child malnutrition: nutritional interventions for children...

Patricia L. Murray 6/27/2011

CHILD MALNUTRITION: NUTRITIONAL INTERVENTIONS FOR CHILDREN UNDER FIVE

6/27/2011

MHOP

© 2011, All rights reserved. 1

Child Malnutrition: Nutritional interventions for children under five

Mali Health Organizing Project

Contents Situational Background ................................................................................................................. 2

MHOP Program Background ..................................................................................................... 3 Problem and Purpose ..................................................................................................................... 4 Literature Review .......................................................................................................................... 5

Identifying Children At-Risk: Mid Upper Arm Circumference (MUAC), Weight vs. Length, and Edema .................................................................................................................................. 6

Using MUAC: .......................................................................................................................... 7 Weight and Height Measurements (Weight for age, Height for age, and Weight for Height) ..................................................................................................................................... 7 Edema. ..................................................................................................................................... 8

Discharge Criteria ...................................................................................................................... 9 Targeting Children with Co-Diagnosis of Malaria, Diarrhea, Pneumonia, and HIV/AIDS 10 The Old Standards: Zinc, Vitamin A, Iron, and Breastfeeding ............................................. 11

Zinc. ....................................................................................................................................... 11 Vitamin A. ............................................................................................................................. 12 Iron......................................................................................................................................... 12

Exclusive Breastfeeding and Grandmothers .......................................................................... 13 Ready to Use Food (RTUF): ..................................................................................................... 14 Animal Protein, Animal Husbandry, and Gardening Projects .............................................. 14 Vouchers and Food/Cash Transfers ......................................................................................... 15 Conclusion ................................................................................................................................. 16 List of References ..................................................................................................................... 18

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CHILD MALNUTRITION: NUTRITIONAL INTERVENTIONS FOR CHILDREN UNDER FIVE Mali Health Organizing Project

SITUATIONAL BACKGROUND

The Mali Health Organizing Project (MHOP) had devised an Action for Health program which has been strategically addressing child and maternal health initiatives in Sikoro, Mali. The action for Health program has been actively working to train Community Health Workers (CHWs) to identify and treat children suffering symptoms of malnutrition and prevent childhood mortality and morbidity. The current focus in on the improved health outcomes of children ages 0-2 years (MHOP, 2009).

In 2011, program is serving 800 kids. The total catchment for the clinic is around 6000 kids. Food insecurity is referenced by residents as the prime indicator of poverty (i.e. only one or two meals eaten a day; leftovers from midday meal serving as dinner as well). Many families in Sikoro use rice as their base but millet is also common, particularly as porridge for breakfast. Mothers are familiar with porridge as supplements for young children.

Even for the community members that make more than a dollar a day (approximately 350 cfa per dollar), most people are still challenged to make enough money to provide adequate food resources for their families. Currently, a day laborer in Sikoro makes between 1000 and 1500 cfa per day in the informal sector and a teacher makes between 40,000 and 60,000 cfa per month. Thus, financial stability is clearly one of the main contributors to malnutrition as many families struggle to provide their children with high nutrient foods due to cost.

Beyond finances, there are cultural and environmental factors—children are often served last, cooking multiple meals or special meals for young children is labor intensive and not culturally acceptable. Proper hygiene and sanitation is not always practiced which leads to cycles of diarrhea and malnutrition. Moreover, exclusive breastfeeding and good weaning practices are not always followed. Children are also susceptible to other infectious and

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vector born disease like Malaria and HIV/AIDS, thus putting the child at greater risk for malnutrition and possibly death.

