Treatment Of Moderate Acute Malnutrition Research Articles

Effects of Moderate Acute Malnutrition Treatment and HIV-Exposure on Body Composition among Children Under Five Years in SubSaharan Africa: A systematic review

Background: Malnutrition poses a global threat to Childhood growth and survival. Coupled with HIV exposure and infection, under-nutrition risk is greatly increased. Infection with HIV results in Acquired Immune Deficiency Syndrome which increases the body’s nutrient requirements and may significantly affect the body composition parameters. This study aimed to review data from published articles to identify the changes in body composition among children under five in sub-Saharan Africa as a result of Moderate Acute Malnutrition (MAM) and HIV exposure
 Materials And Methods: We conducted a systematic review of published articles on body composition, moderate acute malnutrition treatment and HIV exposure among children under five years. Data was searched from PubMed, Ovid-MedLine, Google Scholar, Cochrane Central Register of Controlled Trials and EMBASE. The review was done as per Cochrane reviews and Preferred Reporting Items for Systematic Reviews and MetaAnalyses guidelines (PRISMA). The articles were then screened for suitability of inclusion and analysis.
 Results: A total of 1,505 records were identified; 520 articles from PubMed, 535 from Medline and 430 from EMBASE. On the first screening step, 755 duplicate records were removed. Screening the articles by abstract and title led to the elimination of 717 records. Further, 88 records were excluded due to a lack of full-text articles, not related to the topic, no prospective studies and the wrong age group (above five years). We finally ended up with 9 articles that were included for review.
 Conclusions: There is an interrelationship between MAM treatment, HIV Exposure and body composition. Treatment of MAM using standard ready-to-use supplemental foods and locally produced specialized nutritious formulas improves the body composition parameters of children under five years. HIV-exposed infected children exhibit poorer body composition parameters than HIV-exposed uninfected and HIV-unexposed uninfected children.

Cost of Acute Malnutrition Treatment Using a Simplified or Standard Protocol in Diffa, Niger.

Evidence on the cost of acute malnutrition treatment, particularly with regards to simplified approaches, is limited. The objective of this study was to determine the cost of acute malnutrition treatment and how it is influenced by treatment protocol and programme size. We conducted a costing study in Kabléwa and N'Guigmi, Diffa region, where children with acute malnutrition aged 6-59 months were treated either with a standard or simplified protocol, respectively. Cost data were collected from accountancy records and through key informant interviews. Programme data were extracted from health centre records. In Kabléwa, where 355 children were treated, the cost per child treated was USD 187.3 (95% CI: USD 171.4; USD 203.2). In N'Guigmi, where 889 children were treated, the cost per child treated was USD 110.2 (95% CI: USD 100.0; USD 120.3). Treatment of moderate acute malnutrition was cheaper than treatment of severe acute malnutrition. In a modelled scenario sensitivity analysis with an equal number of children in both areas, the difference in costs between the two locations was reduced from USD 77 to USD 11. Our study highlighted the significant impact of programme size and coverage on treatment costs, that cost can differ significantly between neighbouring locations, and that it can be reduced by using a simplified protocol.

Outcomes of a food voucher program and factors associated with the recovery rate of children with moderate acute malnutrition in Far North Cameroon

BackgroundResearch on moderate acute malnutrition (MAM) is limited, despite its high prevalence. This study examined outcomes of bi-weekly locally available foods provided via a food voucher program (FVP) on nutritional recovery [mid-upper arm circumference (MUAC) ≥ 125 mm] from MAM (defined as MUAC between 115 and 124 mm) and identified the factors associated with recovery rate in Kaélé health district, Far North Region of Cameroon.MethodsThis was a prospective study with 474 MAM children aged 6–59 months. Food voucher distribution and MUAC screening were conducted at 6 bi-weekly visits or until the child was recovered. Time to recovery was evaluated with multivariate Cox proportional regression hazard models with associations quantified using adjusted hazard ratio (aHR). The trend for MUAC, including its determinants, was examined with multivariate linear mixed effect models.ResultsThe recovery rate was 78.3% by 6 weeks after the first food basket; 3.4% remained MAM, and 5.9% were transferred for treatment for severe acute malnutrition (SAM defined as MUAC < 115 mm). Boys were 34% more likely to recover from MAM than girls [aHR = 1.34, 95%CI (1.09, 1.67)]. Children aged 24–53 months were 30% more likely to recover than those aged 6–11 months [aHR = 1.30, 95%CI (0.99, 1.70)]. A one unit increase in weight-for-height Z-score (WHZ) was associated with 1.89-fold greater likelihood of recovery [aHR = 1.89, 95%CI (1.66, 2.14)]. Male children had on average 1.82 mm greater increase in MUAC than female children (p < 0.001). One unit increase in WHZ was associated with 3.42 mm increase in MUAC (p = 0.025). Children aged 12–23 and 24–53 months had 1.03 mm and 2.44 mm, respectively, greater increase in MUAC over the program than children aged 6–11 months (all p < 0.01).ConclusionThe recovery rate of MAM children treated with the FVP met the Sphere standards for targeted supplementary feeding programs (> 75%). Child’s WHZ, gender and age were significant factors associated with MUAC increase and recovery from MAM in the FVP. These findings indicate the FVP approach shows promise as an effective alternative treatment for MAM with consideration of associated factors and merits further evaluation.

