Introduction to prevention and treatment of acute malnutrition in emergencies and humanitarian crises
In 2017, UNICEF, the World Food Programme (WFP), and other United Nations (UN) agencies estimated that more than 70 million people globally required food or other assistance because of natural disasters, conflict, population displacement, famine or high levels of acute malnutrition.(1) After an initial decline in humanitarian emergencies following the end of the 20th century, there is now an alarming increase in the number of people requiring food and other assistance. In many situations, the crisis is socio-economic – food is available but unaffordable.(2)
Reproduced with permission (FEWS NET, 2017) (3)
In several countries, a very large proportion of the population is affected by humanitarian crises. In Yemen, violent conflict and drought has led to an estimated two thirds of the population (more than 17 million people)(4) facing food insecurity and risk of famine across the whole country.(5) This situation is exacerbated by infectious disease outbreaks, including cholera infecting almost 1 million people, breakdown of health service provision, and poor access to those affected. In Syria, seven years of conflict has resulted in an estimated 13 million people in need of humanitarian assistance in appalling conditions, including up to 3 million people trapped in areas beyond the reach of humanitarian assistance.(6) Following a devastating famine in Somalia in 2011, a combination of ongoing conflict, the El Niño climatic phenomenon, population displacement and livelihood disruption have resulted in food insecurity amongst half of the population.(7)
In many regions people have been displaced internally and across borders. Since mid-2017, more than half a million Rohingya refugees have fled violence in Myanmar to Bangladesh where they have urgent needs for medical, nutritional, shelter and water & sanitation assistance.(8) In the Democratic Republic of the Congo, an estimated more than 4 million people are internally displaced due to armed conflict and insecurity that has gone on for decades.(9) In Nigeria, approximately 2 million people have been displaced by conflict, marginalization and chronic under-development, many across the border to Cameroon, Chad and Niger.(10) In South Sudan, nearly 2 million people, 85% of whom are women and children, have been displaced by conflict, now lasting for more than 5 years.(11)
The right to receive, and the obligations to provide, food, nutrition and medical care in an emergency are clearly enshrined in humanitarian law.(12) Providing appropriate interventions to support prevention and treatment for child and maternal nutrition and health can be life-saving. However, high caseloads of malnutrition occurring in the context of climatic extremes and military or civil conflict result in a pressing need for curative and preventive interventions that achieve high coverage, are effective and cost-effective. To achieve this, agencies increasingly need to base programmes and interventions on strong scientific evidence rather than customary practice. This is recognised by The Food and Agriculture Organization (FAO) of the UN, UNICEF, WFP and other UN agencies who recently concluded that “Addressing food insecurity and malnutrition in conflict-affected situations cannot be business as usual.” (1)
Malnutrition predominantly affects children in the first years of life who are vulnerable from birth, as they transition from breastfeeding through complementary feeding to independent feeding; and because of frequent infectious disease episodes. However, malnutrition may also begin before birth. Low birth weight and premature delivery, as well as posing high risk in themselves, set children on a poor health and nutritional trajectory. The nutrition and health of pregnant and lactating women are critical determinants of the wellbeing of their infants and young children. Families affected by such humanitarian crises often also face limited access to food, water and sanitation, loss of housing or shelter, an increased rate of infectious diseases requiring medical care, an existing poor health infrastructure and grief; all of which impact the nutritional status of children.(13)
To address malnutrition in emergencies, programmes require planning; coordination; communication; multisector collaboration; assessments of the nutritional, health and other basic needs of the population affected, and how they can be targeted; logistics to ensure adequate supplies locally and from outside; protocols for nutritional, health and other forms of care; and a cycle of detailed monitoring of both input and outcomes with feedback. An understanding of costs both to programmes and systems and to families is also essential. Decision making in each of these steps should be informed by the research that forms the evidence base. Evidence from implementation studies – ‘how something is done’ may be as critically important as evidence of its efficacy. Generating high-quality evidence, for example, on programme design, achieving coverage, innovative IT solutions or tools requires assessment in terms of outcomes rather than processes.
This collection provides an overview of relevant evidence that has been synthesised in systematic reviews. It aims to increase the uptake of robust evidence to improve prevention and management of acute malnutrition in emergencies, and to inform decision-making on strategies and policies in the humanitarian and disaster risk reduction sectors. It will guide future research by identifying gaps in robust evidence and areas that are under-researched.
Systematic reviews are the highest level of scientific evidence, combining results from all available trials on a topic and rigorously assessing their quality. The obvious limitation is that not all topics have undergone systematic review. Where well-designed trials have not been undertaken a systematic review may be published as ‘empty’ or be missing altogether.(14) This may indicate areas where the priorities of decision-makers and practitioners, and those of researchers are not aligned. One important example is the specific treatment of kwashiorkor.(15) Systematic reviews are also not possible where only descriptive studies have been conducted, as this is a type of study that cannot be used to assess true efficacy (effect under controlled conditions) or effectiveness (effect in natural settings) against a suitable comparator.
Some interventions are not amenable to randomisation, and a genuinely informative before/after comparison is challenging to achieve. Methods of integrating nutrition with other services (e.g. health, water, sanitation & hygiene, and food security), structured monitoring and evaluation of coverage and performance, for example, as well as qualitative research may provide evidence that could be reviewed; however, the indicators for how to synthesise and systematically measure potential biases and the quality of such research are yet to be developed. Therefore, some areas that are heavily debated, such as criteria to assess the nutritional status of communities or optimal food security assessment methods cannot be synthesised in systematic reviews and therefore are not considered in this collection.
