengthen the quality of inpatient care and community participation activities. Experience suggests that the implementation of CMAM as
an addition to the existing standard health services is cost effective [19, 20]. However, several contextual and programmatic factors should be considered when generalizing CMAM to diverse contexts. Human resources for health and health systems
Human resource and health systems fall under a broad spectrum of policy work. Bangladesh is classified by WHO as one of the 58 countries facing an acute crisis of human resources for health [21]. Ahmed et al. found in a recent study that the density of formally qualified healthcare professionals is 7.7 per 10,000 population, which is much lower than that in other South Asian countries (e.g., 21.9 in Sri Lanka, 14.6 in India, and 12.5 in Pakistan) and falls far short of the desired estimate of 23.0 projected by WHO [21, 22]. Moreover, the overwhelming urban bias of the distribution of formally trained healthcare professionals has been a constant problem [22, 23]. Other than formally qualified healthcare professionals, there are other healthcare providers, such as Community Health Workers (CHWs) from the state and nongovernmental sector and village doctors who practice allopathic medicine in rural areas. Given the limited and inequitable health workforce, the Government of Bangladesh has taken some initiatives and made major changes in health systems to overcome the human resource crisis that has been the center of discussion in the country for the past several years. One of the major changes that have been initiated by the government is closing down the National Nutrition Program (NNP). Since 1995, there has been a vertical program for nutrition in Bangladesh, the Bangladesh Integrated Nutrition Project (BINP), and its successor the NNP. Despite various positive outcomes, the BINP and NNP have been heavily criticized in terms of their cost-effectiveness, poor coverage, and impact in reducing malnutrition at a rate to achieve the Millennium Development Goal target for nutrition [24, 25]. Considering the multifaceted underlying factors of malnutrition and also the importance of an integrated approach for better nutrition in the new Health, Population and Nutrition Sector Development Plan (HPNSDP) (2011–16), the vertical program for nutrition was closed. The government has decided instead to mainstream nutrition within the Ministry of Health and Family Welfare through the National Nutrition Services (NNS), which have been in operation since July 2011. An operational plan to improve public health nutrition has been developed by the NNS. The operational plan has provision for management of SAM at the upazila (subdistrict) health complex level. The Sixth Five Year Plan of the government also emphasizes the preventive component along with appropriate management of SAM. Scaling up the management of acute malnutrition has also been highlighted in the draft National Nutrition Policy 2013 [26]. Another major initiative is the revamping of community healthcare
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initiatives to extend one-stop integrated health and family planning services at the grassroots level by establishing community clinics at the ward or village level, one clinic for a population of 6,000 to 8,000. The purpose of the community clinic is to provide first-level services of the essential service packages (ESP). The performance and quality standards of the community clinics are based on the technical standards and norms for ESP intervention. A three-member team composed of one Family Welfare Assistant (FWA), one Health Assistant (HA), and one Community Health Care Provider (CHCP) is engaged for ESP and behavioral change communication services from the community clinics. The specific functions of community clinics are (as laid out in the community clinic operation plan) provision of maternal and neonatal health services; Integrated Management of Childhood Illnesses (IMCI); reproductive health and family planning services; Extended Program on Immunization (EPI), acute respiratory infection (ARI), control of diarrheal disease; registration of newly married couples, pregnant women, births, and deaths and estimation of date of delivery; nutritional education and micronutrient supplementation; identification of illnesses such as tuberculosis, malaria, pneumonia, influenza, obstetrical emergencies; identification of emerging and re-emerging diseases and referral to higher facilities; provision of other services as identified by the Government of Bangladesh under HPNSDP; treatment of minor ailments; and establishing upward referral linkages with higher facilities. A Community Group (CG) composed of 9 to 13 members has been formed for each community clinic to ensure participation of the local community in the overall management of community clinics. To supplement each CG, there are three Community Support Groups (CSGs) composed of 13 to 15 members. Specific responsibilities have been given to the CGs by the government, including site selection and land donation for community clinics, supervision of construction, operational management, minor repair maintenance, and campaigns in the community to motivate people to seek health and family planning services from the community clinics. It is clear that we need to bring forth the preventive component, which includes Growth Monitoring and Promotion (GMP) and scaling up essential nutrition-specific interventions, such as counseling on appropriate infant and young child feeding, vitamin A capsule distribution, micronutrient powder supplementation, deworming, and hygiene and sanitation. Over time, this preventive component would also result in fewer SAM and MAM cases. The community clinics are likely to be effective in rendering public health services to the people; however, their full effectiveness and impact will depend on the establishment and maintenance of community clinics throughout the country. This initiative could be one of
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the major strengths of CMAM. Since in the short term it is nearly impossible to recruit and mobilize the huge numbers of community healthcare providers needed for active case finding (i.e., children in the community with SAM and MAM), utilization of the workforce assigned to community clinics could be a cost-effective option, although this calls for evidence-based information. To run the community clinics, the Ministry of Health and Family Welfare (MoHFW), Government of Bangladesh, has recruited 13,240 full-time Community Health Care Providers. Furthermore, in each ward, the lowest administrative unit in rural areas, there is one Health Assistant (HA) for each 5,000 to 6,000 population. There are 26,416 sanctioned posts of HAs under the Directorate General of Health Services (DGHS) [27]. The cadre of CHWs under the Directorate General of Family Planning also serve maternal and child nutrition interventions, such as Infant and Young Child Feeding (IYCF), and they could be complementary to the DGHS workforce. Case detection at the community level with appropriate referral and admission mechanisms is important for achieving adequate coverage for the treatment of children with SAM and MAM. CHWs, who have little or no education, have been successful in managing SAM in the community [10, 11, 28]. However, there is a need to determine by operations research how nongovernmental CHWs can complement the work of the public sector in tackling acute malnutrition in the country on a broader scale. Readiness of the health systems in Bangladesh to manage acute malnutrition in the community
