Menu ENN Search

Risk factors for severe acute malnutrition in infants <6 months old in semi-urban Bangladesh: A prospective cohort study to inform future assessment/treatment tools

Summary of conference abstract1

Presented at the ACF research conference, November 9th, 2016. 

By M Munirul Islam, Yasir Arafat, Nicki Connell, Golam Mothabbir, Marie McGrath, James Berkley, Tahmeed Ahmed,  and Marko Kerac

M Munirul Islam and Tahmeed Ahmed both work at the Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b). Yasir Arafat and Golam Mothabbir work in the Health Nutrition and HIV/AIDS Sector, Save the Children, Bangladesh. Nicki Connell works in the Department of Global Health, Save the Children USA. Marie McGrath works with the Emergency Nutrition Network, UK. James Berkley is based with the KEMRI/Wellcome Trust Research Programme, Kenya. Marko Kerac is based at the Department of Population Health, London School of Hygiene & Tropical Medicine,

Video footage of the conference presentation is available here.  

MUAC case definition does not exist for infants <6m; data were collected for research purposes onlyLocation: Bangladesh

What we know: The burden of acute malnutrition in infants < 6 months varies by country. Community-based case management for uncomplicated cases is lacking.

What this article adds: A recent study investigated the prevalence of acute malnutrition in infants<6m in semi-urban Bangladesh (two seasons) and undertook a prospective cohort study to describe current outcomes of identified cases at six months (180 days) of age. Prevalence of acute malnutrition was low post-harvest but increased pre-harvest; from 0.4% to 5.9% for severe acute malnutrition (SAM) and 2.8% to 10.1% for global acute malnutrition. At age six months, 24% of identified SAM cases (by eight weeks of age) and referred for available treatment (inpatient), remained severely malnourished. A range of infant and maternal risk factors for infant SAM were identified, involving breastfeeding status, the nutrition and mental health of the mother, infectious disease and water/sanitation/hygiene. A package of care is warranted in this age group.

Current WHO guidelines on severe acute malnutrition (SAM) management recommend outpatient management of uncomplicated acute malnutrition in infants under six months of age (infants <6m), in line with the now-established treatment approach for older children (WHO, 2013). However, there is a lack of practical guidance on how to identify those infants <6m at risk and how to manage them. Current WHO case definition for SAM in infants <6m is weight-for-length of less than -3 Z-score (WLZ); visible severe wasting; and/or bilateral pitting oedema.

To inform the development of assessment tools and treatment approaches for SAM in infants <6m, a study was conducted in semi-urban Bangladesh in 2015/2016 with the following objectives:

  1. To estimate the prevalence of infants <6m with acute malnutrition in the community;
  2. To develop an assessment tool/case definition checklist for infants <6m with acute malnutrition; and
  3. To describe current outcomes following infant <6m with acute malnutrition.

The study involved two prevalence surveys (in distinct seasons) and a prospective cohort study of three infant groups (77 in each group), followed from 4-8 weeks to 180 days post-partum. The groups comprised:

Standard SAM:           WLZ <-3 and/or bipedal oedema;

Normal:                       WLZ ≥-2 to <+2 z-scores, no oedema;

Expanded SAM:         MUAC <115mm but WLZ ≥-2, no oedema.

MUAC case definition does not exist for infants <6m; data were collected for research purposes only. Mother/caregiver interviews at enrolment assessed potential risk factors. Infants with ‘Standard SAM’ were referred to existing services for treatment (inpatient care) according to existing protocols. The primary outcome was nutritional status at age completion of 180 days.

Preliminary results

Prevalence survey

The prevalence of GAM and SAM were low in the post-harvest period but increased pre-harvest; from 0.4% to 5.9% for SAM and 2.8% to 10.1% for GAM. Severe underweight (weight for age < -3 Z- score (WAZ)) slightly increased (severe: 5% to 6.1% and severe/moderate combined, from 14.4% and 16.3%).

