Including whey protein and whey permeate in ready-to-use supplementary food improves recovery rates in children with moderate acute malnutrition: a randomized, double-blind clinical trial

Ready-to-use therapeutic/supplementary foods from local food resources: Technology accessibility, program effectiveness, and sustainability, a review

Ready-to-Use Therapeutic Food (RUTF) or Ready-to-Use Supplementary Food (RUSF) has been widely used in home-based treatment for severely and moderately acute malnourished children. These programs showed positive results in short term nutritional recovery in children, which were reported in some research settings. Nowadays, the RUTF/RUSF formulation has been improved using a variety of RUTF/RUSF from locally available food ingredients. This paper aims to review the essential aspects of the development and provision of RUTF/RUSF made from local food resources and monitor program effectiveness that warrants the program's sustainability. The modified recipes of RUTF/RUSF were developed following the international dietary guidelines for the rehabilitation of severely and moderately acute malnourished children. The local production of RUTF/RUSF provided some benefits that include empowering the local community, consideration of the common eating pattern, promoting the diversification of food consumption, strengthening food security, as well as supporting the sustainability of RUTF/RUSF production. Results of the PRISMA-based systematic literature review revealed various ingredient developments and processing techniques which could improve the product characteristics and sensory evaluation. RUTF/RUSF in local food production provided different food carriers (e.g., biscuits, wafers) and seemed to be more readily accepted by the children. Furthermore, the program sustainability of RUTF/RUSF depends on a continuous ingredients supply and support from the local government. The findings presented the importance of development of such food supplements based on the local food resources and with improved technology for prevention and rehabilitation of malnourished children.

Systematic Review of Management of Moderate Wasting in Children over 6 Months of Age

The effective management of the 33 million children with moderate acute malnutrition (MAM) is key to reducing childhood morbidity and mortality. In this review, we aim to evaluate the effectiveness of specially formulated foods (SFFs) compared to non-food-based approaches to manage MAM in children >6 months old. We conducted a search on ten databases until 23 August 2021 and included five studies, covering 3387 participants. Meta-analysis of four studies comparing SFFs to counselling or standard of care showed that SFFs likely increase recovery rate, reduce non-response, and may improve weight-for-height z-score, weight-for-age z-score and time to recovery, but have little or no effect on MUAC gain. One study on a multicomponent intervention (SFFs, antibiotics and counselling provided to high-risk MAM) compared to counselling only was reported narratively. The intervention may increase weight gain after 24 weeks but may have little or no effect on weight gain after 12 weeks and on non-response and mortality after 12 and 24 weeks of enrollment. The effect of this intervention on recovery was uncertain. In conclusion, SFFs may be beneficial for children with moderate wasting in humanitarian contexts. Programmatic recommendations should consider context and cost-effectiveness.

A protocol for a proof-of-concept randomized control trial testing increased protein quantity and quality in ready-to-use therapeutic food in improving linear growth among 6-23-month-old children with severe wasting in Malawi

INTRODUCTION

Ready-to-use therapeutic foods (RUTFs) have successfully promoted recovery from severe wasting and increased treatment coverage. However, RUTFs do not sufficiently improve linear growth, leaving many survivors of severe wasting at risk of persistent stunting, which is associated with high mortality risk, poor child development and non-communicable diseases in adulthood. High protein quantity and quality can stimulate linear growth.

AIM

The trial aims to assess whether higher-protein-RUTF leads to higher concentrations of markers of linear growth compared to standard RUTF among 6-23 months old children with severe wasting.

METHODS

We designed a higher protein quantity and quality RUTF for a proof-of-concept (PoC) double-blind randomized controlled trial.

OUTCOMES

The primary outcome is a change in insulin-like growth factor-1 (IGF-1), a hormone positively associated with linear growth after four weeks of treatment. Secondary outcomes include changes in ponderal and linear growth and in body composition from baseline to eight weeks later; plasma amino acid profile at four weeks; acceptability and safety.

IMPLICATIONS

These findings will help in informing the potential impact of increased protein in RUTF on linear growth when treating severe wasting towards conducting a larger clinical trial.

TRIAL REGISTRATION

The trial has been registered on clinicaltrial.gov (NCT05737472).

Standard RUTF vs. locally-made RUSF for acutely malnourished children: A quasi-experimental comparison of the impact on growth and compliance in a rural community of Pakistan

BACKGROUND

The reduction in severe and moderate acute malnutrition (SAM and MAM) rates in Pakistan has been sub-optimal compared to other low-and middle-income countries (LMICs). Specially-formulated products have been designed globally to manage SAM and MAM, such as ready-to-use therapeutic food (RUTF) and ready-to-use supplementary food (RUSF), with variable efficacies. RUTF is primarily produced and patented in industrialized countries, raising supply challenges in resource-constrained regions with a high burden of acute malnutrition. RUSF minimizes costs by using locally-available ingredients while providing similar nutritional value. In this study, we compared the efficacy, side effects, and compliance of two months of supplementation with either RUTF or RUSF.

METHODS

Children aged nine months in the rural district of Matiari, Pakistan, with a weight-for-height z-score (WHZ) <-2 received either RUTF (500 kcal sachet) for two months in 2015 or RUSF (520 kcal sachet) for two months in 2018.

RESULTS

The RUSF group had a higher height gain and mid-upper arm circumferences (MUAC) score. Higher compliance was noted with lower side effects in the RUSF group. A higher compliance rate did correlate with the growth parameters in respective groups.

CONCLUSION

Our study found that both RUTF and RUSF partially improve the anthropometric status of acutely malnourished children, with neither being superior to the other.

Effect of milk protein and whey permeate in large quantity lipid-based nutrient supplement on linear growth and body composition among stunted children: A randomized 2 × 2 factorial trial in Uganda

BACKGROUND

Despite possible benefits for growth, milk is costly to include in foods for undernourished children. Furthermore, the relative effects of different milk components, milk protein (MP), and whey permeate (WP) are unclear. We aimed to assess the effects of MP and WP in lipid-based nutrient supplement (LNS), and of LNS itself, on linear growth and body composition among stunted children.

