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Deterioration of children with MAM who have no access to supplementary feeding programmes

James P, Sadler K, Wondafrash M, Argaw A, Luo H, Geleta B, et al. (2016) Children with Moderate Acute Malnutrition with No Access to Supplementary Feeding Programmes Experience High Rates of Deterioration and No Improvement: Results from a Prospective Cohort Study in Rural Ethiopia. PLoS ONE 11(4): e0153530. doi:10.1371/ journal.pone.0153530

Location: Ethiopia

What we know: There is no consensus on how best to treat moderate acute malnutrition (MAM) in children; Supplementary Feeding Programmes (SFPs) are commonly used. In Ethiopia, SFPs are only implemented in selected woredas defined as chronically food insecure.

What this article adds: A recent study in two woredas of Ethiopia where no SFPs were in place investigated outcomes among moderately malnourished children. At baseline, the majority of households were food insecure (one third severely); over two thirds of enrolled children (median age 12 months) were stunted (47.3% severe, 20% moderate); 25.1% were moderately wasted; and 12.7% severely wasted. At endline (28 weeks), one third (32.5%) remained moderately malnourished; 9.3% had experienced at least one episode of severe acute malnutrition (SAM); and 0.9% had died. Only 54.2% of the children recovered from MAM with no episode of SAM by the end of the study. Children with the lowest MUAC at baseline had the highest risk of developing SAM or failing to recover from MAM. Independent predictors of relapse after recovery were MUAC, age, and weight-for-height z score (WHZ) at admission. Independent predictors of remaining MAM included MUAC and WHZ at baseline, wealth and maternal work indexes, feeding practice scores, WASH intakes and self-reported vitamin A intake. Further preventive and curative approaches should urgently be considered.

Children with moderate acute malnutrition (MAM) have an increased risk of mortality, infections and impaired physical and cognitive development compared to well-nourished children. Consensus on how to manage MAM most effectively has still not been reached internationally, although targeted supplementary feeding programmes (TSFPs) are the most common approach, using a variety of supplements such as fortified blended flour and ready-to-use supplementary food (RUSF). Other approaches include nutrition counselling and increasing dietary diversity from existing natural food sources.

In Ethiopia, acute malnutrition remains an extensive and seemingly embedded problem. In 2011, 10% of children under five years old were acutely malnourished, 70% of whom had MAM (DHS, 2011). The current strategy in Ethiopia is to restrict SFPs for treatment of MAM to selected woredas (districts) of the country defined as chronically food insecure. In remaining woredas, there are no food supplementation programmes. The short-term outcomes of children who have MAM in such areas are not currently described; an urgent need for evidence-based policy recommendations remains.


A recent observational, prospective cohort study was carried out with children aged 6-59 months with MAM living in two rural areas of Ethiopia with no access to SFP. The objectives of the study were to determine the proportion of recovery, non-response and deterioration to SAM; the incidence of mortality and SAM; and the average duration of the MAM episode. The Mana and Dedo woredas of Jimma Zone in south-western Ethiopia were selected to represent rural settings with no access to SFPs but where other health and nutrition services were delivered according to national policy. These services included the Integrated Management of Maternal, Neonatal and Childhood Illnesses (IMNCI), the Integrated Community Case Management of illness (ICCM), and the Community-based Management of Acute Malnutrition (CMAM) to treat severe acute malnutrition (SAM). Through the Enhanced Outreach Strategy (EOS), vitamin A supplementation and deworming treatment was scheduled for distribution in six-month campaigns. Immunisation, basic nutrition and sanitation counselling were provided through the health extension system.

In the study MAM was defined as mid-upper arm circumference (MUAC) of ≥11.0cm and <12.5cm with no bilateral pitting oedema. SAM was defined as MUAC <11.0cm and/or bilateral pitting oedema. The research team surveyed 884 children aged 6-59 months living with MAM in a rural area of Ethiopia not eligible for a SFP. Children were identified during a 10-day (five days per woreda) exhaustive house-to-house MUAC and bilateral pitting oedema screening implemented by 82 trained community health volunteers (CHVs) in August and September 2013.

During the initial screening, 923 children were identified as eligible after determining their  nutritional status and that they were not planning to move out of the study area. Forty data collectors then implemented a baseline household questionnaire within the following week and performed weekly home visits for the subsequent 28 weeks, covering the end of the peak malnutrition season through to the post-harvest period (the most food secure window). Anthropometric, socio-demographic and food security data were gathered. Final outcomes were assigned to children after 28 weeks of follow-up.

