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Maru Y, Tamiru D, Baye K, Chitekwe S, Lailou A, Darsene H, Abdulai R, Worku M, Belachew T. Effect of a simplified approach on recovery of children 6-59 months with wasting in Ethiopia: A noninferiority, cluster randomized controlled trial. MATERNAL & CHILD NUTRITION 2024:e13670. [PMID: 38800892 DOI: 10.1111/mcn.13670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 05/06/2024] [Accepted: 05/07/2024] [Indexed: 05/29/2024]
Abstract
Worldwide, nearly 45 million children under the age of 5 years were affected by wasting in 2022. Ethiopia has been challenged by disasters increasing the caseload of children with wasting. This study aimed to determine the effect of a simplified approach on recovery of children with acute malnutrition as compared with the standard protocol. A cluster randomized, controlled, noninferiority trial was carried out in three regions of Ethiopia from December 4, 2021, to July 30, 2022. A total of 58 clusters (health posts) were randomized into intervention and control groups. Children with SAM in the intervention groups received two sachets of Ready-to-Use Therapeutic Food (RUTF), whereas children in the control groups received RUTF based on their body weight. Children with moderate acute malnutrition (MAM) received one sachet of RUTF and one sachet of Ready-to-Use Supplementary Food (RUSF) daily in the intervention and control groups, respectively. Per protocol (PP) and intention-to-treat analysis were used to compare recovery at a noninferiority margin of 15%. Data were collected from 55 health posts and 1032 children. In the PP analysis, the recovery rate of children with wasting among the simplified group (97.8%) was noninferior to the standard protocol group (97.7%), p = 0.399. The RUTF cost per treatment of child with SAM was 56.55 USD for the standard versus 42.78 USD for the simplified approach. The simplified approach is noninferior to the standard protocol in terms of recovery and has a lower cost of RUTF. Further study is recommended to assess the effectiveness of the simplified approach in emergency contexts.
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Affiliation(s)
- Yetayesh Maru
- Nutrition and Dietetics Department, Faculty of Public Health, Jimma University, Jimma, Ethiopia
| | - Dessalegn Tamiru
- Nutrition and Dietetics Department, Faculty of Public Health, Jimma University, Jimma, Ethiopia
| | - Kaleab Baye
- Center for Food Science and Nutrition, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Arnaud Lailou
- UNICEF West and Central Africa Regional Office, Nutrition Section, Dakar, Senegal
| | - Hiwot Darsene
- Nutrition Coordination Office, Ethiopian Ministry of Health, Addis Ababa, Ethiopia
| | - Rashid Abdulai
- Nutrition Section, UNICEF Ethiopia, Addis Ababa, Ethiopia
| | - Mesfin Worku
- Nutrition Section, UNICEF Ethiopia, Addis Ababa, Ethiopia
| | - Tefera Belachew
- Nutrition and Dietetics Department, Faculty of Public Health, Jimma University, Jimma, Ethiopia
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Maru Y, Tamiru D, Baye K, Chitekwe S, Kifle YG, Lailou A, Belachew T. Comparing time to recovery in wasting treatment: simplified approach vs. standard protocol among children aged 6-59 months in Ethiopia-a cluster-randomized, controlled, non-inferiority trial. Front Pediatr 2024; 12:1337370. [PMID: 38840802 PMCID: PMC11150620 DOI: 10.3389/fped.2024.1337370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 05/03/2024] [Indexed: 06/07/2024] Open
Abstract
Introduction Wasting occurs when the body's nutritional needs are unmet due to insufficient intake or illness. It represents a significant global challenge, with approximately 45 million infants and children under 5 years of age suffering from wasting in 2022. Methods A cluster-randomized, controlled, non-inferiority trial was conducted in three regions of Ethiopia. A non-inferiority margin of 15%, along with a recovery rate of 90% and a minimum acceptable recovery rate of 75%, were considered alongside an intra-cluster correlation coefficient of 0.05 and an anticipated loss to follow-up of 10% in determining the total sample size of 1,052 children. Children with severe acute malnutrition (SAM) in the simplified group received two sachets of ready-to-use therapeutic food (RUTF) daily, while the standard group received RUTF based on their body weight. For moderate acute malnutrition (MAM) cases, the simplified group received one sachet of RUTF, whereas the standard group received one sachet of ready-to-use supplementary food daily. A non-parametric Kaplan-Meir curve was utilized to compare the survival time to recovery. Results A total of 1,032 data points were gathered. For SAM cases, the average length of stay was 8.86 (±3.91) weeks for the simplified protocol and 8.26 (±4.18) weeks for the standard protocol (P = 0.13). For MAM cases, the average length of stay was 8.18 (±2.96) weeks for the simplified approach and 8.32 (±3.55) weeks for the standard protocol (P = 0.61). There was no significant difference (P = 0.502) observed between the simplified protocol [8 weeks, interquartile range (IQR): 7.06-8.94] and the standard protocol [9 weeks (IQR: 8.17-9.83)] among children with SAM on the median time to cure. There was no significant difference (P = 0.502) in the time to cure between the simplified approach [8 weeks (IQR: 7.53-8.47)] and the standard protocol [8 weeks (IQR: 7.66-8.34)] among children with MAM. The survival curves displayed similarity, with the log-rank test not showing significance (P > 0.5), indicating the non-inferiority of the simplified approach for cure time. Conclusion The findings showed that the simplified and standard protocols demonstrated no significant differences in terms of the average duration of stay and time required for recovery. Clinical Trial Registration https://pactr.samrc.ac.za/, Identifier (PACTR202202496481398).
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Affiliation(s)
- Yetayesh Maru
- Nurition and Dietetics Department, Faculty of Public Health, Jimma University, Jimma, Ethiopia
| | - Dessalegn Tamiru
- Nurition and Dietetics Department, Faculty of Public Health, Jimma University, Jimma, Ethiopia
| | - Kaleab Baye
- Center for Food Science and Nutrition, Addis Ababa University, Addis Ababa, Ethiopia
- Nutrition and Food Systems Division, Research Center for Inclusive Development in Africa (RIDA), Addis Ababa, Ethiopia
| | | | - Yehenew G. Kifle
- Department of Mathematics and Statistics, University of Maryland Baltimore County, Baltimore, MD, United States
| | - Arnaud Lailou
- Nutrition Section, UNICEF West and Central Africa Regional Office, Dakar, Senegal
| | - Tefera Belachew
- Nurition and Dietetics Department, Faculty of Public Health, Jimma University, Jimma, Ethiopia
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López-Ejeda N, Charle-Cuéllar P, Samake S, Dougnon AO, Sánchez-Martínez LJ, Samake MN, Bagayoko A, Bunkembo M, Touré F, Vargas A, Guerrero S. Effectiveness of decentralizing outpatient acute malnutrition treatment with community health workers and a simplified combined protocol: a cluster randomized controlled trial in emergency settings of Mali. Front Public Health 2024; 12:1283148. [PMID: 38450139 PMCID: PMC10915236 DOI: 10.3389/fpubh.2024.1283148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 01/12/2024] [Indexed: 03/08/2024] Open
Abstract
Background Outpatient treatment of acute malnutrition is usually centralized in health centers and separated into different programs according to case severity. This complicates case detection, care delivery, and supply chain management, making it difficult for families to access treatment. This study assessed the impact of treating severe and moderate cases in the same program using a simplified protocol and decentralizing treatment outside health centers through community health workers (CHWs). Methods A three-armed cluster randomized controlled trial under a non-inferiority hypothesis was conducted in the Gao region of Mali involving 2,038 children between 6 and 59 months of age with non-complicated acute malnutrition. The control arm consisted of 549 children receiving standard treatment in health centers from nursing staff. The first intervention arm consisted of 800 children treated using the standard protocol with CHWs added as treatment providers. The second intervention arm consisted of 689 children treated by nurses and CHWs under the ComPAS simplified protocol, considering mid-upper arm circumference as the sole anthropometric criterion for admission and discharge and providing a fixed dose of therapeutic food for severe and moderate cases. Coverage was assessed through cross-sectional surveys using the sampling evaluation of access and coverage (SLEAC) methodology for a wide area involving several service delivery units. Results The recovery rates were 76.3% in the control group, 81.8% in the group that included CHWs with the standard protocol, and 92.9% in the group that applied the simplified protocol, confirming non-inferiority and revealing a significant risk difference among the groups. No significant differences were found in the time to recovery (6 weeks) or in anthropometric gain, whereas the therapeutic food expenditure was significantly lower with the simplified combined program in severe cases (43 sachets fewer than the control). In moderate cases, an average of 35 sachets of therapeutic food were used. With the simplified protocol, the CHWs had 6% discharge errors compared with 19% with the standard protocol. The treatment coverage increased significantly with the simplified combined program (SAM +42.5%, MAM +13.8%). Implications Implementing a simplified combined treatment program and adding CHWs as treatment providers can improve coverage while maintaining non-inferior effectiveness, reducing the expenditure on nutritional intrants, and ensuring the continuum of care for the most vulnerable children.