METHODS AND FINDINGS

We performed a randomized, double-blind, 2 × 2 factorial trial among 12 to 59 months old stunted children in Uganda. Children were randomized to 4 formulations of LNS with MP or soy protein isolate and WP or maltodextrin (100 g/day for 12 weeks) or no supplementation. Investigators and outcome assessors were blinded; however, participants were only blinded to the ingredients in LNS. Data were analyzed based on intention-to-treat (ITT) using linear mixed-effects models adjusted for age, sex, season, and site. Primary outcomes were change in height and knee-heel length, and secondary outcomes included body composition by bioimpedance analysis (ISRCTN13093195). Between February and September 2020, we enrolled 750 children with a median age of 30 (interquartile range 23 to 41) months, with mean (± standard deviation) height-for-age z-score (HAZ) -3.02 ± 0.74 and 12.7% (95) were breastfed. The 750 children were randomized to LNS (n = 600) with or without MP (n = 299 versus n = 301) and WP (n = 301 versus n = 299), or no supplementation (n = 150); 736 (98.1%), evenly distributed between groups, completed 12-week follow-up. Eleven serious adverse events occurred in 10 (1.3%) children, mainly hospitalization with malaria and anemia, all deemed unrelated to the intervention. Unsupplemented children had 0.06 (95% confidence interval, CI [0.02, 0.10]; p = 0.015) decline in HAZ, accompanied by 0.29 (95% CI [0.20, 0.39]; p < 0.001) kg/m2 increase in fat mass index (FMI), but 0.06 (95% CI [-0.002; 0.12]; p = 0.057) kg/m2 decline in fat-free mass index (FFMI). There were no interactions between MP and WP. The main effects of MP were 0.03 (95% CI [-0.10, 0.16]; p = 0.662) cm in height and 0.2 (95% CI [-0.3, 0.7]; p = 0.389) mm in knee-heel length. The main effects of WP were -0.08 (95% CI [-0.21, 0.05]; p = 220) cm and -0.2 (95% CI [-0.7; 0.3]; p = 403) mm, respectively. Interactions were found between WP and breastfeeding with respect to linear growth (p < 0.02), due to positive effects among breastfed and negative effects among non-breastfed children. Overall, LNS resulted in 0.56 (95% CI [0.42, 0.70]; p < 0.001) cm height increase, corresponding to 0.17 (95% CI [0.13, 0.21]; p < 0.001) HAZ increase, and 0.21 (95% CI [0.14, 0.28]; p < 0.001) kg weight increase, of which 76.5% (95% CI [61.9; 91.1]) was fat-free mass. Using height-adjusted indicators, LNS increased FFMI (0.07 kg/m2, 95% CI [0.0001; 0.13]; p = 0.049), but not FMI (0.01 kg/m2, 95% CI [-0.10, 0.12]; p = 0.800). Main limitations were lack of blinding of caregivers and short study duration.

CONCLUSIONS

Adding dairy to LNS has no additional effects on linear growth or body composition in stunted children aged 12 to 59 months. However, supplementation with LNS, irrespective of milk, supports linear catch-up growth and accretion of fat-free mass, but not fat mass. If left untreated, children already on a stunting trajectory gain fat at the expense of fat-free mass, thus nutrition programs to treat such children should be considered.

TRIAL REGISTRATION

ISRCTN13093195.

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

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.

How do children with severe underweight and wasting respond to treatment? A pooled secondary data analysis to inform future intervention studies

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.

The management of moderate acute malnutrition in children aged 6-59 months in low- and middle-income countries: a systematic review and meta-analysis

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.

A local-ingredients-based supplement is an alternative to corn-soy blends plus for treating moderate acute malnutrition among children aged 6 to 59 months: A randomized controlled non-inferiority trial in Wolaita, Southern Ethiopia

BACKGROUND

Globally, moderate acute malnutrition (MAM) affects approximately 5% of children below five years of age. MAM is a persistent public health problem in Ethiopia. The current approach in Ethiopia for managing MAM is a supplementary feeding program; however, this is only provided to chronically food-insecure areas. The objective of the study was to compare a local-ingredients-based supplement (LIBS) with the standard corn-soy blend plus (CSB+) in treating MAM among children aged 6 to 59 months to test the hypothesis that the recovery rate achieved with LIBS will not be more than 7% worse than that achieved with CSB+.

METHODS AND FINDINGS

We used an individual randomized controlled non-inferiority trial design with two arms, involving 324 children with MAM aged 6 to 59 months in Wolaita, Southern Ethiopia. One hundred and sixty-two children were randomly assigned to each of the two arms. In the first arm, 125.2 g of LIBS with 8 ml of refined deodorized and cholesterol-free sunflower oil/day was provided. In the second arm, 150 g of CSB+ with 16 ml of refined deodorized and cholesterol-free sunflower oil/day was provided. Each child was provided with a daily ration of either LIBS or CSB+ for 12 weeks. Both intention-to-treat (ITT) and per-protocol (PP) analyses were done. ITT and PP analyses showed non-inferiority of LIBS compared with CSB+ for recovery rate [ITT risk difference = 4.9% (95% CI: -4.70, 14.50); PP risk difference = 3.7% (95% CI: -5.91, 13.31)]; average weight gain [ITT risk difference = 0.10 g (95% CI: -0.33 g, 0.53 g); PP risk difference = 0.04 g (95% CI: -0.38 g, 0.47 g)]; and recovery time [ITT risk difference = -2.64 days (95% CI: -8.40 days, 3.13 days); PP difference -2.17 days (95% CI: -7.97 days, 3.64 days]. Non-inferiority in MUAC gain and length/height gain was also observed in the LIBS group compared with the CSB+ group.

CONCLUSIONS

LIBS can be used as an alternative to the standard CSB+ for the treatment of MAM. Thus, the potential of scaling up the use of LIBS should be promoted.

TRIAL REGISTRATION

Pan-African Clinical Trial Registration number: PACTR201809662822990.

The Role of Milk Protein and Whey Permeate in Lipid-based Nutrient Supplements on the Growth and Development of Stunted Children in Uganda: A Randomized Trial Protocol (MAGNUS)

Stunting is associated with cognitive impairment and later chronic disease. Previous trials to prevent stunting have had little effect, and no trials seem to have provided larger amounts of energy and high-quality proteins to already stunted children. We aimed to assess the effects of milk protein (MP) and whey permeate (WP) in large-quantity lipid-based nutrient supplements (LNS-LQ), among stunted children, on linear growth and child development. This was a randomized, double-blind, 2-by-2 factorial trial. Stunted children aged 12-59 mo from eastern Uganda (n = 750) were randomly assigned to receive 100 g LNS-LQ with or without MP and WP (n = 4 × 150) or no supplement (n = 150) for 3 mo. The primary outcomes were change in knee-heel and total length. Secondary outcomes included child development, body composition, anthropometry, and hemoglobin. Micronutrient status, intestinal function, and microbiota were also assessed. Our findings will contribute to an understanding of the role of milk ingredients and LNS in linear catch-up growth. This trial was registered at www.isrctn.com as ISRCTN13093195.

Development of milk drink with whey fermented and acceptability by children and adolescents

Malnutrition is one of the main trouble relationship children development, it is linking of infectious disease, affect brain development, learning delay and others. The school feeding is an important action to mitigate this, but the acceptability of new and healthy products still a challenge. The goal of this article was to develop a fermented drink, replacing milk to whey, added of mangaba pulp and iron, to improve the nutritional quality of products. Two formulations were developed with a difference in ratio milk and whey. The pH, acidity, nutritional label, microbiology and sensorial assay with target public (children and adolescents) of formulations were evaluated. Highlights the contribution of protein, calcium and iron to daily value of intake recommended of formulations, 8.4%, 15.2% and 44.3%, respectively. The microbiological parameters founded shows that the formulations were developed according to good manufacture practice. The formulation and age showed significant effect in acceptability of judges, but gender did not effect. The increase of whey concentration in formulation improved the acceptability, ranking to 91.5% to children and 73.6% to adolescents. The developed formulations are a great option to novel food products, given the high acceptance of the fermented milk drink by potential consumers and nutritional aport.

