Abstract
BackgroundThe case fatality rate of severely malnourished children during inpatient treatment is high and mortality is often associated with diarrhea. As intestinal carbohydrate absorption is impaired in severe acute malnutrition (SAM), differences in dietary formulations during nutritional rehabilitation could lead to the development of osmotic diarrhea and subsequently hypovolemia and death. We compared three dietary strategies commonly used during the transition of severely malnourished children to higher caloric feeds, i.e., F100 milk (F100), Ready-to-Use Therapeutic Food (RUTF) and RUTF supplemented with F75 milk (RUTF + F75).MethodsIn this open-label pilot randomized controlled trial, 74 Malawian children with SAM aged 6–60 months, were assigned to either F100, RUTF or RUTF + F75. Our primary endpoint was the presence of low fecal pH (pH ≤ 5.5) measured in stool collected 3 days after the transition phase diets were introduced. Secondary outcomes were duration of hospital stay, diarrhea and other clinical outcomes. Chi-square test, two-way analysis of variance and logistic regression were conducted and, when appropriate, age, sex and initial weight for height Z-scores were included as covariates.ResultsThe proportion of children with acidic stool (pH ≤5.5) did not significantly differ between groups before discharge with 30, 33 and 23% for F100, RUTF and RUTF + F75, respectively. Mean duration of stay after transitioning was 7.0 days (SD 3.4) with no differences between the three feeding strategies. Diarrhea was present upon admission in 33% of patients and was significantly higher (48%) during the transition phase (p < 0.05). There was no significant difference in mortality (n = 6) between diets during the transition phase nor were there any differences in other secondary outcomes.ConclusionsThis pilot trial does not demonstrate that a particular transition phase diet is significantly better or worse since biochemical and clinical outcomes in children with SAM did not differ. However, larger and more tightly controlled efficacy studies are needed to confirm these findings.Trial registrationISRCTN13916953 Registered: 14 January 2013.
Highlights
The case fatality rate of severely malnourished children during inpatient treatment is high and mortality is often associated with diarrhea
severe acute malnutrition (SAM) is defined by a weightfor-height Z-score greater than three below the mean, a midupper arm circumference (MUAC) of less than 115 mm or by the presence of nutritional edema [3]
Malnourished children without complications are currently treated as outpatients in community-based management (CMAM) programmes using specially formulated ready-to-use therapeutic food (RUTF) [3]
Summary
The case fatality rate of severely malnourished children during inpatient treatment is high and mortality is often associated with diarrhea. Children with complicated SAM (i.e. SAM plus the presence of ‘danger signs’ such as fever, absent appetite, pneumonia, dehydration, severe edema) require inpatient treatment. Therapeutic feeding for these children involves three phases. Feeds are being finished and edema has started to resolve, the child will be gradually transitioned to a diet with a higher protein and energy content. In this transition phase three nutritional strategies are commonly used: F100, RUTF or RUTF supplemented with F75. Mortality is still substantial later during admission [4, 7] and even after discharge [8]
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