Treatment Of Acute Malnutrition Research Articles

Research Gaps in the Use of Dairy Ingredients in Food Aid Products.

Nutritional interventions to help prevent stunting, particularly in the first 1000 days from conception to 2 years of a child's life, are a major focus of numerous food aid organizations worldwide. Dairy ingredients can play an important role in enhancing the nutritional value and effectiveness of food products used in food aid. This article addresses gaps in research on malnutrition from both a broad perspective and specific to dairy ingredients. Narrative review. From a broad perspective, there is a need for gaining a consensus by the research community and funders of research on best practices for protocol development, outcomes measured, and reporting of study outcomes. Identification of biomarkers and rapid screening methods and consistent application of their use would expedite future research. A better understanding of nutritional requirements for malnourished populations, including the effects of energy deficits and disease on those requirements, is needed. More specific to dairy ingredients, a key research question is: Does dairy protein or the package of nutrients provided by dairy ingredients have a unique impact on growth, and if so, how? Also, data on the optimal levels of dairy ingredients based on the effective cost of treatment are needed, particularly in the treatment and prevention of moderate acute malnutrition and during pregnancy.

Optimizing Ready-to-Use Therapeutic Foods for Protein Quality, Cost, and Acceptability.

This article describes current research on the development of alternative ready-to-use therapeutic foods (RUTFs) in the treatment of severe acute malnutrition. An innovative and versatile linear programming tool has been developed to facilitate the creation of therapeutic formulas that are determined acceptable on multiple levels: costs, ingredient acceptability, availability and stability, nutrient requirements, and personal preferences. The formulas are analyzed for ease of production by Washington University team members and for organoleptic properties acceptability to target populations. In the future, RUTF products that are cost-effective, acceptable, sustainable, and widely available will become a reality.

Routine Amoxicillin for Uncomplicated Severe Acute Malnutrition in Children

BackgroundHigh-quality evidence supporting a community-based treatment protocol for children with severe acute malnutrition, including routine antibiotic use at admission to a nutritional treatment program, remains limited. In view of the costs and consequences of emerging resistance associated with routine antibiotic use, more evidence is required to support this practice.MethodsIn a double-blind, placebo-controlled trial in Niger, we randomly assigned children who were 6 to 59 months of age and had uncomplicated severe acute malnutrition to receive amoxicillin or placebo for 7 days. The primary outcome was nutritional recovery at or before week 8.ResultsA total of 2412 children underwent randomization, and 2399 children were included in the analysis. Nutritional recovery occurred in 65.9% of children in the amoxicillin group (790 of 1199) and in 62.7% of children in the placebo group (752 of 1200). There was no significant difference in the likelihood of nutritional recovery (risk ratio for amoxicillin vs. placebo, 1.05; 95% confidence interval [CI], 0.99 to 1.12; P=0.10). In secondary analyses, amoxicillin decreased the risk of transfer to inpatient care by 14% (26.4% in the amoxicillin group vs. 30.7% in the placebo group; risk ratio, 0.86; 95% CI, 0.76 to 0.98; P=0.02).ConclusionsWe found no benefit of routine antibiotic use with respect to nutritional recovery from uncomplicated severe acute malnutrition in Niger. In regions with adequate infrastructure for surveillance and management of complications, health care facilities could consider eliminating the routine use of antibiotics in protocols for the treatment of uncomplicated severe acute malnutrition. (Funded by Médecins sans Frontières Operational Center Paris; ClinicalTrials.gov number, NCT01613547.)

Acceptability of locally produced ready-to-use therapeutic foods in Ethiopia, Ghana, Pakistan and India.

