|Year : 2016 | Volume
| Issue : 1 | Page : 20-23
Improving the outcome of severe acute malnutrition by community-based management
Zubaida Ladan Farouk1, Garba Dayyabu Gwarzo1, Aisha Zango2, Halima Abdu3
1 Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University Kano, Kano, Nigeria
2 Nutrition Unit Gunduma Health System Board, Jigawa, Nigeria
3 Department of Paediatrics, University of Jos Teaching Hospital, Jos, Nigeria
|Date of Web Publication||25-Feb-2016|
Zubaida Ladan Farouk
Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University Kano, Kano
Source of Support: None, Conflict of Interest: None
Background: Undernutrition is the leading underlying cause of death among under-five children in Nigeria. The few functioning inpatient health facilities are unable to carry the heavy prevalence burden. The community management of acute malnutrition (CMAM) targets children aged 6–59 months with severe acute malnutrition (SAM), providing maximum access, coverage, and appropriate clinical and nutritional care before life-threatening complications set in. Aim: The aim of this study is to evaluate the outcome of the outpatient therapeutic program (OTP) component of CMAM using the SPHERE indicators,a rural Nigerian community. Settings and Design: Jigawa state is located in the Sahel region of Northwestern Nigeria. It is a prospective cross-sectional study. Statistics: Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 17.5 statistical software. Descriptive statistics was used. Materials and Methods: Prospective data were collected from 16 United Nations Children's Fund (UNICEF)-assisted CMAM OTP sites in three local governments areas between its inceptions in July 2010 and end in August 2011 in a rural Nigerian state. The estimated number of children with SAM in communities and the actual number of children with SAM enrolled into the CMAM program was used to calculate the point treatment coverage in the CMAM program was used to calculate the point treatment coverage. Results: were represented in tables and graphs. Analyzed data were compared with the minimum SPHERE indicators as cutoff points for outcome performance. Result: A total of 24,419 children were admitted to the program accounting for 12% of the SAM target population with 12,073 children seen in in the three LGA that are assisted by UNICEF. Of 7,742 (64%) children who exited the program, 58% were cured and 40% defaulted, and all these children fell below the accepted minimum SPHERE standards. Death occurred in 2% and none were discharged non-recovered. Only 27% of the government-owned health facilities in these the selected local government areas were utilized to provide CMAM services. Conclusion: The performance of the CMAM program in Nigeria is 58% cure rate, 40% defaulter rate and 2% death rate standards. Large number of children with SAM were cured and prevented from dying.
Keywords: Nigeria, severe acute malnutrition, SPHERE indicators
|How to cite this article:|
Farouk ZL, Gwarzo GD, Zango A, Abdu H. Improving the outcome of severe acute malnutrition by community-based management. J Health Res Rev 2016;3:20-3
|How to cite this URL:|
Farouk ZL, Gwarzo GD, Zango A, Abdu H. Improving the outcome of severe acute malnutrition by community-based management. J Health Res Rev [serial online] 2016 [cited 2020 Mar 29];3:20-3. Available from: http://www.jhrr.org/text.asp?2016/3/1/20/177492
| Introduction|| |
Undernutrition is a major public health issue and an estimated 20 million children are suffering from a severe acute form of undernutrition worldwide. Severe malnutrition is the cause of 1 million under-five deaths annually.,,,, Nigeria is among the 20 countries in the world that account for 80% of undernourished children., There also is wide regional differences in the relative severity of malnutrition among under-five children in Nigeria, with the Northern region being the worst affected area. Acute malnutrition occurs due to inadequate intake or utilization of food, medical complications, poor appetite, and natural or man-made crises such as the recent insurgency witnessed in several regions of the world.,,, Though there is weak or no association between the economic growth of a country and the prevalence or the outcome of childhood undernutrition, yet other factors, such as illiteracy, infections,,, and poor infant and young child feeding practices, in combination with poverty make undernutrition endemic in sub-Saharan Africa. Severe acute malnutrition (SAM) if untreated timely becomes complicated and has a case fatality rate of 20–40%.,,