Development and nutritional evaluation of local ingredients-based supplements to treat moderate acute malnutrition among children aged below five years: A descriptive study from rural Wolaita, Southern Ethiopia

In Ethiopia, moderate acute malnutrition (MAM) is a persistent public health problem. The current management approaches for MAM among children are counseling in food-secure settings and food supplementation in chronically food-insecure areas. The objective of this study was to develop a local ingredients-based supplement (LIBS) for treating MAM among children. Collection of food ingredients (pumpkin seed, amaranth grain, flaxseed, peanut, and emmer wheat) was made. Sorting, soaking, drying, roasting, and milling of ingredients were done. Nutrient analysis was done using triplicate measurements of each nutrient. One-way ANOVA was used to analyze differences in means with ± standard deviation of nutrient measurements among the supplements. The nutrient content of four developed LIBS ranged from 20.3 g to 22.5 g for protein, 29.3 g to 33.5 g for fat, 509.5 kcal to 570.0 for kcal, 6.0 g to 8.5 g for fiber, 2.8 g to 3.7 g for moisture, and 2.1 g to 4.3 g for ash. The mineral and antinutrient components ranged from 75.6 mg to 115.6 mg for calcium, 473.1 mg to 570.2 mg for potassium, 79.3 mg to 114.4 mg for sodium, 4.1 mg to 5.6 mg for zinc, 8.2 mg to 10.2 mg for iron, 442.6 mg to 470.4 mg for phosphorous, and 2.1 mg to 4.3 mg for phytate. The LIBS with the highest portion of pumpkin seed had significantly highest amounts of protein, fat, calories, iron, zinc, and potassium. The results found were within the recommended range of required nutrients for the treatment of children with MAM. Therefore, LIBS may be used for the management of children with MAM.

Protein quality in ready-to-use supplementary foods for moderate wasting

There are no guidelines for the optimal protein quality of ready-to-supplementary food (RUSF) for moderate acute malnutrition (MAM). This randomized, controlled, double-blinded, clinical effectiveness trial evaluated two RUSFs in the treatment of MAM. Both foods contained greater than 7% dairy protein, but the protein-optimized RUSF had a calculated digestible indispensable amino acid score (DIAAS) of 95%, whereas the control RUSF had a calculated DIAAS of 63%. There were 1,737 rural Malawian children 6-59 months of age treated with 75 kcal/kg/day of either control or protein quality-optimized RUSF for up to 12 weeks. There was no difference in the proportion of children who recovered from MAM between the group that received protein-optimized RUSF (759/860, 88%) and the group that received control RUSF (766/877, 87%, difference 1%, 95% CI, -2.1 to 4.1, p = 0.61). There were no differences in time to recovery or average weight gain; nor were adverse effects reported. Both RUSFs showed indistinguishable clinical outcomes, with recovery rates higher than typically seen in treatment for MAM. The DIAAS of these two RUSFs was measured using a pig model. Unexpectedly, the protein quality of the optimized RUSF was inferior to the control RUSF: DIAAS = 82% for the protein quality optimized RUSF and 96% for control RUSF. The controlled conditions of this trial suggest that in supplementary food products for MAM, protein quality is not an independent predictor of clinical effectiveness.

Fortified blended flour supplements displace plain cereals in feeding of young children

Lipid-based nutritional supplements (LNS) and fortified blended flours (FBF) are widely used to increase the nutrient density of children's diets and improve their health, but their effectiveness could be modified by displacement of other foods. We reanalysed data from a cost-effectiveness trial comparing impacts on anthropometry of three FBFs (Corn Soy Blend Plus [CSB+], Corn Soy Whey Blend [CSWB], SuperCereal Plus [SC+]) and one LNS (Ready-to-use Supplementary Food [RUSF]) among infants aged 7-23 months in Burkina Faso. Using dietary diversity data from a single 24-h recall period (n = 1,591 children, observed once over 18-month study period), we fit logistic regression models to estimate differences in intake of each food group making up the infant and young child minimum dietary diversity score and linear models to test for differences in dietary diversity score among children in each supplement arm. We tested for differences in breastfeeding time using the subsample for which breastfeeding was observed (n = 176). Children who consumed one of the three FBFs had lower odds of consuming household grains, roots and tubers compared with the LNS consumers (odds ratios [ORs] = 0.35-0.47; 95% confidence intervals [CIs]: 0.20-1.05). Consumption of other foods, dietary diversity and breastfeeding did not differ significantly at the 5% significance level. FBFs displaced the household's own cereals more than LNS, with no difference in the child's consumption of other more nutrient-rich family foods. Given limited stomach capacity and feeding time, providing fortified cereals may help improve children's overall diet quality in settings where children would otherwise be fed nutrient-poor root crops or cereal grains.

Association between admission criteria and body composition among young children with moderate acute malnutrition, a cross-sectional study from Burkina Faso

Children with moderate acute malnutrition (MAM) are treated based on low weight-for-length z-score (WLZ), low mid-upper arm circumference (MUAC) or both. This study aimed to assess associations of admission criteria and body composition (BC), to improve treatment of MAM. We undertook a cross-sectional study among 6–23 months old Burkinabe children with MAM. Fat-free (FFM) and fat mass (FM) were determined by deuterium dilution and expressed as FFM (FFMI) and FM index (FMI). Of 1,489 children, 439 (29.5%) were recruited by low MUAC only (MUAC-O), 734 (49.3%) by low WLZ and low MUAC (WLZ-MUAC) and 316 (21.2%) by low WLZ only (WLZ-O). Thus, 1,173 (78.8%) were recruited by low MUAC, with or without low WLZ (ALL-MUAC). After adjustments, WLZ-O had 89 g (95% confidence interval (CI) 5; 172) lower FFM compared to MUAC-O. Similarly, WLZ-O had 0.89 kg/m² (95% CI 0.77; 1.01) lower FFMI compared to MUAC-O, whereas there was no difference for FMI. However, boys included by WLZ-O compared to MUAC-O had 0.21 kg/m² (95% CI 0.05; 0.38) higher FMI. In contrast, girls included by WLZ-O had 0.17 (95% CI 0.01; 0.33) kg/m² lower FMI compared to MUAC-O (interaction, p = 0.002). We found that different criteria for admission into MAM treatment programmes select children with differences in BC, especially FFMI.

Trial registration: ISRCTN42569496.

Effect of a newly developed ready-to-use supplementary food on growth indicators in children with mild to moderate malnutrition

OBJECTIVES

Malnutrition is one of the leading causes of death among children younger than five years. In this study, we aimed to formulate a ready-to-use supplementary food (RUSF), based on local food products, and investigate its efficacy on growth indicators in children with mild to moderate malnutrition.

STUDY DESIGN

This is a randomized controlled clinical trial.

METHODS

This study was performed in six health centers in Shahr-e-Rey, Tehran, Iran, between April and October 2017. One hundred children, aged 24-59 months, with mild to moderate malnutrition (weight-for-height Z-score [WHZ] between -3 and -1) were randomly assigned to two groups to receive either 1-3 sachets of RUSF or normal diet for 8 weeks. All mothers and caregivers received nutrition education. Growth indicators including weight and height, WHZ, and body mass index (BMI), along with clinical outcomes, were assessed.

