Severe Acute Malnutrition Cases Research Articles

Prescribing practices in the treatment of wasting: secondary analysis from a randomised trial

IntroductionCurrent guidelines for the outpatient treatment of severe acute malnutrition (SAM) recommend the provision of routine medications to all children at admission and prescribed medications as clinically indicated thereafter. The...

Comparing time to recovery in wasting treatment: simplified approach vs. standard protocol among children aged 6-59 months in Ethiopia-a cluster-randomized, controlled, non-inferiority trial.

Wasting occurs when the body's nutritional needs are unmet due to insufficient intake or illness. It represents a significant global challenge, with approximately 45 million infants and children under 5 years of age suffering from wasting in 2022. A cluster-randomized, controlled, non-inferiority trial was conducted in three regions of Ethiopia. A non-inferiority margin of 15%, along with a recovery rate of 90% and a minimum acceptable recovery rate of 75%, were considered alongside an intra-cluster correlation coefficient of 0.05 and an anticipated loss to follow-up of 10% in determining the total sample size of 1,052 children. Children with severe acute malnutrition (SAM) in the simplified group received two sachets of ready-to-use therapeutic food (RUTF) daily, while the standard group received RUTF based on their body weight. For moderate acute malnutrition (MAM) cases, the simplified group received one sachet of RUTF, whereas the standard group received one sachet of ready-to-use supplementary food daily. A non-parametric Kaplan-Meir curve was utilized to compare the survival time to recovery. A total of 1,032 data points were gathered. For SAM cases, the average length of stay was 8.86 (±3.91) weeks for the simplified protocol and 8.26 (±4.18) weeks for the standard protocol (P = 0.13). For MAM cases, the average length of stay was 8.18 (±2.96) weeks for the simplified approach and 8.32 (±3.55) weeks for the standard protocol (P = 0.61). There was no significant difference (P = 0.502) observed between the simplified protocol [8 weeks, interquartile range (IQR): 7.06-8.94] and the standard protocol [9 weeks (IQR: 8.17-9.83)] among children with SAM on the median time to cure. There was no significant difference (P = 0.502) in the time to cure between the simplified approach [8 weeks (IQR: 7.53-8.47)] and the standard protocol [8 weeks (IQR: 7.66-8.34)] among children with MAM. The survival curves displayed similarity, with the log-rank test not showing significance (P > 0.5), indicating the non-inferiority of the simplified approach for cure time. The findings showed that the simplified and standard protocols demonstrated no significant differences in terms of the average duration of stay and time required for recovery. https://pactr.samrc.ac.za/, Identifier (PACTR202202496481398).

Effectiveness of a nonweight-based daily dosage of ready-to-use therapeutic food in children suffering from uncomplicated severe acute malnutrition: A nonrandomized, noninferiority analysis of programme data in Afghanistan.

Severe acute malnutrition (SAM) remains a major global public health problem. SAM cases are treated using ready-to-use therapeutic food (RUTF) at a dosage of ∼200 kcal/kg/day per the standard treatmentprotocol (STD). Emerging evidence on simplifications to the standard protocol, which among other adaptations, includes reducing the daily RUTF dosage, indicates that it is effective and safe for treating children with SAM. In response to a foreseen stock shortage of RUTF, the government of Afghanistan endorsed the temporary use of a modified treatment protocol in which the daily RUTF dosage was prescribed at 1000 kcal/day (irrespective of body weight) until the child achieved moderate acute malnutrition status (weight-for-heightz-score ≥ -3 or mid-upper arm circumference [MUAC] ≥ 115 mm), at which point 500 kcal/day was prescribed until cured (modified treatment protocol [MTP]). In this paper, we report the results of this nonweight-based daily RUTF dosage experience. Data of 2042 children with SAM, treated using either the STD protocol (n = 269) or the MTP protocol (n = 1773) from August 2019 to March 2021 in five provinces, were analyzed. The per-protocol analyses confirmed noninferiority of MTP protocol when compared to STD protocol for recovery rate [93.3% vs. 90.2%; ∆ (95% confidence interval,CI) = 3.1 (-0.9; 7.2) %] and length-of-stay [82.6 vs. 75.6 days; ∆ (95%CI) = 6.9 (3.3; 10.5) days], considering the margin of noninferiority of -10% and +14 days, respectively. Weight gain velocity was smaller in theMTP protocol group than in the STD protocol group [3.7 (1.7) vs. 5.2 (2.9) g/kg/day; ∆ (95%CI) = -1.5 (-1.8, -1.2); p < 0.001]. The STD group had a significantly higher mean than the MTP group for absolute MUACgain [∆ (95%CI) = 1.7 (1.0; 2.3) mm; p < 0.001] and the MUAC velocity [∆ (95%CI) = 0.29 (0.20; 0.37) mm/week; p < 0.001]. Our results confirm the noninferiority of a nonweight-based daily dosage and support the endorsement of this modification as an alternative to the standard protocol in resource-constrained contexts.

