A conceptual framework for Project MAMI (Management of Acute Malnutrition in Infants 0-5.9m)

1. A conceptual framework for Project MAMI(Management of Acute Malnutrition in Infants 0-5.9m) Towards a common understanding of the causes and classification of infant malnutrition

2. NB. DRAFT!!! • THANK YOU FOR COMMENTS / FEEDBACK!!!

3. AIM To investigate the management of acutely (moderately and severely) malnourished infants under six months age (0-5.9m) in emergency programmes, in order to establish consensus on (interim) good practice guidelines: ‘DOABLE’ EVIDENCE BASED INDIVIDUAL(CLINICAL) vs PUBLIC HEALTH

4. To discuss • What do we mean by “malnutrition” (10mins) • Conceptual framework for causes of acute malnutrition in infants 0-5.9m (10mins) • Way forward for MAMI: (10mins) • FOCUS: What do you need from the project • SCOPE: What data is available what is realistic to do within the timeframe • OUTPUTS: What like to see • OTHER….

5. Why does MAMI need a conceptual framework? • Classification of malnutrition in infants 0-5.9m is not simple • Preventative as well as curative interventions are vital for the ‘management’ of acute malnutrition • Developing a common understanding of: • What causes are • How to classify cases  is therefore important as we start the project  JOINT UNDERSTANDING  BETTER COMMUNICATION (internal AND external…)

6. 1st: What do we mean by ‘Malnutrition’A (DRAFT) Working Classification ?? (how) can we distinguish?? MAMI

7. The UNICEF Conceptual Framework

8. (DRAFT) Expanded Framework for 0-5.9m ?constitutional? INADEQUATE INTAKE + INADEQUATE ACCESS • Disease • Acute - infection • BMS related • (pneumo, GE, sepsis) • Malabsorbtion • Chronic - Syndrome (Downs, other) • - Metabolic • - congenital infection. • treatable – e.g. syphilis • ??treatable-CMV, rubella • - HIV • - TB B) NOT CURRENTLY EBF (BMS =whole/part of diet A) CURRENTLY ‘EBF’ MAMI

9. (DRAFT) Expanded Framework for 0-5.9m ?constitutional? • INADEQUATE CARE • 1) Reduced time for infant feeding • economic factors • - employment law / conditions • 2)BF ‘Environment’ difficult • - cultural / employment / religious issues • 3) Orphans • 4) Myths & Misconceptions INSUFFICIENT HEALTH SERVICES & UNHEALTHY ENVIRONMENT 1)Myths & misconceptions -’stress’ & BF 2)TREATABLE disease not adequately treated 3)Inadequate clean water (quality; quality) MAMI

10. (DRAFT) Expanded Framework for 0-5.9m ?constitutional? INADEQUATE INTAKE + INADEQUATE ACCESS • Disease • Acute - infection • BMS related • (pneumo, GE, sepsis) • Malabsorbtion • Chronic - Syndrome (Downs, other) • - Metabolic • - congenital infection. • treatable – e.g. syphilis • ??treatable-CMV, rubella • - HIV • - TB B) NOT CURRENTLY EBF - Inadequate quantity of BMS (formula/other milk/ solid food) - Inadequate quality of BMS - inappropriate dilution - inappropriate BMS - inadequate equipment - inadequate fuel a) No chance resume BF -orphan, no wetnurse ib Possibility to resume BF - HIV related choice Frequent pregnancy • A) CURRENTLY EBF • i) Suboptimal BF performance: • a) Infant reasons • - ‘skills’ e.g. dev. delay/CP -- illness (acute) • - Congenital problem • - e.g cleft palate • b) Maternal reasons: • Skills • Lack of emotional support • Psychological (clinical depression) • Severe maternal malnutrition (macronuts) • Severe maternal malnutrition (micronuts) • ii)Ex premature inf • - increased micronut needs • INADEQUATE CARE • 1) Reduced time for infant feeding • economic factors • - employment law/conditions • 2)BF ‘Environment’ difficult • - cultural / employment / religious issues • 3) Orphans • 4) Myths & Misconceptions INSUFFICIENT HEALTH SERVICES & UNHEALTHY ENVIRONMENT 1)Myths & misconceptions -’stress’ & BF 2)TREATABLE disease not adequately treated 3)Inadequate clean water (quality; quality) MAMI

11. Other Aspects - Critical but outside project scope Factors to note: MAMI

12. WAY FORWARD • FOCUS: What do you need from the project? • SCOPE: What data is available? What is realistic to do within the timeframe? • OUTPUTS: What would you like to see? • OTHER….

