I think there are many issues here ... including ... (1) MAM and mortality ... There are quiet a few papers showing that MAM is a big killer but these should be interpreted carefully. MAM is not the killer but it is a major contributing factor. Children die of nasty infections. Children with MAM and infection do worse than children without MAM or SAM with the same infection. Not just that. Infection might cause MAM which leasve the child susceptible to infection which causes more MAM &c. This is what we call the infection-nutrition cycle (see Scrimshaw et al. (1959) and later papers). So ... preventing and treating MAM will reduce mobidity and mortality but the effect is indirect. (2) MAM and mortality (again) ... SAM kids just don't appear as SAM kids. Most are MAM kids before they are SAM kids. A lot of kids with SAM die if SAM is untreated. So ... preventing and treating MAM prevents SAM and SAM-associated mortality. (3) Can we do it? The most common intervetion against MAM is the "supplementary feeding program" (SFP). There is not one type of SFP. It seems that SFP is a name that is applies to just about any intervention that isn't treating SAM or isn't a general ration. Also, the term "SFP" seems to be used for programs that treat stunting and programs that treat wasting. Let's stick with SFP for wasting (MAM). There is little evidence that these program work. They usually have very low coverage, high defaulting, and deliver low-grade food. The SFP for MAM tends to use fortified cereal-legume mixes provided by WFP. I hear bad stories about poor supply lines, unilateral ration reductions, overly complex monitoring, &c. about dealing with WFP. (5) NCHS, WGS, and MAM ... W/H measures a sort of thinness that is not always wasting (it can just be thinness or long limbs and short bodies). It doesn't matter which W/H reference you use you won't be doing much good because using W/H is a barrier to coverage. MUAC is the better indicator to use (for so many reasons) and we should soon see the WHO releasing MUAc case-defintions. In the meantime we can use: 115 mm <= MUAC < 125 mm without bilateral pitting oedema for MAM and: MUAC < 115 mm or bilateral pitting oedema for SAM. Summing up ... It is pretty clear that preventing and treating MAM makes sense as a child survival program strategy but the sorts of intervention used are not very effective and use the wrong case-definition. If what you write about agencies refusing to get involved in prevention and treatment of SAM is true then it is a REAL PROBLEM and a STUPID RESPONSE. I think they should be thinking about and testing new program modalities. We have been here before. For years we had TFCs for SAM which had very low coverage and very high mortality and defaulting rates. Now we have CTC which (even when done badly) is much better than TFCs. We need a similar revolution for MAM. I think that something like the CTC Research Program (i.e. a consortium of donors, UNOs, and NGOs led by a dedicated technical team) might be required. Four years and four million dollars should be mor ethan enough. Better to try this and risk failure than just turn our backs on the problem. Just my tuppence.

Thanks Mark for your response. That is exactly what I wanted to hear! However, I think, we have to point out that the SFPs are not ineffective per se but there are a lot of quality issues in the design and implementation of SFPs to be discussed. With regard to the "revolution for MAM", I would say we still need more advocacy as well as evidence to make some people (and agencies) understand that SAM children are not popping up all on the sudden one day but that they have in most of the cases a long history.

Mark, While we wait for generation of sufficient evidence on this subject via concrete operational research,I see a critical need for interim guidance at the global, regional, national level that will ensure response approaches do not fall short of, or deliberately ignore the problem of MAM. Who can generate this guidance? I think this is the prime time to ensure some level of either national, regional or global coherence in response strategies. What do you fore see as the specific components for the proposed multi-year research of moderate malnutrition?

I think you are right. SFPs are not INEVITABLY poor quality and low coverage interventions. I have seen quite a few SFPs. Recently this has been because of work on CSAS and SQUEAC (i.e. CTC / CMAM coverage). When I find SAM kids languishing in SFP (a SAM coverage failure) I review the SFP and tend to see all sorts of problems. Most SFPs I have looked at recently have come to my attention because they are failing. If I sample SFPs in this way I will always see poor practice. This is a source of bias ... but ... the failing SFPs I see now do not look very different from SFPs I reviewed before the CSAS and SQUEAC work. I agree that "there are a lot of quality issues in the design and implementation of SFPs to be discussed". This is, perhaps, what I meant by a "revolution". Perhaps "revolution" was a bit pretentious. Perhaps all that is required is as set of well-designed reforms. For example: (1) Proper queuing systems aimed at minimising crowing and waiting times would greatly improve many SFPs. (2) Better and more compact rations are required. I believe that work is being done on this. I have been looking (e.g.) at using RUTFs in MAM programming. (3) Simpler record-keeping is needed. (4) Good patient monitoring is needed. Mike Golden has written about this. (5) We have to get rid of W/H. (6) We need to improve case-finding and recruitment. I'm sure we can come up with a longer shopping list (and in a better order too!). My concern is that if we treat each item as an isolated reform then we may create complicated and unworkable programs ... a bit like those Health-Robinson / Rube Goldberg / Wallace and Grommet machines for tying shoelaces that do the job with expensive and comical inelegance. I think the reforms need to come as a set. That's what I meant by "revolution".