One of the key elements identified by Deconinck et al. for effective integration of CMAM with existing health systems that should be considered by the Government of Bangladesh is an enabling environment for CMAM, which eventually underpins the technical leadership and coordination provided by the Ministry of Health within a country [29]. An oversight and support unit of the MoHFW of Bangladesh for technical guidance on CMAM is essential for implementation, coordination, and capacity development at the policy and implementation levels. This unit should also include experts from the nonstate sectors. Development of national guidelines on the management of SAM and on CMAM, as mentioned above, is a step in the right direction. In light of this, a national guideline has already been published for the management of SAM. Initiatives have been taken to train healthcare providers to develop capacity in management of SAM. The health system in Bangladesh suffers from a lack of qualified staff and a high turnover of health professionals, which is a challenge to implementation of CMAM and to sustaining the quality of services. There has to be a single protocol and guideline for use by care providers for successful implementation of CMAM [29]. The major challenge to implementing CMAM on a national scale would be
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lack of staff to screen children, identify children with acute malnutrition, provide management at the community level, and refer children requiring treatment of SAM and complications to the Sub-District Health Complex or any other stabilization center. The next challenge is the absence of an inexpensive, sustainable therapeutic food for treating SAM in the community. Finally, we still do not have any program of food supplementation for children with MAM living in foodinsecure conditions. Overcoming these challenges will require political commitment, consensus, and financial allocation as well as appropriate human resources. Health-seeking behavior
Health-seeking behavior is any activity undertaken by individuals who perceive themselves to have a health problem or to be ill, for the purpose of finding an appropriate remedy [30]. According to the Bangladesh Bureau of Statistics [31], the most common illnesses for which people seek care are, in order of frequency, fever (55%), pain (10%), diarrhea (6%), and dysentery (4%). It is noteworthy that in Bangladesh, acute malnutrition was not perceived as a common illness for which caregivers seek care for their children [27]. This is due to the fact that the caregivers usually do not seek care unless children with acute malnutrition also have other complications. The culture of health service utilization in Bangladesh is one of the major determinants of health-seeking behavior. Given the shortage of qualified health workforce in Bangladesh and the inequity of their distribution between rural and urban areas, people prefer to seek healthcare from nonqualified providers in the informal sector, especially the poor and the disadvantaged [32]. On the demand side, various barriers also impede the use of qualified providers, such as lack of access to information on available services, lack of health awareness, lack of opportunity due to exclusion from social and health institutions, cultural factors prohibiting women from seeking care from male providers outside the home, and inability to pay [33]. A study revealed that 60% of outpatient visits were to informal healthcare providers [34]. These informal providers are deeply embedded in the local community and culture, are easily accessible, and provide inexpensive services to villagers with acceptance of deferred payment and payment in kind instead of cash [32]. With this scenario, involving community members or CHWs to detect children with acute malnutrition in the community could be a feasible option, as we found that involving CHWs was successful in one pilot project run in Barisal by Save the Children in collaboration with Tufts University [10, 28]. This can be tried with volunteer mothers and the CSGs. Financing of CMAM
Although the cost effectiveness of treating SAM is well established, the real costs of taking CMAM to scale are
not clear and vary between countries [35, 36]. Costs for startup, sustained coverage, personnel and community mobilization, and in relation to the cost benefits of integration or convergence with other programs and sectors are not yet well established in many countries. The Lancet Maternal and Child Nutrition Series (2013) mentions delivery platforms as being very important for scaling up nutrition interventions in general [37]. The Scaling Up Nutrition (SUN) movement is supporting some governments to cost nutrition scale-up plans, and CMAM is part of this exercise in a number of these countries. On the other hand, whether local production of RUTF yields cost savings is debatable. Recent evidence has shown that local production may not yield cost savings in all settings [38, 39]. But in Bangladesh, the government is not in favor of imported RUTF, and there is a need for research on the cost of treating children with SAM using local RUTF. Programmatic activities and operational research
Since there is no policy for implementation of CMAM with the health system, possible models should be tested to determine the effectiveness of CMAM by utilizing existing health resources, such as community clinics, and by involving CHWs of nongovernmental organizations. It is also imperative to assess health facility and community capacity for management of acute malnutrition in Bangladesh. One community clinic usually serves a population of about 6,000 to 8,000 in about 1,200 households, which is supposed to be staffed by one CHCP, one HA, and one FWA who work for 6 days a week. An additional field health worker will be recruited in the NNS priority upazilas for the nutrition-related interventions. However, this is yet to be decided upon and finalized by the government. If the government decides later to hire CHWs dedicated to nutrition, the services of newly recruited workers could be used for planning a CMAM model using the community clinic as a hub. Therapeutic food to manage and treat SAM
In the CMAM context, the nutritional component of SAM treatment is RUTF, which is referred to as “nutritional treatment” in the national guideline on CMAM in Bangladesh [18]. RUTF is an energy-dense, lipid-based paste enriched with vitamins and minerals, which is administered to children with SAM in a dose of 175 to 200 kcal/kg/day, once they demonstrate a reasonable appetite [40]. The prototype RUTF is Plumpy’nut, a peanut-based paste formulated and developed by Nutriset and currently being produced by Nutriset and the PlumpyField network of producers in Ethiopia, Malawi, Niger, DR Congo, India, Mozambique, and Uganda. Plumpy’nut is equivalent in formulation to F-100, which is the WHO-recommended fortified liquid milk–based diet for the nutritional
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rehabilitation of children with SAM in a hospital setting. RUTF has very low water activity and therefore can be stored and administered at home with little risk of microbial contamination. It requires no mixing, dilution, or cooking, and it can be eaten directly from the package, with a shelf life of up to 24 months. The typical composition of the prototype RUTF (by weight) is whole milk powder 30%, sugar 28%, vegetable oil 15.4%, peanut paste 25%, and mineral–vitamin mix 1.6%. The case fatality rates typically achieved with CMAM using RUTF compare favorably with rates observed with facility-based management [41]. This comparison, however, must be interpreted cautiously, since the severity of cases in the facility-based trials and the community-based observational studies differs. In a community-based observational study, the use of Plumpy’nut to treat SAM had a favorable result [5, 10, 28]. However, it is well known that importation of RUTF will never be a sustainable option for successful implementation of the CMAM program, and there is no in-country favorable evidence on the large-scale use of RUTF. Because of the importance of