Rate, risk factors and estimated time to develop attrition after under-five children started moderate acute malnutrition treatment in Gubalafto, North East Ethiopia.

Lost from follow-up, after starting moderate acute malnutrition (MAM) is an ongoing challenge of public health until the admitted children reached the standard weight of a reference child. Thus, the present study aimed to assess the rate and estimated time to attrition after under-five children started treatment for MAM in the Gubalafto district. A facility-based retrospective cohort study was employed among 487 participant children who had been managed targeted therapeutic feeding from 1 June 2018 to 1 May 2021. The overall mean (±sd) age of the participants' children was 22⋅1 (±12⋅6) months. At the end of the study period, 55 (11⋅46 %) under-five children developed attrition from the treatment after starting ready use of therapeutic feeding. After checking all assumptions, a multivariable Cox regression model was used to claim independent predictors for time to attritions. The median time of attrition after starting treatment of MAM was 13 (IQR ±9) weeks, with the overall incidence of attrition rate reported at 6⋅75 children Per Week (95 % CI 5⋅56, 9⋅6). In the final model of multivariable Cox regression, the hazard of attrition was significantly higher for children from rural residence (AHR 1⋅61; 95 % CI 1⋅18, 2⋅18; P = 0⋅001), and caregivers with their dyads did not get nutritional counselling at baseline (AHR 2⋅78; 95 % CI 1⋅34, 5⋅78; P = 0⋅001). The findings of the present study showed that nearly one in every eleven under-five children was attrition (lost to follow-up) in a median time of 13 (IQR ±9) weeks. We strongly recommended for caregivers provisions of diversification of daily nutrition supplementation of their dyads.

Factors Associated With Failure to Respond to Treatment for Moderate Acute Malnutrition in Sierra Leone

ObjectivesTo assess factors associated with failure to respond to treatment for moderate acute malnutrition (MAM) while enrolled in a supplementary feeding program (SFP) in Pujehun District, Sierra Leone. MethodsThis was a secondary analysis of a cluster-randomized trial. The main study examined the cost-effectiveness of four specialized nutritious foods (SNFs) for treating MAM in children 6–59 months. Each SNF (Corn Soy Blend Plus, Corn Soy Whey Blend, Super Cereal Plus with Amylase, and Ready to Use Supplementary Food) was provided to caregivers in 14-day isocaloric rations for 12 weeks or until reaching an outcome. Outcomes were: Recovery (mid-upper arm circumference [MUAC]≥12.5cm), Failure (11.5 > MUAC < 12.5 after 12 weeks of treatment), severe acute malnutrition [SAM] (MUAC ≤ 11.5), Default (3 consecutive missed visits), or Death. Beneficiary caregivers provided standard demographic information at enrollment. Height, weight, and MUAC were taken every 14 days during a clinical visit as was information on illness (incidence of diarrhea, fever, cough, and vomit). Multinomial logistic regression assessed demographic and illnesses’ influence on the relative risk of Failure or developing SAM compared to Recovery. ResultsOf enrolled children (N = 2682), 1675 (63%) recovered, 498 (19%) worsened to SAM, and 259 (10%) failed to respond. In the 2 weeks prior to enrollment, more children who recovered experienced fever (30%), cough (23%), diarrhea (9%), or vomit (7%) than children who did not recover. By exit, a larger % of children who developed SAM reported fever (30%), cough (27%), diarrhea (16%), or vomit (10%) in the 2 preceding weeks than children who failed or recovered. In both adjusted and unadjusted models, children who entered the program with higher MUACs or reported any illness in the 2 weeks preceding enrollment were at significantly lower risk of worsening to SAM or failing to recover. Children who were transferred from a SAM treatment program were at significantly greater risk of worsening to SAM and failing to respond as were children with any illness in the 2 weeks preceding exit. ConclusionsUnderlying infections or illness may explain why some children with MAM fail to recover. Illness at enrollment may signal a transitory condition remedied with treatment. Funding SourcesBureau for Humanitarian Assistance, U.S. Agency for International Development.

