Indian Pediatr 2010;47: 655-659
Therapeutic Nutrition for Children with Severe
Acute Malnutrition: Summary of African Experience
André Briend and Steve Collins*
From the Department of International Health, University
of Tampere, Finland; and *Valid International Ltd, 35, Leopold Street,
Oxford, OX4 1 TW, UK.
Correspondence to: Dr Steve Collins, Valid International
Ltd, 35, Leopold Street, Oxford, OX4 1 TW, UK.
Across Africa, Severe Acute Malnutrition (SAM) affects approximately 3%
of children under five at any time and is associated with several
hundred thousand child deaths each year. Since the 1950s, efforts to
treat these children as inpatients in hospitals or clinics have failed
to lower mortality rates and have achieved very poor coverage. During
the past 10 years new community-based management approaches treating
over 85% of SAM cases solely as outpatients using nutrient dense,
lipid-based Ready to Use Therapeutic Foods have dramatically reduced
mortality and increased coverage rates. In 2005, this new model was
endorsed by the UN under the name Community-based Management of Acute
Malnutrition (CMAM) and has now been adopted by over 25 National
governments and all major relief agencies. By 2009, approximately 1
million cases of SAM were being treated annually, with programs
expanding by approximately 30% year on year.
Severe Acute Malnutrition (SAM) is common
in sub-Saharan Africa, with approximately 3% of children under five
affected at any one time, it is also associated with several hundred
thousand child deaths each year. Between 1950 and 2000, efforts to treat
these children as inpatients in district hospitals or clinics failed to
address the problem; mortality rates amongst those undergoing treatment
remained extremely high at 20-30% and unchanged from those seen in the
1950s(1), and only a tiny proportion of those in need were able to access
care(2). Over the same period, every time a major crisis emerged in
Africa, relief agencies established inpatient feeding centres to treat the
large number of children requiring care. During the 80s and 90s, research
into rehabilitation diets rapidly allowed these centres to lower mortality
rates amongst those treated to <10%; however, coverage rates remained very
low and the centres themselves were costly to implement and undermined the
existing infrastructure. In response to these problems, agencies working
in collaboration with National governments in Malawi and Ethiopia,
developed simple effective community-based treatment models that could be
implemented rapidly on large numbers of SAM children with minimum
resources(3). Major progress has been achieved over the past ten years in
refining this new model and extending its implementation. By 2005, when
the model was endorsed by the UN(4), mortality rates had been reduced to
<5% and coverage rates increased to >50%(5). By 2009, all major relief
agencies and 25 National governments had formally adopted this new model
and approximately 1 million cases of SAM were treated annually, with
programs expanding by approximately 30% every year.
The Inpatient Treatment Approach
The initial efforts to treat large numbers of children
with severe acute malnutrition emerged during the Ethiopia famine of the
mid-70s(6). Children were then admitted to large inpatient feeding centres
based on their arm circumference for height or for age, and then treated
with a mixture of dried skimmed milk, oil, and sugar, diluted into clean
water. At that time, it was already acknowledged that SAM children needed
additional potassium and magnesium, and these minerals were added to the
diet. Other minerals and vitamins were given directly.
Over the years, changes were made to this protocol; a
standard mineral mix was developed in the mid-90s(7) based on research
carried out in Jamaica to promote not only weight gain, but also recovery
of different body functions. Ready-made recovery diets, based on the same
basic formula with added improved vitamin and mineral mix became available
in the mid-90s and rapidly became widely used to minimize risk of errors
in the preparation of feeds. A starter diet, F-75, with lower protein and
sodium content was introduced around the same time. With these new dietary
protocols and relatively intensive medical care, recovery rates improved
often exceeding 75%. Mortality rates were reduced to below 10%. From a
clinical perspective, these protocols were considered as rather
However, at the same time, the limitations of the
inpatient model, became clear. Although successful in terms of recovery of
treated children, it failed to tackle SAM as a public health problem.
Demand on staff and infrastructure were so large that the model was not
sustainable outside emergency situations where these protocols were
implemented by international, well funded organisations. Also, in terms of
coverage, i.e. the number of children effectively treated compared
to the total number of children with SAM, remained very low. This was
especially the case in open situations amongst dispersed communities
living in chronic poverty where often specialized inpatient feeding
centers were not accessible. In their absence, children had to be referred
to overcrowded pediatric or general wards ill-equipped to give adequate
care to malnourished children. Having the mother staying with the child
for several weeks was also a major problem when they were engaged in
agriculture or other life sustaining activities.
Mid-90s: Development of the Community Based Management
The limitations of the inpatient model led to
innovations in the mid-90s, which progressively introduced a radically new
approach, moving the treatment of SAM from inpatient hospitals and feeding
centres into the community. Three key innovations underpinned this
revolution in care: (i) the introduction of technique to engage
with communities to promote early presentation and compliance(2); (ii)
handing over the identification of SAM to the community through the use of
MUAC; and (iii) the development of Ready to Use Therapeutic Foods (RUTF).