Successful treatment of severe acute malnutrition has been achieved with ready-to-use therapeutic food (RUTF), but only 15% of children with severe acute malnutrition receive RUTF. The objective of this study was to determine whether new formulations of RUTF produced using locally available ingredients were acceptable to young children in Ethiopia, Ghana, Pakistan and India. The local RUTFs were formulated using a linear programming tool that allows for inclusion of only local ingredients and minimizes cost. The study consisted of 4 two-arm, crossover, site-randomized food acceptability trials to test the acceptability of an alternative RUTF formula compared with the standard peanut-based RUTF containing powdered milk. Fifty children with moderate wasting in each country were enrolled in the 2-week study. Acceptability was measured by overall consumption, likeability and adverse effects reported by caregivers. Two of the four RUTFs did not include peanut, and all four used alternative dairy proteins rather than milk. The ingredient cost of all of the RUTFs was about 60% of standard RUTF. In Ethiopia, Ghana and India, the local RUTF was tolerated well without increased reports of rash, diarrhoea or vomiting. Children consumed similar amounts of local RUTF and standard RUTF and preferred them similarly as well. In Pakistan, local RUTF was consumed in similar quantities, but mothers perceived that children did not enjoy it as much as standard RUTF. Our results support the further investigation of these local RUTFs in Ethiopia, Ghana and India in equivalency trials and suggest that local RUTFs may be of lower cost.

Moderate malnutrition in children aged five years and younger in South Africa: are wasting or stunting being treated?

Objectives: The objective of the study was to describe wasting and stunting in children aged 12–60 months, admitted to targeted supplementary feeding programmes for the treatment of moderate acute malnutrition (MAM) in South Africa.Design: A cross-sectional, descriptive study was performed.Subjects and setting: Children with MAM, managed as outpatients at primary healthcare facilities in three provinces, were included in the study conducted between September 2012 and August 2013.Outcome measures: Weight, height and mid-upper-arm circumference (MUAC) measurements were collected to classify the children as moderately or severely stunted or wasted.Results: Of the total sample (n = 225), 13% (n = 30) were diagnosed as wasted, 58% (n = 131) as stunted, and 21% (n = 47) as both wasted and stunted. MUAC was significantly associated with wasting. However, an association was not found between MUAC and stunting. Of the sample, 32% (n = 72) presented with severe stunting, and 29% (n = 65) with moderate wasting. Food insecurity was associated with wasting, but not with stunting.Conclusion: A low weight-for-age z-score resulted more from stunting than from wasting in this study. Severe stunting presented as a greater health concern than moderate wasting. Without scrutinising wasting and stunting, healthcare professionals may remain unaware of the drivers of underweight for age in children treated at South African primary healthcare facilities. Following this study’s outcomes, the sensitivity of MUAC in screening for moderate malnutrition in South African settings with a high prevalence of stunting is questionable. It is recommended that current nutritional interventions are revisited to explore the efficacy of treating children with wasting, stunting or both.

Evaluation of the acceptability of improved supplementary foods for the treatment of moderate acute malnutrition in Burkina Faso using a mixed method approach

The objective of this study was to evaluate, within the context of a randomized controlled trial of product effectiveness, the acceptability of new formulations of six corn-soy blended flours (CSB) and six lipid-based nutrient supplements (LNS) with different quantities of milk and qualities of soy for the treatment of children with moderate acute malnutrition (MAM).Our study included 1546 children aged 6–23 months and involved questionnaires after one month of supplementation home visits and interviews with a sub-sample of 20 trial participants and their caretakers, and nine focus group discussion.All 12 products were well accepted in terms of organoleptic qualities and received good ratings. However, LNS were more appreciated by caretakers and children. Additionally, an effect of soy isolate was detected on child appreciation where products with high milk content also received better ratings. CSB were not consumed as readily; 33.9% (n = 257) of children receiving CSB were reported to have leftovers compared to 17.3% (n = 134) of children receiving LNS (p=<0.001). Both CSB and LNS were referred to as foods with medicinal properties and perceived as beneficial to child health. They were both reported to have high priority in the daily feeding of the child.In conclusion, there were minimal differences in acceptability of the various CSB and LNS formulations, although CSB were less readily consumed and required smaller meal volumes. Since all products were well-accepted, decisions regarding whether the more expensive products should be used for the treatment of MAM will need to be based on their effect on child nutrition, growth and health. Future supplementary feeding programs in similar contexts could furthermore consider introducing supplementary foods as a medical treatment, as this may increase adherence and decrease sharing.

Characteristics of admissions and variations in the use of basic investigations, treatments and outcomes in Kenyan hospitals within a new Clinical Information Network

BackgroundLack of detailed information about hospital activities, processes and outcomes hampers planning, performance monitoring and improvement in low-income countries (LIC). Clinical networks offer one means to advance methods for data...