Humanitarian emergencies were defined as situations of increased mortality that entail interventions with a relatively short time frame. The specific topic ‘prevention and treatment of acute malnutrition in emergencies and humanitarian crises’ was derived by consultation of a steering group (see below) and informed by an overview of key interventions specified in guidelines, including those from WHO,(16) the Sphere Handbook,(17) and in the Interagency Standing Committee (IASC) Nutrition toolkit.(18) The collection’s scope for prevention aims to include strategies directed at the immediate causes of malnutrition and at immediate results, as defined in the UNICEF conceptual framework on malnutrition.(19) The scope for treatment includes nutritional and medical strategies for prevention and treatment that have direct impact on health and nutritional outcomes, including admission and discharge, use of antibiotics, feeding strategies, micronutrients, food supplements, medical and fluid management. Relevant evidence is included if the research comes from populations at risk of moderate (MAM) or severe (SAM) acute malnutrition, such as low or middle-income countries and does not involve high-tech interventions or a level of background care that would not be possible in a humanitarian emergency setting. The evidence collated in this review should inform evidence-based programming in any setting where there is a burden of SAM and MAM.
This initiative was implemented by a collective collaboration involving a wide range of stakeholders (led by Evidence Aid, with input from Action Against Hunger, Cochrane, Cochrane Nutrition, Cochrane Switzerland, Emergency Nutrition Network, KEMRI/Wellcome Trust Research Programme, London School of Hygiene and Tropical Medicine, Médecins Sans Frontières, Save the Children, Scaling up Nutrition (SUN) Movement Secretariat, University of Oxford, and World Food Programme) and volunteers (Carmelia Alae-Carew, Jessica Bourdaire, Hannah Hafezi, Isla Kuhn, Shona Lang, Shaun Lee, Alex Nevitte, Beth Sommerville and Georgina Taylor).
The Evidence Aid Collection is a curated list of systematic reviews with summaries of each review, published on the Evidence Aid website; identified systematic reviews that have been published in the Cochrane Library make up the content of two separate collections, both only published in the Cochrane Library – Treatment of acute malnutrition and Prevention of acute malnutrition. The two collections are linked, and readers are encouraged to visit both collections while we are bringing both collections into a single collection below. Details of the search terms and process are available on request from Evidence Aid.
Where available summaries are also provided in Spanish [ES] and French [FR] – just click on the link for those translations.
Pictures were provided by Action Against Hunger.
Author James A Berkley is Professor of Paediatric Infectious Diseases at the University of Oxford, UK, based at the KEMRI/Wellcome Trust Research Programme in Kenya; and Director of the Childhood Acute Illness & Nutrition (CHAIN) Network www.chainnetwork.org
If you would like to use an appraisal framework when considering the relevance and quality of the full reviews that Evidence Aid links to, a few useful tools are: AMSTAR, CASP and ROBIS. Guidance is also available on reporting reviews: PRISMA.
- FAO, IFAD, UNICEF, WFP and WHO. 2017. The State of Food Security and Nutrition in the World 2017. Building resilience for peace and food security. Rome, FAO. https://www.unicef.org/publications/files/State_of_Food_Security_and_Nutrition_in_the_World_2017.pdf
- World Economic Forum. 2017. 21st century famines have nothing to do with a lack of food. https://www.weforum.org/agenda/2017/03/21st-century-famines-have-nothing-to-do-with-a-lack-of-food
- FEWS NET. 2017. Emergency food assistance needs unprecedented as famine threatens four countries. http://www.fews.net/global/alert/january-25-2017
- United Nations Office for the Coordination of Humanitarian Affairs. 2018. https://www.unocha.org/yemen
- Inter-Cluster Operational Responses in South Sudan, Somalia, Yemen, and Nigeria. 2017. Promoting an Integrated Famine Prevention Package: Breaking Bottlenecks. Call for Action. http://fscluster.org/event/gfsc-and-gnc-event-promoting-integrated
- United Nations Office for the Coordination of Humanitarian Affairs. 2018. http://www.unocha.org/country/syria
- United Nations High Commission for the Coordination of Humanitarian Affairs. 2018. https://www.unocha.org/country/somalia
- United Nations High Commission for Refugees. 2018. Rohingya emergency. http://www.unhcr.org/rohingya-emergency.html
- United Nations Office for the Coordination of Humanitarian Affairs. 2018. Democratic Republic of the Congo. https://www.unocha.org/drc
- United Nations Office for the Coordination of Humanitarian Affairs. 2018. https://www.unocha.org/nigeria
- United Nations Office for the Coordination of Humanitarian Affairs. 2018. South Sudan. https://www.unocha.org/country/south-sudan
- International Committee of the Red Cross. 2005. Humanitarian Law, Human Rights and Refugee Law – Three Pillars. https://www.icrc.org/eng/resources/documents/statement/6t7g86.htm
- FAO, Rome. 2006. Nutrition in conflict situations. http://www.fao.org/tempref/AG/agn/nutrition/bjn.pdf
- Yaffe J et al. PLoS One. 2012. Empty Reviews: A Description and Consideration of Cochrane Systematic Reviews with No Included Studies. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0036626
- Briend A. 2014. Kwashiorkor: still an enigma – the search must go on. https://www.ennonline.net/attachments/2314/Kwashiorkor-still-an-enigma-CMAM-Forum-Dec-2014.pdf
- Nutrition Guidelines. http://www.who.int/nutrition/publications/guidelines
- The Sphere Project. 2010. Sphere Handbook. http://www.spherehandbook.org/
- Inter-agency Standing Committee Global Nutrition Cluster. 2008. A toolkit for addressing nutrition in emergency situations. http://nutritioncluster.net/topics/im-toolkit/
- Conceptual Framework. https://www.unicef.org/nutrition/training/2.5/4.html