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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 Masters in Clinical and Public Health Nutrition from University College London. She has four years of clinical experience in oncology and nearly two years of experience in child nutrition in Guinea Bissau and Malawi.

The author would like to thank her MSc supervisor, Dr Marko Kerac, for his guidance during the project described in this article. Marko Kerac gratefully acknowledges support from an Academy of Medical Sciences Clinical Lecturer Starter Grant supported by the Wellcome Trust, the British Heart Foundation, Arthritis Research UK, the Medical Research Council, Prostate Cancer UK and the Royal College of Physicians ( for supporting the fieldwork described in this project.

This article is a summary of an MSc thesis1.

Women's focus group

Location: Malawi

What we know: The global burden of SAM in infants under 6 months of age is significant. To date, treatment options have depended on inpatient care. Community based management is an option in the latest update of WHO guidance on SAM treatment. Context specific management options are lacking.

What this article adds: In Malawi, the perceptions of carers and health professionals regarding outpatient treatment of SAM in infants under 6 months were explored in a small qualitative study. Participants preferred inpatient management based on high expectations (rather than experience) of care. Early clinical signs of malnutrition were known but considered under-recognised in the community. Maternal mental health was not considered relevant. Priority actions included education of key community leaders. Expectations are compatible with community-based care. A strong informal community network was identified that could help shape future interventions.

As highlighted by the Management of Acute Malnutrition in Infants (MAMI) project2, malnutrition in infants below six months (infants <6m) has often been considered rare and has often been neglected. Yet, a recent study estimated that of 20 million children under five years with severe acute malnutrition (SAM) worldwide, 3.8 million are infants< 6m3. CMAM (Community-based Management of Acute Malnutrition) treatment is modelled on outpatient treatment, targeting children 6-59 months4. By contrast, international and national SAM guidance (including Malawi guidelines5) for infants <6m, recommend only inpatient-based care6. This may change with the just released WHO SAM guidelines7. For the first time, these describe outpatient-based treatment options for infants <6m.

The motivation for this research was to respond to the knowledge gap of how Malawian carers and healthcare professionals will perceive future changes from inpatient to outpatient treatment for infants <6m and what benefits and risks they expect. The study also aimed to identify key elements that might help to roll out future infants <6m SAM guidelines at the country level.



This was a qualitative study based on 12 interviews with health professionals (Nurses, Health Surveillance Assistants (HSAs)) and 20 focus group discussions (FGD) with carers (mothers, fathers and grandparents). The study was conducted in three urban and two rural health centres in the Blantyre district of Malawi. A pilot phase was conducted at the Queen Elizabeth Central Hospital, Blantyre. Further logistic support was given by the Malawi-Liverpool Wellcome Trust Science Communications team and by the Community of Sant’ Egidio.

A total of 143 people took part in the study. All participants signed informed consent. Sample size was determined by data saturation. Interviews and FGDs revolved around a topic guideline. Most of the FGDs were conducted in Chichewa language, while all the interviews (mainly with healthcare workers) where conducted in English. Focus groups had 5-7 participants each. A thematic analysis methodology was used.


The theme of infant malnutrition opened up different topics related to husband-wife relationships, the role of men and women in society, and the role of grandparents and traditional beliefs. The six major themes that emerged from the data (see Figure 1) were:

HSA: Health Surveillance Assistant;
CAG: Community Advisory Group;
CITE: Community Initiative for Tuberculosis Eradication

Both health professionals and carers were generally able to describe most of the multifactorial causes of malnutrition, including social and cultural, and the clinical symptoms of early and acute phases of SAM. However the early signs of acute malnutrition in infants <6m were considered under-recognised in the community. Most health workers relied on weight based anthropometric assessment; advantages of using MUAC assessment in this age group were recognised but some expressed doubts about its use in very young infants.

Among the causes of malnutrition, behavioural taboos were commonly mentioned in interviews and FGDs, e.g. unfaithfulness or another pregnancy. Most people considered causes related to the ability of the mother to produce enough milk, due to lack of food for example, rather than the causes related to the infant. The relationship between maternal mental health and child health was poorly understood and not considered to be a common factor.

Participants instinctively preferred the inpatient-based approach to treating infants <6m with SAM. This preference was based on relatively superficial risk-benefit judgments and (unrealistically) high expectations of care in this setting, not necessarily based on experience, e.g. hospitals viewed as educational centres of excellence, medicine and food availability with inpatient treatment.

Participants were asked who they seek help from in the community setting if infants <6m are malnourished. The majority identified the HSA, who is trained and close to the community, as well as the Community Advisory Group (CAG) volunteers, who are present in the rural centres, chosen from the community, and receive training on a health topic. Regarding outpatient treatment, respondents reported advantages (able to look after the home and older siblings) and disadvantages (challenge to follow prescribed care, sharing food with siblings, and weak community settings where mothers have little support). Family support included fathers, as provider and a key decision-maker on infant health, grandmothers and older siblings. “Well educated” women, in particular, influenced infant related decisions.

Participants identified that a priority for addressing infant malnutrition problems was more education at the family and community level, targeting key community figures such as HSAs, village chiefs, grandparents, religious leaders and traditional doctors. Interviewees preferred to receive training and education in groups in order to learn from each other and to access peer support, but favoured individual case management.


The approach to managing infants with SAM must be framed in the context of both the mother-infant dyad and wider social-family relationships (e.g. fathers and grandparents). To do this, close engagement with families and communities is crucial. Four out of six of the main themes emerging from the data were related to caregiving resources in the community. Expectations expressed for inpatient treatment are not incompatible with community-based care. A strong informal community network exists in this Malawian community that can support the mother-infant dyad and could help shape future interventions.

For more information, contact: Concetta Brugaletta, email:

Show footnotes

1Brugaletta C. An exploration of how Malawian carers and health professionals perceive the community-based management of acute malnutrition (CMAM) approach in infants aged <6 months. Unpublished MSc thesis, UCL 2013.


3Kerac M, Blencowe H, Grijalva-Eternod C, et al. Prevalence of wasting among under 6-month-old infants in developing countries and implications of new case definitions using WHO growth standards: a secondary data analysis. Arch Dis Child 2011; 96(11): 1008-13.

4For more information on CMAM, see

5MALAWI. Guidelines for community management of acute malnutrition. 2012.

6Kerac M, Trehan I, Weisz A, Agapova S, Manary M. Admisison and Discharge criteria for the management of severe acute malnutrition in infants < 6 months: an AGREE appraisal of national protocols and GRADE review of published literature. Presented to WHO NUGAG meeting, Feb 2012, Geneva 2012.

7Updates on the management of severe acute malnutrition in infants and children Guideline. WHO 2013.

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Concetta Brugaletta (). Perceptions of SAM treatment in infants under 6 months in Malawi. Field Exchange 47, April 2014. p14.



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