Menu ENN Search

“There are MAMs, then there are MAMs”

View this article as a pdf

Lisez cet article en français ici

By Kirrily de Polnay

Kirrily de Polnay is a Nutrition Adviser for MSF based in Brussels and is leader of the MSF Nutrtion Working Group. She is a medical doctor by training, with a background in paediatrics. She previously worked in the field with MSF and at the Institute of Tropical Medicine in Antwerp before returning to MSF in a headquarters role in 2016.

Five expectant faces are staring at me, waiting for me to answer the question. “Well,” I start, “There are MAMs, and then there are MAMs”. Five expectant faces show a variety of frowning, nervous smiles and confused expressions.

I am standing in our inpatient nutrition ward in a hospital in Masisi, Democratic Republic of Congo. The five expectant faces are two doctors, two nurses and a nutrition assistant – we are doing the morning ward round together. Once we have all established, yes, I meant to say that, it wasn’t my bad French, I try my best to explain.

The question they asked me is one of a suite of questions I get asked by many of our projects in many different countries and continents: ‘How should we treat the children with moderate acute malnutrition (MAM) with medical complications who need hospitalisation – do we treat them as if they were suffering from severe acute malnutrition (SAM)? Do we put them through the whole nutritional treatment protocol, starting with F-75 onwards? Do we refer them to outpatient therapeutic feeding programme (OTP) nutritional care when they exit the hospital?’

At Médecins Sans Frontières (MSF), pratically all of our projects are implemented directly by MSF doctors, nurses, midwives, pharmacists, psychologists, etc., working on the ground, whether with ministry of health staff or in our own projects. We try to equip our staff to deal with the many different contexts and medical conditions with which they will be confronted through medical protocols and guidelines that take into account the latest evidence, combined with our communal clinical experience. We then try to support them through field visits, calls, skypes and emails to make sure that these protocols are achieving the quality of patient care that we all aspire to.

One of the biggest goals of this approach is to provide guidance for clinicians with differing levels of clinical experience and expertise, from the community health officer in Sierra Leone who is now working in our paediatric intensive care unit with only three years of medical education, to the first mission doctor who has ten years of experience in Europe, but has never seen a malnourished child.

We don’t always have the luxury of experienced clinicians who can take our protocols, but then use their own knowledge and experience to adapt treatment to each specific patient. This is especially the case for children with MAM with medical complications who need inpatient treatment. Complications may include shock, altered state of consciousness (coma, lethargy, drowsiness), seizures, pneumonia, diarrhoea with severe dehydration or bloody diarrhoea, severe anaemia, severe malaria, other severe infections (e.g., meningitis), severe skin condititions and congenital malformations leading to feeding difficulties, among others.  

The most common approach in MSF has been to treat these children the same as those suffering from SAM, providing the same medical and nutritional treatment.  

Indeed, this was the approach that I followed as a field doctor when I started with MSF in 2011. I was very new to seeing malnutrition; my training in south London had actually exposed me to advanced tuberculosis, HIV and even rickets in children, but treating kwashiorkor and other aspects of malnutrition was a huge learning curve. Even then, I had concerns as to whether this was the right thing to do for all of these children, but there were no strong international recommendations that were different to MSF’s.

The more time that I have spent caring for malnourished children, both in the field and now from headquarters, still giving clinical input into individual cases as well as working on the aforementioned protocols and guidelines, the more complicated I see the ‘MAMs with medical complications’.

One of the main issues here is a chicken-and-egg conundrum. MSF is likely to see two main profiles of MAM with medical complications – and probably everything in between. There are children who come into our health facilities who are very sick, perhaps even in a coma, who may be having a seizure, who are found to be MAM in triage. After 24 to 48 hours of appropriate treatment and close monitoring, these children are bright as buttons. This Lazarus-like ability of children to recover from illness quickly is why we love paediatrics so much.

Then there is the other profile. These children have the same presenting condition and after the initial 24 to 48 hours of treatment and monitoring are usually slightly better, but are most definitely not bouncing around the ward. These children are slower to repond and may experience some ups and downs in their condition. The general feeling is that this is a vulnerable child – one we need to watch.