The baseline questionnaire was designed to capture potential predictors of the children’s final outcomes and included child, household and caretaker-related variables. Child-related variables included sex, age at enrolment, feeding index, immunisation status, access to the EOS, common illnesses in the previous two weeks (diarrhoea, fever, cough, difficulty breathing), handwashing practices, bed net use and baseline weight, height and MUAC. Household variables included questions to assess wealth index, household size, main income-generating activity, food security status, water and sanitation questions, geographical access to primary healthcare, death of a family member and household head information. Caretaker-related variables included relationship to the child, age, educational status, occupation, work-burden index, access to and sources of information about recommended child feeding and care practices, handwashing practices, disposal of young child faeces, health-seeking behaviour and MUAC.

Weekly questionnaires were designed to track the cohort’s anthropometric, mortality and morbidity profile over the follow-up period. Information was obtained on common childhood illnesses, weight, MUAC and development of nutritional oedema. Height was measured monthly. Both the baseline and weekly questionnaires were pre-tested and translated into Amharic and Afan Oromo languages. Any child who deteriorated to SAM at any point during the follow-up was referred to the nearest health facility for outpatient therapeutic feeding programmes as per existing national protocol and continued to be followed up.


At baseline, the majority of households were categorised as food insecure, with a third experiencing severe food insecurity. Over two thirds of children were stunted (height for age z score (HAZ) <-2) at enrolment; 20% were moderately stunted and 47.3% severely stunted (HAZ <-3). One quarter (25.1%) of children were moderately wasted and 12.7% severely wasted (MUAC criteria). Morbidity was high as indicated by the proportion of children who experienced diarrhoea and cough in the past two weeks (28.4% and 28.2% respectively). By the end of the study follow-up, 32.5% (287/884) remained with MAM; 9.3% (82/884) experienced at least one episode of SAM; and 0.9% (8/884) had died. Only 54.2% of children recovered from MAM with no episode of SAM by the end of the study. Of those who developed SAM, half still had MAM at the end of the follow-up period. The mean (95% CI) cumulative probability of recovering by the 28th week of follow-up without experiencing an episode of SAM was 65.9 (62.0-69.8)%. The median time to recovery was 9 (4-15) weeks. Children with the lowest MUAC at enrolment had a significantly higher risk of remaining with MAM and a lower chance of recovering.

In terms of predictors of outcomes, MUAC at enrolment was the only variable independently associated with risk of developing SAM during follow-up. Independent predictors of relapsing to MAM after recovering were MUAC, age and weight-for-height z score (WHZ) at admission. Independent predictors of remaining MAM throughout the follow-up period were MUAC, WHZ at admission, food insecurity level, child feeding practices score, WASH (water, sanitation and hygiene) practices (source of drinking water, child stools disposal practices), mother’s working index, household wealth quintile and self-reported intake of Vitamin A in the previous six months.


The findings reflect that, while an area may not be classified as food insecure, sub-sets of the population may be; in this instance, households with a MAM child. This study highlights that nearly half of children who were suffering from MAM at the beginning of the post-harvest season either developed SAM or lived through the four months of best food security without recovering. Many are therefore in danger of entering the next hunger season in a highly vulnerable condition.

These risks are accentuated among those with low MUAC at enrolment. Furthermore, those children who do manage to recover take a long time to do so (nine weeks); such a prolonged exposure to MAM risks serious negative consequences for their health and development (Black et al, 2008).

The authors conclude that children with MAM during the post-harvest season in an area not eligible for SFP experience an extremely high incidence of SAM and a low recovery rate. Not having a targeted, nutrition-specific intervention to address MAM in this context places children with MAM at excessive risk of adverse outcomes. Further preventive and curative approaches should urgently be considered.



Black et al, 2008. Black RE, Allen LH, Bhutta ZA, Caulfield LE, de Onis M, Ezzati M et al. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet. 2008; 371:243–60. doi: 10. 1016/S0140-6736(07)61690-0 PMID: 18207566

DHS, 2011. Ethiopia Central Statistical Agency and ICF International, 2012. Ethiopia Demographic and Health Survey 2011. Addis Ababa, Ethiopia and Calverton, Maryland, USA: Central Statistical Agency and ICF International.

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Deterioration of children with MAM who have no access to supplementary feeding programmes. Field Exchange 54, February 2017. p22.



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