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Affiliation(s)
- Noemí López-Ejeda
- EPINUT Research Group (ref. 920325), Unit of Physical Anthropology, Department of Biodiversity, Ecology and Evolution, Faculty of Biological Sciences, Complutense University of Madrid, Madrid, Spain
| | | | - Salimata Samake
- Nutrition and Health Department, Action Against Hunger, Bamako, Mali
| | | | - Luis Javier Sánchez-Martínez
- EPINUT Research Group (ref. 920325), Unit of Physical Anthropology, Department of Biodiversity, Ecology and Evolution, Faculty of Biological Sciences, Complutense University of Madrid, Madrid, Spain
| | - Mahamadou N’tji Samake
- Nutrition Directorate of the General Directorate of Health and Public Hygiene, Ministry of Health, Bamako, Mali
| | - Aliou Bagayoko
- Nutrition Directorate of the General Directorate of Health and Public Hygiene, Ministry of Health, Bamako, Mali
| | - Magloire Bunkembo
- Nutrition and Health Department, Action Against Hunger, Bamako, Mali
| | - Fanta Touré
- West and Central Africa Regional Office, Action Against Hunger, Dakar, Senegal
| | - Antonio Vargas
- Nutrition and Health Department, Action Against Hunger, Madrid, Spain
| | - Saul Guerrero
- Child Nutrition and Development Office, UNICEF, New York, NY, United States
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Kangas ST, Ouédraogo CT, Tounkara M, Ouoluoguem B, Coulibaly IN, Haidara A, Diarra NH, Diassana K, Tausanovitch Z, Ritz C, Wells JC, Briend A, Myatt M, Radin E, Bailey J. Nutritional treatment of children 6-59 months with severely low weight-for-age z-score: a study protocol for a 3-arm randomized controlled trial. Trials 2024; 25:30. [PMID: 38191436 PMCID: PMC10773065 DOI: 10.1186/s13063-023-07890-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 12/18/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND Admission criteria that treat children with low mid-upper-arm circumference (MUAC), and low weight-for-height z-score (WHZ) are not aligned with the evidence on which children are at risk of mortality. An analysis of community-based cohort data from Senegal found that a combination of weight-for-age (WAZ) and MUAC criteria identified all children at risk of near-term death associated with severe anthropometric deficits. This study will address whether children with WAZ <-3 but MUAC ≥125 mm benefit from therapeutic feeding with ready-to-use therapeutic foods (RUTF) and whether a simplified protocol is non-inferior to the weight-based standard protocol. METHODS This is a prospective individually randomized controlled 3-arm trial conducted in the Nara health district in Mali. Children aged 6-59 months presenting with MUAC ≥125 mm and WAZ <-3 will be randomized to (1) control group receiving no treatment, (2) simplified treatment receiving 1 sachet of RUTF daily until WAZ ≥-3 for 2 visits, (3) standard treatment receiving RUTF according to WHZ category: (a) WHZ <-3 receive 200 kcal/kg/day until WHZ ≥-2 for 2 visits, (b) WHZ ≥-3 but <-2 receive 1 sachet daily until WHZ ≥-2 for 2 visits or (c) WHZ ≥-2 receive no treatment. All children will be followed up first fortnightly for 12 weeks and then monthly until 6 months post-enrolment. The primary endpoint will be measured at 2 months with the primary outcome being WAZ as a continuous measure. Other outcomes include other anthropometric measurements and a secondary endpoint will be observed at 6 months. A total of 1397 children will be recruited including 209 in the control and 594 in both the simplified and standard arms. The sample size should enable us to conclude on the superiority of the simplified treatment compared to no treatment and on the non-inferiority of the simplified treatment versus standard treatment with a margin of non-inferiority of 0.2 WAZ. DISCUSSION This trial aims to generate new evidence on the benefit of treating children with WAZ <-3 but MUAC ≥125 mm in order to guide the choice of admission criteria to malnutrition treatment and build evidence on the most efficient treatment protocol. TRIAL REGISTRATION This trial was registered at ClinicalTrials.gov: NCT05248516 on February 21, 2022.
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Affiliation(s)
| | | | - Moctar Tounkara
- Department of Education and Research in Public Health and Specialties, Faculty of Medicine and Dentistry, University of Sciences, Technics and Technologies of Bamako, Bamako, Mali
| | | | | | | | | | | | | | - Christian Ritz
- National Institute of Public Health, Copenhagen, Denmark
| | - Jonathan C Wells
- Population Policy and Practice Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - André Briend
- Department of International Health, University of Tampere School of Medicine, Tampere, Finland
- Department of Nutrition, Exercise and Sports, Faculty of Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Mark Myatt
- Brixton Health, Brixton, UK
- Emergency Nutrition Network, Kidlington, Oxforshire, UK
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Alier KK, Tappis H, Ismail S, Doocy S. Impact of COVID-19 program adaptations on costs and cost-effectiveness of community management of acute malnutrition program in South Sudan. Public Health Nutr 2023; 27:e15. [PMID: 38095095 PMCID: PMC10830371 DOI: 10.1017/s1368980023002719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 08/14/2023] [Accepted: 09/18/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVE We assessed the impact of the COVID-19 pandemic and the protocol adaptations on cost and cost-effectiveness of community management of acute malnutrition (CMAM) program in South Sudan. DESIGN Retrospective program expenditure-based analysis of non-governmental organisation (NGO) CMAM programs for COVID-19 period (April 2020-December 2021) in respect to pre-COVID period (January 2019-March 2020). SETTING Study was conducted as part of a bigger evaluation study in South Sudan. PARTICIPANTS International and national NGOs operating CMAM programs under the nutrition cluster participated in the study. RESULTS The average cost per child recovered from the programme declined by 20 % during COVID from $133 (range: $34-1174) pre-COVID to $107 (range: $20-333) during COVID. The cost per child recovered was negatively correlated with programme size (pre-COVID r-squared = 0·58; during COIVD r-squared = 0·50). Programmes with higher enrollment were cheaper compared with those with low enrolment. Salaries, ready to use food and community activities accounted for over two-thirds of the cost per recovery during both pre-COVID (69 %) and COVID (79 %) periods. While cost per child recovered decreased during COVID period, it did not negatively impact on the programme outcome. Enrolment increased by an average of 19·8 % and recovery rate by 4·6 % during COVID period. CONCLUSIONS Costs reduced with no apparent negative implication on recovery rates after implementing the COVID CMAM protocol adaptations with a strong negative correlation between cost and programme size. This suggests that investing in capacity, screening and referral at existing CMAM sites to enable expansion of caseload maybe a preferable strategy to increasing the number of CMAM sites in South Sudan.
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Affiliation(s)
- Kemish Kenneth Alier
- Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD21205, USA
| | - Hannah Tappis
- Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD21205, USA
| | - Sule Ismail
- US Centers for Disease Control and Prevention, Juba, South Sudan
- Integral Global Consulting, Atlanta, GA
| | - Shannon Doocy
- Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD21205, USA
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Sánchez-Martínez LJ, Charle-Cuéllar P, Gado AA, Dougnon AO, Sanoussi A, Ousmane N, Lazoumar RH, Toure F, Vargas A, Hernández CL, López-Ejeda N. Impact of a simplified treatment protocol for moderate acute malnutrition with a decentralized treatment approach in emergency settings of Niger. Front Nutr 2023; 10:1253545. [PMID: 38099186 PMCID: PMC10719846 DOI: 10.3389/fnut.2023.1253545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 11/14/2023] [Indexed: 12/17/2023] Open
Abstract
Introduction Of the 45.4 million children under five affected by acute malnutrition in the world, the majority (31.8 million) are affected by moderate acute malnutrition (MAM). Its treatment is particularly complex in emergency settings such as the Diffa region in Niger. This study aims to evaluate the effectiveness and coverage of a simplified treatment protocol with Community Health Workers (CHWs) as treatment providers. Methods This study is a non-randomized controlled trial. The control group (n = 181) received the standard protocol currently used in country, delivered by nursing staff only in health centres and health posts, while the intervention group (n = 483) received the simplified protocol which included nursing at health centres and CHWs at health post as treatment providers. Results The recovery rate was higher in the simplified protocol group (99.6% vs. 79.56%, p < 0.001) recording lower time to recover and higher anthropometric gain. Treatment coverage in the intervention group increased from 28.8% to 84.9% and reduced in the control group (25.3% to 13.6%). No differences were found in the recovery rate of children treated by CHWs and nursing staff. Conclusion The outcomes using the simplified protocol exceeded humanitarian requirements and demonstrated improvements compared to the standard protocol showing that the simplified protocol could be safely provided by CHWs in an emergency context. Further research in other contexts is needed to scale up this intervention.
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Affiliation(s)
- Luis Javier Sánchez-Martínez
- Unit of Physical Anthropology, Department of Biodiversity, Ecology and Evolution, Faculty of Biological Sciences, Complutense University of Madrid, Madrid, Spain
| | | | | | | | - Atté Sanoussi
- Nutrition Direction, Ministry of Health, Niamey, Niger
| | | | | | - Fanta Toure
- Action Against Hunger, West and Central Africa Regional Office, Dakar, Senegal
| | | | - Candela Lucía Hernández
- Unit of Physical Anthropology, Department of Biodiversity, Ecology and Evolution, Faculty of Biological Sciences, Complutense University of Madrid, Madrid, Spain
| | - Noemí López-Ejeda
- Unit of Physical Anthropology, Department of Biodiversity, Ecology and Evolution, Faculty of Biological Sciences, Complutense University of Madrid, Madrid, Spain
- EPINUT Research Group (Ref. 920325), Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
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Mdege ND, Masuku SD, Musakwa N, Chisala M, Tingum EN, Boachie MK, Shokraneh F. Costs and cost-effectiveness of treatment setting for children with wasting, oedema and growth failure/faltering: A systematic review. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002551. [PMID: 37939029 PMCID: PMC10631642 DOI: 10.1371/journal.pgph.0002551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 10/05/2023] [Indexed: 11/10/2023]
Abstract
This systematic review aimed to address the existing evidence gaps, and guide policy decisions on the settings within which to treat infants <12 months of age with growth faltering/failure, and infants and children aged <60 months with moderate wasting or severe wasting and/or bilateral pitting oedema. Twelve electronic databases were searched for studies published before 10 December 2021. The searches yielded 16,709 records from which 31 studies were eligible and included in the review. Three studies were judged as low quality, whilst 14 were moderate and the remaining 14 were high quality. We identified very few cost and cost-effectiveness analyses for most of the models of care with the certainty of evidence being judged at very low or low. However, there were 17 cost and 6 cost-effectiveness analyses for the initiation of treatment in outpatient settings for severe wasting and/or bilateral pitting oedema in infants and children <60 months of age. From this evidence, the costs appear lowest for initiating treatment in community settings, followed by initiating treatment in community and transferring to outpatient settings, initiating treatment in outpatients then transferring to community settings, initiating treatment in outpatient settings, and lastly initiating treatment in inpatient settings. In addition, the evidence suggested that initiation of treatment in outpatient settings is highly cost-effective when compared to doing nothing or no programme implementation scenarios, using country-specific WHO GDP per capita thresholds. The incremental cost-effectiveness ratios ranged from $20 to $145 per DALY averted from a provider perspective, and $68 to $161 per DALY averted from a societal perspective. However, the certainty of the evidence was judged as moderate because of comparisons to do nothing/ no programme scenarios which potentially limits the applicability of the evidence in real-world settings. There is therefore a need for evidence that compare the different available alternatives.
