Evaluation of Nutrition Interventions in Children in Conflict Zones: A Narrative Review

Food and nutrition insecurity becomes increasingly worse in areas affected by armed conflict. Children affected by conflict, or in war-torn settings, face a disproportionate burden of malnutrition and poor health outcomes. As noted by humanitarian response reviews, there is a need for a stronger evidence-based response to humanitarian crises. To achieve this, we systematically searched and evaluated existing nutrition interventions carried out in conflict settings that assessed their impact on children's nutrition status. To evaluate the impact of nutrition interventions on children's nutrition and growth status, we identified published literature through EMBASE, PubMed, and Global Health by using a combination of relevant text words and Medical Subject Heading terms. Studies for this review must have included children (aged ≤18 y), been conducted in conflict or postconflict settings, and assessed a nutrition intervention that measured ≥1 outcome for nutrition status (i.e., stunting, wasting, or underweight). Eleven studies met the inclusion and exclusion criteria for this review. Five different nutrition interventions were identified and showed modest results in decreasing the prevalence of stunting, wasting, underweight, reduction in severe or moderate acute malnutrition or both, mortality, anemia, and diarrhea. Overall, nutrition interventions in conflict settings were associated with improved children's nutrition or growth status. Emergency nutrition programs should continue to follow recent recommendations to expand coverage and access (beyond refugee camps to rural areas) and ensure that aid and nutrition interventions are distributed equitably in all conflict-affected populations.

Increase in acute malnutrition in children following the 2014-2015 Ebola outbreak in rural Sierra Leone

Setting: All health facility and community malnutrition screening programmes in Tonkolili, a rural Ebola-affected district in Sierra Leone. Objectives: Before the Ebola disease outbreak, Sierra Leone had set a goal to reduce the prevalence of severe acute malnutrition (SAM) in children aged <5 years to <0.2%. We compared the number of children screened, diagnosed and treated for malnutrition before, during and after the outbreak (2013-2016). Design: This was a retrospective cross-sectional study. Results: Health facility screening declined from 16 805 children per month pre-outbreak to 13 510 during the outbreak (P = 0.02), and returned to pre-outbreak levels after the outbreak. Community-based screening remained stable during the outbreak, and increased by 30% post-outbreak (P < 0.001). The proportion diagnosed with moderate acute malnutrition using mid-upper arm circumference increased from respectively 3.6% and 5.1% pre-outbreak in the community and health facilities to 8.2% and 7.9% post-outbreak (P < 0.001, P = 0.003). The proportion of children diagnosed with SAM using a weight-for-age ratio at health facilities increased from 1.5% pre-outbreak to 3.5% post-outbreak (P = 0.003). On average, for every four children diagnosed with SAM per month, one child completed SAM treatment. Conclusion: After a decline in screening during the Ebola outbreak, diagnoses of acute malnutrition increased post-outbreak. Nutrition programmes need to be strengthened to pre-empt such effects in the event of future Ebola outbreaks.

Changes in plasma phosphate during in-patient treatment of children with severe acute malnutrition: an observational study in Uganda

BACKGROUND

Children treated for severe acute malnutrition (SAM) are at risk of refeeding hypophosphatemia. Therapeutic diets have only recently become fortified with phosphorus to meet United Nations (UN) specifications, but to our knowledge no studies have investigated the effect.

OBJECTIVE

The aim was to assess concentrations and correlates of plasma phosphate (P-phosphate) at admission and during treatment and to identify correlates of changes in P-phosphate.

DESIGN

This was a prospective observational study in 6- to 59-mo-old children admitted for treatment of SAM to Mulago Hospital, Uganda. P-phosphate was measured at admission, on the second day of treatment with a therapeutic formula containing 75 kcal/100 mL and 560 mg phosphorus/L (F-75, Nutriset), at the start of the transition to a therapeutic formula containing 100 kcal/100 mL and 579 mg phosphorus/L (F-100; Nutriset), at day 2 of transition, and at discharge.

RESULTS

Among 120 children, mean ± SD P-phosphate at admission was 1.04 ± 0.31 mmol/L and increased by 0.43 (95% CI: 0.35, 0.52) mmol/L during the first 2 d and more slowly toward discharge. Most (79%) children experienced their lowest P-phosphate concentration at admission, and none developed severe hypophosphatemia. P-phosphate was lowest in children with edema and with elevated C-reactive protein, and a lower increase was seen with increasing caretaker-reported severity of illness. Partially or fully replacing F-75 with rice porridge (i.e., a local practice to reduce diarrhea) during the first 2 d of stabilization was associated with a 0.34-mmol/L (95% CI: 0.18, 0.50 mmol/L) lower increase in P-phosphate during the same first 2 d.

CONCLUSIONS

F-75, which complies with UN specifications and provides 73 mg phosphorus · kg(-1) · d(-1) (130 mL · kg(-1) · d(-1)), seems to prevent refeeding hypophosphatemia in children with SAM. Replacing this formula with rice porridge during the first days of treatment to manage diarrhea may have an adverse effect on P-phosphate concentrations. This study was registered at http://www.isrctn.com as ISRCTN55092738.

