How can we guarantee the treatment of millions of children suffering from severe acute malnutrition when almost all of them live in regions marked by a chronic lack of resources (healthcare infrastructures, human resources, funding)?
This was the challenge that, in 1996, led Nutriset and IRD to invent Plumpy’Nut®, the first ready-to-use product for the treatment of severe acute malnutrition (Ready-to-Use Therapeutic Food or RUTF).
Using a product suitable for their requirements, field workers were then able to develop a community-based model for the management of acute malnutrition (CMAM - Community-based Management of Acute Malnutrition).
Simplifying the work of healthcare teams
Back in 1993, Nutriset’s development of F-100 and F-75 therapeutic milks in ready-to-dilute form already represented a marked improvement, making the work of medical teams easier.
Previously, teams had had to prepare their renutrition milks themselves, using skimmed milk powder, sugar, vegetable oil and a mix of minerals and vitamins in drinking water.
The use of F-100 and F-75 milks reduced the risks linked to getting the dosage of the different ingredients wrong. It also made it easier to implement a new protocol improving the management of patients and their chances of recovery, leading to a reduction in the mortality rates recorded in nutritional programmes.
But neither F-75 nor F-100 got round the two main constraints related to the management of severe acute malnutrition: the need for drinking water, and the very short shelf-life of therapeutic milks once reconstituted.
As a result of these two difficulties, all severely malnourished children needed to be hospitalised for several weeks at a time, with round-the-clock medical supervision.
Yet in countries affected by malnutrition, the lack of infrastructures (hospitals, clinics with in-patient beds) and qualified human resources drastically limited the number of children treated. Without mentioning the cost of lengthy hospital stays, prohibitive to impoverished Ministries of Health.
The need for a care giver – generally the mother – to stay with the child throughout hospitalisation was another major obstacle. Very often, the mothers were in no position to stay away from home – where their other children were waiting for them, along with their work in the fields or other tasks vital to the economic and social life of the household – for such an extended period of time.
As a result, whenever the hospitalised malnourished child began to recover, many mothers took their child home, without waiting for the treatment to be completed, thereby leading to a greater risk of relapse and mortality.
It was to compromise these realities – those of families and organisations fighting malnutrition – that Plumpy’Nut® was developed.
To seek an alternative to therapeutic milks, Nutriset joined forces with André Briend, a physician specialising in nutrition who at the time worked at the Institut de recherche pour le développement (IRD). Along with Michel Lescanne, Nutriset’s founder, they tested several products – pancakes, doughnuts, biscuits – but these tests were not conclusive; up until the idea emerged in 1996 for a ready-to-eat peanut-based nutrient paste. A few weeks later in Nutriset’s laboratory the idea became an industrially viable product: Plumpy’Nut®.
Plumpy'Nut®, a product with interesting properties
A peanut paste fortified with milk, vegetable fat, sugar, vitamins and micronutrients (see the technical data sheet for a full list of ingredients), Plumpy’Nut® has a nutritional value equivalent to that of F-100 milk, but requires no preparation (no dilution, no cooking).
In 1997 in Chad, a first trial conducted on a small number of children by Action Contre la Faim in collaboration with the Chad Ministry for Health demonstrated the good acceptability of the product. In 1998, Médecins Sans Frontières (MSF) used it during a famine in Southern Sudan, again with good results.
In 2000 the NGO Concern Worldwide tried out non-hospital management of cases of severe acute malnutrition in Ethiopia using Plumpy’Nut®. On the basis of this experience, the article by Steve Collins, a physician specialising in nutrition, published in August 2001 in the prestigious scientific journal The Lancet, sketched out the basic principles for a community-based model for the management of severe acute malnutrition (CMAM - Community-based management of severe acute malnutrition).
Treating malnutrition at home
After having tried out this approach in Malawi, a country where the security conditions facilitate monitoring of children at home, Valid International and Concern Worldwide organised a symposium in Dublin in October 2003 to share the impressive results of their research conducted in community treatment centres (CTC) with the major humanitarian nutrition players.
In 2006, on the basis of the results obtained in Malawi, Valid International and Concern Worldwide produced the first field manual dedicated to the implementation of Community-based Therapeutic Care (CTC).
In 2007, a joint statement by the World Health Organisation (WHO), the World Food Programme (WFP), UNICEF and the United Nations Standing Committee on Nutrition (SCN) approved the CMAM model and the use of RUTF*.
The basis of the CMAM approach
The CMAM approach is based on a simple observation: during seasonal (as in Sahel countries or Ethiopia) or exceptional (related to wars or natural disasters, for example) malnutrition peaks, hospitalising the tens of thousands of children affected is quite simply untenable.