MHOP Program Background

The MHOP’s Community Health Worker (CHW) program is one year old and is currently in the process of reviewing and updating protocols. Currently the Mali Health Organizing Project (MHOP) tracks nutritional status via upper arm band measurements (MUAC) and weight for age measurements taken every two weeks. Referrals to the clinic are made for children falling in the red zone. At the clinic, children whom fall in the red zone are usually prescribed Plumpy’Nut, a high protein packed mixture made of peanut butter, milk powder, sugar, and flour. Plumpy’Nut is almost always out of stock, but when available it is occasionally also given a micronutrient supplement. MHOP current uses the amount spent on foodstuffs per person per day as one of main indicators for selecting program participants; below 200 cfa/person/day has been our initial selection criteria; during surveys we saw variation on daily per person expenditures from 50 cfa to nearly 1000 cfa.

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PROBLEM AND PURPOSE

Children in Mali are at high risk for micronutrient deficiency, child mortality, and morbidity, but meeting these needs in a cost effective manner is often a daunting task for small health organizations. The current program is designed to prevent 91% of child deaths in a place where one in five children dies before his or her fifth birthday, however to do that best practice initiatives need to be targeted, culturally sensitive, and cost effective (MHOP, 2009).

The purpose of this paper is to provide guidance for new protocols which follow current best practice guidelines for early childhood malnutrition. These are the guidelines that we use for determining when treatment/referral should be made. MHOP desires to balance evidence-based practice, considerations specific to Mali and urban areas, our budgetary capacity, and streamlined delivery.

In order to better understand the current issues surrounding child malnutrition, MHOP has devised several nutritional protocol questions:

• What are reasonable goals for the current program? • What types of food supplements are best or most often recommended?

Micronutrient vs. food supplement Particular foods/supplements (effectiveness, simplicity, cost)

• When and how to intervene? Should it be targeted to only a specific age group, weight, or size? How can MHOP build better prevention into monitoring efforts

• Review budget issues: Currently the program usually serves 54 of 400 kids at any one time,

considering budgetary challenges, what makes sense? What should be priority?

• Good projection for length of treatment • Benchmarks for phasing out of treatment and targets for weight gain by week during

treatment • What is adequate progress? For example, 10g/kg/day indicating good progress and

5g/kg/day as moderate progress? • M&E indicators

In the case that clinic does have Plumpy’Nut in stock, what makes senses for us to do in terms of supplementing their prescriptions?

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LITERATURE REVIEW

Malnutrition continues to be a major health burden in developing countries especially when combined with the ever increasing threats of malaria and rise of infectious diseases such as HIV/AIDS, Malaria, Tuberculosis, diarrhea disease, and Pneumonia. Worldwide, it is the most important risk factor for illness and death and is often caused by protein-energy malnutrition, and deficiencies in iron, iodine, vitamin A and zinc.

Questions surrounding how to best tackle this nutrient deficiency has long been debated with many solutions given such as exclusive breast feeding practices, food supplementation schemes, food based strategies including home gardens and livestock, and food fortification.

All of these interventions require health education campaigns, community based health interventions, and community buy-in. It often seems that these solutions become related to the latest trend and hot development buzz words rather than targeted schemes based on best practice and research. However, some interventions have shown proven success overtime and have gained recognition worldwide by development actors as not only being cost effective but effective in preventing childhood death.

Basic Definitions

Malnutrition: “bad nutrition” otherwise known as undernutrition or undernourishment which involves not having enough food with adequate amounts of protein, vitamins, minerals, and calories to support growth and development. Micronutrient malnutrition: deficiencies of essential vitamins and nutrients needed for physical and mental growth. Weight-for Age: Where the height of the child is compared with the weight of a well-nourished child of that age and sex. Malnutrition results in “underweight” status. Height-for-age: Where the height of the child or infant is compared with the height of a well-nourished child of the same age and sex. Malnutrition results in “stunting” status Weight-for Height: comparison used to reveal acute malnutrition or “wasting” severe acute malnutrition or SAM is a weight for height measurement of 70 percent or less. Source: Munoz, 2009

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Identifying Children At-Risk: Mid Upper Arm Circumference (MUAC), Weight vs. Length, and Edema

