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Under six months management of SAM and MAM without medical complications

This question was posted the Management of small and nutritionally at risk infants under six months and their mothers (MAMI) forum area and has 20 replies.

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Anonymous_A_W_40

Nutritionist/ M40Re Analytics

Normal user

11 May 2022, 19:49

Hello, While managing a child below six months with either SAM or MAM without any underlying medical complications, and you have counselled the mother on proper lactation practises ( from diet, positioning, attachment) is it advisable to give the mother supplement ( Example Fortified Blended Flour -Advantage) even though the mother is nutritionally Okay? 

Rosemary

MOH

Normal user

12 May 2022, 09:50

Hidden hunger is a common occurance in mothers with children having MAM or SAM which is often overlooked but by supporting these mothers with FBF you get better results rather than just leaving them without. I would encourage you to give FBF for pregnant and lactating mothers if you have access to it

hellena

nutrition intern

Normal user

12 May 2022, 14:50

Hello,since its a supplement,its not advisable to give FBF.Ask the mother if she has enough milk for the baby even if she is practicing proper lactation and make a follow up after every two weeks to see how the baby is progressing.

Pamela Morrison

Lactation Consultant

Normal user

12 May 2022, 15:32

A baby who is falling down the percentiles on a weight chart is usually failing to get enough breastmilk during breastfeeding even if the mother is making enough.  But since poor breast drainage over time will lead to inadequate breastmilk production, this becomes a chicken-or-egg situation.  Feeding a mother more when her weight is already OK wont help the baby who is not breastfeeding effectively. Often a baby like this wants to breastfeed "all day" but what's really happening is that a weak baby is often just flutter-sucking for long times without ingesting an adequate quantity to thrive. To turn this around, it's often necessary to ensure that the mother breastfeeds 8-10 times in 24 hours, for short times, (she can use breast compression and switch-nursing to keep maximize the baby's intake with the least effort on his part) and then after breastfeeding have the mother manually express what the baby is _not_ taking, to use as a supplement. This milk can be stored to be cup-fed after the next breastfeed.  Over time, more efficient breast drainage leads to increased breastmilk production, and increased breastmilk intake for the baby leads to higher weight gain.  In my experience, a low weight gain baby may need to be helped to get enough milk in this way until he reaches the weight he should be for age on a weight chart.  This sounds time-consuming but the breastfeed-supplement-express routine can be over in an hour giving the mother an hour's break before she needs to start again. it does work!  It usually takes as long to "fix" this kind of breastfeeding problem as it took to occur.   

Anonymous_A_W_40

Nutritionist/ M40Re Analytics

Normal user

13 May 2022, 05:00

Thanks Rosemary for your response

Anonymous_A_W_40

Nutritionist/ M40Re Analytics

Normal user

13 May 2022, 05:01

Thanks Hellena for your response.

Anonymous_A_W_40

Nutritionist/ M40Re Analytics

Normal user

13 May 2022, 05:02

Thanks Pamela Morrison for your response.

Anonymous_A_W_40

Nutritionist/ M40Re Analytics

Normal user

13 May 2022, 05:03

Thanks Pamela Morrison for the response

Anonymous_A_W_40

Nutritionist/ M40Re Analytics

Normal user

13 May 2022, 05:06

I asked because in some instances when you supplement with FBF regardless of the mother's nutrition status you get better results the mother starts producing enough milk and the baby start gaining weight...... While in others just counselling, teaching on attachment and positioning, and proper follow up plan also works well.

So I was wondering which is the best recommended practise

ENUNU Henry

Normal user

9 Jun 2022, 21:19

It depends on various factors. You have counselled the mother on propper lactating practices . The question that I might ask you is. How is she in terms of household food security? Does she has enough food  to meet the requirements of breastfeeding mother? During breastfeeding, the mother needs to eat an extra food ( to meet the requirement for her and the infant  about 550 Kcal per day 

Secondly, based on your counselling what is her MAD at household level and is she financially able to buy 5 food groups + during lactation as well as ensuring diet that  is rich in proteins? 