13. Invitation to Collaborate Please help us develop the evidence base to improve the management of malnourished young infants Project websites: http://www.ucl.ac.uk/cihd/research/nutrition/mami http://www.ennonline.net/ife/ Contact: Marko Kerac Email: marko.kerac@gmail.comom

14. MAMI(Management of Acute Malnutrition in Infants)Funded by UNICEF-led IASC Nutrition Cluster A retrospective review of the current field management of acutely malnourished infants under 6 months of age http://www.ucl.ac.uk/cihd/research/nutrition/mami

15. AIM To investigate the management of acutely (moderately and severely) malnourished infants under six months age (0-5.9m) in emergency programmes, in order to establish consensus on (interim) good practice guidelines

16. Objectives • To establish what currently is advised or recommended in the form of guidelines, policies and strategies by different organisations. Particularly to consider: - admission and discharge criteria - therapeutic management - care practices & psychosocial support - breastfeeding support

17. Objectives • To determine what is carried out in practice - are policies reflected by practice? - numbers and % of TFP/SFP admissions 0-5.9m age - numbers admitted vs numbers expected (DHS surveys) (proxy measures of coverage) • To examine current outcomes for 0 – 5.9m infants - what affects outcomes? - key contextual factors (modifablevs non-modifiable) - what are key challenges and constraints?

18. Collaboration TO BE OF PRACTICAL RELEVANCE TO FIELD-BASED PROGRAMMES:  We need your inputs NOW… *** INVITATION TO COLLABORATE ***  The closer our collaboration…  The better & more useful the final outputs… Interagency Steering Group Research Advisory Group

19. Background • Very few formal research studies investigating acute malnutrition in infants 0- 5.9 months of age  Poor evidence base upon which to base field guidance materials  Difficult to know how best to support these infants in practice  Many current malnutrition strategies do not specifically address the needs of this age group

20. Background • Over 6 years of published concerns, documented field experiences and debate by ENN and by the IFE Core Group • WHO Technical review of the Management of Severe Acute Malnutrition (2004): “ No new research was identified pertaining to the optimum dietary management of severely malnourished infants aged < 6 months. The evidence base for defining the most advantageous formulations for feeding this age group remains weak ”

21. Field Reality • Young infants still present to field based programmes ! • Variable capacity and skills to manage them: • Some programmes good  we need to learn from them • Some ‘could be better’ • Lactating women with infants 0-5.9 months may be admitted to Supplementary Feeding Programmes (SFPs), But… • No standard guidance on the breastfeeding & infant feeding support that should form part of the package of care.

22. Field Reality & Field Evidence • Operational agencies undertake different types of intervention sometimes guided by applied / operational research.  field experience is growing / significant… But… • Field evidence too often hidden… • Programme data collected but not formally analysed • Internal reports written but not routinely disseminated / shared

23. Why field evidence is vital • ‘Background’ for changes in official guidance (WHO) • Knowing about current field practices  helps inform, target, and manage change • Stronger understanding of ‘who does what, where’ for MAMI  directly facilitates future collaborations and research • Project ownership • Collaborations and partnerships during the review process  project more focused, more relevant to field organizations • Shared project ownership  guidelines & recommendations more likely to be taken up

24. Planned Project Outputs • (Interim) ‘Best Practice’ guidelines ~ Based on best currently available evidence ~ Explicit about underlying evidence (or lack of) for each step • Research Agenda ~ Understanding of gap areas  can suggest specific studies • Bigger IYCF picture ~ Consider management strategy in the context of IYCF recommendations for general population • Strengthened organizational linkages / ongoing collaborative efforts ~ Supporting guideline implementation ~ Facilitating new or ongoing research / operational research

25. Results Dissemination • ENN Special Supplement • Peer reviewed paper(s) • International fora: • IASC Nutrition Cluster meetings • UN SCN meeting in 2009 • Inputs into review / update of WHO guidance for Management of Acute Malnutrition

26. Some contextual issues • The rise of CMAM (CTC) • What place for young infants within current CMAM contexts? • What place for young infants in future projects? • Rollout of new WHO standards • Numbers diagnosed with SAM/MAM differ if NCHS references vs new WHO standards % of median vs Z-score  Understand likely effects of change in diagnostic criteria

27. Other issues to discuss.. • ? Disaggregateage groups (0-1.9m, 2-3.9m, 4-5.9m) • ? ‘malnutrition’ aetiology: • ex-premature infants; LBW infants; postnatal growth failure alone • ? Infants older than six months but less than 4kg • ? HIV related issues • ‘rapid weaning’ of breastfed infants at ~6 months of age • ? Focus on NGO programmes (?context of other services/providers) • ? Other  YOUR inputs /ideas / comments are CRITICAL…

28. Please get involved… *** ‘INVITATION TO COLLABORATE’ document *** ** Special session MAMI WEDNESDAY 7pm ** * email: marko.kerac@gmail.com *