Screening for malnutrition is often done at health centers, immunization points, and communities out-reach events such as baby weighing clincis, ART sites, and young child clinics (The Mother and Child Health Education Trust, 2011). However, usually screening focuses on acute malnutrition so that children that are at-

risk for severe malnutrition get targeted. However, recent evidence has shown that children that fall within the mild to moderate risk for malnutrition are often just as likely to die if untreated. In fact, according to Levinson and Bassett (2007), in 56% of all child deaths, undernutrition was a contributing factor and 83% of these deaths were associated with mild or moderate rather than severe malnutrition (Levinson & Basset, 2007; Rudan, et al., 2007) Eliminating malnutrition would remove 1/3 of the global burden of the disease and increase child survival.

MUAC is usually used as a quick and simple way to determine if a child is malnourished. It involves using a simple plastic colored strip that is placed on the midpoint between the left elbow and the shoulder. The tape is snug around the arm and the measurement is read from the window of the tape at the nearest 0.1 or 1mm (The Mother and Child Health Education Trust, 2011).

MUAC is recommended for children 6 months to five years of age, but during emergencies MUAC is only recommended for use with children between ages one and five years of age (UN System Archives, 2011). It has been recommended for predicting mortality and in some studies, MUAC predicted death in children better than any other anthropometric indicator. The advantage of

The Mother and Child Health Education Trust, 2011

The Mother and Child Health Education Trust, 2011

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MUAC was found to be the highest when the follow-up period was soon after diagnosis (UN System Archives, 2011).

Using MUAC: WHO standards for mid-upper arm circumference (MUAC)-for-age reveal, in a well-nourished population, there are very few children aged 6–60 months with a MUAC less than 115 mm. Children with a MUAC less than 115 mm have a highly elevated risk of death compared to those who are above. Thus it is recommended to increase the cut-off point from 110 to 115 mm to define SAM with MUAC. (World Health Organization and UNICEF, 2009) Often children are targeted for treatment if they fall within the red zone/the acutely malnourished zone (The Mother and Child Health Education Trust, 2011). MUAC can be used to identify children from the age of 12 months to the age of 59 months, but it can also be used for children over six months with the length above 65 cm (The Mother and Child Health Education Trust, 2011). However, due to the implication that children are still a great risk for child morbidity and mortality in the moderately malnourished zone (orange) these children should also be targeted for follow-up treatment to prevent further decline. Children that fall in the yellow zone are still at risk for malnutrition and should have follow-up by health clinician.

Weight and Height Measurements (Weight for age, Height for age, and Weight for Height) have been standard measures in checking for malnutrition. Children fewer than 5 years, and especially those aged 6 months to 2 years, are at particular risk for low height/length verses weight ratios. In 2004, about 20% (112 million) of children under 5 years were underweight (more than two standard deviations below the WHO Child Growth Standards median weight-for-age) in developing countries (2009). Underweight children suffer more frequent and severe infectious illnesses; furthermore, even mild under nutrition increases a child’s risk of dying. Chronic under nutrition in children aged 24–36 months can also lead to long-term developmental problems; in adolescents and adults it is associated with adverse pregnancy outcomes and reduced ability to work. Around one third of diarrhea, measles, malaria and lower respiratory infections in childhood are attributable to underweight. Of the 2.2 million child deaths attributable to under-weight globally in 2004, almost half, or 1.0 million, occurred in the WHO African Region, and more than 800 000 in the South-East Asia Region (World Health Organization, 2009).

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Baby weighing schemes have been popular throughout Africa and other countries as one way to monitor the health of children, but now many of these measurements have been updated and standardized for the broader public by the WHO. Weight for age has been associated with child development in India, Ethiopia, and Bangladesh and has been used instead of stunting to measure nutrition in young children (Grantham-McGregor, Cheung, Cueto, Glewwe, Richter, & Strupp, 2007). Recently, the WHO has designed the standardized Body Mass Index - BMI - charts for infants to age five. In 2006 they created the Child Growth Standards and Windows of Achievement which described the range and timeline for six key motor development milestones for children, such as sitting, standing and walking. There are more than 30 Child Growth Standard charts in all currently available from the WHO as well as diagnostic software/tools available on their website: http://www.who.int/childgrowth/software/en/ (World Health Organization, 2009).

