Management Of Moderate Acute Malnutrition Research Articles

A comparison of risk factors for cryptosporidiosis and non-cryptosporidiosis diarrhoea: A case-case-control study in Ethiopian children.

Cryptosporidiosis is a major cause of diarrhoea in young children in low-and-middle-income countries. New interventions should be informed by evidence pertaining to risk factors and their relative importance. Inconsistencies in the literature may to some extent be explained by choice of methodology, furthermore, most previous risk factor studies compared cryptosporidiosis cases to diarrhoea cases of other aetiologies rather than with controls without diarrhoea. We investigated a broad set of factors in under-2-year-olds presenting with diarrhoea to a hospital and a health center in southwestern Ethiopia. We applied quantitative cut-offs to distinguish between cryptosporidiosis and incidental Cryptosporidium infection or carriage, a hierarchical causal framework to minimize confounding and overadjustment, and a case-case-control design, to describe risk factors for both cryptosporidiosis and non-cryptosporidiosis diarrhoea. Moderate and severe acute malnutrition were strongly associated with both cryptosporidiosis and non-cryptosporidiosis diarrhoea. Previous healthcare attendance and low maternal education were only associated with cryptosporidiosis, whereas unsafe child stool disposal, prematurity and early cessation of exclusive breastfeeding were significantly associated with non-cryptosporidiosis diarrhoea only. By estimation of population attributable fractions, socioeconomic factors-specifically low maternal education-and public tap water use, were apparently more important risk factors for cryptosporidiosis than for non-cryptosporidiosis diarrhoea. Nutritional management of moderate acute malnutrition may be an effective intervention against cryptosporidiosis, particularly if combined with targeted therapy for cryptosporidiosis which, again, may mitigate nutritional insult. Focused caregiver education in healthcare settings and follow-up of children with acute malnutrition may prevent or improve outcomes of future episodes of cryptosporidiosis.

Effectiveness and tolerability of standardized milk based, standardized non-milk based and hospital-based formulations in the management of moderate acute malnutrition in under-five children: A randomized clinical trial

Introduction : Moderate acute malnutrition (MAM) is a leading cause of under-five morbidity and mortality globally. Supplementary feeding is a strategy recommended by WHO for managing the condition.Objective: To evaluate the effectiveness and tolerability of standardized milk-based formulation (SMBF), standardized non-milk based formulation (SNMBF) and hospital-based formulation (HBF) in under-fives with MAM.Method: This was an open label randomized clinical trial in which eligible children aged 6 – 59 months with MAM were assigned to receive the SMBF, SNMBF or HBF at 50% of their daily caloric requirement with their regular family diet for four months. Their baseline characteristics and anthropometric indices were noted. They were followed up on two weekly basis during which further assessments were performed. The analysis for effectiveness and tolerability of the formulations were based on “per protocol”.Results: A total of 687 children were screened and 188 enrolled. Seventy children received SMBF, 63 received SNMBF while 55 received HBF. There were 54/70 (77.1%), 57/64 (89.1%) and 46/55 (83.6%) evaluable participants in the SMBF, SNMBF and HBF group respectively. Recovery from MAM was 43/54 (79.6%), 40/57 (70.2%) and 32/46 (69.6%) in the SMBF, SNMBF and HBF group respectively. Normal nutritional status was attained by 13 (24.0%), 10 (17.6%) and 5 (10.9%) children in the SMBF, SNMBF and HBF group respectively. Diarrhea and skin rashes were the main features of poor tolerability.Conclusions: The formulations were effective in managing MAM in childhood but the SMBF was the most effective. Diarrhea and skin rashes were the main features of poor tolerability.

Barriers to Management of Moderate Acute Malnutrition Among Children Aged 6 to 59 Months in Damot Pulassa, Wolaita, South Ethiopia: A Phenomenological Study of Mothers and Health Service Providers.

