Starved for Attention

An MSF staff member measures a child's mid-upper arm circumference at a nutrition program in the Guéra region. © Boris Revollo / MSF

MSF is conducting emergency nutrition interventions in Chad, in the Sahel region, where approximately 10 million people are expected to suffer from food insecurity. Hear more from the latest MSF Frontline Reports Podcast.

New research points to successful prevention of malnutrition in Niger. 

By Dr. Susan Shepherd, Nutrition Coordinator, Médecins Sans Frontières (MSF), New York, USA     

A recent study in the journal Pediatrics shows how the timing of a nutrition intervention in Niger during the first years of a child’s life, as well as the extended duration of food supplementation with high-quality, balanced food supplements – in amounts as small as 250 kcal/day – can have positive effects on the growth of young children and protect them from episodes of weight loss during the critical hunger gap (most food-insecure months of the year).

Dr. Susan Shepherd

The study, Reducing wasting in young children with preventive supplementation: a cohort study in Niger, compared the effects of ready-to-use supplementary food (RUSF) and ready-to-use therapeutic food (RUTF). It was conducted by Epicentre, the research affiliate of Doctors Without Borders/Médecins Sans Frontières (MSF), in Maradi, Niger – a region where food security is a chronic concern.

The 1,645 children who received nutritional supplementation were 6 months to 3 years of age, which is widely regarded as the critical window of opportunity when the quality of a child’s diet has a profound, sustained impact on his or her health and physical and mental development. One group received 250 kcal/day of RUSF for 6 months, and the other received 500 kcal/day of RUTF for 4 months.

Just under half of the children participating in this study had received a short-term (3-month) distribution of RUTF (500 kcal/day) the previous year, 2006 (Isanaka et al, JAMA 2009). At the beginning of the second distribution round in 2007 (6 months after the end of the previous one), these children had less wasting and stunting compared to those who received no supplementation. This finding suggests that lasting benefits on children’s growth can result from even short-term distributions of high-quality, calorie- and micronutrient-rich foods like RUTF.

For the 2007 distribution, the duration of supplementation appeared to be more important than the amount of calories provided by the food. Among the children who received both the 2006 and 2007 distributions, those who were supplemented with RUSF fared better and had 50 percent less wasting compared to those who received RUTF.

These two studies by Isanaka et al complement work done in Malawi, where Phuka et al (Archives of Pediatrics and Adolescent Medicine 2008) showed that daily supplementation with 250 kcal/day of RUSF in children 6-18 months of age improved growth in stunted children significantly better than a fortified corn-soya blend.

Taken as a group, these studies lend credence to the use of balanced, complete food supplements tailored to the nutritional requirements of young children as an effective way to promote healthier growth in the 6-35 month age group and protect these young children from weight loss during the hunger gap.

Although this is a particularly difficult year in Niger and elsewhere in the Sahel requiring expensive, rapid-response programming, every year MSF and others treat hundreds of thousands of malnourished children in this region. These emergencies come as no surprise. The growing evidence of benefit to children who receive high-quality food supplements should compel aid organizations and international donors to make wiser use of resources and develop strategies and interventions that aim to reduce the burden of childhood malnutrition.

“Reducing wasting in young children with preventive supplementation: a cohort study in Niger” by Sheila Isanaka et al.  Pediatrics 2010;126(2):e442-e450

Dr. Susan Shepherd

We got some great feedback on this recent blog post about treating malnutrition in Niger.  Here, Dr. Shepherd responds.

Darrel H. (on Facebook): FYI…As you share Plumpy nut, make sure it is only given to children 6 months to 2 years. It has to high of a content of fat for older children. Just learned this at the International Food Aid and Development Conference in Kansas City.

Dr. Susan Shepherd: PlumpyNut is given to severely malnourished children at any age for a limited period of time (6-8 weeks) to support lean tissue weight gain after a period of weight loss. The issue is not fat content for a specific age group, but for a specific metabolic state. A high fat diet is appropriate for people who have abnormal weight loss (catabolic state); it is not appropriate for healthy children who are growing at a normal rate (anabolic state).

