Treatment of severe and moderate acute malnutrition in low- and middle-income settings: a systematic review, meta-analysis and Delphi process.

Patrick Webb,Kerri Wazny,Zulfiqar A Bhutta,Lindsey M Lenters,Tahmeed Ahmed

doi:10.1186/1471-2458-13-s3-s23

Abstract

BackgroundGlobally, moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) affect approximately 52 million children under five. This systematic review evaluates the effectiveness of interventions for SAM including the World Health Organization (WHO) protocol for inpatient management and community-based management with ready-to-use-therapeutic food (RUTF), as well as interventions for MAM in children under five years in low- and middle-income countries.MethodsWe systematically searched the literature and included 14 studies in the meta-analysis. Study quality was assessed using CHERG adaptation of GRADE criteria. A Delphi process was undertaken to complement the systematic review in estimating case fatality and recovery rates that were necessary for modelling in the Lives Saved Tool (LiST).ResultsCase fatality rates for inpatient treatment of SAM using the WHO protocol ranged from 3.4% to 35%. For community-based treatment of SAM, children given RUTF were 51% more likely to achieve nutritional recovery than the standard care group. For the treatment of MAM, children in the RUSF group were significantly more likely to recover and less likely to be non-responders than in the CSB group. In both meta-analyses, weight gain in the intervention group was higher, and although statistically significant, these differences were small. Overall limitations in our analysis include considerable heterogeneity in many outcomes and an inability to evaluate intervention effects separate from commodity effect. The Delphi process indicated that adherence to standardized protocols for the treatment of SAM and MAM should have a marked positive impact on mortality and recovery rates; yet, true consensus was not achieved.ConclusionsGaps in our ability to estimate effectiveness of overall treatment approaches for SAM and MAM persist. In addition to further impact studies conducted in a wider range of settings, more high quality program evaluations need to be conducted and the results disseminated.

Highlights

Approximately 33 million children under five years of age are affected by moderate acute malnutrition (MAM), defined as a weight-for-height z-score (WHZ) between -2 and -3, and at least 19 million children under five by severe acute malnutrition (SAM), defined three times more slowly than for stunting, decreasing by 11% and 35% respectively.SAM inpatient management guidelines have been published by the World Health Organization (WHO), and updates to the protocol are pending [1,4]
All participants provided input on what constitutes ‘optimal care’ of MAM; 13 participants contributed to the mortality and recovery rates in each round
The lower bound of the recovery rate is 25% results from one expert who expressed that a large proportion of admissions would default before recovery is reached

Summary

Introduction

SAM inpatient management guidelines have been published by the World Health Organization (WHO), and updates to the protocol are pending [1,4]. Practitioners and WHO experts endorse community-based management for uncomplicated SAM while still advising that children who are severely malnourished and have medical complications, such as severe oedema, should be treated in an appropriate health facility [1,5]. Moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) affect approximately 52 million children under five. This systematic review evaluates the effectiveness of interventions for SAM including the World Health Organization (WHO) protocol for inpatient management and community-based management with ready-to-use-therapeutic food (RUTF), as well as interventions for MAM in children under five years in low- and middle-income countries

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Discussion

Conclusion