RESULTS

Children who received RUSF had a significant increase in weight (1.44 ± 0.38 vs 0.7 ± 0.32 kg, respectively, P < 0.001), and BMI (1.2 ± 0.47 vs 0.35 ± 0.33 kg/m², respectively, P < 0.001) compared with the control group. There was a greater daily weight gain during the first 4 weeks (P < 0.001) and throughout the study (P = 0.013) in the RUSF group. Daily height gain was considerably higher in the RUSF group during the first 4 weeks (P = 0.027). Children in the RUSF group had more improvement in WHZ (1.18 ± 0.41 vs 0.41 ± 0.31, P < 0.001) after supplementation. Besides, 92% of the RUSF and 12% of the control group reached to WHZ > -1 at the end of the study (P < 0.001). There was lower prevalence of diarrhea (12% vs 28.6%, respectively, P = 0.01) and marginally lower fever (16% vs 36.7%, respectively, P = 0.05) in the intervention than in the control group.

CONCLUSIONS

A newly developed RUSF improved growth indicators and clinical outcomes in children with mild to moderate malnutrition.

CLINICAL TRIAL REGISTRY NUMBER

IRCT2017021315536N6 (registered at www.irct.ir).

Applications of Ma'aljobon, a natural remedy from traditional Persian medicine, in dermatology: A journey from past to modernity

Ma'aljobon, a handmade substance, is the liquid portion of coagulated milk after adding vinegar to the heated milk. In traditional Persian medicine (TPM) it has been known as a useful remedy for the treatment of some skin disorders. The aim of this study was to review the applications of Ma'aljobon for skin diseases according to the sages of TPM and modern medicine. Main TPM sources were reviewed with the keyword of "Ma'aljobon." Furthermore, electronic databases including Scopus, PubMed, SID, and Google Scholar were searched with the keyword "Whey protein" during 2000 to 2018. According to TPM sources, Ma'aljobon was used by Iranian sages as a safe and effective remedy to treat a wide range of skin diseases, such as pimples, and ulcers. Meantime, recent evidence has also shown the effectiveness of whey protein in treating some skin disorders such as atopic dermatitis. Gastrointestinal discomfort was the most adverse effect of Ma'aljobon mentioned in TPM sources. In conclusion, there were several applications for Ma'aljobon in treatment of dermatologic disease according to TPM, as well as modern medicine. These finding could be the basis of future clinical trials on the effects of Ma'aljobon in the treatment of skin problems.

Effectiveness of interventions to manage acute malnutrition in children under 5 years of age in low- and middle-income countries: A systematic review

Background

Childhood malnutrition is a major public health concern as it is associated with significant short- and long-term morbidity and mortality.

Objectives

To comprehensively review the evidence for the management of severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) according to the current World Health Organization protocol using facility- and community-based approaches as well as the effectiveness of ready-to-use therapeutic food (RUTF), ready-to-use supplementary food (RUSF), prophylactic antibiotic use and vitamin A supplementation.

Search methods

We searched relevant electronic databases till 11 February 2019. No date or language restrictions were applied.

Selection criteria

We included randomised controlled trials (RCTs) and quasi-experimental studies including controlled before-after (CBA) studies and interrupted time series (ITS) studies.

Data collection and analysis

Two review authors independently screened studies for relevance, extracted data, assessed risk of bias and rated the quality of the evidence using the GRADE approach. We carried out statistical analysis using Review Manager software and set out the main findings of the review in "Summary of findings" tables.

Main results

This review summarises findings from a total of 42 studies (48 papers) including 35,017 children. Thirty-three of the included studies were RCTs; six studies were quasi-experimental and three studies were cost studies. Majority of the studies were judged to be at high risk of bias for blinding of the participants, personnel and outcome assessment. Majority of the outcomes were rated as either moderate or low quality. Outcomes were downgraded mainly due to study limitations, high heterogeneity, imprecision and small sample size. Community-based strategies to screen and manage SAM/MAM versus no community-based strategies (two studies): Integrated community-based management probably improves recovery rate by 4% [risk ratio (RR): 1.04; 95% confidence interval (CI): 1.00 to 1.09; one study; 1,957 participants; moderate-quality outcome], and reduces weight gain by 0.8 g·kg^-1·day^-1 [mean difference (MD): -0.80 g·kg^-1·day^-1; 95% CI: -0.82 to -0.78; one study; 1,957 participants; moderate-quality outcome] compared with no community-based strategies, while mortality was similar between the two groups (RR: 0.93; 95% CI: 0.60 to 1.45; one study; 1,957 participants; moderate-quality outcome). Facility-based strategies to screen and manage uncomplicated SAM versus other standard of care (four studies): There was no evidence of effect on recovery (RR: 1.00; 95% CI: 0.80, 1.25; one study; 60 participants; very-low-quality evidence) and mortality (RR: 1.21; 95% CI: 0.75 to 1.94; two studies; 473 participants; low-quality outcome). Facility-based management with RUTF versus F100 ("catch-up" formula to rebuild wasted tissues containing 100 kcal and 2.9 g protein per 100 ml) for SAM (three studies): There was no evidence of effect on weight gain (MD: 2 g·kg^-1·day^-1; 95% CI: -0.23 to 4.23; three studies; 266 participants; very-low-quality outcome) and mortality (RR: 1.20; 95% CI: 0.34 to 4.22; two studies; 168 participants; low-quality outcome). Community-based management of SAM with standard RUTF compared with other foods (14 studies): There was no evidence of effect on recovery rate when standard RUTF was compared to non-milk/peanut butter-based RUTF (RR: 1.03; 95% CI: 0.99 to 1.08; five studies; 5743 participants; I² 50%; moderate quality outcome), energy-dense, home-prepared food (RR: 1.14; 95% CI 0.95 to 1.36; four studies; 959 participants; I² 75%; low quality outcome), or high oleic RUTF (RR: 1.06; 95% CI: 0.85 to 1.31; one study; 141 participants; moderate quality outcome). Standard RUTF may improve weight gain by 0.5 g·kg^-1·day^-1 (MD: 0.5 g·kg^-1·day^-1; 95% CI: 0.02 to 0.99; three studies; 3,069 participants; low-quality outcome) when compared with non-milk/peanut butter-based RUTF and by 5.5 g·kg^-1·day^-1 when compared with F100 (MD: 5.50 g·kg^-1·day^-1; 95% CI: 2.92 to 8.08; one study; 70 participants; low-quality outcome). There was no evidence of effect on mortality when standard RUTF was compared with other foods (RR: 0.99; 95% CI: 0.69 to 1.41; nine studies; 7,667 participants; low-quality outcome). RUSF for MAM compared with other foods (14 studies): There was no evidence of effect on recovery rate when standard RUSF was compared with local/home made food (RR: 0.92; 95% CI: 0.64 to 1.33; three studies; 435 participants; low-quality outcome) and whey RUSF (RR: 0.96; 95% CI: 0.92 to 1.00; one study; 2230 participants; high-quality outcome); while standard RUSF may improve recovery by 7% when compared with corn-soy blend (CSB) (RR: 1.07; 95% CI: 1.02 to 1.13; six studies; 5,744 participants; low-quality outcome). There was no evidence of effect on weight gain when standard RUSF was compared with local home made food (MD: -0.75 g·kg^-1·day^-1; 95% CI: -2.03 to 0.43; one study; 73 participants; low-quality outcome) and whey RUSF (MD: -0.16 g·kg^-1·day^-1; 95% CI: -0.33 to 0.01; one study; 2,230 participants; high-quality outcome); while standard RUSF may improve weight gain by 0.49 g·kg^-1·day^-1 when compared with CSB (MD: 0.49 g·kg^-1·day^-1; 95% CI: 0.10 to 0.87; five studies; 4,354 participants; low-quality outcome). There was no evidence of effect on mortality when standard RUSF was compared with other foods (RR: 0.98; 95% CI: 0.57 to 1.68; eight studies; 8,310 participants; moderate-quality outcome). Prophylactic antibiotic versus no antibiotic (three studies): Prophylactic antibiotic therapy for uncomplicated SAM improves recovery rate by 6% (RR: 1.06; 95% CI: 1.03 to 1.08; two studies; 5,166 participants; high-quality outcome), probably improves weight gain by 0.67 g·kg^-1·day^-1 (MD: 0.67 g·kg^-1·day^-1; 95% CI: 0.28, 1.06; two studies; 5,052 participants; moderate-quality outcome) and probably reduces mortality by 26% (RR: 0.74; 95% CI: 0.55, 0.98; three studies; 6944 participants; moderate quality outcome) compared to no antibiotics group. High-dose vitamin A versus low-dose vitamin A (two studies): There was no evidence of effect on weight gain (MD: 0.05 g·kg^-1·day^-1; 95% CI: -0.08 to 0.18; one study; 207 participants; moderate-quality outcome) and mortality (RR: 7.07; 95% CI: 0.37 to 135.13; one study; 207 participants; moderate-quality outcome).