Chika O. (on Facebook): What is the government of Niger doing to solve this problem? Why are they abdicating that responsibility to MSF? That is the real question.

Dr. Susan Shepherd: The government of Niger has supported the development and revision of a national protocol for the treatment of malnutrition. It has included severe and moderate malnutrition in its health statistics, monitored weekly, similar to other diseases that require rapid response (meningitis, cholera, measles). Childhood malnutrition is now being taught to medical students at the University in Niamey. In 2010, the Ministry of Health is participating in the oversight of innovative programs to reduce the incidence of severe malnutrition in the under 2 year age group. Niger is one of the regions of the world most affected by childhood malnutrition, it is a huge public health concern. The real challenge is to devise strategies to address the problem that don’t break a weak, developing health system.

Caro O. (on Facebook): God bless, its breast feeding week from 16th to 20th in Kenya, wish you would attend. Breast feeding is suppose to stop malnutrition to the still breast feeding kids, i agree with you Darrel H, plumpy nuts does miracle, have seen its amazing positive effect,they are great!

Dr. Susan Shepherd: Breast milk is all a child needs for the first 6 months, but at that point, all infants need quality complementary foods that provide quality protein, fats and vitamins/minerals: particularly calcium, zinc and iron [breast milk cannot meet babies' requirements for these]. So breastfeeding is essential, but it is not sufficient on its own to assure proper nutrition from 6 months – 2 years, the transition period when children shift from breast milk alone to family food. This is why children need baby foods that are calibrated to their particular nutritional needs. Foods similar to PlumpyNut can provide the proper nutritional balance in an infant’s diet, in addition to breast milk, of course.

We welcome more feedback or questions.  You can leave them in the comments here, post them on our Facebook page, or tweet them to us at @MSF_USA.

Interview with MSF President, Dr. Marie-Pierre Allié 

Dr. Marie-Pierre Allié, president of Doctors Without Borders/Médecins Sans Frontières (MSF), returned recently from a trip to Niger. With another nutritional emergency underway, new preventive approaches are emerging in the struggle against malnutrition. 

Mothers wait to receive ready-to-use therapeutic food at a nutrition program in the district of Guidan Roumdji. © Alessandra Vilas Boas/MSF

What is your analysis of the situation? 

Clearly, Niger is experiencing a serious food and nutritional crisis. Last year’s poor rainfall produced inadequate harvests in a food security context already weakened by a gradual increase in food prices over recent years. 

The most recent data on the country’s nutritional situation showed that rates of childhood malnutrition are above the emergency threshold of 15 percent in many regions of the southern part. In certain areas, such as Maradi, where we work, one child out of five is suffering from acute malnutrition. And four percent of children under 5 [years of age] suffer from the most severe form of malnutrition. 

Some people describe this as a “famine,” saying that this is a “crisis of previously unheard-of proportions.” Is that true?
 

It would be counter-productive to exaggerate. We should be careful about our choice of language. We don’t have to go to extremes to dramatize the situation in order to emphasize that this is a serious situation, nutritional indicators are alarming, and an appropriate response must be organized. Furthermore, we should also put the current situation in perspective with respect to recent years. Although the crisis of 2010 is certainly more serious, it is not radically different than those the country has experienced in the last few years. Unfortunately, we are witnessing recurrent crises that vary only by intensity from year to year. 

Therefore, the key is not to rank them by severity—which would also be extremely complex—but, rather, to emphasize their periodic occurrence. 

Is there a difference between the crises of 2010 and 2005?
 

Yes, in terms of the breadth and quality of the response. Both have changed dramatically since 2005. At that time, response was slow, both because the regime in power was unwilling to acknowledge the problem and because of the lack of effective warning and response mechanisms. MSF sounded the alarm, calling for deployment of international aid and the adoption of new treatment protocols. 

At that time, we heard a lot of talk about “ready-to-use therapeutic foods.”
 