A pilot study using hospital surveillance and a birth cohort to investigate enteric pathogens and malnutrition in children, Dili, Timor-Leste.

In low-to-middle-income countries (LMICs), enteric pathogens contribute to child malnutrition, affecting nutrient absorption, inducing inflammation, and causing diarrhoea. This is a substantial problem in LMICs due to high disease burden, poor sanitation and nutritional status, and the cyclical nature of pathogen infection and malnutrition. This relationship remains understudied in Timor-Leste. In our pilot study of enteric pathogens and malnutrition in Dili, Timor-Leste (July 2019-October 2020), we recruited 60 infants in a birth cohort from Hospital Nacional Guido Valadares (HNGV) with up to four home visits. We collected faecal samples and details of demographics, anthropometrics, diet and food practices, and animal husbandry. Additionally, we collected faecal samples, diagnostics, and anthropometrics from 160 children admitted to HNGV with a clinical diagnosis of severe diarrhoea or severe acute malnutrition (SAM). We tested faeces using the BioFire® FilmArray® Gastrointestinal Panel. We detected high prevalence of enteric pathogens in 68.8% (95%CI 60.4-76.2%) of infants at home, 88.6% of SAM cases (95%CI 81.7-93.3%) and 93.8% of severe diarrhoea cases (95%CI 67.7-99.7%). Diarrhoeagenic Escherichia coli and Campylobacter spp. were most frequently detected. Pathogen presence did not significantly differ in birth cohort diarrhoeal stool, but hospital data indicated associations between Salmonella and Shigella and diarrhoea. We observed wasting in 18.4% (95%CI 9.2-32.5%) to 30.8% (95%CI 17.5-47.7%) of infants across home visits, 57.9% (95%CI 34.0-78.9%) of severe diarrhoea cases, and 92.5% (95%CI 86.4-96.2%) of SAM cases. We associated bottle feeding with increased odds of pathogen detection when compared with exclusive breastfeeding at home (OR 8.3, 95%CI 1.1-62.7). We detected high prevalence of enteric pathogens and signs of malnutrition in children in Dili. Our pilot is proof of concept for a study to fully explore the risk factors and associations between enteric pathogens and malnutrition in Timor-Leste.

Changes in biochemical profiles of children with severe acute malnutrition on admission and after nutritional rehabilitation

Purpose: The given study was done to find out the changes in biochemical profiles before and after nutritional rehabilitation of the children admitted at the Department of Paediatrics, Assam Medical College with severe acute malnutrition (SAM). Materials and Methods: A hospital based observational study was conducted from May 2020 to April 2021 with 55 consecutive cases of SAM. Vitros System 5600 was used for analysis of 13 biochemical parameters. Results: The mean values of serum sodium, potassium, and chloride at admission were 134.59±19.37 mEq/L, 4.22±0.80 mEq/L, and 101.12±16.36 mEq/L and that after rehabilitation were 136.66±19.95 mEq/L, 4.42±0.68 mEq/L, and 103.97±4.83 mEq/L. While that for magnesium, calcium, and phosphorous on admission were 2.11±0.38 mg/dL, 8.70±1.00 mg/dL, and 4.33±1.23 mg/dL and that after rehabilitation were 2.10±0.29 mg/dL, 9.45±0.65 mg/dL, and 4.76±0.84 mg/dL, respectively. The mean values of serum total protein, albumin, globulin, and A: G on admission were 6.53±1.44 g/dL, 3.30±0.88 g/dL, 3.23±0.87 g/dL, and 1.06±0.33, respectively, and that after rehabilitation were 6.84±0.98 g/dL, 3.86±0.57 g/dL, 2.98±0.69 g/dL, and 1.34±0.28, respectively. The mean of urea and creatinine on admission were found to be 26.25±19.30 mg/dL and 0.34±0.24 mg/dL, respectively, and that after rehabilitation were 23.91±11.76 mg/dL and 0.31±0.15 mg/dL respectively. Random blood sugar (RBS) on admission was 85.20±17.88 mg/dL and that after rehabilitation was 94.18±14.82 mg/dL. After rehabilitation, the mean value of calcium, phosphorous, albumin, A: G, and RBS were significantly raised. The minimum duration required for rehabilitation was 12 days with prevalence being maximum among the Tea-tribes (80.00%). Conclusion: The biochemical derangements in a patient with SAM are associated with significant morbidity and get improved after nutritional rehabilitation.