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Affiliation(s)
- Noreen Dadirai Mdege
- Department of Health Sciences, University of York, York, United Kingdom
- Centre for Research in Health and Development, York, United Kingdom
| | - Sithabiso D. Masuku
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nozipho Musakwa
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mphatso Chisala
- Department of Population, Policy and Practice, Great Ormond Street Hospital, Institute of Child Health, University College London, London, United Kingdom
| | | | - Micheal Kofi Boachie
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Farhad Shokraneh
- Department of Evidence Synthesis, Systematic Review Consultants LTD, Nottingham, United Kingdom
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Abdullahi SU, Gambo S, Murtala HA, Kabir H, Shamsu KA, Gwarzo G, Acra S, Stallings VA, Rodeghier M, DeBaun MR, Klein LJ. Feasibility trial for the management of severe acute malnutrition in older children with sickle cell anemia in Nigeria. Blood Adv 2023; 7:6024-6034. [PMID: 37428866 PMCID: PMC10582275 DOI: 10.1182/bloodadvances.2023010789] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/28/2023] [Accepted: 06/30/2023] [Indexed: 07/12/2023] Open
Abstract
Children with sickle cell anemia (SCA) living in Nigeria are at an increased risk of malnutrition, which contributes to increased morbidity and mortality. However, evidence-based guidelines for managing malnutrition in children with SCA are lacking. To address this gap, we conducted a multicenter, randomized controlled feasibility trial to assess the feasibility and safety of treating children with SCA aged from 5 to 12 years and having uncomplicated severe acute malnutrition (body mass index z score of <-3.0). Children with SCA and uncomplicated severe acute malnutrition were randomly allocated to receive supplemental ready-to-use therapeutic food (RUTF) with or without moderate-dose hydroxyurea therapy (20 mg/kg per day). Over a 6-month enrollment period, 3190 children aged from 5 to 12 years with SCA were evaluated for eligibility, and 110 of 111 children who were eligible were enrolled. During the 12-week trial, no participants withdrew or missed visits. One participant died of unrelated causes. Adherence was high for hydroxyurea (94%, based on pill counts) and RUTF (100%, based on the number of empty sachets returned). No refeeding syndrome event or hydroxyurea-related myelosuppression occurred. At the end of the trial, the mean change in body mass index z score was 0.49 (standard deviation = 0.53), and 39% of participants improved their body mass index z score to ≥-3.0. Our findings demonstrate the feasibility, safety, and potential of outpatient treatment for uncomplicated severe acute malnutrition in children with SCA aged from 5 to 12 years in a low-resource setting. However, RUTF sharing with household and community members potentially confounded the response to malnutrition treatment. This trial was registered at clinicaltrials.gov as #NCT03634488.
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Affiliation(s)
- Shehu U. Abdullahi
- Department of Pediatrics, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Safiya Gambo
- Department of Pediatrics, Murtala Mohammed Specialist Hospital, Kano, Nigeria
| | - Hassan Adam Murtala
- Department of Pediatrics, Murtala Mohammed Specialist Hospital, Kano, Nigeria
| | - Halima Kabir
- Department of Pediatrics, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Khadija A. Shamsu
- Department of Pediatrics, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Garba Gwarzo
- Department of Pediatrics, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Sari Acra
- Department of Pediatrics, D. Brent Polk Division of Pediatric Gastroenterology, Hepatology, and Nutrition at Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | - Virginia A. Stallings
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA
| | | | - Michael R. DeBaun
- Department of Pediatrics, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN
| | - Lauren J. Klein
- Department of Pediatrics, D. Brent Polk Division of Pediatric Gastroenterology, Hepatology, and Nutrition at Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN
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Cichon B, Lopez Ejeda N, Charle Cuellar P, Hamissou IA, Karim AAA, Aton C, Sanoussi A, Ousmane N, Lazoumar RH, Gado AAO, Harouna ZY, Oteyza SG. Cost of Acute Malnutrition Treatment Using a Simplified or Standard Protocol in Diffa, Niger. Nutrients 2023; 15:3833. [PMID: 37686865 PMCID: PMC10490076 DOI: 10.3390/nu15173833] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/21/2023] [Accepted: 08/28/2023] [Indexed: 09/10/2023] Open
Abstract
Evidence on the cost of acute malnutrition treatment, particularly with regards to simplified approaches, is limited. The objective of this study was to determine the cost of acute malnutrition treatment and how it is influenced by treatment protocol and programme size. We conducted a costing study in Kabléwa and N'Guigmi, Diffa region, where children with acute malnutrition aged 6-59 months were treated either with a standard or simplified protocol, respectively. Cost data were collected from accountancy records and through key informant interviews. Programme data were extracted from health centre records. In Kabléwa, where 355 children were treated, the cost per child treated was USD 187.3 (95% CI: USD 171.4; USD 203.2). In N'Guigmi, where 889 children were treated, the cost per child treated was USD 110.2 (95% CI: USD 100.0; USD 120.3). Treatment of moderate acute malnutrition was cheaper than treatment of severe acute malnutrition. In a modelled scenario sensitivity analysis with an equal number of children in both areas, the difference in costs between the two locations was reduced from USD 77 to USD 11. Our study highlighted the significant impact of programme size and coverage on treatment costs, that cost can differ significantly between neighbouring locations, and that it can be reduced by using a simplified protocol.
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Affiliation(s)
| | - Noemi Lopez Ejeda
- EPINUT Research Group (Ref. 920325), Unit of Physical Anthropology, Department of Biodiversity, Ecology and Evolution, Faculty of Biological Sciences, Complutense University of Madrid, 28040 Madrid, Spain;
| | | | | | | | | | - Atté Sanoussi
- Nutrition Direction, Ministry of Health, Niamey BP 623, Niger; (A.S.)
| | - Nassirou Ousmane
- Nutrition Direction, Ministry of Health, Niamey BP 623, Niger; (A.S.)
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Lelijveld N, Cox S, Anujuo K, Amoah AS, Opondo C, Cole TJ, Wells JCK, Thompson D, McKenzie K, Abera M, Berhane M, Kerac M. Post-malnutrition growth and its associations with child survival and non-communicable disease risk: a secondary analysis of the Malawi 'ChroSAM' cohort. Public Health Nutr 2023; 26:1658-1670. [PMID: 36876519 PMCID: PMC10466107 DOI: 10.1017/s1368980023000411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 01/05/2023] [Accepted: 02/06/2023] [Indexed: 03/07/2023]
Abstract
OBJECTIVE To explore patterns of post-malnutrition growth (PMGr) during and after treatment for severe malnutrition and describe associations with survival and non-communicable disease (NCD) risk 7 years post-treatment. DESIGN Six indicators of PMGr were derived based on a variety of timepoints, weight, weight-for-age z-score and height-for-age z-score (HAZ). Three categorisation methods included no categorisation, quintiles and latent class analysis (LCA). Associations with mortality risk and seven NCD indicators were analysed. SETTING Secondary data from Blantyre, Malawi between 2006 and 2014. PARTICIPANTS A cohort of 1024 children treated for severe malnutrition (weight-for-length z-score < 70 % median and/or MUAC (mid-upper arm circumference) < 110 mm and/or bilateral oedema) at ages 5-168 months. RESULTS Faster weight gain during treatment (g/d) and after treatment (g/kg/day) was associated with lower risk of death (adjusted OR 0·99, 95 % CI 0·99, 1·00; and adjusted OR 0·91, 95 % CI 0·87, 0·94, respectively). In survivors (mean age 9 years), it was associated with greater hand grip strength (0·02, 95 % CI 0·00, 0·03) and larger HAZ (6·62, 95 % CI 1·31, 11·9), both indicators of better health. However, faster weight gain was also associated with increased waist:hip ratio (0·02, 95 % CI 0·01, 0·03), an indicator of later-life NCD risk. The clearest patterns of association were seen when defining PMGr based on weight gain in g/d during treatment and using the LCA method to describe growth patterns. Weight deficit at admission was a major confounder. CONCLUSIONS A complex pattern of benefits and risks is associated with faster PMGr. Both initial weight deficit and rate of weight gain have important implications for future health.
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Affiliation(s)
- Natasha Lelijveld
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, LondonWC1E 7HT, UK
- Emergency Nutrition Network (ENN), Oxford, UK
- Centre for Maternal, Adolescent & Reproductive Child Health (MARCH), London School of Hygiene & Tropical Medicine, London, UK
| | - Sioned Cox
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, LondonWC1E 7HT, UK
| | - Kenneth Anujuo
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, LondonWC1E 7HT, UK
| | - Abena S Amoah
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, LondonWC1E 7HT, UK
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | - Charles Opondo
- Department of Medical Statistics, Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Tim J Cole
- Population Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Jonathan CK Wells
- Population Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Debbie Thompson
- Caribbean Institute for Health Research, The University of the West Indies, Kingston, Jamaica
| | - Kimberley McKenzie
- Caribbean Institute for Health Research, The University of the West Indies, Kingston, Jamaica
| | | | | | - Marko Kerac
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, LondonWC1E 7HT, UK
- Centre for Maternal, Adolescent & Reproductive Child Health (MARCH), London School of Hygiene & Tropical Medicine, London, UK
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11
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Phelan K, Seri B, Daures M, Yao C, Alitanou R, Aly AAM, Maidadji O, Sanoussi A, Mahamadou A, Cazes C, Moh R, Becquet R, Shepherd S. Treatment outcomes and associated factors for hospitalization of children treated for acute malnutrition under the OptiMA simplified protocol: a prospective observational cohort in rural Niger. Front Public Health 2023; 11:1199036. [PMID: 37475774 PMCID: PMC10354363 DOI: 10.3389/fpubh.2023.1199036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/14/2023] [Indexed: 07/22/2023] Open
Abstract
Introduction Globally, access to treatment for severe and moderate acute malnutrition is very low, in part because different protocols and products are used in separate programs. New approaches, defining acute malnutrition (AM) as mid-upper arm circumference (MUAC) < 125 mm or oedema, are being investigated to compare effectiveness to current programs. Optimizing Malnutrition treatment (OptiMA) is one such strategy that treats AM with one product - ready-to-use therapeutic food, or RUTF - at reduced dosage as the child improves. Methods This study aimed to determine whether OptiMA achieved effectiveness benchmarks established in the Nigerien National Nutrition protocol. A prospective cohort study of children in the rural Mirriah district evaluated outcomes among children 6-59 months with uncomplicated AM treated under OptiMA. In a parallel, unconnected program in one of the two trial sites, all non-malnourished children 6-23 months of age were provided small quantity lipid-based nutritional supplements (SQ-LNS). A multivariate logistic regression identified factors associated with hospitalization. Results From July-December 2019, 1,105 children were included for analysis. Prior to treatment, 39.3% of children received SQ-LNS. Recovery, non-response, and mortality rates were 82.3%, 12.6%, and 0.7%, respectively, and the hospitalization rate was 15.1%. Children who received SQ-LNS before an episode of AM were 43% less likely to be hospitalized (ORa=0.57; 0.39-0.85, p = 0.004). Discussion OptiMA had acceptable recovery compared to the Nigerien reference but non-response was high. Children who received SQ-LNS before treatment under OptiMA were less likely to be hospitalized, showing potential health benefits of combining simplified treatment protocols with food-based prevention in an area with a high burden of malnutrition such as rural Niger.
