Community Management of Acute Malnutrition CMAM Guidelines
Maternal and child malnutrition is a significant public health problem in South Sudan. Among children aged 6-59 months, 31% are stunted, 28% are underweight, and nearly 23% are acutely malnourished of which 13% are estimated to suffer from moderate acute malnutrition and 10% from severe acute malnutrition.
In the absence of a single nation-wide nutrition surveillance system, NGO-implemented location specific SMART surveys and the government-UN collaborative Food Security and Nutrition Monitoring System (FSNMS) are currently the two best sources of information. Global acute malnutrition (GAM) rates vary seasonally and substantially across states; with peaks of up to 30 percent in some locations. Overall, South Sudan’s nutrition situation is worrisome, with GAM persistently above the emergency threshold in the Greater Upper Nile, Northern Bahr el Ghazal and Warrap states. Though data on micronutrient deficiencies is scanty, Vitamin A Supplementation (VAS) among children 6-59 months stood at only 2.6% in 2010, showing low uptake (SHHS, 2010). This is against a backdrop of high morbidity levels and a negligible proportion of children 6 to 23 months receiving at least the recommended minimum acceptable diet. In order to ensure optimal child growth, it is essential to ensure good nutrition and basic health care from pregnancy through two years of age (the first 1000 days).
Management of severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) was previously guided through the interim guidelines for Integrated Management of Severe Acute Malnutrition (IM-SAM) (2009), and the Draft Guidelines for Management of MAM (2011), respectively. These guidelines provided a framework for early identification, referral, treatment, and prevention of acute malnutrition. Over the years, there have been various developments and lessons learnt through their use, namely:
• Both guidelines focused mainly on treatment of acute malnutrition in children under-five years of age, and pregnant and lactating women with infants less than 6 months of age. Therefore, there was need to strengthen the component on the management of the increasing number of cases of acute malnutrition in the context of HIV/AIDS, tuberculosis (TB), Kala Azar and other chronic conditions/illness and in older people (≥60years). Further, guidance on nutrition service delivery needed to be extended to address the root causes of malnutrition through prevention and promotion programs such as education and counseling services on optimal maternal, infant and young child nutrition (MIYCN) as well as water, sanitation and hygiene (WASH) practices among others.
• The implementation strategy’s limited integration with the primary health care system, led to limited linkage with other treatment and prevention services at the health facility level, such as the Integrated Management of Newborn and Common Childhood Illnesses (IMNCI), Integrated Community Case Management (iCCM), Expanded Programme on Immunization (EPI), Antenatal Care (ANC)/reproductive health, HIV and TB, among others;
• Existence of the guidelines as two separate documents was contrary to the MOH Policy Framework (2013-2016) direction to implement and ensure a continuum of care where nutrition services are offered holistically. Besides, the four components of CMAM are complementary to each other; hence having them in different documents distorted the continuum of care.
• The separate guidelines required harmonization into one guideline for the integrated management of acute malnutrition within the context of South Sudan, while adhering to the latest World Health Organization (WHO) and other global evidence based recommendations and best practices.
Cognizant of the above, The Ministry of Health (MOH) through the department of nutrition, developed these comprehensive and standardized guidelines for management of acute malnutrition in line with the basic package of health and nutrition services (BPHNS, 2011). These guidelines were developed in collaboration with partners, through a consultative process involving international and national technical experts.
The purpose of these guidelines is to provide a standardized model as an operational reference for integrated management of acute malnutrition across all levels of the health care system, focusing on the following groups:
• Children under five years of age;
• Pregnant and lactating women (PLW) with infants less than six months old;
• Other vulnerable groups including children ≥5 years, adolescents, adults infected with (and exposed to) HIV/TB/Kala Azar and other chronic conditions/illnesses;
• Older people (60years and above).