Mid-upper arm circumference only protocol in Pakistan: missed opportunities for children suffering from severe acute malnutrition? A mixed-methods observational study.

We investigated the missed treatment opportunities affecting programmes using mid-upper arm circumference (MUAC) as the sole anthropometric criterion for identification and monitoring of children suffering from severe acute malnutrition (SAM). Alongside MUAC, we assessed weight-for-height Z-score (WHZ) in children screened and treated according to the national MUAC only protocol in Pakistan. Besides, we collected parents' perceptions regarding the treatment received by their children through qualitative interviews. Data were collected from October to December 2021 in Tando Allah Yar District, Sindh. All children screened in the health facilities (n 8818) and all those discharged as recovered (n 686), throughout the district, contributed to the study. All children screened in the community in the catchment areas of five selected health facilities also contributed (n 8459). Parents of forty-one children randomly selected from these same facilities participated in the interviews. Overall, 80·3 % of the SAM cases identified during community screening and 64·1 % of those identified in the health facilities presented a 'WHZ-only' diagnosis. These figures reached 93·9 % and 84·5 %, respectively, in children aged over 24 months. Among children treated for SAM and discharged as recovered, 25·3 % were still severely wasted according to WHZ. While parents positively appraised the treatment received by their children, they also recommended to extend eligibility to other malnourished children in their neighbourhood. In this context, using MUAC as the sole anthropometric criterion for treatment decisions (referral, admission and discharge) resulted in a large number of missed opportunities for children in need of timely and adequate care.

A comparison of mid-upper arm circumference and weight-for-height Z score of world health organization growth standards in detecting moderate and severe acute malnutrition in children aged 6-60 months

Background: World health organization (WHO) had defined severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) by weight for height Z score (WHZ) and mid upper arm circumference (MUAC) criteria. Several studies indicate discrepancies in the prevalence of malnutrition on using either WHZ or MUAC. The prevalence of SAM was nearly same when using either criterion and only 40% children showed overlapping by using both the criteria. Present study was taken to identify the overlapping of cases by applying both the WHO criteria in children aged 6-60 months. It also identifies the optimal screening cut off values of MUAC if used as a sole criterion. Method: It was a hospital based descriptive cross-sectional study done on 640 cases who were assessed for MAM /SAM by using anthropometric WHO criteria. Results: From 67 SAM cases who were identified by WHZ, only17 cases had SAM on using MUAC too. The sensitivity of MUAC was 25.4% and specificity of 92.0%. From 94 MAM cases, 19 cases showed overlapping by using both the WHO criteria. At MUAC of &lt;13.5 cm, the sensitivity increased to 86.6% for SAM and 81.6% for MAM cases at the cost of decreased specificity which was at around 36% for both the types of malnutrition. Conclusions: The number of malnourished cases, identified by using either of WHO criteria were nearly same but both these criteria detect different subgroups of malnourished children in most cases. A MUAC of &lt;13.5 cm may be used as a sole-criteria in the community by the health workers to detect acute malnutrition.

Serum Inflammatory Markers in Children with Severe Acute Malnutrition with Systemic Infections: A Case-Control Study.

Severe acute malnutrition (SAM) is a major contributor to under-five mortality in developing countries such as India, where SAM children are susceptible to infections. However, there is inconsistent literature on the derangement of immune mechanisms and subsequent infection-related mounting of inflammatory responses in SAM cases compared to nutritionally-normal controls with infections. To address this, authors conducted a case-control study comparing serum inflammatory markers in 60 SAM children with systemic infections to nutritionally-normal children with infection. Cases had a lower mean serum C-reactive protein (CRP) on admission compared to controls (p-value <0.001), which continued during the follow-up (p-value <0.001). Cases also had a lower mean serum interleukin-6 (IL-6) on admission (p-value = 0.04). Baseline CRP, procalcitonin, and follow-up procalcitonin were positively correlated with antibiotic therapy duration (p-value = 0.018, 0.025, and 0.007, respectively). This study suggests that SAM children had some ability to mount an inflammatory response during a systemic infection, but it was weaker compared to nutritionally normal children with a systemic infection.