Cohort study

At enrolment, ‘Standard SAM’ and ‘Expanded SAM’ were younger than ‘Normal’ infants (5.1, 5.5, 6.5 weeks respectively, p<0.001). A selection of characteristics that differed between these groups at enrolment is shown in Table 1. Type of toilet was significantly different among the groups; Standard SAM had more people with a pit latrine vs. a flushing toilet compared to the other two groups. Handwashing and source of water were not significantly different among the groups. Duration of breastfeeding was not significantly different among the groups.

At age six months, ~24% of ‘Standard SAM’, 1% of the “Normal”, and 5% of ‘expanded SAM’ infants had SAM (p≤0.001). Three infants with ‘Standard SAM’ died; compared to none in the ‘Normal’ group and one in the ‘Expanded SAM’ group.

In the Standard and Expanded SAM groups, significantly fewer infants were still being breastfed, more infants were fed anything other than breastmilk at enrolment and endline, and more infants were given animal milk at an earlier age, compared to the Normal group. Duration of exclusive breastfeeding was also shorter in both groups, mothers breastfed less often, had higher mental health/distress score and were significantly less satisfied when asked how breastfeeding was going. Maternal Body Mass Index (BMI) and MUAC were lower in the Standard SAM group. More infants in the Standard SAM group had at least one episode of illness that required hospitalisation at enrolment; this proportion (21%) had increased to 40% by endline.

Challenges to implementing the research included:

  • Access to villages in the rainy season; surveyors had to cross many bodies of water with equipment including motorbikes.
  • Randomly selected villages were geographically spread out, so travel time was high.
  • Measuring anthropometry in infants <6m is difficult, especially length.
  • The number of questions in the questionnaire was a challenge as many were necessary to ensure comprehensiveness.

Discussion and conclusions

A range of maternal, infant and environmental risk factors are associated with SAM among infants <6m. Successful future treatments should focus on a package of care rather than single interventions that include breastfeeding support; the nutrition, physical and mental health of mothers; infectious disease management; and water/sanitation/hygiene conditions. Over one quarter of the infants identified with SAM at the outset remained severely malnourished at six months of age; this suggests inadequate provision and/or access to treatment of SAM and a risky environment. It is necessary to distinguish these vulnerable infants from those who had recovered by six months; indicators in addition to anthropometry are probably necessary.

For more information, contact: Nicki Connell, email:



WHO. Guideline: Updates on the management of severe acute malnutrition in infants and children. Geneva: World Health Organization; 2013.

1Presented at the ACF research conference, November 9th, 2016.

More like this

FEX: MUAC outperforms weight-based measures of nutritional status in children with diarrhoea

Summary of research1 Location: Bangladesh What we know: Undernutrition and diarrhoea often present concurrently in children. Weight is affected by hydration status; there is...

FEX: Diagnostic criteria for severe acute malnutrition among infants under six months of age

Summary of research1 Location: Kenya What we know: Diagnosis of acute malnutrition in infants under six months old (U6M) is currently based on weight-for-length z score...

FEX: Methods to detect cases of severely malnourished infants under six months

Summary of research1 Location: Global What we know: The World Health Organization (WHO) recommends weight-for-length z score (WLZ) as an anthropometric indicator to identify...

FEX: MAMI Interest Group meeting

On 27th January 2016, ENN, London School of Hygiene and Tropical Medicine (LSHTM) and Save the Children co-hosted a one day meeting of a Management of Acute Malnutrition in...

FEX: Management of acute malnutrition in infants less than six months in a South Sudanese refugee population in Ethiopia

By Mary T Murphy, Kassahun Abebe, Sinead O'Mahony, Hatty Barthorp & Chris Andert Sinead O'Mahony is a nutrition advisor at GOAL's HQ. She has both a research and operational...

FEX: The MAMI Project – Key findings and recommendations

Summary of report1 Child malnutrition is a major global public health issue. The burden of acute malnutrition in children 6 months to 5 years is well recognised, and the...

