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Preventing and treating childhood malnutrition 

Preventing and treating childhood malnutrition
Preventing and treating childhood malnutrition

Ted Lankester

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date: 17 June 2021

What we need to know

Why adequate nutrition is important

In 2016, UNICEF issued a statement that ‘nearly half of all deaths in children under 5 are attributable to undernutrition. This translates into the unnecessary loss of about 3 million young lives a year’.1 Malnutrition weakens children’s immunity, making it much more likely they will die from diseases in childhood. The three infections that cause most deaths are pneumonia, diarrhoea, and malaria (Chapter 16). Measles is still common in many parts of the world and is much more dangerous in malnourished children. Malnourished children are more likely to catch infections, more likely to become severely ill, and take longer to recover Figure 14.1).

Figure 14.1 In low-income countries, five out of ten children can have their lives saved by good nutrition, and a further three by actions at community level.

Figure 14.1 In low-income countries, five out of ten children can have their lives saved by good nutrition, and a further three by actions at community level.

Reproduced courtesy of David Gifford. This image is distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 International licence (CC-BY-NC), a copy of which is available at

Childhood malnutrition diminishes adult quality of life

Poor nutrition in the womb and during early childhood, especially the first 1000 days of a child’s life, leads to stunting. This has serious long-term consequences. Children who are stunted grow up to be shorter and weaker than those who are well fed in childhood. The World Bank estimates that nearly a quarter (159 million) of the world’s children under five are stunted,2 over a third of whom are in India.3 WHO’s Global Nutrition Report gives more details.4

Stunted children tend to do less well in school. They are likely to become less productive farmers and earn lower wages.

Malnourished children often have impaired mental development. This means they do not reach their full intellectual potential as adults, are less likely to get good jobs and so are less able to provide for their children.5

Thus, reducing malnutrition in this generation of children will contribute directly to greater health and wellbeing in the next. Of course malnutrition can affect people of all ages. Chapter 28 has some details on this.

Different forms of malnutrition

Severe acute malnutrition (SAM)

This form of malnutrition is commonly associated with severe food insecurity during famine, civil conflict, failure of rain or crops, or other natural or man-made catastrophes. However, it can also occur in more stable circumstances, especially in cases of HIV6 and disability.7 Children with mild or moderate malnutrition may also become severely malnourished for various reasons, including infections, intestinal parasites, and poor absorption of food from other causes.

SAM is defined as infants and children who are 6–59 months of age and have a mid-upper arm circumference (MUAC) less than 115 mm, and/or a weight-for-height/length less than -3 Z-scores of the WHO Child Growth Standards median, and/or have bilateral pitting oedema.

For an explanation of Z scores see the section ‘Measure malnutrition’. SAM is a life-threatening condition. Without effective treatment, case-fatality rates in hospitalized children range from 30% to 50%.8

Severe wasting or marasmus means extreme thinness, which is most visible over the shoulders, ribs, upper arms, buttocks, and thighs. The skin on the buttocks may look like ‘baggy pants’ (Figure 14.2).

Figure 14.2 (a) Marasmus and (b) kwashiorkor (oedematous malnutrition) and (c) child obesity are three forms of dangerous malnutrition

Figure 14.2 (a) Marasmus and (b) kwashiorkor (oedematous malnutrition) and (c) child obesity are three forms of dangerous malnutrition

Reproduced from This image is distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 International licence (CC-BY-NC), a copy of which is available at

Malnutrition with oedema, or Kwashiorkor, usually occurs first in the lower legs and feet. To test for oedema, grasp each foot with thumb on top and press gently for ten seconds. The child has oedema if a dent remains after removing the thumb.

(a) Marasmus and (b) kwashiorkor (oedematous malnutrition) are two forms of SAM and can overlap and be present in the same child.

It is not fully understood why some children tend to develop one form of malnutrition rather than the other.

SAM in practice nearly always results from a combined lack of energy foods, protein, and micronutrients, especially Vitamin A and zinc.

Moderate malnutrition

Moderate malnutrition is far more widespread and less easy to recognize than severe malnutrition. It is defined as an MUAC ≥ 115mm to < 125mm and/or weight-for-age between -3 and -2 Z-scores below the median of the WHO child growth standards.

It can take the form of wasting (low weight for height—indicating acute malnutrition) or stunting (low height for age—indicating chronic or recurring malnutrition), or a combination of both.

Faltering growth is an early sign of malnutrition, and unless urgent action is taken, the child may become severely malnourished very quickly. This underlines the importance of regular weighing (or MUAC in children over 6 months) so malnutrition can be picked up early. Most cases of mild or moderate malnutrition are not obvious to the mother or even to the health worker. This ‘hidden’ group of malnourished children has higher than average health risks.

Childhood obesity

The World Health Organization (WHO) declared that:

Childhood obesity is one of the most serious public health challenges of the 21st century. The problem is global and is steadily affecting many low- and middle-income countries, particularly in urban settings. The prevalence has increased at an alarming rate. Globally, in 2015 the number of overweight children under the age of five, is estimated to be over 42 million. Almost half of all overweight children under 5 lived in Asia and one quarter lived in Africa.9

Obesity usually continues into adulthood and greatly increases the risk of Type 2 diabetes, hypertension, heart attacks, and stroke (Chapter 22) and also (See Figure 14.2).

Anaemia or iron deficiency

This is nearly always present in undernourished children, and often also in apparently well-nourished children. Anaemia is defined as less than 11 g/dl, unless severe anaemia as below 8 g/dl.

There are few obvious signs of anaemia. Pallor is not an accurate way to identify it. However, anaemic children will often be tired, catch infections easily, and perform poorly at school. Anaemia is usually caused by insufficient iron in the diet, but especially in Africa, malaria, schistosomiasis (bilharzia), hookworm (also In South Asia), and whipworm can make it worse. Infections can reduce iron absorption. Iron-rich foods include meat, eggs, lentils, and green leafy vegetables.

Vitamin A deficiency or blinding malnutrition

An estimated 250 million preschool children worldwide are vitamin A deficient. Pregnant women are also affected, especially in the last trimester of pregnancy. It is the commonest cause of blindness in children. An estimated 250,000 to 500,000 vitamin A-deficient children become blind every year, half of them dying within twelve months of losing their sight.10

Vitamin A deficiency, even if not low enough to cause eye problems, lowers immunity, and increases the danger from diarrhoea, respiratory infections, measles, and probably malaria, meaning that Vitamin A supplementation reduces mortality rates. Many infections such as measles further reduce Vitamin A levels. Eating green vegetables and yellow fruit helps but oils are also needed in the diet to help absorption.

Zinc deficiency

Zinc deficiency is often associated with Vitamin A deficiency and lowers resistance to diarrhoeal diseases and acute respiratory infections. In addition to its effect on the immune system zinc deficiency harms the intestinal tract leading to greater volumes of stool and to malabsorption. This is why zinc is now included in ORS (Figure 14.3).

Figure 14.3 Some causes of malnutrition from a community workshop in Bangladesh.

Figure 14.3 Some causes of malnutrition from a community workshop in Bangladesh.

Reproduced courtesy of Professor Andrew Tomkins. This image is distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 International licence (CC-BY-NC), a copy of which is available at

Iodine deficiency

Iodine deficiency is still the commonest cause of mental impairment worldwide, and continues to affect people in 54 countries.11 People in mountainous areas are especially likely to develop symptoms. Low-lying flood-prone areas, such as Bangladesh, are also affected, as iodine is washed out of the soil. The use of iodized salt is gradually reducing the number of people affected, though some areas still have a significant problem.

For example, in Nepal, where salt is still transported by yak to very remote areas, about one quarter of Nepali school children have actual or borderline iodine deficiency despite the widespread use of iodized salt.12 One reason is that salt is not properly iodized by the companies despite legislation. There are simple testing kits that can be used at community level, and indeed some child health programmes have tested salt in the markets for their iodine level.