Management of moderate acute malnutrition (MAM) in children needs to improve to reduce the transition from MAM to severe acute malnutrition (SAM). This study aimed to assess barriers to management of MAM among children aged 6 to 59 months in Damot Pulassa, Wolaita, South Ethiopia. This descriptive phenomenological design used 6 focus group discussions with mothers or caregivers of children aged 6 to 59 months and 10 in-depth interviews with health service providers. Data were analyzed using Colaizzi's descriptive phenomenological method. Six themes were identified: Possible reasons for MAM; identification of a child with MAM; management services of MAM; maternal-level barriers; service provider-level barriers; and suggestions to improve the service. Shortage of food and money, selling out of self-produced food without having sufficient reserves at home, large household size, shame from having children with malnutrition, occasional house-to-house screening for MAM, family-initiated screening, leaving the management responsibility of children with MAM to the family, no provision of supplementary food, and lack of repeated follow-up visits were the main obstacles for managing MAM. Maternal-level barriers and service provider-level barriers affect the management of MAM negatively in Damot Pulassa, Wolaita. Children with MAM living in the area ineligible for food supplementation could deteriorate to SAM. The provision of nutrition counseling to the mothers of children with MAM without food supplementation placed children with MAM at increased risk of negative outcomes. Thus, the government should give more attention and facilitation in promoting supplementary food into the existing management of MAM.

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

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. 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. 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). 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.

Formulation, Sensory Attributes and Nutrient Content of a Malted Sorghum-based Porridge: Potential for the Management of Moderate Acute Malnutrition among Infants and Young Children

Introduction: Substituting corn in a fortified corn-soy blend (CSB+) with enzyme-active sorghum malt has the potential to be used as a suitable alternative supplementary porridge in the management of infants and young children (IYC) with moderate acute malnutrition (MAM) in Uganda. Objective: This study aimed to develop acceptable malted sorghum-based supplementary porridge (MSBP) that meets the energy and protein specifications for the management of IYC with MAM, using locally-available ingredients. Methods: MSBP formulations included the use of malted sorghum flour and extruded soy and corn flour. The ratio of the soy to corn ingredients was 3:7 (F617/F593), 1:1 (F892/F940), and 4:1 for CSB+, which is the standard care for the management of IYC with MAM in Uganda. The sorghum malt content for F617/F892 and F593/F940 was 25% and 30%, respectively. F617, F593, F892 and F940 met international specifications for a supplementary porridge. A comparison of the consumer acceptability scores and viscosity levels of these formulations was made, using analysis of variance. Results and Discussion: The scores for flavour, taste, mouth feel, sweetness and overall consumer acceptability differed among the formulations (p&lt;0.05). F617 had a higher mean acceptability score than F593, F892 and F940 (p&lt;0.05), as well as a higher energy and protein content than CSB+ (p&lt;0.01). The energy density, protein density and viscosity of F617 were 1.6kcal/ g, 4g/100 kcal and 2809 cP, respectively, with a flour rate of 25%. Conclusion: Sorghum malt is suitable for the development of an acceptable supplementary porridge (MSBP). It meets the international energy and protein specifications for the management of IYC with MAM, and the F617 formulation meets these specifications.

Impact of effective counselling on management of moderate acute malnutrition in a community

Background: Moderate Acute Malnutrition (MAM) is defined as Weight for Height between -2SD to -3SD, and/or Mid Upper Arm Circumference (MUAC) 11.5 cm to 12.5 cm. Effect of not treating MAM has a significant impact on Severe Acute Malnutrition (SAM) burden. Management of MAM is possible through supplementary feeding or Community centre counselling.Methods: Present study was a prospective case control study done in 2013-14 in 200 children in adjacent communities. Community in which intervention (dietary counselling) was planned, it was labelled as case group. For dietary counselling ‘structured group counselling’ method was selected in which at a time parents of six MAM children were involved. Counselling was done by a trained counsellor using all techniques proposed by IYCF. Counselling sessions were scheduled at 0, 1, 3 and 6 months.Results: 60% children of case group moved to improved or well- nourished nutritional status (p-value 0.00001). Amongst improved group, weight for height improvement is statistically significant (p-value 0.001), average weight attained is 2-3 kg in 6 months with average weight gain of 1.5-3 grams/kg/day. MUAC improvement was also found to be statistically significant (p-value 0.003), there was 47% improvement in case group with average MUAC gain is 0.6 cm to 1 cm in 6 months (0.13 cm/month). Also, there is early rise in weight for height then MUAC. Average duration to achieve target weight for height is 4.3 months in case group as compare to 5.3 months in control group.Conclusions: Structured and integrated group counselling using all counselling skills by a trained counsellor should be an integral part of managing MAM in community. Weight for height should be primary indicator in early phase of response as compare to MUAC in measuring impact of counselling.