The REFANI-N study protocol: a cluster-randomised controlled trial of the effectiveness and cost-effectiveness of early initiation and longer duration of emergency/seasonal unconditional cash transfers for the prevention of acute malnutrition among children, 6–59 months, in Tahoua, Niger

BackgroundThe global burden of acute malnutrition among children remains high, and prevalence rates are highest in humanitarian contexts such as Niger. Unconditional cash transfers are increasingly used to prevent acute malnutrition in emergencies but lack a strong evidence base. In Niger, non-governmental organisations give unconditional cash transfers to the poorest households from June to September; the ‘hunger gap’. However, rising admissions to feeding programmes from March/April suggest the intervention may be late.Methods/designThis cluster-randomised controlled trial will compare two types of unconditional cash transfer for ‘very poor’ households in ‘vulnerable’ villages defined and identified by the implementing organisation. 3,500 children (6–59 months) and 2,500 women (15–49 years) will be recruited exhaustively from households targeted for cash and from a random sample of non-recipient households in 40 villages in Tahoua district. Clusters of villages with a common cash distribution point will be assigned to either a control group which will receive the standard intervention (n = 10), or a modified intervention group (n = 10). The standard intervention is 32,500 FCFA/month for 4 months, June to September, given cash-in-hand to female representatives of ‘very poor’ households. The modified intervention is 21,500 FCFA/month for 5 months, April, May, July, August, September, and 22,500 FCFA in June, providing the same total amount. In both arms the recipient women attend an education session, women and children are screened and referred for acute malnutrition treatment, and the households receive nutrition supplements for children 6–23 months and pregnant and lactating women. The trial will evaluate whether the modified unconditional cash transfer leads to a reduction in acute malnutrition among children 6–59 months old compared to the standard intervention. The sample size provides power to detect a 5 percentage point difference in prevalence of acute malnutrition between trial arms. Quantitative and qualitative process evaluation data will be prospectively collected and programme costs will be collected and cost-effectiveness ratios calculated.DiscussionThis randomised study design with a concurrent process evaluation will provide evidence on the effectiveness and cost-effectiveness of earlier initiation of seasonal unconditional cash transfer for the prevention of acute malnutrition, which will be generalisable to similar humanitarian situations.Trial registrationISRCTN25360839, registered March 19, 2015.

CATCH-UP GROWTH IN CHILDREN WITH SEVERE ACUTE MALNUTRITION: COMPARISON OF TWO THERAPEUTIC FEEDING APPROACHES AT A DISTRICT HOSPITAL, SOUTH AFRICA

Although the World Health Organisation (WHO) guidelines have proved to be effective in the treatment of severe acute malnutrition (SAM) in other countries, limited data is available in South Africa, especially in relation to HIV-infected children. This study aimed to describe the recovery of clinically stable children with SAM, 12–60 months of age, treated as in-patients at a specialised district hospital in KwaZulu-Natal, South Africa, using two WHO recommended treatment approaches. A prospective cohort with clinically stable SAM referred to Clairwood Hospital between August 2012 and September 2013 was followed from admission until discharge in this descriptive study. Children were nutritionally managed, after being stratified and randomly assigned to one of the two suggested nutritional treatment groups, F-100 or Ready-to-use Therapeutic Foods (RUTF). Of the total of 41 children admitted with SAM during the year, 35 children participated and 34 completed the study. About 56% were younger than 18 months and 73.5% HIV-infected. A mean growth velocity of 7.77g/kg/day (RUTF group) versus 6.11g/kg/day (F100 group) was observed (p = 0.23). Recovery was achieved in 88.8% (n=15) of children on RUTF, and 64.7% (n=11) in the F-100 group, within 2.7 and 4.4 weeks, respectively. The RUTF group recovered significantly (p=0.02) faster. HIV-infection in this study did not affect growth velocity. RUTF can be used as effectively as F-100 in the rehabilitation of SAM to achieve catch-up growth and similar recovery rates are possible in HIV-infected children if managed according to WHO guidelines.