If you have counselled her on proper lactation practices and she can be able to afford to eat extra meals with dietary diversity. I don't see the need for her to get any supplement. But if you see her she is at risk of getting malnourished with inadequate food security at household I will advise you can give her a supplement and with justification as to  why. you did that 

NB// Ensure the underlying causes of malnutrition are taken care of for both the mother and the infant.

Anonymous_A_W_40

Nutritionist/ M40Re Analytics

Normal user

10 Jun 2022, 18:26

@ ENUNU Henry Thanks for the response,, Quite a good number of lactating mothers I encounter are mostly food insecure and they rarely meet the 5 groups recommended since they come from humble backgrounds. So we mostly supplement with Advantage to just "boost" their calorie intake regardless of mother's nutrition status as long as the child is SAM or MAM as a part of management in addition to the named services like counselling. ( I wanted to confirm is this is correct)

Carrie Hubbell Melgarejo

Sr. Nutrition Component Lead/PATH

Normal user

10 Jun 2022, 22:18

Hi All,

There are at least two different topics going on in this thread, and--although related--we should probably keep them clear.

1) Giving a MOTHER (for her own consumption) fortified blended flour (or any of the fortified blended food commodities). Can you clarify for us though how you know that “the mother’s nutrition is fine;” i.e., are you talking about micronutrient profile or macronutrient status (like you’ve got her MUAC or BMI or weight/height? Though I can appreciate that if her dietary diversity is quite poor, fortified commodities may be attractive, I would agree that if the mother's weight is good, it's probably not a great idea to give her supplemental commodities that have the main purpose of providing calories. Maybe instead, better to consider small-quantity lipid nutrient supplements, micronutrient powders (if that is part of the national protocols), or multiple micronutrient supplements (sometimes called prenatal vitamins and they may ultimately come to replace iron-folate). Hopefully as multiple micronutrient supplements become the norm, that will be a good option for mothers who are already at a healthy weight. Those amongst us who work on micronutrients or food assistance can advise.

2) Breastfeeding, and how to ensure adequate milk production, for the CHILD's nutrition. On this I would most trust the lactation consultant who's advising on this thread; Pamela Morrison always gives brilliant advice. She's telling us (I believe) that the way to increase milk production is through ensuring the breasts are emptied, through frequent feeds, alternating between breasts (I used to hear "empty one first" but I think she's saying we can be flexible and give the other breast if the baby seems they're doing a lot of work for the milk they’re getting), emptying the breast manually if needed and storing that milk and feeding it to the baby later from a cup (not a bottle). 

But if a baby is already SAM/MAM, we should probably focus on addressing him/her being underweight as a primary concern, before worrying too much about the micronutrient content of the mother's milk. In addition to whether baby is getting enough to eat, it's critical to consider why else could the baby be SAM/MAM... I know original poster said there are no medical complications, but illness is an important cause/effect of SAM/MAM. With friends from FCDO and ENN, we developed a diagram (Figure 2 here: https://mqsunplus.path.org/wp-content/uploads/2021/10/MQSUNAssumption-Map-brief_wasting-prevention-case-study_26October2021.pdf) to show the different factors involved.

Side note: if anyone's interested in doing research on the complexities of wasting, we and FCDO supported an ENN-led group to try to come to consensus on what the most important research questions might be: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0228151 .

Anonymous_A_W_40

Nutritionist/ M40Re Analytics

Normal user

11 Jun 2022, 18:06

@ Carrie Hubbell Melgarejo, Thanks for the response and the PDF.