The CMAM model is based on the properties of RUTFs such as Plumpy’Nut® to overcome this requirement: ready to eat, from the pot or sachet in which it is packaged, able to be kept for 24 months after the date of manufacture and for up to 24 hours after opening.
Because they make the home management of malnutrition possible, RUTFs such as Plumpy’Nut® have helped increase the number of children treated tenfold, at the same time relieving pressure on hospitals to allow them to concentrate on the most serious cases.
Community-based screening and out-patient treatment
In parallel, screening can be decentralised on a community level, significantly improving families’ access to treatment and increasing the coverage rate of malnutrition management. Measurement of a child’s arm circumference using a coloured, graduated bracelet – MUAC or Middle Upper-Arm Circumference – and observation of a few simple physiological and clinical signs (presence of oedema, extreme emaciation, loss of appetite, etc.) make initial diagnosis possible.
If they have no medical complications and have an appetite, children suffering from severe acute malnutrition go home with enough RUTF for one week of treatment (2 to 3 sachets of Plumpy’Nut® per day, depending on the child’s weight). Their mothers are responsible for giving them the product every day and must bring them back to the clinic for a weekly visit to check weight gain, make sure that the child has not become sick and obtain further supplies of RUTF. This follow-up lasts 6 to 10 weeks, until children have reached a target weight defined in relationship to their height and are no longer acutely malnourished.
Only cases of severe acute malnutrition exacerbated by a complication (respiratory infection, diarrhoea, loss of appetite, etc.) are referred to hospital for medical and nutritional management. Once their condition has been treated and they have begun to gain weight, children may complete their treatment at home, with weekly out-patient follow-up.
Demonstrated large-scale effectiveness
The food crisis in Niger in 2005, during which Médecins Sans Frontières (MSF) treated over 60,000 children with Plumpy’Nut®, with a recovery rate of more than 90% in the space of a few months, demonstrated the effectiveness of RUTFs on a large scale. Today, they have won the support of the main players involved in tackling malnutrition and are used on a large scale by United Nations agencies, such as UNICEF and the WFP. Several NGOs in the process of setting up the CMAM model (MSF, ACF, Save the Children, etc.) and organisations such as GAIN or the Bill & Melinda Gates Foundation have launched campaigns calling for action against malnutrition.
Despite an increase in the number of children treated, much progress still needs to be made: of the 26 million children suffering from severe acute malnutrition, only 10 to 15% are adequately treated.
Stepping up the fight against malnutrition
A number of obstacles continue to hamper the extension of the model. While the World Bank estimates the required budget to be 11.8 billion dollars**, the funding allocated to nutrition was only 350 million dollars per year over the period 2004-2007. In some countries, national management protocols are slow to integrate the CMAM model. And the political will to recognise and tackle this phenomenon of malnutrition is sometimes lacking.
In 2000, The United Nations set eight Millennium Development Goals (MDGs), including, in particular, a target to halve by half the proportion of people who suffer from hunger by 2015 and to reduce by two-thirds the under-five mortality rate.
As the deadline approaches, the interim assessment is disappointing overall. Much work remains to be done to decrease the number of severely malnourished children: to increase the management by RUTF treatments and to ensure a better continuum between this treatment and that of moderate acute malnutrition. In terms of prevention, intervention strategies must be lead, improving the nutritional status of pregnant women at the beginning of their pregnancy. More than ever before actions to fight undernutrition needs to be stepped up.
At the start of 2010, Nutriset and the PlumpyField® network (producers of Plumpy’Nut® and RUSFs in developing countries) officially endorsed the World action plan against malnutrition (Scaling-up Nutrition: a Global Framework for Action) – the result of cooperation between United Nations agencies, developing countries, humanitarian organisations and funding bodies.
In his article advocating the CMAM model published in The Lancet in 2001***, Doctor Steve Collins saw the community-based management of malnutrition as a means of “creating a continuum between emergency and developmental approaches”. By seeking to find new products capable of tackling malnutrition at a more upstream stage, and also by expanding production capacities directly in those countries affected by malnutrition in order to have an impact on economic development Nutriset and PlumpyField® are helping to make nutritional autonomy a reality.
* "Community-based management of severe acute malnutrition, A joint statement" Authors: WHO; UNICEF; WFP; UN System Standing Committee on Nutrition, ISBN: 9789280641479, published: 2007
** "Scaling Up Nutrition: What Will It Take? The Window of Development Opportunity", November 12, 2009, The World Bank
*** "Changing the way we address severe malnutrition during famine", Steve Collins, The Lancet, Vol. 358, No. 9280, p498–501, published: August 11, 2001