Comparison of Clinical Characteristics and Treatment Outcomes of Children Selected for Treatment of Severe Acute Malnutrition Using Mid Upper Arm Circumference and/or Weight-for-Height Z-Score

ObjectivesDebate for a greater role of mid-upper arm circumference (MUAC) measures in nutritional programming continues, but a shift from therapeutic feeding programs admitting children using MUAC and/or weight-for-height Z (WHZ) to a new model admitting children using MUAC only remains complicated by limited information regarding the clinical profile and response to treatment of children selected by MUAC vs. WHZ. To broaden our understanding of how children identified for therapeutic feeding by MUAC and/or WHZ may differ, we aimed to investigate differences between children identified for therapeutic feeding by MUAC and/or WHZ in terms of demographic, anthropometric, clinical, and laboratory and treatment response characteristics.MethodsUsing secondary data from a randomized trial in rural Niger among children with uncomplicated severe acute malnutrition, we compared children that would be admitted to a therapeutic feeding program that used a single anthropometric criterion of MUAC< 115 mm vs. children that are admitted under current admission criteria (WHZ< -3 and/or MUAC< 115 mm) but would be excluded from a program that used a single MUAC< 115 mm admission criterion. We assessed differences between groups using multivariate regression, employing linear regression for continuous outcomes and log-binomial regression for dichotomous outcomes.ResultsWe found no difference in terms of clinical and laboratory characteristics and discharge outcomes evaluated between children that would be included in a MUAC< 115 mm therapeutic feeding program vs. children that are currently eligible for therapeutic feeding but would be excluded from a MUAC-only program.ConclusionsA single anthropometric admission criterion of MUAC < 115 mm did not differentiate well between children in terms of clinical or laboratory measures or program outcomes in this context. If nutritional programming is to use a single MUAC-based criterion for admission to treatment, further research and program experience can help to identify the most appropriate criterion in a broad range of contexts to target children in most urgent need of treatment.

Seasonal effect and long-term nutritional status following exit from a Community-Based Management of Severe Acute Malnutrition program in Bihar, India.

Background/Objectives:Children aged 6 months to 5 years completing treatment for severe acute malnutrition (SAM) in a Médecins Sans Frontières Community Management of Acute Malnutrition (CMAM) program in Bihar, India, showed high cure rates; however, the program suffered default rates of 38%. This report describes the nutritional status of 1956 children followed up between 3 and 18 months after exiting the program.Subjects/Methods:All children aged 6–59 months discharged as cured with mid-upper arm circumference (MUAC) ⩾120 mm or who defaulted from the program with MUAC <115 mm were traced at 3, 6, 9, 12 and 18 months (±10 days) before three exit reference dates: first at the end of the food insecure period, second after the 2-month food security and third after the 4-month food security.Results:Overall, 68.7% (n=692) of defaulters and 76.2% (n=1264) of children discharged as cured were traced. Combined rates of non-recovery in children who defaulted with MUAC <115 mm were 41%, 30.1%, 9.9%, 6.1% and 3.6% at 3, 6, 9, 12 and 18 months following exit, respectively. Combined rates of relapse among cured cases (MUAC ⩾120 mm) were 9.1%, 2.9%, 2.1%, 2.8% and 0% at 3, 6, 9, 12 and 18 months following discharge, respectively. Prevalence of undernutrition increased substantially for both groups traced during low food security periods. Odds of death were much higher for children defaulting with MUAC <110 mm when compared with children discharged as cured, who shared the same mortality risk as those defaulting with MUAC 110–<115 mm.Conclusions:Seasonal food security predicted short-term nutritional status after exit, with relapse rates and non-recovery from SAM much higher during food insecurity. Mortality outcomes suggest that a MUAC of 110 mm may be considered an appropriate admission point for SAM treatment programs in this context.

Survival status and predictors of mortality in severely malnourished children admitted to Jimma University Specialized Hospital from 2010 to 2012, Jimma, Ethiopia: a retrospective longitudinal study.