That was the first time these new products had been used on a large scale, allowing us to treat cases of severe malnutrition on an outpatient basis. Thanks to this strategy, MSF’s sections managed to treat 63,000 malnourished children. It had previously been impossible to treat such a large number of children because of the burden (volume and cost) their hospitalization would have represented. Since that time, Nigerien health authorities have adopted these new strategies for treating severe malnutrition, thus increasing the number of children who can be treated. 

However, Nigerien authorities seem to have been less open concerning nutritional issues after 2005.
 

Yes, there’s a certain paradox. President Tandja chose to deny the seriousness of the situation and the significance of the stakes involved in responding appropriately. In 2008, the French section of MSF was forced to leave the country. 

However, some important changes did occur, including new protocols for treating malnutrition, free medical care for children under five, the adoption of new standards for defining severe malnutrition (recommended by the World Health Organization) and, last, local production of ready-to-use therapeutic foods. 

What measures have been adopted to address the crisis of 2010?
 

The new Nigerien authorities began alerting the international community to the seriousness of the situation in March. They organized sales of cereal at low prices and free food distributions. The response plan should also make it possible to treat more than 300,000 severely malnourished children in the country, which is four times more than in 2005. 

In addition, we should emphasize that widespread preventive measures are also part of this approach, including the distribution of complementary foods intended for infants, who constitute the most vulnerable populations. 

Is the response meeting the needs?
 

What we can say for sure is that the response is ambitious and will certainly make it possible to save many children. The response plan has evolved as the situation has changed. Unfortunately, it did not target immediately the areas most affected by childhood malnutrition but instead, gave priority to areas experiencing agricultural production deficits. Here again, the issue is emergency response, which requires considerable resources to treat children who are already severely malnourished. The malnutrition prevention measures that have been implemented are a good way to begin moving beyond this approach and to respond sooner. 

It will be particularly important to make sure that these measures are maintained after the most difficult period winds up and that they are implemented systematically to prevent the recurrent peaks in severe malnutrition that we see every year, from June to October. 

What role is MSF playing in this context?
 

MSF teams are working in the regions that have been the most seriously affected by the crisis: Tahoua, Maradi, Zinder and Agadez. We have strengthened our treatment programs to face the crisis and are now managing 8 nutritional hospitalization centers and approximately 60 outpatient centers, working in conjunction with the Nigerien Ministry of Health. Since January, we have treated approximately 65,000 children and expect to treat a total of 150,000 this year. 

We are also organizing supplemental food distributions for children from six months up to two years, in the areas where we are working. This should allow us to reduce significantly the number of malnourished children during the second part of the season. We also hope to continue these distributions beyond the crisis period, to get ahead of the “hunger gap” of 2011. 

MSF’s French section has returned to Niger. What does that mean?
 

It signals the common willingness for both Nigerien authorities and MSF to resume our joint efforts to address the pediatric and nutritional problems in that country. To do that, we are working with a Nigerien medical NGO, Forsani. We had decided to support the organization after we left in late 2008. In 2009, more than 12,600 severely malnourished children were treated under the joint program in Madarounfa. 

We hope to develop sustainable treatment and preventive programs by working with these young Nigerien doctors, health authorities and other aid actors.

Dr. Susan Shepherd

By Dr. Susan Shepherd, MSF Medical Advisor, just returned from Niger

In Niger, MSF Works Out Agreement to Add Nutrient-Rich Supplement to Food Aid for Malnourished Children

In terms of nutrition emergencies, 2009 was a relatively calm year for MSF—but still we treated about 250,000 children for acute malnutrition—100,000 children in Niger alone. 2010 is another story entirely. There are reports of increasing numbers of malnourished children from the eastern regions of Southern Sudan to Chad, and across the Sahel to Mali. Once again, the children of Niger appear to be facing a particularly difficult year. The UN agencies operating there estimate that as many as 340,000 children will develop severe malnutrition, and they are anticipating an unimaginable 1.2 million children will suffer from moderate malnutrition.