Simplifying and optimising the management of uncomplicated acute malnutrition in children aged 6–59 months in the Democratic Republic of the Congo (OptiMA-DRC): a non-inferiority, randomised controlled trial

Global access to acute malnutrition treatment is low. Different programmes using different nutritional products manage cases of severe acute malnutrition and moderate acute malnutrition separately. We aimed to assess whether integrating severe acute malnutrition and moderate acute malnutrition treatment into one programme, using a single nutritional product and reducing the dose as the child improves, could achieve similar or higher individual efficacy, increase coverage, and minimise costs compared with the current programmes. We conducted an open-label, non-inferiority, randomised controlled trial in the Democratic Republic of the Congo. Acutely malnourished children aged 6-59 months with a mid-upper-arm circumference (MUAC) of less than 125 mm or oedema were randomly assigned (1:1), using specially developed software and random blocks (size was kept confidential), to either the current standard strategy (one programme for severe acute malnutrition using ready-to-use therapeutic food [RUTF] at an increasing dose as weight increased, another for moderate acute malnutrition using a fixed dose of ready-to-use supplementary food [RUSF]) or the OptiMA strategy (a single programme for both severe acute malnutrition and moderate acute malnutrition using RUTF at a decreasing dose as MUAC and weight increased). The primary endpoint was a favourable outcome at 6 months, defined as being alive, not acutely malnourished as per the definition applied at inclusion, and with no further episodes of acute malnutrition throughout the 6-month observation period; the endpoint was analysed in the intention-to-treat (all children) and per-protocol populations (participants who had a minimum prescription of 4 weeks' RUTF, received at least 90% of the total amount of RUTF they were supposed to receive as per the protocol, or were prescribed RUSF rations for a minimum of 4 weeks [ie, minimum of 28 RUSF sachets], and had a maximum interval of 6 weeks between any two visits in the 6-month follow-up). The non-inferiority analysis (margin 10%) was to be followed by a superiority analysis (margin 0%) if non-inferiority was concluded. This trial is registered at ClinicalTrials.gov, NCT03751475, and is now closed. Between July 22 and Dec 6, 2019, 912 children were randomly assigned; after 16 were excluded, 896 were analysed (446 in the standard group and 450 in the OptiMA group). In the intention-to-treat analysis, 282 (63%) of 446 children in the standard group and 325 (72%) of 450 children in the OptiMA group had a favourable outcome (difference -9·0%, 95% CI -15·9 to -2·0). In the per protocol analysis, 161 (61%) of 264 children in the standard group and 291 (74%) of 392 children in the OptiMA group had a favourable outcome (-13·2%, -21·6 to -4·9). In this non-inferiority trial treating children with MUAC of less than 125 mm or oedema, decreasing RUTF dose according to MUAC and weight increase proved to be a superior strategy to the standard protocol in the Democratic Republic of the Congo. These results demonstrate the safety and benefits of an approach that could substantially increase access to treatment for millions of children with acute malnutrition in sub-Saharan Africa. Innocent Foundation and European Civil Protection and Humanitarian Aid Operations. For the French translation of the abstract see Supplementary Materials section.

Effects of a supplementary feeding program on the nutritional status of children in Daynile District Hospital Mogadishu, Somalia

Infant growth is an important variable that determines the nutritional and health status of children and during growth faltering supplementary feeding is very essential and saves a child’s life. The overall purpose of this study was to establish the association between dietary intake of supplementary foods on recovery and growth of children attending Daynile district hospital in Mogadishu, Somalia. A one month follow-up period longitudinal study with 28 participants was pulled from a baseline study that included 196 children (6-59 months) attending Daynile District Hospital. Children with global acute malnutrition (z-score less than minus two (-2)) were selected for the follow up study. Data was collected using digitized questionnaires in the Open Data Kit (ODK). Baseline data was analyzed using SPSS v20 software, nutrient intake and follow up data were analyzed using Python version 3.7 while Ena-For-SMART version 2015 was used for analysis of anthropometric data. P-value less than 0.05 were considered significant. From the baseline study, majority (90.3%) of the children had eaten food prepared from dairy products. Carbohydrates such as grains, tubers, and roots were also among the highest (88.8%) consumed foods. The study children had a high prevalence of stunting (18.4%), wasting (17.3%), and underweight (27%). A significant association (p=0.032) between mother’s complementary feeding practices, household income and minimum meal frequency was observed. From the longitudinal study, the feeding regime indicated that 9 out of 28 children (32%) transitioned from Ready to Use Supplementary Foods (RUSF) to Lipid based Nutrient Supplement (LNS), 7 out of 28 (25%) did not transition from RUSF while the remaining 12 (43%) children received LNS all through the entire one month of monitoring. At the end of the follow up, 56% (16 children) improved and were transitioned to LNS. The overall mean height, weight, and mid upper arm circumference differences for all the children who took RUSF and LNS slightly increased throughout the assessment period though the mean difference was not statistically significant. Treatment of moderate acute malnutrition with RUSF and LNS resulted in recovery of children. Therefore, there’s need to introduce effective and sustainable supplemental feeding programmes as a stop-gap solution in an effort to address the high malnutrition rates among these children. Keywords: child growth, nutrition status, supplementary foods, dietary intake

A local-ingredients-based supplement is an alternative to corn-soy blends plus for treating moderate acute malnutrition among children aged 6 to 59 months: A randomized controlled non-inferiority trial in Wolaita, Southern Ethiopia.