Goitre (a swollen thyroid gland) is the most obvious sign of iodine deficiency and is most commonly seen in women. The most dangerous effect, sometimes known as cretinism, is found in children born to iodine-deficient mothers. These children will typically be deaf, dumb, slow, have a ‘puffy’ appearance, and a tendency to constipation. Importantly, iodine-deficient babies may show very few signs, yet grow up suffering cognitive impairment.

Other deficiency diseases

These include:

  • Lack of vitamin B leading to pellagra and beriberi.

  • Lack of vitamin C leading to scurvy, commonly found in refugee camps and among displaced people.

  • Lack of vitamin D or calcium leading to rickets—found mainly in women and girls where custom forbids exposing their skin to sunlight. This can lead to a malformed pelvis and extra dangers in giving birth.

Mild degrees of insufficient vitamin D levels are very widespread, even in resource-rich countries and may increase the likelihood of fractures and hip pain, especially in the elderly.

The root causes of malnutrition

It is helpful to understand the wider causes, or ‘social determinants’ of malnutrition because sometimes we can address these ‘upstream’ causes. Look at the causes below to see if they are locally important and if there are solutions within reach (See Figure 14.3).

  1. 1. Famine, war, and disasters lead to food insecurity where food supply is unreliable or unaffordable.

  2. 2. Poverty and illness—where people are unable to grow or buy sufficient food; lack adequate water supplies and sanitation; live in overcrowded conditions; and are unable to afford health care.

  3. 3. Lack of relevant knowledge—where food is available but diet and feeding practices are inadequate.

The starting point in understanding the levels and causes of malnutrition will usually be information found in our Participatory Appraisal or community survey. If our programme focuses on malnutrition because of current food insecurity, we will need to do this by gathering information in greater detail from the community or from other information sources for our region.

We will now look at some causes of malnutrition in different groupings.

Causes of malnutrition in the child

  • Low birth weight.

  • Exposure to parasitic infections, e.g. hookworm, roundworm, whipworm, Giardia.

  • Measles and failure to vaccinate against it.

  • Bottle feeding with infant formula, which is less nutritious, may be over-diluted and often causes diarrhoea.

  • Inadequate complementary feeding after six months.

  • Feeding practices such as giving watery gruels, giving too few meals, no encouragement or assistance at meal times.

  • Frequent drinking of dirty water with damage to the intestine, leading to poor absorption (enteropathy) and stunting, even without diarrhoea.

  • Exposure to frequent infections such as diarrhoea, coughs and malaria leading to poor appetite, loss of weight and decreased resistance to further infection (see Figure 14.4).

  • AIDS contracted from the mother, or other infections, including TB, heart disease, kidney disease.

  • Disability, which is a growing issue as neonatal care improves and survival increases and as more children survive diseases such as meningitis and cerebral malaria.

  • Being a ‘fussy eater’ can add to the above problems.

Figure 14.4 The circle of infection and malnutrition in an urban slum.

Figure 14.4 The circle of infection and malnutrition in an urban slum.

Reproduced courtesy of the Accredited Social Health Activist (ASHA) Programme, Delhi. Copyright © 2013 - NHM, Government of India. All rights reserved. This image is distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 International licence (CC-BY-NC), a copy of which is available at

Causes of malnutrition in the mother

  • Mother herself tired, ill, depressed, or malnourished.

  • Mother unable to establish adequate breastfeeding routine.

  • Overwork in home, the daily need to collect fuel and water, and demands of other children.

  • Work outside the home to supplement family income.

  • Mother illiterate and uneducated, so follows incorrect practices, such as withholding food from an ill child and fluids in diarrhoea.

  • Mother divorced, separated, widowed, or otherwise unsupported.

  • Mother married as minor rather than adult.

  • Adolescent pregnancy contributing to low birthweight children and subsequent malnutrition.

Causes of malnutrition in the family

  • Shortage of food due to poverty.

  • Husband or partner chronically unwell, uncaring, absent, drunk, addicted, unemployed, overworked, violent.

  • Too many children to feed and care for, no access to or use of family planning, no child spacing, multiple pregnancies

  • Disagreement between family members on how to feed the child.

  • Tensions with mother-in-law and other family members.

  • Cash crops replacing food crops, meaning less food for children. Extra money spent on cigarettes, tonics and soft drinks rather than better food.

  • Daughters not wanted.

  • One or both parents living with untreated HIV/AIDS.

Causes of malnutrition in the community

  • Insufficient land or employment.

  • Poor farming practices, soil erosion and deforestation, no irrigation, unproductive land, no land at all.

  • Remote area with poor transport and little access to markets.

  • Poor water supply and sanitation leading to diarrhoeal illnesses.

  • Inappropriate advice from some traditional practitioners recommending ‘holy food’ or ‘holy water’, which may be contaminated

  • Debt, bonded labour; threats from landlords and moneylenders.

  • Money overspent on weddings, religious ceremonies, and dowries.

  • Tribal, class, and religious conflicts.

Causes of malnutrition in the country

  • War, civil unrest, famine, seasonal floods or hurricanes, drought.

  • Effects of climate change giving unpredictable weather.

  • Depressed economy, national debt, lack of foreign exchange.

  • Education and health not government priorities.

  • Previous food aid leading now to attitude of dependence. Depressed prices for locally grown food and commodities and so no incentive to grow. Seed grain used up.

  • Corrupt, inefficient, or extreme political system causing the poor to suffer the most.

  • Unjust trading laws that favour wealthy countries.

  • Structural adjustment programmes.

  • High levels of HIV/AIDS or lack of access to antiretroviral therapy (ART), leading to premature death and illness, in turn affecting the local and national economy.

The common ages for malnutrition

The key period for malnutrition is the first 1,000 days of a child’s life, from conception to two years. This includes in-utero malnutrition, classically seen in war zones and sieges, but also with any significant reduction in maternal intake.13 More specific at-risk periods partly depend on local customs, the season of the year, and the types of food available in the community. The greatest risks usually occur at specific times.

  1. 1. In the first month of life in poorer communities, the child will often have a low birth weight.

More than two-fifths of all deaths in children under five occur in the first month.14 Low birth weight often contributes to this. It has been shown that intermittent preventative treatment of malaria in pregnancy where malaria is common can improve the birth weight of neonates.15

  1. 2. Between the ages of six and 24 months.

In many communities, complementary feeding occurs either too early, too late, or is insufficient, which can have a major impact on nutrition. Ideally, children should be fed on breast milk alone for the first six months, except in special situations such as when the mother is HIV positive (see Chapter 20). Breastfeeding should then be continued until at least two years of age. Furthermore, breastfeeding is often stopped early, which may happen either gradually, or suddenly if the mother becomes pregnant, develops an illness, or has to start working or travelling to work—a common situation in urban areas.

  • Inadequate amounts of food may be given, and contribute to the problem, and foods may be contaminated with germs, leading to diarrhoea.

  • Infants may get infections by placing objects in their mouths and through dirty feeding bottles, or from infant formula that may itself be made with untreated water.

  • Toxins in food can also contribute to malnutrition.

For example, in parts of West Africa aflatoxins from stored peanuts infected with a fungus can affect health and nutrition. However, this is probably overstated and peanuts remain an excellent source of food, providing they are well prepared and well stored, as is necessary with all foods.

  1. 3. Whenever a new child is born.

After the birth of a new baby, the mother will then give her time, attention, and breast milk to the newborn. The result is that the next-to-youngest child receives less of each. This effect is most important when the birth interval is less than three years.

  1. 4. Any time of family crisis.

What we need to do

Measuring malnutrition

There are a variety of useful ways to measure malnutrition, and the most important ones are listed here.