The overall effect of these changes was to make treatment accessible,
understandable and affordable (in terms of opportunity costs to poor
people). The result was that people presented for treatment early and in
large numbers, at a time when their condition was still easily treatable
1. Community Engagement
During the development of the community-based model,
anthropological studies showed that most people did not understand the
bio-medical model of SAM and instead sought treatment with traditional
practitioner(8). This prolonged the time to presentation, thereby
increasing the frequency of complications. These studies also observed
that the inpatient model, which separated families and took mothers and
children away from husbands, siblings and farms was unpopular; and this
unpopularity further delayed the presentation and reduced the compliance.
The new community-based approach was based upon
proactive engagement with communities combined with a simple outpatient
treatment model that, so long as children presented for treatment early,
resulted in the vast majority not requiring admission into hospitals or
clinics. The community-engagement recognized that the decision making
process relied upon key individuals within families and communities and
once these people understood and appreciated the care provided, early
presentation and case finding increased dramatically. Based around local
capacity and simple measures to inform and engage with people, this model
was easily implemented and resourced even in impoverished environments.
2. Decentralization of Access and the Use of MUAC
for Diagnosis of SAM
Early anthropological work also identified access and
diagnosis of SAM as major barriers to early admission and compliance(9).
To address this, the community-based model adopted a system of
decentralized points of access using the lowest levels of the existing
public health system (health posts) to screen and admit patients. The aim
was to enable the client to travel to and from the clinic and receive
treatment in less than a day. To simplify the admission procedures, avoid
confusion with ongoing growth monitoring activities and facilitate
community-based screening by volunteer workers, MUAC was chosen as the
anthropometric measure of choice(10).
The use of MUAC is easy, fast to perform on large
numbers of children and is understandable to patients and staff. It also
removes confusion with growth monitoring weight for age indicators. MUAC
without correction for age or height was used, as early studies from
Africa and Bangladesh showed that correction of MUAC for age or height did
not improve the assessment of the risk of death(11,12).
The value of MUAC to identify children with a high risk of death may be
related to the selection of younger children who have a higher risk.
However, the close relationship of MUAC with muscle mass(13,14) and the
importance of muscle in general metabolism(15) suggest that it may have a
specific physiological meaning. In any case, the use of MUAC has greatly
simplified the process of case identification and admission, simplified
protocols, reduced staff workloads, and reduced training needs.
3. The Use of Ready to Use Therapeutic Food (RUTF)
Treatment with liquid diets used since the 1970s was
only possible in inpatient settings, as liquid foods, whether milk based
or traditional cereal based foods, are excellent media for growth of
pathogenic bacteria. As a result, if water used for preparing these feeds
is not prepared or stored in perfect hygienic conditions, pathogenic
bacteria grow rapidly in them and they may induce life threatening
diarrhea(16). In these conditions, contaminated foods often contain more
than 10 times as many pathogenic bacteria than water itself(17). To
prevent this risk, liquid diets had to be used with perfectly clean water
and in places where refrigeration was not possible; discarded if not
consumed immediately, which meant they had to be prepared as many times as
children were fed every day. In practice, this was possible only in
inpatient facilities where children had to stay until their recovery was
achieved, which usually took several weeks.
To avoid this problem, a simple solution was to use a
Ready-to-Use Therapeutic Food (RUTF) which can be consumed directly by the
child without the addition of water. In 1997, it was proposed to use a
diet with a nutritional composition very close to the F-100 diet
recommended by WHO for the recovery phase(18) obtained by replacing in the
original recipe about half of the dried skimmed milk with peanut butter,
removing all the water and increasing the amount of oil(19). The
elimination of water from the RUTF recipe removes the dangers of bacteria
contamination as bacteria need water to grow, making this food safe for
use in the community. Acceptability and efficacy trials proved
encoura-ging(20,21), and the major constraint imposing that children
should stay for several weeks in the inpatient centres was removed.
Inpatient treatment of SAM became necessary only for complicated forms of
SAM and only until medical complications requiring medical attention were
The change of the initial F-100 recipe needed to
produce RUTF is minimal, and in theory it can be produced in any health
facility with a clean kitchen and a mixer(23). Studies have demonstrated
an equivalent efficacy of RUTF made locally in Malawi and Senegal to
product imported from France using a more complex recipe(24,25). RUTF is
now manufactured to international quality standards in several countries
across Africa. This has reduced the cost of RUTF, created some employment
and upgraded food manufacturing in several countries; it also provides
some demand local farm crops that through the targeted purchase from small
holder farmers is providing economic benefits back to vulnerable
The move to the community-based treatment of SAM has
made it possible to address SAM as a public health problem treating
millions of children across 35 countries in the past few years. This
change has addressed key capacity constraints especially those of trained
staff and hospital inpatient capacity, that previously limited both the
numbers of children treated and the quality of treatment for those that
did manage to gain access. The result is huge improvements in program
coverage and greatly reduced mortality rates. Community-based management
using RUTF has reduced costs and, in terms of the cost per disability
adjusted life year (DALY) gained, delivers a cost effectiveness comparable
to mainstream public health interventions such as vitamin A
distribution(27). The local production of RUTF using local crops grown by
small holder farmers affords a mechanism to link nutritional treatment
with improvements in agricultural incomes that, if targetted correctly,
could be a valuable tool to improve food security in selected vulnerable
Contributors: Both authors collaborated on all
parts of the article.
Conflict of interest: None stated.
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