Globally, moderate acute malnutrition (MAM) affects approximately 5% of children below five years of age. MAM is a persistent public health problem in Ethiopia. The current approach in Ethiopia for managing MAM is a supplementary feeding program; however, this is only provided to chronically food-insecure areas. The objective of the study was to compare a local-ingredients-based supplement (LIBS) with the standard corn-soy blend plus (CSB+) in treating MAM among children aged 6 to 59 months to test the hypothesis that the recovery rate achieved with LIBS will not be more than 7% worse than that achieved with CSB+. We used an individual randomized controlled non-inferiority trial design with two arms, involving 324 children with MAM aged 6 to 59 months in Wolaita, Southern Ethiopia. One hundred and sixty-two children were randomly assigned to each of the two arms. In the first arm, 125.2 g of LIBS with 8 ml of refined deodorized and cholesterol-free sunflower oil/day was provided. In the second arm, 150 g of CSB+ with 16 ml of refined deodorized and cholesterol-free sunflower oil/day was provided. Each child was provided with a daily ration of either LIBS or CSB+ for 12 weeks. Both intention-to-treat (ITT) and per-protocol (PP) analyses were done. ITT and PP analyses showed non-inferiority of LIBS compared with CSB+ for recovery rate [ITT risk difference = 4.9% (95% CI: -4.70, 14.50); PP risk difference = 3.7% (95% CI: -5.91, 13.31)]; average weight gain [ITT risk difference = 0.10 g (95% CI: -0.33 g, 0.53 g); PP risk difference = 0.04 g (95% CI: -0.38 g, 0.47 g)]; and recovery time [ITT risk difference = -2.64 days (95% CI: -8.40 days, 3.13 days); PP difference -2.17 days (95% CI: -7.97 days, 3.64 days]. Non-inferiority in MUAC gain and length/height gain was also observed in the LIBS group compared with the CSB+ group. LIBS can be used as an alternative to the standard CSB+ for the treatment of MAM. Thus, the potential of scaling up the use of LIBS should be promoted. Pan-African Clinical Trial Registration number: PACTR201809662822990.

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.

Treating high-risk moderate acute malnutrition using therapeutic food compared with nutrition counseling (Hi-MAM Study): a cluster-randomized controlled trial

ABSTRACTBackgroundThere is a lack of consensus on what is the most appropriate treatment of moderate acute malnutrition (MAM).ObjectivesWe aimed to determine if provision of ready-to-use-therapeutic food (RUTF) and antibiotics to “high-risk” MAM (HR-MAM) children in addition to nutritional counseling would result in higher recovery and less deterioration than nutrition counseling alone.MethodsAt the 11 intervention clinics, HR-MAM children were given RUTF and amoxicillin along with standard nutrition counseling, for 2–12 wk. All others received 6 wk of nutrition counseling alone. HR-MAM was defined as midupper arm circumference (MUAC) <11.9 cm, weight-for-age z score (WAZ) <−3.5, mother not the main caregiver, or a child <2 y old not being breastfed. Outcomes were compared using intention-to-treat analysis.ResultsAnalysis included 573 children at the intervention sites and 714 children at the control sites. Of the intervention group, 317 (55%) were classified as HR-MAM. Short-term recovery was greater at the intervention sites [48% compared with 39% at week 12; risk difference (rd): 0.08; 95% CI: 0.03, 0.13]. The intervention group had lower risk of deteriorating to severe acute malnutrition (SAM) (18% compared with 24%; rd: −0.07; 95% CI: −0.11, −0.04), lower risk of dying (1.8% compared with 3.1%; rd: −0.02; 95% CI: −0.03, −0.00), and greater gains in MUAC and weight than did children at the control sites. However, by 24 wk, the risk of SAM was similar between the 2 arms (31% compared with 34%; rd: −0.03; 95% CI: −0.09, 0.02). Control group data identified recent illness, MUAC <12.0 cm, WAZ <−3, dropping anthropometry, age <12 mo, being a twin, and a history of previous SAM as risk factors for deterioration.ConclusionsProvision of RUTF and antibiotics to HR-MAM children improved short-term recovery and reduced short-term risk of deterioration. However, recovery rates were still suboptimal and differences were not sustained by 6 mo post enrollment.This trial was registered at clinicaltrials.gov as NCT03647150.

Host Fecal mRNAs Predicted Environmental Enteric Dysfunction among Children with Moderate Acute Malnutrition in Sierra Leone.