Authors’ conclusions

Limited data show some benefit of integrated community-based screening, identification and management of SAM and MAM on improving recovery. Facility-based screening and management of uncomplicated SAM has no benefit on recovery and mortality, while the effect of F100 for SAM is similar to RUTF for weight gain and mortality. Local food and whey RUSF have similar effects as standard RUSF on recovery rate and weight gain in MAM, while standard RUSF has additional benefits to CSB. Prophylactic antibiotic administration in uncomplicated SAM improves recovery rate, weight gain and reduces mortality, while limited data suggest that high-dose vitamin A supplementation is comparable with low-dose vitamin A supplementation for weight gain and mortality among children with SAM.

Cost-Effectiveness of 4 Specialized Nutritious Foods in the Prevention of Stunting and Wasting in Children Aged 6-23 Months in Burkina Faso: A Geographically Randomized Trial

BACKGROUND

There is a variety of specialized nutritious foods available for use in programs targeting undernutrition, but evidence supporting the choice of product is limited.

OBJECTIVES

We compared the cost-effectiveness of 4 specialized nutritious foods to prevent stunting and wasting in children aged 6-23 mo in Burkina Faso.

METHODS

Four geographic regions were randomly assigned to 1 of 4 intervention arms: Corn-Soy Blend Plus (CSB+) programmed with separate fortified vegetable oil (the reference food), Corn-Soy-Whey Blend (CSWB; a new formulation) with oil, SuperCereal Plus (SC+), and ready-to-use supplementary food (RUSF). We compared the effects of each intervention arm on growth (length-for-age z score (LAZ), weight-for-length z score (WLZ), end-line stunting (LAZ < -2), and total monthly measurements of wasting (WLZ < -2). Rations were ∼500 kcal/d, distributed monthly. Children were enrolled in the blanket supplementary feeding program at age ∼6 mo and measured monthly for ∼18 mo. Average costs per child reached were linked with effectiveness to compare the cost-effectiveness of each arm with CSB+ with oil.

RESULTS

In our sample of 6112 children (CSB+, n = 1519; CSWB, n = 1503; SC+, n = 1564; RUSF, n = 1526), none of the foods prevented declines in growth. Children in the SC+ and RUSF arms were not significantly different than those in the CSB+ with oil arm. Children in the CSWB with oil arm experienced higher end-line (measurement at age 22.9-23.9 mo) stunting (OR: 2.07; 95% CI: 1.46, 2.94) and more months of wasting (incidence rate ratio: 1.29; 95% CI: 1.09, 1.51). CSB+ with oil was the least-expensive ration in all costing scenarios ($113-131 2018 US dollars/enrolled child) and similar in effectiveness to SC+ and RUSF, and thus the most cost-effective product for the defined purposes.

CONCLUSIONS

CSB+ with oil was the most cost-effective ration in the prevention of wasting and stunting in this trial. This trial was registered at clinicaltrials.gov as NCT02071563.

Effectiveness of Interventions for Managing Acute Malnutrition in Children under Five Years of Age in Low-Income and Middle-Income Countries: A Systematic Review and Meta-Analysis

Childhood malnutrition is a major public health concern, as it is associated with significant short- and long-term morbidity and mortality. The objective of this review was to comprehensively review the evidence for the management of severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) according to the current World Health Organization (WHO) protocol using facility- and community-based approaches, as well as the effectiveness of ready-to-use therapeutic food (RUTF), ready-to-use supplementary food (RUSF), prophylactic antibiotic use, and vitamin A supplementation. We searched relevant electronic databases until 11 February 2019, and performed a meta-analysis. This review summarizes findings from a total of 42 studies (48 papers), including 35,017 children. Limited data show some benefit of integrated community-based screening, identification, and management of SAM and MAM on improving recovery rate. Facility-based screening and management of uncomplicated SAM has no effect on recovery and mortality, while the effect of therapeutic milk F100 for SAM is comparable to RUTF for weight gain and mortality. Local food and whey RUSF are comparable to standard RUSF for recovery rate and weight gain in MAM, while standard RUSF has additional benefits to CSB. Prophylactic antibiotic administration in uncomplicated SAM improves recovery rate and probably improves weight gain and reduces mortality. Limited data suggest that high-dose vitamin A supplementation is comparable with low-dose vitamin A supplementation for weight gain and mortality among children with SAM.

Effects of animal protein supplementation of mothers, preterm infants, and term infants on growth outcomes in childhood: a systematic review and meta-analysis of randomized trials

BACKGROUND

Child stunting is a major public health problem, afflicting 155 million people worldwide. Lack of animal-source protein has been identified as a risk, but effects of animal protein supplementation are not well established.

OBJECTIVE

The aim of this study was to investigate effects of animal protein supplementation in mothers, preterm infants, and term infants/children on birth and growth outcomes.

METHODS

PubMed, EMBASE, Cochrane library, Web of Science, Cumulative Index of Nursing and Allied Health Literature, and Latin American and Caribbean Health Sciences Literature were searched for randomized controlled trials of animal protein supplementation in mothers or infants and children (≤age 5 y), evaluating measures of anthropometry (≤age 18 y). Main outcomes included birth weight, low birth weight, small for gestational age at birth; height, height-for-age, weight, weight-for-age, weight-for-length, stunting, and wasting ≤18 y of age. Data were extracted independently in duplicate, and findings pooled using inverse variance meta-analysis. Heterogeneity was explored using I2, stratified analysis, and meta-regression, and publication bias by funnel plots, Egger's test, and fill/trim methods.

