Severe Acute Malnutrition – what is the best way forward for the region – A panel Discussion Colombo 19 th November 2009

Extent of the problem in Bangladesh 500,000 cases of SAM (WHZ<-3.00) Total under-5 deaths 216,000 75,600 deaths from malnutrition (35% of all U5 deaths) So how many die from SAM? Don’t know.

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Why does it happen?

Data from 39 developong countries

Appropriate infant feeding practices result in better growth of infants and young children in rural Bangladesh Kuntal Saha, AJCN 2008

Comparisons between South Asia and Sub-Saharan Africa UNICEF: The State of the World’s Children 2009

240 U-5 DEATHS EVERY DAY FROM MALNUTRITION Death is also a nutrition parameter

The tragic story of Shathi and Bithi Birth weight 800 and 650 g More than doubled to 1.7 kg by 3 months of age on exclusive breastfeeding Then formula fed And died of pneumonia and sepsis soon afterwards 11

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IYCF challenges efforts to improve breastfeeding practices have not reached the majority of mothers Only 15% of women deliver in a health facility Community-based activities through the National Nutrition Program extend to 20 % of the country only women in government service—a small fraction of the work force—are eligible for maternity leave lack of overall program coordination and oversight weak national commitment and sporadic donor support

IYCF challenges cont. lost momentum due to bureaucratic delays high staff turnover inadequately trained communitybased workers missed opportunities within the health system to counsel women on IYCF lack of a standardized monitoring system decline in the quality of baby-friendly hospitals No national IYCF working group

Best way forward Optimal IYCF monitoring and promotion in the community If not optimal – then weigh/measure MUAC If SAM – refer to hospital – If SAM and sick – admit to hospital – If SAM and not sick - home management

Food-health-care educational intervention to prevent malnutrition. Roy et al: FNB 2007

Reducing moderate malnutrition Roy et al: JHPN 2005

Home treatment studies for SAM Khanum S, Ashworth A, Huttly SRA. Controlled trial of three approaches to the treatment of severe malnutrition. Lancet 1994;344(8939–8940):1728–32. Ashworth A, Khanum S. Cost-effective treatment for severely malnourished children: what is the best approach? Health Policy Plan 1997;12:115–21. Khanum S, Ashworth A, Huttly SRA. Growth, morbidity, and mortality of children in Dhaka after treatment for severe malnutrition: a prospective study. Am J Clin Nutr 1998;67:940–5. Ahmed T, Islam MM, Nahar B, Azam MA, Salam MA, Ashworth A, Fuchs GJ. Home-based nutritional rehabilitation of severely- malnourished children recovering from diarrhea and other acute illnesses. Paper presented at the 10th Annual Scientific Conference, ICDDRB, Dhaka. 11–13 June 2002.

Home-based foods Advantages Disadvantages Cost-effectiveFamilies must have food resources Liked by caregivers; few defaultersCaregiver must be at home full-time Teaches mothers about child-feeding Requires formative research to develop advice Family foods for rehabilitation also form the basis for good Requires clinic nearby or community health workers to monitor progress and provide timely treatment for ill children complementary foods Need to provide micronutrient supplements Potential to prevent malnutrition in the long term by teaching mothers to prepare good food mixtures, and to feed frequently and responsively Requires motivated staff and good communicators Potential ripple effect Responsive to fluctuating numbers

Costs of domiciliary care

How to feed hungry children Omar ibn Khattab Amir-ul-Muminin 1,400 years ago in Saudi Arabia

Feeding people in emergencies

Cooking food for 2 million people in Tongi

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Thank you for your attention