  1. 1. In community health programmes, the weight for age chart (growth chart) is most commonly used. The WHO has recently revised its growth charts, which set an overall universal standard of how infants and children should grow, using a choice of percentiles or Z-scores. Z-scores (also known as standard deviation scores) are a measure of the distance between the child’s value and the expected value of the reference population. Many national health ministries have used WHO data to develop their own country-specific growth charts.

  2. 2. In situations where SAM frequently occurs, it is also important to measure Mid Upper Arm Circumference (MUAC)—this can be done by community health workers (CHWs) and even by mothers and carers themselves.

  3. 3. Finally, in adults and older children, the weight to height ratio (weight divided by square of the height) is used to calculate the Body Mass Index (BMI) which is currently defined as between 18.5 and 24.9. This is the commonly used measure in adolescents and adults and increasingly in younger age groups also.

A warning: Measuring malnutrition does not improve matters by itself. Some programmes spend a lot of time measuring without doing health teaching or involving parents and carers. But if time is limited and problems are severe, we should concentrate on educating and training mothers about nutrition, rather than on measuring the problem. There are two methods of measuring malnutrition: weighing scales and MUAC (Figure 14.5).

Figure 14.5 Measuring mid-upper-arm circumference (MUAC).

Figure 14.5 Measuring mid-upper-arm circumference (MUAC).

Since this classic image was first drawn newer evidence suggests that MUAC measurements can be started from 6 months (see note in text).Reproduced with permission from Morley D. (1973). Paediatric Priorities in Developing Countries. Cambridge, UK: Butterworths. Copyright © 1973 TALC. This image is distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 International licence (CC-BY-NC), a copy of which is available at

Weighing scales

The advantages of scales, if used carefully, is that weighing shows us accurately the degree of individual and community-wide malnutrition. Disadvantages include that scales are expensive, may be difficult to obtain, and many brands are heavy to carry and break easily if dropped. Unless everyone is trained how to use them, mistakes can easily be made, especially in completing the growth chart.

How often should weighing be done?

Usually once per month in healthy children under three years of age. It should usually be done weekly in community-based management of acute malnutrition (CMAM) programmes.

Where should it be done?

Weighing should be done in health centres, clinics, or feeding centres. It can also be done by mothers in small community-based groups (see Figure 14.6), or in homes, but if time is limited, home visits should concentrate on education rather than weighing.

Figure 14.6 Community weighing session in Zimbabwe.

Figure 14.6 Community weighing session in Zimbabwe.

Reproduced with permission from World Health Organization. Copyright © 2012 WHO. This image is distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 International licence (CC-BY-NC), a copy of which is available at

Who should do the weighing?

At first, probably a nurse, other health worker, or CHW will teach the procedure. Then, weighing can be done by the mother, father, or older sibling. Also, members of women’s clubs or health committees can weigh children either from house to house or as a community activity, giving feeding advice at the same time. All those involved in weighing will need careful teaching and supervision until they can do it quickly and accurately, leaving time for identifying problems and explaining better ways of feeding.

Safeguarding is an important concern in any community activity which involves children or vulnerable adults.

How to weigh very young children

  1. 1. The child sits on the parent’s or guardian’s lap and a pair of specially designed strapped trousers (pants) which fit reasonably well are fitted onto the child.

  2. 2. The parent lifts the child by the body, not by the straps, and hangs the child on the weighing scales.

  3. 3. The child hangs just long enough for an accurate weight to be measured, and is then lifted down.

  4. 4. The weight is plotted on the growth chart.

  5. 5. The card is explained to the parent. Feeding advice is given where necessary.

Arm measurers

Measuring the mid-upper arm circumference (MUAC) is increasingly taking over from the use of weighing scales. This is for two main reasons. It is accurate and reliable. It is also quicker, easier to use, and cheaper than weighing scales. See Figure 14.5 with the comment below it.

In children, the MUAC hardly changes between the ages of 6 months and 60 months (previously thought to be between 12 months and 60 months) WHO standards for MUAC show that in a well-nourished population there are very few children aged 6–60 months with an MUAC less than 115 mm. Children with an MUAC less than 115 mm have a highly elevated risk of death compared to those who are above that level. Thus, it is recommended to increase the cut-off point from the previous 110, to 115 mm to diagnose SAM using the MUAC.16

Revised measurements are therefore as follows:

  • Well-nourished child: MUAC from 125mm

  • Acutely malnourished child:

    • moderate: MUAC 115-125mm

    • severe: MUAC 115 mm or less.

UNICEF has now incorporated these into colour-coded tapes: severe, red: moderate, yellow, well-nourished, green.

Locally appropriate colours can be used instead.

Tapes can either be bought, e.g. from UNICEF, or made, e.g. from strips of X-ray film.

Using the MUAC

When using the MUAC, the child should be sitting or standing with the arm hanging unsupported from the shoulder. Wrap the tape firmly but not too tightly around the left mid-upper arm, i.e. half way between the tip of the shoulder and the tip of the elbow. The CHW, mother, or older siblings can make this measurement, but will need supervised practice, and training to interpret measurements and act.

Advantages and disadvantages of MUAC measuring

The MUAC strip is cheap and easy to carry, and it is quicker and easier than scales, allowing more time for health education. It is ideal to use in homes, scattered communities, and refugee camps. It can be used by those who are unable to read, write, or understand numbers.

Disadvantages include that it does not measure stunting, and mistakes can be made if the person measuring is in a hurry or if the child is fretful (NB: this is also true for weighing).

Further use of the MUAC

MUAC measurements can also be used at birth to give an indication of whether the newborn has a low birth weight.

An MUAC of 8.7 cm at the time of birth is approximately equivalent to a birth weight of 2500 grams, although this level has not yet been finally agreed. If a tape is marked at 8.7 cm, any measurement below this gives a probable indication of low birth weight (Figure 14.7).

Figure 14.7 Mid-upper arm circumference (MUAC) measuring card.

Figure 14.7 Mid-upper arm circumference (MUAC) measuring card.

Reproduced courtesy of Professor Andrew Tomkins. This image is distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 International licence (CC-BY-NC), a copy of which is available at

Measuring the MUAC enables illiterate CHWs (or traditional birth attendants) to discover low weight children at the time of birth and target care towards them. There is even discussion about using a variant of this in schoolage children instead of BMI but no conclusions yet.

Recording malnutrition on growth charts

Having weighed a child or measured MUAC, we need to record it on the child’s record, retained by the family. For recording weight, we should ideally use the Growth Chart used in the country or region where we are working, and we should teach all team members and CHWs (where literate) how to use them. Many growth charts are completed incorrectly. Health workers should not start training others until they no longer make mistakes themselves.

When using a growth chart (see Figure 14.8):

  • Fill in the month and year of birth.

  • Fill in the month and year or highlight this each time the child is weighed.

  • Put a dot (and a ring), or a (x) for the measurement, checking and rechecking that it is in the right place, and linking it up with previous measurements using a pencil.

Figure 14.8 Growth chart for two children born in the same month in the same village. From an example of one of the original growth charts developed in Nigeria by the late Professor David Morley.

Figure 14.8 Growth chart for two children born in the same month in the same village. From an example of one of the original growth charts developed in Nigeria by the late Professor David Morley.

Reproduced with permission from Morley, D. (1973). Paediatric Priorities in Developing Countries. Cambridge, UK: Butterworths. Copyright © 1973 TALC. This image is distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 International licence (CC-BY-NC), a copy of which is available at

Learn to interpret the findings, and explain these to the parents, family members and other carers.

The direction of the growth curve is the most crucial.

  • If it is rising—good. Reinforce teaching.

  • If it is flat—this is a warning. Find the cause, act, and give suitable teaching to the parents. If the line is flat for two months or more, this is known as growth faltering. Recognizing this and acting is one main reason why we monitor weights.

  • If it is falling—there is a serious problem. We must discover and treat the problem as soon as possible.

