Prevention and treatment of acute malnutrition in emergencies and humanitarian crises
Photo credit: © Sanjida Tawhid for Action Against Hunger Ethiopia
This collection was first published on 12 March 2018. Last updated 8 July 2019.
Evidence Aid and a consortium of our partners are pleased to bring you this special collection of systematic reviews relevant to nutrition in emergencies and humanitarian crises. You will find links to the free, full text of more than 35 reviews below the introduction.
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. Details of the search terms and process are available on request from Evidence Aid.
Pictures were provided by Action Against Hunger.
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.
Summaries of all systematic reviews, listed below, are also available in French and Spanish.
Alcoba G., Kerac M., Breysse S., et al. Do children with uncomplicated severe acute malnutrition need antibiotics? A Systematic Review and Meta-Analysis. PLoS ONE, 2013;8(1):1-9.
Gera T. Efficacy and safety of therapeutic nutrition products for home based therapeutic nutrition for severe acute malnutrition: A systematic review. Indian Pediatrics 2010;47(8):709-18.
Gera T., Pena-Rosas J.P., Boy-Mena E., et al. Lipid based nutrient supplements (LNS) for treatment of children (6 months to 59 months) with moderate acute malnutrition(MAM): A systematic review. Plos One, 2017;12(9):1-41.
Lazzerini M., Tickell D. Antibiotics in severely malnourished children: systematic review of efficacy, safety and pharmacokinetics, Bulletin of the World Health Organization 2011;89(8):593-606.
Lenters L.M., Wazny K., Webb P., et al. Treatment of severe and moderate acute malnutrition in low- and middle-income settings: A systematic review, meta-analysis and Delphi process. BMC Public Health, 2013;13(Suppl 3):1-15.
Mitchell H., Porter J. The cost effectiveness of identifying and treating malnutrition in hospitals: a systematic review. Journal of Human Nutrition and Dietetics, 2015;29(2):156-64.
Picot J., Hartwell D., Harris P., et al. The effectiveness of interventions to treat severe acute malnutrition in young children: A systematic review. Health Technology Assessment, (2012). 16(19), 1-100.
Devakumar D., Fall C.H.D., Sachdev H.S., et al. Maternal antenatal multiple micronutrient supplementation for long term health benefits in children: a systematic review and meta-analysis. BMC Medicine, 2016;14(90):1-20.
Dror D.K., & Allen L.H. Interventions with vitamins B6, B12 and C in pregnancy. Paediatric and Perinatal Epidemiology, 2012;26(1):55–74.
Gresham E., Byles J.E., Bisquera A., et al. Effects of dietary interventions on neonatal and infant outcomes: a systematic review and meta-analysis. The American Journal of Clinical Nutrition, 2014;100(5):1298-1321.
Horvath A., Koletzko B., & Szajewska H. Effect of supplementation of women in high-risk pregnancies with long-chain polyunsaturated fatty acids on pregnancy outcomes and growth measures at birth: a meta-analysis of randomized controlled trials. British Journal of Nutrition, 2007;98(02):253.
Kawai K., Spiegelman D., Shankar A.H., et al. Maternal multiple micronutrient supplementation and pregnancy outcomes in developing countries: meta-analysis and meta-regression. Bulletin of the World Health Organization, 2011;89(6):402-11.
Liberato S.C., Singh G., Mulholland K. Effects of protein energy supplementation during pregnancy on fetal growth: a review of the literature focusing on contextual factors. Food & Nutrition Research, 2013;57(1):1-14.
Ramakrishnan U., Grant F.K., Goldenberg T., et al. Effect of multiple micronutrient supplementation on pregnancy and infant outcomes: A systematic review. Paediatric and Perinatal Epidemiology 2012;26(1):153-67.
Shah P.S., Ohlsson A. Effects of prenatal multimicronutrient supplementation on pregnancy outcomes: a meta-analysis. Canadian Medical Association Journal, 2009;180(12):99-108.
Stevens B., Buettner P., Watt K., et al. The effect of balanced protein energy supplementation in undernourished pregnant women and child physical growth in low- and middle-income countries: a systematic review and meta-analysis. Maternal and Child Nutrition, 2015;11(4):415-32.
Bassani D.G., Arora P., Wazny K., et al. Financial incentives and coverage of child health interventions: A systematic review and meta-analysis. BMC Public Health, 2013;13(Suppl 3).
De Silva A., Jones P., & Spencer S. Does human milk reduce infection rates in preterm infants? A systematic review. Archives of Disease in Childhood Fetal and Neonatal Edition, 2004;89(6):F509–F513.
Gale C., Logan K., Santhakumaran S., et al. Effect of breastfeeding compared with formula feeding on infant body composition: a systematic review and meta-analysis. SciVee. 2012;95(3):656–69.
Hall J. Effective community-based interventions to improve exclusive breast feeding at four to six months in low- and low-middle-income countries: a systematic review of randomised controlled trials. Midwifery, 2011;27(4):497-502.
Oliveira M.I., Camacho L.A., & Tedstone A.E. Extending breastfeeding duration through primary care: A Systematic Review of Prenatal and Postnatal Interventions. Journal of Human Lactation, 2001;17(4):326-43. [Please note that this is not an open access review.]
Pérez-Escamilla R., Pollitt E., Lönnerdal B., et al. Infant feeding policies in maternity wards and their effect on breast-feeding success: An analytical overview. American Journal of Public Health. 1994;84(1):89-97.
Szajewska H., Horvath A., Koletzko B., et al. Effects of brief exposure to water, breast milk substitutes, or other liquids, on the success and duration of breastfeeding: A systematic review. Acta Paediatrica 2006;95(2):145-52. doi:10.1111/j.1651-2227.2006.tb02199.x
Barros S.F., & Cardoso, M. A. Adherence to and acceptability of home fortification with vitamins and minerals in children aged 6 to 23 months: a systematic review. BMC Public Health, 2016;16(299):1-11.
