SCN News No 36 - UNSCN

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Comments to the Lancet Nutrition Series
In addition to the comments from the Working Groups on the preceding pages, the SCN Secretariat has received this article by
Briend et al as a comment to the Lancet Nutrition Series.
Management of severe acute malnutrition
A comment to the Lancet Series on maternal and child nutrition
André Briend (WHO), Zita Weise-Prinzo (WHO), Flora Sibanda-Mulder (UNICEF), Tanya Khara (UNICEF), Martin Bloem (WFP),
Tina van den Briel (WFP) and Claudine Prudhon (SCN)
We welcome the new Lancet Series on Maternal and Child Undernutrition, an excellent opportunity to galvanise the nutrition
community and governments into common action. The Series rightly identifies severe acute malnutrition (SAM) as an
important cause of child death and lists its treatment among the recommended priority interventions. Paper 3 of the Series,
however, only recommends the scale up and improvement of hospital based SAM management to prevent this important
cause of death. We agree that improvement of hospital-based management is indeed important, and an integral
part of a strategy to address SAM. However, documented experience in countries - especially developing countries -
demonstrates that hospital-based management reaches only a small percentage of children and falls far short of a sufficient
response (Schoffield and Ashworth 1996, Briend 2001, Karaolis et al 2007). On the other hand, the addition of a
community based component leads to a sharp increase in programme coverage (Sadler et al 2007).
This motivated UN agencies and partners to review the evidence of the effectiveness of a community-based approach
relying on ready-to-use therapeutic foods (RUTF) to treat children in their own homes at an informal WHO/UNICEF/WFP/
SCN meeting held in November 2005 (Prudhon et al 2006) As a result of the review, WHO, UNICEF, WFP and SCN recommended
concerted action to develop and strengthen the community-based component of SAM management as a
means of reaching the majority of children suffering from SAM (WHO/WFP/UNSCN/UNICEF 2007). This recommendation
is already bringing partners and governments together to address this important cause of child mortality.
The authors of the Lancet Series do acknowledge that observational data based on large scale programmes from Ethiopia,
Malawi and Sudan suggest that the community based approach is largely successful (Collins et al 2006). We very much
support the inclusion of this type of observational evidence in paper 3 of the series, as for evaluating large-scale interventions,
studies with plausibility designs are often the only feasible option and may provide valid evidence of impact (Victoria
et al 2004). This is particularly true in the case of community-based management of SAM.
The authors state that their methodology included identifying unpublished literature by contacting experts and agencies
that work on undernutrition. Again we very much support this, given the large amount of unpublished literature that is
building on the subject of community-based management of SAM. Growing numbers of programme reports of a whole
range of agencies (such as Concern Worldwide, Save the Children UK and US, MSF, CARE, ACF, Tearfund, World Vision),
show that the community based approach allows the successful treatment of unprecedented large numbers of children
with SAM. They also provide valuable evidence of the effectiveness of the approach. Examples of this type of literature
are available on the web (Chamois 2006, Defourny et al 2006).
It would have been useful to have a more detailed set of recommendations on the type of research recommended for
covering the gaps the authors summarize in the evidence-gap section. The present UN recommendation is to implement
both the community and facility based treatment in parallel, the community component ensuring a high coverage, and
the facility component also providing medical treatment for complicated cases recognising that strong ongoing monitoring
of these programmes is vital (WHO/WFP/UNSCN/UNICEF 2007). Robust experiments, as suggested by the authors
of the Lancet Series, that test these components in isolation would deprive some children of optimal treatment and lead
to unnecessary deaths. Specifically, through hospital care children would not be reached due to low coverage and in
community-based care children with medical complications would not receive adequate medical treatment.
In conclusion, while the importance of the Lancet series for prioritizing research as well as interventions is evident, we
would like to greater recognition for the need to promote the new community based approach as an integral part of the
management of children with SAM (WHO/WFP/UNSCN/UNICEF 2007). This is critical if we are to reach the majority of
children with SAM at the large-scale required to significantly impact this important cause of death.
Contact: brienda@who.int
The authors declare no conflict of interest. AB and ZWP are staff members of the World Health Organization. These authors alone are
responsible for the views expressed in this publication and they do not necessarily represent the decisions or stated policies of the
World Health Organization.
References
Briend A (2001) Management of severe malnutrition: efficacious or effective? J Pediatr Gastroenterol Nutr 32: 521-2.
Chamois S (2006) Ethiopia Experience in the Management of Severe Acute Malnutrition (2003-2005). SCN News 33: 45-48. (online)
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