ABSTRACT.Examining the role of environmental enteric dysfunction (EED) in child growth requires noninvasive, field-appropriate biomarkers. Alternatives to the traditionally used lactulose:mannitol (L:M) test have been explored, but few studies have compared the L:M test to host fecal mRNA transcripts. The objectives of this study were to examine whether 1) host fecal mRNA transcripts could predict presence and severity of EED, measured using the L:M test, and 2) EED modifies the effect of specialized nutritious foods (SNFs) on recovery from moderate acute malnutrition (MAM). This substudy was nested within a cluster randomized trial comparing four SNFs in the treatment of MAM among children 6 to 59 months in Sierra Leone. EED was assessed at enrollment using the L:M test and 15 host fecal mRNA transcripts on 522 children. Recovery from MAM was defined as achieving mid-upper arm circumference ≥ 12.5 cm within 12 weeks of supplementation. Random forest classification models were used to examine prediction of presence and severity of EED by host fecal mRNA transcripts. Logistic regression was used to test for effect modification by L:M test variables including % lactulose excreted (%L). Eight host fecal mRNA transcripts (AQP9, REG3A, IFI30, DECR1, BIRC3, SELL, PIK3AP1, DEFA6) identified EED (%L ≥ 0.2) and severe EED (%L ≥ 0.45) with high sensitivity and specificity. The L:M test variables did not modify the effect of SNFs on recovery from MAM. In this study, we found host fecal mRNA transcripts that could be biomarkers of EED but did not find EED to modify the effect of SNFs on MAM treatment.

Nutrition Assessment of Under-Five Children in Sudan: Tracking the Achievement of the Global Nutrition Targets.

Background: Malnutrition places a heavy burden on the health, well-being, and sustainable development of populations in Sudan, especially a country affected by conflict, which continues to experience high levels of food insecurity, undernutrition, and micronutrient deficiencies; 3.3 million are acutely malnourished, with 522,000 children suffering from severe acute malnutrition and approximately 2.2 million children requiring treatment for moderate acute malnutrition. This study aims to describe the nutritional status of children under five years old and identify the progress toward the achievement of the Global Nutrition Targets. Methods: This is a secondary data analysis of a quantitative survey, using the second-round of the Simple Spatial Survey Method (S3M II) in Sudan in the period 2018–2019. The analysis used an area-based sampling methodology in all 18 Sudanese states. Data from the WHO Tracking Tools of the Global Nutrition Targets was used to reflect the progress in achieving the targets in Sudan. Results: Global stunting prevalence was at 36.35 percent including moderate stunting prevalence and severe stunting prevalence (21.25 percent and 15.06 percent respectively). Global wasting prevalence was 13.6 percent including moderate wasting prevalence and severe wasting prevalence (10.8 percent and 2.7 percent respectively). Sudan has made great progress in achieving the target of increasing exclusive breastfeeding. However, despite the welcome commitments by the Government and all stakeholders, Sudan is still struggling to implement strategies, policies, and regulatory measures to address malnutrition and achieve the Global Nutrition Targets in 2025 and the Sustainable Developmental Goals in 2030. Therefore, more than ever, there is a need for comprehensive, multi-sectoral action to address malnutrition in all its forms.

Body Composition Changes in Children during Treatment for Moderate Acute Malnutrition: Findings from a 4-Arm Cluster-Randomized Trial in Sierra Leone.

ABSTRACTBackgroundMeasures that better describe “healthy” and sustainable recovery during nutritional treatment of children with moderate acute malnutrition (MAM) are needed.ObjectivesWe compared changes to body composition among children receiving 1 of 4 specialized nutritious food (SNFs) during treatment of MAM and by recovery and relapse outcomes.MethodsThe study was nested within a prospective, cluster-randomized, community-based, cost-effectiveness trial assessing 4 SNFs to treat children aged 6–59 mo with MAM [midupper arm circumference (MUAC) ≥11.5 cm and <12.5 cm without bipedal edema] in Sierra Leone. Biweekly SNF rations (1 of 3 fortified-blended foods or a lipid-based nutrient supplement) were given until children recovered (MUAC ≥12.5 cm), or up to 7 rations (∼12 wk). Deuterium dilution was used to estimate fat-free mass (FFM) and fat mass (FM) at enrollment and after 4 wk of treatment to ensure similar treatment exposure among the participants. Another MUAC measurement was performed among recovered children 4 wk after program exit to determine whether recovery was sustained. ANOVA, paired t tests, and linear regression models were used to determine significant differences in changes from baseline to 4 wk.ResultsAmong 312 analyzed participants, mean baseline weight comprised ∼80% FFM; mean weight gained after 4 wk comprised ∼82% FFM. Changes in FM and FFM among 4 SNFs were similar. Children who recovered gained more weight (241%), FFM (179%), and weight-for-height z score (0.44 compared with 0) compared with those who did not recover; sustainers gained 150% more weight. FM gains were positive among recovered children and sustainers, as well as negative among those who did not recover or sustain recovery, but not significantly different.ConclusionsFour SNFs had similar effects on body composition in children after 4 wk of treatment for MAM, showing a healthy pattern of weight gain, the majority being FFM. Differential responses to treatment underscore a need for further research to provide targets for healthy, sustainable recovery. This trial was registered at clinicaltrials.gov as NCT03146897.

Impact of food supplements on early child development in children with moderate acute malnutrition: A randomised 2 x 2 x 3 factorial trial in Burkina Faso.