Severe acute malnutrition promotes bacterial binding over proinflammatory cytokine secretion by circulating innate immune cells.

Children with severe acute malnutrition (SAM) have high infectious mortality and morbidity, implicating defects in their immune defenses. We hypothesized that circulating innate immune cells from children (0 to 59 months) hospitalized with SAM in Zambia and Zimbabwe (n = 141) have distinct capacity to respond to bacteria relative to adequately nourished healthy controls (n = 92). SAM inpatients had higher neutrophil and monocyte Escherichia coli binding capacity but lower monocyte activation and proinflammatory mediator secretion in response to lipopolysaccharide or heat-killed Salmonella typhimurium than controls. Among SAM cases, wasting severity was negatively associated with cytokine secretion, children with HIV had lower monocyte activation, and the youngest children released the least myeloperoxidase upon stimulation. Inpatient bacterial binding capacity and monocyte activation were associated with higher odds of persistent SAM at discharge, a risk factor for subsequent mortality. Thus, SAM shifts innate immune cell function, favoring bacterial containment over proinflammatory activation, which may contribute to health deficits after discharge.

Role of nutrition in curing dysphagia: a case series of five rare cases of severe acute malnutrition with severe megaloblastic anaemia

Severe acute malnutrition (SAM) is associated with multiple vitamin deficiencies, including vitamin B12. Vitamin B12 deficiency is commonly found in the Indian subcontinent, and has devastating clinical consequences. It leads to megaloblastic anaemia and several other complications. Dysphagia is an unusual symptom of the same. The present study was undertaken to evaluate the reversal of dysphagia with vitamin B12 supplements. A hospital-based retrospective case series was conducted at the B. J. Wadia Hospital for Children. Cases were collected from 19 November 2021, to 25 August 2022. Five children less than two years of age, who presented with complaint of dysphagia, presence of megaloblastic anaemia and concurrent nutritional compromise were evaluated for their clinical profiles, and the outcomes were analysed. We found that dysphagia was a reversible symptom with medical nutrition therapy and injectable B12 therapy in children with SAM who had severe megaloblastic anaemia. The present study has identified the prevalence of dysphagia in cases of SAM with megaloblastic anaemia. This dysphagia is reversible and curable with nutritional rehabilitation and injectable B12 therapy without any further invasive intervention.

FLOODS HAVE POSED SERIOUS HEALTH AND ECONOMIC CHALLENGES IN AFFECTED AREAS OF PAKISTAN

Climate changes can contribute to flooding. Adverse effects of flooding include loss of life, property, and infrastructure damage, road closures, erosion and landslide risks, crop destruction and livestock loss, health risks due to water contamination, housing displacement and economic impacts. Exposure to contaminated floodwater can cause wound infection, skin rash, gastrointestinal disorders, and tetanus etc. Around 33 million people in Pakistan were affected by devastating floods that killed over 1,700 people. One-third of Pakistan was inundated and 116 out of 154 districts of Pakistan have been affected by floods. Frail, hungry, children are fighting a losing battle against severe acute malnutrition, diarrhoea, malaria, dengue fever, typhoid, acute respiratory infections, and painful skin conditions. The longer the crisis continues, the greater the risk to children’s mental health. According to National Disaster Management Authority (NDMA), 2,000 health facilities, representing 10% of all health facilities in the country have been damaged. Over 8 million people in flood-affected districts are in urgent need of health assistance. Less than 50% of all people needing health services are currently able to access health facilities. Cases of Severe Acute Malnutrition (SAM) with complications are on the rise. Floods have disrupted immunization campaigns. United Nation’s revised Floods Response Plan was released on 4 Oct and seeks $816 million to provide humanitarian assistance to 9.5 million people. As of 16 Dec 2022, donors had funded only 26.7% of the $816 million requested. Lack of resources will definitely worsen health crisis during winter season. Pak J Physiol 2022;18(4):1–2

Incidence and predictors of attrition rate after children started inpatient treatments for complicated severe acute malnutrition in North West Ethiopia