The actual weight itself is also important. However, if a child is stunted, in other words periods of malnutrition in the past have reduced child’s growth in height, then this will be shown by persistently lower actual weights on the chart. The most common causes of poor weight gain are that child is not getting enough food or that the child has an infection.

Remember the purpose of the chart: it is an early warning system. The growth chart tells us if things are going wrong before we (or the mother) would otherwise notice them. This means we can find and treat the cause at an early stage, which reduces the danger of related health problems in the future. It also helps us to evaluate whether parents have understood and successfully followed the nutrition guidance we have given.

Ensure the mother keeps the card. She should bring it whenever she visits the CHW, the clinic or the hospital. Other points to note:

  1. 1. The card can help us to correct any common mistakes: for example, mother forgets the date of birth—often has forgotten the month, sometimes the year, of the birth, or she may never have known it.

We can help by purchasing or making a local events calendar. This has festivals, seasons, etc., marked on it, which serve as a reminder. Using this, we can take time to work out the date with the mother. Always consider if the child appears and behaves the age the mother says.

  1. 2. The health worker may also get confused, and need plenty of supervised practice. A ruler or straight edge helps in plotting the correct weight.

  2. 3. The mother may not understand the chart.

It can seem complicated and she may think that it belongs to the health worker. Include the mother and, where possible, other family members or carers at every stage in weighing and recording, taking time to explain how the card works and how it shows the progress of the baby. She will soon start taking a pride not only in the card, but also in the weight gain of the child.

Most mothers, even those who are illiterate, will be able to understand a growth chart. At the very least, they will see whether the line is rising, flat, or falling. Many mothers or other family members will be able to weigh children themselves. However, if a mother is slow to understand the chart, spend time in health education instead.

  1. 4. The mother may forget the card or spoil it. Try to provide a protective envelope for any self-retained card.

  2. 5. The health worker must never show anger or be irritable when weighing as a mother may get discouraged and stop coming to the clinic. Teach the team to be patient and to make sure that weighing is enjoyable, and always praise the mother for something done well.

Understand parents’ response to advice

A mother, father or older family member will only improve feeding practices if they follow this ‘chain of action’.

  • Understanding that the child is malnourished. How? By our patient explanation, ideally with a growth chart, and, where possible, also to other family members.

  • Being able to do something about it. How? Foods we recommend must be locally available and affordable. The family must give time to feeding and be prepared to alter some of their practices. Older siblings may be able to help.

  • Having knowledge and skills to prepare and store food correctly, feed it appropriately and give it in sufficient amount. How? Our teaching must be based on insight into community lifestyle, foods available and how families function. Home visits fine-tune our advice and are a chance to answer questions.

We must always ensure we listen to the mother or family caregiver and respond to any concerns. We need to discuss action plans with her and make sure she understands, agrees and is able to carry them out.

Prevent and cure malnutrition

There is a well-known health programme in north India where many children attend local clinics and parents hear health talks. Yet studies here have shown that children who attend these clinics continue to have levels of malnutrition little different from those who do not attend. The health teaching does not lead to behavioural change (see Chapter 4). In contrast, in a small Himalayan health programme (SHARE) 32 per cent of children aged one to five were found to be severely or moderately malnourished when the programme started (Table 14.1). After CHWs were trained to give nutritional advice by visiting house to house, using foods grown by each family, only two severely malnourished children remained two years later. From these examples we learn that giving health talks in clinics is unlikely to be effective in itself. Where food supplies are adequate, one key method of curing and preventing malnutrition is to train CHWs to make regular visits to each home. In that environment they are able give practical advice according to the exact needs of the family, and ensure that any advice is put into practice. This is explained in some detail in Figures 14.9 and 14.10.

Table 14.1 Children from ages 1 to 5 with MUAC of or less

Village name

April 1985

January 1988











U. Sarab





L. Sarab





U. Kandi





L. Kandi










Reproduced courtesy of Ted Lankester, SHARE Project, North India. This table is not covered by the Creative Common licence terms of this publication. For permission to reuse please contact the rights holder.

Figure 14.9 Nutrition enabling and nutrition resourcing.

Figure 14.9 Nutrition enabling and nutrition resourcing.

Reproduced courtesy of Professor Andrew Tomkins. This image is distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 International licence (CC-BY-NC), a copy of which is available at

Figure 14.10 Nutrition enabling and nutrition resourcing.

Figure 14.10 Nutrition enabling and nutrition resourcing.

Reproduced courtesy of Professor Andrew Tomkins. This image is distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 International licence (CC-BY-NC), a copy of which is available at

The six rules of good nutrition

Rule 1. Ensure pregnant mothers have adequate nutrition

The baby’s weight at birth and during the first few weeks of life depends mainly on the health and nutritional state of the mother.

In order to achieve adequate nutrition for the child at the time of birth:

  1. 1. Encourage adequate weight gain in pregnancy.

Mothers should ideally gain about five to eight kilograms during pregnancy. This depends on:

  • Eating sufficient, well-balanced food, with plenty of fluids throughout pregnancy.

  • Taking enough rest and helping other family members to recognize and support this.

  1. 2. Prevent and treat anaemia.

Prevention of anaemia should start pre-conception: adolescent girls after starting menstruation, and all women of child-bearing age should eat iron-rich foods, such as green leafy vegetables, eggs, and meat where locally available and acceptable.

  • Daily iron-folate tablets should be given in pregnancy. For example, it has been shown in Nepal that the children of mothers who take iron, folic acid and vitamin A supplements in pregnancy perform better than children whose mothers did not take these supplements17 (but see note below regarding vitamin A).18

  • Prevent and treat malaria (see Chapter 17), hookworm, and schistosomiasis (bilharzia), ideally before becoming pregnant.

  1. 3. Prevent and treat vitamin A deficiency in mothers and infants.

    • The mother should eat foods rich in vitamin A—green leafy vegetables; orange, red, or yellow fruits or vegetables; fish; red palm oil in small quantities.

    • Mothers are only recommended to take vitamin A supplements if the prevalence of night blindness is higher than 5 per cent or more. It should then be given for the 12 weeks before delivery either as a capsule of 10,000 units per day or 25,000 IU per week. Mothers are not otherwise recommended to take vitamin A supplements.18

  2. 4. Prevent and treat iodine deficiency.

WHO and UNICEF recommend iodine supplements for pregnant and lactating women in countries where less than 20 per cent of households have access to iodized salt.19 As mentioned, this salt needs to be reliably iodized in areas where there is iodine deficiency. Communities can be taught how to test this and take action through advocacy if legalized levels are not reached.

Children under six months should receive their iodine through breastmilk but will need extra iodine supplements between six and 24 months. We should follow specific national guidelines as to how this is best done at community level. Where goitre is commonly observed and in many mountainous areas, iodine supplements are especially important unless mothers are regularly using iodized salt (see Figure 14.11). If salt is not reliably iodized they can take a capsule of iodized poppy-seed oil.

Figure 14.11 Iodine deficiency affecting three generations in the Bolivian Andes.

Figure 14.11 Iodine deficiency affecting three generations in the Bolivian Andes.

Reproduced with permission from World Health Organization. Copyright © 2017 WHO. This image is distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 International licence (CC-BY-NC), a copy of which is available at

  1. 5. Discourage smoking, alcohol, and drug-abuse.

If the mother smokes or drinks alcohol during pregnancy, the baby is often born smaller and weaker and is more likely to die in the first months of life. Mothers should not drink alcohol nor smoke during pregnancy.

  1. 6. Treat and prevent serious illness.

Tuberculosis, sexually transmitted infections, HIV/AIDS and other chronic illnesses can all seriously affect the baby’s health.

  1. 7. Ensure regular antenatal care (see Chapter 17).

Teaching pregnant women about nutrition is much more effective if we also encourage husbands and other family members to support them in this.