Early development in children with moderate acute malnutrition: A cross‐sectional study in Burkina Faso

Malnutrition impairs cognitive, communication, and motor development, but it is not known how nutrition and health are associated with development in children with moderate acute malnutrition (MAM). We aimed to describe motor and language development of children with MAM and explore its nutrition and health‐related correlates. This cross‐sectional study used baseline data from a nutritional trial in children with MAM aged 6–23 months in Burkina Faso. Motor and language skills were assessed using the Malawi Development Assessment Tool (MDAT). Linear mixed models were used to explore potential correlates of MDAT including socio‐economic status, anthropometry, body composition, whole‐blood polyunsaturated fatty acids (PUFA), haemoglobin (Hb), iron status, and morbidity. We also assessed child and caregiver participation during MDAT procedures and their associations with correlates and development. MDAT data were available for 1.608 children. Mean (95% CI) MDAT z‐scores were −0.39 (−0.45, −0.34) for gross motor, 0.54 (0.48, 0.59) for fine motor, and −0.91 (−0.96, −0.86) for language skills. Children with higher mid‐upper arm circumference, weight‐for‐height, height‐for‐age, fat‐free mass, n‐3 PUFAs, Hb, and iron status had better MDAT z‐scores, whereas children with more fat mass index, anaemia, illness, and inflammation had poorer z‐scores. In addition, children living in larger households or with an unmarried mother had poorer MDAT z‐scores. Associations between morbidity and z‐scores were largely explained by children's poorer participation during MDAT assessment. The identified factors associated with child development may inform interventions needed to stimulate development during or after management of MAM.

Research protocol local ingredients-based supplementary food as an alternative to corn-soya blends plus for treating moderate acute malnutrition among children aged 6 to 59\u2009months: a randomized controlled non-inferiority trial in Wolaita

BackgroundIn Ethiopia, 12.5% of children below 5 years are wasted, and 9.7% are moderately wasted. The present strategy for the management of moderate acute malnutrition (MAM) is a supplementary feeding program; however, this is only provided to chronically food-insecure areas. This randomized controlled non-inferiority trial examines if Local ingredients-based supplement (LIBS) is as effective as corn-soya blends plus (CSB+) in treating moderate acute malnutrition among children aged 6–59 months.MethodsA randomized controlled non-inferiority trial will be conducted with moderately wasted children aged 6 to 59 months in Wolaita, Ethiopia. The calculated sample size is 324 (i.e. with 162 children in each of two arms, to be assigned by randomization). The daily ration will be: 100 g of LIBS plus 25.2 g of sugar with 8 ml oil in the intervention group, and 150 g of CSB+ with 16 ml of oil in the control group. These interventions will be provided for a maximum period of 12 weeks, with follow-up performed on a weekly basis. Data analysis will be done using SPSS and STATA software. Both intention-to-treat and per protocol analyses will be done. Hazard ratio and Kaplan-Meier (log rank) curves of survival analysis will be done to predict the probability of recovery rate. Logistic regression will be used to test for interactions between independent and dependent variables. Analysis of variances, t-tests, fisher’s exact test and chi-square tests will be used to assess baseline characteristics.ConclusionsThis paper will introduce to the existing research locally available nutritious foods which have the potential to enhance recovery from moderate acute malnutrition and to reduce the burden of malnutrition. The perceptions of mothers on feeding children with local ingredient-based supplementary food to assist recovery from moderate acute malnutrition will be the focus of in a qualitative study to follow; this will provide a further contribution in an evolving area of research.Trial registrationPan-African Clinical Trial Registration number: PACTR201809662822990, retrospectively registered on 11/09/2018.