Again, thanks Mark. We are together on this!

Happy to be of use. How can we take this forward? Perhaps we could start a thread on this forum with a title such as "What's wrong with SFPs (and how to fix them)" and invite suggestions for problems, fixes, &c. That might start the ball rolling. Do you want to do that? This is something that. I think, ENN should run with. I understand that there is some work being proposed but I am not sure this will get us past looking at existing designs and saying "none of them are any good". Can anyone at ENN advise?

This is a good idea. Happy to go for it! I also hope that ENN comes as you suggested.

Responding to "Anonymous 184" ... I agree that we need "concrete operational research". I don't think it need take a generation. Take some of the examples on my "shopping list" ... (1) Queuing systems to minimise wating times and crowding - Some of this is quite well understood and simulation tools are available so we can do some "virtual testing" to identify candidate methods worth trying in the field. (2) Better and more compact rations - These are on their way. It's not rocket science to develop these. We do, perhaps, need some streamlining of testing protocols to get these in use quicker. (3) Simpler record keeping - Some of the systems in use are Dickensian. I saw one last year that had five pieces of paper with three duplicates (8 papers in all) for a few kilos of CSB. Streamlining this is not beyond the with of any O&M consultant. I could go on. It seems to me that we have problems that already have candidate solutions. The big problem is little more than identifying the right mix of solutions. I take your point about the need for interim guidance. Do we not have a lot of that already? The UNOs (WHO, UNICEF, WFP, &c.) have had meeting recently and advice should be forthcoming. I am not convinced that these big meetings are the best way forward. CTC, for example, was developed and tested by a small technical team. I think a similar approach might be fruitful for MAM. One hope that I have for the ENN forums is that practictioners can "meet" to discuss and resolve problems and go some way towards developing a body of guidelines based on what has worked and what has not worked. I think that this does happen on some threads. As for "specific components" ... I can think of specific activities (all of the top of my head) ... (a) We identify problems and solutions (b) We test specific solutions by simulation and in the field (c) We build our mix of solutions (d) We test our mix of solutions in the field at a few sites ... using audit techniques to improve the mix over time. (e) We describe, produce guidelines, tools, &c. Specific components ... (i) A good program manager. (ii) A strong technical team. VALID International Ltd staff and outside consultants led by Steve Collins, Kate Sadler, and Tanya Khara provided this in the CTC Research Program. (iii) The recoginition that many problems have already been solved in other field ane the ability to recruit staff from these fields. (iv) One or more open-minded NGOs willing to take advice and take risks. The role was played by Concern and, to a lesser extent, SC-UK in the CTC Research Program. (v) A supportive donor with technical and political expertise. This role was played by the Irish government and FANTA in the CTC Research Program. (vi) Some oponents to keep the project on its toes. This role was played by ... they know who they are and I don't want to start name-calling. (vii) A commitment to evidence-based programming (on the part of everyone involved ... not so important for (vi)!) (viii) Money to get it all done. All off the top of my head.

Thanks alot for the very useful response, I do indeed concur with you that there is the obvious that can be done to ensure that managment of MAM via SFP approaches work effectively and efficiently, and totally agree with you that commitment from CTC-like small technical team could play some role in resolving part of the problem and I hope something can be done or is being done. Regarding interim guidance: I am not sure if this has been disseminated to the field, otherwise we wouldn't be concerned by the questionable position of different agencies on this matter. This is particularly worrying where management of MAM is neglected even when substantial needs of MAM have been reported via assessments or regular community screening exercises indicate significant needs amongst the moderates. It would be useful if this guidance (if available?) could trickle down to the operational level, better still the other alternative could be that the global technocrates (ENN, GNC, UNOs) collate different field experiences on how countries/regions have dealt with this issue (?? I wonder if there is any example -just a thought) and formulate an all encompassing guidance that captures different but broad contextual scenarios. How can contribute the ENN and the GNC to this important issue???? It is clear that some increased momentum is needed in addressing this issue.