Rule 2. Promote breastfeeding

If a new vaccine became available that could prevent almost one million child deaths per year, was cheap, safe, could be given orally, had no side effects and needed no cold chain, it would be a public health triumph. Interestingly, if every child was breastfed within an hour of birth, was given only breast milk for their first six months of life, and continued to breastfeed up to the age of two years, about 800,000 child lives would be saved every year.20, 21

Many mothers today are being wrongly persuaded to use the bottle instead of the breast. They may listen to the advertising of artificial milk manufacturers, or think that wealthy, fashionable women use infant formula. They may start thinking that breastfeeding is dirty or old-fashioned. What often happens is that a mother tries to combine breastfeeding and formula, then finds her supply of breast milk reduces until she becomes dependant on formula to feed her baby.

Bottle-fed babies are much more likely to die than breastfed babies. Our job is to make sure that our teaching in favour of breastfeeding is more powerful than the pressures on mothers to adopt bottle feeding.

Breast is best because:

  1. 1. It is the natural food for babies, having the perfect balance of nutrients and providing natural protection against illness.

  2. 2. It is free and easily available.

  3. 3. It is clean, so the breastfed baby is far less likely to die from diarrhoea than bottle-fed babies. Washing and sterilizing bottles is tiresome and expensive.

  4. 4. Skin-to-skin contact between mother and baby has added benefits, including boosting the child’s immunity

  5. 5. Breastfeeding is best for the mother. It reduces risks of breast and ovarian cancer, type 2 diabetes, and postpartum depression. It strengthens the bond between mother and child.

  6. 6. Breastfeeding, if regular and frequent, acts as a contraceptive and so helps child spacing.

  7. 7. Adolescents and adults who were breastfed as babies are less likely to be overweight or obese. They are less prone to type 2 diabetes and perform better in intelligence tests.

Help mothers to understand:

  1. 1. Be imaginative.

When helping mothers understand why breast is best, e.g. discuss the money aspect. Families sometimes spend up to one quarter of their income on infant formula.

  1. 2. Colostrum is good

The milk produced in the first few days is not ‘bad milk’, but full of nutrients and valuable antibodies that the child really needs.

  1. 3. WHO now recommends exclusive breastfeeding until six months.

Exclusive means breast milk alone—no water, teas or anything else.

  1. 4. Breastfeeding should be continued where possible for at least two years.

Breastfeeding is usually possible but it has to be learned and many women encounter difficulties at the beginning. To provide support for mothers and newborns, there are ‘baby-friendly’ facilities in about 152 countries thanks to the WHO-UNICEF Baby-friendly Hospital Initiative.22

One method that can help mothers to follow exclusive breastfeeding for the first six months is through peer counsellors. For example, in Burkina Faso and Uganda well-trained peer counsellors visit mothers once before delivery and four times after delivery to encourage exclusive breastfeeding. This has proved inexpensive and effective.23

In situations where mothers have to go out to work while still breastfeeding, we need to help families and employers to understand just how important this is.

Mothers often incorrectly believe they cannot make enough milk. Where this is the case encourage them:

  • to allow the baby to suckle often, both day and night.

  • to drink more fluids.

The more the baby suckles, the more milk is produced. This is especially important in the few days after birth when milk may not flow easily (See Figure 14.12).

Figure 14.12 Members of a women’s club help a recently widowed mother.

Figure 14.12 Members of a women’s club help a recently widowed mother.

Reproduced from Hesperian Health Guides, Copyright © 2017 Hesperian Health Guides. This image is distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 International licence (CC-BY-NC), a copy of which is available at

The author is currently observing from his own daughter that establishing breastfeeding is not always easy. We need to give imaginative support and encouragement to mothers who are struggling. One helpful website is La Leche League International at

Strong advocacy remains essential to promote breastfeeding against strong pressures. If the mother has tried breastfeeding and despite her best efforts it does not work, perhaps because of her lifestyle or work patterns, we should avoid being coercive and instead make sure she uses infant formula correctly with very careful hygiene precautions.

Rules for breast milk substitutes—mothers should use these only if:

  • she finds it impossible to breastfeed despite her best efforts;

  • the formula milk is very safely prepared and is used at the correct strength and with careful hygiene precautions.

If the mother is not able to breastfeed, one solution to consider is to find a healthy, HIV-negative ‘wet nurse’ in the community (both Moses and Muhammad were reputedly fed in this way). Other mothers in the family, even grandmothers, may be able to provide breast milk, but this is acceptable only in some communities.

Note on breastfeeding and HIV

The following details are current best-practice at the time of writing but advice changes quite frequently, so we should check any guidelines being used in our country or district.

Women known to be HIV-positive have a significant risk of passing on HIV infection to their infants through breastfeeding, especially if they have become infected during pregnancy or breastfeeding or if they have symptoms of AIDS. This risk is greatly reduced if they use anti-retroviral therapy (ART).

Research shows that partial breastfeeding is more likely than exclusive breastfeeding to cause mothers to pass on HIV to their children. Current advice is that, wherever possible, an HIV-positive mother should receive ART during pregnancy, delivery, and lactation, and that exclusive breastfeeding should be continued for six months. The HIV-positive mother should use ART lifelong but from the child’s viewpoint she must continue therapy for at least twelve months.

If ART is not available the preferred option is infant formula. However, it is important that there should be a reliable supply of infant formula, and the mother has been carefully instructed how to use it hygienically.24 If this is not possible, exclusive breastfeeding is still recommended. The mother should be given the opportunity of making the choice herself, after the options have been carefully explained to her. In areas where HIV is common, encouraging mothers to go for voluntary counselling and testing (VCT) is extremely important. In some areas there are visiting teams who can do this testing in homes or in the community (see Chapter 20). Antenatal clinics are also an ideal location. Testing before the twenty-eighth week of pregnancy is crucial in order to draw up the best action plan for mother and baby.

Rule 3. Introduce complementary feeding at six months

This is a summary of advice from the World Health Organization. In order to meet the growing nutritional needs of babies at six months of age, mashed solid foods should be introduced as a complement to continued breastfeeding. Foods for the baby can be specially prepared or modified from family meals. The WHO notes that breastfeeding should not be decreased when starting on solids; food should be given with a spoon or cup, not in a bottle; food should be clean and safe; and young children should be given ample time to learn to eat.25

Follow these guidelines:

  1. 1. Find out about local food.

Make sure that health workers recommend only foods that are locally available and affordable to all, not the foods they are used to eating, from a different part of the country (see Figure 14.13).

Figure 14.13 Make sure that health workers encourage only the use of foods that are available locally and are affordable.

Figure 14.13 Make sure that health workers encourage only the use of foods that are available locally and are affordable.

Reproduced courtesy of David Gifford. This image is distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 International licence (CC-BY-NC), a copy of which is available at

  1. 2. Encourage appropriate foods.

Such foods should be:

  • easy to prepare;

  • rich in energy content, protein and micronutrients

  • not too watery;

  • soft and easy for the child to eat, such as mashed fruits and vegetables;

  • clean and safe;

  • without added salt or spice;

  • free from hard pieces or bones that cause choking.

  • Use correct foods for different ages.

From 6 to 12 months:

  • Feed a little at a time, twice a day, to start with, building up to at least four times a day.

  • Foods should be soft and easy to swallow and digest.

  • Include soft fruits and thick porridge mixes with milk if available.

  • Introduce new foods one at a time. Wait until the child is used to one food before offering it another. A good rule is to start a new food about every two weeks.

  • From about eight months children enjoy holding small pieces of food (finger food), but wash their hands first.

  • Feed the child gently, never using force (Figure 14.14)

  • Give mixtures of mashed foods: include such foods as legumes, potatoes, roots such as cassava and yam, eggs, finely chopped meat or fish, as well as cereals and fruit. These can be prepared according to local custom.