RESULTS

Of 6808 unique abstracts and 357 full-text articles, 62 trials were included. The 62 trials comprised over 30,000 participants across 5 continents, including formula-based supplementation in infants and food-based supplementation in pregnancy and childhood. Maternal supplementation increased birth weight by 0.06 kg, and both formula and food-based supplementation in term infants/young children increased weight by ≤0.14 kg. Neither formula nor food-based supplementation for term infants/young children increased height, whereas the height-for-age z-score was increased in the food-based (+0.06 z-score) but not formula-based (-0.11 z-score) trials reporting this outcome. In term infants, the weight-for-length z-score was increased in trials of formula (+0.24 z-score) and food supplementation (+0.06 z-score), whereas food supplementation was also associated with reduced odds of stunting (-13%).

CONCLUSIONS

Supplementation of protein from animal-source foods generally increased weight and weight-for-length in children, but with more limited effects on other growth outcomes such as attained height.

Undernutrition and growth in the developing world

PURPOSE OF REVIEW

Despite targeted interventions, an estimated 150.8 million children under 5 years globally are still stunted, of which more than half live in Asia and more than one-third live in Africa. This review summarizes our current knowledge regarding how longitudinal bone growth is regulated by nutritional intake in the developing world. Dietary macronutrients and micronutrients necessary for growth are also briefly reviewed.

RECENT FINDINGS

Recent advances include investigations of nutritionally sensitive regulators of growth as well as prospective evaluations of the role of specific dietary components on growth in order to better assess their impact.

SUMMARY

Further investigation is required to understand how nutrition impacts growth, the mechanisms underlying stunting and to optimize therapeutic strategies for children who are at risk for growth attenuation or are stunted in low and middle-income countries (LMICs).

Valorisation of Whey and Buttermilk for Production of Functional Beverages - An Overview of Current Possibilities

Whey and buttermilk are the main by-products of the dairy industry, both having excellent nutritional properties. Buttermilk contains a unique component, the milk fat globule membrane (MFGM). MFGM contains bioactive compounds with positive health effects like antitumour or cholesterol-lowering impact. Whey proteins are found in whey and are a source of bioactive peptides acting positively on coronary, gastrointestinal, immune and nervous systems. Yet, buttermilk and whey are insufficiently utilized in functional food production. Various technological solutions have been studied in order to increase the production of foods based on whey and/or buttermilk whereby the production of beverages appear to be most acceptable from the economic and technological point +of view. Thus, the aim of this paper is to give an overview of current knowledge about the possibilities of creating whey and/or buttermilk beverages.

Useful Tools for Food Aid: Linear Programming and Protein Quality Tools

The development of a superior treatment option for severe acute malnutrition (SAM) which allowed for home-based therapy put in place constraints that are crucial for ensuring the feasibility and nutritional integrity of the treatment. Soon after the initial success of ready-to-use therapeutic food (RUTF), there were attempts to modify the formulation for cost and other areas of acceptability. While alternative formulations have been taken on in clinical trials, they have been inferior to the standard RUTF recipe. Linear programming (LP) technology, however, has streamlined the formulation process allowing the user to account for the crucial constraints required to maintain the feasibility and nutritional integrity of standard RUTF. With the aid of an LP tool and other functional tools for assessing nutrient quality, nutrition researchers can use innovative approaches in food development that could potentially revolutionize food aid products.

Maximizing Recovery and Growth When Treating Moderate Acute Malnutrition with Whey-Containing Supplements

BACKGROUND

Much debate exists about the utility of dairy ingredients in the supplementary foods used to treat childhood moderate acute malnutrition (MAM).

OBJECTIVE

To review the evidence regarding the effectiveness of dairy-containing supplements, particularly specially formulated foods containing whey permeate and whey protein concentrate, in treating children with MAM.

METHODS

A summary of a conference presentation regarding an overview of current evidence behind the use of whey in supplementary foods, including results of a randomized double-blinded clinical effectiveness trial involving 2259 Malawian children treated for MAM using either a soy ready-to-use supplementary food (RUSF) or a novel whey RUSF treatment.

RESULTS

While the majority of the evidence base only suggests potential benefits of including whey in supplementary foods to treat MAM, a recent study specifically demonstrates that a whey RUSF produced superior recovery and growth outcomes in treating children with MAM when compared with a soy RUSF.

CONCLUSIONS

The use of whey ingredients has been shown to improve outcomes in the treatment of MAM; however, further research is needed to identify the ideal amount and type of dairy protein required to produce the best outcomes for the lowest cost.

How Milk and Its Proteins Affect Growth, Bone Health, and Weight

Milk has long been recognized to constitute a complete, well-balanced source of the nutrients and energy required to ensure the proper postnatal growth and development of infants. A growing body of evidence suggests the positive effects of dairy products and particularly of milk proteins on linear growth also in older children, both healthy or during recovery from malnutrition. This evidence led the way to the performance of extensive research aimed to delineate the components of milk and the mechanisms acting to make milk so effective. The present review summarizes the current knowledge regarding the influence of milk and its proteins on linear growth in healthy and malnourished children, focusing also on other important aspects of healthy growth, including bone health, weight status, and body composition.
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Growth Components of Cow's Milk: Emphasis on Effects in Undernourished Children

BACKGROUND

Cow's milk is a core ingredient in foods for prevention and treatment of undernutrition in children. It promotes growth, but there is limited knowledge of which components in milk have growth-stimulating effects.

OBJECTIVE

To discuss the growth-stimulating effects of milk in undernourished children with emphasis on protein, lactose, and minerals.

METHODS

We reviewed literature on dairy and growth in undernourished children.

RESULTS

Cow's milk has a specific stimulating effect on linear growth, even in well-nourished children, and it may stimulate weight gain and muscle accretion in wasted children. Dairy protein has high protein quality scores with no major differences between whey protein concentrate and dried skimmed milk. Lactose has potential growth-stimulating effects, and the high content of potassium, phosphorus, magnesium, and zinc in milk is also likely to stimulate growth. Furthermore, a high dairy content reduces the amount of antinutrients from plant protein.

CONCLUSIONS

Dairy protein, lactose, and bioavailable minerals all have potential growth-stimulating effects, which make cow's milk an important ingredient in foods for undernourished children. Different dairy ingredients vary with regard to protein amount and quality, content of lactose, and minerals, and thereby growth stimulating effects. This should be taken into consideration when deciding which dairy ingredient to use. Challenges include the relatively high cost of dairy. Therefore, future studies should include cost-effectiveness analysis and assessment of the desirable content of each growth-promoting milk component.

Impact of food supplements on hemoglobin, iron status, and inflammation in children with moderate acute malnutrition: a 2 × 2 × 3 factorial randomized trial in Burkina Faso

Background

Children with moderate acute malnutrition (MAM) are treated with lipid-based nutrient supplements (LNSs) or corn-soy blends (CSBs) but little is known about the impact of these supplements on hemoglobin, iron status, and inflammation.

Objective

The objective of this study was to investigate the impact of supplementary foods for treatment of MAM on hemoglobin, iron status, inflammation, and malaria.