Low-dose RUTF protocol and improved service delivery lead to good programme outcomes in the treatment of uncomplicated SAM: a programme report from Myanmar

The treatment of uncomplicated severe acute malnutrition (SAM) requires substantial amounts of ready-to-use therapeutic food (RUTF). In 2009, Action Contre la Faim anticipated a shortfall of RUTF for their nutrition programme in Myanmar. A low-dose RUTF protocol to treat children with uncomplicated SAM was adopted. In this protocol, RUTF was dosed according to beneficiary's body weight, until the child reached a Weight-for-Height z-score of ≥-3 and mid-upper arm circumference ≥110 mm. From this point, the child received a fixed quantity of RUTF per day, independent of body weight until discharge. Specific measures were implemented as part of this low-dose RUTF protocol in order to improve service quality and beneficiary support. We analysed individual records of 3083 children treated from July 2009 to January 2010. Up to 90.2% of children recovered, 2.0% defaulted and 0.9% were classified as non-responders. No deaths were recorded. Among children who recovered, median [IQR] length of stay and weight gain were 42 days [28; 56] and 4.0 g kg(-1) day(-1) [3.0; 5.7], respectively. Multivariable logistic regression showed that children older than 48 months had higher odds of non-response to treatment than younger children (adjusted odds ratio: 3.51, 95% CI: 1.67-7.42). Our results indicate that a low-dose RUTF protocol, combined with specific measures to ensure good service quality and beneficiary support, was successful in treating uncomplicated SAM in this setting. This programmatic experience should be validated by randomised studies aiming to test, quantify and attribute the effect of the protocol adaptation and programme improvements presented here.

Effectiveness of milk whey protein-based ready-to-use therapeutic food in treatment of severe acute malnutrition in Malawian under-5 children: a randomised, double-blind, controlled non-inferiority clinical trial

The cost of ready‐to‐use therapeutic food (RUTF) used in community‐based management of acute malnutrition has been a major obstacle to the scale up of this important child survival strategy. The current standard recipe for RUTF [peanut‐based RUTF (P‐RUTF)] is made from peanut paste, milk powder, oil, sugar, and minerals and vitamins. Milk powder forms about 30% of the ingredients and may represent over half the cost of the final product. The quality of whey protein concentrates 34% (WPC34) is similar to that of dried skimmed milk (DSM) used in the standard recipe and can be 25–33% cheaper. This blinded, parallel group, randomised, controlled non‐inferiority clinical trial tested the effectiveness in treating severe acute malnutrition (SAM) of a new RUTF formulation WPC‐RUTF in which WPC34 was used to replace DSM. Average weight gain (non‐inferiority margin Δ = −1.2 g kg⁻¹ day⁻¹) and recovery rate (Δ = −10%) were the primary outcomes, and length of stay (LOS) was the secondary outcome (Δ = +14 days). Both per‐protocol (PP) and intention‐to‐treat (ITT) analyses showed that WPC‐RUTF was not inferior to P‐RUTF for recovery rate [difference and its 95% confidence interval (CI) of 0.5% (95% CI –2.7, 3.7) in PP analysis and 0.6% (95% CI –5.2, 6.3) in ITT analysis] for average weight gain [0.2 (−0.5; 0.9) for both analyses] and LOS [−1.6 days (95% CI, −4.6, 1.4 days) in PP analysis and −1.9 days (95% CI, −4.6, 0.8 days) for ITT analysis]. In conclusion, whey protein‐based RUTF is an effective cheaper alternative to the standard milk‐based RUTF for the treatment of SAM.

Assessing the impact of the introduction of the World Health Organization growth standards and weight-for-height z-score criterion on the response to treatment of severe acute malnutrition in children: secondary data analysis

OBJECTIVE

The objective of our study was to assess the impact of adopting the World Health Organization growth standards and weight-for-height z-score criterion on the response to treatment of severe acute malnutrition in children compared with the use of the National Center for Health Statistics growth reference.

METHODS

We used data from children aged 6 to 59 months with acute malnutrition who were admitted to the Médecins sans Frontières nutrition program in Maradi, Niger, during 2006 (N = 56214). Differences in weight gain, duration of treatment, recovery from malnutrition, mortality, loss to follow-up, and need for inpatient care were compared for severely malnourished children identified according to the National Center for Health Statistics reference and weight-for-height <70% of the median criterion versus the World Health Organization standards and the weight-for-height less than -3 z-score criterion.

RESULTS

A total of 8 times more children (n = 25754) were classified as severely malnourished according to the World Health Organization standards compared with the National Center for Health Statistics reference (n = 2989). Children included according to the World Health Organization standards had shorter durations of treatment, greater rates of recovery, fewer deaths, and less loss to follow-up or need for inpatient care.

CONCLUSIONS

The introduction of the World Health Organization standards with the z-score criterion to identify children for admission into severe acute malnutrition treatment programs would imply the inclusion of children who are younger but have relatively higher weight for height on admission compared with the National Center for Health Statistics reference. These children have fewer medical complications requiring inpatient care and are more likely to experience shorter durations of treatment and lower mortality rates. The World Health Organization standards with the z-score criterion might become a useful tool for the early detection of acute malnutrition in children, although additional research on the resource implications of this transition is required.