Figure 14.14 Until nutrition workers have experienced the cranky child who refuses to eat what the mother has prepared, they have not come to grips with the most essential element of applied nutrition.

Figure 14.14 Until nutrition workers have experienced the cranky child who refuses to eat what the mother has prepared, they have not come to grips with the most essential element of applied nutrition.

Reproduced from Hesperian Health Guides, Copyright © 2017 Hesperian Health Guides. This image is distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 International licence (CC-BY-NC), a copy of which is available at

The use of flour porridge or super-flour porridge started in Nepal and has become increasingly popular. It is especially helpful for feeding children whose growth is faltering on the growth chart, who are recovering from illness, and in areas of food insecurity. Box 14.1 provides a recipe and information for super-flour porridge.

From 12 months upwards:

  • The child can eat ‘from the family pot’.

Children can eat the same food as adults, but they should have their own plate to make sure they get their fair share. By the age of one year children are eating about half the amount per day that their mothers eat.

  • Feed four to six times a day.

Young children will not be able to manage on the one to three main meals a day that adults eat. They have small stomachs and ‘like chickens should often be pecking’ (see Table 14.2).

Table 14.2 A final point: suggested snacks for young children

Snacks for young children

Fruits such as mango, pawpaw, banana, avocado.

Boiled egg.

Boiled, pasteurized, or soured animal milk.

Chapati or bread with groundnut paste/peanut butter, or margarine, or dipped in milk.

Small pieces of boiled or fried cassava, plantain, or yam.

Sweet potatoes (orange coloured).

Rule 4. Continue to feed sick children

The belief that food should not be given to sick children is a dangerous one, and many children die as a result. Illness leads to malnutrition and malnutrition to illness.

Mothers should continue breastfeeding when children are ill, as much and as often as the child can manage. A child who has started complementary feeding should be gently encouraged to eat, even if not very hungry. We should give soft foods especially if the mouth and throat are sore, and we must give extra fluids if the child has a fever or diarrhoea. Sick children will have small appetites; they should therefore eat their favourite soft foods in small quantities as often as they like.

After an illness there will be catching up to do. Children will need to eat more often than usual, with extra oil or super-flour porridge, until they have regained any weight lost. Children with diarrhoea should also continue to be fed. Oral rehydration can be done with home-prepared liquid foods such as rice water instead of salt-sugar solution (see Chapter 16). We must ensure that sick children eat enough so they can fight any infection successfully.

Rule 5. Prepare, cook and store food correctly

This section is adapted from the WHO Golden Rules of Food Preparation.26

Clean or process food appropriately

While many foods, such as fruits and vegetables, are best in their natural state, others are not safe unless they have been processed. For example, always buy pasteurized milk.

Cook food thoroughly

Many raw foods, most notably poultry, meats, eggs, and unpasteurized milk, may be contaminated with disease-causing organisms. Thorough cooking will kill the germs but it must reach all parts of the food.

Eat cooked foods immediately

When cooked foods cool to room temperature, germs start to multiply. To be on the safe side, eat cooked foods as soon as they come off the heat, and always within two hours.

Store cooked foods carefully

If foods are prepared in advance or leftovers are kept, they must be stored in hot (near or above 60 °C) or cool (near or below 10 °C) conditions. This is very important if foods are to be stored for more than four or five hours.

Reheat cooked foods thoroughly

This is the best protection against germs that may have developed during storage. All parts of the food must be thoroughly recooked, in other words, reach at least 70 °C.

Avoid contact between raw foods and cooked foods

Safely cooked food can become contaminated through any contact with raw food. For example, this can happen when raw meat comes into contact with cooked foods, or the same surface and knife are used to cut both raw and cooked food.

Wash hands repeatedly

Wash hands thoroughly before starting to prepare food and after every interruption—especially after cleaning the baby, going to the toilet, or touching animals. Any sores on hands should be covered before cooking. Fingernails should be kept short. Teach children to wash their hands regularly, and always before eating.

Keep all surfaces meticulously clean where food is prepared

Cloths that come into contact with dishes and utensils should be changed and washed frequently. Use separate cloths for cleaning the floor and any surfaces where food is prepared. Avoid feeding infants with a bottle, as bottles and teats are very difficult to clean. Use a cup and spoon instead. Never use containers that have contained chemicals or pesticides for food. Bury or burn any rubbish.

Protect foods from insects, rodents, and other animals

Animals frequently carry germs which cause foodborne disease. Storing foods in closed containers is the best protection. Keep poultry and animals away from the kitchen.

Use safe water

Safe water is just as important for food preparation as for drinking. Wash fruit and vegetables using the cleanest water available, or peel them instead. Be especially careful with any water used to prepare an infant’s meal.

Rule 6. Avoid harmful and unnecessary foods

Harmful foods include spoiled or mouldy cereals, beans, and groundnuts, and food that has been inadequately recooked, or stored in containers that have held pesticides, fuels, or chemicals.

The use of unnecessary foods is becoming common in developing countries. Overweight children are fed on ‘junk foods’ such as artificial milk, tinned baby foods, tonics, bottled drinks, excessive sweets, biscuits, or other fashionable products seen on TV. The money could have been spent to buy healthy, nutritious foods.

Malinche was a Mexican woman who helped the foreign soldier Cortes invade Mexico and conquer the country. Beware the ‘Curse of Malinche’, which is the belief that anything foreign or western is good and must be better than things made in our own country. We need to help families use foods from their own communities, or only to buy healthy and nutritious food from outside. We also need to be aware of the growing problem of childhood obesity, present in many resource-poor countries as well as richer nations.

Tackle nutritional deficiencies

Sometimes it may be appropriate to consider tackling specific deficiencies with supplementation. Some examples are:

  • Iron: a study in Zanzibar found that children aged between one and four years given a small iron supplement daily had improved language and motor skills development.27

  • Vitamin A: Current WHO guidelines recommend infants 6–11 months of age should receive 100,000 IU once and children 12–59 months of age should receive 200,000 IU every four to six months as an oral liquid oil-based preparation, or as a capsule in settings where vitamin A deficiency is a public health problem.28 Vitamin A has often been distributed at the time of polio vaccination Where this vaccination is no longer given, other routes for giving regular Vitamin A need to be set up.29

  • Zinc: There is evidence that regular zinc supplements can reduce pneumonia and mortality in young children.30 One project in an Indian slum community found that daily zinc supplementation using 10 mg elemental zinc for infants and 20 mg for children reduced the number of children between six months and three years catching pneumonia, especially if they were also receiving vitamin A.

Consider special feeding programmes

Sometimes more serious levels of malnutrition in a community mean that ‘The Six Rules’ alone are inadequate. We need to assess with the community whether this is a short-term local shortage that the community and programme can manage together, or whether this is a more serious problem that requires specialist outside help.

Feeding programmes are described in some detail due to the periods of food insecurity or famine that are affecting more areas especially in Saharan and sub-Saharan Africa. We always need to be aware of the food security situation in our area and estimates from the best sources about whether a deterioration is likely.

Local/short-term food shortages

In community-based health care (CBHC) we should only start a feeding programme if:

  1. 1. There is evidence of worsening food security, i.e. food shortage with increasing evidence of malnutrition.

Early warning signs may be more children with growth faltering or weight loss on the growth chart, or more children with low MUACs. There may be a regional alert, or warnings and instructions from the government or from the World Food Programme or UNICEF.

  1. 2. The community is able to share responsibility and take action.

This can be through a health committee, or a church, temple, mosque, school or social committee. It can be a single enthusiastic CHW supported by motivated community volunteers.

  1. 3. There is available food from sources fairly close to the community.

We should use the most local and familiar foods available.

How to run a feeding programme

We can help the volunteers, CHW or committee do the following:

  1. 1. Select a suitable time and place for feeding.

For example, midday or evening in the CHW’s house; morning outside the clinic.

  1. 2. Collect and prepare suitable food.

