Severe Acute Malnutrition
Severe acute malnutrition is the most extreme and visible form of undernutrition. Its face is a child – frail and skeletal – who requires urgent treatment to survive.
Children with severe acute malnutrition have very low weight for their height and severe muscle wasting. They may also have nutritional oedema – characterized by swollen feet, face and limbs. About two thirds of these children live in Asia and almost one third live in Africa.
Severe acute malnutrition is a major cause of death in children under 5, and its prevention and treatment are critical to child survival and development.
Across the globe, an estimated 16 million children under the age of 5 are affected by severe acute malnutrition. This number is staggering – most importantly, because children with severe acute malnutrition are nine times more likely to die than well-nourished children. These deaths are the direct result of malnutrition itself, as well as the indirect result of childhood illnesses like diarrhoea and pneumonia that malnourished children are too weak to survive.
Severe acute malnutrition can increase dramatically in emergencies. But despite what we see in the headlines, the majority of cases occur in developing countries not affected by emergencies. These settings are plagued by chronic poverty, lack of education, poor hygiene, limited access to food and poor diets. The result is significant barriers to sustainable development in these nations.
How is severe acute malnutrition prevented and treated?
Ending acute malnutrition is a complex social and political challenge. Prevention and long term solutions involve dismantling unequal power structures, improving equitable access to health services and nutritious foods, promoting breastfeeding and optimal infant and young child feeding practices, improving water and sanitation, and planning for cyclic food shortages and emergencies.
But in the short term, children with severe acute malnutrition need urgent life saving treatment to survive.
Until relatively recently, these children were only treated in hospitals where they received therapeutic milks along with medical care; and many more were never reached at all. With the creation of ready-to-use therapeutic food (RUTF) however, the picture has changed dramatically.
Ready-to-use therapeutic food (RUTF) is a high-energy, micronutrient enhanced paste used to treat children under age 5 who are affected by severe acute malnutrition. As its name implies, RUTF does not need to be cooked or prepared before consumption. This makes it a practical solution where cooking facilities and fuel are limited. RUTF has a long shelf life and is safe for use even in the absence of clean drinking water.
The use of RUTF has transformed the treatment of severe acute malnutrition, in part, because it allows those children without medical complications to be cured right in their own homes and communities. This approach is referred to as the community-based management of severe acute malnutrition.
In this approach, community health workers are trained in early detection to recognize cases of severe acute malnutrition and provide RUTF and routine medical care. At the same time, health workers learn to recognize medical complications and refer those children to hospitals and health centres for further in-patient treatment. Many children with severe acute malnutrition also have infections, including HIV, making interactions with health workers important opportunities for voluntary HIV testing and treatment counselling.
The power of the community-based approach is that early detection and early treatment leads to better rates of survival and the treatment of many more children. It also empowers communities and is much more cost-effective than in-patient treatment.
In 2007, the United Nations endorsed the community-based management of severe acute malnutrition, and since then, millions more children are now being treated and cured globally than with the facility-based approach alone.
The treatment of severe acute malnutrition is a last opportunity to save a child’s life when all else has failed. It is not a substitute for promoting equitable access to nutritious food, ending poverty and supporting other timely interventions that can prevent malnutrition before it starts.
What are the challenges?
In 2014, just over 3 million children under age 5 were treated for severe acute malnutrition. This figure had almost doubled in only a few years, yet much more remains to be done to reach the millions of remaining children with this condition worldwide.
Governments face immense challenges in building capacity and allotting sufficient resources to prevent and treat acute malnutrition. Progress has been particularly slow in non-emergency contexts. This is partly due to limited prioritization of the issue on the part of national governments, donors, and the international community, and limited acknowledgement that severe acute malnutrition is an ‘everyday problem’ – not just the result of emergencies.
There is also work to be done in making governments aware of the links between acute malnutrition (wasting) and chronic malnutrition (stunting) and the need to address these issues in tandem.
Introducing treatment for severe acute malnutrition in health facilities and communities can be extremely challenging in some contexts. Countries need to have supportive national policies, well-trained health workers, adequate supplies and financing, and a central operational plan to scale-up treatment at all levels.
To achieve this, governments need to be fully convinced of the need and the benefits. Therapeutic supplies such as RUTF are often not well integrated into national health care and distribution systems due to their costs and relative bulk. It can help to identify appropriate, cost effective and locally produced options. All of these challenges are further exacerbated in emergency situations.
Addressing the underlying social determinants of severe acute malnutrition is perhaps the greatest challenge of all.
How is UNICEF responding?
Supply and delivery – UNICEF is the world’s largest provider of therapeutic supplies, including RUTF. The organization is continually identifying new ways to strengthen supply chain management and improve the complex process of delivering supplies to remote locations, in difficult conditions and emergencies. UNICEF also supports local production of RUTF.
Capacity building – UNICEF strengthens the capacities of national governments and local actors to scale-up treatment for severe acute malnutrition in over 75 different countries. This includes supporting governments to institutionalize treatment programmes through national planning mechanisms and policy changes.
Leadership and technical guidance – UNICEF works with governments to develop national policies, strategies, protocols, and training packages for health workers, and provides technical support to national actors in their implementation.
Norms and standards setting – UNICEF gathers global data and captures lessons learned to update treatment approaches and protocols, and provide guidance to improve the coverage and quality of programmes. A key example is the UNICEF Management of Severe Acute Malnutrition Programme Guide, which provides guidance on programme assessment, design, planning and implementation.
Advocacy – At global and national level, UNICEF works to position acute malnutrition as a public health priority and improve understanding of the scope and scale of the problem.