This study showed that most of the children admitted to the hospital with SAM <−3SD, were actually discharged as cured when using WHZ as an indicator (>−3SD). The latest report from the on-going monitoring from the government (personal communication) stated that >65 % of SAM children were not cured if the threshold of 15 % weight gain was used; however, our results indicate that the proportion is substantially lower, with 41.4 % not defined as cured at discharge. According to the current guidelines , the period of in-patient treatment is meant to last until the child has gained 15 % of their own bodyweight; however, we found that the average duration of stay in the hospital was 8.7 days (±5.8), with an average weight increase of only 7.4 %. This finding indicates that there is a need to revise the current guidelines, which would make the management and treatment of SAM more efficient and cost-effective for the government as well as the caretakers. As highlighted by the 2013 WHO update on the treatment of severe acute malnutrition, 15 % weight gain is not an appropriate discharge criterion . This report emphasizes that the anthropometric indicator that is used to confirm severe acute malnutrition should also be used to assess whether a child has reached nutritional recovery .
One of the major findings from this research was that the children who completed three follow-up visits were not only cured based on the above −3SD but were also no longer moderately malnourished, as most of them ended up >−2SD.
Mothers staying in average of 8.7 days in the hospital are already an achievement in Cambodia, as most mothers and caretakers proved unwilling to stay at the hospital for much longer, due to reasons like responsibility for other children at home and the need to tend to farm and livestock. Additionally, research on dropping out by Noij & Un (UNICEF personal communication) found that after the complementary disease was treated, mothers were unwilling to stay for malnutrition only, as her child could walk and play again and “did no longer look ill”. However, mothers are increasingly bringing back their children to follow-up visits. There has been an increase in follow-up visits over the last years, and compliance for the third follow-up has increased by 40 % from 2011 to 2013. To ensure that this compliance continues to increase, we need to ensure that mothers or caregivers are motivated. It appears from the study of Noij & Un that compliance in Cambodia depend much on the motivation of the mother/caretaker which was in many cases not very high. With a limited motivation of mothers and caretakers, there does not need to be much of a reason to discontinue treatment and many small reasons were provided to justify default. The reasons to stop treatment included the taste of the therapeutic food but also the limited time to devote to the treatment as they needed to focus on other household and economic activities.
The substantial weight gain of most children using BP100 can be considered to provide a stimulus for caretakers to come for follow-up visits, as they see that the treatment does provide beneficial results for the child concerned. The mothers and caretakers that do come for three follow-up visits are often characterized as those that are “eager to see their child gain weight”, i.e., they recognize the importance of weight gain given the condition of the child (UNICEF personal communication).
This finding clearly shows that IPD and follow-up visits work as a program for treatment of SAM with complications. Our study emphasizes the importance of follow-up visits to further lower the WHZ and decrease the risk of relapse.
When looking at the progress and achievements in regard to IPD, treatment in hospitals has gone from a few days of hospitalization and low compliance regarding follow-up visits to an extended stay in hospital with a take-home ration of ready-to-use therapeutic foods (RUTFs) and improved compliance regarding follow-up visits. The increase found in the duration of stay in hospital might be explained by incentives provided to the caretakers, such as Health Equity Funds (HEF) . The provision of HEF in regard to treatment of malnutrition was started in 2012 and are a pro-poor third party health financing mechanism providing health services for the identified poor (UNICEF personal communication). This means that the child is treated for free, including therapeutic foods, antibiotics, and any other drugs or supply needed. There is no charge for overnight stay, and they are provided with a food allowance per day. Additionally, the caretaker is reimbursed for transport fees, based on the distance and quality of the road. Transport support was also provided for follow-up visits; financial support and the introduction of a take-home ration are likely contributors to increased compliance .
In addition, the actual Cambodian guidelines and intervention emphasize the need to have a follow-up visit 5 weeks after discharge to avoid a relapse. In the context of Cambodia with a prevalence of wasting around 10 %, this final visit is essential to screen any tendency to prevent another episode of SAM (it seems not be the case for children having three follow-up visits). It is not yet well understood how much wasting contributes to conditions such as stunting. Evidence does suggest , however, that episodes of wasting negatively affect linear growth and, therefore, undermine child growth and development. It is, therefore, urgent to find a sustainable way to screen those children 5 weeks after; as of today only less than half of the children are coming back to these third visits.
Nineteen hospitals over the 35 existing were assessed. The authors decided to assess the hospitals that have been implementing SAM for at least 3 years (since the national guideline was approved). The newly open hospitals have learned from those hospitals, and therefore, we used the hypothesis that they will perform better than the one trained previously. Severe acute malnutrition (SAM) is a nationwide issue with a national prevalence of 2.5 % in 2010 . The 13 provinces are homogeneous mixed of provinces with prevalence above and below the national prevalence for SAM.
The quality of the recording of patient files was poor in several hospitals. This might be due to a lack of training of staff or a lack of a proper system for recording. Therefore, we could not further analyze the use of the treatment (antibiotics, F75, F100, vitamin A, BP100) in the management of children with severe acute malnutrition in out-patient care. Even though there was limited recording of types of antibiotics received, one concern that has been aired is that antibiotics are given to all children, whether the child has SAM with complications or not thus increasing the risk of antibiotic resistance. There is a need to reeducate health care staff on proper use of antibiotics, and specify that if antibiotics are given it needs to be given consistently, the same type taken over a minimum of 10 days .
The collection of data on the treatment of SAM at the level of Hospitals did not appear to be standardized. Nutrition and treatment for SAM indicators have not yet been included in the Health Monitoring Information System. It is therefore urgent to develop a web-based monitoring system at hospital and health center level to ensure that the correct protocols are used and children are well-treated.
Take-home rations are an important aspect of the treatment to ensure that the children will reach a WHZ > −2 z-scores. In order to be sustainable, the Government of Cambodia will have to include RUTF in their essential medical drug list to be able to purchase it and be less dependent on the funds of developing partners.
Capacities have been built in particular at the hospital, and attention has been paid to policy and guidelines, in particular the protocol for treatment of acute malnutrition. The limitation in terms of capacity development has been that much that the attention was focused at the individual level. Much less attention was paid to the institutional capacities, one of which concerns staffing structures, which leaves hospitals as well as health centers without staff with nutrition pre-service training. The establishment of an MSc course on Nutrition is an important step towards a more institutional approach to develop the capacities of health staffs and other individuals and can be expected to bear fruit only a few years from now.
With only 1600 cases annually referred to hospital and treated with F75, F100, and BP100 among an estimated 6000 cases of severe acute malnutrition with complications, mass screening is still a bottleneck as almost no routine screening is performed at the health center level or community level. In addition, unfortunately, the methodology used (mid-upper arm circumference (MUAC)) had a very small sensitivity and specificity to find the severely malnourished children . It is essential to revise the guidelines for mass screening to ensure that children are well-screened.