A multicenter, randomized controlled comparison of three renutrition strategies for the management of moderate acute malnutrition among children aged from 6 to 24\xa0months (the MALINEA project)

BackgroundThe aim of this open-label, randomized controlled trial conducted in four African countries (Madagascar, Niger, Central African Republic, and Senegal) is to compare three strategies of renutrition for moderate acute malnutrition (MAM) in children based on modulation of the gut microbiota with enriched flours alone, enriched flours with prebiotics or enriched flours coupled with antibiotic treatment.MethodsTo be included, children aged between 6 months and 2 years are preselected based on mid-upper-arm circumference (MUAC) and are included based on a weight-for-height Z-score (WHZ) between − 3 and − 2 standard deviations (SD). As per current protocols, children receive renutrition treatment for 12 weeks and are assessed weekly to determine improvement. The primary endpoint is recovery, defined by a WHZ ≥ − 1.5 SD after 12 weeks of treatment. Data collected include clinical and socioeconomic characteristics, side effects, compliance and tolerance to interventions. Metagenomic analysis of gut microbiota is conducted at inclusion, 3 months, and 6 months. The cognitive development of children is evaluated in Senegal using only the Developmental Milestones Checklist II (DMC II) questionnaire at inclusion and at 3, 6, and 9 months. The data will be correlated with renutrition efficacy and metagenomic data.DiscussionThis study will provide new insights for the treatment of MAM, as well as original data on the modulation of gut microbiota during the renutrition process to support (or not) the microbiota hypothesis of malnutrition.Trial registrationClinicalTrials.gov, ID: NCT03474276 Last update 28 May 2018.

Household-level factors associated with relapse following discharge from treatment for moderate acute malnutrition.

Factors associated with relapse among children who are discharged after reaching a threshold denoted 'recovered' from moderate acute malnutrition (MAM) are not well understood. The aim of this study was to identify factors associated with sustained recovery, defined as maintaining a mid-upper-arm circumference≥12·5 cm for 1 year after release from treatment. On the basis of an observational study design, we analysed data from an in-depth household (HH) survey on a sub-sample of participants within a larger cluster randomised controlled trial (cRCT) that followed up children for 1 year after recovery from MAM. Out of 1497 children participating in the cRCT, a subset of 315 children participated in this sub-study. Accounting for other factors, HH with fitted lids on water storage containers (P=0·004) was a significant predictor of sustained recovery. In addition, sustained recovery was better among children whose caregivers were observed to have clean hands (P=0·053) and in HH using an improved sanitation facility (P=0·083). By contrast, socio-economic status and infant and young child feeding practices at the time of discharge and HH food security throughout the follow-up period were not significant. Given these results, we hypothesise that improved water, sanitation and hygiene conditions in tandem with management of MAM through supplemental feeding programmes have the possibility to decrease relapse following recovery from MAM. Furthermore, the absence of associations between relapse and nearly all HH-level factors indicates that the causal factors of relapse may be related mostly to the child's individual, underlying health and nutrition status.

Management of Moderate Acute Malnutrition: Comparison of Different Approaches

Management of Moderate Acute Malnutrition: Comparison of Different Approaches

Effectiveness of a homemade supplementary food in the management of severe acute malnutrition in 2-5 year old children in the Kopay MOH area

Introduction Reducing wasting in children under 5 years is a challenge in Sri Lanka. Management strategy of moderate acute malnutrition (MAM) is to have target food supplementation as energy dense snacks. Objectives To assess the feasibility, acceptability and effectiveness, of a homemade supplementary food (HMSF) in the management of moderate acute malnutrition in 2-5 year old children. Methods A community based quasi experimental study was carried out from October to December 2014. The test population (n=275) were 2-5 year old children with MAM from Kopay MOH area. The control group (n=285) were children of similar age with MAM from Uduvil, Nallur area. HMSF consisted of a pre-packed cereal mixture (50g), with sugar (20g) and scraped coconut (20g) added at home (calorie content =500 kcal/90g), as a daily snack to the intervention group. Baseline weight and monthly weight gain was measured using standard calibrated weighing scales. Compliance and any acute illnesses were monitored weekly by calling or visiting households. Average weight gain of both groups was analysed using independent sample t–test. The acceptability and feasibility of the HMSF was assessed by focus group discussions with the PHMs and the mothers. Results: Mean age of test group and control group was 42.6 months and 43.1 months respectively. There was no difference in the baseline weight of the two groups (95%CI -0.059-0.416: p=0.14). The mean weight gain in the test group and control group after 3 months was 688.5g (SD=437gm) and 583g (SD=461gm) respectively (p=0.006). The mean gain in length in the test group and control group after 3 months was 1.5cm (SD=0.93cm) and 1.66cm (SD 1.3 cm) (p=0.234) respectively. Conclusions and Recommendations: This HMSF was effective, feasible and acceptable in improving weight in MAM children under the age of five years.