SAM leads to poor cognitive development, in the long term, causing poor work productivity and consequently loss of gross domestic product (GDP) of a nation. Early intervention before the onset of complications has been shown to improve the outcome.,,,
SAM defined is by a mid-upper arm circumference (MUAC) measurement of less than or equals to 115 mm in children aged 6–59 months,,,, or by weight-for-height measurement less than <-3 Z score of World Health Organization (WHO) growth standard, or by the presence of bilateral edema of nutritional origin.,,, The use of MUAC for screening simplifies the process of case finding such that community health workers and volunteers can do it efficiently. Traditionally, children with SAM are treated as inpatients.,, The CMAM program differs from inpatient base care or inpatient-based model follows the WHO guidelines for the management of SAM, which has had several challenges such as limited bed spaces resulting in low coverage and late presentation, heavy workload for the hospital staff, and infections., Furthermore, the duration of hospital admission is long leading to additional stress on the family., To deal with some of these problems, a community-based approach to treat SAM was developed., The program comprises four major components–community involvement, outpatient care, inpatient care, and services addressing the immediate and underlying causes of under nutrition such as supplementary feeding and food security programs., Children with uncomplicated SAM are treated at accessible and decentralized sites called the outpatient therapeutic program (OTP) clinics. The children with SAM and other complications are admitted into a hospital. The CMAM program differs from inpatient-base care model, and it provides take-home ready-to-use therapeutic food (RUTF) as well as appropriate medical treatment on outpatient basis., Regular monitoring at the OTP clinic and within the community is done by trained health workers and community volunteers. The CMAM approach empowers the community to identify early signs using the MUAC tapes, check for pedal edema, provide home visits, and refer to OTP clinic.,
The quality of intervention of this program is measured against the SPHERE indicators,, which are as follows: Recovery/cure rate of >75%, defaulter rate of <15%, and death rate of <10%. Recovery is defined as achieving MUAC of >12.5 cm on three consecutive visits, progressive weight gain on three consecutive visits, good appetite, absence of complications and edema. Default is defined as absence from care for three consecutive visits without cure. Nonrecovered is defined as not achieving the discharge criteria after 12 weeks of appropriate medical and nutritional care.,
The aim is to evaluate the outcome of the OTP component of CMAM using the SPHERE indicators in selected local government areas (LGAs) in Jigawa state, Nigeria, in the first year of implementation (2010–2011).
| Materials and Methods|| |
Jigawa state is located in the Sahel region of northwestern Nigeria and it shares borders with the Republic of Niger. Population of under-five children is about 1,005,323 in this region,, the prevalence of wasting was estimated to be 17.5%, exclusive breastfeeding rates was 9%, and full immunization coverage was 4%. The study was approved by the state Ad Hoc Committee on Nutrition, the Ministry of Health, and was supported by the development partners. A total of 19 basic health centers served as OTP clinics in three LGAs. The program rolled out with advocacy and sensitization meetings with 150 policymakers and community leaders. The community volunteers were trained (N = 375) on active case finding using MUAC tape and home visits. Ninety health workers were trained based on the WHO protocol. Criteria for admission were as follows: MUAC of <115 mm, age 6–59 months, and absence of complications or severe edema. The weights of the eligible children were measured and bio data and general physical examination were noted. The mothers washed their hands and that of their children before the appetite tests for RUTF were done, those with good appetite were given weekly RUFT ratio based on their weight, over a period of 8 weeks. They were given antibiotics, albendazole, and vitamin A. The outcomes were noted. Those with poor appetite, complications, or severe edema were referred to the inpatient care.