Lipid-based nutrient supplements (LNS) and corn-soy blends (CSBs) with varying soy and milk content are used in treatment of moderate acute malnutrition (MAM). We assessed the impact of these supplements on child development. We conducted a randomised 2 × 2 × 3 factorial trial to assess the effectiveness of 12 weeks' supplementation with LNS or CSB, with either soy isolate or dehulled soy, and either 0%, 20%, or 50% of protein from milk, on child development among 6-23-month-old children with MAM. Recruitment took place at 5 health centres in Province du Passoré, Burkina Faso between September 2013 and August 2014. The study was fully blinded with respect to soy quality and milk content, while study participants were not blinded with respect to matrix. This analysis presents secondary trial outcomes: Gross motor, fine motor, and language development were assessed using the Malawi Development Assessment Tool (MDAT). Of 1,609 children enrolled, 54.7% were girls, and median age was 11.3 months (interquartile range [IQR] 8.2-16.0). Twelve weeks follow-up was completed by 1,548 (96.2%), and 24 weeks follow-up was completed by 1,503 (93.4%); follow-up was similar between randomised groups. During the study, 4 children died, and 102 children developed severe acute malnutrition (SAM). There was no difference in adverse events between randomised groups. At 12 weeks, the mean MDAT z-scores in the whole cohort had increased by 0.33 (95% CI: 0.28, 0.37), p < 0.001 for gross motor; 0.26 (0.20, 0.31), p < 0.001 for fine motor; and 0.14 (0.09, 0.20), p < 0.001 for language development. Children had larger improvement in language z-scores if receiving supplements with milk (20%: 0.09 [-0.01, 0.19], p = 0.08 and 50%: 0.11 [0.01, 0.21], p = 0.02), although the difference only reached statistical significance for 50% milk. Post hoc analyses suggested that this effect was specific to boys (interaction p = 0.02). The fine motor z-scores were also improved in children receiving milk, but only when 20% milk was added to CSB (0.18 [0.03, 0.33], p = 0.02). Soy isolate over dehulled soy increased language z-scores by 0.07 (-0.01, 0.15), p = 0.10, although not statistically significant. Post hoc analyses suggested that LNS benefited gross motor development among boys more than did CSB (interaction p = 0.04). Differences between supplement groups did not persist at 24 weeks, but MDAT z-scores continued to increase post-supplementation. The lack of an unsupplemented control group limits us from determining the overall effects of nutritional supplementation for children with MAM. In this study, we found that child development improved during and after supplementation for treatment of MAM. Milk protein was beneficial for language and fine motor development, while suggested benefits related to soy quality and supplement matrix merit further investigation. Supplement-specific effects were not found post-intervention, but z-scores continued to improve, suggesting a sustained overall effect of supplementation. ISRCTN42569496.

Association between admission criteria and body composition among young children with moderate acute malnutrition, a cross-sectional study from Burkina Faso

Children with moderate acute malnutrition (MAM) are treated based on low weight-for-length z-score (WLZ), low mid-upper arm circumference (MUAC) or both. This study aimed to assess associations of admission criteria and body composition (BC), to improve treatment of MAM. We undertook a cross-sectional study among 6–23 months old Burkinabe children with MAM. Fat-free (FFM) and fat mass (FM) were determined by deuterium dilution and expressed as FFM (FFMI) and FM index (FMI). Of 1,489 children, 439 (29.5%) were recruited by low MUAC only (MUAC-O), 734 (49.3%) by low WLZ and low MUAC (WLZ-MUAC) and 316 (21.2%) by low WLZ only (WLZ-O). Thus, 1,173 (78.8%) were recruited by low MUAC, with or without low WLZ (ALL-MUAC). After adjustments, WLZ-O had 89 g (95% confidence interval (CI) 5; 172) lower FFM compared to MUAC-O. Similarly, WLZ-O had 0.89 kg/m2 (95% CI 0.77; 1.01) lower FFMI compared to MUAC-O, whereas there was no difference for FMI. However, boys included by WLZ-O compared to MUAC-O had 0.21 kg/m2 (95% CI 0.05; 0.38) higher FMI. In contrast, girls included by WLZ-O had 0.17 (95% CI 0.01; 0.33) kg/m2 lower FMI compared to MUAC-O (interaction, p = 0.002). We found that different criteria for admission into MAM treatment programmes select children with differences in BC, especially FFMI.Trial registration: ISRCTN42569496.

A simplified, combined protocol versus standard treatment for acute malnutrition in children 6-59 months (ComPAS trial): A cluster-randomized controlled non-inferiority trial in Kenya and South Sudan.