BackgroundRetaining children for inpatient treatment of complicated severe acute malnutrition (SAM) is a growing challenge until achieved the reference weight of a child. In Ethiopia, there is limited information regarding the time to be lost from the stabilizing centers after initiation of treatment. Thus, this study aimed to identify incidence and predictors of attrition for children suffering from SAM after started inpatient treatment in North West Ethiopia.MethodsA retrospective cohort study was conducted among under-five children admitted and started inpatient treatment for complicated SAM from 2015/2016 to 2020/2021. Data were entered using Epi-data version 4.2 and then exported to STATA (SE) version R-14 software for further analysis. The analysis was computed using Cox proportional hazard regression model after checking all proportional hazard assumptions. Covariates having < 0.2 of P values in the bi-variable analysis were candidates transferred to the multivariable Cox proportional hazard regression model. Finally, a statistical significance was declared at a P value of < 0.05.ResultOverall, 760 files of under-five children were analyzed with a mean (± SD) age of participants 27.8 (± 16.5) months. About 6944 child-days of treatment observation were recorded with the crude incidence of attrition rate of 9.7% (95% CI 7.9–12.6). The overall median time of attrition and half-life time S(t1/2) of survival rates was determined as 14 (IQR = ± 7) days and 91.6% (95% CI 88.2–93.1), respectively. The attrition rate was significantly associated with cases living in rural residents (AHR = 6.03; 95% CI 2.2; 25.2), being re-admitted SAM cases (AHR = 2.99; 95% CI 1.62; 5.5), and caregivers did not have formal education (AHR = :5.6, 95% CI 2.7; 11.7) were all independent predictors for attrition from inpatient treatment.ConclusionsNearly one in every ten severely acute malnourished under-five children defaulted at the end of treatment observation with a median time of 14 (IQR = ± 7) days. Living in a rural residence, being re-admitted cases, caregivers who did not have a formal education were significantly associated with the attrition rate. Hence, it is crucial to detect and control the identified causes of defaulting from treatment observation promptly. Furthermore, serious counseling during admission and nutritional provision strategies are essential for virtuous treatment outcomes.

Prevalence of Tuberculosis in Severe Acute Malnutrition: A Prospective Observational Study

Introduction: Tuberculosis (TB) and malnutrition are important causes of morbidity and mortality in children in the developing world. This study was done to determine the prevalence of tuberculosis in severe acute malnutrition (SAM) cases and to observe different presentations of SAM. Method: This prospective observational study was carried out in the Department of Paediatrics and Adolescent Medicine at a tertiary care center in Nepal for a duration of one year from December 2018 to November 2019. All cases of SAM meeting the inclusion criteria were evaluated with Mantoux test, chest X-ray, gastric aspirate / sputum analysis and gene-Xpert for diagnosis of TB. Other relevant investigations for diagnosis of TB were also sent as per the clinical scenario. Data were entered and analyzed using Microsoft excel. Descriptive statistics was used for analysis of data. Results: Total 107 SAM cases were analyzed. The hospital prevalence of wasting and severe wasting was 11.98% and 0.73% respectively. The prevalence of TB in SAM was 4.67%, commonest being pulmonary TB (60%). Among TB cases, 40% were without any systemic complaints. Only 19.6% cases presented with nutritional complaint. Conclusions: This study found that a significant percentage of cases with SAM had TB and hence adds on the importance of screening for TB (Pulmonary TB) in every case of SAM, irrespective of symptoms.

Echocardiographic based cardiac evaluation in children with severe acute malnutrition.

To identify echocardiography-based myocardial changes in children with severe acute malnutrition. The prospective study was conducted from January to November 2020 at a territory care paediatric hospital in Multan, Pakistan, and comprised severe acute malnutrition patients of either gender aged 1-60 months and an equal number of matching healthy controls. Malnutrition was categorised using the World Health Organisation criteria. Echocardiographic evaluation was done by expert cardiologists. Values for ejection fraction shortening, left ventricular mass, E/A wave ratio as well as mitral and tricuspid annular plane systolic excursions were noted. Data was analysed using SPSS 21. Of the 150 subjects, 75(50%) each were cases and controls. Age and gender were not significantly different between the groups (p>0.05). Left ventricular mass and left ventricular mass index with body surface area were significantly reduced in the cases compared to the controls, and the same was the case with left ventricular ejection fractional shortening (p<0.05). There was no significant difference between the groups in terms of E/A wave ratio as well as mitral and tricuspid annular plane systolic excursions (p>0.05). Among the cases, cardiac evaluation showed 26(34.6%) were kwashiorkor and 49(65.3%) were marasmic patients. Left ventricular parameters in malnourished children were found to be reduced. As such, the assessment of these parameters may appear to be a significant indicator for timely identification of cardiac malfunction in severe acute malnutrition cases.