This must be well-balanced and high in energy, protein, and micronutrients. A ‘super-porridge’ may be appropriate (see Box 14.1). Where available, at least some food should be supplied by the community. Wealthier members can be encouraged to contribute. Volunteers should cook the food themselves in their own homes or communally.

  1. 3. Assemble the children, feed them, and keep order.

  2. 4. Teach and motivate the parents.

This is an excellent time to teach good nutrition, weigh children with parents’ help, and distribute vitamin A and worm medicine if needed. The village health committee or an experienced CHW will usually be the organizer and the motivator, but feeding will always be done in partnership with the community and often as part of a district or regional government programme (see ‘Widespread, longer-term food shortages’).

For example, in Jamkhed, India, special feeding was needed when the programme first started. Young Farmers’ clubs were formed whose members would help to collect the food, assemble the children, and motivate the community. They were careful always to give the same advice and teaching as the CHW. In this way the programme achieved quick results and could then be discontinued.

Some Dos and Don’ts:


  1. 1. Run the programme for a short time only.

As soon as food supplies improve, discontinue, but follow up vulnerable children.

  1. 2. Include children with moderate acute malnutrition (MAM).

Choose a cut-off point on the growth chart or the yellow zone on MUAC. Explain eligibility criteria clearly to the community, otherwise envy or mistrust can easily develop. Where malnutrition is widespread and severe, one option is to include all children under five at the start.

  1. 3. Follow up each child at home through the CHW or family folder system.

When the feeding programme ends, make sure that each child receives appropriate food at home and continues to gain weight.


  1. 4. Run the programme for the people.

It should be community-run with our help.

  1. 5. Give out free supplies through clinics.

Free supplies should only be given when no food is available and a relief situation applies. Otherwise, we can create dependence and can even make malnutrition worse

  1. 6. Start a community feeding programme unless the need for it is confirmed by someone with expert knowledge on nutrition.

It is much easier to start programmes than to stop them, as communities quickly become dependent.

Widespread, longer-term food shortages

If food security is confirmed by experts as deteriorating, we must call on outside help, be in touch with government agencies, and make sure we and the community are involved in an effective response that is co-ordinated with any official national response.

In this situation, relief and aid agencies typically start to arrive, often saving lives but sometimes bypassing or disempowering the community in the process. A good model for us to consider is Community Based Management of Acute Malnutrition (CMAM). Originally known as CTC—community-based therapeutic care—it was originally pioneered in the early 2000s, focusing on emergency settings. It is now widely used in food emergencies. Adequate resources and training are needed for its success.31

CMAM is based on building the capacity of local communities and existing structures to respond as effectively as possible.

Its core operating principles include:

  • Maximum coverage and access.

Programmes should be designed to achieve the greatest possible coverage. CMAM aims to reach the entire severely malnourished population.

  • Timeliness.

Programmes should catch the majority of cases of acute malnutrition before additional medical complications occur. In humanitarian situations, CMAM programmes aim to start case-finding and treatment before the prevalence of malnutrition escalates.

  • Appropriate care.

Programmes should provide simple, effective outpatient care for those who can be treated at home and inpatient care for those who require inpatient treatment for survival.

  • Care for as long as it is needed.

Programmes should be designed so that people can stay in the programme until they have recovered. CMAM aims to ensure that appropriate services continue for as long as acute malnutrition is present in the population (Figure 14.15).

Figure 14.15 Adult female literacy and schooling for girls leads to improved family nutrition.

Figure 14.15 Adult female literacy and schooling for girls leads to improved family nutrition.

Reproduced courtesy of David Gifford. This image is distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 International licence (CC-BY-NC), a copy of which is available at

Here is one example on how this can work in practice.

In discussion with the community, those implementing CMAM will define three levels of care.

  1. 1) Supplementary feeding.

This is extra food for children with moderate wasting. Guidelines are available that can be adapted.32 Usually specially formulated foods are used.

  1. 2) Outpatient therapeutic care.

This is needed when a child has uncomplicated severe acute malnutrition, i.e. the child is clinically stable (i.e., alert, no IMCI ‘danger signs’) and has an adequate appetite (passes the appetite test by being able to eat a set amount of Ready-to-Use Therapeutic Food, RUTF).

  1. 3) Inpatient care for a child who has ‘complicated SAM.’

This is when a child loses its appetite, is unwell with fever, has dehydration, other danger signs, or complex underlying problems needing admission for more specialized care and investigation. Admission may also be needed if the home situation is difficult and carers cannot adequately look after the child at home.

If a child is admitted, it is for ‘stabilization care’—feeding with specially formulated therapeutic milks and treatment of associated clinical problems. As soon as the clinical condition improves, the child may be discharged back to the community to complete treatment at home under the outpatient treatment programme.

In CMAM programmes SAM is treated with specially formulated RUTF. Originally and still most commonly, this is based on a fortified peanut paste (one brand is called Plumpy-Nut), but versions based on other ingredients also exist. RUTF is a nutrient-dense, micronutrient-enriched, easy-to-digest food. It is easy to use at community level.

SAM, whether complicated or not, should be seen as a clinical priority, if not a clinical emergency, and treated accordingly. These are very vulnerable children with high case fatality, hence the need to use WHO-specified RUTF.33

In areas of severe food shortage, it is essential that community-based health programmes work alongside respected agencies such as the World Food Programme, UNICEF, and official government programmes.

At the same time, however, we should encourage as much community involvement as possible so that outsiders do not overrule the abilities and wishes of the community. But the community needs to engage with the key principles of treating SAM, using the CMAM principles outlined.

Address root causes: encourage micro-enterprise

As mentioned earlier, poverty is often the root cause of chronic malnutrition. This means that helping a community to generate income can be the most useful way to address the problem. Also increasing female literacy (See Figure 14.15). Ask an expert for help before rushing into this, or collaborate with another CSO that specializes in income generation or micro-enterprise (see Chapter 12).

Many income generation programmes find it helpful to work with women’s groups (see Chapter 2) as the cash earned by women tends to go towards feeding the family, rather than alcohol or cigarettes. The two diagrams in Figures 14.9 and 14.10 give further higher-level ideas which can help our health programmes to think ‘upstream’ about useful actions we can take, including advocacy.

Address food supply: set up kitchen gardens

Kitchen, or home food gardens, can be planted almost anywhere, including urban areas where crops can be grown in buckets or old tyres, near the house, or on ledges or roofs. In many rural areas fewer traditional foods are being grown for family consumption, wild fruit and berries are more difficult to find, and money is often spent on buying less nutritious, ‘fashionable’ food. This makes it very useful to grow a few highly nutritious foods near the home especially for the benefit of children. Therefore, we can use the following guidelines to address food supply:

  1. 1. Assess what crops are most suitable.

If protein is in short supply, beans and lentils can be grown. If there is Vitamin A deficiency, grow green leafy vegetables, and carrots. Pawpaw (papaya) or mango trees can be planted.

  1. 2. Choose crops that are easy to grow.

They will ideally need a short growing season and a long cropping season, should be familiar to the community, popular with children, and not prone to disease and pests.

  1. 3. Make sure there is sufficient water throughout the growing season.

This can be household waste water providing it is not toxic, or rainwater can be collected from roofs.

  1. 4. Feed the soil.

For example, use compost. If on a slope, protect the soil from being washed away, using stones or fixed contours.

  1. 5. Involve children in the project or delegate the care of the garden to children.

  2. 6. Consider planting trees, especially native ones, that provide nutritious leaves or fruit.

For example, The San Lucas Association in Peru discussed home gardens in village meetings, owing to high rates of malnutrition and because few vegetables were grown locally. They started with a gardening project in four schools, and then many families started to set up their own. Then women’s groups started to co-ordinate these gardens in nearby villages. Childhood nutrition improved and sometimes surpluses could be sold for family income.