ensuring a regular, sustainable supply of RUTF and, in some cases, opposition to the use of imported products, Bangladesh is exploring options for locally produced RUTF. To address the lack of data from within the country, the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), an international research organization, has developed two different types of RUTF using local food ingredients through operational research with support from UNICEF and Nutriset. Moreover, this organization is conducting a carefully designed study comparing the gold standard RUTF, Plumpy’Nut, with locally developed RUTFs for the facility-based nutritional rehabilitation of children with SAM. The findings of this research will definitely provide a clear direction for policy makers to implement CMAM in Bangladesh. Moreover, icddr,b with support from the Department for International Development (DFID), is also working with government and other local and international nongovernmental organizations in planning to implement the CMAM program on a pilot scale where the community clinics would be considered as the hub for all the field-level activities of this proposed program. The program will be implemented in the near future after completion of a series of research activities on locally made RUTF. The use of locally developed RUTF for treating SAM might have different challenges, which could be identified by efficacy and effectiveness trials of the locally developed food products. While the Government of Bangladesh is awaiting full-scale production of a local RUTF, an interim strategy is needed to effectively treat these severely wasted children on an outpatient basis Food supplementation and management of MAM
Children with MAM should be treated at home with
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energy- and nutrient-dense local foods. Management of MAM cases in the community can be supervised by a trained CHW. This delivery platform ideally requires one trained CHW for an average of 200 households to ensure a manageable caseload. The nutritional management of MAM aims to provide additional energy and increase the nutrient density of the existing home-based diet to support catch-up growth. This means adding at least 25 kcal/kg/day over and above the energy requirements of a well-nourished child [16]. This should be done by encouraging increased intake of home foods. The staple cereal (rice) should be fortified with micronutrient powder, and animalsource foods (fish, egg, milk, etc.) should be included in the diet. Deworming should be done at least at 6-monthly intervals. Intercurrent infections should be appropriately treated. Sanitation and hygiene should be promoted to prevent infection. This will also prevent and alleviate malnutrition by controlling environmental enteropathy, which is now widely believed to be responsible for stunting in many populations [42–44]. However, children with MAM living under food-insecure conditions may not be able to receive the required nutrition, not to speak of the additional food recommended by WHO. These children will require a nutritional supplement. The nutritional supplement should ideally provide about 250 kcal/child/day, with 25% to 30% of energy from fat and 10% to 12% of energy from protein. The National Nutrition Program of Bangladesh used to provide a supplementary food called Pushti packet for the management of severely underweight children. This supplementary food is a mixture of toasted rice powder, roasted lentil powder, molasses, and vegetable oil. Children with severe underweight received two sachets of Pushti packet daily for an additional 300 kcal. Pushti packet, which is cereal-based, contains phytate, an antinutrient factor that impedes the absorption of primarily iron and zinc and possibly other minerals in the intestine. It does not contain any added micronutrients and is not meant for the management of acute malnutrition. If a supplement diet based on similar locally available food ingredients can be developed, there is no reason why it could not be delivered in a similar large-scale program for the management of MAM. Researchers at icddr,b have also developed a ready-to-use complementary food supplement (RUCFS) with support from the World Food Programme using locally available food ingredients for use in food-insecure populations. This food supplement is now under trial. A child with MAM can be discharged from a CMAM program when MUAC is at least 125 mm for two consecutive visits (1 week apart). Finally, a national or subnational program should aim not just at treating children with acute malnutrition. It should have robust components to promote nutrition in general and to prevent malnutrition. These include scaling up or strengthening existing interventions on IYCF,
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micronutrient supplementation, and hygiene and sanitation interventions, and linking food-insecure households to safety nets and livelihood creation programs. Without such preventive components in the program, acutely malnourished children are likely to slide back into malnutrition once their treatment is complete. Existing CMAM program in Bangladesh
full-scale production of a local RUTF, an interim strategy is needed to effectively treat these severely wasted children on an outpatient basis. Preventive nutrition services are an essential prerequisite to establishing MAM and SAM treatment service delivery.
Conflicts of interest
International nongovernmental organizations, including Save the Children, Action Against Hunger (ACF), Médecins Sans Frontières (MSF), and Terre des Homes, deliver imported RUTF to children with SAM and in specific contexts such as in the case of specific disease outbreaks, healthcare exclusion, and natural or manmade disasters in Bangladesh. Although they work on the small scale, these nongovernmental organizations might help to move large-scale implementation of CMAM in Bangladesh forward by using locally produced RUTF. Use of such a RUTF will contribute to effective scale-up of a program for treating children with SAM with good appetite and free from any acute illnesses in their communities, while also convincing policymakers to promote CMAM in the country.
The authors declare that they have no conflicts of interest.
Conclusions
Acknowledgments
A recommended approach for Bangladesh for the management of acute malnutrition would be to integrate CMAM into the rollout of the NNS so that screening, identification, referral, and treatment of acutely malnourished children could be effectively managed within the community-based health service delivery system. Given that the vast majority of children are moderately wasted and could be treated with locally prepared food supplements, a significant emphasis of the CMAM approach in Bangladesh should be to screen and treat moderately malnourished children. Over time, this would also result in fewer SAM cases. However, even with this approach, there would still be a small number of children who are severely wasted and ideally should be treated with specialized therapeutic foods. While the Government of Bangladesh is awaiting
This research activity was funded by TRAction project under United States Agency for International Development (USAID) through University Research Co., LLC (URC), Sub agreement No. FY11-G04-699 under Cooperative Agreement No. GHS-A-00-09-00015-00. icddr,b acknowledges with gratitude the commitment of USAID to its research efforts. However, the contents herein do not necessarily reflect the views of USAID. icddr,b also gratefully acknowledges the following donors which provided unrestricted support: Australian Agency for International Development (AusAID), Government of the People’s Republic of Bangladesh, Canadian International Development Agency (CIDA), Swedish International Development Cooperation Agency (Sida), and the Department for International Development, UK (DFID).