Using weight-for-height: WHO and UNICEF (2009) recommend the use of a cut-off for weight-for-height of below -3 standard deviations (SD) of the WHO standards to identify infants and children. The reasons for the choice of this cut-off are as follows (World Health Organization & UNICEF, 2009, p. 8):

• Children below this cut-off have a highly elevated risk of death compared to those who are above;

• These children have a higher weight gain • When receiving a therapeutic diet compared to other diets, which results

in faster recovery; • In a well-nourished population there are virtually no children below -3

SD (<1%). • There are no known risks or negative effects associated with therapeutic

feeding of these children applying recommended protocols and appropriate therapeutic foods.

Edema. Another method for checking for severe malnutrition is checking for pitting and nutritional edema (The Mother and Child Health Education Trust, 2011).

http://twodegreesfood.com/2011/the-importance-of-community-healthcare-workers/



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Edema is the retention of water in the tissues of the body is a key sign of kwashiorkor (World Health Organization and UNICEF, 2009). These children are a need to be placed on a list of urgency for high risk of child morbidity and mortality and should be immediately sent for treatment and placed in a therapeutic feeding program (The Mother and Child Health Education Trust, 2011).

Edema is checked by using normal thumb pressure to the tops of feet for about three full seconds. If there is edema an impression remains for some times (at least a few seconds where the fluid has been pressed out of the tissue. The child should only be recorded as having edema if both feet present pitting. It is noted that this type of edema always starts from the feet and moves upward to other body parts (World Health Organization & UNICEF, 2009).

However, it is interesting to note that the WHO has recognized that these measurements have different results, thus does not recognize one method as being more valid than another but suggests the use of a combination of these methods to identify children at risk and to treat them in a timely manner (World Health Organization & UNICEF, 2009).

Discharge Criteria

The WHO (2009) suggested a 15 % weight gain as discharge criterion for all infants and children admitted to therapeutic feeding programs. The use of 15% weight gain as a discharge criterion is a general recommendation and can be adjusted up to 20% weight gain depending on the local situation. However, they devise discharge of children at weight/height -1 SD. For children with edema, the same discharge criterion should be applied using the weight after edema has disappeared as the baseline. However, for children who have a weight/height above -3 SD or a MUAC above 115 mm once they are free from edema, a discharge two weeks after the disappearance of edema is recommended.

The WHO stated that discharge criteria can be modified according to the available services in the community. The better the community services are the less need to keep children for longer stays at the clinic. However they suggested looking at the needs of the community and whether or not the following community resources exist before altering the discharge criteria: access to a high quality diet, supplementary feeding programs, cash transfer,

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microcredit initiatives, support for improved agriculture, the good food security, access to nutrient dense family foods, and manageable number of children treated by the health system.

Targeting Children with Co-Diagnosis of Malaria, Diarrhea, Pneumonia, and HIV/AIDS

When malnutrition is combined with another illness or disease, the risk for morbidity and mortality increased traumatically (Winch, Doumbia, Kante, Male, Swedberg, Gilroy, Ellis, Cisse, & Sidibe, 2008). Moreover, the chance that a child with a severe illness will become malnourished is also high especially in the cases of malaria, diarrhea, pneumonia, and HIV/AIDS (Winch, et al., 2008).