Time to readmission and associated factors after post treatment discharge of severe acute malnourished under-five children in Pawe General Hospital

BackgroundRelapse or repeated episodes is the admission of a child with the diagnosis of severe acute malnutrition (SAM) after being discharged to a status of treated and cured from a stabilizing center. A child may experience more than one episode of SAM depending on the improvement of the underlying comorbidity. Thus, this study aimed to estimate the time to readmission of SAM and associated factors for under-five children in North West Ethiopia.MethodsAn institution-based retrospective cohort study was employed in 760 files of under-five children spanning from 2014/15 to 2019/20. The data extraction tool was developed from SAM treatment guidelines and medical history sheets. Epi Data version 3.2 and STATA version 14 were used for data entry and final analysis, respectively. After checking all assumptions, the multivariable Cox Proportional Hazard model was fitted to the isolated independent predictors for time to readmission. A categorical variable with p < 0.05 was considered a risk factor for the relapse of SAM.ResultThe mean (± SD) age of participant children was 27.8 (± 16.5) months with mean (± SD) time to relapse of SAM cases were 30.4(± 21.39) weeks posttreatment discharge. The overall incidence density rate of relapse was determined as 10.8% (95% CI 8.3; 12.6). The average time (± SD) for treatment recovery from the first admission of the SAM case was 28.8(± 18.7) days. Time of readmission was significantly associated with living in rural resident (AHR 5⋅3 = 95% CI, 2⋅95, 13⋅87, p = 0.021), having HIV infection (AHR6⋅8 = 95%CI; 4.1–11.9 p = 0.001), and first admission with edema (AHR = 3.5 = 95% CI; 1.92, 6.2, p = 0.018).ConclusionNearly one in every ten severely acute malnourished under-five children relapsed within a mean time to relapse 30.4(± 21.39) weeks posttreatment discharge. Time to relapse was significantly associated with being a rural resident for children, having edema during the first admission, and being HIV-infected cases. A protocol ought to be drafted for extending Supplementary Nutrition in Acute Malnutrition management program following discharge is highly needed.

Key Challenges to Optimal Therapeutic Coverage and Maternal Utilization of CMAM Program in Rural Southern Pakistan: A Qualitative Exploratory Study.

Severe Acute Malnutrition (SAM) is a serious public health problem in many low- and middle-income countries (LMICs). Therapeutic programs are often considered the most effective solution to this problem. However, multiple social and structural factors challenge the social inclusion, sustainability, and effectiveness of such programs. In this article, we aim to explore how poor and remote households face structural inequities and social exclusion in accessing nutrition-specific programs in Pakistan. The study specifically highlights significant reasons for the low coverage of the Community Management of Acute Malnutrition (CMAM) program in one of the most marginalized districts of south Punjab. Qualitative data are collected using in-depth interviews and FGDs with mothers and health and nutrition officials. The study reveals that mothers’ access to the program is restricted by multiple structural, logistical, social, and behavioral causes. At the district level, certain populations are served, while illiterate, and poor mothers with lower cultural capital from rural and remote areas are neglected. The lack of funding for nutrition causes the deprioritization of nutrition by the health bureaucracy. The subsequent work burden on Lady Health Workers (LHWs) and the lack of proper training of field staff impact the screening of SAM cases. Moreover, medical corruption in the distribution of therapeutic food, long distances, traveling or staying difficulties, the lack of social capital, and the stigmatization of mothers are other prominent difficulties. The study concludes that nutrition governance in Pakistan must address these critical challenges so that optimal therapeutic coverage can be achieved.

