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The much-anticipated 2023 WHO guideline on the prevention and management of wasting and nutritional oedema (acute malnutrition) in infants and children under 5 years has finally landed. Some of you have asked us, where’s MAMI? Rest assured it’s there!

If you need convincing, it might help to clarify first what exactly MAMI is (and is not). MAMI refers to continuity of respectful quality care for at-risk infants under 6 months and their mothers across systems of health and nutrition. You don’t need to call it MAMI but we’ve found it a useful shorthand for a big (but important) mouthful. ‘At-risk’ infants come in different shapes and forms, or at least are described in different ways. They may present as small vulnerable newborns including low birth weight, premature, small for gestational age; wasted/stunted/underweight infants or infants at risk of poor growth and development. Risks may also arise due to maternal health, nutrition or social factors that warrant attention and action. The MAMI Care Pathway applies an integrated care pathway approach to the context of at-risk mother-infant pairs. The MAMI Care Pathway Package is a resource material that was collaboratively developed under the MAMI Global Network to help put this approach into practice to guide context-specific implementation. It applies and expands on what exists, such as the Integrated Management of Childhood Illness (IMCI) and breastfeeding counselling materials, that plausibly could be applied to improve care of these vulnerable pairs. 

Rest assured, the MAMI Care Pathway and WHO 2023 recommendations are aligned. Just like the MAMI approach, WHO has expanded the scope to way beyond the severely wasted infant under 6 months (target group of the WHO 2013 guidelines) to infants under 6 months ‘at risk of poor growth and development.’ Expanded criteria to identify those at risk include weight-for-age, MUAC and growth faltering, and maternal factors. This welcome clarification on how to define those infants under 6 months of age at risk helps address a critical longstanding gap highlighted in earlier published summaries of research priorities. WHO 2023 emphasises and addresses mothers and infants' health and nutrition needs, as an interdependent pair, as does MAMI. The MAMI Care Pathway embeds and builds on IMCI as WHO 2023 does; in fact, WHO 2023 expands considerably on details of clinical care that hopefully can (and really should) feed directly into the WHO-led update of IMCI now well underway. WHO 2023 also provides guidance to support decision-making on referral pathways (continuity of care in action) informed by the individual mother-infant circumstances (person-centred care in action) and prevailing inpatient and outpatient service capacities. In both MAMI and WHO 2023, prevention and treatment are intertwined through early identification and action, responsive growth monitoring and attending to maternal mental health and early child development.

Does it matter that MAMI is not explicitly mentioned in the WHO 2023 guideline? NO.

What is important is what you do, not what you call it. Indeed, a drawback of our framing MAMI as a ‘package’ is that it can be seen as a standalone or rigid or non-negotiable way to do care – it’s not. Implementation modalities for MAMI are not limited to those that explicitly use the MAMI Care Pathway Package and approaches. To achieve continuity of respectful quality care this may come in many different guises and we should and must welcome, be open to, and embrace such diversity. 

When it comes to the nitty-gritty details, there are some differences between WHO 2023 and MAMI. Take MUAC1 for example. The WHO guideline include for the first time a welcome recommendation for MUAC (<110mm) in infants from 6 weeks to 6 months based on the latest evidence presented. The MAMI Care Pathway Package suggests a less conservative cut off: <115mm for infants 6 weeks of age and above and <110mm for infants under 6 weeks of age. Differences are only to be expected when you consider the different timelines, processes, remits, and authorities involved in normative guideline and implementation/operational guidance development. For the WHO guideline update, the independent WHO Guideline Development Group considered the latest evidence identified through systematic reviews and were informed by an appraisal of the balance of good practices (in case evidence was absent or very weak), benefits and harms, values and preferences, certainty, resources, equity, acceptability, and feasibility.2 In the MAMI Care Pathway Package, MUAC cut-offs were proposed in the context of lack of global guidance and an urgent demand from practitioners for direction. An expert/peer consultation, facilitated by ENN, considered evidence available up to 2021 (last update), implementation experiences and pragmatic operational considerations. Implementation guidance often can and needs to go further than normative guidelines, such as when there is a need to ‘stop gap’ an immediate void in global guidance that is hampering practice. Indeed, by going further to address urgent needs in real time, and documenting process and outcomes along the way, such guidance can support ‘learning by doing,’ generating evidence that can in turn inform normative guideline development. Considering the WHO 2023 recommendations, we’ll be critically examining the specific ‘technical’ consistencies and differences between MAMI approaches and the WHO recommendations – better aligning where we can, and explaining where we are not (or not yet).

While keeping this in mind, let’s not get too hung up on technicalities but capitalise on the wonderful opportunities this guideline presents. The release of the WHO 2023 guideline truly marks an exciting phase of MAMI (or whatever you want to call it). Our many years of groundwork on MAMI means we are now primed to help support national WHO guideline uptake (if wanted and needed), to achieve continuity of respectful, quality care for at risk mother-infant pairs, and to learn from that process. If it helps, be guided by our framing of MAMI, but do not let it limit how you see it, or how you do it, or interpret what others do. 

As highlighted in the WHO 2023, there remains a dearth of direct evidence of not only what works but how, for whom, and under what circumstances. Context makes and shapes everything – the ‘how’ of MAMI will and should be different wherever you are as realities are diverse. Embrace the rich tapestry of life in your evidence generation – at ENN, we’re planning to do so through three deep-dive case studies on MAMI care from Yemen, Pakistan and South Sudan. We’re happy to share our approach to help others do the same and would love to join forces to learn together. The WHO will be managed as dynamic ‘living guidelines’3 – let’s walk that walk together.

This MAMI/WHO 2023 alignment is no accident. The MAMI Care Pathway Package was first developed in 2014 to fill a guidance void on how to put the (then) ground-breaking 2013 WHO recommendation for outpatient care of ‘uncomplicated’ severely wasted infants under 6 months into practice.  Evidence generation and strategic policy brokerage since, by so many members of the MAMI Global Network, has been instrumental in informing the WHO 2023 content. From where I am sitting, the WHO 2023 guideline is not just an evolution but a revolution in care! Your collective work and gentle unfailing determination to build evidence and raise attention to at-risk infants under 6 months and their mothers has been instrumental in achieving this. A huge thanks to you all out there who have and continue to make this happen.

If you’d like to talk about our case studies approach, share yours, or have any other thoughts/questions/suggestions, drop us a line at: mami@ennonline.net

Marie McGrath is a Technical Director with Emergency Nutrition Network (ENN). She is ENN’s technical lead on the Management of small & nutritionally At-risk Infants under six months & their Mothers (MAMI) and Co-Chair of the MAMI Global Network. On the MAMI front, she is also undertaking a part-time PhD at the London School of Hygiene and Tropical Medicine to investigate implementation experiences during a randomised controlled trial of the MAMI Care Pathway Package within health services in Ethiopia (involving ENN/ LSHTM/ Jimma University/ GOAL Ethiopia).

1 Mid -upper-arm circumference

2 The evidence required for the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) Evidence to Decision (EtD) criteria

3 For an example of this in action, see: Vogel, J. P., et al. (2019). "Developing and applying a 'living guidelines' approach to WHO recommendations on maternal and perinatal health." BMJ Glob Health 4(4): e001683.