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Affiliation(s)
- Kevin Phelan
- The Alliance for International Medical Action (ALIMA), Dakar, Senegal
| | - Benjamin Seri
- PRISME-CI ANRS|MIE Research Programme, University Hospital of Treichville, Abidjan, Côte d'Ivoire
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Maguy Daures
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Cyrille Yao
- PRISME-CI ANRS|MIE Research Programme, University Hospital of Treichville, Abidjan, Côte d'Ivoire
| | - Rodrigue Alitanou
- The Alliance for International Medical Action (ALIMA), Niamey, Niger
| | | | | | - Atté Sanoussi
- Ministry of Health, Nutrition Division, Niamey, Niger
| | - Aboubacar Mahamadou
- High-Commission of the Nigériens Nourrissent les Nigériens (3N) Initiative, Niamey, Niger
| | - Cécile Cazes
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Raoul Moh
- PRISME-CI ANRS|MIE Research Programme, University Hospital of Treichville, Abidjan, Côte d'Ivoire
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
- Dermatology and Infectiology Pedagogical Unit, Training and Research Units in Medical Sciences, Abidjan, Côte d'Ivoire
| | - Renaud Becquet
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Susan Shepherd
- The Alliance for International Medical Action (ALIMA), Dakar, Senegal
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Kangas ST, Coulibaly IN, Tausanovitch Z, Ouologuem B, Marron B, Radin E, Ritz C, Dembele S, Ouédraogo CT, Bailey J. Post-Recovery Relapse of Children Treated with a Simplified, Combined Nutrition Treatment Protocol in Mali: A Prospective Cohort Study. Nutrients 2023; 15:nu15112636. [PMID: 37299599 DOI: 10.3390/nu15112636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 05/26/2023] [Accepted: 05/29/2023] [Indexed: 06/12/2023] Open
Abstract
The present study aimed to determine the 6-month incidence of relapse and associated factors among children who recovered from acute malnutrition (AM) following mid-upper arm circumference (MUAC)-based simplified combined treatment using the ComPAS protocol. A prospective cohort of 420 children who had reached a MUAC ≥ 125 mm for two consecutive measures was monitored between December 2020 and October 2021. Children were seen at home fortnightly for 6 months. The overall 6-month cumulative incidence of relapse [95%CI] into MUAC < 125 mm and/or edema was 26.1% [21.7; 30.8] and 1.7% [0.6; 3.6] to MUAC < 115 mm and/or edema. Relapse was similar among children initially admitted to treatment with a MUAC < 115 mm and/or oedema and among those with a MUAC ≥ 115 mm but <125 mm. Relapse was predicted by lower anthropometry both at admission to and discharge from treatment, and a higher number of illness episodes per month of follow-up. Having a vaccination card, using an improved water source, having agriculture as the main source of income, and increases in caregiver workload during follow-up all protected from relapse. Children discharged as recovered from AM remain at risk of relapsing into AM. To achieve reduction in relapse, recovery criteria may need to be revised and post-discharge strategies tested.
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Affiliation(s)
| | | | | | | | | | | | - Christian Ritz
- National Institute of Public Health, Copenhagen, Denmark
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13
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Briend A, Myatt M, Berkley JA, Black RE, Boyd E, Garenne M, Lelijveld N, Isanaka S, McDonald CM, Mwangwome M, O’Brien KS, Schwinger C, Stobaugh H, Taneja S, West KP, Khara T. Prognostic value of different anthropometric indices over different measurement intervals to predict mortality in 6-59-month-old children. Public Health Nutr 2023; 26:1210-1221. [PMID: 36722310 PMCID: PMC10346023 DOI: 10.1017/s1368980023000149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 11/18/2022] [Accepted: 12/26/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare the prognostic value of mid-upper arm circumference (MUAC), weight-for-height Z-score (WHZ) and weight-for-age Z-score (WAZ) for predicting death over periods of 1, 3 and 6 months follow-up in children. DESIGN Pooled analysis of twelve prospective studies examining survival after anthropometric assessment. Sensitivity and false-positive ratios to predict death within 1, 3 and 6 months were compared for three individual anthropometric indices and their combinations. SETTING Community-based, prospective studies from twelve countries in Africa and Asia. PARTICIPANTS Children aged 6-59 months living in the study areas. RESULTS For all anthropometric indices, the receiver operating characteristic curves were higher for shorter than for longer durations of follow-up. Sensitivity was higher for death with 1-month follow-up compared with 6 months by 49 % (95 % CI (30, 69)) for MUAC < 115 mm (P < 0·001), 48 % (95 % CI (9·4, 87)) for WHZ < -3 (P < 0·01) and 28 % (95 % CI (7·6, 42)) for WAZ < -3 (P < 0·005). This was accompanied by an increase in false positives of only 3 % or less. For all durations of follow-up, WAZ < -3 identified more children who died and were not identified by WHZ < -3 or by MUAC < 115 mm, 120 mm or 125 mm, but the use of WAZ < -3 led to an increased false-positive ratio up to 16·4 % (95 % CI (12·0, 20·9)) compared with 3·5 % (95 % CI (0·4, 6·5)) for MUAC < 115 mm alone. CONCLUSIONS Frequent anthropometric measurements significantly improve the identification of malnourished children with a high risk of death without markedly increasing false positives. Combining two indices increases sensitivity but also increases false positives among children meeting case definitions.
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Affiliation(s)
- André Briend
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Rolighedsvej 30, DK-1958, Frederiksberg, Denmark
- Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Arvo building, Arvo Ylpön katu 34, FIN-33014Tampere, Finland
| | - Mark Myatt
- Brixton Health, Cilfach Greigiog, Fford Celynin, Llwyngwril, Gwynedd, UK
- Emergency Nutrition Network, Kidlington, OX, UK
| | - James A Berkley
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine & Global Health, University of Oxford, UK
| | - Robert E Black
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Erin Boyd
- USAID, Bureau for Humanitarian Assistance, Washington, DC, USA
- Tufts University, Boston, MA, USA
| | - Michel Garenne
- IRD, UMI Résiliences, Paris, France
- FERDI, Université d’Auvergne, Clermont-Ferrand, France
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Sheila Isanaka
- Department of Research, Epicentre, Paris, France
- Departments of Nutrition and Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Christine M McDonald
- Departments of Pediatrics, and Epidemiology and Biostatistics, University of California, San Francisco, Oakland, CA, USA
| | - Martha Mwangwome
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Kenya Medical Research Institute (KEMRI), Centre for Geographic Medicine Research-Coast (CGMRC), Kilifi, Kenya
| | - Kieran S O’Brien
- Department of Ophthalmology, University of California, Francis I. Proctor Foundation, San Francisco, CA, USA
| | - Catherine Schwinger
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Heather Stobaugh
- Tufts University, Boston, MA, USA
- Action Against Hunger USA, New York, NY, USA
| | - Sunita Taneja
- Center for Health Research and Development, Society for Applied Studies, New Delhi, India
| | - Keith P West
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Tanya Khara
- Emergency Nutrition Network, Kidlington, OX, UK
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14
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Charle-Cuéllar P, Lopez-Ejeda N, Aziz Gado A, Dougnon AO, Sanoussi A, Ousmane N, Hamidou Lazoumar R, Sánchez-Martínez LJ, Toure F, Vargas A, Guerrero S. Effectiveness and Coverage of Severe Acute Malnutrition Treatment with a Simplified Protocol in a Humanitarian Context in Diffa, Niger. Nutrients 2023; 15:nu15081975. [PMID: 37111194 PMCID: PMC10146545 DOI: 10.3390/nu15081975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 04/15/2023] [Accepted: 04/18/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND the aim of this study is to evaluate the effectiveness and coverage of a simplified protocol that is implemented in health centers (HCs) and health posts (HPs) for children who are suffering from severe acute malnutrition (SAM) in the humanitarian context of Diffa. METHODS We conducted a non-randomized community-controlled trial. The control group received outpatient treatment for SAM, without medical complications, at HCs and HPs with the standard protocol of community management of acute malnutrition (CMAM). Meanwhile, with respect to the intervention group, the children with SAM received treatment at the HCs and HPs through a simplified protocol wherein the mid-upper arm circumference (MUAC) and the presence of edema were used as the admission criteria, and the children with SAM were administered doses of fixed ready-to-use therapeutic food (RUTF). RESULTS A total of 508 children, who were all under 5 years and had SAM, were admitted into the study. The cured proportion was 87.4% in the control group versus 96.6% in the intervention group (p value = 0.001). There was no difference between the groups in the length of stay, which was 35 days, but the intervention group used a lower quantity of RUTF-70 sachets versus 90 sachets, per child cured. Coverage increases were observed in both groups. DISCUSSION the simplified protocol used at the HCs and HPs did not result in worse recovery and resulted in fewer discharge errors compared to the standard protocol.