Capacity-building in the management of moderate acute malnutrition.

Evidence from low- and middle-income countries indicates that although there is a willingness to prevent and treat malnutrition at scale, there is very limited capacity to achieve this. Three broad areas of concern are human resources and the quality of services; management systems and supplies; and demand side factors. This paper focuses on building human resources in the context of preventing and managing malnutrition. Training should provide several options and approaches suitable for different settings and focus on core competencies. Preservice training should be the main focus of training, while in-service training should be used for continuing medical education and refresher training. Communities of Practice, in which national and international health professionals come together to deepen their knowledge and pool their skills to pursue a common ambition, are seen as one way forward to building the necessary human resources for scaling up training.

Management of acute malnutrition in infants aged under 6 months (MAMI): current issues and future directions in policy and research.

Globally, some 4.7 million infants aged under 6 months are moderately wasted and 3.8 million are severely wasted. Traditionally, they have been over-looked by clinicians, nutritionists, and policy makers. To present evidence and arguments for why treating acute malnutrition in infants under 6 months of age is important and outline some of the key debates and research questions needed to advance their care. Narrative review. Treating malnourished infants under 6 months of age is important to avoid malnutrition-associated mortality in the short-term and adverse health and development outcomes in the long-term. Physiological and pathological differences demand a different approach from that in older children; key among these is a focus on exclusive breastfeeding wherever possible. New World Health Organization guidelines for the management of severe acute malnutrition (SAM) include this age group for the first time and are also applicable to management of moderate acute malnutrition (MAM). Community-based breastfeeding support is the core, but not the sole, treatment. The mother-infant dyad is at the heart of approaches, but wider family and community relationships are also important. An urgent priority is to develop better case definitions; criteria based on mid-upper-arm circumference (MUAC) are promising but need further research. To effectively move forward, clinical trials of assessment and treatment are needed to bolster the currently sparse evidence base. In the meantime, nutrition surveys and screening at health facilities should routinely include infants under 6 months of age in order to better define the burden and outcomes of acute malnutrition in this age group.

Ready-to-use foods for management of moderate acute malnutrition: considerations for scaling up production and use in programs.

Ready-to-use foods are one of the available strategies for the treatment of moderate acute malnutrition (MAM), but challenges remain in the use of these products in programs at scale. This paper focuses on two challenges: the need for cheaper formulations using locally available ingredients that are processed in a safe, reliable, and financially sustainable local production facility; and the effective use of these products in large-scale community-based programs. Linear programming tools can be used successfully to design local compositions that are in line with international guidelines, low in cost, and acceptable, and the efficacy of these local formulations in the treatment of MAM was recently demonstrated in Malawi. The production of local formulations for programs at scale relies on the existence of a reliable and efficient local production facility. Technical assistance may be required in the development of sustainable business models at an early stage in the process, taking into account the stringent product quality and safety criteria and the required investments. The use of ready-to-use products, as of any food supplement, in programs at scale will be affected by the practice of household sharing and diversion of these products for other uses. Additional measures can be considered to account for sharing. These products designed for the treatment and prevention of MAM are to be used in community-based programs and should therefore be used in conjunction with other interventions and designed so that they do not replace the intake of other foods and breastmilk. Remaining challenges and implications for the (operations) research agenda are discussed.