Authors’ contributions Nuzhat Choudhury and Tahmeed Ahmed conceptualized and drafted the manuscript. Md. Iqbal Hossain, Barendra Nath Mandal, Golam Mothabbir, Mustafizur Rahman, M. Munirul Islam, Mohammad Mushtuq Husain, Makhduma Nargis, and Ekhlasur Rahman helped in conceptualization of the manuscript and interpretation of the findings and contributed to the revision of the final draft for submission. All authors read the final draft and approved it for submission.
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Nuzhat Choudhury, Tahmeed Ahmed, Md. Iqbal Hossain, Barendra Nath Mandal, Golam Mothabbir, Mustafizur Rahman, M. Munirul Islam, Mohammad Mushtuq Husain, Makhduma Nargis, and Ekhlasur Rahman Abstract Background. To achieve the United Nations Millennium Development Goals, particularly reduction in child mortality (Millennium Development Goal 4), effective interventions to address severe and moderate acute malnutrition (SAM and MAM) among children under 5 years of age must be implemented and brought to scale alongside preventive measures. Bangladesh has an estimated 600,000 children with SAM, for a prevalence of 4%, while 1.8 million children suffer from MAM. Objective. To assess the feasibility and constraints of community-based management of acute malnutrition (CMAM), a relatively new approach, in managing SAM and MAM among children in Bangladesh. Methods. The methodology involved desk reviews of documents by searching through PubMed and other databases for published literature on CMAM in Bangladesh. We also did a hand search of policy and program documents, including the draft National Nutrition Policy 2013; the Health, Nutrition, Population Sector
Nuzhat Choudhury, Tahmeed Ahmed, Md. Iqbal Hossain, and M. Munirul Islam are affiliated with the Centre for Nutrition and Food Security, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka; Tahmeed Ahmed and Md. Iqbal Hossain are also affiliated with the James P. Grant School of Public Health, BRAC University, Dhaka; Barendra Nath Mandal and Makhduma Nargis are affiliated with Revitalization of Community Health Care Initiatives in Bangladesh, Ministry of Health and Family Welfare, Dhaka; Golam Mothabbir is affiliated with Save the Children, Dhaka; Mustafizur Rahman and Ekhlasur Rahman are affiliated with the Institute of Public Health and Nutrition, Ministry of Health and Family Welfare, Dhaka; Mohammad Mushtuq Husain is affiliated with the Institute of Epidemiology, Disease Control and Research, Ministry of Health and Family Welfare, Dhaka. Please direct queries to the corresponding author: Tahmeed Ahmed, Centre for Nutrition and Food Security, icddr,b, 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh; e-mail: [email protected].
Development Program document of the Ministry of Health and Family Welfare, Government of Bangladesh; the Sixth Five Year Plan; and the Operational Plans of the National Nutrition Services of Bangladesh. Results. The conventional approach in Bangladesh has been to treat children suffering from SAM and associated complications in hospital settings. There is no program to take care of children with MAM. There is a dearth of local evidence to operationalize and implement CMAM in the context of Bangladesh. This paper summarizes the scientific literature and rationale for the implementation of CMAM in Bangladesh. It also provides recommendations to improve health strategies related to CMAM, discusses diets being developed that may result in better implementation of CMAM, and offers recommendations for areas of additional necessary research. Conclusions. A recommended approach for Bangladesh on the management of acute malnutrition would be to integrate CMAM into the rollout of the National Nutrition Services so that screening, identification, referral, and treatment of acutely malnourished children could be effectively managed within the communitybased health service delivery system. Given that the vast majority of children are suffering from MAM and could be treated with locally developed food supplements, a significant emphasis of the CMAM approach in Bangladesh should be to screen and treat MAM. Over time, this would also result in fewer SAM cases. However, even with this approach, there would still be a small number of children who have SAM and who ideally should be treated with specialized therapeutic foods. While the Government of Bangladesh is awaiting full-scale production of a local ready-to-use therapeutic food (RUTF), an interim strategy is needed to effectively treat these severely wasted children on an outpatient basis.