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Affiliation(s)
| | - Noemi Lopez-Ejeda
- EPINUT Research Group (Ref. 920325), Unit of Physical Anthropology, Department of Biodiversity, Ecology, Faculty of Biological Sciences, and Evolution, Complutense University of Madrid, 28040 Madrid, Spain
| | | | | | - Atté Sanoussi
- Nutrition Direction, Ministry of Health, Niamey BP 623, Niger
| | - Nassirou Ousmane
- Centre de Recherche Médicale et Sanitaire (CERMES), Niamey BP 10887, Niger
| | | | - Luis Javier Sánchez-Martínez
- EPINUT Research Group (Ref. 920325), Unit of Physical Anthropology, Department of Biodiversity, Ecology, Faculty of Biological Sciences, and Evolution, Complutense University of Madrid, 28040 Madrid, Spain
| | - Fanta Toure
- Action against Hunger, West and Central Africa Regional, Dakar BP 29621, Senegal
| | - Antonio Vargas
- Action against Hunger, C/Duque de Sevilla no. 3, 28002 Madrid, Spain
| | - Saul Guerrero
- United Nations International Children's Emergency Fund-UNICEF, 3 United Nations Plaza, New York, NY 10017, USA
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15
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Cazes C, Phelan K, Hubert V, Boubacar H, Bozama LI, Sakubu GT, Senge BB, Baya N, Alitanou R, Kouamé A, Yao C, Gabillard D, Daures M, Augier A, Anglaret X, Kinda M, Shepherd S, Becquet R. Optimising the dosage of ready-to-use therapeutic food in children with uncomplicated severe acute malnutrition in the Democratic Republic of the Congo: a non-inferiority, randomised controlled trial. EClinicalMedicine 2023; 58:101878. [PMID: 36915287 PMCID: PMC10006445 DOI: 10.1016/j.eclinm.2023.101878] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 01/24/2023] [Accepted: 02/03/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Current standard management of severe acute malnutrition uses ready-to-use therapeutic food (RUTF) at a single weight-based calculation resulting in an increasing amount of RUTF provided to the family as the child's weight increases during recovery. Using RUTF at a gradually reduced dosage as the child recovers could reduce costs while achieving similar growth response. METHODS We conducted an open-label, non-inferiority, randomised controlled trial in the Democratic Republic of the Congo. Children aged 6-59 months with a mid-upper-arm circumference (MUAC) of less than 115 mm or a weight-for-height z-score (WHZ) of less than -3 or bipedal oedema and without medical complication were randomly assigned (1:1 ratio) using a specially developed software and random blocks (size was kept confidential), to either the current standard treatment (increasing the RUTF amount with increasing weight) or the OptiMA strategy (decreasing the RUTF dose with increasing weight and MUAC). The main endpoint was proportion of children who achieved recovery over the 6 months follow up period, as defined as meeting the following criteria for two consecutive weeks after a minimum of 4 weeks' treatment: axillary temperature less than 37.5 °C, no bipedal oedema, and anthropometric improvement (either MUAC 125 mm or greater or WHZ -1.5 or higher). We performed analyses on the intention-to-treat (ITT) (all children) and per-protocol populations (participants who had a minimum prescription of 4 weeks' RUTF, received at least 90% of the total amount of RUTF they were supposed to receive as per the protocol, and had a maximum interval of 6 weeks between any two visits in the 6-month follow-up). The non-inferiority margin was 10%. This trial is registered at ClinicalTrials.gov, and is now closed NCT03751475. FINDINGS Between July 22, 2019, and January 20, 2020, 491 children were randomly assigned, of whom 482 were analysed (240 in the standard group and 242 in the OptiMA group). In the ITT analysis, 234 (98%) children in the standard group and 231 (96%) children in OptiMA recovered (difference 2.0%, 95% CI -2.0% to 6.4%). In the PP analysis, 234 (98%) children in the standard group and 228 (97%) in OptiMA recovered (difference 1.3%, 95% CI -2.3% to 5.1%). Sensitivity analyses applying the same anthropometric recovery criteria to each group also showed non-inferiority of the OptiMA strategy in ITT and PP analysis. INTERPRETATION This non-inferiority trial treating uncomplicated children with MUAC of less than 115 mm or a WHZ of less than -3 or bipedal oedema with decreasing RUTF dose as MUAC and weight increase demonstrated non-inferiority compared to the standard protocol in a highly food-insecure context in the Democratic Republic of the Congo. These findings add evidence on the safety of RUTF dose reduction with significant RUTF cost savings. FUNDING Innocent Foundation and European Civil Protection and Humanitarian Aid Operations. TRANSLATION For the French translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Cécile Cazes
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Kevin Phelan
- The Alliance for International Medical Action (ALIMA), Paris, France
| | - Victoire Hubert
- The Alliance for International Medical Action (ALIMA), Kamuesha, Democratic Republic of the Congo
| | - Harouna Boubacar
- The Alliance for International Medical Action (ALIMA), Kamuesha, Democratic Republic of the Congo
| | - Liévin Izie Bozama
- National Nutrition Programme (PRONANUT), Ministry of Health, Kinshasa, Democratic Republic of the Congo
| | - Gilbert Tshibangu Sakubu
- Kamuesha Health Zone in the Kasaï Province, Ministry of Health, Kamuesha, Democratic Republic of the Congo
| | - Bruno Bindamba Senge
- National Nutrition Programme (PRONANUT), Ministry of Health, Kinshasa, Democratic Republic of the Congo
| | - Norbert Baya
- National Nutrition Programme (PRONANUT), Ministry of Health, Kinshasa, Democratic Republic of the Congo
| | - Rodrigue Alitanou
- The Alliance for International Medical Action (ALIMA), Kamuesha, Democratic Republic of the Congo
| | - Antoine Kouamé
- PACCI ANRS Research Programme, University Hospital of Treichville, Abidjan, Côte d'Ivoire
| | - Cyrille Yao
- PACCI ANRS Research Programme, University Hospital of Treichville, Abidjan, Côte d'Ivoire
| | - Delphine Gabillard
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Maguy Daures
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Augustin Augier
- The Alliance for International Medical Action (ALIMA), Paris, France
| | - Xavier Anglaret
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Moumouni Kinda
- The Alliance for International Medical Action (ALIMA), Dakar, Senegal
| | - Susan Shepherd
- The Alliance for International Medical Action (ALIMA), Dakar, Senegal
| | - Renaud Becquet
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
- Corresponding author. Bordeaux Population Health Centre, Team GHiGS, University of Bordeaux, Bordeaux 33076, France.
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Acute malnutrition recovery rates improve with COVID-19 adapted nutrition treatment protocols in South Sudan: a mixed methods study. BMC Nutr 2023; 9:46. [PMID: 36906599 PMCID: PMC10008100 DOI: 10.1186/s40795-023-00696-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 02/27/2023] [Indexed: 03/13/2023] Open
Abstract
BACKGROUND Globally, emergency nutrition program adaptations were implemented as part of COVID-19 mitigation strategies, but the implications of the adoption of all protocol changes at scale in the context of deteriorating food security are not yet well characterized. With ongoing conflict, widespread floods, and declining food security, the secondary impacts of COVID-19 on child survival in South Sudan is of great concern. In light of this, the present study aimed to characterize the impact of COVID-19 on nutrition programming in South Sudan. METHODS A mixed methods approach including a desk review and secondary analysis of facility-level program data was used to analyze trends in program indicators over time and compare two 15-month periods prior to the onset of COVID-19 (January 2019 - March 2020; "pre-COVID period") and after the start of the pandemic (April 2020 - June 2021; "COVID" period) in South Sudan. RESULTS The median number of reporting Community Management of Acute Malnutrition sites increased from 1167 pre-COVID to 1189 during COVID. Admission trends followed historic seasonal patterns in South Sudan; however, compared to pre-COVID, declines were seen during COVID in total admissions (- 8.2%) and median monthly admissions (- 21.8%) for severe acute malnutrition. For moderate acute malnutrition, total admissions increased slightly during COVID (1.1%) while median monthly admissions declined (- 6.7%). Median monthly recovery rates improved for severe (92.0% pre-COVID to 95.7% during COVID) and moderate acute malnutrition (91.5 to 94.3%) with improvements also seen in all states. At the national level, rates also decreased for default (- 2.4% for severe, - 1.7% for moderate acute malnutrition) and non-recovery (- 0.9% for severe, - 1.1% for moderate acute malnutrition), with mortality rates remaining constant at 0.05-0.15%. CONCLUSIONS Within the context of the ongoing COVID-19 pandemic in South Sudan, improved recovery, default, and non-responder rates were observed following adoption of changes to nutrition protocols. Policymakers in South Sudan and other resource-constrained settings should consider if simplified nutrition treatment protocols adopted during COVID-19 improved performance and should be maintained in lieu of reverting to standard treatment protocols.
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Cichon B, Das JK, Salam RA, Padhani ZA, Stobaugh HC, Mughal M, Pajak P, Rutishauser-Perera A, Bhutta ZA, Black RE. Effectiveness of Dietary Management for Moderate Wasting among Children > 6 Months of Age-A Systematic Review and Meta-Analysis Exploring Different Types, Quantities, and Durations. Nutrients 2023; 15:nu15051076. [PMID: 36904076 PMCID: PMC10005276 DOI: 10.3390/nu15051076] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/09/2023] [Accepted: 02/14/2023] [Indexed: 02/24/2023] Open
Abstract
Currently, no World Health Organization guidelines exist for the management of approximately 31.8 million moderately wasted children globally. The objective of this review was to synthesise evidence on the optimal type, quantity, and duration of dietary treatment for moderate wasting. Ten electronic databases were searched until the 23rd of August 2021. Experimental studies comparing interventions for the dietary management of moderate wasting were included. Meta-analyses were conducted and results were presented as risk ratios or mean differences with 95% confidence intervals. Seventeen studies comparing specially formulated foods were included involving 23,005 participants. Findings suggest little or no difference in recovery between Fortified Blended Foods (FBFs) with improved micronutrient and/or milk content (enhanced FBFs) and lipid-based nutrient supplements (LNS), whereas children treated with non-enhanced FBFs (locally produced FBFs or standard corn-soy blend) may have lower recovery rates than those treated with LNS. There was no difference in recovery when ready-to-use therapeutic and ready-to-use supplementary food were compared. Other outcomes mostly aligned with results for recovery. In conclusion, LNSs improve recovery compared to non-enhanced FBFs, but are comparable to enhanced FBFs. Programmatic choice of supplement should consider factors such as cost, cost-effectiveness, and acceptability. Further research is required to determine optimal dosing and duration of supplementation.
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Affiliation(s)
- Bernardette Cichon
- Action Against Hunger UK, Operations Department, London SE10 0ER, UK
- Correspondence:
| | - Jai K. Das
- Institute for Global Health and Development, Aga Khan University, Karachi 74800, Pakistan
- Division of Women and Child Health, Aga Khan University, Karachi 74800, Pakistan
| | - Rehana A. Salam
- The Daffodil Centre, The University of Sydney, Sydney 2006, Australia
| | - Zahra A. Padhani
- Institute for Global Health and Development, Aga Khan University, Karachi 74800, Pakistan
| | - Heather C. Stobaugh
- Action Against Hunger USA, Technical Services and Innovation Department, Washington, DC 20463, USA
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA 02111, USA
| | - Muzna Mughal
- Action Against Hunger UK, Operations Department, London SE10 0ER, UK
| | - Patrizia Pajak
- Action Against Hunger UK, Operations Department, London SE10 0ER, UK
| | | | - Zulfiqar A. Bhutta
- Institute for Global Health and Development, Aga Khan University, Karachi 74800, Pakistan
- Division of Women and Child Health, Aga Khan University, Karachi 74800, Pakistan
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Robert E. Black
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
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18
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Effectiveness of Acute Malnutrition Treatment at Health Center and Community Levels with a Simplified, Combined Protocol in Mali: An Observational Cohort Study. Nutrients 2022; 14:nu14224923. [PMID: 36432609 PMCID: PMC9699530 DOI: 10.3390/nu14224923] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/02/2022] [Accepted: 11/07/2022] [Indexed: 11/22/2022] Open
Abstract
A simplified, combined protocol was created that admits children with a mid-upper-arm circumference (MUAC) of <125 mm or edema to malnutrition treatment with ready-to-use therapeutic food (RUTF) that involves prescribing two daily RUTF sachets to children with MUAC < 115 mm or edema and one daily sachet to those with 115 mm ≤ MUAC < 125 mm. This treatment was previously shown to result in non-inferior programmatic outcomes compared with standard treatment. We aimed at observing its effectiveness in a routine setting at scale, including via delivery by community health workers (CHWs). A total of 27,800 children were admitted to the simplified, combined treatment. Treatment resulted in a 92% overall recovery, with a mean length of stay of 40 days and a mean RUTF consumption of 62 sachets per child treated. Among children admitted with MUAC < 115 mm or edema, 87% recovered with a mean length of stay of 55 days and consuming an average of 96 RUTF sachets. The recovery in all sub-groups studied exceeded 85%. Treatment by CHWs resulted in a similar (94%) recovery to treatment by formal healthcare workers (92%). The simplified, combined protocol resulted in high recovery and low RUTF consumption per child treated and can safely be adopted by CHWs to provide treatment at the community level.
