The elephant moves into the sunlight: progress in childhood malnutrition

Beginning with a historical summary of investigative work into protein-energy malnutrition, now termed 'severe acute malnutrition', this review ends by summarizing recent initiatives to tackle the global problem of malnutrition, specifically Scaling-Up Nutrition (SUN). In early years, macronutrient deficiency or imbalance was considered the principal cause of complex metabolic disturbances, including kwashiorkor, whereas, now, micronutrient deficiency infections, including HIV, and a background of deprivation are implicated. Different approaches to management are reviewed. The rehabilitation of individual children by protocolised-phased feeding has largely given way to community-based therapeutic feeding. Despite sporadic successes, the overall impact on morbidity and mortality has been so disappointing that the global community now plans a new initiative, viz. SUN. Its focus on the critical window of 1000 days (from conception to 2 years) is similar to the earlier focus on early childhood vulnerability which inspired the under-5 clinics and their integration into maternal and child health programmes. 'Targeted' interventions, recently more prominent than integrated community-based primary care, often undertaken by NGOs, have been effective, although sometimes imperfectly accountable. Will SUN, aiming for a broad approach, and the participation of recipient communities finally succeed in integrating nutrition into child health?