For countries like Mali which have experienced high rates of HIV/AIDS infections, malnutrition appears to increase vulnerability to infection and render antiretroviral medication less effective (Levinson & Bassett, 2007). Since the prevalence of HIV infection has increased in some populations, the some of the reported deaths due to malnutrition could have been due to AIDS. Thus there is a need for continued guidance and adherence to HIV/AIDS best practice guidelines for infants and children with HIV/AIDS (Allen, Bhutta, Caulfield, Onis, Ezzati, Mathers, & Rivera, 2008)

Pneumonia and diarrhea are jointly responsible for nearly 40% of all child deaths globally (Rudan, et. al, 2007) and treatments such as antibiotics, zinc, and oral rehydration solution have been proven both cost effective in preventing and treating both diseases (Rudan, et al., 2007). Illnesses can prolong malnutrition when diseases such as diarrhea keep children from being able to digest the food they eat (Munoz, 2009).

Unfortunately, targeting these illness can be challenging if they are not diagnosed and targeted by communities. Common illnesses such as diarrhea are often treated at home first before at Malian health centers. Often antibiotics are obtained from market venders, and pills can be purchased individually or a few at a time. In one study, only 11% of children received any Oral Rehydration Therapy Solution when they had diarrhea. Diarrhea was also often seen as a result of teething therefore no immediate action was taken to prevent dehydration and further wasting (Winch, et al., 2008)

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The Old Standards: Zinc, Vitamin A, Iron, and Breastfeeding

For the most parts, the standards for treating malnutrition have not changed too drastically overtime. Increasing micronutrients in children’s diets such as zinc, vitamin A, iron, and breastfeeding have all been standard practice. However, with each of the above, there are specific measures and precautions that should be taken in order to ensure success of any micronutrient supplement program including: early initiation during pregnancy; good quality of delivery systems accessible to the target populations; timely supply of low cost supplements; supplements of good quality, stability, and shelf life; and simple but effective monitoring at all levels of the system from supply through compliance (Gillespie & Haddad, 2001).

Zinc. Zinc deficiency largely arises from inadequate intake or absorption from the diet, although diarrhea may contribute (World Health Organization, 2009). It increases the risk of diarrhea, malaria and pneumonia, and is highest in South-East Asia and Africa (9). For children under 5 years, zinc deficiency is estimated to be responsible for 13% of lower respiratory tract infections (mainly pneumonia and influenza), 10% of malaria episodes and 8% of diarrhea episodes worldwide (World Health Organization, 2009).

Zinc is vital for several body functions including protein synthesis, cell growth, and cell differentiation(Haider & Bhutta, 2009). Several research studies have found that zinc supplementation for children with acute to severe diarrhea is highly effective for children older than six months of age. A beneficial effect of zinc is also found in persistent diarrhea which decreased the overall duration of the illness (Haider & Bhutta, 2009). The WHO /UNICEF recommend that zinc be used along with oral rehydration therapy for all childhood diarrhea as well as use preventive zinc supplementation (Allen, et al., 2008)

http://www.basics.org/about_basics/infant_kids_nutrition.htm

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Vitamin A. Vitamin A deficiency raises the risk of mortality in children suffering from diarrheal diseases: 19% of global diarrhea mortality can be attributed to this deficiency (World Health Organization, 2009). It also increases the risk of mortality due to measles, prematurity and neonatal infections. Vitamin A deficiency is responsible for close to 6% of child deaths under age 5 years in Africa and 8% in South-East Asia (World Health Organization, 2009).

A study in Asia found that supplementation of Vitamin A in newborn infants showed reductions in mortality in the first 6 months of life (Allen, et al, 2008).

Iron. However, there is some evidence that iron supplementation can exacerbated malaria among young children therefore the WHO revised their guidelines in malaria endemic areas (Levinson & Bassett, 2007). The main cause for anemia is low consumption of meat, fish, or poultry, especially in developing nations. In children peak prevalence in iron deficiency occurs around 18 months of age, thus marking the significance of complementary foods but also maternal iron supplementation (Allen, et al. 2008).