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19
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Odei Obeng‐Amoako GA, Stobaugh H, Wrottesley SV, Khara T, Binns P, Trehan I, Black RE, Webb P, Mwangome M, Bailey J, Bahwere P, Dolan C, Boyd E, Briend A, Myatt MA, Lelijveld N. How do children with severe underweight and wasting respond to treatment? A pooled secondary data analysis to inform future intervention studies. MATERNAL & CHILD NUTRITION 2022; 19:e13434. [PMID: 36262055 PMCID: PMC9749592 DOI: 10.1111/mcn.13434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/13/2022] [Accepted: 09/07/2022] [Indexed: 12/15/2022]
Abstract
Children with weight-for-age z-score (WAZ) <-3 have a high risk of death, yet this indicator is not widely used in nutrition treatment programming. This pooled secondary data analysis of children aged 6-59 months aimed to examine the prevalence, treatment outcomes, and growth trajectories of children with WAZ <-3 versus children with WAZ ≥-3 receiving outpatient treatment for wasting and/or nutritional oedema, to inform future protocols. Binary treatment outcomes between WAZ <-3 and WAZ ≥-3 admissions were compared using logistic regression. Recovery was defined as attaining mid-upper-arm circumference ≥12.5 cm and weight-for-height z-score ≥-2, without oedema, within a period of 17 weeks of admission. Data from 24,829 children from 9 countries drawn from 13 datasets were included. 55% of wasted children had WAZ <-3. Children admitted with WAZ <-3 compared to those with WAZ ≥-3 had lower recovery rates (28.3% vs. 48.7%), higher risk of death (1.8% vs. 0.7%), and higher risk of transfer to inpatient care (6.2% vs. 3.8%). Growth trajectories showed that children with WAZ <-3 had markedly lower anthropometry at the start and end of care, however, their patterns of anthropometric gains were very similar to those with WAZ ≥-3. If moderately wasted children with WAZ <-3 were treated in therapeutic programmes alongside severely wasted children, we estimate caseloads would increase by 32%. Our findings suggest that wasted children with WAZ <-3 are an especially vulnerable group and those with moderate wasting and WAZ <-3 likely require a higher intensity of nutritional support than is currently recommended. Longer or improved treatment may be necessary, and the timeline and definition of recovery likely need review.
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Affiliation(s)
| | - Heather Stobaugh
- Action Against Hunger USANew York CityNew YorkUSA,Friedman School of Nutrition Science and Policy at Tufts UniversityBostonMassachusettsUSA
| | | | - Tanya Khara
- Emergency Nutrition Network (ENN)KidlingtonUK
| | | | - Indi Trehan
- Departments of Paediatrics, Global Health, and EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
| | - Robert E. Black
- Institute for International ProgrammesJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Patrick Webb
- Friedman School of Nutrition Science and Policy at Tufts UniversityBostonMassachusettsUSA,Emergency Nutrition Network (ENN)KidlingtonUK
| | - Martha Mwangome
- Kenya Medical Research Institute (KEMRI)Centre for Geographic Medicine Research‐CoastKilifiKenya
| | | | - Paluku Bahwere
- Center for Epidémiology, Biostatistics and Clinical Research (CR2), School of Public HealthUniversité Libre de BruxellesBrusselsBelgium
| | | | - Erin Boyd
- Friedman School of Nutrition Science and Policy at Tufts UniversityBostonMassachusettsUSA,USAID/BHAWashingtonDistrict of ColumbiaUSA
| | - André Briend
- Department of Nutrition, Exercise and Sports, Faculty of ScienceUniversity of CopenhagenFrederiksbergDenmark,Center for Child Health Research, Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
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20
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Wrabel M, Stokes‐Walters R, King S, Funnell G, Stobaugh H. Programmatic adaptations to acute malnutrition screening and treatment during the COVID‐19 pandemic. MATERNAL & CHILD NUTRITION 2022; 18:e13406. [PMID: 35929509 PMCID: PMC9480950 DOI: 10.1111/mcn.13406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 06/13/2022] [Accepted: 06/21/2022] [Indexed: 11/30/2022]
Abstract
The COVID‐19 pandemic presented numerous challenges to acute malnutrition screening and treatment. To enable continued case identification and service delivery while minimising transmission risks, many organisations and governments implemented adaptations to community‐based management of acute malnutrition (CMAM) programmes for children under 5. These included: Family mid‐upper arm circumference (MUAC); modified admission and discharge criteria; modified dosage of therapeutic foods; and reduced frequency of follow‐up visits. This paper presents qualitative findings from a larger mixed methods study to document practitioners' operational experiences and lessons learned from these adaptations. Findings reflect insights from 37 interviews representing 15 organisations in 17 countries, conducted between July 2020 and January 2021. Overall, interviewees indicated that adaptations were mostly well‐accepted by staff, caregivers and communities. Family MUAC filled screening gaps linked to COVID‐19 disruptions; however, challenges included long‐term accuracy of caregiver measurements; implementing an intervention that could increase demand for inconsistent services; and limited guidance to monitor programme quality and impact. Modified admission and discharge criteria and modified dosage streamlined logistics and implementation with positive impacts on staff workload and caregiver understanding of the programme. Reduced frequency of visits enabled social distancing by minimising crowding at facilities and lessened caregivers' need to travel. Concerns remained about how adaptations impacted children's identification for and progress through treatment and programme outcomes. Most respondents anticipated reverting to standard protocols once transmission risks were mitigated. Further evidence, including multi‐year programmatic data analysis and rigorous research, is needed in diverse contexts to understand adaptations' impacts, including how to ensure equity and mitigate unintended consequences. COVID‐19 CMAM programme adaptations enabled service continuity despite pandemic‐related challenges. Further evidence is needed on long‐term impacts. Family MUAC was well‐accepted and addressed screening gaps from COVID‐19 disruptions. Challenges included sustaining caregiver measurement accuracy; handling inaccurate self‐referrals to encourage health‐seeking behaviours; and limited programme design and monitoring guidance and tools. Modified admission criteria and therapeutic food dosage reduced contact between staff and children and streamlined logistics and implementation. Concerns remained about effects on programme admissions and outcomes. Reduced frequency of follow‐up visits successfully reduced facility crowding and need for caregiver travel. However, infrequent monitoring of childrenmay miss deterioration.
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Affiliation(s)
| | | | - Sarah King
- Action Against Hunger USA Washington, DC USA
| | | | - Heather Stobaugh
- Action Against Hunger USA Washington, DC USA
- Friedman School of Nutrition Science and Policy Tufts University Boston Massachusetts USA
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21
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Simplifying and optimising the management of uncomplicated acute malnutrition in children aged 6–59 months in the Democratic Republic of the Congo (OptiMA-DRC): a non-inferiority, randomised controlled trial. THE LANCET GLOBAL HEALTH 2022; 10:e510-e520. [DOI: 10.1016/s2214-109x(22)00041-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 12/22/2021] [Accepted: 01/24/2022] [Indexed: 12/20/2022] Open
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22
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Daures M, Hien J, Phelan K, Boubacar H, Atté S, Aboubacar M, Aly AAGM, Mayoum B, Azani JC, Koffi JJ, Séri B, Beuscart A, Gabillard D, Hubert V, Cazes C, Kinda M, Anglaret X, Kangas S, Shepherd S, Becquet R. Simplifying and optimising management of acute malnutrition in children aged 6 to 59 months: study protocol for a 3 arms community-based individually randomised controlled trial in decentralised Niger. Trials 2022; 23:89. [PMID: 35090531 PMCID: PMC8796195 DOI: 10.1186/s13063-021-05955-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 12/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Simplified approaches of acute malnutrition (AM) treatment have been conducted over the past 5 years intending to unify processes and increase coverage among children aged 6 to 59 months without medical complication. The Optimsing treatment for Acute Malnutrition (OptiMA) and the Combined Protocol for Acute Malnutrition Study (ComPAS) are mid-upper arm circumference (MUAC)-based approaches treating children with MUAC < 125 mm or oedema with one sole product-ready-to-use therapeutic food-at a gradually tapered doses. This trial aims to compare the OptiMA and ComPAS strategies to the standard nutritional protocol of Niger assessed by a favourable outcome in the treatment of uncomplicated AM at 6 months post-randomisation and in terms of recovery rate after treatment of uncomplicated SAM (WHZ < - 3 or MUAC < 115mm or oedema) and among the most vulnerable children (MUAC < 115mm or oedema). METHODS A non-inferiority individually randomised controlled clinical trial was conducted at the primary health centres level and in the community in the Zinder region in Niger in March 2021. Participants are children aged 6-59 months attending outpatient health centres with MUAC < 125mm or oedema without medical complications. All participants are followed for 6 months. Simplified strategies propose a gradual reduction of RUTF according to MUAC and weight in OptiMA and MUAC only in ComPAS. Favourable outcome is compositely defined at 6 months post-inclusion as being alive, not acutely malnourished by the definition applied at inclusion and without any additional episode of AM throughout the 6-month observation period. Recovery is defined throughout the 6 months post-randomisation by a minimum of 4-week duration of treatment, an axillary temperature < 37.5°C, an absence of bipedal oedema and a MUAC ≥ 125 mm for two consecutive weeks. The sample size calculation required 567 children per arm for the main objective, 295 and 384 children per arm for the secondary objectives among SAM and MUAC < 115 mm children, respectively. Per-protocol and intention-to-treat analyses will be conducted for each outcome. DISCUSSION This trial is intending to generate much-needed evidence on various simplified and optimised AM treatment approaches and to participate in reaching a consensus on such nutrition protocols. TRIAL REGISTRATION ClinicalTrials.gov NCT04698070 . Registered on January 6, 2021.