Just to reply to the question you asked on how the mother was stated as being " fine'', it  was based on MUAC assessment being > 23cm, we still have a challenge in assessing for micronutrient status of mothers because of limited resources, what can be assessed mostly is the Iron status.

vukoni

nutritionist

Normal user

17 Jun 2022, 22:35

Thanks for the  various inputs from members,it would be good to first consult from your national protocol and how is your programming  as for Uganda we have integrated management of acute malnutrition where we have   4 components; inpatient therapeutic care(management of SAM with medical complications  and  anorexia),outpatient therapeutic care (management of SAM without complications and appetite presence),community nutrition(active case screening ,mobilisation  and linkages) and finally supplementary feeding care(only in emmergencies ,or GAM rate of >15  +aggravating factors usually in refugee settlements ,it can be targetted or blanket supplementary feeding ,in your case if its BSFC then you can go ahead and supplement the mother whose child I  guess in this case is on your OTC program, In some settings especially for refugee settlements WFP  implement  a project on prevention  of  stunting usually called MCHN i.e maternal  child health nutrition along side TSFP where mothers attending ANC(0-9months and 6months postpartum receive super cereal ++ or corn soya blend ++ irregardless of their nutrition status and attention is turned to the child immediately complementary feeding is commenced at 6months,so there is nothing totally wrong with supplementing a mothers diet but it shouldnt be on bases of increasing maternal breastmilk supply.

Anonymous_A_W_40

Nutritionist/ M40Re Analytics

Normal user

19 Jun 2022, 15:59

@Vukoni, Thanks for your input.

Purnima Thakur

Faculty, NIPCCD, GOI

Normal user

20 Jun 2022, 06:23

Hi, Thanks for the question 

  • First assess the household and reason for SAM / MAM in a child 
  • Don't forget to check the child for IDDM , and get the routine blood test done for the child. Even if there won't be complications but Juvenile Diabetes is also one of the leading cause for SAM/MAM. Advise mother also to run for Blood Routine. 

1. SAM/ MAM Children without any complications are preferentially given community based management treatment which includes focus on time and active breast feeding as well as follow up of immunization schedules and WASH practices. 

2. Mothers Nutritional needs should also be assessed , also check for househols food security and mother should be taking her IFA supplements and Calcium supplements.

3. Focus on diet diversification and yes fortified foods add on the supplements. 

4. Mother might seem nutritionally okay but might have anaemia or other micronutrient deficiencies. 

5. fortnightly follow up of such cases is important. 

since i am not aware of your geographic location i would have given you a more concrete reply. 

Anonymous_A_W_40

Nutritionist/ M40Re Analytics

Normal user

21 Jun 2022, 06:30

@ Purnima Thakur, Thanks for the response.

Marie McGrath

Emergency Nutrition Network

Frequent user

22 Jun 2022, 08:08

Dear Anonymous

Thank you for the very important question you raised about management of these nutritionally at risk infants under 6 months and their mothers.  I'd like to highlight the MAMI Care Pathway Package which is a resource material that helps guide through assessment and care of the mother-infant pair, and is particularly suitable for outpatient management.  It supports implementation of intergrated management of childhood illnesses, has valuable resource materials to support breastfeeding counselling (eg counselling cards to address specific problems and concerns), and has core support topics on crying, sleep, maternal mental wellbeing, complementary feeding, and family and community support.  If you have further questions about applying it in your context, do not hesitate to contact us. If you could share what country you are based in, we may be able to connect you to other practitioners local to you through the MAMI Global Network.

Marie McGrath

Emergency Nutrition Network

Frequent user

22 Jun 2022, 08:12

Dear Purnima

Thank you very much for taking the time to respond to the question.  Can I ask regarding your assertion that juvenile diabetes is a leading cause of SAM and MAM in infants under 6 months of age? Could you share the evidence on which this is based? I have never seen this evidenced nor has it been my experience or others that I have spoken to who work with this age group.  Many thanks

Anonymous_A_W_40

Nutritionist/ M40Re Analytics

Normal user

24 Jun 2022, 09:38

@Marie McGrath Thanks for your response and the MAMI care pathway package.

My current location is Kenya. 

Marie McGrath

Emergency Nutrition Network

Frequent user

24 Jun 2022, 09:44

Dear Anonymous, many thanks for sharing.  I have connected you offline to expert support in Kenya. Best regards, Marie

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