Malnutrition underlies 3 million child deaths worldwide. Current treatments differentiate severe acute malnutrition (SAM) from moderate acute malnutrition (MAM) with different products and programs. This differentiation is complex and costly. The Combined Protocol for Acute Malnutrition Study (ComPAS) assessed the effectiveness of a simplified, unified SAM/MAM protocol for children aged 6-59 months. Eliminating the need for separate products and protocols could improve the impact of programs by treating children more easily and cost-effectively, reaching more children globally. A cluster-randomized non-inferiority trial compared a combined protocol against standard care in Kenya and South Sudan. Randomization was stratified by country. Combined protocol clinics treated children using 2 sachets of ready-to-use therapeutic food (RUTF) per day for those with mid-upper arm circumference (MUAC) < 11.5 cm and/or edema, and 1 sachet of RUTF per day for those with MUAC 11.5 to <12.5 cm. Standard care clinics treated SAM with weight-based RUTF rations, and MAM with ready-to-use supplementary food (RUSF). The primary outcome was nutritional recovery. Secondary outcomes included cost-effectiveness, coverage, defaulting, death, length of stay, and average daily weight and MUAC gains. Main analyses were per-protocol, with intention-to-treat analyses also conducted. The non-inferiority margin was 10%. From 8 May 2017 to 31 March 2018, 2,071 children were enrolled in 12 combined protocol clinics (mean age 17.4 months, 41% male), and 2,039 in 12 standard care clinics (mean age 16.7 months, 41% male). In total, 1,286 (62.1%) and 1,202 (59.0%), respectively, completed treatment; 981 (76.3%) on the combined protocol and 884 (73.5%) on the standard protocol recovered, yielding a risk difference of 0.03 (95% CI -0.05 to 0.10, p = 0.52; per-protocol analysis, adjusted for country, age, and sex). The amount of ready-to-use food (RUTF or RUSF) required for a child with SAM to reach full recovery was less in the combined protocol (122 versus 193 sachets), and the combined protocol cost US$123 less per child recovered (US$918 versus US$1,041). There were 23 (1.8%) deaths in the combined protocol arm and 21 (1.8%) deaths in the standard protocol arm (adjusted risk difference 95% CI -0.01 to 0.01, p = 0.87). There was no evidence of a difference between the protocols for any of the other secondary outcomes. Study limitations included contextual factors leading to defaulting, a combined multi-country power estimate, and operational constraints. Combined treatment for SAM and MAM is non-inferior to standard care. Further research should focus on operational implications, cost-effectiveness, and context (Asia versus Africa; emergency versus food-secure settings). This trial is complete and registered at ISRCTN (ISRCTN30393230). The trial is registered at ISRCTN, trial number ISRCTN30393230.

Behavioral Factors Related to Use of Specialized Nutritious Foods in a MAM Treatment Program in Sierra Leone

Abstract Objectives This analysis describes differences in household-level use of four specialized nutritious foods (SNFs) for treatment of moderate acute malnutrition (MAM) in children 6–59 months of age in Sierra Leone and explores whether these behaviors influenced recovery. Methods From 4/2017 to 11/2018, sub-samples of caregivers whose children were enrolled in a supplemental feeding program (SFP) for a MAM treatment study were randomly selected for in-depth interviews and in-home observations. This was a cluster-randomized trial of 2653 children with MAM in Sierra Leone evaluating cost-effectiveness of 4 SNFs: Super Cereal Plus w/amylase (SC + A), Corn-soy Blend Plus w/oil (CSB + w/oil), Corn-soy-whey Blend w/oil (CSWB w/oil), and Ready-to-Use Supplementary Food (RUSF). Caregivers received bi-weekly isocaloric distributions of 1 of the 4 SNFs until recovery or up to 12 weeks. The purpose of the in-depth interviews was to understand caregivers’ experiences with the SFP and the SNF which they received. In-home observations gathered information about observed behaviors related to SNF use over 5 consecutive days. Descriptive statistics were calculated and stratified by study arm and by outcome to explore: consumption of the SNF by the target child, sharing and selling, and diversion of other household foods. Results A total of n = 949 caregivers completed an in-depth interview. Of these, n = 323 also had an in-home observation. Observed consumption of the SNF was high in all study arms (&amp;gt;60%), with no discernible differences among arms. Consumption of the study food by anyone other than the beneficiary child (i.e., sharing) was similar across arms (9–12% reported, 19–27% observed), with the lowest reported and highest observed in RUSF. Very few reported giving the SNF away or selling it to others (&amp;lt;1%). Sharing and displacement did not differ by recovery status, but children who recovered were observed consuming the SNF more often than those who failed (82% vs. 46%). Conclusions Sharing of the SNF was common among all arms but did not affect likelihood of recovery. Ensuring adequate consumption of the SNF by the beneficiary child is critical for effectiveness. Qualitative data can expand on these findings. Funding Sources Office of Food for Peace, United States Agency for International Development.

A Local Ingredients-Based Supplement Is Not Inferior to Corn-soya Blends Plus for the Treatment of Moderate Acute Malnutrition Among Children Aged 6 to 59 Months in Wolaita