Key words: Acute malnutrition, Bangladesh, CMAM, health system
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Introduction If the United Nations Millennium Development Goals are to be met, particularly the reduction in child mortality (Millennium Development Goal 4), effective interventions to address acute malnutrition among children under 5 years of age must be implemented and brought to scale alongside preventive measures. Childhood malnutrition continues to be a significant public health problem in the world, especially in Asia, and is recognized as the leading underlying cause of mortality among children in developing countries. Acute malnutrition, including moderate acute malnutrition (MAM) and severe acute malnutrition (SAM), is responsible for 14.6% of all deaths of children under 5 years of age globally [1, 2]. In Asia, SAM among children under 5 years of age remains a major embarrassment and impediment to optimal human capital development [3]. The World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) diagnostic criteria for SAM in children 6 to 59 months of age include any of the following: weight-for-height z-score < –3 SD of WHO child growth standards, presence of bilateral pedal edema, and mid-upper-arm circumference (MUAC) < 115 mm [4]. According to the weight-forheight criterion, globally close to 4% (19 million) of all children under 5 years of age are affected by this serious nutritional disorder [1, 5]. India alone is home to an estimated 8 million children living with SAM, while Bangladesh has about 600,000 children (4%) with SAM [6, 7]. SAM is one of the important comorbidities leading to hospital admissions and deaths. The mortality associated with SAM is also high, ranging from 73 to 187 per 1,000 [1, 8]. The risk of death sharply increases with the severity of malnutrition. Besides prevention of SAM, early detection and treatment of SAM and MAM are equally crucial in reducing mortality and morbidity. The diagnostic criteria for MAM in children 6 to 59 months of age are weight-for-height z-score between –3 and –2 SD of the WHO child growth standards or MUAC between 115 and 125 mm. There are about 1.8 million children under 5 years of age in Bangladesh with MAM. The current WHO recommendations for management of SAM are based on facility-based treatment for initial stabilization and nutritional rehabilitation followed by continued management at home. Facilitybased treatment is based on providing frequent, small feedings initially of a fortified milk diet that is rich in energy but low in protein (e.g., F-75), as well as preventing and treating hypoglycemia, judicious use of rehydration fluids when required (ReSoMal), broadspectrum antibiotic therapy, providing the appropriate micronutrients (including iron during nutritional rehabilitation), and timely identification and management of complications [9]. Children with SAM, however, do not require hospital admission unless they are suffering
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from acute complications; these children are about 4% or 5% of the total number of children with SAM [2]. Home-based management with ready-to-use therapeutic food (RUTF) in children suffering from SAM without any complications has been found to be associated with good outcomes [2] but is yet to be used in the public sector of Bangladesh. RUTF has been used in Bangladesh by few international nongovernmental organizations [10, 11]. Moreover, inpatient care for children with SAM has encountered several problems in Asian countries [3, 12], which include poor quality of hospital care and shortage of trained health staff [13, 14]. These problems largely account for the reluctance of families to keep their children in the hospital for a prolonged period of time until discharge criteria are reached. Children with MAM have different nutritional requirements from children with SAM. The dietary management of MAM should be based on the optimal use of locally available foods to improve the nutritional status of children and prevent their condition from deteriorating to SAM. In situations of food insecurity, or where nutrients are not sufficiently available from local foods, supplementary foods with various nutrient compositions have been used to facilitate the recovery of children with MAM [15]. Since there is a huge caseload of SAM and MAM in Asia, incorporation of alternative strategies such as home-based management of uncomplicated SAM and provision of management of MAM is essential. Currently there is a dearth of evidence-based information on the management of MAM in children. The current consensus is that children with MAM should receive 25 kcal per kilogram per day in addition to what is needed for a healthy child and that their diet should include animal-source foods [16]. In Bangladesh, children with SAM have traditionally been treated as inpatients in a few healthcare facilities. A national guideline has been published to streamline and facilitate the treatment of children with SAM [17]. This guideline has been developed for doctors, senior nurses, and other senior health professionals responsible for inpatient care of children with SAM in health facilities. It was designed for circumstances where community-based management of acute malnutrition (CMAM) is not available. Nevertheless, the district and subdistrict facilities have a substantial case load of acutely malnourished children, which includes SAM and MAM. In view of this burden of acute malnutrition, a national guideline for a community-based approach to manage acute malnutrition has recently been developed to complement the inpatient guidelines [18]. However, there is universal consensus that acute malnutrition without complications does not require inpatient treatment and can be effectively managed at the community level, provided that the health system has the capacity to identify children with acute malnutrition in the community and can provide effective counseling to parents, and that children with SAM
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can access RUTF, preferably made locally from locally available food ingredients. This review summarizes the scientific literature and government policies to facilitate the implementation of CMAM through the national health system to treat children suffering from acute malnutrition in Bangladesh. It attempts to assess the health facility and community capacity to manage acute malnutrition in the country, discusses new techniques that may result in implementation of CMAM and highlights areas of research needs. It also includes an analytical discussion on the feasibility of and constraints to implementing CMAM in the country.
Methods The methodology involved desk reviews of documents by searching through PubMed and other databases for published literature on CMAM in Bangladesh. We also did a hand search of policy and program documents, including the draft National Nutrition Policy 2013; the Health, Nutrition, Population Sector Development Program document of the Ministry of Health and Family Welfare, Government of Bangladesh; the Sixth Five Year Plan; and the Operational Plans of the National Nutrition Services of the Government of Bangladesh.
