Severe malnutrition in infants under six months old: outcomes and risk factors in Bangladesh
Summary of research1
Location: Bangladesh
What we know: The World Health Organization (WHO) recommends that infants under six months with uncomplicated severe acute malnutrition (SAM) are treated in the community.
What this article adds: A prospective cohort study was undertaken on infants under six months (<6m) in Barisal district, Bangladesh, of one group of 77 infants with SAM (weight for length z-score <-3 and/or bipedal oedema) and 77 non-SAM infants, all enrolled at four to eight weeks of age and followed up at six months. Maternal education and satisfaction with breastfeeding were among factors associated with SAM. Duration of exclusive breastfeeding was shorter at enrolment (3.9 ±2.1 vs. 5.7 ± 2.2 weeks, P < 0.0001) and at age six months (13.2 ± 8.9 vs. 17.4 ± 7.9 weeks; P = 0.0003) among SAM infants. Despite referral, only 13 (17%) reported for inpatient care and at six months 18 (23%) infants with SAM still had SAM and 3 (3.9%) died. In the non-SAM group, one child developed SAM and none died. Current inpatient-focused treatment strategies have limited practical effectiveness due to poor uptake of inpatient referral. WHO recommendations of outpatient-focused care for malnourished but clinically stable infants <6m must be tested. Breastfeeding support must be central to future interventions but may be insufficient alone. Better case definitions are needed in this age group.
Severe acute malnutrition (SAM) affects around four million infants under six months old (infants <6m) worldwide, but evidence underpinning their care is of very low quality. To inform future research, the objectives of this study were to identify risk factors for infant <6m SAM and describe the clinical and anthropometric outcomes of treatment with current management strategies. A prospective cohort study was undertaken involving two groups of infants aged four to eight weeks (the age when future interventions to treat infant <6m SAM will be anticipated to begin). One group comprised 77 infants with SAM (defined as weight-for length z-score (WLZ) <-3 and/or bilateral nutritional oedema); the other comprised 77 age- and sex-matched infants who were not severely malnourished. Exclusions were infants from twin/multiple pregnancies and those with obvious congenital anomalies that could affect feeding. The primary outcome was the proportion of infants who died or who had SAM at follow-up at age six months. Secondary outcomes were changes in and absolute values of WLZ, weight-for-age z-score (WAZ) and length-for-age z-score (LAZ). SAM ‘case’ infants and non-SAM infants were identified by household visits in Barisal district, Bangladesh; anthropometric measurements were taken according to standard guidelines and were recorded electronically.
By six-month endline, statistically significant differences were apparent between SAM and non-SAM infants: daily weight gain was better among the SAM group (8.6 vs 4.3 g/kg/day, P<0.0001) and mid-upper arm circumference (MUAC) increase was greater (35.7 vs 13.2mm, P <0.0001), WLZ change was greater (2.0 vs -0.24, P<0.0001) and WAZ change was greater (0.9 vs -0.4, P<0.0001). However, there was a similar decline in LAZ of 0.6 z-scores in both groups. Maternal education and satisfaction with breastfeeding were among factors significantly associated with SAM, as well as age at time of enrolment into the study, years of maternal schooling and access to household electricity. Duration of exclusive breastfeeding was shorter at enrolment (3.9 ±2.1 vs. 5.7 ± 2.2 weeks, P < 0.0001) and at age six months (13.2 ± 8.9 vs. 17.4 ± 7.9 weeks; P = 0.0003) among SAM infants. Despite referral, only 13 (17%) reported for inpatient care and at six months, 18 (23%) infants with SAM still had SAM and 3 (3.9%) died. In the non-SAM group, one child developed SAM and none died. Maternal mental health was worse among mothers of SAM infants with a higher mean self-reporting questionnaire (SRQ) score at baseline (8.4 ± 3.6 versus 6.8 ±3.8, P = 0.003).
Results show that most infants identified as having SAM at four to eight weeks of age did not access inpatient treatment when referred as per national protocol. Deaths in this age group were higher than in the control group, but not as high as have been previously reported in inpatient studies. Although only one quarter of those with SAM at enrolment still had SAM at six months, other anthropometric deficits were marked, including significantly more stunting (62% vs. 15%), more severe stunting (40% vs. 0%) and more underweight (68% vs. 7%). The authors discuss the fact that few of the SAM infants who were referred to inpatient care actually accessed that care is reminiscent of past experiences with older SAM-affected children. Before community-based management of acute malnutrition (CMAM), when only inpatient-based care was available, coverage for such programmes was poor due to the high direct and opportunity cost of treatment. However efficacious such inpatient-only treatments might be, their overall effectiveness and public health impact is severely limited by the low numbers of eligible patients accessing care they need. Also reminiscent of the shift from inpatient-only care to CMAM outpatient-focused models, some professionals now are concerned about the safety of outpatient care for SAM infants <6m. Addressing this concern, it is reassuring that despite the minimal (or no direct) treatment, over three quarters of infants with SAM at four to eight weeks baseline no longer had SAM at age 6 months. This may represent catch-up growth, as suggested by greater rates of weight gain in the SAM group, and emphasises infancy as a dynamic and important period of life. Nevertheless, interventions are needed: ex-SAM infants had considerably more other anthropometric deficits than infants who did not have SAM at baseline, suggesting ongoing vulnerability.