Abstract Objectives Moderate acute malnutrition (MAM) is widespread and a persistent public health problem in developing countries. Currently, the management approach of MAM is focused on food supplementation, but it is limited to chronically food-insecure areas. This study aims to develop local-ingredients based supplement (LIBS) and evaluate if it is comparable to the corn-soya blend plus (CSB+) in treating MAM among children aged 6 to 59 months in Wolaita, Ethiopia. Methods Collection of food ingredients that have the potential for making LIBS was done. Sorting, soaking, roasting, and milling of ingredients were done. The LIBS, with an improved amount of nutrients, was used to test the effectiveness in treating MAM. To evaluate the effectiveness of LIBS compared with CSB+ in treating MAM, we used a randomized controlled non-inferiority trial among 324 moderately wasted children aged 6 to 59 months in Wolaita, Ethiopia. The daily ration was: 100 gm of LIBS plus 25.2 gm of sugar with 8 ml oil in the intervention group and 150 gm of CSB+ with 16 ml of oil in the control group. A chi-square test was used for the comparison of recovery rates between two groups. Kaplan-Meier (log-rank) survival analysis was done to estimate the recovery time and survival curves. Results Four food samples of LIBS were made with different portions of ingredients. One of the LIBS with the highest portion of pumpkin seed and selected for testing had an improved amount of protein, fat, energy, iron, zinc and potassium contents. Its proximate composition indicated protein and fat contents of 22.6 g/100 g and 32.9 g/100 g respectively. The trial results showed that there is no difference in baseline characteristics between the two groups (p &amp;gt; 0.05). The recovery rate for LIBS (n = 105 of 162; 64.8%) was similar to that for CSB+ (n = 108 of 162; 66.7%) (P = 0.6). The duration of recovery was similar for the LIBS group, with a median of 56 days compared to 63 days for the CSB+ group (P = 0.92). Conclusions The LIBS has contained adequate amount of nutrients needed for the treatment of MAM. There was no difference in recovery rates as well as recovery times for those who received LIBS and those who received CSB+ . Thus, LIBS has the same potential to treat MAM as CSB+ . Funding Sources Norwegian Agency for Development Cooperation (NORAD); Norwegian Program for Capacity Development in Higher Education and Research for Development Program (NORHED).

The Cost of a Counseling-Based Intervention for Moderate Acute Malnutrition (MAM) in Kenya Compared to Treatment with Ready-to-Use Foods (RUF)

Abstract Objectives Supplementary feeding with RUF is currently the recommended treatment for MAM in Kenya, although trials suggest it produces only modest medium-term benefits. An alternative counseling-based approach which identified and addressed the varied underlying causes for MAM would involve increased staff time. In order to model the future cost of providing a targeted, problem solving intervention for MAM instead of supplementary foods, we aimed to estimate the current staff and facility cost of managing acute malnutrition using RUF. Methods We studied 6 health facilities in Nairobi, Kenya in 2019, assessing the amount of staff time spent in treatment of AM and managing RUF supplies, via interview and observation. Information was collected on: time spent per child per visit, number of children with AM seen by nutritionists annually, time spent by staff per year on requisition and management of RUF and in relevant training, staff wage rates and RUF transport costs. Costs were calculated in US$, per child/month, assuming each child was seen once and supplied with 28 RUF sachets. Results Centers saw 7–80 children per clinic and staff spent 5–9 minute seeing each child. The contact cost per child visit was $0.14–0.25 and the dispensing cost $0.02–0.34, giving a mean (range) total cost of $0.24 (0.17 – 0.59). The hourly pay for nutritionists was $1.67. The exact cost of RUF varies, depending on supplier and purchaser, but was estimated to vary from $0.25 to $0.50 per sachet, giving a monthly cost of $7–14. This represents 96–98% of total current MAM treatment costs. Conclusions Very little time is currently spent speaking to mothers of malnourished children. An intervention for MAM could involve up to 8 hours counseling per month per child and still be cheaper to provide than supplementary RUTF. Well-staffed trials of the efficacy of problem-oriented counseling interventions need to be undertaken. Funding Sources Scottish Funding Council (Global Challenges Research Fund).

Protein quality in ready-to-use supplementary foods for moderate wasting.

There are no guidelines for the optimal protein quality of ready‐to‐supplementary food (RUSF) for moderate acute malnutrition (MAM). This randomized, controlled, double‐blinded, clinical effectiveness trial evaluated two RUSFs in the treatment of MAM. Both foods contained greater than 7% dairy protein, but the protein‐optimized RUSF had a calculated digestible indispensable amino acid score (DIAAS) of 95%, whereas the control RUSF had a calculated DIAAS of 63%. There were 1,737 rural Malawian children 6–59 months of age treated with 75 kcal/kg/day of either control or protein quality‐optimized RUSF for up to 12 weeks. There was no difference in the proportion of children who recovered from MAM between the group that received protein‐optimized RUSF (759/860, 88%) and the group that received control RUSF (766/877, 87%, difference 1%, 95% CI, −2.1 to 4.1, p = 0.61). There were no differences in time to recovery or average weight gain; nor were adverse effects reported. Both RUSFs showed indistinguishable clinical outcomes, with recovery rates higher than typically seen in treatment for MAM. The DIAAS of these two RUSFs was measured using a pig model. Unexpectedly, the protein quality of the optimized RUSF was inferior to the control RUSF: DIAAS = 82% for the protein quality optimized RUSF and 96% for control RUSF. The controlled conditions of this trial suggest that in supplementary food products for MAM, protein quality is not an independent predictor of clinical effectiveness.