Results and discussion Community-based management of acute malnutrition (CMAM)
CMAM is a relatively new approach to early diagnosis and treatment of SAM and MAM in ambulatory primary healthcare settings. It includes four primary components: community mobilization and case finding, outpatient therapeutic care for SAM without complications, inpatient therapeutic care for SAM with complications, and management of MAM where appropriate services are in place. This paper is structured into two separate pieces. One is on policy issues and financing, and the other is on past and current programmatic activities and operational research. Policy issues and financing of CMAM
CMAM emphasizes integration of the management of acute malnutrition into existing health services so that it may be better sustained with government budgets over the longer term. It aims to establish outpatient therapeutic care within the community that will eventually improve coverage of and access to nutrition services and strengthen the quality of inpatient care and community participation activities. Experience suggests that the implementation of CMAM as
an addition to the existing standard health services is cost effective [19, 20]. However, several contextual and programmatic factors should be considered when generalizing CMAM to diverse contexts. Human resources for health and health systems
Human resource and health systems fall under a broad spectrum of policy work. Bangladesh is classified by WHO as one of the 58 countries facing an acute crisis of human resources for health [21]. Ahmed et al. found in a recent study that the density of formally qualified healthcare professionals is 7.7 per 10,000 population, which is much lower than that in other South Asian countries (e.g., 21.9 in Sri Lanka, 14.6 in India, and 12.5 in Pakistan) and falls far short of the desired estimate of 23.0 projected by WHO [21, 22]. Moreover, the overwhelming urban bias of the distribution of formally trained healthcare professionals has been a constant problem [22, 23]. Other than formally qualified healthcare professionals, there are other healthcare providers, such as Community Health Workers (CHWs) from the state and nongovernmental sector and village doctors who practice allopathic medicine in rural areas. Given the limited and inequitable health workforce, the Government of Bangladesh has taken some initiatives and made major changes in health systems to overcome the human resource crisis that has been the center of discussion in the country for the past several years. One of the major changes that have been initiated by the government is closing down the National Nutrition Program (NNP). Since 1995, there has been a vertical program for nutrition in Bangladesh, the Bangladesh Integrated Nutrition Project (BINP), and its successor the NNP. Despite various positive outcomes, the BINP and NNP have been heavily criticized in terms of their cost-effectiveness, poor coverage, and impact in reducing malnutrition at a rate to achieve the Millennium Development Goal target for nutrition [24, 25]. Considering the multifaceted underlying factors of malnutrition and also the importance of an integrated approach for better nutrition in the new Health, Population and Nutrition Sector Development Plan (HPNSDP) (2011–16), the vertical program for nutrition was closed. The government has decided instead to mainstream nutrition within the Ministry of Health and Family Welfare through the National Nutrition Services (NNS), which have been in operation since July 2011. An operational plan to improve public health nutrition has been developed by the NNS. The operational plan has provision for management of SAM at the upazila (subdistrict) health complex level. The Sixth Five Year Plan of the government also emphasizes the preventive component along with appropriate management of SAM. Scaling up the management of acute malnutrition has also been highlighted in the draft National Nutrition Policy 2013 [26]. Another major initiative is the revamping of community healthcare
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initiatives to extend one-stop integrated health and family planning services at the grassroots level by establishing community clinics at the ward or village level, one clinic for a population of 6,000 to 8,000. The purpose of the community clinic is to provide first-level services of the essential service packages (ESP). The performance and quality standards of the community clinics are based on the technical standards and norms for ESP intervention. A three-member team composed of one Family Welfare Assistant (FWA), one Health Assistant (HA), and one Community Health Care Provider (CHCP) is engaged for ESP and behavioral change communication services from the community clinics. The specific functions of community clinics are (as laid out in the community clinic operation plan) provision of maternal and neonatal health services; Integrated Management of Childhood Illnesses (IMCI); reproductive health and family planning services; Extended Program on Immunization (EPI), acute respiratory infection (ARI), control of diarrheal disease; registration of newly married couples, pregnant women, births, and deaths and estimation of date of delivery; nutritional education and micronutrient supplementation; identification of illnesses such as tuberculosis, malaria, pneumonia, influenza, obstetrical emergencies; identification of emerging and re-emerging diseases and referral to higher facilities; provision of other services as identified by the Government of Bangladesh under HPNSDP; treatment of minor ailments; and establishing upward referral linkages with higher facilities. A Community Group (CG) composed of 9 to 13 members has been formed for each community clinic to ensure participation of the local community in the overall management of community clinics. To supplement each CG, there are three Community Support Groups (CSGs) composed of 13 to 15 members. Specific responsibilities have been given to the CGs by the government, including site selection and land donation for community clinics, supervision of construction, operational management, minor repair maintenance, and campaigns in the community to motivate people to seek health and family planning services from the community clinics. It is clear that we need to bring forth the preventive component, which includes Growth Monitoring and Promotion (GMP) and scaling up essential nutrition-specific interventions, such as counseling on appropriate infant and young child feeding, vitamin A capsule distribution, micronutrient powder supplementation, deworming, and hygiene and sanitation. Over time, this preventive component would also result in fewer SAM and MAM cases. The community clinics are likely to be effective in rendering public health services to the people; however, their full effectiveness and impact will depend on the establishment and maintenance of community clinics throughout the country. This initiative could be one of
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the major strengths of CMAM. Since in the short term it is nearly impossible to recruit and mobilize the huge numbers of community healthcare providers needed for active case finding (i.e., children in the community with SAM and MAM), utilization of the workforce assigned to community clinics could be a cost-effective option, although this calls for evidence-based information. To run the community clinics, the Ministry of Health and Family Welfare (MoHFW), Government of Bangladesh, has recruited 13,240 full-time Community Health Care Providers. Furthermore, in each ward, the lowest administrative unit in rural areas, there is one Health Assistant (HA) for each 5,000 to 6,000 population. There are 26,416 sanctioned posts of HAs under the Directorate General of Health Services (DGHS) [27]. The cadre of CHWs under the Directorate General of Family Planning also serve maternal and child nutrition interventions, such as Infant and Young Child Feeding (IYCF), and they could be complementary to the DGHS workforce. Case detection at the community level with appropriate referral and admission mechanisms is important for achieving adequate coverage for the treatment of children with SAM and MAM. CHWs, who have little or no education, have been successful in managing SAM in the community [10, 11, 28]. However, there is a need to determine by operations research how nongovernmental CHWs can complement the work of the public sector in tackling acute malnutrition in the country on a broader scale. Readiness of the health systems in Bangladesh to manage acute malnutrition in the community