BackgroundAlthough community based treatment of severe acute malnutrition has been advocated for in recent years, facility based treatment of severe acute malnutrition is still required. Therefore, information on the treatment outcomes of malnutrition and potential predictors of mortality among severely malnourished children admitted to hospitals is critical for the improvement of quality care. Thus, the aim of this study was to assess survival status and predictors of mortality in severely malnourished children admitted to Jimma University Specialized Hospital from September 11, 2010 to September 10, 2012.MethodsRetrospective longitudinal study was conducted at Jimma University Specialized Hospital. From September 11, 2010 to September 10, 2012 available data from severely malnourished children admitted to the hospital were reviewed. Data were analyzed using SPSS version 20 for windows. Bivariate and multivariable analyses were performed by Kaplan-Meier and Cox regression to identify clinical characteristics associated with mortality.ResultA total of 947 children were enrolled into the study. An improvement, death and abscond rate were 77.8, 9.3 and 12.9 % respectively. The median duration from admission to death was 7 days. The average length of stay in the hospital and average weight gain were 17.4 days and 10.4 g/kg/day respectively. The main predictors of earlier hospital deaths were age less than 24 months (AHR = 1.9, 95 % CI [1.2–2.9]), hypothermia (AHR = 3.0, 95 % CI [1.4–6.6]), impaired consciousness level (AHR = 2.6, 95 % CI [1.5–4.5]), dehydration (AHR = 2.3, 95 % CI [1.3–4.0]), palmar pallor (AHR = 2.1, 95 % CI [1.3–3.3]) and co-morbidity/complication at admission (AHR = 3.7, 95 % CI [1.9–7.2]).ConclusionThe treatment outcomes (improvement rate, death rate, average length of stay in the hospital and average weight gain) were better than most reports in the literatures and in agreement with minimum international standard set for management of severe acute malnutrition. Intervention to further reduce earlier deaths should focus on young children with hypothermia, altered mental status, dehydration, anemia and comorbidities.

Food Sharing Practices in Households Receiving Supplemental Foods for the Treatment of Moderate Acute Malnutrition in Ethiopian Children

The objective of this article is to evaluate food sharing practices in households receiving corn–soya blend (CSB) and ready-to-use supplementary food (RUSF) in southern Ethiopia. Ethiopian children with moderate acute malnutrition from 10 supplementary feeding sites received CSB (1413 kcal/day) or RUSF (500 kcal/day). Data on food sharing and consumption practices were collected from 1125 households via structured questionnaires administered by trained local health professionals after 6 weeks of treatment. CSB was shared among a significantly higher number of family members (1.9 ± 1.0) compared to RUSF (0.1 ± 0.4; P < .001). In only 14% of CSB households, children consumed equal or more than three quarters of the ration, compared to 98% of RUSF households. Only 9% of RUSF households reported food sharing, the majority (86%) of whom were children in the same household under 5 years of age. Comparatively, CSB was shared within the household with a greater number of family members and in greater quantities compared to RUSF. CSB was reported to be widely consumed by all members of the household, whereas RUSF was sparingly shared and only with children under 5 years of age in the household.

High-Oleic Ready-to-Use Therapeutic Food Maintains Docosahexaenoic Acid Status in Severe Malnutrition.

Ready-to-use therapeutic food (RUTF) is the preferred treatment for uncomplicated severe acute malnutrition. It contains large amounts of linoleic acid and little α-linolenic acid, which may reduce the availability of docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) to the recovering child. A novel high-oleic RUTF (HO-RUTF) was developed with less linoleic acid to determine its effect on DHA and EPA status. We conducted a prospective, randomized, double-blind clinical effectiveness trial treating rural Malawian children with severe acute malnutrition. Children were treated with either HO-RUTF or standard RUTF. Plasma phospholipid fatty acid status was measured on enrollment and after 4 weeks and compared between the 2 intervention groups. Among the 141 children enrolled, 48 of 71 receiving HO-RUTF and 50 of 70 receiving RUTF recovered. Plasma phospholipid samples were analyzed from 43 children consuming HO-RUTF and 35 children consuming RUTF. The change in DHA content during the first 4 weeks was +4% and -25% in the HO-RUTF and RUTF groups, respectively (P = 0.04). For EPA, the change in content was 63% and -24% in the HO-RUTF and RUTF groups, respectively (P < 0.001). For arachidonic acid, the change in content was -3% and 13% in the HO-RUTF and RUTF groups, respectively (P < 0.009). The changes in DHA and EPA seen in the children treated with HO-RUTF warrant further investigation because they suggest that HO-RUTF support improved polyunsaturated fatty acid status, necessary for neural development and recovery.

Coverage of community-based management of severe acute malnutrition programmes in twenty-one countries, 2012-2013.