Data were collected monthly at each LGA and collated at the state level. The research team did monthly supportive supervision. The data were entered into an Excel spreadsheet and were analyzed using Statistical Package for the Social Sciences (SPSS) version 17.5 statistical software (SPSS-Inc., Chicago, IL). The performance indicators  were calculated as follows:
| Results|| |
A total of 24,419 children were admitted, with half seen at the United Nations Children's Fund (UNICEF)-supported clinics and the other half seen at MSF clinics. Only 3% (19 of 625) of the basic health clinics in the state were utilized. Merely, 12% (24,419 of 203,491) of the estimated population of children with SAM in the whole state were enrolled in the study. Data obtained only from the three LGAs were further analyzed due to the incompleteness of data from the other sites. [Table 1] shows the proportion of health facilities covered in the three selected LGAs, with only 41% target population enrolled. Out of the 12,073 cases enrolled, 7,742 (64%) exited; the cure rate is 58%, mortality rate is 2%, and the defaulter rate is 40%; none of the cases were discharged non-recovered as shown in [Table 2].
|Table 2: Outcome of children admitted in OTP clinics in three LGAs with complete data in Jigawa, Nigeria 2010/2011|
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| Discussions|| |
Over 24,000 children were treated for SAM in the community within a year. It is higher than what was reported from Ethiopia, but less than what was reported from Republic of Niger. In contrast to our study, the report from Niger was obtained during a famine, this could explain the higher cases reported from Niger. Furthermore, only 12% of the target population was recruited in our study. Usually, such large numbers of SAM is seen during acute food shortage related to famine or civil strife, yet we are reporting these large numbers during peace time with no draught in the year. A large population of under-five children, high level of illiteracy among women, and large family size, could have contributed to this burden during a nonemergency period., Cultural practices inimical to health, poor exclusive breastfeeding rate, and infant and young child feeding practices , might have contributed as well. Additionally, being an agrarian society, borderline rainfall, desertification, outdated farming method, and large family size might have led to food insecurity , accounting for the high incidence of malnutrition. It is obvious that this large number of children could not have been absorbed into the already overstretched inpatient care centers. There are relatively few health facilities and fewer health professionals to handle them. Jigawa state has 1.5 doctors to 100,000 population and one health facility per 150, 000 population. Without CMAM services many of these children would die.
Only 3% of the health facilities and 12% of the target population were covered, which is inadequate. A minimum of 50% of target population is required. The low coverage in this study indicates that a significant proportion of affected children did not access nutritional intervention. A higher coverage with a low cure rate may be better than a low coverage with a high cure rate in meeting the needs of these children. The high cost of the program and lack of community ownership, of the program, being largely a donor driven program makes rapid scale up and better coverage daunting. Nonintegration of nutrition into the existing child-health programs and or poor community mobilization could have also contributed. Although the active participation of the community volunteers was not assessed in this report, improved participation by community volunteers would enhance the active case search and consequently improve the coverage. Only one LGA achieved up to 53% coverage, indicating better community mobilization than the others. About two-third of the enrolled children exited the program. An appreciable number of cases (58%) were cured and saved from death due to malnutrition, which is below the minimum standard of 75%. In contrast, a higher cure rate was reported from Ethiopia. The lowest cure rates were recorded from Birniwa, the highest defaulter rate was also recorded from the same place. The defaulter rate of 40% in this study is more than the minimum rate of 15%. The long distances over difficult terrains that the mothers have to travel to reach the OTP clinics as well as the poor transportation system could have contributed to the high default rate observed. The death rate of 2% is within the recommended limit of <10%. The case fatality rate of complicated SAM in inpatient care is as high as 40.1%. Furthermore, malnutrition is the underlying cause of death in 40–50% of all cases of death of children under the age of 5 years.,,, Hence, early intervention in SAM by community base management approach has the potential to decrease under-five mortality rate in our environment.
| Conclusion|| |
A large number of children can be successfully treated for SAM on outpatient basis, with a low mortality rate. There is a high default rate. CMAM program has the potential of reducing under-five mortality rate. Rapid scale-up and government/community ownership will increase the coverage and improve the outcome of this program. We recommend the promotion of public health education and integration of nutrition into the basic child health programs as preventive strategies.
Financial support and sponsorship
Jigawa State Ad Hoc Committee on Food and Nutrition Presentation at a meeting: 43rd Annual General and Scientific meeting of the Paediatrics Association of Nigeria Conference.
