Malnutrition is the underlying cause of death for between three and five million children under five every year. Images of starving children in emergency settings are part of the public conscious, but the reality is that the vast majority of children suffering from malnutrition do so in silence, far away from the public eye.

Insufficient diets are a fact of every day life for hundreds of millions of children. The signs of malnutrition are so common - a short child or a child who has lost some weight - that we don't see these children as sick or suffering. But they are. When a child's diet fails to give her/him all the nutrients the body needs to maintain normal functioning, not only does growth falter, but susceptibility to common diseases increases. This is why a common cold or bout of diarrhea can kill a malnourished child.

Malnutrition is a medical emergency. MSF teams see the devastating impact of childhood malnutrition every day, having treated more than 150,000 children per year in 2006 and 2007. Malnutrition weakens resistance and increases the risk of dying from pneumonia, diarrhea, malaria, measles or AIDS - five diseases that are responsible for half of the nearly ten million deaths in children under five every year. Persistent high rates of child mortality in sub-Saharan Africa and South Asia will not be reduced if malnutrition is not addressed more aggressively.

Childhood malnutrition receives insufficient international attention. Despite its overwhelming contribution to child mortality and its impact on long-term health, the treatment and prevention of malnutrition has not been a high enough priority in international and national public health planning and programming.

Current approaches to address malnutrition have serious limitations. In places where highly-nutritious foods are not available, or where people do not have the money to buy such foods, behavior change approaches to malnutrition that focus on education about proper food choices, hand-washing and breastfeeding are not enough to address the problem.

Such strategies are insufficient because mothers in the Sahel, the Horn of Africa or Asia don't just need advice about how to feed their children. They need access to energy-dense, nutrient-rich foods, including animal-source foods to provide the 40 essential nutrients a young child needs to grow and be healthy. Exclusive breastfeeding meets nutritional needs until six months of age, and beyond that, young children need the addition of foods that include dairy, eggs, meat or fish.

Addressing the long-term challenges of poverty and food security is important - but addressing the needs of malnourished children today requires specific and targeted strategies to ensure children under two have access to the minimum nutrition they require. Existing interventions that fail to ensure the nutritional needs of children under two are met must be overhauled and new strategies that target these children need to be devised.

UN recommendations call for children with severe acute malnutrition to receive treatment through community-based nutrition programs, without being admitted to a health facility or therapeutic feeding center, unless the child has a medical complication. These recommendations must not be allowed to remain a dead letter.

Simple, highly-nutritious ready-to-use foods (RUFs), specifically designed to address the nutritional needs of young children, have greatly expanded the potential for effective nutritional interventions. Therapeutic treatment programs with ready-to-use foods (RUFs) allow the vast majority of seriously malnourished children to receive treatment at home, under the supervision of their mother or other caregiver, instead of in hospital. MSF and others have documented the successes that can be achieved through use of RUFs - high cure rates with high coverage, as well as low mortality and default rates.

However, according to MSF estimates, only 3% of the 20 million children suffering from severe acute malnutrition each year receive the treatment they need.

RUFs also hold great promise for reaching children earlier, before their growth starts to falter, or to help them catch up after illness. Current programs to prevent and address less-severe forms of malnutrition are inadequate, because they don't provide the right foods. Between six and 24 months of age, young children need energy-dense, nutrient-rich foods to support them during a period of rapid growth and development. This concentration and diversity of nutrients requires a diverse diet including animal-source foods, which are expensive and often not accessible, making children particularly vulnerable to food insecurity.

However, international food aid continues to supply fortified blended flours that don't contain animal-source foods. The fact that milk was removed from these flours targeted at young children for economic reasons in the late 1980s indicates a deadly double standard in which nutritional science is ignored. Donors and UN agencies must revisit the food that is given as a part of food aid programs.

New strategies of delivering essential nutrients must be developed, and scaled up. RUFs should be placed in the larger context of innovating strategies that can help families give the youngest children the nutrient-rich diets they need. Other strategies, such as providing income support to households should also be pursued.

(MSF via China.org.cn December 2, 2008)