Regarding the question on "WHO": I know that the GNC has recently (during the Genva GNC meeting) established a working group on CMAM - I think this is an entry point especially as one of the objectives is "new research and debate on CMAM (and linked to the community practice on MAM)". What worries me a bit is the time factor: Guidance is needed now and Working Groups tend to take too long to come up with results.

From André Briend: Dear Anonymous, (Remark: there seems to be a majority of anonymous users in this forum) Usually, most academic public health specialists argue that MAM is a more important cause of death than SAM. This predominant view is based on a paper published in 1995. See abstract below. Pelletier DL, Frongillo EA Jr, Schroeder DG, Habicht JP. The effects of malnutrition on child mortality in developing countries. Bull World Health Organ. 1995;73(4):443-8. Abstract Conventional methods of classifying causes of death suggest that about 70% of the deaths of children (aged 0-4 years) worldwide are due to diarrhoeal illness, acute respiratory infection, malaria, and immunizable diseases. The role of malnutrition in child mortality is not revealed by these conventional methods, despite the long-standing recognition of the synergism between malnutrition and infectious diseases. This paper describes a recently-developed epidemiological method to estimate the percentage of child deaths (aged 6-59 months) which could be attributed to the potentiating effects of malnutrition in infectious disease. The results from 53 developing countries with nationally representative data on child weight-for-age indicate that 56% of child deaths were attributable to malnutrition's potentiating effects, and 83% of these were attributable to mild-to-moderate as opposed to severe malnutrition. For individual countries, malnutrition's total potentiating effects on mortality ranged from 13% to 66%, with at least three-quarters of this arising from mild-to-moderate malnutrition in each case. These results show that malnutrition has a far more powerful impact on child mortality than is generally appreciated, and suggest that strategies involving only the screening and treatment of the severely malnourished will do little to address this impact. The methodology provided in this paper makes it possible to estimate the effects of malnutrition on child mortality in any population for which prevalence data exist. Full paper available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2486780/pdf/bullwho00408-0029.pdf This paper has several problems however. First malnutrition was assessed with weight for age. Second, it uses old NCHS reference and not current WHO standards, and third, and maybe more importantly, it is based on nutritional assessment and then long follow up (up to 2 y) during which a MAM child can become SAM. More recently, the Lancet series attempted to give an update estimate of SAM mortality based on WHO growth standard. They came to the same conclusion that the number of SAM deaths is small compared to MAM. See: Prof Robert E Black MD a Corresponding AuthorEmail Address, Prof Lindsay H Allen PhD b, Prof Zulfiqar A Bhutta MD c, Prof Laura E Caulfield PhD a, Mercedes de Onis MD d, Majid Ezzati PhD e, Colin Mathers PhD d, Prof Juan Rivera PhD f, for the Maternal and Child Undernutrition Study Group? Maternal and child undernutrition: global and regional exposures and health consequences. The Lancet, Volume 371, Issue 9608, Pages 243 - 260, This paper however is based on the same old studies with the same problem, ie initial assessment and then long follow-up. In other words, it relates mortality to initial SAM prevalence and not to SAM incidence as would be needed. This also results is gross under estimation of SAM deaths. Unfortunately, SAM and MAM incidence are difficult to measure, and we have no reliable assessment of SAM MAM related mortality. Your mail suggests that some NGOs feel that SAM is the main contributor for mortality. This is interesting. This shows that field nutritionists have a different perception from desk public health specialists. Field nutritionists may know better however and they may be right. At this stage, a word of caution is needed. Even if SAM is a more important contributing cause of death than MAM (not sure), it would be a big mistake to concentrate programmes on SAM. A well run MAM program should be effective in preventing SAM and we all know that prevention is far better than cure. If MAM programmes were effective, there would be no need for SAM programmes altogether, no need for expensive RUTF and this would be much better. We should all aim for that. There is a problem however. Most MAM programmes currently have a dubious efficacy. There is indeed little evidence they make a difference. The way forward is not to stop MAM programmes but to improve them. Mark mentioned a few suggestions on how to move forward on this issue. I fully agree with all of them. I would stress the importance of having around NGOs ready to be innovative and constantly critically assessing what they are doing. Over the last 10-20 y, this is how SAM programmes vastly improved.

