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Leading the way for the last 25 years – Community Management of Acute Malnutrition

Bangladesh

Over the past 25 years there has been major progress in the treatment of severe acute malnutrition. This has been largely down to two interventions: Ready-to-use therapeutic food (RUTF) and community management of acute malnutrition (CMAM). We have written much about RUTF; however, it is also important to understand how CMAM fits into treating malnutrition.

In conception, CMAM is rather simple – maximise access to treatment by extending treatment from hospitals into communities, using hospitals for only the very sickest children. This was made possible with the advent of a ready to use therapeutic food that could be given to carers to treat their child at home. CMAM goes beyond the treatment of malnutrition, with far reaching positive impact for communities and societies as a whole.

Before CMAM, access to treatment was often the biggest barrier for children suffering from severe acute malnutrition (SAM, also known as severe wasting). Historically, treatment for SAM would involve visiting an in-patient facility, often far away from a child’s home and family. This meant the parent of a malnourished child requiring treatment would need to stay in the facility with the child. Parents who had more than one child would therefore have to leave their other children, often for weeks. Parents would also be taken away from work, threatening a family’s income and potentially further increasing food insecurity. Treatment in traditional in-patient facilities could therefore perpetuate a vicious cycle, leading to more children becoming acutely or chronically malnourished.

The main principal of CMAM is to end this cycle - enabling treatment of acute malnutrition to be managed at home with weekly or fortnightly visits to the local clinic to check on progress. But how do we put it into practice? To make CMAM work, you need the following things in place:

  • A robust local health system, including health workers who are trained and equipped to recognise and treat severe acute malnutrition.
  • A treatment that parents and carers can easily administer to their child and keep safely at home.
  • Capacity on the ground; trained community health workers able to conduct follow-up visits to children and check their recovery is progressing or take action if they are not adequately responding to treatment.
A community group set-up to identify, refer and monitor children suffering from severe acute malnutrition in Côte d’Ivoire.

Creating strong health systems and training enough people to be able to identify and treat as many children as possible requires investment in time and money. With this being said, CMAM is a more cost-effective way of treating children - due to avoiding the high associated costs with in-patient treatment. Treating children at home also lowers the risk of developing hospital acquired infections and allowing families to continue to stay together and care for the malnourished child, along with the rest of the family.

CMAM would not have been possible if it weren't for the innovative malnutrition treatment known as RUTF. RUTF is highly effective in the treatment of severe acute malnutrition and vitally its ingredients (peanuts, oil, sugar, milk powder and vitamin and mineral supplements), means that it does not have to be refrigerated and has a long shelve life – so can be safely and effectively used at home.

How we are using CMAM in our programmes - an example from Nimba County, Liberia

On a visit to Liberia, we met with Wotoe Dahn from Ganta, Nimba county, grandfather to nine-month-old Esther. Having lost his daughter and two other grandchildren, Wotoe Dahn became the primary caregiver of Esther. Unfortunately, when Esther was six months old, she “was just getting sick… [we] were confused until [we] brought her to the clinic”, Wotoe Dahn explained. The community clinic in Wotoe Dahn’s village of Ganta was able to diagnose her as suffering from severe acute malnutrition and admit her into the CMAM programme. She was given enough RUTF to have two packets every day until she returned to the clinic the next week to check how she was responding to treatment. This was repeated every week until she had gained enough weight, was healthy and had recovered from SAM. She was then discharged home with advice to her grandfather on how to continue to give her a good diet to keep her strong, and to return if they were concerned that she was becoming unwell again. In Nimba county, the nutrition interventions available are government run health facilities with trained health workers.

Esther and her grandfather during a visit to the clinic. Credit: @UNICEF Liberia/2022

When she was first diagnosed “she was so sick that people in the community thought she will not make it. Fortunately, she started gaining strength and gradually gained weight and became a happy baby again” said Teewon Karnue, a community health worker at the clinic.

Without the work of the community health workers, Esther would not have been identified as being malnourished and referred to the clinic for treatment. The treatment very likely saved her life. After treatment, the clinic also provides vitamins for Esther and advice for Wotoe Dahn on how to include different food groups in Esther’s diet to keep her healthy and thriving.

Liberia isn’t the only one of our programmes where we include CMAM. Interventions, such as the one detailed in Esther’s story, are also implemented in Benin and Côte d’Ivoire, where we have treated over 16,600 children with SAM. As well as Bangladesh where 96,000 children have been reached with nutrition services.

CMAM has revolutionised how we treat severe acute malnutrition. Despite huge progress over the last almost three decades, climate, covid the cost of living is stalling it - even reversing the trend. We need committed donors to invest in this tried and tested intervention, so that together, we can save more child lives.

Header image credit: @UNICEF UNI532493 Muac test at Mughurali immunisation centre - photographer: Isam Bitu.