Globally, about 150 million under five children are estimated to be too short for their age or stunted and about 50 million too thin for their height or wasted (1). Most of the world’s wasted children are living in South Asia and Sub-Saharan Africa (1,2) and account for about 50% of direct or indirect cause of global under-five mortality (3,4).
Malnutrition, in all its forms, is due to deficiency, excesses or imbalances in a person’s intake of energy and/ or nutrients. Malnutrition includes under nutrition, micronutrient-related malnutrition and overweight, obesity and diet –related non communicable diseases (5,6). Undernutrition includes wasting (acute malnutrition), stunting (chronic malnutrition) and underweight (both acute and chronic malnutrition) and micronutrient deficiency. Acute malnutrition can present as wasting (marasmus), oedema (kwashiorkor), or both wasting and oedema (marasmic kwashiorkor) (7,8).
Adequate nutrition is crucial for a child’s physical and cognitive development, especially in the first 1,000 days of live (9,10). The causes of undernutrition are complex and interwoven. Immediate causes include lack of access to highly nutritious foods, especially in a low socio-economic context and infectious diseases, including pneumonia, measles and malaria. Other causes include poor maternal health and nutrition, and/or inappropriate infant and young child feeding and care in early life (WHO, 2018). The World Health Organization (WHO) defines Severe Acute Malnutrition (SAM) in children aged 6–59 months as weight for height/length below ratio < -3SD, the presence of any bilateral pitting oedema (when all other non-nutritional causes are excluded), and/or a mid-upper arm circumference (MUAC) of < 11.5 cm.
Before the advent of CMAM in 2007, therapeutic feeding interventions depend on the traditional hospital-based Therapeutic Feeding Centers (TFCs) as the primary mode of interventions (11). SAM patients are admitted for a period of three weeks or longer and caregivers are required to stay with their malnourished children for that period in the centres. The limitations of the hospital-based approach include delay in accessing optimal care for a condition affecting large numbers of children, particularly when hospital capacity is poor (12–14). Moreover, hospital stays of several weeks for a child and mother are disruptive for families, especially when the mother’s is essential for the economic survival of the household. In a hospital setting where SAM patient are managed with other children with infectious disease, prolonged hospital stay expose them to nosocomial infection [11–13]
Community Management Acute Malnutrition (CMAM) is designed to address the limitations of hospital based inpatient care [13]. CMAM intervention use decentralized networks of outpatient treatment sites (located at existing primary health-care facilities) for SAM without medical complications, small inpatient stabilization centres (SCs) for SAM with medical complications, and large numbers of community-based volunteers to provide case detection and follow-up of patients in their home environments (15). Medical complications include poor appetite, signs of infection, severe oedema, hypothermia, lethargy, hypoglycaemia, vomiting, diarrhoea with dehydration, severe anaemia (7,16). The minimum international standard set to evaluate the quality of management of SAM according to SPHERE is a cure rate of a least 75% and death rate less than 10% (16).
Northern Nigeria has been experiencing drought and chronic food insecurity for the past three decades. The situation in the last decades has worsened due to insurgency and Herder/farmer crises (17). In the most recent survey conducted in Nigeria (18), 37% of children were found to be stunted, 7% were wasted and 22% were overweight. Only 29% of children under the age 6 months were breastfed exclusively (18,19). In the 2018 NDHS, there were marked variations by zone in the prevalence of stunting and wasting. The North West region of Nigeria, where this study was conducted, had the highest proportions of stunted (57%) and wasted children (9%) while the South East had the least, with 18% of children found to be stunted and 5% wasted (18).
From 2010 to 2016, Save the Children implemented an integrated CMAM programme for under–fives in Baure, Daura, Dutsi and Zango Local Government Areas (LGA), in Katsina state, Northwest region of Nigeria. The success of a CMAM programme relies on early case finding combined with effective follow up actions at the community level. Community volunteers were selected and trained to identify malnourished children using a Mid Upper Arm Circumference (MUAC) strip and refer children to the OTP, depending on the severity of malnutrition (7,20). In the OTP, SAM cases that developed medical complications were referred to the SC for inpatient care (7,16). At the health facility level, health care workers were given training annually in the WHO treatment guidelines for the management of SAM with comorbidity in the in-patient setting (4).
So, the objectives of this study were to investigate the time to recovery and it’s predictor among under-five children admitted into SC and managed for complicated SAM; and also to investigate whether the outcomes met the minimum Sphere standards and compare with intervention where tertiary health facilities were used for inpatient management of complicated SAM.