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Affiliation(s)
- Maguy Daures
- Fench National Institute for Health and Medical Research (Inserm), French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, University of Bordeaux, 146 rue Léo Saignat, 33076, Bordeaux, France.
| | - Jérémie Hien
- The Alliance for International Medical Action (ALIMA), Zinder, Niger
| | - Kevin Phelan
- The Alliance for International Medical Action (ALIMA), Paris, France
| | - Harouna Boubacar
- The Alliance for International Medical Action (ALIMA), Zinder, Niger
| | - Sanoussi Atté
- Nutrition Directorate, Ministry of Health, Niamey, Niger
| | - Mahamadou Aboubacar
- Commission for the Initiative "les Nigériens Nourrissent les Nigériens" (HC3N), Niamey, Niger
| | - Ahmad A G M Aly
- The Alliance for International Medical Action (ALIMA), Zinder, Niger
| | - Baweye Mayoum
- The Alliance for International Medical Action (ALIMA), 15 rue des immeubles industriels, 75011, Dakar, Senegal
| | - Jean-Claude Azani
- PACCI Research Programme, University Hospital of Treichville, Abidjan, Côte d'Ivoire
| | - Jean-Jacques Koffi
- PACCI Research Programme, University Hospital of Treichville, Abidjan, Côte d'Ivoire
| | - Benjamin Séri
- PACCI Research Programme, University Hospital of Treichville, Abidjan, Côte d'Ivoire
| | - Aurélie Beuscart
- Fench National Institute for Health and Medical Research (Inserm), French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, University of Bordeaux, 146 rue Léo Saignat, 33076, Bordeaux, France
| | - Delphine Gabillard
- Fench National Institute for Health and Medical Research (Inserm), French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, University of Bordeaux, 146 rue Léo Saignat, 33076, Bordeaux, France
| | - Victoire Hubert
- The Alliance for International Medical Action (ALIMA), 15 rue des immeubles industriels, 75011, Dakar, Senegal
| | - Cécile Cazes
- Fench National Institute for Health and Medical Research (Inserm), French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, University of Bordeaux, 146 rue Léo Saignat, 33076, Bordeaux, France
| | - Moumouni Kinda
- The Alliance for International Medical Action (ALIMA), 15 rue des immeubles industriels, 75011, Dakar, Senegal.
| | - Xavier Anglaret
- Fench National Institute for Health and Medical Research (Inserm), French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, University of Bordeaux, 146 rue Léo Saignat, 33076, Bordeaux, France
| | - Suvi Kangas
- International Rescue Committee (IRC), Dakar, Senegal
| | - Susan Shepherd
- The Alliance for International Medical Action (ALIMA), 15 rue des immeubles industriels, 75011, Dakar, Senegal
| | - Renaud Becquet
- Fench National Institute for Health and Medical Research (Inserm), French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, University of Bordeaux, 146 rue Léo Saignat, 33076, Bordeaux, France
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23
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Gluning I, Kerac M, Bailey J, Bander A, Opondo C. The management of moderate acute malnutrition in children aged 6-59 months in low- and middle-income countries: a systematic review and meta-analysis. Trans R Soc Trop Med Hyg 2021; 115:1317-1329. [PMID: 34535798 DOI: 10.1093/trstmh/trab137] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 06/11/2021] [Accepted: 08/24/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Malnutrition is a leading cause of morbidity and mortality in children aged <5 y, especially in low- and middle-income countries (LMICs). Unlike severe acute malnutrition, moderate acute malnutrition (MAM) affects greater numbers globally, and guidelines lack a robust evidence base. This systematic review and meta-analysis assessed the evidence for lipid-based nutrient supplements (LNSs), fortified blended flours (FBFs) and nutrition counselling, in the treatment of MAM. METHODS Four databases were systematically searched for studies conducted in LMICs that compared the effectiveness of food-based products with any comparator group in promoting recovery from MAM in children aged 6-59 mo. Where appropriate, pooled estimates of effect were estimated using random-effects meta-analyses. RESULTS A total of 13 trials were identified for inclusion. All used active controls. There was evidence of increased probability of recovery (gaining normal weight-for-height and/or mid-upper arm circumference) among children treated with LNSs compared with children treated with FBFs (risk ratio 1.05, 95% CI 1.01 to 1.09, p=0·009). CONCLUSION Based on a relatively small number of studies mainly from Africa, LNSs are superior to FBFs in improving anthropometric recovery from MAM. Current evidence for the use of food supplements in MAM treatment is based on comparisons with active controls. Future studies should assess a wider range of comparator groups, such as nutrition education/counselling alone, and outcomes, including body composition, morbidity and development.
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Affiliation(s)
- Imara Gluning
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.,Brighton and Sussex University Hospitals Trust, Brighton, BN2 5BE, UK
| | - Marko Kerac
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.,Centre for MARCH (Maternal, Reproductive, Adolescent & Child Health Centre), London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Jeanette Bailey
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.,International Rescue Committee, New York, NY, 10168-1289, USA
| | - Amela Bander
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Charles Opondo
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.,National Perinatal Epidemiology Unit, University of Oxford, Oxford, OX3 7LF, UK
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24
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Garba S, Salou H, Nackers F, Ayouba A, Escruela M, Guindo O, Rocaspana M, Grais RF, Isanaka S. A feasibility study using mid-upper arm circumference as the sole anthropometric criterion for admission and discharge in the outpatient treatment for severe acute malnutrition. BMC Nutr 2021; 7:47. [PMID: 34380573 PMCID: PMC8359601 DOI: 10.1186/s40795-021-00448-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 05/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The World Health Organization recommends the use of a weight-for-height Z-score (WHZ) and/or mid-upper arm circumference (MUAC) as anthropometric criteria for the admission and discharge of young children for the community-based management of severe acute malnutrition. However, using MUAC as a single anthropometric criterion for admission and discharge in therapeutic nutritional programs may offer operational advantages to simplify admission processes at therapeutic nutritional centers and improve program coverage. METHODS This pragmatic, non-randomized, intervention study compared a standard outpatient nutritional program (n = 824) for the treatment of uncomplicated severe acute malnutrition using WHZ < - 3 and/or MUAC< 115 mm and/or bipedal edema for admission and discharge to a program (n = 1019) using MUAC as the sole anthropometric criterion for admission (MUAC< 120 mm) and discharge (MUAC ≥125 mm at two consecutive visits) in the Tahoua Region of Niger. RESULTS Compared to the standard program, the MUAC-only program discharged more children as recovered (70.1% vs. 51.6%; aOR 2.31, 95%CI 1.79-2.98) and fewer children as non-respondent or defaulters, based on respective program definitions. The risk of non-response was high in both programs. Three months post-discharge, children who were discharged after recovery in the MUAC-only program had lower WHZ and MUAC measures. Sixty-three children ineligible for the MUAC-only program but eligible for a standard program (MUAC ≥120 mm and WHZ < -3) were followed for twelve weeks and the anthropometric status of 69.8% of these children did not deteriorate (i.e. MUAC ≥120 mm) despite not immediately receiving treatment in the MUAC-only program. CONCLUSIONS The results from this study share the first operational experience of using MUAC as sole anthropometric criterion for admission and discharge in Niger and overall support the consideration for MUAC-only programming: the MUAC-only model of care was associated with a higher recovery and a lower defaulter rate than the standard program with very few children found to be excluded from treatment with an admission criterion of MUAC < 120 mm. Further consideration of the appropriate MUAC-based discharge criterion as it relates to an increased risk of non-response and adverse post-discharge outcomes would be prudent.
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Affiliation(s)
| | | | - Fabienne Nackers
- Médecins Sans Frontières Operational Center Brussels, Brussels, Belgium
| | | | - Montse Escruela
- Médecins Sans Frontières Operational Center Barcelona, Barcelona, Spain
| | | | - Mercé Rocaspana
- Médecins Sans Frontières Operational Center Barcelona, Barcelona, Spain
| | | | - Sheila Isanaka
- Epicentre, 14-34 avenue Jean Juarès, 75019, Paris, France.
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25
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Lelijveld N, Godbout C, Krietemeyer D, Los A, Wegner D, Hendrixson DT, Bandsma R, Koroma A, Manary M. Treating high-risk moderate acute malnutrition using therapeutic food compared with nutrition counseling (Hi-MAM Study): a cluster-randomized controlled trial. Am J Clin Nutr 2021; 114:955-964. [PMID: 33963734 PMCID: PMC8921644 DOI: 10.1093/ajcn/nqab137] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 04/01/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND There is a lack of consensus on what is the most appropriate treatment of moderate acute malnutrition (MAM). OBJECTIVES We aimed to determine if provision of ready-to-use-therapeutic food (RUTF) and antibiotics to "high-risk" MAM (HR-MAM) children in addition to nutritional counseling would result in higher recovery and less deterioration than nutrition counseling alone. METHODS At the 11 intervention clinics, HR-MAM children were given RUTF and amoxicillin along with standard nutrition counseling, for 2-12 wk. All others received 6 wk of nutrition counseling alone. HR-MAM was defined as midupper arm circumference (MUAC) <11.9 cm, weight-for-age z score (WAZ) <-3.5, mother not the main caregiver, or a child <2 y old not being breastfed. Outcomes were compared using intention-to-treat analysis. RESULTS Analysis included 573 children at the intervention sites and 714 children at the control sites. Of the intervention group, 317 (55%) were classified as HR-MAM. Short-term recovery was greater at the intervention sites [48% compared with 39% at week 12; risk difference (rd): 0.08; 95% CI: 0.03, 0.13]. The intervention group had lower risk of deteriorating to severe acute malnutrition (SAM) (18% compared with 24%; rd: -0.07; 95% CI: -0.11, -0.04), lower risk of dying (1.8% compared with 3.1%; rd: -0.02; 95% CI: -0.03, -0.00), and greater gains in MUAC and weight than did children at the control sites. However, by 24 wk, the risk of SAM was similar between the 2 arms (31% compared with 34%; rd: -0.03; 95% CI: -0.09, 0.02). Control group data identified recent illness, MUAC <12.0 cm, WAZ <-3, dropping anthropometry, age <12 mo, being a twin, and a history of previous SAM as risk factors for deterioration. CONCLUSIONS Provision of RUTF and antibiotics to HR-MAM children improved short-term recovery and reduced short-term risk of deterioration. However, recovery rates were still suboptimal and differences were not sustained by 6 mo post enrollment.This trial was registered at clinicaltrials.gov as NCT03647150.
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Affiliation(s)
| | - Claire Godbout
- Project Peanut Butter, Freetown, Sierra
Leone,Washington University School of Medicine, St. Louis, MO,
USA
| | - Destiny Krietemeyer
- Project Peanut Butter, Freetown, Sierra
Leone,Washington University School of Medicine, St. Louis, MO,
USA
| | - Alyssa Los
- Project Peanut Butter, Freetown, Sierra
Leone,Washington University School of Medicine, St. Louis, MO,
USA
| | - Donna Wegner
- Washington University School of Medicine, St. Louis, MO,
USA
| | | | - Robert Bandsma
- Centre for Global Child Health, Hospital for Sick Kids,
Toronto, Ontario, Canada
| | | | - Mark Manary
- Project Peanut Butter, Freetown, Sierra
Leone,Washington University School of Medicine, St. Louis, MO,
USA
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26
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Heidkamp RA, Piwoz E, Gillespie S, Keats EC, D'Alimonte MR, Menon P, Das JK, Flory A, Clift JW, Ruel MT, Vosti S, Akuoku JK, Bhutta ZA. Mobilising evidence, data, and resources to achieve global maternal and child undernutrition targets and the Sustainable Development Goals: an agenda for action. Lancet 2021; 397:1400-1418. [PMID: 33691095 DOI: 10.1016/s0140-6736(21)00568-7] [Citation(s) in RCA: 92] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 07/28/2020] [Accepted: 09/23/2020] [Indexed: 12/14/2022]
Abstract
As the world counts down to the 2025 World Health Assembly nutrition targets and the 2030 Sustainable Development Goals, millions of women, children, and adolescents worldwide remain undernourished (underweight, stunted, and deficient in micronutrients), despite evidence on effective interventions and increasing political commitment to, and financial investment in, nutrition. The COVID-19 pandemic has crippled health systems, exacerbated household food insecurity, and reversed economic growth, which together could set back improvements in undernutrition across low-income and middle-income countries. This paper highlights how the evidence base for nutrition, health, food systems, social protection, and water, sanitation, and hygiene interventions has evolved since the 2013 Lancet Series on maternal and child nutrition and identifies the priority actions needed to regain and accelerate progress within the next decade. Policies and interventions targeting the first 1000 days of life, including some newly identified since 2013, require renewed commitment, implementation research, and increased funding from both domestic and global actors. A new body of evidence from national and state-level success stories in stunting reduction reinforces the crucial importance of multisectoral actions to address the underlying determinants of undernutrition and identifies key features of enabling political environments. To support these actions, well-resourced nutrition data and information systems are essential. The paper concludes with a call to action for the 2021 Nutrition for Growth Summit to unite global and national nutrition stakeholders around common priorities to tackle a large, unfinished undernutrition agenda-now amplified by the COVID-19 crisis.