We have come to think that the first profile is likely to be a child who has become severely unwell (over a period of time that it is often hard to determine) and then slipped into MAM. This child likely still has the physical resources and homeostatic buffers to br able to bounce back with appropriate treatment. The second profile is likely to be a child who has been MAM for a longer period of time, whose physiology has had to adapt and adapt again to decreasing resources, perhaps also suffering from a number of episodes of illness. There is then one severe episode that pushes them over the edge; homeostasis breaks down and their bodies can no longer cope. Their slower response to treatment, with a bumpier course, is most likely related to their exisiting MAM.

Following this train of thinking, it would seem logical that the first profile of children could be treated as MAM rather than SAM; i.e.; start them on normal food as soon as their condition is stable enough for enteral feeds (whether initially through a naso-gastric tube or straight to oral), with supplementation such as a ready-to-use-supplementary food. Indeed, as I started children with this profile on the full nutritional protocol with F-75 in my early experiences in the field, I worried they were not getting enough calories or protein to help fight their infection. Furthermore, these children were hungry! It is hard enough when you see a SAM child cry for normal food rather than F-75, but at least you know that this is the best treatment we currently have available for their condition, and that giving them normal home food could make them worse through refeeding syndrome.

For the second profile of child, the one who has likely had MAM for a long time, one can feel more confident starting them on the full nutritional protocol as it seems logical that they need a slower approach, with more attention to their metabolic stabilisation.

More often than not, it is extremely difficult to be able to tell if the sickness or the MAM came first when a child first presents. Why? There are many reasons. For example, the history given by the child’s caregiver may not be precise enough to help you to work out which profile the child fits. We often see that caretakers may not feel confident talking about a lack of food at home or a difficult situation that has led to the child having less food. We also frequently see these children brought in by their mothers, but with a history of staying with other family members while the mother works or studies elsewhere. This is a stressful time for this mother. She is unlikely to have wanted to leave her child in the first place, but it was the only way to keep her family afloat. She may feel guilty because the child became unwell or did not have access to enough food, or the right kind of food, while she was away. She is unlikely to be able to give a clear account of her child’s health during the time she was not with the child.

As mentioned previously, these two profiles are perhaps the extremes of the spectrum. The added complication to this already-complicated issue occurs when a child presents in between these two extremes: it can be even more difficult to work out the best course of action. So, how can we write a clear protocol that accounts for this complexity and caters to clinicians with differing levels of experience and capacity? Well, we probably haven’t come up with the right answer yet. What we have tried to do is to put huge emphasis on assessing next steps of care by the clinical response that we see when we start treatment, close monitoring to pick up on subtle changes in clinical condition, and discussing these cases with our medical team. That team starts with the medics in the field, but extends all the way to me in Brussels through direct emails and calls or via our telemedicine platform.

And what about follow-up? Again, we advise case-by-case and give our teams the autonomy to adapt to their context, but we all know paediatricians are control freaks, so we usually advise them to come back to our outpatient clinic for follow-up, even if our outpatient programmes don’t normally admit MAMs (something else we are trying to change at MSF…)

We all grew up in medicine working in teams; they are our support network and often our lifeline. With some of these difficult and complex questions regarding malnourished children, my medical team extends beyond MSF and into the nutrition community. I often send out my distress calls to clinicians I trust and respect, such as Jay Berkley and Indi Trehan. It brings me comfort when I find them thinking along the same lines (although they usually express it more eloquently and with a whole bunch of papers for me to read to back it up!). It is also a comfort to know that there is great research in progress, such as Mark Manary’s high-MAM tudy in Sierra Leone. Hopefully, we will soon be able to provide better guidance to our clinicians in the field and deliver the best possible care to these little ones with MAM.

For more information please contact Kirrily de Polnay.