Design

A randomized 2 × 2 × 3 factorial trial was conducted in Burkina Faso. Children aged 6-23 mo with MAM received 500 kcal/d as LNS or CSB, containing either dehulled soy (DS) or soy isolate (SI) and different quantities of dry skimmed milk (0%, 20% or 50% of total protein) for 12 wk. The trial was double-blind with regard to quality of soy and quantity of milk, but not matrix (CSB compared to LNS). Hemoglobin, serum ferritin (SF), serum soluble transferrin receptor (sTfR), serum C-reactive protein (CRP), serum α1-acid glycoprotein (AGP), and malaria antigens were measured at inclusion and after supplementation.

Results

Between September 2013 and August 2014, 1609 children were enrolled. Among these, 61 (3.8%) were lost to follow-up. During the 12-wk supplementation period, prevalence of anemia, low SF adjusted for inflammation (SFAI), elevated sTfR, and iron-deficiency anemia decreased by 16.9, 8.7, 12.6 and 10.5 percentage points. Children who received LNS compared to CSB had higher hemoglobin (2 g/L; 95% CI: 1, 4 g/L), SFAI (4.2 µg/L; 95% CI: 2.9, 5.5 µg/L), and CRP (0.8 mg/L; 95% CI: 0.4, 1.2 mg/L) and lower sTfR (-0.9 mg/L, 95% CI: -1.3, -0.6 mg/L) after the intervention. Replacing DS with SI or increasing milk content did not affect hemoglobin, SFAI, sTfR, or CRP.

Conclusion

Supplementation with LNS compared to CSB led to better hemoglobin and iron status, but overall prevalence of anemia remained high. The higher concentrations of acute-phase proteins in children who received LNSs requires further investigation. This trial was registered at www.controlled-trials.com as ISRCTN42569496.

Milk products in the dietary management of childhood undernutrition - a historical review

The present narrative review outlines the use of milk products in infant and young child feeding from early history until today and illustrates how research findings and technical innovations contributed to the evolution of milk-based strategies to combat undernutrition in children below the age of 5 years. From the onset of social welfare initiatives, dairy products were provided by maternal and child health services to improve nutrition. During the last century, a number of aetiological theories on oedematous forms of undernutrition were developed and until the 1970s the dogma of protein deficiency was dominant. Thereafter, a multifactorial concept gained acceptance and protein quality was emphasised. During the last decades, research findings demonstrated that the inclusion of dairy products in the management of severe acute malnutrition is most effective. For children suffering from moderate acute malnutrition the evidence for the superiority of milk-based diets is less clear. There is an unmet need for evaluating locally produced milk-free alternatives at lower cost, especially in countries that rely on imported dairy products. New strategies for the dietary management of childhood undernutrition need to be developed on the basis of research findings, current child feeding practices, socio-cultural conditions and local resources. Exclusive and continued breast-feeding supported by community-based nutrition programmes using optimal combinations of locally available complementary foods should be compared with milk product-based interventions.

Complementary Feeding Interventions Have a Small but Significant Impact on Linear and Ponderal Growth of Children in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

Background: World Health Assembly member states have committed to ambitious global targets for reductions in stunting and wasting by 2025. Improving complementary diets of children aged 6-23 mo is a recommended approach for reducing stunting in children <5 y old. Less is known about the potential of these interventions to prevent wasting.Objective: The aim of this article was to review and synthesize the current literature for the impact of complementary feeding interventions on linear [length-for-age z score (LAZ)] and ponderal [weight-for-length z score (WLZ)] growth of children aged 6-23 mo, with the specific goal of updating intervention-outcome linkages in the Lives Saved Tool (LiST).Methods: We started our review with studies included in the previous LiST review and searched for articles published since January 2012. We identified longitudinal trials that compared children aged 6-23 mo who received 1 of 2 types of complementary feeding interventions (nutrition education or counseling alone or complementary food supplementation with or without nutrition education or counseling) with a no-intervention control. We assessed study quality and generated pooled estimates of LAZ and WLZ change, as well as length and weight gain, for each category of intervention.Results: Interventions that provided nutrition education or counseling had a small but significant impact on linear growth in food-secure populations [LAZ standardized mean difference (SMD): 0.11; 95% CI: 0.01, 0.22] but not on ponderal growth. Complementary food supplementation interventions with or without nutrition education also had a small, significant effect in food-insecure settings on both LAZ (SMD: 0.08; 95% CI: 0.04, 0.13) and WLZ (SMD: 0.05; 95% CI: 0.01, 0.08).Conclusions: Nutrition education and complementary feeding interventions both had a small but significant impact on linear growth, and complementary feeding interventions also had an impact on ponderal growth of children aged 6-23 mo in low- and middle-income countries. The updated LiST model will support nutrition program planning and evaluation efforts by allowing users to model changes in intervention coverage on both stunting and wasting.

The Nutrient and Metabolite Profile of 3 Complementary Legume Foods with Potential to Improve Gut Health in Rural Malawian Children

Background: Environmental enteric dysfunction (EED), frequently seen in rural Malawian children, causes chronic inflammation and increases the risk of stunting. Legumes may be beneficial for improving nutrition and reducing the risk of developing EED in weaning children. Objective: The objectives of this study were to determine the nutritional value, verify the food safety, and identify metabolite profiles of 3 legume-based complementary foods: common bean (CB), cowpea (CP), and traditional corn-soy blend (CSB). Methods: Foods were prepared by using local ingredients and analyzed for nutrient composition with the use of Association of Official Analytical Chemists (AOAC) standards (950.46, 991.43, 992.15, 996.06, and 991.36) for macro- and micronutrient proximate analysis. Food safety analysis was conducted in accordance with the Environmental Protection Agency (7471B) and AOAC (2008.02) standards. The metabolite composition of foods was determined with nontargeted ultra-performance LC-tandem mass spectrometry metabolomics. Results: All foods provided similar energy; CB and CP foods contained higher protein and dietary fiber contents than did the CSB food. Iron and zinc were highest in the CSB and CP foods, whereas CB and CP foods contained higher amounts of magnesium, phosphorus, and potassium. A total of 652 distinct metabolites were identified across the 3 foods, and 23, 14, and 36 metabolites were specific to the CSB, CB, and CP foods, respectively. Among the potential dietary biomarkers of intake to distinguish legume foods were pipecolic acid and oleanolic acid for CB; arabinose and serotonin for CSB; and quercetin and α- and γ-tocopherol acid for CP. No heavy metals were detected, and aflatoxin was measured only in the CSB (5.2 parts per billion). Conclusions: Legumes in the diet provide a rich source of protein, dietary fiber, essential micronutrients, and phytochemicals that may reduce EED. These food metabolite analyses identified potential dietary biomarkers of legume intake for stool, urine, and blood detection that can be used in future studies to assess the relation between the distinct legumes consumed and health outcomes. This trial was registered at clinicaltrials.gov as NCT02472262 and NCT02472301.