Efficacy of sorghum peanut blend and corn soy blend plus in the treatment of moderate acute malnutrition in children aged 6&amp;ndash;59 months in Karamoja, Uganda: a cluster randomized trial

Efficacy of sorghum peanut blend and corn soy blend plus in the treatment of moderate acute malnutrition in children aged 6&ndash;59 months in Karamoja, Uganda: a cluster randomized trial Andrew Kiri Amegovu,1 Sophie Ochola,1 Patrick Ogwok,2 Peter Yiga,2 Juliet Musalima,2 Mandha Juliana2 1Department of Food, Nutrition and Dietetics, Kenyatta University, Nairobi, Kenya; 2Department of Food Technology, Kyambogo University, Kampala, Uganda Abstract: More than half of the world&#39;s deaths in children below 5 years of age are caused by under nutrition. Early management of moderate acute malnutrition (MAM) is necessary to avoid deterioration to severe acute malnutrition. Corn soy blend plus (CSB+) mixed with vegetable oil and sugar is the traditional treatment for MAM but is too expensive for poor countries. The effectiveness of affordable and available local food materials are currently being studied as alternative food supplements to treat malnutrition. In this trial, the efficacy of sorghum peanut blend (SPB) mixed with ghee and honey for the treatment of MAM was compared to that of CSB+ among children 6&ndash;59 months old in Karamoja, Uganda. This was a single-blind randomized parallel trial in which two health centers were assigned on a 1:1 ratio to the two study groups. The participants (mothers and their moderately malnourished children) were recruited at the health centers and assigned to the groups depending on the health facility attended. Each child received a daily ration of either CSB+ or SPB for a maximum period of 3 months. Anthropometric measurements of the children were taken on a bi-weekly basis. The primary outcomes were the recovery rate and duration on the program before recovery. Of the recruited 440 participants, 392 completed the study and were included in the analysis (SPB group 194; CSB+ group 198). Analysis was by intention to treat. The recovery rates were not significantly different for the SPB group and the CSB+ group (82.3% and 76.8%, respectively; chi-square test P=0.093). Duration of recovery was significantly shorter for the SPB+ group, with a median of 43 days compared to 57 days for the SPB group (Kaplan&ndash;Meier survival test). The recovery rate and the duration of stay in the program were all within the acceptable Sphere Standards (&ge;75% and &le;90 days, respectively). SPB has the potential to treat MAM. Keywords: rehabilitation, Uganda, randomized trial, corn soy blend plus (CSB+), acute malnutrition

Treating moderate acute malnutrition in first-line health services: an effectiveness cluster-randomized trial in Burkina Faso

Management of moderate acute malnutrition (MAM) is, currently, focused on food supplementation approaches. However, the sustainability of these strategies remains weak in low- and middle-income countries. In food-secure settings, an educational/behavioral intervention could be an alternative for improving MAM management. This study compared the effectiveness of weekly context-appropriate child-centered counseling (CCC), with an improved corn-soy blend [corn-soy blend with added micronutrients (CSB++)] or a locally produced ready-to-use supplementary food (RUSF), in treating MAM through first-line rural health services. We used a cluster randomized controlled trial design with 3 arms, involving 18 rural health centers (6 by arm) and children aged 6-24 mo with uncomplicated MAM. In the first arm (CCC), trained health workers provided weekly personalized counseling to caretakers. In the 2 other arms, children received weekly either 455 g CSB++ or 350 g locally produced soy-based RUSF. Both food supplements provided ∼250 kcal/d. The recovery rate after 3 mo of treatment was significantly lower with CCC (57.8%) than with CSB++ (74.5%) and RUSF (74.2%) (P < 0001). Mothers' attendance at health facilities was also substantially lower in the CCC arm (P < 0001); this arm had a high defaulter rate (P < 0.003). When the analysis was adjusted for attendance, we did not find a significant difference between the 3 arms, with incidence rate ratios of 1.14 (95% CI: 0.99, 1.31) and 1.13 (95% CI: 0.98, 1.30) for the CSB++ and RUSF arms, respectively, compared with the CCC arm. Whereas supplement-based treatment of MAM was found to be more effective than the provision of CCC, we hypothesize that appropriate and specific nutrition counseling centered on children's needs, through primary health facilities, might be an alternative strategy for MAM treatment in rural food-secure areas, provided that attendance at counseling sessions by the caregiver is ensured. This trial was registered at clinicaltrials.gov as NCT01115647.