More like this

en-net: Inpatients with moderate malnutrition and medical complications

I am responsible for our inpatient treatment unit for children with SEVERE malnutrition and I am being asked by our medical staff to provide F100/Plumpy for the treatment of...

en-net: Do we have "SAM Cure Rate" in health facilities running CMAM program

In a health facility where there is both SAM and MAM services (CMAM). Admitted SAM cases who reached to MAM criteria by anthropometric measurements, What are we going to...

en-net: Treatment of SAM children in the absence of RUTFs

In an area where there is targeted feeding programme for moderately undernourished children and PLW with supercereal plus and supercereal and oil respectively but no RUTF for...

en-net: Simplified protocol - RUSF SAM treatment

As per the MAM Decision Tool, there is a recommendation to use expanded admissions criteria to admit children 6-59 months classified with MAM into the OTP (MUAC <125mm), or...

en-net: What first? Medical treatment or Nutritional treatment.

If a child does not recover from SAM due to illness, what should be done in that case? He should be treated for illness first? Will the medical treatment be effective in...

en-net: edematous malnutrition

The current CTC guidelines recommend to treat uncomplicated SAM and MAM exclusively in outpatient, including children with grade 1 and grade 2 edema. I am interested in any...

FEX: Editorial

View this article as a pdf Lisez cet article en français ici We are delighted to mark our 60th edition of Field Exchange with an issue dedicated to the continuum of...

en-net: How to report the uncured registered cases at the end of the program?

In last one year CMAM program in our region has been implemented intermittently; necessitating discharge of a large number of enrolled cases each time the program halted. Now...

FEX: Simplified approaches to treat acute malnutrition: Insights and reflections from MSF and lessons from experiences in NE Nigeria

View this article as a pdf Lisez cet article en français ici By Kerstin Hanson Kerstin Hanson has a background in paediatrics and public health. She most recently...

FEX: Editorial perspective on the continuum of care for children with acute malnutrition

View this article as a pdf Lisez cet article en français ici By Jeremy Shoham and Marie McGrath, Field Exchange Co-Editors Rationale for FEX special edition We are...

FEX: MSF experiences from Afghanistan: Maslakh camp

by Saskia van der Kam Saskia van der Kam is the headquarters nutritionist in MSF Holland. This article draws on her field trips to Afghanistan and a number of other MSF Field...

FEX: Introduction (Special Supplement 2)

Glossary ACF Action Contre la Faim CHA Community Health Assistant CHAM Christian Health Association of Malawi CNW Community Nutrition Worker CTC Community Therapeutic...

en-net: Regarding Moved out beneficiaries

Hello Dear Colleges, Hope you all will be good health and will doing good work. I want to clear my some confusion regarding the CMAM Minimum Performance Indicator. We are...

en-net: MUAC and oedema

Hi there, I have read several times in this forum that MUAC is NOT affected by oedema or pregnancy. I can not find any study about it. Could anyone give me some references...

en-net: Guidance for CMAM expanded admissions criteria

From Jeanette Bailey: Dear colleagues, In recent months a number of agencies have come together to consider simplified and temporary measures to expand their reach to...

FEX: Letter on background to 1999 WHO guidelines on malnutrition, by Mike Golden

Dear ENN, Further to your article on the technical debate regarding the management of severe malnutrition, I wish to offer some contextual information to the development of...

FEX: Scaling up the treatment of acute childhood malnutrition in Niger

Milton Tectonidis By Isabelle Defourny, Emmanuel Drouhin, Mego Terzian, Mercedes Tatay, Johanne Sekkenes and Milton Tectonidis Emmanuel Drouhin is the Niger Desk Officer,...

en-net: discharge criteria of SAM

In a CMAM program where RUTF (EezyPaste) is provided to SAM children under 5 with no complications, when should they be discharged, meaning on what criteria (MUAC and WHZ)? Is...

FEX: Ambulatory treatment of severe malnutrition

Severely malnourished child with father Commentary by Dr. Steve Collins Dr. Steve Collins is a medical doctor with a doctorate in nutrition during emergency operations. He is...

FEX: Reflections on the United Nations draft Global Action Plan on wasting

View this article as a pdf Click here to listen to an interview with the author on the ENN podcast channel By Steve Collins In July 2019, ENN produced a special edition of...


Reference this page

Kirrily de Polnay (). “There are MAMs, then there are MAMs”. Field Exchange issue 60, July 2019. p89.



Download to a citation manager

The below files can be imported into your preferred reference management tool, most tools will allow you to manually import the RIS file. Endnote may required a specific filter file to be used.