André, Thanks a lot for this response (very useful), I realy hope that we can get concrete direction in this matter sooner rather than later. Thanks again

Dear André, Thank you very much for this clear contribution. However, I think that if we really want to reduce GAM prevalence and not only saving lives, we should go further by applying a new paradigm on child undernutrition. Instead of focusing on SAM and MAM, to make sure in addition that "non-malnourished" children have constant adequate weight gain, through an EFFECTIVE growth PROMOTION strategy using effective INTERPERSONAL COMMUNICATION at community level. Otherwise, we will continue to treat thousand of SAM children, save their lives without reducing GAM prevalence.

The relative importance of SAM and MAM in terms of mortality is very confused because we ignore morbidity. Quite a time ago, Steve Collins and colleagues proposed that the way we pick an arbitrary cut-point in an anthropometric indicator to distinguish between SAM and MAM is not useful and suggested that morbidity be included. The proposed method divided acute malnutrition (AM) into: (1) SAM without complications. For example, MUAC < 115 mm OR bilateral pitting oedema (I or II) AND good appetite for RUTF AND clinically well AND alert. treated with OTP protocol. (2) MAM without complications. For example, 115 mm <= MUAC < 125 mm AND no bilateral pitting oedema AND good appetite for RUTF AND clinically well AND alert. Treated with MAM protocol (3) Any AM with complications, For example, MUAC < 125 mm OR bilateral pitting oedema (III+) AND one or more of the following : no appetite for RUTFm LRTI, high fever, severer dehydration, severe anaemia, not alert. Treated with WHO/IMCI inpatient protocol. The third class is the interaction between wasting and morbidity. Many of these kids will be "MAM" kids. If you doubt the idea that a simple anthroprometric indicator is arbitrary remember that (e.g.) a girl with height = 90 cm and weight = 9.8 kg gets CSB ... but a girl with height = 90 cm and weight = 9.7 kg gets RUTF and systemic antimicrobials. The 100 g difference is less than the weight of a full ballder of urine.

management of Moderate Acute Malnutrition is one of the most important area of treatment. This is because it prevent deterioration of MAM child to become severe. The management of this area could be through the direct interaction of the caretakers at the targeted SFP centers whether through the comperhensive health and nutrition education or through the proper management at the SFP centers and it could be more efficient and effective if the SFP allocated and supervised by MoH. The role of MoH is very crucial in terms of creation of partnership with nutrition relevant agencies and provision of updated protocols and guidelines at country level.The supportive materials that help in the implementation of such programme is behind the successful of the programme. The absence of the MoH will bring us to the above mentioned that more agencies refuse to be involved in this area.

management of Moderate Acute Malnutrition is one of the most important area of treatment. This is because it prevent deterioration of MAM child to become severe. The management of this area could be through the direct interaction of the caretakers at the targeted SFP centers whether through the comperhensive health and nutrition education or through the proper management at the SFP centers and it could be more efficient and effective if the SFP allocated and supervised by MoH. The role of MoH is very crucial in terms of creation of partnership with nutrition relevant agencies and provision of updated protocols and guidelines at country level.The supportive materials that help in the implementation of such programme is behind the successful of the programme. The absence of the MoH will bring us to the above mentioned that more agencies refuse to be involved in this area.

I have been involved in a SFP program for over a year now, with a focus of integration into the health services. To be honest I do not see a future in this as they workload is too great with premix rations to be given to the beneficiaries and we have been doing SFP programming for 5 years and the MAM rates remain high each year and are even increasing in teh past year due to unfavourable climatic conditions. The program itself is taking away the focus from the preventative programming, its using up all our resources to support teh logistics of this program. If you think about it - if you were to use those resources you have and put them into growth monitoring and early detection of MAM cases who once identified should receive counselling followed by monitoring - would you not be treating the MAM issue in a sustainable way!!