Table 2: World Health Organization ten step scheme: Elements in the management of severe protein energy malnutrition Problem Management Hypothermia Warm patient up and monitor body temperature Hypoglycemia Monitor blood glucose; provide oral (or intravenous glucose) Dehydration Rehydrate carefully with oral solution containing less sodium and

more potassium than standard mix Micronutrients Provide copper, zinc, vitamin A, and multivitamins Infections Administer antibiotic and anti-malarial therapy even in the absence of

typical symptoms Electrolytes Supply plenty of potassium and magnesium Starter nutrition Keep protein and volume load low Tissue-building nutrition

Furnish a rich diet dense in energy, protein and all essential nutrients that is easy to swallow and digest

Stimulation Prevent permanent psychosocial effects of starvation with psychomotor stimulation

Prevention of relapse

Start early to identify causes of protein energy malnutrition in each case; involve the family and the community in prevention

Source: Miller & Krawinkel, 2005

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Exclusive Breastfeeding and Grandmothers

Breastfeeding reduces the risk of many prenatal infections, acute lower respiratory infections and diarrhea in infants below 23 months. Despite the higher prevalence of breastfeeding found in the developing world, developing countries bear more than 99% of the burden of suboptimal breastfeeding. Suboptimal breastfeeding is responsible for 45% of neonatal infectious deaths, 30% of diarrheal deaths and 18% of acute respiratory deaths in children under 5 years (World Health Organization, 2009). Suboptimal breast feeding has resulted in 1.4 million child deaths (Allen, et al., 2008).

Exclusive breastfeeding has long been a standard for best practice interventions in preventing malnutrition as well as providing the added benefit of natural family planning. It has also found that improved nutritional practices for children should include continued breastfeeding during episodes of infant diarrhea and other illnesses. However, from 6 to 24 months of age, children need food that complements the nutrients they receive through breast milk (Path, 2008).

Maternal undernutrition has little effect on the composition of breast milk unless the mother is severely malnourished. In that case the mother and infant benefit from maternal supplementation of micronutrients including Vitamin A, iodine, thiamin, riboflavin, pyridoxine, and cobalamin. Maternal supplementation with these vitamins increases the amount secreted in breast milk which can improve the infant’s health (Allen, et al., 2008). Moreover, micronutrient deficiencies in nutrients such as Iodine, folic, acid, and B12 have resulted in birth defects, growth stunting, rickets, and other adverse health problems (Allen, et al., 2008).

However, because exclusive breastfeeding has been found to have cultural constraints the promotion of breastfeeding has to be coupled with behavior change communications programs that emphasize the benefits of the practice and help women overcome practical, social, and cultural constraints that limit the adoption of these practices. Therefore health initiatives especially those concerning breastfeeding, need to take in the entire ecological system and family into consideration (Keer, Dakishoni, Shumba, Masachi, & Chirwa, 2007). Studies in both Senegal and Malawi, found that involving maternal and paternal grandmothers in breastfeeding education improved the willingness of mothers to breastfeed exclusively and then add age appropriate

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complimentary foods after six months (Kerr, et al., 2007). The reason being is that when given a choice between listening to a health practitioner and elders in the family, mothers often sided with her elders. Also, if the grandmother or extended family was watching the baby when the mother was out, extended family members would often give complimentary traditional foods/drinks to the baby. Involving the grandmothers (and extended family) in the educational sessions allowed the elder women in the community to voice their concerns about exclusive breastfeeding and encouraged them to be champions for breastfeeding for their granddaughters (Kerr, et al., 2007).

Ready to Use Food (RTUF):

Ready to Use Food includes “foodstuff” such as the popular brand ‘Plumpy’Nut’. Often it is made of milk, sugar, peanut butter, oil, and multi-vitamins. It was original created to be a source of nutritional supplementation during emergencies but has now spread for use as treatment for severe and acute malnutrition. When these products are produces locally, they are an effective and feasible means provide micronutrient fortification to children (Levinson & Bassett, 2007).

Challenges surrounding its use relate to the overall continued supply of the product and stock-outs, as well as the danger of focusing on single sources for protein and nutrients rather than the vast variety of natural nutrients, fiber, and proteins found in grains, fruits, vegetables and animal sources.