Treating even 80% of 340,000 severely malnourished children seems out-of-reach. Last year the health system with support from NGOs treated about 125,000 severely malnourished children. But UNICEF assures that it has the necessary medications and therapeutic foods lined up to meet this overwhelming need. As of mid June, the health system has already treated 114,000. Experience tells us that the health system will have to treat more than double this number before the end of October; it will also have thousands of patients – many young children – with malaria in the months of August to November.  Faced with numbers like this, what to do? Nurses, doctors and health workers in Niger already have more than enough to do. Reaching out to young children at risk of severe malnutrition and preventing them from losing weight is essential not only to protecting their health, but also to protecting the integrity of the health system.

The World Food Program (WFP) has launched large scale food distributions that provide grains and pulses (beans) for families, but these foods are lacking in the quality proteins, vitamins and minerals that young, rapidly growing children need. The WFP had planned to distribute a cereal porridge that contains some milk powder, but the supplies were not sufficient. So the back up plan is distribution of 8.3 kg per month of corn-soy blend [CSB] to 500,000 children under two years old for May through July, and an astounding 925,000 under 2’s for August and September. Already there have been distribution delays because CSB must be mixed with oil and sugar; the oil stocks were blocked in transport which meant that the June distribution took place two weeks late. Much of this food comes from far away. About half of the tonnage of CSB will come from the USA.

A young Nigerien eats ready to use therapeutic food at the Intensive Nutritional Rehabilitation Centre (CRENI) supported by MSF in Guidan Roumdi. ©Alessandra Vilas Boas/MSF

CSB is not the right food for young children. The protein quality is poor compared to milk or eggs, the porridge often is diluted in order to make it stretch further (many families report that the ration that was meant to last 1 month is gone in 1 week), and the balance of vitamins and minerals is not tailored to children’s needs. MSF has worked out an agreement with the Government of Niger and WFP to add on a ready-to-use food supplement to the CSB distribution for about 120,000 children in the areas where we have nutrition programs. The WFP is planning to provide ready-to-use food supplements to all 925,000 children, at least for the month of September. One month is better than none, but we need to do better.

Of the organizations distributing food, many are local groups. MSF is partnering with Nigerien organizations for distribution of special foods for children under 2s and for treatment of malnourished children. A small daily amount of about 45 grams of the ready-to-use supplement, or three tablespoons, should substantially improve diet quality for these young children. It provides milk powder, mixed into peanut butter with added vitamins and minerals tailored to the needs of young, rapidly growing children. The idea is that they will be better protected against weight loss and illness.

Although it is pretty widely accepted that young children need special foods, “baby food,” to meet their nutritional requirements, until very recently this concept has not been integrated into international food assistance. A one year old child is given the same food rations, in quantity and quality, as a 50 year old: generally cereals, pulses and some oil. Fortunately, this is starting to change. To help accelerate and expand this change, it is important to carefully document the impact of these improved food distributions on the health and growth of young children. Epicentre, the epidemiologic research center founded by MSF, is working closely with the Ministry of Health to monitor and evaluate how children do and what families think of this new “baby food.”

The children in Niger, and millions of others in similar situations, are at the heart of the Starved for Attention campaign. Let’s work towards convincing others that quality diets for young children make a big difference.

Dr. Susan Shepherd is a pediatrician who has worked full-time for Doctors without Borders/Médecins sans Frontières for the past 4 years. She currently coordinates MSF’s work in nutrition. Dr Shepherd’s interest in childhood malnutrition has grown out of her time in the field; she began volunteering with MSF in 2003 in a pediatric ward in Uganda, then in 2005 worked in a nutrition program in Chad during a measles epidemic. In the aftermath of the 2005 nutritional crisis, she worked in Niger for almost 2 years as a field doctor and then as medical coordinator. She appeared on CBS’ 60 Minutes in October 2007 while in Niger, advocating for MSF’s new approach to treat and prevent malnutrition. In addition to working for MSF, Dr Shepherd has spent time at the Children’s Hospital in Accra, Ghana as a Yale/Johnson & Johnson Physician Scholar in International Health. Dr. Shepherd received her BA in biology from Lawrence University in Wisconsin, and her MD from Université Libre de Bruxelles in Belgium. She completed her residency in pediatrics at the University of Chicago. Prior to joining MSF full-time she worked as a general pediatrician in Butte, Montana.