An SFP that is well implemented will have high coverage and efficacy in preventing further SAM and stabilizing the situation thereby reducing mortality risks at a greater proportion, but this is as long as conflicts emergencies and other food shocks are concerned, But how about recurrent malnutrition cases where there is always high relapse for non programmatic reasons? I happen to have worked on a pilot MAM management program- a model based on the use of RUSF (Ready to Use Supplementary Food--a more compact and nutritious product which eases off the huge logistics needs with premix rations and favors the effective management of MAM within existing local capacity), where the objective of the program was to integrate the management of MAM into government health facilities (Health posts and Health centers) and foster a sustainability approach in MAM management programming, like the initiative with the management of SAM which has proved to be very effective in situations where there is a significant political commitment from the part of government (MOH). As the CTC initiative has been a substantial step in SAM management, I believe the current focus or future initiatives in revitalizing MAM management should be on capacitating local health facilities from Growth monitoring and Promotion to early detection, referral and treatment of pocket malnutrition cases (mostly MAM if it is detected at a very early stage) at community level and prepositioning of resources for treatment in health facilities during shocks and targeting on infection treatment with strong focus on delivery of primary prevention packages. The site based treatment of MAM cases (with SFPs) seems to be a conventional approach that everyone else wants to stick to in most cases. At the point where we have MAM cases that need extensive SFPs with huge logistics and other operational needs (except with conflict and complex emergencies and non recurrent food shocks), we would already have high contributions of the situation to mortality due to the infection-malnutrition cycle. An area with high caseload of MAM is obviously expected to already have high infectious disease prevalence, which is more likely to be exacerbated by MAM as a complementary incidence. Though the relation between MAM and Mortality is indirect (due to the crucial role of morbidity effects), its contribution to Mortality is yet significant as opposed to the conventional mindset that SAM is the single most contributor to Mortality. The above situation would have been easily averted if the community based management of MAM approach mostly focusing on providing capacity building support was in place in the first place. It would be sound an approach to consider these paradigms and others in the context of sustainability and adoptability of programming approaches while “revolutionizing” the management of MAM. That is; -the product for treatment…at this point RUSF is coming in handy -Capacity to manage and still maintain sustainability…political commitment +model of intervention -Integration with other PHCS packages…more reliable and strong monitoring opportunity -the CMAM approach is one way to see the way forward with MAM programming

From Massimo Serventi: Anonymous 673 underlines that MAM should be prevented through Growth Monitoring. This was done in the past ....then 2 articles (2...no more than 2) declared that GM is not effective. From then RUFT started to become fashionable : today emphasis, attention,funds are for RUFT. I keep waiting for an article (or 2) that will declare RUFT detrimental for the culture and nutrition of Africans. Is anonymous African? why do we keep reading letters on RUFT written by white-nutritionists and NOT by African ones? they know much better their people and culture: why then they stay silent? Thanks Massimo Serventi Pediatre en Bangui

Dear Massimo, To start with I believe any intervention should be culturally sound, and context-wise innovative in order to be effective. However we are talking about the management of MAM in emergencies (given that the nature of emergency differs from place to place). However in other contexts there are more sustainable approaches already implemented and proved to be effective like for example the PD-Hearth model, meanwhile this kind of intervention approach is not yet feasible in life-saving emergency responses. And in the management of SFPs in emergencies the need for highly nutritious/LNS products is critical-one which provides easy logistic workload, and easy storage, minimizes sharing, that is perceived as a medicine by beneficiaries than food-as a result avoids the issues of cultural unacceptability, more hygienic (avoids hygiene issues during household preparation like in case of premix ration) and with better taste (appetite of malnourished child is affected by infection). In my opinion RUSF is just an alternative approach in MAM management and there will be and are supposed to be more alternative, effective approaches in place that take into account local contexts…as for example opportunities for local production(UNICEF has done it in a number of countries) and local food cultures. BTW I am not affiliated with the group producing Supplementary Plumpy doz/RUSF and nor am I promoting the product, I am only sharing the field experience because I found it more effective as opposed to the conventional premix ration based SFPs. This is all secondary prevention and usually happens in emergency contexts. However in situations where there is not an emergency and yet the situation is detected at a late stage that requires massive SFPs, there rises the need for more innovative programming. This is where other preventive measures come in (surveillance systems included- though not preventive) and to say the least GMP is only part of these measures, but even so, would any two articles (as a result of perhaps two isolated incidents in some settings) mean anything in terms effective programming (you are talking about a failure probability of may be 1/100,000th or more?). You are right on the fact that indigenous local talent works better, but only if complemented by research based strategies, regarding issues of cultural soundness- that is why program strategies need to stem from the field and polished by desk officers than the contrary, and let’s hope this idea of local solutions becomes part of our programming approaches, more with political commitment of local governments taking the initiative…the technical expertise can always be pooled from elsewhere if not available. Last, does it really matter who is presenting ideas in this forum as long as the target is improving intervention models in life-saving responses? (FYI -I happen to be an African in this case if not professionally…lol)