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Affiliation(s)
| | - Ellen Piwoz
- Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Stuart Gillespie
- International Food Policy Research Institute, Washington, DC, USA
| | - Emily C Keats
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Purnima Menon
- International Food Policy Research Institute, Delhi, India
| | - Jai K Das
- Division of Women and Child Health, The Aga Khan University, Karachi, Pakistan
| | | | | | - Marie T Ruel
- International Food Policy Research Institute, Washington, DC, USA
| | - Stephen Vosti
- Department of Agricultural and Resource Economics, and Institute for Global Nutrition, University of California, Davis, CA, USA
| | | | - Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada; Centre of Excellence in Women and Child Health and Institute for Global Health and Development, The Aga Khan University, Karachi, Pakistan.
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Response to Malnutrition Treatment in Low Weight-for-Age Children: Secondary Analyses of Children 6-59 Months in the ComPAS Cluster Randomized Controlled Trial. Nutrients 2021; 13:nu13041054. [PMID: 33805040 PMCID: PMC8064102 DOI: 10.3390/nu13041054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/15/2021] [Accepted: 03/19/2021] [Indexed: 11/16/2022] Open
Abstract
Weight-for-age z-score (WAZ) is not currently an admission criterion to therapeutic feeding programs, and children with low WAZ at high risk of mortality may not be admitted. We conducted a secondary analysis of RCT data to assess response to treatment according to WAZ and mid-upper arm circumference (MUAC) and type of feeding protocol given: a simplified, combined protocol for severe and moderate acute malnutrition (SAM and MAM) vs. standard care that treats SAM and MAM, separately. Children with a moderately low MUAC (11.5–12.5 cm) and a severely low WAZ (<−3) respond similarly to treatment in terms of both weight and MUAC gain on either 2092 kJ (500 kcal)/day of therapeutic or supplementary food. Children with a severely low MUAC (<11.5 cm), with/without a severely low WAZ (<−3), have similar recovery with the combined protocol or standard treatment, though WAZ gain may be slower in the combined protocol. A limitation is this analysis was not powered for these sub-groups specifically. Adding WAZ < −3 as an admission criterion for therapeutic feeding programs admitting children with MUAC and/or oedema may help programs target high-risk children who can benefit from treatment. Future work should evaluate the optimal treatment protocol for children with a MUAC < 11.5 and/or WAZ < −3.0.
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Lelijveld N, Musyoki E, Adongo SW, Mayberry A, Wells JC, Opondo C, Kerac M, Bailey J. Relapse and post-discharge body composition of children treated for acute malnutrition using a simplified, combined protocol: A nested cohort from the ComPAS RCT. PLoS One 2021; 16:e0245477. [PMID: 33534818 PMCID: PMC7857614 DOI: 10.1371/journal.pone.0245477] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 01/01/2021] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Severe and moderate acute malnutrition (SAM and MAM) affect more than 50 million children worldwide yet 80% of these children do not access care. The Combined Protocol for Acute Malnutrition Study (ComPAS) trial assessed the effectiveness of a simplified, combined SAM/MAM protocol for children aged 6-59 months and found non-inferior recovery compared to standard care. To further inform policy, this study assessed post-discharge outcomes of children treated with this novel protocol in Kenya. METHODS Six 'combined' protocol clinics treated SAM and MAM children using an optimised mid-upper arm circumference (MUAC)-based dose of ready-to-use therapeutic food (RUTF). Six 'standard care' clinics treated SAM with weight-based RUTF rations; MAM with ready-to-use supplementary food (RUSF). Four months post-discharge, we assessed anthropometry, recent history of illness, and body composition by bioelectrical impedance analysis. Data was analysed using multivariable linear regression, adjusted for age, sex and allowing for clustering by clinic. RESULTS We sampled 850 children (median age 18 months, IQR 15-23); 44% of the original trial sample in Kenya. Children treated with the combined protocol had similar anthropometry, fat-free mass, fat mass, skinfold thickness z-scores, and frequency of common illnesses 4 months post-discharge compared the standard protocol. Mean subscapular skinfold z-scores were close to the global norm (standard care: 0.24; combined 0.27). There was no significant difference in odds of relapse between protocols (SAM, 3% vs 3%, OR = 1.0 p = 0.75; MAM, 10% vs 12%, OR = 0.90 p = 0.34). CONCLUSIONS Despite the lower dosage of RUTF for most SAM children in the combined protocol, their anthropometry and relapse rates at 4 months post-discharge were similar to standard care. MAM children treated with RUTF had similar body composition to those treated with RUSF and neither group exhibited excess adiposity. These results add further evidence that a combined protocol is as effective as standard care with no evidence of adverse effects post-discharge. A simplified, combined approach could treat more children, stretch existing resources further, and contribute to achieving Sustainable Development Goal Two.
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Affiliation(s)
- Natasha Lelijveld
- No Wasted Lives, Action Against Hunger, London, United Kingdom
- Emergency Nutrition Network, Oxford, United Kingdom
- * E-mail:
| | | | | | - Amy Mayberry
- No Wasted Lives, Action Against Hunger, London, United Kingdom
| | - Jonathan C. Wells
- Childhood Nutrition Research Centre, UCL Great Ormond Street, Institute of Child Health, University College London, London, United Kingdom
| | - Charles Opondo
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Marko Kerac
- Department of Population Health, Centre for Maternal, Adolescent and Child Health (MARCH), London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jeanette Bailey
- Department of Population Health, Centre for Maternal, Adolescent and Child Health (MARCH), London School of Hygiene and Tropical Medicine, London, United Kingdom
- International Rescue Committee, New York City, New York, United States of America
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29
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Stephenson KB, Agapova SE, Hendrixson DT, Koroma AS, Manary MJ. An Optimized Dose of Therapeutic Feeding Results in Noninferior Growth in Midupper Arm Circumference Compared with a Standard Dose in Children in Sierra Leone Recovering from Acute Malnutrition. Curr Dev Nutr 2021; 5:nzab007. [PMID: 33659773 PMCID: PMC7904386 DOI: 10.1093/cdn/nzab007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/25/2021] [Accepted: 01/28/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Ready-to-use therapeutic food (RUTF) given at 175 kcal/kg per day throughout severe acute malnutrition (SAM) treatment is recommended. Some treatment programs have diverged from this paradigm in 2 ways: reducing the supplemental food dose to 75 kcal/kg per day when midupper arm circumference (MUAC) is >11.4 cm or simplifying to a fixed-dose regimen. OBJECTIVE The objective was to determine if transitioning to an optimized, fixed-dose supplementary feeding regimen during SAM treatment when MUAC is >11.4 cm would result in noninferior gain in MUAC compared with standard treatment. METHODS Using data from 2 clinical trials conducted in Sierra Leone, a retrospective dual-cohort study was performed. The 2 cohorts included children with SAM who had improved to meet criteria for moderate acute malnutrition (MAM). The standard dose cohort continued to receive weight-based RUTF at 175 kcal/kg per day, while the optimized dose cohort received fixed-dose, 500 kcal/d of supplementary feeding. The primary outcome was a noninferiority margin of 1 mm of MUAC after 4 wk of treatment, while secondary outcomes included rate of anthropometric changes as well as time-to-relapse to SAM or death. RESULTS MUAC after 4 wk was noninferior (Δ: -0.1 mm; 95% CI: -0.05, 0.03; inferiority rejected P = 0.008). Rates of weight gain and MUAC gain were the same in the optimized-dose and standard-dose groups, whereas the rate of length gain was slower in the optimized-dose cohort. Time-to-relapse to SAM or death was not different (HR: 1.05; P = 0.71). CONCLUSIONS This study supports the practice of treating children with SAM who have recovered to meet criteria for MAM with a reduced and fixed-dose regimen of RUTF. The results also raise the question of whether this strategy might adversely impact linear growth during SAM treatment.
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Affiliation(s)
| | - Sophia E Agapova
- Department of Pediatrics, Washington University, St. Louis, MO, USA
| | | | - Aminata Shamit Koroma
- Ministry of Health and Sanitation, The Republic of Sierra Leone, Freetown, Sierra Leone
| | - Mark J Manary
- Department of Pediatrics, Washington University, St. Louis, MO, USA
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30
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Kerac M, McGrath M, Connell N, Kompala C, Moore WH, Bailey J, Bandsma R, Berkley JA, Briend A, Collins S, Girma T, Wells JC. 'Severe malnutrition': thinking deeplyS, communicating simply. BMJ Glob Health 2020; 5:e003023. [PMID: 33208313 PMCID: PMC7677332 DOI: 10.1136/bmjgh-2020-003023] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/14/2020] [Accepted: 09/28/2020] [Indexed: 12/02/2022] Open
Affiliation(s)
- Marko Kerac
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
- Centre for MARCH (Maternal, Adolescent, Reproductive & Child Health), London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | | | - Jeanette Bailey
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
- Centre for MARCH (Maternal, Adolescent, Reproductive & Child Health), London School of Hygiene & Tropical Medicine, London, UK
- International Rescue Committee, New York, New York, USA
| | - Robert Bandsma
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
- The CHAIN Network, Nairobi, Kenya
| | - James A Berkley
- The CHAIN Network, Nairobi, Kenya
- KEMRI/Wellcome Come Research Programme, Kilifi, Kenya
| | - André Briend
- Center for Child Health Research, Tampere University, Faculty of Medicine and Health Technology, Tampere, Finland
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Faculty of Science, Copenhagen, Denmark
| | - Steve Collins
- Valid International, Oxford, United Kingdom
- Valid Nutrition, Cork, Ireland
| | - Tsinuel Girma
- Department of Pediatrics and Child Health, Jimma University, Faculty of Medical Sciences, Jimma, Ethiopia
| | - Jonathan C Wells
- Population, Policy & Practice Department, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
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