Das J.K., Kumar R., Salam R.A. et al. Systematic review of Zinc fortification trials. Annals of Nutrition and Metabolism. 2013;62(S1):44-56.
De-Regil L.M., Suchdev P.S., Vist G.E., et al. Home fortification of foods with multiple micronutrient powders for health and nutrition in children under two years of age. Cochrane Database of Systematic Reviews 2011, Issue 9. Art. No.: CD008959.
Eichler K., Wieser S., Rüthemann I., et al. Effect of micronutrient fortified milk and cereal food for infants and children: a systematic review. BMC Public Health, 2012;12(506):1-13.
Els A., & Walsh C. The impact of preschool feeding programmes on the growth of disadvantaged young children in developing countries: A systematic review of randomised trials. South African Journal of Clinical Nutrition, 2013;26(2):33-40.
Gogia S., & Sachdev H.S. Maternal postpartum vitamin A supplementation for the prevention of mortality and morbidity in infancy: a systematic review of randomized controlled trials. International Journal of Epidemiology, 2010;39(5):1217-26.
Gulani A., Bhatnagar S., & Sachdev H.P. Neonatal zinc supplementation for prevention of mortality and morbidity in breastfed low birth weight infants: Systematic review of randomized controlled trials. Indian Pediatrics 2011;48(2):111-7.
Kristjansson E., Francis D.K., Liberato S., et al. Food supplementation for improving the physical and psychosocial health of socio-economically disadvantaged children aged three months to five years. Cochrane Database of Systematic Reviews 2015;Issue 3:Art. No.: CD009924.
Haider B.A., Yakoob M.Y., & Bhutta Z.A. Effect of multiple micronutrient supplementation during pregnancy on maternal and birth outcomes. BMC Public Health, 2011;11(3):1-9.
Lassi Z.S., Das J.K., Zahid G. et al. Impact of education and provision of complementary feeding on growth and morbidity in children less than 2 years of age in developing countries: a systematic review. BMC Public Health, 2013;13(Suppl 3):1-10.
Long H., Yi J., Hu P., et al. Benefits of iron supplementation for low birth weight infants: A systematic review. BMC Pediatrics. 2012;12(99);1-11.
Masset E., Haddad L., Cornelius A., et al. Effectiveness of agricultural interventions that aim to improve nutritional status of children: systematic review. BMJ. 2012;344:1-7.
Nkonki L., Tugendhaft A., & Hofman K. A systematic review of economic evaluations of CHW interventions aimed at improving child health outcomes. Human Resources for Health 2017;15(1):1-19.
Onubi O.J., Poobalan A.S., Dineen B., et al. Effects of probiotics on child growth: A systematic review. Journal of Health, Population and Nutrition, 2015;34(1):1-15.
Pasricha S., Hayes E., Kalumba K., et al. Effect of daily iron supplementation on health in children aged 4-23 months: A systematic review and meta-analysis of randomised controlled trials. The Lancet Global Health. 2013;1(2):77-86.
Petry N., Olofin I., Boy E., et al. The effect of low dose iron and zinc intake on child micronutrient status and development during the first 1000 days of life: A Systematic Review and Meta-Analysis. Nutrients, 2016;8(12):1-22.
Ramakrishnan U., Nguyen P., Martorell R. Effects of micronutrients on growth of children under 5 y of age: meta-analyses of single and multiple nutrient interventions. The American Journal of Clinical Nutrition, 2009;89(1):191–203.
Ramakrishnan U., Goldenberg T., Allen L.H. Do multiple micronutrient interventions improve child health growth and development? The Journal Of Nutrition 2011;141(11):2066-75.
Stammers A., Lowe N.M., Medina M.W., et al. The relationship between zinc intake and growth in children aged 1-8 years: A systematic review and meta-analysis. European Journal of Clinical Nutrition, 2014;69(2):147-53.
Sunguya B.F., Poudel K.C., Mlunde L.B. et al. Effectiveness of nutrition training of health workers toward improving caregivers feeding practices for children aged six months to two years: a systematic review. Nutrition Journal, 2013;12(66):1-14.
Gaffey M.F., Wazny K., Bassani D.G., et al. Dietary management of childhood diarrhea in low- and middle-income countries: a systematic review. BMC Public Health, 2013;13(Suppl 3):S17.
Galvao T.F., Thees M.F.R.S., Pontes R.F., et al. Zinc supplementation for treating diarrhea in children: a systematic review and meta-analysis. Rev Panam Salud Publica. 2013;33(5):370–7.
McHenry M.S., Dixit A., Vreeman R.C. A systematic review of nutritional supplementation in HIV-infected children in resource limited settings. Journal of the International Association of Providers of AIDS Care 2015;14(4):313-23.
Muscaritoli M., Krznarić Z., Singer P., et al. Effectiveness and efficacy of nutritional therapy: A systematic review following Cochrane methodology. Clinical Nutrition, 2017;36(4):939-57.
Si Z.L., Kang L.L., Shen X.B., et al. Adjuvant efficacy of nutrition support during pulmonary tuberculosis treating course: systematic review and meta-analysis. Chinese Medical Journal, 2015;128(23):3219-30.
Tang A.M., Quick T., Chung M., et al. Nutrition assessment, counseling, and support interventions to improve health-related outcomes in people living with HIV/AIDS. Journal of Acquired Immune Deficiency Syndromes, 2015;68:1-26.
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
Please contact us with suggestions and comments at firstname.lastname@example.org, so we can improve this page. We will add to this page whenever we find other relevant materials, so please return to this page if you are interested.
- 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