ObjectiveThis paper reviews coverage data from programmes treating severe acute malnutrition (SAM) collected between July 2012 and June 2013.DesignThis is a descriptive study of coverage levels and barriers to coverage collected by coverage assessments of community-based SAM treatment programmes in 21 countries that were supported by the Coverage Monitoring Network. Data from 44 coverage assessments are reviewed.SettingThese assessments analyse malnourished populations from 6 to 59 months old to understand the accessibility and coverage of services for treatment of acute malnutrition. The majority of assessments are from sub-Saharan Africa.ResultsMost of the programmes (33 of 44) failed to meet context-specific internationally agreed minimum standards for coverage. The mean level of estimated coverage achieved by the programmes in this analysis was 38.3%. The most frequently reported barriers to access were lack of awareness of malnutrition, lack of awareness of the programme, high opportunity costs, inter-programme interface problems, and previous rejection.ConclusionsThis study shows that coverage of CMAM is lower than previous analyses of early CTC programmes; therefore reducing programme impact. Barriers to access need to be addressed in order to start improving coverage by paying greater attention to certain activities such as community sensitisation. As barriers are interconnected focusing on specific activities, such as decentralising services to satellite sites, is likely to increase significantly utilisation of nutrition services. Programmes need to ensure that barriers are continuously monitored to ensure timely removal and increased coverage.

Stigma as a barrier to treatment for child acute malnutrition in Marsabit County, Kenya.

Acute malnutrition affects millions of children each year, yet global coverage of life-saving treatment through the community-based management of acute malnutrition (CMAM) is estimated to be below 15%. We investigated the potential role of stigma as a barrier to accessing CMAM. We surveyed caregivers bringing children to rural health facilities in Marsabit County, Kenya, divided into three strata based on the mid-upper arm circumference of the child: normal status (n = 327), moderate acute malnutrition (MAM, n = 241) and severe acute malnutrition (SAM, n = 143). We used multilevel mixed effects logistic regression to estimate the odds of reporting shame as a barrier to accessing health care. We found that the most common barriers to accessing child health care were those known to be universally problematic: women's time and labour constraints. These constituted the top five most frequently reported barriers regardless of child acute malnutrition status. In contrast, the odds of reporting shame as a barrier were 3.64 (confidence interval: 1.66-8.03, P < 0.05) times higher in caregivers of MAM and SAM children relative to those of normal children. We conclude that stigma is an under-recognized barrier to accessing CMAM and may constrain programme coverage. In light of the large gap in coverage of CMAM, there is an urgent need to understand the sources of acute malnutrition-associated stigma and adopt effective means of de-stigmatization.

Ready-to-use therapeutic food with elevated n-3 polyunsaturated fatty acid content, with or without fish oil, to treat severe acute malnutrition: a randomized controlled trial.

BackgroundReady-to-use therapeutic foods (RUTF) are lipid-based pastes widely used in the treatment of acute malnutrition. Current specifications for RUTF permit a high n-6 polyunsaturated fatty acid (PUFA) content and low n-3 PUFA, with no stipulated requirements for preformed long-chain n-3 PUFA. The objective of this study was to develop an RUTF with elevated short-chain n-3 PUFA and measure its impact, with and without fish oil supplementation, on children’s PUFA status during treatment of severe acute malnutrition.MethodsThis randomized controlled trial in children with severe acute malnutrition in rural Kenya included 60 children aged 6 to 50 months who were randomized to receive i) RUTF with standard composition; ii) RUTF with elevated short chain n-3 PUFA; or iii) RUTF with elevated short chain n-3 PUFA plus fish oil capsules. Participants were followed-up for 3 months. The primary outcome was erythrocyte PUFA composition.ResultsErythrocyte docosahexaenoic acid (DHA) content declined from baseline in the two arms not receiving fish oil. Erythrocyte long-chain n-3 PUFA content following treatment was significantly higher for participants in the arm receiving fish oil than for those in the arms receiving RUTF with elevated short chain n-3 PUFA or standard RUTF alone: 3 months after enrolment, DHA content was 6.3% (interquartile range 6.0–7.3), 4.5% (3.9–4.9), and 3.9% (2.4–5.7) of total erythrocyte fatty acids (P <0.001), respectively, while eicosapentaenoic acid (EPA) content was 2.0% (1.5–2.6), 0.7% (0.6–0.8), and 0.4% (0.3–0.5) (P <0.001). RUTF with elevated short chain n-3 PUFA and fish oil capsules were acceptable to participants and carers, and there were no significant differences in safety outcomes.ConclusionsPUFA requirements of children with SAM are not met by current formulations of RUTF, or by an RUTF with elevated short-chain n-3 PUFA without additional preformed long-chain n-3 PUFA. Clinical and growth implications of revised formulations need to be addressed in large clinical trials.Trial registrationClinicaltrials.gov NCT01593969. Registered 4 May 2012.Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-015-0315-6) contains supplementary material, which is available to authorized users.