A Quality Improvement Initiative to Enhance the Treatment of Children With Severe Acute Malnutrition in Nepal

ObjectivesDespite being implemented for decades, Nepal’s Integrated Management of Acute Malnutrition program has experienced several implementation challenges such as low coverage, stock outs of ready-to-use therapeutic food supplies, poor reporting, loss to follow up and sub-optimal counselling. To address these and build a culture of continuous service delivery improvement, the Suaahara-II program adopted and assessed a quality improvement (QI) approach. MethodsChange ideas, including increasing case identification through various platforms, developing QA standards to measure service quality, and providing incentives for female community health volunteers, were implemented as part of the QI initiative in four pilot municipalities. To assess changes in outcomes such as cure rate and number of cases identified and lost to follow-up, baseline information was collected over six months pre-implementation and performance was monitored throughout the QI implementation cycle of 17 months (February 2019—June 2021). We also analyzed secondary data from the government health management information system and established a monitoring mechanism to ensure data quality for outcome measures. For the outcome measure of service quality score, we developed a quality assurance (QA) checklist to score services while treating children with severe acute malnutrition (SAM). ResultsOur findings suggest that the QI effort was effective. The SAM cure rate increased from 67.4% pre-implementation to 80% post-implementation and the loss-to-follow-up rate declined from 26% to 8%. The number of new SAM cases fluctuated between 0–20 cases per month likely due to restrictions to mobility caused by the COVID-19 pandemic. Although there is no comparison to facilities that did not participate in the QI pilot, those that did had an average quality assurance score of 82.4%–above the 80% benchmark. ConclusionsWe found that the QI approach helped improve SAM cure rate, limited loss-to-follow-up and improved quality of case management for children with SAM. To successfully and sustainably implement QI to improve service delivery, leadership and local government accountability, regular coaching support and collaborative team efforts are key. Funding SourcesUnited States Agency for International Development (USAID).

Validation of MUAC Cut-Offs of WHO for Diagnosis of Acute Malnutrition among Children under 5 Years in Karachi, Pakistan

Objective: To validate the WHO recommended Mid-Upper Arm Circumference (MUAC) cut-offs for acute malnutrition screening in children younger than five in Karachi, Pakistan.&#x0D; Methods: A cross-sectional study was conducted, including an anthropometric examination following WHO guidelines. Height was measured using Stadiometer and Infantometer. The link between MUAC and Weight-for-Height-Z score (WHZ) for different cut-offs of MUAC for Moderate Acute Malnutrition (MAM) and Severe Acute Malnutrition (SAM) was shown using Receiver Operator Characteristics (ROC) curves and the Youden index. Sensitivity and specificity of MUAC &lt;11.5 cm and ≥11.5 to &lt;12.5cm were determined using WHZ scores of -3 Standard Deviation (SD) and ≥-3 to &lt;-2 SD for SAM and MAM, respectively.&#x0D; Results: Among 499 children, as per WHZ score, 9.6% and 27.1% had SAM and MAM, respectively, whereas according to MUAC, 6.4% and 3.6% had MAM and SAM, respectively. At the maximum value of the Youden index of 55.6%, an optimum cut-off of 12.7cm for screening of SAM with MUAC was found compared to the recommended cut-off of 11.5cm. Similarly, at the maximum value of the Youden index of 57.7%, an optimum cut-off of 13.9cm for screening of MAM with MUAC was found compared to the recommended cut-off of 12.5cm.&#x0D; Conclusion: The current MUAC cut-off of WHO for screening SAM and MAM cases captures only a small percentage of children under five. This needs to be revised to capture children with acute malnutrition for timely treatment in Pakistan.

A novel screening tool to predict severe acute malnutrition through automated monitoring of weight-for-age growth curves.

Weight‐for‐age (WFA) growth faltering often precedes severe acute malnutrition (SAM) in children, yet it is often missed during routine growth monitoring. Automated interpretation of WFA growth within electronic health records could expedite the identification of children at risk of SAM. This study aimed to develop an automated screening tool to predict SAM risk from WFA growth, and to determine its predictive ability compared with simple changes in weight or WFA z‐score. To develop the screening tool, South African child growth experts (n = 30) rated SAM risk on 100 WFA growth curves, which were then used to train an artificial neural network (ANN) to assess SAM risk from consecutive WFA z‐scores. The ANN was validated in 185 children under five (63 SAM cases; 122 controls) using diagnostic accuracy methodology. The ANN's performance was compared with that of changes in weight or WFA z‐score. Even though experts' SAM risk ratings of the WFA growth curves differed considerably, the ANN achieved a sensitivity of 73.0% (95% confidence interval [CI]: 60.3; 83.4), specificity of 86.1% (95% CI: 78.6; 91.7) and receiver‐operating characteristic curve area of 0.795 (95% CI: 0.732; 0.859) during validation with real cases, outperforming changes in weight or WFA z‐scores. The ANN, as an automated screening tool, could markedly improve the identification of children at risk of SAM using routinely collected WFA growth information.

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.