One of the key elements identified by Deconinck et al. for effective integration of CMAM with existing health systems that should be considered by the Government of Bangladesh is an enabling environment for CMAM, which eventually underpins the technical leadership and coordination provided by the Ministry of Health within a country [29]. An oversight and support unit of the MoHFW of Bangladesh for technical guidance on CMAM is essential for implementation, coordination, and capacity development at the policy and implementation levels. This unit should also include experts from the nonstate sectors. Development of national guidelines on the management of SAM and on CMAM, as mentioned above, is a step in the right direction. In light of this, a national guideline has already been published for the management of SAM. Initiatives have been taken to train healthcare providers to develop capacity in management of SAM. The health system in Bangladesh suffers from a lack of qualified staff and a high turnover of health professionals, which is a challenge to implementation of CMAM and to sustaining the quality of services. There has to be a single protocol and guideline for use by care providers for successful implementation of CMAM [29]. The major challenge to implementing CMAM on a national scale would be
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lack of staff to screen children, identify children with acute malnutrition, provide management at the community level, and refer children requiring treatment of SAM and complications to the Sub-District Health Complex or any other stabilization center. The next challenge is the absence of an inexpensive, sustainable therapeutic food for treating SAM in the community. Finally, we still do not have any program of food supplementation for children with MAM living in foodinsecure conditions. Overcoming these challenges will require political commitment, consensus, and financial allocation as well as appropriate human resources. Health-seeking behavior
Health-seeking behavior is any activity undertaken by individuals who perceive themselves to have a health problem or to be ill, for the purpose of finding an appropriate remedy [30]. According to the Bangladesh Bureau of Statistics [31], the most common illnesses for which people seek care are, in order of frequency, fever (55%), pain (10%), diarrhea (6%), and dysentery (4%). It is noteworthy that in Bangladesh, acute malnutrition was not perceived as a common illness for which caregivers seek care for their children [27]. This is due to the fact that the caregivers usually do not seek care unless children with acute malnutrition also have other complications. The culture of health service utilization in Bangladesh is one of the major determinants of health-seeking behavior. Given the shortage of qualified health workforce in Bangladesh and the inequity of their distribution between rural and urban areas, people prefer to seek healthcare from nonqualified providers in the informal sector, especially the poor and the disadvantaged [32]. On the demand side, various barriers also impede the use of qualified providers, such as lack of access to information on available services, lack of health awareness, lack of opportunity due to exclusion from social and health institutions, cultural factors prohibiting women from seeking care from male providers outside the home, and inability to pay [33]. A study revealed that 60% of outpatient visits were to informal healthcare providers [34]. These informal providers are deeply embedded in the local community and culture, are easily accessible, and provide inexpensive services to villagers with acceptance of deferred payment and payment in kind instead of cash [32]. With this scenario, involving community members or CHWs to detect children with acute malnutrition in the community could be a feasible option, as we found that involving CHWs was successful in one pilot project run in Barisal by Save the Children in collaboration with Tufts University [10, 28]. This can be tried with volunteer mothers and the CSGs. Financing of CMAM
Although the cost effectiveness of treating SAM is well established, the real costs of taking CMAM to scale are
not clear and vary between countries [35, 36]. Costs for startup, sustained coverage, personnel and community mobilization, and in relation to the cost benefits of integration or convergence with other programs and sectors are not yet well established in many countries. The Lancet Maternal and Child Nutrition Series (2013) mentions delivery platforms as being very important for scaling up nutrition interventions in general [37]. The Scaling Up Nutrition (SUN) movement is supporting some governments to cost nutrition scale-up plans, and CMAM is part of this exercise in a number of these countries. On the other hand, whether local production of RUTF yields cost savings is debatable. Recent evidence has shown that local production may not yield cost savings in all settings [38, 39]. But in Bangladesh, the government is not in favor of imported RUTF, and there is a need for research on the cost of treating children with SAM using local RUTF. Programmatic activities and operational research
Since there is no policy for implementation of CMAM with the health system, possible models should be tested to determine the effectiveness of CMAM by utilizing existing health resources, such as community clinics, and by involving CHWs of nongovernmental organizations. It is also imperative to assess health facility and community capacity for management of acute malnutrition in Bangladesh. One community clinic usually serves a population of about 6,000 to 8,000 in about 1,200 households, which is supposed to be staffed by one CHCP, one HA, and one FWA who work for 6 days a week. An additional field health worker will be recruited in the NNS priority upazilas for the nutrition-related interventions. However, this is yet to be decided upon and finalized by the government. If the government decides later to hire CHWs dedicated to nutrition, the services of newly recruited workers could be used for planning a CMAM model using the community clinic as a hub. Therapeutic food to manage and treat SAM
In the CMAM context, the nutritional component of SAM treatment is RUTF, which is referred to as “nutritional treatment” in the national guideline on CMAM in Bangladesh [18]. RUTF is an energy-dense, lipid-based paste enriched with vitamins and minerals, which is administered to children with SAM in a dose of 175 to 200 kcal/kg/day, once they demonstrate a reasonable appetite [40]. The prototype RUTF is Plumpy’nut, a peanut-based paste formulated and developed by Nutriset and currently being produced by Nutriset and the PlumpyField network of producers in Ethiopia, Malawi, Niger, DR Congo, India, Mozambique, and Uganda. Plumpy’nut is equivalent in formulation to F-100, which is the WHO-recommended fortified liquid milk–based diet for the nutritional