Consider mass deworming

Although some recent research has cast doubt on the policy of mass deworming, it is still recommended by the WHO and other experts as a valuable and cost-effective public health measure. We should therefore consider setting up a programme, and work closely with any government programmes which may be present.

Children often have very high intestinal worm (Helminth) levels. Roundworms (Ascaris) reduce absorption of food and worsen malnutrition. Hookworm (Ancylostoma and Necator), whipworm (Trichuris), and schistosomiasis (bilharzia) reduce iron levels and can cause anaemia. Often, two or more of these helminths are found together. Regular deworming therefore improves nutrition, reduces anaemia, and enables children to have more energy and, according to many parents, learn more quickly (although this is unconfirmed). Well-run programmes are considered to be cost-effective.

The WHO recommends periodic treatment with anthelminthic (deworming) medicines of all at-risk people living in endemic areas. People at risk include preschool-age children, school-age children, women of childbearing age (particularly pregnant women in the second and third trimesters) and breastfeeding women.

There are various things we can do (and not do!) to make deworming programmes a success in schools.


  • Make deworming an integral component of a school health programme. Combine deworming with providing iron and other micronutrient supplements when there are known shortages in the children’s diet.

  • Identify the different roles of teachers and health providers and ensure they work together at all stages of the programme.

  • Help teachers understand the benefits of deworming, so that they are supportive and recognize that the investment of time is a useful contribution to education.

  • Make careful plans to manage possible side effects. Side effects are uncommon but failure to manage them can ruin the programme’s future.

  • Make sure that treatment is provided both for intestinal worms as well as for schistosomiasis where needed.

  • Make sure that a regular ongoing plan is followed.

  • Protect children’s development by starting treatment early and continuing throughout primary school.

  • Reach out to non-enrolled school-age children. This both enhances the public health impact and encourages children, especially girls, to attend school.


  • Waste time and resources trying to examine each school or child. Deworming drugs are safe and can be given to uninfected children.

  • Exclude adolescent girls from systematic treatment. The drugs are safe, even in pregnancy.

  • Be afraid to give albendazole 400 mg or mebendazole 500 mg, even to small-looking children. The dose is independent of age and weight.

  • Hesitate to use a dose pole instead of a scale to decide the appropriate dose of praziquantel for treating bilharzia. It accurately calculates the dosages for school age children.

  • Wait for sanitation to improve before starting deworming—regular treatment will help all children.

See the latest WHO factsheet for an overview.34

Two deworming drugs are especially useful—mebendazole 500 mg or albendazole 400 mg given as a single dose. Both are largely free of side effects. Albendazole is now favoured by most donation programmes. Seek advice from the district medical officer (DMO) about any national programme and what drugs are being used. Schistosomiasis (bilharzia) has to be treated with a different drug: praziquantel. Height measuring sticks are often available to calculate the dose easily. If weighing is used, the dose is usually 40mg/kg.

Current WHO guidance indicates that mebendazole or albendazole needs to be given yearly when the prevalence of worm infections in the community is over 20 per cent and every six months if it is over 50 per cent. Although neither drug is completely effective, by using them this frequently worm levels are kept so low that they cause little harm. Using the drugs less often allows worm populations to build up and iron levels to fall. We should follow the guidelines used by our District Health Team or Ministry of Health.

Drug distribution depends on the local situation. If school children are being targeted, the health team can arrange distribution within the school. If school age children who do not attend school are being included (which they should be) CHWs or members of the health team can distribute them in the community. The benefits of the programme can be used to persuade families to send their children to school. Some programmes also distribute other medicines. For example, a project in Gujarat, India distributes vitamin A capsules 200 000 IU and iron tablets (60 mg equivalent Fe) at the same time, also making sure that schools use iodized salt for their cooking. Children have become taller, heavier, less anaemic, see better in the dark, and have felt more active than before.

CBHC should never depend purely on medicine distribution to solve a problem. Our aim is always to improve the health of communities so that outside programmes become less necessary. We should start a deworming programme only if at the same time we actively consider three other areas:

  • Working with the community to provide safe water for drinking and washing.

  • Working with the community to improve sanitation—this may mean promoting latrines.

  • Improving personal and community hygiene.

A combination of these programmes is now a worldwide movement known as a water and sanitation programme, or WAter, Sanitation, and Hygiene programme (WASH;

Evaluate the programme

This is most simply done by seeing how the nutritional status of children changes over a period of time. The percentage of children under five who are underweight on the growth chart or those aged six months to 60 days with MUACs under 125 mm is compared between the start of the programme and a resurvey two, three, or five years later. However, nutritional status varies with seasons and repeat surveys should therefore be done at the same time of year.

The community can be asked to rank how happy they are with the programme, or the nutrition aspect, on a scale of 1 to 5. Regardless, all stages of the evaluation should be done in partnership with the community. Results should be explained carefully as changes in child nutrition may not be obvious and the community may not realize that improvements have occurred unless this is clearly presented to them (see Chapter 9).

The evaluation of a response to an acute food shortage is best done with expert help and as part of a regional programme.

Further reading and resources

Baby Milk Action. Wide ranging resources on promoting breastfeeding. Available from:

Burgess A, Bijlsma M, Ismael C, editors. Community nutrition: A handbook for health and development workers. Oxford: Macmillan; 2009.Find this resource:

Carter I. Healthy Eating: A PILLARS Guide. Teddington: Tearfund; 2003. Practical advice on making the most of available food. Available from: this resource:

Collins S. Community-based therapeutic care: A new paradigm for selective feeding in nutritional crises. London: Humanitarian Practice Network; 2004. Available from: this resource:

Food and Agriculture Organization of the United Nations (FAO). FAO Hunger Map. 2015. Available from:

Food and Agriculture Organization of the United Nations (FAO)/EU Facility Project. Complementary feeding for children aged 6–23 months: A recipe book for mothers and caregivers. Phnom Penh: Food and Agriculture Organization of the United Nations (FAO): 2011. Available from: this resource:

Food and Agriculture Organization of the United Nations (FAO), Government of Nepal, Government of Spain. Nutrition handbook for the family. 2009. Available from:

Han JC, Lawlor DA, Kimm SYS. Childhood obesity. The Lancet. 2010; 375 (9727): 1737–48.Find this resource:

International Zinc Nutrition Consultative Group. Zinc nutrition publications. Available from:

The Johns Hopkins Center for Communication Programs (CCP). How to make superflour for complementary feeding of an infant. Uploaded 13 July 2015. Available from:

Kerac M, Trehan I, Weisz A, Agapova S, Manary M. Admission and discharge criteria for the management of severe acute malnutrition in infants aged under 6 months. Geneva: World Health Organization; 2012. Available from: this resource:

Liu L, Johnson HL, Cousens S, Perin J, Scott S, et al. Global, regional, and national causes of child mortality: An updated systematic analysis for 2010 with time trends since 2000. The Lancet. 2012; 379 (9832): 2151–61.Find this resource:

Living Well with HIV/AIDS, A manual on nutritional care and support of people living with HIV/AIDS, WHO and Food and Agriculture Organization of the United Nations (FAO), 2002. Available from:

MUAC measuring tapes, child health charts, weight-for-height charts, etc. Available from TALC.Find this resource:

Sadler K. Community-based therapeutic care: Treating severe acute malnutrition in sub-Saharan Africa. PhD [dissertation]. London: University College London; 2009. Available from: this resource:

Savage King F, Burgess A, Quinn VJ, Osei AK, editors. Nutrition for developing countries. 3rd ed. Oxford: Oxford University Press; 2016.Find this resource:

UNICEF WASH programme. Available from:

World Food Programme. Available from:

World Health Organization. Complementary feeding: Family foods for breastfed children. Geneva: World Health Organization; 2000. Available from: this resource:

World Health Organization. Infant and young child feeding list of publications. a list of resources to access or download. Available from:


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