FEX: Auditing the identification and inpatient management of acute malnutrition in infants under six months in Malawi

Summary of MSc thesis By Laura White Laura White is a Canadian-trained registered dietitian who recently completed an MSc in Nutrition for Global Health at the London School...

FEX: Perceptions of SAM treatment in infants under 6 months in Malawi

By Concetta Brugaletta Concetta Brugaletta is a clinical research nurse working in neurology. Currently based in the UK, she is interested in infant malnutrition and holds a...

FEX: Diluted F100 v infant formula in treatment of severely malnourished infants < 6 months

By Caroline Wilkinson and Sheila Isanaka Caroline Wilkinson was Nutrition Advisor with Action Contre la Faim - France (ACF-F), until November 2008. She spent most of 2007 in...

FEX: Improving community management of uncomplicated acute malnutrition in infants under six months (C-MAMI): Developing a checklist version of the C-MAMI tool

Summary of MSc project report1 By Sonja Read Sonja Read is a public health nutritionist from the London School of Hygiene and Tropical Medicine. She has previously worked in...

en-net: Biomarkers for Acute MN

Would anyone be able to shed light on reliable biomarkers that can be used to assess acute MN in young children and infants <6m? Background reading suggests there is...

FEX: Risk factors associated with severe acute malnutrition in infants under six months in India: a cross sectional analysis

By Susan Thurstans Susan is a registered nurse and midwife with over 12 years' experience in maternal and child health and nutrition programmes in both development and...

FEX: Wasting is associated with stunting in early childhood

Summary of published research1 Location: Africa, Asia, Latin America What we know already: Wasting and stunting are respectively short term and longer term conditions of...

NEX: Perceptions of severe acute malnutrition and its management in infants under six months of age: An exploratory study in Bangladesh

Yasir Arafat1is a medical doctor and public health practitioner, managing community-based nutrition programmes targeting acute malnutrition. He is currently working with Save...

FEX: Qualitative study of supplementary suckling as a treatment for SAM in Infants

This article summarises key findings of an MSc thesis1 By Natasha Lelijveld Natasha Lelijveld has recently completed her MSc in International Child Health at UCL. She is...

FEX: Disaggregation of health and nutrition indicators by ageand gender in Dadaab refugee camps, Kenya

By Henry Mark Henry recently graduated with a BSc in Food and Human Nutrition from Newcastle University. He has conducted research in The Gambia and interned with UNHCR at the...

FEX: Nutritional rehabilitation of infants < 6 months with severe acute malnutrition

Summary of published research1 Location: India What we know: There is a significant burden of acute malnutrition in infants under 6 months of age in nutritionally vulnerable...

FEX: Letter on WHO 2006 Growth Standards, by Marko Kerac and Andrew Seal

This new 2006 WHO Growth standards: What will they mean for emergency nutrition programmes? Dear Editor Whilst welcoming the principles which have driven the development of...

FEX: Severe malnutrition in children presenting to health facilities in an urban slum in Bangladesh

Summary of research1 Location: Urban slum, Bangladesh What we know already: Both severe acute malnutrition (wasting) and severe chronic malnutrition (stunting) are prevalent...

FEX: Nutrition Impact and Positive Practice (NIPP) Circles

By Vimbai Chishanu, Okello Aldo Frank, Sarah Ibrahim Nour, Hatty Barthorp and Nikki Connell Vimbai Chishanu is a former nutritionist with GOAL Zimbabwe Okello Aldo Frank is a...


Reference this page

M Munirul Islam, Yasir Arafat, Nicki Connell, Golam Mothabbir, Marie McGrath, James Berkley, Tahmeed Ahmed, and Marko Kerac (2017). Risk factors for severe acute malnutrition in infants <6 months old in semi-urban Bangladesh: A prospective cohort study to inform future assessment/treatment tools. Field Exchange 54, February 2017. p62.