Acceptability of new formulations of corn-soy blends and lipid-based nutrient supplements in Province du Passoré, Burkina Faso

The objective of this study was to evaluate the acceptability of new formulations of six corn-soy blended flours (CSB) and six lipid-based nutrient supplements (LNS) with different quantities of milk and qualities of soy to be used for the treatment of moderate acute malnutrition (MAM). Furthermore, we wanted to explore the acceptability of foods currently used for the prevention and treatment of malnutrition in Burkina Faso to identify possible barriers that could affect the acceptability of the new formulations of supplementary foods. The study was carried out prior to a randomized controlled trial evaluating the effectiveness of these new formulations. The study involved an observed test-meal and a three-day take-home ration of the experimental food supplements to 6- to 30-months-old healthy children, followed by questionnaire-based interviews about the acceptability of these supplements. Interviews and focus group discussions were carried out to explore the acceptability of foods currently used for the prevention and treatment of malnutrition. The results suggest that both LNS and CSB products with different quantities of milk and qualities of soy are equally well accepted among healthy children in rural Burkina Faso based on general appreciation of the supplements and organoleptic properties. All experimental foods received good ratings and there was no significant difference between the foods. However, after the take-home ration, 58% of participants receiving CSB reported having left-overs at the end of the day compared to 37% (n = 33) of the participants receiving LNS (p = 0.004), suggesting that CSB was not as readily consumed as LNS. Yet, both CSB and LNS products were perceived as easy to administer and the frequency of feeding was estimated to be adequate. The study also found that similar foods, used for the prevention and treatment of malnutrition, were well appreciated in the study location. LNS were to a higher degree associated with medicine or foods with medicinal properties, but both LNS and CSB were perceived as beneficial to child health.

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.

Comparison of Four Different Supplementary Foods in the Treatment of Moderate Acute Malnutrition (MAM) in Children Under Five in Sierra Leone

ObjectiveA prospective cluster randomized control trial, supported by WFP and USAID, compared the effectiveness of four supplementary foods in the treatment of moderate acute malnutrition (MAM) in children 6‐59 months of age in normal programmatic settings in Sierra Leone.MethodsTwenty clinics in Kenema District were randomly assigned to one of four treatment foods: Super Cereal (SC) plus fortified vegetable oil (FVO) and sugar (acting as the comparison group), Super Cereal Plus (SC+), Corn Soy Blend 14 (CSB14) plus FVO, and Plumpy'Sup (PS). Children 6‐59 months with MAM (MUAC &gt; 11.0 cm and &lt; 12.5 cm) were enrolled in the clinic‐based supplementary feeding programs, receiving a food ration every 2 weeks for 12 weeks or until recovered from MAM (determined by MUAC 蠅 12.5 cm). Beneficiaries' anthropometric data were collected during each clinic visit including MUAC, height, and weight.ResultsThe study was terminated early due to the Ebola outbreak and our sample size was reduced from 5000 to 1153 children who enrolled and completed the study. Out of these, recovery rates were 61% in the SC plus FVO group (comparison), 56% in the CSB14 group, 57% in the PS group, and 63% in the SC+ group. There were no significant differences in recovery rates, SAM, or failure to respond between each study arm and the SC comparison group; death rates were significantly higher in SC+ compared with SC (0.9% vs 3.2%, p=0.046).ConclusionWe found no significant difference in MAM recovery rates among the four supplementary foods. However, due to our limited sample size the power to detect a significant difference was reduced.