The authors conclude that the current inpatient-focused treatment approaches to infant <6m SAM are sub-optimal. Some form of treatment is needed, as suggested by infants in the SAM group being more underweight and more stunted than non-SAM controls. However, the fact that many showed weight catch-up and no longer had SAM by six months suggest that it is reasonable to classify infants in the same way as older children with SAM, recognising that some are sufficiently clinically stable (“uncomplicated SAM”) to be safely managed in community-based programmes, as recommended by WHO2. In terms of risk factors, sub-optimal breastfeeding is key and breastfeeding support is likely central to future interventions, but may be insufficient alone. Further interventions should evaluate the effectiveness of a package of interventions which also addresses wider issues, such as home environment and maternal support/maternal mental health. Finally, the authors call for better ways of identifying at-risk infants. Current case definitions of SAM are widely used, but do not fully capture the many possible reasons why an infant may be small. Improved classification and understanding of underlying aetiology in individual cases may allow more tailored treatments with greater probability of success.
Endnotes
1Islam MM, Arafat , Connell N, Mothabbir G, McGrath M, Berkley JA, Ahmed T and Kerac M. (20180). Severe malnutrition in infants <6 months – Outcomes and risk factors in Bangladesh: A prospective cohort study. Maternal Child Nutrition.2018:e12642 https://doi.org/10.1111/mcn.12642
2WHO (2013) Updates on the management of severe acute malnutrition in infants and children. Available here.
More like this
Resource: Severe malnutrition in infants aged <6 months—Outcomes and risk factors in Bangladesh: A prospective cohort study
Abstract Severe acute malnutrition (SAM) affects ~4 million infants under 6 months (u6m) worldwide, but evidence underpinning their case is "very low" quality. To...
Resource: Severe malnutrition in infants aged <6 months—Outcomes and risk factors in Bangladesh: A prospective cohort study
Abstract Severe acute malnutrition (SAM) affects ~4 million infants under 6 months (u6m) worldwide, but evidence underpinning their case is "very low" quality. To...
FEX: Outcomes and risk factors for infants under six months old with severe acute malnutrition in Bangladesh
Research snapshot 1 Severe acute malnutrition (SAM) affects around four million infants under six months of age (u6m) worldwide, but evidence underpinning their care is...
FEX: 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...
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: Piloting the C-MAMI approach in the Rohingya response in Bangladesh
By Anne Marie Kueter, Alice Burrell, Sarah Butler, Mostofa Sarwar and Habibur Rahaman View this article as a pdf Anne Marie is a nutritionist with over five years'...
FEX: Community management of uncomplicated malnourished infants under six months old: barriers to national policy change
By Sonja Read and Marie McGrath View this article as a pdf Sonja Read is a public health nutritionist and was lead researcher (ENN consultant) on the project. Marie McGrath...
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: 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: 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: Integration of management of children with severe acute malnutrition in paediatric inpatient facilities in India
View this article as a pdf Lisez cet article en français ici By Praveen Kumar, Virendra Kumar, Sila Deb, Arpita Pal, Keya Chatterjee, Rajesh Kumar Sinha and Sanjay...
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: 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: 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: 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 View this article as a pdf Lisez cet article en français ici Sinead O'Mahony is a...
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: 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...
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: Making connections: Joint meeting of WaSt Technical Interest Group and MAMI Special Interest Group
ENN coordinates two international technical groups, the Management of at-risk Mothers and Infants under six months Special Interest Group (MAMI SIG) and the Wasting and...
FEX: Routine amoxicillin use in treatment of uncomplicated SAM in children
Summary of research1 Location: Niger What we know: Routine use of broad-spectrum antibiotics is recommended in uncomplicated SAM case management; there is a lack of evidence...
Reference this page
Severe malnutrition in infants under six months old: outcomes and risk factors in Bangladesh. Field Exchange 58, September 2018. p58. www.ennonline.net/fex/58/severemalnutritionininfants
(ENN_6109)