Animal Protein, Animal Husbandry, and Gardening Projects

Animal source proteins are important for continued child health as a major source of protein and micronutrients. Low intake of these foods is a risk factor for stunting. Malnutrition is often caused by the result of poverty and the lack of available food. Often, severe malnutrition increased during the hunger season before crops are harvested (Munoz, 2009).

Table 1: A typical recipe for Ready to Use Therapeutic Food Ingredients % weight Full fat milk 30 Sugar 28 Vegetable oil 15 Peanut butter 25 Mineral Vitamin Mix 1.6 Source: http://www.who.int/nutrition/topics/backgroundpapers_Local_production.pdf

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While ready RTUF provides much needed protein and vitamins, it is often lacking in other essential vitamins, fiber, and the variety of nutrients that plants and animals provide (Allen, et al., 2008). A principle limitation of most interventions (except for dietary diversification) is there orientation toward single nutrients rather than plant and animal ingredients, not to mention the fact that diverse diets also help prevent both cancer and cardiovascular disease (Muller & Krawinkel, 2005).

The importance of animal source foods is that they have a high content of micronutrients; high protein content and quality; high energy density and fat content. Animal source foods also do not have anti nutrients which have a negative impact on solubility or digestion (Sari, Pee, Bloem, Sun, Thorne-Lyman, Moench-Pfanner, Akhter, Kraemer, & Semba, 2011). Moreover, research has found that that Animal Source protein and non-grain source foods (i.e. vegetables and fruits), have a positive impact on reducing stunting and malnutrition in children ages 0 to 59 months. (Sari, et al., 2011)

The ultimate goal of these programs should be to empower families with the resources and knowledge needed to prevent malnutrition and raise healthy kids (Munoz, 2009). Projects involving animal husbandry, gardening, and raising high protein legumes for consumption and profit (for example, beans and soy) allow for improved food security and access to healthy food. These methods allow communities the opportunity to create sustainable outcomes for their children and take back the control over their own health. Increasing dietary diversification through a wide variety of food, preferably from permaculture gardens and small livestock production is an effective long-term control method (Muller & Krawinkel, 2005).

Vouchers and Food/Cash Transfers

There are several programs currently being promoted to help boost the purchase of more nutrient dense foods in developing countries. Each program has some advantages and disadvantages which have to be weighed against the ultimate return of investment. However, when these efforts are gender focused and provide educational assistance they can have a powerful impact on changing nutritional behaviors (Levinson & Bassett, 2007).

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The advantage of a voucher system is that it can harness normal market mechanisms with sales at subsided/low profit commercial prices to lower middle class consumers. Eligibility for vouchers can be linked to participation in other programs for the most vulnerable such as a receipt of food assessment. It can be conditional based upon the use of specific services or based on the vulnerability criteria such as age (Pee, Brinkman, Webb, Godfrey, Darnton-Hill, Alderman, Semba, Piwoz, & Bloem, 2011)

Cash transfer programs are often used to augment household food consumption expenditures and food diversity. However, its impact on malnutrition is limited because households tend to use some of the extra money on health care education, and other investments (Pee, et al., 2011).

Conclusion

Unfortunately, when it comes to treating malnutrition there is no one size fits all solution. Rather the effort has to be a multifaceted approach which takes note of the many different micronutrient causes and deficiency and then tackles the problem in a comprehensive manner. By using a range of diagnostic tools, treatment, and prevention methods children are likely to come out healthier and with stronger health outcomes. The key remains being proactive with interventions and target kids before nutritional deficits reach severe levels so that challenges can be addressed before the onset of permanent health risks take place.

