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Treating children who suffer from acute malnutrition – one text message at a time

fanzoblog1This article was originally posted on the ChildCount+ blog. ChildCount+ is an mHealth platform aimed at empowering communities to improve child survival and maternal health using mobile technologies.

Severe acute malnutrition (SAM) affects 20 million children under five years of age each year and contributes to 1 million child deaths per year. Moderate acute malnutrition contributes more to the overall burden of disease, as it affects many more children. As a nutritionist, these statistics are devastating, and largely go unrecognized by many working in global health. Why is this? Often, children who are malnourished suffer from complications of other diseases and nutrition is often an orphan – misunderstood in diagnosis and treatment. Nutrition is often seen as “complicated.” It is not totally untrue – in the past, treating malnutrition has been cumbersome, requiring hospital services and complex medical treatment. However, in the last few years the game has changed.

An innovative community-led public health model to address acute malnutrition in developing countries has been established called Community-Based Management of Acute Malnutrition (CMAM). The community-based approach engages the community to detect signs of SAM early by sensitizing communities and subsequent active case finding, and provides treatment for those without medical complications with ready-to-use therapeutic foods (RUTF) or other nutrient-dense foods at home. If properly combined with clinical care for those malnourished children with medical complications and implemented on a large scale, community-based management of severe acute malnutrition could prevent the deaths of hundreds of thousands of children. The CMAM combines three treatment modalities, inpatient therapeutic (IP), outpatient therapeutic (OTP) and supplementary feeding (SFP) according to the clinical and anthropometric characteristics at presentation. CMAM can maximize treatment by improving coverage, access, and cost-effectiveness of treatment.

Originally termed Community-based Therapeutic Care (CTC), CMAM was used mainly in emergency settings. However, the CTC approach was shown to be useful in non-emergency settings when the right components were in place. In the Millennium Village of Sauri Kenya, the components were there and ready for the MVP team to think creatively. In 2009, Community Health Workers (CHWs) and clinical staff in Sauri were trained on CMAM complemented with an SMS technology platform. With levels of acute malnutrition amongst children under five years of age above 5% in Sauri, CMAM provides a way to prevent death amongst these children and avoid inpatient treatment which can increase morbidity with high economic costs, particularly if mothers have to get to the district hospital in Siaya – a very long way away. When children are identified by CHWs at the household as having acute malnutrition and are referred to the nearest village clinic, the child is directed into one of three treatment scenarios shown below.

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So how does the CHW determine if a child is acutely malnourished? Sauri’s community health program is made up of 110 CHWs supporting 8 clinics and one sub-district hospital. Health care workers are assigned to a particular community or sub-community with specific number of households assigned to them. On average, a CHW is responsible for about 100 children under five at any time. When the program first began, the Sauri team used a RapidResponse to register all children under the age of five that could serve as a “living” registry. In the first month alone, 9,500 children were registered into the system.

When the CHW visits a household in the community, the CHW is equipped with a mobile phone (provided by Sony Ericsson and service by local company Zain), a mid-upper arm circumference band and some basic medicines. The CHW uses the MUAC band to measure whether or not the child is acutely malnourished (using a number and color code of green [well], yellow [moderate malnourished] and red [severely malnourished]). They also look for some signs and symptoms of malnutrition such as edema, appetite, vomiting and other signs. Once they have this information, the MUAC reading and symptoms are typed into the mobile phone using SMS text messages coded with pre-registered patient data. The information is then submitted and an automated alert and notification system is then triggered. The CHW will continue to receive messages to follow-up at the household once the child is in a treatment program. How simple is that? A lot more simple than treating at the hospital where infectious disease and overcrowding can increase the mortality of those same children admitted for severe malnutrition.

After 9 months of the system up and running in Sauri, the case detection and screening has increased drastically. However, it will be critical to now ensure that the “back end” of the system runs smoothly. Continuous supply of Plumpynut, supplementary therapeutic foods and MUACs need to be ensured. Refresher trainings for CHWs and clinical staff need to be done on a continuous basis and the data monitoring systems that integrate the SMS technology to ensure that children are treated and cured will be crucial to the success of the CMAM project. What is the point of letting mothers know their child is malnourished and that they should go to a clinic for treatment if that support is not there when they arrive 15 km later?

With the rapid assessment using CHWs integrated within the community and using SMS technology, children are being detected quicker and more efficiently. What is even more critical for the SMS technology system is that other diseases can also be integrated into the platform – such as rapid diagnostic and treatment of malaria, diarrhea and other basic primary pediatric illnesses. Treatment of these diseases will be essential in attributing to overall wellness of children and prevent repeated bouts of acute malnutrition.  Integrating SMS technology into CMAM is an exciting way for nutritionists such as myself to detect cases of acute malnutrition in real time using simple tools. No longer will nutrition be orphaned or complicated – it just takes a community health worker, a muac band, a mobile phone and some therapeutic food. If only now we could integrate a twitter platform…

Follow Jessica on Twitter @jessfanzo

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Jessica Fanzo is Director of Nutrition at the Center for Global Health and Economic Development.

The Center for Global Health and Economic Development (CGHED) mobilizes health research and programs that enable low-resource countries to develop quality health systems for the poor, promote sustainable economic development and achieve the Millennium Development Goals (MDGs) – global targets for reducing extreme poverty and hunger and improving education, health, gender equality and environmental sustainability.  For more information about CGHED’s work, please visit  our website.


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