Effectiveness of food supplements in increasing fat-free tissue accretion in children with moderate acute malnutrition: A randomised 2 × 2 × 3 factorial trial in Burkina Faso

BACKGROUND

Children with moderate acute malnutrition (MAM) are treated with lipid-based nutrient supplement (LNS) or corn-soy blend (CSB). We assessed the effectiveness of (a) matrix, i.e., LNS or CSB, (b) soy quality, i.e., soy isolate (SI) or dehulled soy (DS), and (c) percentage of total protein from dry skimmed milk, i.e., 0%, 20%, or 50%, in increasing fat-free tissue accretion.

METHODS AND FINDINGS

Between September 9, 2013, and August 29, 2014, a randomised 2 × 2 × 3 factorial trial recruited 6- to 23-month-old children with MAM in Burkina Faso. The intervention comprised 12 weeks of food supplementation providing 500 kcal/day as LNS or CSB, each containing SI or DS, and 0%, 20%, or 50% of protein from milk. Fat-free mass (FFM) was assessed by deuterium dilution technique. By dividing FFM by length squared, the primary outcome was expressed independent of length as FFM index (FFMI) accretion over 12 weeks. Other outcomes comprised recovery rate and additional anthropometric measures. Of 1,609 children, 4 died, 61 were lost to follow-up, and 119 were transferred out due to supplementation being switched to non-experimental products. No children developed allergic reaction. At inclusion, 95% were breastfed, mean (SD) weight was 6.91 kg (0.93), with 83.5% (5.5) FFM. In the whole cohort, weight increased 0.90 kg (95% CI 0.88, 0.93; p < 0.01) comprising 93.5% (95% CI 89.5, 97.3) FFM. As compared to children who received CSB, FFMI accretion was increased by 0.083 kg/m2 (95% CI 0.003, 0.163; p = 0.042) in those who received LNS. In contrast, SI did not increase FFMI compared to DS (mean difference 0.038 kg/m2; 95% CI -0.041, 0.118; p = 0.35), irrespective of matrix. Having 20% milk protein was associated with 0.097 kg/m2 (95% CI -0.002, 0.196) greater FFMI accretion than having 0% milk protein, although this difference was not significant (p = 0.055), and there was no effect of 50% milk protein (0.049 kg/m2; 95% CI -0.047, 0.146; p = 0.32). There was no effect modification by season, admission criteria, or baseline FFMI, stunting, inflammation, or breastfeeding (p > 0.05). LNS compared to CSB resulted in 128 g (95% CI 67, 190; p < 0.01) greater weight gain if both contained SI, but there was no difference between LNS and CSB if both contained DS (mean difference 22 g; 95% CI -40, 84; p = 0.49) (interaction p = 0.017). Accordingly, SI compared to DS increased weight by 89 g (95% CI 27, 150; p = 0.005) when combined with LNS, but not when combined with CSB. A limitation of this and other food supplementation trials is that it is not possible to collect reliable data on individual adherence.

CONCLUSIONS

Based on this study, children with MAM mainly gain fat-free tissue when rehabilitated. Nevertheless, LNS yields more fat-free tissue and higher recovery rates than CSB. Moreover, current LNSs with DS may be improved by shifting to SI. The role of milk relative to soy merits further research.

TRIAL REGISTRATION

ISRCTN registry ISRCTN42569496.

Effect of a package of health and nutrition services on sustained recovery in children after moderate acute malnutrition and factors related to sustaining recovery: a cluster-randomized trial

Background: Children who recover from moderate acute malnutrition (MAM) have high rates of relapse in the year after nutritional recovery. Interventions to decrease these adverse outcomes are needed to maximize the overall effectiveness of supplemental feeding programs (SFPs).Objective: We evaluated the effectiveness of a package of health and nutrition interventions on improving the proportion of children who sustained recovery for 1 y after MAM treatment. We further explored factors related to sustained recovery.Design: We conducted a cluster-randomized clinical effectiveness trial involving rural Malawian children aged 6-62 mo who were enrolled on discharge from an SFP for MAM. We enrolled 718 children at 10 control sites and 769 children at 11 intervention sites. In addition to routine health and nutrition counseling, the intervention group received a package of health and nutrition interventions that consisted of a lipid nutrient supplement, deworming medication, zinc supplementation, a bed net, and malaria chemoprophylaxis. A survival analysis was used to determine the effectiveness of the intervention as well as to identify factors associated with sustained recovery.Results: Of 1383 children who returned for the full 12-mo follow-up period, 407 children (56%) and 347 children (53%) sustained recovery in the intervention and control groups, respectively. There was no significant difference in relapse-free survival curves between the treatment and control groups (P = 0.380; log-rank test). The risk factors for relapse or death after initial recovery were a smaller midupper arm circumference on SFP admission (P = 0.01) and discharge (P < 0.001), a lower weight-for-height z score on discharge (P < 0.01), and the receipt of ready-to-use supplementary food as opposed to ready-to-use therapeutic food during treatment (P < 0.05).Conclusion: The provision of a package of health and nutrition services in addition to traditional SFP treatment has no significant effect on improving sustained recovery in children after treatment of MAM. This trial was registered at clinicaltrials.gov as NCT02351687.

Which dietary components modulate longitudinal growth?

PURPOSE OF REVIEW

Linear growth in children is sensitive to nutritional status; the growth of the human skeleton requires many different nutritional factors for energy and building blocks: proteins, lipids, carbohydrates and micronutrients. However, what are the specific nutritional factors that are required for proper growth and what is the composition that will be most beneficial is still not known.

RECENT FINDINGS

Recent findings indicate that macro and micronutrients are required as building blocks and as cofactors for important enzymes. In addition, they stimulate linear growth by acting as regulatory factors and also affect gut microbiome. Some interesting studies regarding the effect of proteins and amino acids are presented.

SUMMARY

Most studies investigated the effect of replacing a single micronutrient that was deficient; however, in real life, deficiency of one nutritional element is commonly associated with other deficiencies. Therefore, it is a reasonable clinical approach, both in developing and developed countries, to use a mixture of both macro and micronutrients to support growth. How much of each of the components and what is the best composition are still open questions that require more research.

Sufficient Protein Quality of Food Aid Varies with the Physiologic Status of Recipients

Protein quality scores use the amino acid (AA) requirements of a healthy North American child. AA requirements vary with physiologic status. We estimated AA requirements for healthy North American children, children with environmental enteric dysfunction, children recovering from wasting, and children with an acute infection. The protein quality of food aid products was then calculated to determine whether it was sufficient in all these groups, and we found that it may not be adequate for all of them. Physiologic status is important when assessing the protein quality of food aid. Rates of weight gain from 8 published trials treating children with moderate acute malnutrition were abstracted, and protein quality scores from the corresponding food aid products were calculated with the use of the digestible indispensable amino acid score (DIAAS). Two DIAAS values were calculated, one in healthy children aged 1-3 y as a reference population and the other in malnourished children aged 1-3 y as a reference population. These data were used to calculate the best fit regression line between weight gain and protein quality. The slope of the regression line was greater when malnourished children were used as a reference population than when healthy children were used (0.128; 95% CI: 0.118, 0.138 compared with 0.097; 95% CI: 0.090, 0.105 measured in g · kg^-1 · d^-1 · DIASS U^-1). These findings suggest that adjusting AA requirements for physiologic status may more accurately estimate the minimum protein quality of food aid products.