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rehabilitation of children with SAM in a hospital setting. RUTF has very low water activity and therefore can be stored and administered at home with little risk of microbial contamination. It requires no mixing, dilution, or cooking, and it can be eaten directly from the package, with a shelf life of up to 24 months. The typical composition of the prototype RUTF (by weight) is whole milk powder 30%, sugar 28%, vegetable oil 15.4%, peanut paste 25%, and mineral–vitamin mix 1.6%. The case fatality rates typically achieved with CMAM using RUTF compare favorably with rates observed with facility-based management [41]. This comparison, however, must be interpreted cautiously, since the severity of cases in the facility-based trials and the community-based observational studies differs. In a community-based observational study, the use of Plumpy’nut to treat SAM had a favorable result [5, 10, 28]. However, it is well known that importation of RUTF will never be a sustainable option for successful implementation of the CMAM program, and there is no in-country favorable evidence on the large-scale use of RUTF. Because of the importance of ensuring a regular, sustainable supply of RUTF and, in some cases, opposition to the use of imported products, Bangladesh is exploring options for locally produced RUTF. To address the lack of data from within the country, the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), an international research organization, has developed two different types of RUTF using local food ingredients through operational research with support from UNICEF and Nutriset. Moreover, this organization is conducting a carefully designed study comparing the gold standard RUTF, Plumpy’Nut, with locally developed RUTFs for the facility-based nutritional rehabilitation of children with SAM. The findings of this research will definitely provide a clear direction for policy makers to implement CMAM in Bangladesh. Moreover, icddr,b with support from the Department for International Development (DFID), is also working with government and other local and international nongovernmental organizations in planning to implement the CMAM program on a pilot scale where the community clinics would be considered as the hub for all the field-level activities of this proposed program. The program will be implemented in the near future after completion of a series of research activities on locally made RUTF. The use of locally developed RUTF for treating SAM might have different challenges, which could be identified by efficacy and effectiveness trials of the locally developed food products. While the Government of Bangladesh is awaiting full-scale production of a local RUTF, an interim strategy is needed to effectively treat these severely wasted children on an outpatient basis Food supplementation and management of MAM
Children with MAM should be treated at home with
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energy- and nutrient-dense local foods. Management of MAM cases in the community can be supervised by a trained CHW. This delivery platform ideally requires one trained CHW for an average of 200 households to ensure a manageable caseload. The nutritional management of MAM aims to provide additional energy and increase the nutrient density of the existing home-based diet to support catch-up growth. This means adding at least 25 kcal/kg/day over and above the energy requirements of a well-nourished child [16]. This should be done by encouraging increased intake of home foods. The staple cereal (rice) should be fortified with micronutrient powder, and animalsource foods (fish, egg, milk, etc.) should be included in the diet. Deworming should be done at least at 6-monthly intervals. Intercurrent infections should be appropriately treated. Sanitation and hygiene should be promoted to prevent infection. This will also prevent and alleviate malnutrition by controlling environmental enteropathy, which is now widely believed to be responsible for stunting in many populations [42–44]. However, children with MAM living under food-insecure conditions may not be able to receive the required nutrition, not to speak of the additional food recommended by WHO. These children will require a nutritional supplement. The nutritional supplement should ideally provide about 250 kcal/child/day, with 25% to 30% of energy from fat and 10% to 12% of energy from protein. The National Nutrition Program of Bangladesh used to provide a supplementary food called Pushti packet for the management of severely underweight children. This supplementary food is a mixture of toasted rice powder, roasted lentil powder, molasses, and vegetable oil. Children with severe underweight received two sachets of Pushti packet daily for an additional 300 kcal. Pushti packet, which is cereal-based, contains phytate, an antinutrient factor that impedes the absorption of primarily iron and zinc and possibly other minerals in the intestine. It does not contain any added micronutrients and is not meant for the management of acute malnutrition. If a supplement diet based on similar locally available food ingredients can be developed, there is no reason why it could not be delivered in a similar large-scale program for the management of MAM. Researchers at icddr,b have also developed a ready-to-use complementary food supplement (RUCFS) with support from the World Food Programme using locally available food ingredients for use in food-insecure populations. This food supplement is now under trial. A child with MAM can be discharged from a CMAM program when MUAC is at least 125 mm for two consecutive visits (1 week apart). Finally, a national or subnational program should aim not just at treating children with acute malnutrition. It should have robust components to promote nutrition in general and to prevent malnutrition. These include scaling up or strengthening existing interventions on IYCF,
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micronutrient supplementation, and hygiene and sanitation interventions, and linking food-insecure households to safety nets and livelihood creation programs. Without such preventive components in the program, acutely malnourished children are likely to slide back into malnutrition once their treatment is complete. Existing CMAM program in Bangladesh
full-scale production of a local RUTF, an interim strategy is needed to effectively treat these severely wasted children on an outpatient basis. Preventive nutrition services are an essential prerequisite to establishing MAM and SAM treatment service delivery.
Conflicts of interest
International nongovernmental organizations, including Save the Children, Action Against Hunger (ACF), Médecins Sans Frontières (MSF), and Terre des Homes, deliver imported RUTF to children with SAM and in specific contexts such as in the case of specific disease outbreaks, healthcare exclusion, and natural or manmade disasters in Bangladesh. Although they work on the small scale, these nongovernmental organizations might help to move large-scale implementation of CMAM in Bangladesh forward by using locally produced RUTF. Use of such a RUTF will contribute to effective scale-up of a program for treating children with SAM with good appetite and free from any acute illnesses in their communities, while also convincing policymakers to promote CMAM in the country.
The authors declare that they have no conflicts of interest.
Conclusions
Acknowledgments
A recommended approach for Bangladesh for the management of acute malnutrition would be to integrate CMAM into the rollout of the NNS so that screening, identification, referral, and treatment of acutely malnourished children could be effectively managed within the community-based health service delivery system. Given that the vast majority of children are moderately wasted and could be treated with locally prepared food supplements, a significant emphasis of the CMAM approach in Bangladesh should be to screen and treat moderately malnourished children. Over time, this would also result in fewer SAM cases. However, even with this approach, there would still be a small number of children who are severely wasted and ideally should be treated with specialized therapeutic foods. While the Government of Bangladesh is awaiting
This research activity was funded by TRAction project under United States Agency for International Development (USAID) through University Research Co., LLC (URC), Sub agreement No. FY11-G04-699 under Cooperative Agreement No. GHS-A-00-09-00015-00. icddr,b acknowledges with gratitude the commitment of USAID to its research efforts. However, the contents herein do not necessarily reflect the views of USAID. icddr,b also gratefully acknowledges the following donors which provided unrestricted support: Australian Agency for International Development (AusAID), Government of the People’s Republic of Bangladesh, Canadian International Development Agency (CIDA), Swedish International Development Cooperation Agency (Sida), and the Department for International Development, UK (DFID).
Authors’ contributions Nuzhat Choudhury and Tahmeed Ahmed conceptualized and drafted the manuscript. Md. Iqbal Hossain, Barendra Nath Mandal, Golam Mothabbir, Mustafizur Rahman, M. Munirul Islam, Mohammad Mushtuq Husain, Makhduma Nargis, and Ekhlasur Rahman helped in conceptualization of the manuscript and interpretation of the findings and contributed to the revision of the final draft for submission. All authors read the final draft and approved it for submission.
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