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Table 3: Key Messages The combinations of MUAC, Height for Weight and Length for age and edema health checks are recommended for early identification of children with symptoms undernutrition and malnutrition. Children with other symptoms, diseases, or illnesses need to be marked as priority and urgent care cases due to the risks associated with the combination of malnutrition and other diseases such as HIV/AIDS, Malaria, Diarrhea, and pneumonia. Treatment and prevention of these illnesses needs to be provided in conjunction with treatment for malnutrition. Vitamin A and Zinc Deficiencies have by far the largest remaining disease burden among the micronutrients considered and should be considered targeted and strategic intervention points Exclusive breastfeeding for the first 6 months and complementary breastfeeding remains a priority best practice, but it needs to be combined with behavior change communication activities in order for effective community uptake. Fortified Ready to Eat Foods is the first line of defense in treating malnutrition but is not a sustainable source of micronutrients and protein. Although important for treatment of severe malnutrition and for use in emergencies, the next step in treatment and prevention is to increase the intake of fruits, vegetables, and animal source proteins and increase overall community food stability. Poverty is closely tied with malnutrition; therefore other considerations besides nutritional projects must be taken into consideration when treating the disease such as microfinance projects, cash and food transfers, and community health insurance to allow for the purchase of healthier foods and the coverage of medical costs at the health centers.

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List of References

Ager, A., Stark, L., Akesson, B., & Boothby, N., (2010). Defining best practice in care and protection of children in crisis-affected settings: A Delphi study. Child Development, 81 (4), 1271-1286

Allen, L. H. (2003). Interventions for micronutrient deficiency control in developing countries: past, present and future. American Society for Nutritional Sciences, 133, 3825-3828.

Black, R. E., Allen, L. H., Bhutto, A. Z. , Caulfield, L. E., Onis, M, Ezzati, M., Mathers, C., Rivera, J., (2008). Maternal and child undernutrition: Global and regional exposures and health consequences. The Lancet, 1, 5-22

Gillespie, S & Haddad, L. (2001). Attacking the double burden of malnutrition in Asia and the Pacific. Manila, Philippians: Asian Development Bank.

Grantham-McGregor, S., Cheung, Y. B., Cueto, S., Glewwe, P, Richeter, L, & Strupp, B. (2007). Developmental potential in the first five years for children in developing countries. Lancet, 369 (9555), 60-70.

Haider, B. A. & Bhutta, Z. A. (2009). The effect of therapeutic zinc supplementation among young children with selected infections: A review of the evidence. Food and Nutrition Bulletin, 30 (1), 41-55.

Levinson, F. J. & Bassett, L. (2007). Malnutrition is still a major contributor to child deaths: But cost-effective interventions can reduce global impacts. Washington D.C.: Population and Reference Bureau, 1-7

Kerr, R. B., Dakishoni, L., Shumba, L., Masachi, R., & Chirwa , M. (2007). We grandmothers know plenty: Breastfeeding, complementary feeding, and the multifaceted role of grandmothers in Malawi. Social Science and Medicine, 66, 1095-1105

Mali Health Organizing Project (2009). Manuel De Formation Agent De Sante Communitaire, Association Setigiya Sabatili/Mali Health Organizing Project, 1-58

Mother and Child Information and Education Trust (2011). Mother and child nutrition. Retrieved on June 5, 2011 from http://motherchildnutrition.org/early-malnutrition-detection/detection-referral-children-with-acute-malnutrition/screening-for-acute-malnutrition.html

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Muller, O., & Krawinkel, M. (2005). Malnutrition and health in developing countries. CMAJ, 173 (3), 279-286.

Munoz, E., (2009). New hope for malnourished mothers and children. Bread of the world Institute, 7, 2-11.

Path (2008). Improving nutrition for infants and young children. Directions in Global Health, 2-3.

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Sari, M., Pee, S., Bloem, M. W., Sun, K., Thorne-Lyman, A., Moench-Pfanner, R., Akhter, N., Kraemer, K., & Semba, R. D., (2011). Higher Household Expenditure on Animal-Source and Nongrain Foods Lowers the Risk of Stunting among Children 0–59 Months Old in Indonesia: Implications of Rising Food Prices. The Journal of Nutrition. Retrieved on June 27, 2011 from www.jnofnutrtion.org

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