All moderately wasted children are at risk, but some are more at risk than others

A multi-country, randomized trial of three nutritional supplements on short-term and sustained anthropometric recovery in children 6-24 months of age with moderate wasting and acute illnesses: the NUTRIMAM study protocol

BACKGROUND

Globally, moderate wasting affects approximately 33 million children. Complex bidirectional interactions exist between wasting and infection in children. Children who experience both conditions have an increased risk of adverse outcomes including progression to severe wasting and mortality. Breaking the cycle between moderate wasting and infection could help improve growth and survival in these children. The NUTRIMAM trial will aim to investigate the efficacy of a 12-week regimen of three different nutritional interventions in at-risk young children (i.e., children who are moderately wasted and have one/more acute infections) on anthropometric recovery. Further, the study will explore whether recovery can be sustained with a post-intervention package that includes counseling and food vouchers. Sustaining anthropometric recovery beyond supplement administration will have important implications for programs.

METHODS

NUTRIMAM is a multi-country, multi-center individually randomized, open-label, trial in five countries including Bangladesh, India, Mali, Pakistan, and Tanzania. A total of 6360 moderately wasted children aged 6 to 24 months with acute illness will be enrolled at health centers. Children will be randomly allocated to receive one of three dietary supplements (locally available foods, ready-to-use supplementary foods, or microbiota-directed supplementary foods) for 12 weeks. Anthropometric recovery will be assessed over this period. Participants who recover will then be re-randomized to a post-recovery support intervention comprising either counseling and food vouchers or routine standard of care for recovered children for an additional 12 weeks to determine if this intervention facilitates sustained recovery at 24 weeks.

DISCUSSION

Children who are moderately wasted and have an infection are at higher risk of adverse outcomes. There are very few clinical trials that have been performed among children with moderate wasting with infectious illnesses to investigate if it is possible to break the undernutrition-infection cycle and thereby reduce the risk of nutritional deterioration to severe wasting or mortality and decrease the risk of acute infections. The results of the trial are anticipated to fill important evidence gaps in feeding recommendations for moderately wasted children with acute illness as well as interventions to sustain anthropometric recovery in children beyond the period of the nutritional intervention.

TRIAL REGISTRATION

ISRCTN registry, ISRCTN53213318 . Registered on April 03, 2023.

Supplementary Feeding of Moderately Wasted Children in Sierra Leone Reduces Severe Acute Malnutrition and Death When Compared to Nutrition Counseling: a Retrospective Cohort Study

BACKGROUND

There is uncertainty about whether children with moderate wasting should receive supplementary feeding.

OBJECTIVES

We examined whether supplementary feeding compared to counseling alone in children with moderate wasting prevented progression to severe acute malnutrition (SAM) or death.

METHODS

This was a retrospective, dual cohort study in which 1,791 children with moderate wasting were drawn from two prior randomized controlled trials that took place in the same location in rural Sierra Leone. 1,077 children received supplementary feeding, while 714 children received counseling alone. Children in both cohorts were followed for at least 24 weeks from enrollment. The primary outcome was time to SAM or death using Kaplan-Meier analysis. Secondary outcomes included time to death as well as proportions of children with healthy mid-upper arm circumference (MUAC), moderate wasting, SAM, or death at 6, 12, and 24 weeks from enrollment.

RESULTS

Children who received supplementary feeding were less likely to develop SAM or die across the entire follow-up period (HR 0.53, 95% CI 0.44, 0.65, P < 0.001). Time to event for death alone also revealed a lower risk for children who received supplementary feeding (HR 0.52, 95% CI 0.28, 0.94, P = 0.03). Children who received supplementary feeding were more likely to have a healthy MUAC at 6 weeks (RR 2.0, 95% CI 1.7, 2.2) and 12 weeks (RR 1.3, 95% CI 1.2, 1.5), were less likely to develop SAM at 6 (RR 0.7, 95% CI 0.6, 0.9), 12 (RR 0.5, 95% CI 0.3, 0.8), and 24 weeks (RR 0.2, 95% CI 0.1, 0.5), and had higher rates of gain in weight and MUAC at 6 and 12 weeks.

CONCLUSIONS

Supplementary feeding of children with moderate wasting reduces risk of SAM and death across 24 weeks of follow-up.