Conflicts of interest
We have no conflicts of interest.
| References|| |
de Onis M, Brown D, Blo ̈
ssner M, Borghi E. UNICEF-WHO- The World Bank. Joint Child Malnutrition Estimates. Levels and Trends in Child Malnutrition, 2012. Available from: . [Last accessed on 2015 Dec 02].
World Health Organization. World Health Statistics. Geneva: World Health Organization (WHO); 2012.
Schroeder DG, Brown KH. Nutritional status as a predictor of child survival: Summarizing the association and quantifying its global impact. Bull World Health Organ 1994;72:569-79.
Black RE, Allen LH, Bhutta ZA, Caulfield LE, de Onis M, Ezzati M, et al
. Maternal and child undernutrition: Global and regional exposures and health consequences. Lancet 2008;371:243-60.
Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet 2003;361:2226-34.
Nigerian National Demographic and Health Survey 2008. Abuja, Nigeria: National Population, Commission, Federal Republic of Nigeria; 2009. p. 163-65.
Minimum Standards in Food Security and Nutrition: The Sphere Handbook. p. 164-75. Available from:
. [Last accessed on 2015 Sep 04].
Walton E, Allen E. Malnutrition in developing countries. Paediatr Child Health 2011;21:418-24.
Vollmer S, Harttgen K, Subramanyam MA, Finlay J, Klasen S, Subramanian SV. Association between economic growth and early childhood under nutrition. Evidence from 121 demographic and health surveys from 36 low income and middle-income countries. Lancet Glob Health 2014;2:e225-34.
Keusch GT. The history of nutrition: Malnutrition, infection and immunity. J Nutr 2003;133:336-40S.
Rice AL, Sacco L, Hyder A, Black RE. Malnutrition as an underlying cause of childhood deaths associated with infectious diseases in developing countries. Bull World Health Organ 2000;78:1207-21.
Jones KD, Berkley JA. Severe acute malnutrition and infection. Paediatr Int Child Health 2014;34(Suppl 1):S1-29.
Matthew AK, Amodu AD, Sani I, Solmon SD. Infant feeding practices and nutritional status of children in north western Nigeria. Asian J Clin Nutr 2009;1:12-22.
Benyera O, Hyera FL. Outcomes in malnourished children at a tertiary hospital in Swaziland after implementation of the World Heath Organization treatment guidelines. S Afr J CH 2013;7:135-8.
Collins S, Dent N, Binns P, Bahwere P, Sadler K, Hallam A. Management of severe acute malnutrition in children Lancet 2006;368:1992-2000.
Collins S. Treating severe acute malnutrition seriously. Arch Dis Child 2007;92:453-61.
CTC Research and Development Program, Collaboration between Valid International and Concern Worldwide. Community- based Therapeutic Care (CTC), A Field Manual. 1st
ed. Oxford: Valid International; 2006. Available from: . [Last accessed on 2014 Dec 30].
Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, Giugliani E, et al
. Maternal and Child Undernutrition Study Group. What works? Interventions for maternal and child undernutrition and survival. Lancet 2008;371:417-40.
Cook R. Is hospital the place for treatment of malnourished children? J Trop Pediatr Environ Child Health 1971;17:15-25.
World Health Organization. Management of Severe Malnutrition: A Manual for Physicians and other Senior Health Workers. Geneva: 21 World Health Organization (WHO); 1999. p. 4-24.
Teferi E, Lera M, Sita S, Bogale Z, Datiko DG, Yassin MA. Treatment outcome of children with severe acute malnutrition admitted to therapeutic Feeding centers in Southern Region of Ethiopia. Ethiop J Health Dev 2010;24.
Tectonid M. Crisis in Niger--Out patient care for severe acute malnutrition. N Engl J Med 2006;354:224-7.
FEWS NET, Save The Children Nigeria, UNICEF. Nutrition Assessment in Northwest Millet and Sesame Livelihood of Northern Nigeria 26th
[Table 1], [Table 2]