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Treatment of infants <6m with SAM in the community?

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Anonymous 557

Normal user

1 Mar 2011, 11:16

Hi,
I am trying to find out the best way to treat infants below 6 months that are malnourished but whose mothers refuse to stay in a Stabilisation Centre as they have to care for their other children. Hence Supplemental Suckling Technique can't be done as not sterile and can't use diluted F100. I know that the MAMI report looks at community care of these infants but basically hypothesises about a CMAM type triage but wondered what others were actually doing in the field now if they come up against this problem.
Thanks.

Marie McGrath

ENN

Forum moderator

14 Jun 2011, 12:06

Dear Anon
We empathise with your situation, there is indeed a lack of guidance on what to do with this age group that frustrates those working in programmes faced with cases just like you described. Some suggestions regarding the case you describe.
1) A key question is how are you defining acute malnutrition in the infant in question – is it purely based on anthropometry or on a clinical history? Since “malnutrition” is defined statistically rather than clinically, it’s important to remember that some normal, well, infants have to be small. Equally others who may appear to be “in-range” may not be achieving their full genetic potential.

Guidance on clinical assessment in infants <6m that are malnourished is included in Module 2 on IFE, available at:
http://www.ennonline.net/pool/files/ife/module-2-v1-1-core-manual-english.pdf

2. If an infant is “malnourished” in terms of WFH<-3 z-scores (especially if assessed by WHO growth standards) but clinically well and feeding well, then there’s a common-sense / clinically plausible argument NOT to admit and instead treat as “uncomplicated” malnutrition, i.e. through community based support. A jey question of course is why the infant is “malnourished”. A thorough clinical history would be key: e.g
• Could it be a recent problem like diarrhoea or RTI from which infant has not recovered and is likely to continue to do well?
• Could it be an underlying chronic problem like HIV or TB?
• Could there be a maternal problem such as depression/other mental health or social issues which are resulting in secondary lactation failure?

Unlike for older children, a trickier thing for uncomplicated cases of SAM in infants <6m is what ‘treatment’ to offer. Good breastfeeding advice and skilled support is core to all interventions – even if another primary cause for the problem is identified. Are there any breastfeeding support services available where you are based?
Again, Module 2 on IFE includes details on infant feeding assessment and skilled breastfeeding support.

3. Infants <6m are quite a heterogeneous group – an infant at 1 month of age is very different to an infant at 5 months of age. What age is the case that presented to you? This may have quite a bearing on why an infant presents (e.g. a 1 month old that was low birth weight v a 5 month old where poor quality complementary foods have been introduced early), and their management. Individual assessment is key.

Finally, I’d like to highlight another training resource, to integrate IYCF in CMAM: http://www.ennonline.net/pool/files/ife/iycf-cmam-facilitators-a4large-final%281%29.pdf
Many elements, including the approach of identifying IYCF characteristics of the community, history taking, and negotiating small, doable actions with a mother may be valuable in your managing this case.

The feasibility and efficacy of integrating IYCF in CMAM is being explored in a 2 year piece of research in Ethiopia under the Alive and Thrive Project, led by SC US. While not targeting infants <6m, strengthening IYCF support at key contact points in a CMAM programme may have an impact in prevention in younger siblings. We’ll keep en-net posted on findings and any other work that materialises on MAMI.

Marie McGrath & Marko Kerac

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